cbs anti migraine

CBS

Serotonergic & Histaminergic system

Case 1

• Q-1• What is the case?

A-1• Severe headache, vomiting, unilateral and

throbbing.

• This is case of migraine.

• Types of Migraine.

• Classical migraine :aura, nausea, vomiting, visual scotomas (severe, unilateral)

• Common migraine: lacks aura.

Pathophysiology of migraine.

Three fundamental views:

1.The classical vascular theory.

2.The brain hypothesis.

3.The sensory nerve hypothesis

The classical vascular theory:

• Initial humorally mediated intracerebral vasoconstriction causing aura.

• Followed by extracerebarl vasodilatation phase causing headcahe.

The brain hypothesis

• Links migraine to the phenomenon of cortical spreading depression.

• Associated with disturbed ionic balance and high K+ (potassium) concentration and reduced blood flow in depressed areas.

The sensory nerve hypothesis

• Activation of trigeminal nerve terminals in the meninges and extracranial vessels

causes pain directly.

• induction of inflammatory changes through the release of neuropeptide and calcitonin gene related peptide released into meningeal circulation.

Over all Pathology of migraine

• Migraine involves the trigeminal nerve distribution to intracranial (possible extracranial) arteries.

• Calcitonin gene related peptide are extreme vasodilators.

Q-2

• Why was Aspirin not effective in this case?

Q.3

• Why was she prescribed:

• Tab. Ergotamine tartarate 1mg + caffeine 100mg.

A-3

• Tab. Ergotamine tartarate

• Ergot alkaloid

• Act on several types of receptors.

• (alpha adrenoceptor, serotonin receptor

• 5-HT1A & 5-HTID and dopamine receptor).

• Routes of Administration-

• Oral, sublingual, rectal suppository, inhaler.

• Caffeine + ergotamine tartrate- facilitates absorption.

Side effects

• Emesis,

• vasoconstriction,

• hypertension,

Q-4

• Importance of family history?

A- 4

• It can be inherited

Q.5

• Why was prescribed Inj. Diclofenac?

A-5

• Non-selective non steroid

anti-inflammatory

• MOA

• SE

Q-6

• Tab Zolmitriptan

A-6

• It belongs to a group “Triptans”

• Activate 5-HT1D/1B receptors on presynaptic trigeminal nerve ending to inhibit release of vasodilator peptides

• Vasoconstrictor action of direct 5-HT agonist (triptan & ergot) may prevent vasodilation and stretching of pain endings.

Other Triptans

• Almotriptan,

• Eletriptan

• Frovatriptan

• Naratriptan

• Rizatriptan

• Sumatriptan

Treatment options of migraine

• FOR ACUTE ATTACKS

• Triptans

• Ergot alkaloids.

• NSAIDS.

• Analgesic agents.

FOR PROPHYLAXIS

• Considered for patients that have attack of migraine more than 1 per month

• 5HT2 receptors anatagonists.

• Β- adrenoceptor blockers.

• Calcium channel blockers.

• Tricyclic Antidepressants.

• Selective Serotonin Reuptake Inhibitors.

Examples of drugs in other groups• 5HT2 receptors anatagonists.eg.pizotifen

• Β- adrenoceptor blockers. eg Propranolol

• Calcium channel blockers. eg.Nifedipine

• Tricyclic Antidepressants.• eg: Amitriptyline,Imipramine,

• Selective Serotonin Reuptake Inhibitors. eg: Fluoxetine, citalopram

Case 2

• Q.1. What is the case?

• Motion sickness

• Q.2. Why was prescribed

tab. Meclizine?

• H1 antagonist.

• Piperazine derivatives.

• Uses- allergic reactions, motion sickness.

• Side effects-

• Sedative (interfere with safe operation of machinery)

• Postural hypotension

Anti-motion sickness drugs

• Diphenhydramine

• Dimenhydrinate

• Cyclizine

• Meclizine

• Promethazine

Other HI- Blockers

• Ist generation

• Diphenhydramine

• Chlorpheniramine and cyclizine

• 2nd generation

• cetirizine

• Fexofenadine

• loratidine

USES - HI- Blockers

• Allergies

• Hay fever

• Urticaria

• Anti -motion sickness

• Management chemotherapy vomiting (diphenhydramine)

Toxicity

• Sedation

• Antimscarinic effects- dry mouth, blurred vision.

• Alpha-adrenoceptor block- orthostatic hypotesion

Figure 1: Vestibular signals from the labyrinth are transferred to the vestibular nuclei (VN) through the vestibular afferents. Several pathways connect VN to other areas: signals can be transmitted: 1) to contralateral VN, 2) to the abducens nucleus (ABD) to produce the vestibulo-ocular reflex, 3) to higher brain centers to provide information about spatial orientation, or 4) to the spinal cord motor neurons that produce reflexes to stabilize posture.

• The vestibular system is comprised of two types of sensors: the two otolith organs (the saccule and utricle), which sense linear acceleration (i.e., gravity and translational movements), and the three semicircular canals, which sense angular acceleration in three planes. The receptor cells of the otoliths and semicircular canals send signals through the vestibular nerve fibers to the neural structures that control eye movements, posture, and balance (Fig.1).