2. Migraines are a recurring type of headache. They cause moderate to severe pain
that is throbbing or pulsing. The pain is often on one side of your head. You may
also have other symptoms, such as nausea and weakness. You may be sensitive to
light and sound.
3. Patient Details
• NAME: ABC
• MRD NO : xxx
• AGE: 60 years
• DOA:14/02/2018
• SEX : Female
• DOD 16/02/2018
• Dept: General Medicine I
4. Subjective Data
• Complaints on Admission-
Irritability, headache with flickering lights and visual disturbances, and generalized weakness since one day. Patient
was also suffering from sleepiness and giddiness.
• Medical History-
-Type 2 DM , Hypertension, diabetic neuropathy, Age related functional dyspepsia, History of abnormal sensation of
abdominal and limb muscles.
• Medication History-
-Inj. Human mixtrad.
-Levosulpiride 25mg- For gastric movement discomfort.
5. Objective Data
• O/E- conscious, oriented, afebrile.
• PR- 92/min
• B.P - 160/100mmhg
• RR- 16/min
• P/A- Soft
• Chest- NVBS
• CVS- S1S2+
• Elevated RBS, WBC is observed.
• Restlessness of limbs was observed during examination.
10. Assessment of current therapy
1. TAB.TELISTA - P/O- (Telmisartan)- 1-0-1- {day-1,2}
• Category: Angiotensin 2 receptor blocker.
• Indication: Hypertension.
• Dose range: 40 mg.
• MOA: Telmisartan is nonpeptide AT1 and 2 receptor antagonist. This binding prevents angiotensin 2 from binding to
receptor, thereby blocking the vasoconstriction and aldosterone secreting effects of angiotensin 2.
• ADR: dizziness, fatigue, diarrhoea, UTI, dyspepsia.
• DI: Amifostine, nitroprusside, ramipril, tacrolimus.
• CTN: fructose intolerant, hyperkalaemia, angioedema.
• Justification-
Telmisartan, an angiotensin II receptor blocker, as well as having a terminal elimination half life of 24 h, has a large volume
of distribution due to its high lipophilicity. The efficacy of telmisartan 80 mg monotherapy has been demonstrated using
ABPM, with superior reduction in mean values for the last 6 h of the dosing interval compared with ramipril 10 mg and
valsartan 80 mg. In addition, telmisartan 80 mg provides superior blood pressure control after a missed dose compared with
valsartan 160 mg. When combined with hydrochlorothiazide (HCTZ) 12.5 mg, telmisartan 40 mg and 80 mg is more
effective than losartan/HCTZ (50/12.5 mg) at the end of the dosing interval. Furthermore, greater reductions in last 6 h
mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) are achieved with telmisartan/HCTZ (80/12.5 mg)
than with valsartan/HCTZ (160/12.5 mg) in obese patients with type 2 diabetes and hypertension. Recent data from a large
group of patients show that telmisartan 80 mg controls the early morning blood pressure surge more effectively than
ramipril 5–10 mg and, thus, may have a greater beneficial effect on long-term cardiovascular risk.
12. 3. TAB. NAPROSYN- P/O- (Naproxen)- 1-0-1- {day- 1,2}
• Category: Non steroidal anti inflammatory drug.
• Indication: headache, muscle aches, tendonitis, dental pain, and menstrual cramps.
• Dose range: 500 mg.
• MOA: naproxen exerts it's clinical effects by blocking COX-1 and COX-2 enzymes leading to decreased
prostaglandin synthesis. The COX-1 enzymes is constitutively active and can be found in normal tissues such as the
stomach lining, while the COX-2 enzyme is inducible and produces prostaglandins that mediate pain, fever and
inflammation. The COX-2 enzyme mediates the desired antipyretic, analgesic and anti-inflammatory properties
offered by Naproxen.
• ADR: dizziness, edema, vertigo, heartburn.
• DI: macimorelin, sincalide, cyclosporine.
• CTN: asthma, peptic ulcers, GI bleeding, hyperkalaemia.
• Justification-
Lawrencew Richer et. Al 2016 identified 27 randomized controlled trials (RCTs)of migraine symptom-relieving
medications, in which 9158 children and adolescents were enrolled and 7630 (range of mean age between 8.2 and
14.7years) received medication, Naproxen was more effective than placebo in producing pain freedom in two small
studies involving children. In one small cross-over study in adolescents, naproxen was not superior to placebo for
pain freedom, but it was for headache relief (Evers 2006).
13. 4. TAB. OXETOL- P/O- TID- (oxcarbazepine)- P/O TID- {day- 1,2,3}
• Category: Anticonvulsants.
• Indication: used to treat partial seizures.
• Dose range: 150mg.
• MOA: Oxcarbazepine binds to sodium channels and inhibits the high-frequency repetitive neuronal firing. Oxcarbazepine
also inhibits the release of glutamate.
