Name 3 types of primary headaches and one secondary type.
- 1. Migraines (with or without aura)
- 2. Tension
- 3. Cluster
What diagnostic clues indicate that a headache is of vascular origin (migraine)?
Pulsatile, pounding, throbbing (changes in intensity)
What diagnostic clues indicate a headache is a tension headache?
Constant tight pressure, "hatband" distribution, NOT pounding
What diagnostic clues may indicate a headache is d/t a tumor?
Steady aching pain, may have acute onset
What type of headache may present as sudden severe pain, possibly described as the "worst headache of my life"?
Do migraine headaches count as a disability?
They do count as an impairment according to the EEOC, so if the migraines limit any major life activities of the patient, then yes, they'd be considered a disability under the ADA.
What are the diagnostic criteria for migraines?
- More than 5 episodes of headache lasting from 4 to 72 hours with at least 2 of the following:
- unilateral location
- pulsating quality
- moderate or severe intensity
- aggravation by or avoidance of routine physical activity
- AND, during HA, at least 1 of the following:
- nausea, vomiting, or both
- photophobia and phonophobia
What part of the brain is thought to be responsible for the pain of migraines?
Neurotransmitters involved in the pathophys of migraines
- GABA (GABA agonist may prevent HA)
- NMDA (stimulation by glutamate, aspartate may lead to HA)
- Calcitonin gene-receptor peptide
name some chemical migraine triggers
- potassium metabisulfite
name some drug triggers for migraines
- Cardiac/antihypertensive agents
- Hormonal therapies
- Others/stimulants/substances (bactrim, caffeine withdrawal, tobacco)
name some non-chemical stimuli that may be migraine triggers
- physical factors (bright lights, weather changes, physical activity)
- psychological factors (stress)
- hormonal changes
- lifestyle triggers (fasting, over/under sleeping)
- metabolic triggers (hypoglycemia)
Name 2 preheadache phases the patient might experience
- Premonitory symptoms (neurologic, psychologic, other)
Features of the aura
Most common is visual (positive sx: photopsia, scintillations, teichopsia - lines, brightness)(negative sx: scotoma, hemianopsia - interruptions in visual field)
Sensory/motor features (parasthesias, dysphasia/aphasia, weakness)
Do all patients with migraines have an aura?
No - only about 30%
How long before the HA starts does one usually experience an aura?
about 5-20 minutes
How long do migraines usually last?
Clinical features of the HA phase
- unilateral/bilateral throbbing pain in frontotemporal region
- GI sx (nausea in 90%, vomiting in 33%)
- phono- and photo- phobias
- systemic sx (nasal congestion, diaphoresis, periorbital edema)
Describe the resolution phase
- Also called postdromal
- May last 1-2 days
- Fatigue, irritability, weakness, euphoria, scalp tenderness, anorexia
What are the phases of migraine clinical presentation?
- 1. preheadache phases
- 2. headache phase
- 3. resolution phase
What class of drugs are DOC for moderate to severe migraines when simple analgesics or NSAIDS have failed?
Triptans - serotonin receptor agonists
What is the next step if pt fails to respond to one triptan?
Try a different triptan
Which triptan is now generic?
Do we generally see rebound HA with triptan treatment?
MOA of serotonin agonists
- vasoconstriction of intracranial blood vessels
- inhibition of vasoactive neuropeptide release
- block trigeminal nuclei pain signal transmission
- Dizziness, somnolence, fatigue
- Parasthesias, tingling sensations, burning or warm sensations, flushing
- Transient increases in BP
- Chest symptoms (worst with SQ sumatriptan)
- pain, pressure, heaviness in chest, neck, jaw
- MI, death
CI for triptan use
- Uncontrolled HTN
- Pregnancy (caution)
- Hx of CVAs
- Ischemic bowel
DIs with triptans
- MAOIs (wait at least 2 weeks in between)
- Propranolol (decreases triptan metabolism)
- Other serotonergic drugs (ADs, buspirone, selegiline, dextromethorphan, lithium, cocaine)
- Use of ergot or another triptain within 24 hours
Name some triptans
Which triptans have a fast onset?
which triptans have a slow onset and long duration?
Which triptan has an active metabolite that is 2-6 times more potent than the parent?
What is a big issue with tolerance of ergot alkaloids?
Nausea/GI SEs (use with antiemetics)
SEs of ergot alkaloids
- Peripheral vascular effects ( leg cramps, tingling, numbness in extremities)
- Claudication (impaired circulation)
- Ergotism (severe vasoconstrictive crisis)
- CNS SEs (sedation, depression, fatigue)
- Intranasal DHE: rhinitis, nasal congestion, taste disturbances
- Cardiac effects (ergots change the blood vessels) - chest pain, heart valve probs
Cautions with ergot alkaloids
- Pregnancy category X
- Use in pts >60 not recommended
DIs with ergot alkaloids
- Triptan use within 24 hours
- Other serotonergic agents
- CYP 450 3A4 inhibitors (antifungals, macrolides, etc)
name 2 ergot alkaloid agents
- 1. Ergotamine tartrate
- 2. Dihydroergotamine mesylate
What medication is commonly given with ergot alkaloids to counter gastric stasis and GI SEs?
How well are ergot alkaloids absorbed orally?
Poorly - extensive first pass effect
When might we use IV valproic acid in migraine patients? How fast is the onset?
Refractory patients or if they have CIs to triptans or ergots
Onset: 8-15 minutes
Why do we use metoclopramide in migraine patients?
