Term
|
Definition
| Treatment of the acute headache |
|
|
Term
|
Definition
| Treatment to try to lessen the frequency or severity of headache recurrence |
|
|
Term
| What type of headaches are treated on either an acute or a chronic, daily basis? |
|
Definition
|
|
Term
| What type of headaches are treated on an either an abortive or prophylactic basis? |
|
Definition
| Migraines and Cluster Headaches |
|
|
Term
| Clinical characteristics of migraines |
|
Definition
Unilateral, moderate to severe pain, pulsating
N/V, sensitivity to light & sound
Difficult concentrating, can interrupt ADLs
With or without auras
Last 4-72 hours untreated
Can run in families & are more prevalent in females |
|
|
Term
| What method of treatment is best for migraines? |
|
Definition
| ABORTIVE (EARLY) TREATMENT IS BEST REGARDLESS OF MEDICATION SELECTED |
|
|
Term
| What type of treatment is best for patients moderately disabled by migraine? |
|
Definition
| Start with high-dose NSAID or oral triptan |
|
|
Term
| What treatment is best for patients severely disabled by migraines? |
|
Definition
| Oral, intranasal, or SQ triptans |
|
|
Term
| How can you describe the dosing for acute treatment of migraines with NSAIDs? |
|
Definition
HIGH DOSES are used
Can repeat the same dose in ONE HOUR for acute treatment
Examples are 600-800 mg Ibuprofen or 550-660 mg Naproxen sodium (3 Aleve) |
|
|
Term
| What patients should you have caution for using NSAIDs in acute treatment of migraines? |
|
Definition
HTN
Kidney disease
History of gastritis/PUD |
|
|
Term
| Most common AE of use of NSAIDs in acute treatment of migraines |
|
Definition
|
|
Term
|
Definition
| Work on serotonin receptors on intracranial blood vessels and the trigeminal nerve. Activation of receptors causes vasoconstriction & inhibits nerve inflammation |
|
|
Term
| How effective are triptans? |
|
Definition
| Triptans relieve migraine pain within 2 hours in up to 70% of patients |
|
|
Term
| How much time should elapse between doses of triptans and how many doses can be given in a day? |
|
Definition
May repeat triptan dosage after 2 hours
No more than 2 doses in 24 hours |
|
|
Term
| What should be done if one triptan fails? |
|
Definition
Try another triptan!
Try 2 different triptans before moving on to other categories of treatment |
|
|
Term
| What are adverse effects of triptans called & what do they include? |
|
Definition
"Triptan sensations" include
Flushing/warmth
Paresthesias
Dizziness
Heaviness or pressure in the throat & chest |
|
|
Term
| What are the contraindications of Triptans? |
|
Definition
Contraindicated in basilar-type & hemiplegic migraine.
Caution in patients with coronary or cerebral vascular disease or uncontrolled HTN.
Caution in pregnancy - Category C - inadequate data |
|
|
Term
| Is a large single dose or repetitive small doses more effective for use of Triptans? |
|
Definition
| A large single dose works better than repetitive small doses - go up on initial dose as needed |
|
|
Term
| What can be done to help with nausea associated with triptan use? |
|
Definition
Antiematics can be added (as they can to any therapy) to help control nausea.
