Anesthetics and Narcotics © Paradigm Publishing, Inc. Chapter 6 Anesthetics and Narcotics © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Learning Objectives Understand the central and peripheral nervous systems, their functions, and their relationship to drugs. Recognize different dosage forms and understand how the drug delivery system works. Learn how drugs affect body systems and where they work in the body. Understand the concepts of general and local anesthesia, and know the functions of these agents © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Learning Objectives Define the action of neuromuscular blocking agents in reducing muscle activity. Distinguish between narcotic and nonnarcotic analgesia. Understand the different classes of narcotics and the role of the technician in monitoring these drugs. Become familiar with the various types of agents for migraine headaches. © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. The Nervous System Transmits information over vast network throughout the body Neuron: nerve cell that transmits information Neurotransmitter: chemical substance released from neuron Stimulates or inhibits activity in target cells, especially other neurons © Paradigm Publishing, Inc.

Neurotransmitters Being Released from a Neuron © Paradigm Publishing, Inc.

Divisions of the Nervous System: CNS Central Nervous System (CNS) Brain and spinal cord Spinal cord receives information and sends to brain Brain evaluates information and sends out a response © Paradigm Publishing, Inc.

Divisions of the Nervous System: PNS Peripheral Nervous System (PNS) made up of nerves and sense organs Afferent system: nerves and sense organs bring information to CNS Efferent system: nerves send information out from the CNS © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. PNS Efferent System Autonomic nervous system (ANS) Involuntary activities: respiration, circulation, digestion, body temperature, metabolism, blood glucose, sweating Somatic nervous system Voluntary activities: skeletal muscles Acetylcholine only neurotransmitter between CNS and skeletal muscles © Paradigm Publishing, Inc.

Autonomic Nervous System © Paradigm Publishing, Inc.

CNS and PNS Primary Neurotransmitters Acetylcholine (Ach) GABA (gamma-aminobutyric acid) Dopamine Norepinephrine Serotonin Glutamate PNS Acetylcholine (Ach) Norepinephrine © Paradigm Publishing, Inc.

Sympathetic and Parasympathetic Primary Neurotransmitters Sympathetic System Acetylcholine (Ach) Norepinephrine Dopamine Epinephrine Parasympathetic System Acetylcholine (Ach) © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. ACh and GABA ACh acts on receptors in smooth and cardiac muscle, and exocrine glands ACh receptors blocked by anticholinergics GABA regulates message delivery system of the brain © Paradigm Publishing, Inc.

Dopamine, Epinephrine, and Norepinephrine Dopamine acts on receptors in the CNS and kidneys Epinephrine acts on cardiac and bronchodilator receptors Norepinephrine acts on alpha and beta receptors © Paradigm Publishing, Inc.

Serotonin and Glutamate Serotonin acts on smooth muscle and gastric mucosa Causes vasoconstriction which decreases blood flow Emotional responses: depression, anxiety Glutamine may be crucial to some forms of learning and memory © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Types of Receptors Alpha Vasoconstriction, raises blood pressure Beta-1 Increases heart rate and contractive force of the heart Beta-2 Vasodilation, increases blood flow Bronchodilator, relaxes smooth muscles © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Discussion What are three important types of receptors in the study of drugs? Three important types of receptors are alpha, beta-1, and beta-2. © Paradigm Publishing, Inc.

Drug Effects on the Nervous System Two types of effects on receptors Stimulating, causing a reaction Blocking, preventing a reaction Anticholinergics © Paradigm Publishing, Inc.

Side Effects of Anticholinergics Decreased GI motility (constipation) Decreased sweating Decreased urination Dilated pupil and blurred vision Dry eyes Dry mouth © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Terms to Remember neuron neurotransmitter central nervous system (CNS) peripheral nervous system (PN) afferent system efferent system © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Terms to Remember autonomic nervous system (ANS) somatic nervous system alpha receptors beta-1 receptors beta-2 receptors © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Anesthesia Allows painless and controlled surgical, obstetric, and diagnostic procedures Most potent anesthetics are gases or vapors Two classes of anesthesia: general and local Anesthesiologist oversees administration of anesthesia during surgery © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Anesthesia One anesthetic may be superior to another, depends on clinical situation Final choice based on drugs and anesthetic techniques safest for patient © Paradigm Publishing, Inc.

