Babalola Headaches

Headache Therapy

MOH

Management: -outpatient -recovery w/i 2 mo. of withdrawal -prevention: limit acute migraine therapies to <10 days per mo

Causes: -triptans -ergotamine -lasmiditan -opiates -combos -NSAIDs

Cluster headache

First line: verapamil -lithium -corticosteroids -galcanezumab

-initiate early to reduce remission

Treatment -Oxygen for pts who smoke/COPD -intranasal/SubQ triptans -Ergotamine derivatives

Prevention

Agents: -TCAs -Topiramate, Gaba, tizanidine, botulinum toxin -consider SSRI/SNRI in pts w/ depression

Consider for pts w >2 per weak lasting 3-4hrs + -severe that might result in MOH

Management

Pharm: -NSAIDs -Acetaminophen -Combo w/ caffeine

Nonpharm: -Behavioral treatment -Phys therapy

Preventative therapies:

Algorithm for Choosing

Periodic use: NSAIDs, triptans

-Naproxen 550mg BID -Frovatriptan BID or Nara/zolm as alts. -Candesartan -Lisinopril

CGRP antagonists (+monoclonal antibodies)

Cautions

Galcanezumab: AVOID in pts w/ CVD or recent CV event

Fremanezumab: AVOID in pts w/ CVD or thromboembolic events

Eptinezumab: AVOID in pts w/ CVD

Atogepant: -AVOID in severe hepatic impairment -reduce dose w/ severe or ESR impairment

ADEs:

-Atogepant -Rimegepant -Eptinezumab -Erenumab -Fremanezumab -Galcanezumab

B-adrenergic antagonists

ADEs: -Drowsiness/fatigue -sleep disturb -vivid dreams 👻 -memory disturbance -depression -bradycardia -hypotension

MOA: -raise migraine threshold via adrenergic/serotonergic modulation

Metoprolol, Propranolol, Timolol

Antidepressants

Ven: Risk of serotonin syndrome if combined w/ other agents

Ami: AVOID in pts w/ glaucoma. BPH, recent MI

ADEs: -Ami: anticholinergic effects, inc appetite, weight gain, sedation, ortho hypotension, slow AV conduction -Ven: N/V, drowsiness

MOA: -downregulation of central 5-HT -inc synaptic norepinephrine -enhance opioid receptor action

Amitriptyline Venlafaxine

Antiepileptics

Topiramate: -Avoid in history of kidney stones or cog impairment

Diva: -CI in pregnancy, women of child-bearing age not on contraception -BOXED WARNING: pancreatitis, hepatotoxicity

ADEs: -Diva: alopecia, weight gain, tremors, nausea, hepatotoxicity -Topiramate: paresthesia, fatigue, anorexia, diarrhea, weight loss

Remember that Diva Val got pregnant (gained weight)

+

find a Top zaddy when I lose weight

MOA: -enhance GABA inhibition -Mod excitatory glutamate -inhibit Na/Ca channel activity

-Valproate -Divalproex -Topiramate

Acute therapies: -should be offered to all pts w confirmed diagnosis -more effective when admin. early in the attack

Combo therapies

Selective serotonin receptor agonists (5HT+/- antiemetics)

DDIs: -SSRI, SNRI, TCA, MAOIs, etc (Serotonin syndrome) -Avoid other CNS depressants -Heart rate lowering meds (monitor/caution)

Do NOT drive or operate heavy machinery w/in 8hrs of use

ADEs: -Dizziness -fatigue/sedations -parasthesia -N/V -Muscle weakness

MOA: Bind to 5-HT1F receptor

Lasmiditan (C-V)

-2nd line for mod-severe --use when contraindication for triptan or inadeq response to >+2 oral triptans

CGRP Antagonists

Acute txtm: -Ubro: ONLY for acute treatment -Rime: ALSO for prevention

DDIs: -CYP3A4 inhibitors/inducers -Rime: P-gp inhibitors/2nd dose w/in 48hrs -Ubro: BCRP/P-gp inhibitors, decrease dose

Cautions: -Rime: Avoid in child-push C, ESRD -Ubro Avoid ESRD, dec dose in severe renal/hepatic impairment

ADEs: -Rime: N, abdom pain, hypersensitivity -Ubro: N, somnolence, dry mouth

Rimegepant Ubrogepant

-2nd line for mod-severe sxs -use when contraindication for triptan or inadeq response to >+2 oral triptans

Ergot alkaloids and derivatives

Fomulations: -oral absorption erratic/consider other forms -ergot combined w/ caffeine to enhance absorption + longer analgesia

