Migraine Flashcards
What is a migraine?
- chronic headaches lasting for hours or days.
- accompanied by other symptoms including:
Nausea
Vomiting
Photophobia (sensitivity to light)
Phonophobia (sensitivity to sound) - most migraines cause nausea, vomiting, and sensitivity to light and sound
- some migraines are accompanied by auras
Migraines are often divided into two categories:
1)
2)
1) may occur with aura
2) may occur without aura
Aura: sensory warning symptoms or signs (auras)
- examples:
-such as flashes of light
- blind spots
- tingling in the arms or legs “pins and needles “ sensation
- the aura symptoms are reversible and will resolve overtime on their own
“Most migraines do not have aura”
While it is important to know that a migraine is a headache, NOT ALL headaches are migraines!
a patient should seek medical attention when a headache is accompanied with:
- fever -rash
- stiff neck
- confusion
(all above are classic symptoms of meningitis) - confusion
- seizures
-double vision
-weakness - numbness
- aphasia
(all of the above symptoms are classic for TMJ or stroke)
a headache accompanied by:
-fever, stiff neck, rash, confusion, seizures, double vision, weakness, numbness, chest pain, shortness of breath, or aphasia (trouble speaking) could indicate __________
serious cardiovascular, cerebrovascular, or infectious event. Patient should seek medical attention.
Causes of Migraines: Not Well Understood
from a pathophysiology standpoint, we believe one of the first things that occurs is ___________
Cortical spreading depression: meaning there is an increased neuronal activity happening across the cerebral cortex.
This is believed to activate the trigeminal nerve and resulting in the release of (CGRP) Calcitonin gene-related peptide and other neurotransmitters.
The neurotransmitters and neuropeptides that are released contribute to the process of neurogenic inflammation. Also called aseptic or sterile inflammation.t bacterial or viral cause.
Serotonin is a neurotransmitter involved in the neurogenic inflammation process. Its release is believed to be partly responsible for the release of CGRP.
Serotonin, CGRP, and other neurotransmitters and neuropeptides involved in migraine pathogenesis are sometimes referred to as vasoactive neuropeptides. Because one of the results of neurogenic inflammation is vasodilation. In other words, the release of these substances has an effect on the cranial blood vessels.
CGRP is a potent __________
vasodilator
serotonin can act as a ________
vasoconstrictor or vasodilator
Vasodilation of the intracranial blood vessels is believed to be:
at least partially responsible for migraine headache pain
Causes of Migraines: Not Well Understood
Another result of this cascade of events, is the ______.
This is also called the _________
sensitization of the trigeminal nerve, which also contributes to migraine pain.
sensitization of the trigeminal nerve is called “Central sensitization”, is believed to be responsible for the long duration of migraine attacks.
By definition a migraine lasts ________
4-72 hours when untreated.
allodynia:
pain due to a stimulus that does not normally provoke pain
We need to understand a little of this pathophysiology because ________ and _________ are drug targets for treating and in some cases preventing migraines.
serotonin
(CGRP) Calcitonin gene-related peptide
Triggers are stimuli that patients should identify and avoid to
reduce migraine incidence.
-
-
-
-
-
Hormonal Changes in Women
- one common trigger in women is hormone fluctuations specifically with estrogen (these can sometimes be prevented using hormonal contraception)
Foods
- beer, red wine, aged cheeses, chocolate, aspartame, (MSG) monosodium glutamate, salty foods, processed foods
Stress
- stress is a major cause of migraines
Sensory Stimuli
-bright lights, sun glare, loud sounds and certain scents (pleasant or unpleasant odors)
Changes in Wake-Sleep pattern
- either missing sleep or getting too much sleep (including jet lag)
Changes in the environment
- a change of weather or barometric pressure
Migraines associated with hormone fluctuations are called ___
(MAM) Menstrual-Associated Migraine
Women who experience (MAM) Menstrual associated migraines with aura should use ____________
Progestin-only pills, because these women are at an increased risk of stroke. Should NOT USE estrogen contraceptives since further increases risk!!!
