Drugs for migraine

Question 1

Drugs for acute Tx. of migraine

Answer 1

Acetaminophen and NSAIDs

• mild to moderate pain
• not associated with vomiting or severe nausea

Question 2

Drugs for severe to moderate attacks

• DOC for moderate to severe migraine?
• MOA
• what combo provides better pain relief?
• what is the fastest acting formulation for these drugs?

Answer 2

• Triptans are the DOC
• Selective agonists at 5-HT1D
• combo of Sumatriptan and naproxen provide better relief than either drug alone!
• Subcutaneous sumatriptan*

Question 3

Drugs for severe to moderate attacks:
Ergot Alkaloids
MOA

Answer 3

Ergotamine and Dihydroergotamine

• agonists at alpha-adrenoceptors 5-HT an D2 receptors
• also have actions at 5-HT1B/1D which mediates their anti-migraine effects.

Question 4

Ergot alkaloids AE:

CI

Answer 4

Nausea and vomitting that can be prevented w/ metoclporamide.

Serious adverse effects: Vascular occlusion and Gangrene. Rare. Usually assciated with overdose.

Dihydroergotamine is a weaker vasoconstrictor than ergotamine an causes fewer AE.

CI in arterial disease or uncontrolled HTN

Question 5

drugs for prevention of migraines Second or third line
First line?
Second or third line?

Answer 5

First line:

• Beta blockers
• valproate
• Topiramate

Second or third line:

• Tricyclic antidepressants
• SNRI (for neuropathic pain)
• Calcium Channel Blocker’s
• Gabapentin
• ACEIs or ARBs
• Botulinum Toxin
• NSAIDs

Question 6

what drugs are used for continuous migraine prophylaxis?

Answer 6

Beta blockers:
Propranolol
Timolol
Metoprolol
Nadolol
Atenolol

Question 7

Drug indicated for Bipolar disorder/ epilepsy and migraine prophylaxis?
MOA?
AE?

Answer 7

1. Valproate
2. Inhibits voltage gated Na+ channels and T-type Ca+2 channels
3. GI side effects. Thrombocytopenia. Rarely hepatotoxicity. TERATOGENIC*

Question 8

Indicated for epilepsy and migraine prophylaxis and inhibits voltage gated Na+ channels. GABAa receptor agonist and glutamate receptor antagonist?

Answer 8

Topiramate

Question 9

Topiramate AE

Answer 9

Somnolence
Fatigue
Cognitive slowing
nervousness
confusion
Acute myopia
glaucoma
hyperthermia
renal stones
TERATOGENIC!

Question 10

Tricyclic antidepressants
MOA
AE

Answer 10

Amitryptyline
Norptriptyline
Imipramine
- Inhibit norepinephrine and serotonin reuptake
- Sedation/ dry mouth/ weight gain.

Question 11

Serotonin Norepinephrine Reuptake inhibitors (SNRIs)

AE?

Answer 11

Venlafaxine

Nausea/ constipation/ insomnia/ headaches/ sexual dysfunction.

Question 12

drugs for prevention of migraines Second or third line agents: Calcium channel blockers

Answer 12

Verapamil
CCBs weak evidence of effectiveness
Verapamil has most efficacy within CCBs

Question 13

drugs for prevention of migraines Second or third line agents: Gbapentin
AE?

Answer 13

Gabapentin
- decreases glutamate release by blocking presynaptic voltage gated calcium channels

AE: sleepiness dizziness fatigue

Question 14

drugs for prevention of migraines Second or third line agents: ACEIs and ARBs

Answer 14

Lisinopril and candesartan

- have reduced migraine fequency by about 30%

Question 15

drugs for prevention of migraines Second or third line agents: Botulinum toxin

Answer 15

pericranial injections of toxin is marginally effective for prophylaxis of headaches in adults with chronic migraine (patients with 15 or more headaches days/month)

Question 16

drugs for prevention of migraines Second or third line agents: NSAIDs

Answer 16

Naproxen and ibuprofen

- have been used for short term prevention of migraine

Question 17

TRIPTANS: ADVERSE EFFECTS

Answer 17

• Tingling, flushing, dizziness, fatigue.
• Chest tightness.
• Rare: Angina, MI, arrhythmia, stroke, and death.
• Contraindicated in coronary, cerebrovascular or other arterial disease, or uncontrolled hypertension.