University:
West Coast University
Course:
PHAR 835 | IPC Neurology/Psychiatry
Academic year:

2024
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452

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63
Author:

Asal A.

0903 after Lecture Eton HeadacheTherapeutics Parna Haghparast, Pharm.D., BCPS Fall Semester 1 This Photo by Unknown author is licensed under CC BY-NC. Headache (HA) Introduction Headache y Primary Tension Migraine duetomedicalcondition Secondary Cluster Substance use/withdrawal Trauma to head/ neck Cranial or cervical vascular d/o Sinus HA Infection 3 Tension-Type Headache (TTH) your303 main  Prevalence peaks in the fourth decade and is higher among women 21  The most common form of headache  The incidence EDT decreases with age  Unclear pathophysiology  Precipitating factors:  Stress  Tension in muscle  Head and neck movements 5 bilateralneck jaw shoulder no Tension-Type Headache (TTH) MM Location Pain (type, severity, duration)-non-pulsating, dull, tightness, mild-mod intensity, lasting 30 min-7 days Associated symptoms- no N/V. May have mild photophobia/phonophobia light sound 6 Tension-Type HA ICHD-3 criteria A. At least 10 episodes of headache occurring and fulfilling criteria B-D B. Lasting from 30 minutes to 7 days C. At least 2 of the following 4 characteristics: 1. bilateral location 2. pressing or tightening (non-pulsating) quality 3. mild or moderate intensity 4. not aggravated by routine physical activity such as walking or climbing stairs D. Both of the following: 1. no nausea or vomiting 2. no more than one of photophobia or phonophobia 7 Tension HA Referrals  Headaches > 15 day/month  Increasing frequency of headaches  Those not fitting the diagnostic criteria  Standard treatments with analgesics are ineffective 9 Tension-Type Headache Non-Pharmacological  Physical therapy  Behavioral treatments  Physical therapeutic options-------Somewhat inconsistent evidence • Relaxation training • Heat or cold pack • Biofeedback • Electrical nerve stimulation • Stretching • Exercise • Massage • Acupuncture 12 13 Pharmacological Therapy  Treatment Options: • Tylenol Simple analgesics e.g. acetaminophen (+/- caffeine) • APAP + ASA + caffeine (Excedrin ® extra strength) acetaminopL • NSAIDS (e.g. ASA, ibuprofen, naproxen, diclofenac, ketorolac)—avoid ASA if have asthma • Butalbital combinations tension muscle release help 14 lessG TH IAdvil t 39 Tension-Type Headache Butalbital combinations y noonettsedfy Generic Brand Dosing Comments Butalbital + APAP + caffeine Fioricet ® Butalbital 50 mg/ APAP 300 mg/caffeine 40 mg 1-2 tablets or capsules every 4 hours; Max 6 tablets or capsules daily Also available in liquid NOT scheduled Butalbital + APAP + caffeine + codeine* Fioricet/codeine ® Butalbital 50 mg/acetaminophen 300 mg/caffeine 40 mg/codeine 30 mg: 1 to 2 capsules every 4 hours as needed; Max: 6 capsules C-III Butalbital + ASA + caffeine Fiorinal ® Butalbital 50 mg/ ASA 325 mg/caffeine 40 mg 1-2 tablets or capsules every 4 hours; Max 6 tablets or capsules daily C-III so Butalbital + ASA + caffeine + codeine* Ascomp-Codeine ®, Fiorinal/Codeine #3 ® Butalbital 50 mg/ ASA 325 mg/caffeine 40 mg/codeine 30 mg 1-2 capsules every 4 hours; Max: 6 capsules/day C-III 16 *Codeine combos rarely used due to potential overuse and dependency ows.INT 17 Tension-Type Headache General Approach to Treatment y OTC analgesics  2 High-dose NSAIDS OR butalbital combinations 3 Preventative treatment Max duration of therapy/month to prevent development of chronic TTH or medication overuse  10 days (butalbital-containing drugs or combination analgesics)  15 days (NSAID monotherapy)  Avoid codeine combination (last line)  