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3 primary h/a disorders
- 1. migraine
- 2. tension
- 3. cluster
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migraines epidemiology (6)
age, gender, severity, comorbidities, frequency, timing
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6 etiology of migraines
- 1. vascular hypothesis
- 2. neuronal dysfunction (aura, pain, associated sx)
- 3. neurovascular migraines
- 4. brainstem
- 5. genetics
- 6. mediators
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migraines definition
- common, recurrent, severe H/A
- interferes with normal functioning
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secondary H/A disorders
- CNS infections like meningitis, head
- trauma, tumors/stroke/hemorrhaging
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presentation of migraines
premonitary sx --> aura --> h/a --> resolution
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symptoms of migraines (5)
- 1. throbbing/pulsating (4-72 hours - untreated)
- 2. unilateral (usually)
- 3. frontotemporal region
- 4. associated with N/V, photo/phonophobia w/o aura
- 5. worsens with physical activity
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signs of migraines (4)
- 1. +family history
- 2. food triggers
- 3. menstrual association
- 4. improvement with sleep
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alarm symptoms - rule out
- acute onset
- first h/a ever
- worst h/a ever - stroke!!
- onset after age 50
- associated with systemic illness - infection
- h/a with focal neurologic symptoms or papilledema - stroke
- new onset h/a in patient with cancer/HIV
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nonpharm for migraines
diary, avoid triggers
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frequent attacks >2-3 days of the week
prophylactic NOT abortive therapy
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treatment migraines: infrequent mild-moderate
analgesics
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treatment migraines: moderate - severe
first line: triptans, ergotamines, dihydroergotamines, opioids
GI issues: can't use oral
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FDA approved migraine prophylaxis (4)
- propranolol
- timolol
- valproate
- topiramate
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migraine prophylaxis (5)
- 1. NSAIDs - ASA, IBU, naproxen, APAP/ASA/CAF (Exedrin)
- 2. BB - metoprolol, atenolol, nadolol
- 3. CCB - verapamil
- 4. Antidepressants - TCAs (Amitriptyline), SSRIs/SNRIs
- 5. Anticonvulsants - divalproex, gabepentin
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Most common type of primary h/a
tension
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presentation of tension h/a
- NO premonitory symptoms of aura
- mild-moderate - dull, NONPULSATILE tightness or pressure
- BILATERAL
- frontal, temporal pain
- NOT worsened with physical activity
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nonpharm tx for tension h/a
stress management
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Rx therapy for tension h/a
- simple analgesics
- -monotherapy
- + caffeine
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most serious type of primary h/a
cluster h/a
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presentation of cluster h/a
- MEN > women
- NO premonitory symptoms or aura
- severe - excruciating, penetrating, boring
- UNILATERAL
- orbital, supraorbital, temporal
- occurs in series
- occurs at night (spring/fall) - lacrimation, congestion, facial swelling
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abortive tx for cluster h/a
- oxygen 100% x 15-30 mins - delays attack only
- ergotamine derivatives - combo with Li/verapamil
- triptans
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prophylactic tx for cluster h/a
- verapamil
- lithium - combo w/verapamil (monitor thyroid
- and renal function - NSAIDs)
- ergotamine - combo w/Li & verapamil
- corticosteroids - induce remission (3 wks)
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H/A diary (5) to log
- 1. frequency - need for prophylaxis
- 2. severity
- 3. duration
- 4. med use - response, assess for adequate/overuse
- 5. potential triggers
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