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
  • Without aura
  • With aura

List medications used for cluster or tension type headaches

• Cluster headaches
  • treatment:
    • Oxygen
    • Sumatriptan 6 mg SQ, can also use nasal triptans
  • Prophylaxis:
    • Verapamil
    • Emgality
    • Lithium
• 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
  • Topamax
  • Valproic acid
• Antidepressants
  • Amitriptyline
  • Venlafaxine
• 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