PATIENT CASE

PRESENTATION
HEADACHE: MIGRAINE AND TENSION TYPE

BALDADO, CHEZA MAY

BS – PHARMACY III-A
TYPES OF HEADACHE: MIGRAINE

is a common, recurrent, primary headache of moderate to

severe intensity that interferes with normal functioning and is
associated with GI, neurologic, and autonomic symptoms. In
migraine with aura, a complex of focal neurologic symptoms
precedes or accompanies the attack.
 • Twin studies suggest 50% heritability of migraine, with a multifactorial
polygenic basis. Migraine
MIGRAINE PATHOPHYSIOLOGY
• Replacing previous neuronal and vascular theories of
migraine pathophysiology, a combined theory has
emerged. Activity in the trigeminovascular system may
be regulated partly by serotonergic neurons within the
brainstem. Pathogenesis may be related to a defect in
the activity of neuronal calcium channels mediating
neurotransmitter release in brainstem areas that
modulate cerebral vascular tone and nociception. The
result may be vasodilation of intracranial extracerebral
blood vessels with activation of the trigeminovascular
system.

triggers may be modulators of

the genetic set point that
predisposes to migraine
headache.
• Specific populations of
serotonin (5-
hydroxytryptamine [5-HT])
receptors may be involved in the pathophysiology and treatment of migraine resulting in vasoconstriction and inhibition of vasoactive neuropeptide
headache. Acute antimigraine drugs such as ergot alkaloids and triptan release and pain signal transmission.
derivatives are agonists of vascular and neuronal 5HT1 receptor subtypes,

TENSION TYPE mechanisms are also

involved. Mental stress,
Tension-type headache is
nonphysiologic motor
the most common type
stress, a local myofascial
of primary headache and
release of irritants, or a
is more common in
combination of these
women than men. Pain is
may be the initiating
usually mild to moderate
stimulus. In predisposed
and nonpulsatile.
individuals, chronic,
Episodic headaches may
tension-type headache
become chronic.
can evolve. • After
activation of supraspinal
pain perception
TENSION TYPE
structures, a headache
PATHOPHYSIOLOGY
occurs because of central
Pain is thought to modulation of incoming
originate from peripheral stimuli.
myofascial factors and
peripheral sensitization
of nociceptors. Central

HISTORY OF PRESENT ILLNESS
Sarah Miller is a 34-year-old woman who presents to the Neurology
Clinic for a follow-up of migraine headaches. She states that she used to get
about two migraines every month; however, she recently went back to
work full-time and has two young children, ages 3 and 5, to care for. Since
then, the frequency of her migraines has increased to about four to five per
month. She states her migraines usually occur in the morning and are more
frequent around her menses. Her typical headache evolves quickly (within
1 hour) and involves severe throbbing pain which is unilateral and temporal
in distribution. Her headaches are preceded by an aura which consists of
nausea and pastel lights flashing throughout her visual field. Photophobia
occurs frequently, and vomiting may occur with an extreme headache. She
reports experiencing severe migraine attacks that cause her to miss 1 day of
work each month. She is unable to complete household chores and has a
difficult time caring for her children on the days she has severe migraine
attacks. She also complains of having mild migraine attacks lasting 3 days
per month during which her productivity at work and at home is reduced by
half. She typically has to retreat to a dark room and avoid any noise, or the
severity of the migraine increases. She rates her migraines as 7–8 on a
headache scale of 1–10, with 10 being the worst. At her previous visit to
the Neurology Clinic 3 months ago, she was prescribed naratriptan 2.5 mg
orally to be taken at the onset of headache. However, naratriptan has not
been effective for half of the migraines she has had in the last 3 months.
During two of the attacks, she experienced partial pain relief, with the pain
returning later in the day. She mentions that she was prescribed
naratriptan when the Cafergot she was taking stopped working. She states
she has taken her medications exactly as advised. She prefers to use
medications that can be taken orally.
She was started on valproic acid at her last clinic visit for headache
prophylaxis and has noticed a 10-lb weight gain. She inquires about
switching from valproic acid to another medication.
CHIEF COMPLAINT
“This new medication is not working for my migraines. My headaches are
worse around my period and I have gained 10 pounds!”
PAST MEDICAL HISTORY FAMILY MEDICAL HISTORY
Migraine with aura since 29, previous medical workup, increasing an ❖ Mother: Positive for migraines,
EEG and a head MRI, demonstrated no PVD, CVA, brain tumor, infection, Hypertension and Type II Diabetes
cerebral aneurysm or epileptic component. Drug therapies have included the ❖ Father: Positive for migraines
following:
SOCIAL HISTORY
Abortive therapies: ❖ Marital Status: Mother of 2 boys, ages 3 and 5
❖ Employment: Secretary, recently changed jobs to a full-time
1. Simple analgesics, NSAIDs and Cafergot (good efficacy until 3 months
positions.
ago)
2. Narcotics ( good efficacy, but puts her “ out of commission for days” )
3. Midrin (no efficacy) LIFESTYLE
4. Naratriptan (minimal efficacy)
❖ Alcohol: Denies alcohol use
❖ Smoking: 3 months ago due stress, 1ppd
Prophylactic therapies: ❖ Caffeine intake: Occasional
❖ Drugs: N/A
1. Valproic acid 500 mg daily (weight gain)
2. Propranolol 20mg BID (increase episodes of dizziness and light REVIEW OF SYSTEMS
headedness; patient discontinued medication)
Complains of increased frequency of migraine headaches starting
Mild depression for 8 months, treated such about 6 months ago; increased frequency around menses. Limited efficacy
with naratriptan; no nausea, vomiting, diarrhea, or flashing lights at present
1. Phenelzine 15mg po TID (minimal efficacy, discontinued 2 months
ago)
2. Sertraline 50 mg po at bed time (recently started 1 month ago)
  Temperature: 37.2ᵒC
 Pulse Rate: 76 bpm
 Respiratory Rate: 18cpm
 Blood Pressure: 142/86 mmHg
 Weight: 75kg
 Height: 5’3

