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32 case sTudy Cluster headache in a 24 year old woman a 24-year-old female patient presented with a four year history of daily headaches. She reported 8-10 attacks per day and the duration of attacks lasted from 30- 90 minutes. Most of these attacks would occur spontaneously but she always got an attack awakening her from sleep at around 2am. When she awoke with this attack it would make her restless and agitated, forcing her to pace the bedroom floor until it subsided after approximately 30 minutes. The typical clinical characteristics of her headaches and associated symptoms were: • Abrupt in onset and occurred without warning • Always unilateral in location in the left periorbital/frontal region and extending to the temple • Duration 30-90 minutes • Sharp, piercing and burning in character • Very severe • Forehead sweating • Associated with restlessness, agitation and a feeling like ‘banging’ her head off a wall • Ipsilateral conjunctival tearing • Ipsilateral conjunctival reddening • Ipsilateral nasal congestion. • Ipsilateral nasal rhinorrhoea. • Ipsilateral ptosis of left upper eye lid. • Ipsilateral miosis of left pupil. Other symptoms associated with some attacks included intermittant photophobia, Prevalence Common: 10-12 per cent population phonophobia, nausea and occasional vomiting. The rest of the physical and neurological examination was normal. These headaches were having a major impact on her life. She was unable to get any relief from the attacks and as an acute therapy she was consuming up to 10 paracetamol daily without benefit. She was also on amitriptylline 25mg nocte as a preventive therapy, with no resultant change in the frequency of attacks. Over the years she had tried many other analgesics and preventive therapies without benefit. In addition she had been prescribed courses of antibiotics for a presumptive diagnosis of chronic sinusitis. Her life was being controlled by the headaches and she was unable to pursue a career or get a job. She previously had been working as a clerical officer but was forced to give up her job. Her social life had become non-existent. During this four-year period she had attended emergency departments and GP out-of-hours services on many occasions, all of whom either diagnosed ‘severe migraine’ or ‘sinusitis’ and for immediate pain relief she was treated acutely with either parenteral courses of nSAIDs or narcotic agents, all of which were ineffective. Investigations carried out over the four-year period included a CTScan brain, CTScan sinuses, MRI scan brain and many blood tests, all of which were entirely normal. This patient has a diagnosis of chronic cluster headaches, a benign primary headache disorder. Migraine Cluster headache Femalea:Male 3:1 1:5 Rare:0.5 per cent Population Frequency of attacks 2 attacks per month 2-8 attack per day Duration 4-72 hours 15 minutes –180 minutes Headache Unilateral (70 per cent) or bilateral (30 per cent) Always unilateral Character of headache Throbbing and Pounding Sharp/piercing or ‘boring’ Location Vary from frontal to temporal, parietal and occipital locations. Periobital, orbital and temporal in location severity Severe Excruciatingly painful autonomic symptoms Seldom Frequent nausea / vomiting Common Rare Photophobia and Phonophobia Common Rare impact Patient needs to lie down in a quiet dark room Patient becomes restless, agitated and paces the floor issue 10 volume 12 • novemBeR 2010 dr edwArd M. o’sullIvAN ClINICAl dIreCtor HeAdACHe/MIGr AINe dePArtMeNt of NeuroloGy Cork uNIversIt y HosPItAl ANd GP Cork CIt y. At her initial consultation, the following management plan was put in place: • Keep a headache diary • Discontinue paracetamol and amitriptylline • As an acute therapy, the patient was commenced on 100 per cent oxygen through a non re-breathing mask at a high flow rate of 7-10 litres per minute for 15 minutes for each attack. • As a preventive therapy, she was prescribed verapramil 240mg daily. • Patient was advised to stop smoking. Ten days after presentation the patient was followed-up with a telephone consultation. She was much improved. Her cluster attack rate was now two per day and the attacks were relieved by the oxygen therapy within 10 minutes. The attacks were also less severe. At a subsequent telephone consultation another week later the patient was experiencing her first headache-free days in four years. The frequency of attacks was 1-2 per day and with the oxygen therapy, the attack was aborted in 10 minutes. discussion Cluster headache is a rare primary benign headache disorder which exists in acute and chronic forms. It is characterised by a headache described as being excruciatingly painful and known as one of the ‘worst pains known to man’. Women have described it as being more painful then childbirth. Many patients have been driven to suicide because