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Pharmacology > Week 9: Headaches > Flashcards

Week 9: Headaches Flashcards

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?

A

oxygen (7L/min x 15 minutes)

25
Q

What are acute or abortive treatment options for cluster headaches? (besides oxygen)

A

sumatriptan (imitrex) 6mg SQ; 20mg nasal spray
intranasal dihydroergotamine
intranasal lidocaine
intranasal capsaicin

26
Q

Is oral sumatriptan effective for cluster HA prophylaxis?

A

NO

27
Q

What are the treatment options for CH prophylaxis?

A 
verapamil (Calan)
prednisone
valproic acid (depakote)
topirmate (topamax)
ergotamine (Ergomar)
28
Q

What type of headache has effective therapies but is often underused and undertreated?

A

migraine headache (MH)

29
Q

Why do half of patients with MH stop medical care?

A

secondary to dissatisfaction

30
Q

How is migraine headache classified?

A

based on clinical features- with or without aura

31
Q

Aura includes what visual distortions?

A

positive: scintillations (sparks), teichopsia (luminous appearance), photopsia (flashes)
negative: visual field defects

32
Q

What is the presentation of a migraine headache?

A

pain is usually unilateral, throbbing, temporal and incapacitating

33
Q

How can pain be minimized with a migraine headache?

A

in a dark, quiet location

34
Q

What are the prodromal symptoms that many experience with a migraine headache? (5)

A 
nausea, 
vomiting, 
food cravings, 
heightened sensory perceptions and 
alternation in mood or behavior
35
Q

What are the common triggers of a migraine headache? (3)

A

Food- alcohol, caffeine, chocolate, MSG, tyramine and nitrate containing foods
Behavioral- physiologic
Environmental-loud noises, flickering lights

36
Q

What is the #1 goal of ACUTE migraine headaches?

A

treat attacks RAPIDLY and consistently

37
Q

What are 2 goals of pharmacotherapy for long-term MH?

A

reduce the frequency and severity of the attacks

avoid escalation of medications

38
Q

What is the treatment of ACUTE mild to moderate migraines or unresponsive severe attacks?

A

oral NSAIDs
combo analgesics containing caffeine
isometheptene combos (isometheptene, acetaminophen & dicloralohenazone= Midrin)

39
Q

What is the treatment of ACUTE moderate-severe migraine or moderate migraine unresponsive to NSAIDs?

A

migraine specific meds (triptans, dihydroergotamine (DHE) or combo (asa+ APAP+ caffeine)

40
Q

What is no longer widely used in acute migraine headache

A

sedatives

41
Q

Is acetaminophen mono therapy recommended for acute MH therapy?

A

NO

42
Q

Which approach to MH treatment was found superior?

A

Recent RCT found stratified-care superior

43
Q

What is the stratified care approach for MH?

A

treatment based on severity of disability
non specific therapies for minimal disability
specific therapies for mod-severe disability

44
Q

What is the step care approach for MH treatment?

A

initially treat with safest, least expensive therapies

pts progress to more expensive, specific MH meds only if treatment fails

45
Q

What is a non selective 5-HT1 agonist that is used for abortive therapy for migraine headaches?

A

ergotamine

risk of ergotism “ergot poisoning”

46
Q

What is also a non selective 5-HT1 agonist that largely replaced ergotamine? (less overuse)

A

Dihydroergotamine (DHE)

47
Q

What abortive therapies are oxytocin and therefore contraindicated in pregnancy?

A

ergotamine and dihydroergotamine

48
Q

Why should ergotamine and dihydroergotamine only be used short term?

A

both cause peripheral vasoconstriction

49
Q

What is a specific 5HT1 receptor agonist that is now widely used for abortive therapy for MH?

A

triptans

50
Q

what are triptans reserved for?

A

moderate-severe migraine headache, unresponsive to other medications

51
Q

What are the contraindications of triptans? (3)

A

uncontrolled htn
ischemic vascular conditions
vasospastic CAD

52
Q

What are the triptan medications for migraine headaches? (3)

A

SubQ sumatriptan (Imitrex)
Rizatriptan (Maxalt)
Naratriptan (Amerge)

53
Q

What is the peak time of SubQ sumatriptan (Imitrex)?

A

15 minutes

54
Q

What is the peak time of Rizatriptan(Maxalt)?

A

peaks in 60-90 minutes

55
Q

What is the half life of naratriptan (Amerge)?

A

the longest half life

may decrease chance of recurrence headaches

56
Q

What are the principles of triptan therapy?

A

try one for 2-3 headaches episodes before changing
if one is ineffective, try another
match the drug characteristics to a pts needs

57
Q

When should you consider preventive therapy (prophylaxis) for migraines?

A

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
Q

What is the MOA of Onabotulinumtoxin A (Botox)?

A

neuromuscular blocking agent

59
Q

How many sites is Onabotulinumtoxin A (Botox) injected into for chronic migraine prophylaxis?

A

31 total sites

Pharmacology (17 decks)

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