T2 EX4 L8 (HEADACHE DISORDERS) (JOHNSON)

Three types of primary headaches?

Cluster headaches

Migraine

Tension headaches

Define migraine headaches

Recurring episodes of unilateral throbbing head pain

Autonomic and constitutional symptoms of migraines? (eight)

1. Polyuria

2. Diarrhea

3. Constipation

4. Stiff neck

5. Yawning

6. Thirst

7. Food cravings

8. Anorexia symptoms

Define aura in migraines

Seeing bright flashing dots, sparkles, or lights

Blind spots in your vision

Numb or tingling skin

Speech changes

Tinnitus

Temporary vision loss

Describe prodrome symptoms

Occur between several days before and up to 3 hours prior to headache onset

Problems concentrating, irritability, depression, etc.

T/F: Aura phase of a migraine generally occurs between 5 and 60 minutes prior to onset.

True

How long can migraine headaches last? (estimated range)

4-72 hours

What are the postdrome symptoms of migraine?

Being unable to concentrate

Feeling depressed

Fatigue

Not being able to understand things

Feeling euphoria

How long does the postdrome phase of migraines last?

About 1-2 days

Describe tension headaches

Dull, persistent bilateral and hatband distribution

Occur during or after stress

Intensity fluctuates throughout the day

May be accompanied by skeletal muscle over-contraction, depression, nausea

Where are cluster headaches usually felt?

Behind the eyes

About how long can cluster headaches last?

Periods of daily headaches and remission lasting month to years

T/F: Cluster headaches are usually unilateral, behind the eye.

True

Which signs or symptoms are consistent with cluster headaches?

A. Unilateral pain behind the eye

B. Uniform flashes of light

C. Bilateral pain back of the head

D. Fluctuating headache pain

A. Unilateral pain behind the eye

The vascular hypothesis of headaches hypothesis

Focal neurologic symptoms (aura) are caused by vasoconstriction and reduction in cerebral blood flow; headache caused by compensatory vasodilation with displacement of pain-sensitive intracranial structures

The trigeminovascular mechanism of headaches hypothesis

Neurons originating in the trigeminal ganglion, which innervate the cerebral circulation

Potent vasodilator neuropeptides contained within trigeminal neurons (CGPR, substance P, neurokinin A)

The abnormalities of serotonin activity in headaches hypothesis

Decrease in 5-HT levels during headache, increase in urinary 5-hydroxyindoleacetic acid levels

POUND acronym?

P - pulsatile quality of headache

O - one day duration (4-72 hours)

U - unilateral location

N - N/V

D - Disabling intensity

What are some potential triggers for migraine headaches?

MSG

Exercise

Altered sleep pattern

Aspartame

Alcohol

Acetaminophen indicated in what severity of migraine attacks?

Mild to moderate

MOA of acetaminophen in migraines?

Prevent neurogenically mediated inflammation in the trigeminovascular system through the inhibition of prostaglandin synthesis.

T/F: Oral contraceptives (OC) may worsen or precipitate migraine attacks in women without a previous history.

True; they may manifest within first few months or years of use.

Acetaminophen dosing for migraine attacks?

1000 mg PO q4h (max: 3000 mg)

NSAIDs MOA for migraine attacks?

Prevent neurogenically mediated inflammation in the trigeminovascular system through the inhibition of prostaglandin synthesis via COX1/COX2 inhibition

T/F: NSAIDs are contraindicated in CABG.

True

T/F: NSAIDs should be avoided in patients with previous PUD, renal disease.

True

T/F: Exedrin has greater efficacy than either components alone at comparable doses.

True

MOA of serotonin receptor agonists (triptans)?

Selective agonist activity at 5-HT 1B/1D

Reduces excitability of neurons in trigeminovascular system (5-HT 1B/1D)

Reduces release of inflammatory, vasodilating neuropeptides (5-HT 1D)

Vasoconstriction of cerebral and extracerebral vessels (5-HT 1B)

Adverse effects associated with serotonin receptor agonists (triptans)?

Paresthesias, fatigue, dizziness, flushing, warm sensations, and somnolence

Bitter taste (intranasal, ODT)

"Triptan sensations) (25%) including tightness, pressure, heaviness, or pain in the chest, neck, or throat)

Contraindications for triptans?

Ischemic heart disease

Uncontrolled hypertension

CVD

Hemiplegic and basilar migraine

Cautions for triptans?

Don't give within 2 weeks of MAOI

Eletriptan should not be given with CYP3A4 inhibitors

Triptans should not be given within 24 hours of ergotamine derivatives

Anyone with risk of bad heart should get cardio assessment prior to initiation

Caution for concomitant SSRI/SNRI therapy for 5-HT syndrome

T/F: Triptans not for routine use in pregnancy.

True

Almotriptan brand name?

Axert

Eletriptan brand name?

Relpax

Frovatriptan brand name?

Frova

Naratriptan brand name?

Amarge

Rizatriptan brand name?

Maxalt

Sumatriptan brand name?

Imitrex

Zolmitriptan brand name?

Zomig

Mechanism of action of ergotamines, dihydroergotamiones?

Nonselective 5-HT1 receptor agonists that constrict intracranial blood vessels and inhibit the development of neurogenic inflammation in the trigeminovascular system

Central inhibition of the trigeminovascular pathway is also reported as well as agonist activity at dopaminergic receptors

Venous and arterial constriction occur with therapeutic dose

Adverse effects associated with ergotamine/dihydroergotamine?

N/V (most common), abdominal pain, weakness, fatigue, paresthesias, muscle pain, diarrhea, severe peripheral ischemia (rare)

Contraindications to ergotamine/dihydroergotamine use?