Diagnosis Criteria of a Migraine:
To be diagnosed with migraine, an adult must have:
At least 5 attacks fulfilling the following criteria:
1) Each attack of headache must:
- last 4-72 hours
- and headache attacks recur
2) The attacks must be accompanied by at least 2 characteristics:
- unilateral location (pain is only on one side of the head)
- pulsating pain “throbbing pain”
- moderate to severe pain
- worse with physical activity
3) the headache attack must also have one other symptom
- Nausea with or without vomiting
- Photophobia (sensitivity to light, which makes pain worse)
- Phonophobia (sensitivity to sound, which makes pain worse)
osmophobia
sensitivity to smells
Non-Drug treatments available for Migraine:
Some of these are preventative measures instead of taking a treatment.
- Keeping a headache diary can be helpful at identifying triggers
- Stress Management techniques
- Cold compresses
- massage (used for prevention NOT particularly useful in stopping an attack that is in progress)
- spinal manipulation (performed by a chiropractor, used as a preventative treatment)
- acupuncture (more likely used for prophylaxis)
- Transcutaneous electrical nerve stimulation units (TENS units)
TENS units approved for the prevention and/or treatment of migraines include:
Cephaly
Relivion
- these are worn by the patient and provide small electrical pulses that ultimately block pain signals
gammaCore Sapphire device is approved for both migraines and cluster headaches.
Natural products that can be used for Migraines alone or in combination include:
Vitamins:
- Riboflavin (vitamin B2), can be used prophylaxis
Minerals:
- Magnesium for migraine prophylaxis, diarrhea possible side effect
Herbals:
- Butterbur for migraine prophylaxis, avoid in patients allergic to ragweed
- Feverfew for migraine prophylaxis, avoid in patients allergic to ragweed
- Peppermint, the oil can be used topically for acute migraine attacks or for migraine prevention
Others:
- Coenzyme Q10 (Ubiquinone), used for migraine prevention
- caffeine with Tylenol or with aspirin to treat migraine headaches
Acute Treatment of Migraine is also called ____
Abortive Treatment
- treats a migraine attack
- taken only as needed
Prophylactic Treatment of Migraine is also called ________
Preventive Treatment
- reduces attack frequency, severity
- taken regularly
Acute Drug Treatment: For MILD attacks
Options for treating a migraine that is in progress include:
For MILD attacks
OTC analgesics:
-Tylenol- acetaminophen
-Bayer/Bufferin/Ecotrin - aspirin
-Advil/Motrin/Advil Migraine - ibuprofen
-Aleve - naproxen
Combination OTC products:
- Excedrin Migraine (aspirin/acetaminophen/caffeine)
Why do some of these combination products for migraines contain caffeine?
Caffeine acts as a cerebral vasoconstrictor
- so, it is going to help shrink down some of those over inflamed blood vessels in the head. Which will help to reduce migraine pain.
- it also improves absorption of other drugs
The recommendation for caffeine consumption is no more than 400mg caffeine per day for healthy adults.
Acute Drug Treatment: For Moderate-Severe Migraine attacks
Options for treating a migraine that is in progress include:
For Moderate-Severe Migraine attacks
- prescription NSAIDs
-Triptans - CGRP antagonists
- Ergotamine derivatives & butalbital containing medications
- Lasmiditan (Reyvow)
What classes of medications are NOT recommended for the acute treatment of migraine?
- Butalbital containing combinations (Fioral & Fiorset), NOT very good at treating & (high risk for abuse and dependance)
- Opioids (high risk for abuse and dependance)
- Tramadol & Tapentadol, (high risk for abuse and dependance)
These ARE ALL LAST LINE OPTIONS!!!!!
Medication Overuse/ Rebound Headaches
What is Medication Overuse Headache?
- patient has headaches that occur more than 10-15 days per month
- due to the overuse of a medication
- let patient know to limit use of acute treatment to no more than 2-3 times per week
Triptans
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Class:
Indications: 1st line for acute treatment of moderate to severe migraines
MOA:
Selective agonists for the serotonin receptor (1B/1D subtypes). These drugs bind to these serotonin receptors, this causes vasoconstriction of cranial blood vessels and inhibits neuropeptide release (so also inhibit release of CGRP) which is stopping this neurogenic inflammation and ultimately decreasing pain transmission.
” Selective 1B&1D serotonin receptor agonists”
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes: Should be taken at the 1st sign of a migraine for best efficacy.
