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Pain
• Physiological and psychological experience for patients
• Can be seen as body’s defense mechanism physiologically
– Avoid damaging situation
– Seek help
• Psychological factors can increase or decrease perception of pain
– E.g., anxiety vs positive attitude and support
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Pain Assessment
• Subjective experience for patients
• Numerical scales and surveys assist in assessment
• Effective pharmacotherapy depends on
– Assessment of degree of pain
– Determining underlying disorders
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Acute Pain
• Intense
• Defined period of time
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Chronic Pain
• Lasts longer than six months
• Interferes with daily activities
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Nociceptive Pain
• Due to injury to tissues
– Somatic: Sharp, localized sensation
– Visceral: Dull, throbbing, aching pain
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Figure 18.3 Mechanisms of pain transmission at the nociceptor level
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Neuropathic Pain
• Due to injury to nerves
• Burning, shooting, numbing
• More difficult to manage
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Neuropathic Pain - Examples
• Carpal tunnel syndrome
• Degenerative disk disease
• Diabetic retinopathy
• Intractable cancer pain
• Phantom limb pain
• Postsurgical pain
• Sciatica
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Treatment for Intractable Cancer Pain
• Radiation or chemotherapy
• Relieving nerve stimulation
• Surgery
• Nerve block
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Pain Transmission
• Nociceptor stimulation
• Spinal cord receives pain impulse through
– A fibers (myelin) —believed to signal sharp, well-defined pain
– C fibers (unmyelinated) —believed to conduct dull, poorly localized pain
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Substance P
• Neurotransmitter
• Passes on pain message from spinalchord to brain
• Affected by other neurons
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Endogenous Opioids
• Group of neurostransmitters
• May modify sensory information, interrupting pain transmission
• Endorphins, dynorphins, enkephalins
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Interruption of Pain Transmission
• Several target areas
– Peripheral level NSAIDs
– CNS levelOpioids
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Neural pathways for pain
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• Analgesics: Medications used to relieve pain.
– Opioids
– Non-opioids
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Opioids
• Natural or synthetic morphine-like substances responsible for reducing moderate to severe pain
• Obtained naturally from opium (10% morphine, 2% codeine).
• SyntheticMeperidine
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Opioid Receptors
• Receptors: mu, kappa, delta, nociceptin/orphanin FQ peptide
– For pain management, mu and kappa receptors are most important
• Opioid agonist drugs: stimulate mu and kappa receptors
• Opioid antagonist drugs: block mu and kappa receptors
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Opioid antagonists
• Agents that displace opioid molecules from their
neuroreceptors, and block opioids activating those
receptors.
• Used effectively to quickly reverse toxic effects of
opioid overmedication or overdose.
• The unexpected, paradoxical effects of opioid
antagonists as adjuvants for enhancing rather
than attenuating analgesic effects of opioids like
morphine, oxycodone, and others.
