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Headaches Flashcards

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1
Q

Abortive meds for HAs?

A
  • analgesics
  • NSAIDS
  • combo analgesics
  • antiemetics
  • triptans (5-HT agonists)
  • ergot alkaloids
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2
Q

preventative meds for HAs?

A
  • BBlockers
  • anticonvulsants
  • antidepressants
  • CCBs
  • serotonin antagonists
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3
Q

Analgesics used for tx HA sxs?

A 
- tylenol:
325- 650 q 4-6 hrs
not to exceed 3250 mg/day
* watch for liver toxicity
* 1st choice during PG and breastfeeding

- Aspirin:
325-650 mg q 4-6 hrs
- don't exceed 4000 mg/day
- inhibits prostaglandin synthesis, reducing inflamm. response and platelet aggregation
- CIs:
hx of bleeding disorders
asthma hypersensitivity
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4
Q

NSAIDS use in tx HA? MOA, SE? BBW?

A
  • MOA: inhibit cox-2 enzyme
  • SEs: abdominal cramps, nausea, indigestion, Renal impairment
    BBW: CV events
  • Ibuprofen (motrin):
    200-400 mg, don’t exceed 2400 mg/ 24 hrs
  • naproxen: initial 500 mg then 250 mg q 6-8 hrs, not to exceed 1250 mg/day
  • these are first line!!
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5
Q

Combo analgesics used for HA tx? barbiturates

A
  • barbiturates:
    fiorinal: butalbital/caffeine/ASA, 50/40/325 dose, give 1-2 tabs q 4hr, max 6 tabs/day
  • MOA: inhibit prostaglandin, sedation, cerebral vasoconstriction
  • preg C
    SEs:
    drowsiness, N/V, abdominal pain
fioricet:
butalbital/caffeine/acetaminophen
50/40/325 dose, 1-2 tabs q 4 hr, max 6/day
- preg C
- BBW: hepatotoxicity
SEs:
drowsiness, N/V, and abdominal pain
  • habit forming
  • can cause overuse HAs
  • don’t use more than 3 days/month
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6
Q

Combo analgesics? Midrin

A

isometheptren/dichloraphenazone/acetaminphen

  • 65/100/325 dose
  • 1-2 caps q 4 hrs, max 8 caps/day
  • MOA: cerebral vasoconstriction, sedation, analgesia
  • Preg C
  • Ses: drowsiness, N/V, and abdominal pain
  • not used as much
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7
Q

Antiemetics - phenothiazines?

BBW?

A
  • promethazine (phenergan) PO, IM, IV, rectal
  • prochlorperazine (compazine) PO, IM, IV, rectal, PO sustained release capsule
  • MOA: non-selectively antagonizes central and peripheral histamine H1 receptors
  • Preg C
  • SE: drowsiness, sedation

BBW: resp depression in younger than 2 yo and tissue necrosis with injections (phenergan)
- dementia related psychosis (compazine)

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8
Q

Antemetics - metoclopromide (reglan)? BBW?

A
  • PO/IV/IM
  • MOA: antagonizes central and peripheral dopamine receptors
  • Preg B
  • SEs: drowsiness, restlessness, fatigue

BBW: tardive dyskinesia

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9
Q

Triptans used in HA relief?

A
  • 5-HT1 receptor agonists:
    sumatriptan (imitrex): PO at HA onset, SC, nasal

naratriptan (amerge): has higher bioavailability, longer acting, lower rate of HA recurrences

rizatriptan (maxalt): early onset of action (30 min)

zolmitriptan (zomig): PO/nasal/disintegrating tablet onset of migraine

Frovatriptan (Frova): half life 26 hrs, works well for menstrually related migraines
2 day miniprophylaxis

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10
Q

MOA, CI, Preg, and SEs of triptans?

A

MOA: agonist effect on serotonin 5-HT1 receptors in cranial bood vessels and subsequent inhibition of pro-inflammatory neuropeptide release
- CIs:
CAD, PVD, stroke, hemiplegic and basilar migraine
use of SSRIs (serotonin syndrome)
MAOI use

Preg C
Don’t use for more than 9 days/month

SEs: nausea
 jaw, neck, or chest pressure or tightness
fatigue
burning sensation of the skin
increased BP
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11
Q

Onset of sxs and triptans use?

A
  • all efforts should be made to initiate therapy as soon as possible after first sxs of attack, since success is proportional to rapidity of tx, and lower dosages will be effective with less SEs
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12
Q

ergot alkaloids use? MOA? preg? BBW?

