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Headaches Flashcards

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1
Q

Migraines

  • Name comes from Greek hemi (_____) and kranion (head)
  • Known for being _____lateral, but can be bilateral in about 40% of adults and 60% of children
  • May occur with or without ____
  • Typical duration of ____ to ____
  • Typically a po_____, th_____, or p_______ pain

A
  • Name comes from Greek hemi (half) and kranion (head)
  • Known for being unilateral, but can be bilateral in about 40% of adults and 60% of children
  • May occur with or without aura
  • Typical duration of hours to days
  • Typically a pounding, throbbing, or pulsating pain
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2
Q

Migraine Pathophysiology is complicated and includes

  • Increased intracellular _______ – why (1) Rx helps
  • Waves of __________ across the cerebral cortex
  • (1) release à cause blood vessels to dilate which then causes the pain
  • _____ cell activation (vasodilation and inflammation)
  • Release of (3) by trigeminal neurons innervating the dural blood vessels – all neurotransmitters that increase pain perception. This causes these blood vessels to dilate and become inflamed.
  • Although the brain _________ doesn’t have pain receptors, the CNS blood vessels do
  • Overall, a lot of mechanisms that can cause Migraine which is why we have many medications to treat

A
  • Increased intracellular calcium – why Ca channel blockers help
  • Waves of depolarization across the cerebral cortex
  • Nitric oxide (NO) release à cause blood vessels to dilate which then causes the pain
  • Mast cell activation (vasodilation and inflammation)
  • Release of calcitonin gene-related peptide (CGRP), substance P, and neurokinin A by trigeminal neurons innervating the dural blood vessels – all neurotransmitters that increase pain perception. This causes these blood vessels to dilate and become inflamed.
  • Although the brain parenchyma doesn’t have pain receptors, the CNS blood vessels do
  • Overall, a lot of mechanisms that can cause Migraine which is why we have many medications to treat
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3
Q

Migraine Without Aura

  1. At least __ attacks fulfilling criteria B through D
  2. Headache attacks lasting __ to ___ hours (untreated or unsuccessfully treated)
  3. Headache has at least 2 of the following characteristics:
  4. _______ location

2. ________ quality

  1. moderate or ______ pain intensity
  2. aggravation by or causing _______ of routine physical activity (eg, walking or climbing stairs)
  3. During headache at least 1 of the following:
  4. (1) and/or (1)
  5. (1) and (1)
  6. Not attributed to?

A
  1. At least 5 attacks fulfilling criteria B through D
  2. Headache attacks lasting 4 to 72 hours (untreated or unsuccessfully treated)
  3. Headache has at least 2 of the following characteristics:
  4. unilateral location

2. pulsating quality

  1. moderate or severe pain intensity
  2. aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)
  3. During headache at least 1 of the following:
  4. nausea and/or vomiting
  5. photophobia and phonophobia
  6. Not attributed to another disorder
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4
Q

Migraine With Aura

  1. At least __ attacks fulfilling criteria B through D
  2. Aura consisting of at least one of the following, but no motor weakness
  3. Fully reversible ______ symptoms including positive features (eg, flickering lights, spots, or lines) and/or negative features (eg, loss of vision)
  4. Fully reversible _______ symptoms including positive features (eg, pins and needles) and/or negative features (eg, numbness)
  5. Fully reversible dysphasic ______ disturbance
  6. At least 2 of the following:
  7. _______ visual symptoms and/or ___lateral sensory symptoms
  8. At least 1 aura symptoms develops gradually over at least 5 minutes and/or different aura symptoms occur in succession over at least __ minutes
  9. Each symptom lasts at least __ minutes and no longer than __ minutes
  10. Headache fulfilling criteria B through D for “migraine without aura” (see previous slide) begins during the aura or follows aura within 60 minutes
  11. Not attributed to?

