Headache

Question 1

What are the signs and symptoms necessary to meet the diagnostic criteria for migraine headache?

Answer 1

At least 2 of POUND –> pulsatile, one-day duration, unilateral, nausea/vomiting, disabling intensity
At least 1 of –> nausea/vomiting, photophobia or phonophobia

Question 2

Describe an aura as it relates to migraine headaches.

Answer 2

Positive symptoms (flashing lights, slots, lines) or negative symptoms (loss of vision, blind spot, numbness) that occur within 60 minutes of the headache’s onset

Question 3

Describes the general pathophysiology associated with all headaches.

Answer 3

Long thought to have a vasodilatory component. But recently discovered to also be caused by a range of pro-inflammatory factors.

Question 4

How is chronic tension headache disorder defined?

Answer 4

Headache at least 15 days per month

Question 5

What are 4 risk factors for tension headache disorder?

Answer 5

Coexisting migraine disorder, depression, anxiety, poor stress management

Question 6

Describe the typical clinical presentation of tension headache syndrome.

Answer 6

Dull, non-pulsatile tightness or pressure of mild to moderate severity that is usually bilateral

Question 7

T/F: Migraine is the most severe headache disorder.

Answer 7

False: cluster headache disorder is most severe

Question 8

Describe the clinical presentation of cluster headache disorder.

Answer 8

Unilateral, deep, excruciating non-pulsatile pain usually in or near the orbital region.

Question 9

Describe the typical duration interval of cluster headache disorder.

Answer 9

Attacks occur daily for weeks or months followed by long (sometimes years) pain-free intervals

Question 10

Describe the term secondary headache, list some common causes, and describe generally how they are treated.

Answer 10

Headache is a symptom of some other abnormality such as infection, stroke, tumor, hypertension, or hypoxia. The headache is resolved by treating the underlying cause.

Question 11

Describe the concept of medication overuse headache.

Answer 11

Headache for 15+ days per month with regular overuse of headache drugs for 3+ months

Question 12

What are the long term goals in management of a headache disorder?

Answer 12

Reduce frequency, severity, and disability
Prevent recurrence
Improve quality of life

Question 13

What are the short term goals in management of a headache disorder?

Answer 13

Treat migraines rapidly and effectively
Minimize use of rescue meds
Cause minimal or no AEs

Question 14

What medications are used to abort a headache once the symptoms have started?

Answer 14

APAP, NSAIDs, triptans, ergotamines, getants, ditan, opioids (rare)

Question 15

What medications are used as prophylaxis for headache disorder and in what comorbid conditions might they ne most beneficial?

Answer 15

Predictable pattern: NSAIDs or triptans
HTN or angina: beta-blockers
Depression or insomnia: TCAs or SNRIs
Seizure or bipolar disorder: anticonvulsant or beta blockers if anticonvulsants ineffective

Question 16

What medications are considered to be first line in prophylaxis for headache disorders?

Answer 16

Beta blockers

Question 17

Which beta blocker is specifically approved for prophylactic use in headache disorder?

Answer 17

Propranolol

Question 18

What is true about dosing of anticonvulsants in headache prophylaxis?

Answer 18

Used in lower doses than for seizure disorders

Question 19

Describe the use of calcitonin gene-related peptide (CGRP) antagonists.

Answer 19

Block CGRP receptor just like getants do. But these medications are used for prophylaxis where getants are used to abort headaches.

Question 20

Why are CGRP antagonists not commonly used in headache prophylaxis?

Answer 20

High cost

Question 21

All four CGRP antagonist medications end in what suffix?

Answer 21

-umab

Question 22

T/F: Some CGRP medications are available PO.

Answer 22

False: all are given by injection

Question 23

In what patients would you not want to use a beta blocker as prophylaxis?

Answer 23

Asthma, COPD, bradycardia, AV nodal blocks

Question 24

What are the simple analgesic treatment options in the treatment of a headache?

Answer 24

APAP and NSAIDs

Question 25

Describe the mechanism of action of APAP and NSAIDs.

Answer 25

APAP: Inhibits synthesis of prostaglandins primarily in the CNS NSAIDs: Inhibits synthesis of prostaglandins systemically by blocking COX-1 and COX-2

Question 26

What is the primary AE of APAP use?

Answer 26

Hepatotoxicity: monitor LFTs and avoid alcohol

Question 27

What are the primary AEs associated with NSAID use?

Answer 27

Dyspepsia, N/V, somnolence, dizziness

Question 28

What are the warnings/precautions to consider before prescribing NSAIDs?

