A case of classic migraine, arranged in the SOAP format for presentation for PharmD or M Pharm pharmacy practice students.

1. Abel C. Mathew
4th year PharmD
Al Shifa College of Pharmacy
1
A CASE ON CLASSIC
MIGRAINE

2. • NAME : XYZ
• AGE : 60 years
• SEX : Female
• MRD NO : xxxxx
• DOA :14/02/2018
• DOD :16/02/2018
• Dept: General Medicine I
2
PATIENT DEMOGRAPHIC DETAILS

3. REASON FOR ADMISSION
Irritability, headache with flickering lights and visual disturbances,
and generalised weakness since one day. History of abnormal
sensation of abdominal and limb muscles. Patient was also
suffering from sleepiness and giddiness
3

4. MEDICAL HISTORY
Type 2 DM , Hypertension, diabetic neuropathy,
Age related functional dyspepsia
MEDICATION HISTORY
•Inj. Human Mixtard
•Levosulpiride 25mg
FAMILY HISTORY
No relevant family history
SOCIAL HISTORY
Not relevant
4

5. ON EXAMINATION
• Conscious
• Oriented
• Afebrile
• PR -92/mt, B.P- 160/100 mmHg, RR- 16 /mt ,
• P/A- soft
• Chest – NVBS
• CVS- S1S2+
5

6. PROVISIONAL DIAGNOSIS
Classic Migraine, Type 2 DM, Hypertension, diabetic neuropathy,
Akathisia- Levosulpiride induced
6

7. LAB ADVICES
• BRE
• LFT
• RBS
• URINE ACETONE
7

8. TEST VALUE NORMAL
RBC 4.44million/mm3 150-450
WBC 11.64x1000c/cu 4-11
NEUTROPHILS 65% 45-75
LYMPHOCYTES 28% 20-45
BASOPHILS 00% 0-1
EOSINOPHILS 03% 0-6
MONOCYTES 04% 0-7
PLATELETS 330 X 1000 c/cu 150-450
MCV 66.3FL 66-96
MCH 30.1pg 27-32
MCHC 34.1% 32-36
8
LAB REPORTS

9. RDW 12.8% 11-16
PCT 0.25% 0.13-0.35
PDW 44.2% 24-65
ESR 80mm/hr 0-20
ALBUMIN 4.4g/dl 3.5-5.5
GLOBULIN 3.3g/dl 2.3-3.5
TOTAL PROTEIN 7.7g/dl 6.4-8.3
AST 29.8 U/I 8-40
9

10. 10
ALT 28.2 U/I 5-35
ALKALINE PHOSPHATASE 125U/I 30-130
BILIRUBIN TOTAL 0.45 mg/dl 0.29-1.2
DIRECT BILIRUBIN 0.23mg/dl 15-45
INDIRECT BILIRUBIN 0.22mg/dl 70-150
URINE ACETONE NEGATIVE
SERUM SODIUM 138mEq/L 135-145
SERUM POTASSIUM 4.18mEq/L 3.5-5.5
RBS 173mg/dl 70-150

11. Classic Migraine, Type 2 DM, Hypertension, diabetic neuropathy,
Akathisia- Levosulpiride induced
11
FINAL DIAGNOSIS

12. PHARMACOTHERAPY
12

13. DRUG
BRAND NAME GENERIC NAME WITH DOSE,
ROUTE, FREQUENCY
Day1 Day 2 Day3
1. TAB.TELISTA Telmisartan 40 mg P/O BD + +
2. CAP.RENERVE PLUS Alpha lipoic acid 200 mg + Chromium
200 mcg + folic acid 1.5 mg + inositol
100 mg + mecobalamin 1500 MCG
+ + +
3. TAB.NAPROSYN Naproxen 500 mg P/O 1-0-1 + +
4. TAB.OXETOL Oxcarbazepine 150mg P/O TID + + +
5. TAB.PHENERGAN Promethazine 50 mg P/O HS + +
6.TAB.ACOTRUST Acotiamide 100mg P/O ½ -½ -½ + +
7. TAB.SEMSIVAL P Pregabalin (75mg)+ Nortryptyline(10
mg) P/O ½ HS
+
8. GABAPENTIN
OINTMENT 20g L/A
Gabapentin apply to affected area +
9.INJ. HUMAN
MIXTARD (30/70)
Isophane insulin(70%) + Soluble
insulin(30%) s/c BD
+ + +
1313

