Headache/Migrane (Test 2)

- unilateral

- pulsating, throbbing

- moderate to severe

- worse with activity

- more common in women

migraine

- 4-72hrs

- N/V

- photophobia

- phonophobia

- +/- aura

migraine S/S

- bilateral

- pressing, tightening, band-like

- mild to moderate

- most common headache

tension-type headache

- 30 min to 7 days

- none or mild

- photophobia

- phonophobia

tension-type headache S/S

- unilateral

- stabbing, dull, excruciating

- severe to extreme

- more common in men

cluster headache

- 15-180 minutes, up to 8 attacks per day

- ipsilateral autonomic signs

- tearing, red eye

- runny or stuffy nose

- ptosis (droopy eyelids)

- pinpoint pupils

cluster headache S/S

- stress

- hormonal changes

- sleep

- skipped meals or fasting, dehydration

- foods and drinks

- caffeine

- sensory

- weather

- medications

- medication overuse

common migraine triggers

menstruation (estrogen drop), ovulation, contraceptives

hormonal changes

too little or too much

sleep

- alcohol (especially red wine)

- aged cheese

- chocolate

- processed meats (nitrates)

- Monosodium glutamate (MSG)

- aspartame

foods and drinks

too much or withdrawl

caffeine

- bright or flickering lights

- strong odors

- loud noise

sensory

barometric pressure changes

weather

nitroglycerin and other vasodilators

medications

- NSAIDs (ibuprofen, naproxen, aspirin)

- acetaminophen

- excedrine

acute mild to moderate migraine first-line treatment

- triptans

- gepants as an alternative

acute moderate to severe migraine first-line treatment

- NSAIDs

- acetaminophen

acute tension type first-line treatment

- oxygen

- SC sumatriptan

acute cluster first-line treatment

- beta-blockers

- antiseizure

- antidepressants

- CGRP mAbs

- botulinum toxin

migraine preventative first-line treatment

- propranolol

- timolol (best evidence)

- metoprolol

- atenolol

- nadalol

beta-blockers

- topiramate

- divalproex

antiseizure

- amitriptyline

- nortriptyline

- venlafaxine

- duloxetine

antidepressants

- erenumab

- fremanezumab

- galcanezumab

- eptinezumab

CGRP mAbs

- OnabotulunumtoxinA

- chronic migraine only

botulinum toxin

- 5-HT1B/1D agonist

- constrict cranial vessels

- block CGRP release

triptans MOA

- CAD

- uncontrolled HTN

- stroke/TIA

- PVD

- hemiplegic/basilar migraine

- MAOIs within 2 weeks

- ergots within 24 hours

triptans avoid in

- chest, neck, throat tightness

- tingling

- flushing

- dizziness

- drowsiness

triptans AE

- sumatriptan (SC fastest)

- rizatriptan

- zolitriptan

- eletriptan

- almotriptan

triptans fast onset

- frovatriptan

- naratriptan (good for menstrual migraine)

triptans slow onset

- avoid strong CYP3A4 inhibitors

- Clarithromycin

- Ketoconazole

Eletriptan

use ODT, nasal or SC forms

N/V with triptans

- CGRP receptor antagonists

- no vasoconstriction (okay is CV disease)

gepants MOA

Nurtec ODT

Rimegepant

- 75 mg

- max 75 mg in 24 hours

- also approved for preventionn

Rimegepant need to know

Ubrelvy

Ubrogepant

- may repeat once after 2 hours

- max 200 mg/day

Ubrogepant need to know

Zavzpret

Zavegepant

- intranasal

- taste disturbance

Zavegepant

- nausea

- somnolence

- avoid strong CYP3A4 inhibitors

gepants AE

- migrainal

- trudhesa nasal

Dihydroergotamine (DHE)

- strong CYP3A4 inhibitors (macrolides, azoles, protease inhibitors)

- CAD

- uncontrolled HTN

- pregnancy

- triptans within 24 hours

DHE CI

- nausea

- rhinitis

DHE AE

- APAP + aspirin + caffeine

- OTC

- mild to moderate

excedrin migraine

butalbital + APAP + caffeine

fioricet

butalbital + APAP + caffeine

fiorinal

APAP + isometheptene + dichloralphenazone

midrin

- not first-line

- dependence, medication overuse headache

Butalbital products

- Take at the first sign of headache, while pain is mild.

- Triptans: don't repeat if the first dose didn't help that attack.

- Triptans: If it helps and the headache returns, repeat after 2 hrs (1 hr for SC sumatriptan), up to the daily max.

- Chest tightness: transient is common, but severe chest pain needs medical attention.

- Keep a headache diary.

counseling

3,000 mg - 4,000 mg

Acetaminophen

- 1,200 mg (OTC)

- 3,200 mg (Rx)

Ibuprofen

660 mg

Naproxen