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PR3153 > IC5- Headache > Flashcards

IC5- Headache Flashcards

1
Q

What is the International Classification of Headache Disorders 3 (ICHD-3)?

A

It classifies headaches according to different categories like “Primary”, “Secondary” and “Neuropathies, Facial pains, Other headaches”

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2
Q

According to the ICHD-3, what are the types of headaches under “Primary”, “Secondary”, and “Neuropathies, Facial pains, Other headaches”?

(just read through, if can list some then good)

A

Primary
- Migraine
- Tension Type Headache (TTH)
- Trigeminal Autonomic Cephalalgias (TACs)
- Other primary HA disorders

Secondary
- Trauma/ injury to head and/ or neck
- Cranial or cervical vascular disorder
- Non-vascular intracranial disorder
- Infection
- Homeostasis Disorder
- HA/facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial/ cervical structures
- Psychiatric Disorder

Neuropathies, Facial pains, Other Headaches
- Panful lesions of the cranial neuropathies & other facial pain
- Other HA disorders

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3
Q

List the factors in the SNNOOP10 guide (ie. red flags that present with the headache which could suggest a more serious underlying cause)

A

Systemic symptoms inclu fever
Neoplasm Hx
Neurologic deficit/ dysfunction
Onset of headaches sudden/ abrupt
Older age (> 50 y/o)
Pattern change/ recent onset of headache
Positional headache
Precipitated by sneezing, coughing, or exercise
Papilledema
Progressive headache with atypical presentation
Pregnancy/ puerperium
Painful eye with autonomic features
Post-traumatic onset of headache
Pathology of immune system such as HIV/ immunocompromised
Painkiller overuse/ new drug at onset of headache

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4
Q

Describe TTH in terms of:

  • Pain location
  • Pain quality
  • Pain intensity
  • Effect on activities
  • Other SSx
  • Duration
A
  • Pain location: bilateral
  • Pain quality: pressing/ tightening (nonpulsatile,
  • Pain intensity: mild-moderate
  • Effect on activities: not aggravated by routine activities of daily living
  • Other SSx: none
  • Duration: 30 mins-7 days
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5
Q

Describe migraine in terms of:

  • Pain location
  • Pain quality
  • Pain intensity
  • Effect on activities
  • Other SSx
  • Duration
A
  • Pain location: unilateral/bilateral
  • Pain quality: pulsating/ throbbing
  • Pain intensity: moderate-severe
  • Effect on activities: aggravated by or causes avoidance of routine activities of daily living
  • Other SSx: n/v, unusual sensitivity to light or sight, aura (visual, sensory, speech disturbance)
  • Duration: 4-72h
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6
Q

Describe cluster headache in terms of:

  • Pain location
  • Pain quality
  • Pain intensity
  • Effect on activities
  • Other SSx
  • Duration
A
  • Pain location: unilateral (around eye/ along the face)
  • Pain quality: variable
  • Pain intensity: severe-very severe
  • Effect on activities: restlessness/ agitation
  • Other SSx: cranial autonomic SSx in same side as headache (red, watery, swollen eye, nasal congestion/ runny nose, sweating)
  • Duration: 15-180 min
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7
Q

Which age does TTH peak? Does it occur more in females/ males?

A

– Peaks in the 4th decade
– Female > male

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8
Q

What are the different types of frequencies of TTH?

A

Infrequent episodic TTH:
- >10 headaches
- <1 episode/ month
- <12 headaches/ year

Frequent episodic TTH:
- >10 headaches
- 1-14 days/ month for over 3 months

Chronic TTH:
- 15 or more days/ month for over 3 months
- Associated with vitamin deficiencies

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9
Q

What are the triggers of TTH? (7)

A
  • Physical/ emotional stress
  • Activities that cause the head to be held in one position for a long time
  • Alcohol
  • Caffeine
  • Cold/flu or Sinus infections
  • Dehydration
  • Hunger
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10
Q

What are the goals for TTH management? (2)

A
  1. Pain relief
  2. Prevent progression to chronic TTH
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11
Q

What pharmacological tx can we give for acute TTH? (3)

A
  • Paracetamol (alone or with caffeine), aspirin
  • NSAIDs: Ibuprofen, Naproxen, Diclofenac, Ketoprofen
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12
Q

What Tx can we give for chronic TTH? (eL video)

A
  • TCAs (amitriptyline)
  • CBT
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13
Q

What prophylactic pharmacological Tx can we give for TTH? (2)

A
  • *Amitriptyline (1st line)
  • Mirtazapine, Venlafaxine
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14
Q

What are some non-pharmacological Tx can we suggest for TTH?

