Neurology Case No 5.Post Spinal Headache

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Neurology Case No 5.Post Spinal Headache

Definition : Spinal anesthesia দেওয়ার পরে post operative period (2nd and 3rd POD) তে প্রচন্ড মাথা ব্যাথা হয়,

১০০ জনের মধ্যে ৭০ জনের এমন হতে পারে,

এই কন্ডিশন কে Post spinal headache or post spinal puncture headache বলে–

️Cause: CSF leakage

️Sustainability : 2 days to 2 weeks

️Pathophysiology :

স্পাইনাল অ্যানেস্থেসিয়া দেওয়ার সময় ডুরা ম্যাটার কে puncture করেই নিডল ভিতরে প্রবেশ করে, সেখানে যে hole তৈরি হয়, সেটা দিয়ে CSF বেরিয়ে চলে আসে৷ আর CSF বেরিয়ে আসলে CSF এর প্রেশার কমে যায়, ব্রেইণ এ CSF প্রেশার কমে গেলে তখন headache শুরু হয়, এইটা মোটামুটি Throbbing type হেডেক

এই পেইন Analgesic এ ততটা রেস্পন্স করেনা, কারণ Analgesic pain কমায় pain pathway inhibit করার মাধ্যমে, যেটা মূলত Prostaglandin synthesis inhibits করে, কিন্ত এখানে পেইন হচ্ছে CSF প্রেশার fall করার কারণে, তাই এখানে analgesic দিয়ে কাজ হবেনা.

কিভাবে vesodilation হচ্ছে??

spinal Anaesthesia তে কমন physiologic effect হচ্ছে hypotension, কারণে এখানে sympathetic Nervous সিস্টেম কে ব্লক করে দেওয়াহ হয়, সিম্প্যাথেটিক নার্ভাস সিস্টেম ব্লক হলে arterial and venous vasodilation হয়, সাথে functional hypovolemia হয়।

️Treatment :

যেহেতু এখানে CSF লিকেজ হচ্ছে,>>> CSF pressure কমতেছে >>cerebral vasodilation হচ্ছে >>>ব্যাথা হচ্ছে

তাহলে আমাদের কি করতে হবে ব্যাথা কমানোর জন্য?

Vasoconstriction করে CSF pressure কে একটা sustained condition এ রাখতে হবে, তাহলে ব্যাথা কমে যাবে,..

সে জন্য Drug of choice intravenous **Theophylline*

এইটা vasoconstriction করে,

Management of Spinal headache :

1. Bed rest এ থাকবে

2. Plenty of Fluid including Tea and Coffee

3. Pain killer (ibuprofen)

Tablet 1.Ketorolac 10mg (AS A Ketorolac Tromethamine ,AS a Drugs used for Rheumatoid Arthritis, Non-Opioid Analgesics).

Indications of Tablet:-Ketorolac 10mg (AS A Ketorolac Tromethamine ,AS a Drugs used for Rheumatoid Arthritis, Non-Opioid Analgesics).

Ketorolac is indicated for the short-term management of moderate to severe acute post-operative pain. Ketorolac ophthalmic solution helps relieve pain, inflammation, and light sensitivity after ocular surgery. It may also be used to decrease eye inflammation or redness caused by seasonal allergies.

Description Tablet:-Ketorolac 10mg (AS A Ketorolac Tromethamine ,AS a Drugs used for Rheumatoid Arthritis, Non-Opioid Analgesics).

Ketorolac is a drug of pyrrolo-pyrrole group of nonsteroidal anti-inflammatory drug (NSAID). Chemically it is known as 5 benzoyle-2,3-dihydro-1H-pyrroligine-1-carboxylic acid, compound with 2 – amino-2-(hydroxymethyl)-1,3-propanediol (1:1). Ketorolac inhibits synthesis of prostaglandins and may be considered as a peripherally acting analgesic. The biological activity of Ketorolac is associated with the S-form. Pharmacokinetic property of Ketorolac is linear. It is highly protein bound and is largely metabolized in liver. The products of metabolism and some unchanged drugs are excreted in the urine.

Pharmacology of Tablet:-Ketorolac 10mg (AS A Ketorolac Tromethamine ,AS a Drugs used for Rheumatoid Arthritis, Non-Opioid Analgesics).

