Insomnia To get away from this!

Insomnia (Difficulty Initiating or Maintaining Sleep) Insomnia is often characterized by difficulty falling asleep, frequent nocturnal awakenings, early morning awakenings, and non-restorative sleep, which may result in daytime impairments in concentration and school or work performance. In comorbid (secondary) insomnia, social factors (e.g., family difficulties, bereavement), medications (e.g., antidepressants, β-agonists, corticosteroids, decongestants), and coexisting medical or psychiatric conditions (e.g., depression, bipolar disorder) may help to explain difficulties in initiating and maintaining sleep.

Non-pharmacologic Recommendations for Insomnia Stimulus control procedures Establish regular times to wake up and to go to sleep Sleep only as much as necessary to feel rested. Go to bed only when sleepy. Avoid long periods of wakefulness in bed. Avoid trying to force sleep. Avoid daytime naps. Schedule worry time during the day. Do not take your troubles to bed

Non-pharmacologic Recommendations for Insomnia Sleep hygiene recommendations Exercise routinely. Create a comfortable sleep environment Discontinue or reduce the use of alcohol, caffeine, and nicotine. Avoid drinking large quantities of liquids in the evening to prevent nighttime trips to the restroom. Do something relaxing and enjoyable before bedtime.

Pharmacologic Therapy Benzodiazepine Receptor Agonists Benzodiazepines Dose in mg nonBenzodiazepines GABAA Agonists Diazepam 2–5 Zaleplon 10 Loprazolam 1 Zolpidem 5-10 Lorazepam Zopiclone 3.75-7.5 Lormetazepam 0.5–1.5 eszopiclone 2-3 Nitrazepam 5–10   Temazepam 10–20

Pharmacologic Therapy Miscellaneous Agents Antihistamines (Diphenhydramine and doxylamine ) exhibit sedating properties and are included in many nonprescription sleep agents. Antidepressants are alternatives for patients with nonrestorative sleep who should not receive benzodiazepines, especially those who have depression, pain, or a risk of substance abuse. Ramelteon

Headache Tension Headache Everybody experiences the occasional tension headaches. They are caused by muscle contraction over the neck and scalp. Often they respond to simple analgesics available overthe- counter, such as paracetamol and NSAIDs. They may also respond to TCA drugs given as a single dose at night. NSAIDs may be indicated if the headache is associated with cervical spondylosis or neck injury.

Headache Migraine Migraine is a common, recurrent, severe headache that interferes with normal functioning. It is a primary headache disorder divided into two major subtypes, migraine without aura and migraine with aura.

migraine The pathophysiology of migraine headache. Vasodilation of intracranial extracerebral blood vessels (possibly the result of an imbalance in the brain stem) results in the activation of the perivascular trigeminal nerves that release vasoactive neuropeptides to promote neurogenic inflammation. Central pain transmission may activate other brain stem nuclei, resulting in associated symptoms (nausea, vomiting, photophobia, phonophobia).

Migraine Symptoms Migraine is characterized by recurring episodes of throbbing head pain, frequently unilateral, that when untreated can last from 4 to 72 hours. Migraine headaches can be severe and associated with nausea, vomiting, and sensitivity to light, sound, and/or movement. Not all symptoms are present at every attack.

Migraine Migraine Triggers 1. Behavioral: Fatigue, Menstruation or menopause, Sleep excess or deficit, Stress, Vigorous physical activity 2. Environmental: Flickering lights. High altitude, Loud noises, Strong smells, Tobacco smoke,Weather changes 3. Food: Caffeine intake or withdrawal, Chocolate, Citrus fruits, bananas, figs, raisins and Dairy products 4. Medications: Cimetidine, Estrogen or oral contraceptives, Indomethacin, Nifedipine, and Nitrates

Migraine General Approach to Treatment Nonpharmacologic and pharmacologic interventions are available for the management of migraine headache; however, drug therapy remains the mainstay of treatment for most patients. Pharmacotherapeutic management of migraine can be acute (i.e., symptomatic or abortive) or preventive (i.e., prophylactic).

Migraine Pharmacologic Management of Acute Migraine 1. Analgesics and NSAIDs: Simple analgesics and NSAIDs are effective medications for the management of many migraine attacks. They offer a reasonable first-line choice for treatment of mild to moderate migraine attacks or severe attacks that have been responsive in the past to similar NSAIDs or nonopiate analgesics. Of the NSAIDs, aspirin, diclofenac, ibuprofen, ketorolac, naproxen sodium, tolfenamic acid, and the combination of acetaminophen plus aspirin and caffeine have demonstrated the most consistent evidence of efficacy

Migraine Pharmacologic Management of Acute Migraine 2. Opiate Analgesics: The use of narcotic analgesic drugs (e.g., meperidine, butorphanol, oxycodone, and hydromorphone) in migraine treatment is controversial, and evidence for use is generally negative. Use should generally be reserved for patients with moderate to severe infrequent headaches in whom conventional therapies are contraindicated or as “rescue medication” after patients have failed to respond to conventional therapies.