A
  • first migrain specific drug
  • have fallen out of favor d/t unpredictable pt response
  • dihydroergotamine (DHE) and Ergotamine

MOA: nonspecific 5-HT agonist, antagonist, or both types of activity for serotonergic, dopaminergic and alpha-adrenergic receptors
- results in constriction of peripheral and cranial vessels

preg X

BBW: life threatening peripheral ischemia
- effects are woorse with admin with potent CYP 3A4 inhibitors, protease inhibitors and macrolide abx

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13
Q

Admin of ergotamine tartrate (ergots, ergomar) and SEs?

A
  • PO, SL, PR
    don’t exceed 6 mg/attack
  • SEs:
    rebound HA, vascular occlusion, dependence
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14
Q

Admin of DHE 45 (migranal)? Adverse effects?

A
  • IM/SQ and IV - al max 6 mg/week
  • nasal 1 spray each nostril, repeat q 15 min to max 4-6 sprays/day, max: 8 sprays/ week
Adverse effects -
more common: 
burning or tingling sensation
dry mouth
dryness, soreness or pain in nose
runny or stuffy nose, change in sense of taste, diarrhea, dizziness, fatigue, HA, increased sweating, N/V, muscle stiffness

less common:
anxiety, blurred vision, cold clammy skin, confusion, congestion in chest, cough, decreased appetite, pounding heartbeat, depression, nervousness

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15
Q

Recommendations in HA care?

A
  • tx with safest, least expensive drug during first attack
  • progress to more expensive and specific therapies for subsequent attacks if initial tx unsuccessful
  • stratified care: tx assigned based on severity of HA
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16
Q

Narcotic analgesics?

A
  • meperidine (demerol)
  • morphine
  • oxymorphone
  • hydromorphone (dilaudid)
  • Norco
  • percocet
  • oxycodone
  • hydrocodone
  • fentanyl
  • in general NOT recommended for tx of HAs
  • use in migraines for:
    rescue med for severe migraine, and infrequent migraines with CIs to other agents
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17
Q

Combo therapy in HA relief tx?

A
  • Triptan+OTC naproysn (aleve) 220 mgx1 with onset of HA
  • NSAID with antiemetic
  • moderate narcotic with antiemetic
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18
Q

When should preventative therapy be initiated?

Goals of preventative therapy?

A
  • recurring HA that significanly interferes with daily routine in pt’s opinion
  • CIs or failure of overuse of acute therapies
  • adverse reaction with acute therapies
  • pt preference

goals of preventative therapy:

  • decrease attack frequency and duration
  • improve responsiveness to tx of acute attacks
  • improve fxn and decrease disability
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19
Q

Meds used for preventative therapy?

A
  • BBlockers: propranolol (inderal)
  • anticonvulsants: valproic acid (depakote), topramax (topiramide)
  • antidepressants: TCAs, SSRIs
  • CCBs - Calan (verapamil)
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20
Q

BBlocker use as preventative therapy? Caution in? SEs?

A
  • propanolol (Inderal) and TImolol have been approved by FDA for migraine prophylaxis
  • *** Considered FIRST line for prophylactic tx of migraines
  • propanolol stary 40 mg bid daily
  • timolol: 5 mg once daily
- used with caution:
baseline bradycardia
asthma
2nd or 3rd degree AV block
CHF

SEs:
- fatigue, depression, impotence, hypotension

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21
Q

CCBs - MOA, CI, Meds, SE?

A
  • MOA: inhibition of serotonin release
  • CI: bradycardia, heart block, a-fib
  • meds: verapamil (calan): start at 40-80 mg tid daily, considered 2nd or 3rd line tx, but ** 1st for cluster HA
- SEs:
flushing
dizziness
constipation
peripheral edema
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22
Q

Anticonvulsants? Depakote

A
  • valproic acid (depakote)
  • may decrease HA frequency by as much as 50%
  • effects seen within first 4 weeks of therapy
  • dose ranges: 250 mg bid
  • SEs:
    wt gain, tremor, nausea, hair loss
  • preg: D
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23
Q

Anticonvulsants? topiramate (topamax)
SEs?
CI?

A
  • FDA approved in 2004
  • dose 25 mg qhs for 1st week
  • increase weekly by 25 mg
  • SEs:
    concentration and memory impairment
    fatigue
    wt loss
    nausea

preg C

CIs: liver and renal impairment

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24
Q

Antidepressants use in preventative therapy? Most effective?

