Ch 13: Headache Flashcards
What is the most common form of pain experienced by Americans?
Headache
Over 95% of population experiences it at some point
What is the most common type of headache?
What is the most likely headache type to present in clinic?
While tension type headaches are the most common…
migraines are the most likely to present in clinic.
Good to note : Over time, most patients with one type of headache will have cross-over symptoms of another type
What are the most common triggers for migraine
- Stress (80%)
- Hormones
- Skipped meals
- Weather
- Sleep disturbacnes
- Perfume/odor (44%)
Other triggers: neck pain, lights, alcohol, smoke sleeping late, heat, food, exercise
What are the most common comorbidities found in migraine disorder?
- Insomnia
- Depression
- Anxiety
- Gastric ulcer/ GI bleed
- PAD
- Angina
Others: allergies, epilepsy, arthritis, stroke/TIA, RA, asthma, Vit D deficiency
Most common food triggers for migraine?
- Alcohol
- Caffeine
- MSG
- aspartame
- cocoa
- cheese / dairy
- sulfate and nitrate containing foods (aged & processed meats and cheese, dried fruits)
Most frequently used CAM types for headache
- Manipulative therapy
- dietary supplements
- acupuncture
- mind-body therapies
What 3 questions / signs have 93% PPV in diagnosing migraine
- Has a headache limited your activities for a day or more in the last 3 months?
- Are you nauseated or sick to your stomach when you have a headache?
- Does light bother you when you have a headache?
SNOOP4
A Mnemonic to rule out emergent secondary causes of HA
S = systemic symptoms (fever, myalgia, weight loss) –> cancer, infxn
N = neuro sx –> stoke, lesion
O = older age (> 50 yrs old ) at onset –> TA, glaucoma, mass
O = onset thunderclap –> bleed
P = papillodema –> elevated ICP
P = positional –> intracranial hypotension
P = precipitated by valsalva or exertion –> elevated ICP
P = progressive or pattern change –> any secondary cause
Pathophysiology of Migraine
Tigerring of trigeminal (sensory), parasympathetic, and sympathetic nerve fibers
PLUS
Release of **vasoactive neuropeptides **(like CGRP, serotonin, substance P, NO-synthase, VIP, neuropeptide Y, acethylcholine, NE, and orexin)
LEADING TO
vasodilation
sterile inflammation
cortical spreading / propogation of aberrant electrical signaling
EXTENDING TO
brainstem, cortex, dura, and other cranial structures such as the vagal nerve
LEADING TO
neuro sx, autonomic sx, GI sx
CGRP = calcitonin gene-related peptide
Beta Blockers
Propranolol, timolol
Consider: HTN
Caution: renal or hepatic impairment, chronic fatigue, POTS
as a preventative
Anticonvulsants
Divalproate, topiramate
Consider: epilepsy, obesity (topiramate)
Caution: hepatic impairment, concomitant alcohol use, depression
as a preventative
Valproic acid is not FDA approved but likely also efficacious.
Calcitonin gene-related peptide (CGRP) inhibitors
Erenumab
Galcanezumab
Fremanezumab
Eptinezumab
Consider: previous failed preventatives
Caution: history of constipation, hypertension, injection hypersensitivity
a preventative
OnabotulinumtoxinA
Consider: chronic migraine, failed preventatives
Caution: history of muscle weakness, injection sensitivity
as a preventative
Antihypertensives, Not FDA approved, for migraine
CCB, ACE inhibitors, ARBs
probably efficacious
ANtidepressants, Not FDA approved, for migraine
TCAs, SSRI, SNRI
Amitryptiline, fluoxetine, venlafaxine
Consider: sleep disruption, depression, anxiety, amplified pain syndromes
Caution: fatigue. Polypharmacy because of cytochrome P450 pathway and caution regarding serotonin syndrome if using triptans,
Selected: renal and hepatic impairment; alcohol use
Memantine
Consider: chronic migraine. Not FDA approved but likely efficacious.
Cognitive dysfunction, amplified pain syndromes
Caution: can initially worsen headache; dizziness