Transcript Document

Principles of pharmacology in
neurology
Presented by:Dr mehran Homam
Neurologist &
Neurophysiologist
Department of neurology
Mashhad azad university
Topics
1-Headache
 2-Parkinson
 3-Multiple Sclerosis
 4-Dementia
 5-Epilepsy
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(from Solomon S, Lipton RB. Headache 1991;31(6):384-7.)
1-Headache
Headache
A Common Health Problem
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Headache has troubled
humankind from the dawn
of civilization
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Evidence of trepanation,
an early form of
neurosurgery, was found
on skulls from 7000 BC
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Migraine symptoms,have
been described for over
1,000 years
Primary Headaches
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Benign, recurrent
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NOT associated with underlying
pathology
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The headache is the disease
(from Solomon S, Lipton RB. Headache 1991;31(6):384-7.)
Primary Headaches
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Migraine (with or without aura)
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Tension-type headache (episodic or
chronic)
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Cluster headache
(from Solomon S, Lipton RB. Headache 1991;31(6):384-7.)
Primary Headache
Tension
Cluster
Migraine
QUESTIONS
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1-SEVERITY
2-QUALITY
3-DURATION
4-ASSOCIATED SYMPTOMS & SIGNS
5-PEAK ONSET
6-FREQUENCY
7-AGGREVATING AND RELIEVING
8-LOCATION
Migraine Headaches
Famous people suffering from migraine
Hildegard von Bingen
Ludwig van
Beethoven
Madame de
Pompadour
Sigmund Freud
What is Migraine?
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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
How Migraine Works
3
4
Changes in nerve cell
activity and blood flow
may result in visual
disturbance,
numbness or tingling,
and dizziness.
Chemicals in the brain
cause blood vessel
dilation and inflammation
of the surrounding tissue
5
2
The inflammation
irritates the trigeminal
nerve, resulting in
severe or throbbing pain
Electrical impulses
spread to other
regions of the brain.
1
Migraine originates deep
within the brain
Migraine
Major Forms:
 Migraine without aura (common) 70%
 Migraine with aura (classical) 25%
 Migraine variants and complicated
migraine 5%
How Migraine Stacks Up Against Other
Common Diseases
12%
Affected patientss:
7%
5%
6%
1%
Rheumatoid
arthritis
Asthma
Diabetes
Osteoarthritis
Migraine
From the Centers for Disease Control and Prevention, the US Census Bureau,
and the Arthritis Foundation.
Migraine Prevalence
30
25
Women
Percentage
20
15
Men
10
5
0
10
20
30
40
50
Age (years)
Stewart WF, Lipton RB, et al. JAMA. 1992;267(1):64-69.
60
70
80
90
The Stages of a Migraine Attack
Most Patients’ Headaches Are
Severe or Extremely Severe
Mild
1.2%
33.2%
Extremely
severe
18.4% Moderately
severe
47.2%
Severe
National Headache Foundation. American Migraine Study II: Migraine in the
United States: Burden of Illness and Patterns of Treatment
Migraine Takes Quality Time Out
From Your Life
Can work as normal
9%
39%
Can work with
some difficulty
52%
Need bed rest
National Headache Foundation. American Migraine Study II: Migraine in the
United States: Burden of Illness and Patterns of Treatment
Unnecessary 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
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National Headache Foundation. American Migraine Study II: Migraine in the
United States: Burden of Illness and Patterns of Treatment
What You Might Experience
During an Attack
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Nausea
Vomiting
Diarrhea
Sweating
Cold hands
Sensitivity to light
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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 Cycles
Triggers: Environment or Diet
Triggers: Mental
Protective Factors
Regular sleep
 Regular meals
 Regular exercise
 Biofeedback
 Healthy lifestyle
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Treatment
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Acute:1-nsaids
2-Ergo
3-Triptans
4-Corton
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Prophylactic
DHE
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Dihydroergotamine
– Nasal Spray (Migranal®)
– Injectable (D.H.E. )
- Supp
- Tab
Your Symptoms May Affect The
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
Works fast
Fewer choices
Injection
Harder to use
1-Ergotamines
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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-triptans
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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
Migraine Attack
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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 Treatment
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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
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
Self Treatment Efforts:
What You Can Do For Your Migraines
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Rest
Biofeedback
Ice/heat
Massage
Exercise
Avoid triggers
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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 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
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Treatment of Cluster Headache
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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
Treatment of Cluster Headache
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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
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
Secondary Headache
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Sudden, progressive
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Associated with pathology
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May require immediate action
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
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