Neurology > Headaches > Flashcards

Headaches Flashcards

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1
Q

What are the preventatives
medications for headaches?
5

A
  1. Beta Blockers
  2. Anticonvulsants
  3. Antidepressants
  4. Calcium channel blockers
  5. Serotonin antagonists
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2
Q

Abortive Medications for headaches?

6

A
  1. Analgesics
  2. NSAIDS
  3. Combination analgesics
  4. Antiemetics
  5. Triptans (5-HT agonists)
  6. Ergot Alkaloids
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3
Q
  1. Dosing of tylenol (acetometaphen)?
  2. Do not exceed how many per day?
  3. What should we watch for in high doses?
  4. 1st line for what pt populations? 2
A
  1. 325mg–650mg every 4-6 hours
  2. Not to exceed 3250 mg/day
  3. Watch liver toxicity at these high doses
  4. 1st choice during PG and breastfeeding
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4
Q
  1. Aspirin dosing?
  2. Do not exceed how many per day?
  3. MOA? 3
  4. Contraindications? 3
A
  1. 325-650 mg every 4-6 hours
  2. Not to exceed 4000 mg/day
    3.
    - Inhibits prostaglandin synthesis, - reducing inflammatory response - platelet aggregation
  3. Contraindications
    -History of bleeding disorders
    -Asthma
    -Hypersensitivity
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5
Q
  1. NSAIDS MOA?
  2. SE? 3
  3. BBW?
A 
1. MOA
Inhibits the enzyme cyclooxygenase-2 (COX-2)
2. SE
-Abdominal cramps
-Nausea
-Indigestion
  1. Contain Black-Box Warning for cardiovascular events
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6
Q

Ibuprofen (Motrin)

  1. Dosing?
  2. Do not exceed how much in a day?

Naproxen (Naproxen)

  1. Dosing?
  2. Do not exceed?
A
  1. 200-400mg
  2. Don’t exceed 2400mg/24hrs
  3. Initial 500mg then,
    250mg every 6-8 hours
  4. Not to exceed 1250mg /day
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7
Q

What are the barbiturates?

2

A
  1. Fiorinal

2. Fioricet

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8
Q
  1. What medications are in Florinal? 3
  2. MOA? 3
  3. Preg Cat?
  4. SE? 3
A
  1. Butalbital/Caffeine/ASA
  2. MOA:
    - inhibit prostaglandin,
    - sedation,
    - cerebral vasoconstriction
  3. Preg C
  4. SE
    - Drowsiness
    - N/V
    - Abdominal pain
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9
Q
  1. What medications are in Floricet?
  2. MOA? 3
  3. Preg cat?
  4. BBW?
  5. SE? 3
A
  1. Butalbital/Caffeine/Acetaminophen
  2. MOA:
    - inhibit prostaglandin,
    - sedation,
    - cerebral vasoconstriction
  3. Preg C
  4. Black-Box Warning: Hepatotoxicity
  5. SE
    - Drowsiness
    - N/V
    - Abdominal pain
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10
Q

What is the Combination analgesics?

A

Midrin

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11
Q
  1. What medications are in midriff?
  2. MOA? 3
  3. Preg Cat?
  4. SE? 3
A

1.Isometheptene/dichloralphenazone/acetaminophen

  1. MOA:
    - cerebral vasoconstriction,
    - sedation,
    - analgesia
  2. Preg C
  3. SE
    - Drowsiness
    - N/V
    - Abdominal pain
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12
Q

What are the Antiemetics?

4

A
  1. Phenothiazines
    - Promethazine (Phenergan)
    - Prochlorperazine (Compazine)
  2. Metoclopromide (Reglan)
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13
Q

Phenothiazines

  1. MOA?
  2. Preg cat?
  3. BBW? 3
A
  1. MOA
    Non-selectively antagonizes central & peripheral histamine H1 receptors
  2. Preg C
  3. Black Box:
    - Respiratory depression in less than 2 y/o and
    - Tissue Necrosis with injections (Phenergan)
    - Dementia-Related Psychosis (Compazine)
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14
Q

Metoclopromide (Reglan)

  1. MOA?
  2. Preg Cat?
  3. BBW?
A
  1. MOA
    antagonizes central and peripheral dopamine receptors
  2. Preg B
  3. Black Box: Tardive Dyskinesia
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15
Q

Triptans are what category of drug?

