Headache

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Author:
timothy.pdlt
ID:
211829
Filename:
Headache
Updated:
2013-04-06 21:42:48
Tags:
headache migraine tension type
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Description:
therapeutics, side-effects, drug interactions
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  1. GoT of HA Tx
    • 1. relieve S/S
    • 2. prevent recurrence
    • 3. diagnose serious HA
    • 4. minimize S/E
  2. Epidemiology of HA
    • lifetime risk= >90%
    • >1 severe HA annually= 25%
    • migraines= 6%M + 16% F
    • chronic daily HA= 3%
  3. If recent onset of HA, what do you do?
    • CT/MRI
    • lumbar puncture
    • metabolic/electrolyte abnormalities
    • drug-induced/withdrawal
    • temporal enteritis
  4. Red flags for HA
    • middle-aged and elderly
    • severe and abrupt onset
    • progressing severity
    • change in HA pattern
    • neurological S/S
    • systemic S/S (ie. fever)
    • new HA with cancer, pregnancy, immunosuppression
  5. Common Migraine classification
    • minimum of Dx: 5 (1.5/month)
    • duration: 4-72 hours
    • >1 of: unilateral, pulsating, mod-severe, aggravated by routine
    • >1 of: N/V, photophobia+phonophobia
  6. Classic Migraine classification
    • minimum of Dx: 5 (1.5/month)
    • duration: 4-72 hours
    • >1 of: unilateral, pulsating, mod-severe, aggravated by routine
    • >1 of: N/V, photophobia+phonophobia
    • preceded by aura within 60mins: visual s/s (positive and negative), sensory s/s (tingling, numbness)
  7. Infrequent Episodic Tension classification
    • minimum of Dx: 10 (>1/month)
    • duration: 30min-7days
    • >2 of: bilateral, not throbbing, mild-mod, not aggravated by routine
    • both of: no N/V, either photophobia or phonophobia
  8. Episodic Cluster classification
    • minimum of Dx: 5 (EOD to 8/day)
    • duration: 15-180mins
    • severe: unilateral orbital/suborbital/temporal pain
    • >1 of: conjunctival injection, lacrimation, nasal congestion, rhinorrhea, facial sweating, miosis, ptosis, eyelid edema
  9. Non-pharm Tx
    • Migraine
    • 1. avoid triggers
    • 2. cold/pressure to the head
    • 3. reduce activity and sensory input
    • 4. relaxation, hypnosis, biofeedback, visual imagery, PT

    • Tension-type HA
    • 1. heating pad
    • 2. stretching, strengthening, massage, ultrasound
    • 3. relaxation
  10. Associated drugs with secondary HA
    • amitriptyline, imipramine
    • frequent ASA/APAP
    • NSAIDs
    • BDZs
    • NTG
    • MAOIs
    • metoclopramide
    • estrogen
    • sulfa
    • theophylline
  11. Withdrawal of these drugs cause secondary HA
    • BDZs
    • caffeine
    • ergotamine
    • methysergide
    • ASA, APAPĀ±codeine
    • anti-hypertensives
  12. Indications for preventative HA Tx
    • >2 attacks/month causing >3days/month disability
    • CI or failure to abortive Tx
    • use of abortive Tx >2days/week
    • uncommon type of HA
  13. Preventative HA Tx
    • propranolol 40-120mg BID
    • amitriptyline 25-75mg QHS
    • divalproex 400-600mg BID
  14. S/E of triptans (5HT 1b/1d agonist)
    • N/V
    • photophobia
    • asthenia
    • chest S/S
    • paresthesia
    • MOH if >1/week
  15. DI of triptans (5HT 1b/1d agonist)
    • space from ergots by >24hours
    • 5HT syndrome with SSRIs
  16. Dosage forms of triptans (5HT 1b/1d agonist)
    • PO: suma, zolmi, nara, riza, almo, ele
    • Nasal spray: suma, zolmi
    • SC: suma
  17. Dose-response effect of triptans (5HT 1b/1d agonist)
    • rizatriptan 10mg= higher recurrence
    • eletriptan 40mg= lower recurrence
    • naratriptan 2.5mg= less effective but less recurrence
  18. Dihydroergotamine for migraine
    • lower recurrence rate than sumatriptan
    • dosage forms: SC, IM, IV, intranasal
  19. S/E of dihydroergotamine
    more nausea and less chest pain than sumatriptan
  20. Ergotamine for migraine
    • increase effectiveness if taken during aura or very early in the attack
    • dosage forms: PO, SL, PR
  21. S/E of ergotamine
    similar to DHE but more nausea
  22. Tension-type HA guidelines
    • Tx: APAP, ASA, NSAIDs
    • +caffeine >100mg= increased analgesia
    • MOH if drug use >2x/week
  23. Preventative Tx for tension-type HA
    • amitriptyline 10-25mg QHS-->50-75mg
    • ami S/E: dry mouth, constipation, sedation, weight gain
    • ami CI: glaucoma, epilepsy, BPH, cardiac arrythmias

    alternative: doxepin, imipramine, TCAs, SSRIs
  24. Cluster HA guidelines
    can be hard to treat: rapid onset, increase in intensity, short duration

    • acute:
    • sumatriptan 6mg SC
    • 100% oxygen 8-10L/min x15mins
    • DHE/ergotamine
  25. Preventative Tx for cluster HA
    verapamil* PO 120-160mg TID

    alternative: lithium, prednisone, methysergide (need drug holiday after 6 months), VPA, TPM

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