Tension HA characteristics and?
Pressing/tightening (non-pulstatile), mild-mod intensity, bilateral, no aggravation by physical activity. Both: Nausea/Vomiting, +/- photophobia, phonophobia
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
Antiemetics are usually used as?
Adjunctive treatment with acute attacks
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
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
Secondary Causes of infection
Infection, head injury, hemorrhage, Brain tumor, Drug induced (vasodilator, estrogen)
More common for women or men?
What triptan should generally be avoided because of drug interactions?
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
Titration, might need to try more than one.
What triptans should be used with N/V?
Lower level evidence migraine prevention
SSRis, Gaba, Carb
Antiepileptics for migraine prevention?
- Divalproex sodium
- Gabapentin and Carbamazepine are less effective
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
What ergot alkaloid derivative is the only first line for treatment?
DHE NS after an NSAID is tried
- Beta blockers, antiepileptics, antidepressants, others
Acute Migraine Treatment DIs
Ergot and Derivatives?
- Triptans within 24 hours
- MAOIs (CI within 2 weeks)
- Potent 3A4 inhibitor (CI)
Physicals and Labs for headache?
Physical exam, CT, MRI, LP, CBC, TSH
Pulsating, One day, Uni, N/V, Disabling
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
Ergot Alkaloid derivatives are generally?
Acute treatment goals
- Dont want recurrence, restore function
MAOIs and ergot Dont use within 24 hours SSRIs and risk of serotonin syndrome -
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
Types of Headaches 4
Migraine, Tension, Cluster, Rebound headache (medication overuse)
Complementary/alternative products for migraine prevention?
- Petasites (Butterbur extract)
Types of Migraines 4 types
Migraine with aura, migraine without, Menstrual migraine, Hemiplegic migraine
History of Headaches
- Age of onset, location, quality, severity, frequency, duration, triggers
What triptans are a good choice for quick relief?
Beta blockers prophylactic?
What are the preferred ones?
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
- 2nd/3rd degree heart block
No contra, no monitoring
AEs: Dizziness, somnolence, cognitive impairment, weight loss, nephrolithiasis, paresthesia
Triptans and ____ interact with each other?
Beta blockers interact with?
Migraine treatment Menstrual migraine
Prophylactic, NSAIDs, Triptans, Use OCs 2 days prior to menses then 3 days after onset of menses
TCAs, SNRI, Beta-blocker (atenolol, Nadolol)
Migraine for Acute
- NSAIDs, APAP/ASA/Caffeine, triptans, Ergot alkaloids, Narcotic and other analgesics, antiemetics
Triptans Drug interactions
- Potent 3A4 inhibitors
Triptan AEs 1st line for?
For moderate-severe migraine - Somnolence, dizziness, paresthesias, warm sensation, flushing, chest symptoms (mimic angina)
If there is patient tolerance what triptans should you use?
- Almotriptan and Naratriptan
- only women no real difference in normal migraines
Contraindication with Triptan
Cardiovascular disease, stroke, PVD, hemiplegic migraine, Multiple risk factors for coronary disease
Level A migraine prevention
- Divalproex/Sodium valproate - Topiramate - Beta-blocker (Meto, PRo, TImi)
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
What tripans should be used in HA recurrence?