Pharmacotherapy of Primary Headache Syndromes Flashcards
For headaches, physician should record
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!!)
Most common type of headache is
tension-type»_space; migraine > chronic daily headache
Prevalence of migraine greatest in
25-55 group
Migraine phases are
- prodrome 2. aura 3. headache 4. resolution
Prodrome of migraine involves changes in ____ and occurs
Psychological (depressed, irritable, talkative, drowsy), neurological (photophobia/phonophobia, yawning, difficulty concentrating), constitutional, autonomic features; HOURS to DAYS before headache onset
Aura will have _____ symptoms that typically occur ____ headache; how long do the symptoms last? Most common type of aura?
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
Headache of migraine will usually be; what will the patient try to do?
- unilateral, throbbing, moderate-severe, aggravated by physical activity and relieved by rest
- Usually between 5am-12 noon
- Think 4-72 HOURS!!
- Also N/V, photo/phonophobia possible!!;
SEEK A DARK QUIET ROOM!!!
Resolution of migraine is
- headache wanes
- patient is tired, washed out, irritable
- Still have issues with concentration, scalp tenderness, mood changes
For migraine genetics, in familial hemiplegic migraine
there is mutations of calcium channel on chromosome 19
Some patients might have a _____ brain, leading to
sensitive; more susceptibility to developing headache in the face of certain stimuli
For aura phase, this is assicated with
neuronal dysfunction called the cortical spreading depression (CSD): reduction of cerebral blood flow moving across cortex at rate of 2-3 mm/min
For headache of migraine, what is activated? Write out the steps of this pathophys…
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
For treatment of migraines, what do you start with?
Non-pharm measures (BEHAVIORAL);
- regular meals, exercise, rest
- avoid TRIGGERS (maybe in food, perhaps weather)
- Address psychological factors
- Consider SPECIFIC therapies (biofeedback!!!)
Acute pharm therapies for headaches used; migraine-specific meds include; nonspecific meds (good for both migraine and nonheadache pain disorders) include
after attack has begun in an attempt to reverse or stop the progression;
ergots, triptans;
analgesics, antiemetics, NSAIDS, steroids, etc.
For the nonspecific treatments of migraine headache, what is a caution?
Avoid overuse; also think about pregnancies, children, cardiovascular risk
Overuse of nonspecific meds can lead to
rebound phenomenon
For analgesics, what can they treat and list some examples
Good for mild-moderate migraine: acetaminophen, aspirin, naproxen, indmethacen, piroxicam, diclofenac, ibuprofen;
moderate migraine: acetaminophen, aspirin, caffeine combo (Excedrin)
For barbs, what are the side effects associated when it treats ___?
Think OVERUSE and WITHDRAWAL; also drowsiness and dizziness;
MIGRAINE
Opioids: Wat are some examples, forms, thera, SE’s, contraindications?
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
For migraines, ergotamines and DHE now thought to work though
reducing cell activity in the tregeminovascular system (5 HT 1 b-d agonists)
Ergotamine available as; contraindicated in; SE’s
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
DHE: forms, thera, SE’s, contra
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
What are premire migraine abortive meds? List the forms of the main one;
what if there’s recurrence?
Triptans;
usually give something like sumatrip SC, or can give oral/nasal triptans;
if recurrence of headache, give second dose 2 hours later
Triptans also effective against;
use for aura?;
contra and SE’s?
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
