S: a 46-year-old Caucasian man presents with a three year history of migraine headaches for management evaluation. He has additional medical history of hypertension and a myocardial infarct

Scenario:  A 46-year-old white male comes in for evaluation of his migraine

headache management.  His medical history is inclusive for hypertension and a myocardial

infarction at the age of 39. He was diagnosed with migraine headaches three years ago.

 Current medications include Losartan 50 mg a day, verapamil SR 100 mg at bedtime, Carvedilol 25 mg a day, Lipitor 40 mg a day, Topamax 50mg a day

 He has been admitted to the hospital for migraine management 3 times over the last 6 months. Inpatient admissions have ranged anywhere from 3 to 6 days. Management strategies utilized during the hospitalization include IV corticosteroids, IV Dilaudid and IV magnesium sulfate.

 BP 132/84, P 82, R 15  Skin: pink, warm, dry  Neuro: alert and oriented, CNs II – XII intact  Cardio: radial and pedal pulses 2+, heart regular rate and rhythm

without murmur or gallop  Lungs: clear to auscultation  Abdomen: large, non-distended, active bowel sounds all quadrants,

non-tender to palpation

S: a 46-year-old Caucasian man presents with a three year history of migraine headaches for management evaluation. He has additional medical history of hypertension and a myocardial infarction at age 39. His medications include Losartan 50mg daily, Verapamil SR 100mg at night, Carvedilol 25mg daily, Lipitor 40mg daily and Topamax 50mg daily. He has had three half week to week admissions in the past six months for migraines and received IV Dilaudid, corticosteroids and magnesium sulfate as treatment.

O: VS: BP 132/84, P 82, R 15; Skin is warm, dry, pink in color. Neuro, pt is A&O with cranial nerves II-XII intact; Pulses +2, HR regular

A: Migraines

P: Therapeutic: Per Arcangelo et al. (2017), the goal in treating this patient’s migraines is to prevent and relieve his attacks with minimal side effects. In the acute time frame, treatment goals include reducing the migraine severity, amount of migraine days and nausea. In addition to the short term goals, long term goals also include decreasing disability, increasing quality of life, avoiding increases in medication(s), providing education and empowering the patient to manage his migraine disorder. During assessment, a detailed account of the patient’s headaches should be retrieved including what period of the day his migraines usually occur, how long the last, how often they occur, presence of an aura, identified factors that may cause or relieve it, the quality, location and severity of his migraine pain, if he experiences any other

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https://www.coursehero.com/file/128074895/W7-Disc-Q2docx/

symptoms like nausea or photophobia, and if he uses OTC analgesics. The patient’s family history and social history should also be retrieved (Arcangelo et al., 2017).

Per Arcangelo et al. (2017), his blood pressure medications, as vasodilators, may be contributing to his migraine disease process and should be reviewed for potential adjustments or modifications. For current migraine treatment regimens, due to the patient’s hypertension and cardiovascular disease history, he cannot use the second line treatment of triptans. Third line treatment includes triptans combined with an NSAID. Other third line treatments for infrequent migraines include ergotamine 1-2mg or dihydroergotamine 2mg nasal spray. However, I feel that this patients migraines may be too frequent (Arcangelo et al., 2017). “Lasmiditan selectively targets 5-HT1F receptors on neurons in the central and peripheral trigeminal system, decreasing neuropeptide release and inhibiting pain pathways, including the trigeminal nerve” (Shapiro et al., 2019, p. 2). Lasmiditan is safe and effective in the treatment of migraines in cardiovascular risk factor patients as it does not cause vasoconstriction (Shapiro et al., 2019). A study by Shapiro et al. (2019) evaluated doses between 50mg to 200mg. I would start this patient on 50mg Lasmiditan and reevaluate the patient’s symptoms for symptom relief effectiveness.

Per Arcangelo et al. (2017), both aspirin, NSAIDs and/or OTC caffeine-containing NSAID compounds are effective in treating migraines and may offer this patient relief. For the treatment of migraine headaches, oral NSAIDs or aspirin are first line treatment. With his history of HTN, NSAIDs should be used with caution. He is presently not taking an NSAID or aspirin and I would start with prescribing 325mg aspirin q4-6hrs. Additionally, should the patient become nauseous, either due to the migraine or as a side effect from a medication, promethazine or prochlorperazine are two antiemetic medications that could be prescribed to offer the patient nausea relief. Antiemetics can also reduce gastric emptying, thus improve pain relieving properties. Complementary and alternative medicine options that demonstrate migraine reduction for the patient to consider include feverfew, butterbur, magnesium, coenzyme Q10 and high-dose riboflavin (vitamin b2) (Arcangelo et al., 2017).

