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Migraine

 

This Article written by Udergraduate Pharmacy Students. Some information may not accurate and not suitable for clinical practices

 

FAR 453E/3

CLINICAL PHARMACY AND THERAPY 1

TOPIC 12: MIGRAINE

ASSOC: P.M DR AZMI

GROUP C:

AWANIS BINTI ZAINUDDIN                                      84802

CHIA CHEN YIN                                                            84812

FOO CHEE YEW                                                             84818

LIM SOOK CHING                                                          84851

LIT CHEE CHOONG                                                        84854

NOOR FATINA ABDUL AZIZ                                         84879

NUR ZAWANI BTE MAT YUSOFF                                  84894

SITI RABI’ATUL ‘ADAWIYAH BT NASRI                     84909

TEOH SHYE LING                                                          84922

WONG WAI KIT                                                            84925

 

 

Defines abbreviations

 

CC

Chief Complaint

HPI

History of present illness

PMH

Past medical history

FH

Family history

SH

Social history

PE

Physical examination

WDWN

Well develop, Well nourish

VS

Vital sign

HEENT

Head, Eye, Ear, Nose, Throat

Abd

Abdomen

WNL

Within Normal Limits

NT/ND

Non-tender/ Non-distended

BS

Bowel Sound

A&O X 3

Alert & Oriented to person, place and time

CN

Cranial nerve

EtOH

Ethanol

HA

Headache

SOB

Shortness of breath

c/o n/v

Complain of nausea and vomiting

GU

Genitourinary

NAD

No Abnormality detected

CTA

Clears to auscultation

RRR

Regular Rate and Rhythm

BCP

Birth control pill

 

Medical terminology

 

Medical terminology

Meaning

Kernig sign

In meningitis, inability to extend the leg when sitting/ lying with thigh flexed upon abdomen.

Brundzinski sign

In meningitis, flexion of neck usually causes flexion of hip and knee

Dental caries

The formation of cavities in the teeth by the action of bacteria

Menarche

The first menstrual period usually occurring during puberty

 

 

Branded products

ASA

Aspirin

Panadol

Paracetamol, 500mg, < 4g/day

Xanax (benzodiazepine)

XANAX tablets contain alprazolam which is a triazol analog of the 1, 4 benzodiazepine class of central nervous system-active compounds

Sunprox (mild to moderate pain)

Naproxen Na

Feldene (analgesic)

Piroxicam 10mg capsule, 20mg tablet

Elavil (antidepressant)

Elavil (amitryptyline HCl) is supplied as 10mg, 25mg, 75mg, 100mg, and 150mg tablets and as a sterile solution for intramuscular used.

Ketanov

Ketorolac prometamine

Cafergot (migraine)

Ergotamine tartrate 1mg tablet

Midrin (relief of migraine and tension headache)

Each capsule contains Isometheptene Mucate 65mg, Dichloralphenazone 100mg, and acetaminophen 325mg.

Phenergan (antiemetic, antihistamine, sedative)

Each tablet consists of 12.5mg, 25mg or 50mg promethazine HCl

Naprosyn (analgesia, migraine)

Naproxen 250mg tab

Imigran (acute relief of migraine with or without aura)

Sumatriptan as succinate 50mg tab

Codimol (mild to moderate pain)

Codein phosphate + paracetamol

Corgard (angina)

Nadolol is a synthetic nonselective beta adrenergic receptor blocking agent. Nadolol is available as oral administration 20mg, 40mg, 80mg, 120mg and 160mg tablets

 

1. Identify the problem (common migraine or migraine with aura)

 

        Migraine is a recurring headache of moderate to severe intensity associated with gastrointestinal, neurologic and autonomic symptoms. In migraine with aura, a complex of focal neurologic symptoms precedes or accompanies the attack.

          An aura is the perceptual disturbance experienced by some migraine sufferers before a migraine headache, and the telltale sensation experience by some people with epilepsy before a seizure. It often manifests as the perception of a strange light or unpleasant smell.

         A migraine aura is experienced by approximately 31% of migraineurs. The aura typically evolves over 5 to 20 minutes and lasts less than 60 minutes. Headache usually occurs within 60 minutes of the end of the aura. Visual auras can include both positive features and negative features. Sensory and motor symptoms may also occur.