General Survey
 WDWN woman in mild distress
Skin
 Normal skin turgor
 Diaphoresis (-)

HEENT

 PEERLA; EOMI; no fundoscopic exam performed

Neck
• Supple; no masses
All: NKDA • Thyroid enlargement
Physical Examination Findings • Bruits or IVD

Chest
Vital signs and Anthropometric Measurements
• Good breath sounds bilaterally; clear to A and P
  Fasciculations (-)
CV  Tremor or ataxia (-)
• RRR; S1, S2 normal; no murmurs, rubs or gallops  Romberg: CN II-XII intact
 Sensory intact
 DTRs: 2+ throughout
Abd  Babinski (-) bilaterally
 Soft, NT/ ND,
 Hepatosplenic (-)
 (+) BS

Gest/ Rect
 Deferred

MS/ Ext
 UE/ LE strength 5/5 with normal tone,
 Radial and femoral pulses 3+ bilaterally
 No edema
 No evidence of thrombophlebitis
 Full ROM

Neuro
 A and O x 3
 Dysarthria (-)
 Aphasia (-)
 Memory intact (+) LABORATORY RESULTS
 Nystagmus (-)
SERUM ELECTROLYTES HEMATOLOGY

Sodium (Na) 142 mEq/L COMPLETE BLOOD COUNT

Potassium (K) 4.2 mEq/L Results Reference Range

Chloride (Cl) 101 mEq/L Hemoglobin 13.0 g/dL 12-16 g/dL

Carbon Dioxide 23 mEq/L Hematocrit 40% 36-46%

WBC 8.0 × 103 / mm3 5-10 × 103 / mm3

DIFFERENTIAL COUNT ASSESSMENT

❖ Increase of frequency of migraines related to menses and increased
Results Reference Range stress.
❖ Minimal efficacy of naratriptan 25 mg po as an abortive treatment.
Blood Urea Nitrogen 12 mg/dL 10-20 mg/dL ❖ Previous prophylactic treatments have been unsuccessful and cause
(BUN) unwanted adverse effects.
Serum Creatinine 0.8 mg/dL <1.5 mg/dL ❖ Patient is hypertensive due to increase blood pressure count.
(SCr) ❖ Patient is overweight.
Glucose (Glu) 95 mg/dL <140 mg/dL

