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Diagnosis and acute management of migraine

Author/s: 
Tzankova, V., Becker, W. J., Chan, T. L. H.

Migraine is a leading cause of disability across all age groups.
• Routine imaging is not recommended in patients with migraine
who have no red flags, atypical symptoms or abnormal findings
on neurologic examination.
• A stratified approach for acute migraine treatment empowers
patients to choose from different treatment options
depending on attack symptoms and severity and encourages
patients to combine medications from different classes.
• Effective acute migraine treatment includes acetaminophen,
nonsteroidal anti-inflammatory drugs and triptans.
• Ubrogepant and rimegepant are new, effective migraine
treatments, suitable for patients with cardiovascular disease in
whom triptans are contraindicated.

Keywords 
migraines acetaminophen Migraine Disorders Pain therapy pain management

Prescribing for common complications of spinal cord injury

Author/s: 
McColl, M. A., Gupta, S., McColl, A., Smith, K.

Objective: To describe prescribing patterns for 3 common complications associated with spinal cord injury (SCI) and to provide family doctors with strategies for optimizing the care of patients with SCI.

Sources of information: Results of a nationwide survey of prescription medication use among people with SCI in Canada and a longitudinal study of secondary complications associated with SCI.

Main message: Altered neurologic and cardiometabolic function in patients with SCI make it difficult for family physicians to predict optimal medication regimens for these patients. Three common problems seen in primary care among patients with SCI that require pharmacologic treatment are pain (treated in 57% of survey respondents), muscle spasms (54%), and recurrent urinary tract infections (43%). Pain management may require multiple medications, depending on the source or nature of the pain. Some prescription medications recommended for treating pain may be underused in this population, such as amitriptyline, while others may be overused in this population, such as antibiotics for urinary tract infections. Spasticity is often related to an underlying problem such as pain, and treatment of concomitant conditions may also reduce spasticity. Short-acting benzodiazepines were found to have been prescribed for spasticity outside the recommended treatment paradigm at a surprisingly high rate. The longitudinal study of secondary complications associated with SCI led to the development of Actionable Nuggets, an innovative knowledge translation tool for primary care providers.

Conclusion: To provide optimal treatment to patients with SCI, family doctors are encouraged to engage in open communication with them about prescription medications, including aspects of cost, polypharmacy, and therapeutic substitutions. Family physicians should also explore interprofessional collaboration with SCI specialists and allied health providers to provide patients with nonpharmacologic strategies tailored to their activity levels and nutritional needs. The Actionable Nuggets mobile app provides family doctors with brief, actionable, evidence-based information on the top 20 health concerns associated with SCI.

Keywords 
Pain therapy Muscle spasticity spinal cord injuries common complications prescriptions
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