Drug-Drug/Food interactions:
serotonin type 3 antagonists are antiemetics used for chemotherapy induced N/V
ondansetron
Acute (abortive) treatment of Migraine is when ______
we are treating a migraine that is already present.
Preventative (prophylactic) treatment of migraine is when ___
we are taking treatment regularly to prevent a migraine from occurring.
Which triptan medication is contraindication with Strong CYP3A4 inhibitors?
eletriptan (Relpax)
Which triptan medications are contraindicated with MAO inhibitors? or within two weeks of stopping a MAO inhibitor?
Sumatriptan/Rizatriptan/Zolmitriptan
Which triptans are available as ODT?
rizatriptan/zolmitriptan
which triptans are available as nasal sprays?
Should these nasal devices be primed?
sumatriptan/zolmitriptan
No, they contain 1 dose, DO NOT prime.
Which triptan medication is available as a nasal powder?
sumatriptan (Onzetra Xsail)
Which triptan medications should not be given to a patient who has phenylketonuria?
Maxalt-MLT & Zomig ZMT
Which triptan medication has the longest duration?
frovatriptan (longest half-life of 26 hours)
Which triptan medications car considered to be long- acting but have a slower onset?
frovatriptan & naratriptan
Which triptan medications have a short half-life but a fast onset of action?
almotriptan/eletriptan/rizatriptan/sumatriptan/zolmitriptan
Which triptan medication should be dispensed in its original container/manufacturer bottle to protect from moisture?
Treximet (sumatriptan +naproxen)
Which triptan medications are approved for children and adolescents greater than or equal to 12 years old?
almotriptan tablets, zolmitriptan nasal spray & Treximet
Which triptan medication is approved for children and adolescents of age 6 years old - 17?
rizatriptan
what triptan is available as an injectable form?
Sumatriptan
The triptans that come in alternative dosage forms besides tablets are preferred in patients who ________. Another advantage with these alternative dosage forms is there ________
have nausea or vomiting as part of the migraine attacks.
faster onset of action
Contraindications with triptans:
remember these agents cause vasoconstriction of cranial blood vessels.
Almotriptan
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
class: selective serotonin agonists for subtypes 1B/1D
Indications: 1st line Acute Tx “abortive treatment” of migraine
- treating a migraine that is in progress
MOA: Selective agonists for the serotonin receptor (1B/1D subtypes). These drugs bind to these serotonin receptors, this causes vasoconstriction of cranial blood vessels and inhibits neuropeptide release (so also inhibit release of CGRP) which is stopping this neurogenic inflammation and ultimately decreasing pain transmission.
” Selective 1B&1D serotonin receptor agonists”
Dosage forms: tablet
Dosing:
Initial: 6.25 - 12.5mg, can repeat for 1 dose after 2 hours
Max dose: 25mg/day
Contraindications:
Cerebrovascular disease (past stroke/TIA), uncontrolled hypertension, ischemic heart disease, cardiovascular disease (MI, heart disease)
Warnings:
Risk of Increased blood pressure, increased risk for serotonin syndrome
Side Effects:
Paresthesias (tingling/numbness), dizziness, Triptan sensations (pressure or heaviness in the chest or pressure in the neck region)
Monitoring:
Pearls/Notes: Should be taken at the First sign of a migraine for best efficacy.
Drug-Drug/Food interactions:
Zembrace SymTouch
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
sumatriptan SQ prefilled auto injector
class: selective serotonin agonists for subtypes 1B/1D
Indications: 1st line Acute Tx “abortive treatment” of migraine
- treating a migraine that is in progress
MOA: Selective agonists for the serotonin receptor (1B/1D subtypes). These drugs bind to these serotonin receptors, this causes vasoconstriction of cranial blood vessels and inhibits neuropeptide release (so also inhibit release of CGRP) which is stopping this neurogenic inflammation and ultimately decreasing pain transmission.
