APEA Clinical Guidelines > Headaches > Flashcards

Headaches Flashcards

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1
Q

What is cluster headache?

A

A primary neurovascular headache disorder that causes a grouping of headaches, usually over a period of several weeks.

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2
Q

How are cluster headaches classified?

A

They are classified as a trigeminal autonomic cephalalgia and may be classified as episodic or chronic.

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3
Q

What is the etiology of cluster headaches?

A

The pathophysiology is incompletely understood, but periodicity suggests a possible biological clock within the hypothalamus.

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4
Q

What is a possible causative factor for cluster headaches?

A

Release of histamines or serotonin may be a causative factor.

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5
Q

What is the incidence of cluster headaches?

A

1% of the population or 124 per 100,000, with men affected 2-3 times more often than women.

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6
Q

What are the risk factors for cluster headaches?

A

Heritable tendency, age of onset 20-40 years, previous head trauma or surgery, and small amounts of vasodilators like alcohol.

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7
Q

What are common triggers for cluster headaches?

A

Histamine, stress, allergens, seasonal changes, nitroglycerin, tobacco use, and alcohol intake.

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8
Q

What are the symptoms of cluster headaches?

A

Sudden onset, severe pain intensity, unilateral location, and duration of 15 minutes to 3 hours.

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9
Q

What are characteristic assessment findings in cluster headaches?

A

Leonine facies, ipsilateral lacrimation, conjunctival injection, and mild Horner syndrome.

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10
Q

When do cluster headaches most commonly occur?

A

They most commonly occur at night with the onset of REM sleep.

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11
Q

What is a common behavior observed in patients during a cluster headache attack?

A

Rocking and pacing occur in 90% of patients.

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12
Q

What common migraine features may be present in cluster headache patients?

A

Photophobia, phonophobia, nausea, and vomiting may be present but are not key diagnostic features.

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13
Q

What is the basis for diagnosis of cluster headaches?

A

Diagnosis is based on clinical history and symptoms fulfilling diagnostic criteria set by the International Headache Society.

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14
Q

How many attacks are required to fulfill the diagnostic criteria for cluster headaches?

A

At least five attacks fulfilling criteria B-D.
B. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes (when untreated)

C. One or both of the following:

At least one of following symptoms or signs, ipsilateral to the headache:
    Conjunctival injection and/or lacrimation
    Nasal congestion and/or rhinorrhea
    Eyelid edema
    Forehead and facial sweating
    Miosis and/or ptosis
A sense of restlessness or agitation

D. Frequency of one every other day to eight per day
E. Not attributed to another ICHD-3 diagnosis

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15
Q

What characterizes the pain in cluster headaches?

A

Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes (when untreated).

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16
Q

What are the accompanying symptoms or signs for cluster headaches?

A

At least one of the following symptoms or signs, ipsilateral to the headache: conjunctival injection and/or lacrimation, nasal congestion and/or rhinorrhea, eyelid edema, forehead and facial sweating, miosis and/or ptosis, or a sense of restlessness or agitation.

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17
Q

What is the frequency of attacks for cluster headaches?

A

Frequency of one every other day to eight per day.

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18
Q

What must cluster headaches not be attributed to?

A

Not attributed to another ICHD-3 diagnosis.

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19
Q

What are the two main forms of cluster headaches?

A

Episodic form and chronic form.

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20
Q

What characterizes the episodic form of cluster headaches?

A

Distinct circannual periodicity with at least two cluster phases lasting 7 days to 1 year; separated by a cluster-free interval of >3 months.

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21
Q

What characterizes the chronic form of cluster headaches?

A

Occurring without periods of remission, or remissions lasting <3 months, for at least 1 year.

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22
Q

What laboratory tests may be considered to rule out other causes of headaches?

A

ESR, pituitary function, thyroid function, luteinizing hormone, follicle-stimulating hormone, insulin-like growth factor 1, cortisol, prolactin, testosterone, estradiol, progesterone, glucose, growth hormone.

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23
Q

What imaging studies may be performed for cluster headaches?

A

CT or MRI of the brain.

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24
Q

What additional testing may be considered for cluster headaches?

A

Polysomnography and ECG (to exclude conduction abnormalities resulting from medications).

