Primary Headache Syndromes

Question 1

The “headache” phase of a migraine involves activation of what system?

Answer 1

Trigeminovascular system

Question 2

During a migraine attack, sensory nerve fibers from the ophthalmic divison of CN V innervate meningeal bv’s, large cerebral vessels and venous sinuses. They release vasodilating and permeability promoting peptides such as what? These peptides promote a sterile inflammation, which leads to pain following central processing. This cascade of events is mediated by what presynaptic receptors?

Answer 2

Nuerokinin A, Substance P, CGRP. 5HT1B-D, inhibitory GPLRs.

Question 3

Migraine tx begins with what measures?

Answer 3

Behavioral, non-pharm

Question 4

The migraine-specific ACUTE tx medications include what two types? The nonspecific meds include what 6?

Answer 4

Ergots and triptans. Analgesics, antiemetics, NSAIDs, steroids, anxiolytics, opioids.

Question 5

Traditionally thought to act by vasoconstriction, expt evidence shows DHE and ergotamine to act by…? DHE IV is used mainly for what?

Answer 5

reducing cell activity in the trigeminovascular system (5HT1b-d agonists). Status migrainosus.

Question 6

S.E.s of DHE and ergotamine. Who should they be avoided in?

Answer 6

n/v/cp/abd pain/dizziness/etc. Pregnant women, uncontrolled htn, sepsis, renal or hepatic failure, and coronary, cerebral pr peripheral vasc disease.

Question 7

What class are the premier migraine abortive medications?

Answer 7

Triptans

Question 8

Mech of action of triptans

Answer 8

5 HT 1B-D agonists that penetrate CNS causing vasoconstriction of extracerebral intracranial vessels and inactivation of the tgmvasc system.

Question 9

What additional symptoms do the triptans reduce?

Answer 9

Assoc’d symptoms such as photo/phonophobia, n , v.

Question 10

Avoid the use of triptans in whom? S.E.s of triptans?

Answer 10

ppl with vasc disease, uncontrolled htn, and complicated migraine syndromes such as hemiplegia migraine. S.E.s flushing, tingling, dizziness, CP (noncardiac).

Question 11

Antidepressants used for preventive/prophylactic tx of migraines: drug types and representative drug names within

Answer 11

TCAs (amitriptyline), SSRIs (fluoxetine, paroxetine, sertraline all used to tx coexistent depression and chronic daily HA).

Question 12

Antidepressants used for preventive/prophylactic tx of migraines: SEs and contra’s

Answer 12

TCAs include dry mouth, constipation, wt gain, cardiac tox, and orthostatic hypotension. SSRIs may cause wt gain and sexual dysfunction.

Question 13

Antiepileptic drugs used for preventive/prophylactic tx of migraines: drug types and representative drug names within

Answer 13

Divalproex sodium most used of valproic acid formulations. Topiramate most frequently used AED.

Question 14

Antiepileptics used for preventive/prophylactic tx of migraines: SEs and AEs

Answer 14

Divalproex: Sedation, hair loss, wt gain. tremor, and changes in cognition. Hepatotoxicity, blood dyscrasias and pancreatitis most serious AEs. Topiramate: Changes in cognition, paresthesias and wt loss, ?kidney stones, acute angle-closure glaucoma, dec bicarb levels.

Question 15

Antihypertensive drugs used for preventive/prophylactic tx of migraines: drug types and representative drug names within

Answer 15

Beta-blockers (timolol and propranolol), Ca-channel blocker (verapamil) for chronic and disabling aura and complicated migraine syndromes.

Question 16

Antihypertensive drugs used for preventive/prophylactic tx of migraines: SEs and contra’s

Answer 16

Drowsiness, depression, dec libido, hypotension, memory disturbance. Contra’d in asthma, diabetes, CHF or Raynaud’s. For Ca-channel blocker SEs are constipation and dizziness.

Question 17

Acute pharm therapies for TTH

Answer 17

Simple analgesics (NSAIDs) alone or with caffeine, codeine or anxiolytics (avoid frequent use of these meds). No evidence in ETTH for muscle relaxants.

Question 18

Preventive pharm therapies for TTH should be considered when and include what

Answer 18

Considered if freq (more than 2 per wk), duration, (more than 4 hrs) and severity of ETTH might lead to significant disability or med overuse. TCAs followed by SSRIs; amitriptyline is best. Muscle relaxants may be effective for CTTH.

Question 19

What should patients with cluster headaches avoid if experiencing a cluster?

Answer 19

Don’t nap during the day and avoid etoh.

Question 20

Prophylactic therapies for CH include short-term for when already experiencing a cluster and long-term preventive drugs for reducing frequency. List the two short-term and 4 long-term drugs.

Answer 20

Oral corticosteroids and daily ergotamine. Verapamil, topiramate, divalproex, and lithium.

Question 21

Side effects of lithium

Answer 21

Weakness, nausea, thirst, tremor, lethargy, blurred vision, and slurred speech. Tox may lead to vom, anorexia, diarrhea, confusion, nystagmus, extrapyramidal signs and seizures. Avoid indomethacin and sodium depleting diuretics since they increase Li levels.

Question 22

Acute therapies are limited cuz attacks peak quickly, thus ROA is important (should be parenteral or oxygen). What’s the tx of choice and secondary tx options?

Answer 22

High flow O2. Sumatriptan SC, DHE IM and nasal, lidocaine intranasal.