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7005PHM Pharmthera II > Headaches/Migraines > Flashcards

Headaches/Migraines Flashcards

1
Q

List some primary headaches

A

Migraine

Tension

Cluster

Sinus

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2
Q

What is a secondary headache?

A

Sign or symptoms of underlying disease

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3
Q

What are the most common types of primary headaches?

A

Tension type (69%)

Migraine (16%)

Cluster (0.1%)

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4
Q

What are some key characteristics of secondary headache and the causes?

A

Sudden onset (e.g. subarachnoid haemorrhage)

Usually in older people = e.g. temporal arthritis >50 y/o

Associated sx of = fever, neck stiffness –> bacterial meningitis or herpes simplex encephalitis

Brain tumour = mental deterioration, seizures, weakness of extremities or face

Head trauma = headache soon after trauma –> subdural or epidural hematoma

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5
Q

What are the characteristics of a tension headache?

A

Chronic head-pain syndrome = bilateral tight, band-like discomfort

Builds slowly, fluctuates in severity, may persist more or less continuously for many days

Episodic or chronic (>15 days/month)

No migraine sx

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6
Q

Briefly summarise the pathophys of a tension headache

A

Disorder of CNS modulation

*A migraine has generalised disturbance of sensory modulation

No inc contraction or ischaemia in scalp muscle or cervical spine

Diagnosis relies on characteristic sx and exclusion of secondary causes

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7
Q

What are the acute treatments for tension headaches

A

Aspirin

Diclofenac potassium

Ibuprofen

Naproxen sodium

Paracetamol sodium

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8
Q

What is a medication-overuse (rebound) headache

A

A headache which develops insidiously due to analgesia use on a regular bases for more than 2-3 days in a week

For people with frequent headaches, use preventative meds

Overuse analgesics markedly impair preventative medicines

Some will improve after cessation of analgesics

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9
Q

What preventative medications are used in tension headaches?

A

Amitriptyline

Preventative Rx = may take several weeks to act, effect may be blocked by freq analgesia use

- continued for min 3-6 months and then tapered and then ceased

Alternative to amitriptyline:
- nortriptyline
- dothiepin

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10
Q

What are the characteristics of cluster headaches?

A

Cluster headaches rare = men (3x more) > women, nocturnal onset (50% of patients

Pain = deep, retro-orbital and excruciating, non-fluctuating, explosive in quality

Attacks = bouts of one to two attacks, short duration unilateral pain for 8 to 10 wks followed by pain free interval (1 yr)

Key feature = periodic, same hour each day

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11
Q

How does someone behave when they have a cluster headache?

A

Tend to move about during attack

Pacing, rocking, rubbing their head for relief

Some may become aggressive

Migraine patients prefer to be motionless during attacks

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12
Q

Explain the acute treatment of cluster headaches

A

Oxygen therapy (100% for 15 mins), analgesics such as opioids have no place in therapy

Cease O2 therapy if no improvement after 15 mins

Sumatriptan 6mg subcut is effective but expensive

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13
Q

What is the bridging therapy for cluster headaches?

A

Needed while preventative treatment is commenced

Prednis(ol)one = produce rapid suppression of attacks (w/in 24-48 hrs)

Cluster headache may recur when steroid is tapered, important to start preventative drug alongside steroid

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14
Q

What is the preventative therapy for cluster headaches?

A

1) Verapamil sustained release

2) methysergide (discontinued in Aus

3) lithium

Preventative Rx continued until attacks have ceased for 1 week+
- same preventative drug is effective if attack recurs

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15
Q

What are the characteristics of a sinus headache?

A

Acute sinusitis = headache or facial pain

Maxillary sinusitis = tooth pain

deep sinus inflammation = parietal or vertex headache

Nasal congestion or purulent discharge together with fever –> clues for diagnosis

*Note: migraine can be misdiagnosed as sinus pathology as some sit below eye level

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16
Q

How is a sinus headache/sinusitis treated?

A

Treated with vasoconstrictor nose drops/sprays, antihistamines, antibiotics

Pain = OTC analgesics –> paracetamol or ibuprofen

Chronic sinus pain = unlikely to have recurrent sinus inflammation –> likely primary headache syndrome

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17
Q

How is medication overuse headache treated?