AST 23 U/L 5 - 40 U/L

ALT 23 U/L 29 - 33 U/L

Alk Phos 35 U/L 44 – 147 U/L

Platelet 302 × 103 / mm3 150–450 × 103 / mm3

MEDICATIONS

DRUG INDICATION COMPLIANCE

Naratriptan - reduces substances in the body that can trigger headache pain, Take 2.5-mg tablets, one tablet po at onset
sensitivity to light and sound, and other migraine symptoms. of migraine, repeat dose of 2.5 mg po in 4
hours if partial response or if headache
returns. Maximum of 5mg per 24 hours.
-a selective serotonin (5-HT1B/1D) agonist in intracranial blood vessels,
which causes vasoconstriction and reduction in oedema formation in the
meninges thus alleviating migraine. It is also thought to inhibit trigeminal
nerve activity.

Metoclopramide  It helps to prevent and relieve nausea and vomiting. Take 10mg po at onset of migraine
Valproic Acid -used on its own or together with other medicines to treat epilepsy (also Take 500 mg po at bed time
known as fits or seizures).

-Valproic acid may also be used to treat mood disorders such as bipolar
disorder, to prevent migraine headaches and other conditions

Sertraline -used to treat depression. Take 50 mg po at bed time

 -It can also be used to treat certain anxiety disorders such as social
anxiety disorder, panic disorder, posttraumatic stress disorder (a
condition that occurs after a very emotional traumatic experience),
obsessive-compulsive disorder or OCD (a disorder characterised by
uncontrollable urge to do repetitive and ritualised behaviours), and
premenstrual dysphoric disorder (a condition characterised by
depression, irritability and tension before menstruation).

PROBLEM LIST INTERVENTION/ ACTION

DRUG-DRUG INTERACTIONS:

Valproic Acid + Metoclopramide- may increase side effects such as dizziness, Use with caution. Seek medical attention if symptoms occur.
drowsiness, confusion, and difficulty concentrating. Some people, especially
the elderly, may also experience impairment in thinking, judgment, and motor
coordination.

Valproic Acid + Sertraline- may occasionally cause blood sodium levels to get
too low, a condition known as hyponatremia, and using it with valproic acid
can increase that risk. In addition, sertraline can cause seizures in susceptible
patients, which may reduce the effectiveness of medications that are used to Modify Therapy/Monitor closely sodium levels when used concomitantly
control seizures such as valproic acid.

Naratriptan + Sertraline - can increase the risk of a rare but serious condition
called the serotonin syndrome, which may include symptoms such as
confusion, hallucination, seizure, extreme changes in blood pressure,
increased heart rate, fever, excessive sweating, shivering or shaking, blurred
vision, muscle spasm or stiffness, tremor, incoordination, stomach cramp,
nausea, vomiting, and diarrhea. Severe cases may result in coma and even Modify Therapy/Monitor Closely
death.

Metoclopramide + Sertraline- can increase the risk of a rare but serious

condition called the serotonin syndrome, which may include symptoms such
as confusion, hallucination, seizure, extreme changes in blood pressure,
increased heart rate, fever, excessive sweating, shivering or shaking, blurred
vision, muscle spasm or stiffness, tremor, incoordination, stomach cramp,
nausea, vomiting, and diarrhea. In addition, movement disorders such as Use with caution. Seek medical attention if symptoms occur.
twitching of the jaw and limbs, teeth clenching, severe jerking, and tongue and
neck stiffness have been reported. 

Metoclopramide + Naratriptan- combi of these drugs is used to treat

nausea, and may also enhance absorption of these medications owing to
its prokinetic effect. 
 Modify Therapy/Monitor Closely

DRUGS-DISEASE INTERACTION:

Sertraline + Hypertension- Antidepressants work by changing your body's BP should be monitored.

response to brain chemicals, including serotonin, norepinephrine and
dopamine, that affect your mood. These chemicals may also cause an increase
in blood pressure.

