CNS

Question 1

What Makes Up The Central Nervous System (CNS)?

Answer 1

• Brain & Spinal Cord

Question 2

What Is The Role Of The CEntral Nervous System (CNS)

Answer 2

Its major function is to process and integrate information arriving from sensory pathways and communicate an appropriate response back via afferent pathways.

Question 3

Headache Definition

Answer 3

Headache is not a disease state or condition but rather a symptom, of which there are many causes

Question 4

Causes Of Headaches & Their Relative Incidence In Community Pharmacy

Answer 4

Most Likley: Tension-type Headache
Likely: Migrane, Sinusitis, Eye Strain
Unlikely: Cluster Headache, Medication Overuse Headache, Temporal Arteritis, Trieminal Neuralgia, Depression.
**Very Unlikely: **Glaucoma, Meningitis, Subarachnoid Haemorrhage, Raised Intracranial Pressure.

Question 5

Primary Headache - What is defined as a primary headache by the International Headache Society Classification Of Headache?

Answer 5

1. Migrane with/without aura
2. Tension-type headache; Infrequent Episodic; Frequent Episodic; & Chronic.
3. Cluster Headache; Cluster Headache & other trigeminal autonomic cephalagiase.
4. Other primary headache

In early childhood or as a young adult, primary headache is most likely.

Question 6

**Secondary Headache **- What is defined as a secondary headache by the International Headache Society Classification Of Headache?

Answer 6

• Symptomatic of an underlying cause
• Usually requires referral from community.
• 50 years of age, the likelihood of a secondary cause is much greater.

1. Headache attributed to head &/or neck trauma:
   - Chronic posttraumatic headache.
2. Headache attributed to** cranial or cervical vascaular disorder: **
   - Headache attributed to subarachnoid haemorrhage;
   - Headache attributed to giant arteritis.
3. Headache attributed to nonvascular intracranial disorder, including:
   - Headache attributed to idiopathic intracranial hypertension;
   - Headache attributed to intracranial neoplasm
4. Headache attributed to a substance or its withdrawal, including:
   - Carbon monoxide–induced headache;
   - Alcohol-induced headache;
   - Medication-overuse headache (Ergotamine, Triptan, Analgesic)
5. Headache attributed to infection, including:
   - Headache attributed to intracranial infection
6. Headache attributed to disorder of homoeostasis
7. Headache or facial pain, attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures including:
   - Cervicogenic headache
   - Headache attributed to acute glaucoma
8. Headache attributed to psychiatric disorder

Question 7

Neuralgias & Other Headaches **- What is defined as these by the International Headache Society Classification Of Headaches?

Answer 7

1. Cranial neuralgias, central and primary facial pain, and other headaches, including:
   - Trigeminal neuralgia
2. Other headache, cranial neuralgia, central or primary facial pain

Question 8

Tension Type Headaches

Answer 8

Defintion/Background:
- Can be Infrequent Episodic; Frequent Episodic; & Chronic.
- Most patients will present to the pharmacist with the infrequent episodic form; that is, they occur less than once per month.
- Frequent Episodic; more than monthly episodes
- Chronic; >10 episodes a months(might be daily)/lasting for at least 3 months (or occur on >15 days of the month & lasts for >3 months at a time)
- Peak age 20-40Y

Symptoms/Features:
- Headaches that occur on most days with the same pattern suggest tension-type headache.
- Tension-type headache is often bilateral, either in frontal or occipital areas, and described as a generalised dull, pressing tightness/weight on head/band-like pain.
- The pain is gradual in onset and tends to worsen progressively throughout the day.
- Pain is normally mild to moderate and is not aggravated by movement, although it is often worse under pressure or stress.
- Generally pain will have a limited impact on the individual, although OTC products tried may still have failed for them.
- Tension-type headaches last between a 30minutes/few hours and several days(7 days/+).

• Nausea & Vomitting are not associated with tension-type headaches.
• Rarely photophobia/phonophobia will be present.
• Pain is not a pulsing pain.
• Routine physical activity does not aggrevate

Management:
- Analgesia: paracetamol, ibuprofen, aspirin
- Codeine containing product if these not helping.

• Avoid triggers

Referral:
- Frequent Episodic
- Chronic
- Nausea/Vomiting - rule out more sinister pathoology
- Analgesia not touching pain

Question 9

Migrane

Answer 9

**Defintion/Background: **
- 2 major subclasses; Common Migrane(without aura) & Classic Migrane(with aura).
- 2-3 times more likley in women.
- Probably a combination of vascular and neurochemical changes; not fully know though.
- Also appears to have a genetic component, with about 70% of patients having a first-degree relative with a history of migraine.