A

Cessation of analgesics –> gradual dec in headache over wks to months (reduce med dose by 10% every 1-2 wks)

Long acting NSAIDs, amitriptyline, antiemetics, antihistamine use is possible

Short course of high-dose oral prednisolone

Reduction of acute drug must be preceded or accompanied by a preventative drug

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18
Q

What medications are known for causing headaches?

A

Vasodilators = dihydropyridine CCB, nitrates, phosphodiesterase type V inhibitors, dipyridamole

COC, HRT

Tetracycline: Intracranial HTN

NSAIDs, esp indomethacin, may be associated with paradoxical headache

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19
Q

What is an ice pick headache?

A

sudden stabbing pains, bilateral, last a few seconds

Can occur 30+ times/day

Pain can occur anywhere and change location

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20
Q

What is chronic paroxysmal hemicrania?

A

Pain may affect one half of the head

More temporal and around the eye

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21
Q

What is a SUNCT headace?

A

Short-lasting, unilateral, Neuralgiform headache attack with conjunctival injection and tearing

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22
Q

What are some symptoms of a migraine headache?

A

Nausea
Vomiting
Photophobia
Phonophobia
Osmophobia
Throbbing, and aggravation with movement

23
Q

What is a migraine?

A

Recurring syndrome of headache associated with other symptoms of neurologic dysfunction in varying admixtures

Understanding triggers can be a good treatment strategy to prevent attacks

24
Q

What are some migraine triggers?

A

Glare, bright light, sounds, odours or other afferent stimulation

Hunger

let-down from stress, physical exertion

Stormy weather or barometric pressure changes

hormonal fluctuations during menses

Lack of sleep or excess

Alcohol or other chemical stimulation, such as nitrates

25
Q

What is the pathophysiology of a migraine?

A

Neurovascular pain syndrome due to altered central neuronal processing
- activation of brain stem nuclei, cortical hyper-excitability, spreading cortical depression

Involves trigeminovascular system –> trigger neuropeptide release causing painful inflam in cranial vessels and dura mater

26
Q

What neurotransmitter are suspected to attribute to migraines?

A

Serotonin = nociceptive pathways of trigeminovascular system and cranial vasoconstriction

Dopamine = sx induced by dopaminergic stimulation

27
Q

Which following features must a headache have in order to be considered a migraine?

A

At least 2 of:

- Unilateral pain 
- Throbbing pain 
- Pain aggravated by movement
- moderate or severe intensity

Plus at least one of the following:

- N/V
- photophobia and phonophobia
28
Q

Describe the nature of a migraine without aura

A

Common

Recurrent episodes of headache, often unilateral and throbbing, but without focal neurological symptoms

N/V, photophobia or phonophobia accompany pain

29
Q

Describe the nature of a migraine with aura

A

Similar to common migraine but associated with neurological sx that precede or accompany the headache

Sx = visual disturbances, dizziness, paraesthesia or impaired speech, mood disturbances

Aura sx can predominate and headache is mild or short lived

30
Q

What is an aura?

A

visual disturbances with flashing lights or zig zag lines moving across visual field

31
Q

What are the symptoms of the migraine premonitory and resolution stage?

A

Hyperactivity, hypoactivity

Depression

Cravings for particular foods

Repetitive yawning

Fatigue and neck stiffness and/or pain

32
Q

What is a migraine acute attack?

A

Varies from moderate to severe (can be incapacitating), lasts from 4h to several days

Routine physical activity aggravates headache

Resolves with sleep, sedating antihistamine may be combined with analgesics if sleep is desired

33
Q

What are the step 1 medications for acute migraine attacks?

A

Aspirin sodium

diclofenac potassium

Ibuprofen

Naproxen sodium

Paracetamol soluble

ketoprofen

34
Q

What is something to be mindful of with acute migraine rx?

A

Regular use at high freq >2days/week –> risk of development of medication overuse headache

35
Q

What antiemetics are suitable for acute migraines? (step 1)

A

Domperidone

Metoclopramide

prochlorperazine

*help improve absorption of analgesics
*can be introduced if aspirin, NSAID, or paracetamol do not reliably work

36
Q

What is the acute step 2 migraine rx?

A

(triptans)

Eletriptan

naratriptan

rizatriptan

sumatriptan (50-100mg) or sumatriptan (10 to 20mg)

zolitriptan

37
Q

What is some important information about triptan use in migraines?

