Unit II D Anti-migraine Drugs and its side affect

It best for care of headache client

1. Unit II D : Anti Migraine and drugs for Trigeminal neuralgia By: Muhammad Aurangzeb Lecturer-INS/KMU

2. Objectives By the completion of this session learners will be able to: Discuss the action, contraindication and side effects of Antimigraine and Trigeminal neuralgia Drugs Identify most commonly used drugs for migraine and Trigeminal neuralgia State the major nursing care if client is using drugs for migraine and Trigeminal neuralgia. Calculate the drug dosage accurately for oral anti migraine and drugs for trigeminal neuralgia.

3. Migraine “Migraine is a familial disorder characterized by recurrent attacks of headache widely variable in intensity, frequency and duration. A pulsating headache, which comes in attacks lasting 2 - 72 hours Attacks are commonly unilateral and are usually associated with anorexia, nausea and vomiting ”.

4. Simplified Diagnostic Criteria for Migraine Repeated attacks of headache lasting 2 –72 h in patients with a normal physical examination, no other reasonable cause for the headache, and: At Least 2 of the Following Features: Plus at Least 1 of the Following Features : Unilateral pain Nausea/vomiting Throbbing pain Photophobia and Phonophobia Aggravation by movement Moderate or severe intensity

5. Types of Migraine Two Types:- Migraine with aura ( classical migraine ) :-headache preceded by visual or other neurological symptoms Migraine without aura( common migraine )

6. Migraine without aura (Common Migraine) Migraine without aura, is a severe, unilateral, pulsating headache that typically lasts from 2 to 72 hours. These headaches are often aggravated by physical activity and are accompanied by nausea, vomiting , photophobia (hypersensitivity to light), and phonophobia (hypersensitivity to sound). The majority of patients with migraine do not have aura.

7. Migraine with aura (Classical Migraine) Migraine with aura, the headache is preceded by neurologic symptoms called auras, which can be visual, sensory, and/or cause speech or motor disturbances. Most commonly, these prodromal symptoms are visual ( flashes, zigzag lines, and glare), occurring approximately 20 to 40 minutes before headache pain begins. In the 15% of migraine patients whose headache is preceded by an aura

8. 4 Stages of Migraine 1.Prodrome Aura Headache Postdrome

9. Prodrome Vague premonitory symptoms that begin from 12 to 36 hours before the aura and headache. Symptoms: Yawning Excitation Depression Lethargy Craving or distaste for various foods Duration: 15 to 20 min.

10. Aura Aura is a warning or signal before onset of headache. Symptoms: Flashing of lights Zigzag lines Difficulty in focusing Duration : 15-30 min.

11. Headache Headache is generally unilateral and is associated with SYMPTOMS like: Anorexia Nausea Vomiting Photophobia Phonophobia Tinnitus Duration: 4-72 hrs. 8

12. Postdrome Following headache, patient complains of - Fatigue Depression Severe exhaustion Some patients feel unusually fresh Duration: Few hours or up to 2 days. 9

13. Pathophysiology of Migraine Increased excitability of CNS (Cortical Spreading Depression) Meningeal blood vessel dilation Activation of perivascular sensory trigeminal nerves Pain impulses and inflammation due to neuropeptides Vasoactive neuropeptides contain: Substance P Calcitonin gene-related peptide (CGRP) Neurokinin A Combination of increased pain sensitivity, tissue and vessel swelling, and inflammation

14. Theories about Pathophysiology: Vascular Theory:- Intracranial/Extra-cranial blood vessel vasodilation – headache. Intracerebral blood vessel vasoconstriction – aura. Serotonin Theory:- Decreased serotonin levels linked to migraine. Specific serotonin receptors found in blood vessels of brain.

15. Hunter Area Toxicology Service

16. Classification Mi l d Less than one attack a M onth Lasting up to 8 hours Throbbing but tolerable headache Moderate One or more attacks per M onth 6-24 hours Intense throbbing headache with nausea and vomiting Severe 2-3 attacks or more every month 12-48 hours Intense throbbing headache with nausea and vomiting, vertigo, GIT instability, fatigue, photophobia

17. Antimigraine agents Antimigraine agents  are drugs used to treat migraine headaches Pharmacological treatment of migraine includes Acute (abortive) treatment Preventive (prophylaxis) treatment

18. Classification of drugs used to treat migraine headache Specific Treatment TRIPTANS Almotriptan AXERT Eletriptan RELPAX Frovatriptan FROVA Rizatriptan MAXALT Naratriptan AMERGE Sumatriptan IMITREX, ALSUMA Zolmitriptan ZOMIG ERGOTS Dihydroergotamine MIGRANAL, VARIOUS Non-specific Treatment NSAIDs Aspirin BAYER, BUFFERIN, ECOTRIN Ibuprofen ADVIL, MOTRIN Indomethacin INDOCIN Ketorolac TORADOL Naproxen ALEVE, ANAPROX, NAPROSYN Anti-emetics PROPHYLACTIC AGENTS Anticonvulsants Beta-blockers Calcium channel blockers Tricyclic antidepressants

19. Management of Migraine Mild migraine: Analgesics with or without antiemetic. Moderate migraine: NSAIDs combinations / a triptan /ergot alkaloids (+antiemetic) Severe migraine: A triptan /ergot akaloids (+antiemetic) + prophylaxis

