Dublin November 13 th 2011 By Dr. Edward OSullivan 13-Nov-2011 1.

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

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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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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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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

Dublin November 13 th 2011 By Dr. Edward OSullivan 13-Nov-2011 1.

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