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頭痛之藥物治療及病例用藥討論指導藥師：朱佩欣、陳靖文 藥師

指導幹部：劉俐婷 主任

組員：黃威倫、張之浩、王琦

2011 / 03 / 21

Group 5

1

Contents

Introduction壹

貳 Classification

參 Epidemiology

肆

2

Pathophysiology

Contents

Clinical manifestations & Diagnosis伍

陸 Treatment

柒

Reference

Case report

捌

3

Headache: A Common Problem

Headache Migraine

One of the commonest symptoms that clinicians

evaluate.

Misdiagnosed and under-treated?

Effective treatment is often possible but depends

on correct diagnosis

The Revised International Classification of

Headache Disorders ( ICHD-2) provide a

framework for headache diagnosis.

Headache: A Disabling Problem

The burden of headache:

The International Classification of

Headache Disorders, 2nd edition

6

ICHD-2 criteria-1

7

ICHD-2 criteria-2

The primary

headache

Migraine With aura(~31%) / without aura

Female > male (hormone)

Tension-type headache Episodic(2-3hr), chronic

Cluster headache Episodic, chronic

Male > female, smokers

※ International Classification of Headache Disorders-2

9

ICHD-2 criteria-3

Epidemiology of Migraine

Headache

Epidemiology-1

Results of the Taiwan Migraine Study indicate

that 96% people in Taiwan experience one or

more headaches per year.

A study in Taipei (age over 15) in 1997-1999:

-Migraine: 14% of women and 5% of men

(Cp: U.S.A. : 18.2% of women and 6.5% of men)

( women :men = 3:1 )

-other headaches: 57% of women and 46% of men

12

Epidemiology-2

Migraine prevalence :highest in both men and

women between the ages of 25 and 45 years.

1. Before the age of 12 : boys > girls

2. After age 12 : females are two to three times

more likely than males

Epidemiology-3

Chronic daily headache (CDH) :

about 4%(0.6 million), over 15 days a

month, in which 30% drug overuse.

14

Epidemiology-4

Comorbidity with migraine:

neurologic and psychiatric disorders, including

stroke, epilepsy, major depression, and anxiety

disorder

Whether this relationship is causal or

representative of a common pathophysiologic

mechanism is unknown.

Epidemiology-5

The Pathophysiology of Migraine

Headache

Pathophysiology of migraine

Clinical Presentation of Migraine

Before migraine attack:

Prodrome (Premonitory symptoms) : 20-60%

Aura: 31%

Personal Triggers:

Food

Environment

Behavior

Migraine attack:

What is Aura?

Clinical Presentation

Neurologic symptoms :are most common.

phonophobia, photophobia, hyperosmia, and

difficulty concentrating

Psychological :

anxiety, depression, euphoria, irritability,

drowsiness, hyperactivity, and restlessness

Autonomic :

polyuria, diarrhea, and constipation

Constitutional symptoms :

stiff neck, yawning, thirst, food cravings, and

anorexia

.

Symptoms of Tension-type headache

The most common type of primary headache.

Symptoms include bilateral pain, nonpulsatile

tightness, or pressure.

No aura.

No family history.

Mental stress, non-physiologic motor stress

Symptoms of Cluster headache

The most severe of the primary headache

Symptoms of severe, unilateral head pain that

occur in series lasting for weeks or months.

Commonly in night, and appear to be more

common in the spring and fall.

