Primary and Secondary Headache Syndromes Flashcards
(55 cards)
What are important facts to elicit in the history of a headache?
Onset/ peak: acute vs subacute
Relieving features: posture, headache
Exacerbating features: posture, valsalva, diurnal variation
Assoc features; autonomic, photophobia, phonophobia, positive visual symptoms, ptosis, miosis, nasal stuffiness
Consider demographic
What are the red flags in terms of headaches?
New onset headache >55yrs Known/ previous malignancy Immunosuppressed; think about intracranial infection Early morning headache Exacerbation by valsalva
What is the demographics of a migraine?
Commoner in women
Most will have an attack once a month
Migraine without aura: 80%
Migraine with aura: 20%
What is the IHS criteria for a migraine without aura?
At least 5 attacks of duration 4-72 hours
2 of: moderate/severe pain, unilateral, throbbing, worse with movement
1 of: autonomic features, photophobia, phonophobia, N+V
What is the pathophysiology of migraines?
Vascular and neural influences
Stress will trigger changes in the brain resulting in the release of serotonin
Blood vessels constrict and dilate
Chemicals including substance P, neurokinin A and CGRP irritate nerves and blood vessels resulting in pain
In what stages of a migraine will the blood vessels constrict and dilate?
Constrict: aura phase
Dilate: headache phase
What are common triggers of migraines?
Lack of sleep Dietary; dark chocolate, cheese, alcohol, hangovers Stress Hormonal; menstrual cycle Physical exertion
What are the non-pharma treatments of migraines?
Set realistic goals Education; avoid triggers CHOCOLATE: Chocolate Hangovers Orgasms Cheese/ caffeine OCP Lie-ins Alcohol Travel Exercise Headache diary Relaxation/ stress management
What are the pharmacological principles to treating migraines?
Acute treatment
Prophylactic treatment
What drugs are used in the acute management of a migraine?
NSAID; 900mg aspirin, 350mg naproxen, 400mg ibuprofen
+/- antiemetic
Triptans - selective 5-HT agonists
Do NSAIDs help with migraine pain?
60% significant reduction in headache at 2 hours
Only 25% to complete pain relief
What are triptans?
5-HT agonist
When should triptans be give?
At the start of the headache; similar efficacy to NSAIDs
What are examples of triptans?
Rizatriptan
Eletriptan
Sumatriptan
Fovatriptan
How can triptans be given?
Oral
Sub-lingual
Subcut
When should you consider prophylaxis for migraines?
More than 3 attacks a month or very severe
What is the aim with prophylaxis?
Titrate drug as tolerated to achieve efficacy at the lowest dose possible
Must trial each for a minimum of 3 months
GO SLOW AND KEEP LOW
What are examples of migraine prophylaxis?
Amitriptyline Propranolol Topiramate Gabapentin Pizotifen Sodium valproate Botulinum toxin Anti calcitonin gene related peptide (CGRP) Ab
What dose of amitriptyline is given in migraine prophylaxis and what are the adverse effects?
10-25 mg - max 75mg
Adverse: dry mouth, postural hypotension, sedation: Anticholinergic effects
What dose is given on propranolol in migraine prophylaxis and what are the contraindications?
80-240 mg daily
Avoid in asthma, PVD
What mechanism of action of topiramate?
Carbonic anhydrase inhibitor
What dosage of topiramate is given in migraine prophylaxis and what are the adverse effects?
25-100mg
Adverse: weight loss, paraesthesia, impaired concentration, enzyme inducer, teratogenic
Should you give sodium valproate in young women?
No - highly teratogenic
Give in menopausal women
What lifestyle factors can be used as prophylaxis of migraines?
Diet; regular intake, avoid triggers, healthy balanced diet
Hydration; at least 2 L/ day, decrease caffeine
Stress - decrease
Regular exercise