Symptoms/Features:
- Headache associated with the menstrual cycle(1-2 days before & up to 3 days after menstration) or at certain times (e.g. weekend, holiday) suggests migraine.
- Migraine headache is unilateral in 70% of patients but can change from side to side and from attack to attack.
- Moderate to severe throbbing pain that often starts as dull ache suggests migraine. Can also be generalised & diffuse.
- Food (in 10% of sufferers), menstruation and relaxation after stress are indicative of migraine.
- Typically, migraine attacks last between a few hours(4) and 3 days; the average lemgth of attack is 24 hours.
- Pt presenting with symptoms will normally have a histroy of recurrent/episodic attacks of headaches.
- Nausea can be present, but less than 1/3 of pts will vomit.
- Physical activity & movement tends to intensify the pain.
- Photophobia/Phonophobia is often present.
- Pts may also suffer fatigue, find concentrating difficult & be irritable.

Management:
Analgesia; soluble or orodispersible best for quicker action.
1. Paracetamol, Ibuprofen, Aspirin
+ 1 of following if these are unsuccessful
2. Codeine (Migraleve yellow or pink if need anti-nausea medication too)
2.Sumtriptan (if clear diagnosis of migrane either through GP or have clear history of symptoms for you to diagnose confidently)

For Nausea/Vomirting associated with migrane -Buccastem

Referral:
- >50Y (rare over this age & anyone presenting for the first-time with migrane like symptoms should be referred to GP to eliminate secondary causes of headache).
- More than 3 day duration
- Prochlorperazine not effective enough (GP needed to prescribe alternative e.g. metoclopramide).
- Preservative treatment indicated for
- Pt on combined oral contraceptives; these should not be used in pts with classic or severe common migranes and alternative treatments will be required due to increased risk of stroke.

Question 10

Classic Migrane VS Common Migrane - Symptoms/Features

Answer 10

Classic Migrane:
- Accounts for less than 25% of migrane causes.

Aura/Symptoms:
- is fully reversible, develops over 5-20 minutes & can last for up to 1 hour.
- It can be Visual(90% auras experienced): scotomas(blind spots), Fortification spectra(zigzag lines), flashing/flickering lights.
- It can be neurological: pins & needles, typically starting in the hand, migratingup the arm before jumping to the face & lips.
- Within 60 minutes of the aura ending, the headache usually occurs.
- Pain is unilateral, throbbing & moderate/severe. It can sometimes be generalised & diffuse.
- Physical activity & movement tenda to intensify the pain.
- Nausea affects almost all pts but less than 1/3 will vomit.
- Photophobia/Phonophobia often mean Pts will seek out a dark quiet room to relieve their symptoms.
- Pts may also suffer fatigue, find concentrating difficult & be irritable.

Common Migrane:
The remaining 75% of sufferes do not experience an aura but do suffer all the same symptoms outwith this associated with migrane:
- Pain is unilateral, throbbing & moderate/severe. It can sometimes be generalised & diffuse.
- Physical activity & movement tenda to intensify the pain.
- Nausea affects almost all pts but less than 1/3 will vomit.
- Photophobia/Phonophobia often mean Pts will seek out a dark quiet room to relieve their symptoms.
- Pts may also suffer fatigue, find concentrating difficult & be irritable.

Question 11

ID Migrane Screening Tool/The international classification of headache disoprders.

Answer 11

ID Migraine: This is a screening tool that has shown to be a valid and reliable screening test for migraine. Nearly all patients that answer yes to two of the questions opposite have migraine.
- During the last 3 months, did you have any of the following symptoms together with a headache?
Question 1: Did you feel nauseated or sick?
Question 2: Did light bother you (a lot more than when you didn’t have a headache)?
Question 3: Did your headache limit your ability to work, study, play or do what you wanted to do for at least 1 day?

Migrane Without Aura: headache lasting 4-72 hours (untreated or unsuccessfully treated).

Headache has at least 2 of the following 4 characteristics:
- Unilateral
- Pulsing quality
- Moderate or severe intenstiy of pain
- Aggrevated by or causing avoidance of routeine physical activity.

During headache at least 1 of the followign symptoms:
1. nausea &/or vomiting
2. Photophobia & Phonophobia

Migrane with aura:
1 or more of the following fully reversibel aura symptoms:
1. visual
2. sensory
3. Speech &/or language
4. Motor
5. Brainstem
6. Retinal

At least 2 of thje following 4 characteristics:
1. at least 1 aura symptoms spread gradually over >5minuted, &/or 2 or more symptoms occur in succession
2. Each individual; aura symptoms lasts 5-60 minutes
3. At least 1 aura symptoms is unilateral
4. The aura is accompanied or followed within 60 minuted by headache.