       The actual migraine headache may occur at any time of day or night but usually occurs in the early morning hours on awakening. Pain is usually gradual in onset, peaking in intensity over minutes to hours, and lasting between 4 and 72 hours.

 

2. What signs/ symptoms identified by the patient are consistent with this problem?

 

-severe, throbbing, right sided headaches

-recurring episodes of throbbing head pain

-history of intermittent headache (last 12-48 hours per episode)

-sensitive to light and sound during attack

-positive family history

-longer duration of attack

This patient suffers from migraine without aura because she did not experience any visual disturbance.

 

3. Discuss factors which may precipitate a migraine headache.

 

Food triggers

-          alcohol

-          caffeine/ caffeine withdrawal

-          chocolate

-          fermented and pickled food

-          citrus fruits/ bananas/ figs/ raisins

-          dairy product

-          monosodium glutamate

-          nitrate-containing food

-          saccharine/ aspartame

-          sulfites in shrimp

-          tyramine/ containing food

-          yeast product

       

Environmental triggers

-          glare or flickering light

-          high altitude

-          loud noises

-          strong smell and perfume

-          tobacco smoke

-          weather changes

 

Behavioral- Physiologic triggers      

 

-          excess or insufficient sleep

-          fatigue

-          menstruation/ menopause

-          skipped meal

-          strenuous physical activity

-          stress or post stress

 

 

Medications

 

-          analgesic overused

-          benzodiazepine withdrawal

-          cimetidine

-          decongestant overuse

-          ergotamine overuse

-          estrogen therapy

-          indomethacine

-          nifedipine

-          nitrates

-          oral contraceptive

-          reserpine

-          theophylline

 

 

 

4. Create a list of patient’s DRPs related to this ER visit (including OTC drug use)

 

a) migraine without aura without proper treatment

b) opiate drug should be avoided because patient allergy to codeine

c) risk of rebound headache because the use of multiple OTC products
d) caffeine is predisposed factors of migraine

e) use more than one NSAIDs at a one time will increase the risk of GI bleeding

 

 

5. Define aura, photophobia, phonophobia, and epitaxis

 

Aura

-          perceptual disturbance experience by some migraine sufferers before a migraine headache, and the telltale sensation experience by some people with epilepsy before a seizure.

 

Photophobia

-          abnormal visual intolerance to light

 

Phonophobia

-          fear of loud sound

 

Epitaxis

-          nosebleed presenting hemorrhage from the nose due to rupture of small vessels  

      overlying the anterior part of the cartilaginous nasal septum

 

 

 

6. Discuss the rational for treatment at this visit

 

Naprosyn® 500mg. po BiD prn HA

·         a type of NSAIDs

·         manage mild to moderate pain of migrain headache

·         dose-initial 500mg, then 250mg every 6-8 hours (max 1250mg/day)

 

 

 

Discontinue all OTC products

·         concurrent use of Naproxen and other OTC products such as other NSAIDs may cause GI ulceration and bleeding

·         this is to reduce the risk of medication errors

·         other OTC products such as birth control pill may trigger migraine headache

 

Phenergan® 25mg. pr or po q6hr. prn n/v

 

  • as antiemetic

 

 

 

7. Discuss the type of abortive therapies for migraine attack

( drugs, route of administration, duration of therapy)

 

 

Drugs

Dosage

Route of administration

Analgesics

 

 

Acetaminophen, 25mg

1000mg at onset, repeat every 4-6hrs as needed. Max daily dose is 4g

oral

Aspirin or acetaminophen with butalbital, caffeine 65mg

Limit dose to 4 tablets/ day

Oral

NSAIDS

 

 

Ibuprofen

200-800mg every 6 hrs. avoid doses > 2.4mg/day

oral

Naproxen sodium

550-825mg at onset. May repeat 220mg in 3-4 hrs. avoid doses > 1.375g/day

oral

Ergotamine tartrate

 

 

Oral tablet with caffeine 100mg

2mg at onset, then 1-2mg every 30 minutes as needed. Max dose is 6mg/day @ 10mg/week.

