Headache

Question 1

what is a Medication-overuse HA or Rebound HA?

Answer 1

frequent or excessive use of acute migraine medications

HA returns as the med wears off

Question 2

How many days per month can you take acute migraine therapies in order to avoid med-overuse ha’s?

Answer 2

fewer than 10 days per month

Question 3

Presentation for migraine ha?

Answer 3

Recurring episodes of throbbing head pain

frequently unilateral
untx’d can last from 4-72 hrs

assoc w/ N/V and sensitivity to light, sound, and/or movement

Question 4

Pathogenesis for migraine ha’s?

Answer 4

complex dysfunctions in neuronal and broad sensory processing

Activation of trigeminal sensory nerves triggers the release of vasoactive neuropeptides –> promote vasodilation and dural plasma extravasation –> neurogenic inflammation

sensitization of central sensory neurons, producing a hyperalgesic state that responds to previously innocuous stimuli and maintains the headache

Question 5

OTC acute migraine therapies?

Answer 5

Analgesics- Acetaminophen, and aspirin/caffeine (excedrin migraine)

NSAID’s - Aspirin, Ibu, Naproxen, diclofenac

Question 6

What are some Rx meds to tx acute migraines?

Answer 6

TRIPTANS

serotonin agonists (triptans
sumatriptan (imitrex)
Zolmitriptan

Metoclopramide and prochlorperazine

Question 7

what are 2 older acute migraine therapies?

Answer 7

ergotamine tartrate and dihydroergotamine

Question 8

ergot MOA for?

Answer 8

5-HT1 receptor agonists

Constrict intracranial blood vessels and inhibit the development of neurogenic inflammation in the trigeminovascular system

Question 9

Triptan MOA?

Answer 9

Selective agonists of the 5-HT1B and 5-HT1D receptors

1. normalization of dilated intracranial arteries through enhanced vasoconstriction
2. inhibition of vasoactive peptide release from perivascular trigeminal neurons
3. inhibition of transmission through second-order neurons ascending to the thalamus

Question 10

appropriate 1st line therapy for pt’s w/mild to severe migraines?

Answer 10

TRIPTANS

Question 11

what is the max daily dosage for sumatriptan alone? and a combination product of sumatriptan and naproxen?

Answer 11

200mg

combo = 85/500mg

Question 12

what dose should you given of Rizatriptan if a pt is also on propranolol?

Answer 12

5mg (15mg/day max)

Question 13

what medication should you given along with ergotamine tartrate?

Answer 13

pretreatment of anti-emetic

Question 14

Patient education for nasal spray dihydroergotamine?

Answer 14

prime sprayer 4x before using

do not tilt head back or inhale through nose while spraying

discard open ampules after 8 hours

Question 15

what 2 meds are useful for acute relief of migraine in office or ER setting?

Answer 15

metoclopramide (reglan)

prochlorperazine (compazine)

Question 16

Triptan ADE’s

Answer 16

“triptan sensations”

tightness, pressure, heaviness, or pain in the chest, neck, or throat

Question 17

MOA for sumatriptan

Answer 17

5-HT1D agonist
• causes vasoconstriction
• modulates neurotransmitter release

Question 18

clinical applications for triptans?

Answer 18

migraine and cluster headache

Question 19

P-kinetics for sumatriptan?

Answer 19

oral, inhaled, parental

duration = 2-4hrs

Question 20

toxicities and interactions for triptans?

Answer 20

paresthesias, dizziness, CP and possible coronary vasospasm

Question 21

triptans syndrome can cause…

Answer 21

serotonin syndrome:
neuroleptic malignant syndrome
malignant hyperthermia

Question 22

therapy if pt gets serotonin syndrome??

Answer 22

Sedation (benzodiazepines), paralysis, intubation and ventilation

Question 23

presentation of serotonin syndrome?