Name the drugs in this class? 7

A

5-HT1 Receptor Agonists

  1. Sumatriptan (Imitrex)
  2. Naratriptan (Amerge)
  3. Rizatriptan (Maxalt)
  4. Zolmitriptan (Zomig)
  5. Almotriptan (Axert)
  6. Eletriptan (Relpax)
  7. Frovatriptan (Frova)
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16
Q

Triptans

  1. MOA?
  2. Contraindications?4
  3. Preg cat?
  4. Triptans SE? 4
A
  1. Agonist effects on serotonin 5-HT1 receptors in cranial blood vessels and subsequent inhibition of pro-inflammatory neuropeptide release
  2. Contraindications
    - CAD
    - PVD
    - Stroke
    - Hemiplegic and basilar migraine
  3. Preg C
    • Nausea
    • Jaw, neck, or chest pressure or tightness
    • Fatigue
    • Burning sensation of the skin
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17
Q

Sumatriptan (Imitrex)
administrations?
3

A

PO
SC
Nasal

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18
Q

How is Naratriptan (Amerge)
different from Sumatriptan (Imitrex)?
2

What makes Rizatriptan (Maxalt)
different?

Which triptan works well for menstrually related migraines?

A
  1. has higher bioavailability, longer acting
  2. Lower rate of headache recurrences
  3. Early onset of action (30min)
    - Eletriptan (Relpax) more rapid onset
  4. Frovatriptan (Frova)
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19
Q

All efforts should be made to initiate therapy as soon as possible after the first symptoms of the attack are noted, since success is proportional to rapidity of treatment. Why is this important?

A

lower dosages will be effective with less side-effects.

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20
Q

Ergot Alkaloids

  1. Specific drug for what?
  2. What are the two drugs in this category?
  3. MOA? 2
  4. Preg cat?
  5. BBW 2
A
  1. First migraine-specific drug
    - -Have fallen out of favor d/t unpredictable patient response
    • Dihydroergotamine (DHE)
    • Ergotamine
  3. MOA
    - Nonspecific 5-HT agonist, antagonist, or both types of activity for serotonergic, dopaminergic, and alph-adrenergic receptors
    - This results in constriction of periheral and cranial vessels.
  4. Preg X
  5. Black Box Warning
    - Life-threatening peripheral ischemia
    - Effects are worse with administration with potent CYP3A4 inhibitors, protease inhibitors, and macrolide antibiotics
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21
Q

Ergotamine tartrate (Ergostat, Ergomar) is associated with significant SE such as? 3

A
  1. REBOUND HEADACHE
  2. Vascular occlusion
  3. Dependence
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22
Q

DHE Adverse effects more common adverse affects?

11

A 
1. Burning or tingling sensation
dry mouth
2. Dryness, soreness or pain in the nose
3. runny and or stuffy nose
4. change in sense of taste
5, Diarrhea
6. Dizziness
7. Fatigue
8. Headache
9. increased sweating
10. nausea and or vomiting
11. muscle stiffness
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23
Q

When would we use narcotics for heaches?

2

A
  1. Rescue med for severe migraine
  2. Infrequent migraines with contraindications to other agents
Meperidine (Demerol)
Morphine
Oxymorphone
Hydromorphone (Dilaudid)
Hydrocodone + acetaminophen (Norco)
Oxycodone + acetaminophen (Percocet)
Oxycodone
Hydrocodone
Fentanyl
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24
Q

What are some common combination therapies for headaches?