Question 12

Phases Of A Migrane

Answer 12

A migrane attack can be divided into 3 phases (migrane with aura has all three stages, migrane without only has stages 2&3):

1. Premonitory phase, which can occur hours or possibly a couple of days before the headache. The patient might complain of a change in mood or notice a change in behaviour. Feelings of well-being, yawning, poor concentration and food cravings have been reported. These prodromal features are highly individual but are relatively consistent to each patient. Identification of triggers is sometimes possible.
2. Headache with or without aura.
3. Resolution phase, as the headache subsides; The patient can feel lethargic, tired and drained before recovery, which might take several hours.

Question 13

Triggers Of A Migrane & How To Manage/Reduce.

Answer 13

Stress:
- Maintain regular sleep patterns
- Perform regular excercise
- Modify work environment
- Do relaxation techniques e.g. yoga.

Diet: Any food can be a potential trigger, but food that is implicated includes cheese, citrus fruit, chocolate, alcohol.
- Maintain a food diary (if an attack occurs within 6 hours of food ingestion & is reproducible it is lijkley that it is a trigger for migrane.
- Eat food regulary & do not skip meals

• Bright lights
• Extremes of weather
• Long distance travel
• Dehydration
• Strenuous unaccustomed exercise
• Altered sleep patterns
• Loud noises

Question 14

Cluster Headaches

Unlikley Cause Of Headache

Answer 14

Definition/Background:
- More common in men
- Episodic cluster accounts for 90% of cases.
- Age of onset 20-40Y

Symptoms/Features:
- Headaches that occur abruptly, episodically at the same time of day or night suggest cluster headache.
- Cluster headache is nearly always unilateral in the frontal and ocular areas(affecting one eye) (can also be felt in the temporal areas).
- Piercing, boring, searing eye pain suggests cluster headache. If it is at night time Pt will usually be awoken 2-3 hours after falling asleep.
- Lying down makes cluster headache worse, alcohol can also trigger an attack during thr acute phases.
- Cluster headache will only normally last between 10 minutes and 3 hours, with 2–3 hours being most common duration.
- Associated symptoms - conjunctival redness, lacrimation and nasal congestion (which laterally becomes watery) are observed on the pain side of the head. Facial flushing & sweating are aslo common.
- Pts tend to be restless , irritable & often pace.

• Nausea is usually absent.
• Family history is uncommon.
• The Headaches usually occur in periods of acute attacks, typically lasting a number of weeks to a few months, with sufferers experiencing between 1 & 3 attacks per day.
• This is then followed by periods of remission, which can last months or years.

Management:
Referral to GP is usually required as subcutaneous sumatriptan is required for treatment.

Question 15

**Location Of Pain In Headache **- What Does Each Of The Following Suggest?
- Unilaterial in frontal) & ocular areas
- Unilateral, can change from side to side
- Biltaeral, within frontal/occipital areas, described as tight band.
- Orbital (eye area)
- Frontal (Forehead, can be bilateral or unilateral)
- Occipital (back of head)
- Temporal (side of head at temple(soft indent above ear)
- Very localised

Answer 15

• Cluster headache is nearly always unilateral in the frontal and ocular areas (can also be felt in the temporal areas).
• Migraine headache is unilateral in 70% of patients but can change from side to side and from attack to attack.
• Tension-type headache is often bilateral, either in frontal or occipital areas, and described as a tight band.

- Orbital Pain suggests potential cluster or glaucoma or sinusitis if unilateral in nature
- Frontal (unilateral -migrane, Bilateral-Tension)
**- Occipital(Back of head) **- subarachnoid haemorrhage, tension
- Temporal(forehead) - Migrane, Temporal Arteritis

• Very localized pain suggests an organic cause.

Question 16

**Frequency & Timing Of Pain In Headaches **- What Does Each Of The Following Suggest?
- Associated with the menstral cycle/at certain times
- Occur episodically at same time of day/night
- Occur on most days with same pattern

Answer 16

• Headache associated with the menstrual cycle or at certain times (e.g. weekend, holiday) suggests migraine.
• Headaches that occur episodically at the same time of day or night suggest cluster headache.
• Headaches that occur on most days with the same pattern suggest tension-type headache.

Question 17

Age Of Onset Of Headache - What Does Each Of The Following Suggest?
- Early childhood/ young adult
- >50Y

Answer 17

In early childhood or as a young adult, primary headache is most likely. After 50 years of age, the likelihood of a secondary cause is much greater.