14. • 1.TAB.TELISTA 40 mg (Telmisartan) 1-0-1
• 2.CAP. RENERVE PLUS( Folic acid+ mecobalamin+
chromium+Inositol+ Alpha lipoic acid) 1- 0-0
• 3.TAB PHENERGAN 50mg (Promethazine) 0 – 0-1
• 4.TAB.ACOTRUST (Acotiamide) ½ -½ -½
• 5.TAB VENTAB DXT 25mg (Desvenlafaxine) 0 - 0- ½
• 6.GABAPENTIN OINTMENT 20g L/A (Gabapentin)
• 7.T.SIBELIUM 10 mg (Flunarizine) 0-0-1
• 8. SYP. MUCAINE GEL 2tsp (½ hour before food )
14
4 DAYS

15. PROGRESS CHART
15
DAYS INVESTIGATIONS
14/02
15/02
16/02
Irritability, Headache and patient suffered from heart burn and Syp.
Mucaine gel 2 tsp was given as stat. (PR 92b/min ; RR 16 b/min ;
BP 100/80 ; Temp98.6º F)
Pain was decreased and vitals were stable (PR 82 b/min ; RR 18
b/min ; BP140/90 ; Temp; 98.6º F)
All vital signs were normal and symptomatically better( PR
76b/min ; RR 18 b/min ; BP 130/90; Temp 98.6ºF)

16. • Review after 4 days with FBS, PPBS reports .
16

17. • Avoid migraine triggers like stress, bright lights, some
foods and medications, too much or too little sleep, and
menstruation.
• Keep well hydrated.
• Maintain a regular schedule for eating and sleeping
17

18. 18

19. • A 64 year old female patient having weight of 55 kg was
admitted in the department of general medicine with
complaints of Irritability, headache, and generalised weakness
since one day. History of abnormal sensation of abdominal and
limb muscles. Patient was also suffering from sleepiness and
giddiness.
19

20. 20.
Past history of classic migraine and age related gastric
movement discomfort for which patient was on levosulpiride
1. Elevated WBC (11640 cells/ cu)
2. Restlessness of limbs was observed during examination
3. Elevated RBS (173 mg/dl)

21. Based on subjective and objective evidences the case was
diagnosed Classic Migraine, Type 2 DM , Hypertension,
diabetic neuropathy, Akathisia- Levosulpiride induced
Etiology :
• Genetic predisposition
• Previous episodes of migraine headaches
• Bright lights
• Akathisia was propably levosulpiride induced
21

22. Assessment of current therapy-
Rationality of each drug:
• Flunarizine
Lucking et al. (1988) compared flunarizine 10 mg daily with
propranolol 40 mg 3 times a day over a 16-week period in 2 identically
designed double-blind studies in Germany in adults with a history of
migraine. The first study included 87 people and second study included
434 people. In the primary care study, the frequency of migraine
attacks was reduced in 54.5% of people in the flunarizine group and
53.1% of people in the propranolol group after 4 months of treatment
• Oxcarbazepine
A study conducted by Muke Zou et.al 2013 randomised, placebo-
controlled, double-blind trials with a total of 862 participants the
review found evidence to support the effectiveness of oxcarbazepine in
painful diabetic neuropathy, neuropathic pain from radiculopathy and
mixed neuropathies of various causes.
22

23. • Desvenlafaxine
In a randomised double blind controlled trial done by Boyer.P et.al (2015), which
analysed 874 patients at the end of 6 month double blind treatment, better efficacy
was found among the desvenlafaxine than placebo treated patients on all efficacy
end points.
• Nortryptyline & Gabapentin
Chandra 2006 reported that 14/34 participants experienced our preferred outcome
of at least 50% reduction in pain intensity (using 100 mm VAS) with nortriptyline,
and 13/36 with gabapentin. Numbers were somewhat lower in both groups using a
Likert scale. The study also reported a responder outcome of 'good or excellent',
defined as participants with "no worse than mild pain and disability, tolerable side
effects, who slept well and were satisfied with treatment". This was experienced by
16/36 participants with nortriptyline and 16/34 with gabapentin.
• Naproxen
Lawrencew Richer et. Al 2016 identified 27 randomized controlled trials (RCTs)
of migraine symptom-relieving medications, in which 9158 children and
adolescents were enrolled and 7630 (range of mean age between 8.2 and 14.7
years) received medication. Naproxen was more effective than placebo in
producing pain freedom in two small studies involving children. In one small
cross-over study in adolescents, naproxenwas not superior to placebo for pain
freedom, but it was for headache relief (Evers 2006).
23

