Pharm7e-Ch18-Presentation

[Audio] Welcome to the Pharmacology for Technicians Seventh Edition Watch and Learn Lessons!.

[Audio] Chapter 18, Pain, Anesthesia, and Drug Therapy..

[Audio] In the first section, you will learn about sources of pain and the difference between acute and chronic pain. In the opioids and pain management section, you will develop an understanding of the role of opioid analgesics in pain management and the primary hazards of their use. You will also develop an awareness of the role of nonopioid analgesics in pain management. In the section on opioid use disorder and treatments, you will learn the signs of opioid use disorder and the drugs used to treat the disorder..

[Audio] In the anesthesia section of this chapter, you will learn about the purpose of anesthesia and compare the different types of interventions. You will also develop an understanding of how medications help support sedation and analgesia and the primary risks with their use. In addition, you will discover different types of neuromuscular blocking agents and how these agents can be reversed. In the migraine headaches and drug treatments section, you will learn about current medications used to manage migraines..

[Audio] Chapter 18, Section 1, Physiology of Pain..

[Audio] Pain is defined as physically or emotionally sensed discomfort that is associated with acute tissue damage or a sensory system malfunction. Pain receptors, known as nociceptors, are activated when a stimulus could damage tissue. Extreme temperature or a cut could activate pain receptors. As a protective signal, pain warns of damage or the presence of disease. Pain is a normal part of healing..

[Audio] The types of pain mechanisms include nociceptive, neuropathic, and centralized. Nociceptive pain is perceived when pain receptors sense damage to tissues and is classified as either somatic or visceral. Somatic nociceptive pain originates from the bones, muscles, and ligaments. Somatic nociceptive pain presents as the throbbing, localized pain experienced with a broken arm. Visceral nociceptive pain stems from organs such as the kidneys. Visceral nociceptive pain manifests as an aching, throbbing, sharp, gnawing, cramping, or deep squeezing pain. This is the type of pain that stems from kidney stones. Neuropathic pain is often associated with nerve damage. It occurs when nerve fibers are overactive and send pain signals when no pain should be felt. It presents as a burning, tingling, numbing, or shooting pain. Conditions that involve neuropathic pain include diabetic neuropathy and postherpetic neuralgia. Centralized pain occurs due to dysregulated pain processing in the central nervous system and can overlap with nociceptive and neuropathic pain. This overlap may be due to heightened pain receptor sensitivity or a reduction in the body's ability to suppress pain signaling. Centralized pain is present in conditions such as chronic pelvic pain and fibromyalgia..

[Audio] Another way to categorize pain is by the timing. Acute pain is associated with trauma or surgery, and normally occurs within 6 weeks of a pain-inducing event. Acute pain usually disappears once the body has healed which is typically within three months. Chronic nonmalignant pain may not have a diagnosed cause and lasts longer than 12 weeks. Chronic malignant pain describes pain that accompanies malignant disease. Chronic malignant pain increases in severity as the disease progresses and when patients near the end of life..

[Audio] An additional way of categorizing pain is by how it is experienced. Background pain describes a constant level of pain. Breakthrough pain, on the other hand, describes when pain of greater intensity occurs intermittently for no particular reason. Provoked pain describes pain that is more intense than background pain but has a clear cause. The experience of pain is unique to each person regardless of whether it follows a surgical incision, is persistent lower back pain, or is pain secondary to cancer. Because the perception of pain can be subjective, thorough patient assessment and selection of the most successful and cost-effective therapy in pain management is challenging. Inadequate treatment of pain can have adverse physiological, psychological, and immunological effects..

[Audio] Chapter 18, Section 2, Opioids and Pain Management..

[Audio] An analgesic is a drug that alleviates pain. In practice, analgesics describe drugs addressing nociceptive pain. Most drugs used for neuropathic or centralized pain have other indications and are often described as having analgesic activity. Opioids are a type of analgesic frequently encountered in a pharmacy. The opioid drug class includes morphine, codeine, and their semisynthetic or synthetic derivatives. The term opiate refers only to naturally occurring forms of the opioids, while the term narcotic is used when referring to the DEA regulations. Opioid effects include analgesia, anxiety reduction, sedation, euphoria or dysphoria, and tolerance and dependence. They provide analgesia by binding to the mu, delta, or kappa receptors..

