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172 Cards in this Set
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headaches are...
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UNDERTREATED
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primary headache
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clinical condition due to a neurologic process (not caused by another disorder)
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3 examples of primary HA
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migraine, tension-type, clus
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% of benign HAs that are primary
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Comprise 90% of all benign headaches
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secondary HA
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have a specific underlying cause
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types of secondayr HA
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Sinus Headache
post traumatic HA HA due to organic cause |
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sinus HA- how to dx
characteristic tx |
◦Dx: based on history & clocklike pattern of symptoms
◦Characteristics: pain located over affected sinuses ◦Treatment: OTC analgesics to blunt pain |
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Post-Traumatic Headache dx and tx
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Dx: based on history
tx is symptomatic- if it's tension headache like they will treat like that, etc. |
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onset
course of PTHA (when does it worsen, resolve) |
start within 24h of head injury
worsen over several weeks resolve in less than a yea |
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characteristics of PTHA
features of what type of HA |
dull, THROBBING ache
features of tension HA |
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benign vs. malignant organic HA- as in etiology
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◦Benign organic headache – due to cerebrovascular insufficiency or benign tumor
◦Malignant headache – secondary to carcinoma |
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drug induced HA aka...(2)
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Medication-overuse headache, analgesic rebound headache
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definition of drug induced HA (2)
like how often of which drug do you have to be taking a drug for it to be associated.. |
Intake of simple analgesics more than 15 days per month OR
any migraine specific, opioid or combination of medications for at least 10 days per month for 3 months or longer |
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mechanisms of drug induced/rebound HA (2)
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Chronic analgesic exposure causes antinociceptive tolerance & diminished medication effect
◦Medication tolerance & dependence results in repeated “mini-withdrawals” = why they occur more often in the morning |
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common complaint of drug induced HA
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Neck pain is a common complaint
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drug induced HA characteristics
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Chronic daily headaches despite/because of daily analgesic use (TTH)
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incidence of drug induced HA
gender |
1%
women more than men |
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drug induced HA- associated/risk factors (5)
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low income, low educational level, smoking, obesity, physical inactivity
poor dumb lazy fat people |
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pt with hx of what are more susceptible to rebound HA
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Patients with histories of migraines are more susceptible to developing rebound headaches
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highest risk drugs that cause rebound HA (2)
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Opioids and butalbital are highest risk agents
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tx of drug induced HA (does it require hospital?)
tx of withdrawal sx- drugs to give (2) limit what |
Stop acute pain meds
◦Detoxification: Sometimes requires hospitalization Treating Withdrawal sx: NSAIDs -10 days, triptans – 4 days Limit use of acute migraine therapies to 2-3 days per week to avoid rebound headaches |
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What is the best way to avoid overuse of abortive medications?
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USE PPX meds
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pathophys of giant cell/temporal arteritis (2)
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Chronic inflammatory process of large blood vessels, particularly arteries of the extracranial carotid tree
◦Causes lymphocytic infiltrate and giant cells to assemble around the lumen |
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how to dx temporal arteritis (2)
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Based on temporal artery biopsy
◦ESR (erythrocyte sedimentation rate) is elevated |
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temporal arteritis- gender
age |
◦Female 2:1 Male
◦10x more common in those over age 80 than those in 5th decade of life |
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S/Sx of tepmoral arteritis (3)
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Severe, continuous throbbing headache, usually over one temporal artery
◦Artery is usually tender, may be thickened or nodular and sometimes pulseless ◦Pain secondary to chewing, talking or swallowing is due to ischemia of the associated muscles when the carotid branches are involved |
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tx for temporal arteritis
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Prednisone 60mg/day for 2-4 weeks even without positive biopsy results to prevent bad consequences (blindness) when waiting for biopsy. will still give even if biopsy comes back neg.
