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Headache (HA) and Migraine (migraine etiology and pathophysiology (aura - …

- - - - acetaminophen
        
        CIs: alcohol, liver damage
        
        dosing: 1g at onset PO q4-6 hrs PRN (max: 4g)
        
        AEs: hepatotoxicity, hypersensitivity
        
        some combination products include caffeine and aspirin
        
        produces analgesia through central
        inhibition of prostaglandin synthesis
      - NSAIDs
        
        not preferred in pregnancy!
        
        CIs: CHF, gout, anticoagulant therapy
        
        naproxen should not be used for patients < 12 YO
        
        adverse effects: GI upset/ulceration, renal impairment, edema
        
        diclofenac, ibuprofen, ketorolac, and naproxen are most consistent in efficiency for headache
      - serotonin receptor agonists (triptans)
        
        sumatriptan (Imitrex), zolmitriptan (Zomig), rizatriptan (Maxalt), naratriptan (Amerge), frovatriptan (Frova), eletriptan (Relpax)
        
        selective agonists of 5-HT1B and 5-HT1D receptors
        
        frovatriptan and naratriptan have the longest half-lives, the slowest onset of action, and less headache recurrence
        
        rebound headache is prominent (Rx is for 9/mo)
      - opiate analgesics
        
        controversial and evidence is generally negative since they have no vasopressor or anti-inflammatory effects
        
        rebound headache is prominent
        
        reserve for pts with moderate to severe infrequent headaches
      - ergot alkaloid and derivatives
        
        for pts with moderate to severe migraine
        
        non-selective 5HT1 receptor agonist
        
        ergotamine tartrate: PO, sublingual, or rectal suppository
        
        ergotamine tartrate can cause rebound headache, so dosage restrictions should be observed strictly
        
        dihydroergotamine: intranasal or parenteral (IM, SubQ, IV)
        
        AEs: N/V, abdominal pain, weakness, fatigue, paresthesias, muscle pain, diarrhea, chest tightness
        
        triptans should not be used within 24 hours of each other
        
        constrict intracranial blood vessels and inhibit the development of neurogenic inflammation in the trigeminovascular system
        
        pre-treatment with an antiemetic agent should be considered
        
        CIs: concurrent use with CYP3A4 inhibitors, pregnancy, uncontrolled HTN
      - biologics
        
        reserved for resistant migraines
        
        monthly subQ injection
        
        erenumab (Aimovig)
        
        monoclonal antibody that targets calcitonin gene-related peptide (CGRP)
    - - beta blockers (propranolol)