[Audio] In terms of dosing, morphine is the standard by which other opioids are measured. Some drugs are more potent than morphine, but doses can be adjusted to provide an equivalent effect. An equianalgesic dose offers the same amount of analgesia. Equianalgesic doses can be approximated using opioid conversion charts to determine the morphine milligram equivalent. Opioids do not have a target dose and are titrated. The right dose is one that allows the patient to complete daily activities and supports quality of life, without excessive or intolerable adverse effects. Routes of administration of the opioids include oral, rectal, intramuscular, subcutaneous, intravenous, patient-controlled analgesic pump, and transdermal. Intravenous doses are usually more potent than intramuscular doses. Intramuscular doses are essentially equivalent to subcutaneous doses. Both intravenous and intramuscular are more potent than oral or rectal doses, which are approximately equal..

[Audio] Opioids have a number of side effects. Most of these fade within a week or two, except for constipation. This can last for the entire duration of opioid therapy. Side effects of opioids include confusion, reduced alertness, nausea, vomiting, dry mouth, constipation, difficulty urinating, flushing, decreased blood pressure, difficulty breathing, risk of seizures in epileptic disorders, risk of coma in severe liver disease, and risk of infection with long term use..

[Audio] There are a number of cautions and considerations to keep in mind when patients are prescribed opioids. Cautions and considerations include caution in liver or kidney disease; caution in respiratory depression; caution in thyroid dysfunction, head injury, mental health disorders; caution with use of other CNS depressants; not to be used in substance disorder; risk of neonatal opioid withdrawal syndrome in exposed infants at birth; risk of hypogonadism; risk of drug interactions with drugs that slow opioid metabolism; and risk of serotonin syndrome when combined with drugs affecting serotonin. All opioids carry boxed warnings for risk of misuse, abuse, and addiction, which can lead to overdose or death. They all carry this warning for the risk of life-threatening respiratory depression, particularly in certain situations. They also carry the boxed warning for the risk of neonatal opioid withdrawal syndrome in exposed infants at birth following the pregnant parent's opioid use during pregnancy..

[Audio] Opioids work by binding and activating the mu receptor and are referred to as mu opioid agonists. These agonists are presented in the following three slides. The side effects and cautions and considerations of the opioid class also apply to these drugs. Codeine is used for mild to moderate pain, cough, and restless leg syndrome, and is available in tablet form. Codeine should be used with caution in the elderly. Fentanyl is used for various pain indications and is available in buccal, injection, nasal, sublingual, oral, and transdermal dosage forms. An important consideration is that different fentanyl products should not be converted on a microgram per microgram basis. Another caution is the risk of hypoventilation with any transmucosal administration. Proper disposal of patches is an important point of patient education, particularly if children are in the household. Patches must be folded in half, sticky sides together, and flushed down the toilet or returned to a drug take-back program. Hydrocodone is used to treat pain and is available in oral dosage forms. In products containing acetaminophen, it is important to note the daily limits on acetaminophen dosing..

[Audio] Hydromorphone is used for pain and is available as an injection, tablet, oral solution, and suppository. In addition to the opioid class cautions and considerations, hydromorphone should be used with caution in the elderly. Methadone is indicated in pain and in the prevention of withdrawal in patients enrolled in substance use disorder programs. Methadone is available in oral, injectable, and rectal dosage forms. An important caution with the use of methadone is the risk of QT prolongation in higher doses of the injectable product. There is also the risk of death with rapid titration and drug interactions. Methadone should be used with caution in the elderly and in pregnancy. Morphine's indications include pain, preoperative sedation, supplement to anesthesia, MI pain, and air hunger. Morphine is available as an injection and in various oral dosage forms. In addition to the standard opioid precautions, it is important to note that injectable morphine products are available in various concentrations. These products should not be confused with one another. An additional consideration is that morphine is the opioid most likely to cause itching..

