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PHAR 557 > Headache > Flashcards

Headache Flashcards

1
Q

Headache disorder classifications:

A
  1. primary h/a disorder

2. secondary h/a disorder

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2
Q

Name 3 types of primary headache disorder

A

migraine, tension-type h/a’s, and cluster h/a’s

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3
Q

Which gender suffers from migraines more?

A

Females

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4
Q

Why are migraines a huge economic burden?

A

Bc they often affect ppl during the most productive yrs of life

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5
Q

What is the most accepted etiology of migraines?

A

complex dysfns in neuronal and sensory processing

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6
Q

Where does migraine pain START?

A

trigeminovascular system activity

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7
Q

Pathophysiology of migraines:

A

Trigeminal sensory nerves activate > vasoactive neuropeptides released > vasodilation of dural blood vessels > inflammation > pain impulses travel along trigeminovascular fibers > pain impulses arrive at trigeminal nucleus and higher cortical pain centres > continued pain input from afferent sensory fibers > hyperalgesic state > previously innocuous stimuli now cause h/a perpetuation

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8
Q

What’re the 4 phases assoc w/ the clinical presentation of migraine h/a’s?

A

premonitory sx’s, aura, migraine attack, postdrome

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9
Q

Distinguishing feature of premonitory phase of migraine h/a’s.

A

There’s no pain involved

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10
Q

Premonitory phase of migraine h/a synonyms:

A

prodrome, warning

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11
Q

Common sx’s of premonitory phase of migraine h/a’s?

A
  1. neurological (allodynia [pain from normally non-painful stimuli], phono/photophobia)
  2. psychological (anxiety, dep, euphoria)
  3. autonomic (polyuria, diarrhea)
  4. constitutional (neck stiffness, yawning, thirst)
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12
Q

How long before migraine attack do premonitory sx’s usually appear?

A

hours to days before h/a

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13
Q

how long before a migraine h/a do auras usually appear?

A

5-20mins

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14
Q

Sx’s of aura?

A

Often visual (flashes, colours appear brighter, blind spot, sig blindness)

sensory and motor sx’s are also possible

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15
Q

How long do migraine attacks usually last

A

4-72h

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16
Q

T or F: All migraine sufferers experience auras before their migraine attacks

A

F

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17
Q

What is the most important element in establishing a clinical dx of migraine?

A

a h/a hx

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18
Q

Shorthand way of dx’ing migraine:

A

POUND

  1. pulsatile
  2. one to three day duration
  3. unilateral
  4. N/V
  5. Disabling intensity of h/a
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19
Q

Red flag sx’s assoc w/ h/a (refer immediately):

A
  1. suspected stroke/TIA
  2. head trauma
  3. h/a gets worse
  4. memory loss
  5. suspected glaucoma (eye pain = major sx)
  6. sudden onset (seconds to 5 mins)
  7. worst h/a ever
  8. fever, neck stiffness, impaired level of consciousness accompany h/a
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20
Q

What’s the main goal when tx’ing migraines?

A

Getting the pt to return to normal activities within 2h’s of tx

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21
Q

Primary non-pharm approach to migraine tx:

A

Identify and avoid triggers

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22
Q

What approach to tx should be used when tx’ing acute migraines?

A

stratified approach

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23
Q

What’s the stratified approach to tx’ing migraines?

A

severity of migraine informs tx choice (i.e. drug is chosen based on how bad the migraine is/how disabled the pt is by it)

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24
Q

What are the advantages of using a stratified approach to acute migraine tx?

A

Works faster + lower numbers of initial tx failures

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25
Q

T or F: Opioids are first line for acute migraines.

A

F > weak evidence

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26
Q

What can be added if pt is experiencing N during an acute episode of migraine?

A

metoclopramide

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27
Q

Which drug classes have been shown to be the best for tx’ing acute migraines?

A

triptans, NSAIDs (inc. ASA), and acetaminophen

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28
Q

MOA of triptans

A

5HT-1B/1D agonists

vasoconstriction of meningeal blood vessels, inhibit vasoactive neuropeptide release by trigeminal nerves, and inhibit pain signal transmission

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29
Q

CI of triptans

A

Cerebrovascular/cardiac dz, HTN (since triptans constrict cerebral blood vessels), hemiplegic migraine

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30
Q

If s.o is experiencing N/V during an acute migraine, what route(s) of triptan should be used for triptan admin?