Physiologic Effects of Anesthesia Involves many systems Nervous Respiratory Endocrine Cardiovascular Skeletal muscular GI Hepatic © Paradigm Publishing, Inc.

Goals of Balanced Anesthesia Amnesia to eliminate patient’s memory of procedure Adequate muscle relaxation, no contracting of muscles Adequate ventilation by maintaining oxygen concentration Pain control © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Discussion What are some of the indicators used to assess general anesthesia? Some indicators include: blood pressure, hypervolemia, oxygen level, pulse, respiratory rate, tissue perfusion, and urinary output. © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. General Anesthetics General anesthesia is the unique condition of reversible unconsciousness and absence of response to painful stimuli Four reversible actions Unconsciousness Analgesia (relieving pain) Skeletal muscle relaxation Amnesia on recovery © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. General Anesthetics Preanesthetic medications Control sedation Reduce postoperative pain Provide amnesia Decrease anxiety Drugs often used: narcotics, benzodiazepines, phenothiazines © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. General Anesthetics Malignant hyperthermia is a serious side effect of anesthesia Fever of 110°F or more Life threatening Treatment: dantrolene (Dantrium) Always check expiration date Warning! © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Drug List Inhalant Anesthetics desflurane (Suprane) enflurane (Ethrane) halothane (none) isoflurane (Forane) nitrous oxide (none) © Paradigm Publishing, Inc.

Side Effects of Inhalant Anesthetics Reduce blood pressure May cause nausea and vomiting © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. nitrous oxide Causes analgesia only Given alone or with more powerful anesthetics to hasten uptake of other agent(s) Commonly used for dental procedures Advantage: rapidly eliminated © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. desflurane (Suprane) Easily controllable Rapid onset and recovery Often used in ambulatory surgery © Paradigm Publishing, Inc.

Injectable Anesthetics Very lipid soluble Most dispensed by IV drip Most are controlled substances © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Drug List Injectable Anesthetics alfentanil (Alfenta) etomidate (Amidate) fentanyl (Sublimaze) fentanyl-droperidol (none) ketamine (Ketalar) © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Drug List Injectable Anesthetics morphine (various) propofol (Diprivan) remifentanyl (Ultiva) sufentanil (Sufenta) © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Drug List Injectable Anesthetics Barbiturates methohexital (Brevital) thiopental (Pentothal) Benzodiazepines © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Drug List Injectable Anesthetics Benzodiazepines diazepam (Valium) lorazepam (Ativan) midazolam (Versed) © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. propofol (Diprivan) Used for maintenance of anesthesia, sedation, or treatment of agitation Antiemetic properties Side effects: drowsiness, respiratory depression, motor restlessness, increased blood pressure © Paradigm Publishing, Inc.

Dispensing Issues of Injectable Anesthetics Warning! Diprivan (anesthetic) and Diflucan (antifungal) may be confused A mix-up could be life-threatening © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. fentanyl Used extensively for open-heart surgery due to lack of cardiac depression Analogs used in the operating room Alfentanil (Alfenta) Sufentanil (Sufenta) Reminfentanil (Ultiva) © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Benzodiazepines Used for induction, short procedures, and dental procedures Used in controlling and preventing seizures induced by local anesthetics midozolam (Versed) fastest onset of action greatest potency most rapid elimination © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Drug List Antagonist Agents flumazenil (Romazicon) nalmefene (Revex) naloxone (Narcan) © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Antagonist Agents flumazenil (Romazicon) reverses overdoses of benzodiazepine nalmefene (Revex) and naloxone (Narcan) reverse overdoses of narcotics All operating and emergency rooms maintain a supply of antagonists © Paradigm Publishing, Inc.