[Audio] Oxycodone is generally used to treat moderate to severe pain. Oxycodone is available in various dosage forms. With oral solutions, care should be taken not to confuse milligrams with milliliters. Similar to hydrocodone, it is important to note the daily limits on acetaminophen dosing when using combination products. Tapentadol is used to treat moderate to severe pain as well as diabetic neuropathy pain. Tapentadol is only available in tablet form. Particular caution is warranted in patients with a history of alcohol use or severe liver disease. Tramadol is used to treat pain and is available in various oral dosage forms as well as a cream. Tramadol carries the risk of significant drug interactions and the risk of hypoglycemia in patients with diabetes..

[Audio] Certain opioids are considered mixed agonists, meaning that sometimes they fully activate receptors while at other times, they do not. Buprenorphine is used for either acute or chronic pain that is moderate to severe, and is also used to prevent opioid withdrawal. Buprenorphine is available in buccal, sublingual, injectable, and transdermal dosage forms. It is important to note that buprenorphine should not be swallowed. Butorphanol is used for acute, severe pain often related to surgery or childbirth. Butorphanol is available as an injection and as a nasal spray. Nalbuphine is used for pain and for morphine-related itching. Nalbuphine does not provide a euphoric effect like what often occurs with mu receptor agonism. In fact, the patient may feel a "heaviness." Nalbuphine is only available as an injection..

[Audio] Chapter 18, Section 3, Opioid Use Disorder and Treatments.

[Audio] Although patients undergoing chronic opioid therapy do become physically dependent, addiction must not be confused with dependence. Dependence is a physical and emotional reliance on a drug. Patients who are dependent will experience withdrawal when the drug is discontinued or the dose is reduced. Addiction is a compulsive disorder leading to continued use of the drug despite harm. Symptoms of addiction include preoccupation with drugs, refusal to taper off medication, strong preference for a specific opioid, and decreased ability to function. Forged prescriptions, prescription loss, unsanctioned dose escalation, and reports of shorted medication supply may indicate addiction. Pharmacy technicians should watch for these signs..

[Audio] Opioid antagonists work by replacing opioids that were binding to the mu receptor. Naloxone is used for respiratory emergencies in known or suspected opioid toxicity. It is available as an injection and as a nasal spray. The side effects of naloxone when injected include flushing, sweating, increased blood pressure, agitations, confusion, dizziness, and nausea. After administration of naloxone, a patient who is physically dependent on opioids will manifest withdrawal symptoms such as pain, tachycardia, hypertension, sweating, and agitation. Recurrence of respiratory and CNS depression may occur after naloxone's effect wears off. Naltrexone works the same way as naloxone, preventing activation of opioid receptors by binding to them. Naltrexone is used in the treatment of alcohol dependence and opioid use disorder. The mechanism through which it reduces alcohol consumption is not understood. Common side effects of naltrexone include headache, dizziness, nausea, and vomiting. There is a risk of injection site reactions with naltrexone, and should be used with caution in liver dysfunction. In addition, naltrexone has a risk of eosinophilic pneumonia with its use. Any patient taking naltrexone must have abstained from opioid use for the previous one to two weeks before receiving it in order to prevent acute withdrawal effects..

[Audio] Chapter 18, Section 4, Anesthesia.. © Paradigm Education Solutions.

[Audio] Anesthesia is an intervention for intentional loss of feeling in a person's body or part of the body when pain relief, anxiety relief, or muscle relaxation is required for patient care. Particular types of anesthesia are selected based on the situation. General anesthesia causes reversible unconsciousness and absence of response to painful stimuli. During general anesthesia, the patient is unconscious and usually airway support or intubation is required. Neuroaxial anesthesia blocks sensation through injection of an anesthetic into the CNS without making the patient unconscious. Neuroaxial anesthesia is often used during childbirth. Local anesthesia is used for local pain reduction such as a procedure on an arm or a leg..

[Audio] An anesthesiologist is a physician who oversees administration of anesthesia. General anesthesia is marked by four reversible conditions: unconsciousness, analgesia, paralysis, and amnesia. Unconsciousness means the patient is unaware, analgesia is the relief of pain, and paralysis is skeletal muscle relaxation. To properly maintain anesthesia, four indicators are used to assess the patient's status: oxygenation, ventilation, circulation, and temperature..