A
  1. At least 2 attacks fulfilling criteria B through D
  2. Aura consisting of at least one of the following, but no motor weakness
  3. Fully reversible visual symptoms including positive features (eg, flickering lights, spots, or lines) and/or negative features (eg, loss of vision)
  4. Fully reversible sensory symptoms including positive features (eg, pins and needles) and/or negative features (eg, numbness)
  5. Fully reversible dysphasic speech disturbance
  6. At least 2 of the following:
  7. Homonymous visual symptoms and/or unilateral sensory symptoms
  8. At least 1 aura symptoms develops gradually over at least 5 minutes and/or different aura symptoms occur in succession over at least 5 minutes
  9. Each symptom lasts at least 5 minutes and no longer than 60 minutes
  10. Headache fulfilling criteria B through D for “migraine without aura” (see previous slide) begins during the aura or follows aura within 60 minutes
  11. Not attributed to another disorder
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5
Q

Acute Treatment of Migraines

TEN SEE V

A

Triptans, Ergots, NSAIDs

Steroids, Esgic, Excedrin/Acetaminophen

Valproate IV

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6
Q

Triptans

  • _____stay*
  • ____ line/most common: ______ (Imitrex)*

A
  • Mainstay*
  • First line/most common: Sumitriptan (Imitrex)*
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7
Q

Triptans

MOA (4)

Causes constriction of blood vessels, inhibit neurons transmission, and enhance inhibitory pain pathways – which is why it can precipitate (2)– ideal patient is someone young and with no (1)

A

Selective Serotonin 5-hydroxytriptamine 1B and 1D agonists

  1. Constriction of intracranial vessels (5-HT 1B)
  2. Peripheral neuronal inhibition (5-HT-1D)
  3. Brainstem neuronal inhibition (5-HT-1D)
  4. Enhancement of descending inhibitory pain pathways

Causes constriction of blood vessels, inhibit neurons transmission, and enhance inhibitory pain pathways – which is why it can precipitate heart attack and stroke– ideal patient is someone young and with no CVD

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8
Q

Triptans Admin Considerations

  • When should the patient take the medication?
  • (1) formulations take effect within 20-60min. (2) work faster
  • Depending on dose and type of triptan, often may repeat dose in __-__ hours if the first does doesn’t work well enough

A
  • Patient should take at first sign of migraine and/or migraine aura
  • Oral formulations take effect within 20-60min. SC and intranasal work faster
  • Depending on dose and type of triptan, often may repeat dose in 2-4 hours if the first does doesn’t work well enough
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9
Q

Triptans CI

  • Not for _____ use
  • CI in patients with or risk factors of (1)
  • Should not use within 2 weeks of an (1) Rx – can precipitate serotonin syndrome (although triptan use in patients on SSRIs may be safe)

A
  • Not for daily use
  • CI in patients with CAD or risk factors of CAD
  • Should not use within 2 weeks of an MAOI – can precipitate serotonin syndrome (although triptan use in patients on SSRIs may be safe)
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10
Q

Ergots

MOA

A

Serotonin agonism, but less selective than triptans

Triptans more selective and constrict cerebral blood vessels, ergots constrict all vessels

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11
Q

Ergots Admin Considerations

Comes in what types of formulations?

A

Sublingual, intransal spray, IM, SC, IV

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12
Q

Ergots CI

(5)-(1)**

A

Vascular disease

HTN

Renal failure

Hepatic failure

Pregnancy* (ergots are class D) (whereas sumatriptan is pregnancy class C)

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13
Q

Ergots SE

_____ SE than triptans

(1) is common

A

More SE than triptans (less selective)

Nausea is common

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14
Q

NSAIDs

Rx such as (7)

Efficacy for acute migraine tx?

