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22 Cards in this Set
- Front
- Back
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Recommend appropriate situations when prophylaxis is needed.
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d
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Know the common triggers of migraine headache.
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1. Food
Alcohol, caffeine, chocolate, fermented or pickled foods, MSG, nitrates, saccharin/aspartame, tyramine 2.Environmental Glare or flickering lights, high altitude, loud noises, strong smells, tobacco smoke, weather changes 3.Behavioral – physiologic triggers Excess or insufficient sleep, fatigue, menstruation or menopause, skipped meals, strenuous physical activity, stress or post-stress |
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Using the IHS definition, know the diagnostic criteria for migraine with and without aura.
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IHS Diagnostic Criteria – rule out stroke or tumors
Migraine without aura 1. At least 5 attacks 2. Headache attacks last 4-72 hours untreated 3. Headache has at least two of the following ---Unilateral ---Pulsating ---Moderate or severe intensity 4. Aggravation by or avoidance of routine physical activity (walking or climbing stairs) 5. During headache at least one of the following ---Nausea and/or vomiting ---Photophobia or phonophobia Migraine with aura At least two attacks Migraine aura fulfills criteria for aura |
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Define medication overuse and know how to counsel your patients to prevent this.
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unknown
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Identify the clinical presentation of CLUSTER headaches
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Suddenly, unilateral peaks quickly 15-180 minutes
Excruciating! –limits physical activity Can be accompanied by nasal stuffiness, rhinorrhea, eyelid edema, restlessness or agitation - pacing Commonly at night and in the spring or fall 2 weeks to 3 months Remission periods average 2 years in length No aura |
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Identify the clinical presentation of TENSION headaches
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Pain is mild to moderate, bilateral, band-like
Frontal/temporal regions most commonly Mild photophobia or phonophobia may be reported Patient physical activity is rarely limited and does not affect headache severity Premonitory symptoms and aura are absent |
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Identify the clinical presentation of MIGRAINE headaches,
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1. Premonitory symptoms
Neurologic (most common), psychological, autonomic, constitutional 2. Aura: only 20% of patients present Symptoms that precede or accompany an attack; lasts less than 60 minutes; headaches occurs within 60 minutes of end of aura; most often half of the visual field is affected 3. Migraine headache Throbbing head pain, gradual in onset; unilateral; can last 4-72 hours untreated; can be associated with nausea, vomiting, sensitivity to light/sound/movement; can occur at any time of day or night but most often occurs during early waking hours Not all symptoms are present at every attack 4. Resolution phase Feeling tired, exhausted, irritable, listless, impaired concentration may continue, scalp tenderness, mood changes, depression, malaise, refreshed, euphoric |
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Know non-pharmacologic treatments you can discuss with your patients.
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Ice to the head
Periods of rest or sleep in a dark, quiet, environment Headache diary Wellness program of regular sleep, exercise and eating habits, smoking cessation and limiting caffeine intake Relaxation therapy, biofeedback, cognitive therapy Trigger avoidance |
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Recommend appropriate situations when prophylaxis is needed.
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Use lowest effective dose
Give adequate trial (2-3 months) If the patient has coexisting conditions, consider prophylaxis choice Consider if any of the following are met: -Migraines are recurrent & interfere with daily routine -Migraines are frequent -Low efficacy with acute treatment -Inability of patient to use acute treatment -Patient prefers prophylaxis -Cost of acute medication is problematic -ADRs with acute medications -Migraine presentation is uncommon |
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A migraine patient also has epilepsy?