” Selective 1B&1D serotonin receptor agonists”
Dosage forms: Subcutaneous autoinjector
Dosing: 3mg, can repeat up to 4 times per day ** wait a minimum of 1 hour between doses or 1 hour following use of another sumatriptan product**
Max dose: 12mg/day
Contraindications:
Warnings:
Side Effects: injection site reactions (pain/redness at injection site)
Monitoring:
Pearls/Notes: Preferred sites: lateral thigh & upper arm
Drug-Drug/Food interactions:
Maxalt
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
rizatriptan
class: selective serotonin agonists for subtypes 1B/1D
Indications:1st line Acute Tx “abortive treatment” of migraine
- treating a migraine that is in progress
MOA: Selective agonists for the serotonin receptor (1B/1D subtypes). These drugs bind to these serotonin receptors, this causes vasoconstriction of cranial blood vessels and inhibits neuropeptide release (so also inhibit release of CGRP) which is stopping this neurogenic inflammation and ultimately decreasing pain transmission.
” Selective 1B&1D serotonin receptor agonists”
Dosage forms: tablet
Dosing:
initial 5 -10mg, can repeat for 1 dose after 2 hours
Max dose: 30mg/day
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Relpax
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
eletriptan
class: selective serotonin agonists for subtypes 1B/1D
Indications:1st line Acute Tx “abortive treatment” of migraine
- treating a migraine that is in progress
MOA: Selective agonists for the serotonin receptor (1B/1D subtypes). These drugs bind to these serotonin receptors, this causes vasoconstriction of cranial blood vessels and inhibits neuropeptide release (so also inhibit release of CGRP) which is stopping this neurogenic inflammation and ultimately decreasing pain transmission.
” Selective 1B&1D serotonin receptor agonists”
Dosage forms: tablet
Dosing:
Initial 20 -40mg, can repeat for 1 dose after 2 hours
Max dose: 80mg/day
Contraindications: Contraindicated with Strong CYP3A4 inhibitors
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Zomig ZMT
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
zolmitriptan ODT
class: selective serotonin agonists for subtypes 1B/1D
Indications:1st line Acute Tx “abortive treatment” of migraine
- treating a migraine that is in progress
MOA: Selective agonists for the serotonin receptor (1B/1D subtypes). These drugs bind to these serotonin receptors, this causes vasoconstriction of cranial blood vessels and inhibits neuropeptide release (so also inhibit release of CGRP) which is stopping this neurogenic inflammation and ultimately decreasing pain transmission.
” Selective 1B&1D serotonin receptor agonists”
Dosage forms: ODT scored
Dosing:
PO- 1.25-5mg, can repeat for one dose if needed after 2 hours
Max dose: 10mg/day [ALL Zomig Formulations]
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes: Should NOT be used in patients with phenylketonuria since ODT product contains phenylalanine.
Drug-Drug/Food interactions:
Frova
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Frovatriptan
class: selective serotonin agonists for subtypes 1B/1D
Indications:1st line Acute Tx “abortive treatment” of migraine
- treating a migraine that is in progress
MOA: Selective agonists for the serotonin receptor (1B/1D subtypes). These drugs bind to these serotonin receptors, this causes vasoconstriction of cranial blood vessels and inhibits neuropeptide release (so also inhibit release of CGRP) which is stopping this neurogenic inflammation and ultimately decreasing pain transmission.
” Selective 1B&1D serotonin receptor agonists”
Dosage forms: tablet
Dosing:
Initial 2.5mg, can repeat for 1 dose after 2 hours
Max dose: 7.5mg/daily
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes: Has the longest duration (half-life 26 hours) but slower onset
Drug-Drug/Food interactions:
Tosymra
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
sumatriptan nasal spray
class: selective serotonin agonists for subtypes 1B/1D
Indications:1st line Acute Tx “abortive treatment” of migraine
- treating a migraine that is in progress
MOA: Selective agonists for the serotonin receptor (1B/1D subtypes). These drugs bind to these serotonin receptors, this causes vasoconstriction of cranial blood vessels and inhibits neuropeptide release (so also inhibit release of CGRP) which is stopping this neurogenic inflammation and ultimately decreasing pain transmission.
” Selective 1B&1D serotonin receptor agonists”
Dosage forms: nasal spray
Dosing: 10mg in one nostril and can repeat for 1 dose after 1 hour
Max dose: 30mg/day
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes: Nasal spray devices contain 1 dose, DO NOT prime device! One spray into One Nostril
Drug-Drug/Food interactions:
Amerge
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
naratriptan
class: selective serotonin agonists for subtypes 1B/1D
Indications:
1st line Acute Tx “abortive treatment” of migraine
- treating a migraine that is in progress
MOA: Selective agonists for the serotonin receptor (1B/1D subtypes). These drugs bind to these serotonin receptors, this causes vasoconstriction of cranial blood vessels and inhibits neuropeptide release (so also inhibit release of CGRP) which is stopping this neurogenic inflammation and ultimately decreasing pain transmission.