A

Aspirin, Ibuprofen, Naproxen, Indomethacin, Diclofenac, Ketoprofen, Ketorolac

Generally good efficacy for acute migraine tx

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15
Q

NSAIDs Admin Considerations

In the outpatient setting, NSAIDs are a _____ expensive alternative to triptans and ergots

In the inpatient/ER setting, Rx (1) 15-60mg IV or IM often works well for acute migraine tx

A

In the outpatient setting, NSAIDs are a less expensive alternative to triptans and ergots

In the inpatient/ER setting, ketorolac 15-60mg IV or IM often works well for acute migraine tx

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16
Q

Other Analgesics

  1. A_______
  2. (1) Combination of acetaminophen, butalbital, and caffeine
  3. (1) Combination of acetaminophen, aspirin, caffeine

A
  1. Acetaminophen
  2. Esgic
  3. Excedrin
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17
Q

Acetaminophen Admin Consideration

Acetaminophen vs. other NSAIDs efficacy?

A

Acetaminophen often less effective than NSAIDs

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18
Q

Other Analgesics SE

All of these can lead to ______ (medication overuse) headaches- causes a vicious cycle, need to get off these meds

The ________ (can cause barbiturate w/drawal when getting off) in Esgic can be s______

A

All of these can lead to rebound (medication overuse) headaches- causes a vicious cycle, need to get off these meds

The butalbital (can cause barbiturate w/drawal when getting off) in Esgic can be sedating

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19
Q

Steroids

Rx (1) Dose Pack

Used for migraines that?

A

Medrol (Methylprednisolone) Dose Pack

Used for migraines that just won’t go away

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20
Q

Steroids Admin Considerations

  • Dosing
    • Day 1: __mg
    • Day 2: __mg
    • Day 3: __mg
    • Day 4: __mg
    • Day 5: __mg
    • Day 6: __mg
  • A large (but non-blinded and non-randomized) study showed benefit to a short course of oral prednisone for (1) in medication overuse HA

A
  • Dosing
    • Day 1: 24mg
    • Day 2: 20mg
    • Day 3: 16mg
    • Day 4: 12mg
    • Day 5: 8mg
    • Day 6: 4mg
  • A large (but non-blinded and non-randomized) study showed benefit to a short course of oral prednisone for analgesic detoxification in medication overuse HA
    • Pts were instructed to gradually taper off of their analgesic over a 7d period.
    • Days 1-2: pred 60mg/day, Days 3-4: pred 40mg/day, Days 5-6: pred 60mg/day
    • Ranitidine 300mg/day for all 6 days of steroids
    • Start of the headache prophylactic medication on day 7
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21
Q

IV Valproate

_____ opinions/evidence. Some studies have shown IV valproate to be more effective than DHE plus metoclopramide for acute migraine, while other studies have not shown this.

HA relief has been shown to take effect anywhere from __ hour to ___ hours after infusion

A

Mixed opinions/evidence. Some studies have shown IV valproate to be more effective than DHE (ergotamine) plus metoclopramide for acute migraine, while other studies have not shown this.

HA relief has been shown to take effect anywhere from one hour to 24 hours after infusion

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22
Q

IV Valproate Admin Considerations

Dosing =

Typically used for (2) but used commonly in _______ settings/as _____ medication

A

500mg IV once (Diluted in 5mL of NS, given over 15-30min)

Typically a antiepileptic/mood stabilizer but used commonly in emergency settings/as rescue medication​

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23
Q

IV Valproate

SE

A

Generally well tolerated

However has many SE (decreased bone density (fracture risk), liver dysfunction, etc)

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24
Q

Acute Treatment of Migraines

First line is usually at (1) - but if the patient has CAD then use (2)