Answer 28

Pregnancy, elderly, renal impairment, peptic ulcer disease, HTN, bleeding disorders

Question 29

When considering NSAIDs for headache disorders, what strategy is employed to avoid medication overuse disorder?

Answer 29

Limit NSAID use to fewer than 10 days per month

Question 30

What NSAIDs are commonly used in the treatment of headache disorder?

Answer 30

Aspirin, Ibuprofen, Naproxen, Diclofenac, Ketorolac

Question 31

What is unique about the use of ketorolac for headache use disorder?

Answer 31

Limit to use for no more than 5 consecutive days

Question 32

What are the three combination products used in the management of headache disorder

Answer 32

Excedrin: APAP, ASA, and caffeine Fiorinal: ASA, caffeine, and butalbital Fioricet: APAP, caffeine, and butalbital

Question 33

What is the mechanism of action of triptans?

Answer 33

Selective serotonin receptor agonists causing vasoconstriction and inhibition of vasoactive peptides

Question 34

Why are triptans not used as antidepressant medications?

Answer 34

There are many serotonin receptors. Triptans agonize two specific receptors that are not related to depression.

Question 35

What are the AEs associated with triptans?

Answer 35

Chest pain, somnolence, dizziness, flushing

Question 36

What drug interactions are associated with use of triptans?

Answer 36

Do not use within 24 hours of ergotamines Do not use within 2 weeks of MAOIs Caution with serotonergic agents (SSRIs, SNRIs, tramadol, linezolid, ondansetron)

Question 37

What are the warnings/precautions to consider before prescribing triptans?

Answer 37

``` Contraindicated in coronary artery disease Uncontrolled HTN Cerebrovascular disease Hemiplegic and basilar migraines Postmenopausal women and men > 40 ```

Question 38

When is the best time to take a triptan medication?

Answer 38

At the onset of pain

Question 39

T/F: All triptans have roughly the same efficacy in all patients.

Answer 39

False: patients may respond to some triptans but not others

Question 40

T/F: Adding an NSAID or APAP to a triptan has greater efficacy for headache disorders.

Answer 40

True: triptans work better than NSAIDs or APAP alone. But adding either to use of a triptan increases efficacy

Question 41

Which triptans may be used if the patient has severe nausea or vomiting associated with their headache and why?

Answer 41

Sumatriptan: can be given nasally or SubQ | Zolmitriptan or Rizatriptan: can be given as an orally dissolving tablet

Question 42

What is the mechanism of action of ergotamine medications?

Answer 42

Non-selective serotonin agonist that causes vasoconstriction and blocks inflammation

Question 43

What are the common AEs associated with ergotamine medications?

Answer 43

Abdominal pain, muscle pain, N/V (most common), weakness, fatigue, chest tightness

Question 44

What is the black box warning for ergotamine medications?

Answer 44

Severe peripheral ischemia --> cold/numb extremities, peripheral paresthesia, diminished peripheral pulses

Question 45

What drug interactions are associated with use of ergotamine medications?

Answer 45

Do not use within 24 hours of triptans

Question 46

What are the warnings/precautions to consider before prescribing ergotamine medications?

Answer 46

Hepatic/renal failure, sepsis, vascular disease, uncontrolled HTN, pregnant or nursing women

Question 47

What are two key considerations when prescribing an ergotamine?

Answer 47

High risk of rebound headache and pretreat with an antiemetic

Question 48

What is the mechanism of action of getants?

Answer 48

Calcitonin gene related peptide receptor antagonist

Question 49

What are the AEs associated with use of getants?

Answer 49

Drowsiness, nausea, xerostomia

Question 50

T/F: The getants have a lot of drug interactions.

Answer 50

True: inhibits CP-450 enzymes

Question 51

What are the warnings/precautions to consider before prescribing getants?

Answer 51

Hepatic or renal impairment

Question 52

Why are getants not commonly used in headache disorders?

Answer 52

Cost

Question 53

What is the mechanism of action of ditan?

Answer 53

Selective serotonin receptor agonist that treats pain without vasoconstriction

Question 54

What are the AEs associated with use of ditan?

Answer 54

Dizziness, N/V, chest discomfort, palpitations

Question 55

What drug interactions are associated with ditan use?

Answer 55

Other serotonergic agents

Question 56

What are the warnings/precautions to consider before prescribing ditan?

Answer 56

Hepatic or renal impairment and the elderly

Question 57

Why is ditan not commonly used in headache disorders?

Answer 57

Cannot drive or operate machinery for 8 hours after ingestion