” Selective 1B&1D serotonin receptor agonists”
Dosage forms: tablet
Dosing:
Initial: 1 - 2.5mg, can repeat for 1 dose after 4 hours
Max dose: 5mg/day
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes: Long duration of action (long half-life) but slow onset
Drug-Drug/Food interactions:
Maxalt-MLT
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
rizatriptan ODT
class: selective serotonin agonists for subtypes 1B/1D
Indications:1st line Acute Tx “abortive treatment” of migraine
- treating a migraine that is in progress
MOA: Selective agonists for the serotonin receptor (1B/1D subtypes). These drugs bind to these serotonin receptors, this causes vasoconstriction of cranial blood vessels and inhibits neuropeptide release (so also inhibit release of CGRP) which is stopping this neurogenic inflammation and ultimately decreasing pain transmission.
” Selective 1B&1D serotonin receptor agonists”
Dosage forms: ODT
Dosing:
Initial: 5-10mg, can repeat for 1 dose after 2 hours
Max dose: 30mg/day
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes: Should NOT be used in patients with phenylketonuria since ODT product contains phenylalanine.
Drug-Drug/Food interactions:
Imitrex
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
sumatriptan
class: selective serotonin agonists for subtypes 1B/1D
Indications:1st line Acute Tx “abortive treatment” of migraine
- treating a migraine that is in progress
MOA: Selective agonists for the serotonin receptor (1B/1D subtypes). These drugs bind to these serotonin receptors, this causes vasoconstriction of cranial blood vessels and inhibits neuropeptide release (so also inhibit release of CGRP) which is stopping this neurogenic inflammation and ultimately decreasing pain transmission.
” Selective 1B&1D serotonin receptor agonists”
Dosage forms: tablet, prefilled syringe, nasal spray
Dosing:
- (tablet)PO: 25mg, 50mg, or 100mg, can repeat for 1 dose after 2 hours if needed
- (nasal spray): 5, 10, or 20mg spray in one nostril and can be repeated for one dose after 2 hours.
Max dose:
200mg/day (tablet)
40mg/day (nasal spray)
Contraindications:
Warnings:
Side Effects:
- injection site reactions (pain/redness at injection site)
Monitoring:
Pearls/Notes: Preferred sites: lateral thigh & upper arm
Dose should only be repeated if patient did receive some relief after the first dose.
Drug-Drug/Food interactions:
Zomig
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
zolmitriptan
class: selective serotonin agonists for subtypes 1B/1D
Indications: 1st line Acute Tx “abortive treatment” of migraine
- treating a migraine that is in progress
MOA: Selective agonists for the serotonin receptor (1B/1D subtypes). These drugs bind to these serotonin receptors, this causes vasoconstriction of cranial blood vessels and inhibits neuropeptide release (so also inhibit release of CGRP) which is stopping this neurogenic inflammation and ultimately decreasing pain transmission.
” Selective 1B&1D serotonin receptor agonists”
Dosage forms: tablet, nasal spray
Dosing:
PO (tablet): 1.25-5mg, can repeat for one dose if needed after 2 hours
Nasal spray: 2.5-5mg into ONE nostril, can repeat for one dose if needed after 2 hours
Max dose: All formulations 10mg/day MAX
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes: nasal spray devices have 1 dose, DO NOT prime! One spray into One Nostril.
Drug-Drug/Food interactions:
Imitrex STATdose System
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
sumatriptan SQ autoinjector
class: selective serotonin agonists for subtypes 1B/1D
Indications:1st line Acute Tx “abortive treatment” of migraine
- treating a migraine that is in progress
MOA: Selective agonists for the serotonin receptor (1B/1D subtypes). These drugs bind to these serotonin receptors, this causes vasoconstriction of cranial blood vessels and inhibits neuropeptide release (so also inhibit release of CGRP) which is stopping this neurogenic inflammation and ultimately decreasing pain transmission.
