Therapeutics I Exam III - Headache - HM

symptoms of a migraine without aura

pain increases with physical activity, unilateral pain, pulsating pain, moderate to severe pain

symptoms of a migraine with aura

visual/sensory/speech difficulties, aura lasting from 5-60 minutes, at least one aura symptom is unilateral, and aura is accompanied with a headache

what are the clinical characteristics of a migraine without aura

no nausea/vomiting or photophobia

what are the clinical characteristics of a migraine with aura

nausea/vomiting and photophobia

what is the severity of a migraine

severe enough to interfere with daily functioning

what is the duration of a migraine

4-72 hours (treated or untreated)

what is the frequency of migraines

more than 15 days/month for 3+ months without overuse of analgesic medications would be classified as "chronic"

what are the clinical characteristics of a tension-type headache

band-like tightness or pressure around the head (no transient neurologic deficits and systemic symptoms are rare

what are the symptoms of a tension-type headache

bilateral, non-pulsating pain, mild or moderate pain intensity, no nausea/vomiting, and either photophobia or phonophobia (not both)

what is the duration of tension-type headaches

30 minutes to 7 days

what is the frequency of tension-type headaches

more than 15 days/month for 3+ months without overuse of analgesic medications would be classified as "chronic"

what are the clinical characteristics of cluster headaches

usually unilateral pain and NOT pulsatile (explosive and excruciating pain)

what is the severity of cluster headaches

pain severity often peaks early but may persist for hours

what are the symptoms of cluster headaches

lacrimation, nasal congestion, eyelid edema, forehead/facial sweating, sensation of fullness on the ear, miosis and/or ptosis, sense of restlessness or agitation

what is the duration of a cluster headache

15 minutes to 3 hours (untreated)

what is the frequency of cluster headaches

usually occurs at night but may occur multiple times per day

what is the vascular hypothesis

intracerebral vasoconstriction has led to neural ischemia, followed by reflex vasodilation and pain (theory no longer accepted)

what is the neuronal hypothesis

depressed neuronal electrical activity spreads across the brain causing dysfunction; activation of trigeminal sensory nerves will cause release of vasoactive neuropeptides which produce an inflammatory response provoking sensation of pain

what are some risk factors for migraines

prevalence is higher in females than males (theorized that it may be associated with hormonal differences

what are some risk factors for tension-type headaches

environmental factors are more prevalent than genetic disposition

what are some risk factors for cluster headaches

more frequently found in men (usually 20-40 years old), genetic predisposition, history of tobacco use, caffeine intake, and alcohol abuse

what are some examples of visual aura symptoms

flashes of light, blind spots

what are some examples of sensory aura symptoms

sensitivity to light, sound, or smell

what are some examples of speech and/or language aura symptoms

speech or language difficulty

what are some examples of motor aura symptoms

heaviness of limbs

what are some examples of brain stem aura symptoms

vertigo or tinnitus

what are some examples of retinal aura symptoms

change in vision or vision loss

what information would you recommend a patient record in a headache diary

frequency, duration, severity, possible triggers, and medication reponse

what are the four main classes of potential headache triggers

behavioral, environmental, food, and medications

what are some behavioral headache triggers

emotional let down, fatigue, sleep excess or deficit, stress, vigorous physical activity

what are some environmental headache triggers

flickering lights, high altitude, loud noises, strong smells such as perfumes, tobacco smoke, weather changes

what are some food headache triggers

alcohol, caffeine intake or withdrawal, chocolate, citrus fruits/bananas/figs/raisins/avocados, dairy products, fermented pickled products, missing meals, and others

what are some medication headache triggers

cimetidine, estrogen oral contraceptives, indomethacin, nifedipine, nitrates, reserpine, theophylline, withdrawal due to the overuse of analgesics, benzos, decongestants, or ergotamines

what are some non-pharmacological therapies for all types of headaches

create a "headache diary", prevent exposure to triggers, environmental control, biofeedback/relaxation therapy, cognitive behavior training, stress management training, acupuncture (possibly), and advise moderate alcohol/tobacco use

what are some pharmacologic therapies for migraines

analgesics (aspirin, NSAIDs, APAP, combo products with caffeine, opioids), "triptans", and ergotamine derivatives

what are some pharmacologic therapies for tension-type headaches

OTC analgesics (APAP or NSAIDs), APAP/opioid analgesic

what are some pharmacologic therapies for cluster headaches

admin of high-flow-rate oxygen (100% at 12-15 L/min for 15 minutes), triptans (onset of action may limit), octreotide (when triptans and ergotamine derivatives are contraindicated), and glucocorticoids

why is it important to start pharmacologic abortive treatment early for acute headache

to stop intensification of pain and improve response to therapy

what pharmacologic treatments would you recommend for a patient with mild/moderate/severe migraine

analgesics (aspirin, NSAIDs, APAP, or combo products of caffeine with or without an opioid)

which triptans have a short elimination half life (~2-3 hours)

sumatriptan, rizatriptan, and zolmatriptan

which triptans have a long elimination half life (~6-26 hours)

frovatriptan and naratriptan

which triptans can you repeat in 1 hour

sumatriptan subQ injection

which triptans can you repeat in 2 hours

almotriptan, eletriptan, frovatriptan, rizatriptan, sumatriptan (tablets, nasal spray, nasal powder), and zolmitriptan

which triptans can you repeat in 4 hours

naratriptan tablets

which triptans come in oral tablets

almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, sumatriptan/naproxen, and zolmitriptan