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consequences of not treating temporal arteritis
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Failure to treat results in blindness and possibly death
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temporal arteritis- when can you start to taper steroids
most pt will require tx for how long |
◦After normalization of ESR, steroids can be tapered to a level that maintains response
◦Most patients require corticosteroids therapy for 2-3 years |
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4 types of primary HA
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Tension Type Headache
Migraine Mixed Headache Syndrome Cluster Headache |
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3 types of migraines and describe each
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◦Classic - migraine with aura
◦Common - migraine without aura ◦Complicated - hemiplegic, ophthalmoplegic, basilar artery (neuro features) |
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Least studied primary headache disorder
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tension type HA- because most ppl self medicate
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pathpohys of TTH
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Mechanism of pain in chronic TTH originates from myofascial factors & peripheral sensitization of nociceptors
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3 initiating stimulus of TTH
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Initiating stimulus may include nonphysiologic motor stress, mental stress, local myofascial release of irritants
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TTH: infrequent
frequent chronic |
Infrequent episodic TTH 1 or less day/month
frequent episodic TTH = episodes 1-14 days/mo., chronic TTH more than 15 days/mo. |
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Most common recurrent headache syndrome, mild in nature so 85% of patients self-diagnose & treat
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TTH
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TTH gender
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male 2x more than female in all ages?? ?she said female in class
i think its females... |
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TTH clinical disease manifestations (4)
premonitory sx? aggravated? which side of head pulsatile? pt complaint cease or ceaseless |
No premonitory symptoms, not aggravated by physical activity, nonpulsatile
Pt complains of gradual progression of dull, nagging pain perceived to be deep Usually affects both sides of entire head Tension headache is the ONLY headache that is ceaseless for long periods of time |
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goal of non pharm therapy for TTH
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decrease anxiety and tension in patient
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non drug therapy for TTH (3)
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Biobehavioral techniques
◦Eliminate caffeine ◦Reaffirmation of patient's self-administered therapy |
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tx for TTH- start with what?
ppx for chronic |
◦Start with simple analgesics: 650mg ASA, l000mg APAP alone or with caffeine- improves ability for analgesic to work??
◦Use tricyclics (amitriptyline) for prophylaxis in patients with chronic headaches |
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HA emergencies (6)
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Headache pain that feels like an explosion or thunderclap
Severe headache that is clearly your “worst-ever” Persistent headache after head injury Headache associated with systemic illness New-onset headache in HIV or cancer patient onset of hA in pt 50+ yo |
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associated sx with HA that would institute an emergency (4)
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Stiff neck, rash, fever, nausea/vomiting
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why are HA in 50+ yo people worrisom (3)
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d/t possible etiologies like temp. arteritis, mass lesion, cerebrovascular disease
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pathophys of migraine
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Migraines are caused by the stimulation of the trigeminal nerve pain pathways - trigeminal fibers in migraineurs develop hypersensitivity/peripheral sensitization which makes them excessively responsive to stimuli that is normally non painful
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Migraine attacks involve physiological mechanisms initiated by
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migraine specific triggers
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won't ask MoA of migraine
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--just that for years we thought it was the wrong pathophys
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migraine attacks occur when?
what modulates this (2) |
Attack occurs when threshold is reduced or triggers are particularly strong or frequent
Internal & environmental factors modulate the point of no return |
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internal/environmental factors that play a role in migriane attacks (5)
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hormonal fluctuations, fatigue, relaxation after stress, meteorological changes, substance abuse
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NT/receptors that mediate migraines (2 specific subfamilies)
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Serotonin (5-HT) receptor subfamilies (5-HT1 -5-HT7) are mediators of migraines
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how to ID migraine triggers
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keep migraine diary for 3 months
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4 categories of triggers for migraines
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diet
environmental lifestyle drugs |
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7 lifestyle factors that can cause migraines
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stress or post-stress, depression, fasting, menstruation, excessive sleep, head trauma, fatigue
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3 drugs that can cause migraines
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HRT, oral contraceptives, nitroglycerin
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other triggers
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--
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Prevalence is highest in men and women between the ages of
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30-49 years
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HA- genetics
prevalence gender avg attacks per month |
Genetic
One-year prevalence rate in U.S. is 13% More women than men Patients average 1-4 attacks per month |
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manifestations of symptoms in migraines (3 properties)- duration, clinical course
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Attacks last 4-72 hours
Pain increases in severity over time Aura |
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what is aura
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sensory or physical occurrences that immediately proceed a migraine by minutes or up to an hour
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types of aura (5)
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Visual (99%) - flashing lights, zigzag lines, blurred or lost vision
Weird ****: Hallucinations, numbness, aphasia (18%), motor |
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premonitory signs of migraine- definition
average time of onset |
signals that occur hours or days prior to an attack (avg. = 10 hrs.)