Neuromuscular Blocking Agents Causes immediate skeletal muscle relaxation of short, long, and extended durations Used to facilitate endotracheal intubation and ensure patient does not move during surgery © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Drug List Neuromuscular Blocking Agents Short Duration succinylcholine (Quelicin) Long Duration atracurium (Tracrium) cisatracurium (Nimbex) rocuronium (Zemuron) vecuronium (Norcuron) © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Drug List Neuromuscular Blocking Agents Extended Duration mivacurium (Mivacron) pancuronium (none) © Paradigm Publishing, Inc.

Neuromuscular Blocking Agents Dispensing Issues Warning! Be conscious of storage requirements Store away from look-alike drugs © Paradigm Publishing, Inc.

succinylcholine (Quelicin) Often called “sux” Only depolarizing agent; all others are nondepolarizing agents Persistent depolarization at motor endplate. Shorts out electrical signal. Result: sustained, brief period of flaccid skeletal muscle paralysis © Paradigm Publishing, Inc.

Reversal of Neuromuscular Blocking Agents Antiacetylcholinesterase agents increase action of acetylcholine Inhibits acetylcholinesterase Restores transmission of impulses, reversing neuromuscular blocking agent © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Drug List Anticholinesterase Agents edrophonium (Enlon) neostigmine (Prostigmin) pyridostigmine (Mestinon) © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Local Anesthesia Relieves pain without altering alertness or mental function Affect all types of nervous tissue Commonly combined with other drugs Variety of combinations available © Paradigm Publishing, Inc.

Dosage Forms of Local Anesthetics Topical: drops, sprays, lotions, ointments Infiltration: superficial injection Nerve block: injection IV Epidural: regional anesthesia Spinal: blocks afferent pain nerve impulses from lower part of the body © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Discussion What are the two classes of local anesthetics? The two classes are esters and amides. © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Local Anesthetics Esters Short acting Metabolized in plasma and tissue fluids Excreted in urine Amides Longer acting than esters Metabolized by liver enzymes Excreted in urine © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Drug List Local Anesthetics Esters benzocaine (Americaine) chloroprocaine (Nesacaine) dyclonine (Cēpacol Maximum Strength) procaine (Novocain) tetracaine (Cēpacol Viractin, Pontocaine) © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Drug List Local Anesthetics Amides bupivacaine (Marcaine) levobupivacaine (Chirocaine) lidocaine (L-M-X, Solarcaine Aloe Extra Burn Relief, Xylocaine, Lidoderm) © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Drug List Local Anesthetics Amides lidocaine-epinephrine (Xylocaine with Epinephrine) lidocaine-prilocaine (EMLA) mepivacaine (Carbocaine) © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Discussion What functions are lost with local anesthetics? Functions that are lost include: pain perception, temperature sensation, touch sensation, proprioception, and skeletal muscle tone. © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Discussion Under what conditions would a local anesthetic be used over a general anesthetic? It is chosen when a well-defined area of the body is targeted. © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Terms to Remember anesthesiologist general anesthesia malignant hyperthermia neuromuscular blocking endotracheal intubation anticholinesterase © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Terms to Remember local anesthesia ester amide © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Pain Management Pain is protective mechanism to warn of damage or the presence of disease Part of the normal healing process Can be a disease Considered the “fifth” vital sign © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Pain Management Acute Pain Associated with trauma or surgery Warns of a problem Easier to manage by treating the cause Disappears when body heals Has beginning and end © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Pain Management Chronic nonmalignant pain Lasts more than 3 months Diagnosed or undiagnosed cause May respond poorly to treatment Depression, sense of helplessness and hopelessness Affects all aspects of life © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Pain Management Chronic malignant pain Accompanies malignant disease Often increases in severity with disease progression © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Major Sources of Pain Source: somatic Areas: body framework Characteristics: throbbing, stabbing, localized Treatment: narcotics, NSAIDs, nerve blockers © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Major Sources of Pain Source: visceral Areas: kidneys, intestines, liver Characteristics: aching, throbbing, sharp, gnawing, crampy Treatment: narcotics, NSAIDs, nerve blockers, antiemetics © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Major Sources of Pain Source: neuropathic Areas: nerves Characteristics: burning, aching, numbing, tingling, constant Treatment: antidepressants, anticonvulsants © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Major Sources of Pain Source: sympathetically mediated Areas: overactive sympathetic system Characteristics: occurring when no pain should be felt Treatment: nerve blockers © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Narcotics Pain-modulating chemicals that cause insensibility or stupor Opiates Derived from opium or synthetic Agonists of opioid receptor sites Main effects on CNS and GI tract Lesser effects on peripheral tissues © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Natural Opioids Endorphins, enkephalins, and dynorphins Brain produces in response to pain stimuli When receptors are activated Causes decreased nerve transmission Sensation of pain diminished Opioids bind to these same receptors © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Effects of Narcotics Analgesia: reduces pain from most sources Sedation: decrease anxiety and cause drowsiness Euphoria and dysphoria: feelings of well-being, disquiet, restlessness Narcotics have potential for tolerance and dependence © Paradigm Publishing, Inc.

