headache - zach

what type of headache is ~90% of headaches and is NOT associated with underlying illness?

a. primary

b. secondary

a.

what type of headache is a symptom of underlying illness?

a. primary

b. secondary

b.

what acronym is used for “red flags” of headaches?

SNOOP

systemic symptoms (fever, weight loss)

neurologic symptoms (confusion, impaired alertness/consciousness)

onset (sudden, abrupt, or split second)

older (new onset or progressive headache, especially if > 50 yo)

previous history (first headache or new/different headache)

are migraines more prevalent in men or women? is with or without aura more common?

women; without aura

how can medication-overuse cause headaches?

rebound effect from withdrawal of an analgesic

NSAIDs, ASA, caffeine, triptans, opioids, butalbital, ergotamine

list exclusions for self-treatment (there’s a bunch but i just picked out the important ones)

persistent (10 days)

last trimester of pregnancy

< 8 y.o.

what are the neurologic (most common) premonitory symptoms that occur hours-days before migraine?

allodynia

photophobia

phonophobia

hyperosmia

difficulty concentrating

list the visual effects of aura

positive: scintillations, photopsia, teichopsia

negative: scotoma, hemianopsia

headaches are usually ________ and described as throbbing or pulsating

a. bilateral

b. unilateral

b.

what other symptoms can occur with headaches?

N/V

photophobia (light)

phonophobia (sounds)

osmophobia (odors)

what questionnaire is used to assess impact of migraines on daily life?

MIDAS

if a migraine is mild-moderate, what agents should we use?

a. non-migraine-specific

b. migraine-specific

a.

if a migraine is severe, what agents should we use?

a. non-migraine-specific

b. migraine-specific

b.

abortive therapies should be limited to a maximum of ________ to reduce incidence of overuse HA

2-3 times/week

what is first line for mild-moderate migraines?

APAP

NSAIDs: diclofenac, ibuprofen, ketorolac, naproxen

salicylates

APAP/ASA/caffeine combo

what combination OTC product has shown benefit in mild-moderate migraines?

APAP/ASA/caffeine

when are opiates used for migraines? why do we not want to use them?

CI to other therapies

risk for medication-overuse headaches

when should we administer antiemetics to help with N/V associated with migraines?

15-30 minutes prior to abortive therapy

what drug class are nonselective 5HT1 agonists?

ergot alkaloids and derivatives

list ADRs of ergot alkaloids and derivatives

N/V

diarrhea

chest tightness

elevated BP

what drug class can you not use within 24 hours of triptans?

ergot alkaloids and derivatives

list CIs of ergot alkaloids and derivatives

renal and hepatic failure

CAD

PVD

cerebrovascular disease

uncontrolled HTN

sepsis

pregnancy

lactation

what is first line therapy for moderate-severe migraine as abortive therapy?

TRIPTANS!!!!!! (5HT agonists)

if you fail 1 triptan, what should you do?

a. switch to lasmiditan

b. switch to CGRP antagonists

c. switch to another triptan

d. switch to a prophylactic agent

c.

what drug class is contraindicated with a history of ischemic heart disease (angina, previous MI), uncontrolled HTN, and cerebrovascular disease?

triptans

what drug class can you NOT give within 24 hours of ergotamine derivatives?

triptans

you cannot give ________ within 2 weeks of MAOI therapy

sumatriptan

rizatriptan

zolmitriptan

triptans:

which ones are better for pts with migraines that are slow onset/long duration? (SATA)

a. frovatriptan

b. naratriptan

c. sumatriptan

d. almotriptan

e. eletriptan

a. b. e.

triptans:

what dosage form should be used for patients that have early onset of N/V? (SATA)

a. regular oral tablet

b. nasal spray

c. SQ injection

d. ODT tablet

b. c. d.

triptans:

which are the best tolerated? (SATA)

a. sumatriptan

b. naratriptan

c. frovatriptan

d. eletriptan

e. almotriptan

b. c. e.

what is the brand name of the sumatriptan injection? (SATA)

a. imitrex

b. tosymra

c. amerge

d. zembrace symtouch

a. d.

what are the brand names of the sumatriptan nasal products (powder and spray)?

powder: onzetra xsail

spray: imitrex, tosymra

what is the brand name of zolmitriptan?

a. zomig

b. tosymra

c. maxalt

d. zembrace symtouch

a.

what is the brand name of naratriptan?

a. imitrex

b. tosymra

c. amerge

d. axert

c.

what is the brand name of almotriptan?

a. imitrex

b. tosymra

c. amerge

d. axert

d.

what is the brand name of eletriptan?

a. frova

b. relpax

c. amerge

d. onzetra xsail

b.