Diagnosis of Migraine-1

24

(典型偏頭痛)

Diagnosis of Migraine-2

25

(一般型偏頭痛)

26

27

Diagnosis of secondary headache

28

Treatment

Migraine

Nonpharmacologic Therapy

General approach to Treatment

Acute Therapy

Prophylactic Therapy

Tension-type headache

Nonpharmacologic Therapy

Acute Therapy

Prophylactic Therapy

Cluster headache

Acute Therapy

Prophylactic Therapy

29

Nonpharmacologic Therapy-1

Limited

Ice to the head and periods of rest or sleep in a

dark, quiet environment

Headache diary

Relaxation therapy, biofeedback, cognitive

therapy

Changes in estrogen levels associated with

menarche, menstruation, pregnancy,

menopause, oral contraceptive use, and other

hormone therapies can trigger, intensify, or

alleviate migraine

30

Nonpharmacologic Therapy-2

31

General Approach To Treatment

32

Acute Therapy-1

Drug Role in therapyGrade of

recommendation

Impression of

effect

NSAIDs

ketorolac (im, iv)

aspirin (po)

Ibuprofen (po)

diclofenac (po)

tolfenamic acid (po)

naproxen (po)

ketoprofen (po)

Rescue therapy

First-line for mild to

moderate

First-line for children

Same as aspirin

B

A

A

B

++

++

++

++

Analgesics

acetaminophen (po)

dipyrone(sulpyrine)

(im)

First choice for

pregnant& children

Not for first-line

B

C

+

+

33

Abortive treatment of migraine: (from Taiwan Headache Society )

Acute Therapy-2

Drug Role in therapyGrade of

recommendation

Impression of

effect

Triptans

sumatriptan (po, in,FDT) Moderate to severe

or mild to moderate

when first-line fail

A +++

Ergots

ergotamine/caffeine(po)

Dihydroergotamine (po)

B

B

++

++

Antiemetics

prochlorpromazine (im)

metochlopramide(im,iv)

chlorpromazine (po, iv)

droperidol (iv)

Adjunctive therapy

weaker effect

Severe AEs

For status migraine

B

B

B

B

++

++

+

++

Corticosteroids

dexamethasone

hydrocotisone

Methylprednisolone

Use with dopamine

antagonist. Rescue

therapy for status

migrainous

B ++

Opiates For rescue therapy

& pregnant

C ++

Magnesium For pregnant &

hypomagnesemia

C ?

NSAIDs

Mechanism

Inhibition of PG synthesis prevent

neurogenically mediated inflammation in the

trigeminovascular system

Aspirin, ibuprofen, naproxen, tolfenamic

acid, ketoprofen, diclofenac

Ketorolac 2 mg (IM)

For nausea, vomiting & migraine relief

Side effects

GI & CNS effect

35

Simple Analgesics

Acetaminophen

First-line for pregnancy & children

Weaker than NSAIDs

Combination therapy recommended

• Acetaminophen + aspirin + caffeine

Dipyrone(sulpyrine) (IM, SC)

Side effects:

• Dizziness

• Mouth dryness

• agranulocytosis

36

Triptans-1

5HT1B/1D receptor agonist

Sumatriptan (Imigran® ) (po, in,FDT)

Also effect for nausea, vomiting, photophobia,

and phonophobia

Onset: 40-60 mins

Abolish pain: 2-4 hours

37

38

Triptans-3

39

Triptans-4

Side effects

Mild to moderate, short duration

Paresthesias, fatigue, dizziness, flushing,

warm sensations, somnolence

Chest symptoms: tightness, pressure,

heaviness, pain in the chest, neck, or throat

Nasal spray: nasal discomfort

40

Triptans-5

Contraindication

Should not be given within 12 hr of ergots der.

hemiplegic and basilar migraine

SSRI or SNRI serotonin syndrome

IHD, uncontrolled hypertension,

Cerebrovascular disease

Pregnancy (class C), children under 15

Administration within 2 weeks of therapy with

MAOI is not recommended

41

Triptans-6

第一次服用

英明格

42

Triptans-健保規範1

Sumatriptan succinate（如Imigran）；rizatriptan（如Migoff）

1. 限符合國際頭痛協會(International Headache Society)

一九八八年訂定的「偏頭痛」診斷標準者：

(1) 至少有五次能符合(2)至(4)項的發作。

(2) 頭痛發作持續4至72小時。

(3) 頭痛至少具下列二項特徵：

Ⅰ.單側 Ⅱ.搏動性Ⅲ.程度中等或重度(日常生活受限制甚或禁絕)