Patient-Controlled Analgesia Pump PCA pump effective means of controlling pain Patient regulates, within limits, amount of drug received Better pain control with less drug © Paradigm Publishing, Inc.

Analgesic Ladder of Pain Relief Mild to moderate pain Acetaminophen or NSAID and an adjuvant If adequate relief not achieved NSAID plus a “weak” opioid (codeine) Strong opioid (morphine) with an adjuvant analgesic if indicated © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Transdermal Patch Provides pain control Allows patient to remain more alert than with most other methods © Paradigm Publishing, Inc.

Analgesic Ladder of Pain Relief © Paradigm Publishing, Inc.

Addiction and Dependence Chronic opioid therapy has low risk of addiction when used appropriately © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Discussion What is the difference between addiction and dependence? © Paradigm Publishing, Inc.

Dependence and Addiction Physical and emotional reliance on a drug Withdrawal Addiction Compulsive disorder © Paradigm Publishing, Inc.

Signs of Narcotics Addiction Preoccupation with drugs Refusal of medication tapers Strong preference for a specific opioid Decrease in ability to function Medication often not taken as prescribed Tendency to rely on multiple prescribers and pharmacies to conceal behavior © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Withdrawal Patients more successful overcoming addiction if withdrawal symptoms are handled appropriately Opioid antagonists have stronger attraction for receptors than analgesic agents Blocking opioid action may prevent withdrawal symptoms © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Drug List Drugs to Treat Opioid Addiction buprenorphine (Buprenex, Subutex) buprenorphine-naloxone (Suboxone) methadone (Dolophine) © Paradigm Publishing, Inc.

Dispensing Issues of Narcotics Warning! Technicians have a legal and moral responsibility to alert pharmacist of suspected abuse and addiction Documentation must be in medical record Low addiction rate if no history of addiction © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Narcotic Analgesics Analgesic is a drug that alleviates pain Narcotic analgesic is pain medication containing an opioid © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Drug List Narcotic Analgesics butorphanol (Stadol) codeine (Codeine Contin) fentanyl (Actiq, Duragesic, Fentora, Ionsys) hydromorphone (Dilaudid) meperidine (Demerol) © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Drug List Narcotic Analgesics morphine (Astramorph/PF, Avinza, Duramorph, MS Contin, MSIR) oxycodone (OxyContin) oxymorphone (Numorphan, Opana, Opana ER) pentazocine (Talwin) propoxyphene (Darvon) © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Narcotic Analgesics Dose requirements vary with Severity of pain Individual response to pain Patient’s age and weight Presence of concomitant disease Morphine is standard against which all other narcotic analgesics are measured © Paradigm Publishing, Inc.

Goal of Narcotic Analgesics Many dosage forms and strengths Delivered by various routes Goal: Patient comfort Key to reaching goal: Constant reassessment © Paradigm Publishing, Inc.

Dispensing Issues of morphine Warning! Avinza (morphine) and Invanz (eratpenem) often confused Morphine sulfate (MSO4) and magnesium sulfate (MgSO4) often confused © Paradigm Publishing, Inc.