Answer 23

Hyperthermia, hyperreflexia, tremor, clonus, HTN, hyperactive bowel sounds, D, mydriasis, agitation, coma

onset w/in hours

Question 24

presentation of neuroleptic malignant syndrome?

Answer 24

Hyperthermia, acute severe parkinsonism; hypertension, normal or reduced bowel sounds, onset over 1–3 days

Question 25

tx for neuroleptic malignant syndrome??

Answer 25

Diphenhydramine (parenteral) also, cooling if temp is very high, sedation w/ benzodiazepines

Question 26

presentation of malignant hyperthermia?

Answer 26

Hyperthermia, muscle rigidity, HTN, tachycardia; onset w/in minutes

Question 27

therapy for malignant hyperthermia?

Answer 27

dantrolene, cooling

Question 28

what can be used for preventative therapy for migraine headaches?

Answer 28

Butterbur FDA approved agents - Propranolol, Timolol, Divalproex sodium, topiramate

Question 29

when should consider preventative therapy for migraines?

Answer 29

in the setting of recurring migraines that produce significant disability despite acute therapy - more than 2x per week d/t risk of med overuse HA - sx. therapies ineffective or contraindicated

Question 30

when do you see max benefits of therapeutic trial of preventative therapy?

Answer 30

by 6 mo's of tx

Question 31

prophylactic tx for migraines?

Answer 31

at least 6-12 mo's after frequency and severity of ha's have diminished

Question 32

what are some prophylactic migraine therapies?

Answer 32

``` atenolol metoprolol nadolol *propranolol timolol ``` amitriptyline venlafaxine topiramate valproic acid *ibuprofen ketoprofen naproxen frovatriptan naratriptan zolmitriptan ``` magnesium MIG-99 riboflavin melatonin butterbar ```

Question 33

what drug is recommended for menstrual migraine prevention?

Answer 33

ibuprofen frovatriptan - taken in perimenstrual period

Question 34

Mechanism of pain in chronic tension-type ha?

Answer 34

myofascial factors and peripheral sensitization of nociceptors central mechanism -- heightned sensitivity of pain pathways in the CNS

Question 35

nonpharm tx options for tension-type HA

Answer 35

CBT (stress, relax training, biofeedback) heat/cold packs, U/S, massage, acupuncture, manipulations, trigger point injections

Question 36

pharm tx's for tension ha's?

Answer 36

simple analgesics (acetominophen) or NSAID's high dose NSAIDs and combo of ASA or acetaminophen w/butalbital

Question 37

Acute medications should be taken for episodic tension-type headache no more than

Answer 37

3 days (butalbital-containing) 9 days (combination analgesics) or 15 days (NSAIDs) per month to prevent the development of chronic tension-type headache

Question 38

preventative therapy for tension-type HA's?

Answer 38

Similar to those for migraine headache TCAs (tricyclic antidepressants)

Question 39

cluster ha features?

Answer 39

excruciating, unilateral head pain that occur in series lasting for wks or mo's (i.e., cluster periods) separated by remission periods usu lasting months or years Activation of the ipsilateral hypothalamic gray area

Question 40

hallmark of cluster ha's

Answer 40

circadian rhythm of painful attacks.

Question 41

cranial autonomic sx. assoc. w/cluster ha's

Answer 41

``` Conjunctival injection Lacrimation Nasal stuffiness Rhinorrhea Eyelid edema Facial sweating Miosis/ptosis ```

Question 42

Abortive therapy for cluster ha's?

Answer 42

oxygen 100% by nonbreather facial mask 12L/min for 15 to 30 mins triptan injections or sprays >> oral Ergotamine Derivatives--> Clinically IV dihydroergotamine , or ergotamine tartrate

Question 43

1st line prophylactic therapy for prevention of cluster ha's?

Answer 43

Verapamil -- given 2-3wks before benefit

Question 44

Prophylactic therapy options for cluster ha?

Answer 44

verapamil lithium corticosteroids (prednisone) also, intranasal lidocaine, hyperbaric oxygen, subQ octreotide