Headache

Question 1

Sinus HA

Answer 1

Pain is behind browbone and/or cheekbones

Question 2

Cluster HA

Answer 2

Pain is in and around one eye

Question 3

Tension HA

Answer 3

Pain is like a band squeezing the head

Question 4

Migraine HA

Answer 4

Pain, nausea and visual changes are typical of classic form

Question 5

Migraine criteria

Answer 5

5 attacks of

• HA lasting 4-72hrs
• Must be associated with N or V or photophobia/phonophobia

Must have 2 or the following

• Unilateral
• Pulsating
• Moderately severe
• Aggravated by physical activity

Question 6

Acute therapy

Answer 6

• Match agent to HA intensity
• Prescribe an adequate dose
• Consider the route
• Avoid rebound (can have rebound headache with pain meds)

Goals:

• Treat attacks rapidly and consistently without recurrence
• Restore pt’s ability to function
• Minimize use of back up and rescue medications (used at home when other treatments fail; permits pt to achieve relief w/o discomfort and expense of visit to physician’s office or ED)
• Optimize self-care and reduce use of resources
• Be cost effective for overall management
• Have minimal or no adverse events

Question 7

Nonpharmacologic Treatments

- Aimed at reducing stress

Answer 7

• Acupuncture
• Biofeedback
• Message
• Exercise
• Regular sleep
• Acupressure
• Relaxation techniques
• Diet changes

Question 8

Abortive agents for self administration

Answer 8

Triptans

• Sumatriptan (Imitrex)
• Zolmitriptan (Zomig)
• Rizatriptan (Maxalt)
• Naratriptan (Amerge)
• Eletriptan (Relpax)
• Almotriptan (Axert)
• Frovatriptan (Frova)

Dihydroergotamine (DHE)
Simple analgesics and NSAIDs
Compound preparations
Narcotics

Question 9

I. Prodrome

Answer 9

Craving
Tired, yawning
Heightened perception
Fluid retention

Question 10

II. Aura

Answer 10

Aura

Question 11

III. HA

Answer 11

Anorexia, N, V
Sleepy, yawning
Photophobia
Phonophobia
Osmophobia

Question 12

IV. Postdromes

Answer 12

Limited food tolerance
Tired
Feeling high or low
Diuresis

Question 13

Mild-moderate HA/migraines

Answer 13

OTC pain meds
Tylenol– worry liver
NSAIDs– worry ulcer

Question 14

Caffeine

Answer 14

• Most widely used psychoactive substance in the world
• Methylxanthine
• Competitively antagonizes adenosine receptors
• Stimulant: tolerance rapidly develops
• Withdrawal: HA, fatigue, sedation, N

Question 15

Fiorinal/Fioricet

• Fiorinal: Butalbital, aspirin, caffeine
• Fioricet: Butalbital, acetaminophen, caffeine

Answer 15

• INDICATION: tension HA
• USE: migraine
• ADR: N, abd pain, drowsiness, dizziness
• Watch for over use, rebound HA, withdrawal (overuse- using more than 2x/weekly)
• Preparations w/ codeine (CIII)

Question 16

Triptans
- First line

• Almotriptan (Axert): oral
• Naratriptan (Amerge): oral
• Eletriptan (Relpax): oral
• Rizatriptan (Maxalt): oral, MLT
• Frovatriptan (Frova): oral
• Sumatriptan (Imitrex): subQ, nasal spray, oral
• Zolmitriptan (Zomig): oral, ZMT, nasal spray

Answer 16

• MOA: serotonin receptor agonist (5-HT1 receptor found on cranial arteries, basilar artery, dura mater vasculature); mediates vasoconstriction
• Anti-migraine action: vasoconstriction, trigeminal inhibition, decreased pain transmission
• INDICATIONS: Acute migraine w/ or w/o aura
• USE: moderate/severe migraine, mild/moderate migraine that doesn’t respond to NSAIDs
• ADR: coronary arter vasospasm, transient myocardial ischemia, MI, V tach, V fib; HTN; Paresthesias, fatigue, flushing; chest tightness; sweating
• CONTRAINDICATIONS: basilar migraine; history, s/sx of ischemic cardiac, cerebrovascular, peripheral vascular syndromes; uncontrolled HTN; liver disease
• DRUG INTERACTIONS: Serotonin drugs (will have elevated HTN), P450 drugs, antiemetics