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25
What are some prevention strategies for triggering substances?
Avoid triggering substances such as alcohol and nicotine.
26
How can strong emotions be managed as a preventive measure?
Temper strong emotions.
27
What should be maintained for better prevention?
Maintain usual sleep/wake hours.
28
What type of interventions can be used for prophylaxis?
Pharmacologic interventions (see Pharmacologic Management).
29
What should be avoided to prevent vasodilation?
Avoid vasodilators such as nitroglycerin and alcohol.
30
What are some nonpharmacologic management techniques?
Deep brain stimulation, greater occipital nerve blocks, relaxation training, thermal biofeedback, and cognitive behavioral therapy.
31
What are the two general approaches to pharmacologic management of cluster headaches?
Abortive/symptomatic and prophylactic treatments.
32
What is the purpose of abortive/symptomatic treatments?
To abort individual attacks of cluster headaches.
33
What are examples of abortive therapies?
Oxygen and triptans.
34
Why are oral agents not effective for abortive treatment?
They are not fast acting due to the short duration of cluster headaches.
35
What is the purpose of prophylactic treatments?
To decrease the duration of clusters.
36
When should prophylactic treatments be initiated?
Simultaneously with abortive therapies.
37
Who should be referred for prophylaxis?
Neurology.
38
When are triptans most effective?
When given during the early headache phase.
39
What should be avoided when using triptans?
Concomitant use of triptans and ergotamine within a 24-hour period.
40
What alternative treatment may help prevent cluster headaches?
Melatonin, with doses of up to 9 mg daily.
41
What are some less well-studied alternatives for treatment?
Intranasal dihydroergotamine and intranasal lidocaine.
42
What is advised regarding the use of narcotics?
Reserve for infrequent use due to addiction potential and risk of rebound headaches.
43
What lifestyle changes are recommended for cluster headache management?
Smoking cessation and trigger avoidance.
44
What is the mechanism of action (MOA) of compressed air?
The MOA is not fully understood, but it is believed to have a direct inhibitory effect on cranial parasympathetic fibers. It appears that oxygen acts as a neuromodulator affecting neurotransmitter levels and works through deactivation of the trigeminal-autonomic reflex arc.
45
What is the FDA indication for compressed air?
The FDA indication is the treatment of cluster headaches.
46
Is compressed air generally safe?
Yes, it is generally safe, but caution is advised in lung disease and it should be avoided in patients with COPD. Safety precautions are necessary for smokers.
47
What is the first line treatment for cluster headaches?
100% oxygen is the first line for abortive treatment of cluster headaches.
48
What are the side effects of using compressed air?
There are no side effects; however, repeated or frequent use may cause rebound headaches from oxygen overuse.
49
What is the adult dosage for oxygen?
Begin at 10 L/min and titrate up as needed to a maximum of 15 L/min.
50
What is the pediatric dosage for oxygen?
10-15 L/min using a non-rebreather mask with a reservoir. Continue for at least 15 minutes, even if relief is obtained earlier.
51
Is oxygen contraindicated in hypertension or vascular disease?
No, it is not contraindicated in hypertension or vascular disease.
52
What is the pregnancy classification for oxygen?
Oxygen is not classified in pregnancy.
53
What should be ordered for home use of oxygen?
Home oxygen must be ordered.
54
How quickly does oxygen provide relief?
Oxygen provides relief in 5-15 minutes.
55
What position should a patient be in while administering oxygen?
Administer while sitting upright.
56
What is the mechanism of action (MOA) of Serotonin 5HT1 Receptor Agonists (Triptans)?
Activate vascular serotonin 5-HT1 receptors, producing vasoconstriction (selective serotonin agonist).
57
What is the FDA indication for Triptans?
Treatment of cluster headaches.
58
What should be monitored when using Triptans?
Angina, cerebrovascular events, gastrointestinal ischemic events, ventricular tachycardia, hypertensive crisis.
59
What is the baseline evaluation required before using Triptans?
Baseline BP and cardiovascular evaluation.
60
In which patients should Triptans be avoided?
Patients with coronary artery disease and poorly controlled hypertension.
61
What is the availability of Sumatriptan (Imitrex)?
Injection (preferred): 4 mg/0.5 mL, 6 mg/0.5 mL; Nasal Spray (alternate): 5 mg/spray, 20 mg/spray.
62
What is the adult dosage for Sumatriptan injection?
6 mg SQ; may repeat in 1 hr. Max: 6 mg/dose; 12 mg/24 hr.
63
What is the adult dosage for Sumatriptan nasal spray?
20 mg once intranasally, contralateral to affected side. May repeat once ≥2 hr. Max: 40 mg/24 hr.
64
What should be monitored when using Sumatriptan?
Watch for drug interactions, especially with SSRIs; consider ECG monitoring in patients with likelihood of unrecognized coronary disease.
65
What is the safety concern for Sumatriptan when treating more than 4 headaches in 30 days?