Preventative (prophylaxis) therapy in e.g. TCA/SSRIs  Chronic TTH (CTTH)  Episodic TTH if frequency (more than 2/wk), duration (>3-4 hrs), or severity results in medication overuse or disability Imitated Ebing Ssri TCA 19 T 4Faraday't Migraine Assessment Location Pain (type, severity, duration)- throbbing, pulsating, mod-severe. Lasts 4-72 hrs t Associated symptoms Premonitory sx (hrs/days before HA): e.g. photophobia/phonophobia, anxiety, irritability, food cravings, hypersomnia Ignore sleepy 22 Migraine Types With Aura Classic Migraine-18% Without Aura Common Migraine-65% Migraine 23 Migraine without Aura ICHD-3 Diagnostic Criteria A. At least 5 attacks fulfilling criteria B-D B. HA lasting 4-72 hrs (untreated or unsuccessfully treated) C. At least 2 of the following 1. Unilateral location 2. Pulsating quality D. During HA at least one of the following A. N/V B. Photophobia and phono phobia E. No better accounted for by another ICHD-3 diagnosis É 3. Moderate-Severe pain 4. Aggravation by or causing avoidance of routine physical activity (eg. Walking or climbing stairs) 24 Migraine With Aura ICHD-3 Diagnostic Criteria A. At least two attacks fulfilling criteria B and C B. One or more of the following fully reversible aura symptoms: C. At least three of the following six characteristics:  at least one aura symptom spreads gradually over ≥5 minutes is Q  visual  two or more aura symptoms occur in succession  sensory  each individual aura symptom lasts 5-60 minutes  speech and/or language  at least one aura symptom is unilateral  motor  at least one aura symptom is positive  brainstem  the aura is accompanied, or followed within 60 minutes, by headache  retinal D. Not better accounted for by another ICHD-3 diagnosis. 25 contracep To Migraine oral Patients who have migraine with aura should avoid combination OC that contain estrogen, as risk of stroke is increased Typical Aura Visual Sensory Language/speech tinglingburning Positive features Paresthesia Negative features Numbness, tingling Aphasia/dysphasia (loss of ability to understand or express speech) 26 Scotoma (negative feature) Photopsia (positive feature) Migraine Phases startwithin60min of guy S 60min Istired 27 Migraine Pathophysiology Vasodilation Activation of trigeminal nerves Neuropeptides released Inflammation  Neuropeptides  Neurokinin A  Substance P  Calcitonin gene–related peptide (CGRP) 28 Signs and Triggers of Migraine Signs • Absence of daily headache • Positive family history for migraine • Normal neurologic examination • Long-standing history • Improvement with sleep • Aura can signal the migraine headache but is not required for diagnosis Triggers Behavioral-psychological triggers • • • • • Environmental • • • • • Strong odors Bright light Loud noises Change in weather or barometric pressure Smoking • • • • • • Monosodium glutamate (MSG)-preservative Aspartame-sweetener (diet foods/drinks) Chocolate Tyramine Processed foods (nitrite-containing) Excess caffeine/withdrawal • • • • • Alcohol Estrogen Analgesics Cocaine Vasodilators such as NTG Food/drinks Drugs Foods and Headaches: The Link. 34 Menopause Symptoms, 2016, www.34-menopause- Stress Sleep deprivation Skipping meals, fasting Menses Physical exertion/fatigue 30 Migraine Non-Pharmacological  Headache prevention  Headache diary  Regular sleep, food and exercise Ice pack Massage  Smoking cessation  Limiting caffeine  Identifying and avoiding triggers Rest in a dark room  Behavioral interventions  Relaxation therapy  Biofeedback Non-pharmacological treatment 33 patient case ML ML is 20 year old female who reports severe migraine headaches at your community pharmacy. She reported that she frequently misses