” Selective 1B&1D serotonin receptor agonists”
Dosage forms: Subcutaneous
Dosing: 4 or 6mg, can be repeated for 1 dose if needed after 1 hour
Max dose: 12mg/day
Contraindications:
Warnings:
Side Effects: injection site reactions (pain/redness at injection site)
Monitoring:
Pearls/Notes: Preferred sites: lateral thigh & upper arm
Drug-Drug/Food interactions:
Treximet
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
sumatriptan + naproxen
class: selective serotonin agonists for subtypes 1B/1D + NSAID
Indications:1st line Acute Tx “abortive treatment” of migraine
- treating a migraine that is in progress
MOA: Selective agonists for the serotonin receptor (1B/1D subtypes). These drugs bind to these serotonin receptors, this causes vasoconstriction of cranial blood vessels and inhibits neuropeptide release (so also inhibit release of CGRP) which is stopping this neurogenic inflammation and ultimately decreasing pain transmission.
” Selective 1B&1D serotonin receptor agonists”
Dosage forms: tablet
Dosing:
Adults: 1 adult tablet (85/500mg) and can repeat for 1 dose after 2 hours
Peds/adols 12-17yo: 1 ped tablet (10/60mg) for 1 dose
Max dose:
Adult: 2 tablets/24 hours
Peds/adols 12-17yo: 1 tablet
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes: ** Must be dispensed in its original container**
Drug-Drug/Food interactions:
Onzetra Xsail
class:
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
sumatriptan nasal powder
class: selective serotonin agonists for subtypes 1B/1D
Indications:1st line Acute Tx “abortive treatment” of migraine
- treating a migraine that is in progress
MOA: Selective agonists for the serotonin receptor (1B/1D subtypes). These drugs bind to these serotonin receptors, this causes vasoconstriction of cranial blood vessels and inhibits neuropeptide release (so also inhibit release of CGRP) which is stopping this neurogenic inflammation and ultimately decreasing pain transmission.
” Selective 1B&1D serotonin receptor agonists”
Dosage forms: POWDER
Dosing: 11mg into EACH NOSTRIL USING NOSEPIECE, can repeat for one dose after 2 hours
(has a mouthpiece that the patient blows through to deliver the dose through the nose piece), the nose piece is removed, and process is repeated for 2nd nostril**
Max dose: 44mg/day
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes: Once spray into EACH NOSTRIL
Drug-Drug/Food interactions:
Treximet
class:
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
sumatriptan + naproxen
class:
Indications:
MOA:
Dosage forms: (adults 85/500mg tab), [pediatric(12-17 years) 10/60mg tab]
Dosing:
Adults: 1 tablet, can repeat for 1 dose after 2 hours.
Pediatrics (12-17 years): 1 tablet for 1 dose
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Ergotamines
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Indications:
- 2nd line for acute “abortive Tx” migraine attack. Generally considered in patients who do not respond to Triptans.
MOA: nonselective serotonin agonist which causes cerebral vasoconstriction.
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
D.H.E 45 (DiHydroErgotamine)
class:
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
class: ergotamine
Indications: 2nd line: Acute Tx “abortive treatment” of migraine
- treating a migraine that is in progress. Generally considered in patients who do not respond to Triptans.
MOA: nonselective serotonin agonist which causes cerebral vasoconstriction.
Dosage forms: IM injection/ SC injection/IV/nasal spray
Dosing:
Boxed Warning:
-Contraindicated with potent CYP3A4 inhibitors (grapefruit juice, verapamil, diltiazem** G <3 PACMAN**) due to serious and life- threatening peripheral ischemia. These will cause an increase in their concentrations, which they are already strong enough on their own.
Contraindications:
DO NOT USE IN:
-uncontrolled hypertension, ischemic heart disease, angina, MI, peripheral vascular disease.
-pregnancy, these drugs cause the uterus to contract. They also cause vasoconstriction of the blood vessels supplying the fetus which endangers it.
- Use of a triptan drug or another ergotamine drug within the last 24 hours, causes dangerous additive vasoconstriction.
Warnings:
- Cardiovascular effects, these drugs can cause cardiovascular effects even in people without cardiovascular problems. We want to avoid using these agents in patients with cardiovascular disease. Counsel patients to watch for chest pain, although rare, if it occurs to seek medical attention.