• ADR: abdominal pain, tremor, indigestion.
• DI: cabotegravir, cobicistat, elvitegravir.
• CTN: liver disease, renal dysfunction, hyponatremia.
• Justification-
A study conducted by Muke Zou et.al 2013 randomised, placebo-controlled, double-blind trials with a total of 862
participants there view found evidence to support the effectiveness of oxcarbazepine in painful diabetic neuropathy,
neuropathic pain from radiculopathy and mixed neuropathies of various causes.
14. 5. TAB PHENERGAN- P/O- HS (Promethazine) 0-0-1- {day- 1,2}
• Category: anti- emetic, antihistamines.
• Indication: nausea, vomiting, allergy.
• Dose range: 50 mg.
• MOA: Promethazine antagonizes the central and peripheral effects of histamine mediated by histamine H1 receptors.
• ADR: Hallucinations, Muscle spasms, Catatonic states, Euphoria.
• DI: astemizole, Cisapride, disopyramide.
• CTN: intra-arterial administration, Coma, Treatment of lower respiratory tract symptoms, including asthma.
15. 6. TAB.ACOTRUST- P/O- (Acotiamide) ½-½-½ - {day- 2,3}
• Category: gastrokinetics.
• Indication: dyspepsia, bloating, nausea, vomiting.
• Dose range: 100mg.
• MOA: 'Acotiamide' that increases the level of a chemical (acetylcholine) concentration, which increases the
gastrointestinal peristalsis movement. Therefore, it increases the intestine motility, accelerates gastric emptying time, and
improves food movement throughout the gastrointestinal tract.
• ADR: diarrhoea, constipation, rashes.
• DI: flavoxate, atropine, scopolamine.
• CTN: gastrointestinal haemorrhage and allergy.
• Justification-
Acotiamide Masahiro Ueda, et. al 2016 Efficacy of Acotiamide for improving symptoms in patients with functional
dyspepsia was shown by several clinical trials. In a randomized, double-blind, placebo-controlled, parallel-group
comparative Phase III trial conducted in Japan, 100 mg of Acotiamide three times a day for 4 weeks was more effective than
a placebo for improving symptoms, and quality of life.
16. 7. TAB SENSIVAL P- (Pregabalin- 75mg + nortriptyline- 10 mg)- P/O ½ HS- {day- 2}
• Category: Antidepressant.
• Indication: neuropathic pain.
• Dose range: (Pregabalin- 75mg + nortriptyline- 10 mg).
• MOA: Pregabalin works by reducing the release of a chemical (neurotransmitter) in the brain responsible for the sensation
of pain. Nortriptyline works by acting on the release of certain chemicals and electrical activity in the brain.
• ADR: nausea, dry mouth, difficulty in urination, weight gain, constipation, weakness, confusion.
• DI: Propoxyphene, Pioglitazone, Ramipril.
• CTN: angioedema, heart disease.
17. 8. GABAPENTIN OINTMENT 20g L/A (Gabapentin)- {day 2}
• Category: Anticonvulsants.
• Indication: used to treat seizures, nerve pain, diabetic neuropathy.
• Dose range: 20g.
• MOA: gabapentin modulates the action of the GABA synthetic enzyme, glutamic acid decarboxylase (GAD) and the
glutamate synthesizing enzyme, branched-chain amino acid transaminase.
• ADR: redness, burning, itching, irritation on application site.
• DI: magaldrate, sodium bicarbonate.
• CTN: breastfeeding, pregnancy.
• Justification-
Seven new studies with 1919 participants were added. Another report (147 participants) provided results for a study already
included, but which previously had no usable data. A further report (170 participants) used an experimental formulation of
intrathecal gabapentin. Thirty‐seven studies (5633 participants) studied oral gabapentin at daily doses of 1200 mg or more
in 12 chronic pain conditions; 84% of participants were in studies of postherpetic neuralgia, painful diabetic neuropathy or
mixed neuropathic pain. There was no first tier evidence.
Second tier evidence for the outcome of at least 50% pain intensity reduction, considered valuable by patients with chronic
pain, showed that gabapentin was significantly better than placebo in postherpetic neuralgia (34% gabapentin versus 21%
placebo; NNT 8.0, 95% CI 6.0 to 12) and painful diabetic neuropathy (38% versus 21%, NNT 5.9, 95% CI 4.6 to 8.3).
18. 9. INJ. HUMAN MIXTARD- s/c- B/D- {DAY- 1,2,3}
• Category: intermediate acting and short acting type of insulin.
• Indication: Diabetes mellitus.
• Dose range: 100 IU/ml - (30/70)- (Isophane insulin-70% + soluble insulin- 30%).
• MOA: The blood glucose lowering effect of insulin is due to the facilitated uptake of glucose following binding of insulin
to receptors on muscle and fat cells and to the simultaneous inhibition of glucose output from the liver.
