PHARM: Headache – Flashcards
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TTH
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tension-type headache
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TTH, Dx
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Bilateral head pain lasting from 30mins to 7 days Steady, non-pulsating pain Mild to moderate pain intensity Normal physical activity does not aggravate the headache AND No aura, nausea or vomiting (anorexia may occur) May have photophobia OR phonophobia
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TTH, Tx, 1st line
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OTC analgesics prescription NSAIDs
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TTH, Tx, 2nd line
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butalbital combination products Midrin APAP + opioid combinations
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butalbital combination products
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Fiorinal (CIII)- butalbital/ASA/caffeine Fioricet - butalbital/APAP/caffeine
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butalbital
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barbiturate
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Midrin
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(CIV) isometheptene/dichloralphenazone /APAP
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APAP + opioid combinations
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Tylenol w/codeine (CIII) Vicodin (CIII) Percocet (CII)
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TTH, episodic
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~3d/month
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TTH, chronic
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>15d/month 5% of population
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TTH, prophylaxis, indications
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If medication needed more than 2 days/week
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TTH, prophylaxis, agents
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TCA's Skeletal muscle relaxants Botulinum toxin
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TCA's in TTH prophylaxis
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Amitriptyline Nortriptyline
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TCA's, AE's
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sedating weight gain, dry mouth, constipation Contraindicated in severe heart disease
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Duloxetine in TTH, prophylaxis
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(Cymbalta) for MDD and chronic daily headache Course of therapy is usually 8 weeks Improvements in depression and headache
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Skeletal Muscle Relaxants in TTH, prophylaxis
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taken at first sign of neck or head tension may be taken 2-4 times a day if needed
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Skeletal Muscle Relaxants in TTH, agents
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Cyclobenzaprine Flexeril® Methocarbamol: Robaxin® Tizanidine: Zanaflex®
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Tizanidine:
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Zanaflex® drug-drug interactions hypotension and sedation Monitor LFTs
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Migraine, types
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+/- aura
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Migraine, complications
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Status migrainous Persistent aura Migrainous infarction Seizure
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Status migrainous
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debilitating >72hrs
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MIgraine, - aura
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4-72hrs Dx after 5 attacks
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MIgraine, - aura, Dx
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>2 of: unilateral location (frequently) pulsating quality moderate or severe pain intensity (gradual onset) aggravated by or causing avoidance of physical activity PLUS N/V or photophobia and phonophobia
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Migraine with aura, Dx
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20% at least 1: Fully reversible visual symptoms Fully reversible sensory symptoms Fully reversible dysphasic speech disturbance PLUS 5-60m or aura Sx develop over >5m
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Migraine Precipitators/Exacerbators
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Stress Hormones (i.e. menstrual migraine) Hunger Sleep deprivation Odors Smoke Alcohol Medications
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Abortive Migraine Therapy
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stoppage of migraines
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Abortive Migraine Therapy, goals
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Treat attacks early Restore ability to function Minimize rescue med Emphasize self-care Cost-effective Avoid adverse effects
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Abortive Migraine Therapy, non-pharmacologic
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Ice Rest Dark quiet room
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Abortive Migraine Therapy, mild-moderate
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NSAIDS, anti-emetics, analgesics
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Abortive Migraine Therapy, moderate - severe
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Triptans, ergot alkaloids
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Abortive Migraine Therapy, non-opiod agents
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ASA, IBUP, naproxen, diclofenac Rectal indomethacin OR IM ketorolac aspirin/APAP/caffeine
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Cambia
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diclofenac powder packet - 50mg x 1; mix with 1-2 ounces of water and drink at headache onset
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Abortive Migraine Therapy, triptans MOA
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constrict intracranial blood vessels (5-HT1B), inhibit vasoactive neuropeptide release (5-HT1D), & interrupt pain signal transmission centrally (5-HT1D
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triptans, AE's
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paresthesias, fatigue, dizziness, flushing, warm sensations, somnolence, chest tightness (up to 15%), possible rebound headache with overuse
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triptans, CI's
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ischemic heart disease, uncontrolled hypertension, cerebrovascular disease (stroke), basilar or hemiplegic migraines
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triptans, DDI's
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MAOIs w/in 2 wks, ergot w/in 24 hrs, caution w/SSRIs (serotonin syndrome), some 3A4 interactions unrecognized heart disease postmenopausal women, men > 40 years, patients with multiple cardiovascular risk factors
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***slide 22, 23
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goodRx app (resource)
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Treximet
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Triptan and NSAID combo Sumatriptan 85mg/Naproxen 500mg Potentially more effective in combination Max dose 2 tablets/24hrs May repeat in 2 hrs
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Ergotamine
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ergot alkaloid Abortive Therapy direct smooth muscle vasoconstrictor; non-selective 5-HT1 receptor agonists
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Ergotamine, AE's
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vasoconstriction, HTN, peripheral ischemia, N/V/D, pruritus, vertigo, cramps, paresthsias, cold skin, decr. pulses in extremities; rebound HA, fibrosis long term
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Ergotamine, CI's
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CAD, PVD, HTN, renal/hepatic failure, protease inhibitors, pregnancy (X)
