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Flashcards in Headaches Deck (73):
1

What % of office and ER visits involving headaches have serious pathology?

< 2%
< 4%

2

How do we classify headaches?

Primary (no other cause)
Secondary (some other cause)

3

What are some red flags of secondary headaches?

Change/progression in headache pattern
Abrupt onset
Neurological sx > 1 hour

4

How do you describe the pain of a tension headache?

Mild-moderate dull ache

5

What are tension headaches usually lacking?

Signs of serious underlying conditions
Visual disturbances
Generalized pain. fever, stiff neck, recent trauma
Bruxism

6

What are the OTC analgesics that pts often self treat tension headaches with?

Acetaminophen (56%)
Aspirin (15%)
Ibuprofen (12%)
Other agents (17%)

7

What NSAIDS and acetaminophen agents are more effective than placebos 2 hours after tx? What is their dosage?

Ibuprofen 400 mg po
Acetaminophen 1000 mg po
Ketoprofen 25 mg po

8

What should you limit analgesia intake per week to? Why?

2-3x/week
Prevent medication overuse headaches

9

What can you augment tension headache (TH) tx with? Give some examples.

Sedating antihistamines
Diphenhydramine
Promethazine

10

If augmented TH tx isnt working, what should you try?

Acetaminophen/ asprin w/ caffeine and butalbital

11

How often can you use the acetaminophen/caffeine/butalbital combination?

< 2xs weekly

12

What might the use of the combo TH therapy precipitate?

Chronic daily headahce

13

What are some things to worry about with the TH combo therapy? What do we do to deal with this?

Sedation
Limit alcohol

14

What are two drugs that are used as prophylaxis for TH?

Amitriptyline
SSRIs

15

How long might SSRIs take to be effective for TH?

1-2 months

16

What are some examples of SSRIs used for TH?

Paroxetine
Venlafaxine
Fluoxetine

17

What are the most painful of primary headaches?

Cluster headaches

18

What are some associated sx with cluster headaches (CH)?

Aura
Photophobia
Phonophobia
Osmophobia

19

What is a key feature of CHs?

Recurrent bouts of near daily attacks

20

How long may CHs last?

Weeks-months

21

When do CH attacks usually begin?

W/ REM phase sleep

22

What to pts susceptible to CHs fear?

Going to sleep

23

List some precipitants of a CH:

Hypoxia (sleep apnea)
Vasodilators
Alcohol
CO2

24

How are CHs dx?

Hx

25

Is CH pain UL or BL?

Unilateral

26

Where is the CH pain usually localized?

Orbital
Supraorbital
Temporal

27

CH pain is accompanied by >1 of:

Ipsilateral conjunctival injection or lacrimation
Ipsilateral nasal congestion or rhinorrhea
Ipsilateral eyelid edema, forehead & facial sweating
Ipsilateral miosis or ptosis, or
A sense of restlesness or agitation

28

What is the dual strategy for CH?

Acute attacks must be aborted or subdued
Prophylaxis used to suppress remaining CH

29

What is the tx of choice for CH? What is the dosage?

O2
7 L/min x 15 min

30

What is the medication commonly given for CH? What is the dose?

Sumatriptan
6 mg SQ
20 mg NS

31

What is an under prescribed combo therapy for CH?

O2 and sumatriptan

32

Give some other examples of CH tx:

Dihydroergotamine
Lidocaine
Capsaicin

33

What is a tx for CH that is not effetive for CH prophylaxis?

Sumatriptan

34

List the prophylactic drugs for CH:

Verapamil
Prednisone
Valproic acid
Topiramate
Ergotamine

35

How do we classify migraines?

By their clinical features

36

What is one major feature of migraines?

Aura

37

What can aura present with? How is that classified?

Visual distortions
Positive (scintillations, photopsia)
Negative (visual field defects)

38

Describe migraine pain:

Unilateral
Throbbing
Temporal
Incapacitating

39

How do you minimize migraine pain?

Dark, quiet location

40

What are other sx that accompany migraines called?

Prodromal sx

41

What are some common triggers for migraines? Give some examples.

Food (alcohol, caffeine, chocolate, MSG, tyramine, nitrate)
Behavioral/physiologic (changes in sleep, skipped meals)
Environmental (flickering lights)

42

How quickly do we need to treat migraines?

Rapidly

43

What are the goals of migraine tx?

Reduce frequency/severity of attacks
Avoid escalation of medications

44

What should mild-moderate or unresponsive severe migraine attacks use for tx?

Oral NSAIDS
Combination analgesics containing caffeine
Isometheptene combinations

45

What should mod-severe or mild mod unresponsive to NSAIDs migraine attacks use?

Migraine specific meds
Combo tx (APC = aspirin, APAP, caffeine)

46

What two things are not part of migraine tx?

Sedatives
Acetaminophen monotherapy

47

Which is the superior care approach for migraines?

Stratified care (based on severity of disability)

48

What are two abortive txs for migraines?

Ergotamine
Dihydroergotamine

49

What is ergotamine?

Nonselective 5-HT1 agonist

50

What is an advantage of dihydroergotamine?

Less overuse headache (replace ergotamine)

51

What are some drawbacks of the abortive meds?

Both are oxytocic
Contraindicated in pregnancy
Peripheral vasoconstriction (short term use)

52

What are triptans?

Specific 5HT1 receptor agonists

53

What are triptans usually reserved for?

Mod-severe migraines unresponsive to other meds

54

When are triptans contraindicated?

Uncontrolled HTN
Ischemic vascular conditions
Vasospastic CAD

55

How quickly does subQ sumatriptan peak?

15 minutes

56

How quickly does oral rizatriptan peak?

60-90 minutes

57

What triptan has the longest half life? What might happen with this?

Naratriptan
Decrease chance of recurrence HA

58

What are the principles of triptan therapy?

Try for 2-3 headache episodes before changing
If one is ineffective try another
Match drug characteristics to patient's needs

59

When do you consider prophylaxis for migraines?

> 2 attacks/month w/ disability > 3 days/month
Contraindications to/failure of abortive therapy
Presence of uncommon migraine conditions (hemiplegic migraine, prolonged aura)

60

What is an uncommon tx for migraines?

OnabotulinumtoxinA

61

What is the MOA of botox?

Neuromuscular blocking agent

62

How many different sites do you inject with botox?

31 total sites

63

What are CGRP antagonists for migraines?

Potent vasodilators of cerebral vessels

64

What two things do CGRP antagonists do?

Block CGRP receptors
Inhibit CGRP directly

65

What is CGRP receptor antagonist?

Monoclonal antibody

66

What is the MOA of CGRP receptor antagonist?

Bind CGRP receptor blocking activation

67

How much do CGRP receptor antagonists reduce migraines?

To 1-2 episodes/month

68

How do you administer CGRP receptor antagonists?

SC injection once monthly

69

When are CGRP receptor antagonists indicated?

Pts who fail other drugs
Prophylaxis of migraine

70

What is the MOA of CGRP antagonists?

Prevents receptor activation by binding directly to CGRP

71

How much do CGRP antagonists reduce migraine frequency?

1-2 episodes per month

72

How do you administer CGRP antagonists?

SubQ injection once monthly

73

When are CGRP antagonists indicated?

Prophylaxis when other drugs fail