Ⅳ.上下樓梯或類似之日常活動會使頭痛加劇

(4) 當頭痛發作時至少有下列一情形：

Ⅰ.噁心或嘔吐 Ⅱ.畏光及怕吵

2. 偏頭痛之發作嚴重影響日常生活 (無法工作或作家事或上課) 者。

3. 經使用其他藥物無效者。

43

Triptans-健保規範2

4. 每月限用四次，且

(1) Sumatriptan succinate口服劑型藥品每次用量不超過100 mg，毎月不超過400 mg。

(2) Sumatriptan succinate鼻噴劑型藥品每次用量不超過一劑 (10mg

或20mg)，毎月不超過四劑 (10mg或20mg)。

(3) Rizatriptan口服劑型藥品每次用量不超過10 mg，毎月不超過40

mg。

5. 不得同時處方含有ergotamine 製劑或其衍生物類藥物。

6. 不得作為預防性使用。

7. 不得使用於曾患有心肌梗塞、缺血性心臟病、Prinzmetal氏狹心症、冠狀血管痙攣者及高血壓未受控制的患者。

8. 青少年符合上述第1、2、3項者，限使用鼻噴劑型藥品。

44

Ergotamine derivatives-1

Nonselective agonist

5HT1 & 5HT2 receptor agonist

Dopaminergic & α.β-adrenergic agonist

Mechanism

Constrict intracranial blood vessels

Inhibit the development of neurogenic

inflammation in the trigeminovascular system

Central inhibition of the trigeminovascular

pathway

45

Ergotamine derivatives-2

Ergotamine tartrate (po, SL, rectal, parental)

Cafergot® - ergotamine 1mg/ caffeine 100 mg

Can cause rebound headache

Dihydroergotamine (Seglor® ) cap 5 mg

Also available for in & parenteral

Does not cause rebound headache

46

Ergotamine derivatives-3

Side effects

Nausea & vomiting

Abdominal pain, weakness, fatigue,

paresthesias, muscle pain, diarrhea and chest

tightness

Vasoconstriction severe peripheral ischemia

Triptan SEs

Caution

CYP3A4 inhibitor can increase ergotamine

blood levels

47

Ergotamine derivatives-4

Contraindications

Angina, coronary heart disease

Glaucoma

Uncontrolled hypertension

Renal or hepatic failure

Cerebral or Peripheral vascular disease

Pregnancy & breast-feeding

PUD & severe pruritus

sepsis & stroke

48

Triptans vs Ergots

49

5-HT Ergots Triptans Effects

1A ++++ + Dysphoria,

nausea, emesis

1B +++ ++Anti-migraine

1D +++ +++

2A & 2C +++ - Peripheral vascular

effects,

asthenia, dizzinessAdrenergic

α +++ -

Dopaminergic

D2 +++ - GI, nausea, emesis

Antiemetics

Adjunctive therapy

For nausea, vomiting & migraine relief

Dopamine antagonist

Treatment of intractable or refractory migraine

SEs: drowsiness & dizziness, EPS

Chlorpromazine, proclorperazine

Metoclopramide

Also useful to reverse gastroparesis and

improve absorption from the GI tract

50

Miscellaneous Medications

Corticosteroids

Dexamethasone (iv) 6 mg

Rescue therapy for status migrainous

Lidocaine (in)