Migraine Pharmacologic Management of Acute Migraine 3. Antiemetics: Adjunctive antiemetic therapy is useful for combating the nausea and vomiting that accompany migraine headaches and the medications used to treat attacks (e.g., ergotamine tartrate). A single dose of an antiemetic, such as metoclopramide, chlorpromazine, or prochlorperazine, administered 15 to 30 minutes before ingestion of oral abortive migraine medications is often sufficient.

Migraine Pharmacologic Management of Acute Migraine 4.Ergot Alkaloids and Derivatives: Ergotamine tartrate (cafregote 2 mg at onset; then 1–2 mg every 30 minutes as needed Maximum dose is 6 mg/day or 10 mg/week) and dihydroergotamine (0.25–1 mg at onset IM or subcutaneous; repeat every hour as needed Maximum dose is 3 mg/day or 6 mg/week ) are useful and can be considered for the treatment of moderate to severe migraine attacks.

Migraine Pharmacologic Management of Acute Migraine 5. Serotonin Receptor Agonists (Triptans): Introduction of the 5-HT receptor agonists, or triptans, represented a significant advance in migraine pharmacotherapy. Sumatriptan (Optimal oral dose is 50–100 mg; maximum daily dose is 200 mg), Zolmitriptan (Optimal oral dose is 2.5 mg; maximum daily dose is 10 mg), and Frovatriptan (Optimal oral dose is 2.5-5 mg; maximum daily dose is 7.5 mg) are selective agonists of the 5-HT1B and 5-HT1D receptors.

Migraine Pharmacologic Management of Acute Migraine 6. Miscellaneous Nonspecific Medications A. Corticosteroids can be considered as rescue therapy for status migrainous (a severe, continuous migraine that can last up to 1 week). has also been used as an adjunct to abortive therapy. B. Intranasal lidocaine, one to four drops of a 4% solution, provides rapid pain relief within 15 minutes. C. IV valproate 500 to 1,000 mg and magnesium sulfate 1,000 mg are nonsedating options for use in acute migraine treatment.

Migraine Prophylactic Pharmacologic Therapy To determine maximal clinical benefits, a therapeutic trial of 6 months is recommended when initiating treatment for episodic migraine prevention. Despite this recommendation, most migraine prevention studies have relatively brief treatment durations of only 12 to 16 weeks.

Migraine Prophylactic Pharmacologic Therapy β-Adrenergic antagonists: β-Adrenergic antagonists are among the most widely used drugs for migraine prophylaxis. Metoprolol (100-200mg\day in divided doses), propranolol (40-160mg\day in divided doses), and timolol (20-160\day in divided doses) have established efficacy in controlled clinical trials, reducing the frequency of attacks by 50% in greater than 50% of patients.

Migraine Prophylactic Pharmacologic Therapy. Antidepressants: The beneficial effects of antidepressants in migraine are independent of their antidepressant activity and may be related to down-regulation of central 5-HT2 receptors, increased levels of synaptic norepinephrine, and enhanced endogenous opioid receptor actions.30 The tricyclic antidepressant (TCA) amitriptyline (20-50 mg) and SNRI venlafaxine (75-150mg) have demonstrated efficacy

Migraine Prophylactic Pharmacologic Therapy. Anticonvulsants: Anticonvulsant medications have emerged as important therapeutic options for migraine prophylaxis with valproate, divalproex,(500-1500mg) and topiramate (50-200) all having established efficacy NSAIDs: are modestly effective for reducing the frequency, severity, and duration of migraine attacks, but potential GI and renal toxicity limit the daily or prolonged use of these agents. Consequently, NSAIDs have been used intermittently to prevent headaches that recur in a predictable pattern, such as menstrual migraine.

Migraine Prophylactic Pharmacologic Therapy. Triptans: Triptans are also useful for the prevention of menstrual migraine. Frovatriptan has established efficacy, while naratriptan and zolmitriptan are probably effective. The triptan is usually started 1 or 2 days before the expected onset of headache and continued during the period of vulnerability

Migraine Prophylactic Pharmacologic Therapy. Miscellaneous Prophylactic Agents: riboflavin (vitamin B2) 400 mg daily cyproheptadine (4 mg/day) The calcium channel blockers, primarily verapamil, have been widely used for preventive treatment