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Responses Produced by Activation of Specific Opioid Receptors
Table 18.2 Responses Produced by Activation of Specific Opioid Receptors
Response Mu Receptor Kappa Receptor
Analgesia ✓ ✓
Decreased GI motility ✓ ✓
Euphoria ✓
Miosis ✓
Physical dependence ✓
Respiratory depression ✓
Sedation ✓ ✓
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Opioid receptors
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Table 18.3 Opioids for Pain Management (1 of 3)
Table 18.3 Opioids for Pain Management
Drug
Route and Adult Dose
(max dose where indicated) Adverse Effects
OPIOID AGONISTS WITH HIGH EFFECTIVENESS
fentanyl (Actiq, Abstral, Duragesic,
Fentora, Lazanda, Onsolis, Oralet)
Transdermal patch: 25 mcg/h
PO: 100 mcg initial dose (max: 100 mcg units
provided at a time)
Nasal spray: 100 mcg initial dose (max 800 mcg)
Buccal transmucosal: 200 mcg initial dose (max:
no more than six 200-mcg units should be in the
patient’s possession for titration)
Pruritus, constipation, nausea, sedation,
drowsiness, dizziness
Anaphylactoid reaction, cardiac arrest,
severe respiratory depression or arrest,
convulsions, abuse potential
hydromorphone (Dilaudid, Exalgo) PO/Subcutaneous/IM/IV: 1–4 mg every 4–6 h prn
levorphanol (Levo-Dromoran) PO: 2–3 mg tid—qid prn
Subcutaneous/IV: 1–2 mg q6-8h
meperidine (Demerol) PO: 50–150 mg q3–4h
IM: 50–100 mg q3–4h
IV: 1–1.5 mg/kg q3–4h
morphine (Astramorph PF,
Duramorph, others)
PO: 10–30 mg q4h prn
Sustained release: 15–30 mg q8–12h
IM: 10 mg q4h
IV: 2–10 mg q2–4h
oxymorphone (Opana) Subcutaneous: 1–1.5 mg q4–6h
Rectal: 1 suppository (5 mg) q4–6h
PO (extended release): 5–20 mg bid
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Table 18.3 Opioids for Pain Management (2 of 3)
Table 18.3 Opioids for Pain Management
Drug
Route and Adult Dose
(max dose where indicated) Adverse Effects
OPIOID AGONISTS WITH MODERATE EFFECTIVENESS
codeine PO: 15–60 mg qid
IM: 15–30 mg q4–6h
Sedation, nausea, constipation,
dizziness
Hepatotoxicity, respiratory depression,
circulatory collapse, coma, abuse
potential
hydrocodone (Hycodan) PO: 5–10 mg q4–6h prn (max: 15 mg/dose)
oxycodone (OxyContin, Oxecta) PO: 5–10 mg qid prn
Controlled release: 10–20 mg q12h
OPIOID ANTAGONISTS
naloxone (Evzio, Narcan) IV: 0.4–2 mg; may be repeated q2–3min
up to 10 mg if necessary
Muscle and joint pain, sleep anxiety,
headache, nervousness, withdrawal
symptoms, vomiting, diarrhea, insomnia
naltrexone (ReVia, Trexan, Vivitrol) PO: 25 mg followed by another 25 mg in 1 h if no
withdrawal response (max: 800 mg/day)
Hepatotoxicity
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Table 18.3 Opioids for Pain Management (3 of 3)
Table 18.3 Opioids for Pain Management
Drug
Route and Adult Dose
(max dose where indicated) Adverse Effects
OPIOIDS WITH MIXED AGONIST–ANTAGONIST EFFECTS
buprenorphine (Buprenex,
Butrans, Suboxone)
IM/IV: 0.3 mg q6h (max: 0.6 mg q4h)
Topical: one patch every 7 days
Sublingual: 12–16 mg/day
Drowsiness, dizziness, light-
headedness, euphoria, nausea, clammy
skin, sweating, insomnia, abdominal
pain, constipation
butorphanol (Stadol) IM: 1–4 mg q3–4h prn (max: 4 mg/dose)
IV: 2.5–10 mg (usually 5 mg) q2–4h
Respiratory depression, shock
dezocine (Dalgan) IM: 5–10 mg (usually 10 mg) q3–4h
nalbuphine (Nubain) Subcutaneous/IM/IV: 10–20 mg q3–6h prn (max:
160 mg/day)
pentazocine (Talwin) PO: 50–100 mg q3–4h (max: 600 mg/day)
Subcutaneous/IM/IV: 30 mg q3–4h (max: 360
mg/day)
Note: Italics indicate common adverse effects; underlining indicates serious adverse effects.