20. Acute Treatment: Step 1 Simple oral analgesic ± anti-emetic: Soluble Aspirin 600-900mg orally STAT OR Ibuprofen 400mg (Maximum of 4 doses over 24 hours) AND/OR Paracetamol 1g orally every 4 hours (Maximum of 4 g over 24 hours) for non-incapacitating headache Efficacy of analgesia may be improved by giving a pro-kinetic anti- emetic to promote gastric emptying with: Metoclopramide 10-20mg orally Domperidone 10-20mg orally. For nausea and vomiting (if required): Prochlorperazine 5mg orally or Prochlorperazine 25mg suppository Domperidone 10mg-20mg orally. If unable to tolerate either of the above due to prominent nausea and vomiting: Metoclopramide 10- 20mg IM or IV STAT

21. Step 2 Acute Treatment: Prescription NSAID (± anti-emetic as described in step 1) Naproxen 500mg-750mg with a further 250mg- 500mg in 6 hours if required (Maximum dose=1250mg/day) OR Diclofenac 50-100mg (maximum 200mg /day). Diclofenac 100mg suppository (maximum 100mg BD ) Analgesics inhibit release of prostaglandin release due to neurogenic inflammation . Metoclopramide besides being antiemetic enhances absorption of analgesics

22. Pharmacology of specific antimigraine drugs: Triptans: Selective 5-HT 1B/1D agonists Triptan includes- Sumatriptan, naratriptan, rizatriptan, eletriptan, zolmitriptan, almotriptan & frovatriptan Therapeutic Action : Triptans   is a relatively new antimigraine agent that causes cranial vascular constriction and relief of migraine headache pain. They do this by binding to serotonin receptors . Indications: Triptans   are indicated for the treatment of acute migraine and are not used for prevention of migraines .

23. Adverse Effects and Contraindications of Triptans Coronary artery vasospasm, transient myocardial ischemia, atrial and ventricular arrhythmias, MI Irritation at the site of injection. The most common side effect of sumatriptan nasal spray is a bitter taste. Contraindicated - coronary artery disease , history of stroke or transient ischemic attacks, cerebrovascular or peripheral vascular disease

24. Ergot a mine Therapeutic Action: Partial agonist at α- adrenoceptors . Partial agonist at serotonergic receptors. Constricts all peripheral arteries. Ergotamine  was the drug of choice for migraines before triptans were developed. Dose: Oral/ sublingual route is preferred,1mg is given at half hours intervals till relief is obtained or total of 6mg is given

25. Adverse Effects and Contraindications of Ergot Alkaloids Nausea and vomiting, due to a direct effect on CNS emetic center. Ergotism: repeated doses cause cumulative toxicity, Severe peripheral vasoconstriction, hypertension, gangrene of extremities, anginal pain. Contraindicated in pregnant, peripheral vascular disease, coronary artery disease, hypertension, impaired hepatic or renal function. In contrast to triptans, the contractile effect of ergotamine in the human isolated coronary artery is long- lasting and persists even after repeated washings

26. Migraine Prophylaxis to reduce Frequency Raising the threshold to migraine activation by stabilizing a more reactive nervous system Enhancing antinociception Inhibiting CSD Blocking neurogenic inflammation

27. Drugs Used For Prophylaxis of Migraine

28. Trigeminal Neuralgia Sudden, usually unilateral Brief, stabbing , electric shock like recurrent pain Pain is limited to the sensory distribution of trigeminal nerve that includes middle face (maxillary division)– being most frequently involved, lower (mandibular division) & upper (ophthalmic division)– being least frequently involved

29. TN symptoms Pain in areas supplied by CN V Usually unilateral Sharp, stabbing, electric shock like pain Lasts for few seconds to minutes This transient attack may be repeated in matter of minutes or hours

30. 1st step of treatment Pharmacotherapy (Medical management of TN) Trigeminal neuralgia is usually treated with drugs called anti- convulsants which include: Carbamazepine (drug of choice) (400 1000mg/day) Phenytoin (300mg/day) Oxycarbazepine Gabapentin (600-1200mg/day) Baclofen , lamotrigine, clonazepam

31. Non Pharmacological Measures There are some things that a patient can do to minimize the frequency and intensity of TN attacks : Apply ice packs. Cold often numbs the area and will reduce the pain Get adequate rest in normal rest cycles Manage your stress well and keep stress levels low Avoid foods that may act as nerve stimulants, such as coffee , tea, and foods that are high in sugar Maintain adequate hydration and electrolyte levels Practice healthy living principles such as diet and exercise

32. Nursing Role Assess aforementioned cautions and contraindications (e.g. drug allergy, history of myocardial infarction and CAD, hepatic-renal dysfunction, etc.) to prevent complications . Administer drug to relieve acute migraines (at first sign of headache) Monitor for complaints of extremity numbness and tingling to identify effects on vascular constriction .

33. Nursing Role Educate client on drug therapy to promote understanding and compliance. Monitor patient response to therapy (relief of acute migraine headache). Monitor for adverse effects (e.g. CV changes, arrhythmias, hypertension, etc ). Monitor patient compliance to drug therapy.

34. References Karch , A. M., & Karch . (2011).  Focus on  nursing pharmacology . Wolters Kluwer Health/Lippincott Williams & Wilkins. Katzung , B. G. (2017).  Basic and clinical pharmacology . McGraw-Hill Education. Lehne , R. A., Moore, L. A., Crosby, L. J., & Hamilton, D. B. (2004). Pharmacology for nursing care. Smeltzer , S. C., & Bare, B. G. (1992).  Brunner & Suddarth’s textbook of medical-surgical nursing . Philadelphia: JB Lippincott