A
  • CBT, biofeedback, relaxation
  • Physical and/or occupational therapy
  • Lifestyle modification (include sleep hygiene)
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15
Q

Which age does migraine peak? Is it more prevalent in females or males?

A
  • Peaks in middle life (30-49 years of age)
  • 2-3x more prevalent in females than males
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16
Q

What are the 5 stages of migraine? How long does each stage last for?

A
  1. Prodrome: ≤48h
  2. Aura: 5-60min
  3. Headache (ictal): 4-72h
  4. Postdrome: ≤ 48h
  5. Interictal
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17
Q

What are the SSx of the prodrome stage (≤ 48h) of migraine? (8)

A
  • Fatigue
  • Food cravings
  • Nausea
  • Cognitive difficulties
  • Neck discomfort
  • Photophobia and phonophobia
  • Yawning
  • Mood changes
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18
Q

What are the SSx of the aura stage (5-60min) of migraine? (4)

A
  • Visual aura (scotoma, fortification spectrum)
  • Sensory disturbance
  • Speech disturbance
  • Motor symptoms
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19
Q

What are the SSx of the headache ictal stage (4-72h) of migraine? (8)

A
  • Moderate-to-severe head pain
  • Photophobia and phonophobia
  • N/V
  • Allodynia
  • Neck discomfort
  • Cranial autonomic ssx
  • Cognitive ssx
  • Fatigue
20
Q

What are the SSx of the postdrome stage (≤ 48h) of migraine? (5)

A
  • Photophobia and phonophobia
  • Nausea
  • Fatigue
  • Cognitive ssx (eg. difficulty concentrating)
  • Neck discomfort
21
Q

What are the SSx of the interictal stage of migraine? (3)

A
  • Photophobia and phonophobia
  • Cognitive symptoms
  • Fatigue
22
Q

Explain the pathophysiology of migraine

A

Dysfunction of trigeminovascular system (major pain-signalling pathway): trigeminovascular neurons activated and relay migraine pain signal from periphery to CNS → repeated activation of the trigeminovascular system over time → hypersensitivity and sustained pain in nervous system → feedback from sensitised brain potentiates pain signalling and contributes to common migraine ssx

23
Q

Explain what happens in the prodrome phase of migraine

A
  • Activation of hypothalamus and neuropeptides involved in
    homeostatic functions
  • Hypothalamic neurons that regulate homeostasis may cause burdensome, non-pain ssx (n/v, appetite changes, fatigue)
24
Q

Explain what happens in the aura phase of migraine

A

Cortical spreading depression (CSD)

25
Q

Explain generally what happens at the headache (ictal) phase of migraine

A
  • Several neuropeptides → sensitization of the central and peripheral trigeminovascular system → state of hypersensitivity → contibutes to both pain and non-pain ssx in this phase
  • Calcitonin gene-related peptide (CGRP)
26
Q

Pathophysiology of allodynia in the ictal stage of migraine?

Which medical condition can lead to greater ssx of allodynia and hypersensitivity to migraine pain?

A

In migraine, sensitisation of 1. Primary nociceptors and 2. Central trigeminovascular neurons → allodynia

Brainstem abnormalities can lead to greater ssx of allodynia and hypersensitivity to migraine pain

27
Q

Pathophysiology of photophobia in the ictal stage of migraine?

A

Retinal (peripheral) and trigeminal nociceptive input (central) are sensitised → projects to Nociceptive areas of the cortex (S1/ S2) → hypersensitised visual cortex (V1/ V2)

28
Q

What do we know about the postdrome phase of migraine?

