Lecture 8 - Migraine 2 Flashcards
Nerivio indiication
migraines in 12yrs or older
Relivion MG Indication
migraines in > 18yrs old
Spring TMS Indication
prevent & treatment > 12yrs old
Gammacore
prevention and treatment migraines > 12yrs old
Cefaly
prevention & treatment in pts over 18yrs old
Who should use migraine devices?
cant take other meds
prescribed by headache specialist
Acute migraine goals of therapy
Restore ability to function treat attacks rapidly and consistently minimize the use of backup/rescue meds optimize self-care utilize cost-effective management cause minimal to no side effects
pts not candidates for self care
recent trauma new onset > 50 under age 18 history of liver disease or alcohol abuse associated with fever complains of confusion,dizziness,etc
Migraine step up approach
use of NSAIDs and combo products 1st, then move up to other therapies
Migraine stratified care
Initial migraine treatment used on symptoms severe and headache related disability
What did DISC study show
stratified care wasn’t better
Triptans MOA
- vasocronstriction via activation or 5-HT1B (postsynap) receptors on smooth-muscle of blood cells
- presynap 5-HT1D receptors activity leading to blockade of release of vasoactive peptides from trigeminal neurons. also leads to blockade of NT and activation of 2nd order neurons = facilitate descending pain inhibitory systems
Sumatriptan DDI
avoid in use w/in 2 weeks of MOAI
Sumatriptan Clinical considerations
not recommended with severe hepatic impairment
SQ has fastest onset and has some of best efficacy data
Zolmitriptan DDI
Avoid in use w/in 2 weeks of MAOI
max single dose = 2.5, max daily = 5mg when used with cimetidine
Zolmitriptan clinical considerations
no renal adjustment
CYP1A2
avoid ODT/nasal spray in mod/sev hepatic impairment
Almotriptan DDI
Redce dose to 6.25mg when w/ CYP3A4 inhib
Eletriptan DDI
should not use w/in 3 days of potent CYP3A4 inhib
Eletripatn Clinical considerations
avoid in sev hepatic impairment
CYP3A4
Almotriptan Clinical considerations
contains sulfa group, CI in sulfa allergy
dose adjust renal/hepatic impairment
Rizatriptan DDI
5mg/dose, max of 3/day w/ propranolol
dont use w/in 3 weeks of MAOI
Frovatriptn Clinical considerations
less effective than other triptans
slower onset/longer duration
CYP1A2
Naratriptan clinical considerations
Renal/hepatic impairment
Triptans CI
CAD - angina, vasospastic angina, uncontrolled HTN,etc
hepatic disease
if have risk factors for CAD
Triptans ADE
Fatigue Dizziness flushing warm sensations somnolence paresthesia medication overuse headache
Triptan sensations
can go away by switching to another one
Triptan place in therapy
mod-seer migraine with no CI
severe migraine which responded poorly to NSAIDs or combo analgesics
If triptans ineffective then….
inc dose try another one try another formulation combine with other agents try different type of therapy
Ergot-Alkaloids MOA
Non-selective 5-HT1 receptors agonists, a1/2 receptors, DA2 receptors
Dihydroergotamine DDI
CI w/ CYP3A4 strong inhib
Ergot-Alkaloids CI
Renal/hepatic failure
women preg/nursing (class X)
vascular disease
Ergot-Alkaloids Side effects
Nausea + Vomiting super common, pretreat w/ antiemetic
Ergot-Alkaloids DDI
dont use within 24hrs of triptans
Ditans MOA
selective 5-HT1F agonist
Lasmiditan DDI
Serotonergic agents
PGP substrates
Lasmiditan precaution
impaired driving
CNS oppression
risk of med overuse headache
risk of SS
Ditans place of therapy
pts who are CI to or unable to tolerate triptans or failed 2+ therapies
mod-severe headache
Gepants moa
CGRP receptor antagonists
Ubrogepant DDI
CI w/ strong CYP3A4
avoid grapefruit dose
Rimegepant DDI
avoid w/in 48hr mod CYP3A4 inhib
avoid continent admin w/ strong CYP3A4 inhib or mod CYP3A4 induce
think about hepatic/renal disease
Ditans and Gepants criteria for initiation
18+
licensed clinician
ICHD-3 Dx migraine
CI/cant tolerate triptan/2+ failed
Lamiditain patient ed
avoid driving or operating heavy machinery 8hrs after
Ergotamine patient ed
med can cause sensitivity to cold temp
NSAIDs with best efficacy
Excedrin
ASA
Ibuprofen
Naproxen
Antiemetics Agents Side effects
QTc prolongation
Antiemetics place in therapy
adjunct in tx of N/V
pre tx to prevent induced N/V
metoclopramide can improve absorption of oral meds
Prochlorperazine/metoclopramide can be used as monotherapy in intractable headaches
Pediatrics w/ migraines
Management: APAP Ibuprofen Rizatriptan Zolmitriptan nasal spray
Pregnancy w/ migraines
- inc risk of pre-eclampsia and gestational HTN
Management: APAP NSAIDs in 1/2 trimester, avoid 3rd Metoclopramide IV AVOID triptans + ergo alkaloids
Purpose of Migraine Prophylaxis therapy
prevent headache improve QOL reduce severity, freq, disability associated w/ headache educate and enable pts reduce headache related distress
How long to see effect of prophylaxis therapy?
about 2-6 months
Indication for Migraine Prophylaxis therapy?
Frequent attacks Headaches in predictable pattern cause significant disability profound disruption and/or risk of neurologic injury acute meds ineffective, CI, ADE
FDA approved for migraine prophylaxis
Propranolol
timolol
Valrproic acid
Divalproex sodium
Topiramate
Valrproic acid, Divalproex sodium CI
Lamtorigine, estrogen contraceptives, warfarin
CI in liver disease, hx of pancreatitis, preg
Topiramate CI
hx of nephroithiasis
renal/hepatic dysfunction
oral contraceptives
Gepants for Prevention of migraine FDA approved
Rimegepant (Nurtec)
Atogepant (Quilpta)
Anti-CGRP antibodies
FDA approved for migraine prevention
all 18+, given Q3 months except emagility which is monthly
Botox DDI
aminoglcosides or other agents impacting nmt, muscle relaxants
When to use Botox?
when other things have failed
If co-morbid obestity/fat
Topiramate
If com-morbid seizure or bipolar
AED
If co-morbid depressed or cant sleep
TCA or SNRI
If co-morbid HTN/angina/anxiety or healthy
BB or verapamil
If menstrual related migraine
Frovatriptan
naratriptan
zolmitriptan
If HA recurring in predictable pattern
NSAID or triptan at time of vulnerability
Menstrual related migraines
-2 to +3 days of menstruation, at least 2 of 3 cycles
start 6 days before menstruation and continue for 5-7das after
