Headache Management

Question 1

Which medications are implicated in medication overuse headaches?

Answer 1

simple and combination analgesics and opiates

triptans (M w/ high frequency HA)

Question 2

What is the recommendation for frequency of use of acute migraine therapies?

Answer 2

limit to < 10d/mo

Question 3

Medication overuse headache: description

Answer 3

gradual onset of an atypical daily or near-daily headache with superimposed episodic migraine attacks

Question 4

Migraine: description

Answer 4

recurring episodes of throbbing head pain

• unilateral
• 4-72hrs
• w/ N/V, sensitivity to light/sound/movement

Question 5

What substance is implicated as an important mediator of migraine headaches?

Answer 5

5-HT (serotonin)

Question 6

Migraines: acute migraine therapies

Answer 6

analgesics (acetaminophen, excedrin migraine)

NSAIDs (ASA, IBU, naproxen sodium, diclofenac)

serotonin agonists (triptans: sumatriptan, zolmitriptan)

adjunctive therapies:

• metoclopramide (prokinetic, antiemetic)
• prochlorperazine (antiemetic)

older:

• ergotamine tartrate
• dihydroergotamine

Question 7

Ergot: MOA

Answer 7

nonselective 5 HT1 receptor agonist

venous and arterial constriction –> inhibits neurogenic inflammation

central inhibition of trigeminovascular pathway

Question 8

Triptan: MOA

Answer 8

selective agonist of 5 HT1B and 5 HT1D receptors

• vasoconstriction
• inhibition of vasoactive peptides
• inhibition of transmission

Question 9

What is first line therapy for patients with mild-severe migraines?

Answer 9

triptans

Question 10

What drug interacts with rizatriptan?

Answer 10

propanolol (reduce dose of rizatriptan)

Question 11

What is unique about frovatriptan, in relation to the other triptans?

Answer 11

most triptans can only be repeated once daily

frovatriptan can be taken 3x/d

Question 12

What should be considered when prescribing ergotamine tartrate?

Answer 12

consider pretreatment with an antiemetic

Question 13

Triptans: ADEs

Answer 13

triptan sensations:

• tightness
• pressure
• heaviness
• pain in chest/throat/neck

Question 14

Sumatriptan: clinical applications

Answer 14

migraine HA

cluster HA

Question 15

Which drug can precipitate serotonin syndrome?

Answer 15

sumatriptan

Question 16

Serotonin Syndrome: clinical presentation

Answer 16

hyperthermia
hyperreflexia
tremor
clonus
hypertension
hyperactive bowel sounds
diarrhea
mydriasis
agitation
coma

Question 17

Serotonin Syndrome: treatment

Answer 17

discontinue precipitating drugs
sedation (benzodiazepines)
paralysis
intubation
ventilation

Question 18

Serotonin Syndrome: look alikes

Answer 18

neuroleptic malignant syndrome (longer onset, acute sev parkinsonism)

malignant hyperthermia (quicker onset, muscle rigidity, tachycardia)

Question 19

What is the first line treatment for migraine prophylaxis?

Answer 19

propranolol

Question 20

Migraine: indications for preventative therapy

Answer 20

> 2 attacks/wk

sx therapies are ineffective/contraindicated/cause serious ADEs

Question 21

Migraine: preventative therapy: agents

Answer 21

propranolol
timolol
divalproex sodium (valproic acid)
topiramate
CGRP monoclonal antibodies (erenumab, galcanezumab)

Question 22

When do you see maximal benefits of preventative therapy in migraines?

Answer 22

6 months

Question 23

CGRP monoclonal antibodies:

• effects
• agents
• benefits
• ADEs

Answer 23

dec migraine frequency

erenumab, galcanezumab

reduce CNS ADEs
long half lives

ADEs:

• form neutralizing antibodies
• constipation
• muscle cramps/spasms

Question 24

Prophylactic Migraine Therapies

Answer 24

metoprolol
propranolol
timolol

topiramate
valproic acid/divalproex sodium

ibuprofen (menstrual migraines)
ketoprofen
naproxen sodium

Question 25

Frovatriptan: prophylactic special instructions

Answer 25

take in perimenstrual period to prevent menstrual migraines

Question 26

Supplemental Prophylactic Migraine Therapies

Answer 26

``` magnesium feverfew riboflavin melatonin butterbur ```

Question 27

you need to know

Answer 27

slide 42

Question 28

Tension Type Headache: treatment options

Answer 28

CBT (stress management, relaxation training, biofeedback) simple analgesics (+/- caffeine)(acetaminophen) NSAIDs (ASA, diclofenac, IBU, naproxen, ketoprofren, ketorolac)

Question 29

Effective options in tension type headaches

Answer 29

high dose NSAID | + (ASA or APAP) w/ butalbital or codeine

Question 30

Tension Type Headaches: limit on acute medications

Answer 30

butalbital containing: 3d combination analgesics: 9d NSAIDs: 15d (per month)

Question 31

There is no evidence to support the efficacy of _________ in the management of episodic tension type headaches.

Answer 31

muscle relaxants

Question 32

Tension Type Headaches: preventative therapy

Answer 32

``` TCAs SSRIs (not effective unless they have depression) SNRIs? topiramate, gabapentin? botulinum toxin? ```

Question 33

Cluster Headache: description

Answer 33

excruciating unilateral head pain lasts wks or months separated by remission periods lasting months or years accompanied by cranial autonomic sx hallmark: circadian rhythm of painful attacks

Question 34

Cluster Headache: abortive therapy

Answer 34

oxygen (100% by non rebreather facial mask) triptans (sprays or injections) ergotamine derivatives (IV dihydroergotamine or ergotamine tartrate)

Question 35

Cluster Headache: prophylactic therapy

Answer 35

verapamil lithium (monitor thyroid and renal function) corticosteroids

Question 36

What is the preferred 1st line treatment for prevention of cluster headaches?

Answer 36

verapamil

Question 37

Sumatriptan: ADEs

Answer 37

paresthesias dizziness chest pain possible coronary vasospasm