A

Used after NSAIDs or simple analgesics = use if no improvement after 1-2 hrs or treatment failed in previous attack

Most effective if taken when headache is beginning to develop (not during aura or later when severe

Can use higher dose of triptan if lower doses are tolerated but ineffective

Headache may recur 6-24 hours after last dose –> repeat dose, no benefit if 1st dose was ineffective

38
Q

Can triptans be used regularly for migraines?

A

No, they should not be used on more than 10 days/month –> avoid risk of medication-overuse headache

39
Q

What are the step 3 medications for acute migraines?

A

Dihydroergotamine (do not take a triptan w/in 24 hours of this)

Sumatriptan

Both SC/IM

40
Q

What are some acute migraine rx precautions?

A

Do not use dihydroergotamine or triptan if = vascular or coronary artery disease, uncontrolled HTN

Use opioids w/ great reluctance, only after all measures failed
- pethidine associated with dependence and abuse –> repeated dose inc toxic metabolite (confusion and seizures)

- alternative to pethidine = morphine, oxycodone, tramadol ---> all used w/ caution
41
Q

What are some drug interactions associated with acute migraine rx?

A

Triptan can inc serotonin = monitor its repeated use w/ other drugs that do the same

Moclobemide (MAO-A inhibitor) –> inc plasma lvl of sumatriptan, zolmitriptan, rizatriptan

St John’s wort = inc risk of ADRs w/ triptans

42
Q

What medication is used in status migrainosus?

A

Chlorpromazine IV

Dihydroergotamine IV

Droperidol IM

Prochlorperazine IV

Sumatriptan SC

*severe migraine that fails to resolve after several days may require hospitalisation –> rehydration w/ IV fluids, parenteral therapy

43
Q

What are the 1st line migraine preventative medications?

A

Amitriptyline

pizotifen

propranolol

44
Q

What are the 2nd line migraine preventative medications?

A

Topiramate

verapamil SR

sodium valproate

45
Q

What is a non-drug preventative therapy for migraines?

A

CBT –> relaxation exercise, stress management, acupuncture, reduce caffeine intake

Clinician showing interest in condition

46
Q

What is something important to note about migraine preventative medication?

A

Commenced if person experiences 2-3 acute attacks of migraines per month

Takes several weeks to work, continue for 1 month at max tolerated dose before switching

Don’t combine preventative meds

W/draw preventers if migraine controlled for 3-6 months

47
Q

What is the acute treatment of menstrual migraine?

A

Same as normal migraine

Short term prophylaxis may be useful in those w/ regular cycles = take before and during expected time of attack

48
Q

What are the preventative therapies for menstrual migraines?

A

Naproxen sodium 48 hrs before expected migraine attack

Oestradiol gel trans dermally - migraine with aura ‘’
- not likely to be effective if migraine occurs after menstruation

mefenamic acid ‘’, continue beyond expected duration of attack

49
Q

What are the acute migraine treatments in pregnancy?

A

Paracetamol but may be inadequate

Metoclopramide, may be added to paracetamol to inc effectiveness

AVOID triptans and dihydroergotamine

NSAIDs = not in late preg
Aspirin = affect maternal platelet function –> inc risk of peripartum haemorrhage

50
Q

How are migraine attacks treated in children?

A

Short-lived, resolved in 2-3 hrs of sleep = ibuprofen or paracetamol can be given

Aspirin = avoided in under 16s –> Reyes syndrome

Metoclopramide and prochlorperazine = use w/ caution –> restlessness, dystonia, sedation

Triptan use possible in older children

51
Q

Summarise the use of COC in migraines

A

COC + other oestrogen –> exacerbate migraines
- switch to progestin only contraceptive

COC w/ migraine = inc risk of stroke (esp when aura present)

Migraine w/ aura = use COC w/ caution, esp if freq migraine attack
- cease COC if migraine attacks are more intense or prolonged

52
Q

What contraceptives are safe in migraine prone women?

A

Condoms

Progestin only

etonogestrel implant

levonorgestrel IUD

Copper IUD

53
Q

What hormones are safe in migraine prone women w/ menopause?

A

Low dose oestrogen preparations are safer

Transdermal therapy is better

Cease oestrogen if aura sx or headaches are more intense or prolonged

7005PHM Pharmthera II (18 decks)

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