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Flashcards in Headaches Deck (44):
1

Tension HA characteristics and?

Pressing/tightening (non-pulstatile), mild-mod intensity, bilateral, no aggravation by physical activity. Both: Nausea/Vomiting, +/- photophobia, phonophobia

2

Divalproex sodium contraindications

AEs, monitoring? What form is best 

  • Severe hepatic insufficiency, preg, pancreatitis
  • GI upset, somnolence, weight gain, tremor, alopecia, hepatotoxic, thrombocytopenia, pancreatitis
  • CBT, LFTs
  • ER is better

3

Antiemetics are usually used as?

Adjunctive treatment with acute attacks

4

Rebound HAs Whats mess commonly cause?

Occur when analgesic medications are used excessively to treat HA - HAs increase in pain and intensity/ pain and occur daily - Discontinuation often leads to gradual reduction in frequency. - Analgesics, mixed analgesics containing but albeit also, caffeine, or isometheptene, erogotamine, opiates, triptans, Opiods and butalbital - Acute therapy no more than twice/week to protect against rebound

5

Other analgesics

Pts that are intolerant or contraindicated or for rescue therapy - Short acting barbiturates combined with ASA or APAP - Isometheptene compounds (Midrin) - Opiate analgesics (oral combos, parenteral, and butorphenol NS) - Tramadol - These commonly cause rebound headaches

6

Secondary Causes of infection

Infection, head injury, hemorrhage, Brain tumor, Drug induced (vasodilator, estrogen)

7

More common for women or men?

Women

8

What triptan should generally be avoided because of drug interactions?

  • Eletriptan 

9

Summary of acute treatment guidelines

Nate SAID hid Pappy Trips ERlot when he takes Narcotics and Pukes 

Typically you usually start with an NSAID, the APAP + ASA + Caffeine Then DHE nasal spray, Triptan Initial treatment with triptans in patient with mod-severe migraines

10

Preventative treatment

Titration, might need to try more than one.

11

What triptans should be used with N/V?

  • Sumatriptan
  • Zolmitriptan 

12

Lower level evidence migraine prevention

SSRis, Gaba, Carb

13

Antiepileptics for migraine prevention?

 

 

  • Divalproex sodium
  • Topiramate
  • Gabapentin and Carbamazepine are less effective 

 

 

14

Stratified and Step care approach

Strat: Rate HA prior to treatment - Use treatment based on severity, Better outcomes, Examples 1/5 main NSAID, 4/5 triptan Step care- always start with mild therapy and step up if HA persists Example: 1 use NSAID, 2nd analgesic combo, 3rd use triptan

15

What ergot alkaloid derivative is the only first line for treatment?

DHE NS after an NSAID is tried

16

Migraine prophylaxis

- Beta blockers, antiepileptics, antidepressants, others

17

Acute Migraine Treatment DIs

Ergot and Derivatives?

  • Triptans within 24 hours 
  • MAOIs (CI within 2 weeks) 
  • Potent 3A4 inhibitor (CI) 
  • SSRIs

18

Physicals and Labs for headache?

Physical exam, CT, MRI, LP, CBC, TSH

19

POUND

Pulsating, One day, Uni, N/V, Disabling

20

Antiemetics Commonly used agents

- Combat N/V and vomiting that accompany the HA - IV metoclopramide has been known to treat pain - metoclopramide, prochlorperazine, promethazine - 15 minutes prior to oral acute treatment med - May be given parenterally or via suppository if needed - AEs CNS and EPS

21

Ergot Alkaloid derivatives are generally?

Not recommended

22

Acute treatment goals

- Dont want recurrence, restore function

23

Triptan DIS

MAOIs and ergot Dont use within 24 hours SSRIs and risk of serotonin syndrome -

24

Non pharm treatment for HA

- Relaxation training, Biofeedback, CBT, Avoid migraine triggers (bright lights, loud noise, allergens, weather changes, chocolate/cheese/ caffeine, Alcohol, MSG, Aspartame), Hormonal changes, sleep deprivation

25

Types of Headaches 4

Migraine, Tension, Cluster, Rebound headache (medication overuse)

26

Complementary/alternative products for migraine prevention?

  • Petasites (Butterbur extract)
  • Magnesium 
  • Riboflavin
  • Feverfew

27

Types of Migraines 4 types

Migraine with aura, migraine without, Menstrual migraine, Hemiplegic migraine

28

History of Headaches

- Age of onset, location, quality, severity, frequency, duration, triggers

29

What triptans are a good choice for quick relief?

  • Almotriptan
  • Rizatriptan
  • Sumatriptan

 

30

Beta blockers prophylactic?

What are the preferred ones?

Contraindications?

1st line prevention for migraines

  • Indicated for HTN, post MI, angina, HF, Anxiety, 
  • Propranolol, Timolol, Metoprolol 

Atenolol and Nadolol are also used but not as effective 

  • Contraindication:
    • Bradycardia
    • 2nd/3rd degree heart block
    • Asthma/COPD 

31

Topiramate

Contraindications

AEs

Monitoring

No contra, no monitoring

AEs: Dizziness, somnolence, cognitive impairment, weight loss, nephrolithiasis, paresthesia

32

Triptans and ____ interact with each other?

Triptans 

33

Beta blockers interact with?

RizaTriptan

34

Migraine treatment Menstrual migraine

Prophylactic, NSAIDs, Triptans, Use OCs 2 days prior to menses then 3 days after onset of menses

35

Level B

TCAs, SNRI, Beta-blocker (atenolol, Nadolol)

36

Migraine for Acute

- NSAIDs, APAP/ASA/Caffeine, triptans, Ergot alkaloids, Narcotic and other analgesics, antiemetics

37

Triptans  Drug interactions

  • Ergots 
  • MAOIs 
  • Potent 3A4 inhibitors 
  • SSRIs 

38

Triptan AEs 1st line for?

For moderate-severe migraine - Somnolence, dizziness, paresthesias, warm sensation, flushing, chest symptoms (mimic angina)

39

If there is patient tolerance what triptans should you use?

  • Almotriptan and Naratriptan

40

Menstrual Migraine

- only women no real difference in normal migraines

41

Contraindication with Triptan

Cardiovascular disease, stroke, PVD, hemiplegic migraine, Multiple risk factors for coronary disease

42

Level A migraine prevention

- Divalproex/Sodium valproate - Topiramate - Beta-blocker (Meto, PRo, TImi)

43

NSAIDs

1st line, Aspirin, Ibuprofen, Naproxen Excedrin - Dont recommend products with salicylates and caffeine such as (percogesic, BC, Goody's Powder) - Monitor for rebound HAs - Caution with pts with renal disease, ulcer disease (GI bleed), or hypersensitivity to ASA - AEs: GI and CNS

44

What tripans should be used in HA recurrence?

  • Frovatriptan
  • Naratriptan