Differentiate primary and secondary headaches.
- Primary headache: classic big 3 headaches
- Secondary headache: Caused by underlying medical condition
- Subdural hematoma, medication overuse, tumor, infection, stroke, intracerebral hemorrhage
Recognize signs and symptoms of various headaches (including cluster,tension-type, migraines)
- Cluster: feels like a hot pepper in the eyes, most severe, unilateral, lasts several minutes to an hour, more common in males
- Episodic: 2+ cluster periods within a year and remission for over 3 months between
- Chronic: Attacks occur without remission or less that 3 months for at least a year
- Tension type: Bilateral, most common, feels like a headband, stress related, dull persistent pain
- Infrequent: < 1 day per month
- Frequent: 1-14 days per month for an average of >3 months
- Chronic: >15 days per month for >3 months; must also not have more than 1 of the following- photophobia, phonophobia, or nausea
- Migraine: Generally unilateral and pulsatile in nature, dull ache to intense pulsatile pain, N/V with or without aura, may last as long as 72 hours, more common in females
List medications used for cluster or tension type headaches
- Cluster headaches
- treatment:
- Oxygen
- Sumatriptan 6 mg SQ, can also use nasal triptans
- Prophylaxis:
- Tension type headaches
- Treatment:
- First line= OTCs (APAP, IBU, naproxen, ASA)
- Rx NSAIDs
- Butalbital combinations with caffeine and sometimes codeine
- Nonpharm: CBT, relaxation, cold packs, stretching, exercise
Identify potential migraine triggers
- Seizures
- Smells
- Light
- Sound
- Certain foods- MSG, tyramine, nitrates, phenylethylamine, aspartame
- Hormonal fluctuations- period, pregnancy
- Medications- hormones, cocaine nitroglycerin
- Caffeine
- Stress
- Emotions
- Hypoglycemia
- Sleep
- Alcohol
- Pressure changes
Recall non pharmacological migraine management options.
- Avoid triggers
- Migraine diary
- Supplements
- Mediation
- Essential oils
- Ice packs
- CBT
- Exercise
- Caffeine
- sleep
Identify acute migraine treatment medications.
- Ergot alkaloids
- MOA: 5-HT, dopamine, and adrenergic receptor agonists
- May need pretreatment with antiemetics
- Avoid use with triptans within 24 hours
- Triptans
- First line for severe migraines
- MOA: selective 5-HT1B/1D receptor agonist
- Ditans
- Reyvow (lasmiditan)
- MOA: Selective 5-HT1F agonist, less vasoconstriction and blocks neurogenic inflammation and stimulation of trigeminal nerve
- Controlled substance
- Analgesics
- Same as before, OTC preferred, can use Rx, narcotics last line
- CGRP antagonists
- Ubrogepant, Rimegepant, Zavegepant
- Very quick onset
- All CYP3A4 substrates
- Antiemetics
- Metoclopramide, prochlorperazine don’t use Zofran (serotonin antagonist that can worsen migraines)
- Mild migraine
- Otc analgesics
- Combination otc analgesics
- Triptans
- Ergot derivatives
- Severe migraine
- Triptans
- Ergot derivatives
- CGRP antagonists
Identify migraine prophylaxis medications.
- Beta blockers
- Metoprolol, propranolol, timolol
- AEDs
- Antidepressants
- CGRP antagonists
- CGRP antibodies
- CGRP receptor antagonists
- CGRP receptor antibodies
- Botox
Differentiate CGRP antagonists for migraine treatment/prophylaxis.
- Nurtec ODT (Rimegepant) is the only one used for both treatment and prophylaxis
- All others are for prophylaxis
Evaluate the safety and effectiveness of medication options for treating migraines and headaches
Identify patients at risk of medication overuse headaches
- Polypharmacy womp womp
- Most are using >10 days per month on a regular basis for > 3 months
- CGRP antagonists not at risk for overuse headaches
Create personalized treatment plans for individuals with a headache or migraine disorder
