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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2892_Библиотеки_им_академика_М_И_Перельмана
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380 CASE FILES: FAMILY MEDICINE
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Table 34–4 • TREATMENT OF ACUTE MIGRAINE
(continued)
Drug Trade Name Dosage
III. 5-HT1 Receptor Agonists (Cont.)
• Parenteral
Dihydroergotamine DHE-45 1 mg IV, IM, or SC at onset and every 1h
(max 3 mg/d, 6 mg per week)
Sumatriptan Imitrex Injection
Alsuma
Sumavel DosePro
IV. Dopamine Receptor Antagonists
• Oral
Metoclopramide Reglan,a generic
Prochlorperazine Compazine,a
generic
a
• Parenteral
Chlorpromazine Generic
a
Metoclopramide Reglan,a generic 10 mg IV
Prochlorperazine Compazine,a
generic
a
V. Other
• Oral
Acetaminophen, 325 mg, plus
Midrin, generic Two capsules at onset followed by
dichloralphenazone, 100 mg,
plus isometheptene, 65 mg
• Nasal
Butorphanol Generic 1 mg (1 spray in 1 nostril), may repeat if
• Parenteral
Opioids Generic
a
6 mg SC at onset (may repeat once
after 1h for max of 2 doses in 24 h)
a
5-10 mg/d
1-25 mg/d
0.1 mg/kg IV at 2 mg/min; max 35 mg/d
10 mg IV
1 capsule every 1 h (max 5 capsules)
necessary in 1-2 h
Multiple preparations and dosages
Abbreviations:5-HT, 5-hydroxytryptamine; IV, intravenous; IM, intramuscular; max, maximum; NSAIDs, nonsteroidal antiinflammatory drugs; SC, subcutaneous.
Note:Antiemetics (eg, domperidone 10 mg or ondansetron 4 or 8 mg) or prokinetics (eg, metoclopramide 10 mg) are
sometimes useful adjuncts.
a
Not all drugs are specifically indicated by the FDA for migraine. Local regulations and guidelines should be consulted.
Reproduced with permission, from Kasper D, Fauci A, Hauser S, et al, eds. Harrison’s Principles of Internal Medicine.
19th ed. 2015. Copyright © McGraw Hill LLC. All rights reserved.
Treatment. Initial medical therapy of episodic tension-type headache includes
aspirin, acetaminophen, and NSAIDs. Combination analgesics containing caffeine
are second-line options. Use of analgesics for more than 15 days a month may paradoxically lead to a “rebound” or medication overuse headache. Measures to minimize risk of medication overuse headaches include limiting use of drugs to treat
acute headache to two to three days/week, avoiding opioids and sedative hypnotics,
and monitoring medication intake.
The general management principles for the treatment of migraine headaches
can also be applied to the treatment of chronic tension-type headaches. In frequent
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Table 34–5 • PREVENTIVE TREATMENTS IN MIGRAINE
a
Drug Dose Selected Side Effects
b
Pizotifen
Beta-blockers
Propranolol 40-120 mg twice daily Reduced energy
Metoprolol 25-100 mg twice daily Tiredness
Postural symptoms
Contraindicated in asthma
Antidepressants
Amitriptyline 10-75 mg at night Drowsiness
Dosulepin 25-75 mg at night
Nortriptyline 25-75 mg at night Note:Some patients may only
Venlafaxine 75-150 mg daily
Anticonvulsants
Topiramate 25-200 mg daily Paresthesias
Cognitive symptoms
Weight loss
Glaucoma
Caution with nephrolithiasis
Valproate 400-600 mg twice daily Drowsiness
Weight gain
Tremor
Hair loss
Fetal abnormalities
Hematologic or liver
Serotonergic drugs
Methysergide
c
Leg cramps
Hair loss
Retroperitoneal fibrosis
Other classes
Flunarizine
b
Weight gain
Depression
Parkinsonism
Candesartan 16 mg daily Dizziness
0.5-2 mg daily Weight gain
Drowsiness
need a total dose of 10 mg,
although generally 1-1.5 mg/kg
body weight is required
abnormalities
1-4 mg daily Drowsiness
(1-mo drug holiday is required
every 6 mo)
5-15 mg daily Drowsiness
(Continued)
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a
Table 34–5 • PREVENTIVE TREATMENTS IN MIGRAINE
(continued)
Drug Dose Selected Side Effects
Chronic migraine
Onabotulinum toxin type A 155 U Loss of brow furrow
No convincing evidence from controlled trials
Verapamil
Controlled trials demonstrateno effect
Nimodipine
Clonidine
Selective serotonin reuptake
inhibitors: fluoxetine
a
Commonly used preventives are listed with typical doses and common side effects. Not all listed medicines are approved
by the US Food and Drug Administration; local regulations and guidelines should be consulted.
b
Not available in the United States.
c
Not currently available worldwide.
