Psych 4 - Franko Headache

Front 1

Which headache is pain behind browbone and/or cheekbones?

Back 1

Sinus headache

Front 2

Which headache is pain in and around one eye?

Back 2

Cluster headache

Front 3

Which headache is like a band squeezing the head causing pain?

Back 3

Tension headache

Front 4

Which headache causes pain, nausea, and visual changes?

Back 4

Migraine

Front 5

Which is the most common type of headache?

Back 5

Tension

Front 6

Tension headaches occur most often in?

Back 6

Women

Front 7

Episodic tension headache?

Back 7

Occur randomly, usually triggered by temporary stress, anxiety, fatigue, or anger

Front 8

Chronic tension headache?

Back 8

Daily or continuous headache with fluctuations; always present; linked to anxiety/depression

Front 9

Tension headache presentation?

Back 9

Moderate/dull tightness; spreads around the head and can localize at various points; bilateral; absense of neurologic effects

Front 10

Cluster headaches are more common in?

Back 10

Men

Front 11

What plays a large role in cluster headaches?

Back 11

Genetics; as well as smoking, high caffeine use, and alcohol abuse

Front 12

Cluster headaches can last for up to?

Back 12

months at a time, followed by periods of remission lasting months to years (rarely never resolve)

Front 13

Which headache has a parasympathetic nervous system response?

Back 13

cluster headaches

Front 14

Cluster headache presentation?

Back 14

severe pain around the eye; pain can last up to 3 hours and up to 8 times daily; tearing, runny nose, eyelid edema, and facial swelling may be present; described as explosive; patients may be restless and excited

Front 15

Migraines are more common in?

Back 15

adult women (can appear at an early age in children) and lower income households

Front 16

4 phases of a migraine?

Back 16

1. prodrome

2. aura

3. headache

4. postdrome

Front 17

Prodrome phase?

Back 17

can occur hours to days prior to the headache; photophobia, phonophobia, irritability, and loss of appetite

Front 18

Aura phase?

Back 18

not seen in all patients; develop over 5-20 minutes and can last up to 1 hour; one of the following MUST be present: reversible visual changes, reversible sensory changes, or reversible speech changes)

Front 19

Headache phase?

Back 19

usually unilateral; gradual onset; more felt in front and side of head; throbbing/pulsating and intense pain

Front 20

Postdrome phase?

Back 20

migraine hangover; can last for days; irritable, fatigued, depressed, lack of concentration

Front 21

Diagnosis of a migraine with aura?

Back 21

-at least 1 aura symptom that gradually spread over at least 5 minutes

-at least 1 aura symptom is unilateral

-accompanied by or followed by headache within 1 hour

-2 attacks fitting these criteria

Front 22

Diagnosis of migraine without aura?

Back 22

-2 or more: pain worse with activity, unilateral pain, pulsating pain, moderate/severe in intensity

-1 or more present during headache: N/V, photophobia/phonophobia

-5 or more attacks fitting these criteria

Front 23

Chronic migraine diagnosis?

Back 23

Headache on at least 15 days/month for at least 3 months with at least 8/15 headaches meeting criteria for migraine without aura

Front 24

Common migraine triggers?

Back 24

stress, fatigue, lack of sleep, menstruation, flashing lights, loud noises, weather changes, tobacco smoke, strong smells, alcohol, caffeine intake/withdrawal, chocolate, certain fruits, fermented/pickled products, MSG, nitrates, aspartame, sulfites, tyramine, yeast, oral contraceptives, indomethacin, nifedipine, withdrawal from certain medications

Front 25

NSAID adverse reactions?

Back 25

bleeding, upset stomach

Front 26

Ketorolac IV or IM max use?

Back 26

5 days!

Front 27

Caution with NSAIDs?

Back 27

renal dysfunction, PUD

Front 28

Fioricet?

Back 28

Butalbital + APAP + caffeine

Front 29

Fiorinal?

Back 29

Butalbital + ASA + caffeine

Front 30

How may tablets of butalbital products can be taken daily?

Back 30

up to 6/day

*caution with prolonged use, controlled substance

Front 31

adverse effects of butalbital products?

Back 31

CNS depressant

tachycardia, confusion, lightheadedness, sedation

Front 32

Contraindications to butalbital products?

Back 32

PUD, renal dysfunction, history of drug abuse

Front 33

Butalbital products are ideally used in what type of headache?

Back 33

Tension type headaches

Front 34

Ergot alkaloids MOA?

