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MOH
medication overuse headache, ≥5-10 days/month opioid or combo analgesics, triptans can contribute to MOH if high freq of migraine at baseline: more than 10/mo, antiinflammatories may be protective is less than 10 at baseline, ≥15 days/mo of simple analgesics
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migraine with aura
visual and/or sensory, 5-20 minutes and lasts less than or equal to 60 minutes, 18% of migraines
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migraine without aura
can have prodome, same length and aura sx-irritability, depre, difficulty concentrating, photophobia, and phonophobia
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tension HA
not aggravated by activity, bilateral, pressing, non-pulsating, hatband HA, mild-mod, can also have muscle tenderness or knots, can be infreq or nearly daily
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cluster HA
daily for weeks to months, severe pain, lasts 20-2 hours, unilateral orbital and/or temporal, often w ipsilateral rhinorrhea, lacrimation, eyelid edema, blurred vision, forehead or facial sweating and feeling of restlessness or agitation, NSAIDs not effective
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no OTC recommendation for HA
rapidly increasing HA freq, hx of lack of coordination, hx or localized neurologic signs or sx, hx of HA causing awakeing from sleep
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pathogenesis of migrain
depressed electrical activity(consistent with spread of aura sx), decreased blood flow, imbalance of serotonergic and noradrenergic neuronal activity?, vasodilation, activation of trigeminal nerve, release of neuropeptides and calcitonin-gene-related peptides, neurogeni inflamm of dural blood vessels, transmission of nociceptive info from trigem to thalamus and cortex where pain is perceived
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5HT-1B
constriction of some vascular smooth muscle and vasoconstr-agonists useful in acute migraine tx
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5HT-1D
inhibits neurogenic inflammatory response presynaptically, inhibits n&v w migraine
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5HT-2
causes vasoconstriction, platelet aggregation, useful in prophylactic migraine tx and can prevent initial vasodilation that leads to migraine
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acute tx of episodic tension HA
should not be more than 2-3 days/wk to prevent MOH, ASA, NSAIDs, APAP, NSAIDs probably more effective +- caffeine, analgesics with sedation(butalbital or codeine) high potential for overuse and dependency, use only in refractory cases
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Preventative tx of chronic tension HA
if: >2 HA/wk, duration >3-4 hours, severity results in medication overuse or substantial disability, ami 75-150mg/d, tizanidine(limited efficacy), botulinum toxin inj(conflicting studies)
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Acute (abortive) tx of migraine
limit to 2 days/wk, use as early as possible, triptans, selective for 5_HT-1B/1D agonists
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triptan SE
parasthesias, dizziness, warm sensations, somnolence, chest pressure, tightness (15), CONTRA MI and angina, may repeat X1 after 2 hours
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zolmitriptan
zomig, 2.5 mg and 5 mg, eletriptan 40 mg, and rizatriptan 5 mg all showed similar results
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naratriptan
amerge, 2.5 mg and eletriptan 20 mg showed lower efficacy and better tolerability
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rizatriptan
maxalt, 10 mg showed better efficacy and consistency and similar tolerability
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almotriptan
axert, 12.5 mg showed similar efficacy at 2 hours but better other results, may be helpful for pts who are especially sens to feelings of chest pressure and other side effects
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frovatriptan
frova, longest half-life
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eletriptan
relpax, 80 mg showed better efficacy, similar consistency, but lower tolerability, may work if not responding to others
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INX with triptans
ergot-separate at least 24 hours from triptan, SNRI and SSRI-serotonin syn
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metoclopramide
may facilitate abs of the acute drug and decrease vomiting
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isometheptene
sympathomimetic amine, in midrin with APAP and dichloralphenazone
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dichloralphenazone
chloral hydrate derivative
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APAP
not approved on its own for migraine but is contained in OTC prep with ASA and caffeine
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ketorolac
IM only in supervised settings
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ergotamine tartrate and dihydroergotamine (DHE)
nonsel 5-HT-1 agonists=potent vasocontrictors, N&V, ergotism sx of peripheral ischemia, rebound HA with ergotamine, CONTRA-CVD, preg, ergot and triptans not within 24 hours
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max ergotamine dose
6mg/d; 10mg/wk
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preventative tx of migraines
consider if disabling, acute tx >2 days/wk, cannot tolerate abortive tx, tx not effective, 2 to 3 month trial, continue 3-6 months, so up to 6-9 months
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beta blockers for migraine prevention
propranolol(A), timolol(A), atenolol, meto, nado(B)
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amitriptyline, migraine
50-100
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anticonvulsants-migraine
valproate (A), topiramate(C-but will probably change, most common), gabapentin(B)
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calcium channel blocker-migraine
verap(B), 2nd or 3rd line
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methysergide-migraine
(A) blocks dev of neurogenic inflam via stabilization of 5-HT neurotransmission, drug holiday one month out of 6 due to fibrosis, SE-claudication, GI upset, wt gain, muscle ache, refractory
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abortive tx for cluster HA
oxygen, 6-7 L/min for 10-15 min, ergotamine (IV or IM), 3-7 d of admin can break cycle of freq attacks, triptans(nasal or SQ)
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preventative tx for cluster HAs
short-term:CSs, 7-10 d then taper 5-10mg/d, rapid onset but high recurrence rate, methysergide, ergotamine, long-term preventative: verap(DOC) effective after 1 week and 70%, lithium, gabe, topi, valpro, melatonin
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