Drug Management of Selected Pain Syndromes Flashcards
What are the treatment options for bony metastasis associated with cancer pain?
Aspirin, NSAIDs, paracetamol, opioids, hormonal therapy for metastases arising from hormone-dependent cancers (e.g. goserelin in prostate carcinoma bone metastases)
What are the treatment options for neurogenic pain associated with cancer pain?
Opioids, tramadol, TCAs, anti-seizure drugs, local anaesthetics, mexiletine
What are the treatment options for tumor associated cerebral oedema associated with cancer pain?
Dexamethasone
Aspirin
What are the treatment options for visceral pain associated with cancer?
Opioids
What are the treatment options for skin infiltration/ulceration associated with cancer?
Aspirin
Opioids
Corticosteroids
What is a migraine?
Migraine is a chronic neurological disease characterized by recurrent moderate to severe headaches often in association with a number of autonomic nervous system symptoms
What is the pathophysiology of a migraine?
Pathophysiology
• Neuropeptides (calcitonin gene-related peptide, substance P and neurokinin A) released from the trigeminal nerve result in cerebral vasodilatation and perivascular oedema
• The mechanical stretching caused by the perivascular oedema results in activation of pain nerve endings in the dura, causing the headache
What is the analgesic treatment of a migraine?
Analgesia
• NSAIDs, aspirin, paracetamol, tramadol and opioid analgesics
• Analgesics are given to control the pain of migraine
What is the abortive treatment of a migraine?
Abortive treatment:
• Taken to prevent headache when first signs of attack begin
• 5-HT,/D agonists (triptans): sumatriptan, zolmitriptan, naratriptan (activate the 5-HT,/ receptors on presynaptic trigeminal nerve endings to inhibit the release of the neuropeptides and also directly activate postsynaptic 5-HT,B/I receptors found in cerebral and meningeal blood vessels to prevent vasodilatation). The triptans are first line drugs for the treatment of severe acute migraine attacks.
The triptans can cause angina and myocardial infarction and should therefore be avoided in ischaemic heart disease.
Ergot alkaloids: ergotamine and dihydroergotamine (partial agonists on alpha, adrenoceptors and 5-HT receptors - have vasoconstrictor activity, and therefore prevent vasodilatation and stretching of the pain nerve endings). Avoid repeated because of cumulative effects on blood vessels that can result in gangrene of extremities.
What is the prophylactic treatment of a migraine?
Prophylactic treatment:
Given if more than one attack per week. The drugs used for prophylaxis are not effective in the treatment of acute migraine.
• TCAs: amitryptiline
• 5-HT, antagonists: methysergide (use has declined because it causes retroperitoneal fibrosis), pizotifen and cyproheptadine
• Beta blockers (lipid soluble): propranolol, timolol, nadolol, metoprolol (stabilize neuronal membranes)
• Anti-seizure drugs: valproate, lamotrigine, gabapentin, tiagabine, topiramate (stabilize neuronal membranes)
• Calcium channel blockers: verapamil (avoid dihydropyridines as they cause vasodilatation and can precipitate headache)
What is a cluster headache?
Cluster headache is a neurological disorder characterized by recurrent, severe headaches on one side of the head, typically around the eye. There are often accompanying autonomic symptoms during the headache such as eye watering, nasal congestion and swelling around the eye, typically confined to the side of the head with the pain. The cause is unknown.
What is the acute treatment of a cluster headache?
Acute treatment: (1) 5-HT,/D agonists (triptans) e.g. sumatriptan (2) ergot alkaloids: ergotamine and dihydroergotamine (3) 100% oxygen inhalation
What is the prophylactic treatment of a cluster headache?
Prophylaxis:
(1) corticosteroids (to provide temporary prevention while preventive drugs with slower onset of action take effect)
(2) verapamil (recommended first-line preventive therapy)
(3) other preventive therapy: lithium, methysergide and topiramate
What is a tension type headache?
Tension-type headache is the most common type of primary headache. The pain can radiate from the lower back of the head, the neck, eyes, or other muscle groups in the body. Tension-type headaches account for nearly 90% of all headaches.
What is the acute treatment for a tension type headache?
Acute treatment: paracetamol, codeine, NSAIDs (e.g. ibuprofen, aspirin) ‡ sedatives (e.g. benzodiazepines)