A

Triptan -> Analgesics/Esgic

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25
Migraine Prophylaxis Treatment ## Footnote **_G_**i_VVV_ _TPA_ **_B_**efore _C_risis
**Gabapentin** **Verapamil** **Venlafaxine XR** **Valproate** **Topiramate (Topamax)** **Propranolol** **Amitriptyline** **Botox** **CGRP Inhibitor**s (Erenumab (Aimovag), Galcanezumab (Emgality))
26
Topiramate (Topamax) Dosing ## Footnote = Target dose =
Start with 25mg once daily, and increase weekly by 25 mg/day up to a target dose of 50mg twice a day
27
Topiramate SE ## Footnote **(4) - (1)\***
Weight loss *– avoid in thin pts* Word finding difficulties Paresthesias **Kidney stones\***
28
Topiramate Efficacy ## Footnote Efficacy? Often can help with other comorbidities (3)
**Highly efficacious** at preventing migraines 1. Obesity 2. Epilepsty 3. Essential tremor
29
Propranolol Dosing ## Footnote (1) * Start with 80 mg/day divided every 6-8 hours. * Increase by 20-40 mg/dose every 3-4 weeks to effective dose. * Maximum dose for migraine prophylaxis is 240 mg/day given in divided doses every 6-8 hours. (1) * Start with 80 mg once daily. * Maximum dose for migraine prophylaxis is 240 mg once daily
Regular Release * Start with 80 mg/day divided every 6-8 hours. * Increase by 20-40 mg/dose every 3-4 weeks to effective dose. * Maximum dose for migraine prophylaxis is 240 mg/day given in divided doses every 6-8 hours. Long Acting Formulation * Start with 80 mg once daily. * Maximum dose for migraine prophylaxis is 240 mg once daily
30
Propranolol ## Footnote **Efficacy?** Vs other beta blockers?
**Highly efficacious** at preventing migraines, and propranolol is more efficacious than other beta blockers ## Footnote *If pt has migraines and already on a BB for heart disease – try to switch to propranolol*
31
Amitriptyline ## Footnote MOA
Blocks neuronal uptake of serotonin and norepinephrine
32
Amitriptyline Dosing ## Footnote * Start with 10-25 at **(1) time *bc \_\_\_\_\_\_*,** and increase (if needed and tolerated) gradually up to 150mg * If 10mg QHS is not tolerated, there are reports of patients experiencing relief at doses as small as \_\_-\_\_mg QHS
* Start with 10-25 at **QHS time *bc sedating***, and increase (if needed and tolerated) gradually up to 150mg * If 10mg QHS is not tolerated, there are reports of patients experiencing relief at doses as small as 2.5-5mg QHS
33
Amitriptyline ## Footnote **SE (1)\***
**Sedating\*** *AmiTRIPtyline (you're sedated so you trip)*
34
Amitriptyline Efficacy ## Footnote Also good for treating (3)**-(1)\***
* **comorbid insomnia\*** (which can further improve migraine control, as sleep deprivation often triggers migraines) * neuropathy * fibromyalgia
35
Gabapentin ## Footnote **MOA**
**Mechanism of pain control not well understood, but may relate to binding to voltage dependent Ca channels, thereby inhibiting the release of excitatory neurotransmitters**
36
Gabapentin Dosing ## Footnote Start w \_\_\_\_\_mg/day and increase (if needed and tolerated) gradually, up to 2400mg/day **(1)** reduces the chance of **(2)**
Start w 300mg/day and increase (if needed and tolerated) gradually, up to 2400mg/day **Gradual titration** reduces the chance of **dizziness and somnolence**
37
Gabapentin ## Footnote SE (1)
Peripheral Edema (maybe) "*ive seen it once"*
38
Gabapentin Efficacy ## Footnote Good choice for patients with impaired? Why?
**Good choice for patients with impaired liver function,** cleared by kidneys with no hepatic metabolism
39
Verapamil MOA and Dosing ## Footnote MOA Typical target dose?
Antihypertensive and Ca channel blocker 120-480mg/day divided Q6-12hrs
40
Verapamil ## Footnote SE (5)-**(3)\***
Dizziness **Hypotension** Constipation **Cardiac conduction blocks (heart blocks)** **CYP3A inhibition may cause drug-drug interactions**