A

Nasal or SC

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31
Q

T or F: Serotonin syndrome is possible with triptans.

A

T (it’s a 5HT agonist)

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32
Q

When should triptans be taken?

A

At earliest onset of migraine pain

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33
Q

T or F: Taking a triptan before onset of pain (i.e. during premonitory or aura phases) is more effective than taking it during the acute migraine phase.

A

F

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34
Q

Which triptans are postulated to be the most effective in relieving acute migraine pain?

A

Eletriptan and rizatriptan

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35
Q

Why would rizatriptan be preferred over eletriptan in SK?

A

Rizatriptan (eletriptan is non-forumulary in SK)

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36
Q

Sumatriptan + naproxen combo tx has been shown to be better for acute migraine tx than either monotx.

A

T

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37
Q

What should triptans not be used with? Why?

A

dihydroergotamine (DHE) > additive vasoconstriction

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38
Q

Ergots - MOA

A

5-HT-1D agonists > vasoconstriction of intracranial blood vessels and inhibition of proinflam neuropeptide release

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39
Q

T or F: Ergots and triptans have similar MOAs

A

T

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40
Q

T or F: Ergots are first line for acute migraines

A

F (NSAIDs/triptans/acetaminophen are)

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41
Q

Regular intake of ergotamine or DHE can cause what?

A

Ergotism and gangrenous sx’s

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42
Q

When would dihydroergotamine be used?

A

moderate-sev migraine attacks or refractory h/a’s

43
Q

Sumatriptan nasal spray vs. dihydroergotamine nasal spray: which is better for acute migraine tx?

A

sumatriptan nasal spray

44
Q

Opioids: Place in tx for acute migraine?

A

None - they do not change the pathophys of acute migraines

45
Q

MOA of antiemetics used for migraine-induced N/V?

A

D2 antagonists (reduces N), increases absorption of other meds, decreases gastric stasis

46
Q

Which oral antiemetic is used for migraine-induced N/V?

A

metoclopramide

47
Q

What can be used for acute migraines if triptans are CI’ed or not tolerated?

A

Metoclopramide + analgesic (NSAID)

48
Q

T or F: Tx’s for migraines can end up causing migraines if used too much.

A

T (medication-overuse headache)

49
Q

What are the diagnostic criteria for med-overuse h/a?

A
  1. h/a for ≥ 15 d/month in a pt w/ pre-existing h/a disorder

2. regular overuse for > 3 months of ≥ 1 drug that is used for h/a tx

50
Q

T or F: In med-overuse h/a’s, analgesic overuse can lead to migraine h/a’s, whereas triptan overuse can lead to tension-type headaches

A

F

Other way around (analgesic > tension-type; triptan > migraines)

51
Q

Which med classes are consistently linked to med-overuse h/a’s?

A

Opioids and barbiturates (hence another reason to avoid them to tx h/a’s)

52
Q

What med class is MOH-protective? What is the caveat to its protective property?

A

NSAIDs > protective if used for < 10d/month

53
Q

When should a migraine sufferer be admitted into hospital?

A
  1. status migrainosus - severely painful and lasting > 72h
  2. severe N/V that leads to dehydration
  3. detox from overuse of combo of analgesics, ergots, or opioids
54
Q

What should be used for status migrainosus?

A

1L of NS bolus (PRN); if not effective…

sumatriptan (if triptans/DHE not tried yet) and/or ketorolac; if not effective…

metoclopramide; if not effective…

DHE + metoclopramide

55
Q

When should DHE be taken if triptan taken previously?

A

12h after triptan dose

56
Q

How long will migraine prevention tx take?

A

Several weeks for full effect

57
Q

When is migraine prevention indicated?

A

When there’s sig disability or reduced QoL despite appropriate acute tx

58
Q

When should preventative tx of migraines be tapered/stopped?

A

After 6-12 mths of benefit

59
Q

When are preventative tx’s of migraines considered to be successful/beneficial?

A

when freq of attacks are reduced by ≥ 50%

OR

when number of days w/ headache/month is reduced by ≥ 50%

60
Q

First line for migraine prophylaxis:

A

Beta blockers (propranolol, metoprolol, timolol) or TCAs (amitriptyline, nortriptyline)

61
Q

1st line for severe migraine prophylaxis:

A

Anticonvulsants

62
Q

Which anticonvulsants are recommended for severe migraine prophylaxis?