Back 34

agonist of serotonin, alpha, beta, and dopamine receptors

Front 35

Most common ergot alkaloid agents?

Back 35

Ergotamine:

-oral = Cafergot

-sublingual = Ergomar

-suppository = Migergot

Dihydroergotamine (DHE)

-nasal = Migranal

-injection = DHE-45

Front 36

Oral ergotamine?

Back 36

Cafergot

Front 37

Sub-lingual ergotamine?

Back 37

Ergomar

Front 38

Suppository ergotamine?

Back 38

Migergot

Front 39

Nasal dihydroergotamine (DHE)?

Back 39

Migranal

Front 40

Injectable dihydroergotamine (DHE)?

Back 40

DHE-45

Front 41

onset of ergot alkaloids?

Back 41

~4 hours

Front 42

What is usually given with ergot alkaloids?

Back 42

Antiemetic when given IV due to increased risk of N/V; DOC = metoclopramide or chlorpromazine

Front 43

Adverse effects of ergot alkaloids?

Back 43

abdominal pain

*rarely: ischemia, necrosis, gangrene, heart attack

Front 44

Contraindications to ergot alkaloids?

Back 44

Hx of CV dz (heart attack, stroke, uncontrolled HTN), renal/hepatic failure, sepsis, or triptan use within past 24hrs

Front 45

Triptan MOA?

Back 45

serotonin receptor agonists; stabilize neuropeptides and trigeminal nerve function modulating pain sensations; potent vasoconstrictors

Front 46

Adverse effects of triptans?

Back 46

fatigue, dizziness, sensation of warmth, chest fullness/tightness, nausea

Front 47

Contraindications of triptans?

Back 47

hx of heart attack, stroke/TIA, uncontrolled HTN

Front 48

Dosing of triptans?

Back 48

all product differ; patient should be tried on at least two before deemed unresponsive; best administered at the onset of symptoms for best response; relief usually seen in 2-4 hours

Front 49

Almotriptan brand?

Back 49

Axert

Front 50

Almotriptan formulation?

Back 50

tablet

Front 51

Almotriptan time to next dose?

Back 51

2 hours

Front 52

Eletriptan brand?

Back 52

Relpax

Front 53

Eletriptan formulation?

Back 53

tablets

Front 54

Eletriptan time to next dose?

Back 54

2 hours

Front 55

Frovatriptan brand?

Back 55

Frova

Front 56

Frovatriptan formulation?

Back 56

tablets

Front 57

Frovatriptan time to next dose?

Back 57

2 hours

Front 58

Naratriptan brand?

Back 58

Amerge

Front 59

Naratriptan formulation?

Back 59

tablets

Front 60

Naratriptan time to next dose?

Back 60

4 hours

Front 61

Rizatriptan brand?

Back 61

Maxalt

Front 62

Rizatriptan formulation?

Back 62

tablets/ODT

Front 63

Rizatriptan time to next dose?

Back 63

2 hours

Front 64

Sumatriptan brand?

Back 64

Imitrex

Front 65

Sumatriptan formulation?

Back 65

Tablets, SC injection, or nasal spray

Front 66

Sumatriptan time to next dose?

Back 66

Tablets = 2 hours

SC injection = 1 hour

Nasal spray = 2 hours

Front 67

Sumatriptan/naproxen brand?

Back 67

Treximet

Front 68

Sumatriptan/naproxen formulation?

Back 68

Tablets or nasal spray

Front 69

Sumatriptan/naproxen time to next dose?

Back 69

Tablets = 12 hours

Nasal spray = 2 hours

Front 70

Zolmitriptan brand?

Back 70

Zomig

Front 71

Zolmitriptan formulation?

Back 71

tablets, ODT, or nasal spray

Front 72

Zolmitriptan time to next dose?

Back 72

2 hours for all formulations

Front 73

Abortive tx for tension headaches

Back 73

Mostly use OTC (APAP or NSAIDs); if OTC fail, use prescription medication (NSAIDs, Opioid/APAP, Butalbital formulation)

Front 74

Medication overuse headache?

Back 74

MOD; can result from excessive use of prescription/more potent medications (ergotamine, triptan, opioid or other potent combination) for more than 10 days/month or non-specific agents for more than 15 days/month

Front 75

Cluster headache abortive treatment?

