PATIENT CASE

College of PRESENTATIO
Nursing
Pharmacy N
Allied Headache:
Health Migraine and Tension type
Sciences

Cheza May B. Baldado

BS- Pharmacy III-A
 Migraine
It 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.
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TYPES OF HEADACHE:
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 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
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vasodilation of intracranial extracerebral blood

vessels with activation of the trigeminovascular
system.

Twin studies suggest 50% heritability of

migraine, with a multifactorial polygenic basis.
Migraine 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 headache. Acute antimigraine drugs
such as ergot alkaloids and triptan derivatives
are agonists of vascular and neuronal 5HT1
receptor subtypes, resulting in vasoconstriction
and inhibition of vasoactive neuropeptide
release and pain signal transmission
 TENSION TYPE HEADACHE
is the most common type of primary headache and is more
common in women than men. Pain is usually mild to moderate
and nonpulsatile. Episodic headaches may become chronic.
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 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
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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
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headaches are worse around

my period and I have gained
10 pounds!”
 Past Medical History:
-Type 2 DM x 6 months
-HTN x 17 years
Migraine with aura since 29, previous medical workup, increasing an
EEG and a head MRI, demonstrated no PVD, CVA, brain tumor,
College of infection, cerebral aneurysm or epileptic component. Drug therapies have
included the following:
Nursing  
Abortive therapies:
Pharmacy 1.Simple analgesics, NSAIDs and Cafergot (good efficacy until 3
Allied months ago)
2.Narcotics ( good efficacy, but puts her “ out of commission for
Health days” )
Sciences 3.Midrin (no efficacy)
4.Naratriptan (minimal efficacy)
Prophylactic therapies:
5.Valproic acid 500 mg daily (weight gain)
6.Propranolol 20mg BID (increase episodes of dizziness and light
headedness; patient discontinued medication)
Mild depression for 8 months, treated such
7.Phenelzine 15mg po TID (minimal efficacy, discontinued 2 months
ago)
8.Sertraline 50 mg po at bed time (recently started 1 month ago)
 Family Medical History:

Mother: Positive for migraines,

* Hypertension and
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* Type II Diabetes

Father: Positive for migraines

 SOCIAL HISTORY
Marital Status: Mother of 2 boys, ages 3 and 5
Employment: Secretary, recently changed jobs to a full-time
positions.
 
LIFESTYLE
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Alcohol: N/A
Smoking: 3 months ago due stress, 1ppd
Caffeine intake: Occasional
Drugs: N/A
 
REVIEW OF SYSTEMS
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
 
 ASSESSMENT
❖ Increase of frequency of migraines related to menses
and increased stress
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❖ Minimal efficacy of naratriptan 25 mg po as an abortive

treatment
❖ Previous prophylactic treatments have been unsuccessful
and cause unwanted adverse effects

Patient is hypertensive due to increase blood pressure count.

Patient is overweight.
 Laboratory Results
SERUM ELECTROLYTES
Sodium (Na) 142 mEq/L

Potassium (K) 4.2 mEq/L

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Chloride (Cl) 101 mEq/L

Carbon Dioxide 23 mEq/L

HEMATOLOGY
COMPLETE BLOOD COUNT

Results Reference Range

Hemoglobin 13.0 g/dL 12-16 g/dL

Hematocrit 40% 36-46%

WBC 8.0 × 103 / mm3 5-10 × 103 / mm3

 DIFFERENTIAL COUNT

Results Reference Range

Blood Urea Nitrogen 12 mg/dL 10-20 mg/dL

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(BUN)
Serum Creatinine 0.8 mg/dL <1.5 mg/dL
(SCr)
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

 Vital Signs
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BP HR RR T

142/86 mmHg 76 bpm 18 37.2

Weight Height

75 kg. 5’3”
 Medications
DRUG INDICATION COMPLIANCE
Naratriptan - reduces substances in the body that can trigger Take 2.5-mg tablets, one tablet po
headache pain, sensitivity to light and sound, and other  at onset of migraine, repeat dose
migraine symptoms. 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
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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 Take 500 mg po at bed time
treat epilepsy (also 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 INTERACTION INTERVENTION/ACTION
DRUG-DRUG
INTERACTIONS:
Valproic Acid + may increase side effects such as dizziness, Use with caution. Seek
Metoclopramide drowsiness, confusion, and difficulty concentrating. medical attention if
Some people, especially the elderly, may also symptoms occur.
experience impairment in thinking, judgment, and
motor coordination.
may occasionally cause blood sodium levels to get
too low, a condition known as hyponatremia, and
Valproic Acid + Sertraline using it with valproic acid can increase that risk. In Modify Therapy/Monitor
addition, sertraline can cause seizures in susceptible closely sodium levels when
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patients, which may reduce the effectiveness of used concomitantly