school because of headaches. She reported drinking 5 cups of coffee and 1 coke daily to get her through the day. She pulls “all nighters” during exam weeks. On the weekends she goes out with friends and drinks 2 shots of tequila and 2 Coronas. Meds: Ventolin (albuterol), Advair (fluticasone and salmeterol), PMH: asthma 34 Patient Case-ML limitsaffein Betterstudytab Betterdiet no limitallohol Is  What counselling points can you suggest to ML to prevent migraines? message To dark  What are some non-pharmacological therapies that you can suggest to ML? red ice pack 35 Migraine Management Goals Long-term goals • Reduce frequency, severity and disability • Improve quality of life • Prevent headaches • Avoid escalation of headache medication use Acute treatment goals • Treat migraine attaches rapidly without recurrence • Restore function • Cost-effective management • Minimal or no adverse effects • Minimize use of rescue medications ppl wt a Rescue wit medications are defined as medications used at home when other treatments fail that permit the patient to get relief without a visit to the physician’s office or emergency department 37 Migraine Abortive Pharmacological Therapy j Treatment NonSpecific Simple analgesi cs Combinatio n analgesics Migraine -Specific Opioids (not preferred) misuse Triptans Ergots aby withded Miscellaneou s recue medications eg steroids Ditans CGRP antagoni sts t 38 Examples of Simple Analgesics  Analgesics  Acetaminophen 500-1,000 mg Q4-6 hrs (Max 4 g)  Acetaminophen 250 mg/ASA 250 mg/ caffeine 65 mg (Excedrine ®)--OTC  NSAIDS  ASA 500-1,000 mg q4-6 hrs (MAX 4 g)  IBU 400-800 q6 hrs(MAX 3.2 g)  Naproxen 220-550 q8-12 hrs (avoid doses > 1.375 g/d)  Diclofenac  Ketorelac (Nasal, IM)  Celecoxib 39 Migraine Triptans  Mechanism: Selective 5-HT1 agonist (1B/1D) Bind to 5-HT receptors to inhibit release of CGRP (presynaptic)inhibiting cAMP cascade Normalizes dilated intracranial arteries (vasoconstriction) O Inhibits pain transmission through second order neurons ascending to the thalamus x 40 Optimal Dose Migraine Triptan a Triptans Sumatriptan (Imitrex) Injection (Self administered)- Zembrace Symtouch ®, Imitrex ® Oral Tablet Nasal Spray (Imitrex ®, Tosymra ®)/Nasal powder (Ozentra Xsail ® ) Onset (min) Comments Imitrex: 6 mg SC at onset; may repeat in 1 hr if needed Zembrace: 3 mg SC at onset; may repeat in 1 hr if needed 10-15 Max: 12 mg/day. Faster onset of action and enhanced efficacy compared to oral sumatriptan 50-100 mg at onset; may repeat in 2 hr if needed 30-90 Max: 200 mg/day Treximet® (combination w/ Naproxen: 85/500 mg Imitrex: 5 or 20 mg at onset; may repeat in 2 hr if needed Tosymra: 10 mg at onset; may repeat in 1 hr Ozentra: 22 mg (one 11-mg nosepiece in each nostril) at 15 Max: 40 mg/day (Imitrex); 30 mg (Tosymra) One spray in one nostril (single-dose delivery device). Faster onset but similar response rate compared to oral 2.5 mg at onset; may repeat in 1-2 hr if needed 45-60 (ZMTperceived faster onset) Max: 10 mg/day (do not divide ODT tablet) 5 mg (one spray) at onset; may repeat in 2 hr if needed 15-20 Max: 10 mg/day 2.5 mg PO at onset; may repeat in 4 hr if needed 60-180 Max: 5 mg/day; slow onset, long duration 10 mg at onset at onset; may repeat in 2 hr if needed 30-120 (MLTperceived faster onset) Max: 30 mg/day (use lower dose if on propranolol) jogger nasal00470 onset; can repeat after 2 hours if needed Zolmitriptan (Zomig, ZomigZMT) 2 Oral Tablet (regular/ODT) Nasal Spray Naratriptan (Amerge) Lygon Rizatriptan (Maxalt, MaxaltMLT)-Regular/ODT u Almotriptan (Axert) s 12.5 mg PO at onset; may repeat in 2 hr if needed 30-60 Max: 25 mg/day Frovatriptan (Frova) 6 2.5-5 mg PO at onset; may