Rapid relief but headache recurrence is

common

Opiates analgesics

Meperidine, butorphanol, oxycodone,

hydromorphone

Dependency & rebound headache

51

Guideline of acute therapy

52

Diagnosis of migraine

Patient education

Access severity & disability

Pretreat antiemetics if

nausea or vomiting

Mild-moderate: analgesics &

NSAIDs

Combination analgesics

Triptans & Ergot

derivatives

Opioid combination analgesics

Prophylactic Therapy

Anti-convulsants

β-Adrenergic Antagonists

Calcium Channel Blockers

Anti-Depressants

Methysergide

Miscellaneous Prophylactic Agents

53

Prophylactic Therapy

When to use

Migraine attacks more than three times per month or chronic migraine

Migraine disturbs daily life or lasts > 48 hr

Acute therapy > 2 times/week

Uncommon migraine conditions

Criteria for prophylactic agents

Response

Tolerability

Comorbidities

Individualized

54

Anticonvulsants

Mechanism： ↑GABA-mediated inhibition

↓Glutamate related excitatory receptor activity

↓Na & Ca channel activity

55

Valproate sodium 250-500 mg/day BID-QID PO

Topiramate 50-100 mg/day QHS-BID PO

Gabapentin 900-2400 mg/day QHS-TID PO

Anticonvulsants

Adverse effects:

Valproate

• Nausea, somnolence, tremor, dizziness, weight

gain, and hair loss

• Teratogenicity (Pregnancy risk D)

Topiramate

• Diarrhea, weight loss, urinary tract stone, fatigue,

nausea

• Teratogenicity (Pregnancy risk D)

Gabapentin

• Dizziness and somnolence

56

β-Adrenergic Antagonists

β-blockers are the most widely used drugs for

migraine prophylaxis.(first-line)

Propranolol BID-TID

60-320 mg/day

Metoprolol(Betaloc) BID-TID

50-300 mg/day

Atenolol BID-TID

50-150 mg/day

Timolol BID-TID

10-40 mg/day

Nadolol BID-TID

40-240 mg/day

57

β-Adrenergic Antagonists

Mechanism:

β-adrenergic antagonists raise the migraine

threshold by modulating adrenergic or

serotonergic neurotransmission

→reducing migraine frequency

Adverse effects:

Drowsiness, fatigue, sleep disturbances, vivid

dreams, memory disturbance, depression,

impotence, bradycardia, hypotension

58

β-Adrenergic Antagonists

Contraindications:

Contraindicated in patients with asthma,

diabetes mellitus, heart failure, heart block;

depression, impotence, or hypotension may

limit use

ISA β blockers should not be used

Comorbid conditions:

Anxiety, hypertension, or angina.

59

Calcium Channel Blockers

SEs for Flunarizine:

Weight gain, sedation, depression, abdomol

pain, EPS

60

Flunarizine 5-10 mg/day QHS-BID PO

Verapamil 120-720 mg/day TID-QID PO

Nimodipine 60-120 mg/day QD PO

Nifedipine 30-180 mg/day TID PO

Diltiazem 60-360 mg/day TID PO

Antidepressants

TCAs (tricyclic antidepressant)

SSRIs (Selective serotonin reuptakeinhibitors )

SNRIs (Serotonin norepinephrine reuptake inhibitors )

MAOIs (Monoamine oxidase inhibitors)

61

Antidepressants- TCAs

Mechanism：

Block serotonin and norepinephrine reuptake

62

Amitriptyline 10-150 mg/day QHS PO

Desipramine 10-150 mg/day QD PO

Nortriptyline 10-150 mg/day QD PO

Antidepressants- TCAs

Adverse effects：

Anticholinergic effect

• Constipation, dry mouth, urinary retention, etc.

Antihistamine effect

• Weight gain, etc.

Adrenergic effect

• Orthostatic hypotension, tachycardia, etc.

Contraindiction

BPH, glaucoma

63

Antidepressants- SSRIs

Selective serotonin reuptake inhibitors

SSRIs are less effective than TCAs

Adverse effects:

Weight gain, nausea, constipation, reduced libido

64

Fluoxetine 10-20 mg/day QD PO

Paroxetine 10-20 mg/day QD PO

Antidepressants- SNRIs

Serotonin norepinephrine reuptake inhibitors

Serotonin syndrome might happen sometimes

Do not combine with a triptan

65

Venlafaxine 75-150 mg/day QD PO

Duloxetine 35-90 mg/day QD PO

Antidepressants- MAOI & DNRI

Monoamine oxidase inhibitor

Tyramine-free diet

DA-NE reuptake inhibitor

→Last choice

66

Phenelzine 15-60 mg/day QD PO

Bupropion 75-300 mg/day QD PO

5-HT2 Receptor Antagonist

Adverse effects:

