Pharmacotherapy of Primary Headache Syndromes

Question 1

For headaches, physician should record

Answer 1

attack onset, duration, timing and frequency; pain location and severity and quality; associated features; aggravating, precipitating, ameliorating factors; also past SH, FH, impact on daily living
(As if we’re taking a history on the headache!!)

Question 2

Most common type of headache is

Answer 2

tension-type&raquo_space; migraine > chronic daily headache

Question 3

Prevalence of migraine greatest in

Answer 3

25-55 group

Question 4

Migraine phases are

Answer 4

1. prodrome 2. aura 3. headache 4. resolution

Question 5

Prodrome of migraine involves changes in ____ and occurs

Answer 5

Psychological (depressed, irritable, talkative, drowsy), neurological (photophobia/phonophobia, yawning, difficulty concentrating), constitutional, autonomic features; HOURS to DAYS before headache onset

Question 6

Aura will have _____ symptoms that typically occur ____ headache; how long do the symptoms last? Most common type of aura?

Answer 6

focal neurologic; prior to (sometimes accompanies or follows headache);
think 5-20 minutes (less than 60 FOR SURE);
Most Common: VISUAL, followed by paresthesias as 2nd

Question 7

Headache of migraine will usually be; what will the patient try to do?

Answer 7

1. unilateral, throbbing, moderate-severe, aggravated by physical activity and relieved by rest
2. Usually between 5am-12 noon
3. Think 4-72 HOURS!!
4. Also N/V, photo/phonophobia possible!!;
   SEEK A DARK QUIET ROOM!!!

Question 8

Resolution of migraine is

Answer 8

1. headache wanes
2. patient is tired, washed out, irritable
3. Still have issues with concentration, scalp tenderness, mood changes

Question 9

For migraine genetics, in familial hemiplegic migraine

Answer 9

there is mutations of calcium channel on chromosome 19

Question 10

Some patients might have a _____ brain, leading to

Answer 10

sensitive; more susceptibility to developing headache in the face of certain stimuli

Question 11

For aura phase, this is assicated with

Answer 11

neuronal dysfunction called the cortical spreading depression (CSD): reduction of cerebral blood flow moving across cortex at rate of 2-3 mm/min

Question 12

For headache of migraine, what is activated? Write out the steps of this pathophys…

Answer 12

Trigeminovascular system;
1. Sensory nerve fibers from ophthalmic division of CN V release VASODILATING AND PERM-promoting peptids (substance P, calcitonon gene-related peptid) from perivascular nerve endings
2. Peptides promote sterile inflamm, leading to pain following central processing;
process mediated by PRESYN SEROTONIN (5 HT 1B-D) receptors

Question 13

For treatment of migraines, what do you start with?

Answer 13

Non-pharm measures (BEHAVIORAL);

1. regular meals, exercise, rest
2. avoid TRIGGERS (maybe in food, perhaps weather)
3. Address psychological factors
4. Consider SPECIFIC therapies (biofeedback!!!)

Question 14

Acute pharm therapies for headaches used; migraine-specific meds include; nonspecific meds (good for both migraine and nonheadache pain disorders) include

Answer 14

after attack has begun in an attempt to reverse or stop the progression;
ergots, triptans;
analgesics, antiemetics, NSAIDS, steroids, etc.

Question 15

For the nonspecific treatments of migraine headache, what is a caution?

Answer 15

Avoid overuse; also think about pregnancies, children, cardiovascular risk

Question 16

Overuse of nonspecific meds can lead to

Answer 16

rebound phenomenon

Question 17

For analgesics, what can they treat and list some examples

Answer 17

Good for mild-moderate migraine: acetaminophen, aspirin, naproxen, indmethacen, piroxicam, diclofenac, ibuprofen;
moderate migraine: acetaminophen, aspirin, caffeine combo (Excedrin)

Question 18

For barbs, what are the side effects associated when it treats ___?

Answer 18

Think OVERUSE and WITHDRAWAL; also drowsiness and dizziness;

MIGRAINE

Question 19

Opioids: Wat are some examples, forms, thera, SE’s, contraindications?

Answer 19

Codeine, meperidine, oxycodone, hydromorphone, morphine, methadone, butorphanol;
Forms: oral, parenteral, transnasal formulations
Thera: migraine
SE’s: High risk of OVERUSE (should not use more than 2 days per week) and used for pts with infrequent headaches
Contra: think pregnancy or can’t tolerate it

Question 20

For migraines, ergotamines and DHE now thought to work though

Answer 20

reducing cell activity in the tregeminovascular system (5 HT 1 b-d agonists)

Question 21

Ergotamine available as; contraindicated in; SE’s

Answer 21

oral tablet and suppository (use in combo with CAFFEINE);
pregnant women, uncontrolled HTN, sepsis, renal/hepatic failure, different vascular diseases!!;
SE’s: N/V, CP, abdo pain, dizziness

Question 22

DHE: forms, thera, SE’s, contra

Answer 22

Forms: nasal spray, IM, IV
Thera: IV for status migranosus (SEVERE and INTRACTABLE constant headache-state lasting > 72 hours);
same SE’s and contra as ergotamines

Question 23

What are premire migraine abortive meds? List the forms of the main one;
what if there’s recurrence?