24. • Acotiamide Masahiro Ueda, et. al 2016 Efficacy of acotiamide for
improving symptoms in patients with functional dyspepsia was shown by
several clinical trials. In a randomized, double-blind, placebo-controlled,
parallel-group comparative Phase III trial conducted in Japan, 100 mg of
acotiamide three times a day for 4 weeks was more effective than a placebo
for improving symptoms, and quality of life.
24

25. • Patient responded well to the therapy , symptoms was
reduced
25

26. The administration of promethazine with nortryptyline
increases sedation.
26
Sl
No
Drug 1 Drug 2 Intensity of
interaction
Significant effects in
Patient
Whether if it
is clinically
seen
1 Promethazine Nortryptyline Minor Both drugs increases
sedation
No

27. • Patient was found to be compliant to the medications
given.
27

28. • 1. Tricyclic antidepressants are the second line drugs used in the
prophylactic management of migraine Tricyclic antidepressants
are good second-line alternatives because of their adverse-effect
profile and efficacy.
• 2. Some anti-seizure drugs, such as valproate and topiramate seem
to reduce the frequency of migraines.
28

29. Goals of therapy:
• 1. Reduce attack frequency and severity.
• 2. Reduce disability
• 3. Improve quality of life
• 4. Prevent headache
• 5. Avoid headache medication escalation
• 6. Educate and enable patients to manage their
disease
29

30. • 1. Symptomatic improvement is seen
• 2. Patient is stable at the time of discharge.
30

31. 1. NAPROXEN
- Monitor for signs/symptoms of gastrointestinal
bleeding. -Monitor blood counts, renal, and hepatic function
periodically for patients receiving long-term therapy.
2. TELMISARTAN
Monitoring: Monitor serum electrolytes periodically.
3. PROMETHAZINE
Excessive sedation -Respiratory rate, especially in paediatric
patients -Localized injection site reactions
4. OXCARBAZEPINE
-Monitor for serious dermatologic reactions, such as Stevens- Johnson syndrome
and toxic epidermal necrolysis , Hyponatremia ---
-Psychiatric: Emergence or worsening of depression, suicidal thoughts or
behaviour, and/or any unusual changes in mood or behavior.
31

32. Drugs that can cause rebound headaches are:
• • NSAIDs
• • Codeine andprescription pain relievers
• • Medicines that contain caffeine
• • Birth control pills
• • Triptans
.
32

33. • Tricyclic antidepressants can be used instead of SNRIs for
better prophylactic management of migraine. No NSAIDs
was given to patient for the acute migraine attack
management
33

34. 34
A. On disease
• A migraine is a primary headache disorder characterized by
recurrent headaches that are moderate to severe. Typically,
the headaches affect one half of the head, are pulsating in
nature, and last from two to 72 hours. Associated symptoms
may include nausea, vomiting, and sensitivity to light, sound,
or smell.
• Extrapyramidal symptoms are forms of abnormal body
movements that are caused by a blockade of normal
dopamine functions in the brain. occur most commonly as
side-effects of antipsychotics

35. B. On diet
Certain foods can be triggers for migraines in susceptible
people. These foods include:
• red wines,
• aged cheeses,
• preservatives used in smoked meats (nitrates)
• monosodium glutamate
• artificial sweeteners
• chocolate, and
• Dairy products.
35

36. C. On lifestyle modifications
• • Keep well hydrated since dehydrationhas been
identified as a migraine trigger for some people
• • Avoid certain foods that might trigger a migraine
• • Maintain a regular schedule for eating and
sleeping
• • Exercise regularly
36

37. D. On drugs
• • Ibuprofen
• Stop this drug if you have symptoms of stomach bleeding such as
black, bloody, or tarry stools, or coughing up blood or vomit that
looks like coffee grounds.
• • Telmisartan
• Avoid drinking alcohol. It can lower your blood pressure. Do not
use potassium supplements or salt substitutes while you are taking
telmisartan
• • Promethazine
• Stop using this medication if you have twitching or uncontrollable
movements of your eyes, lips, tongue, face, arms, or legs
37

38. 38
• Oxcarbazepine
It reduces the sodium in your body to dangerously low levels, which can
cause a life-threatening electrolyte imbalance. Headache, weakness, loss
of appetite, feeling unsteady
• Flunarizine
Swallow it as a whole. Do not chew, crush or break it. Tablet may be
taken with or without food
•Desvenlafaxine
Swallow it as a whole. Do not chew, crush or break it.

39. Review after 4days days in General medicine department with
FBS, PPBS results
39

40. 40