medications that are used to control seizures such as
valproic acid.
combi of these drugs is used to treat nausea, and may
Metoclopramide + also enhance absorption of these medications owing to Modify Therapy/Monitor
Naratriptan its prokinetic effect.  Closely
can increase the risk of a rare but serious condition
Naratriptan + Sertraline called the serotonin syndrome, which may include
symptoms such as confusion, hallucination, seizure,
extreme changes in blood pressure, increased heart Modify Therapy/Monitor
rate, fever, excessive sweating, shivering or shaking, Closely
blurred vision, muscle spasm or stiffness, tremor,
incoordination, stomach cramp, nausea, vomiting,
and diarrhea. Severe cases may result in coma and
even death.
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 DRUGS-DISEASE INTERACTION:
 Sertraline + Hypertension-
Naratriptan + Hypertension-
Metoclopramide
Hypertension-
Naratriptan + headache-
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Antidepressants work by changing your body's response to
brain chemicals, including serotonin, norepinephrine and
dopamine, that affect your mood. These chemicals may
also cause an increase in blood pressure.
can raise blood pressure to dangerous levels.
In a study involving patients with essential hypertension,
intravenously administered metoclopramide was shown to
+ induce the release of catecholamines.
reduces substances in the body that can
trigger headache pain, sensitivity to light and sound, and
BP should be monitored.
BP should be monitored. If you
use naratriptan long-term, your heart
function may need to be checked using
an electrocardiograph or ECG 
BP should be monitored. Therapy with
metoclopramide should be
administered cautiously in patients
with hypertension because of potential
increases in blood pressure.

other migraine symptoms. Naratriptan is used to Modify Therapy/Monitor Closely

treat migraine headaches.  
works by restoring the balance of certain natural substances Modify Therapy/Monitor Closely
(neurotransmitters) in the brain.  
Valproic acid+ headache-

decrease weight Modify Therapy/Monitor Closely

Naratriptan + overweight-  
Sertraline + overweight-
Metoclopramide + overweight-   indicates an association between valproic acid therapy
Valproic acid+ 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
Modify Therapy/Monitor Closely
rapid weight gain  
Modify Therapy/Monitor Closely
and weight gain. Weight gain during valproate treatment can  
be observed within the first 3 months of therapy and women
seem to be more susceptible than men

 
 PHARMACIST CARE PLAN
HEALTH CARE PHARMACOTHERAPEUTIC RECOMMENDATION MONITORING DESIRED FREQUENCY OF
NEED GOAL FOR THERAPY PARAMETERS ENDPOINT MONITORING

Prevention and migraine monitoring; therapy Topiramate Activity limitation; Controlled Daily
control of management including assessment of the migraine
migraine factors that provoke migraine Candesartan(Atacand) patient for modifiable attacks;
attacks and and tension type headache or sumatriptan exacerbating factors tension-type
injections, the or and comorbidities headache
  zolmitriptan (Zomig) while managing attacks
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nasal spray. prophylactic and as

  needed treatments.
  Metoclopramide  
  Sertraline Encouraging the
patient to maintain a
    headache diary will
    provide physicians
with a helpful tool for
    gauging improvement
and identifying as-
needed medication
tension type Naproxen
headache
Prevention of BP control; management of - BP monitor 120/80 or less Daily
hypertesion hypertension Candesartan(Atacand) ,
or 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
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Physical therapeutic options (e.g., heat or cold packs,

ultrasound, electrical nerve stimulation,application of
ice to the head and periods of rest or sleep, usually in
a dark, quiet environment, may be beneficial.
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.
 PHARMACOLOGIC INTERVENTION
❖ Adherence to migraine and tension type medications
❖ Adherence to antihypertensive drugs
❖ Adhere to the decisions you make
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❖ Control universal triggers by maintaining a healthy

lifestyle of regular sleep, exercise and eating plan,
practicing relaxation and stress management techniques
❖ Seek professional help if necessary
 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
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increasing to 50 mg at night. Utilizing the topiramate at night

may minimize cognitive side effects and fatigue.
Naratriptan replaced with ARBs such as candesartan (Atacand) or
losartan. It lowers blood pressure and used in the treatment of
migraine prevention.
In case of nausea, prescribe 8 mg ondansetron, as this is the only
antiemetic that is non-sedating.
Recommend patient to consider 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
 Subjective- Objective - to manage manic ↑frequency of ↑Blood Pressure
Therapeutic Therapeutic depressive attacks manic-depressive
↓Blood Pressure and migraine and episodes General: will not be BP:>120 /80 mmHg
General: able to BP ≤ 120 /80 mmHg tension type able to control blood
control blood headache attacks.
pressure and ↓weight
pressure and ↑weight
monitor weight; able ↑blood pressure monitor weight; able
to manage mild ↓frequency of to manage manic ↑frequency of
depression and depressive episodes ↑ frequency,
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migraine and severity, and depressive attacks manic-depressive

tension type duration of migraine and migraine and episodes
headache attacks. attacks
tension type
↓ frequency, ↓tolerance to headache attacks.
severity, and exercise and diet
duration of migraine
attacks ↑blood pressure
↓weight
↑ frequency,
↓blood pressure severity, and
duration of migraine
↑tolerance to
exercise and diet attacks
Subjective -Toxic Objective - Toxic
↑Blood Pressure
↓tolerance to
General: will not be BP:>120 /80 mmHg exercise and diet
able to control blood
pressure and ↑weight
monitor weight; able
 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:
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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.
 REFERENCES:

Wells, Barbara, et.al (2006). Pharmacotherapy

Handbook.7th Edition. McGrawHill Education, Singapore
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http://reference.medscape.com/drug-interactionchecker
www.ncbi.nlm.nih.gov/pubmed/16493121
www.drugs.com/drug-interactions
Migraine Headache Medications, Symptoms, Causes, Tre
atment (medicinenet.com)
 Thank you.

College of
Nursing
Pharmacy
Allied
Health
Sciences