Headache

Question 1

primary headaches

Answer 1

migraine
cluster
tension
medication overuse headaches

Question 2

secondary headaches (mass, edema, fluid)

Answer 2

blood/bleeds/clots
brain tissue
cerebral spinal fluid
other causes

Question 3

red flags for headaches (SN3OOP8 DOG)

Answer 3

systemic symptoms
new onset
neoplasm history
neurologic deficits
older (≥50 or ≤ 5)
onset is acute
papilledema
positional
pattern change
progressive headache with an atypical presentation
pushing pain (valsalva maneuvers)
pregnancy or postpartum period
post traumatic onset of headache
pathology of immune system
drug over or misuse/coagulation
ocular
giant cell temporal arteritis

Question 4

triggers for migraine

Answer 4

red wine, chocolate, cheese, genetics, hormone meds = oral contraception pills, stress

Question 5

what causes aura in migraine

Answer 5

Cortico-spreading depression [CSD] theory

Question 6

contraindication for migraine

Answer 6

NEVER use OCP with migraine with aura

Question 7

which nerve is triggered causing the sensation of headache pain

Answer 7

CN 5 tirgeminal ganglion

Question 8

migraine: A POUND

Answer 8

Aura
Pulsatile
One day duration
Unilateral (except pediatric population-bilateral)
Nausea
Disabling

Question 9

Drugs for migraine

Answer 9

ergots and triptans

Question 10

Pharmacologic Tx for migraine (MOA)

Answer 10

1. decrease neuropeptide release
   cause direct vasoconstriction

Question 11

Triptans MOA

Answer 11

act on serotonin (5-HT) subclass 1B and 1D receptors found on blood vessels and neurons to inhibit the release of vasoactive neuropeptides, decreases trigeminal nerve CN 5 activation and causes vasoconstriction of the pain-sensitive blood vessels.

Question 12

triptans contraindications

Answer 12

do not use if any cardiac like symptoms
serotonergic medication- serotonin syndrome

Question 13

drug interaction of triptan with

Answer 13

warfarin: increased anticoagulation effects
antihypertensive
lithium
do not use with MAOIs

Question 14

ergot alkaloids MOA

Answer 14

Agonists to 5HT receptors but are non-specific. Ergots have similar actions to the triptans but also interacts centrally with dopamine and adrenergic receptors, accounting for some of its side effects.

Question 15

contraindication for ergots

Answer 15

contraindicated cardiac disorders, hypertension, sepsis, PVD, PUD, renal or liver disease,
contraindicated in pregnancy
Patients taking potent inhibitors of CYP3A4
Serotonergic medication: serotonin syndrome

Question 16

Ergotism [intoxicate with ergot alkaloids] symptoms

Answer 16

Spasms
Seizures
Psychiatric symptoms
Gastrointestinal symptoms
Gangrene in hands/feed [vasoconstriction of limbs]

Question 17

Tx of ergotism

Answer 17

Tx this with anticoagulants, vasodilators, low molecular weight dextran

Question 18

acute management for migraine 1st line

Answer 18

Nonpharmacologic [e.g., dark room, rest, quiet, cold/heat to head]

Hydration [IV bolus fluids]

Anti-emetics [antiemetic/prokinetic agents (e.g., metoclopramide and domperidone) 1st line], also Antinauseants (e.g., dimenhydrinate)

Analgesics: Acetaminophen, ASA** or NSAIDS* [decrease inflammation/pain at the first sign of attack]

Triptan* nasal spray or IM

Pediatrics: Intranasal 2% lidocaine [off label]

Question 19

acute management for migraine 2nd line

Answer 19

Ergots] nasal/IM/IV/SC
Dexamethasone glucocorticoids steroids
Occipital nerve blocks using anesthetics

Question 20

migraine prophylactic treatment

Answer 20

Beta blockers
Anti-seizure medications
Tricyclic anti-depressant agents
SNRI Venlafaxine
Calcium channel blockers (ECG baseline required and careful titration of dose with close monitoring to cardiac symptoms )
Serotonin Modulators
Occipital nerve blocks using anesthetics
Botox

Question 21

new medications for migraine

Answer 21

Anti-CGRP antibodies
atogepant
rimegepant

Question 22

natural health products for headache

Answer 22

Butterbur (Petasites hybridus extract) Must be pyrrolizidine alkaloids (PA) free – liver toxic of PA
Magnesium citrate
Riboflavin (Vit B2)
Coenzyme Q 10
Melatonin [as effective as amitriptyline]