Ketorolac Tromethamine is a potent analgesic of the non-steroidal anti-inflammatory drugs (NSAIDs). It acts by inhibiting the cyclooxygenase enzyme system and hence inhibits the prostaglandin synthesis. It demonstrates a minimal anti-inflammatory effect at its analgesic dose.

Dosage & Administration of Tablet:-Ketorolac 10mg (AS A Ketorolac Tromethamine ,AS a Drugs used for Rheumatoid Arthritis, Non-Opioid Analgesics).

Tablet: Recommended dose is 10 mg every 4-6 hours. It should be used short-term only (up to 7 days) and are not recommended for chronic use. Doses exceeding 40 mg/day is not recommended.

Injection: Ketorolac injection may be used as a single or multiple doses, on a regular or when necessary schedule for the management of moderately severe, acute pain that requires analgesia at the opioid level, usually in a postoperative setting. When administering Ketorolac injection, the IV bolus must be given over no less than 15 seconds. The IM administration should be given slowly and deeply into the muscle. The analgesic effect begins within 30 minutes with maximum effect in 1 to 2 hours after dosing IV or IM. Duration of analgesic effect is usually 4 to 6 hours.

Single-Dose Treatment-
IM Dosing (Adult):

Patients <65 years of age: One dose of 60 mg.
Patients >65 years of age, renally impaired and/or less than 50 kg of body weight: One dose of 30 mg.

IV Dosing (Adult):

Patients <65 years of age: One dose of 30 mg.
Patients >65 years of age, renally impaired and/or less than 50 kg of body weight: One dose of 15 mg.

IV or IM Dosing (2 to 16 years of age):

IM Dosing: One dose of 1 mg/kg up to a maximum of 30 mg.
IV Dosing: One dose of 0.5 mg/kg up to a maximum of 15 mg.

Multiple-Dose Treatment (IV or IM)-

Patients <65 years of age: The recommended dose is 30 mg Ketorolac injection every 6 hours. The maximum daily dose should not exceed 120 mg. Patients >65 years of age, renally impaired patients and patients less than 50 kg: The recommended dose is 15 mg Ketorolac injection every 6 hours. The maximum daily dose for these populations should not exceed 60 mg. For breakthrough pain, do not increase the dose or the frequency of Ketorolac Tromethamine.
Conversion from Parenteral to Oral Therapy: Ketorolac tablets may be used either as monotherapy or as follow-on therapy to parenteral Ketorolac. When Ketorolac tablets are used as a follow-on therapy to parenteral Ketorolac, the total combined daily dose of ketorolac (oral + parenteral) should not exceed 120 mg in younger adult patients or 60 mg in elderly patients on the day the change of formulation is made. On subsequent days, oral dosing should not exceed the recommended daily maximum of 40 mg. Ketorolac IM should be replaced by Ketorolac tablet as soon as feasible. The total duration of combined parenteral and oral treatment should not exceed 5 days.

Eye Drops: Adults: 1 drop in each eye 4 times daily.

Interaction of Tablet:-Ketorolac 10mg (AS A Ketorolac Tromethamine ,AS a Drugs used for Rheumatoid Arthritis, Non-Opioid Analgesics).

Other NSAIDs or aspirin: Increase the side effects of Ketorolac.
Anti-coagulants: Enhance anti-coagulant effect.
Beta Blocker: Reduce the anti-hypertensive effect .
ACE Inhibitors: Increase the risk of renal impairment.
Methotrexate: Enhance the toxicity of methotrexate.

Contraindications of Tablet:-Ketorolac 10mg (AS A Ketorolac Tromethamine ,AS a Drugs used for Rheumatoid Arthritis, Non-Opioid Analgesics).

Ketorolac is contraindicated in patients having hypersensitivity to this drug or other NSAIDs. It should not be used in children under 16 years of age. lt is also contraindicated as prophylactic analgesic before surgery.

Side Effects of Tablet:-Ketorolac 10mg (AS A Ketorolac Tromethamine ,AS a Drugs used for Rheumatoid Arthritis, Non-Opioid Analgesics).

Commonly occurring side effects are nausea, vomiting, gastro-intestinal bleeding, melana, peptic ulcer, pancreatitis, anxiety, drowsiness, headache, excessive thirst, fatigue, bradycardia, hypertension, palpitation, chest pain, infertility in female and pulmonary edema.

