Headache

Question 1

Headaches

Answer 1

One of the most common medical complaints.
Can be triggered by a variety of stimuli
Mild, episodic versus severe, re-current debilitating headaches
Want to identify between no identifiable cause and an identifiable cause.

Question 2

Primary Headaches

Answer 2

Migraine with or without aura
Tension-type
Cluster headache
Chronic daily
Childhood Periodic Syndrome
Abdominal migraines

Question 3

Unilaterail in most, gradual in onset, patient prefers dark, duration 4 to 72 hours, nausuea, vomiting, photophopia, aura

Answer 3

migraine

Question 4

bilateral, pressure or tightness which waxes and wanes, patient may remain active or may need to rest, duration 30 minutes to 7 days

Answer 4

tension type

Question 5

always unilateral, usually begins around the eye or tempole, pain beings quickly and reaches a crescendo in minuts, 15 minutes to three hours, lacrimation and redness of the eye, stuffy nose, pallor, sweating

Answer 5

cluster

Question 6

Secondary headaches

Answer 6

Trauma
Cranial/cervical vascular disorder
Substance use (substance withdrawal)
Infection
Metabolic disturbance
Systemic problem
Neck/sinus/teeth/eye/nose
Anxiety
Neuralgias/other headaches

Question 7

Headache preceded by visual symptoms (flashes of light, a blank area in the field of vision, zigzag patterns).

Answer 7

Migraine with aura

Question 8

Migraine patho

Answer 8

Neurovascular disorder that involves the dilation and inflammation of intracranial blood vessels
Vasodilation leads to pain
Neurons of the trigeminal vascular system
Calcitonin gene–related peptide (CGRP)
Serotonin (5-hydroxytryptamine [5-HT])

Question 9

Goals of Acute Treatment of Migraine

Answer 9

Rapid and consistent freedom from pain and associated symptoms without recurrence
Restored ability to function
Minimal need for repeat dosing or rescue medications
Optimal self‐care and reduced subsequent use of resources
Minimal or no adverse events

Question 10

Goals of Migraine Prevention

Answer 10

Reduce attack frequency, severity, duration, and disability
Improve responsiveness to and avoid escalation in use of acute treatment
Improve function and reduce disability
Reduce reliance on poorly tolerated, ineffective, or unwanted acute treatments
Reduce overall cost associated with migraine treatment
Enable patients to manage their own disease to enhance a sense of personal control
Improve health‐related quality of life
Reduce headache‐related distress and psychological symptoms

Question 11

Contraindication to, failure, or overuse of acute treatments, with overuse defined as:

Answer 11

10 or more days per month for ergot derivatives, triptans, opioids, combination analgesics, and a combination of drugs from different classes that are not individually overused
15 or more days per month for nonopioid analgesics, acetaminophen, and nonsteroidal antiinflammatory drugs (NSAIDs [including aspirin])

Question 12

Medication Choice for Prophylaxis

Answer 12

Side-effect profile
Comorbid conditions
Medication interactions
Evidence-based efficacy
Patient preference

Question 13

Start the drug at a

Answer 13

low dose.
Increase the dose gradually until therapeutic benefit develops, the maximum dose of the drug is reached, or side effects become intolerable.

Question 14

Give the chosen medication an adequate

Answer 14

trial in terms of duration and dosage.

Clinical trials suggest efficacy is often first noted at four weeks and can continue to increase for three months.

Question 15

Avoid overuse of acute

Answer 15

headache therapies including analgesics, triptans, and ergots.

Question 16

Opioids and barbiturates should not

Answer 16

be used for the acute or preventive treatment of migraine.

Opioid use can contribute to development of chronic daily headache and can interfere with other preventive therapies.

Question 17

Address patient expectations and

Answer 17

consider patient preferences when deciding between drugs of relatively equivalent efficacy.
Discuss the rationale, dosing, and likely side effects for a particular treatment.
Discuss expected benefits of therapy and how long it will take to achieve them. Preventive migraine therapy requires a sustained commitment on the part of the patient and provider to achieve benefit.

Question 18

If the headaches are well controlled, slowly

Answer 18

taper the drug if possible.

Question 19

Many patients experience continued

Answer 19

relief with either a lower dose or cessation of the medication.

