Lecture 50 - Pharmacotherapy of Migraines Flashcards
Migraine types
migraine without aura (common)
migraine with aura (classic)
Migraine without aura (common) - diagnostic criteria
◦ At least five attacks
◦ Headache lasting 4 – 72 hours
◦ Unilateral location, pulsating quality, moderate/severe pain, aggravation
by routine activity
◦ Nausea and/or vomiting,
photophobia, phonophobia
Migraine with aura (classic)
◦ At least two attacks
◦ At least one fully reversible aura
◦ No aura lasting more than 60 minutes
◦ Headache follows aura within 60 min
◦ Aura symptoms: visual, sensory, speech/language, motor, brainstem, retinal
Migraine headache phases
1: prodrome
2: aura
3: migraine headache
4: postdromal
Prodrome
- Hours or days
before onset of
headache - May experience
euphoria, depression,
irritability, food
craving, constipation, neck
stiffness, yawning
Aura
15-30% of patients
* Commonly visual, may be sensory, verbal, or motor
* Before or during migraine, lasts less than 60 minutes
* Photopsia (flash of
light or floater in
eye), scotoma (blind spot), zigzag lines, numbness/tingling
in arms, legs, face
Migraine headache
- Dull ache that intensifies
- Unilateral and throbbing
- Phonophobia, photophobia
Postdromal
- May last several days after headache has ended
- Tiredness, head pain, GI distress, mood changes, weakness, cognitive difficulties
Migraine triggers
Medication Overuse Headache
* Associated with analgesics, ergots, triptans – rebound headaches from medication overuse more than two times per headache or two times per week chronically
* Can be managed by gradual reduction of medication use limited to no more than 2 doses per headache or two times per week and avoidance of butalbital/opioids – use meds with less withdrawal potential (low-dose NSAID)
Medications: oral contraceptives, hydralazine, nitroglycerin, nifedipine, cocaine
Diet: chocolate, oranges, tomatoes, onions, aged cheese, processed meats, cultured dairy, alcohol (specifically red wine and champagne), caffeine
Additives/preservatives: aspartame and monosodium glutamate
Environment: altitude/weather changes, perfume, tobacco smoke, loud noises, flickering lights Too little or too much sleep, skipping meals, stress, hormone changes
Avoid _____ in treatment
analgesic overuse
Abortive treatment
◦ Education to avoid medication overuse
◦ Mild-moderate: NSAIDs, acetaminophen
◦ Moderate-severe: triptans/ergots
Preventive treatment
◦ Four or more attacks/month with disability at least 3 days/month
Abortive treatment guidelines
first line: triptans, NSAIDs
second line: NSAIDs
Prevention treatment guidelines
first line: monotherapy: valproate, topiramate, metoprolol, propranolol, frovatriptan
second line: monotherapy: amitriptyline
Non-pharmacolgical therapy
biofeedback and relaxation therapy
cognitive behavioral therapy
diet
sleep
transcutaneous electrical nerve stimulatiion device
exercise, massage, acupuncture, thermal biofeedback, heat/cold applications, headache diary
Overview of triptans for abortive treatment: contraindications
Contraindications: recent use (within 24 hours) of an ergot or other triptan, MAO-A inhibitor use in the last 2 weeks (frovatriptan, rizatriptan), ischemic heart disease, angina, history of stroke or TIA or hemiplegic/basilar migraine, arrhythmias, peripheral vascular disease, uncontrolled hypertension, ischemic bowel disease, severe hepatic impairment
Overview of triptans for abortive treatment: warnings/precautions
Warnings/precautions: MI, pain/pressure/tightness in chest/throat/neck/jaw, CVA, HTN, GI ischemic reactions or peripheral vasospasm, medication overuse headache, serotonin syndrome, sulfa allergy (almotriptan), corneal opacities (almotriptan), seizures (use with caution)
Overview of triptans for abortive treatment: SEs
*Oral – tingling, dizziness, drowsiness, fatigue, chest tightness/pressure, flushing
Overview of triptans for abortive treatment: drug interactions
*SSRIs/SNRIs – theoretically, the use of a triptan with SSRI/SNRI can increase the risk of serotonin syndrome. This drug interaction is extremely rare and may not be due to the triptans.