Education: Per Arcangelo et al. (2017), there are numerous topics to educate this patient on. He needs to be provided general education regarding his headaches and also ensure he has a realistic perception of what to expect from treatment. Medication education should be provided regarding drug information, dosage prescribed, frequency of dosage, maximum dosage per day, common side effects, and potential adverse effects. Education regarding acetaminophen overdose should be discussed, making the patient aware that some combination medications contain Tylenol and not to exceed 3,250mg of overall Tylenol per day. If the patient is being prescribed a nasal spray or injectable drug, proper administration techniques should be reviewed with and demonstrated by the patient, such as in a teach back fashion. I’d advise the patient to start a journal documenting detailed accounts of factors before, during and after migraines to help the provider and the patient identify his specific triggers. The journal should include factors such as prescribed medication, supplement and OTC medicine use, detailed account of diet and ingredients, and potential environmental factors. Keeping a daily symptom/disease diary will also help the provider track the effectiveness of his treatment plan and/or interventions. Foods that the patient may find trigger his migraines include aspartame, chocolate, caffeine, monosodium glutamate, and alcohol such as red wine (Arcangelo et al., 2017).

Consult/Collaboration: Cardiology, Neurology

Reference

This study source was downloaded by 100000760925736 from CourseHero.com on 04-11-2024 16:46:08 GMT -05:00

https://www.coursehero.com/file/128074895/W7-Disc-Q2docx/

Arcangelo, V. P., Peterson, A. M., Wilbur, V. F., & Reinhold, J. A. (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Wolters Kluwer.

Shapiro, R. E., Hochstetler, H. M., Dennehy, E. B., Khanna, R., Doty, E. G., Berg, P. H., &

Starling, A. J. (2019). Lasmiditan for acute treatment of migraine in patients with

cardiovascular risk factors: post-hoc analysis of pooled results from 2 randomized,

double-blind, placebo-controlled, phase 3 trials. The Journal of Headache and

Pain, 20(1). https://doi.org/10.1186/s10194-019-1044-6

Disc Response #1 Hello Sherna, I also agree with Teressa's response and respectfully disagree with your plan of prescribing Imitrex to this patient. Per Shapiro et al. (2019), many of the treatment options that specifically target migraines are contraindicated in patients with cardiac disease. Imitrex is a 5-HT1 receptor agonist which causes vasoconstriction and are contraindicated in patients with ischemic heart disease, uncontrolled hypertension, cerebrovascular ischemic events, peripheral vascular disease, etc. A large number of American men, six hundred sixty-five thousand, not only have migraines but also a medical history of one or more cardiac events which would contradict the use of triptans (Shapiro et al., 2019). This patient may be interested in trying a newer migraine medication that has thus far performed well in patients similar to him. As of 2019, two randomized, double-blind, placebo-controlled, phase three studies have proven the safety and efficteveness of lasmiditan’s use for migraines in cardiac patients (Shapiro et al., 2019). Lasmiditan was not discussed in our textbook as it is a new FDA approved medication and first of its class, called ditans, that has emerged on the market. Where dihydroergotamine and triptans target 5-HT1B and 1D receptors, ditans specifically targets the 5-HT1F receptor and stops migraine attacks (Tepper, 2020). It’s most important advantage for this patient is that it does not cause vasoconstriction and studies show that it is safe to use in vascular and cardiac disease patients (Tepper, 2020).

Reference Shapiro, R. E., Hochstetler, H. M., Dennehy, E. B., Khanna, R., Doty, E. G., Berg, P. H., &

Starling, A. J. (2019). Lasmiditan for acute treatment of migraine in patients with cardiovascular risk factors: post-hoc analysis of pooled results from 2 randomized, double-blind, placebo-controlled, phase 3 trials. The Journal of Headache and Pain, 20(1). https://doi.org/10.1186/s10194-019-1044-6

Tepper, D. (2020). Lasmiditan for the acute treatment of migraine. Headache: The

Journal of Head and Face Pain, 60(6), 1225–1226.