Metoclopramide (Reglan) - 10 mg po
Promethazine (Phenergan) - 125 to 25 po or pr |
|
|
Term
| What is the starting dosage for PO Sumatriptan (Imitrex) to abort migraine? |
|
Definition
50 mg po at onset of headache
May repeat dosage every 2 hours if needed, up to 200 mg/day |
|
|
Term
| what forms is Sumatriptan (Imitrex) available in? |
|
Definition
| Tablets, Injectable (may repeat dose in one hour; use up to 12 mg/day), Nasal Spray (up to 40 mg/day) |
|
|
Term
| What is the dosage of Rizatriptan (Maxalt) in absence of propranolol? |
|
Definition
| 10 mg po at onset of headache, may repeat in two hour if needed. Max 30 mg/day |
|
|
Term
| What is the dosage of Rizatriptan (Maxalt) WITH use of propranolol? |
|
Definition
| 5 mg po at onset of HA, may repeat in 2 hours if needed. Max dose of 15 mg/day |
|
|
Term
| When do you use prophylactic migraine treatment? |
|
Definition
| Used for patients with frequent severe migraines (patient should not be using abortive medicines more than twice per week). It is an individualized decision. |
|
|
Term
| How long does it take for prophylactic migraine treatments to take effect? |
|
Definition
| Takes ~1 month for prophylactic treatment to effect headache pattern. Benefits may continue to increase over three months. |
|
|
Term
| How effective are prophylactic migraine treatments? |
|
Definition
| Only ~50% effective. Don't help some people. |
|
|
Term
| How should prophylactic treatments for migraines be initiated? |
|
Definition
Choose med based on comorbid conditions, potential AEs, convenience, and cost
Start low & gradually increase dose as needed/tolerated |
|
|
Term
| How long should you allow prophylactic med before giving up on it & how should it be discontinued? |
|
Definition
| Allow 3-4 months. If no improvement, taper, discontinue, and select an alternative prophylactic agent to try. |
|
|
Term
| What types of prophylactic agents have the best evidence of efficacy? |
|
Definition
Beta blockers-propranolol (Inderal) & atenolol (Tenormin)
Tricyclic antidepressants-amitriptyline (Elavil) or nortriptyline (Pamelor)
Anticonvulsants-divalproex sodium (Depakote) & topiramate (Topomax) |
|
|
Term
| What migraine prophylactic agents are best for people with co-existing HTN? |
|
Definition
Beta blockers (proranolol & atenolol)
Calcium Channel Blockers (verapamil) |
|
|
Term
| What type of prophylactic treatment is best to use for a patient with migraines and insomnia, anxiety, & depression? |
|
Definition
| Tricyclic Antidepressants (amitryptiline & nortriptyline) |
|
|
Term
| What prophylactic meds are best to use for a patient with migraines and seizure disorder or who have obtained no relief after adequate trials of other meds? |
|
Definition
| Anticonvulsants (Depakote & Topomax) |
|
|
Term
| How do ergotamine derivatives work? |
|
Definition
Bind to serotonin receptors on intracranial blood vessels & the trigeminal nerve, causing vasoconstriction & inhibiting nerve inflammation (like triptans).
Also have similar AEs (including N/V), contraindications, and cautions. |
|
|
Term
| What forms of ergotamine are rarely used due to efficacy & side effects? |
|
Definition
| Sublingual, oral, & rectal forms of ergotamine derivatives |
|
|
Term
| Available forms & use of Dihydroergotamine (DHE 45) |
|
Definition
IV, IM, SQ, or intranasal spray
ER: given IV & used in combination with an antiemetic drug.
Home: given as a nasal spray (Migrainol) or a SQ injection (it is NOT available in prefilled syringe form) |
|
|
Term
| Contraindications for DHE 45 |
|
Definition
| Dihydroergotamine is contraindicated in patients with hypertension or ischemic heart disease (similar to triptans) |
|
|
Term
| Use of Fiorinal & Fioricet for migraine treatment |
|
Definition
NOT FDA approved
Contain butalbital, caffeine, and either aspirin or acetaminophen |
|
|
Term
| AEs/Cautions for use of Fiorinal & Fioricet for migraine treatment |
|
Definition
High potential for rebound headache
More likely to be abused or misused due to psychoactive properties |
|
|
Term
| ER treatment of Migraines |
|
Definition
IV metoclopramid (Reglan), IV chlorpromazine (Thorazine) or IV prochlorperazine (Compazine)
IV dihydroergotamine with IV metoclopramide
Dexamethasone (10-25 mg IV or IM) was significantly more effective than placebo for reducing migraine recurrence from 24 to 72 h after treatment |
|
|
Term
| Treatment of menstrual migraines |
|
Definition
"Mini-prophylaxis" - consists of preventative meds started 1-2 days prior to expected onset of HA & continued for duration of HA
Naproxen or Naratriptan |
|
|
Term
| Relationship between migraines & oral contraceptives |
|
Definition
NOT contraindicated, but risk & benefit must be discussed and watch for other stroke risk factors (i.e., older women & women who smoke)
Consider extended-cycle estrogen-progestin OCPs
Migraines typically improve during pregnancy |
|
|
Term
| Clinical presentation of cluster headaches |
|
Definition
Male smokers 20-50 yo
Severe, UNILATERAL, retro-orbital stabbing pain for 15min-2h
IPSILATERAL tearing, conjunctival redness, nasal congestion & draining, ptosis & miosis of the eye
Generally comes in "cluster" then can remit for several months |
|
|
Term
| Drug of choice for ACUTE cluster headache treatment |
|
Definition
OXYGEN!!