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Opioid Agonists
• Mechanism of action: to interact with specific receptors
• Primary use: to relieve moderate to severe pain; some used for anesthesia
• Examples: OxyContin, Percocet
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Opioid (Narcotic) Agonist
• Prototype drug: Opioid agonists—morphine (Astramorph PF, Duramorph, others)
• Mechanism of action: interacts with mu and kappa receptor sites
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Opioid (Narcotic) Agonist
• Primary use: for analgesia and anesthesia
• Adverse effects: respiratory depression, sedation, nausea, and vomiting
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Opioid Antagonists
• Block opioid activity
– Compete for opioid receptor
• Reverse symptoms of addiction, toxicity, and overdose
– Naloxone (Evzio, Narcan) may be used to reverse respiratory depression and other acute symptoms
– Also used to diagnose overdose
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Opioid Antagonists
• Prototype drug: naloxone (Evzio, Narcan)
• Mechanism of action: interact with receptors
• Primary use: to reverse respiratory depression and other acute symptoms of opioid addiction, toxicity, overdose
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Role of the Nurse: Opioid Antagonist Therapy
• Continue careful monitoring of patient's condition
– Especially respiratory status
• Have resuscitative equipment available
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Opioids with Mixed Agonist-Antagonist Activity
• Stimulate opioid receptor, thus causing analgesia
• Withdrawal symptoms and side effects not as intense as those of opioid agonists
• Example: pentazocine (Talwin)
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Opioid Dependence
• Potential to cause physical and psychologic dependence
• Patient-controlled analgesia (PCA)
• Combinations with nonnarcotic analgesics
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• Vicodin: Hydrocordone 5mg, acetaminophen
500mg
• Percodan:Oxycodone hyrdochloride 7.5mg
acetaminophen 325 mg)
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Treatment for Opioid Dependence
• Switch from IV and inhalation forms to methadone, the oral form
• Methadone maintenance
– Does not cure but avoids withdrawal symptoms
– Treatment may be needed for many months or years
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Newer Treatment
• Early treatment: buprenorphine (Buprenex, Butrans, Suboxone)
– Mixed opioid agonist-antagonist
– Sublingual or transdermal route
• Later maintenance: bunavail, Suboxone, and Zubsolv contain both buprenorphine and naloxone
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Role of the Nurse: Opioid Therapy
• Assess potential for opioid dependency
– Have narcotic antagonists available to reverse negative effects
• Monitor urine output for retention
• Monitor patient's bowel habits for constipation
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Nonopioid Analgesics
• Used for fever, inflammation, and analgesia
• Used for mild or moderate pain associated with inflammation
• Include NSAIDs, acetaminophen, and a few centrally acting drugs
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Table 18.4 Nonopioid Analgesics (1 of 3)
Table 18.4 Nonopioid Analgesics
Drug
Route and Adult Dose
(max dose where indicated) Adverse Effects
NSAIDs: ASPIRIN AND OTHER SALICYLATES
aspirin (acetylsalicylic acid, ASA) PO: 350–650 mg q4h (max: 4 g/day) Heartburn, stomach pains, ulceration
salsalate (Disalcid) PO: 325–3,000 mg/day in divided
doses (max: 4 g/day)
Bronchospasm, anaphylactic shock,
hemolytic anemia
NSAIDs: IBUPROFEN AND SIMILAR DRUGS
diclofenac (Cambia, Cataflam, Voltaren,
Zipsor)
PO: 50 mg bid–qid (max: 200
mg/day)
Indigestion, nausea, occult blood loss,
anorexia, headache, drowsiness, Dizziness
diflunisal PO: 1,000 mg followed by 500 mg
bid–tid
etodolac PO: 200–400 mg tid–qid
fenoprofen (Nalfon) PO: 200 mg tid–qid Aplastic anemia, drug-induced peptic