https://doi.org/10.1111/head.13798

This study source was downloaded by 100000760925736 from CourseHero.com on 04-11-2024 16:46:08 GMT -05:00

https://www.coursehero.com/file/128074895/W7-Disc-Q2docx/

Migraine: Disc Response #2

Hello Kimberly,

Your plan differs from mine, however, I agree with your intervention. There seems to be various interventions and medications with migraine patients and seeking one medication that treats dual disease processes, such as this patients hypertension and migraine, is an effective treatment strategy and reduces the number of pills this patient is taking and medication adverse effects experienced. You mentioned reviewing complementary and alternative medicine (CAM) with the patient as migraine prophylactics. In one online survey of migraine patients, eighty six percent used CAM concurrently with their medical migraine treatments (Kuruvilla et al., 2021). Besides cognitive behavioral therapy (CBT), acupuncture and electromyographic biofeedback, other CAM therapies that migraine patients reported they use to treat their migraines include butterbur, relaxation training and medical cannabis (Kuruvilla et al., 2021). Per Kuruvilla et al. (2021), providers should ensure that the butterbur formulation does not have pyrrolizidine- alkaloid in it due to the risk for liver toxicity. If the patient decides to use butterbur, his liver function should be closely monitored during therapy. Medical cannabis is becoming popular and more commercially available from pharmaceutical companies following law changes throughout the country. It has been used for head diseases, such as migraines, since the third century BCE. Cannabis “shows potential to interrupt glutamate signaling leading to cortical spreading depression, serotonin release from platelets and cranial blood vessel dilation caused by nitrous oxide and calcitonin gene-related peptide” (Kuruvilla et al., 2021, p. 5). As thirty percent of migraine patients reported using medical cannabis with moderate to extremely effective reports, it is important to be open and nonjudgmental about perspective treatments. Using the C.A.R.E. mnemonic can be helpful when talking about CAM treatment options: Conventional treatments; Avoiding judgement; Review integrative options; Explore patients interest (Kuruvilla et al., 2021).

Reference

Kuruvilla, D. E., Mehta, A., Ravishankar, N., & Cowan, R. P. (2021). A patient perspective of

complementary and integrative medicine (CIM) for migraine treatment: a social media

survey. BMC Complementary Medicine and Therapies, 21(1).

https://doi.org/10.1186/s12906-021-03226-0

This study source was downloaded by 100000760925736 from CourseHero.com on 04-11-2024 16:46:08 GMT -05:00

https://www.coursehero.com/file/128074895/W7-Disc-Q2docx/ Powered by TCPDF (www.tcpdf.org)

Scenario:  A 46-year-old white male comes in for evaluation of his migraine

headache management.  His medical history is inclusive for hypertension and a myocardial

infarction at the age of 39. He was diagnosed with migraine headaches three years ago.

 Current medications include Losartan 50 mg a day, verapamil SR 100 mg at bedtime, Carvedilol 25 mg a day, Lipitor 40 mg a day, Topamax 50mg a day

 He has been admitted to the hospital for migraine management 3 times over the last 6 months. Inpatient admissions have ranged anywhere from 3 to 6 days. Management strategies utilized during the hospitalization include IV corticosteroids, IV Dilaudid and IV magnesium sulfate.

 BP 132/84, P 82, R 15  Skin: pink, warm, dry  Neuro: alert and oriented, CNs II – XII intact  Cardio: radial and pedal pulses 2+, heart regular rate and rhythm

without murmur or gallop  Lungs: clear to auscultation  Abdomen: large, non-distended, active bowel sounds all quadrants,

non-tender to palpation

S: a 46-year-old Caucasian man presents with a three year history of migraine headaches for management evaluation. He has additional medical history of hypertension and a myocardial infarction at age 39. His medications include Losartan 50mg daily, Verapamil SR 100mg at night, Carvedilol 25mg daily, Lipitor 40mg daily and Topamax 50mg daily. He has had three half week to week admissions in the past six months for migraines and received IV Dilaudid, corticosteroids and magnesium sulfate as treatment.

O: VS: BP 132/84, P 82, R 15; Skin is warm, dry, pink in color. Neuro, pt is A&O with cranial nerves II-XII intact; Pulses +2, HR regular

A: Migraines

P: Therapeutic: Per Arcangelo et al. (2017), the goal in treating this patient’s migraines is to prevent and relieve his attacks with minimal side effects. In the acute time frame, treatment goals include reducing the migraine severity, amount of migraine days and nausea. In addition to the short term goals, long term goals also include decreasing disability, increasing quality of life, avoiding increases in medication(s), providing education and empowering the patient to manage his migraine disorder. During assessment, a detailed account of the patient’s headaches should be retrieved including what period of the day his migraines usually occur, how long the last, how often they occur, presence of an aura, identified factors that may cause or relieve it, the quality, location and severity of his migraine pain, if he experiences any other

This study source was downloaded by 100000760925736 from CourseHero.com on 04-11-2024 16:46:08 GMT -05:00

https://www.coursehero.com/file/128074895/W7-Disc-Q2docx/

symptoms like nausea or photophobia, and if he uses OTC analgesics. The patient’s family history and social history should also be retrieved (Arcangelo et al., 2017).

