dublin november 13 th 2011 by dr. edward osullivan 13-nov-2011 1
DESCRIPTION
Primary or Benign Tension Type Headache Migraine With or Without Aura Chronic Daily Headache Medication-Overuse- Headache Sinus Headache Cluster Headache Chronic Paroxysmal Hemicrania 3TRANSCRIPT
113-Nov-2011
Dublin November 13th 2011
ByDr. Edward O’Sullivan
The Role of The Pharmacist in Headache
Management
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Lifetime ------>90%1 Year---------> 40%4.2%----------> G.P. Consultations30%----------> Neurology Consultations
Prevalence of Headache
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Primary or BenignTension Type HeadacheMigraine With or
Without AuraChronic Daily HeadacheMedication-Overuse-
HeadacheSinus HeadacheCluster HeadacheChronic Paroxysmal
Hemicrania
Headache Disorders
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History and Examination
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HistorySiteFrequencyDurationOnsetCharacterSeverityExacerbating / Relieving
FactorsNeck StiffnessExacerbating / Relieving
factors Impact
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C.N.S. ExaminationMental StateNeck StiffnessInspectionTonePowerCo-OrdinationSensationReflexesPlanter Response
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Pain Sensitive Structures
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Tension Type HeadacheBilateral Frontal
HeadacheMildTightness / Dull /
AchingDuration: 30 minutes
to 1 weekMuscle tendernessMild photophobia
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PREVALENCE OF MIGRAINE
Lipton RB, Stewart WF. Neurology. 1993.
Mig
rain
e P
reva
lenc
e (%
)
1013-Nov-2011
Epidemiology of Migraine
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Migraine With Aura
Transient 5-60 minutes
FocalReversibleVisual, Sensory,
Motor and Dysphasia
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Migraine Aura
Sensory Parasthesia1. Pins
and Needles 2. or Numbness
MigratoryDysphasiaMotor weakness
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Migraine Without Aura
At least 5 attacksDuration: 4-72 hoursUnilateral HeadachesThrobbing and
PoundingExacerbated by
movementSevere.
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Migraine Without Aura
Nausea ------80%Vomiting---- 50%PhotophobiaPhonophobiaCutaneous
Alloydynia
1513-Nov-2011
Phases of Migraine Attack
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Triggers of MigraineIdentifiable in 30%DietaryAlcoholStressMissed meals,
Overtiredness, Lack of sleep
Menstrual CycleCombined Oral
ContraceptivesStrong odoursEnvironmental factors
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Migraine Disability
Need to lie downPersonalSocialFamilial
3-5 days lost AnnuallyLost Productivity
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Migraine Disability
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Aura
Pathophysiology of MigraineHeadache
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Management of Migraine
ReassuranceHeadache DiaryAvoidance of Trigger
FactorsAcute TherapiesPreventative
TherapiesNon-Drug Therapies
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Avoidance of Trigger FactorsStress:1. Psychological2. Missed Meals3. Overtiredness4. Lack of Sleep
Promote Exercise
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Goals of Acute Therapies
Rapid and Complete Headache relief
Consistant in response
Relief of associated symptoms
Free of side effectsCost
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Acute Management of Migraine
TREAT EARLY IN ATTACK:
ParacetamolParacetamol / CodieneAnalgesic / CaffieneAspirinN.S.A.I.D’sTriptans
Limit use of acute agents to twice weekly.
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Acute Management of Migraine
Mode of action: anti-prostaglandin activity
Take as early as possible
Anti-nausea agents:domperidone
Route of administration
Recurrence – 40%--repeat the dose
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Triptans 5 HT 1B/1D Antagonists
Serotonin
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Triptans :5HT1B/1D Receptor Agonists
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Preventative Migraine Therapies
> 2 attacks per monthUnresponsive to acute
therapiesReduction in
frequency, severity and duration of attacks
Evaluate after 3 months
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Preventative Migraine Therapies
B-Blockers: propanolol; atenolol
Tricyclic Antidepressants : Amitriptyline
Anti-convulsants : topiramate, sodium valproate
5 HT3 Antagonists:Pizotifen
Calcium Antagonists:Flunarizine
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Chronic Daily Headache3-5% population> 15 days per month> 4 hours durationPresent > 4 monthsPast history of Tension
Type Headaches or Migraine
Co-Morbidity: Anxiety or Depression
Medication-Overuse-Headache
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Medication-Overuse-Headache1% of Adult Population> 25% of patients
attending Headache / Migraine Clinic
Triptan Use: > 10 days per month (18 doses/month)
Ergot Preparations (37 doses / month)
Simple Analgesics (114 doses per month)
1.7 Years to onset
2.7 Years to onset
4.8 Years to onset
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Medication-Overuse-Headache
Migraine Patients Particularly Vulnerable
Cutaneous Alloydynia
Periphereal Sensitization
Central Sensitization
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Medication-Overuse-Headache‘Medication
Containing Codiene, Caffiene or Sedatives should be restricted’ for acute migraine attacks
Risks: 1. Habituation2. Dependence3. Tolerance
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Medication-Overuse-Headache
Limit the use of Acute therapies: Consider:N.S.A.I.D’s
Detoxification programme
Preventative therapies
Non-drug therapies
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Case No: 1History of headaches
> 4 years16-20 days per
monthLasting 48 hoursBilateral Occipital
HeadachesDull / AchingMild4-6 Paracetamol
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Case No: 1Chonic Tension Type
HeadacheMedication-Overuse-
HeadacheTREATMENT:1. Stop Analgesics2. Commence
Amitriptyline 10-25mg nocte
3. Naproxyn 250mg prn4. Review 3 months later-
Headache free.
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Case No:220 year old female—
5 year history of frequent headache. Daily x 2 years
Unilateral Right Sided Headaches. Severe—2 days per week.
Photophobia.Cutaneous
AlloydyniaMed: nil
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Case No:2Chronic Migraine
TREATMENT:1. Preventative
Therapies: Atenolol 25mg + Amitriptyline 25mg ½ nocte
2. Eletriptan 40mg—releif within -2 hours
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Migraine for many years:
On Meeting Dr.Nielsen