GI pain, Vasular disease, liver or kidney

dysfunction, fibrotic disease →Drug holiday

Contraindication in pregnancy & CV disease

Cyproheptadine

• Weight gain, sedation

67

Methysergide 2-8 mg/day TID-QID PO

Cyproheptadine 4-8 mg/day QHS-TID PO

Miscellaneous Agents

Riboflavin(B2)

400mg QD (RDA: 1.7 mg/day)

Coenzyme Q10

Botulinum toxin type A

ACEI

Lisinopril

ARB

Candesartan

Feverfew & butterbur

68

Drug Choice for Comorbidities

69

Comorbidities First-choice Others

Depression TCA β-blocker, flunarizine

Anxiety TCA, β-blocker -

Sleep disturbance TCA -

Overweight Topiramate TCA, Valproate,

gabapentin

Bipolar disorder Valproate, Topiramate TCA

Seizure Topiramate, Valproate TCA

Raynaud’s syndrome CCB β-blocker, ergotamine

CV disease CCB, Valproate,

Topiramate, ARB, ACEI

TCA, β-blocker

Guideline for Prophylactic agents

70

Patient meets criteria

Headache recur

NSAIDs

Healthy or comorbid

hypertention, angina, or

anxiety

β-blocker

(or CCB if unable to

use)

Comorbiddepression or insomnia

TCA & SNRI

Comorbidseizure or

bipolar disorder

Anti-convulsant

β-blocker

(or CCB if unable to

use)

Other agents

ineffective

Methy-

sergide

Tension-type headache

Nonpharmacologic therapy Psychophysiologic therapy

Physical therapy

Relaxation training

Biofeedback training

Pharmacologic therapy

Abortive therapy

• Mild to moderate → NSAIDs & Simple analgesics

• Moderate to Severe → Ketorolac 60 mg IM

Prophylactic therapy

• TCAs

71

Cluster headache: Abortive therapy

Oxygen

Inhalation 100% oxygen for 15 to 25 minutes

Caution: smoke & COPD patients

Triptans

Sumatriptan 6 mg SC/ 20 mg IN

Zolmitriptan 5 mg IN / 10 mg PO

Ergotamine derivatives

IV Dihydroergotamine for 3 to 7 days

72

Cluster headache: Prophylactic therapy

Verapamil (360-720 mg/day)

Corticosteroids Prednisolone 40-60 mg/day BID

Dexamethasone 8 mg/day BID

Lithium (600-1200 mg/day BID )

Ergotamine (1-2 mg/day QHS )

Methysergide (4-12 mg/day TID-QID)

Miscellaneous agents Lidocaine, cocaine, capsaicin, civamide

73

Therapeutic Outcomes

Patients should be monitored for frequency,

intensity, and duration of headaches, as well as

any change in the headache pattern.

Keep a headache diary

Identify potential medication-misuse headache

Early use

Follow the guidelines

Therapies should be monitored

74

Case Report

75

Case Report-1

Name：Mr. Q

Gender：male

Age：30 y/o

– (born 1980)

Height：173.5cm

Weight：70kg

2011

• 0103-0115(GN)

Chief complaint

Headache for more

than 10 years,

exacerbated since

last January.

Case Report-2

Past medical history Patient suffered from headache for more than 10

years.