[Audio] Inhaled general anesthetics are administered through a facemask during surgery. The respiratory system excretes 80 to 90% of a given dose. Common side effects of inhaled general anesthetics include decreased blood pressure, hypervolemia, decreased renal function, nausea, and vomiting..

[Audio] An overview of the inhaled general anesthetics' side effects and cautions is provided in the following two tables. Nitrous oxide's side effects include memory loss, and mildly slowed breathing. Nitrous oxide should not be used in hypovolemia, shock, pneumothorax, or cardiac disease. Isoflurane is not to be used with carbon dioxide absorbents. Deep anesthesia with isoflurane may cause dose-related hypotension, respiratory depression, and may increase cerebrospinal fluid pressure. Isoflurane is not recommended in coronary artery disease as it may increase the risk of myocardial ischemia..

[Audio] Desflurane is another commonly used inhaled anesthetic used in general anesthesia. The main side effects of desflurane are nausea, vomiting, and cough. Desflurane is not recommended as the sole anesthetic induction agent in coronary artery disease or other conditions for which increases in heart rate or blood pressure are undesirable. Similar to isoflurane, desflurane has the potential for dose-related hypotension, respiratory depression, and increased cerebrospinal fluid pressure. Sevoflurane's common side effects include nausea, vomiting, drowsiness, agitation, cough, and shivering. Serious cautions associated with sevoflurane include QT prolongation which is a concern in certain clinical situations. Dose-related hypotension or respiratory depression may occur. In addition, there is a risk of hepatic injury with sevoflurane if previously exposed to halogenated hydrocarbon anesthetics. As well, there is a risk of preoperative seizures in young adults and in children older than two months..

[Audio] An overview of the injectable general anesthetics' side effects and cautions is provided in the following two tables. Etomidate is a hypnotic with ultrashort-acting properties. The main side effects of etomidate are nausea and vomiting. This drug presents a risk of cardiac depression in the elderly especially in those with hypertension. Etomidate is also associated with the risk of adrenal insufficiency and drug toxicity in renal impairment. As discussed under the opioid section of this chapter, fentanyl is an opioid analgesic. Fentanyl is used as an adjunct medication in anesthesia procedures, as most anesthesia agents do not provide pain relief when they sedate the patient. Fentanyl's side effects include confusion, dizziness, drowsiness, nausea, and vomiting. Cautions and considerations of fentanyl are consistent with those of other opioids. An additional caution is the increased risk of respiratory depression in the elderly. Ketamine produces a type of anesthesia in which the patient appears to be awake but neither responds to pain nor remembers the procedure. Side effects of ketamine include an extended emergence period, rash, nausea, vomiting, and increased urination. Ketamine should not be used for patients with a history of alcohol abuse. Cautions of ketamine include the risk of respiratory depression and apnea with rapid administration or overdose, the risk of increased blood pressure, and the risk of cardiac decompensation..

[Audio] Propofol is an injectable general anesthetic that is also used to treat agitation in patients in the intensive care unit. Side effects of propofol include drowsiness, respiratory depression, motor restlessness, and decreased blood pressure. There is a risk of cardiorespiratory effects with the use of propofol including hypotension. In addition, continuous propofol can increase the risk of hyperlipidemia due to the nature of its formulation. Dexmedetomidine is used as a sedative in less invasive procedures and for patients being weaned off propofol. Common side effects of dexmedetomidine are increased blood pressure, nausea, and fever. This medication should be used with caution in cardiac dysfunction. Potential for tolerance and dose-related adverse effects are more likely if dexmedetomidine is used beyond 24 hours..