which triptans come in ODT

rizatriptan and zolmitriptan

which triptans come in a subQ injection

sumatriptan

which triptans come in a nasal spray

sumatriptan and zolmitriptan

which triptans come in a nasal powder

sumatriptan

when might a longer half life be beneficial

(Melissa made this answer up but it makes sense so I'm sticking with it): helpful for patients with prolonged/recurring migraines and less frequent dosing (lower risk of medication overuse)

what is the MOA of ergotamine derivatives

produce salutary effect on 5HT receptors (similar to triptans); also impact adrenergic and DA receptors

what are the most common ergotamine derivatives

ergotamine tartrate and dihydroergotamine (DHE)

what is the analgesic onset of ergotamine derivatives

within 4 hours (additional dosing may be required)

why is outpatient use limited for ergotamine derivatives

due to subQ formulation (it does come in an intranasal form though so that's an exception)

CGRP antagonists MOA

binds to the CGRP (calcitonin gene-related peptide) receptor and inhibits its function

what is CGRP

a potent vasodilator and pain signaling neurotransmitter

what are the two types of CGRP antagonists

monoclonal antibodies (used for migraine prevention) and small CGRP antagonists "gepant" (for acute treatment)

what are some examples of CGRP antagonist monoclonal antibodies

erenumab (aimovig), fremanezumab (ajovy), galcanezumab (emgality), and eptinezumab (vyepti)

what are some examples of CGRP antagonist small molecules

ubrogepant (ubrelvy) tablet and rimegepant (nurtec) ODT

what are some advantages of CGRP antagonists

well tolerated, can be taken upon symptoms onset for migraines with or without aura, and fewer side effects than others

what are some disadvantages of CGRP antagonists

common side effect is nausea and there are cost limitations

what is reyvow

a CGRP antagonist

what is reyvow used for

as an acute treatment for migraine attacks, not a preventative treatment

how do the triptans differ from reyvow

triptans target serotonin receptors to constrict vessels whereas reyvow targets 5HT1F receptors and does not cause blood vessel constriction

which dosage forms might be helpful for a patient with nausea

ODTs, intranasals, and injectables

what options are available for treating an acute tension headache

OTC analgesics (APAP and NSAIDs), topical analgesics (ice packs), physical manipulation (massage), relaxation techniques, prescriptions, and prophylactic measures

what is rebound/medication overuse headache (MOH)

use of analgesic for 10+ days per month OR other nonspecific analgesics for more than 15+ days per month

which dosage forms work best for early treatment of cluster headache

intranasals, subQ, and IV

what is the primary novel therapy for early treatment of cluster headache

administration of high flow-rate oxygen for about 15 minutes; if pain remains then re-treatment is indicated

other than the primary novel treatment, what other treatments are there for cluster headache

triptans, ergotamine agents, octreotide (does not have vasoconstrictive effects and is used if other options are contraindicated), or glucocorticoids (if not controlled by other options)

what options are available for adjunctive therapy for a patient experiencing nausea

antiemetic meds (ondansetron, metoclopramide, prochlorperazine)

when would prophylactic treatment be warranted

may be necessary to obtain intermediate term outcome of reducing frequency and severity of headaches

what are some antiepileptic drugs that can be used as a prophylaxis for headaches

topiramate, valproic acid, and divalproex sodium

what are some beta blockers that can be used as a prophylaxis for headaches

atenolol, metoprolol, nadolol, propranolol, and timolol

what are some antidepressants than can be used as a prophylaxis for headaches

amitriptyline and venlafaxine

which medications are the mainstay of tension type headache prophylaxis

tricyclic antidepressants (amitriptyline and nortriptyline)

which medications are the mainstay of cluster headache prophylaxis

calcium channel blocker (verapamil)

what are common side effects of triptans

dizziness, sensation of warmth, chest fullness, nausea, and paresthesia

when can a dose of triptans be repeated

all but two can be repeated in 2 hours (sumatriptan subQ is 1 hour and naratriptan tablets is 4 hours)

what are some contraindications to taking triptans

hepatic or renal impairment and drug interactions (ergot derivatives, CYP3A4/2D6/1A2 substrates, and MAO-A inhibitors)

what dosage forms are FDA approved for ergotamine derivatives

subQ or IM injection, IV route, and intranasal (DHE only)

when ergotamine derivatives are dose parenterally, what medication is recommended to be administered concurrently

antiemetic due to worsening nausea

what are some side effects of ergotamine derivatives

nausea and adrenergic/dopaminergic effects due to specific receptor binding

what are some contraindications to taking ergotamine derivatives

vascular events

what monitoring parameters would you have for a patient taking NSAIDs and octreotide

GI effects

what monitoring parameters would you have for a patient taking triptans

vasoconstrictive symptoms

what monitoring parameters would you have for a patient taking ergotamine derivatives

nausea and vascular problems

what monitoring parameters would you have for a patient taking beta blockers

reactive airways and cardiac conduction disturbances

what monitoring parameters would you have for a patient taking tricyclic antidepressants (TCAs)

sedation and ACh effects (dry mouth, constipation, and urinary retention)

what monitoring parameters would you have for a patient taking CCBs

GERD symptoms/constipation

what monitoring parameters would you have for a patient taking lithium

tremor, GI distress, and lethargy

when should you follow up with a patient who just started a new medication for headache

within 4 weeks to assess efficacy

once the patient becomes aware of headache symptoms and the medications seem to be helping, when should follow up be

3-6 months