Principles of pharmacology in n eurology

1. Principles of pharmacology inneurology Presented by:DrmehranHomam Neurologist & Neurophysiologist Department of neurology Mashhad azad university

2. Topics (from Solomon S, Lipton RB. Headache 1991;31(6):384-7.) 1-Headache 2-Parkinson 3-Multiple Sclerosis 4-Dementia 5-Epilepsy

3. 1-Headache

4. HeadacheA Common Health Problem • Headache has troubled humankind from the dawn of civilization • Evidence of trepanation, an early form of neurosurgery, was found on skulls from 7000 BC • Migraine symptoms,have been described for over 1,000 years

5. Primary Headaches (from Solomon S, Lipton RB. Headache 1991;31(6):384-7.) Benign, recurrent NOT associated with underlying pathology The headache is the disease

6. Primary Headaches (from Solomon S, Lipton RB. Headache 1991;31(6):384-7.) Migraine (with or without aura) Tension-type headache (episodic or chronic) Cluster headache

7. Primary Headache Tension Migraine Cluster

8. QUESTIONS • 1-SEVERITY • 2-QUALITY • 3-DURATION • 4-ASSOCIATED SYMPTOMS & SIGNS • 5-PEAK ONSET • 6-FREQUENCY • 7-AGGREVATING AND RELIEVING • 8-LOCATION

9. Migraine Headaches

10. Famous people suffering from migraine Hildegard von Bingen Ludwig van Beethoven Madame de Pompadour Sigmund Freud

11. What is Migraine? World Federation of Neurology • Repeated attacks of throbbing headache • Moderately or severely painful • Frequent or infrequent • Last a few hours to a couple of days • Often only one side of the head hurts • Often experience loss of appetite, nausea, and vomiting;photophobia;phonophobia • Periodic • familial

12. How Migraine Works 3 Changes in nerve cell activity and blood flow may result in visual disturbance, numbness or tingling, and dizziness. 4 Chemicals in the brain cause blood vessel dilation and inflammation ofthe surrounding tissue 5 The inflammation irritates the trigeminal nerve, resulting in severe or throbbing pain 2 Electrical impulses spread to other regions of the brain. 1 Migraine originates deep within the brain

13. Migraine Major Forms: Migraine without aura (common) 70% Migraine with aura (classical) 25% Migraine variants and complicated migraine 5%

14. 12% Affected patientss: 7% 6% 5% 1% Rheumatoid arthritis Asthma Diabetes Osteoarthritis Migraine How Migraine Stacks Up Against Other Common Diseases From the Centers for Disease Control and Prevention, the US Census Bureau, and the Arthritis Foundation.

15. 30 25 Women 20 15 Men 10 5 0 10 20 30 40 50 60 70 80 90 Migraine Prevalence Percentage Age (years) Stewart WF, Lipton RB, et al. JAMA. 1992;267(1):64-69.

18. The Stages of a Migraine Attack

19. Mild 1.2% Moderately severe 18.4% 33.2% Extremely severe 47.2% Severe Most Patients’ Headaches Are Severe or Extremely Severe National Headache Foundation. American Migraine Study II: Migraine in the United States: Burden of Illness and Patterns of Treatment

20. Can work as normal 9% 52% 39% Need bed rest Can work with some difficulty Migraine Takes Quality Time Out From Your Life National Headache Foundation. American Migraine Study II: Migraine in the United States: Burden of Illness and Patterns of Treatment

21. Unnecessary Suffering National Headache Foundation. American Migraine Study II: Migraine in the United States: Burden of Illness and Patterns of Treatment More than half of people with migraine suffer for at least a year before they are diagnosed with migraine 38% suffer for 3 or more years

22. What You Might Experience During an Attack • Nausea • Vomiting • Diarrhea • Sweating • Cold hands • Sensitivity to light • Sensitivity to sound • Scalp tenderness • Pale color • Pulsing temple • Pressure pain