idk if we need to know the actual half lives

what are the half-lives of the slow onset, long duration triptans?

eletriptan: 4-5 hours

naratriptan: 5-6 hours

frovatriptan: 25 hours

what drug is a selective 5HT1F agonist and is a schedule V controlled substance?

lasmiditan

list the CGRP antagonists used for abortive tx

-gepant/gapant

ubrogepant (Ubrelvy)

rimegepant (Nurtec ODT)

zavegapant (Zavzpret)

which CGRP antagonists are contraindicated with strong CYP3A4 inhibitors? (SATA)

a. ubrogepant

b. rimegepant

c. zavegapant

a. b.

which CGRP antagonists need to be avoided with nasal decongestants? (SATA)

a. ubrogepant

b. rimegepant

c. zavegapant

c.

which CGRP antagonists have a side effect of nausea? (SATA)

a. ubrogepant

b. rimegepant

c. zavegapant

a. b. c.

which CGRP antagonist has a side effect of somnolence?

a. ubrogepant

b. rimegepant

c. zavegapant

a.

which CGRP antagonist has a side effect of nasal discomfort?

a. ubrogepant

b. rimegepant

c. zavegapant

c.

when are prophylaxis agents indicated for migraines?

recurring —> significant disability with acute tx

acute tx > 2x/week

abortive therapy ineffective

uncommon variants

pt prefernce

list abortive agents for migraines

APAP/NSAIDs/salicylates

opiates

ergot alkaloids/derivatives

triptans

lasmiditan

CGRP antagonists

list FDA-approved agents for migraine prophylaxis

propranolol

timolol

valproate

topiramate

botulinum toxin A

CGRP agents

list the CGRP monoclonal antibodies (-umab) used for migraine prophylaxis

fremanezumab-vfrm (ajovy)

galcanezumab-gnlm (emgality)

eptinezumab-jjmr (vyepti)

erenumab-aooe (aimovig)

which drug is a monoclonal antibody targeting CGRP receptor antagonist?

a. fremanezumab (ajovy)

b. galcanezumab (emgality)

c. eptinezumab (vyepti)

d. erenumab (aimovig)

d.

which criteria must be met for CGRP monoclonal antibodies to be used for migraine prophylaxis? (SATA)

a. > 18 years old

b. at least one of the following: 4-7 headaches/month with moderate disability, 8-14 headaches/month, chronic migraines (cannot use botulinum toxin A)

c. failed a 6 week trial of ≥ 2 other meds for migraine prophylaxis

a. b. c.

list the CGRP antagonists used for migraine prophylaxis

-gepant

rimegepant (nurtec ODT)

atogepant (qulipta)

what CCB is used most commonly for migraine prophylaxis?

a. verapamil

b. amlodipine

c. diltiazem

d. nifedipine

a.

what drug class is ONLY useful as prevention therapy if it’s menstrual migraines?

a. NSAIDs

b. CCBs

c. triptans

d. butterbur

c.

T/F tension headaches can be acute or chronic

TRUE

which of the following describes the clinical presentation of tension headaches? (SATA)

a. premonitory and aura symptoms present

b. mild-moderate bilateral pain in a “hatband” pattern

c. associated symptoms, like photophobia, phonophobia, and osmophobia are always present

d. worsened by shivering/cold temps

b. d.

list tx options for tension headache

just think of normal OTC pain/headache meds

APAP

ASA

APAP/ASA/caffeine combo

NSAIDs

T/F APAP and ASA should always be used in combination with butalbital and caffeine for tension headaches

FALSE — avoid due to risk of dependency and overuse potential

what type of headache is described as dull, pressure-like pain in the periorbital, forehead area, with pain worse in the morning?

a. migraine

b. tension

c. sinus

d. cluster

c.

how are sinus headaches treated?

same as tension + decongestant

what is considered the most severe of the primary headache disorders?

a. migraine

b. tension

c. sinus

d. cluster

d.

what kind of headache is this: episodic, attacks occur daily for weeks-months, occur more commonly at night and spring/fall

a. migraine

b. tension

c. sinus

d. cluster

d.

what is considered chronic cluster headaches?

attacks recur over the course of 1 year w/o a remission period of at least 1 month

cluster headaches are sharp/penetrating pain in _______ locations

a. unilateral

b. bilateral

a.

list abortive therapy (managing acute attacks) options for cluster headaches

oxygen

triptans

ergotamine derivatives

galcanezumab

list prophylactic therapy (start early in cluster period in attempt to induce remission) options for cluster headaches

verapamil

lithium

corticosteroids

what is the preferred 1st line treatment for prevention of cluster headaches?

a. lithium

b. verapamil

c. corticosteroids

b.