repeat in 2 hr if needed 120-240 Max: 7.5 mg/day (3 tablets); slow onset, long duration of action 41 2,316 electrygerg Migraine Triptan Side Effects, Precautions & Contraindications Side Effects longer actingtripton suseformenstal association Esty's •Paresthesia, dizziness, flushing, warm sensations, somnolence, fatigue •Triptan sensation(25%): tightness, pressure in the chest, neck and throat Precautions D •Cardio vascular events (MI, uncontrolled HTN)-CV risk assessment •SSRI/SNRI serotonin syndrome •Frequent use misuse & MOH Contraindication •Ischemic heart disease •Hemiplegic and brainstem migraine •Use within 24 hours of ergots (enhanced vasoconstriction) or within 2 weeks of MAOIs (risk of SS) •Not to be routinely used in pregnancy (category C) 43 Migraine Triptan Clinical Pearls tofirstlinetherapy For mild-severe attacks (when cannot use simple/combination analgesics) Selection of a triptan is based on characteristics of the HA, convenience of dosing, and the patient’s preference Effective and generally well tolerated (PO) Combination therapy with naproxen may also improve response rates and diminish migraine recurrence eg. Treximet 45 Migraine Ergot Derivatives no effectthentripton side more  Mechanism: Non-selective 5-HT agonists (5-HT 1A,B,D,F and 5-HT2) Bind to 5-HT receptors to inhibit release of CGRP (presynaptic)inhibiting cAMP cascade Constriction of cranial and peripheral blood vessels Inhibit development of neurogenic inflammation in the trigeminovascular system Also activity at alpha-adrenergic and dopaminergic system 47 Migraine Ergot Derivatives Continued Ergotamine Tartarate (ET) Dihydroergotamine (DHE) • Formulations (Oral, SL, Rectal)—poor bioavailability • Limited use due to efficacy issues and side effect profile • More alpha-blocking activity (less peripheral vasoconstriction) • Formulations (IV/IM/SC/IN) • Patient can be trained to self-administer PreffrggiIIIIfts 48 Migraine Ergot Derivatives Ergot Derivatives Dose Comment 2 mg at onset; then 1-2 mg q 30 min prn Max: 6 mg/day or 10 mg/wk Insert 0.5-1 suppository at onset; may repeat after 1 hr if needed Max: 4 mg/day or 10 mg/wk Injection 1 mg/ml (D.H.E 45) 0.25-1 mg at onset IM, IV, SC; repeat every hour as needed Max: 3 mg/day or 6 mg/wk Pt can self-administer IM/SC DHE Nasal spray 4 mg/ml (Migranal) One spray (0.5 mg)in each nostril at onset and repeat 15 min later (for total dose of 2 mg or 4 sprays) Max: 3 mg/day; prime with 4 sprays; do not tilt head back or inhaler thru nose while spraying; discard open ampules after 8 hrs Ergotamine Tartarate Oral tablet 1mg + caffeine 100 mg (Cafergot) Et Sublingual 2mg (Ergomar) caffain Rectal suppository 2 mg + caffeine 100 mg (Cafergot, Migergot) Dihydroergotamine 49 Migraine Ergot Derivatives Side Effects, Precautions & Contraindications Side Effects • Abdominal pain, weakness, fatigue, paresthesia, muscle pain, diarrhea and chest tightness • N/V(stimulation of chemoreceptor trigger zone)-dose related • Peripheral ischemia (ergotism) including cold, numb, painful extremities, claudication as a result of vasoconstriction esp above recommended dose Precautions • Cardio vascular events (MI, uncontrolled HTN)-CV risk assessment • SSRI/SNRI serotonin syndrome • Frequent use misuse & MOH • Concomitant use: Use with other vasoconstrictors (eg, sympathomimetic, propranolol, nicotine) is not recommended Contraindication Alevel ofthedog • Potent CYP3A4 inh eg. azoles • Ischemic heart disease, renal and hepatic disease • Hemiplegic and brainstem migraine • Pregnant and nursing mothers (category X) 50 Migraine Ergot Derivative Clinical Pearls For moderate-severe attacks (when cannot use triptans) Most efficacy data favors DHE vs ET Fewer side effects and rebound HA with DHE compared to ET Iain Treatment with antiemetic agent should be considered with ergots due to N/V Most effective when administered early in the migraine attack, preferably at the first indication of migraine. 