ulcer, GI bleeding, agranulocytosis,
laryngospasm, laryngeal edema;
peripheral edema, anaphylaxis, acute
renal failure; vomiting, constipation,
Diarrhea
flurbiprofen (Ansaid, Ocufen) PO: 50–100 mg tid–qid (max: 300
mg/day)
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Table 18.4 Nonopioid Analgesics (2 of 3)
Table 18.4 Nonopioid Analgesics
Drug
Route and Adult Dose
(max dose where indicated) Adverse Effects
ibuprofen (Advil, Motrin, others) (see page
506 for the Prototype Drug box)
PO: 400 mg tid–qid (max: 1,200 mg/day)
indomethacin (Indocin, Tivorbex) PO: 25–50 mg bid–tid (max: 200 mg/day), or 75 mg
sustained release one to two times/day
ketoprofen (Actron, Orudis) PO: 12.5–50 mg tid–qid
ketorolac (Toradol) PO: 10 mg qid prn (max: 40 mg/day)
mefenamic acid (Ponstel) PO: Loading dose: 500 mg; Maintenance dose: 250 mg
q6h prn
meloxicam (Mobic) PO: 7.5 mg/day (max: 15 mg/day) 7.5–15 mg daily
nabumetone (Relafen) PO: 1,000 mg/day (max: 2,000 mg/day)
naproxen (Naprelan, Naprosyn) PO: 500 mg followed by 200–250 mg tid–qid (max: 1,250
mg/day)
naproxen sodium (Aleve, Anaprox, others) PO: 250–500 mg bid (max: 1,000 mg/day naproxen)
oxaprozin (Daypro) PO: 600–1,200 mg/day (max: 1,800 mg/day)
piroxicam (Feldene) PO: 10–20 mg one to two times/day (max: 20 mg/day)
sulindac (Clinoril) PO: 150–200 mg bid (max: 400 mg/day)
tolmetin (Tolectin) PO: 400 mg tid (max: 2 g/day)
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Table 18.4 Nonopioid Analgesics (1 of 3)
Table 18.4 Nonopioid Analgesics
Drug
Route and Adult Dose
(max dose where indicated) Adverse Effects
NSAIDs: COX-2 INHIBITORS
celecoxib (Celebrex) PO: 100–200 mg q6-8h or 200 mg
qid
Abdominal pain, dizziness, headache,
sinusitis, hypersensitivity
Cautious use due to FDA review
CENTRALLY ACTING DRUGS
acetaminophen (Tylenol, others) (see page
509 for the Prototype Drug box)
PO: 325–650 mg q4–6h (max
3g/day)
Hypotension, dry mouth, constipation,
drowsiness, sedation, dizziness,
vertigo, fatigue, headache
tramadol (Ultram) PO: 50–100 mg q4–6h prn (max: 400
mg/day); may start with 25 mg/day,
and increase by 25 mg every 3 days
up to 200 mg/day
Anaphylactic reaction, hepatotoxicity,
hepatic coma, acute renal failure
ziconotide (Prialt) Intrathecal 0.1 mcg/h via infusion,
may increase by 0.1 mcg/h every 2–3
days (max: 0.8 mcg/h)
Note: Italics indicate common adverse effects; underlining indicates serious adverse effects.
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Salicylates
• Prototype drug: aspirin (ASA)
• Mechanism of action: Inhibits prostoglandin
synthesis by inhibiting cyclooxygenase (COX)
• Adverse effects: with high doses may cause GI distress and bleeding
• May increase action of oral hypoglycemic agents
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Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
• Prototype drug: ibuprofen (Motrin)
• Mechanism of action: to inhibit cyclooxygenase and prevent formation of prostaglandins
• Primary use: for mild or moderate pain and to reduce inflammation
• Adverse effects: GI upset, acute renal failure
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Selective Cox-2 Inhibitors
• Prototype drug: celecoxib (Celebrex)
• Mechanism of action: similar to the NSAIDs
• Primary use: to relieve pain, fever, inflammation
• Adverse effects: mild and related to GI system
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Centrally Acting Nonopioid Analgesics
• Prototype drug: acetaminophen (Tylenol)
• Mechanism of action: to treat fever at the level of the hypothalamus; causes dilation of peripheral blood vessels, enabling sweating and dissipation of heat
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Centrally Acting Nonopioid Analgesics
• Primary use: treatment of fever and to relieve pain
• Adverse effects: uncommon with therapeutic doses
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Centrally Acting Nonopioid Analgesics
• Prototype drug: tramadol (Ultram)
• Mechanism of action: inhibits reuptake of serotonin and norepinephrine in spinal neurons.