41
Venlafaxine XR ## Footnote MOA
Blocks reuptake of serotonin and norepinephrine (SNRI)
42
Venlafaxine XR Dosing ## Footnote Very ____ results seen with \_\_mg daily, and \_\_\_mg daily \_\_\_mg more effective than \_\_mg daily Start with \_\_\_\_mg daily and then increase
Very good results seen with 75mg daily, and 150mg daily 150mg more effective than 75mg daily Start with 37.5mg daily and then increase
43
Valproate Dosing ## Footnote Regular release * Start with \_\_\_\_mg 2x/day * ______ (if needed and tolerated, may increase after one week to 1000mg once daily)
Regular release * Start with 250mg 2x/day * Titrate (if needed and tolerated, may increase after one week to 1000mg once daily)
44
Valproate Efficacy ## Footnote ***\_\_\_\_\_\_ efficacious*** at preventing migraines, but has ***many \_\_\_\_\_\_\_*** (t\_\_\_\_\_\_\_\_, ____ density loss, weight \_\_\_\_\_, \_\_\_\_\_cytopenia, \_\_\_\_\_\_toxicity, possible acceleration of (1) disease, (1) enzyme inhibition causing \_\_\_-\_\_\_ interactions etc.) *– therefore we don’t really use it for HA, more so for seizures (antiquated)*
***Highly efficacious*** at preventing migraines, but has ***many drawbacks*** (teratogenicity, bone density loss, weight gain, thrombocytopenia, hepatotoxicity, possible acceleration of carotid artery disease, liver enzyme inhibition causing drug-drug interactions etc.) *– therefore we don’t really use it for HA, more so for seizures (antiquated)*
45
Valproate Other Uses ## Footnote Can also treat other comorbidities (2) But Rx (1) also treats the same disorders w/o bad SE
Bipolar disorder, Epilepsy Lamotrigine also treats the same disorders w/o bad SE
46
Botulinum Toxin (Botox) ## Footnote Now FDA approved for migrain prevention Typically repeated every ___ months Efficacy? (PREEMPT trial) *However?*
Q3 months Highly efficacious *However* *recently, medicare has been pushing back on approving it for migraines bc new CGRP inhibitors (below) are the new tx for prevention of migraines*
47
CGRP Inhibitors ## Footnote **(2)** Also worth mentioning why? Dosing frequency? Efficacy? Only drawback is?
**Erenumab (Aimovag), Galcanezumab (Emgality)** Newest medication on the block * Injections once a month* * Works very very well, only drawback is before insurance companies will approve will show that pt has been trialed on many other meds first*
48
Menstrual Migraines ## Footnote **Caused by?** **What is priority?**
* Thought to be caused by the **sudden drop of estrogen levels at the beginning of the menstrual cycle** *(estrogen withdrawal)* * Can be treated acutely (triptans, NSAIDs, etc), but the predictable timing of these headaches provides a unique opportunity for successful **PREVENTION,** which should be the priority.
49
Menstrual Migraine Prevention (4)
**Triptans** **NSAIDs** **Magnesium** **Hormonal Prophylaxis**
50
Triptans ## Footnote * **\_\_\_\_\_\_triptan** 2.5mg daily or BID (BID shown to be more effective) for __ days_, starting \_\_days before expected onset of headache_ * **\_\_\_\_\_triptan** 1 mg BID for __ days, _starting __ days before anticipated menses_ * **\_\_\_\_\_\_triptan** (PO) 2.5 mg BID or TID (TID shown to be more effective) for __ days, _starting __ days before anticipated menses_ *So even though used for treatment can be used for prevention if used for a _____ period of time*
* **Frovatriptan** 2.5mg daily or BID (BID shown to be more effective) for 6 days_, starting 2 days before expected onset of headache_ * **Naratriptan** 1 mg BID for 5 days, _starting 2 days before anticipated menses_ * **Zolmitriptan** (PO) 2.5 mg BID or TID (TID shown to be more effective) for 7 days, _starting 2 days before anticipated menses_ ## Footnote *So even though used for treatment can be used for prevention if used for a short period of time*