3

A
  1. Triptan + OTC Naprosyn (Aleve) 220mg x 1 with onset of headache
  2. NSAID w/ antiemetic
  3. Moderate narcotic w/ antiemitc
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25
When would we use preventative medications for headaches? | 4
1. Recurring headache that significantly interferes with daily routine in patient’s opinion. 2. Contraindications or failure of overuse of acute therapies. 3. Adverse reaction with acute therapies. 4. Patient preference.
26
Goals of Preventative Therapy | 3
1. Decrease attack frequency and duration. 2. Improve responsiveness to treatment of acute attacks. 3. Improve function and decrease disability.
27
1. What are Betablockers we can use? 2 2. What are the anticonvulsants we can use? 2 3. What are the antidepressants we can use? 2 4. What are the calcium channel blockers we can use?
Beta-blockers 1. Propranolol (Inderal) 2. Timolol Anticonvulsants 1. Valproic Acid (Depakote) 2. Topromax (Topiramide) Antidepressants 1. TCA’s 2. SSRI’s Calcium Channel Blockers 1. Calan (Verapamil)
28
What is the first line agent for prophylactic treatment of migraines?
Propranolol (Inderal) & Timolol
29
Propranolol (Inderal) & Timolol have been approved by FDA for what?
migraine prophylaxis
30
Who should these be used in caution with? | 4
1. Baseline bradycardia 2. Asthma 3. 2nd or 3rd degree AV block 4. CHF
31
Calcium Channel blockers 1. MOA? 2. Contraindicated in who? 3. What line treatment is this considered?
1. MOA Inhibition of serotonin release 2. Contraindicated with - Bradycardia - Heart block - A-fib 3. Considered 2nd or 3rd line treatment Verapamil (Calan)
32
Valproic acid (Depakote) 1. May decrease H/A frequency by as much as ? 2. Effects of therapy seen how long after initiation of therapy? 3. Preg cat?
1. 50% 2. Effects seen within first 4 weeks of therapy 3. D
33
Topiramate (Topamax) 1. Preg cat? 2. Contraindications? 2
1. Pregnancy Category C 2. Contraindications: - Liver - Renal impairment
34
Which antidepressants are found to be the most effective? | What is the main limiting factor with these medications? name them 4
TCA's -Elavil (Amitryptiline) is the only TCA with proven efficacy 1. Side effects are main limiting factor - Sedation, - dry mouth, - constipation, - weight gain
35
Whats the only SSRI with proven efficacy?
SNRI venlafaxine (Effexor)
36
Recommendations for prevention 1. Who should we prescribe this for? 2. What does the choice of agent depend on? 3. Avoid overuse of what kind of therapy?
1. For most patients with episodic migraine (≤14 HA days/month) 2. Choice of agents depends on the individual situation, associated medical problems. 3. Avoid overuse of abortive therapy.
37
Headache is a non-specific symptom, but has many causes: Some examples? 4
1. Sleep deprivation 2. Stress 3. Effects of medication/drugs 4. Infections
38
Types of Headaches 2 (most common?)
Primary*** 90% | Secondary
39
1. What types of headaches are the most common primary headaches? 2. At what age do they usually start?
1. Most common types are migraines and tension-type headaches 2. Usually start between 20-40 years old
40
What are the three primary headaches?
1. Migraines 2. Tension-type 3. Cluster
41
Types of Secondary headaches? | 5
``` 1. Trauma (Subdural hematoma or Epidural hematoma) 2. Subarachnoid hemorrhage 3. Meningitis 4. Brain tumor 5. Temporal arteritis ```
42
Pathopysiology of a migraine? | 2
1. Primary neurovascular dysfunction that leads to a sequence of change intracranial and extracranial that account for the migraine 2. Headache results from dilation of blood vessels innervated by the trigeminal nerve caused by a release of neuropeptides from parasympathetic nerve fibers
43
There are 4 phases of a migraine. What are they?
1. Migraine Prodrome 2. Migraine Aura 3. Migraine headache 4. Migraine postdrome
44
Migraine Prodrome 1. Symptoms apear when? 2. Symtpoms include? 3