Question 18

Severity Of Pain In Headache - What Does Each Of The Following Suggest?
- Dull/Band Like
- Severe to Intense ache or Throbbing
- Piercing, borning, searing eye pain
- Moderate to severe throbbing pain often starting as a dull ache

Answer 18

Pain is a subjective personal experience and there are therefore no objective measures. Using a numeric pain intensity scale should allow you to assess the level of pain the person is experiencing: 0 represents no pain and 10 the worst pain possible.

• Dull and band-like suggests tension-type headache.
• Severe to intense ache or throbbing suggests haemorrhage or aneurysm.
• Piercing, boring, searing eye pain suggests cluster headache.
• Moderate to severe throbbing pain that often starts as dull ache suggests migraine.

Question 19

Subarachnoid Haemorrhage

Answer 19

Symptoms/features:
- Severe to intense ache or throbbing suggests haemorrhage or aneurysm.
- Patient will describe it as being at the back of the head/neack area.

Management:
- Referral to A&E

Question 20

Triggers Of Headache Pain - What Does Each Of The Following Suggest?
- Pain worsened on exertion, coughing & bending
- Foods, menstration, relaxation after stress
- Lying down

Answer 20

• Pain that worsens on exertion, coughing and bending suggests a tumour.
• Food (in 10% of sufferers), menstruation and relaxation after stress are indicative of migraine.
• Lying down makes cluster headache worse.

Question 21

**Headache Pain Duration **- What Does Each Of The Following Suggest?
- A few hours to 3 days
- Few hours to several days(can be 7 days+).
- 2-3 hours

Answer 21

• Typically, migraine attacks last between a few hours and 3 days.
• Tension-type headaches last between a few hours and several days, such as 1 week or longer.
• Cluster headache will only normally last 2–3 hours.

Question 22

Associated Symptoms Of Headache Pain - What Does Each Of The Following Suggest?
- Headache & Fever
- Nausea
- Scalp Tenderness

Answer 22

• Headache and fever at the same time imply an infectious cause.
• Nausea suggests migraine or more sinister pathology, such as a subarachnoid haemorrhage and space-occupying lesions.
• Scalp tenderness is associated with temporal arteritis.

Question 23

Eye Strain

Likley Cause Of Headache - Condition To Eliminate

Answer 23

Defnintion/Symptoms/Features:
People who perform prolonged close work – for example, visual display unit (VDU) operators – can suffer from frontal-aching headache.

Management:
In the first case, patients should be referred to an optician for a routine eye check.

Question 24

Sinusitis

Likley Cause Of Headache - Condition To Eliminate

Answer 24

Defnintion/Features/Symptoms:
- The pain tends to be relatively localised, usually orbital, unilateral, and dull.
- The pain may be felt behind and around the eye, or over the cheek, with radiation over the forehead and often only one side is affected
- The headache may be associated with runny nose or nasal congestion.
- The affected sinus often feels tender when pressure is applied.
- It is typically worse on bending forwards or lying down.
- Would occur with symptoms/history of either allergies or respiratory tract infection.
- Pain is typically worse if bend over

Management:
- A course of decongestants could be tried, but if treatment failure occurs, referral to the doctor for possible antibiotic therapy would be appropriate.

Question 25

Medication Overuse Headache

Unlikely Cause Of Headache

Answer 25

Definition/Symptoms/Features:
- Patients with long-standing symptoms of headache who regularly use medicines to treat pain can develop medication-overuse headache - often the hsotry will be then taking the pain meds pre-emptively for the headache in the end.
- Usually a chronic intractable headache lasting >15 days a month.
- Pain is persistent throughout the day, often at its worse in the morning, increases with physical exertion & worsens when causative medication is discontinued.

Nitrate use can also just cause a headache if they are having to take it regualry - would want to check if theya re on day a GTN spray if they have taken i recently as if needing it a lot refer for better angina control.

Management:
- In these cases, a medication history is essential and should prompt the pharmacist to refer the patient to the doctor.
- Treatment is to stop all analgesia for a number of weeks, which requires careful planning.
- Symptoms usually resolve within 2 months of withdrawing the medication.

Question 26

Temporal Arteritis (Giant Cell Arteritis)

Unlikely Cause Of Headache

Answer 26

Background/Symptoms/Features:
- The temporal arteries that run vertically up the sides of the head, just in front of the ears, can become inflamed.
- The arteries may appear red and are painful and thickened to the touch.
- Unilateral pain is experienced, and the person generally feels unwell, with fever, myalgia and general malaise.
- Scalp tenderness is seen about 50% of patients.
- It is most commonly seen in older white populations and is three times more common in women.

Management:
- Prompt treatment with oral corticosteroids is required because the retinal artery can become compromised, leading to blindness.
- Urgent referral is needed.