51
NSAIDs ## Footnote **(1) Rx** (550 mg BID for 13 days, starting 7 days before onset of menses) shown to be effective, BUT THIS IS A ____ DOSE AND A _____ DURATION, WITH POTENTIAL FOR ADVERSE EFFECTS SUCH AS \_\_\_.
Naproxen (550 mg BID for 13 days, starting 7 days before onset of menses) shown to be effective, BUT THIS IS A HIGH DOSE AND A LONG DURATION, WITH POTENTIAL FOR ADVERSE EFFECTS SUCH AS GI.
52
Magnesium ## Footnote * Based on the idea that migraine patients may have (1) magnesium levels despite normal serum magnesium levels. * One study found magnesium pyrrolidone carboxylic acid 120mg PO TID (starting on the 15th day of the cycle and continuing until the next menses) to be effective. * *Class __ during pregnancy “we give magnesium like _____ during pregnancy for migraine prevention”* * *Why it works so well?*
* Based on the idea that migraine patients may have low intracellular magnesium levels despite normal serum magnesium levels. * One study found magnesium pyrrolidone carboxylic acid 120mg PO TID (starting on the 15th day of the cycle and continuing until the next menses) to be effective. * *Class B during pregnancy “we give magnesium like candy during pregnancy for migraine prevention”* * *Why it works so well bc it competes with Ca, knocks Ca off and prevents the neuron from firing*
53
Hormonal Prophylaxis ## Footnote To prevent abrupt? * Transdermal estradiol gel * Transcutaneous estradiol patches * Extended-cycle estrogen-progestin contraceptives * Cyclic estrogen-progestin contraception with supplemental estrogen *First thing to do is ______ the contraceptive that the pt is already on*
prevents abrupt decline of estrogen levels that occur at the beginning of the menstrual cycle * Transdermal estradiol gel * Transcutaneous estradiol patches * Extended-cycle estrogen-progestin contraceptives * Cyclic estrogen-progestin contraception with supplemental estrogen *First thing to do is switch the contraceptive that the pt is already on*
54
Tension Headache Classification Criteria ## Footnote * Pretty much _____ intense, always there, th\_\_\_\_\_ d\_\_\_\_ ache, but ____ go about their day* * Tension headache pts usually disappointed when they leave bc there’s not really a good med to fix it acutely besides nsaids and ice*
* Pretty much less intense, always there, throbbing dull ache, but can go about their day* * Tension headache pts usually disappointed when they leave bc there’s not really a good med to fix it acutely besides nsaids and ice*
55
Acute Treatment of Tension Headache (3)
**Simple Analgesics** **Caffeine Combinations** **Triptans**
56
Simple Analgesics ## Footnote * **Ac\_\_\_\_\_\_\_** 1000mg * **As\_\_\_\_\_** 500mg * **I\_\_\_\_\_\_** 200-800mg * **Ke\_\_\_\_\_** 12.5-50mg * **Na\_\_\_\_\_\_** 375-550mg * **Dic\_\_\_\_\_\_\_** 12.5-100mg Studies comparing have these to each other shown widely ______ results
* **Acetaminophen** 1000mg * **Aspirin** 500mg * **Ibuprofen** 200-800mg * **Ketoprofen** 12.5-50mg * **Naproxen** 375-550mg * **Diclofenac** 12.5-100mg Studies comparing have these to each other shown widely variable results
57
Caffeine Combinations ## Footnote (1) + Caffeine (1) + Caffeine (1) + (1) + Caffeine
**Aspirin** 1000mg and **Caffeine** 64mg **Ibuprofen** 400mg and **Caffeine** 200mg **Aspirin** 500mg, **Acetaminophen** 400mg, and **Caffeine** 100mg
58
Triptans ## Footnote Evidence on efficacy for tension headaches?
One study showed triptans to work for tension headache in migraine patients, but this raises the question of whether these were really tension headaches as opposed to migraine headaches
59
NOT RECOMMENDED for Tension HA ## Footnote **(3)** All have the abuse potential and increase the risk of medication overuse for headaches
**Muscle Relaxants** **Barbiturates (Butalbital, Fiorinal)** **Opiates**
60