Depression and bipolar

Probably ADHD when he was young

Personal history Smoking for 20 years, but no drinking

Has used amphetamine, FM2 and cocaine

Food or drug allergy：denied

Family history Father and brother both have major depressive

disorder

Case Report-3

Physical examination

BSA：1.836m*m

T/P/R：36.8℃ 76bpm 16/min

Bp：115/75 mmHg

Case Report-4

Physical examination

Case Report-4

Impression

Chronic migraine

Plan to do

Adjust dosage of anti-migraine medication

Inject the botulinum toxin for pain relieved

On neuro routine

2010-12-03

Drug Dose Route Frequency

Seglor cap 5 mg 1CAP PO BID 2010/12/13-

2011/01/10

Inderal * tab 40 mg 1TAB PO BID 2010/12/13-

2011/01/10

Topamax FC * tab 25 mg 1TAB PO BID 2010/12/13-

2011/01/10

Requip FC * tab 0.25 mg 2TAB PO QN 2010/12/13-

2011/01/10

Drug profile-1

1/ 1/ 1/ 1/ 1/ 1/ 1/ 1/ 1/ 1/ 1/ 1/

4 5 6 7 8 9 10 11 12 13 14 15

1.5 IVA 1AMP

AMP Q8H Q12H

2 PO

CAP QN

2 PO

TAB QPM

1 PO

TAB QD

1 PO

TAB QN

1 IVA

AMP Q8H

1 PO

TAB BIDCC

Drug/Dose/Frequency/Route

Novamin inj 5 mg/ml 1 ml 1amp

Benamine cap 50 mg VPP

Topamax FC * tab 25 mg

Topamax FC * tab 25 mg

Topamax FC * tab 100 mg

Cardolol * tab 40 mg VPP

Binin-U * inj 5 mg/1 mL

Drug profile-2

1/ 1/ 1/ 1/ 1/ 1/ 1/ 1/ 1/ 1/ 1/ 1/

4 5 6 7 8 9 10 11 12 13 14 15

100 IVA

MG BID

1 PO

CAP BID

100 IM

UNIT ST

7 IVA 5AMP

AMP QD STAT

500 IVD

CC QD

Normal saline inj 500 ml "YF"

Mag. Sulfate # inj 10% 20 ml

Cymbalta * cap 30 mg

Solu-medrol * inj 500 mg

Botox for inj (1) unit

Drug/Dose/Frequency/Route

Take home order

Drug Dose Route Frequency

Cymbalta * cap 30 mg 1CAP PO BID 2011/01/14-

2011/01/28

Cardolol * tab 40 mg VPP 1TAB PO BIDCC 2011/01/14-

2011/01/28

Topamax FC * tab 100 mg 1TAB PO BID 2011/01/14-

2011/01/28

Discussion

1. The role of botulinum toxin in chronic migraine

2. The combination use of Benamine and novamin

3. Patient’s comorbidity-depression

4. The mechanism of Mag. Sulfate in chronic migraine therpy.

Discussion-Botulinum toxin

1. What kinds of role does botulinum

toxin play in Chronic migraine?

Botulinum toxin is produced by Clostridium

botulinum

Discussion-Botulinum toxin

1. The role of botulinum toxin in chronic

migraine:

Botulinum toxin is produced by Clostridium

botulinum

Phase III Research Evaluating Migraine

Prophylaxis Therapy (PREEMPT) program

Headaches on ≥15 days per month of which

at least 8 days are with migraine.

100U-150U for chronic migraine.FDA NEWS RELEASE

For Immediate Release: Oct. 15, 2010

Discussion-Botulinum toxin

Oct. 15, 2010, FDA approves Botox to treat chronic migraine

To treat chronic migraines, Botox is given approximately every 12 weeks as multiple injections around the head and neck to try to dull future headache symptoms.

For chronic migraine use only.

Side effects of the botulinum toxin may spread from the area of injection to other areas of the body, causing symptoms similar to those of botulism.