• ADR: vomiting, pain at site of injection, diarrhoea, dry mouth.
• DI: alcohol, beta blockers, gatifloxacin.
• CTN: hypokalaemia, kidney disease, liver disease.
19. Planning
• Goals of therapy:
1. Reduce attack frequency and severity.
2. Reduce disability.
3. Improve quality of life.
4. Prevent headache.
5. Avoid headache medication escalation .
6. Educate and enable patients to manage their disease.
• Goals achieved:
1. Symptomatic improvement is seen.
2. Patient is stable at the time of discharge.
20. • MONITORING PARAMETERS-
1. NAPROXEN- Monitor for signs/symptoms of gastrointestinal bleeding. -Monitor blood counts, renal, and
hepatic function periodically for patients receiving long-term therapy.
2. TELMISARTAN- Monitoring: Monitor serum electrolytes periodically.
3. PROMETHAZINE- Excessive sedation -Respiratory rate, especially in paediatric patients -Localized injection
site reactions.
OXCARBAZEPINE-
Monitor for serious dermatologic reactions, such as Stevens- Johnson syndrome and toxic epidermal necrolysis,
Hyponatremia.
Psychiatric: Emergence or worsening of depression, suicidal thoughts or behaviour, and/or any unusual changes in
mood or behaviour.
• DRUGS/OTC TO BE AVOIDED-
Drugs that can cause rebound headaches are: NSAIDs, Codeine and prescription pain relievers, Medicines that
contain caffeine, Birth control pills, Triptan
• CLINICAL PHARMACIST INTERVENTION –
Tricyclic antidepressants can be used instead of SNRIs for better prophylactic management of migraine. No NSAIDs
was given to patient for the acute migraine attack management.
22. • PROGRESS CHART-
• 14/02-
Irritability, Headache and patient suffered from heart burn and Syp. Mucaine gel 2 tsp was given as stat. (PR 92b/min;
RR 16 b/min, BP- 100/80mmhg, Temp98.6° F)
• 15/02-
Pain was decreased and vitals were stable (PR 82 b/min ; RR 18b/min; BP140/90; Temp; 98.6° F)
• 16/02-
All vital signs were normal and symptomatically better (PR76b/min; RR 18 b/min; BP 130/90; Temp 98.6°F)
• Follow up details-
Review after 4 days in general medicine department with FBS, PPBS Results.
23. PATIENT CONSELLING CARRIED OUT:
• On disease-
1. A migraine is a primary headache disorder characterized by recurrent headaches that are moderate to severe.
Typically, the headaches affect one half of the head, are pulsating in nature, and last from two to 72 hours.
Associated symptoms may include nausea, vomiting, and sensitivity to light, sound, or smell.
2. Extrapyramidal symptoms are forms of abnormal body movements that are caused by a blockade of normal
dopamine functions in the brain. occur most commonly as side-effects of antipsychotics.
• On drugs-
1. Ibuprofen- Stop this drug if you have symptoms of stomach bleeding such as black, bloody, or tarry stools, or
coughing up blood or vomit that looks like coffee grounds.
2. Telmisartan- Avoid drinking alcohol. It can lower your blood pressure. Do not use potassium supplements or salt
substitutes while you are taking telmisartan.
3. Promethazine- Stop using this medication if you have twitching or uncontrollable movements of your eyes, lips,
tongue, lace, arms, or legs.
4. Oxcarbazepine- It reduces the sodium in your body to dangerously low levels, which can cause a life-threatening
electrolyte imbalance. Headache, weakness, loss of appetite, feeling unsteady.
5. Flunarizine- Swallow it as a whole. Do not chew, crush or break it. Tablet may betaken with or without food
6. Desvenlafaxine- Swallow it as a whole. Do not chew, crush or break it.
24. • Response to therapy-
Patient responded well to therapy, symptoms was reduced.
• ADR/drug interactions-
The administration of PROMETHAZINE and NORTRYTYLINE has minor intensity of interaction, significant
effects seen as both drugs increases sedation.
• Patient compliance-
Patient was found to be complaint to the medications given.
• Alternate Therapy If Any-
1. Tricyclic antidepressants are the second line drugs used in the prophylactic management of migraine Tricyclic
antidepressants are good second-line alternatives because of their adverse-effect profile and efficacy.
2. Some anti-seizure drugs, such as valproate and topiramate seem to reduce the frequency of migraines.
25. • Lifestyle Changes-
1. Keep well hydrated since dehydration has been identified as a migraine trigger for some people.
2. Avoid certain foods that might trigger a migraine.
3. Maintain a regular schedule for eating and sleeping.
4. Exercise regularly.
5. Certain foods can be triggers for migraines in susceptible people, these foods include:
Red wines, Aged cheeses, preservatives used in smoked meats, (nitrates) monosodium glutamate, Artificial
sweeteners, chocolate, and Dairy products.
