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53 > 5. Headache, Migraine > Flashcards

5. Headache, Migraine Flashcards

1
Q

ICHD-3 classification: primary vs secondary headaches

A

primary: TTH, migraine
secondary: (due to other sinister conditions) trauma to head/neck, infection, psychiatric disorders etc

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2
Q

Red flag for secondary headache (SNOOP10)

A
  • Systemic sx (eg fever
  • Neoplasm in hx (abnormal growth/ cancer)
  • Neurologic deficit
  • Onset of headache sudden/ abrupt
  • Old age (>50yo)
  • Pattern change or recent onset of headache
  • Positional headache
  • Precipitated by sneezing, coughing, exercising
  • Papilledema (swelling of optic nerve due to elevated intracranial pressure) - need equipment to check
  • Progressive headache with atypical presentation
  • Pregnancy
  • Painful eye with autonomic features (may suggest cluster headache)
  • Post-traumatic onset of headache
  • Pathology of immune system (eg HIV, immunocompromised)
  • Painkiller overused or new drug at onset of headache
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3
Q

characteristics of TTH
- pain location
- pain quality
- pain intensity
- effect on activities
- other sx
- duration

A
  • pain location: Bilateral
  • pain quality: pressing/tightening, nonpulsatile
  • pain intensity: mild to moderate
  • effect on activities not aggravated by routine daily activity
  • other sx: no prodrome sx/ aura, pericranial/ cervical (neck) muscle tenderness
  • duration: 30mins - 7d
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4
Q

characteristics of migraine
- pain location
- pain quality
- pain intensity
- effect on activities
- other sx
- duration

A
  • pain location: Unilateral/ bilateral
  • pain quality: pulsating/throbbing
  • pain intensity: moderate to severe
  • effect on activities: aggravated by/ cause avoidance of daily activity
  • other sx: N/V, sensitive to light/sight, aura
  • duration: 4-72hrs
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5
Q

characteristics of cluster headaches
- pain location
- pain quality
- pain intensity
- effect on activities
- other sx
- duration

A
  • pain location: Unilateral (around eye/ along face)
  • pain quality: variable
  • pain intensity: severe - very severe
  • effect on activities: restlessness on agitation
  • other sx: cranial autonomic sx
  • duration: 15-180mins
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6
Q

classification of TTSH

A
  • Infrequent episodic TTH = <1 episode per mth
  • Frequent episodic TTH = 1-14 days per mth
  • Chronic TTH = ≥15 days per mth
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7
Q

Identify modifiable lifestyle factors that may contribute to headache frequency and severity

A

TTH triggers: physical/emotional stress, straining/head held in a position for too long, alcohol, caffeine, cold/flu/ sinus infection, dehydration, hunger

  • identify triggers using a headache diary
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8
Q

Goal of tx of TTH

A

pain relief, prevent progression to chronic TTH

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9
Q

pharmacological agents for ACUTE TTH

A

paracetamol (+/- caffeine), aspirin, NSAIDs (ibuprofen, naproxen, diclofenac, ketoprofen)

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10
Q

pharmacological agents for PROPHYLATIC TTH

A

(for chronic TTH) amitriptyline (TCA - 1st line), mirtazapine, venlafaxine

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11
Q

Non-pharmacological tx for TTH

A

CBT (cognitive behaviour therapy), relaxation, physical and occupational therapy, lifestyle modification (sleep hygiene)

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12
Q

patho and sx of premonitory/prodrome phase

A
  • Patho: activation of hypothalamus and neuropeptides (contribute to sx in prodrome phase)
  • sx: fatigue, cognitive difficulties, mood changes, food cravings, neck pain, yawning
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13
Q

patho and sx of aura phase

A
  • Patho: cortical spreading depression
  • sx: visual aura, sensory/speech disturbances, motor symptoms
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14
Q

patho and sx of headache/ictal phase

A
  • Patho: neuropeptides implicated in the sensitisation of central and peripheral trigeminovascular system → creating state of hypersensitivity and contributing to both pain and non-pain sx
  • sx: headache, N+/-V, photophobia, phonophobia (fear of loud sounds)
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15
Q

patho and sx of postdrome phase

A
  • patho: unclear
  • sx: tired/weary, difficulty concentrating, neck stiffness
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16
Q

patho and sx of interictal phase

A

patho: some regions of the brain remain abnormally active after headache cessation

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17
Q

dx of migraine with or w/o aura

A

see notes

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18
Q

criteria for episodic migraine

A

≥5 migraine attacks lasting 4-72hrs

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19
Q

criteria for chronic migraine

A

> 3 months with ≥15 MHD of which ≥8 MMD

20
Q

management of migraine

A

identify triggers, headache diary, adopt healthy lifestyle (regular eating habits, good sleep hygiene, regular exercise)

21
Q

acute tx goals

A
  • rapid and consistent freedom from pain and bothersome sx
  • restore ability to function
  • minimal need for repeat dosing or rescue medications
  • optimal self care and reduce use of resources (eg A&E)
  • minimal or no adverse events
  • cost effective tx
22
Q

migraine specific drugs (established efficacy)

A
  1. Triptans
  2. Ergotamine derivatives
  3. Gepants (new agent)
  4. Lasmiditan (new agent)
23
Q

non migraine specific drugs (established efficacy)