Renal or hepatic failure

Coronary, cerebral, or peripheral vascular disease

Uncontrolled HTN

Sepsis

No pregnancy or nursing fr

Who gets opioids for headaches??

Moderate-to-severe infrequent headaches when conventional treatments are contraindicated, or as "rescue medication" after patients ahve failed to respond to conventional treatments

MOA of opioids?

Mu opioid receptor agonists

Adverse effects of opioids?

Constipation

Dizziness

Sedation

Respiratory depression

N/V

Rescue therapy options for status migrainous?

Dexamethasone 4-16 mg IV

Valproate 400 to 1,000 mg IV

Mag Sul 1,000 to 2,000 mg IV and isometheptene combinations are probably effective, but more data is needed

MOA of calcitonin gene-related peptide receptor (CGRP) antagonists?

it just is what it says

MOA of ubrogepant (Ubrelvy), rimegepant (Nurtec), ategopant (Qulipta)?

CGRP antagonists

CGRP antagonists are indicated for...?

Acute treatment of migraine with or without aura in adults (ubrelvy, nurtec) and preventive treatment of episodic migraines (nurtec and qulipta)

Contraindications for CGRP antagonists?

Strong CYP3A4 inhibitors

Listed as a CI specifically for ubrelvy

Adverse effects of CGRP antagonists?

Nausea, constipation

Somnolency (ubrelvy)

Abdominal pain/dyspepsia (when nurtec is given as preventative treatment)

MOA of lasmiditan (Reyvow)?

Activates 5-HT1F receptors, which are found inside and outside the brain to block pain signals; exact role of 5-HT1F receptors unknown

T/F: Lasmiditan is a CIV scheduled substance.

False; CV.

Warnings and precautions for use of Reyvow?

Driving impairment, CNS depression, 5-HT syndrome, medication overuse, headache

Adverse effects of lasmiditan (reyvow)?

Dizziness, fatigue, paresthesia, sedation, N/V, muscle weakness

MOA of antiemetics?

Dopamine receptor antagonists

Antiemetics used in migraines? (four)

1. Metoclopramide (Reglan)

2. Chlorpromazine (Thorazine)

3. Prochlorperazine (Compazine)

4. Droperidol (Inapsine)

First line for severe migraines?

Triptans

Anticonvulsants used in migraines? (two)

Valproate/Divalproex

Topiramate

T/F: Valproate safe for use in pregnancy.

False

Contraindications for valproate?

Pregnant women, hx of pancreatitis or chronic liver disease

Indication for anticonvulsant use in migraines?

Migraine prophylaxis, particularly useful in patients with comorbid seizures, anxiety disorder, or bipolar illness

MOA of anticonvulsants in migraines?

Enhancement of y-aminobutyric acid (GABA)-mediated inhibition, modulation of the excitatory neurotransmitter glutamate, and inhibition of sodium and calcium ion channel activity

Antidepressants used in migraines? (three)

Amitriptyline

Venlafaxine

Duloxetine

Indication for antidepressants in migraines?

Migraine prophylaxis

MOA of antidepressants in migraines?

Downregulation of central 5-HT2 receptors, increased levels of synaptic norepinephrine, and enhanced endogenous opioid receptor actions

Adverse effects associated with amitriptyline?

Anticholinergic

Increased appetite and weight gain

Orthostatic hypotension

Cardiac toxicity

Beta blockers used for migraines? (three)

Metoprolol

Propranolol

Timolol

Indication for beta blockers in migraines?

Migraine prophylaxis, may be useful in patients with comorbid hypertension or angina

MOA of beta blockers in migraines?

Not really known

B-blockers may raise the migraine threshold by modulating adrenergic or serotonergic neurotransmission in cortical or subcortical pathways

Use BB for migraines with caution in what patient populations?

CHF

PVD

Atrioventricular conduction disturbances, asthma, depression, diabetes

First line "other" therapies (not triptans or analgesics) used in migraine treatment? (four drugs)

1. Propranolol (Inderal)

2. Amitriptyline (Elavil?)

3. Valproate (Depakote)

4. Topiramate (Topamax)

CGRP antagonistic MABs used in migraines? (four)

1. Erenumab (Aimovig)

2. Fremanzumab (Ajovy)

3. Galcanezumab (Emgality)

4. Eptinezumab (Vyepti)

Mechanism of action of CGRP antagonist MABs?

It is what it says bro pls

WOTF would be the best prophylactic patient to address migraines in a patient who is depressed?

A. Topamax

B. Imitrex

C. Amitriptyline

D. Divalproex

C. Amitriptyline

T/F: A therapeutic trial of 2-3 months is necessary to achieve clinical benefit with a prophylactic migraine therapy.

True

When are maximal benefits of prophylactic migraine therapy typically observed?

By 6 months

Indication for CPGR antagonist MABs?

Preventative treatment for migraines in adults

WOTF MABs is approved for treatment of episodic cluster headaches?

A. Aimovig

B. Ajovy

C. Emgality

D. Vyepti

C. Emgality

Who should we consider for prophylactic migraine therapy?

Recurring migraines that produce significant disability

Frequent attacks occurring more than twice per week

Symptomatic therapies that are ineffective or contraindicated or produce serious side effects

Uncommon migraine variants that cause profound disruption and/or risk of permanent neurologic injury

Patient preference to limit the number of attacks

Abortive therapy options for cluster headaches? (three)

1. Oxygen

2. Triptans

3. Ergotamine derivatives

Prophylactic therapy for cluster headaches? (four)

1. Verapamil

2. Lithium

3. Corticosteroids

4. Lidocaine, octreotide etc.