[Audio] Medication is sometimes used preoperatively to control sedation, reduce postoperative pain, provide amnesia, and decrease anxiety. This practice is called induction. These medications can also provide mild anesthesia for short and less invasive procedures. Common side effects, cautions, and considerations of induction agents are provided in the table. Methohexital is used primarily for induction in short procedures. Common side effects of methohexital include nausea, vomiting, allergic reaction, headache, and hiccups. Methohexital should be used with caution in severe cardiovascular disease, hypotension or shock, liver or kidney disease, respiratory impairment or obstruction, or severe anemia. The benzodiazepines listed in the table are used for induction in short procedures and dental procedures. Midazolam is the preferred agent. Potential side effects of the benzodiazepines include unexpected aggressive or hyperactive behavior instead of sedation. Sleep-related effects, like performing certain activities without awareness can also occur. Patients should be monitored and informed of these unexpected adverse reactions. In addition, benzodiazepines should be used with caution in respiratory depression..

[Audio] Neuromuscular blocking agents paralyze skeletal muscles during surgery. These agents allow surgeons to operate with better accuracy and safety. These medications are also used as an adjunct to general anesthesia in endotracheal intubation, the procedure in which a breathing tube is inserted into the airway. The neuromuscular blockers are some of the most dangerous medications due to the immediate skeletal muscle paralysis that occurs after administration. When stocking and storing neuromuscular blockers, attach a distinct flag with an alert label and do not store it next to look-alike drugs..

[Audio] Succinylcholine is considered a depolarizing neuromuscular blocker. Succinylcholine works by causing a persistent depolarization at the motor endplate. This essentially shorts out the electrical signal resulting in skeletal muscle paralysis. The main side effect of succinylcholine is bradycardia. Succinylcholine carries a boxed warning for the risk of rhabdomyolysis with hyperkalemia in children followed by ventricular dysrhythmias, cardiac arrest, and death. Succinylcholine should be used with caution in abdominal infections, bradycardia, digoxin toxicity, hyperkalemia and other electrolyte abnormalities, subarachnoid hemorrhage, or in patients who have repeatedly received it. The other neuromuscular blocking agents are nondepolarizing agents. They work by preventing acetylcholine from binding to the receptors to start the electrical signal. This results in paralysis of skeletal muscles. The nondepolarizing neuromuscular blockers include atracurium, cisatracurium, rocuronium, vecuronium, and pancuronium. Their most common side effect is continued effect beyond the time period needed. These medications should be used with caution in patients with a history of allergic reactions to this class, as severe anaphylactic reactions have occurred..

[Audio] When a patient is over sedated with anesthesia or has taken too much of a benzodiazepine or opioid, medications can be used to reverse those effects. Flumazenil and naloxone are used when needed. Flumazenil provides a complete or partial reversal of the effects of benzodiazepines. Flumazenil can be used following general anesthesia or to reverse the effects of a benzodiazepine overdose. Side effects of flumazenil include headache, nausea, vomiting, dizziness, and agitation. Flumazenil carries a boxed warning for the risk of seizures in specific situations. Flumazenil should be used with caution in an ICU setting and in patients with head injuries, respiratory distress, epilepsy, or substance dependence. An additional consideration is that flumazenil has the potential for wearing off sooner than the benzodiazepine, leading to re-sedation. Naloxone, discussed earlier, reverses the effect of opioids. Side effects of naloxone include flushing, sweating, increased blood pressure, agitation, and confusion. Naloxone should be used with caution in abrupt postoperative reversal of opioids, during labor, in neonates, and in agitation, physical dependence of opioids, liver disease, kidney disease, respiratory depression caused by nonopioid drugs, or septic shock. In addition, there is the potential for agitated behavior due to the shock of acute withdrawal and return of pain after naloxone is administered..

[Audio] In order to reverse the effects of nondepolarizing neuromuscular blocking drugs, the process requires the administration of an anticholinesterase agent. Anticholinesterase agents prevent the destruction of acetylcholine by the enzyme acetylcholinesterase, thereby restoring the transmission of impulses across the motor endplate. The anticholinesterases include neostigmine and pyridostigmine. Their main side effects include stomachache, diarrhea, muscle aches, twitching, and dry skin. Anticholinesterases should be used with caution in cardiovascular disease, renal impairment, myasthenia gravis, and hepatic impairment. They should also be used with caution in the elderly and in children..

