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Abortive treatment for Migraine Headache
- Ergotamine-caffiene (Cafergot
- Isometheptene-dichloralphenazone-acetaminophen (Midrin)
- Butalbital-acetaminophen (Fioicet)
- NSAIDs (ASA, ibuprofen, naproxen, ketoprofen)
What are some preventive medications for migraine headaches
- Topirmate (Topamax)
- Calcium channel blockers
- TCA - used as off label
What two classes of drugs are used to "abort" headaches:
- Triptans (Serotonin 5HT1 receptor agonists
- - Almotriptan (Axert)
- - Naratriptan (Amerge)
- - Sumatriptan (Imitrex)
- - Zolmitriptan (Zomig)
- Ergotamine -
- - dihydroergotamine (Migranal)
What are the prophylactic agents used to treate headaches:
- Topiramate (Topomax)
- Propanolol (inderal LA)
In what type of patients should you not describe "Triptans" to?
- patients with coronary artery disease
- patients with poorly controlled hypertension
- Triptans are vasoconstrictors therefore can cause rise in BP and increase risk for Stroke
Can you use triptans and ergotamine together within a 24 hour period?
No, avoid concomitant use of triptans and ergotamine within a 24 hour period
Pregnancy/Lactation Considerations -
What Pregnant Category are Triptans?
What Pregnant Category are Ergotamine?
- Triptans are Pregnancy Cat. C (benefits vs. risk must be weighed)
- Ergotamine are Pregnancy Cat. X (Avoid use in pregnancy)
What is Trigeminal Neuralgia?
A disorder of the 5th cranial nerve (trigeminal nerve) which produces severe pain in the lip, gum, cheek, and/or face
What is the etiology (cause) of Trigeminal Neuralgia?
Compression of the 5th cranial nerve from unknown causes, tumors or vascular malformations
What is the assessment findings of Trigeminal Neuralgia?
- severe pain in the lip, face, mouth, gum, cheek
- pain may be in "bursts", with pain free period after bursts
- pain may be elicited by touch, changes in temperature or a light breeze on the cheek
- May initially thought to be of dental origin. very unbearable
What drug is used as first line treatment for Trigeminal Neuralgia?
- Carbamazepine (anticonvulsants)
- 100mg PO BID
What Pregnant Category is Carbamazepine?
What do you have to monitor?
- Pregnant Category D (not safe to use)
- Check carbamazepine levels
- Check LFT and CBC
- monitor for hyponatremia and decrease WBC or platelet counts, discontinue if evidence of bone marrow depression occurs
Definition of Syncope
A sudden, brief loss of consciousness with a spontaneous recovery
List and explain the seven etiology of Syncope:
- 1. Vasovagal - decrease cardiac output from peripheral vasodilation and bradycardia
- 2. Orthostatic hypotension - due to medications, hypovolemia, autonomic dysfunction
- 3. Situational Syncope - due to coughing, micturition or defecation
- 4. Cardiac - due to sudden decrease in cardiac output (aortic stenosis, arhythmias)
- 5. Carotid sinus syncope - manual pressure/stimulation of the carotid arteries
- 6. other causes - depression, ETOH, Drug abuse, psychogenic, subclavian steal syndrome, cardiomyopathy
What diagnostic studies needs to be done on a patient with syncopal episode?
- BP in both arms (difference of 20 mm Hg or more considered abnormal)
- Orthostatic Vital Signs
- Flexion/Extension of neck 10 times to stimulate vertebrobasilar insufficiency
- Flexion/extension of arms to stimulate sx of subclavian steal syndrome
- Neuro exam (CT, MRI, EEG if abnormal)
- Cardiac Exam
- Tilt testing
What is considered normal on orthostatic vital signs?
- normal findings are systolic pressure decrease of less than 10 mmHg
- increase in diastolic 2-5 mmHg
- increase in heart rate 5-20 beats
- (if HR does not increase, consider cardiac origin)
What are some prevention and nonpharmacological managment for a patient with syncope?
- Prevention - rise slowly from lying or sitting or standing
- Nonpharmacologic Mgmt -
- elevate patients leg if due to vasovagal or hypotension
- elastic support stockings to prevent orthostatic hypotension
- change position slowly
- increased sodium intake to help expand volume
Why do pregnant woman experience synocpal episode?
What position should they be in?