Naratriptan + Hypertension- can raise blood pressure to dangerous levels. BP should be monitored. If you use naratriptan long-term, your heart function
may need to be checked using an electrocardiograph or ECG 

Metoclopramide + Hypertension- In a study involving patients with essential

hypertension, intravenously administered metoclopramide was shown to BP should be monitored. Therapy with metoclopramide should be
induce the release of catecholamines. administered cautiously in patients with hypertension because of potential
 increases in blood pressure.
Naratriptan + headache- reduces substances in the body that can
trigger headache pain, sensitivity to light and sound, and
other migraine symptoms. Naratriptan is used to treat migraine headaches. Modify Therapy/Monitor Closely

Valproic acid+ headache- works by restoring the balance of certain natural

substances (neurotransmitters) in the brain.

Modify Therapy/Monitor Closely

Naratriptan + overweight- decrease weight

Modify Therapy/Monitor Closely

Sertraline + overweight- can cause short-term weight loss by affecting your
appetite. This is most common during the first weeks of treatment.

Modify Therapy/Monitor Closely

Metoclopramide + overweight- rapid weight gain

Valproic acid+ overweight- indicates an association between valproic

acid therapy and weight gain. Weight gain during valproate treatment can be Modify Therapy/Monitor Closely
observed within the first 3 months of therapy and women seem to be more
susceptible than men

Modify Therapy/Monitor Closely

DRUG-ALCOHOL INTERACTION:

Naraptriptan + Alcohol- alcohol make headaches worse or cause new Avoid Alcohol.
headaches to occur.

Valproic Acid + Alohol- it is not recommended to mix high blood pressure

medications with drinking too much alcohol as it can have an effect on how
well they treat your condition.

Avoid Alcohol
Metoclopramide + Alcohol- alcohol can increase the side effects of sleepiness,
dizziness, and confusion from metoclopramide

Sertraline + Alcohol- can increase the nervous system side effects

Avoid Alcohol
of sertraline such as dizziness, drowsiness, and difficulty concentrating. Some
people may also experience impairment in thinking and judgment.

Avoid Alcohol
PHARMACIST CARE PLAN:

HEALTH CARE NEED PHARMACOTHERAPEUTIC GOAL RECOMMENDATION FOR MONITORING DESIRED FREQUENCY OF
THERAPY PARAMETERS ENDPOINT MONITORING
Prevention and migraine monitoring; therapy Topiramate Activity limitation; Controlled Daily
control of migraine management including factors assessment of the patient migraine attacks;
Candesartan(Atacand) or for modifiable exacerbating
attacks and that provoke migraine and tension-type
sumatriptan injections, the factors and comorbidities
tension type headache headache attacks
orzolmitriptan (Zomig) while managing prophylactic
nasal spray. and as needed treatments.

Metoclopramide
Encouraging the patient to
Sertraline
maintain a headache diary
will provide physicians with
a helpful tool for gauging
improvement and
identifying as-needed
medication
Naproxen

Tension type
headache

Prevention of BP control; management of - Candesartan(Atacand) , or BP monitor 120/80 or less Daily

hypertesion hypertension loasartan

- Dietary sodium restriction

mHg
 Overweight Weight reduction Weight loss Weight monitoring Decrease in
weight to have a
normal BMI
PHARMACIST NOTES:
Non- Pharmacologic Intervention
• Physical therapeutic options (e.g., heat or cold packs, ultrasound, electrical Pharmacologic Intervention
nerve stimulation, application of ice to the head and periods of rest or sleep,
 Adherence to migraine and tension type medications
usually in a dark, quiet environment, may be beneficial.
 Adherence to antihypertensive drugs
* Preventive management should begin with identification and avoidance
of factors that provoke migraine attacks. Get a regular blood lipid test
* Behavioral interventions (relaxation therapy, biofeedback, cognitive
therapy, reassurance and counseling, stress management, ) are preventive
options for patients who prefer nondrug therapy or when drug therapy is
ineffective or not tolerated.
* Physical therapeutic options (Massage, acupuncture, trigger point
injections, occipital nerve blocks) have performed inconsistently.
  Temperature: 37.2ᵒC
 Pulse Rate: 76 bpm
 Respiratory Rate: 18cpm
THERAPEUTICS PLANNING
 Blood Pressure: 142/86 mmHg
 Weight: 75kg
 Height: 5’3
1. IDENTIFY THE PROBLEMS