[Audio] Malignant hyperthermia is a sudden and rapid rise in body temperature with irregularities in heart rhythm and breathing. Malignant hyperthermia is a rare but serious side effect of anesthesia, and can lead to cardiac arrest, brain damage and internal hemorrhage. Malignant hyperthermia requires immediate treatment. Malignant hyperthermia is treated with dantrolene, a skeletal muscle relaxant. Hospitals are required to have a specialized drug kit immediately available for the treatment of malignant hyperthermia wherever anesthesia is administered..

[Audio] Local anesthesia produces a transient and reversible loss of sensation in a defined area of the body without altering alertness or mental function. Lidocaine is the most widely used local anesthetic today. Epinephrine is commonly used to keep the local anesthetic at the injection site. Local anesthetics are classified by their chemical structures into esters and amides. Esters are short acting and are metabolized in the plasma and tissue fluids. Amides are longer acting and are metabolized by liver enzymes..

[Audio] Listed are the local anesthetics, classified according to their chemical structure. The esters include benzocaine, chloroprocaine, dyclonine, and tetracaine. The amide products include bupivacaine, lidocaine, the combination of lidocaine and epinephrine, the combination of lidocaine and prilocaine, mepivacaine, and ropivacaine. Local anesthetics are commonly combined with other drugs and are available in a variety of dosage forms. They can be given by various routes of administration including an epidural to block nerve impulses in providing regional anesthesia, through infiltration to suture cuts or block small nerves, by injection to prevent transmission of pain impulses, from an IV for reasons other than anesthesia, through the spine to block pain nerve impulses from the lower part of the body, and topically to treat sunburn or insect bites..

[Audio] Lidocaine is a commonly used local anesthetic. Side effects of lidocaine include low blood pressure, swelling, skin irritation, nausea, and vomiting. Lidocaine carries a boxed warning for risk of seizures, cardiopulmonary arrest, and death when not administered according to dosage and administration instructions in patients under three years of age. Lidocaine should be used with caution in severe shock, bradycardia, impaired cardiovascular function, acute porphyria, severe liver disease, epilepsy, and in elderly and pediatric patients..

[Audio] Chapter 18, Section 5, Migraine Headaches and Drug Treatments..

[Audio] A migraine is a neurological disorder commonly associated with an episodic and painful headache. The headache is moderate to severe in intensity and seems to pulse or throb. A migraine can be accompanied by sensitivity to light, sound, and stimulation as well as vomiting and anorexia. Migraine pain is related to nociceptive pain pathways in the trigeminal ganglion. About 30 percent of migraine attacks are preceded by an aura. An aura is a period in which visual or sensory disturbances are present. Among other sensations, these disturbances can present themselves as flashing lights, shimmering heat waves, bright lights, or even transient loss of vision. Migraine headaches usually last about six hours but may last as long as one to two days..

[Audio] Diet, stress, sleep habits, certain medications, hormonal fluctuations, depression, atmospheric pressure changes, and environmental irritants have all been implicated as causative factors of migraines. Medication overuse can worsen migraines. The initial treatment for a migraine should focus primarily on nondrug therapy. A quiet environment and sleep or lying down in a dark room may help patients get rid of a migraine headache..

[Audio] Prophylactic migraine therapy is aimed at preventing or reducing the recurrence of migraines. Prophylactic migraine therapy is used if migraines occur more than twice a month, occur in predictable patterns, or have become refractory to acute therapy. Prophylactic therapy includes antihypertensives, antidepressants, anticonvulsants, CGRP antagonist monoclonal antibodies, NSAIDs, and SSRIs. Acute or abortive therapy for migraine headaches treats acute migraine headaches after they begin. They should be taken at the first sign of a headache. Acute or abortive drug class therapy includes simple analgesics, triptans, combinations of triptans with NSAIDs, antiemetics, lasmiditan, CGRP antagonists, and ergots..

[Audio] Migraine-specific products called triptans are used in the treatment of acute migraines. Triptans work by causing dilated blood vessels to constrict, preventing inflammation of some nerves, and reducing pain signal transmission. They are available as oral, sublingual, nasal, and injectable products. The main side effect of triptans is an unpleasant taste in the mouth, but patients can also experience dizziness, drowsiness, flushing, and sweating. The triptans should be used with caution in patients with coronary artery disease or hepatic impairment. The use of these medications should be limited to 9 doses per month..

