Likewise, in Norgart, the daughter of the plaintiffs had committed suicide in her 673

Likewise, in Norgart, the daughter of the plaintiffs had committed suicide in her

673

673 home by intentionally taking an overdose of prescription drugs, including Halcion. (Norgart, supra, 21 Cal.4th at p. 390, 87 Cal.Rptr.2d 453, 981 P.2d 79.) We upheld the superior court's grant of summary judgment against the plaintiffs, reversing the Court of Appeal, and finding that the plaintiffs had reason soon after their daughter's death to discover their causes of action for wrongful death against Upjohn for manufacturing and distributing Halcion. (Id. at p. 407, 87 Cal.Rptr.2d 453, 981 P.2d 79.) More specifically, in Norgart we found that there was no triable issue of material fact and that Upjohn was entitled to judgment on the statute of limitations defense because the plaintiffs had reason to discover their cause of action against Upjohn soon after their daughter's death when they learned at that time of her depression and suicide by taking an overdose of prescription drugs, including Halcion. (Ibid.) The plaintiffs also learned of a possible connection between Halcion and the suicide, because such connection was disclosed during the plaintiffs' investigation on the drug's package insert, which warned of a possible suicide risk. (Ibid.)

Question 1

How often does migraine headache present unilaterally?

Question 2

Are ergotamine-containing preparations contraindicated in the

treatment of resistant migraine in hypertensive patients? Can I give it,

under close supervision of the blood pressure, in the emergency room?

Question 3

Should ergotamine be given to abort a migrainous attack in a pregnant

female? If not, what is the recommended alternative?

Question 4

What is the frequency of migrainous attacks above which prophylactic

therapy should be commenced? If commenced, for how long should

the treatment be continued and what should be done if frequent attacks

recur after discontinuation of the prophylactic treatment?

Question 5

Is verapamil more effective in migraine prophylaxis than flunarizine?

Question 6

Are imipramine and fluoxetine effective as a prophylactic treatment

against migraine? Are they as effective as amitriptyline?

Question 7

1. Is sodium valproate more effective than valproic acid with regard to

migraine prophylaxis and anti-epileptic activity?

2. Is carbamazepine effective as a prophylaxis against migraine?

Question 8

Can flunarizine, diltiazem and nifedipine be used in the treatment of a

cluster headache and do they have the same efficacy as verapamil?

Question 9

If cluster headache migraine is confidently diagnosed in general practice,

is it worth trying lithium prophylaxis or should this commence at

secondary care level? Which other treatment is recommended?180

Question 10

Is ergotamine effective in preventing an attack of cluster headache?"

 Migraine and Cluster headache Management – Questions and answers.

 1. Migraine headache is mostly present unilaterally; how often does it show this pattern of occurrence?

 Unilateral Presentation: Migraine headaches affect one side of the head in most of the cases, with a frequency of 60 to 70%. But it is to be noted that migraines can also be bilateral – meaning they can occur on both sides of the head.

 2. Are ergotamine-containing preparations safe in the use for resistant migraine in hypertensive patients? Is it safe to administer it, under close monitoring of the blood pressure, in the emergency room?

 Ergotamine and Hypertension: Preparations containing ergotamine are usually not recommended for patients with hypertension because they increase the tone of blood vessels which in turn will increase the blood pressure. But in a controlled environment such as the ER, in as much as possible, they may be given with very strict monitoring of the blood pressure and frequent checks and interventions as required.

 3. Should ergotamine be used to put an end to a migrainous attack in a pregnant woman? What then should one do if this is not possible?

 Ergotamine and Pregnancy: Ergotamine is usually not recommended for use in pregnant women because of possible harm to the unborn baby. The preferred discipline for abortive management of migraines in pregnant women is paracetamol or some NSAIDs, depending on gestational period and patient’s condition. It is recommended to always seek the opinion of an obstetrician before instituting any treatment.

 4. At what frequency of migrainous attacks should one start prophylactic treatment? If started, how long should the course of the treatment be and what should be done if the attacks occur soon after cessation of prophylactic treatment?

 Frequency for Prophylaxis: Members of the prophylactic therapy are usually prescribed to patients who have from 2 to 4 migraines per month or if the attacks are so severe that they limit the patient’s ability to function. Treatment period is usually 3-6 months and the progress should be assessed from time to time. If the attack continues to appear after the cessation of prophylactic treatment, then the treatment may be continued or another drug may be chosen or the dosage may be changed.

 5. Is verapamil better than flunarizine in the prevention of migraine?

 Verapamil vs. Flunarizine: Verapamil and flunarizine are both employed for the prevention of migraine but the benefits of their use may not always be the same. Verapamil is a CCB while flunarizine is a CCB with other properties. Flunarizine is effective for the prophylaxis of migraine, but the evidence indicates that verapamil may be less effective than flunarizine in preventing migraines.

 6. Is imipramine and fluoxetine useful as preventive therapy in migraine? Are they as useful as amitriptyline?

 Imipramine and Fluoxetine: Imipramine and fluoxetine, both of which belong to the class of antidepressant drugs, are employed in the prophylactic management of migraine with more or less efficacy. Among the antidepressants, amitriptyline, a tricyclic antidepressant, is reputed to be more useful in migraine prevention than imipramine or fluoxetine. Amitriptyline is often used because it has a better empirical support and there are clinical data which support use of this drug in reducing number of migraines.

 7. 1. Is the sodium valproate better than the valproic acid in averting migraine and in the treatment of epilepsy? 2. Does carbamazepine prevent migraine in patients with high risk of developing migraine?

 Sodium Valproate vs. Valproic Acid: Sodium valproate and valproic acid are in fact the same in terms of effectiveness in migraine prevention since sodium valproate is the salt form of valproic acid. Both are equally efficient, though sodium valproate is employed more frequently owing to the patient’s compliance and dosing schedule.

 Carbamazepine: Carbamazepine one of the anticonvulsant medications is not usually recommended for migraine prevention. It is mainly used in the treatment of epilepsy and some forms of neuropathic pain and has no indication for migraine prevention.

 8. Are flunarizine, diltiazem and nifedipine effective for the treatment of a cluster headache and are they as effective as verapamil?

 Flunarizine, Diltiazem, and Nifedipine: Flunarizine and verapamil are extensively used in the prevention of cluster headache; verapamil is reportedly highly effective. Diltiazem and nifedipine that belong to calcium channel blockers are less often used and their efficacy is considered to be lower than that of verapamil for cluster headache prevention.

 9. Should the diagnosis of cluster headache be made with confidence in general practice, it may be useful to attempt lithium prophylaxis, or should this be done in secondary care? What other management do you advise?

 Lithium Prophylaxis: Lithium is considered as a treatment for cluster headaches and it can be used if the diagnosis of cluster headache is rather confident. However, because of the possible complications and side effects of lithium this may be better initiated at secondary care level. Some other medications that are used for the treatment of cluster headaches are verapamil, corticosteroids and oxygen therapy in some occasions.

 10. Does ergotamine work for the prevention of an attack of cluster headache?

 Ergotamine and Cluster Headache: Ergotamine is not usually employed in the prophylaxis of cluster headaches. It is normally prescribed for the management of acute migraines. Preventive therapy for cluster headache is best done using verapamil while ergotamine is not useful in the prevention of the condition.