Headache Flashcards
(31 cards)
classification of headaches
-Cluster
-Migraine
-Tension
-Secondary headache disorders
-Arise from other disorders
-hemorrhage
-infection
-neuropathy
-stroke
-tumor
pathogenesis of migraine headaches
-Neurovascular dysfunction
-1. imbalance of excitatory and inhibitory neurotransmitter activity in CNS - serotonin
-2. the imbalance may be triggered by:
-hormones
-stress
-lack of sleep
-food:
-alcohol (red wine)
-chocolate
-aspartame
-MSG
-coffee
-nitrites/nitrates
-cheese
-pickled meats
-nuts
-drugs:
-danazol (Danocrine) - anti-androtropic for endometriosis
-oral contraceptives
-H2 blockers
-sensorial
-bright or flickering lights
-odors
phases of migraine attack
-1st phase
-characterized by cerebral vasoconstriction and ischemia
-release of 5-HT from CNS neurons and circulating platelets contribute to this phase -> SSRI, antiplatelets can help
-2nd phase (longer than first phase)
-cerebral vasodilation and pain:
-trigeminal neurovascular system has central role
-neurons in trigeminal complex release peptides, including substance P and calcitonin gene-related peptide (CGRP).
-Peptides trigger vasodilation and inflammation of dural vessels -> stimulates nociceptive fibers of trigeminal nerve -> PAIN
migraine with and without aura
-AURA of migraine headaches
-occur in 15% of pts
-may be visual or sensory
-vasoconstriction and ischemia
-Migraine w/o aura – may be accompanied with premonitory symptoms such as photophobia and irritability as well N/V
general approach to tx of migraines
-Goals of long-term migraine treatment (prophylaxis)
-reduce frequency, severity and disability of migraine
-reduce reliance on poorly tolerated medications
-improve QOL
-avoid increased headache medication use
-educate pts to manage their disease
-select medication based on side-effect profile and pt’s underlying disease states. Medication should be used for at least 2-3 months to assess efficacy!!!!!!!!
-Goals of acute/abortive migraine tx
-treat migraine attacks rapidly and consistently without recurrence
-restore the patients ability to function
-minimize the use of backup and rescue medications
-optimize self-care for overall management
-be cost-effective in overall management
-cause minimal or no adverse effects
prophylactic drugs
-Anticonvulsants
-Antidepressants
-NSAIDS
-Beta blockers
-Calcium Channel blockers
-5-HT2 receptor blockers
-Miscellaneous agents
abortive (symptomatic drugs)
-Non-narcotic analgesics
-5-HT1D/1B receptor agonists (triptans)
-Dihydroergotamine and ergotamine
-Miscellaneous
prophylaxis: anticonvulsants
-Onset 2-3 wks
-ADRs – weight gain, sedation, tremor
-Ex:
-Divalproex Na (Depakote, Depakote ER) –
-Topiramate (Topamax)
prophylaxis: antidepressants
-Onset of efficacy is 3-4 weeks
-MOA for prevention of migraine not fully understood – may stabilize seroternergic neurotransmission by antagonizing or down regulating 5HT2 receptors
-Examples:
-Selective Serotonin Reuptake Inhibitors (SSRI) (Prozac and others)
-ADRS – anxiety, GI effects, sexual dysfunction, serotonin syndrome (hyperreflexia, fever, HTN)
-Tricyclic antidepressants (TCA)
-ADRs – drowsiness, tremor and anticholinergic side effects
-Monoamine oxidase inhibitors (MAO inhibitors)
-ADRs – hypertensive crisis with tyramine containing foods, sympathomimetic amine drugs
prophylaxis: NSAIDs
-MOA – inhibit thromboxane synthesis and platelet aggregation -> reduce release of serotonin
-can also be used for treatment of migraines
-Examples:
-Aspirin, naproxen, ibuprofen, diclofenac
-ADRs – GI effects, bleeding, Na and H20 retention, antagonize antihypertensive effects
prophylaxis: beta blockers
-must be without ISA activity (timolol, propranolol)
-MOA – may block beta 2 mediated vasodilation and reduce platelet aggregation (uncertain)
prophylaxis: CCB
-less effective that other prophylactic migraine drugs
-Verapamil primarily used –
prophylaxis: 5-HT2 receptor antagonists
-Methysergide (Sansert) (X) – ergot alkaloid
-MOA – blocks 5-HT2 receptor -> prevents vasoconstrictive phase of migraine