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4 neuro sx of migraine
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phonophobia, photophobia, hyperosmia (heightened sense of smell), poor concentration
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additional associated sx of migraine (5)
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mood changes, excessive yawning, fatigue, rapid mood changes, food cravings
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postdrome syndrome (4)
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patients feel ‘washed out’, hung over, tired, irritable
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COMMON migraine
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migraine without aura
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dx criteria of common migraine (no A in it) (no aura) (5)
not going to be asked to differentiate |
A. At least 5 attacks fulfilling criteria B-D
B. Headache attacks lasting 4-72 hrs Untreated or unsuccessfully treated C. Headache has at least 2 of the following characteristics Unilateral location, pulsating quality, moderate/severe pain intensity Aggravation by or causing avoidance of routine physical activity D. During headache, at least one of the following: Nausea +/or vomiting, photophobia and phonophobia E. Not attributed to another disorder |
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know dx criteria
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--
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clAssic migraine
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migraine with aura
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dx criteria of classic migraine (aura)
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Diagnostic Criteria: Similar to above with the addition of one or more transient focal neurological aura symptoms
◦Positive symptoms/negative sx Gradual development of aura symptom over 4+ min. or several symptoms in succession Aura symptoms last 4-60 min. Headache follows aura within 60 min. |
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positive aura sx (3)
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flickering lights, spot or lines in vision, pins & needles
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negative aura sx (2)
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loss of vision, numbness
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migraine alarm sx (5)
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May warrant a scan:
aura symptoms always on same body side or with acute onset without spread or either of very brief (less than 5 min.) or unusually long (more than 60 min.) Sudden change in migraine characteristics Sudden substantial increase in attack frequency Onset above the age of 50 Aura without headache, high fever, abnormal neurological exam |
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estrogen associated migraine MoA
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serotonergic tone in women is positively correlated with estrogen levels, so as estrogen levels decline, serotonin concentrations fall, causing a cascade of events
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when do estrogen migraines occur
properties in terms of severity and response to tx |
Menstrual migraines occur between 2 days before onset of menses and up to 3 days after onset of bleeding
Often more severe than “normal” migraines and more refractory to treatment |
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most potent and common of all migraine triggers
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menstruation
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why are period headaaches so annoying
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Often more severe than “normal” migraines and more refractory to treatment
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What about post-menopausal women?
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usually don't have estrogen headaches anymore
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what about pregnant women
how to tx |
50-80% will experience improvement in HA due to steady high lvls of estrogen
initiate APAP 1000 mg due to CI of triptans and NSAIDS |
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tx of estrogen migraines
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same as for other types of migraines
◦Menstrual migraines respond best to triptans- UTD says triptans.. |
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peds migraines (2) incidences in different kid populations
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2.5-4% of prepubescent children experience migraines, slight prevalence in boys
After menarche, migraines become much more prevalent in girls |
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non pharm therapy of migraines (3)
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Patient must change lifestyle, learn to moderate emotions, keep regular schedule of sleep and meals
Rapid treatment is essential**** IMPORTANT. if you want your migraine to go away tx as SOON as you can Patient should retreat to dark room, avoid disturbances, sleep if possible |
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◦Abortive treatments of migraines are more effective if given when
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early in the course of HA
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why is it so important to give abortive tx as early as possible in course of migraine
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Lower pretreatment pain severity is strong predictor of treatment response
Due to central sensitization during attack – counteracts triptan and analgesic efficacy if given then (during attack) |
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large single dose vs. several moderate doses (for migraine abortion)
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A large single dose works better than several moderate doses
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PO migraine therapies can be compromised by...