Dispensing Issues of Narcotic Analgesics Warning! Consult policies and procedures of workplace to use the required check systems to make sure narcotic counts are correct. © Paradigm Publishing, Inc.

Side Effects of Narcotic Analgesics Side effects anticipated and minimized for patient comfort Mental confusion Reduced alertness Nausea/vomiting Dry mouth Constipation Inflammatory process Bronchial constriction © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. fentanyl Patch (Duragesic) Approved for chronic use, not acute pain after surgery Lozenge (Actiq) Swabbed on mucosal surfaces inside the mouth and under the tongue Not as effective if swallowed © Paradigm Publishing, Inc.

Combination Drugs for Managing Pain Combinations of narcotics and nonnarcotics are common Increases pain relief Allows use of lower doses Limits intake of addictive substances Decreases side effects © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Drug List Combination Drugs for Pain Control acetaminophen-codeine (Phenaphen with Codeine, Tylenol with Codeine) hydrocodone-acetaminophen (Lortab, Vicodin, Lorcet) meperidine-promethazine (Mepergan) oxycodone-acetaminophen (Endocet, Perocet, Tylox) © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Drug List Combination Drugs for Pain Control oxycodone-aspirin (Endodan, Percodan) oxycodone-ibuprofen (Combunox) pentazocine-naloxone (Talwin NX) propoxyphene-acetaminophen (Darvocet-N 100) © Paradigm Publishing, Inc.

Dispensing Issues of Analgesic Combinations Warning! Serious risk of aspirin or acetaminophen toxicity if dose is overlooked Technicians—check that patient is not getting more than 4 grams of aspirin or acetaminophen per day © Paradigm Publishing, Inc.

Dispensing Issues of Analgesic Combinations Warning! Pharmacy technicians should check C-III, CIV, and C-V drugs Refills no more than 5 times Refills good for no more than 6 months C-II drugs have NO refills © Paradigm Publishing, Inc.

meperidine-promethazine Produces less nausea than similar drugs Promethazine controls nausea Very sedating Used for patients who develop nausea from opioid use © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Terms to Remember pain narcotic opiate opioid patient-controlled analgesia (PCA) nonsteroidal anti-inflammatory drugs (NSAIDs) © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Terms to Remember analgesic ladder dependence addiction analgesic narcotic analgesic © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Migraine Headaches Migraine Headache Severe, throbbing, vascular headache Recurrent unilateral head pain Accompanied by neurologic and GI disturbances 90% of migraine sufferers report nausea Sensitivity to light, sound, and stimulation also common © Paradigm Publishing, Inc.

Components of Migraine Classic migraine components (all five not experienced by everyone) Prodrome Aura Headache Headache relief Postdrome © Paradigm Publishing, Inc.

Components of Migraine Prodrome: Symptom indicating onset Aura: Subjective sensation or motor phenomenon that precedes onset Flashing lights Shimmering heat waves Bright lights Dark holes in visual fields Vision blurred, cloudy transient or loss of © Paradigm Publishing, Inc.

Components of Migraine Headache and Headache Relief Generally dissipates in 6 hours, but may last 1 to 2 days Postdrome Knowing headache is gone © Paradigm Publishing, Inc.

Cause of Migraine Headaches Serotonin appears involved in cause Decreased levels causes excessive vasodilation in cranial arteries and migraine occurs By stimulating serotonin receptors vasoconstriction occurs, alleviating migraine © Paradigm Publishing, Inc.

Causative Factors of Migraine Headaches Diet Stress Depression Sleep habits Certain medications Hormonal fluctuations Atmospheric changes Environmental irritants © Paradigm Publishing, Inc.

Initial Treatment of Migraine Headaches At first hint of migraine, identify and eliminate triggers Quiet environment and sleep may help Lying down in a dark room For severe or debilitating and frequent attacks, drug therapy may be indicated Sedative, antiemetic, and narcotic agents © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Discussion What are the two classes of migraine drug therapy? The two classes are prophylactic therapy and abortive therapy. © Paradigm Publishing, Inc.