- Cerebrovascular effects, remember these drugs increase blood pressure which increases stroke risk, but also can cause vasospasm which can lead to cerebral ischemia. Counseling to watch for stroke, like facial droop, paralysis on one side of the body, and or difficulty speaking or understanding language.
- Ergotism (intense vasoconstriction), the vasoconstriction is very intense that it can result in peripheral ischemia and gangrene. Advise patient to seek medical help if they start to feel intense pain in an arm or leg. The affected limp is likely to feel cold and numb. Is rare but likely happens due to drug overuse.
- Potentially serious drug interactions: Strong CYP3A4 inhibitors G<3PACMAN, patients should also NOT be taking MAO inhibitors while using or after discontinuing MAO inhibitor within the last 2 weeks, increase risk of Serotonin syndrome.
Side Effects: Nausea,
nasal spray: dysgeusia (altered sense in taste), rhinitis, dizziness
Monitoring:
Pearls/Notes:
Nasal spray: Must Prime before first use, Prime by pumping 4 times. Do not inhale deeply (to let drug absorb into the skin in nose). Use at first sign of attack but can be used at any time during migraine.
Drug-Drug/Food interactions:
Migranal
class:
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
class: dihydroergotamine
Indications: 2nd line: Acute Tx “abortive treatment” of migraine
- treating a migraine that is in progress. Generally considered in patients who do not respond to Triptans.
MOA: nonselective serotonin agonist which causes cerebral vasoconstriction.
Dosage forms: nasal spray
Dosing:
Contraindications:
DO NOT USE IN:
-uncontrolled hypertension, ischemic heart disease, angina, MI, peripheral vascular disease.
-pregnancy, these drugs cause the uterus to contract. They also cause vasoconstriction of the blood vessels supplying the fetus which endangers it.
- Use of a triptan drug or another ergotamine drug within the last 24 hours, causes dangerous additive vasoconstriction.
Warnings:
- Cardiovascular effects, these drugs can cause cardiovascular effects even in people without cardiovascular problems. We want to avoid using these agents in patients with cardiovascular disease. Counsel patients to watch for chest pain, although rare, if it occurs to seek medical attention.
- Cerebrovascular effects, remember these drugs increase blood pressure which increases stroke risk, but also can cause vasospasm which can lead to cerebral ischemia. Counseling to watch for stroke, like facial droop, paralysis on one side of the body, and or difficulty speaking or understanding language.
- Ergotism (intense vasoconstriction), the vasoconstriction is very intense that it can result in peripheral ischemia and gangrene. Advise patient to seek medical help if they start to feel intense pain in an arm or leg. The affected limp is likely to feel cold and numb. Is rare but likely happens due to drug overuse.
- Potentially serious drug interactions: Strong CYP3A4 inhibitors G<3PACMAN, patients should also NOT be taking MAO inhibitors while using or after discontinuing MAO inhibitor within the last 2 weeks, increase risk of Serotonin syndrome.
Side Effects:
Nausea,
nasal spray: dysgeusia (altered sense in taste), rhinitis, dizziness
Monitoring:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Trudhesa
class:
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
class: dihydroergotamine
Indications: 2nd line: Acute Tx “abortive treatment” of migraine
- treating a migraine that is in progress. Generally considered in patients who do not respond to Triptans.
MOA: nonselective serotonin agonist which causes cerebral vasoconstriction.
Dosage forms: nasal spray
Dosing:
Contraindications:
DO NOT USE IN:
-uncontrolled hypertension, ischemic heart disease, angina, MI, peripheral vascular disease.
-pregnancy, these drugs cause the uterus to contract. They also cause vasoconstriction of the blood vessels supplying the fetus which endangers it.
- Use of a triptan drug or another ergotamine drug within the last 24 hours, causes dangerous additive vasoconstriction.
Warnings:
- Cardiovascular effects, these drugs can cause cardiovascular effects even in people without cardiovascular problems. We want to avoid using these agents in patients with cardiovascular disease. Counsel patients to watch for chest pain, although rare, if it occurs to seek medical attention.
- Cerebrovascular effects, remember these drugs increase blood pressure which increases stroke risk, but also can cause vasospasm which can lead to cerebral ischemia. Counseling to watch for stroke, like facial droop, paralysis on one side of the body, and or difficulty speaking or understanding language.