• Primary use: as centrally acting analgesic
• Adverse effects can include: dizziness, lethargy, constipation
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Role of the Nurse: Drugs for Control of Pain
• Assessment
– Carefully monitor patient's condition
– Assess vital signs, especially respiratory status
– Assess patient's pain level: character, duration, location, intensity of pain
– Obtain history of medications, alcohol use
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Drugs for Control of Pain
• Planning
– Goal is to explain proper use of medication
– Patient is to be free of pain without dependency
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Drugs for Control of Pain
• Implementation
– Encourage compliance with medication regimen
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Drugs for Control of Pain
• Evaluation
– Patient should have pain control with limited side effects, no dependency
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Headache and Migraines
• Tension headache
– Most common
– Self-limiting annoyance rather than emergency
• Migraine
– Throbbing or pulsating pain
– Often causes nausea and vomiting
– Often have triggers that can be avoided
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Goal for Migraine Therapy
• Stop migraines in progress
• Prevent migraines from occurring
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Antimigraine Drugs
• Triptans
– Serotonin agonists
– Act by constricting certain intracranial vessels
• Ergot alkaloids
– Interact with adrenergic, dopaminergic, and serotonin receptors
– Act as vasoconstrictors
– Terminate ongoing migraines
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Triptans
• Prototype drug: sumatriptan (Imitrex)
• Mechanism of action: to act as serotonin agonists, constricting certain intracranial vessels
• Primary use: to abort migraines
• Adverse effects: GI upset
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Ergot Alkaloids
• Mechanism of action: to promote vasoconstriction
• Primary use: to terminate ongoing migraines
• Adverse effects: GI upset, weakness in the legs, numbness and tingling in fingers and toes, angina-like pain, tachycardia
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Other Drugs for Migraine Prophylaxis
• Antiseizure drugs
• Beta-adrenergic blockers
• Calcium channel blockers
• Tricyclic antidepressants
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Table 18.5 Antimigraine Drugs (1 of 4)
Table 18.5 Antimigraine Drugs
Drug
Route and Adult Dose
(max dose where indicated) Adverse Effects
TRIPTANS
almotriptan (Axert) PO: 6.25–12.5 mg; may repeat in 2 h if necessary (max: 2
tabs/day)
Asthenia, tingling, warming sensation,
dizziness, vertigo
eletriptan (Relpax) PO: 20–40 mg; may repeat in 2 h if necessary (max: 80 mg/day) Coronary artery vasospasm, MI,
cardiac arrest
frovatriptan (Frova) PO: 2.5 mg; may repeat in 2 h if necessary (max: 7.5 mg/day)
naratriptan (Amerge) PO: 1–2.5 mg; may repeat in 4 h if necessary (max: 5 mg/day)
rizatriptan (Maxalt) PO: 5–10 mg; may repeat in 2 h if necessary (max: 30 mg/day);
5 mg with concurrent propranolol (max: 15 mg/day)
sumatriptan
(Imitrex)
PO: 25 mg for 1 dose (max: 100 mg)
zolmitriptan (Zomig) PO: 2.5–5 mg; may repeat in 2 h if necessary (max: 10 mg/day)
ERGOT ALKALOIDS
dihydroergotamine
(D.H.E. 45, Migranal)
IM/subcutaneous: 1 mg; may be repeated at 1-h intervals to a
total of 3 mg (max: 6 mg/wk)
Nasal: 1 spray (0.5 mg) each nostril, may repeat once in 15 min
Weakness, nausea, vomiting,
abnormal pulse, Pruritus
Delirium, convulsive seizures,
intermittent Claudication
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Table 18.5 Antimigraine Drugs (2 of 4)
Table 18.5 Antimigraine Drugs
Drug
Route and Adult Dose
(max dose where indicated) Adverse Effects