A
  • TCAs most effective:
    Elavil (amitryptiline) only TCA with proven efficacy, start at 10 mg/hs

SNRI venlafaxine (Effexor): effective starting 37.5 mg once daily
- insufficient data regarding SSRIs and HAs:
Prozac
zoloft
paxil

SEs: main limiting factor - sedation, dry mouth, constipation, wt gain

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25
Recommendations for prevention of HAs and migraines?
- for most pts with episodic migraine - choice of agents depends on individual situation, assoc medical problems - start low, give adequate time for tx to take effect - avoid overuse of abortive therapy - lifestyle measures
26
Goals for prevention?
- improve pt's quality of life - initiate with meds that have highest level of effectiveness and lowest SEs - may take 2-6 months
27
What is a HA? Causes?
-(cephalalgia) is pain anywhere in region of the head or neck - HA is a non-specific sx, but has many causes: sleep deprivation stress effects of meds/drugs infections
28
Primary HA?
- 90% of HAs - usually start b/t 20-40 - most common types are migraines and tension-type HAs - cluster is also a primary HA
29
Secondary HAs?
- caused by underlying disease - can be harmless or dangerous - red flags indicate the HA may be dangerous!
30
Causes of secondary HAs?
- trauma: subdural hematoma, epidural hematoma - SAH - meningitis - brain tumor - temporal arteritis
31
PP of a migraine?
- primary neurovasular dysfxn that leads to a sequence of change intracranial and extracranial that account for the migraine - HA results from dilation of blood vessels innervated by trigeminal nerve caused by a release of neuropeptides from parasympathetic nerve fibers
32
How common are migraines?
- affect 12% of pop - 17% women, 6% men - most common ages: 30-39 - can be familial - most common type is migraine w/o aura
33
Precipitating and exacerbating factors - migraine?
- emotional stress (80%) - hormones in women (65%) - not eating (57%) - weather (53%) - sleep disturbances (50%) - odors - smoke - light - alcohol
34
Migraine 4 phases - | 1. migraine prodrome?
- 60% people with migraines have prodrome - sxs appear 24-48 hrs prior to onset - sxs include: euphoria, depression, irritability, weird food cravings (apple)
35
Migraine 4 phases - | 2. migraine aura?
- only 25% suffer from this - involves positive and negative sxs - positive: visual, auditory, somatosensory, motor - negative: loss of vision, hearing or feeling, inability to move a part of the body - most often visual - begins as small area of vision loss just lateral to pt of fixation - aura usually moves out to periphery - sensory aura: usually follows visual aura, but can be without, begins as tingling of one limb or side of face, usually lasts up to an hour - language aura: less common, difficulty with speech
36
Migraine 4 phases - | 3. migraine HA?
- usually unilateral - pain tends to be throbbing or pulsatile quality - can experience N/V - pts will have photophobia or phonophobia: most will have to lie down in dark quiet room - can take hrs or days to go away
37
Migraine 4 phases - migraine postdrome?
- pts often feel drained or exhausted | - some report a feeling of mild elation or euphoria
38
Subtypes of migraines?
- migraine with brainstem aura - hemiplegic migraine - retinal migraine - vestibular migraine - menstrual migraine
39
Migraine with brainstem aura characteristics?
- uncommon - females more than males - onset: 7-20 - consist of: vertigo dysarthria tinnitus diplopia ataxia decreased level of consciousness - needs two of above to make dx
40
Hemiplegic migraine charcteristics?
- motor weakness, usually distinguishes from other migraines - typicall unilateral weakness manifestations: - severe HA - scintillating scotoma - visual field defect - numbness. parasthesia, aphasia - fever - lethargy - coma and or seizures
41
Retinal migraine characteristics?
rare condition which involves repeated attacks of monocular scotomata or blindness lasting less than one hour - assoc with or followed by HA
42
Vestibular migraine charactersitics?
- episodic vertigo in pts with hx of migraine - no confirming test - must exclude other brainstem disease
43
Menstrual migraine?
- migraine that occurs before and throughout menstruation | - usually 2 days before through 3 days after onset of bleeding
44
Dx test for migraines?
- no test available - neuroimaging only for: pts with unexplained abnormal finding on neuro exam, or atypical HA features or don't fit definition of migraine
45
What are red flag indications for neuroimaging?
