MIGRAINE, CVT

CASE PRESENTATION ON MIGRAINE &
ACUTE CEREBRAL VENOUS
THROMBOSIS
PRESENTED BY,
Name: Chandana C (IV Pharm D)
Register Number:17Q3306 (06)
Date:30-07-2021
5/3/2021 1
Sree Siddaganga College of Pharmacy, Tumkur

ACUTE CEREBRAL VENOUS
THROMBOSIS
DEFINITION
Cerebral venous thrombosis is the cerebral
vein thrombosis of dural sinus and/or cerebral
veins.
5/3/2021 Sree Siddaganga College of Pharmacy, Tumkur 2

EPIDEMIOLOGY
The incidence of cerebral venous thrombosis is
estimated at 0.2-0.5/1 lakh/year.
0.39 deaths/million of 56million population.
The mortality of CVT probably varied b/w 20%
and 50%.

ETIOLOGY
Inherited thrombophilia:- prothrombin gene
mutation, protein S and C deficiency, ant thrombin
deficinecy,dysfibrogenemia
Vascular injury:- nephrotic syndrome
Medication:- estrogen, heparin
Other medical illness:- CHF, IBD, HIV,Surgery,
Trauma.

PATHOPHYSIOLOGY
 Thrombosis of cerebral or Dural sinuses leading to cerebral
parenchymal lesion or dysfunction
 Occlusion of Dural sinus leading to decreased CSF absorption and
raised ICP
 Cerebral venous thrombosis

RISK FACTORS
 Age:- Above 50 years
 Surgery
 Accidents
 Medications
 Vascular injury
 Pregnancy
 Other medical illness:- CHF, IBD, HIV

CLINICAL MANIFESTATION
Isolated intracranial hypertension syndrome:
headache, vomiting, papilledema, visual
disturbance
Focal syndrome :- focal deficits, seizures
(focal/generalized) or both
Encephalopathy:- multifocal signs, mental
status changes, stupor or coma.

COMPLICATION
 Venous infarction
 Haemorrhage
 Subarachnoid haemorrhage
 Pulmonary embolism
 Epilepsy

DIAGNOSIS
 Neuro imaging:-
 Non invasive- CT,CTV, MRI, MRV,
Ultrasound
 Invasive- cerebral angiography, direct
cerebral venography
 Lab investigation:- D-DIMER,CSF

STANDARD TREATMENT

MIGRAINE
A migraines an recurrent throbbing headache that typically affects one
side of the head and is often accompanied by nausea and disturbed
vision.
EPIDEMIOLOGY
 Results of the American Migraine Prevalence and Prevention Study
indicate that 17.1% of women and 5.6% of men in the United States
experience one or more migraine headaches per year.
 While the prevalence of migraine varies considerably by age and
gender, the epidemiologic profile has remained stable over the past 8
years.
 Gender differences in migraine prevalence have been linked to
menstruation, but these differences persist beyond menopause.
 Prevalence is highest in both men and women between the ages of 18
and 44 years.

ETIOLOGY
 Genetics and environmental factors
 Changes in brainstem and it interaction with the trigeminal nerve, a
major pain pathway, might be involve.
 Imbalance in brain chemicals like serotonin, which helps regulate pain
in nervous system.
 Other neurotransmitters like calcitonin gene related peptide play a role
in pain of the migraine.

RISK FACTORS
 Hormonal changes
 Intake of caffeine and alcohol
 Stress
 Sensory stimuli
 Sleep changes
 Weather changes
 Medications- oral contraceptives, nitroglycerin
 Food additives

PATHOPHYSIOLOGY
 Attack occurrence and frequency are governed by CNS sensitivity to migraine-specific triggers or
environmental factors.
 Patients with migraines appear to have a lowered threshold of response to specific environmental
circumstances as a result of genetic factors that govern the balance of CNS excitation and
inhibition at various levels.
 Thus, trigger factors can be viewed as modulators of the genetic set point that predisposes to
migraine headache.
 The hyper responsiveness of the patient’s brain may be the result of an inherited abnormality in
calcium and/or sodium channels and sodium/potassium pumps that regulate cortical excitability
through the release of serotonin (5-hydroxytryptamine [5-HT]) and other neurotransmitters.
 Increased levels of excitatory amino acids such as glutamate and alterations in levels of
extracellular potassium also can affect the migraine threshold and initiate and propagate the
phenomenon of cortical spreading depression.
 Serotonin (5-HT) has long been implicated as an important mediator of migraine headache and
specific populations of 5-HT receptor subfamilies appear to be involved in the pathophysiology
and treatment of migraine headache.

CLINICAL PRESENTATION
 Common, recurrent, severe headache
 Migraine without aura
 Migraine with aura Symptoms
 Recurring episodes of throbbing head pain, frequently unilateral, lasting from 4 to
72 hours if left untreated
 Headaches can be severe and associated with nausea, vomiting, and sensitivity to
light, sound, and/or movement, but not all symptoms are present in every attack
 Diagnostic alarms from evaluation include
 Acute onset of the “first” or “worst” headache ever ,Accelerating pattern of
headache following sub-acute onset ,Onset of headache after age 50 years
,Headache associated with systemic illness (e.g., fever, nausea, vomiting, stiff
neck, and rash) ,Headache with focal neurologic symptoms or papilledema.

