chapter 35 headaches

Question 1

migraine abortive therapy

Answer 1

• use step wise algorhythm
• OTC analgesics: works best early in migraine, NSAIDS-ibuprofen or naproxen; excedrin migraine or advil migraine
• midrange analgesics: butalbital/ASA or APAP (fiorinal or fioricet); isometheptene/acetaminophen/dichloralphenzaone (Midrin)
• high range analgesics-opioids
• controversial; drug of choice-pregnancy, vasoconstriction are contraindicated, nonresponsive to ergotamine or serotonin agonists
• PO: codeine combined with ASA/APAP
• IM: meperidine
• intranasal butorphanol
• potential for dependence and tolerance

Question 2

migraines

Answer 2

3 categories: migraine with aura (classic), without aura (common), complicated migraine-treated by drugs the same

• patho: vascular theory: aura created by vasoconstriction of intracranial vessels and vasodilation of affected vessels-disproven
  
  • sertonin: changes cause release of vasoactive neurotransmitter, causes inflammatory response, excitory serotonin receptors activated
• acute abortive therapy v. prophylactic therapy

Question 3

ergots and DHE

Answer 3

-act as vasoconstrictors that lead to decline of pulsation to extracranial arteries
ergot: taken early in migraine, po/suppository (absorbed better); cautious with pts pvd, cad, htn, compromised renals; adrs-drug rebound ha, nausea; preg class x
DHE: can be taken later in migraine, safer than ergots; IM or intranasal

Question 4

triptans for migraines

Answer 4

• serotonin receptor agonists causing vasoconstriction and blk release of vasoactive substances
• sumatriptan (Imitrex), almotriptan, naratriptan, rizatriptan, zolmitriptan
• differ slightly in response-may need to try different ones
• taken at onset
• contraindications: CAD, uncontrolled HTN, pregnancy
• drug interactions: ergots, MAOIs, SSRIs

Question 5

antiemetics for migraines

Answer 5

• n/v common
• gastric emptying and oral absorption of meds are decreased in migraine pts
• co-administer with abortive therapy
• metoclopramide (Reglan), phenothiazines (Compazine)

Question 6

preventative therapy for migraines

Answer 6

• used for pts with >2 migraines/mo or unable to tolerate abortive therapy
• goal: to reduce by 50% frequency not to eliminate
• may take minimum 4 wks to start to work
• beta blockers (propanolol, timolol), tricyclic antidepressants, antiepileptics

Question 7

beta blockers for migraines

Answer 7

propanolol: initial dose 60-80 mg/day and slowly titrate 240 mg
- pediatric: 0.5 mg/kg/day and increase to 2-4 mg/kg/day
- 3 month trial
- q6 mo reassess
- adrs: fatigue, lethargy, depression
- failure to respond doesn’t predict use of other beta blockers

Question 8

TCAs for migraines

Answer 8

amitriptyline (Elavil): works on serotonin receptors

• decreases frequency, severity, and duration of migraines
• lower doses than for depression
  adrs: drowsiness, wt gain, constipation
• contraindicated with pts: narrow angle glaucoma, urinary retention, pregnancy/breast feeding, concurrent use of MAOIs
• may use nortriptyline

Question 9

antiepileptics for migraines

Answer 9

divalproex (Depakote): decreases # and severity
-baseline labs and close monitoring (LFTs and CBC)
-preg class D
gabapentin (Neurontin): start low and titrate over 4 wks to target dose
-well tolerated
topiramate (Topamax): dose titrated over 4 wks
-adrs: wt loss, somnolence, kidney stones

Question 10

misc. prophylaxis drugs

Answer 10

NSAIDS: naproxen BID-good for menstrual migraines
calcium channel blk: verapamil-pts with HTN who cant tolerate beta blks
methysergide-ergot derivative; many significant ADRs

Question 11

migraine education

Answer 11

• nonpharmacalogical therapies: ice, mediation, accupuncture etc.
• identification of triggers
• expectation of tx
• not to use OTC unless part of tx plan

Question 12

tension headaches

Answer 12

• band-like pressure, persistent dull pn
• not worsened by exercise
• may last 30min-7 days
• goals of tx: decrease frequency and severity

Question 13

preventative tx for tension headaches

Answer 13

• consider if >2 per week
• beta blks, TCAs, nonpharmacologic tx: stress management, biofeedback, exercise, acupuncture
• consider referral to psychologist

Question 14

rational drug selection for tension HAs

Answer 14

• doesn’t respond to ergots or triptans
• mild analgesics
• combo meds: fiorinal/fioricet or midrin
• nonpharmalogic must be used: message, heat/cold, relaxation tx

Question 15

chronic daily HAs

Answer 15

transformed migraine: overuse of analgesics
-coexisting psychopathology
-DHE and antinausea meds q6 hrs for 48-72
-usually requires inpatient admission
-preventative therapy required: propranolol, amitriptyline, fluoxetine
Hemicrania continua: rare, unknown cause
-responds to indomethacin
goals of tx: break cycle of daily ha

Question 16

cluster headaches

Answer 16

• intense HAs lasting for 15 min-2 hrs
• men>women
• around one eye, tearing, eye symptoms
• unknown cause
• goals of therapy: relieve pn, and decrease length of cluster
• 100% o2 x 15-30 min
• erogotamine derivatives
• intranasal lidocaine-requires admission
• sumatriptan

Question 17

preventative tx for cluster HA’s

Answer 17

• ergots q hs
• verapamil
• divalproex
• lithium
• nonpharmacologic tx: avoid all ETOH, tobacco, stress, vigorous activity

Question 18

medication overuse HAs

Answer 18

-IHS criteria: present>15 days/mo
-regular overuse of drugs for acute HA >3 mo
-HA worsens with drug tx
-resolves/reverts to previous pattern after overuse medication d/c
goals of tx: no longer take daily meds and stabilize on preventative meds
-Education is key

Question 19

rational drug selection of for overuse HAs

Answer 19

-3 stages: withdrawal from offending drug, transition/support during detox, preventative tx
-start preventative tx at beginning of withdrawal or 2-3 wks prior or after withdrawal
-consult with neurologist about detox
butalbitol overuse: serious withdrawal symptoms and may require admission
simple analgesic detox: can be done outpatient