- to prevent gastric stasis and improve oral absorption of other abortive agents
- effective antiemetic - give 15-30 minutes before analgesic
- Used with NSAIDS, simple analgesics, ergots
Why/when would phenothiazines, buryrophenones be used in migraine tx?
- For sedative and antiemetic properties (concurrently with other agents)
- 2nd or 3rd line agents for pts intolerant to ergots and triptans
When using phenothiazines, butyrophenones what must we monitor?
- Blood pressure
- CNS SEs
- EPS SEs
MOA of phenothiazines or butyrophenones
may involve sedative properties or dopamine antagonist activity
Example of phenothiazines or butyrophenones
Other abortive therapies
- Magnesium sulfate
- Calcium channel blockers
- skeletal muscle relaxants
- combos (NSAIDS and triptans, DHE and prochlorperazine)
- Calcitonin gene-related peptide receptor antagonist (telcagepant - efficacy similar to zolmitriptan)
What type of surgery might be available to help migraines?
deactivation of peripheral migraine trigger sites
What is status migrainosus?
headache lasting >72 hours despite treatment - refractory to usual treatments
Features of status migrainosus
persistant, severe head, neck or face pain, GI symptoms, insomnia
Withdrawal of what medications is often associated with status migrainosus?
How is status migrainosus treated?
- DHE or triptans
- narcotic analgesics
- IV phenothiazines
- IV fluids (if N/V has induced dehydration)
Preventative/prophylactic treatment of migraines - goal
- decrease the frequency of migraines
- decrease the severity
- decrease the duration
How often should patients take preventative treatment medications and for how long?
Daily for 3-12 months
How should preventative migraine treatments be started?
- titrated slowly
- periodically re-evaluated for efficacy
Indications for preventative migraine treatment
- excessive use of abortive meds (weekly or greater)
- 2+ migraines per month, >48 hour duration, severe intensity
- ineffective or CIs to abortive therapy
How do we select a preventative treatment medication?
Based on comorbidities, DIs, cost
How long is an appropriate trial of a preventative med before declaring failure?
2-3 months minimum
Agents used for prophylactic treatment of migraines
- Beta Blockers
- Calcium Channel Blockers
- NSAIDS (naprosyn for menstrual migraine prophyl)
Which triptan would be the best choice in pregnancy?
They are all Class C, but sumatriptan doesn't appear to be assoc with birth defects
Should preventative migraine therapy be used in pregnant women?
Why avoid NSAIDs in 3rd trimester?
premature closure of ductus arteriosis
Definition of menstrually related migraine headache
- migraine without aura
- occur on day -2 to +3 of menstruation
Treatment of menstrually related migraines
Symptomatic therapy: triptans (best appear to be sumatriptan and rizatriptan), mefenamic acid
Short-term prevention taken perimenstrually: percutaneous estradiol, frovatriptan, naratriptan
What is the DOC for acute treatment of migraines in children
What is the 2nd line treatment for migraines in children?
What is a med that should be considered for acute treatment of migraine in adolescents?
- Sumatriptan nasal spray
- (3rd line for children?)
Options for preventative therapy of migraine in children and adolescents
- Flunarizine (but not avail in US)
- Cyproheptadine (also anti-itch)
(most are level U treatments)
Tension headache definition
- At least 10 episodes where:
- - HA lasts from 30 min to 7d
- - HA has at least 2 of the following: bilateral location, pressing/tightening quality, mild or moderate severity - not severe, not aggravated by routine physical activity
- - Both of the following: no N/V, no more than one episode of photophobia of phonophobia
What does educational level have to do with tension headaches?
The higher education level one has, the more likely one is to experience tension headaches
Acute treatment for tension headaches
- Simple combos
- other NSAIDs > APAP (limit to 2-3 days/week or can lead to analgesic rebound HAs)
preventative treatment for tension headaches
- (ssri, botulism toxin - no effect!)
Features of cluster headache ("suicide headache")
- cluster lasting 4-8 weeks 1-3 times per year
- intense piercing-throbbing pain
- strictly unilateral
- up to 8 times a day (often nocturnal)
- relatively short (15-180 min)
- frequently occur 1-2 hours after falling asleep or in early morning
- accompanied by autonomic sx (tearing, rhinorrhea)
- pts are restless and prefer to pace or rock back and forth
- pts tend to become aggressive
Ipsilateral autonomic symptoms
- conjunctival injection
- rhinorrhea/nasal congestion
- increased blood flow to skin
Acute treatment for cluster headaches
- 100% oxygen (60% respond within 20-30 minutes)
- intranasal lidocaine
preventative pharmacotherapy for cluster headaches
- during the cluster period:
- - verapamil
- - lithium
- - corticosteroids
- - topiramate
Types of Chronic Daily HeadAche
- transformed migraine (mixed sx of tension and migraine)
- Overuse of Acute HA medication
- Chronic tension-type HA
- Cluster HA
- Paroxysmal hemicrania (identical to clusters, but more often and briefer attacks)(responsive to indomethacin)
risk factors for CDHA
- hx of more than 1 HA per week
- medication overuse (>10 days per month)
What is a medication overuse headache?
HA caused or perpetuated by acute headache relief meds
Definition of overuse (in the context of med-overuse HAs)
- regular overuse of a HA med for > 3 mo
- use of ergots, triptans, opioids or combo analgesics > 10 days per month
- Use of simple analgesics >/= 15 d per month
- Total use of all HA meds >/= 15 d per month