[Audio] Ergot derivatives are used in the treatment of migraine headaches. These medications work by causing dilated blood vessels to constrict. Dihydroergotamine and ergotamine are typically the only two ergot products used. The ergots are available in nasal, injectable, and sublingual dosage forms. Common side effects of the ergots include nausea, vomiting, ergotism, and ergot headache. Ergotism is a syndrome of progressive vasoconstriction and ischemia of vital organs. There is a risk for serious peripheral ischemia when the ergot derivatives are used with CYP3A4 inhibitors. The ergot derivatives should be used with caution in patients at risk for cardiovascular or cerebrovascular events..

[Audio] The calcitonin gene-related peptide receptor antagonists are a new class of drugs used for the treatment of migraines. CGRPs work by blocking activation of the trigeminal pain pathways. The two medications in this class are named rimegepant and ubrogepant and are both available as tablets. The most common side effect of the CGRP class is nausea. These drugs are not to be used in end-stage kidney disease or with severe liver disease. The CGRPs are a good alternative to triptans and ergots especially in patients with cardiovascular conditions..

[Audio] The antiemetics chlorpromazine, metoclopramide, and prochlorperazine are used to alleviate nausea and vomiting associated with migraines. They work by blocking neurotransmitters such as serotonin, dopamine, acetylcholine, and histamine. They are available in multiple dosage forms including injection and rectal suppository. The class side effect of the antiemetics is drowsiness. Side effects specific to chlorpromazine include extrapyramidal side effects and orthostatic hypotension, while those specific to prochlorperazine include hypotension. The antiemetics should be used with caution in liver disease or congestive heart failure. Patients should be advised to avoid alcohol when taking these agents. Metoclopramide treatment is associated with an increased risk of tardive dyskinesia, which is a serious movement disorder..

[Audio] Excedrin is the most used combination product for migraines. It is available over the counter. The combinations of butalbitals, either acetaminophen or aspirin, and caffeine are used in the treatment of migraine and tension headaches. Butalbital combinations are available as oral dosage forms. These medications are not to be used in pediatric patients and in patients with severe liver impairment. In the product containing acetaminophen, it is important to note the daily limits on acetaminophen dosing..

[Audio] Chapter 18, Section 6, Complementary and Alternative Therapies..

[Audio] Caffeine is a CNS stimulant used in combination with other analgesics to treat headache. Caffeine should not be used more than every three to four hours and is available in a number of dosage forms. Side effects of caffeine include rapid heartbeat, palpitations, insomnia, restlessness, ringing in the ears, tremors, light-headedness, nausea, vomiting, stomach pain, and itchy skin rash. Caffeine taken with food can help with these effects, and doses should be decreased if such effects occur..

[Audio] Capsaicin is used as a topical treatment for pain such as diabetic neuropathy, arthritis, and headache pain. Burning, itching, and tingling occur prior to its analgesic action taking effect. Gloves should be used during the application and hands washed afterward. Feverfew is a plant product used orally for migraines, and has been found to improve nausea, vomiting, and light sensitivity experienced during a migraine. Feverfew is generally well tolerated but can cause side effects such as heartburn, nausea, diarrhea, constipation, abdominal pain, and gas..

[Audio] Cannabis sativa, commonly known as marijuana, is a plant used for medical and recreational purposes. The two main compounds of concern in Cannabis sativa are cannabidiol or CBD and tetrahydrocannabinol or THC. CBD is associated with pain relief while THC is associated with psychological effects. Synthetic and natural CBD extracts may be used for relief of chronic or neuropathic pain. CBD can be administered by the oral, sublingual, and intramuscular routes. Side effects of CBD include dizziness, weight gain, and heart disease. Butterbur is an herbal product sometimes used for prevention of migraines. It has been found to reduce the frequency and severity as well as to shorten the length of migraine headaches. Side effects of butterbur include diarrhea, upset stomach, drowsiness, and itchy eyes..