Tension Headache Prophylaxis ## Footnote (2) Rx (2) Non-Rx
**Amitriptyline, SNRI's (mirtazaine, venlafaxine)** **Non-pharm: Relaxation techniques, Cognitive behavioral therapy**
61
Amitriptyline for Tension HA Prophylaxis ## Footnote Start with \_\_-\_\_mg at (1), and increase (if needed and tolerated) gradually up to \_\_\_\_mg
Start with 10-25mg QHS, and increase (if needed and tolerated) gradually up to 150mg QHS
62
SNRI's ## Footnote What about SSRIs? SNRIs have shown benefit 1. **(1) 30mg/day** 2. **(1) 150mg/day**
SSRI's have not shown to be beneficial SNRI's have shown benefit 1. **Mirtazapine 30mg/day** 2. **Venlafaxine XR 150mg/day**
63
Other Headache Types Worth Mentioning (3)
**Occipital Neuralgia** **Cluster Headaches** **Hemicrania continua**
64
Occipital Neuralgia ## Footnote Diagnostic Test = Treatment =
Occipital nerve block – *diagnostic test - if the HA go away for a few days when blocked (numbed)/ can also be tested by reproducing pain radiation pattern by pressing on occipital notch* Radiofrequency ablation – *not an important nerve so it can be killed, just controls sensation to the scalp*
65
Cluster Headaches ## Footnote Prevalence = Symptoms = More frequently seen in what population? Treatment (2)
Rare *VERY SEVERE, comes in clusters, usually with other sx of the eye, usually unilateral* More frequent in *young* males 1. **Sumatriptan 6mg SC or 20mg intranasal** 2. **Inhaled O2 (100% 12L/min, delivered by face mask, for 15 min at the start of an attack of cluster headache)**
66
Hemicrania Continua ## Footnote IHC criteria require at least a 3 months of constant pain but may have fluctuating severity Unilateral, with ipsilateral _________ symptoms (ie: rhinorrhea, lacrimation, conjunctival injection, nasal congestion, ptosis, miosis) but ____ prominent than in cluster headache IHC criteria require a + response to **(1) Rx** (suggested trial) * 50mg BID x3d then * 50mg TID x3d then * 50mg QID x3d
IHC criteria require at least a 3 months of constant pain but may have fluctuating severity Unilateral, with ipsilateral autonomic symptoms (ie: rhinorrhea, lacrimation, conjunctival injection, nasal congestion, ptosis, miosis) but less prominent than in cluster headache IHC criteria require a + response to **indomethacin** (suggested indomethacin trial) * 50mg BID x3d then * 50mg TID x3d then * 50mg QID x3d
67
Headaches in Pregnancy ## Footnote 1. Migraine headaches often improve during pregnancy, why? 2. Medication choices are significantly \_\_\_\_\_\_\_ 3. Acetaminophen is pregnancy class \_\_ 4. (1) is sometimes used for migraines *(class B, used the most, Rx (1) has less diarrhea than (1))* 5. Pregnancy is the time for optimization of \_\_\_-pharm measures 6. Pregnancy class C medications sometimes used in _____ circumstances 7. Breast-\_\_\_\_\_ issues
1. Increased and more steady estrogen levels (*opposite of menstrual HA, estrogen is protective aganst migraines)* 2. limited 3. Tylenol = Class B 4. Magnesium - *Magnesium Oxide 400mg daily has less diarrhea than mag sulfate* 5. extreme 6. breast-feeding issues
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Dangerous Headaches (3)
**Temporal Arteritis** **Pseudotumor Cerebri** **Thunderclap Headache**
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Temporal Arteritis Features ## Footnote 1. age older than ___ *, _____ onset HA* 2. tender t\_\_\_\_\_(s) 3. ____ claudication 4. weight \_\_\_\_\_, malaise, fa\_\_\_\_\_, fe\_\_\_\_, night \_\_\_\_\_ 5. poly\_\_\_\_\_\_ rheumatica 6. v\_\_\_\_\_ problems 7. ***CHECK\* (2)***
1. age older than 50 *, new onset HA* 2. tender temple(s) 3. jaw claudication 4. weight loss, malaise, fatigue, fever, night sweats 5. polymyalgia rheumatica 6. vision problems 7. **elevated ESR (sed rate), elevated CRP** *CHECK\**