A

Valproate, topiramate

63
Q

Which anticonvulsant is NOT recommended for severe migraine prophylaxis?

A

Gabapentin

64
Q

CCB effectiveness in migraine prevention?

A

Limited data, so usually avoid

65
Q

Botulinum toxin place in tx for migraine prophylaxis?

A

For chronic or episodic migraines

66
Q

When must migraines occur in a woman’s cycle for them to be considered “menstrual migraines”?

A

2d before to 3d after menstrual bleeding

67
Q

Prevention tx for menstrual migraines:

A
  1. NSAIDs

2. Triptans

68
Q

What has chasteberry been used for?

A

Menstrual migraine

69
Q

T or F: NHPs are usually used before Rx products wrt migraine tx

A

F

70
Q

Pediatric tx options for migraines?

A

Similar to adults:

  1. NSAIDs
  2. Triptans
  3. Sumatriptan + naptroxen combo
71
Q

Preventative tx for migraine in pediatrics is better supported compared to adults.

A

F

72
Q

1st line migraine tx in preggos?

A

Non-pharm stuff

73
Q

If meds req’d, what’s 1st line in preggos for migraine tx?

A

Acetaminophen

74
Q

If meds req’d, what’s 2nd line in preggos for migraine tx?

A

ibuprofen, naproxen

75
Q

What should we know about NSAID use in preggos for migraines?

A

Avoid in 3rd trimester

76
Q

If meds req’d, what should we use if migraine is assoc w/ severe N in preggos?

A

Metoclopramide or prochlorperazine

77
Q

If meds req’d, what’s used for prophylaxis in preggos?

A

propranolol, magnesium

78
Q

1st line for migraine tx in lactating mothers?

A

acetaminophen

79
Q

2nd line for migraine tx in lactating mothers?

A

ibuprofen (preferred NSAID)

80
Q

What two meds are avoided when tx’ing migraines in preggos?

A

Ergot derivatives and triptans

81
Q

What’s first line in preggos for migraine prophylaxis?

A

propranolol, Mg

82
Q

T or F: Valproic acid/divalproex is CI in lactating mothers for migraine prophylaxis.

A

F (they’re compatible)

83
Q

Sx’s of tension-type h/a’s

A

pain is bilateral, nonpulsatile, mild photophobia/phonophobia may occur, pericranial tenderness

84
Q

1st line for tension h/a tx?

A

ibuprofen, naproxen, acetaminophen

85
Q

What ISN’T helpful for tension h/a’s?

A

codeine products, muscle relaxants

86
Q

Mainstay for tension h/a prophylaxis?

A

lifestyle measures

87
Q

T or F: Caffeine combination products w/ simple analgesics are more effective for tension h/a’s than simple analgesic monotx.

A

T

88
Q

What is a post-traumatic h/a?

A

a h/a that develops within 7 days of a. head injury, b. regaining consciousness post-injury c. d/c’ing med that prevented sensation of h/a following head injury

89
Q

How should post-traumatic h/a’s be tx’ed?

A

Based on standard acute tx protocols (e.g. if it presents like a migraine, tx with migraine meds, etc.)

90
Q

This type of h/a is aggravated by physical activity

A

Migraines

91
Q

This type of h/a lasts 30 mins to 7d

A

Tension

92
Q

Pressing and tightening pain is characteristic of which type of h/a?

A

Tension

93
Q

Describe the pain experienced during a migraine

A

Throbbing, pulsating

94
Q

N/V may accompany this type of h/a

A

Migraine

95
Q

T or F: N/V may be present in both migraines and tension h/a’s.

A

F (not tension h/a’s)

96
Q

How are simple analgesics (acetaminiophen, NSAIDs) used in migraines?

A

first line for mild-mod migraine attacks

97
Q

How are simple analgesics used in tension h/a’s?

A

first line +/- caffeine

98
Q

How are triptans used in migraines?

A

1st line for mod-severe attacks

99
Q

How are triptans used in tension h/a’s?

A

usually no role

100
Q

How is DHE used in migraines?

A

mod-severe pain if triptans fail/not an option

101
Q

How is DHE used in tension h/a’s?

A

no role

102
Q

How’re antiemetics used in migraines?

A

adjunctive role w/ simple analgesics or migraine specific tx for aborting migraine

103
Q

How’re antiemetics used in tension h/a’s?

A

limited role

PHAR 557 (36 decks)

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