1. Symptoms appear 24-48 hours prior to onset 2. Symptoms include: - Euphoria - Depression - Irritability
45
Migraine Aura 1. What are the positive symptoms of a migrain? 4 2. What are the negative sympotms of a migraine? 2
Positive 1. Visual 2. Auditory 3. Somatosensory 4. Motor Negative 1. Loss of vision, hearing or feeling 2. Inability to move a part of the body
46
1. Migraine with aura most often manifests how? 2. How does it present initially? How does it resolve? 3. Sensory aura follows what? 4. Present how? Lasts how long? 5. What is the language aura?
1. Most often visual 2. - Usually begins as a small area of vision loss just lateral to the point of fixation - The aura usually moves to the peripheral fields then disappears 3. Sensory aura Usually will follow visual aura, but can be without 4. Begins as tingling of one limb or side of the face -Usually last up to an hour 5. Language aura Less common Difficulty with speech
47
Migraine headache 1. Unilateral or bilateral? 2. Pain is described how usually? 2 3. pt can also experience what? 2
1. Usually unilateral 2. Pain tends to be throbbing or pulsatile quality 3. - Can experience N/V - Patients will have photophobia or phonophobia Most will have to lye down in a dark quiet room
48
Describe the feeling of a migraine postdrome? | 2
1. Patients often feel drained or exhausted | 2. Some report a feeling of mild elation or euphoria
49
What are the migraine subtypes? | 5
1. Migraine with brainstem aura 2. Hemiplegic migraine 3. Retinal migraine 4. Vestibular migraine 5. Menstrual migraine
50
1. Migraine with brainstem aura is found more commonly in what gender? 2. Usual age of onset? 3. Symptoms? 6 4. What do you need for diagnosis?
1. More often female vs male 2. Onset ages 7-20 y/o 3. Brainstem auras consist of: - Vertigo - Dysarthria - Tinnitus - Diplopia - Ataxia - Decreased level of consciousness 4. Needs two of the above to make diagnosis
51
1. How do you distinguish hemiplegic migraines from other types? 2. Unilateral or bilateral? 3. Symptoms? 7
1. Motor weakness, usually distinguishes from other migraines 2. Typically unilateral weakness 3. - Severe HA - Scintillating Scotoma - Visual field defect - Numbness, parathesia, aphasia - Fever - Lethargy - Coma and or seizures
52
1. What is a retinal migraine? | 2. What is it associated with?
1. Rare condition which involves repeated attacks of monocular scotomata or blindness lasting less than one hour 2. Associated with or followed by headache
53
1. What is a Vestibular migraine? 2. Diagnosis? 3. What must we rule out?
1. Episodic vertigo in patients with history of migraines 2. No confirming test 3. Must exclude other brainstem disease
54
When does a menstrual migraine usually occur?
Usually 2 days before through 3 days after onset of bleeding
55
Who is neuroimaging used for with migraine pts? | 2
1. Patients with unexplained abnormal finding on neurologic exam 2. Atypical HA features or don’t fit definition of a migraine
56
What are the RED FLAGS that would make us want to order neuroimaging for a test? 12
1. The “worst or first” headache 2. Significant change in severity, frequency, or pattern 3. New or unexplained neurologic symptoms 4. Headache always on the same side 5. New onset headaches after age 50 6. Headaches not responding to treatment 7. New onset headache in patients with HIV/cancer 8. Stiff neck 9. fever 10. papilledema 11. cognitive impairments 12. personality changes
57
Diagnostic criteria for migraine without aura? 4 categories (6 signs and symptoms to remember)
A) At least 5 attacks fulfilling criteria B-D B) HA attacks lasting 4-72 hrs C) HA has at least 2 of the following: 1. Unilateral location 2. Pulsating quality 3. Moderate or severe pain intensity 4. Avoidance of routine physical activity D) During HA at least one of the following: 1. Nausea, vomiting, or both 2. Photophobia and phonophobia
58
Diagnostic criteria for migraine with aura? | 3 categories and 8 signs and symptoms to remember)
