HA- Heeter

2 hours

Difference between primary and secondary headaches?

• primary: not associated with underlying illness

• secondary: symptoms of underlying illness

What does the SNOOP acronym stand for in headache red flags?

• S- systemic symptoms (fever, weight loss)

• N- neurologic symptoms (confusion)

• O- onset (sudden, abrupt, etc.)

• O- older (new onset or progressive HA)

• P- previous history (1st HA or new HA)

Examples of primary headaches?

• tension

• migraine w or w/out aura

• chronic migraine

• cluster HA

Which of the following appears to be hereditary (~70%)?

a. tension

b. cluster

c. migraine

c.

Exclusions for Self-Treatment of HA:

• idk how imp

Severe head pain, Headaches persisting for 10 days, Last trimester of pregnancy, < 8 years of age, High fever, Liver disease, Secondary headaches, Symptoms consistent with migraine/cluster HA but no formal diagnosis.

Describe the pathophysiology behind migraines:

• lowkey I feel like he won’t ask—> more of a Khan type question

• combo of neuronal and vascular factors:

  • activation of trigeminal sensory nerves—> releases neuropeptides (sub P, CGRP, neurokinin A)

    • results: vasodilation, inflammation, pain

  • disturbances with serotonin

    • low levels between attacks

    • increased levels during attacks/HA

List migraine triggers for each category:

• environmental

• food

• behavioral/physiologic

• medications

• Environmental:

  • Changes in barometric pressure

  • Bright/flickering lights

  • Loud noise

  • Odors

• Food:

  • Alcohol, Caffeine, Chocolate, Fermented foods, MSG

• Behavioral/Physiologic:

  • Irregular sleep

  • Hormonal changes

  • Skipping meals

  • Strenuous exercise

  • Stress

• Medications:

  • nitrates

  • contraceptives

  • postmenopausal hormones

  • reserpine

Migraine premonitory symptoms occur in up to 79% of patients and can be neurologic, psychologic, autonomic, or constitutional.

List the neurologic premonitory symptoms:

• allodynia (Nerve pain)

• photophobia

• phonophobia

• hyperosmia (Increased sensitivity to smells)

• difficulty concentrating

BASICALLY: sensitivity to all 5 senses 🙃

Is a migraine usually a bilateral or unilateral throbbing or pulsing?

UNILATERAL

What symptoms usually accompany a HA?

GI—> n/v

What are the components of a migraine diagnosis?

• Comprehensive HA history (age, frequency, timing, duration, etc.)

• rule out secondary HA

• MIDAS questionnaire (used to assess impact of migraines on daily life)

What can be used non-pharm for migraines?

(include for prevention and for acute migraine)

prevention:

• identify and avoid triggers (keep a diary)

• adhere to wellness program (sleep, exercise)

• behavioral interventions (therapy)

acute migraine:

• apply ice to head

• rest/sleep in dark/quiet environment

What do medical devices like Cefaly, Nerivio, Relivion MG, and gammaCore do in migraine?

stimulate nerves to prevent/treat migraine

What is the general treatment approach for mild-moderate headaches? what about severe?

mild/mod: use non-migraine specific agents (NSAIDs, steroids, other analgesics)

severe: migraine specific agents (ergos, triptans, etc.)

What is the most common cause of chronic headaches? how to avoid?

• most common—> medication overuse

• how to avoid—> limit abortive therapies to max 2-3x a week

WHAT IS FIRST LINE FOR MILD-MODERATE MIGRAINES:

• APAP/NSAIDS/SALICYLATES

  • best evidence for: ASA, diclofenac, IBU, ketorolac, naproxen, APAP/ASA/caffeine combo

What role do opiates play in migraine treatment?

• any evidence?

• risks?

• when is it used?

• GENERALLY AVOID—> evidence for use is generally negative

• risks: medication-overuse HAs, dependence

• use only for those who have C/I to other therapies

When to administer antiemetics (ex: metoclopramide, chlorpromazine) for n/v associated with migraines?

admin 15-30 min prior to abortive therapy

Ergot Alkaloids MOA

Nonselective 5HT1 agonists —> vasoconstriction of intracranial blood vessels, inhibition of inflammation

Side effects of ergot alkaloids?

• n/v (consider pre-tx)

• diarrhea

• chest tightness

• elevated BP

DO NOT USE ERGOT ALKALOIDS WITHIN 24 HOURS OF _____________.

TRIPTAN

Ergot Alkaloid C/I

• renal and hepatic failure

• CV—> CAD, PVD, uncontrolled HTN

• cerebrovascular disease

• sepsis

• pregnancy

• lactation

WHAT IS THE FIRST LINE TREATMENT FOR MODERATE-SEVERE MIGRAINE AS ABORTIVE THERAPY?

TRIPTANS

Triptans MOA

selective agonists of 5-HT1B and 1D

If I take a triptan and it fails, can I try another triptan or do I switch to another class?

switch to another triptan

TRIPTAN C/I

• history of ischemic heart disease (angina, previous MI), uncontrolled HTN, cerebrovascular disease

• MAOI within 2 weeks (suma, riza, zolmi)

25% of patients that take triptans may experience what symptom?

tightness, pressure, heaviness, or pain in chest

Which triptans have a slower onset, but longer duration?

These triptans would be best in patients with what kind of migraines?

• frovatriptan (t ½ =25hrs), naratriptan (t ½ =5-6hrs), eletriptan (t ½ =4-5hrs)

• best for pts. with migraine with slow onset and long duration

What is the only triptan that comes in injection form?

sumatriptan

Lasmiditan (Reyvow) MOA

Selective 5-HT1F agonist—> Minimized vasoconstriction

Do not drive/operate machinery for at least 8 hrs after taking what drug?

