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Name 3 types of primary headaches and one secondary type.
- 1. Migraines (with or without aura)
- 2. Tension
- 3. Cluster
1. Medication-overuse
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What diagnostic clues indicate that a headache is of vascular origin (migraine)?
Pulsatile, pounding, throbbing (changes in intensity)
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What diagnostic clues indicate a headache is a tension headache?
Constant tight pressure, "hatband" distribution, NOT pounding
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What diagnostic clues may indicate a headache is d/t a tumor?
Steady aching pain, may have acute onset
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What type of headache may present as sudden severe pain, possibly described as the "worst headache of my life"?
Subarachnoid hemorrhage
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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.
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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
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What part of the brain is thought to be responsible for the pain of migraines?
trigeminovascular system
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Neurotransmitters involved in the pathophys of migraines
- serotonin
- dopamine
- GABA (GABA agonist may prevent HA)
- NMDA (stimulation by glutamate, aspartate may lead to HA)
- Calcitonin gene-receptor peptide
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name some chemical migraine triggers
- tyramine
- potassium metabisulfite
- nitrates
- MSG
- CO
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name some drug triggers for migraines
- Cardiac/antihypertensive agents
- Hormonal therapies
- NSAIDS
- Others/stimulants/substances (bactrim, caffeine withdrawal, tobacco)
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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)
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Name 2 preheadache phases the patient might experience
- Premonitory symptoms (neurologic, psychologic, other)
- Aura
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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)
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Do all patients with migraines have an aura?
No - only about 30%
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How long before the HA starts does one usually experience an aura?
about 5-20 minutes
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How long do migraines usually last?
4-72 hours
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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)
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Describe the resolution phase
- Also called postdromal
- May last 1-2 days
- Fatigue, irritability, weakness, euphoria, scalp tenderness, anorexia
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What are the phases of migraine clinical presentation?
- 1. preheadache phases
- 2. headache phase
- 3. resolution phase
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What class of drugs are DOC for moderate to severe migraines when simple analgesics or NSAIDS have failed?
Triptans - serotonin receptor agonists
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What is the next step if pt fails to respond to one triptan?
Try a different triptan
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Which triptan is now generic?
sumatriptan
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Do we generally see rebound HA with triptan treatment?
no
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MOA of serotonin agonists
- vasoconstriction of intracranial blood vessels
- inhibition of vasoactive neuropeptide release
- block trigeminal nuclei pain signal transmission
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Triptan SEs
- Dizziness, somnolence, fatigue
- Parasthesias, tingling sensations, burning or warm sensations, flushing
- N/V
- Transient increases in BP
- Chest symptoms (worst with SQ sumatriptan)
- pain, pressure, heaviness in chest, neck, jaw
- MI, death
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CI for triptan use
- Uncontrolled HTN
- Pregnancy (caution)
- PVD
- Hx of CVAs
- Ischemic bowel
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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
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Name some triptans
- Sumatriptan
- Rizatriptan
- Zolmitriptan
- Naratriptan
- Almotriptan
- Frovatriptan
- Eletriptan
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Which triptans have a fast onset?
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which triptans have a slow onset and long duration?
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Which triptan has an active metabolite that is 2-6 times more potent than the parent?
Zolmitriptan
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What is a big issue with tolerance of ergot alkaloids?
Nausea/GI SEs (use with antiemetics)
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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
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Cautions with ergot alkaloids
- HTN
- Pregnancy category X
- Use in pts >60 not recommended
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DIs with ergot alkaloids
- Triptan use within 24 hours
- Other serotonergic agents
- CYP 450 3A4 inhibitors (antifungals, macrolides, etc)
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name 2 ergot alkaloid agents
- 1. Ergotamine tartrate
- 2. Dihydroergotamine mesylate
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What medication is commonly given with ergot alkaloids to counter gastric stasis and GI SEs?
metoclopramide
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How well are ergot alkaloids absorbed orally?
Poorly - extensive first pass effect
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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
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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
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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
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When using phenothiazines, butyrophenones what must we monitor?
- Blood pressure
- CNS SEs
- EPS SEs
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MOA of phenothiazines or butyrophenones
may involve sedative properties or dopamine antagonist activity
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Example of phenothiazines or butyrophenones
- promethazine
- prochlorperazine
- chlorpromazine
- droperidol/haloperidol
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Other abortive therapies
- Glucocorticoids
- Magnesium sulfate
- Calcium channel blockers
- antihistamines
- lidocaine
- skeletal muscle relaxants
- combos (NSAIDS and triptans, DHE and prochlorperazine)
- Calcitonin gene-related peptide receptor antagonist (telcagepant - efficacy similar to zolmitriptan)
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What type of surgery might be available to help migraines?
deactivation of peripheral migraine trigger sites
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What is status migrainosus?
headache lasting >72 hours despite treatment - refractory to usual treatments
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Features of status migrainosus
persistant, severe head, neck or face pain, GI symptoms, insomnia
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Withdrawal of what medications is often associated with status migrainosus?
analgesics
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How is status migrainosus treated?
- DHE or triptans
- narcotic analgesics
- IV phenothiazines
- IV fluids (if N/V has induced dehydration)
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Preventative/prophylactic treatment of migraines - goal
- decrease the frequency of migraines
- decrease the severity
- decrease the duration
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How often should patients take preventative treatment medications and for how long?
Daily for 3-12 months
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How should preventative migraine treatments be started?
- titrated slowly
- periodically re-evaluated for efficacy
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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
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How do we select a preventative treatment medication?
Based on comorbidities, DIs, cost
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How long is an appropriate trial of a preventative med before declaring failure?
2-3 months minimum
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Agents used for prophylactic treatment of migraines
- Beta Blockers
- Antidepressants
- Anticonvulsants
- Calcium Channel Blockers
- ACE/ARB
- NSAIDS (naprosyn for menstrual migraine prophyl)
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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
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Should preventative migraine therapy be used in pregnant women?
generally, no
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Why avoid NSAIDs in 3rd trimester?
premature closure of ductus arteriosis
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Definition of menstrually related migraine headache
- migraine without aura
- occur on day -2 to +3 of menstruation
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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
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What is the DOC for acute treatment of migraines in children
Ibuprofen
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What is the 2nd line treatment for migraines in children?
Acetaminophen
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What is a med that should be considered for acute treatment of migraine in adolescents?
- Sumatriptan nasal spray
- (3rd line for children?)
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Options for preventative therapy of migraine in children and adolescents
- Flunarizine (but not avail in US)
- Cyproheptadine (also anti-itch)
- Propranolol
(most are level U treatments)
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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
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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
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Acute treatment for tension headaches
- ASA
- Simple combos
- other NSAIDs > APAP (limit to 2-3 days/week or can lead to analgesic rebound HAs)
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preventative treatment for tension headaches
- amitryptiline
- tizanidine
- mirtazapine
- (ssri, botulism toxin - no effect!)
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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
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Ipsilateral autonomic symptoms
- lacrimation
- conjunctival injection
- rhinorrhea/nasal congestion
- miosis/ptosis
- sweating
- increased blood flow to skin
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Acute treatment for cluster headaches
- triptans
- 100% oxygen (60% respond within 20-30 minutes)
- intranasal lidocaine
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preventative pharmacotherapy for cluster headaches
- during the cluster period:
- - verapamil
- - lithium
- - corticosteroids
- - topiramate
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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)
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risk factors for CDHA
- obesity
- hx of more than 1 HA per week
- caffeine
- medication overuse (>10 days per month)
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What is a medication overuse headache?
HA caused or perpetuated by acute headache relief meds
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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
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