52 Ditans  New class of medication (The clinical trial was for patients with 3-8 migraine attacks/months)  Highly selective 5-HT (1f) agonists  Minimal vasoconstrictive activity compared to triptans  Works by blocking the neurogenic inflammation and stimulation of the trigeminal nucleus caudalis  Side effects (reported in <2%): dizziness, paresthesia, sedation (associated w/ driving impairment) , N/V, serotonin syndrome  Counselling point: Do not drive or motor vehicle or operate heavy machinery for at least 8 hours following each dose (Precaution in PI) 53 Ditans Ditans Dose Comment Lasmiditan (Reyvow ®) 50, 100, or 200 mg PO at onset Max of one dose per 24 hours; safety of treating more than four migraine attacks in a 30day period has not been established Scheduled V 54 Calcitonin Gene-Related Peptide (CGRP) Antagonists  CGRP levels rise during a migraine attack  CGRP release leads to activation of cyclic adenosine monophosphate (cAMP) vasodilation  CGRP antagonists binds to receptors to block CGRP activity (ie. Vasodilation and inflammation)  Efficacy similar to triptans and Lasmiditan  Injectable CGRP antagonists known as anti-CGRP antibodies bind to the CGRP receptor to block the effects of CGRP on vasodilation and inflammation. Similarly, oral CGRP antagonists (“gepants”) also inhibit the action of CGRP at the receptor.  Advantages:  CV disease is NOT a contraindication (but studies excluded pts recent CV events)  Not associated with medication over-use  Better tolerability compared to triptans 55 CGRP Antagonists-”gepants” Side Effects •Low incidence of ADR (<5%) •Ubrogepant: Nausea, xerostomia and somnolence •Rimegepant: Nausea •Zavegepant: nausea, vomiting, and nasal irritation, but a higher rate of altered sense of taste (18%) a no t Contraindication •Concomitant strong CYP3A4 inhibitors Other considerations •Avoid in severe renal or hepatic impairment •Dose adjustment required in mild-mod renal/hepatic impairment 56 Calcitonin Gene-Related Peptide (CGRP) Antagonists CGRP Antagonists Dose Comments Ubrogepant (Ubrelvy) 50 or 100 PO mg at onset; can so2 hours if needed repeat after Max dose 200 mg; safety of treating more than eight migraine attacks in a 30-day period has not been established. Shorter half life compared to rimepegant. Rimegepant (Nurtec ODT) 75 mg ODT at onset Max of one dose per 24 hours; take on an empty stomach. Also approved for migraine PPX. Longest half life compared to other gepants 10 mg intranasally at onset Maximum daily dose is 10 mg; safety of treating more than 8 migraine attacks in a 30-day period 57 has not been established longesthalf life Zavegepant nasal spray (Zavzpret) fast Opioids  Inadequate evidence for opioid use for treatment of migraines 8113  Reserve for patients with moderate-severe infrequent headaches in whom conventional therapies are CI or have failed Gina 58 Medication Over-Use Headache (MOH)  Frequent, excessive use of acute migraine medications can result in increasing headache frequency  Commonly occurs with over use of simple or combination analgesics, opioids, ergotamine tartarate and triptans  Limit use of (serotonin agonists) triptan, ergots, ditan to 2 days/week or <10 days/month and to limit ASA, NSAIDs, and APAP to < 15 days/month  Exception: CGRP antagonists  Discontinuation of offending agent leads to gradual decrease in HA freq and severity 62 Back to Patient Case-ML Given the severity of ML’s migraine, you refer her to a clinic nearby. She has tried IBU and other OTC medications in the past with no success. She reported that during her migraine attacks she is severely nauseated to the point that she cannot eat her meals. Triptons Vitals: 70 kg (154 lb), Ht= 165 cm (5’4), BP= 110/60 mg, HR= 55, T= 37.1°C, BMI: 26.4 Meds: Ventolin (albuterol), Advair (fluticasone and salmeterol) PMH: asthma 63 Patient Case-ML Tripton a nonselective NO NI  What drug class would you recommend for this patient and why?  