-ADRs - Associated with several potentially life-threatening ADRs like retroperitoneal, pleural and cardiac valve fibrosis. Rarely used, limit to 6 months of use, monitor serum creatinine and chest x ray
prophylaxis: miscellaneous agents
-Feverfew – herbal preparation -> Contraindicated in pregnancy
-Magnesium
-Riboflavin
prophylaxis: calcitonin gene-related peptide (CGRP) antagonist
-MOA – blocks or reverses CGRP-mediated dilation of intracranial vessels, thereby relieving the pain associated with acute migraine attacks
-galcanezumab-gnlm (Emgality) - SC Inj
-erenumab-aooe (Aimovig)- SC Inj
-Fremanezumab (Ajovy)- SC Inj
-ADRs - Most common side effects are injection site reactions and constipation (erenumab)
non-narcotic analgesics
-FIRST LINE FOR ABORTIVE TREATMENT OF MILD-MODERATE MIGRAINES
-NSAIDs
-Examples – aspirin, ibuprofen, naproxen, ketorolac
-Ketorolac IM (Toradol) - Very effective; Limit use < 5 days due to ADRs
-acetaminophen and aspirin combinations; also combined with caffeine in OTC products like Excederin
5-HT receptor agonists (triptans)
-(C)
-structural analogs of 5-HT
-MOA: activate serotonin 5-HT1D/1B receptors in trigeminal neurovascular system -> produces vasoconstriction -> reverses vasodilation and reduces throbbing. Also inhibits release of peptides that cause vasodilation, inflammation and pain. Also prevents activation of trigeminal nerves involved in migraine
-CI: CAD, PVD, uncontrolled HTN, and in pts using MAO inhibitors, pregnancy
-All have specific dosing recommendations w/ maximum doses!!!!!!!!!!!!!!!!
-ADRs – chest tightness, weakness, dizziness, paresthesias, nausea. More serious – coronary vasospasm
-Examples:
-Sumatriptan – several formulations available
-Imitrex - SC, PO, nasal
-Sumavel DosePro – needless injection
-Treximet - PO combination of sumatriptan and naproxen (combo therapy is more effective and lasts longer than triptan alone, but can use any triptan and any NSAID combo
-Newer triptans:
-more lipophilic with incr bioavailability
-!May be! more effective than Imitrex with less recurrence of headaches
-Examples of newer triptans:
-Almotriptan (Axert)
-Eletriptan (Relpax)
-Frovatriptan (Frova)- rebound headache
-Naratriptan (Amerge)
-Rizatriptan (Maxalt, Maxalt MLT)
-Zolmitriptan (Zomig, Zomig- ZMT)
dihydroergotamine (DHE) and ergotamine
-pregnancy category X
-used for migraine and cluster headaches
-Ergot alkaloids – derived form fungus that grows on rye
-MOA – Similar to “triptans” –
-CI: in CAD, PVD, uncontrolled HTN, and in pts using MAO inhibitors
-Must follow strict dosing guidelines and maximum dosing recommendations!!!!!!!!
-ADRs – N,V,D, muscle cramps. More serious - severe cerebral vasoconstriction, ischemia!!!, rebound vasodilation and headache
-Examples:
-Ergotamine
-Available PO, SC, PR
-Combined w/ caffeine (Cafergot)
-DHE:
-Available Intranasal (Migranal), INJ (DHE-45)
-INJ often combined w/ Metoclopramide to prevent N/V
miscellaneous agents: narcotic analgesics
-opioids effective to relieve pain. Less commonly used
-Pregnancy C/D
-Good for acute migraine when sedation will not put patient at risk
-Examples
-Butorphanol nasal spray (Stadol NS)
-Hydrocodone/APAP (Vicodin)
-Meperidine (Demerol) – !Avoid in elderly!
miscellaneous agents: barnituate hypnotics
-Pregnancy Category D
-Avoid due to overuse and misuse. Max daily dose = 6 doses per day
-Examples:
-butalbital/APAP/ caffeine (Fioricet)
-butalbital/ASA/caffeine (Fiorinal) – CIII
miscellaneous drugs: antiemetics
-Rationale for use: Treat N/V
-Enhance absorption of migraine medication (metoclopramide – Reglan)
-Dopamine antagonists (PTZ, metoclopramide) have demonstrated efficacy in treating acute migraine when given as monotherapy
miscellaneous: steroids
-good for status migrainosus
-MC is dexamethasone IM
miscellaneous: isometheptene
-works like sympathomimetic to treat migraine
-available as combo product w/ APAP and mild sedative dichlorphenazone (Midrin)
-good for mild-moderate headaches
miscellaneous: intranasal lidocaine
-Rapid acting
-Compounded product