ergotamine (Ergostat), ergotamine with
caffeine (Cafergot, Ercaf,
others)
PO: 1–2 mg followed by 1–2 mg every 30
min until headache stops (max: 6 mg/day or
10 mg/wk) Sublingual: 2 mg, may repeat in
30 min for total three doses/24 h
or five doses/wk
ANTISEIZURE DRUGS
topiramate (Topamax) PO: start with 50 mg/day, increase by 50
mg/wk to effectiveness (max: 1600 mg/day)
Nausea, vomiting, sedation, drowsiness,
Weakness
valproic acid (Depakene) (see page 192
for the Prototype Drug box)
PO: 250 mg bid (max: 100 mg/day) Liver failure, bone marrow depression
BETA-ADRENERGIC BLOCKERS
atenolol (Tenormin) (see page 422
for the Prototype Drug box)
PO: 25–50 mg/day (max: 100 mg/day) Bradycardia, hypotension, heart failure
(HF), confusion, drowsiness, insomnia
metoprolol (Lopressor) (see page
404 for the Prototype Drug box)
PO: 50–100 mg one to two times/day (max:
450 mg/day)
Bronchospasm, exfoliative dermatitis,
agranulocytosis, membrane irritation,
rash, heart block, cardiac arrest,
anaphylaxis, Stevens–Johnson syndrome
propranolol (Inderal) (see page 453
for the Prototype Drug box)
PO: 80–240 mg/day in divided doses; may
need 160–240 mg/day
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Table 18.5 Antimigraine Drugs (3 of 4)
Table 18.5 Antimigraine Drugs
Drug
Route and Adult Dose
(max dose where indicated) Adverse Effects
timolol (Blocadren) (see page 871
for the Prototype Drug box)
PO: 10 mg bid; may increase to 60
mg/day in two divided doses
CALCIUM CHANNEL BLOCKERS
nifedipine (Procardia) (see page
385 for the Prototype Drug box)
PO: 10–20 mg tid (max: 180 mg/day) Dizziness, light-headedness, facial flushing,
heat sensitivity, diarrhea, peripheral edema,
headache, hypotension, constipation
nimodipine (Nimotop) PO: 60 mg q4h for 21 days; start
therapy within 96 hours of subarachnoid
haemorrhage
Myocardial infarction (MI), atrioventricular (AV)
block, hepatotoxicity
verapamil (Isoptin SR) (see page
456 for the Prototype Drug Box)
PO: 40–80 mg tid (max: 360 mg/day)
TRICYCLIC ANTIDEPRESSANTS
amitriptyline (Elavil) PO: 75–100 mg/day Sedation, drowsiness, orthostatic hypotension,
blurred vision, slight mydriasis, dry mouth, urinary
retention, constipation
imipramine (Tofranil) (see page 208
for the Prototype Drug box)
PO: 75–100 mg/day (max: 300 mg/day)
protriptyline (Vivactil) PO: 15–40 mg/day in three to four
divided doses (max: 60 mg/day)
MI, dysrhythmias, heart block, agranulocytosis,
angioedema, bone marrow depression
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Table 18.5 Antimigraine Drugs (4 of 4)
Table 18.5 Antimigraine Drugs
Drug
Route and Adult Dose
(max dose where indicated) Adverse Effects
MISCELLANEOUS DRUGS
methysergide
(Sansert)
PO: 4–8 mg/day in divided doses Nausea, vomiting, sedation,
drowsiness, weakness, discoloration of
urine (for vitamin B2), painful Urination
onabotulinumtoxin A
(Botox)
IM: 155 units administered intramuscularly (IM) to
muscles of the head and neck area
riboflavin (vitamin B2) As a supplement: PO: 5–10 mg/day
For deficiency: PO: 5–30 mg/day in divided doses
Shortness of breath
Note: Italics indicate common adverse effects; underlining indicates serious adverse effects.
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Role of the Nurse: Antimigraine Therapy
• Obtaining medical history
• Obtaining list of allergies
• Assessing patient's pain level
• Obtaining history of medications and alcohol and CNS-depressant use
• Assessing frequency and intensity of the migraine headaches
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Role of the Nurse: Antimigraine Therapy
• Providing a quiet, calm environment
• Applying cold packs to help lessen pain
• Assessing pain level before medication administration
• Monitoring for side effects
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