Step 1. Obtain Patient Data Step 2. Group Related Data

Subjective Data:
 “This new medication is not working for my migraines. My
headaches are worse around my period and I have gained 10
pounds!”
 Complains of increased frequency of migraine headaches
starting about 6 months ago;
 Increased frequency around menses.
 Limited efficacy with naratriptan; no nausea, vomiting,
diarrhea, or flashing lights at present
 Migraine with aura since 29
 Caffeine intake: Occasional
 Both parents migraine + (mother: hypertension and type II
diabetis)
Objective Data
Headache: Migraine Headache Group
Subjective Data:
 Complains of increased frequency of migraines for about four
to five per month.
 Increased frequency around menses.
 Typical headache evolves quickly (within 1 hour) and involves
severe throbbing pain which is unilateral and temporal in
distribution.
 Headaches are preceded by an aura which consists of nausea
and pastel lights flashing throughout her visual field.
Objective Data:
 Weight: 75kg,
 Blood Pressure: 142/86 mmHg
  Headache: Migraine and Tension type
 Hypertension
 Overweight
Hypertension Group
Step 4. Assess Each Problem
Subjective Data:
 Migraine: treated but uncontrolled
 Mother has a history of hypertension  Tension type: treated but uncontrolled
Objective Data: BP 142/82 mmHg  Hypertension: uncontrolled
 Overweight: uncontrolled

Tension- type Headache Group

1. PRIORITIZE THE PROBLEM
Subjective Data:
 Photophobia occurs frequently Step 1. Identify the Active Problem
 Patient has to retreat to a dark room and avoid any noise, or  Headache: Migraine and Tension type
the severity of the migraine increases.  Hypertension
 Patient rates her migraines as 7–8 on a headache scale of 1–  Overweight
10, with 10 being the worst.
Step 2. Identify the Inactive Problem

Objective Data:  N/A

 Weight: 75kg, Step 3. Rank the Problems
 Blood Pressure: 142/86 mmHg
Active problem that needs immediate therapeutic intervention
 Migraine headache
Step 3. Determine Each Problem
 Tension-type headache
  Hypertension Long-term Goal: Decrease the frequency, severity, and duration of
 Overweight tension type headache attacks. Avoid Headache medication escalation
and improve quality of life.
Active problem requiring less immediate therapeutic intervention
 Overweight