Back 75

High flow rate O2 100% for about 15 minutes; repeat if symptoms persist; can use triptans or ergotamine if O2 is not available; Nasal or SC sumatriptan or solmitriptan are most effective; IV/IM/nasal ergotamine is an acceptable alternative; if contraindications to triptan/ergotamine, can use octreotide SC; IV steroids by a taper of oral steroids can be effective as well

Front 76

Migraine abortive treatment?

Back 76

Remove triggers; use less specific treatments first

Front 77

Mild migraine abortive treatment?

Back 77

NSAIDs, APAP, or butalbital

Front 78

Mild, but failed non-specific therapy of migraine abortive tx?

Back 78

Triptan

Front 79

Moderate migraine abortive therapy?

Back 79

Ergotamine, DHE, triptan

Front 80

Severe migraine abortive therapy?

Back 80

DHE, triptan

Front 81

All types of migraine abortive therapy?

Back 81

Antiemtics as needed (preferably metoclopramide or chlorpromazine)

Front 82

Prophylactic therapy of tension headaches?

Back 82

TCA's are mainstay of therapy if pt is experiencing frequent attacks or disability

Front 83

Prophylactic therapy of cluster headaches?

Back 83

DOC: Verapamil 240-360 mg/day; results can be seen in little as one week, but usually takes 4-6 weeks; caution in patients with CV dz; AVOID concurrent use with eletripan (CYP 3A4 interaction)

*Lithium also option; dose to low serum concentration of 0.4-0.8 mEq/L; caution with renal failure and CHF; contraindicated in patients on thiazides, ACE/ARB; longterm use may result in tremor, GI upset, and lethargy

*use lower doses of either agent with concurrent use of ergotamine, dose at bedtime if possible

Front 84

Prophylactic therapy of migraines - indication?

Back 84

More than 2 migraines/month; disability lasting at least 3 days/month; use of abortive medications 2x/wk; failure/intolerance/adverse effect/contraindication to acute options; uncommon migraine conditions such as hemiplegic migraine

Front 85

Prophylactic therapy of migraines - medication options?

Back 85

1. Beta blockers: usual first line; careful monitoring in patients not requiring beta-blocker therapy; if unable to use, can consider using CCB, lisiinopril, or candesartan

2. TCAs: must monitor for AE; dose at bedtime; can consider using venlafaxine if unable to use TCA (caution with triptans = serotonin syndrome)

3. Antiepileptics: valproic acid (titrated to 100 mg/day, may cause weight gain) or topiramate (100 mg/day, may cause weight loss, good for nerve based pain) or carbazepine if trigeminal neuralgia suspected

4. Botox (conflicting evidence)

5. Butterbur, riboflavin, magnesium

Front 86

Menstrual headache (migraine) prophylactic therapy?

Back 86

Take NSAIDs prior to start of menstruation, if unresponsive use triptans (Frovatriptan, naratriptan, and zolmitriptan have most efficacy started 2-3 days prior to menstruation)

Front 87

Ideal patient for Beta Blocker migraine prophylaxis?

Back 87

Anxiety, angina, heart disease, otherwise healthy

*use propranolol

Front 88

Ideal patient for Antiepileptic migraine prophylaxis?

Back 88

Seizure, bipolar, nerve based pain/metabolic syndrome (topiramate only)

*use valproic acid or topiramate

Front 89

Ideal patient for Antidepressant (TCA) migraine prophylaxis?

Back 89

Depression, insomnia

*use amitriptyline

Front 90

Ideal patient for NSAID migraine prophylaxis?

Back 90

Predictable migraines (take 1-2 days prior to vulnerable time and throughout)

Front 91

Ideal patient for Botox migraine prophylaxis?

Back 91

Chronic migraine only

*use onabotulinumtoxin A

Front 92

Pediatric headache treatment?

Back 92

Recommended to use ibuprofen first line, then APAP as acute tx in children >6yo; avoid ASA due to risk of Reye syndrome; antiemtic use can be considered (promethazine recommended due to low risk of EPS); triptans are acceptable over 12yo; prophylactic tx not studied

Front 93

Pregnancy headache treatment?

Back 93

use non-pharm as much as possible; APAP safe for mother and fetus if needed; avoid NSAIDs during 3rd trimester; avoid opioid as much as possible; centrally antiemtics can be used; prednisone and methylprednisone can be used safely; if absolutely necessary, can use sumatriptan, naratriptan, or rizatriptan; Ergot based products CONTRINDICATED (can cause contractions, etc)

Front 94

Pregnancy migraine prophylaxis?

Back 94

beta blockers, but monitor carefully