1. Julia Presentation by Gemma Veale

2. Presenting complaint Ongoing migraines Currently taking – amitriptyline 40mg - rizatriptan 10mg

3. Demographics/History 21 year old New Zealand European Healthy and active Non smoker Taking Estelle-35 Family history: mother and sister both frequent migraines BP: 116/70 Pulse: 65 Weight: BMI: 21

4. History of present illness Presented December 2013 - one month of debilitating migraines 3-4 times a week – nausea, vomiting, photophobia, severe headache. - No aura - Unable to work - Had lost 3kg over past month - Taking ibuprofen and paracetamol nearly every day with little effect.

5. Pathophysiology Migraine – vasodilation and intracranial inflammation cause pain 5 Calcitonin gene-related peptide (CGRP) initiates migraine Seratonin suppresses migraine

6. Amitriptyline Tricyclic antidepressant 4 Migraine prophylaxis Acts on norepinephrine and 5HT receptors to block neuronal reuptake of seratonin 5 Side effects: Anticholinergic effects Adverse effects: sedation, orthostatic hypotension, weight gain Interactions: alcohol, antihistamines, oestrogen 7

7. Rizatriptan Serotonin agonist (triptan) used in the acute treatment of migraines 4 selectively acts on the 5HT receptor 4 Adverse effects – chest heaviness/tightness, serotonin syndrome Interactions – other 5HT agonists 9

8. Cyproterone acetate/Ethinyloestradiol Combined oral contraceptive Inhibits ovulation Metabolised by CYP450 enzymes 10 Side effects – increased risk of thrombolysis, breakthrough bleeding Adverse effects – nausea, vomitting, weight gain, migraines Interactions – CYP450 inducers, antibiotics, decreases clearance of tricyclic antidepressants 8

9. Medication Issues 1.Oestrogens can inhibit metabolism of tricyclic antidepressants – potential toxicity 1 2.Migraine is an adverse effect of combined oral contraceptives (COC) 12

10. Plan of action Remain on amitriptyline as prophlyaxis treatment Continue with rizatriptan for treatment of acute migraines Stop COC and start alternative contraception

11. Norethisterone 0.35 mg Progesterone only pill 11 Works by thickening the cervical mucous and suppressing endometrial growth 6 Side effects – menstrual irregularity Adverse effects – can cause fluid retention Interactions – antibiotics, St Johns wort, antihypertensive drugs 6

12. New drug regime Amitriptyine 50mg for 1 month. Then decrease to 40mg 3 Rizatriptan 10mg – no more than twice a week to prevent medication overuse. Noerthisterone 0.35mg Reduce panadol and brufen 2

13. Monitoring/Follow up Patient information to help reduce side effects Follow up at three months – Headaches improved? – Side effects? – BP/weight – Amitriptyline withdrawal symptoms with decreasing dose? – Acne? – Use of analgesics and/or rizatriptan reduced? – Serotonin syndrome?

14. References 1. BPAC. (2006). TCAs are useful for depression and neuropathic pain. Retrieved from: http://www.bpac.org.nz/BPJ/2006/December/tcas.aspx 2. BPAC. (2008b). Medication-overuse headache: when the cure becomes the cause. Retrieved from: http://www.bpac.org.nz/BPJ/2008/September/overuse.aspx 3. BPAC. (2008a). Combined oral contraceptives: Issues for current users. Retrieved from: http://www.bpac.org.nz/BPJ/2008/April/contraceptive.aspx 4. Gutierrez, K. (2008). Pharmacotherapeutics: Clinical reasoning in primary care (2nd ed.). St. Louis, MO: Saunders Elsevier. 5. Lehne, A. (2010). Pharmacology for Nursing Care (7 th ed.). St. Louis, MO: Suanders Elsevier 6. Medsafe. (2005) Noriday 28 Day. Retrieved from: http://www.medsafe.govt.nz/profs/datasheet/n/Noriday28tab.pdf 7. Medsafe. (2013) Amitriptyline Hydrochloride. Retrieved from: http://www.medsafe.govt.nz/profs/datasheet/a/Amiroltab.pdf

15. References continued 8. Medsafe. (2014). Estelle and Estelle 35 ED. Retrieved from: http://www.medsafe.govt.nz/profs/datasheet/e/Estelle3535EDtab.pdf 9. Medsafe. (2014) Rizatriptan Benzoate. Retrieved from: http://www.medsafe.govt.nz/profs/datasheet/m/Maxalttabwaf.pdf 10. MIMS. (2014) amitriptyline hydrochloride »« Estelle 35 ED Tablets. Retrieved from: http://www.mimsonline.co.nz.ezproxy.auckland.ac.nz/DrugAlert/Interaction s/Default.aspx 11. Nappi, R., Merki-Feld, G., Terreno, E., Pellegrinelli, A., Viana, M. (2013). Hormonal contraception in women with migraine: is progestogen-only contraception a better choice? The Journal of Headache and Pain, 14(1), 66. 12. WHO. (2004). Selected practice recomendations for contraceptive use. Retrieved from: http://whqlibdoc.who.int/publications/2004/9241562846.pdf