of their severity. The headache is always a unilateral headache typically located in the periorbital/orbital and temporal regions with ipsilateral autonomic symptoms: conjunctival tearing, reddening, nasal congestion, rhinnorhoea, ptosis and miosis. The case study outlined is a text book description of the disorder, nevertheless the patient went for many years without a correct diagnosis and as a consequence the most appropriate treatment choices to optimise her care were never prescribed. The delay in diagnosis I would attribute to the rarity at which cluster headache is encountered in clinical practice. Many doctors will only see a few cases during the course of their career. It is most often wrongly diagnosed as migraine which, by comparison, is the most frequent headache disorder for which a patient attends their doctor. The clinical symptoms which differentiate between migraine and cluster headache are tabulated below. neurophysiology The understanding of the neuro/ pathophysiology mechanisms of cluster headaches is hypothesised on the activation and integration of the trigeminovascular and cranial parasympathetic systems. The ophthalmic division of the trigeminal nerve is the pain sensitive pathway of the intracranial structures: cerebral arteries, meninges. The driving mechanism for trigeminovascular activation is hypothalamic dysfunction. On activation, neurotransmitters (CGRP, neurokinin and substance P) are released via a retrograde transmission from the peripheral end of the trigeminal nerve which innervate the proximal
Date of preparation: April 2010 Tevirl PO4/04/10 •Effective at reducing headache recurrence 1 PHARMACEUTICALS IRELAND Naramerg Naratriptan 2.5mg •Well tolerated with a lower incidence of adverse events than sumatriptan 2 and zolmitriptan 3 For further information, please contact: Teva Pharmaceuticals Ireland, Unit 1, The Business Centre, Blackthorn Business Park, Coe’s Road, Dundalk, Co Louth Tel 042 939 5892 Fax 042 939 5898 www.teva.ie Freephone 1800 201700 Abbreviated Prescribing Information Naramerg 2.5 mg Film-Coated Tablets Refer to Summary of Product Characteristics before prescribing. Presentation: Each tablet contains 2.5 mg naratriptan (as naratriptan hydrochloride). Indications: Acute treatment of the headache phase of migraine attacks with or without aura. Dosage and Administration: Naramerg should be taken as early as possible after the onset of a migraine headache, but is effective if taken at a later stage. Do not use prophylactically. Swallow whole with water. Adults (18-65 years of age): Single dose of 2.5 mg. A second dose as required, with minimum interval of 4 hours between doses. Do not exceed two 2.5 mg tablets in any 24 hour period. Children and adolescents 65 years: Not recommended. Renal impairment: Mild or moderate renal impairment - maximum total daily dose of 2.5 mg. Severe renal impairment - Do not use. Hepatic impairment: Mild or moderate impairment - maximum total daily dose of single 2.5 mg tablet. Severe impairment - Do not use. Contraindications: Hypersensitivity to any of the ingredients, heart disease, myocardial infarction, vascular disease, cerebrovascular accident, transient ischaemic attack, hypertension, severely impaired renal/hepatic function, concomitant administration of ergotamine, derivatives of ergotamine (including methysergide) and any triptan/5-hydroxytryptamine 1 (5-HT 1 ) receptor agonist with naratriptan. Special Warnings and Precautions for Use: Only use where there is a clear diagnosis of migraine. Not indicated for use in the management of hemiplegic, basilar or ophthalmoplegic migraine. Not be used in patients with risk factors for ischaemic heart disease. Following administration, naratriptan can be associated with transient symptoms including chest pain and tightness. There is a theoretical risk of a hypersensitivity reaction in patients with known hypersensitivity to sulphonamides. Should not be used with products containing St John’s Wort. There is a risk of medication-overuse headache with prolonged use. Contains Lactose. Drug Interactions: Theoretical possibility of increased risk of coronary vasospasm with co-administrations of ergotamine, ergotamine-containing preparations, dihydroergotamine, sumatriptan and 5-HT 1 receptor agonists, risk of serotonin syndrome following the use of selective serotonin reuptake inhibitors or serotonin noradrenaline reuptake inhibitors and triptans. Pregnancy and Lactation: Safety in pregnancy has not been established. Balance risks against benefits. Avoid breast-feeding for 24 hours after treatment. Effects on Ability to Drive and Operate Machines: Drowsiness and other symptoms of migraine may reduce ability to perform skilled tasks. Adverse Reactions: Some of the symptoms reported as adverse events may be part of the migraine attack. Common (≥1/100,
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