Problem No. 3: Hypertension

2. SELECT PATIENT – SPECIFIC DRUG INTERVENTION AND NON-DRUG
Short-term Goal: Monitor blood pressure on a daily basis.
INTERVENTION
Long-term Goal: Prevent morbidity and mortality by maintaining BP
Step 1. Determine the Short-term and Long-term goals to 120/80 mmHg or less.
Problem No. 1: Migraine Headache
Short-term Goal: Pharmacological and Non Pharmacological Problem No. 4: Overweight
Management of migraine attacks
Short-term Goal: Refer the patient to nutritionist for dietary
Long-term Goal: Decrease the frequency, severity, and duration of counselling; initiate an exercise program.
migraine attacks Avoid Headache medication escalation and improve
quality of life. Long term goal: Weight loss by reducing calories and practicing
healthier eating habits regularly exercising and following the diet
recommended by nutritionist to overcoming obesity.
Problem No. 2: Tension- type Headache
Short-term Goal: Pharmacological and Non Pharmacological Step 2. Create a list of options
Management of tension type headache attacks
Problem No. 1: Migraine
  Level A (medications that have proven effectiveness and
should be offered to patients who require migraine
prophylaxis): Sodium valproate, valproic acid, propranolol,
timolol, topiramate, sumatriptan, zolmitriptan
 Level B (medications that are probably effective and should be
considered for migraine prevention): Amitriptyline, feverfew,
naproxen, fenoprofen, ketoprofen, ibuprofen, magnesium,
atenolol, venlafaxine, riboflavin, histamine.
 Level C (medications with possible effectiveness and may be
considered for migraine prevention): Candesartan,
carbamazepine, lisinopril, pindolol, nebivolol, clonidine,
cyproheptadine, coenzyme Q10.
 During a migraine headache, a cold pack may give short term
relief, stress management, physical therapy
 Methysergide and phenelzine are used as last resorts for
severe and refractory cases
Problem No. 2: Tension-Type Headache
 Simple analgesics (alone or in combination with caffeine) and
NSAIDs
 Nonpharmacologic therapies include reassurance and
counseling, stress management, relaxation training, and
biofeedback. Physical therapeutic options (e.g., heat or cold
packs, ultrasound, electrical nerve stimulation, massage,
acupuncture, trigger point injections, occipital nerve blocks)
have performed inconsistently.
 Acetaminophen, aspirin, ibuprofen, naproxen, ketoprofen,
indomethacin, and ketorolac are effective.
 High-dose NSAIDs and the combination of aspirin or
acetaminophen with butalbital or, rarely, codeine, are
effective options. The use of butalbital and codeine
combinations should be avoided when possible.
 Acute medication for episodic headache should be taken no
more often than 2 days/wk to prevent development of chronic
tension-type headache.
Problem No. 3: Hypertension
 Diuretics (loop diuretics [Furosemide], Potassium sparing,
thiazide)
 Alpha1 Blockers ( Doxazosin, Prazosin, Terazosin)
 Alpha2 Agonists (Clonidine)
 ACE Inhibitors (Enalapril, Captopril)
 ARBs (Candesartan, Losartan)
  Ca Channel Blockers (Amlodipine, Diltiazem)
 Vasodilators ( Diazoxide, Fenoldopam, Hydralazine)
Problem No. 4: Overweight
 Sympathomimetics (phentermine, diethylpropion, ephedra)
 Drugs that inhibit absorption (Orlistat)
Step 3. Eliminate Options based on Patient-Specific and External
Factors
Problem No.1: Migraine Headache
Initial medical therapy consists of oral administration including,
abortive treatments, (naratriptan) used only to treat headache and do
not relieve pain from back problems, arthritis, menstruation, or other
conditions. antidopaminergic (metoclopramide) antagonize the
dopamine D2 receptor, also used to treat nausea and vomiting seen in
acute migraines, anticonvusant (valproic acid) drug that prevent or
reduce seizures and headaches.
Problem No. 2: Tension-type Headache
Initial medical therapy consists of oral administration including,
abortive treatments, (naratriptan) used only to treat headache and do
not relieve pain from back problems, arthritis, menstruation, or other
conditions. antidopaminergic (metoclopramide) antagonize the
dopamine D2 receptor, also used to treat nausea and vomiting seen in
acute migraines, anticonvusant (valproic acid) drug that prevent or
reduce seizures and headaches.
Problem No. 3: Hypertension
Beta blockers treat high blood pressure and other conditions, such as
heart problems. ACE inhibitors are also used to treat a number of
heart-related conditions, including high blood pressure, heart failure,
heart attack. Calcium-channel blockers work by slowing the
movement of calcium into the cells of the heart and blood vessel
walls, which makes it easier for the heart to pump and widens blood
vessels. As a result, the heart doesn't have to work as hard, and blood
pressure lowers.
Problem No. 4: Overweight
Common treatments for overweight include losing weight through
diet change, healthy eating and being more physically active.
Step 4. Select Appropriate Drug and Non-drug Intervention
Problem No.1: Migraine Headache
Early pharmacologic therapy recommended in the case of the patient
includes (1) As a headache preventive, topiramate may be a good
choice. It will not cause weight gain and may decrease appetite for
some period of time.  (2) Since Naratriptan given had a minimal
efficacy to the patient, can be employed where it lowers blood
pressure and used in the treatment of migraine prevention.
Problem No. 2: Tension-type Headache
The use of naproxen, can break the cycle of recurrent tension-type
headaches or you can apply an ice compress, heating pad or massage
to any tight areas in the neck and shoulders.  Relaxation techniques
and deep-breathing exercises may help to decrease the frequency
and severity of headaches. Some people get relief with biofeedback
or acupuncture.   is not tolerated well.
Problem No. 3: Hypertension
Candesartan is a widely used angiotensin-receptor blocker (ARB)
that may be used alone or with other agents to treat
hypertension and congestive heart failure.  serotonin and norephinephrine thus leading to improvement in
Problem No. 4: Overweight
As for the case of the patient, to overcome obesity. Patient is advised
to do regular exercise. Diet modification may be recommended by
nutritionist.
Step 5. Identify Alternative Therapeutic Intervention
Problem No.1: Migraine Headache
If the drug therapy recommended is ineffective, then drugs shall be
replaced with its alternatives. If patient did not respond to topiramate
then zonisamide can also be employed along with sumatripan IV or
zolmitriptan nasal spray for most efficient and immediate relief for
pain. Zonisamide is as effective as topiramate in migraine prophylaxis
and can be considered as an alternative treatment when topiramate
Problem No. 2: Tension Type Headache
For the patient’s headaches, other than naproxen, the use of
amitriptyline can be employed to influence the body's use of
depression and several types of chronic pain. It is used to treat
chronic tension-type headache as well as migraine headache.
Problem No. 3: Hypertension
If antihypertensive drugs recommended is ineffective, incorporate
metoprolol with hydrochlorothiazides (a diuretic). Being physically
active is also recommended including diet modification.
Problem No. 4: Overweight
Anti-obesity medications approved by the FDA include Orlistat. Close
medical monitoring is needed while taking a prescription weight-loss
medication.
 In case of nausea, continue with the prescribed antiemetic
drug metoclopramide.
 Recommend patient to consider replacing naratriptan with a
more effective and immediate treatment other than oral such
as sumatriptan injections, the most effective form, or
zolmitriptan (Zomig) nasal spray.
 Advise patient to do regular exercises to decrease weight
 Refer the patient to the nutritionist for diet recommendations
 Methysergide and phenelzine are used as last resorts if other
migraine-prevention drugs is/are unresponsive