Which phases do prodrome symptoms also appear?

A

Uncertain MoA. Similarities observed between prodrome and postdrome phases

Prodrome symptoms: Fatigue, food cravings, cognitive symptoms can endure well into the aura, headache and even postdrome phases of a migraine attack. In headache phase these ssx are overshadowed by other ssx

29
Q

Which parts of the brain are normally affected at the interictal stage of migraine?

Regarding the photophobia experienced at this stage, which part of the brain does it activate?

A

Olfactory regions, the midbrain and the hypothalamus affected after cessation

Photophobia → activation of visual cortex

30
Q

What are the ICHD-3 diagnostic criterias for migraine WITHOUT aura?

Min. how many attacks? Attack duration? Headache ssx? Non-headache ssx? Non-headache ssx

A

≥ 5 attacks that fulfill the following criteria:

  • Attack duration: 4 - 72h
  • Headache ssx: (≥ 2 of the 4) unilateral location, pulsating quality, moderate to severe pain, aggravation by or causing avoidance of routine physical activity (e.g. walking or climbing stairs)
  • Non-headache SSx (≥ 1 of the following): N/V, Photophobia and phonophobia
  • Not better accounted for by another ICHD-3 diagnosis
31
Q

What are the ICHD-3 diagnostic criterias for migraine WITH aura?

A

≥ 2 attacks that fulfil the following criteria:

  • ≥ 1 of the following fully reversible aura symptoms (visual, sensory, speech and/ or language, motor, brainstem, retinal)
  • ≥ 3 of the following characteristics (≥ 1 aura symptom spreads gradually over ≥ 5 min, 2 or more aura symptoms occur in succession, each individual aura symptom lasts 5 – 60 min, ≥ 1 aura symptom is unilateral, ≥ 1 aura symptom is positive, aura accompanied within 60 min by headache
  • Not better accounted for by another ICHD-3 diagnosis
32
Q

What are the ICHD-3 diagnostic criterias for chronic migraine?

A

> 3 months of ≥ 15 MHDs and ≥ 8 MMDs:

MHDs: a day with migraine type or TTH

MMDs (same as ICHD-3 diagnostic criteria for migraine without aura):
- (≥ 2 of the 4) unilateral location, pulsating quality, moderate to severe pain, aggravation by or causing avoidance of routine physical activity (e.g. walking or climbing stairs)
- if no aura, ≥ 1 of the following: n/v, photophobia and phonophobia

33
Q

What are the drugs associated with medication *overuse headaces (MOH)?

A
  • Migraine-specific acute medications: Triptans, Ergotamines, Ditans
  • Non-migraine-specific acute medications: Analgesics, NSAIDs
  • Opioids, Narcotics and Barbiturates: avoid use
34
Q

What’s the limit for the number of days where we should use acute medications for HA per week?

What happens if this limit is exceeded?

A

Acute Tx to be limited to an average of 2 headache days per week

Preventive treatment is considered for patients observed exceeding this limit

35
Q

What is the ICHD-3 diagnostic criteria for medication overuse HA (MOH)?

A
  1. Headache occurring on ≥ 15 days/ month in a patient with a preexisting headache disorder
  • Regular overuse for > 3 months of ≥ 1 drug that can be taken for acute and/or symptomatic treatment of headache with medication overuse defined as:

▪ ≥10 days per month for ergot derivatives, triptans, opioids, combination analgesics, and a combination of drugs from different classes that are not individually overused

▪ ≥15 days per month for simple nonopioid analgesics- paracetamol/ acetaminophen, acetylsalicylic acid, and NSAIDs

▪ Any combination of above-mentioned drugs/ other medications taken for acute or symptomatic Tx of headache for ≥ 10 days/ month

36
Q

What does the American Headache Society (AHS) Treatment Recommendations say with regards to Tx of migraine?