- Vasovagal syncope may present in pregnant women from compression of the vena cava and aorta
- positioning the pregnant woman on her left side should relieve the compression and the symptoms
What is the definition of a Transient Ischemic Attack (TIA)
TIA - a sudden onset of neurological deficits which is caused by cerebral ischemia and lasts less than 24 hours
What are some causes of TIA
- atherosclerotic disease within the brain and/or carotid arteries
- microemboli from atrial fibrillation, cardiac valve disorders
- hypercoagulable states
- could be spontaneous
- cerebral artery vasospasm
- use of oral contraceptive
What medicatons do you need to place patient who just experience a TIA on?
- Antiplatelet therapy (clopidogrel 75mg QD)
- ACE inhibitors
- ASA or Ticlopidine (Ticlid 250mg BID)
What kind of prevention and/or nonpharmalogical management can we do for patients with TIA?
- control their blood pressure, lipids and diabetes
- smoking cessations
Define seizures disorders (convulsion, epilepsy):
seizures which are recurrent are termed:
- a transient alteration in behavior with or without loss of consciousness, sensory perception, motor function and/or autonomic function.
- seizures are due to excessive rate of neuronal discharges
- seizures which are recurrent are termed epilepsy
Which seizure disorder is considered a medical emergency?
Name two types of seizures and their descriptions:
- Partial - begins with motor symptoms characterized by recurrent contractions of muscles in one part of the body
- - Simple - consciousness not impaired, Jacksonian-type seizures begin in one part of the body and progress to contiguous body parts over seconds or minutes
- - Complex - consciousness impaired
- - Mixed - begin as simple or partial and evolve into generalized tonic/clonic; consciousness impaired
- Generalized - bilaterally symmetrical but without local onset
- - Absence (Petit Mal) - brief arrest of activity and loss of consciousness
- - Atypical absence
- - Myoclonic - muscle movements are repetitive
- - Tonic Clonic
- - Tonic, clonic or atonic seizures
Meningitis: inflammation of the brain and spinal cord caused by infection with bacteria, viruses and fungi. Occasionally parasites are responsible for meningitis
List three etiologies of Meningitis:
- Bacterial (strep pneumoniae - most common)
- Viral (enterovirus- most common)
What is the most common meningitis seen in immunocompromised adults, especially those with AIDS
Cryptococcal meningitis - most common meningitis seen in immunocomprised adults, especially those with AIDS
Assessment findings of a patient with Bacterial meningitis:
- recent URI
- neck pain/stiff neck
- headache, fever
- nausea and vomiting, especially in children
- decreased level of consciousness
- meningococcemia rash
- nuchal rigidity
- postitive Kernig and Brudzinksi signs
Assessment findings of an infant with Bacterial meningitis:
- sleeping more than usual
- cries when moved
- cries inconsolably
What is a Positive Kernig Sign?
Kernig Sign - complete extension of leg causes neck pain and flexion
What is a Positive Brudzinski sign?
- Brudzinski sign - flexion of legs when neck is passively flexed.
- (passively flex patient neck, if infection is present, patient will bend their legs)
Assessment findings of a patient with viral meningitis:
- stiff neck
- illness last 2-6 days
Assessment findings of a patient with Fungal Meningitis:
- worsening headaches over a period of days
- vomiting for days or weeks
Diagnostic findings of meningitits:
CSF Gram stain and cultures
- Lumbar puncture: CSF may be turbid, presence of WBC's and elevated protein levels
- CSF decrease glucose if bacterial
- CSF Gram stain and cultures: presence of infectious agent
- CBC: elevated WBC
- Blood cultures: positive 80% of time
What is the pharmacological management of a patient with Meningitis:
- Abx specific for culture
- Empiric Treatment: Ampicillin PLUS 3rd generation cephalosporin; may need to add aminglycoside
- Dexamethasone: may decrease morbidity and mortality
- Analgesics for headache
- Antivirals not recommended.
Define Multiple Sclerosis:
a disease of the central nervous system which is slow and progressive. It is characterized by demyelination of nerve cells in the brain and spinal cord which produces a variety of neurologi deficits
Assessment findings of a patient with Multiple Sclerosis:
- paraesthesias in extremities, weakness or clumsiness of a hand or leg
- stiffness or unusual fatigability of a limb
- transient blindness or pain in the eye
- nystagmus common
- speech may be slow with hesitancy at beginning of word
- mild emotional disturbances (apathy, lack of judgment, emotional lability) due to scattered CNS involvment
- difficulty with bladder control
- deep tendon reflexes increased; superficial reflexes dimished
- Charcot's triad (scanning speech, nystagmus, tremor) common in later stages of disease
Management of a patient with Multiple Sclerosis:
What are the goals of pharmacologic manangement?
- avoid factors which precipitate attacks (hot weather, fatigue)
- Goals of pharmacologic treatment are to slow disease progression, improve symptoms and decrease relapses.
- No current therapy is completely effective