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:-
1. Migraine with aura (classical migraine) :-headache
preceded by visual or other neurological symptoms
2. 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
2. Aura
3. Headache
4. 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
Mild
Less than one attack a
Month
Lasting up to 8 hours
Throbbing but tolerable
headache
Moderate
One or more attacks per
Month
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

20. 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

21. 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

22. 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

23. Pharmacologyof specificantimigrainedrugs:
• Triptans: Selective 5-HT1B/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.

25. 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

26. Ergotamine
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

27. 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

28. 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

29. Drugs Used For Prophylaxis of Migraine

30. 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

32. 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

33. 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

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

35. 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.

36. 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.

37. 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