HA/pain Flashcards
(15 cards)
Structures sensitive to pain
Cranial nerves V, VII, IX, and X; the circle of Willis and proximal continuations; meningeal arteries; large veins in the brain and dura; and structures external to the skull, such as the scalp and its blood supply, neck muscles, cutaneous nerves and skin, the mucosa of paranasal sinuses, teeth, cervical nerves and roots, and the external carotid arteries and branches
Structures that are INSENSATE for pain
brain parenchyma, arachnoid, ependyma, and dura
Pain pathway for migraine
Pain signals in the trigeminocervical complex undergo central processing, with second-order neurons receiving input and projecting rostrally to the contralateral thalamus (ventrobasal complex and medial nuclei) and then to the activating cortex (anterior cingulate, insular, and frontal), the periaqueductal gray matter (dorsal raphe nuclei), and the locus coeruleus
Hemiplegic migraines
FHM type 1 - AD missense mutn, chromosome 19p13. Subunit of VGCC that mediates glutamate release.
FHM2- mutn in a2 subunit of the Na/K pump on chromosome 1q23
FHM3 - missense mutation in SCN1A, which encodes an a1 subunit of a neuronal voltage-gated Na+ channel on chromosome 2q24.
Migraine with brainstem aura (basilar migraine)
This is a rare disorder that most often occurs in children and rarely occurs in patients older than 50 years.
Aura symptoms in this syndrome can include dysarthria, vertigo, tinnitus, hypacusis, diplopia, ataxia, or a decreased level of consciousness. A severe throbbing headache, typically with a bilateral occipital location, is present in 96% of cases. Nausea and vomiting typically occur, with light and noise sensitivity in up to 50% of cases.
Triptan not working for migraineur. Next step?
If a patient has an unsatisfactory or inconsistent response, unpleasant side effects, or an initial good response but later a poor response with one triptan, a DIFFERENT triptan may prove to be effective and tolerable.
About 25% of migraineurs will not respond to any of the triptans
Why not give triptan to a patient with CAD?
Triptans can stimulate 5-HT1B receptors on coronary arteries and result in constriction, which may become clinically significant in patients with coronary artery stenosis or vasospastic disease.
SSRI or SNRIs and triptans?
Risk of serotonin syndrome. FDA warning in 2006 but >29k patients receiving both annually…
ED treatment of acute migraine?
DHE, triptan, dopamine antagonists (metoclopramide, prochlorperazine, and chlorpromazine), and ketorolac, which have response rates of up to 70%.
Migraine pain persists or recurs within 24 hours of discharge from the emergency department regardless of treatment in over half of patients. Intravenous dexamethasone (10 to 24 mg) has a modest effect (the number needed to treat is nine) on preventing recurrence but does not appear to be effective for acute treatment of migraine pain.
Triptans first line for which HA types?
Migraine and CLUSTER
Triptans contraindicated in:
peripheral vascular disease, patients with hemiplegic or basilar migraine, and within 24 hours of dihydroergotamine (DHE).
Cluster HA single episodes treatment
Subcutaneous sumatriptan is the only FDA-approved treatment for individual attacks of cluster headache. In general, treatment of acute attacks of cluster headache should be nonoral because the attacks rarely last longer than 3 hours and oral therapy takes time to become effective. One hundred percent oxygen, administered with a nonrebreather mask, is also an effective treatment for acute cluster headache attacks.
Level A migraine drugs
Beta blockers propranolol, metoprolol, and timolol; the antiseizure medications divalproex sodium and topiramate; and Petasites hybridus (butterbur).
Level B migraine drugs
blocker atenolol, the tricyclic antidepressant amitriptyline, the antidepressant venlafaxine, and the antiinflammatory drugs fenoprofen, ibuprofen, ketoprofen, and naproxen, as well as magnesium, riboflavin, and the herb feverfew
TCAs for migraine
tricyclic antidepressants nortriptyline (taken at bedtime) and protriptyline (may be activating, taken in the morning) may be efficacious with less sedation than amitriptyline
