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Pharmacology > Week 9: Headaches > Flashcards

Week 9: Headaches Flashcards

(59 cards)

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1
Q

What percentage of headache office and ER visits have serious pathology?

A

<2% office

<4% ER

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2
Q

What are the classifications of headaches?

A

primary- NOT caused by secondary)

secondary (caused by secondary)

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3
Q

What are the primary types of headache?

A 
tension-type headache (TTH)
cluster headache (CH)
Migraine Headache (MH)
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4
Q

What are the secondary types of headache?

A

HTN(>200/120), infection, thrombosis
tumors, subarachnoid hemorrhage
trauma, arteritis

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5
Q

What are the “red flags” of secondary headache? (9)

A 
change or progression in headache pattern
first/ OR worst headache
abrupt onset or awakening from sleep
abnormal physical or nuero findings
neuro symptoms >1hour
New HA in pts <5 or >50 years
New HA in pts w/ cancer or pregnancy
loss of consciousness
triggered by exertion, sexual activity or Valsalva maneuver
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6
Q

What type if headache is described as a mile-moderate dull ache?

A

tension-type headache (TTH)

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7
Q

What is generally lacking in TTH?

A

signs of serious underlying conditions
visual disturbances
generalized pain, fever, stiff beck or recent trauma
bruxism

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8
Q

What is the most common treatment for TTH?

A 
OTC analgesics 98%:
acetaminophen- 56%
aspirin-15%
ibuprofen-12%
other agents-17%
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9
Q

What are the NSAIDs and acetaminophen dosages that are more effective compared to placebo at 2 hours?

A

ibuprofen 400mg po
acetaminophen 1,000mg po
ketoprofen (orudis) 25mg po

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10
Q

With TTH how often should analgesics be used and why?

A

limit to 2-3 times/ week to precent medication-overuse headache

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11
Q

What may augment a TTH?

A

sedating antihistamines (benadryl& phenergan)

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12
Q

If treatment in inadequate with OTC analgesics, what can be tried?

A

acetaminophen or aspirin w/ caffeine and butalbital (Butalin)

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13
Q

What can Butalin be taken?

A

may precipitate chronic daily headache

use

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14
Q

What medications can be used for TTH prophylaxis?

A

amitriptyline (Slavic)

SSRIs (may take 1-2 months)

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15
Q

What are the SSRIs that can be given for prophylactic TTH?

A

paroxetine (Paxil)
venlafaxine (Effexor)
fluoxetine (prozac)

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16
Q

what is the most painful primary headache?

A

cluster headache (CH)

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17
Q

what might also accompany a cluster headache?

A

aura
photophobia (56%)
photophobia (43%)
osmophobia (23%)

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18
Q

What is the key feature of cluster headache?

A

recurrent bouts of near daily attacks that may last for weeks or months

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19
Q

What do many CH attacks begin with?

A

REM phase sleep

some pts fear going to sleep

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20
Q

What are precipitants of a CH attack? (4)

A

hypoxia (sleep apnea)
vasodilators (NTG)
alcohol
carbon dioxide

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21
Q

How are CH diagnosed?

A

by history

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22
Q

What is the CH diagnosis criteria?

A

UNILATERAL orbital, supraorbital or temporal accompanied by 1 of more of the following:
ipsilateral conjunctival injection or lacrimation
ipsilateral nasal congestion or rhinorrhea
ipsilateral eyelid edema, forehead & facial sweating
ipsilateral mitosis or ptosis
a sense of restlessness or agitation (98% of patients)

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23
Q

What is the dual strategy for CH treatment?

A

acute attacks must be aborted or subdued

prophylaxis to suppress remaining CH

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24
Q

What is the treatment of choice for a cluster headache?