23. Triggers and Risk Factors Migraine headaches are often triggered by specific things

24. Triggers: Changes in Daily Cycles

25. Triggers: Environment or Diet

26. Triggers: Mental

27. Protective Factors Regular sleep Regular meals Regular exercise Biofeedback Healthy lifestyle

28. Treatment Acute:1-nsaids 2-Ergo 3-Triptans 4-Corton Prophylactic

29. DHE • Dihydroergotamine • Nasal Spray (Migranal®) • Injectable (D.H.E. ) - Supp - Tab

30. Your Symptoms May Affect The Choice of Medication

31. 1-Ergotamines Ergotamine Ergotamine C Mechanism:Ergots 2-advantages:The most effective 3-Contraindications:Htn-Pregnancy-IHD-Raynoud disease 4-Disadventages:Ergotism/limitation of Dosage/age 5-Dosage :6 mg in attack 10mg each week Drug reactions:

32. 2-triptans • Triptans need to be taken as soon as you recognize an attack • Most patients wait too long • No need to suffer • Triptans work best in the first couple of hours of an attack • Mechanism:serotonin agonist • Dihydroergotamine works at any time during an attack • Available :sumatriptan 50 mg also sc 8mg • Dosage; • Advantage:faster Effect / Sc injection • Disadventage:Relapse/Cost

33. 3-(NSAID)Medicines to Stop a Migraine Attack • Mechanism:anti inflammatory • Adventages: Very effective.tension headache • Disadventages:Side effects • medications – use with care and tell your doctor • NSAIDs (eg, ibuprofen, naproxen,indometacin) • Aspirin, acetaminophen, caffeine combination (avoid using more often than twice a week, especially if using several agents or if you drink a lot of coffee, tea, or caffeinated soda)

34. Options for Preventive Treatment These are medicines you take every day to prevent headaches Divalproex sodium/sodium valproate (anticonvulsant) Propranolol (beta-blocker) Timolol (beta-blocker) Methysergide (serotonin antagonist) Other anticonvulsants Other beta-blockers Antidepressants NSAIDs (eg, aspirin)

35. Some Medications May Cause Migraine to Become Chronic May cause chronic headaches: • Opiates • Combination analgesics • Caffeine • Barbiturate-containing medications • Ergotamine tartrate, isometheptene • Triptans • Others Not clearly associated with chronic headaches: • Acetaminophen • Aspirin • Dihydroergotamine • Others

36. Self Treatment Efforts:What You Can Do For Your Migraines • Rest • Biofeedback • Ice/heat • Massage • Exercise • Avoid triggers • Seek treatment early • Keep a headache diary • Take medications as directed by your doctor Many options are available for migraine relief – ask your doctor what’s right for you

37. Cluster Headache • Duration • 15 to 180 minutes untreated • Pain characteristics • Severe unilateral orbital, supraorbital, or temporal pain • Associated symptoms (at least 1) • Conjunctival injection, Lacrimation • Nasal congestion, Rhinorrhea • Forehead and facial swelling • Miosis • Eyelid Edema • Frequency: • between 1 every other day to 8/day

38. Treatment of Cluster Headache • Acute treatment: • 100% Oxygen via face mask at 8liters/min given in a seated position • SL ergotamine at onset of HA and repeated once if needed • Triptans shown effective in two RCTs • Intranasal administration of a local anesthetic (4% lidocaine) may be helpful

39. Treatment of Cluster Headache • Preventive Treatment • Verapamil 80 mg qid • Lithium 300 - 900 mg per day • Prednisone 40 mg per day in divided doses, tapered over 3 weeks • Ergotamine 2 mg 2 hrs before bedtime to prevent nocturnal attacks • Divalproex sodium 600 - 2000 mg per day

40. Tension Headache • Duration • 30 min to 7 days • Pain characteristics (at least 2) • Pressing/tightening quality • Mild to moderate severity • Bilateral location • No aggravation by routine physical activity • Associate symptoms (Must have both) • No vomiting • No more than one of: nausea, photophobia, phonophobia • H&P and diagnostic tests do not suggest underlying organic disease

42. Secondary Headache Sudden, progressive Associated with pathology May require immediate action

43. Patient 45 years old with HTN and migraine once monthly 1-tab;Ergotamine c twice daily 2-tab;valproate Na each night 3-tab:advil; when pain qid