Question 20

Treatment failure – switch to

Answer 20

switch to a different class of medication

Question 21

Educate about

Answer 21

lifestyle measures

Question 22

Women of childbearing potential must be

Answer 22

warned of any potential risks.

Question 23

Select a pharmacological agent

Answer 23

that will treat both disorders

Question 24

Establish that the co-existing

Answer 24

condition is not a contraindication for the selected migraine therapy

Question 25

Establish that the treatments being used

Answer 25

Establish that the treatments being used

Question 26

Be aware of pharmacological agents

Answer 26

being used to treatment migraines and other conditions do not interact

Question 27

Aborting an ongoing attack

Answer 27

``` Nonspecific analgesics Aspirin-like drugs and opioid analgesics Opioid analgesics (e.g., butorphanol, meperidine) Migraine-specific drugs Serotonin1B/1D receptor agonists Ergot alkaloids ```

Question 28

Anti-emetics – important

Answer 28

adjuncts to migraine therapy Metoclopramide [Reglan] – preferred* Prochlorperazine

Question 29

Preventing attacks

Answer 29

from occurring Beta-blockers Tricyclic antidepressant Anti-epileptic drugs

Question 30

Tension-Type Headache

Answer 30

Most common type Moderate, non-throbbing, usually located in a “headband distribution” Can be associate with scalp tingling and a sense of tightness or pressure in the head and neck Precipitating factors: eye strain, aggravation, frustration, and daily stressors Can have depressive symptoms Episodic or chronic Chronic – 15 or more days per month for at least 6 months

Question 31

Tension-Type Headaches - acute attack

Answer 31

Acute attack of mild to moderate intensity – acetaminophen or NSAIDs or an analgesic-sedative combination

Question 32

Tension-Type Headaches - Prophylaxis

Answer 32

Prophylaxis – amitriptyline [Elavil] – tricyclic anti-depressant – at bedtime – can cause anti-cholinergic side effects, pose a risk for cardiotoxicity at high doses

Question 33

Tension-Type Headaches - Manage

Answer 33

Manage stress – cognitive coping skills, information on relaxation techniques

Question 34

tension acute treatment

Answer 34

aceteiminophen aspririn nsaid

Question 35

tension prophylaxis

Answer 35

amitriptyline other TCA venlafaxine XR

Question 36

Cluster Headaches

Answer 36

Occur in a series or “cluster” of attacks Each attack lasts 15 minutes to 2 hours Severe, throbbing, unilateral pain near the eye Lacrimation, conjunctival redness, nasal congestion, rhinorrhea, ptosis, and miosis on the same side of the headache One or two attacks every day for 2 to 3 months An attack-free interval of months to years separates clusters

Question 37

Cluster acute treatment

Answer 37

Oxygen – administered via a non-breathing facial mask with a flow rate of at least 12 L/min, patient is in a sitting, upright position for 15 minutes. Can increase to 12 L/Minutes. Sumatriptan ``` Intranasal lidocaine (small # of studies showed effectiveness) Ergots – effective if started early in the attack. ```

Question 38

Cluster prophylaxis

Answer 38

Verapamil – agents of choice* (episodic and chronic cluster headaches). Corticosteroids (bridging treatment, long-term use – risk of long-term side effects of prolonged systemic glucocorticoid use). Second-line therapy - lithium – evidence for use is limited – narrow therapeutic index. Topamax – add-on medication, add to verapamil. Greater occipital nerve blockade **Limit to the cluster cycle, discontinue when cycle is over.

Question 39

Menstrual Migraine

Answer 39

Migraine that routinely occurs within 2 days of the onset of menses through three days after the onset of menstrual bleeding Can also have migraines at other times of the month. Important trigger is the decline in estrogen levels that precedes menstruation

Question 40

Menstrual Migraine Treatment

Answer 40

Abortive treatment – triptans, NSAIDs, triptans + NSAID. Preventative treatment – lifestyle modifications, cyclic prophylaxis NSAIDs, triptans, magnesium Hormone-based interventions

Question 41

Medication Overuse Headaches

Answer 41

Chronic headache that develops in response to frequent use of headache medicines Resolved by withdrawing use of overused medicine Almost all medicines used for abortive headache therapy can cause medication overuse headache Risk of medication overuse headache can be decreased by limiting the use of abortive medicines and implementing nondrug measures Analgesics, triptans, ergotamine (not dihydroergotamine), caffeine