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PO therapies can be compromised by gastric stasis
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2 principles/key points in abortive migraine drug therapy
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◦Select non-oral route (lingual, SQ, nasal) for patients who frequently present with nausea/vomiting
◦Use migraine specific agents (triptans, DHE) for those with more severe migraine and/or those who respond poorly to simple analgesics |
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1st line agents for the treatment of mild to moderate migraine
what is NOT effective? |
Simple analgesics & NSAIDS
APAP as monotherapy |
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effective analgesics for migraine (3 options)
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◦Aspirin
◦NSAID ◦Combination acetaminophen +aspirin + caffeine |
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3 NSAIDS that work for migraines
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ibuprofen, naproxen sodium, tolfenamic acid (Other NSAIDS show less benefit)
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butalbital MoA
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Short to intermediate acting barbiturate
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butalbital combo agents- efficacy
disadvantage |
Combination agent of limited efficacy with high overuse potential
Combination agents pose greater risk for rebound HA |
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butalbital agents that are controlled substances
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Products containing 50mg butalbital and 325mg ASA are controlled substances
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fiorinal
fioricet fioricet with codeine |
--
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MoA of ergo alkaloids
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Bind to 5HT 1b/d receptors (just like triptans), inhibit trigeminal nerve pathway & nonselective serotonin agonist with activity at several other receptors, which is responsible for extensive side effects
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ergot alkaloids line of therapy
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NOT FIRST line
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idk did she say she wasn't going ot ask anything about ergots?
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23:00?
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oral forms of ergots- downside
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Oral forms have inconsistent effectiveness
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4 AE of ergots- most common
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N/V most common, peripheral ischemia, coronary vasospasm, severe withdrawal symptoms
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Dihydroergotamine (DHE 45) vs. ergotamine
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milder adverse effects than ergotamine – no rebound or physical dependence
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just be aware that ergotamines are out there- tripants are better
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--
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drug of choice for nausea (dosing)
other option |
DOC: Metoclopramide l0-20mg PO at onset of attack to stimulate gastric motility & decrease nausea
Phenothiazines can be used rectally when PO meds are not possible |
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triptans were made due to drive to...
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Resulted from the drive towards more selectivity 5-HT1B/1D agonist
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target receptors for triptans
where they are present (2) |
5HT1 receptors are present on cranial arteries and in vasculature of dura mater
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moa of triptans (3)
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All triptans inhibit release of vasoactive peptides, promote vasoconstriction and block pain pathways in the brainstem
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triptans- efficacy across the different types
what to do if one doesn't work |
Triptans are all similar in efficacy (relief in 2/3 of patients) and well-tolerated
◦If one doesn’t work….try another |
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role of triptans in migraine therapy
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1st line therapy in those with moderate to severe migraines without risk factors
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benefits of taking triptans at onset of symptoms
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Taking them at onset of symptoms improves efficacy and side effect profiles
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rational polypharm- combo of drugs to use in migraines (3)
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combination of triptan + NSAID and/or PO metoclopramide
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sumatriptan (2)
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◦The only 1st generation agent- most vasoactive issues- want to avoid in cardiac pt
◦Nasal spray and SQ injection are preferred for patients when N/V is significant |
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imitrex nasal spray- downside
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Imitrex nasal spray – horrible
taste |
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benefits and downsides to SQ injection of imitrex
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Subcutaneous provides fastest
onset, greater efficacy, but ↑ adverse effects |
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sumatriptan- when to give
2nd dose? |
give at onset of HA
2nd dose can be given an hour later but not that helpful/as effective as first dose |
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zomig (zolmitriptan) preperations (3)
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2.5 & 5mg tablets, 5mg nasal spray
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zomig vs. sumatriptan- designed to be...(3)
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Designed to be more lipophilic and bioavailable than sumatriptan with longer DOA and faster onset of action
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zomig initial dose
max dose |
Initial dose is 2.5mg then MR in 2 hrs. No more than 10mg/24hrs.
wtf is MR and NMT |
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zomig-ZMT- what is it
contains what |
orally disintegrating tablets, contain phenylalanine
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zomig nasal spray dose
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5 mg intranasally, may repeat x1 after 2 hours
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not going to ask doses
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--jk
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benefit of zomig
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no serious heart issues
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4 AE of zomig- and one AE it doesn't have that sumatriptan has
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nausea, dizziness, somnolence and paresthesias, no serious coronary effects
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pt who fail imitrex- might they respond to zomig?
