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GoT of HA Tx
- 1. relieve S/S
- 2. prevent recurrence
- 3. diagnose serious HA
- 4. minimize S/E
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Epidemiology of HA
- lifetime risk= >90%
- >1 severe HA annually= 25%
- migraines= 6%M + 16% F
- chronic daily HA= 3%
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If recent onset of HA, what do you do?
- CT/MRI
- lumbar puncture
- metabolic/electrolyte abnormalities
- drug-induced/withdrawal
- temporal enteritis
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Red flags for HA
- middle-aged and elderly
- severe and abrupt onset
- progressing severity
- change in HA pattern
- neurological S/S
- systemic S/S (ie. fever)
- new HA with cancer, pregnancy, immunosuppression
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Common Migraine classification
- minimum of Dx: 5 (1.5/month)
- duration: 4-72 hours
- >1 of: unilateral, pulsating, mod-severe, aggravated by routine
- >1 of: N/V, photophobia+phonophobia
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Classic Migraine classification
- minimum of Dx: 5 (1.5/month)
- duration: 4-72 hours
- >1 of: unilateral, pulsating, mod-severe, aggravated by routine
- >1 of: N/V, photophobia+phonophobia
- preceded by aura within 60mins: visual s/s (positive and negative), sensory s/s (tingling, numbness)
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Infrequent Episodic Tension classification
- minimum of Dx: 10 (>1/month)
- duration: 30min-7days
- >2 of: bilateral, not throbbing, mild-mod, not aggravated by routine
- both of: no N/V, either photophobia or phonophobia
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Episodic Cluster classification
- minimum of Dx: 5 (EOD to 8/day)
- duration: 15-180mins
- severe: unilateral orbital/suborbital/temporal pain
- >1 of: conjunctival injection, lacrimation, nasal congestion, rhinorrhea, facial sweating, miosis, ptosis, eyelid edema
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Non-pharm Tx
- Migraine
- 1. avoid triggers
- 2. cold/pressure to the head
- 3. reduce activity and sensory input
- 4. relaxation, hypnosis, biofeedback, visual imagery, PT
- Tension-type HA
- 1. heating pad
- 2. stretching, strengthening, massage, ultrasound
- 3. relaxation
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Associated drugs with secondary HA
- amitriptyline, imipramine
- frequent ASA/APAP
- NSAIDs
- BDZs
- NTG
- MAOIs
- metoclopramide
- estrogen
- sulfa
- theophylline
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Withdrawal of these drugs cause secondary HA
- BDZs
- caffeine
- ergotamine
- methysergide
- ASA, APAP±codeine
- anti-hypertensives
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Indications for preventative HA Tx
- >2 attacks/month causing >3days/month disability
- CI or failure to abortive Tx
- use of abortive Tx >2days/week
- uncommon type of HA
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Preventative HA Tx
- propranolol 40-120mg BID
- amitriptyline 25-75mg QHS
- divalproex 400-600mg BID
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S/E of triptans (5HT 1b/1d agonist)
- N/V
- photophobia
- asthenia
- chest S/S
- paresthesia
- MOH if >1/week
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DI of triptans (5HT 1b/1d agonist)
- space from ergots by >24hours
- 5HT syndrome with SSRIs
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Dosage forms of triptans (5HT 1b/1d agonist)
- PO: suma, zolmi, nara, riza, almo, ele
- Nasal spray: suma, zolmi
- SC: suma
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Dose-response effect of triptans (5HT 1b/1d agonist)
- rizatriptan 10mg= higher recurrence
- eletriptan 40mg= lower recurrence
- naratriptan 2.5mg= less effective but less recurrence
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Dihydroergotamine for migraine
- lower recurrence rate than sumatriptan
- dosage forms: SC, IM, IV, intranasal
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S/E of dihydroergotamine
more nausea and less chest pain than sumatriptan
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Ergotamine for migraine
- increase effectiveness if taken during aura or very early in the attack
- dosage forms: PO, SL, PR
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S/E of ergotamine
similar to DHE but more nausea
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Tension-type HA guidelines
- Tx: APAP, ASA, NSAIDs
- +caffeine >100mg= increased analgesia
- MOH if drug use >2x/week
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Preventative Tx for tension-type HA
- amitriptyline 10-25mg QHS-->50-75mg
- ami S/E: dry mouth, constipation, sedation, weight gain
- ami CI: glaucoma, epilepsy, BPH, cardiac arrythmias
alternative: doxepin, imipramine, TCAs, SSRIs
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Cluster HA guidelines
can be hard to treat: rapid onset, increase in intensity, short duration
- acute:
- sumatriptan 6mg SC
- 100% oxygen 8-10L/min x15mins
- DHE/ergotamine
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Preventative Tx for cluster HA
verapamil* PO 120-160mg TID
alternative: lithium, prednisone, methysergide (need drug holiday after 6 months), VPA, TPM
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