Question 27

Trigeminal Neuralgia

Unlikely Cause Of Headache

Answer 27

Background/Symptoms/Features:
- Pain follows the course of the second (maxillary; supplying the cheeks) or third (mandibular; supplying the chin, lower lip, and lower cheek) division of the nerve, leading to pain experienced in the cheek, jaws, lips or gums.
- Pain is short lived, usually lasting from a few seconds to a couple of minutes.
- Pain is severe and lancing (electric shock–like) and is almost always unilateral.
- The person may experience many attacks a day, although the events are episodic and may remit for weeks or months before returning.
- It is more common in women than in men and rarely seen before the age of 40 years.

Question 28

Depression

Unlikley Cause Of Headache

Answer 28

Background/Symptoms/Features:
- A symptom of depression can be tension-type headaches.
- However, other more prominent symptoms should be present. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria are often used to aid a diagnosis of depression.
- The pharmacist should check for a loss of interest or pleasure in activities, fatigue, inability to concentrate, loss of appetite, weight loss, sleep disturbances and constipation.

Management:
- If the patient exhibits some of these features (especially loss of interest in doing things and feeling down and hopeless), referral to the doctor is necessary.
- Recent changes to the patient’s social circumstances might also support your differential diagnosis.

Question 29

Glaucoma

Very Unlikley Cause Of Headache

Answer 29

Background/Symptoms/Features:
Therea are 2 main types of glaucoma;
- Simple chronic open-angle glaucoma which dose not cause pain[this develops slowly, affecting the vision as the optic nerve is slowly damaged. Opticians can pick this up on examination of the eye, so its important people get regular eye check ups, especially if there is a family history of glaucoma].
- Acute closed-angle glaucoma which can present with a painful red eye.
- It is due to inadequate drainage of aqueous fluid from the anterior chamber of the eye, which results in a rapid increase in intraocular pressure.

• Patients experience a frontal-orbital headache, with severe pain in the eye on the same side.
• Onest can be very quick
• The eye appears red and is painful.
• Vision is blurred/decreased, the cornea can look cloudy and haloes might be noticed around the vision.
• Characteristically occurs at night
• Vomitting is often present.
• Classically occurs in older, far sighted patients.
• Dim light can precipitate an attack

Management:
- Immediate referral to an emergency department for acute closed-angle glaucoma is required as the extreme pressure within the eye rapidly damaged the optic nerve.
- After lowering the pressure with drugs, surgery or lazer treatment is usually required to remove part of the iris - this lowers the pressure and should prevent it from re-occuring.

Question 30

Meningitis

Very Unlikley Cause Of Headache

Answer 30

Background/Symptoms/Features:
- Signs and symptoms are nonspecific in the early stages of the disease and are similar to flu, but can develop quickly to severe generalized headache associated with fever (although neonates may not have fever), an obviously ill patient, neck stiffness, nausea and vomiting.
- Latterly a nonblanching purpuric rash are classically associated with meningitis.
- However, not all patients will exhibit all symptoms, and any child that has difficulty in placing the chin on the chest and is running a temperature above 38.9°C (102°F) should be referred urgently.

Management
- Referral Hospital !!!!

Question 31

Subarachnoid Haemorrhage

Very Unlikley Cause Of Headache

Answer 31

Background/Symptoms.Features:
- The patient will experience an incapacitating headache with very intense severe pain, located in the occipital region.
- Nausea and vomiting are often present, and a decreased lack of consciousness is prominent.
- Patients often describe the headache as the worst headache they have ever had.
- It is extremely unlikely that a patient would present in the pharmacy with such symptoms.

Management:
- Immediate Referral to A&E

Question 32

Conditions Causing Raised Intracranial Pressure

Very Unlikley Cause Of Headache

Answer 32

Background/Symptoms/Features:
- Space-occupying lesions (e.g., brain tumour, haematoma, abscess) can give rise to varied headache symptoms, ranging from severe chronic pain to intermittent moderate pain.
- Pain can be localized or diffuse and tends to be more severe in the morning, with a gradual improvement over the next few hours.
- Coughing, sneezing, bending and lying down can worsen the pain.
- Nausea and vomiting are common.
- After a prolonged period of time, neurological symptoms, such as drowsiness, confusion, lack of concentration, difficulty with speech and paraesthesia, start to become evident.