Therapy for Migraine Headaches Prophylactic Therapy Attempts to prevent or reduce recurrence Abortive Therapy Taken after acute migraine occurs Taken at first sign of a migraine, such as aura or headache © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Prophylactic Therapy Anticonvulsants Beta blockers Calcium channel blockers Estrogen Feverfew NSAIDs SSRIs Tricyclic antidepressants © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Abortive Therapy Simple analgesics NSAIDs Ergotamine-containing medications Serotonin-containing medications © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Drug List Migraine Headache Agents Triptans—Selective 5-HT Receptor Agonists almotriptan (Axert) eletriptan (Relpax) frovatriptan (Frova) naratriptan (Amerge) rizatriptan (Maxalt, Maxalt-MLT) sumatriptan (Imitrex) zolmitriptan (Zomig) © Paradigm Publishing, Inc.

rizatriptan (Maxalt-MLT) Sublingual tablet, quickly absorbed Most rapid onset of action of all oral migraine therapies May receive relief after 30 minutes Maxalt not absorbed as quickly as Maxalt-MLT © Paradigm Publishing, Inc.

sumatriptan (Imitrex) Causes vasoconstriction of blood vessels Use at first sign of headache If brings partial relief, patient may receive second dose at least 1 hour after first Available in injection, nasal spray, and tablet © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Drug List Migraine Headache Agents Ergot Preparations dihydroergotamine (D.H.E. 45, Migranal) ergotamine (Ergomar) ergotamine-caffeine (Cafergot) © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Drug List Migraine Headache Agents Antiemetic Agents chlorpromazine (Thorazine) metoclopramide (Reglan) prochlorperazine (Compazine) © Paradigm Publishing, Inc.

metoclopramide (Reglan) Reduces nausea and vomiting Enhances absorption of other antimigraine products Metoclopramide and aspirin prescribed together in place of sumatriptan (Imitrex) due to fewer side effects © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Drug List Migraine Headache Agents Opioid Analgesic butorphanol (Stadol, Stadol NS) Beta Blocker propranolol (Inderal) © Paradigm Publishing, Inc.

butorphanol (Stadol, Stadol NS) Nasal spray used more commonly than injection Used for moderate-to-severe pain Can be addictive C-IV controlled substance © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Drug List Migraine Headache Agents: Other acetaminophen, aspirin, caffeine (Excedrin Migraine) butalbital-acetaminophen-caffeine (Fioricet) butalbital-aspirin-caffeine (Fiorinal) isometheptene-dichloralphenazone-acetaminophen (Midrin) tramadol (Ultram) © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. tramadol (Ultram) High success rate when given with NSAIDs (ibuprofen) Slow onset of action Not a controlled substance, but has shown potential for addiction © Paradigm Publishing, Inc.

Dispensing Issues of Migraine Agents Warning! Tramadol and Toradol could be confused © Paradigm Publishing, Inc.

isometheptene-dichloralphenazine-acetaminophen (Midrin) Fewer side effects than ergotamines Combination of analgesic, sedative, and vasoconstrictor For mild to moderate headaches Take 2 capsules at onset of headache, then 1 every 1 to 2 hours until pain stops, up to 5 capsules in 12 hours © Paradigm Publishing, Inc.

acetaminophen, aspirin, caffeine (Excedrin Migraine) Combination reported to give very good results in migraine pain Many common headaches, including migraines, respond to this combination © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Discussion What are some of the issues facing migraine sufferers and the medication that is used? Some issues are nausea and vomiting, 0.5 to 2 hour onset of action, and side effects. © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Terms to Remember migraine headache a severe, throbbing, unilateral headache, usually accompanied by nausea, photophobia, phonophobia, and hyperesthesia aura a subjective sensation or motor phenomenon that precedes and marks the onset of a migraine headache © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Assignments Complete Chapter Review activities Answer questions in Study Notes document Study Partner Quiz in review mode Matching activities Drug tables © Paradigm Publishing, Inc.