Per Arcangelo et al. (2017), his blood pressure medications, as vasodilators, may be contributing to his migraine disease process and should be reviewed for potential adjustments or modifications. For current migraine treatment regimens, due to the patient’s hypertension and cardiovascular disease history, he cannot use the second line treatment of triptans. Third line treatment includes triptans combined with an NSAID. Other third line treatments for infrequent migraines include ergotamine 1-2mg or dihydroergotamine 2mg nasal spray. However, I feel that this patients migraines may be too frequent (Arcangelo et al., 2017). “Lasmiditan selectively targets 5-HT1F receptors on neurons in the central and peripheral trigeminal system, decreasing neuropeptide release and inhibiting pain pathways, including the trigeminal nerve” (Shapiro et al., 2019, p. 2). Lasmiditan is safe and effective in the treatment of migraines in cardiovascular risk factor patients as it does not cause vasoconstriction (Shapiro et al., 2019). A study by Shapiro et al. (2019) evaluated doses between 50mg to 200mg. I would start this patient on 50mg Lasmiditan and reevaluate the patient’s symptoms for symptom relief effectiveness.

Per Arcangelo et al. (2017), both aspirin, NSAIDs and/or OTC caffeine-containing NSAID compounds are effective in treating migraines and may offer this patient relief. For the treatment of migraine headaches, oral NSAIDs or aspirin are first line treatment. With his history of HTN, NSAIDs should be used with caution. He is presently not taking an NSAID or aspirin and I would start with prescribing 325mg aspirin q4-6hrs. Additionally, should the patient become nauseous, either due to the migraine or as a side effect from a medication, promethazine or prochlorperazine are two antiemetic medications that could be prescribed to offer the patient nausea relief. Antiemetics can also reduce gastric emptying, thus improve pain relieving properties. Complementary and alternative medicine options that demonstrate migraine reduction for the patient to consider include feverfew, butterbur, magnesium, coenzyme Q10 and high-dose riboflavin (vitamin b2) (Arcangelo et al., 2017).

Education: Per Arcangelo et al. (2017), there are numerous topics to educate this patient on. He needs to be provided general education regarding his headaches and also ensure he has a realistic perception of what to expect from treatment. Medication education should be provided regarding drug information, dosage prescribed, frequency of dosage, maximum dosage per day, common side effects, and potential adverse effects. Education regarding acetaminophen overdose should be discussed, making the patient aware that some combination medications contain Tylenol and not to exceed 3,250mg of overall Tylenol per day. If the patient is being prescribed a nasal spray or injectable drug, proper administration techniques should be reviewed with and demonstrated by the patient, such as in a teach back fashion. I’d advise the patient to start a journal documenting detailed accounts of factors before, during and after migraines to help the provider and the patient identify his specific triggers. The journal should include factors such as prescribed medication, supplement and OTC medicine use, detailed account of diet and ingredients, and potential environmental factors. Keeping a daily symptom/disease diary will also help the provider track the effectiveness of his treatment plan and/or interventions. Foods that the patient may find trigger his migraines include aspartame, chocolate, caffeine, monosodium glutamate, and alcohol such as red wine (Arcangelo et al., 2017).

Consult/Collaboration: Cardiology, Neurology

Reference

This study source was downloaded by 100000760925736 from CourseHero.com on 04-11-2024 16:46:08 GMT -05:00

https://www.coursehero.com/file/128074895/W7-Disc-Q2docx/

Arcangelo, V. P., Peterson, A. M., Wilbur, V. F., & Reinhold, J. A. (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Wolters Kluwer.