Unknown safety when treating >4 headaches in 30 days.
66
Is there a dosage adjustment for renal/hepatic impairment when using Sumatriptan?
No adjustment for renal/hepatic impairment.
67
What is the pregnancy and lactation advice for Sumatriptan?
Pregnancy: caution advised; fetal harm risk is low. Lactation: may use; consider holding 8 hr after dose.
68
What is the mechanism of action (MOA) of Analgesics?
Block the initiation and conduction of nerve impulses by decreasing the neuronal membrane's permeability to sodium ions.
69
What is the FDA indication for Analgesics?
Local anesthesia.
70
What is the availability of Lidocaine (Xylocaine)?
4% solution.
71
What is the adult dosage for Lidocaine?
Administer 1 mL of 4% intranasally, ipsilateral to the pain.
72
What is the administration advice for Lidocaine?
Administer with a nasal dropper; may repeat x 1 after 15 min.
73
What is the head position recommended during Lidocaine administration?
Head position should be in extension by 45° and rotated toward the symptomatic side by 30-40°.
74
What is the mechanism of action (MOA) of Transitional Agents?
Exact mechanism unknown; inhibits multiple inflammatory cytokines to reduce inflammation.
75
What is the FDA indication for Transitional Agents?
Treatment of corticosteroid-responsive conditions.
76
What is the treatment course duration for Transitional Agents for effectiveness?
18 days is most effective, providing time to increase prophylactic treatment to therapeutic levels.
77
What should be monitored when using Prednisone?
Cushing syndrome, sodium and fluid retention, mood swings, cataracts.
78
What is the availability of Prednisone?
Tab: 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg, 50 mg; Solution: 5 mg per 5 mL, 5 mg per mL.
79
What is the adult dosage for Prednisone?
1 mg/kg up to 60 mg PO daily x 5 days (in divided doses). Taper by decreasing the dose 10 mg/day every day.
80
What are the precautions for using Prednisone?
Cautious use in cardiovascular disease, hypertension, diabetes; monitor electrolytes.
81
What is the pregnancy and lactation advice for Prednisone?
Pregnancy: caution advised; Lactation: may use.
82
What is the recurrence risk for headaches when tapering Prednisone without prophylactic treatment?
Headaches likely to recur when taper is complete.
83
How often should Prednisone be used to avoid aseptic necrosis?
Use no more than once a year.
84
What is the mechanism of action (MOA) of CGRP antagonists?
Blocks calcitonin gene-related peptide (CGRP) activity (monoclonal antibody)
85
What are the FDA indications for CGRP antagonists?
Treatment of cluster headaches and episodic headaches
86
Why are CGRP antagonists not considered first-line treatment?
Due to high cost, absence of long-term safety data, and lack of comparative data with other first-line agents
87
What are common side effects of CGRP antagonists?
Injection site reaction; constipation; cramps/muscle spasms
88
What is the availability of Galcanezumab (Emgality)?
Inj (pen): 120 mg per injection; Inj (prefilled syringe): 100 mg per mL, 120 mg per mL
89
What is the adult dosage for Galcanezumab?
Loading dose of 300 mg given as three consecutive doses of 100 mg each, then 300 mg monthly
90
Is Galcanezumab available for pediatric use?
Not available
91
What are the side effects/monitoring for Galcanezumab?
Rash, pruritis, urticaria, dyspnea
92
What is a comment regarding Galcanezumab?
Brand only; caution advised in pregnancy and lactation
93
When should a patient be referred to a neurologist?
For severe headaches or headaches unresponsive to drug therapy. ## Footnote Atypical features requiring further investigation include absence of a periodic pattern, residual headache between exacerbations, bilateral headache, incomplete or minimal response to standard therapy, and presence of lateralizing findings on examination.
94
What should a patient do if their headache is unresolved after treatment?
Return to clinic or emergency department if headache becomes more severe or varies from the usual pattern.
95
What periodic monitoring is recommended for patients with headaches?
Monitor ECG, thyroid function, renal function, and electrolytes.
96
What is the purpose of follow-up visits for headache patients?
To monitor headache response to therapy and potential for side effects.
97
When can preventive medications be tapered for episodic headaches?
When the patient is completely headache-free for 2 weeks and/or has moved beyond the typical cluster period duration.
98
When can preventive medications be tapered for chronic headaches?
After 6-12 months of therapy, as long as headaches do not recur.
99
What is the expected course of recurrent headaches?
Recurrent attacks are usual until the cycle can be interrupted, and symptoms typically resolve with increasing age.
100
What are possible complications of severe headaches?
No real long-term complications, but they may be excruciating and incapacitating. Risks include depression, aggression with suicidal ideation, possibility of self-injury during an attack, and risk of addiction to narcotic analgesics.
APEA Clinical Guidelines
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