DIAGNOSIS
 General medical and neurologic physical examination
 Vital signs (fever, hypertension)
 Fundoscopy (papilledema, haemorrhage, and exudates)
 Palpation and auscultation of the head and neck (sinus
tenderness, hardened or tender temporal arteries, trigger points,
temporomandibular joint tenderness, bruits, nuchal rigidity, and
cervical spine tenderness)
 Neurologic examination (identify abnormalities or deficits in
mental status, cranial nerves, deep tendon reflexes, motor
strength, coordination, gait, and cerebellar function)
 Consider neuroimaging studies in patients with abnormal
neurologic examination findings of unknown etiology and in
those with additional risk factors warranting imaging.

COMPLICATION
 Status migrainosus
 Persistent aura without infarction
 Migrainous infarction
 Migraine triggered seizures

STANDARD TREATMENT

PATIENT DEMOGRAPHIC DETAILS
PATIENT NAME: Na…
AGE: 17 years
GENDER: Female
WEIGHT: 52 kg
HEIGHT: 153 cm
BMI: 22.6 kg/m²
IP NO: 21030098
UNIT: General medicine
WARD: General ward
DOA: 7-03-2021
DOD: 12-03-2021
5/3/2021 19

SUBJECTIVE EVIDENCE
Chief complaints on admission:-
C/O Throbbing headache from 15 days(right sided),
myalgia, vomiting since 15 days, ear & eye pain, fever, irritable, neck
stiffness since 1 day.
5/3/2021 20

PATIENT PAST HISTORY
PAST MEDICAL HISTORY: k/c/o Hypothyroidism,Oligomenorrhea since 6 months
PAST MEDICATION HISTORY: Tab.Thyronorm 25mcg 1-0-0, Tab.Folvite 5mg 1-0-0
FAMILY HISTORY: Nothing significant
SOCIAL HISTORY: non smoker and non alcoholic
 PERSONAL HISTORY:BOWL/BLADDER: normal
APPETITE: decreased appetite
SLEEP: normal
DIET: mixed diet
ALLERGIES: Nil known allergies
5/3/2021 21

PHYSICAL EXAMINATION
TEMPERATURE : 99.5°C
BLOOD PRESSURE: 120/80mm Hg
PULSE RATE: 84bpm
SPO₂: 100% on RA
PICCLE: P¯I¯C¯C¯L¯E¯
5/3/2021 22

SYSTEMIC EXAMINATION
RR: 18bpm
CVS: S1S2 Heard
RS: NVBS
CNS: Conscious and oriented
5/3/2021 23

OBJECTIVE EVIDENCE
TEST OBSERVED VALUES NORMAL VALUES
Hemoglobin 7.9 gm/dl 12-14 gm/dl
Mean cell hemoglobin(MCH) 16.4 pg 27-31 pg
Mean cell haemoglobin
concentration(MCHC)
28.1 gm/dl 31-37 gm/dl
Mean cell volume(MCV) 58.2 fl 78-100 fl
Haematocrit 28.1 % 37-47 %
Neutrophills 85.3 % 40-70%
Eosinophills 0 % 1-6%
Lymphocytes 4.2 % 20-40%
5/3/2021 24

PROVISIONAL DIAGNOSIS
Acute cerebral venous thrombosis
Migraine
5/3/2021 25

OTHER TEST
CT BRAIN (Plain+contrast):-
Acute cerebral venous thrombosis of superior sagittal sinus and
few cortical veins.
Peripheral Smear (PS) :-
RBC’s are microcytic hypochromic:- Microcytic hypochromic
anaemia with relative neutrophilia.
5/3/2021 26

FINAL DIAGNOSIS
•Migraine
•Acute cerebral venous thrombosis
•Hypothyroidism
5/3/2021 27

SUBJECTIVE EVIDENCE OBJECTIVE EVIDENCE
C/O Throbbing headache from 15
days(right sided), myalgia,
vomiting since 15 days, ear & eye
pain, fever, irritable, neck stiffness
since 1 day.
• Haemoglobin:-7.9 gm/dl (12-14 gm/dl)
• Haematocrit:-28.1 % (37-47 %)
• MCV:-58.2 fl (78-100 fl)
• MCH:-16.4 pg (27-31 pg)
• MCHC:-28.1 gm/dl (31-37 gm/dl)
• Neutrophills:-85.3 % (40-70 %)
• Eosinophills:-0 % (1-6 %)
• Lymphocytes:-4.2 % (20-40 %)

ASSESSMENT
From the subjective and objective evidence it has
been diagnosed as a:-
Acute cerebral venous thrombosis
Hypothyroidism
Migraine
Anaemia
5/3/2021 29