Management:
- Any patient with a recent history (lasting 2–3 months) of head trauma, headache of long-standing duration, or insidious worsening of symptoms, especially associated with decreased consciousness and vomiting, must be - Immediately referred for fuller evaluation at A&E/GP

Question 33

Referral Signs/Symptoms With Headaches

Answer 33

Immediate Referral to GP/A&E
- Also have a stiff neck, high temperature or skin rash/signs of systemic illness. (meningitis?)
- Headache after recent (within last 3 months) of trauma or injury to head. (Haematoma)
- Nausea &/or vomitting & migrane not suspected (mass lesions/subarachnoid haemorrhage)
- Neurological symptoms if migrane is excluded as cause or if more severe/dont improve as normally would if typical aura, especially changes in consciousness; gait/unsteadyness/clumsiness; visual changes; photophobia.
- Very sudden &/or severe onset of headache
- Migrane like symptoms but lasting longer than 3 days.
- Non throbbing pain thats not orbital
- Pain aggrevated by lying down.
- New or severe headaches in patients>50Y
- Pain that is worse in the morning and improves as the day goes on (intracranial pressure)
- Severe Headache lasting >4hs/headache lasting more than 24.
- Progressive worsening of headache symptoms over time
- Symptoms of headache/migrane has changed from whats normal or worsened.

Referral As Soon A Practicable To GP
- Headache in children <12
- Headache unresponsive to analgesics within a few days of proper use.
- Any patients with newly suspected migraine should be referred but can be given self management options (including simple analgesia) in the interim until diagnosis.
- Medication Induced
- Frequent migranes; .4 per month (may need prophylatic treatment)
- Frequent persistent headache (more than 10 day per month)
- Headache never fully recovers inbetween attacks.

Question 34

Migraleve (Pink+Yellow) - OTC Treatment For Migranes

12Y+ as contains codeine

Answer 34

• Migraleve Pink tablets, which contain a paracetamol-codeine combination (500/8 mg) plus buclizine, 6.25 mg, or
• Migraleve Yellow tablets, which contain only the analgesic combination

Therapeutic Indications:
- For the short-term treatment of acute moderate pain which is not relieved by paracetamol, ibuprofen or aspirin alone such as migraine attacks including the symptoms of migraine headache, nausea and vomiting.
- Codeine is indicated in children older than 12 years of age for the treatment of acute moderate pain which is not considered to be relieved by other analgesics such as paracetamol or ibuprofen (alone).

Administration:
- The duration of treatment should be limited to 3 days and if no effective pain relief is achieved the patients/carers should be advised to seek the views of a physician.

16+) Two Migraleve Pink tablets to be swallowed immediately it is known that a migraine attack has started or is imminent. If further treatment is required, two Migraleve Yellow tablets every 4 hours. (Max 8 per 24H, 2 pink + 4 yellow)

12-15) One Migraleve Pink tablet to be swallowed immediately it is known that a migraine attack has started or is imminent. If further treatment is required, one Migraleve Yellow tablet every 4 hours. (Max 4 per 24H, 1 pink + 3 yellow)

Contraindications:
- Hypersensitivity to ingredients
- In all paediatric patients (0 to 18 years of age) who undergo tonsillectomy and/or adenoidectomy for Obstructive Sleep Apnoea Syndrome due to an increased risk of developing serious and life-threatening adverse reactions.
- Head injury; in conditions in which intracranial pressure is increased; acute respiratory depression; obstructive bowel disorders and in patients at risk of paralytic ileus.
- Breastfeeding
- CYP2D6 ultra-rapid metabolisers (codeine metaboliser to morphine)
- <12Y

Cautions:
- Migrane should be medically diagnosed
- Short term use only

Codeine;
- Tolerance, dependence; should be used with caution in patients with convulsive disorders, decreased respiratory reserve, such as bronchial asthma, pulmonary oedema & obstructive airways disease; withdrawl symptoms may occur if used for extended period.

Buclizine;
- has an antimuscarinic action & therefore should be used with caution in prostatic hypertrophy and urinary retention. Also where susceptibility exists to angle-closure glaucoma.

Interactions:
- CNS depressants(Codeine + Buclizine): alcohol, opioids, barbiturates, chloral hydrate, benzodiazepines, anti-psychotics (including phenothiazines), general anaesthetics and centrally acting muscle relaxants] may cause additive CNS depression and respiratory depression.
- Codeine should be avoided in Pts receiving monoamine oxidase inhibitors (MAOIs) or who have used MAOIs in the previous two weeks; not complete contraindication & could be given with caution but recommeded to just avoid.
- CYP450 Inducers; paracetmol metabolism may be accelerated.
- Chronic Alcphol; hepatotoxicity

Pregnancy/Breastfeeding:
- Should not be used in pregnancy unless potential benefit outweighs possible risk. May cause drug dependence in foetus/respiratory depression if used in labor/third trimester.
- Not recomended in breastfeeding as may be excreted in breastmilk & cause respiratory depression in infant.

Effects On Ability To Drive/Use Machines
- May cause drowsiness. If affected do not operate machinery.