Initial Treatment Regimen

The following nondrug and drug interventions are recommended for
the patient:
 Valproic acid be replaced with Topiramate 25 mg one at night
for the first 6 nights. If that initial dose is tolerated, I would
suggest increasing to 50 mg at night. Utilizing the topiramate
at night may minimize cognitive side effects and fatigue.

 ARBs treatment such as candesartan (Atacand) or losartan. It

lowers blood pressure and used in the treatment of migraine
prevention.
 Naproxen, used to treat chronic tension-type headache as well
as migraine headache.

DRUG THERAPY MONITORING
CASE STUDY
Sarah Miller is a 34 year old woman, a mother of 2 boys, ages 3 and 5 who
works as a full time secretary. Patient’s past medical history of migraine with
aura since 29 and with both parents positive with migraine. She complains of
naratriptan having a minimal efficacy, an increase of frequency of migraine
around her menses, stress and inquires for a switch of her prescribed
valproic acid medication that resulted an unwanted adverse effect of a 10-lb
weight gain. The goal of therapy for migraine prevention is a reduction of
frequency, severity and duration of the migraine attacks and the prevention of
medication overuse and medication-overuse headache and to improve
patient’s quality of life.
Topiramate Monitoring Parameters
Subjective-therapeutic parameters- The patient’s experienced symptoms will
decrease, the frequency of having the migraine attacks or be controlled if
topiramate provides the expected therapeutic benefit.
Subjective-toxic monitoring parameters – The patient’s experienced
symptoms will not be  resolved. Migraine attacks will not be controlled and
may continue to increase if does not provide expected therapeutic outcome.
The patient may also experience weight loss. 
Objective-therapeutic parameters- Fasting Blood Sugar and Random Glucose
test are used to monitor improvement in attaining normal blood sugar level
Objective- toxic parameters- Fasting Blood Sugar and Random Glucose test
are used to monitor for lack of improvement in attaining normal blood sugar
level.
Candesartan monitoring Parameters
Subjective-therapeutic parameters- The patient’s blood pressure will
normalize if Candesartan provides the expected therapeutic benefit.
Subjective-toxic monitoring parameters- The patient’s blood pressure will
not normalize and may continue to increase if Candesartan does not provide
expected therapeutic outcome. The patient may have high risk to develop
nephropathy
Objective-therapeutic parameters- Blood Pressure testing is used to monitor
improvement in attaining normal blood pressure.
Objective- toxic parameters- Blood Pressure testing is used to monitor lack
of improvement in attaining normal blood pressure.
Naproxen monitoring Parameters
Subjective-therapeutic parameters- The patient’s tension headache will be
controlled if Naproxen provides the expected therapeutic benefit.
Subjective-toxic monitoring parameters- The patient’s tension headache will
not be controlled and may continue to increase if naproxen does not provide
expected therapeutic outcome.
Objective-therapeutic parameters- Activity limitation; assessment of current
headache: migraine attack severity and frequency, factors that provoke
migraine and tension type headache
Objective- toxic parameters- Activity limitation; assessment of current
headache: migraine attack severity and frequency, factors that provoke
migraine and tension type headache
Sertraline monitoring Parameters
Subjective-therapeutic parameters- The patient’s mild depression will be
manage along with relief of symptoms if sertraline provides the expected
therapeutic benefit.
Subjective-toxic monitoring parameters – The patient’s mild depression will
not be manage and no relief of symptoms if Sertraline does not provide the
expected therapeutic benefit. Long term use can cause physical dependence
and patient may experience annoying side effects such as loss of orientation,
headache and sleep disturbance.
Objective- toxic parameters- Several psychiatric review test (manic-
depression and bipolar screening test) are used to monitor lack of
improvement in attaining reduction of episodes.
Integrated Monitoring Plan
The drugs in the therapeutic regimen are prescribed for the
management of Headache: Migraine and Tension type and other comorbidity
such as Hypertension and Overweight. Headache: Migraine and Tension type
are important therapeutic and toxic monitoring parameters for several of the
drugs in medication regimen because conditions associated with these may
increase the risk of complications.
The patients need frequent assessment of the patient for modifiable
exacerbating factors and comorbidities while managing prophylactic and as
needed treatments, so as blood pressure in response to therapy. Patient
should weigh on daily basis to achieve the goal of losing weight and
overcome obesity.  Drug therapy is highly recommended. The aim of therapy
for migraine prevention is a reduction of frequency, severity and duration of
the migraine attacks and the prevention of medication overuse and
medication-overuse headache and to improve patient’s quality of life.