5-10 L/min via facemask for 10-15 min with patient sitting up
VERY effective - aborts 70-80% of attacks |
|
|
Term
| What are second line options for acute cluster headache treatment? |
|
Definition
SQ or intranasal sumatriptan (immitrex) is used when O2 isn't available
Intranasal lidocaine works well for some patients |
|
|
Term
| What is the drug of choice for cluster headache PROPHYLAXIS? |
|
Definition
Verapamil (Calan)
Also used for migraine prophylaxis, but is not one of the most efficacious! |
|
|
Term
| Tension-type headache clinical presentation |
|
Definition
Onset in teens to 30s - episodic OR chronic - daily or nearly daily
Generally mild to moderate pain with BILATERAL discomfort
Band of pressure/ache
Associated with fatigue, sleep disturbance, difficulty concentrating
NO MIGRAINE FEATURES (i.e., nausea) |
|
|
Term
| Treatment of acute, episodic tension-type headaches |
|
Definition
No drugs FDA approved specifically for these type of HAs
NSAIDs/aspirin/acetaminophen are generally used acutely, can add caffeine
Options include: Anacin, Excedrin, & Goody's |
|
|
Term
| Chronic tension-type headache treatment |
|
Definition
| Meds with central-pain modulating effects tend to be most effective in lessening the frequency & duration of chronic tension-type HAs |
|
|
Term
| Drug of choice for chronic daily tension headaches |
|
Definition
Tricyclic antidepressents: Amitriptyline
Start at 10-12.5 mg qhs
Increase in 10-12.5 mg steps q 2-3 weeks as tolerated & as needed until headaches improve or until a maximum dose (100-135 mg nightly) is reached |
|
|
Term
| AEs of Amitriptyline in treatment of chronic tension headaches |
|
Definition
|
|
Term
| Are SSRIs effective in treatment of chronic tension type headaches |
|
Definition
|
|
Term
| Anticonvulsants with limited evidence for benefit in chronic tension type headache treatment |
|
Definition
| Topiramate (Topomax) & Gabapentin (Neurontin) |
|
|
Term
| SNRIs with limited evidence of benefit in treatment of chronic tension type headaches |
|
Definition
| Mirtazipine (Remeron) and venlafaxine (effexor) |
|
|
Term
| Drug types to AVOID in treatment of chronic tension type headaches due to potential for abuse/addiction & potential to induce analgesic-rebound HA |
|
Definition
Benzodiazepines
Butalbital
Narcotics
Muscle relaxants |
|
|
Term
| Non-pharm treatment options for chronic tension-type headaches |
|
Definition
Biofeedback
Relaxation training (muscle relaxation, guided imagery)
Cognitive behavioral therapy (stress management) |
|
|
Term
| Non-pharmacologic treatments can be combined with what type of medications to have synergistic effects in chronic tension type headache treatment? |
|
Definition
|
|
Term
| What limitations are there to treatment of chronic tension type headaches? |
|
Definition
Avoid medication overuse!
Limit acute therapy to 10 days (or less) per month on avg, typically a max of 2 doses/day
(Keep headache diary to monitor frequency, triggers, and response to treatment) |
|
|