Reproduced with permission, from Kasper D, Fauci A, Hauser S, et al, eds. Harrison’s Principles of Internal Medicine. 19th ed.
2015. Copyright © McGraw Hill LLC. All rights reserved.
headache sufferers, the combination of antidepressant medications and stress management therapy reduces headache activity significantly. Other prophylactic treatments of chronic tension-type headaches include electromyographic biofeedback,
acupuncture, cognitive behavioral therapy, and relaxation training. Pharmacologic
therapies for prophylaxis include amitriptyline as a first line, mirtazapine, venlafaxine, calcium channel blockers, and beta-blockers.
Cluster Headache
Clinical Presentation. Cluster headache is strictly unilateral in location and can be
located in the orbital, supraorbital, or temporal region. It is generally described as a
deep, excruciating pain lasting from 15 minutes to 3 hours. The frequency can vary
from one every other day to eight attacks per day. Cluster headaches are associated
with ipsilateral autonomic signs and symptoms (conjunctivitis and rhinorrhea) and
have a much greater prevalence in men. Compared to migraine sufferers, who often
desire sleep and a quiet, dark environment during their headache, individuals with
cluster headache pace around, unable to find a comfortable position.
Treatment. The first-line treatment of cluster headache includes the use of 100%
oxygen and triptans. Second-line treatment for acute attacks includes intranasal
lidocaine, dihydroergotamine, prednisone, octreotide, corticosteroids, and somatostatin. Verapamil, lithium, melatonin, and antiepileptics may be used for prophylactic treatment. Because of side effects related to chronic use, ergotamine and
corticosteroids need to be used with caution.
Chronic Medical Conditions
Patients with certain underlying medical conditions have a greater incidence
of having an organic cause of their headache. Patients with cancer may develop
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headaches as a consequence of metastases. Someone with uncontrolled hypertension (with diastolic pressures > 110 mm Hg) may present with the chief complaint
of headache. Patients with HIV infection or AIDS may present with central nervous system metastases, lymphoma, toxoplasmosis, or meningitis as the cause of
their headache. It is always important to evaluate each headache in context and
consider secondary causes.
Medication-Related Headache
Numerous medications have headache as a reported adverse effect. Medicationoveruse headache (formerly drug-induced or “rebound” headache) may occur following frequent use of any analgesic or headache medication. This includes both
nonprescription (eg, acetaminophen, NSAIDs) and prescription medications. Caffeine use, whether as a component of an analgesic or a beverage, is another culprit
in this category. The duration and severity of the withdrawal headache following
discontinuation of the medication vary depending on the medication(s) involved.
Any contributing, underlying psychological conditions that may lead to medication
overuse may make discontinuation of the medication difficult and should be
addressed.
CASE CORRELATION
See also Case 30 (Hypertension) and Case 44 (Cerebrovascular Accident/
Transient Ischemic Attack).
COMPREHENSION QUESTIONS
34.1 A 28-year-old man presents for evaluation of headaches that have been going
on for the past several days. He describes them as unilateral throbbing headaches that last 8 to 12 hours and occur once or twice day. When the headaches
occur, he gets nauseated and just wants to go to bed. Usually, the headaches
improve after he lies down in a dark, quiet room for the remainder of the day.
He is missing significant work time due to the headaches. He has a normal
examination today. Which of the following statements is the most appropriate next step for this patient?
A. Schedule a CT scan of his head.
B. Instruct the patient to breathe in 100% oxygen and use a triptan medica-
tion with next headache.
C. Recommend stress reduction and aspirin orally every 4 hours as needed.
D. Prescribe an injectable or nasal spray triptan.
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34.2 A 52-year-old woman presents to your office for a severe headache of 2 hours’
duration that began earlier that day. She says that the headache came on suddenly and is the worst headache she has ever had. She denies any head trauma.
She has had migraines since she was an early adult. The pain is described as
“stabbing” and is more severe on the left side. She takes no medications and
recently stopped taking oral contraceptive pills after going through menopause. Her blood pressure is elevated at 145/95 mm Hg, but otherwise she
has no focal neurologic abnormalities on examination. She is alert and oriented to person, place, time, and situation. Which of the following is the most
appropriate management at this time?
A. Prescribe a triptan medication.
B. Schedule a noncontrast head CT scan for tomorrow morning.
C. Call 911 and transfer the patient to an emergency center.
D. Prescribe an antihypertensive medication and follow up in 2 weeks.
34.3 A 43-year-old man presents to the office for daily headaches that he has
had now for several months. Every morning at work, usually between 9 and
10, he develops a headache that is bilateral from his forehead to his neck
area. He has to take 650 mg of acetaminophen to relieve the headache, and
he says he takes the acetaminophen at 8 to try to prevent the headache.