*Avoid strong 3A4 inhibitors with eletriptan
Ergot alkaloids in abortive treatment: warnings/precautions
Boxed warning for serious/life-
threatening peripheral ischemia; warnings for cardiac valvular fibrosis, vasospasms or
vasoconstriction, cerebrovascular events, ergotism (overdose of
ergot-containing medication –
cramps, spasms, dry gangrene from vasoconstriction)
Ergot alkaloids in abortive treatment: SEs
retroperitoneal, pleuropulmonary, and valvular fibrosis; ergotism, vasoconstrictive complications (ischemia, cyanosis, cold in extremities, gangrene, numbness, weakness, N/V)
Ergot alkaloids in abortive treatment: drug interactions
3A4 inhibitors – ergot toxicity can result
Calcitonin Gene- Related Peptide (CGRP) Receptor Antagonists Abortive Treatment: contraindications
contraindicated with strong 3A4 inhibitors
Calcitonin Gene- Related Peptide (CGRP) Receptor Antagonists Abortive Treatment: drug interactions
moderate/strong 3A4 inducers and inhibitors, p-glycoprotein inhibitors
Lasmiditan abortive therapy: warnings/precautions
Warnings/precautions:
medication overuse headaches, sedation, dizziness, serotonin syndrome, driving impairment (avoid for at least 8 hours after dose)
Lasmiditan abortive therapy: SEs
Side effects:
dizziness, fatigue, paresthesia, sedation
Lasmiditan abortive therapy: drug interactions
use with caution with other CNS depressants and serotonergic medications; avoid use with p-gp or BCRP substrates, other medications that can decrease heart rate
Lasmiditan abortive therapy: monitoring
LFTs, blood pressure, heart rate (especially in patients with cardiovascular disease)
Other abortive therapies
Butorphanol nasal spray as a rescue medication
Preventive drug therapy: beta blockers
- FDA-approved
*Propranolol 80 – 240 mg/day *Metoprolol 100 – 200 mg/day
*Contraindicated in asthma and Raynaud’s syndrome
Preventive drug therapy: tricyclic antidepressants
*Not FDA-approved
*Amitriptyline 25 – 150 mg/day (mixed migraine/tension-type)
Preventive – CGRP Antagonists: SEs
*Atogepant: nausea, constipation, fatigue
*Rimegepant: nausea, rash, dyspnea
Preventive drug therapy: antiseizure drugs
valproate, topiramate (FDA- approved)
*Valproate – 500 – 1500 mg/day, topiramate – 50 – 100 mg/day
*Not recommended in people of child-bearing age unless using contraception
Preventive therapy: miscellaneous and natural products
butterbur/petasites 150mg/day
Migraine Therapy in Pregnancy: dihydroergotamine/ergotamine
contraindicated in pregnancy,
use of contraception is
recommended
Migraine Therapy in Pregnancy: triptans
recommended for use only if the benefit outweighs the risk to the fetus
Migraine Therapy in Pregnancy: valproate
contraindicated in pregnancy when used for the treatment of migraines, contraception is recommended
Migraine Therapy in Pregnancy: topiramate
may cause fetal harm if used during pregnancy (cleft lip/palate and reduced birth weight); if used during pregnancy, monitor for the development of metabolic acidosis during and after pregnancy
Migraine therapy in children: almotriptan
12 years of age and older
Migraine therapy in children: rizatriptan
6 years of age and older
Migraine therapy in children: zolmitriptan nasal spray
12 years of age and older
Migraine therapy in children: sumatriptan nasal spray
not FDA-approved in children
Migraine therapy in children: sumatriptan/naproxen
12 years and older
Migraine therapy in children: topiramate
12 years of age and older