Answer 23

Triptans;
usually give something like sumatrip SC, or can give oral/nasal triptans;
if recurrence of headache, give second dose 2 hours later

Question 24

Triptans also effective against;
use for aura?;
contra and SE’s?

Answer 24

Thera: photo/phonophobia, N/V;
no evidence for aura use;
Contra: vascular disease, uncontrolled HTN, complicated migraine syndromes like hemiplegic migraine;
SE’s: flushing, tingling, chest discomfort, dizziness

Question 25

For preventive treatment of migraine, when are these taken? Who is it recommended for?

Answer 25

Think every day, in the long term, and maybe preemptive (if migraine likely to occur, like during exercise or menstrual periods);

1. 3 severe headaches per month
2. > 2 mild-moderate headaches per week
3. overuse of acute meds
4. special migraine syndromes (hemiplegic one)
5. can’t use effective symptomatic therapy

Question 26

For preventive treatment of migraine headache, what are the antidepressants used? SE’s of BOTH?

Answer 26

TCA’s like amitriptyline (along with protriptyline and nortriptyline); also SSRI’s like fluoxetine, paroxetine, and sertraline;
TCA SE’s: dry mouth, constipation, weight gain, orthostatic hypotension, cardiac toxicity
SSRI SE’s: weight gain and sexual dysfunction

Question 27

For preventive treatment of migraine headache, what antihypertensives are used? SE’s and conra?

Answer 27

Beta blockers like propanolol along with nadolol and atenolol (these two with longer half life and tolerability);
SE’s: drowsiness, depression, decreased libido, hypotension, memory issues;
Contra: asthma, diabetes, CHF, Raynaud’s;

Ca channel blockers (verapamil): best for prolonged or disabling aura and for complicated migraine syndromes;
SE’s: constipation and dizziness

Question 28

For antiepileptic drugs, which is most frequently used for prevention of migraine?

Answer 28

TOPIRAMATE!!

Question 29

Botox has been approved for treatment of _____; how is this defined? SE’s are usually what?

Answer 29

chronic migraine;
think of migraine headache occurring on 15 or more days/month for >3 months in absence of med overuse;
usually injection site pain, headache post injection; neck weakness and ptosis rarely seen

Question 30

TTH: there is no _____; what are the forms; how is the pain described? trigger? What is usually NOT seen?

Answer 30

prodrome or aura;
episodic and chronic;
dull, achy, non-pulsatile, pressure-like, BILATERAL, no aggravation, MILD or MODERATE intensity;
Trigger: sleep;
Not seen: N/V, photophobia/phonophobia

Question 31

Acute treatment of TTH? Preventive treatment?

Answer 31

Acute: simple analgesics (naproxen, ketorolac, indomethacin); analgesic combo with opioids, barbituates, caffeine;

Preventive: think if you have headache frequency > 2/wk, duration of >4 hrs, headache severity; use TCA’s (amitriptyline) before SSRIs, muscle relaxants (tizanidine), and Botox possibly

Question 32

In cluster headache, what are the types and what is characteristic about them? List some other facts about the patient population?

Answer 32

Episodic and chronic;
annual rhythm and occur at the SAME TIME of day;
1. male:female ratio 4:1
2. age of onset 27-31
3. Have heavy facial features
4. Think SMOKERS!!

Question 33

In episodic CH, what is the time frame? In chronic cluster headahce? What are these headaches associated with?

Answer 33

Episodic: lasts 7 days to 1 year separated by pain-free periods lasting 1 month;
Chronic: >1 year without remission or remissions lasting < 1 month;
Ipsilateral lacrimation, nasal congestion, rhinorrhea, forehead/facial sweating, miosis, ptosis, eyelid edema, think UNILATERAL AND TEMPORAL!!

Question 34

Acute treatment of cluster headahces?

Answer 34

1. High flow O2 with non-rebreathing mask
2. Triptans (SC)
3. DHE (IM and nasal spray)
4. Anesthetics (local intranasal agents like LIDOCAINE)

Question 35

Preventive therapies of cluster headaches? Special note on one of these treatments?

Answer 35

1. Short-term preventives (21-28 days): think corticosteroids and ergotamine
2. Long-term preventives: verapamil, topiramate, divalproex Na, LITHIUM!!;
   Lithium: blood levels necessary to monitor efficacy, SE’s are weakness, nausea, thirst, tremor, lethargy, blurred vision, slurred speech; toxicity can lead to vomiting, anorexia, diarrhea, confusion, seizures, nystagmus (AVOID INDOMETHACIN and Na-depleting DIURETICS!!)