Question 17

Central sensitization theory (Theory of how migraine works)

Answer 17

• Pain
• Allodynia
• Hyperalgesia
• May be due to activation of NMDA receptors

Question 18

Ergotamines

• Ergomar (Ergotamine tartrate)
• Cafergot (Ergotamine and caffeine)
• DHE (dihydroergotamine)

Answer 18

• Nonselective 5HT1 receptor agnoists
• Direct stimulating effect on peripheral smooth muscle and cranial blood vessels–> vasoconstrictor
• May have anti-inflammatory properties

Question 19

Dihydroergotamine (DHE)

Answer 19

• MOA: binds 5HT, NE and DA receptors; stronger vasoconstrictor than nonhydrogenated ergotamines
• INDICATION: acute migraine w/ or w/o aura; cluster HA
• injection or nasal spray

Question 20

Ergotamines

• INDICATION: abort or prevent vasulcar HA
• NO CYP3A4 inhibitors (life threatening ischemia)

Answer 20

• INDICATION: abort or prevent vascular HA
• ADR: N/V (consider antiemetic pretreatment); abd pain, weakness, fatigue, paresthesias, myalgia, D, chest tightness
• CONTRAINDICATION: renal/liver failure; vascular dz; uncontrolled HTN; pregnancy; breastfeeding; basilar or hemiplegic migraine
• WARNING: Ergotism (st anthony’s fire)- HA, V/D, gangrene; Life threatening ischemia- Go administration with strong CYP3A4 inhibitors (macrolides and protease inhibitors), inhibitors increase ergot levels, can lead to cerebral or extremity ischemia
• DRUG INTERACTIONS: other ergot, serotonin drugs; P450 3A4 inhibitors; vasoconstrictors
• Caffeine potentiates effect and enhances absorption– vasoconstriction
• oral, sublingual, rectal

Question 21

Options when self-administered therapy fails

Answer 21

• IV DHE/prochlorperazine or metoclopramide
• IV or IM lorazepam
• IV divalproex
• IM ketorolac
• Steroids
• IV chlorpromazine
• Parenteral narcotics

Question 22

When to get head CT

Answer 22

• Altered mental status
• Worse headache ever
• Late onset in life, when you’ve never had a headache and now first headache

Question 23

Prophylaxis

Answer 23

• Avoid triggers: EtOH, skipping meals, OCP, no sleep , stress
• Consider for pts with > 2 migraines weekly
• Prescribe a dose suitable for an adequate length of time
• Prescribe concomitant abortive medications
• Avoid analgesic overuse
• Encourage compliance

Question 24

Effective Prophylactic Therapy (Level A)

Answer 24

AED

• Divalproex sodium (Depakote ER)
• Topiramate (Topamax)
• Sodium valproate

Beta blockers

• Propranolol (Inderal)
• Metoprolol (Lopressor, Toprol XL)
• Timolol oral

Triptans
- Frovatriptan (Frova): menstrual migraine

Question 25

Natural medicines

Answer 25

Butterbur, Feverfew, Riboflavin, CoQ10, Capsicum, Guarana, Mate, Mg, Melatonin, Chasteberry, Fish oil, Willow bark, Peppermint oil, BoTox

Question 26

Butterbur

Answer 26

- Petasites hybridus - Need to contain petasins - Look for PA free formulations (pyrrolizidine alkaloids, hepatotoxic)

Question 27

Migraine Prophylaxis length

Answer 27

- Treat daily for 2-6 months - Continue for 3-6 months after HA diminish - Gradually taper and discontinue

Question 28

When prophylactic therapy fails

Answer 28

- Confirm pt compliance - Determine if a positive response to therapy has been blocked by analgesic overuse, disrupted sleep, or other factors - Consider referral to a specialist

Question 29

Acute Migraine in Peds

Answer 29

- Dosing by weight - Start with NSAIDs - Triptans: Sumatriptan, Rizatriptan, Zolmitriptan

Question 30

Peds Preventive therapy

Answer 30

- AEDs - Antidepressants - Antihistamines - Antihypertensive (propranolol, clonidine)