This has been going on for the past 3months, and he is at the point of looking
for a new job, as he thinks that job stress is the cause of his symptoms. His
examination is normal. Which of the following is the most appropriate advice
for him?
A. He should continue with the as-needed acetaminophen and find a less
stressful career.
B. He should start an antidepressant for headache prophylaxis.
C. His headaches are most likely to improve if he stops taking the
acetaminophen.
D. A triptan is an appropriate treatment for him.
ANSWERS
34.1 D. This patient gives a history very consistent with common migraine headaches. The best treatment is triptan medications (abortive therapy). There
are no red flags found on history or examination that would be suggestive of
an intracranial process such as neurological symptoms or rapidly progressive
headaches, so no further testing such at CT imaging of the head (answer A)
is necessary at this point. As he has significant nausea, he may benefit from
something other than an oral medication. A triptan delivered by injection or
nasal spray is a reasonable starting point for him. Answer B (100% oxygen)
can be helpful with cluster headaches; often nasal congestion or drainage is
found with this condition. Answer C (aspirin and stress relief) is somewhat
reasonable in that the stress relief recommendation may be helpful, though
this advice may be most useful for tension headaches.
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34.2 C. The acute onset of the most severe headache in a patient’s life is concerning for the presence of a subarachnoid hemorrhage (SAH). This is a medical emergency, and delay in diagnosis and treatment can lead to death. This
patient should be transported by emergency medical services to the nearest
emergency facility for stabilization and management. Scheduling imaging for
the next day (answer B) or following up in 2 weeks (answer D) will be too
long an interval in the case of SAH.
34.3 C. This patient very well could have the recently described “medication overuse headache,” in which the daily use of medication such as acetaminophen or
aspirin or other agents can exacerbate primary headaches (migraines, tension,
or cluster). This patient likely has tension headaches, which may be due to
the daily use of acetaminophen. If the headaches resolve when he stops the
acetaminophen, then the diagnosis is confirmed and treatment enacted.
While finding a new, less-stressful job (answer A) may be beneficial, the problem will not resolve until he discontinues the daily use of his OTC analgesic.
Answer D (triptan medication) is useful for migraine headaches, which would
usually present as a unilateral, throbbing headache.
CLINICAL PEARLS
» Migraine headaches can occur in children and adolescents as well as
adults.
» Most patients presenting for the evaluation of headaches do not need
diagnostic testing beyond the history and physical. However, the presence of focal neurologic deficits or other red flag symptoms/signs should
prompt an immediate workup or referral.
» Tension headache is the most prevalent form of primary headache dis-
order, typically presenting with pericranial muscle tenderness and a
description of a bilateral band-like distribution of the pain.
» Cluster headache is strictly unilateral in location and can be located in the
orbital, supraorbital, or temporal region.
» An individual who complains of the worst headache of their life may have
a subarachnoid hemorrhage, which is a life-threatening condition.
REFERENCES
Clinch C. Evaluation & management of headache. In: South-Paul JE, Matheny SC, Lewis EL, eds.
CURRENT Diagnosis & Treatment: Family Medicine. 4th ed. New York, NY: McGraw Hill; 2015:
Chap. 29. http://accessmedicine.mhmedical.com/content.aspx?bookid=1415§ionid=77057346.
Accessed May 7, 2019.
Goadsby PJ, Raskin NH. Migraine and other primary headache disorders. In: Kasper D, Fauci A,
Hauser S, Longo D, Jameson J, Loscalzo J, eds. Harrison’s Principles of Internal Medicine. 20 ed.
Ne w Yo rk , NY : McGraw Hill; 2018: Chap. 447. http://accessmedicine.mhmedical.com/content
.aspx?bookid=1130&Sectionid=79755453. Accessed Jan 25, 2019.
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Hainer BL, Matheson EM. Approach to acute headache in adults. Am Fam Physician.
2013;87(10):682-687.
Headache Classification Committee of the International Headache Society (IHS). The inter-
national classification of headache disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211.
doi:10.1177/0333102417738202.
Myans L, Walling A. Acute migraine headache: treatment strategies. Am Fam Physician. 2018;
97(4):243-251.
CASE 35
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A 56-year-old man comes in for a routine health maintenance visit. He is new
to your practice and has no specific complaints today. He has hypertension, for
which he takes hydrochlorothiazide. He has no other significant medical history.
He does not smoke cigarettes, occasionally drinks alcohol, and does not exercise.