Lasmiditan

What are the names of the CGRP Antagonists?

• dosage forms of each?

• Ubrogepant (Ubrelvy)- tablet

• Rimegepant (Nurtec ODT)- orally disintegrating tablet

• Zavegepant (Zavzpret)- nasal

What are the C/I of each CGRP antagonist?

• Ubrogepant and Rimegepant—> C/I w strong CYP3A4 inhibitors

• Zavegepant—> avoid with nasal decongestants (easy to remember bc the dosage form of this one is nasal)

What are the migraine prophylaxis indications?

• Recurring migraines with disability (even w/ acute tx)

• frequent attacks requiring use of acute tx more than 2x/week

• ineffective abortive therapy

• patient preference

• uncommon migraine types

Trial of ____-____ months required to assess efficacy of prophylaxis tx of migraines.

2-3 months (some say 6)

What are the FDA approved agents for migraine prophylaxis?

(not off-label drugs, only FDA approved)

• propranolol

• timolol

• valproate

• topiramate

• botulinum toxin A

• CGRP agents

What antidepressants have shown the most efficacy and are used off-label for migraine prophylaxis?

amitriptyline and venlafaxine

What beta-blockers are used for Migraine Prophylaxis? (include FDA and off-label)

• propranolol, timolol—> FDA approved

• nadolol, atenolol, metoprolol—> also effective

What anticonvulsants are used for Migraine Prophylaxis? (include FDA and off-label)

• valproate, topiramate—> FDA approved

• carbamazepine, gabapentin—> off-label

C/I of valproate?

• pregnancy

• liver disease

• pancreatitis

What is the indication of Botulinium toxin A for migraine prophylaxis?

prophylaxis of headaches in adults with chronic migraines (15+ days/month lasting 4hrs a day or longer)

BBW of Botulinum toxin A?

distant spread of toxin may occur hours-weeks after injection leading to swallowing/breathing problems and potentially death

List the CGRP mabs:

• distinguish which target CGRP and which are CGRP receptor antagonists

• CGRP mabs targeting CGRP

  • Fremanezumab

  • Galcanezumab

  • Eptinezumab

• CGRP mabs targeting CGRP receptor

  • Erenumab

What are the 3 criteria a pt. must meet in order to taken a CGRP mab?

1. be at least 18 yrs old

2. have at least one of the following:

   • 4-7 HA/month with moderate disability

   • 8-14 HA/month

   • chronic migraines and can’t use botulinum toxin A

3. failed a 6 week trial of at least 2 other meds for migraine prophylaxis

What CGRP agonists are used for migraine prophylaxis?

• Rimegepant

• Atogepant

Answer the following about prophylaxis medications:

• what NSAID has the most data for use? when are they most useful?

• what CCB can be used as 2nd or 3rd line when other meds have failed?

• what is the only situation where triptans are used for prophylaxis?

• naproxen—> most useful for predictable HA

• verapamil

• only useful for prevention of menstrual migraines (start 1-2 before period)

What is a tension HA?

Is it acute or chronic?

What is the pathophys behind them?

• tension HA—> in response to stress, anxiety, depression

• can be acute or chronic

• pathophys:

  • activation of pain perception structures in brainstem

  • chronic HA evloves from acute, episodic HA

What symptoms are ABSENT in tension headaches?

What are the symptoms of tension HAs?

• premonitory and aura symptoms are ABSENT

• symptoms: mild-mod pain, BILATERAL most common

  • generally no associated symptoms

Nonpharm for tension HA?

• behavior tx (therapy)

• NO CONSISTENT BENEFIT seen with heat, cold, massage, exercise, etc.

What pharm tx is used for tension headaches?

• APAP

• ASA

• APAP/ASA/Caffeine combo

• NSAIDs (IBU, naproxen, indomethacin, ketoprofen, ketorolac)

APAP and ASA are available in combo with bulalbital and caffeine but is generally avoided why?

due to dependency/overuse risk

What are the symptoms of a SINUS HEADACHE?

• dull, pressure-like pain in forehead area

• usually pt. will have other sinus symptoms (nasal discharge, congestion)

Tx of sinus headaches?

• treated like TENSION headaches (APAP, ASA, NSAIDS)

• may be combined with decongestants to help with nasal symptoms

Cluster HAs are rare, but considered the most severe.

What are the symptoms?

• most are episodic in nature—> attacks, then remission

• SEVERE pain, described as sharp, penetrating

• usually UNILATERAL

• often accompanied by cranial autonomic symptoms (face sweating, lacrimation, nasal stuffiness)

• NO AURA

What is the preferred 1st line tx for prevention of cluster HA?

Verapamil

Tx for cluster HA?

• what dosage forms are preferred for abortive therapy?

• abortive therapy

  • oxygen

  • triptans- SC or intranasal formulations (especially sumatriptan SC)

  • ergotamine derivatives- IV dihydroergotamine

  • galcanezumab- 3 injections at onset of HA, then monthly till end of cluster period

• prophylaxis

  • verapamil

  • lithium

  • steroids

REVIEW:

Compare the location, nature, onset, duration, and identify other symptoms associated with each kind of HA:

HA type	Location	Nature	Onset	Duration	Other sx
Migraine
Tension
Sinus
Cluster

PRACTICE:

What is the ONLY type of headache where pts. pay experience aura?

a. tension

b. migraine

c. sinus

d. cluster

b.