Side Effects
- Addiction/Tolerance
- Can worsen headache if used too much/often
- Sedation/drowsiness/dizziness/somnolence, flushing
- Constipation/nausea/vomiting/dry mouth…

Question 35

Midrid - OTC Treatment For Migranes

12+

Answer 35

Midrid capsules contain isometheptene mucate(sympathomimetic), 65 mg, and paracetamol, 325mg.

Therapeutic Indication:
Treatment of acute attack of migrane

Method Of Administration:
- 2 capsules, dose to be taken at onset of attack, followed by 1 capsule every 1 hour if required, maximum of 5 capsules in 12 hours.
- If you still have a migraine 12 hours after you started taking Midrid, you can take one more course of treatment. That is, two capsules to start with followed by one capsule every hour, if needed, up to a maximum of five capsules. After this, you should ask your doctor or pharmacist for advice.

Contraindications:
- Acute porphyrias;
- Glaucoma;
- Severe cardiovascular disease;
- Severe hypertension

Cautions:
- can affect diabetes & hypertension control

Interactions:
- MAOIs - contraindicated if cocomitant use or within last 14 days.
- Linezolid - avoid use
- Alcohol/hepatotoxic drugs (hepatotoxicity risk)
- Warfarin; paracetamol increases anticoagular effects of warfarin, advised monitor INR.

Side Effects:
- rash/allergic symptoms if allergic to paracetamol.
- dizziness
- tingling/cold fingers or toes
Rarely- blood related disorders

Pregnancy/Breastfeeding:
- Avoid due to lack of data

Question 36

Buccastem M (prochlorperazine) - OTC Treatment For Migranes

18Y+

Answer 36

Prochlorperazine has been found to be a potent antiemetic in a number of conditions, including migraine.
- It works by blocking dopamine receptors found in the chemoreceptor trigger zone.
- It is administered via the buccal mucosa, and therefore patients will need to be counselled on correct administration.

Therapeutic Indication:
For nausea and vomiting in previously diagnosed migraine, in adults aged 18 years and over.

Method Of Administration:
- To be placed in the buccal cavity, high up along the top gum under the upper lip, until dissolved. Do not chew or swallow the tablet.
- Duration of treatment: Two days maximum.
- One or two tablets twice a day.

Contraindications:
* Hypersensitivity to the active substance or to any of the excipients listed in section 6.1
* Impaired liver function
* Existing blood dyscrasias
* Epilepsy; prochlorperazine can lower seizure threshold
* Parkinson’s Disease; opposes effects of levadopa
* Prostatic hypertrophy
* Narrow angle glaucoma
* Pregnancy.

Precautions For Use:
- Avoid in pts with stroke risk factors & myasthenia gravis.
- Risk of photosensitisation; avoid exposure to direct sunlight & use sunscreen.
- Cases of venous thromboembolism (VTE) have been reported with antipsychotic drugs. Since patients treated with antipsychotics often present with acquired risk factors for VTE, all possible risk factors for VTE should be identified before and during treatment with Buccastem M tablets and preventive measures undertaken
- QT prolongation; Neuroleptic phenothiazines may potentiate QT interval prolongation which increases the risk of onset of serious ventricular arrhythmias of the torsade de pointes type, which is potentially fatal. Buccastem M tablets should be used with caution in patients with congenital or documented acquired QT prolongation and/or known risk factors for prolongation of the QT interval.
- Increased mortality in elderly patienrts with dementia treated with antipsychotics.

Interactions:
- CNS depressants/alcohol; caution advised due to possible additive effects
- Anticholinergics; mild anticholinergic effects may be potentiated by other anticholinergics.
- Antihypertensives; hypotensive effects may be exaggerated.
- Lithium; concomitant use of lithium may result in severe extrapyramidal side effects or severe neurotoxicity.
- QT prolonging drugs; increase risk of arrthymias with concomitant use.

Pregnancy/Breastfeeding
P) Contraindicated
B) animal studies showed in breastmilk, should not be used

Effects On Ability to Drive/Use Machinery
Patients who drive or operate machinery should be warned of the possibility of drowsiness

Side-Effects:
- Agranulocytosis has been reported with phenothiazines. The occurrence of unexplained infections or fever may be evidence of blood dyscrasia and requires immediate haematological investigation
- Photosensitisation
- Hypotension
- Neuroleptic malignant syndrome (NMS) is a potentially fatal symptom complex associated with antipsychotic medicinal products. Alteration in mental status and other neurological signs often precede systemic signs of NMS. It is imperative that treatment be discontinued in the event of NMS (characterised by unexplained fever, hyperthermia, autonomic dysfunction, altered consciousness, muscle rigidity)
- Drowsiness, dizziness, dry mouth, insomnia and agita- tion.
- Very rarely it can cause muscle stiffness (dystonia).