A
  • NSAIDs: aspirin, celecoxib, diclofenac, ibuprofen, naproxen
  • Combination analgesic: acetaminophen + aspirin + caffeine
24
Q

migraine specific drugs (probably efficacy)

A

ergotamine, other forms of dihydroergotamine

25
Q

non migraine specific drugs (probably efficacy)

A

NSAIDs (ketoprofen, ketorolac), IV magnesium, antiemetics (metoclopramide)

26
Q

Principles of acute tx

A
  • take acute tx as early as possible (more benefits)
  • stratified approach (more serious migraine use more potent meds like triptans) - avoid stepwise approach (start with mild agents)
  • antiemetics for pt with N/V sx (eg metoclopramide, domperidone)
  • choose appropriate formulations (NV take oral disintegrating tablets/parenteral)
27
Q

MOA of triptan

A

selective agonist of 5HT 1B/1D receptors → vasoconstriction, inhibition of vasoactive peptides, inhibit nociception neurotransmission

28
Q

SE of triptans

A

pressure on chest, nausea, distal paraesthesia (tingling/numbness), fatigue

29
Q

CI of triptans

A

stroke/TIA, ischemic CAD, coronary artery vasospasm, uncontrolled HTN, peripheral vascular disease, GI ischemia

30
Q

DDI of triptans

A

ergotamine/ergotamine containing within 24hrs, MAO-A inhibitors within 2 weeks

31
Q

MOA of Ergotamines & Dihydroergotamine (DHE) - Cafergot

A

Ergotamine (main drug)
- 5HT 1B/1D on intracranial vessels → vasoconstriction
- inhibit norepinephrine uptake and partial agonist of alpha-adrenoceptors → prolonged vasoconstriction (risk of ischemic AE)

Caffeine
- adenosine receptor antagonist: vasoconstrict cerebral vasculature
- enhance GI absorption of ergotamine by increasing solubility of ergotamines and decreasing gastric pH

32
Q

SE of cafergot

A

N/V, cramps, insomnia, transient lower limb muscle pain

33
Q

CI of cafergot

A

same as triptan (increase risk for vasospasm leading to cerebral ischemia and/or ischemia of extremities)

34
Q

DDI of cafergot

A

triptans within 24hrs, CYP3A4 inhibitors (eg protease inhibitors - darunavir/atazanavir/ritonavir/fosamprenavir and macrolides)

35
Q

CGRP mAbs and antagonist MOA

A

to block CGRP activity to treat migraine attacks

36
Q

3 ways to block CGRP activity to treat migraine attacks

A
  1. Gepants - CGRP receptor antagonist (bind to CGRP receptors)
  2. Anti-CGRP antibodies - prevent CGRP interacting with receptor
  3. Anti-CGRP receptor antibodies/ CGRP mAB (bind to CGRP receptors) - eg erenumab
37
Q

SE and off target effect of CGRP blockade

A

constipation, nausea, Raynaud (decrease blood flow to fingers), hypertension, joint pain/ osteoporosis, nasopharyngitis

38
Q

Criteria for initiation CGRP mAbs (erenumab)

A
  • not as first line
  • must be prescribed by a licensed clinician
  • pt must be at least 18yo
  • failed other oral preventive meds (topiramate, valproate sodium, beta blocker, TCA - amitriptyline, SNRI - venlafaxine, duloxetine)
39
Q

Criteria for continuing CGRP mAbs (erenumab)

A

reduction in mean MHDs of ≥50% compared to baseline (no CGRP mABs) - usually stopped in 1 year

40
Q

medication overuse headache definition

A

meet all 3 criteria
1. Headache on ≥15 days per month in pt with a preexisting headache disorder
2. Regular overuse of acute and/or symptomatic headache drugs >3 months
- ergotamine, opioids, triptans, combination of analgesics on ≥10 days/mth for >3 mths
- simple analgesics (paracetamol, acetylsalicylic acid/aspirin, NSAIDs) ≥15 days/mth >3 mths
3. Headache cannot be better accounted for by another ICHD-3 diagnosis

41
Q

when is prevention offered

A

based on degree of disability and MHD

42
Q

Preventive tx goals

A
  • reduce attack frequency, severity, duration and disability
  • improve responsiveness to and avoid use of acute tx
  • improve function and reduce disability
  • reduce reliance on ineffective acute tx
  • reduce overall cost
  • enable pt to manage their own disease (personal control)
  • improve QOL
  • reduce headache-related distress and psychological symptoms
43
Q

medication effective for migraine prevention

A

Candesartan (ARB)
Beta blockers (metoprolol, propanolol, timolol)
Frovatriptan (for menstrual migraine prophylaxis)
Topiramate
Valproate sodium
Erenumab (SC)

44
Q

medication probably effective for migraine prevention

A

Amitriptyline
Atenolol, Nadolol
Lisinopril
Memantine (rarely used)
Venlafaxine

45
Q

how to give an adequate trial of preventive tx

A
  • oral tx: min 8 weeks at target therapeutic dose, cumulative benefits may occur over 6-12mths
  • injectable CGRP mAbs:
    • at least 3 mths for monthly administration
    • at least 6 mths for quarterly tx

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