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Flashcards in Headache Deck (96)
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1

Types of overall headaches

Primary
-Migraine
-Tension-type
Related to a disease (secondary)

2

Epidemiology of migraine

Occurs in 17.1% of women and 5.6% of men
After age 12, females 2-3x more likely to experience
Prevalence highest between ages 18-44
Pts that have less income and education are more likely to experience migraines

3

Pathophysiology of migraine

Genetic factors play an important role in susceptibility
Partially a neurovascular process
-Caused by changes in trigeminal nerve, decrease in 5-HT, and cranial vasodilation

4

Migraine without aura

At least 5 attacks
HA lasts 4-72 hrs and has 2 of the following characteristics
-Unilateral location, pulsating quality, moderate or severe intensity, and aggravation by or avoidance of routine physical activity
During HA at least 1 must be present and not attributed to another disorder
-N/V, photophobia, phonophobia
Increased risk for ischemic stroke

5

Migraine with aura

At least 2 attacks
Fulfills criteria for typical, hemiplegic, or basilar-type aura
Not attributed to another disorder

6

Aura

Evolves over 5-20 mins, lasts <60 mins
Most often visual, but can also be sensory and motor
Must have at least one of the following
-One symptom that develops gradually over at least 5 mins or different symptoms that occur in succession or both

7

Visual positive sx of aura

Flickering lights, spots or lines

8

Visual negative sx of aura

Loss of vision

9

Premonitory sx- neurologic

Phonophobia
Photophobia
Hypersomnia
Difficulty concentrating

10

Premonitory sx- psychological

Anxiety
Depression
Irritability
Drowsiness
Fatigue

11

Premonitory sx- autonomic

Polyuria
Diarrhea
Constipation

12

Premonitory sx- constitutional

Stiff neck
Yawning
Thirst
Food cravings
Anorexia

13

Resolution phase of migraine

Once HA pain fades
Tiredness
Exhaustion
Irritability
Scalp tenderness
Mood changes

14

Assessment of migraines

HA hx
HA triggers
Physical exam
Neuroimaging- not routine, only in atypical presentation
Identify HA diagnostic alarms

15

HA triggers

Fatigue
Alcohol
Tobacco smoke
Weather changes
MSG
Caffeine

16

Acute tx goals- migraine

Treat migraine attacks rapidly and consistently without recurrence
Restore pt's ability to function
Minimize use of backup and rescue medications
Minimize use of backup and rescue medications
Optimize self-care for overall management
Be cost-effective in overall management
Cause minimal or no adverse effects

17

Medication overuse

One of the most common causes of daily chronic HA
Results in a pattern of increasing HA frequency
HA returns as medication wears off
Discontinuation of the offending agent leads to a decrease in HA frequency and severity
Limit use of acute therapies to 10 days/mo

18

Nonpharmacologic tx of migraine

Application of ice to head
Periods of rest or sleep
Avoidance of common and personal triggers
Behavioral therapy

19

Acute tx of migraines

Migraine-specific
-Ergots
-Triptans
Nonspecific
-Analgesics
--OTC combo product
-NSAIDS
-Antiemetics
-Corticosteroids

20

Regimen of acute tx for migraines

Should be given at the FIRST sign of sx
Migraine-specific medications used for more severe sx or sx unresponsive to NSAIDs/OTC analgesics

21

Ergot alkaloids

Consider for moderate to severe migraine attacks
Ergotamine tartrate and dihydroergotamine
MOA: nonselective 5-HT receptor agonists
-Constrict intracranial blood vessels
-Inhibit the development of neurogenic inflammation in the trigeminovascular system

22

Ergotamine tartrate (Cafergot)

Routes: oral, SL, rectal
Oral and rectal forms contain caffeine
Has both a daily and weekly maximum dose
Dosed at onset of sx and every 30-60 mins as needed

23

Dihydroergotamine (Migranal)

Routes: intranasal, IM, SQ, IV
Pts can be trained to give IM or SQ at home

24

Adverse effects of ergot alkaloids

Nausea, vomiting, diarrhea
Abdominal pain
Weakness
Fatigue
Paresthesias
Muscle pain
Chest tightness

25

Contraindications of ergot alkaloids

Renal or hepatic failure
Coronary, cerebral, or peripheral vascular disease
Uncontrolled htn
Sepsis
Nursing or pregnant women

26

Triptans

First line for mild to severe migraine
Typically want to treat at least 2-3 attacks before judging efficacy

27

MOA of triptans

5-HT (1b/1d) receptor agonists
Inhibit release of vasoactive peptide
Promote vasoconstriction
Block pain pathways in the brainstem

28

Contraindications of triptans

Hx of ischemic heart disease
Uncontrolled htn
Cerebrovascular disease
Hemiplegic and basilar migraine

29

Drug interactions of triptans

Do not give within 24 hrs of ergotamine derivatives
SSRIs/SNRIs potential to cause serotonin syndrome

30

Serotonin syndrome

Muscle rigidity, hypothermia, sweating