Pregnancy & Lactation of Tablet:-Ketorolac 10mg (AS A Ketorolac Tromethamine ,AS a Drugs used for Rheumatoid Arthritis, Non-Opioid Analgesics).

US FDA Pregnancy category of Ketorolac Tromethamine is C. So, Ketorolac Tromethamine should be avoided in pregnancy and lactation unless the potential benefits to the other outweigh the possible risks to the fetus.

Precautions & Warnings of Tablet:-Ketorolac 10mg (AS A Ketorolac Tromethamine ,AS a Drugs used for Rheumatoid Arthritis, Non-Opioid Analgesics).

Caution should be exercised in patients over the age of 65 years. Caution should also be taken in patients with active or suspected peptic ulcer or gastrointestinal bleeding or asthma and liver dysfunction.

Eye Drops: Patients with evidence of corneal epithelial breakdown should immediately discontinue use of topical NSAIDs and should be closely monitored for corneal health. Lopadol ophthalmic solution should not be administered while wearing contact lenses.

Therapeutic Class of Tablet:-Ketorolac 10mg (AS A Ketorolac Tromethamine ,AS a Drugs used for Rheumatoid Arthritis, Non-Opioid Analgesics).

Drugs used for Rheumatoid Arthritis, Non-Opioid Analgesics

Inj- Theophylline 200 mg + 1000 ml 5% DA @60 drop /min for 1 hour… Then 40 Drop/min.

Oral ও দেওয়া যেতে পারে, ওরাল দিলেও পেইন কমবে, Oral দেওয়া যাবে যদি patient NPO(Nothing BY Mouth). না থাকে। NPO Means “Nothing by Mouth” NPO means “nothing by mouth,” from the Latin nil per os. The acronym is simply a doctor’s shorthand for a period of time in which you may not eat or drink anything (ask about prescription medication). Fasting is generally prescribed in preparation for an operation or exam.

তবে IV দিলে পেইন দ্রুত কমবে।

Tablet 2.Arofil SR 400MG (AS A Theophylline Bronchodilator, Theophylline & related drugs)

Indications of Tablet:-Arofil SR 400MG (AS A Theophylline Bronchodilator, Theophylline & related drugs)

Arofil SR is indicated for the-

Control of acute asthma.
Management of chronic asthma (For both Symptomatic and prophylactic treatment).
For controlling nocturnal asthma and early morning wheezing.
Management of chronic obstructive lung disease (Chronic bronchitis and emphysema) and acute exacerbation of chronic obstructive lung disease.
Control of apnea of pre-maturity.

Pharmacology of Tablet:-Arofil SR 400MG (AS A Theophylline Bronchodilator, Theophylline & related drugs)

Theophylline is a bronchodilator, structurally classified as a Methylxanthine. Theophylline has two distinct actions in the airways of patients with reversible obstruction; smooth muscle relaxation and suppression of the response of the airways to stimuli. Theophylline also increases the force of contraction of diaphragmatic muscles. The half-life of Theophylline is influenced by a number of known variables. In adult nonsmokers with uncomplicated asthma the half-life ranges from 3 to 9 hours

Dosage & Administration of Tablet:-Arofil SR 400MG (AS A Theophylline Bronchodilator, Theophylline & related drugs)

The dose of theophylline must be individualized on the basis of peak serum theophylline concentration measurements in order to achieve a dose that will provide maximum potential benefit with minimal risk of adverse effects. Most of the sustained release preparations may be administered every 12 hours in adults while administration every 8 hours may be necessary in some children with markedly rapid hepatic
metabolism of theophylline. The recommended maintenance dose within accepted therapeutic range is as follows :

16 years or older: 10 mg/Kg/day (Do not exceed 900 mg/day)
12 years-15 years: 13 mg/Kg/day
9-11 years: 16 mg/Kg/day
1 year-8 years: 24-24 mg/Kg/day
6 months-1 year: 12-18 mg/Kg/day
1-6 months: 10 mg/Kg/day.

Contraindications of Tablet:-Arofil SR 400MG (AS A Theophylline Bronchodilator, Theophylline & related drugs)

Theophylline is contraindicated in patients with hypersensitivity to Theophylline or any other component of the product.