zomig spray vs. imitrex spray |
◦Patients who fail to respond to Imitrex may respond to Zomig
◦Zomig spray is much less obnoxious than Imitrex spray |
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naratriptan- onset/safety
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The “gentle” triptan – slow onset of action and favorable safety profile
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naratriptan- issue
advantage/disadvantage compared to imitrex (2) |
Problem with patients who have reduced renal fx and/or liver fx
higher bioavailability (70%) & better CNS distribution than Imitrex disadvantage- less efficacoius |
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Eletriptan (Relpax) metabolism
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exclusively by CYP3A4
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6 CIs with triptans
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pregnancy, Prinzmetal’s angina, uncontrolled HTN, ischemic heart disease, ischemic stroke, basilar or hemiplegic migraine
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3 warnings when using triptans
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◦Concurrent or recent (past 2 weeks) use of MAOI
◦Concurrent or recent (past 24 hrs.) use of ergot-type medication ◦Do not administer if headache is atypical- because might be a stroke (ischemic) which will make it worse |
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triptan rebound HA (3) how many doses can cause
limiting dose how to prevent |
◦As little as 3 doses of a triptan per week caused drug-induced headache increasing attack frequency may be the first sign of developing a drug-induced headache
◦Most experts recommend using these abortive agents no more than two times per week ◦Use adequate prophylactic therapy to prevent analgesic overuse |
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Combination Triptans and NSAIDs (3)
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Some reports conclude that 1/3 of patients may not respond to triptan monotherapy
◦Resent study found combination of a triptan and NSAID more effective than monotherapy with either drug or placebo and resulted in lower recurrence rate (may be greatest result) side effects didn't seem to increase |
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treximet
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Imitrex 85mg, Naproxen 500mg
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opioids moa
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Alter pain sensation in the thalamus – don’t act on underlying headache mechanism
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opioids - usage in headaches
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Rescue treatments with severe headaches unresponsive to other treatments
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other conditions (2) in which opioids are often used for migraines
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in pregnancy- safer
Those with contraindications to or adverse effects from other agents |
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status migrainousis- aka
definition |
AKA: Intractable migraine
Exists when headache phase has been present for 72 hours – 1 week |
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how to tx status migrainosus (3)
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Meperidine l25mg IV or IM??
Prednisone 40-60mg PO x 2 days- easy fix Hospitalization? |
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when to use migraine ppx (wtf she said she wasn't going to ask about this) (4)
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Use when headaches are 4 or more per month, long duration (12 hours or more) or account for significant disability or when vasoconstrictors are contraindicated
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goals of migraine PPX (4)
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Reduce attack frequency by at least 50%
Reduce severity and duration of headaches Improve responsiveness to treatment of acute attacks Improve function and reduce disability |
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non hormonal PPX options for menstrual migraine (don't have to know dose i guess? she said this earlier) (3)
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Naproxen 500mg BID extending to day 3 of menses
Triptans: Dosed over 5 days (2 days before menses and continuing for 3 days into menses) Frovatriptan 2.5mg BID – prolonged half-life |
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hormonal PPX options for migraine: goal of using hormones
tx options |
◦Goal is to minimize premenstrual decline in estrogen
◦Oral contraceptives +/- supplemental estrogens HS- take at night due to more flux of hormones at night maybe |
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antihypertensives- migraine ppx options (3)
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beta blockers, calcium channel blockers, ACE inhibitors & ARBs
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BB options
2 grade A 3 grade B which ones do NOT work |
◦Propranolol, timolol (Grade A) – FDA approved
◦Metoprolol, nadolol, atenolol, (Grade B) ◦BB with ISA do not work for migraines |
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MoA of BBs in migraines
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possibly raise migraine threshold
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◦Most evidence & most widely used agents for prophylaxis
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beta blockers
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Therapeutic trial for BBs
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3 months, allow several weeks for onset & titrate dose as necessary
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CCBs- which one?