A

All patients with a confirmed diagnosis of migraine should be offered a trial of acute pharmacologic and/ or nonpharmacologic treatment

37
Q

What drugs are used for the acute treatment of migraine…

  1. Mild-to-moderate attacks
  2. Mild-to-moderate attacks that respond poorly to non-specific Tx/ moderate/ severe attacks

When do patients take the medication?

A
  1. Mild-to-moderate attacks – General pain medications
  • NSAIDs (eg. aspirin, celecoxib, diclofenac, ibuprofen, naproxen)
  • Nonopioid analgesics
  • Combination analgesics therapy (acetaminophen + aspirin + caffeine)
  1. Mild-to-moderate attacks that respond poorly to nonspecific therapy or moderate or severe attacks – Migraine-specific agents
  • Triptans
  • Ergotamine derivatives
  • Gepants, ditans (newer agents)

Patients should be instructed to take the medications at the FIRST SIGN of pain

38
Q

List the AHS criteria for preventative migraine Tx (5)

A
  • Attacks significantly interfere with patient’s daily routines despite acute treatment
  • Frequent attacks (≥ 4 MHDs)
  • Contraindication to, failure, or overuse of acute treatment
  • Adverse events with acute treatment
  • Patient preference
39
Q

When can CGRP mAbs be prescribed for migraine Tx?

A

When pt is ≥ 18 y and one of the following factors:

  1. 4-7 monthly migraine days and both: (1) inability to tolerate SEs/ inadequate response to 8 week trial of 2 prior Tx classes AND (2) cause at least moderate disability
  2. 8-14 monthly migraine days and: inability to tolerate SEs/ inadequate response to 8 week trial of 2 prior Tx classes
  3. Chronic migraine and either: (1) inability to tolerate SEs/ inadequate response to 8 week trial of 2 prior Tx classes OR (2) inability to tolerate/ inadequate response to a minimum of 2 quarterly injections (6 months) of onabotulinumtoxin A
40
Q

What are the criteria to allow a patient to continue using CGRP mAbs for migraine Tx? (2)

A
  1. Reduction in mean monthly headache days/ headache days of at least moderate severity of ≥ 50% relative to pretreatment baseline
  2. Clinically meaningful improvement in ANY of the following:
    - MIDAS (reduction of ≥ 5 points when baseline score is 11-20), (reduction of ≥ 30% points when baseline scores > 20)
    - MPFID (reduction of ≥ 5 points)
    - HIT-6 (reduction of ≥ 5 points)
41
Q

What are some success markers for migraine preventive Tx? (6)

A
  1. 50% reduction in the frequency of days with headache or migraine
  2. Significant decrease in attack duration, as defined by the patient
  3. Significant decrease in attack severity, as defined by the patient
  4. Improved response to acute treatment
  5. Reduction in migraine-related disability and improvements in functioning in important areas of life
  6. Improvements in HRQoL and reduction in psychological distress because of migraine
42
Q

After medication tx is initiated for migraine, what are some non-pharmacological steps that you can advise the pt to do?

A
  • Encourage patient to keep a headache diary to assess treatment efficacy
  • Assess the number and frequency of headache days after treatment initiation
  • Assess the number of days that acute medication is required
  • Use Patient-reported outcomes (PRO) tools to measure duration and severity of symptoms, and assess the impact of treatment on functional disability and improvement in QoL
43
Q

After migraine Tx is initiated, how often should we assess pts?

A

Assess after 3 months if starting monthly Tx
OR
Assess after 6 months if starting quarterly treatments

44
Q

What are some examples of migraine-specific PRO tools? (3)

A
  • Migraine Disability Assessment Questionnaire (MIDAS)
  • 6-Item Headache Impact Test (HIT-6)
  • Migraine-Specific Quality of Life Questionnaire (MSQ)
45
Q

What are the different types of Tx for migraine? (3)

A
  • *Pharmacotherapy (acute & preventive)
  • Neuromodulation (FDA approved: eTNS, nVNS, REN and sTMS)
  • Biobehavioral (cognitive behavioral therapy, biofeedback, and relaxation therapies)

PR3153 (11 decks)

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