Principles of pharmacology inPrinciples of pharmacology innneurology eurology

Presented by:Dr mehran Homam Neurologist & Neurophysiologist

Department of neurologyMashhad azad university

Topics Topics

1-Headache2-Parkinson3-Multiple Sclerosis4-Dementia5-Epilepsy

(from Solomon S, Lipton RB. Headache 1991;31(6):384-7.)

1-Headache1-Headache

HeadacheHeadacheA Common Health ProblemA 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

Primary Headaches Primary Headaches

Benign, recurrent

NOT associated with underlying pathology

The headache is the disease(from Solomon S, Lipton RB. Headache 1991;31(6):384-7.)

Primary Headaches Primary Headaches Migraine (with or without aura)

Tension-type headache (episodic or chronic)

Cluster headache

(from Solomon S, Lipton RB. Headache 1991;31(6):384-7.)

Primary HeadachePrimary Headache

Migraine

TensionCluster

QUESTIONSQUESTIONS

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

Migraine HeadachesMigraine Headaches

Hildegard von Bingen

Famous people suffering from migraine

Sigmund Freud

Ludwig van Beethoven

Madame de Pompadour

What is Migraine?What is Migraine?

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

World Federation of Neurology

1Migraine originates deep within the brain

2Electrical impulses spread to other regions of the brain.

3Changes in nerve cell activity and blood flow may result in visual disturbance, numbness or tingling, and dizziness.

4Chemicals in the brain cause blood vessel dilation and inflammation of the surrounding tissue

5The inflammation irritates the trigeminal nerve, resulting in severe or throbbing pain

How Migraine WorksHow Migraine Works

MigraineMigraineMajor Forms:Migraine without aura (common) 70%Migraine with aura (classical) 25%Migraine variants and complicated

migraine 5%

How Migraine Stacks Up Against Other How Migraine Stacks Up Against Other Common DiseasesCommon Diseases

From the Centers for Disease Control and Prevention, the US Census Bureau, and the Arthritis Foundation.

1%

5%6%

7%

12%

Rheumatoid arthritis

Asthma Diabetes Osteoarthritis Migraine

Affected patientss:

0

5

10

15

20

25

30

10 20 30 40 50 60 70 80 90

Women

Men

Age (years)

Per

cent

age

Stewart WF, Lipton RB, et al. JAMA. 1992;267(1):64-69.

Migraine PrevalenceMigraine Prevalence

The Stages of a Migraine AttackThe Stages of a Migraine Attack

1.2% 18.4%

47.2%

33.2%

Mild

Moderately severe

Severe

Extremely severe

Most Patients’ Headaches Are Most Patients’ Headaches Are Severe or Extremely SevereSevere or Extremely Severe

National Headache Foundation. American Migraine Study II: Migraine in the United States: Burden of Illness and Patterns of Treatment

52%39%

9%

Need bed restCan work with some difficulty

Can work as normal

Migraine Takes Quality Time Out Migraine Takes Quality Time Out From Your LifeFrom Your Life

National Headache Foundation. American Migraine Study II: Migraine in the United States: Burden of Illness and Patterns of Treatment

Unnecessary SufferingUnnecessary Suffering

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

National Headache Foundation. American Migraine Study II: Migraine in the United States: Burden of Illness and Patterns of Treatment

What You Might Experience What You Might Experience During an AttackDuring an Attack

Nausea Vomiting Diarrhea Sweating Cold hands Sensitivity to light

Sensitivity to sound Scalp tenderness Pale color Pulsing temple Pressure pain

Triggers and Risk Factors

Migraine headaches are often triggered by specific things

Triggers: Changes in Daily CyclesTriggers: Changes in Daily Cycles

Triggers: Environment or DietTriggers: Environment or Diet

Triggers: MentalTriggers: Mental

Protective FactorsProtective Factors

Regular sleepRegular mealsRegular exerciseBiofeedbackHealthy lifestyle

TreatmentTreatment

Acute:1-nsaids

2-Ergo

3-Triptans

4-Corton

Prophylactic

DHEDHE

Dihydroergotamine – Nasal Spray (Migranal®)– Injectable (D.H.E. )

- Supp

- Tab

Your Symptoms May Affect The Your Symptoms May Affect The Choice of Medication Choice of Medication

Medication Type Pro Con

Oral (tablets) Easy to take Won’t work if you are vomiting

Nasal spray Good for patient with nausea/vomiting, easy

to use

Fewer choices

Injection Works fast Harder to use

1-Ergotamines1-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:

2-triptans2-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

3-(NSAID)Medicines to Stop a 3-(NSAID)Medicines to Stop a Migraine AttackMigraine 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)

Options for Preventive TreatmentOptions for Preventive Treatment

Divalproex sodium/sodium valproate (anticonvulsant) Propranolol (beta-blocker) Timolol (beta-blocker) Methysergide (serotonin antagonist) Other anticonvulsants Other beta-blockers Antidepressants NSAIDs (eg, aspirin)

These are medicines you take every day to prevent headaches

Some Medications May Cause Some Medications May Cause Migraine to Become ChronicMigraine 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

Self Treatment Efforts:Self Treatment Efforts:What You Can Do For Your MigrainesWhat 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

Cluster HeadacheCluster 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

Treatment of Cluster HeadacheTreatment of Cluster HeadacheAcute 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

Treatment of Cluster HeadacheTreatment of Cluster HeadachePreventive 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

Tension HeadacheTension 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

Secondary HeadacheSecondary HeadacheSudden, progressive

Associated with pathology

May require immediate action

PatientPatient

45 years old with HTN and migraine once monthly

1-tab;Ergotamine c twice daily2-tab;valproate Na each night3-tab:advil; when pain qid