What drug and route would you recommend? Injection nosed 64 Migraine Prophylaxis SIT  Consider PPX administered daily to reduce fx, severity and duration of attacks  Considered in setting of recurring migraines that  Produce significant disability despite acute therapy  Frequent attacks requiring medication more than 2x/wk  Therapies that are CI, produce serious SE or are ineffective  Uncommon migraines having potential risk of permanent neurological injury  Patient preference to limit number of attacks  May also be given intermittently when HA recur in a predictable manner (e.g. exercise-induced, menses) s Elma  A therapeutic trial= 2-3 months for clinical benefit; Full benefit may take up to 6 months  Duration of use: 6-12 months after freq/severity of HA has diminished, then taper or d/c  No preference for the specific drug but identify which ones are effective 66 Betterfromthis list then the next PPX Treatment page  Effective  Divalproex (Depakote ®)  Topiramate (Topomax ®) Anticonvulsants (FDA approved) needtoGrow coated Focusmore onthis  Erenumab-aooe  Metoprolol (Toprol ®)  Propranolol (Inderal ®)—FDA approved Beta Blockers  Fremanezumab-vfrm  Galcanezumab-gnlm  Timolol (Bocadren ®)-FDA  Eptinezumab-jjmr  NSAIDS (strongest evidence w/ Naproxen)  Atogepant (Quilpta ®)  Frovatriptan (Frova ®)* Triptans (NOT FDA approved for ppx)  Rimegepant CGRP antagonistsFDA approved  Miscellaneous: off-label  Lisinopril * For menstrual-associated migraines  Candesartan  Verapamil 67 PPX Treatment  Probably/possibly effective—all offlabel  Amitriptyline (Elavil ®)  Venlafaxine (Effexor ®) tr to need Antidepressants Beta Blockers  Atenolol (Tenormin ®)  Nadolol (Corgard ®) Triptans  Naratriptan (Amerge ®)* wed  Zolmitriptan (Zomig ®)*  Clonidine  Guanfacine Alpha-2 agonists 68 CGRP antagonists used for Prophylaxis Atleast a Thenpaper Ca  Monoclonal Antibodies  Large molecules---All injectables  No DDIs (no hepatic/renal clearance)  Only approved for ppx  ADR: injection site rxn (most common), anaphylaxis, skin rash, constipation (Aimovig), new-onset or worsening of HTN (Aimovig), nasopharyngitis (Vyepti)  Expensive  Use if not tolerate/respond to at least 2 other PPX meds (w/ highest level of evidence)  Oral CGRP antagonists “gepants”  Small molecules---oral  Significant DDIs with strong/moderate CYP3A4 inhibitors/inducers. Avoid concomitant use  Dose adjust in severe renal and avoid in severe hepatic impairment  ADR  Atogepant: nausea, fatigue, constipation  Rimepegant: Nausea, abdominal pain/dyspepsia  Use if not tolerate/respond to other PPX meds 74 CGRP Antagonists for PPX headach cluster Me  Erenumab-aooe (Aimovig)-Once monthly SC injection needto  Galcanezumab-gnlm (Emgality): once monthly SC injection Monoclonal antibodies Ken  Fremanezumab-vfrm (Ajovy) monthly or every 3 months SC injection (depending on dose)  Eptinezumab-jjmr (Vyepti): IV infusion once every 3 months  Atogepant (Qulipta): PO once a day  Rimegepant (Nurtec ODT): 75 mg ODT once every other day combat 75 Summary of PPX 76 General Approach to Treatment  Pharmacological therapy is mainstay of tx for migraine  Abortive (Migraine specific or simple analgesics)  