NURS 6521 wk 4 Essay Discussion
Neurological Disorder: Headaches (HA)
According to the World Health Organization (WHO), HA disorders affect at least half the adult population once a year. HAs can be classified as either primary or secondary. Primary diagnosis is achieved when all secondary diagnosis possibilities are ruled out. Examples of primary HAs are tension headaches (THA), migraines, and cluster headaches (CHA). Examples of secondary HAs are those caused by head/neck trauma, vascular disease of the cranial or cervical areas, substance abuse (including withdrawal), and diseases of the cranium to name a few (Arcangelo, & Peterson, 2013). This discussion will be focused on the pharmacotherapy of primary HAs.NURS 6521 wk 4 Essay Discussion
Pharmacotherapy for HAs
First line therapy for mild to moderate THAs is the use of acetaminophen (Tylenol) or aspirin (ASA). These medications are to be used no more than two times per week or they risk causing chronic headaches.NURS 6521 wk 4 Essay Discussion This situation is termed medication overuse headache (MOH). Tylenol has a max single dose of 650 mg along with a max of 3250 mg in one 24-hour period. Second line therapy for THAs is the use of NSAIDs (naproxen, ibuprofen) with or without the addition of an antiemetic (prochlorperazine, metoclopramide). If the previously mentioned interventions fail to decrease symptoms, then the practitioner may consider a barbiturate and caffeine combined with either acetaminophen or aspirin (Fiorinal, Fioricet). These combinations have a high risk for addiction and are not to be used more than three times in one month (Arcangelo, & Peterson, 2013). Paracetamol 1000 mg, ibuprofen 400 mg, and ketoprofen 25 mg were found to decrease moderate/severe THA symptoms within 2 hours of administration in a 2014 review conducted by Moore, Derry, Wiffen, Straube, and Bendtsen.
Migraines
Similar to THAs, fist line therapy in treating mild migraines is using Tylenol and ASA. If the migraine is moderate to severe, triptans (sumatriptan, zolmitriptan), as well as NSAIDs, may be used as first-line therapy. Triptans have a broad range of peak onset, duration, efficacy, and side effects that also differ on route of administration. Careful consideration of the patient and comorbidities need to be assured when prescribing triptans. If the migraine is resistant to above therapy, compounds combined with caffeine (Excedrin) or NSAIDs can be used as second-line therapy. Ergotamine derivatives may be attempted if above have failed. Third-line therapy involves the barbiturate combinations mentioned previously. Opioid combinations (Percocet, Vicodin) may be used as “rescue” therapy but are not encouraged for regular use by patients (Arcangelo, & Peterson, 2013). A 2015 literature review by Marmura, Silbersteine, and Schwedt supported the above therapies by naming triptans, NSAIDs, ergotamine derivatives along with opioids as the most effective therapy for acute migraines.NURS 6521 wk 4 Essay Discussion
Cluster HAs
CHAs are rare and need to be consulted with a neurology specialist. Medications found to be effective in treating acute CHAs were subcutaneous sumatriptan, zolmitriptan nasal spray, and oxygen. The use of nasal spray sumatriptan, oral zolmitriptan, codeine/lidocaine nasal spray, and sphenopalatine ganglion stimulation were found to have less evidence to support their utilization. As far as decreasing exasperations, suboccipital steroid injections were found to have the strongest evidence for efficacy (Robbins et al., 2016).
Factor: Gender
Migraine headaches can affect up to 14% of women and 6% of men. Migraines have also been found to have a close link with females in certain families (Arcangelo, & Peterson, 2013). Women are at particularly high risk for migraines before and during menopause (Martin et al., 2016). Migraines may actually decrease after the first trimester in some pregnancies. Unfortunately, triptans and the ergot derivatives are not recommended in pregnancy due to their teratogenic effects. Tylenol is seen as the safest drug to use during pregnancy, and a combination of it with codeine may be utilized infrequently while pregnant (Arcangelo, & Peterson, 2013). A 2015 study by Marchenko et al. found that triptans use during pregnancy does not seem to affect birth defects or prematurity, but the authors say further research is still needed on their effect on spontaneous abortions.NURS 6521 wk 4 Essay Discussion
Factors that I would take into consideration when treating this patient population is to ensure individualized treatment. I would need to know if the patient suffering migraines was pregnant or planning on becoming pregnant. If so, I would conduct patient teaching on the limitations we have on prescriptions available, on using Tylenol appropriately and utilizing non-pharmacological interventions. Spiritual meditation was found to increase tolerance to migraine severity and decrease use of analgesics (Wachholtz, Malone, & Pargament, 2015). If pregnancy was not a factor and the patient was on hormone replacement, I would conduct education in that hormone replacement therapy may increase the incidence of migraines by as much as 40%. If the patient’s HAs are tied to menses, frovatriptan has been shown to be efficacious in treating these types of migraines (Arcangelo, & Peterson, 2013). NURS 6521 wk 4 Essay Discussion