Study These Flashcards
A

oxygen (7L/min x 15 minutes)

25
What are acute or abortive treatment options for cluster headaches? (besides oxygen)
sumatriptan (imitrex) 6mg SQ; 20mg nasal spray intranasal dihydroergotamine intranasal lidocaine intranasal capsaicin
26
Is oral sumatriptan effective for cluster HA prophylaxis?
NO
27
What are the treatment options for CH prophylaxis?
``` verapamil (Calan) prednisone valproic acid (depakote) topirmate (topamax) ergotamine (Ergomar) ```
28
What type of headache has effective therapies but is often underused and undertreated?
migraine headache (MH)
29
Why do half of patients with MH stop medical care?
secondary to dissatisfaction
30
How is migraine headache classified?
based on clinical features- with or without aura
31
Aura includes what visual distortions?
positive: scintillations (sparks), teichopsia (luminous appearance), photopsia (flashes) negative: visual field defects
32
What is the presentation of a migraine headache?
pain is usually unilateral, throbbing, temporal and incapacitating
33
How can pain be minimized with a migraine headache?
in a dark, quiet location
34
What are the prodromal symptoms that many experience with a migraine headache? (5)
``` nausea, vomiting, food cravings, heightened sensory perceptions and alternation in mood or behavior ```
35
What are the common triggers of a migraine headache? (3)
Food- alcohol, caffeine, chocolate, MSG, tyramine and nitrate containing foods Behavioral- physiologic Environmental-loud noises, flickering lights
36
What is the #1 goal of ACUTE migraine headaches?
treat attacks RAPIDLY and consistently
37
What are 2 goals of pharmacotherapy for long-term MH?
reduce the frequency and severity of the attacks | avoid escalation of medications
38
What is the treatment of ACUTE mild to moderate migraines or unresponsive severe attacks?
oral NSAIDs combo analgesics containing caffeine isometheptene combos (isometheptene, acetaminophen & dicloralohenazone= Midrin)
39
What is the treatment of ACUTE moderate-severe migraine or moderate migraine unresponsive to NSAIDs?
migraine specific meds (triptans, dihydroergotamine (DHE) or combo (asa+ APAP+ caffeine)
40
What is no longer widely used in acute migraine headache
sedatives
41
Is acetaminophen mono therapy recommended for acute MH therapy?
NO
42
Which approach to MH treatment was found superior?
Recent RCT found stratified-care superior
43
What is the stratified care approach for MH?
treatment based on severity of disability non specific therapies for minimal disability specific therapies for mod-severe disability
44
What is the step care approach for MH treatment?
initially treat with safest, least expensive therapies | pts progress to more expensive, specific MH meds only if treatment fails
45
What is a non selective 5-HT1 agonist that is used for abortive therapy for migraine headaches?
ergotamine risk of ergotism "ergot poisoning"
46
What is also a non selective 5-HT1 agonist that largely replaced ergotamine? (less overuse)
Dihydroergotamine (DHE)
47
What abortive therapies are oxytocin and therefore contraindicated in pregnancy?
ergotamine and dihydroergotamine
48
Why should ergotamine and dihydroergotamine only be used short term?
both cause peripheral vasoconstriction
49
What is a specific 5HT1 receptor agonist that is now widely used for abortive therapy for MH?
triptans
50
what are triptans reserved for?
moderate-severe migraine headache, unresponsive to other medications
51
What are the contraindications of triptans? (3)
uncontrolled htn ischemic vascular conditions vasospastic CAD
52
What are the triptan medications for migraine headaches? (3)
SubQ sumatriptan (Imitrex) Rizatriptan (Maxalt) Naratriptan (Amerge)
53
What is the peak time of SubQ sumatriptan (Imitrex)?
15 minutes
54
What is the peak time of Rizatriptan(Maxalt)?
peaks in 60-90 minutes
55
What is the half life of naratriptan (Amerge)?
the longest half life | may decrease chance of recurrence headaches
56
What are the principles of triptan therapy?
try one for 2-3 headaches episodes before changing if one is ineffective, try another match the drug characteristics to a pts needs
57
When should you consider preventive therapy (prophylaxis) for migraines?
2+ attacks/month with disability more than 3 days/month contraindications or failure to abortive therapy use of abortive therapy more than twice a week presence of uncommon conditions (hemiplegic migraine or prolonged aura)
58
What is the MOA of Onabotulinumtoxin A (Botox)?
neuromuscular blocking agent
59
How many sites is Onabotulinumtoxin A (Botox) injected into for chronic migraine prophylaxis?
31 total sites

Pharmacology (17 decks)

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