Consider pretreatment with antiemetic

oral

Dihydroergotamine, 1mg/ml

0.25-1 mg at onset IM or SC repeat every hour as needed. Max dose is 3mg/day or 20 mg/week

IM @ SC

Serotonin agonist (Triptants)

 

 

Sumatriptan

25, 50, 100 mg at onset,  may repeat after 2 hrs if needed. Optimal dose is 50-100mg. Max daily dose is 200mg

oral

Zolmitriptan

2.5 or 5mg at onset as regular or orally disintegrating tablet. Optimal dose is 2.5 mg, max dose is 10mg/day

oral

Miscellaneous

 

 

Metoclopramide

10mg at onset. Useful for acute relief in the office or emergency department setting

IV

Procloperazine

10mg at onset. Useful for acute relief in the office or emergency department setting

IM @ IV

 

 

 

 

 

8. List the types of prophylactic therapies for the prevention of migraine attack

 

NSAIDs

Aspirin

1300mg/day in divided dose

Ketoprofen

150mg/day in divided dose

Naproxen sodium

550-1100mg/day in divided dose

Vitamin B12

400mg/day

ANTIDEPRESSANTS

Amitiptyline

25-150 mg at bedtime

Doxepine

10-200 mg at bedtime

Imipramine

10-200 mg at bedtime

Nortriptylin

10-150 mg at bedtime

Protriptylin

5-30 mg at bedtime

Fluoxetine

10-80mg/day

Phenelzine

15-60 mg/day in divided dose

β-ADRENERGIC ANTAGONISTS

Atenolol

25-100mg/day

Metoprolol

50-300 mg/day in divided dose

Nadolol

80-240 mg/day

propranolol

80-240mg/day in divided dose

Timolol

20-60mg/day in divided dose

VALPROIC ACID

Verapamil

240-360 mg/day in divided dose

Methysergide

2-8mg/day in divided dose with food

 

 

 

 

 

9. Prepare a report highlighting the clinical use of the following drugs that are used in the treatment/ prophylaxis of migraines.

 

Drugs

Indication

Dosage

Contraindication

ADR/SE

a. Beta blockers

Migraine Prophylaxis

Atenolol: 25-100mg/day

Propranolol: 80-240mg/day in divided doses

Timolol: 20-60mg/day in divided dose

Nadolol: 80-240mg/day

Be caution in the patients with heart failure, peripheral vascular disease, artrioventricular conduction disturbances, asthma, depressant, diabetes

Drowsiness, fatigue, sleep disturbance, vivid dreams, memory disturbance, depression, impotence, bradycardia, hypotension.

b. Anti

epyleptics- sodium valproate

Migraine prophylaxis

500-1500mg/day in divided doses

Patient with hepatic disorder, hypersensitive

Nausea, tremor, somnolence, weight gain, hair loss, hepatotoxicity

c. Pizotifen

Not for use in acute treatment of migraine attack

-

Concurrent use of MAO inhibitors

Nausea, vomiting, hypotension, fatigue, confusion, nervousness

d. Cypro

heptadine

Treatment of migraine headache

4-8mg tds

Patients with bladder neck obstruction, acute asthmatic attack, stenosing peptic ulcer.

Fatigue, nausea, dry mouth, diarrhea

e. Clonidine

Migraine prophylaxis

-

Hypersensitivity

Drowsiness, orthostatic hypoteasion

f. Tricyclic antideppresant

Migraine prophylaxis

Amitryptilin: Initial dose of 10-25mg at bedtime. The dose can be increase until the max dose = 150mg/day.

Patient that on MAO inhibitors

Palpitation, orthostatic hypotension

g. Calcium Channel Blockers

Migraine prophylaxis

240-360mg/day in divided doses

Hypotension, severe left ventricular dysfunction.

Rash, bradycardia, nausea, dyspnea

 

 

 

 

10. Explain the meaning of rebound headache and medication misuse headache

 

Rebound headache occurs when the frequent or excessive use of acute migraine medication that result in a pattern of increasing headache frequency and drug consumption known as medication misuse headache.

 

 

Reference:

  1. pharmacotherapy textbook
  2. applied therapeutic textbook

Tanya Farmasi Anda

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