A) At least 2 attacks fulfilling criteria B and C B) One or more of the following reversible aura symptoms: 1. Visual 2. Sensory 3. Speech 4. Motor C) At least 2 of the following characteristics: 1. At least one aura symptom spreads gradually over ≥5 min and/or 2 or more symptoms occur in succession 2. Each individual aura symptom lasts 5-60 min 3. At least one aura symptom is unilateral 4. The aura is accompanied, or followed within 60 min by HA
59
1. First line treatment for migraine? 2. Second line? 3. (first tier 4) 4. (second tier 2) 5. Third line? 2 6. When should Opiods/Barbiturates be used?
1. NSAIDs or Aspirin 1. Triptans 2. First tier - Sumatriptan - Almotriptan - Rizatriptan - Eletriptan 3. 2nd tier (slower effect) - Naratriptan - frovatriptan 4. Triptans plus an NSAID 5. Should not be used for treatment of migraines unless last resort
60
What is the most common form of a primary headache disorder?
Tension-type Headache (TTH)
61
1. Describe a Tension-type Headache (TTH)'s intensity? 2. Describe the pain and where its at? 3. What are the three subtypes?
1. Has mild-moderate intensity 2. Bilateral non-throbbing headache without other associated features 3. 3 subtypes - Infrequent episodic: less than 1 day/month - Frequent episodic: 1-14 days/month - Chronic: 15 or more days/month
62
Pathophysiology of a migraine headache?
Peripheral activation or sensitization of myofacial nociceptors that migrate through pain pathways in the central nervous center
63
1. Clinical features of a TTH? 5 2. What kind of muscle tenderness? 3. Neuro affects?
1. Bilateral non-throbbing HA described as: - Dull - Band-like or vise-like - Tight cap - Pressure 2. Pericrainial muscle tenderness - -Muscle tenderness in head, neck, & shoulders 3. Poor concentration
64
Precipitating factors of a TTH? 3 Diagnosis?
1. Precipitating factors - Stress or mental tension most common - Fatigue - Noise 2. Diagnostics - No diagnostic test, based on clinical impression
65
1. TTH treatment? 5 2. 2nd line treatment? 3. Third line?
1. - Techniques to induce relaxation - ASA 600-1000mg - Tylenol 1000mg - Ibuprofen 200-400mg - Naproxen 220-550mg 2. Above meds with caffeine 3. Butalbital (Fioricet or Fiorinal) Third-line
66
When is Butalbital (Fioricet or Fiorinal) indicated in TTH? | 4
``` 1. For when NSAIDs & caffeine isn’t working or contraindicated (eg. 3rd trimester) Used when contraindicated to 2. NSAIDs/ASA 3. Stomach ulcers/renal failure 4. Liver failure ```
67
What is a cluster headache chracterized by? Can have symptoms associated the eye such as? 4
1. Characterized by recurrent severe HA on one side of the head, typically around the eye 2. Can have symptoms associated with the eye like; - Watering of the eye - Nasal congestion - Swelling of the eye - Rhinorrhea - Lacrimation
68
Pathophysiology of cluster headaches?
Characterized by hypothalamic activation with secondary activation of trigeminal-autonomic vascular system via the trigeminal-hypothalamic pathway
69
Clinical features of a cluster headache: 1. unilateral or bilateral? 2. How often can this occur? (hours and days) 3. Signs and symptoms? 4
1. Usually is unilateral 2. Can have 8 episodes/day and last from 7 days to 12 months 3. S/S - Ipsilateral nasal congestion - Rhinorrhea - Lacrimation - Horner’s syndrome
70
What is horners syndrome (you may see this in a cluster headache)? 3
1. Ptosis of the eyelid 2. Meiosis of the pupil 3. anhidrosis
71
1. Triggers of a cluster headache? 4 | 2. Diagnostics? 2 whats preferred
1. - ETOH - Stress - Glare - Ingestion of specific foods 2. Neuroimaging - MRI with or without contrast perfered - Non-contrast CT of the head
72
Diagnostic criteria of a cluster headache: Which of the following symptoms? 7
``` ONE OF THE FOLLOWING AND 1. Conjunctival injections or lacrimation 2. Nasal congestion and/or rhinorrhea 3. Eyelid edema 4. Forehead and facial sweating 5. Forehead and facial flushing 6. Sensation of fullness in the ear 7. Miosis and/or ptosis A SENSE OF RESTLESSNESS OR AGITATION ```