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Temporal Arteritis Dg/Tx ## Footnote 1. **Diagnosis =** 2. **Treatment =**
1. **Diagnosis =** Temporal artery biopsy *(DO NOT miss this dg, can cause permanent blindness)* 2. **Treatment =** Steroids (*start tx before biopsy results, send to ophthalmologist)*
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Pseudotumor Cerebri Features ## Footnote 1. Also called (1) 2. **Increased _____ pressure causing headache and can cause vision problems and visual field problems** 3. Strongly associated with \_\_\_\_\_\_ 4. CN 6 palsy possible = 5. (2) if not sufficiently treated 6. *Over\_\_\_\_\_ pt with HA*
1. Also called “idiopathic intracranial hypertension” 2. **Increased CSF pressure causing headache and can cause vision problems and visual field problems** 3. Strongly associated with obesity 4. CN 6 palsy possible = *abducens: responsible for EOM* 5. Permanent vision problems or blindness if not sufficiently treated 6. *Overweight pt with HA*
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Pseudotumor Cerebri Diagnosis ## Footnote * Opthalmoscopic exam may see (1) * Visual _____ and visual \_\_\_\_\_\_ * **Diagnostic Test =**
* Opthalmoscopic exam (papilledema) *optic disc margins less crisp* * Visual fields and visual acuity * **LP (elevated CSF opening pressure) – *spinal tap right away***
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Pseudotumor Cerebri Treatment ## Footnote 1. **\_\_\_\_\_ removal** 2. **Weight \_\_\_\_** 3. **(1) Rx** 4. Optic nerve fenestration 5. **(1) placement**
1. **CSF removal** 2. **Weight loss** 3. **Carbonic anhydrase inhibitors** 4. Optic nerve fenestration 5. **VP shunt placement**
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Thunderclap Headache Described as? Differential Diagnosis 1. **Vascular =** 2. **Non Vascular =** 3. **Primary headache disorders =**
"Worst headache of my life" 1. **Subarachnoid hemorrhage**, Cerebral venous sinus thrombosis, carotid or vertebral artery dissection, reversible cerebral vasoconstriction syndrome, acute hypertensive crisis, ischemic stroke, pituitary apoplexy 2. Spontaneous csf leak, colloid cyst of the third ventricle 3. Primary cough, exertional, sexual headache
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Thunderclap Headache ## Footnote Work up =
CT head, LP, MRI, MRA, CTA
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Case #1 ## Footnote * 42 –year-old female with 3-year history of R-sided headaches * pulsating * lasting 4-24 apiece, occurring 2-3 times a week * associated with nausea, vomiting, phonophobia, photophobia. * debilitating * OTC analgesics only help slightly. * PMHx of kidney stones, asthma, and tubal ligation. * What type of headaches are these? * How would you treat them?
**Migraines** * NO Topiramate (kidney stones) * NO Propranolol (asthma) * Amitriptyline * Gabapentin * Verapamil * Venlafaxine XR * Valproate * Botox
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Case #2 ## Footnote * 51 –year-old male with 2-year history of **bifrontal headaches “bandlike sensation)** * **tightening/pressure sensation** * lasting 30 minutes to an entire day, occurring 6-7 times a month * no photophobia, phonophobia, nausea, or vomiting * pain is 6/10 * OTC analgesics only help slightly. * PMHx of _insomnia_. * What type of headaches are these? * How would you treat them?
**Tension headaches** * Tension HA Prophylaxis * **Amitriptyline** (good for insomnia, and also for superimposed migraines) * Mirtazapine * Venlafaxine XR (good for superimposed migraines) * Nonpharmacologic (cognitive behavioral therapy, relaxation techniques) \*\*\*\* Each of these may also help with coexisting depression
Diagnosis and Management
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