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HEADACHES (Migraine (Clinical Presentation (N/V (almost always present),…

- - - - May be result of alterations in ion channels and pumps affecting serotonin release or excitatory NT release (glutamate)
    - - caffeine +/-
      - alcohol
      - sleep +/-
      - smells
      - loud noises
      - foods
      - menstruation
      - exercise
  - - - Need strict adherence to daily and weekly max doses to reduce risk of rebound headaches
      - PPX used if headache frequency more than twice weekly. adequate trial needed to assess efficacy of ppx (6 months)
      - 5-HT1B/1D agonists
      - meds are mainstay therapy
      - Acute can be supportive (symptoms) or abortive (resolution of migraine). Or long term with prophylactic treatment.
      - Acute
        
        non-specific
        
        analgesics, steroids, antiemetics, NSAIDs
        
        NSAID MOA: relieve inflammation in trigeminovascular system via prostaglandin synthesis inhibition
        
        combo analgesics can be used with ASA, APAP, caffeine. Butalbital not recommended for migraine
        
        opioids as rescue med or if other meds contraindicated - no MOA that supports curative properties
        
        antiemetics: proclorperazine, metoclopramide, clorpromazine - dopamine antagonists
        
        corticosteroids as rescue med for long-lasting migraine (status migrainous)
        
        migraine specific
        
        ergots
        
        ergotamine tartrate and dihydroergotamine
        
        5-HT1 receptor agonists - constrict intracranial blood vessels, suppress trigeminovascular inflammation
        
        N/V is a commnon AE - chemoreceptor trigger zone
        
        triptans
        
        5-HT1B/1D agonists
        
        vasocontriction, suppress release of vasoactive neuropeptides, inhibit transmission to thalamus
        
        do not use with SSRI/SNRI for risk of serotonin syndrome
        
        acute should be administered at time of onset of migraine symptoms. may need to pre-treat with antiemetics
      - Prophylactic
        
        Propranolol, timolol, divalproex, topiramate
        
        efficacy between agents similar - deciding factor is typically comorbidites (cardiac, seizures)
        
        trial of 2-3 months to determine efficacy
    - - Ice, rest, dark, quiet environment
      - headache journal
      - trigger avoidance
      - wellness programs to support sleep, caffeine and smoking cessation, exercise, lifestyle
    - - pattern of headache returning as meds wear off leading to more med use and cycle
      - Seen with combination analgesics, opioids, triptans
      - Limit use to fewer than 10 days/month to prevent this complication
  - - - almost always present
    - - Labs include: thyroid function tests, serum chemistries, urine tox screen, Lyme disease, CBC, ESR
- - - - Simple analgesics alone or in combo products
      - NSAIDs
      - Risk of rebound headaches - limit thearpy to 3 days for butalbital, 9 days for combo analgesics, 15 for NSAIDs
      - PPX
        
        Can use TCAs, SSRIs, SNRIs, AEDs
        
        choice of therapy driven by comorbidities and AEs
    - - Stress mangement - potentially CBT, biofeedback, relaxation training
      - heat or cold packs, ultrasound, electrical nerve stimulation, stretching, exercise, massage, accupuncture
- - - - Abortive
        
        Oxygen
        
        100% O2 12L/min for 15 minutes
        
        Triptans
        
        SC sumtriptan 6 mg considered most effective
        
        Ergotamine derivatives
        
        dosing similar to migraines
      - Prophylactic
        
        Verapamil, lithium, corticosteroids, lidocaine