- neuroimaging usually isn't necessary unless abnorm neuro findings red flags: - worst or first HA - sig changes in severity, frequency, or pattern - new or unexplained neuro sxs - HA always on same side - new onset HA after 50 (tumor?) - HAs not responding to tx - new onset HA in pts with HIV/cancer - S/S: stiff neck, fever, papilledema, cognitive impairment, or personality change.
46
Dx criteria for migraine w/o aura?
``` - - at least 5 attacks fulfilling criteria B-D B) HA attacks lasting 4-72 hrs C) HA has at least 2 of the following: unilateral location pulsating quality mod or severe pain intensity avoidance of routine physical activity D) during HA at least one of following: N/V or both, photophobia or phonophobia ```
47
Dx criteria for migraine with aura?
- at least 2 attacks fulfulling criteria B and C B) one or more of following reversible aura sxs: visual sensory speech motor C) at least 2 of following: - at least 1 aura sx spreads gradually over 5 min and or 2 or more sxs occur in succession - each individual aura sx lasts 5-60 min - at least one aura sx is unilateral - aura is accompanied or followed within 60 min by HA
48
Tx for migraines?
- first line: NSAIDs or ASA - 2nd line: triptans first tier: sumatriptan, almotriptan, rizatriptan, eletriptan 2nd tier: slower effect - naratriptan, frovatriptan - 3rd line: triptans + NSAID - opiods and barbiturates: shouldn't be used for tx of migraines unless last resort
49
Pharm migraine prophylaxis selection?
- first line agents: amitriptyline, Depakote, propranolol or timolol, topiramate, if not effective after 2-3 months adjust dose until effective and if still not effective at max dose or adverse effects - try a diff first line agent
50
Tension type HA (TTH)? | subtypes?
- most common form of primary HA disorder - has mild-mod intensity - bilateral non-throbbing HA w/o other assoc features - subtypes: infrequent episodic: less than 1 day/month frequent episodic: 1-14 days/month chronic: 15 or more days/month
51
PP of TTH?
- peripheral activation of sensitization of myofacial nociceptors that migrate through pain pathways in the central nervous center
52
Epidemiology of TTH?
- one of most common HA for neuro consult - usually peaks in 40s - women more common than men
53
Clinical features of TTH?
- mild-mod intensity - bilateral non-throbbing HA described as: dull band like or vise like tight cap pressure - pericranial muscle tenderness: muscle tenderness in head, neck and shoulders - poor concentration - no aura, if there is, then it isn't a TTH
54
Precipitating factors of TTH? | Dxs?
- stress or mental tension most common, fatigue, and noise | - no dx test, based on clinical impression
55
episodic TTH dx criteria?
- typically bilateral, lasting minutes to days. Pain doesn't worsen with physical activity, not assoc with nausea, but photo or phonophobia may be present/ A. at least 10 episodes of HA fulfilling criteria B-D, infreq and freq episodic subforms distinguished as follows: infrequent TTH: HA occurring on less than 1 day/month on average frequent: occuring on 1-14 days per month for longer than 3 months B. HA lasting from 30 min to 7 days C. At least 2 of the following 4 characteristics: bilateral location pressing or tightening quality mild or mod intensity not aggravated by routine physical activity such as walking or climbing stairs D. both of the following: no N/V no more than one of photophobia or phonophobia
56
Chronic TTH dx criteria:
A. HA occurring on more than 15 days/month on avg for more than 3 months and fulfilling B-D B. lasting hrs to days or unremitting C. at least 2 of following characteristics: bilateral location pressing or tightening mild or mod intensity not aggravated by routine exercise D. both of following: no more than one of photophobia, phonophobia, or mild nausea 2. neither moderate or severe nausea or vomiting
57
Tx of TTH?
- techniques to induce relaxation: massage hot baths biofeedback ``` - acute initial tx first line: ASA 600-1000 mg tylenol 1000 mg ibuprofen 200-400 mg naproxen 220-550 mg ``` - 2nd line: above meds with caffeine 64-200 mg - adjunct therapy: 3rd line: butalbital (fioricet or fiorinal) - used when NSAIDs and caffeine isn't working or CI (3rd trimester) - used when CI to NSAIDs/ASA: stomach ulcers, renal failure, and liver failure - parenteral options: ketorolac (toradol) 30 mg IM - opioids/muscle relaxants not recommended
58
Cluster HA? Sxs?
- characterized by recurrent severe HA on one side of the head, typically around the eye - sxs assoc with eye: watering of the eye nasal congestion swelling of the eye rhinorrhea lacrimation
59
PP of cluster HAs?