Contraindications: -Hepatic failure -Coronary/cerebral/peripheral VD -Uncontrolled HTN -sepsis -pregnancy/nursing - strong CYP3A4 inhibitors -avoid w/in 24hrs of triptans

ADEs: -N/V -Abdom pain - fatigue/weak -parasthesias -muscle pain -diarrhea -chest tightness -ergotism

MOA: -Non-selec 5-HT1 agonist -constrict blood vessels -inhibit inflammation -dopa agonist -constrict arteries + veins

-Ergotamine tartrate -Dihydroergotamine

-1st option for acute treatment of mod-severe

Serotonin receptor agonists (triptans)

Considerations

DDI: -Avoid w/i 24hrs of ergotamine derivatives -SSRIs/SNRIs (serotonin syndrome) -Avoid w/i 2 weeks of MAOIs (Suma, Riza, Almo, Zolm) - Avoid CYP3A4 inhibitors w/i 72hrs (Ele)

Caution: -Unspecified coronary artery disease -postmenopausal women -men >40yo -uncontrolled CV risk factors

Contraindication: -IHD, uncontrolled HTN -cerebrovasc disease -hemiplegic/basilar migraines

ADEs: -Dizziness 😵💫 - fatigue 😪 - Flushing -Parathesias - N/V 🤢 🤮 - Injection site rxn - taste perversion or nasal discomfort - chest/neck/throat pain

MOA: -Agonist of 5-HT1B/1D -normalize dilated intracranial arteries -inhibit vasoactive peptide release -inhibit transmission thru 2nd order neurons

-Suma -Zolmi -Nara -Riza -Almo -Frova -Ele

-1st line for acute treatment of mod-severe -Variable time to relief, typically 2hrs -inconsistent evd. of switching agents

NSAIDs & Analgesics *1st line for mild-mod migraine attacks

Considerations:

Aspirin: -Tinnitus

Acetaminophen: -⚠️ hepatic dysfunction

NSAIDs: -inc BP, GI upset/bleed, dec kidney func - ⚠️ CVD

Likely effective: -Ketorolac (IV/IM) -Flurbiprofen -Ketoprofen

Efficacious agents: CANADIA -Aspirin -Celexocib -Diclofenac -Ibuprofen -Naproxen -Acetaminophen/aspirin/caffeine

MOA: inhibit prostaglandin synthesis -> prevention of inflammation

Non-pharm

-Wellness -Headache diary -Ice -Relaxation therapy -Cognitive therapy -Environment

Babalola Headaches

Cluster

Presentation: -Deep, non-pulsating, unilateral pain behind the eye -circadian rhythm, occurs in cluster periods -episodic vs. chronic -more common at night, spring/fall -quick onset, last 15-180 mins

Tears, stuffy nose, runny nose, eyelid edema, facial sweating, meiosis/ptosis, restlessness and agitation

Pathophys: -activation in hypothalamus -> activation of trigeminal autonomic reflexes -> pain and cranial autonomic features -cyclical due to hypothalamic dysfunction

Uncommon, 4x more prevalent in males -onset 20s/30s -current/former tobacco smokers -familial predisposition

Tension Headache

Presentation: -bilateral, dull, tight pain/pressure -mild photo/phonophobia -episodic or chronic

Pathophys: -stress/irritants --> increased peripheral sensitization of nociceptors --> activation of supra spinal pain and perception

Most common, high prevalence in women in their 40s

Migraine

Diagnosis criteria

Diagnosis

Pathosphys:

Aura:

-last 5-60mins -+/- visual -sensory or motor include paresthesia/numbness in arms/face, dysphasia/aphasia, weakness, hemiparesis

cortical spreading depression --> inflammation --> activation of trigeminal nucleus caudalis

Lowered threshold of response to triggers -abnormality in Ca/Na channels and/or Na/K pumps -Inc lvls of excitatory AA + changes in K levels -leads to cortical spreading depression

Phases: premonitory symptoms --> aura --> headache --> postdrome

-Women 18-44 -genetic predisposition -recurrent -can be disabling

Premonitory symptoms last hours to days

4 phases of a migraine headache

Reasons for referral: -Systemic illness -focal neurological symptoms or papilledema -onset after 50yo -acute onset of first or worst headache ever -accelerating pattern of headache following subacute onset -secondary: cancer or HIV

Triggers: Smell, chocolate, alcohol, weather, light, lack of sleep, stress, skipped meals, caffeine

Presentation: -4-72 hrs -unilateral, throbbing pain -GI sxs -sensory hyperacidity

Postdrome: AKA resolution of headache -tired, exhausted, irritable -depression/malaise -refreshed and euphoric