Question 37

Sumatriptan - OTC Treatment For Migranes
(Migraitan)
- RPS guidance on POM-P switch

50mg; 18-65Y

Answer 37

Sumatriptan was the first triptan to be marketed in the UK and, subsequently, deregulated to OTC status.
- Triptans are 5-HT1 agonists and stimulate 5-HT1B and 5-HT1D receptors.
- Triptans cause constriction of the cranial blood vessels, stop the release of inflammatory neurotransmitters at the trigeminal nerve synapses, and reduce pain signal transmission.
- works within 30-60 minutes, and effects last for up to 2 hours.
- No limit on how much they can buy; should be based on professional judgement

Therapeutic Indication:
- Sumibril/Migraitan is indicated for the acute relief of migraine attacks, with or without aura.
- Sumibril/Migraitan should only be used where there is a clear diagnosis of migraine either; GP or pharmacist is confident of diagnosis from symptoms.
- In those ages 18-65
[Not to be used prophylatically OTC]

Method Of Administration:
- It is advisable that 1 tablet be taken as early as possible after the onset of a migraine attack but it is equally effective at whatever stage of the attack it is administered.
- If the patient has responded to the first dose but the symptoms recur, a second dose may be taken provided that there is a minimum interval of 2 hours between the two doses. Not more than two 50 mg tablets (total dose 100mg) may be taken in any 24 hour period or to treat the same attack.
- Patients who do not respond to the prescribed dose of Sumibril/ Migraitan should not take a second dose for the same attack. In these cases the attack can be treated with paracetamol, acetylsalicylic acid, or non-steroidal anti-inflammatory drugs. Sumibril/ Migraitan may be taken for subsequent attacks.

Contraindications:
- Hypersensitivity
- Should not be given to patients who have had myocardial infarction or have ischaemic heart disease, coronary vasospasm (Prinzmetal’s angina), peripheral vascular disease or patients who have symptoms or signs consistent with ischaemic heart disease.
- Should not be administered to patients with a history of cerebrovascular accident (stroke) or transient ischaemic attack (TIA).
- Severe Hepatic Impairment
- Uncontrolled hypertension of any stage, controlled moderate/severe hypertension.
- Concurrent Monoamine oxidase inhibitor use or with 14 days off its discontinuation.
- Concurrent ergotamine or derviative use
- Concurrent triptan use.
- Atypical migranes

Special Warnings/Precautions: [consider referral]
- should only be used where there is a clear diagnosis of migranes.
- High risk cardiovasucalr disease profiles- Three or more cardiovascular risk factors, e.g., a man over 40 years old, post-menopausal women, very overweight, diabetes, high cholesterol, family history of heart disease, smoker (+10 daily) or use of nicotine substitution therapies.
- Mild/controlled hypetension; can increase BP
- SSRI/SNRI concurrent use rare cases of serotonin syndrome reported.
- History of seizures
- Hypersenitvitiy to sulphonamides; limited cross-sensitivity evidence.

Interactions:
- Ergotamide/Another Triptan/5HT receptor agonist; theoretical increased risk coronary vasospasm so concurrent use contraindicated. Shouldnt give a triptan within 24 hours of using one of these agents, and shouldnt use these agents within 24 hours of the triptan except the ergotamide which can give after6 hours.
- Monoamide oxidate inhibitors; concomitant use contraindicated.
- st johns wort;increased risk of side effects
- SSRIs/SNRIs; rare cases serotonin syndrome reported.

Pregnancy/breastfeeding:
P; only considered if benefit outweight risk.
B; excreted into breastmilk, can minimise infant exposure by not breastfeeding for 12 hours.

Side-Effects:
Common adverse effects include nausea and vomiting
- disturbances of sensation (including tingling),
- dizziness, drowsiness,
- flushing, warm sensation,
- Feeling of weakness, fatigue
- Heaviness/pressure/tightness and pain in any part of the body.
- Increased BP
- Breathlessness

Question 38

Counselling For The Administration Of Buccal Tablets

Answer 38

1.Place the tablet either between the upper lip and gum, above the front teeth or between the cheek and upper gum.
2.Allow the tablet to dissolve slowly. The tablet will soften and form a gel-like substance after 1–2 hours.
3.The tablet will take from 3 to 5 hours to dissolve completely. If food or drinks are to be consumed during this time, place the tablet between the upper lip and gum, above the front teeth.
4.The tablets should not be chewed, crushed or swallowed.
5.Touching the tablet with the tongue or drinking fluids can cause the tablet to dissolve faster.