-characterized by hypothalamic activation with secondary activation of trigeminal-autonomic vascular system via the trigeminal hypothalamic pathway
60
Epidemiology of cluster HAs?
- predominantly middle aged men - male-female ratio: 4.3:1 - prevalence 124/100,000
61
Clinical features of a cluster HA? S/S's?
- usually unilateral - can have 8 episodes/day and last from 7 days to 12 months - many pts sit and rock back and forth or pace about - S/S: ipsilateral nasal congestion rhinorrhea lacrimation Horner's syndrome: ptosis of eyelid meiosis of pupil anhidrosis (inability to sweat)
62
Cluster HA triggers?
- ETOH - stress - glare - ingestion of specific foods
63
Neuroimaging for cluster HAs?
- MRI w/ or w/o contrast prefered | - non contrast CT
64
Dx criteria for cluster HA?
A. at least 5 attacks fulfilling criteria B through D: B. severe or very severe unilateral orbital, suborbital pain lasting 15-180 min whne untx, C. either or both of the following: 1. at least one of the following sxs or signs ipsilateral to HA: a. conjunctival injection or lacrimation b. nasal congestion and or rhinorrhea c. eyelid edema d. forehead and facial sweating e. forehead and facial flushing f. sensation of fullness in ear g. miosis or ptosis 2. sense of restlessness or agitation D. attacks have freq b/t 1 q other day and 8/day for more than half of time when disorder is active
65
Tx of cluster HAs?
- 1st line: subQ sumatriptan 6 mg and 100% O2 - oxygen helps abort HA - O2 given through nonrebreathing mask with flow rate of at least 12 L/min in sitting upright position: continue for 15 min to prevent attack reoccurring - other options: intra-nasal lidocaine ergotomine
66
Prevention of cluster HAs?
- verapamil: DOC 240 mg daily can titrate up to 480-960 mg - benefit is seen w/in 2-3 weeks
67
What is a SAH? Most common in? PP?
- bleed in subarachnoid space - can occur spontaneously, ruptured aneurysm, stroke or trauma - most common from 40-65 - PP: blood in subarachnoid space causes chemical meningitis that increases ICP - a 2nd rupture sometimes occurs within 7 days
68
Clinical features of SAH?
- severe thunderclap HA or worse HA of your life - N/V confusion - heart and RR abnormal
69
Dx of SAH?
- noncontrast CT | - if neg CT then LP
70
Tx of SAH?
- ABC's - surgical clipping or coiling of aneurysms - Nimodipine for vasospasm - nicardipine if mean arterial pressure is greater than 130 mmHg ``` goals of tx: BP control prevention of seizures tx of nausea management of intracranial pressure ```
71
What is temporal arteritis?
- chronic vasculitis of large and medium size vessels - usually never occurs below age of 50, with mean onset at 70 - more common in Scandinavian descent - women affected more than men - most feared complication is vision loss
72
PP of temporal arteritis?
- affects arteries containing elastic tissue | - mononuclear cells infiltrates the adventitia from granulomas containing activated T cells and macrophages
73
Clinical features of temporal arteritis?
systemic complaints: - fever - HA: new onset in temporal region, scalp tenderness - jaw claudication - visual manifestations: amaurosis fugax (transient monocular loss of vision) - polymyalgia rheumatica: morning stiffness of shoulders, hips, neck and torso - aortic dissections or aneurysms (thoracic)
74
Dx of temporal arteritis?
- temporal artery bx (GOLD Standard) | - CBC, CMP, ESR, CRP
75
Tx of temporal arteritis?
- initiation of corticosteroid therapy: prednisone 40-60 mg daily taper over 2-3 months, requires 1-2 years of tx - low dose aspirin - once vision loss is present, rarely resolves with tx, so TX FIRST then bx
76
Causes of IICP?
- increase rise in pressure of CSF - can be a devastating complication of neuro injury causes: - subdural/epidural hemorrhage from trauma - ruptured aneurysm - CNS infection - ischemic stroke - neoplasm - hydrocephalus
77
PP of IICP?
- normal ICP is less than 15 mm Hg, increased ICP is above 20 mmHg - homeostatic mechanism stabilizes ICP - intracranial component is surrounded by skull which holds 1400-1700 ml brain= 80% csf = 10% blood= 10% increase in spinal fluid or intracranial mass will increase volume inside
78
Clinical features of IICP?
- HA (worse with cough/sneeze) - N/V - ocular palsies - altered Level of consciousness - back pain - papilledema
79
Dx of IICP?
- CT scan head - MRI brain - LP - only if no risk of herniation! CIs to LP: SAH, infection, mass, bleeding disorders
80
Tx of IICP?
ICP monitoring: - intraventricular (Gold standard) - intraparenchymal - subarachnoid - epidural
81
Infectious HAs causes?
- meningitis - encephalitis - brain abscess
Neuro
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