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33 Cards in this Set

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Calamari
MARI
Fried squid battered with seasoned flour, served with spicy marinara sauce
How is migraine commonly described?
Unilateral pulsating pain
How is cluster headache commonly described?
Unilateral pain with rhinorrhea
How is tension headache commonly described?
Bilateral non-pulsating pain
How is migraine with aura commonly described?
Bilateral pain with flashing lights
What are the goals of treatment in migraine headaches?
Decreased frequency
Decrease intensity
Improve quality of life
Decrease need for acute OTC analgesics (could turn into a medication overuse headache via withdrawal)
What non-pharmacologic treatments would you recommend?
Decrease caffeine
Cold compresses
Good sleep hygiene
Describe the treatment algorithm for migraines.
If migraine is diagnosed, you want to educate the patient on non-pharm and avoidance of triggers. If the headache is associated with severe nausea, consider pretreatment with an antiemetic (suppository, parenteral or intranasal formulation)
Continuation of last answer
If symptoms are mild-moderate, use a simple analgesic like acetaminophen/aspirin/caffeine or an NSAID like Ibuprofen, Aspirin or Naproxen. If this is inadequate, use a combination analgesic like aspirin/butalbital/caffeine. If this is still inadequate, use a Triptan or Ergotamine Tartrate. If this is still inadequate, you can try an opiod analgesic (intranasal butorphanol)
Continuation of last answer
If symptoms are severe, skip the analgesics and jump right to a triptan or ergotamine tartrate. If this doesnt work, then try an opioid (butorphanol nasal spray)
If you are considering Triptan therapy, what types of things do you want to make sure of in the patient?
Triptans are serotonin receptor agonists
They are contraindicated in ischemic heart disease, uncontrolled hypertension and cerebrovascular disease.
They should not be given with ergotamine derivatives or MOAIs
They should not be given with SSRIs because this could cause serotonin syndrome.
If considering dihydroergotamine nasal spray, how is it administered and what would you counsel the patient on?
One spray in each nostril, repeat in 15 minutes

Do not tilt head back
Do not sniff or inhale spray
Max sprays = 6 sprays per day
Discard after 8 hours
Side effects: Rhinitis, NV, Taste disturbances
What triptan can you give, at what dose and what side effects would you look for?
Sumatriptan 25-100 mg po daily - You can repeat in 2 hours ***Max Dose 200 mg/day***

Side effects = Fatigue, Dizziness, Somnolence, Flushing, Paresthesia
When are ergot derivatives contraindicated?
Triptan use
Pregnancy
Hepatic/Renal failure
Coronary, cerebral, peripheral vascular disease
Uncontrolled hypertension
CYP 3A4 Inhibitors (azole antifungals, protease inhibitors)
What is the indication for prophylactic migraine therapy?
If the patient is missing time from school or work, having episodes 2 or more times per week while on a triptan or ergot derivative (not NSAIDs because they could be experiencing incomplete relief or a medication use headache)
Fact:
Sumatriptan PO and IN are similar efficacy. However the SC formulation has better efficacy. Use this if you can.

***If one triptan doesnt' work, you can try another***
Describe how you choose prophylactic therapy in migraines.
If the patient has headaches in a predictable manner, you choose an NSAID to be used at the time of vulnerability --> Beta blocker --> tricyclic anti-depressant --> anticonvulsant --> methysergide
Continuation
If the patient has hypertension, angina or anxiety, you skip the NSAIDs and go right to a beta blocker --> tricyclic antidepressant --> anticonvulsant --> methysergide
Continuation
If the patient has depression, you skp the NSAIDs and beta blockers and go to the tricyclic anti-depressant --> anticonvulsant --> methysergide
Continuation
If the patient has a seizure disorder or bipoloar illness, you skip the NSAIDs, beta blockers, tricyclics and go to an anticonvulsant --> methysergide
Name a tri-cyclic antidepressant and an anti-convulsant that can be used as well as a dose.
Nortriptyline 10 mg po QHS

Topiramate 25 mg po QHS
How would you monitor for toxicity in beta blocker therapy?
Decreased HR
Drowsiness/Fatigue
Depression
Impotence
How would you monitor for toxicity in Tri-cyclic antidepressants?
Anti-cholinergic (Sedation, Hypotension, Urinary retention, constipation)
***Nortriptylline is the least***
How would you monitor for toxicity in anti-convulsants?
Topiramate - Nausea, Diarrhea, Fatigue, Weight loss, paresthesias
What could you give for nausea?
Prochlorperazine 10 mg PO or 25 mg PR
In minimizing the risk of a medication overuse headache, what max doses of NSAIDs do you not want to exceed?
Ibuprofen 2.4 g
Aspirin 4 g
Naproxen 1375 mg
Diclofenac 150 mg

You also want to only use these agents 2 times per week or less
Fiorenal and Fiorcet can also cause this. What is in these products?
Fiorenal = aspirin, caffeine and butalbital

Fiorcet = acetaminophen, caffeine and butalbital
If someone has a chronic daily headache that may be caused by medication overuse?
You don't want to stop the NSAID too quickly bc they could get a rebound headache. You want to use the NSAID less than 2 days per week and under the max doses.
You also want to start something to prevent the headaches while tapering down the NSAID.
Continuation
Patients with tension type headaches that turn into medication overuse headache are going to experience a withdrawal period. You need to get the patient to the point where they don't need an NSAID more than the recommended amount. You can do this by trying preventive therapy with a TCA (Nortriptyiline at a low dose and titrate up)
Counsel on what medication overuse headache is and the proper use of NSAIDs.
How long do you treat them with preventive therapy?
You treat them until they get back to the point where they aren't having headaches and then you can begin to taper off preventive therapy.
Cluster headaches are shorter than normal headaches, more debilitating than a migraine and typically occur at night. What are the two big triggers with cluster headaches?
Smoking - Important to recommend cessation
Caffeine
What is recommended in the acute setting for cluster headache?
Sumatriptan 6 mg SC at onset, may repeat in 1 hour
or
Dihydroergotamine 1 mg IV over 2 minutes, may repeat in 1 hour
Oxygen also works well - quick benefit but fades quickly
Patients with cluster headache typically require preventive therapy. Describe what options you have.
Verapamil 120 mg po QHS