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CH30 Drugs for Headache, pharmacology

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Migraine
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Migraine is a neurovascular disorder involving dilation and inflammation of intracranial arteries.
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Antimigraine drugs
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Antimigraine drugs are used in two ways: abortive and prophylactic.
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abortive therapy
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The goal of abortive therapy is to eliminate headache pain and associated nausea and vomiting.
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prophylactic therapy
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The goal of prophylactic therapy is to reduce the incidence and intensity of migraine attacks.
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There are two kinds of drugs for abortive therapy
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: nonspecific analgesics (aspirin-like drugs and opioids) and migraine-specific drugs (ergot alkaloids and triptans).
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Aspirin-like analgesics
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Aspirin-like analgesics (eg, acetaminophen, aspirin, naproxen) are effective for abortive therapy of mild to moderate migraine.
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Opioid analgesics
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Opioid analgesics e.g., butorphanol, meperidine are reserved for severe migraine that has not responded to other drugs.
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Ergotamine
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Ergotamine is a first-line drug for abortive therapy of severe migraine.
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Overdose with ergotamine
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Overdose with ergotamine can cause ergotism, a serious condition characterized by severe tissue ischemia secondary to generalized constriction of peripheral arteries.
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Ergotamine
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Ergotamine must not be taken routinely because physical dependence will occur.
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Ergotamine
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Ergotamine can cause uterine contractions and must not be taken during pregnancy.
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Ergotamine
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Ergotamine must not be combined with potent inhibitors of CYP3A4, owing to a risk of intense vasoconstriction and associated ischemia.
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Triptans
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Triptans (eg, sumatriptan) are first-line drugs for abortive therapy of moderate to severe migraine.
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Triptans
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Triptans activate 5-HT1B/1D receptors and thereby constrict intracranial blood vessels and suppress release of inflammatory neuropeptides.
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Triptans
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All triptans are available in oral formulations, which have a relatively slow onset. Two triptans—sumatriptan and zolmitriptan—are available in fast-acting formulations (either nasal spray, subQ injection, or both).
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Triptans
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Triptans can cause coronary vasospasm, and hence are contraindicated for patients with ischemic heart disease, prior MI, or uncontrolled hypertension.
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Triptans
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Triptans should not be combined with one another or with ergot derivatives because excessive vasoconstriction could occur.
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Triptans
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Triptans should not be combined with SSRIs or SNRIs because serotonin syndrome could occur.
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Prophylactic therapy
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Prophylactic therapy is indicated for migraineurs who have frequent attacks (two or more a month), especially severe attacks, or attacks that do not respond adequately to abortive agents.
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Propranolol
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Propranolol, divalproex, and amitriptyline are preferred drugs for migraine prophylaxis.
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Estrogen
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Estrogen supplements can help prevent menstrualassociated migraine.
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The nurse would administer which drug to a patient with a mild migraine attack?
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Aspirin, acetaminophen, ibuprofen, and other aspirin-like analgesics can provide adequate relief of mild to moderate migraine attacks. Acetaminophen should be used only in combination with other drugs.
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1
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It should not be used alone. One effective combination—marketed as Excedrin Migraine—consists of acetaminophen, aspirin, and caffeine.
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3
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An older and less effective product—marketed as Midrin—consists of acetaminophen, isometheptene a sympathomimetic drug, and dichloralphenazone a sedative
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2
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Opioid analgesics are reserved for severe migraine that has not responded to first-line medications. The agents used most often are meperidine (Demerol) and butorphanol nasal spray (Stadol NS). Of the two, butorphanol is preferred.
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The nurse correlates the action of triptans with which therapeutic effect?
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The serotonin1B/1D-receptor agonists, also known as triptans, are first-line drugs for terminating a migraine attack.
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1
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These agents relieve pain by constricting intracranial blood vessels and suppressing the release of inflammatory neuropeptides, which in turn diminishes perivascular
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Which drug does the nurse recognize as the drug of choice for stopping an ongoing migraine attack?
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Ergotamine is the drug of choice for stopping an ongoing migraine attack. Its mechanism of action may be related to suppression of inflammation of the trigeminal nervous system, but the precise mechanism of action is unknown. Because of the risk of dependence, ergotamine should not be taken daily on a long-term basis.
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The nurse teaches the patient with a history of migraine headaches to avoid which food?
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Chianti wine and aged cheeses contain tyramine, which is a precipitator of migraine headache.
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1
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Other foods to be avoided include nitrates (e.g., cured meat products), phenethylamine (e.g., chocolate), monosodium glutamate (e.g., Chinese food, canned soups), aspartame (e.g., diet sodas, artificial sweeteners), and yellow food coloring.
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In assessing a patient with complaints of headache, the nurse recognizes which symptom as consistent with a migraine headache? (Select all that apply.)
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Migraine headaches are characterized by throbbing head pain that may be unilateral or bilateral. Most patients experience nausea and vomiting and have increased sensitivity to light and sound. Physical activity intensifies pain.
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1
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Attacks usually last 4 to 72 hours and occur about 1.5 times per month. Alcohol is one of the precipitating factors for migraine, along with stress, fatigue, anxiety, menstruation, weather changes, and tyramine-containing foods.
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The nurse would question the administration of sumatriptan in the patient with a history of which condition
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Sumatriptan is generally well tolerated. Most side effects are transient and mild. Coronary vasospasm is the biggest concern
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1
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Because of the risk of coronary vasospasm, sumatriptan is contraindicated for patients with a history of ischemic heart disease, myocardial infarction (MI), uncontrolled hypertension, or other heart disease.
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Which drug would the nurse anticipate being ordered for migraine prevention?
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Prophylactic therapy can reduce the frequency and intensity of migraine attacks. Beta blockers are preferred drugs for migraine prevention. Of the available beta blockers, propranolol is used most often. Treatment can reduce the number and intensity of attacks in 70% of patients
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1
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Beta blockers that possess intrinsic sympathomimetic activity. e.g., acebutolol, pindolol are not effective. . Tricyclic antidepressants /amitriptyline, can prevent migraine and tension-type headaches in some patients but do not constitute the first line of treatment
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Which clinical manifestation in the patient taking ergotamine requires an immediate intervention?
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Common side effects of ergotamine include nausea and vomiting, weakness in the legs, myalgia, numbness and tingling in fingers and toes, angina-like pain, and tachycardia or bradycardia.
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1
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An overdose of ergotamine may cause ischemia as a result of constriction of peripheral arteries and arterioles. The patient should be taught to seek immediate medical treatment if extremities become cold, pale, and numb.
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The nurse correlates the pathophysiology of migraine headaches with what?
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Migraine headache is a neurovascular disorder characterized by dilation and inflammation of intracranial arteries.
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The nurse watches for which side effect in the patient receiving a calcium channel blocker for treatment of migraine headache?
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Calcium channel blockers (CCBs) can be used for migraine prevention. These drugs are less effective than propranolol or divalproex, and their effects develop slowly, reaching a maximum in 1 to 2 months
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1
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When used for prophylaxis, CCBs cause side effects in 20% to 60% of patients. Constipation and orthostatic hypotension are most common.