Objective-therapeutic parameters- Several psychiatric review test (manic-

depression and bipolar screening test) are used to monitor improvement in
attaining reduction of episodes.
 BP: ≤ 120 /80 mmHg

↓weight
Subjective -Toxic Objective - Toxic
↑headache ↑Blood Pressure
MONITORING PLAN
Subjective- Objective - BP: > 120 /80
Therapeutic Therapeutic mmHg
↓frequency and ↓Blood Pressure
severity of migraine ↑weight
and tension type BP: ≤ 120 /80 mmHg Candesartan Monitoring Plan
headache
↓weight
Subjective- Objective -
Subjective -Toxic Objective - Toxic Therapeutic Therapeutic
↑ frequency and ↑Blood Pressure ↓anxiety ↓frequency of
severity of migraine depressive episodes
and tension type BP: > 120 /80
headache mmHg Subjective -Toxic Objective - Toxic
↑headache ↑frequency of
↑weight ↑sleep disturbance depressive episodes
Topiramate Monitoring Plan ↑anxiety
Sertraline Monitoring Plan

Subjective- Objective -
Therapeutic Therapeutic
↓headache ↓Blood Pressure
 ↑tolerance to
exercise and diet

Subjective -Toxic Objective - Toxic

↑Blood Pressure
INTEGRATED MONITORING PLAN General: will not be BP:>120 /80 mmHg
able to control blood
Subjective- Objective -
pressure and ↑weight
Therapeutic Therapeutic
monitor weight; able
↓Blood Pressure
to manage manic ↑frequency of
General: able to BP ≤ 120 /80 mmHg
depressive attacks manic-depressive
control blood
and migraine and episodes
pressure and ↓weight
tension type
monitor weight; able
headache attacks.
to manage mild ↓frequency of
depression and depressive episodes
↑blood pressure
migraine and
tension type
↑ frequency,
headache attacks.
severity, and
duration of migraine
↓ frequency,
attacks
severity, and
duration of migraine
↓tolerance to
attacks
exercise and diet
↓weight

↓blood pressure
References
Ma'am cols
Wells, Barbara, et.al (2006). Pharmacotherapy Handbook.6th Edition.
McGrawHill Education, Singapore
http://reference.medscape.com/drug-interactionchecker
www.ncbi.nlm.nih.gov/pubmed/16493121
www.drugs.com/drug-interactions
Do These Foods Cause Migraines? (webmd.com)