Discussion-Benamine and novamin

2. The combination use of Benamine

and novamin

1/ 1/ 1/ 1/ 1/ 1/ 1/ 1/ 1/ 1/ 1/ 1/

4 5 6 7 8 9 10 11 12 13 14 15

1.5 IVA 1AMP

AMP Q8H Q12H

2 PO

CAP QN

Drug/Dose/Frequency/Route

Novamin inj 5 mg/ml 1 ml 1amp

Benamine cap 50 mg VPP

Discussion-Benamine and novamin

2. The combination use of Benamine and novamin Benamine(antihistamine)

• Diphenhydramine, for nausea, vomiting, and anti-allergy (such as rhinorrhea, rash, itching)

Novamin(dopamine antagonist)

• Prochlorperazine, for anti-emetic, anti-dizziness, for tension headache.

Benamine is used for the prevention of akathisia induced by novamin.

Discussion-Benamine and novamin

Benamine for the prevention of akathisia induced by novamin

Novamin(prochlorperazine)’s mechanism of antimetic action is related to directly affect the medullary chemoreceptor trigger zone(CTZ), apparently by blocking dopamine receptor in the CTZ.

The blocking dopamine receptor action may lead to strong extrapyramidal syndromes(EPS), akathisia.

Benamine(diphenhydramine) can work to treat the involuntary muscle movements or stiffness by blocking acetylcholine.

Discussion-depression

3. Drugs for patients with comorbidity – depression

In this case, patient has chronic migraine together with depression

Use antidepressants to treat and prevent patient’s disorders

Cymbalta (duloxetine hydrochloride) - SNRI

1/ 1/ 1/ 1/ 1/ 1/ 1/ 1/ 1/ 1/ 1/ 1/

4 5 6 7 8 9 10 11 12 13 14 15

1 PO

CAP BID

Cymbalta * cap 30 mg

Drug/Dose/Frequency/Route

Discussion-depression

Why choose SNRI?

serotonin and norepinephrine reuptake inhibitor

Cortical spreading depression (CSD)

Cortical spreading depression (CSD) is thought to be

a neuronal mechanism that expands the penumbra

zone after focal brain ischemia and that causes

migraine aura. Both adrenergic agonists and

antagonists significantly influence the size of the

penumbra zone and decline the frequency of

migraine.

Journal of Cerebral Blood Flow & Metabolism (2005)

25, 1225–1235.

Discussion-depression

NE(norepinephrine)

Because propagation of CSD is mainly driven by

excitatory neurotransmitters, for example, glutamate ,

we suppose that the inhibitory effect of NE is because

of the reduced/inhibited release of glutamate.

The inhibition of CSD initiation/migration is probably

because of an action of NE on presynaptic neuronal

α2-adrenoceptors. These receptors inhibit via G-

proteins the adenylate cyclase, which in turn inhibits

calcium currents necessary for the release of

glutamate.

Discussion-Mag. sulfate

4. Mag. sulfate

1/ 1/ 1/ 1/ 1/ 1/ 1/ 1/ 1/ 1/ 1/ 1/

4 5 6 7 8 9 10 11 12 13 14 15

7 IVA 5AMP

AMP QD STAT

Drug/Dose/Frequency/Route

Mag. Sulfate # inj 10% 20 ml

Discussion-Mag. sulfate

Magnesium Deficiency

One cause of migraine can

be a magnesium deficiency.

Anxiety disorders also have

a close link to magnesium

deficiencies.

Associations have been

noted between anxiety

disorders and migraines.

Symptoms of

Magnesium

Deficiency

Conditions

Linked to

Migraine

Sensitivity to noise

Headache

Mitral valve prolapse

Anxiety disorders

Heart disease

Menstrual Cramps

Nausea

Discussion-Mag. sulfate

Pharmacology

Magnesium blocks neuromuscular transmission and

decreasing the amount of acetylcholine liberated at

the end plate by the motor nerve impulse.

IV Mag. Sulfate Intravenous infusion of Mag. Sulfate results in rapid

relief of headache pain in patients with low serum Mg2+ levels.

Oral magnesium For prophylaxis, take low doses and it will make

more than 3 months of treatment to determine whether this is useful in reducing the migraines.

Am Fam Physician. 2009 Jul 15;80(2):157-162.

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