Shapiro, R. E., Hochstetler, H. M., Dennehy, E. B., Khanna, R., Doty, E. G., Berg, P. H., &

Starling, A. J. (2019). Lasmiditan for acute treatment of migraine in patients with

cardiovascular risk factors: post-hoc analysis of pooled results from 2 randomized,

double-blind, placebo-controlled, phase 3 trials. The Journal of Headache and

Pain, 20(1). https://doi.org/10.1186/s10194-019-1044-6

Disc Response #1 Hello Sherna, I also agree with Teressa's response and respectfully disagree with your plan of prescribing Imitrex to this patient. Per Shapiro et al. (2019), many of the treatment options that specifically target migraines are contraindicated in patients with cardiac disease. Imitrex is a 5-HT1 receptor agonist which causes vasoconstriction and are contraindicated in patients with ischemic heart disease, uncontrolled hypertension, cerebrovascular ischemic events, peripheral vascular disease, etc. A large number of American men, six hundred sixty-five thousand, not only have migraines but also a medical history of one or more cardiac events which would contradict the use of triptans (Shapiro et al., 2019). This patient may be interested in trying a newer migraine medication that has thus far performed well in patients similar to him. As of 2019, two randomized, double-blind, placebo-controlled, phase three studies have proven the safety and efficteveness of lasmiditan’s use for migraines in cardiac patients (Shapiro et al., 2019). Lasmiditan was not discussed in our textbook as it is a new FDA approved medication and first of its class, called ditans, that has emerged on the market. Where dihydroergotamine and triptans target 5-HT1B and 1D receptors, ditans specifically targets the 5-HT1F receptor and stops migraine attacks (Tepper, 2020). It’s most important advantage for this patient is that it does not cause vasoconstriction and studies show that it is safe to use in vascular and cardiac disease patients (Tepper, 2020).

Reference Shapiro, R. E., Hochstetler, H. M., Dennehy, E. B., Khanna, R., Doty, E. G., Berg, P. H., &

Starling, A. J. (2019). Lasmiditan for acute treatment of migraine in patients with cardiovascular risk factors: post-hoc analysis of pooled results from 2 randomized, double-blind, placebo-controlled, phase 3 trials. The Journal of Headache and Pain, 20(1). https://doi.org/10.1186/s10194-019-1044-6

Tepper, D. (2020). Lasmiditan for the acute treatment of migraine. Headache: The

Journal of Head and Face Pain, 60(6), 1225–1226.

https://doi.org/10.1111/head.13798

This study source was downloaded by 100000760925736 from CourseHero.com on 04-11-2024 16:46:08 GMT -05:00

https://www.coursehero.com/file/128074895/W7-Disc-Q2docx/

Migraine: Disc Response #2

Hello Kimberly,

Your plan differs from mine, however, I agree with your intervention. There seems to be various interventions and medications with migraine patients and seeking one medication that treats dual disease processes, such as this patients hypertension and migraine, is an effective treatment strategy and reduces the number of pills this patient is taking and medication adverse effects experienced. You mentioned reviewing complementary and alternative medicine (CAM) with the patient as migraine prophylactics. In one online survey of migraine patients, eighty six percent used CAM concurrently with their medical migraine treatments (Kuruvilla et al., 2021). Besides cognitive behavioral therapy (CBT), acupuncture and electromyographic biofeedback, other CAM therapies that migraine patients reported they use to treat their migraines include butterbur, relaxation training and medical cannabis (Kuruvilla et al., 2021). Per Kuruvilla et al. (2021), providers should ensure that the butterbur formulation does not have pyrrolizidine- alkaloid in it due to the risk for liver toxicity. If the patient decides to use butterbur, his liver function should be closely monitored during therapy. Medical cannabis is becoming popular and more commercially available from pharmaceutical companies following law changes throughout the country. It has been used for head diseases, such as migraines, since the third century BCE. Cannabis “shows potential to interrupt glutamate signaling leading to cortical spreading depression, serotonin release from platelets and cranial blood vessel dilation caused by nitrous oxide and calcitonin gene-related peptide” (Kuruvilla et al., 2021, p. 5). As thirty percent of migraine patients reported using medical cannabis with moderate to extremely effective reports, it is important to be open and nonjudgmental about perspective treatments. Using the C.A.R.E. mnemonic can be helpful when talking about CAM treatment options: Conventional treatments; Avoiding judgement; Review integrative options; Explore patients interest (Kuruvilla et al., 2021).

Reference

Kuruvilla, D. E., Mehta, A., Ravishankar, N., & Cowan, R. P. (2021). A patient perspective of

complementary and integrative medicine (CIM) for migraine treatment: a social media

survey. BMC Complementary Medicine and Therapies, 21(1).

https://doi.org/10.1186/s12906-021-03226-0

This study source was downloaded by 100000760925736 from CourseHero.com on 04-11-2024 16:46:08 GMT -05:00

https://www.coursehero.com/file/128074895/W7-Disc-Q2docx/ Powered by TCPDF (www.tcpdf.org)