A cluster patient has bipolar disorder? A tension patient has depression? A migraine patient has tachycardia? A cluster patient has hypertension? |
A migraine patient also has epilepsy? anticonvulsant
A cluster patient has bipolar disorder? lithium A tension patient has depression? TCA, SSRI A migraine patient has tachycardia? BB, CCB A cluster patient has hypertension? BB |
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Ibuprofen, Naproxen
Class MOA ADRs Interactions Cautions |
nsaid
inh pg synth in inhib of COX enz GI, Z/N/D (dizzi, nausea, diar), high LFTs, fluid retain anticoag drugs Use caution in the elderly, kidney disease, CHF, GI ulceration. Avoid use in patients with allergy to aspirin |
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Aspirin or APAP/butalbital/caffeine +/- codiene (Fiorinal family)Class
MOA ADRs Interactions Cautions |
combo = analgesic
Migraine, Tension vasoconstriction, analgesia dizziness, sedation MAOI use, total daily doses of APAP Glaucoma, concomitant renal failure High risk of rebound headache |
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Ergoamine tartrate (Ergomar) and dihydroergotamine (DHE-45 & Migranal)
Class MOA ADRs Interactions Cautions |
Migraine, Tension
Ergot Derivatives Antagonizes alpha-adrenergic receptors with direct action on vascular smooth muscle in peripheral and cranial blood vessels. N/V vasoconstriction, numbness Triptans in the past 24 hours, SSRIs, Sympathomimetics Avoid other ergots and triptans for 24hr. All ergots contraindicated in pts with or at risk for CAD, stroke, peripheral vascular disease, ischemic bowel, pregnancy. Risk of retroperitoneal and pulmonary fibrosis Contraindicated in hemiplegic or basilar migraines. |
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sumitriptan
Class MOA ADRs Interactions Cautions |
Migraine
Cluster 5HT1d agonists “Triptans” Bind to 5-HT1 receptors, causing vasoconstriction and inhibition of pro-inflammatory neuropeptide release “triptan sensation”: flushing, tight chest or jaw. within 2 weeks of MAOI, within 24 hr ergots, caution with other serotonin-active drugs Sumatriptan available SQ and intranasal, may be considered for pts with N/V; provides fastest action |
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Amitriptyline, Doxepin, Nortriptyline
Class MOA ADRs Interactions Cautions |
prophylaxis
Tricyclic Antidepressents anticholinerig SEs |
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Propranolol, Atenolol, Nadolol
Cass MOA - not tested ADRs Interactions Cautions |
Beta-blockers
fatigue, cold extremities, bradycardia, bronchospasm, hypotension, dizziness, heart block Calcium channel blocks (severe hypotension and heart failure Cluster prophylaxis: Nadolol, Propranolol may be beneficial but role not yet defined |
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Valproic acid, Topiramate, Gabapentin
Cass MOA - not tested ADRs Interactions Cautions |
Cluster prophylaxis: Valproic acid is typically used as monotherapy or in combination as long-term prophylaxis.
Anticonvulsants confusion and memory loss, sedation, increased appetite and weight gain other CNS depressant, oral contraceptives Avoid use in pregnancy |
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Fluoxetine, Paroxetine
Cass MOA - not tested ADRs Interactions Cautions |
SSRI
agitation, anxiety, headache, insomnia, tremor, sexual dysfunction, possible serotonin syndrome concomitant use of 5HT1d agonists? |
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Verapamil
Cass MOA - not tested ADRs Interactions Cautions |
CCBs
constipation, headache, flushing, fatigue, peripheral edema, dizziness, hypotension Interactions: Beta blockers Severe left ventricular dysfunction, hypotension or cardiogenic shock, sick sinus syndrome, AV block, Afib or Aflutter |
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Lithium
Cass MOA - not tested ADRs Interactions Cautions |
tremor, lethergy, nausea, diarrhea.
trough level should not exceed 1.0 mEq/L. Avoid with significant renal or CV disease, dehydration, pregnancy, diuretics, or NSAIDs |
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Indications for:
Opioids Antiemetic Oxygen |
Opioids - migraine
Antiemetic - migraine Oxygen - cluster |
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prophylaxis indications
Oxygen Ergotamine Triptans Analgesics/NSAIDs Opioids Antiemetics |
oxygen -C
ergolamine C-M triptans C-M anaglesic/nsaid T-M opioids - M antiemetics - M |