Preventative (Prophylaxis) siri  Therapy decision should be based on peeped  Individual’s response to specific medications and their tolerability  PMH limiting tx choices  Abortive tx most effective at onset of HA pit ogPa  Anti-emetics for nausea and gastric stasis e.g. metoclopramide (Reglan ®), promethazine (Phenergan ®), chlorpromazine (Thorazine ®), prochlorpromazine (Compazine ®)-- (DA antagonists) 80 Complementary Medicine Prophylactic TX  Established Efficacy  Petasites (butterbur): 50-75 mg BID  ADR: GI upset, belching and less often hepatotoxicity  Probably Effective  Riboflavin: 400 mg daily  Feverfew  Possibly Effective  Coenzyme Q10: 100 mg TID  Magnesium dicitrate: 600 mg daily napwisteep 81 Cluster Headache  The most severe and relatively uncommon primary headache t  Prevalence of 0.5 to 1.0/1000 patients  Occurs primarily in men  Ratio men to women is 3:1  Pathophysiology: not completely understood  Age of onset 20-40 years old 88 Cluster Headache Assessment sik Location (orbital, supraorbital, temporal region) Pain (type, severity, duration)—peaks quickly, lasting 15-180 min, severe, nonpulsating. Occurs in clusters once every other day to 8xday) Associated symptoms 89 Cluster Headache Autonomic symptoms Ooh  Lacrimation (flow of tears)  Nasal congestion  Rhinorrheasorunny nose  Facial sweating  Ptosis (eyelid drooping)/Miosis 90 Cluster HA Abortive Therapy stopsambeforetheyworse  Oxygen  Triptans  PO has limited use due to slow onset (except oral zolmitriptan10 mg PO which is modestly effective)  Use SC or intranasal (nasal sprays less effective) 3  Sumatriptan SC 6 mg  Ergot derivatives  IV DHE has the quickest response (repeat in 3-7 days to break cycle)  Ergotamine tartrate is effective in SL or rectal formulation 95 Cluster HA Prophylactic Therapy sg  Verapamil (CCB) 360-960 mg/day (starting dose 240 mg/d)  1st line e  Galcanezumab (Emgality ®) CPRGantagonist  Reserved for cluster HA > 1 month for pt that first line agent ineffective ifphone Amore  thena month FDA approved for episodic cluster headache  Administered SC at onset of cluster headache, continued monthly until end of cluster headache Lithium Carbonate 600-1200 mg/day (starting 300 mg BID)  Alternative or in combination to verapamil  But monitor and maintain level at: 0.4-1.2 mEq/L 97 Patient Case-ML ML is a 32 yo female who presents to the ED with debilitating on and off headache for 2 months. She reports seeing flashes of light before her headache starts. Past medical history –HTN, DM I, allergic rhinitis, remote history of migraine headache as a teen Home medications –Lisinopril, insulin, singulair –Pain medications as needed for headache 100 Patient Case-ML Pain quality –Achy pressure in neck and forehead (unilateral most time) –Moderate to severe in intensity and occasional throbbing –Severe headache is associated with nausea and vomiting –Sometimes her arm feels “numb” during the attacks a Medication history –Excedrin ® as needed –BC ® powder (ASA + caffeine) as needed if excedrin doesn’t work –Fioricet ® added during severe headache (from her sister who has migraine) 101 CORP Patient Case-ML RayKasserotnogenist selective Diton What type of primary headache disorder does this patient have? A. Migraine without aura B. Tension type headache C. Cluster headache D. Migraine with aura Won PHE Safer lessvaso inteflexor sentence É1otevaso Lanninumb Better absorption parental 401 nasal spray pregnancy c Pain Triptonfatna NOORI102 Bilateral ASANSAIDExotrin unitaterber shipmentsAlloholidial Sager GvasodilationInflanation neuropep 103 Differential diagnosis of Common Primary Headaches 104

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