Term
| What are the S/S of migraines? |
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Definition
Unilateral throbbing pain that can last 4-72 hours. Can have N/V, sensitivity to light, sound, or movement
Can be linked to family history, food, menstrual, or sleep |
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Term
| What are the phases of a migraine? |
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Definition
- Prodrome/Premonitory - before the migraine, only in some patients.
- Aura - precedes/accompanies migraine. Usually a visual disturbance
- Headache - most common in early morning, gradual onset in frontotemportal region. Sensory and concentration
- Resolution - fatigue, scalp tenderness, mood changes |
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Term
| What is required for a diagnosis of migraine attacks? |
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Definition
- 2 attacks if an aura is present
- 5 attacks if an aura is not present |
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Term
| What are the goals of migraine therapy? |
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Definition
- Avoid increased medication use
- minimize use of rescue meds
- Cause minimal AEs and be cost effective |
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Term
| What is non-pharmacologic Tx for migraines |
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Definition
Acute:
- Ice, rest, Darkness
Chronic:
- trigger avoidance
- Wellness: caffeine and smoking sensation
- Cognitive therapy |
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Term
| What are Rx therapies for mild/moderate and severe migraines? |
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Definition
Mild/Moderate: ASA/Naproxen/Ibu, Excedrine Migraine --> 2nd line: Midrin, fioricet/Fiorinal
Severe: 1st line - Triptans and ergots, 2nd line: Opioids and butorphanol |
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Term
| What can cause rebound headaches? |
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Definition
- Misuse or excessive use of acute meds --> combo analgesics and opioids
- Common cause of chronic daily HA
- D/C offending agent, may renew in 2 months. Limit use to 2 days/week. |
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Term
| What are the side effects of Ergots? |
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Definition
- Most common - N/v - pretreat with anti-emetic
- Powerful vasoconstrictor - Ergotism = gangrenous
CANNOT GIVE IN PREGNANCY
Do not give in combo with triptans |
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Term
| What are triptan drug interactions? |
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Definition
Cannot be given with ergots?
Do not give Imitrex, Maxalt, and Zomig within 2 weeks of an MAOI
Eletriptan & 3A4s -- macrolides, antifungals, antivirals. |
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Term
| What is the indication for a preventative migraine therapy? |
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Definition
- Recurring debilitating migraines despite acute therapy
- >2 attacks/week w/ risk of overuse
- therapies ineffective or produce serious side effects
- Risk of injury |
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Term
| What are prophylactic Tx for migraines? |
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Definition
Beta blockers: metoprolol, propanolol, timolol - comorbid HTN
Topamax - comorbid seizures
Depakote/Valproate - comorbid seizures or manic depressive
Verapamil
Herbs: Feverfew or butterbur (petasites)
NSAIDs - Menstrual migraines
TCA's - comorbid depression, caution w/ anticholinergic SEs. Nortriptyline |
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Term
| What is the clinical presentation of tension headaches? |
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Definition
Absence of prodrome or aura
Dull, bilateral pain
No photo/phono-phobia
Same acute therapy as migraines - max 9 days/month
TCAs common for chronic HAs |
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Term
| What is the clinical presentation for cluster headaches? |
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Definition
most uncommon but severe
Unilateral, penetrating pain
No aura
Cyclic - periods of pain followed by remission. Occur at night in the spring/fall
Acute therapy: oxygen delays attack. IV DHE, Imitrex SQ
Prophylaxis: Verapamil or lithium. Ergotamine for nocturnal attacks. Steroids induces remission. |
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Term
| What is the difference between nociceptive and neuropathic pain? |
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Definition
-nociceptive - comes from bone, tissue, visceral injury
-Neuropathic - nerve damage, postherpetic neuralgia, or diabetic neuropathy. Hyperalgesia or allodynia |
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Term
| What is the difference in clinical presentation b/w acute and chronic pain? |
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Definition
-Acure: Obvious distress, timely relationship to stimuli, HTN and diaphoresis usually present, comorbidities generally NOT present, Outcome predictable
- Chronic: Can have no noticable suffering, no relationship to stimuli, no obvious HTN/Diaphoresis, usually has insomnia/depression, unpredictable outcome. |
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Term
| How should opioids be switched? |
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Definition
As pain subsides, patients cannot tolerate the same doses
Histamine reactions - can switch classes
Classes:
- Morphine-like - morphine, -codone, Levorphanol
- Meperidine-like
- Methadone-like |
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Term
| What is the drug of choice (opioid) for severe pain? |
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Definition
Morphine
- renally cleared, monitor renal function
- vasodilation effects - drug of choice in an MI, mindful of head trauma
- Most histamine release |
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Term
| How do other morphine-like opioids compare to morphine? |
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Definition
-Hydromorphone - more potent, less histamine
- Codeine - weak analgesia, more side effects
- Hydrocodone - for moderate to severe pain.
- Oxycodone - most effective when given with non-opioid |
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Term
| Which opioids are meperidine-like? |
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Definition
- Meperidine - short duration, not as potent as morphine. Has a toxic metabolite. Do not use with MAOI
- Fentanyl - more potent and lipophylic, short acting |
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Term
| What opioids are methadone-like? |
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Definition
- Methadone - extended duration of action. Antagonizes NMDA, mu and kappa agonist, and blocks SERT and NET
- Propoxyphene - no longer available |
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Term
| When should opioids be dosed? |
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Definition
| Around the clock in acute pain, then titrated up or down. It's easier to prevent pain than to treat pain. |
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Term
| How are equianalgesic doses calculated? |
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Definition
Morphine oral: 10 mg IV = 30 mg PO.
Oxycodone and hydrocodone are both 30 mg PO |
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Term
| What are barriers to pain management? |
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Definition
- Tolerence
- Dependence
- Addiction |
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Term
| What is the Tx algorhythm for pain? |
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Definition
Mild/Moderate - NSAIDs/APAP/ASA, codeine
Moderate/severe - Hydrocodone, Oxycodone, tramadol. 2nd line - agonists/antagonists
Severe - morphine, hydromorphone, meperidine, fentanyl, methadone |
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