Question 23

triggers for cluster headache

Answer 23

Sex: most common male at birth individuals
Genetic component/predisposition hypothalamic dysregulation
stress, smoking [tobacco/THC], wine [histamine/circadian rhythm disruption]

Question 24

pathophysiology of clustered headache

Answer 24

hypothalamus mediated by a change in neurohumoral and behavioural rhythms can lead to:
Dysregulation of melatonin production (sympathetic pathway)

Triggering/activating the connections with the trigeminal nucleus (trigeminovascular pathway) and the superior salivatory nucleus (parasympathetic pathway) activating the trigeminal autonomic reflex

Question 25

clinical manifestation of clustered headache (A CLUSTER)

Answer 25

A-autonomic parasympthetic (rhinitis, lacrimation, conjunctival hyperemia, miosis, ptosis) C- clustered (vary 5 min-3 hours per episode, multiple episodes) L- lads (male) U- unilateral orbital/supraorbital S- stabbing/burning/sharp T- teaching/assessment for suicidal ideation E- exacerbations/remissions R- restless/pacing/moving

Question 26

1st line treatment acute clustered headache

Answer 26

O2 triptans nasal spary/IM

Question 27

2nd line treatment for acute clustered headache

Answer 27

ergots nasal/IM/SC/IV lntranasal lidocaine

Question 28

1st line maintenance/prevention treatment for clustered headache

Answer 28

calcium channel blocker anticonvulsive (topiramate, valproate) bridging- prednisone to decrease the inflammation 50-80 mg with tapering over 2 weeks until the anticonvulsant are therapeutic

Question 29

tension headache triggers

Answer 29

muscle tension dehydration stress sleep deprivation

Question 30

pathophysiology of tension headache

Answer 30

chronic stress response (elevation of glutamate, NMDA receptors activation, nitric oxide and COX enzymes) precranial tension stimulate MSK vascular nociceptor neuron inflammation and pain in cerebral cortex

Question 31

clinical manifestations of tension headache

Answer 31

bilateral frontal & temporal non-puslating 30 min-1 week MUST have no nausea/vomiting, no phonophobia or photophobia, no aura MUST not be worse with exertion If they are more frequent/long = r/o OTC overuse of NSAIDs or Tylenol – rebound headaches.

Question 32

2 types of tension headache

Answer 32

episodic ( at least 10 episodes < 15 days per month for at least 3 months) chronic tension headache >15 days per month for a duration >3 months.

Question 33

treatment for acute tension headache

Answer 33

avoid triggers resting/dark/quiet hydration NSAIDS Tylenol Caffeine

Question 34

treatment for chronic tension headache

Answer 34

1st line: tricyclic antidepressants cognitive behavioural therapy massage therapy physiotherapy 2nd line: other antidepressants

Question 35

medication overuse headache

Answer 35

medication overuse defined as: ≥10 days/month for ergot derivatives, triptans, and combination analgesics; this also includes combinations of agents from different drug classes that are not individually overused ≥15 days for non-opioid analgesics: acetaminophen and NSAIDs

Question 36

Giant Cell Temporal Arteritis

Answer 36

inflammation/vasculitis of the temporal artery +/- associated with history of Polymyalgia Rheumatica [PMR], geriatric population [headache is over the temporal area, usually unilateral, very sensitive to superficial touch/pain – brushing hair, light touch to temporal area creates pain, facial/jaw claudication/vasculitis s/s weakness or fatigue of the mastication muscles, difficulty/painful chewing, visual changes [ophthalmic artery vasculitis] can lead to permanent blindness, ESR/CRP elevated start prednisone and ER referral for temporal artery biopsy

Question 37

triptan (best tolerated-2)

Answer 37

Almotriptan: [best tolerated than other triptans] Naratriptan [best tolerated than other triptans]

Question 38

Frovatriptan contraindications

Answer 38

oral contraceptives and propranolol may increase frovatriptan serum concentrations by 30–60%

Question 39

Eletriptan contraindications

Answer 39

contraindicated within 72 h of potent CYP3A4 inhibitors, e.g., clarithromycin, itraconazole, ketoconazole, nelfinavir, ritonavir

Question 40

rizatriptan contraindicated

Answer 40

do not use with MAOIs & caution with propranolol increases bioavailability

Question 41

Sumatriptan contraindication

Answer 41

not with MAOIs

Question 42

Zolmitriptan contraindication

Answer 42

do not use with MAOIs. Maximum dose of 5 mg/24h if also taking CYP1A2 inhibitor (e.g., fluvoxamine, cimetidine