Side Effects of Tablet:-Arofil SR 400MG (AS A Theophylline Bronchodilator, Theophylline & related drugs)

Generally side effects are rare at normal dosage. It may include gastrointestinal discomfort, headache, nausea, insomnia and hypotension. CNS stimulation and diuresis may also occur, especially in children.

Pregnancy & Lactation of Tablet:-Arofil SR 400MG (AS A Theophylline Bronchodilator, Theophylline & related drugs)

It is not known whether Theophylline can cause foetal harm when administered to pregnant woman. Xanthines should be given to a pregnant woman only if clearly needed. Theophylline is excreted into breast milk and may cause irritability or other signs of mild toxicity in nursing human infants. Serious adverse effects in the infant are unlikely unless the mother has toxic serum Theophylline concentrations.

Therapeutic Class of Tablet:-Arofil SR 400MG (AS A Theophylline Bronchodilator, Theophylline & related drugs)

Bronchodilator, Theophylline & related drugs

অন্যান্য Headache এর সবচেয়ে পাওয়ারফুল ঔষধ Sumatriptan দিয়েও spinal headache ম্যানেজ করা যায়না…

Spinal headache এ Theophylline এর কার্যকরিতা Sumatriptan থেকে অনেক বেশি…

Theophylline প্রতি ২০ জনের মধ্যে ১৬ জনের ব্যাথা কমাবে,

অন্যান্য analgesic প্রতি ২০ জনের মধ্যে ৫ জনের হেডেক কমায়।

কাদের কে Theophylline দেওয়া যাবেনা?

যাদের previously stroke হয়েছে, অথবা যাদের cerebrovascular disease রয়েছে, কিংবা IHD, or recent MI or Heart failure অথবা

High blood pressure থাকলে দেওয়া যাবেনা।

এবার প্রশ্ন, বাংলাদেশে IV theophyllin পাওয়া যায় কিনা?

উত্তর হচ্ছে, না, পাওয়া যায়না, তাহলে করণীয় কি?

Oral দিবে,

Tab- Contine 200 mg (AS A Theophylline Bronchodilator, Theophylline & related drugs).

2+1+1 (1st day of headache)

1+1+1 (continue.. Till headache subsidies)

Tab- Napa 500 mg AS A Paracetamol AS A Non opioid analgesics

2+2+2 (5-7 days)

Tablet 3.Nomigran 100mg (AS A Sumatriptan AS A 5-HT Agonists).

Indications of Tablet:-Nomigran 100mg (AS A Sumatriptan AS A 5-HT Agonists).

Nomigran is a serotonin (5-HT1B/1D) receptor agonist (triptan) indicated for acute treatment of migraine with or without aura in adults.

Limitations of Use:

Use only if a clear diagnosis of migraine headache has been established.
Not indicated for the prophylactic therapy of migraine attacks.
Not indicated for the treatment of cluster headache.

Pharmacology of Tablet:-Nomigran 100mg (AS A Sumatriptan AS A 5-HT Agonists).

Sumatriptan is an agonist for a vascular 5‑hydroxytryptamine receptor subtype (probably a member of the 5‑HT family) having only a weak affinity for 5‑HT , 5‑HT , and 5‑HT receptors and no significant affinity (as measured using standard radioligand binding assays) or pharmacological activity at 5‑HT, 5‑HT or 5‑HT receptor subtypes or at alpha‑adrenergic or beta‑adrenergic; dopamine; dopamine; muscarinic; or benzodiazepine receptors. The vascular 5‑HT receptor subtype that sumatriptan activates is present on cranial arteries in both dog and primate, on the human basilar artery, and in the vasculature of human dura mater and mediates vasoconstriction. This action in humans correlates with the relief of migraine headache. In addition to causing vasoconstriction, experimental data from animal studies show that sumatriptan also activates 5‑HT receptors on peripheral terminals of the trigeminal nerve innervating cranial blood vessels. Such an action may also contribute to the antimigrainous effect of sumatriptan in humans.

Dosage of Tablet:-Nomigran 100mg (AS A Sumatriptan AS A 5-HT Agonists).

Sumatriptan nasal spray: Single-dose of 10 mg of nasal spray. The maximum dose in a 24 hour period is 30 mg; separate doses by at least one hour or as directed by the physician.

