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Pharm Headaches
Neurology Unit Pharm Headaches
| Question | Answer |
|---|---|
| Most common type of headache | Tension headaches |
| M or F predominance in tension headaches? | adult females have the highest prevalence |
| This type of tension headache is characterized by attacks that occur an average of 3days/month | episodic tension headaches |
| Chronic tension headaches are defined as | 15 or more attacks/month (seen in <5% of population) |
| Overuse of medication can lead to | rebound headache |
| Cause of tension headaches | initially, myofascial head pain with altered central processing |
| Characteristics typical of Tension headaches | bilateral head pain, non-pulsating, Pain intensity mild to moderate, no nausea or vomiting, people DO have either photophobia or phonophobia. Tender points may be palpated on head in some individuals |
| Acute first-line therapy of Episodic Tension-type headaches | OTC analgesics |
| Excedrin Tension HA is made of | APAP (acetominophen) 500mg and 65 mg caffeine per gelcap |
| When should you consider prophylaxis for Tension-type headache? | If medication is needed more than 2days/week. |
| Special consideration is needed for Fiorinal or Fioricet because | Fiorinal and Fioricet have a barbiturate in them (barbituate plus ASA or APAP), so it is hard to get people off of it if they are in a chronic habit of using it. |
| Vicoden and Percocet should be used rarely in | tension-type headaches |
| TTH prophylactic treatment therapies for chronic or frequent TTH | TCAs, Skeletal muscle relaxants (Zanaflex may promote weaning from other analgesics), Botulinum toxin injections |
| At what time of day are TCAs dosed? | At bedtime |
| What are the AEs of TCAs? | weight gain, dry mouth, constipation (anticholinergic effects including sleepiness and confusion) |
| What is the contraindication of TCAs? | Severe heart disease |
| Name two TCAs | Amitryptiline and Nortriptyline |
| This pharmaceutical improves depression and headache (it is also indicated for post herpetic neuralgia and diabetic peripheral neuropathy) | Cymbalta (duloxetine) |
| Muscle relaxants should be dosed when? | Preferably at bedtime. Cause drowsiness, so caution patients not to drive or operate machinery. Avoid alcohol or other sedatives |
| Long term use of Muscle relaxants can cause | liver damage |
| Are muscle relaxants addictive? | No. |
| Which muscle relaxant has several drug-drug interactions and may also increase chance of hypotension and sedation? | Tizanidine. Monitor LFTs periodically with chronic use |
| What percentage of migraines have an aura? | 20% |
| First-line therapy for Migraines | Triptans |
| Abortive Therapy for Migraines: Non-Opioids | NSAIDs, aspirin, acetaminophen (APAP) |
| AE's of NSAIDs, aspirin, and acetominophen used for headache and migraine | GI toxicity, possible rebound HA, sodium and water retention, renal dysfunction, exacerbation of HF, antiplatelet effects, |
| MOA of triptans | constrict intrcranial blood vessels, inhibit vasoactive neuropeptide release (peptides are suspected to be a part of the inflammatory process), and interrupt pain signal transmission |
| AE's of triptans | AEs: paresthesias (b/c they are vasoconstrictors), fatigue, dizziness, flushing, warm sensations, somnolence, chest tightness (up to 15%), possible rebound headache with overuse |
| Contraindications of Triptans | CIs: ischemic heart disease, uncontrolled hypertension and cerebrovascular disease, basilar or hemiplegic migraines |
| What percentage of people get chest tightness with Triptans | 15% |
| Drug-Drug Interactions of Triptans | MAOIs, ergot, caution with SSRIs (serotonin syndrome), some 3A4 inhibitors. |
| SSRI's and Triptans both increase what substance in the brain? | Serotonin |
| How are Triptans taken? | Orally, Injections (never give IV or IM), Nasal (only oral and injection are generic) |
| How do you adjust Triptans in a pt with significant hepatic impairment? | Reduce oral to 50mg |
| Do Triptans needed to be adjusted for renal impairment? | No |
| Oral Triptans are not recommended in which population? | elderly due to increased htn |
| What is the onset of Triptans | Takes one hour to start working |
| Which triptans have fast onset and short duration | Almotriptan (Axert), Rizatriptan (Maxalt), Zolmitriptan (Zomig) |
| Which triptans have slow onset, longer duration and are used in predictable migraines | Naratriptan (amerge), Frovatriptan (Frova). Great in patients who have menstrual migraines |
| The triptan with fast onset and moderate duration | Eletriptan (Relpax) |
| Which triptan is generic? | Sumatriptan |
| Treximet is a combination of | sumatriptan and naproxen. (in this combo sumatriptan peaks in an hour, while sumatriptan alone peaks at about 1.5. Naproxen peaks in 5 hours). Decreases the need for rescue medication |
| When should Treximet be dosed? | 1 tablet at first sign of migraine |
| What is the MOA of Ergotamine? | direct smooth muscle vasoconstrictor. Contraindicated in patients with HTN (can cause gangrenous ischemia) |
| What kind of Ergotamine routes are there? | Oral, nasal, injection, rectal suppositories, sublingual. More commonly used are the DHE nasal spray and injection. |
| Contraindications of Ergotamine | CAD, PVD, HTN, liver/kidney dz, protease inhibitors, pregnancy (X) |
| Drug interactions with Ergotamine | Triptans, methysergide, CYP3A4 inhibitors |
| Pts with Fiorinal and Fioricet addiction who end up in the hospital get what? | IV DHEA (dihydroergotamine) |
| Antiemetics are dosed when in migraine patients who vomit? | 15-30 min before abortive therapy so they have less chance of throwing up expensive migraine pills. Antiemetics: Prochlorperazine and metoclopramide |
| NSAIDs might be appropriate prophylactic therapy in which type of migraine? | Menstrual migraines. NSAIDs can be used for migraines with predictable patterns. Short-term (1wk) use at a time to avoid GI toxicity and drug rebound HA. |
| ________ is a prophylactic migraine therapy used more frequently in kids | Cyproheptadine |
| Most effective abortive therapy in Cluster HA | Oxygen |
| Abortive Treatment of Cluster HA | O2 100% at 6-8 L/min x 15 min;DHE-45 0.25-1 mg IV TID x 2 days, taper on 3rd day; sublingual or rectal ergotamine also used,Sumatriptan or zolmitriptan,Intranasal lidocaine ,Other: intranasal capsaicin, leuprolide IM |
| _______ are effective as rescue medications in carefully selected migraine patients, but have abuse potential | Vicodin, Percocet |
| Other abortive therapies for migraine | intranasal lidocaine (4% solution, rapid but frequent rebound), corticosteroids, droperidol, Nitrous oxide, propfol |
| Prophylactic agents for Migraines | Beta blockers, TCAs, SSRIs, MAOIs, anticonvulsants, NSAIDs, CCBs (used for htn),botulinum, Riboflavin, Alpha2agonists, Cyproheptadine, Magnesium IV, Feverfew |
| Who should receive migraine prophylaxis? | 2+ attacks/month resulting in 3+disability days from work, HA refractory to abortive tx, use of abortive tx >2days/wk, uncommon and serious HA types |
| How to administer NSAIDs to patients with menstrual migraines | begin 2-7 days prior to menses, continue through last day of flow |
| Prophylaxis for cluster HA | Verapamil, Lithium (lots of AEs), Ergotamine, Corticosteroids (prednisone) |
Created by:
ltm12