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
For preventive treatment of migraine, when are these taken? Who is it recommended for?
Think every day, in the long term, and maybe preemptive (if migraine likely to occur, like during exercise or menstrual periods);
- 3 severe headaches per month
- > 2 mild-moderate headaches per week
- overuse of acute meds
- special migraine syndromes (hemiplegic one)
- can’t use effective symptomatic therapy
For preventive treatment of migraine headache, what are the antidepressants used? SE’s of BOTH?
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
For preventive treatment of migraine headache, what antihypertensives are used? SE’s and conra?
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
For antiepileptic drugs, which is most frequently used for prevention of migraine?
TOPIRAMATE!!
Botox has been approved for treatment of _____; how is this defined? SE’s are usually what?
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
TTH: there is no _____; what are the forms; how is the pain described? trigger? What is usually NOT seen?
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
Acute treatment of TTH? Preventive treatment?
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
In cluster headache, what are the types and what is characteristic about them? List some other facts about the patient population?
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!!
In episodic CH, what is the time frame? In chronic cluster headahce? What are these headaches associated with?
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!!
Acute treatment of cluster headahces?
- High flow O2 with non-rebreathing mask
- Triptans (SC)
- DHE (IM and nasal spray)
- Anesthetics (local intranasal agents like LIDOCAINE)
Preventive therapies of cluster headaches? Special note on one of these treatments?
- Short-term preventives (21-28 days): think corticosteroids and ergotamine
- 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!!)