efficacious/recommended? why is it used sometimes? trial period |
verapamil
modest and inconsistent benefit – not recommended Used due to low side effect profile, may relieve aura symptoms 4-8 weeks from onest |
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BBs logical choice when..(2)
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htn or anxiety
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ACE inhibitors (2) efficacy
CI |
◦ Proven efficacy in double blind placebo control study
can't use in preg |
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Tricyclic antidepressants for migraine ppxFUCK
which one is grade A MoA drug of choice for what type of HA |
--◦Amitriptyline - Grade A evidence
◦ Other TCA’s have Grade C evidence probably due to adaptive changes in norepinephrine & 5HT receptors with chronic use ◦Often drug of choice for mixed headache syndrome (common migraine with tension headache) |
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ANTIEPILEPTIC DRUGS choice for migraine
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Divalproex sodium (Grade A evidence) – FDA approved
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VPA- preg category
efficacy/onset (2) use what form to minimize side effects |
◦Reduced headache frequency by 50%, onset within 4 weeks
◦Use extended release to minimize side effects ◦Probably as effective as beta blockers ◦FDA pregnancy category D (X if used for migraine ppx) |
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topamax usage- efficacy
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Reduced headache frequency in 1st month at doses of 100-200mg/day
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most common AE of topamax (3)
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Most common (at therapeutic dose): paresthesia (50%), dysguesia, weight loss(9-12%)
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topamax AE at larger target doses (4)
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fatigue, xerostomia, impaired memory, language and concentration difficulty
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natural meds for HA (1)
safety? |
Butterbur (Peasites hybridus) – spasmolytic and analgesic actions
Safety has not been established for use greater than 16 weeks |
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dangers of butterbur
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Other products may contain pyrrolizidine alkaloids – carcinogenic and cause liver & kidney damage
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misc agents for migraine ppx (5)
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Cyproheptadine PO 4-8 mg TID
Feverfew Magnesium B vitamins Botox |
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pathophys of cluster headaches
how it presents |
Thalamus is “cluster generator”
Attacks victims in rapid fire succession, severe pain |
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risk factors for cluster HA (5)
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Probably some genetic predisposition
Cigarette smoking, caffeine, alcohol use may be factors Affects 4x male as female |
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if butterbur- only want to use which brand
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petadolex- level A evidence
other brands have **** in it |
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onset of cluster HA (age)
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onset 25-50 yrs. of age
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quality of pain in cluster hA
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Excruciating, knife-like, single-sided pain that often radiates from orbit to temple, described as explosive, can be throbbing in nature
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cluster HA- how long do attacks last
recurrence most occur when? pt prefer to remain... |
Attacks last 15 min. to 3 hrs. (mean of 50 minutes) and may recur up to 8 times in 24 hours – most occur at night; patients prefer to remain active
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5 autonomic sx associated with cluster HA
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unilateral and ipsilateral with the pain; ocular tearing and redness, rhinorrhea with simultaneous congestion, sweating, ptosis (drooping eyelid)
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Patients with chronic cluster headaches are at risk of (2)
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self inflicted trauma
suicide |
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cluster HA- usually lasts how long
when do attacks usually start |
Cluster period lasts 3-16 weeks
◦Attacks often starting during sleep |
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KNOW THIS
cluster HA can be precipitated by..(3) |
vasodilating substances
(alcohol, nitro, histamine) |
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cluster HA tx- pt often need...
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Patients often need BOTH abortive and preventative therapy at the same time
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standard abortive therapy for cluster HA
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Standard treatment: inhalation of l00% O2 at 7 liters/min for 15 min – works for most patients
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triptans in cluster HA
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concern is a lot of harm possible esp with sumatriptan
SQ sumatriptan or intranasal |
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other options for cluster HA (5)
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DHE- intranasal
lidocaine- intranasal- numbing...some part of your brain prednisone- "cluster busting" usually relief within 1-2 days very hot/cold compresses vigorous exercise |
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preventive therapy for cluster HA (5) 2 non pharm, 3 pharm
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Avoid triggers (EtOH, NTG etc.)
Trial and error Lithium carbonate (70% effective) – can be used with verapamil Verapamil (70% effective) – effect can be seen after 7 days of treatment Valproic acid |
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Frovatriptan (Frova) unique property (2)
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longest half life (26 hrs.) of all triptans – has a slow onset of action
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rizatriptan vs. imitrex
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faster and greater relief from headache than Imitrex
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