Headache Meds

Question 1

3 primary headaches (see the chart on slide 5)

Answer 1

Migraine headache, tension headache, cluster headache (there’s an “other” category too)

Question 2

Secondary headaches are attributed to:

Answer 2

Head/neck trauma, cranial/cervical vascular disorders, infection, psych disorders

Question 3

Acetaminophen

Answer 3

Acts centrally

Possible 1st choice in acute migraine for those with mild/moderate attacks or CIs to NSAIDs/ASA

Question 4

Butalbital in Fioricet and Fiorinal

Answer 4

Limited efficacy, abuse potential, withdrawal, med overuse

Prob won’t use this

Question 5

Midrin C-IV (ASA, isometheptene, dichloralphenzone)

Answer 5

Alternative for mild/moderate migraine (Iso = vasoconstriction, dichlor = analgesic/sedative)

Question 6

Excedrin Migraine OTC

Answer 6

First-line treatment choice for mild/moderate migraines or severe if worked in the past (has caffeine so watch for caffeine withdrawal headaches if taking daily0

Question 7

NSAIDs

Answer 7

Migraines: prevents trigeminovascular inflammation

DOC for mild/moderate attacks or severe if worked before (use ASA, ibuprofen, or naproxen)

Use <15 days per month to prevent drug overdose headache

Watch for GI SEs

Question 8

Ergotamine

Answer 8

Migraines, administer w/caffeine, lots of bad AEs, potent precipitator of med overuse headaches

CI in PVD, CAD, HTN

Pregnancy risk X, stimulates uterus

Do not use w/i 24hrs of a triptan (less effective than triptans)

Start early, pretreat w/anti-emetic for N/V, lots of AEs

Rectal better than oral

Question 9

Dihydroergotamine

Answer 9

NOT ACCEPTABLE AS MONOTHERAPY

Nasal spray for migraines, but less effective than subQ sumatriptan (IM/subQ is similarly effective)

IV = TREATMENT OF STATUS MIGRAINOSUS (RASKIN PROTOCOL)

Less vasoconstriction & N/V than ergotamine, risk of ergotism, CI in CV conditions, potent precipitator of med overuse headache

Pregnancy risk X

Question 10

List of Triptans

Answer 10

Almotriptan
Eletriptan
Frovatriptan
Naratriptan
Rizatriptan
Sumatriptan
Zolmitriptan

Question 11

1st line therapy for patients with MODERATE TO SEVERE MIGRAINES, and used for rescue therapy when nonspecific meds are ineffective

Answer 11

Triptans

Question 12

AEs of Triptans

Answer 12

Chest symptoms, paresthesia, fatigue, dizziness, flushing, pain at injection site

Question 13

Highest likelihood of consistent success was found w/ which 3 Triptans?

Answer 13

Rizatriptan, eletriptan, almotriptan

Question 14

Most likely of one all triptans to produce short-term and sustained benefit

Answer 14

Eletriptan

Question 15

Two triptans that are slower in onset and have lower efficacy?

Answer 15

Naratriptan and frovatriptan

Question 16

2 Triptans with the most number of dosing formulations available?

Answer 16

Sumatriptan and zolmitriptan

Question 17

How many days per month should triptan use be limited to?

Answer 17

Less than or equal to 9 days per month

Question 18

CIs for use of triptans?

Answer 18

Patients w/ a history of IHD

Question 19

Patients w/CAD need to have their first triptan dose where and how?

Answer 19

In the clinic w/vitals and maybe an ECG

Same in patients at high risk for it (i.e. HTN, hypercholesterolemia, obese, DM, smokers0

Question 20

DIs include?

Answer 20

Don’t use w/i 24hrs of ergotamines

SEROTONIN SYNDROME (they notice b/c their hands start shaking)

Question 21

What is the clinical triad of abnormalities experienced in serotonin syndrome?

Answer 21

Cognitive effects, neuromuscular dysfunction, autonomic dysfunction

Question 22

This triptan contains a sulfa group…

Answer 22

Almotriptan

Question 23

Antiemetic of choice in migraines?

Answer 23

Metoclopramide

Question 24

What is the best way to prevent medication overuse headaches?

Answer 24

Acutely, discontinue the offending agent, but prevention is best - LIMIT USE OF MIGRAINE THERAPIES TO 2 DAYS/WEEK

Question 25

Class of migraine meds absolutely contraindicated in pregnancy?

Answer 25

Ergots

Question 26

What is the most common type of primary headache?

Answer 26

Tension headache

Question 27

Pain thought to originate from myocardial factors and peripheral sensitization of nociceptors describes which type of HA?

Answer 27

Tension HA

Question 28

Less than 10 HA episodes occurring on less than 1 day per month on average is?

Answer 28

Episodic tension-type HA

Question 29

HA occurring greater than or equal to 15 days per month on average for greater than 3 months?

Answer 29

Chronic tension-type HA

Question 30

What are the DOCs for tension HAs?

Answer 30

Analgesics (ASA/NSAIDs) Limit use to no more than 9 days per month. Muscle relaxants can also be used

Question 31

What is the DOC for prophylactic treatment of tension HAs?

Answer 31

Amitriptyline (TCA) - AEs = anticholinergic SEs, weight gain, oHTN, arrhythmia

Question 32

In which type of HA are hypothalamic dysfunction and/or altered circadian rhythms suspected and/or genetic roles suspected?

Answer 32

Cluster HAs

Question 33

The most severe of the primary HAs are?

Answer 33

Cluster HAs

Question 34

HAs that tend to occur nightly, over a short period of time, followed by long periods of complete remission and occur predominantly in males in their 30s?

Answer 34

Cluster HAs

Question 35

These HA attacks last 2 weeks to 3 months, often in spring and fall, occur suddenly with excruciating unilateral orbital/supraorbital/temporal pain where PT may sit and rock, or pace while clutching their head.

Answer 35

Cluster HAs

Question 36

First line treatment of cluster HAs?

Answer 36

Oxygen, NRB, 7-10L/min

Question 37

First line pharm treatment for acute cluster HA?

Answer 37

Sumatriptan is the best, but Zolmitriptan may be better tolerated in some PTs

Question 38

What is the DOC in maintenance prophylaxis for cluster HAs?

Answer 38

Verapamil - reduce frequency and severity of cluster attacks (2nd line is lithium)

Question 39

Transitional prophylaxis meds of choice?

Answer 39

Prednisone | Dihydroergotamine has been used, but lacks evidence