GOALS OF THERAPY
Rapid symptom relief and prompt control of acute attack
Prevent extension of thrombus
Prevent recurrent events
Prevention of serious complications
Morbidity and mortality can also be reduced by the prompt use of
effective and appropriate drug therapy
Treat migraine attacks rapidly and consistently without recurrence
Correct anaemia
5/3/2021 30

TREATMENT PLAN BY CLINICAL
PHARMACIST
Paracetamol: 1g IV twice daily
Ondasetron: 4mg IV twice daily
Normal saline 150ml
Levothyroxine 25mcg PO once daily
Folic acid 5mg PO once daily
Enoxaparin 40mg SC twice daily
Pantoprazole: 40mg IV twice daily
5/3/2021 31

TRATMENT CHART
DRUGS
BRAND GENERIC
ROA DOSE FREQUENCY DAYS
01 02 03 04 05 06
Inj.Pantop Pantoprazole IV 40mg 1-0-1      
IVF NS Normal saline IV 125ml onflow  
Inj.PCT Paracetamol IV 1g 1-1-1      
Inj.Emeset Ondansetron IV 4mg 1-0-1      
Inj.Clexane Enoxaparin IV 40mg 1-0-1     
Inj.Levipil Levetiracetam IV 500mg 1-0-1     
Tab.Thyronorm Levothyroxine PO 25mcg 1-0-0    
Neurobion forte Thiamine, Pyrodoxine, Vit
B12
IV 1-0-0     
Inj.Ferri Ferric Gluconate IV 2amp 100ml/NS   
Syp.gaviscon Aluminium hydroxide and
magnesium carbonate
PO 10ml 1-1-1 
Tab.Folvite Folic acid PO 5mg 1-0-0      
5/3/2021 32

PROGRESS REPORT
DAY 01:-
• Vitals stable DAY 03:-
• Afebrile No fresh complaints
• H/O:- Headache Afebrile
Vitals stable
DAY02:- Advice for discharge
• Pain relieved
• PR:- 80b/m
• BP:- 110/70mmHg
• Afebrile
5/3/2021 33

Day 4:
• No headache/vomiting
• Vitals Stable
• Thrombosis, Papilledema 3mm ®
• No menorrhagia
Day 5:
• No menorrhagia
• No headache
• Advise CST
Day 6:
• Patient feels better
• Advise for Discharge

DISCHARGE MEDICATION
DRUGS
BRAND GENERIC ROUTE DOSE FREQUENCY
Tab.Acitrom Acenocoumarol PO 3mg 0-0-1
Tab.levipil 500mg levetiracetam PO 500mg 1-0-1
Tab.Orofer XT Ferrous ascorbate + folic acid PO 1-0-1
Tab.Thyronorm Levothyroxine PO 25mcg 1-0-0
Cap.Pan-DSR Pantraprozole+domeperidone PO 40mg 1-0-0
Cap.Homin Mecobalamin+pyridoxine+Folic
acid
PO 0-1-0
5/3/2021 35

MONITORING PARAMETERS
Haematology
CT brain
Thyroid function test
Liver function test
Physical examination
5/3/2021 36

PROBLEMS IDENTIFIED
Levetiracetam + acetaminophen:- Levetiracetam
decreases levels of acetaminophen by increasing
metabolism. Enhanced metabolism increase levels of
hepatotoxic metabolites
Acetaminophen + Enoxaparin:- Acetaminophen increase
the effect of enoxaparin.
5/3/2021 37

CLINICAL PHARMACIST SUGGESTION
Alter the frequency or time of administration of the
• Levetiracetam and Acetaminophen
• Enoxaparin and Acetaminophen.
5/3/2021 38

PATIENT COUNSELLING
 ABOUT DISEASE:-
Explain the nature of condition
Explain the role of relevant
risk factors such as environmental factors, diet.
The patient should be informed about established pain and function
can often be improved
Cerebral venous thrombosis is the cerebral vein thrombosis of dural
sinus and/or cerebral veins.
5/3/2021 39

ABOUT MEDICATION:-
Advise patient to take pantoprazole 30 min before food
If hypersensitivity reactions occurs by any medicines
immediately informed to health care professionals
Take levothyroxine before food in the morning
The given drug levetiracetam may cause drowsiness,
sleepiness and Acenocoumarol may cause loss of appetite
Take orofer XT before 1 hour food or after 2 hour food,
should not take with milk, caffeine.
Never take in greater or lesser amounts or more often than
prescribed.
5/3/2021 40

LIFE STYLE MODIFICATION :-
Avoid stress: it can make the signs and symptoms worse and may
trigger
Take rest
Light exercise like meditation, deep breathing and walking
Drink lots of water at least 8 cups of water a day help to avoid
dehydration that caused by vomiting
Identify your triggers and avoid when possible
Eat healthy and regularly; do not skip meals
Keep a regular sleep schedule
5/3/2021 41

 Iron supplement is necessary
 Need supplements due to loss of vitamins and
minerals in vomiting
 Eat banana, apple, papaya, carrot and drink
pomegranate juice, coconut water.

THANK YOU

MIGRAINE, CVT

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