neuro/psych-quiz 2-headache

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

visual and/or sensory, 5-20 minutes and lasts less than or equal to 60 minutes, 18% of migraines

can have prodome, same length and aura sx-irritability, depre, difficulty concentrating, photophobia, and phonophobia

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

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

rapidly increasing HA freq, hx of lack of coordination, hx or localized neurologic signs or sx, hx of HA causing awakeing from sleep

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

constriction of some vascular smooth muscle and vasoconstr-agonists useful in acute migraine tx

inhibits neurogenic inflammatory response presynaptically, inhibits n&v w migraine

causes vasoconstriction, platelet aggregation, useful in prophylactic migraine tx and can prevent initial vasodilation that leads to migraine

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

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)

limit to 2 days/wk, use as early as possible, triptans, selective for 5_HT-1B/1D agonists

parasthesias, dizziness, warm sensations, somnolence, chest pressure, tightness (15), CONTRA MI and angina, may repeat X1 after 2 hours

sumatriptan

zomig, 2.5 mg and 5 mg, eletriptan 40 mg, and rizatriptan 5 mg all showed similar results

amerge, 2.5 mg and eletriptan 20 mg showed lower efficacy and better tolerability

maxalt, 10 mg showed better efficacy and consistency and similar tolerability

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

frova, longest half-life

relpax, 80 mg showed better efficacy, similar consistency, but lower tolerability, may work if not responding to others

ergot-separate at least 24 hours from triptan, SNRI and SSRI-serotonin syn

may facilitate abs of the acute drug and decrease vomiting

sympathomimetic amine, in midrin with APAP and dichloralphenazone

chloral hydrate derivative

not approved on its own for migraine but is contained in OTC prep with ASA and caffeine

IM only in supervised settings

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

6mg/d; 10mg/wk

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

propranolol(A), timolol(A), atenolol, meto, nado(B)

50-100

valproate (A), topiramate(C-but will probably change, most common), gabapentin(B)

verap(B), 2nd or 3rd line

(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

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)

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