NR508 PHARMACOLOGY; Migraine Headache Case Study

NR508 PHARMACOLOGY; Migraine Headache Case Study. 35-year-old adult female comes to the office with complains of the gradual onset of a bad throbbing headache behind her right eye that gradually worsened over several hours, starting in the temporal area. She has difficulty thinking and performing duties at work, and doing housework because activity makes the pain worse. It started 8 hours ago. Reports sensitivity to bright light (photophobia) and to noise (phonophobia). Nausea and vomiting also present. States that her mother and sister have similar headaches. She has had these symptoms three days this month. Denies flickering lights, spots, or lines in front of her eyes. Also denies dizziness, diplopia, tinnitus, or speech disturbances. She has tried OTC Excedrin migraine medication as directed on the label without relief. H & P and neurological exam do not indicate any organic lying disease. Differential diagnosis is Migraine headache without aura. Notes McCance & Huether (2014) and Leik (2014) state that migraine headaches are the most common compliant presented in the primary care office or in the urgent care setting. Because of the limits required for the power point presentation, this author decided to discuss this topic. Fenstermacher & Hudson (2016) state characteristics most patients have a family history of H/A and that symptoms rarely start after 50 years of age. Symptoms for migraine without aura are: (1) lasts 4 to 72 hours (2) unilateral, pulsating, moderate-to-severe intensity, worsens with activity (3) at least one of the following during H/A: nausea, vomiting, photophobia, phonophobia (4) H&P and neuro examinations do not suggest underlying organic disease. To differentiate with Migraine with aura include the above symptoms are symptoms of aura that are transient and reversible symptoms that gradually develop over 5 to 20 minutes and last 60 minutes that include (a) visual: flickering lights, spots, lines, (b) numbness, (c) speech disturbance, (d)brainstem: diplopia, vertigo, tinnitus. McCance & Huether (2014) and Leik (2014) state that the pain is usually located behind one eye that usually begins in the temporal areas that are associated with vascular changes in the cranial arteries. Mayans & Walling (2018) states more women (18-26%) have these headaches when compared to men (9%). The Mnemonic for diagnosis of a migraine is POUND (p 245). Pulsating type of headache One day duration (4- 72 hours if untreated or treated ineffectively) Unilateral Headache Nausea or vomit Disabling headache MEDICAL MANAGEMENT: acute migraines Mild migraine APAP/ASA/caffeine Midrin NSAIDs 5 HT agonists (triptans) Moderate migraine DHE Ergotamine Midrin NSAIDs 5 HT agonists (triptans) Severe migraine Prochlorperazine Chlorpromazine DHE 5 HT agonists (triptans) Ketorolac IM Notes: The table above describes the recommendations for the treatment of acute migraines found in Slater, David, & Esherick, (2018), and Mayans & Walling (2018). The first column represents the first line treatment for mild to moderate migraine. Mayans & Walling (2018) state NSAIDs like ASA, Ibuprofen, Diclofenac, and Naproxen. ASA dose 1000 mg. APAP/ ASA/caffeine combinations taken as directed are as effective (p 244- 245). Abortive agents Triptans and Ergotamine derivatives are the first line of therapy used for moderate to severe migraines. They work on the serotonin receptors. The 5-hydroxytryptamine receptor agonists are specially designed for migraines and are chosen because they have few adverse effects. It is recommended that the patient have the medication on hand to use immediately at the onset of a migraine. The dose of the individual medication varies (p 245). Discussion on drugs is more in depth later in the presentation. Both authors agree on the treatment for the mild to moderate and the moderate to severe and severe migraine.. The dopamine antagonists chlorpromazine and prochlorperazine are effective in relieving migraine pain, and help with the nausea and vomiting. They can be given paternally with the 5H antagonist Sumatriptan and NSAIDs to provide relief within 60-120 minutes (Saquil & Lax, 2014, para 4, lines 5-9). MEDICAL MANAGEMENT: acute migraine (continued) This presentation will discuss the NSAIDs, Sumatriptan, Midrin, DHE. NSAIDs: Drug name Generic dose Voltaren diclofenac 100-200 mg daily Advil Ibuprofen 400 (may repeat in 4hrs Aleve Naproxen 500 to 825 daily Mechanism of Action. They reduce inflammation by blocking the COX enzyme, this inhibits “the production of prostaglandins, prostacyclin, and thromboxanes” in the brain. Contraindications: patients with renal and heart failure, liver disorders Adverse side effects: GI bleeding, renal deficiency and necrosis, acute renal failure Interactions: blood thinners, diuretics, ACEI’s, ARBs., digoxin and Ibuprofen Notes: NSAIDs: According to Edmunds & Mayhew (2013) state the mechanism of action (MOA) is that it reduces inflammation by blocking the COX enzyme, this inhibits “the production of prostaglandins, prostacyclin, and thromboxanes” in the brain (p 205). Adverse effects are GI bleeding, renal deficiency and necrosis, acute renal failure. Contraindicated in patients with renal and heart failure, liver disorders. Do not take with blood thinners, diuretics, ACEI’s, ARBs. Edmunds & Mayhew (2013) state Ibuprofen and digoxin should not be taken together (p 413). Mayans & Walling (2018) states the names of drugs and doses used are Diclofenac (Voltaren) 100-200 mg daily, Ibuprofen (Advil) 400 mg (may need to repeat dose in 4 hours), and Naproxen (Aleve) 500-825 mg daily (p 244-45). For severe migraines the dose of the Ketorolac dose is 30 to 60 mg IM (p 249), oral dose is 20 mg once then 10 mg every 4-6 hrs as needed (Edmunds & Mayhew, 2013, p 414). Toradol Ketorolac Oral: 20 mg once then 10 mg every 4-6 hrs as needed. IM : 30 to 60 mg Sumatriptan MEDICAL MANAGEMENT: acute migraine (continued)