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Ergotamine, DDI's
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triptans w/in 24 hrs, CYP 3A4 inhibitors, SSRIs/SNRIs
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Ergotamine, DHE
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injection given IV, inpatient only r/o cardiac issues with EKG and give test dose plus antiemetic
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Ergotamine, formulations
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Dihydroergotamine nasal (Migranal®) Oral (may be co-formulated with caffeine, includes Cafergot®, Wigraine®) Rectal (may be co-formulated with caffeine as in Migergot®) Sublingual tablet (Ergomar®)
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Other Abortive Therapy
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Combination with sympathomimetics Opioids Combination products with barbiturates Antiemetics migraine cocktail Intranasal lidocaine Corticosteroids
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Combination with sympathomimetics
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Isometheptane with dichloralphenazone plus APAP (Midrin)
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Stadol
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opiod Transnasal butorphanol SE: sedation, rebound with overuse
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Opioid combinations
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(Percocet, Vicodin) Effective as rescue medication in carefully selected patients Abuse potential Overuse may lead to chronic daily headache or rebound headache
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Combination products with barbiturates
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Butalbital with ASA or APAP (Fiorinal, Fioricet) SE: sedation, constipation, cognition DEC High abuse potential
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Antiemetics
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Prochlorperazine Metoclopramide Give 15-30 min before abortive therapy SE: sedation, extrapyramidal effects, anticholinergic effects Antiemetics alone may abort a migraine
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migraine cocktail
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Diphenhydramine, ketorolac, metoclopramide
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Intranasal lidocaine
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4% solution Rapid effect but frequent rebound (20-40% in one hour
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Migralex
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ASA 500mg plus magnesium 75mg
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Prophylactic Migraine Therapy
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incomplete response to acute therapies contraindications to acute therapies Frequent attacks 38% qualify 3-13% are on medication
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rebound HA, Tx goals
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Reduce frequency, severity and disability Reduce reliance on acute treatments Improve quality of life Avoid escalation of use of acute treatments Enable patient to manage migraine
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Migraine Prophylaxis: Beta blockers, agents
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Propranolol 60 LA & timolol (FDA-approved indication) metoprolol, nadolol, atenolol
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Migraine Prophylaxis: Beta blockers, AE's
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sedation, fatigue, dizziness, depression, orthostatic hypotension, impotence
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Migraine Prophylaxis: CCB's
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verapamil Modest efficacy and conflicting data (may take 8 weeks)
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Migraine Prophylaxis: CCB's, AE's
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edema, bradycardia, tachycardia, hypotension, constipation, dizziness, fatigue, HF exacerbation
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Migraine Prophylaxis: NSAIDs
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for migraines with predictable pattern Start 1-2 days prior to expected onset
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Migraine Prophylaxis: TCA's
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Best evidence with amitriptyline MOA: antagonism of vascular or brainstem 5-HT2
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TCA's, CI's
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MAOIs, acute recovery MI Caution in elderly patients, BPH, glaucoma
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Migraine Prophylaxis: SSRI's
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Not as much efficacy data available as with TCAs
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Migraine Prophylaxis: atypical antidepressants
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bupropion (Wellbutrin®) & venlafaxine (Effexor®) Not extensively studied
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Phenelezine
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Monoamine oxidase inhibitor (MAOI) Undesirable adverse effect profile anticholinergic, hypotension, impotence, skin rash, hypertensive crises
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Migraine Prophylaxis: Anticonvulsants
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carbamazepine gabapentin tiagabine topiramate valproic acid divalproex oxcarbazepine lamotrigine vigabatrin zonisamide
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Migraine Prophylaxis: Anticonvulsants to avoid
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topiramate valproic acid divalproex
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Migraine Prophylaxis: Botox
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FDA approved October 2010 May cause neck pain and headaches Approximate cost $2000
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Menstrual Migraines
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Short term prophylaxis Initiate 1-2 days prior Continue for the expected duration of headache NSAIDs (2-7d prior) Frovatriptan 2.5mg QD or BID
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Migraine prophylaxis: Herbals and supplements
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Petasites Coenzyme Q10 Magnesium
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Petasites
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(butterbur extract) 50-75mg BID Herbal supplement found to decrease migraine attacks by 60% from baseline
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Coenzyme Q10
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100mg TID Decreased migraine attacks by 50% from baseline in 47.6% of patients compared to 14.3% for placebo
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Magnesium
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300mg daily
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Considerations
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adequate trial (6-8 weeks) Consider concomitant disease states HA-free intervals may allow for dose reduction Taper slowly
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Cluster Headache
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>5 attacks Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 min if untreated
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Cluster Headache, accompanying Sx
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ipsilateral conjunctival injection and/or lacrimation ipsilateral nasal congestion and/or rhinorrhoea ipsilateral eyelid edema ipsilateral forehead and facial sweating ipsilateral miosis and/or ptosis a sense of restlessness or agitation
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Cluster Headache, abortive therapy
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O2 100% via NRB at 6-12L/min x 15 min Subcutaneous sumatriptan Intranasal sumatriptan or zolmitriptan Octreotide DHE IV Intranasal lidocaine
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Cluster Headache, prophylaxis
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Verapamil (preferred agent) Lithium Ergotamine Corticosteroids Nerve block