Sumatriptan tablets: In controlled clinical trials, single doses of 25, 50, or 100 mg of Sumatriptan tablets were effective for the acute treatment of migraine in adults. There is evidence that doses of 50 and 100 mg may provide a greater effect than 25 mg. There is also evidence that doses of 100 mg do not provide a greater effect than 50 mg. Individuals may vary in response to doses of Sumatriptan tablets. The choice of dose should therefore be made on an individual basis, weighing the possible benefit of a higher dose with the potential for a greater risk of adverse events.

If the headache returns or the patient has a partial response to the initial dose, the dose may be repeated after 2 hours, not to exceed a total daily dose of 200 mg. If a headache returns following an initial treatment with Sumatriptan Injection, additional single Sumatriptan Tablets (up to 100 mg/day) may be given with an interval of at least 2 hours between tablet doses. The safety of treating an average of more than 4 headaches in a 30-day period has not been established.

Use in children and adolescents: Sumatriptan is not recommended for use in patients younger than 18 years of age.

Administration of Tablet:-Nomigran 100mg (AS A Sumatriptan AS A 5-HT Agonists).

How to use the Nasal Spray-

Shake the bottle gently and remove the dust cover.
Hold the spray with your forefinger and middle finger on either side of the nozzle and your thumb underneath the bottle. Press down until a fine spray appears. If using for the first time or if you have not used it for a week or more, press the nasal applicator several times until a fine moist comes out from the container.
Gently blow the nose to clear the nostrils.
Close one nostril and carefully insert the nasal applicator into the open nostril. Tilt your head forward slightly and keep the spray upright. Breathe in through your nose and while breathing in, press the white-collar of nasal applicator firmly down once to release a spray.
Breathe out through your mouth.
Repeat the above steps in the same/ other nostril for consecutive doses.

Cleaning: The nasal spray should be cleaned at least once a week. The procedures are as follows-

Remove the dust cover.
Gently pull off the nasal applicator.
Wash the applicator and dust cover in warm water.
Shake off the excess water and leave to dry in a normal place. Avoid to apply additional heat.
Gently push the applicator back on the top of the bottle and re-fix the dust cover.

Interaction of Tablet:-Nomigran 100mg (AS A Sumatriptan AS A 5-HT Agonists).

Nomigran nasal spray is contraindicated with Ergot-Containing Drugs, Monoamine Oxidase-A Inhibitors, Other 5-HT1 Agonists and Selective Serotonin Reuptake Inhibitors/Serotonin Norepinephrine Reuptake Inhibitors.

Contraindications of Tablet:-Nomigran 100mg (AS A Sumatriptan AS A 5-HT Agonists).

History of coronary artery disease or coronary vasospasm
Wolff-Parkinson-White syndrome or other cardiac accessory conduction pathway disorders
History of stroke, transient ischemic attack, or hemiplegic or basilar migraine
Peripheral vascular disease
Ischemic bowel disease
Uncontrolled hypertension
Recent (within 24 hours) use of another 5 HT1 agonist (e.g., another triptan) or of an ergotamine containing medication
Concurrent or recent (past 2 weeks) use of monoamine oxidase A inhibitor
Hypersensitivity to sumatriptan (angioedema and anaphylaxis seen)
Severe hepatic impairment

Side Effects of Tablet:-Nomigran 100mg (AS A Sumatriptan AS A 5-HT Agonists).

Common side effects: Unusual or unpleasant taste in the mouth; pain, burning, numbness, or tingling in the nose or throat; runny or stuffy nose after using the nasal medicine. Rare side effects: Anxiety, burning sensation, discomfort of the nasal cavity and throat, general feeling of illness or tiredness & vision changes.

Pregnancy & Lactation of Tablet:-Nomigran 100mg (AS A Sumatriptan AS A 5-HT Agonists).

Pregnancy Category C. There are no adequate and well-controlled trials in pregnant women. Sumatriptan is excreted in human milk following subcutaneous administration. Infant exposure to sumatriptan can be minimized by avoiding breastfeeding for 12 hours after treatment with Sumatriptan Tablets.

Raiyyan Tahsan Date:21-01-2025 Tuesday Time:6-52-45 PM

Raiyyan Tahsan

Raiyyan Tahsan