1. GETTING AHEAD OF HEADACHES Ruben T. Dela Cruz MD FPNA Acute Stroke Unit - Manila Adventist Medical Center

9. SYMPTOMS OF SERIOUS UNDERLYING CAUSES OF HEADACHE May present with a unilateral pounding headache. Onset generally in older patients (>50 years) and frequently associated with visual changes. The ESR is the best screening test and is usually markedly elevated (>50). Definitive diagnosis made by arterial biopsy Usually consists of severe eye pain. May have nausea and vomiting. The eye is usually painful and red. The pupils may be partially dilated. Temporal arteritis Glaucoma May present with prostrating pounding headaches that are associated with nausea and vomiting. Should be suspected in progressively severe new “migraine” that is invariably unilateral Brain tumor Nuchal rigidity and headache; may not have clouded consciousness or seizures. Hemorrhage may not be seen on CTscan. Lumbar puncture shows “bloody tap” that does not clear by the last tube. A fresh hemorrhage may not be xanthochromic. Intracranial hemorrhage Nuchal rigidity, headache, photophobia, and prostration; may not be febrile, lumbar puncture is diagnostic Meningitis SYMPTOMS CAUSE

15. DRUGS EFFECTIVE IN THE TREATMENT OF TENSION-TYPE HA 650 mg PO q4-6h 650 mg PO q4-6h 50-100 mg q4-6h max 200mg/d 400 mg PO q3-4h 220-550mg bid 1-2 tbs mx 6 tbs/d 1-2 tbs mx 6 tbs/d 1-2 tbs mx 6tbs/d 10-50 MG at Bedtime 25-75 mg at bedtime 10-75 mg at bt Tylenol Generic Cataflam Advil, Motrin Naproxen,Aleve Phrenelin Fioricet, Fiorinal ELAVIL Pamelor Sinequan NONSTEROIDAL ANTIINFLAMMATORY AGENTS Acetaminophen Aspirin Diclofenac Ibuprofen Naprosyn sodium COMBINATION ANALGESICS Acetaminophen + butalbital Aceta + butalbital + caffeine Aspirin + butalbital + cafeine PROPHYLACTIC MEDICATIONS Amitriptyline Nortriptyline Doxepin DOSAGE TRADE NAME DRUG

18. A staged Approach to Migraine Pharmacotherapy Stage Diagnoses Therapies SC, IM, or IV 5-HT1 agonist IM or IV dopamine antagonist Prophylactic medications Severe headaches >3x per month Significant functional impairment Marked nausea and/or vomiting Severe Migraine Oral, nasal, or SC 5-HT1 agonist Oral dopamine antagonist Moderate or severe headaches Nausea common Some impairment of functioning Moderate Migraine NSAIDs Combination analgesics Oral 5-HT1 agonists Occasional throbbing headaches No major impairment of functioning Mild Migraine

20. A STAGED APPROACH TO MIGRAINE PHARMACOTHERAPY SC, IM, or IV 5-HT1 agonist IM or IV dopamine antagonist Prophylactic medications Severe HA >3x / mo Significant functional impairment Marked nausea and/or vomiting Severe migraine Oral, nasal r SC 5-HT1 agonist Oral dopamine antagonists Moderate or severe HA Nausea common Some impairment of functioning Moderate Migraine NSAIDs Combination analgesics Oral 5-HT1 agonist Occasional throbbing HA No major impairment of functioning Mild Migraine THERAPIES DIAGNOSIS STAGE

21. DRUGS EFFECTIVE IN ACUTE TREATMENT OF MIGRAINE 0ne 2-mg sl tab at onsetand q 1/2h mx 3/d; 5/wk 2.5 mg tb at onset, rpt after 4 hrs 5-10 mg at onset rpt after 2 hrs, mx-10mg/d 50 to 100 mg tb at onset, rpt after 2 hrs. mx 200 mg/d 2.5 mg at onset, rpt after 2 hrs, mx 10mg/d Ergomer Ercaf; Wigraine Amerge Maxalt Imitrex, Imigran Zomig (Rapimelt) 5-HT1 AGONIST ORAL: Ergotamine Ergotamine-caffeine Naratriptan Rizatriptan Sumatriptan Zolmitriptan 2 tab q6h max 8/day Excedrin- Migraine NSAIDs________________ Acetaminophen, aspirin, caffeine DOSAGE TRADE NAME DRUG

22. DRUGS EFFECTIVE IN ACUTE TREATMENT OF MIGRAINE One spray per nostril then 15 minutes after 5 to 20 mg spray as 4 sprays of 5 mg per nostril may rpt once after 2 hrs. mx 40mg/d 1 mg IV<IM<or SC at onset and q1h mx. 3mg/d; 6mg/wk 6 mg SC at onset, rpt once after 1 hr mx- 2 doses/d Migranal nasal spray Imitrex nasal spray DHE-45 Imitrex inj 5-HT1 agonist NASAL Dihydroergotamine Sumatriptan PARENTERAL Dihydroergotamine Sumatriptan

24. DRUGS EFFECTIVE IN PROPHYLACTIC TREATMENT OF MIGRAINE 80-320mg qd 20-60 mg qd 250 mg bid (mx:1000mg/d) 10-5-mg qhs 25-75 mg qhs 15 mg qd 10 mg qd 4-8 mg qd 4-16 mg qd 40-240 mg qd Inderal Blocadren Depakote Elavil, generic Pamelor Nardil Marplan Sansert Periactin Isoptin B- Adrenergic agents Propranolol Timolol Anticonvulsant Sodium valproate Tricyclic antidepressant Amitriptyline Nortriptyline Monoamine oxidase inhibitor Phenelzine Isocarboxazid Serotonergic drugs Methysergide Cyproheptadine Other Verapamil DOSAGE TRADE NAME DRUG