His father died of a heart attack at age 60 years, and his mother died at age 72 years
of cancer. He has two younger sisters who are in good health. On examination,
his blood pressure is 130/80 mm Hg, and his pulse is 75 beats/min. He is 6 ft tall
and weighs 200 lb (body mass index [BMI] 27.1 kg/m2). His complete physical
examination is normal. You order a fasting lipid panel, which subsequently returns
with the following results: total cholesterol 242 mg/dL; triglycerides 138 mg/dL;
high-density lipoprotein (HDL) cholesterol 48 mg/dL; and calculated low-density
lipoprotein cholesterol (LDL-C) 166 mg/dL.
▶ What are the recommendations for providing statin therapy?
▶ What other laboratory testing is indicated at this time?
▶ What is the recommended management at this point?
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ANSWERS TO CASE 35:
Hyperlipidemia
Summary: A 56-year-old man presents with
Well-controlled hypertension
Elevated cholesterol on a screening blood test as part of a physical examination
No known history of coronary artery disease or of any coronary artery disease risk
equivalent
Family history of his father dying of a heart attack at age 60 years and his mother
dying at age 72 years of cancer
Recommendations for statin treatment: American College of Cardiology/American
Heart Association (ACC/AHA) and National Institute for Health and Care
Excellence (NICE) guidelines recommend treatment with statins based on calculated
risk using validated prediction rules.
Other laboratory testing at this time: Blood glucose, creatinine, liver function
tests, and thyroid- stimulating hormone (TSH) to rule out secondary causes of
hypercholesterolemia.
Recommended management: Therapeutic lifestyle changes (TLCs) with consideration for implementation of statin therapy.
ANALYSIS
Objectives
1. State the risk factors for cardiovascular disease (CVD). (EPA 12)
2. Be able to discuss the basic differences between the ACC/AHA, US Preventive Services Task Force (USPSTF), and NICE recommendations for prevention of CVD. (EPA 4)
3. Be able to counsel patients on TLCs to lower their cholesterol levels.
(EPA 4, 12)
Considerations
This case illustrates a 56-year-old man with well-controlled hypertension and
total cholesterol of 242 mg/dL; triglycerides of 138 mg/dL; HDL cholesterol of
48 mg/dL; and a calculated LDL-C of 166 mg/dL. Based on the pooled cohort risk
equation, his 10-year risk of atherosclerotic CVD (ASCVD) is 9.3% (based on his
age, race, nonsmoking status, controlled hypertension, total cholesterol, and HDL
level). Whether medication for cholesterol levels is initiated at this time is based on
the current recommendations you follow; however, any medication regimen should
be accompanied by TLCs such as weight loss, exercise, and diet.
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APPROACH TO:
Hyperlipidemia
DEFINITIONS
ACC/AHA: American College of Cardiology and American Heart Association,
which made joint recommendations for cholesterol management based on risk
assessment, updated in 2018.
HDL CHOLESTEROL: High-density lipoprotein cholesterol, also known as the
“good cholesterol” and helps to decrease the serum LDL fraction by transporting
the latter to the liver.
LDL CHOLESTEROL: Low-density lipoprotein cholesterol, also known as the
“bad cholesterol”, makes up most of the body’s cholesterol, and increases the cardiovascular disease risk.
NICE: National Institute for Health and Care Excellence, which is based in the
United Kingdom and made recommendations in 2014 for cholesterol management
based on risk assessment.
STAT IN: Medication in the beta-hydroxy-beta-methylglutaryl-coenzyme A
(HMG-CoA)–reductase inhibitor class. These are the most widely used medications for lowering LDL cholesterol.
USPSTF: United States Preventive Services Task Force, which made recommendations in 2016 for cholesterol management based on risk assessment.
CLINICAL APPROACH
Pathophysiology
It is important to remember that cholesterol is not a disease. High cholesterol is
a risk factor for coronary heart disease (CHD). As such, an individual’s cholesterol
levels must be interpreted in the context of the individual’s overall risks for CHD.
When high blood cholesterol is identified, an investigation should be performed
to evaluate for secondary causes of dyslipidemia. Included among these causes are
diabetes, hypothyroidism, obstructive liver disease, and chronic renal failure. Consequently, a reasonable laboratory workup includes fasting blood glucose, TSH, liver
enzymes, and a creatinine level. Certain medications, including progestins, anabolic
steroids, and corticosteroids, also can result in elevated cholesterol. Consideration
should be given to changing or discontinuing these when possible.
Statin Therapy Guidelines
In someone with known CHD, statin therapy is recommended in all guidelines.
The first-line pharmacotherapy for LDL-C reduction is a statin. Statins not only
reduce LDL-C but also reduce the rates of coronary events, strokes, cardiac death,
and all-cause mortality.
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