73
1. FIRST LINE treatment for cluster headache? 2 2. Other options?
1. Sub-Q Sumatriptan 6mg & 100% oxygen inhalation 2. Oxygen helps abort the headache Oxygen is given through a nonrebreathing facial mask with flow rate of at least 12L/min in a sitting upright position 2. - Intra-nasal lidocaine - Ergotomine
74
Preventative cluster headache?
Verapamil (drug of choice) | CCB
75
What are the causes of a subarachnoid hemorrhage? | 4
Can occur - spontaneously, - ruptured aneurysm, - stroke, or - trauma
76
Describe the pathpyhsiology of Subarachnoid Hemorrhage? | 2
1. Blood in subarachnoid space cause chemical meningitis that increases intracranial pressure 2. A 2nd rupture sometimes occurs within about 7 days
77
Clinical features of a subarachnoid hemorrhage? 4 Diagnosis? 2
Clinical features 1. Sever “thunderclap” HA or “worse HA of you life” 2. N/V 3. Confusion 4. Heart and respiratory rate abnormal Diagnosis 1. Noncontrast CT 2. If negative CT then lumbar puncture
78
Subarachnoid Hemorrhage treatment? 4 Goals of treatment? 4
Treatment 1. ABC’s 2. Surgical clipping or coiling of aneurysms 3. Nimodipine for vasospasm 4. Nicardipine if mean arterial pressure is >130 mmHg Goals of treatment 1. Blood pressure control 2. Prevention of seizures 3. Treatment of nausea 4. Management of intracranial pressure
79
1. Temporal arteritis is what? 2. Found in what population? 3. What is the most feared complication?
1. Chronic vasculitis of large and medium size vessels 2. Found in Scandinavian descent population 3. Most feared complication is vision loss
80
Pathophysiology of temporal arteritis? | 2
1. Affects arteries containing elastic tissue | 2. Mononuclear cells infiltrates the adventitia form granulomas containing activated T cells and macrophages
81
Clinical features: systemic? | 6
1. Fever 2. HA 3. Jaw claudication 4. Visual manifestations - -Amaurosis fugax (transient monocular loss of vision) 5. Polymyalgia rheumatica - --Morning stiffness of shoulders, hips, neck, & torso 6. Aortic dissections or aneurysms
82
What will the headaches feel like in temporal arteritis? 2
1. New onset in temporal region | 2. Scalp tenderness
83
Diagnostics for temporal arteritis: 1. gold standard? 2. Labs? 4 3. Treatment? 2 What do we have to remember about the vision loss with Temporal arteritis?
Diagnostics 1. Temporal artery biopsy (Gold Standard) 2. - CBC, - CMP, - ESR, - C-reactive protein ``` Treatment 1. Initiantion of corticosteroid therapy Prednisone 40-60mg daily Taper over 2-3 months 2. Requires 1-2 years of treatment Low-dose aspirin ``` Once vision loss is present, rarely resolves with treatment, so treat first then biopsy
84
Intracranial Pressure 1. What is increasing in pressure? 2. Causes? 6
1. Increase rise in pressure of the cerebrospinal fluid 2. - Subdural/Epidural hemorrhage from trauma - Ruptured aneurysm - CNS infection - Ischemic stroke - Neoplasm - Hydrocephalus
85
Pathophysiology 1. Whats the normal ICP? 2. When is it considered increased? 3. Increase in what will cause an increase in the volume inside? 4. What else will cause this?
1. Normal ICP is equal to or less than 15 mmHg, 2. increased ICP is pressure ≥20 mmHg 3. Increase in spinal fluid will increase the volume inside 4. intracranial mass
86
Clinical feature of intracranial pressure? | 6
1. HA (worse with cough/sneeze) 2. N/V 3. Ocular palsies 4. Altered levels of consciousness 5. Back pain 6. Papilledema
87
Diagnosis of intracranial pressure? | Treatment? gold standard 4
Diagnosis 1. CT scan head 2. MRI brain 3. Lumbar puncture ``` Treatment ICP monitoring 1. Intraventricular (Gold Standard) 2. Intraparenchymal 3. Subarachnoid 4. epidural ```
88
What neurological infections cause headaches? | 3
1. Meningitis 2. Encephalitis 3. Brain abscess
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