- Ergotism (intense vasoconstriction), the vasoconstriction is very intense that it can result in peripheral ischemia and gangrene. Advise patient to seek medical help if they start to feel intense pain in an arm or leg. The affected limp is likely to feel cold and numb. Is rare but likely happens due to drug overuse.
- Potentially serious drug interactions: Strong CYP3A4 inhibitors G<3PACMAN, patients should also NOT be taking MAO inhibitors while using or after discontinuing MAO inhibitor within the last 2 weeks, increase risk of Serotonin syndrome.
Side Effects:
Nausea,
nasal spray: dysgeusia (altered sense in taste), rhinitis, dizziness
Monitoring:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Cafergot
class:
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
class: ergotamine + caffeine
Indications: 2nd line: Acute Tx “abortive treatment” of migraine
- treating a migraine that is in progress. Generally considered in patients who do not respond to Triptans.
MOA: nonselective serotonin agonist which causes cerebral vasoconstriction.
Dosage forms: Oral tablet
Dosing:
Contraindications:
DO NOT USE IN:
-uncontrolled hypertension, ischemic heart disease, angina, MI, peripheral vascular disease.
-pregnancy, these drugs cause the uterus to contract. They also cause vasoconstriction of the blood vessels supplying the fetus which endangers it.
- Use of a triptan drug or another ergotamine drug within the last 24 hours, causes dangerous additive vasoconstriction.
Warnings:
- Cardiovascular effects, these drugs can cause cardiovascular effects even in people without cardiovascular problems. We want to avoid using these agents in patients with cardiovascular disease. Counsel patients to watch for chest pain, although rare, if it occurs to seek medical attention.
- Cerebrovascular effects, remember these drugs increase blood pressure which increases stroke risk, but also can cause vasospasm which can lead to cerebral ischemia. Counseling to watch for stroke, like facial droop, paralysis on one side of the body, and or difficulty speaking or understanding language.
- Ergotism (intense vasoconstriction), the vasoconstriction is very intense that it can result in peripheral ischemia and gangrene. Advise patient to seek medical help if they start to feel intense pain in an arm or leg. The affected limp is likely to feel cold and numb. Is rare but likely happens due to drug overuse.
- Potentially serious drug interactions: Strong CYP3A4 inhibitors G<3PACMAN, patients should also NOT be taking MAO inhibitors while using or after discontinuing MAO inhibitor within the last 2 weeks, increase risk of Serotonin syndrome.
Side Effects:
Nausea,
nasal spray: dysgeusia (altered sense in taste), rhinitis, dizziness
Monitoring:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Migergot
class:
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
class: ergotamine + caffeine
Indications: 2nd line: Acute Tx “abortive treatment” of migraine
- treating a migraine that is in progress. Generally considered in patients who do not respond to Triptans.
MOA: nonselective serotonin agonist which causes cerebral vasoconstriction.
Dosage forms: rectal Suppository
Dosing:
Contraindications:
DO NOT USE IN:
-uncontrolled hypertension, ischemic heart disease, angina, MI, peripheral vascular disease.
-pregnancy, these drugs cause the uterus to contract. They also cause vasoconstriction of the blood vessels supplying the fetus which endangers it.
- Use of a triptan drug or another ergotamine drug within the last 24 hours, causes dangerous additive vasoconstriction.
Warnings:
- Cardiovascular effects, these drugs can cause cardiovascular effects even in people without cardiovascular problems. We want to avoid using these agents in patients with cardiovascular disease. Counsel patients to watch for chest pain, although rare, if it occurs to seek medical attention.
- Cerebrovascular effects, remember these drugs increase blood pressure which increases stroke risk, but also can cause vasospasm which can lead to cerebral ischemia. Counseling to watch for stroke, like facial droop, paralysis on one side of the body, and or difficulty speaking or understanding language.
- Ergotism (intense vasoconstriction), the vasoconstriction is very intense that it can result in peripheral ischemia and gangrene. Advise patient to seek medical help if they start to feel intense pain in an arm or leg. The affected limp is likely to feel cold and numb. Is rare but likely happens due to drug overuse.
- Potentially serious drug interactions: Strong CYP3A4 inhibitors G<3PACMAN, patients should also NOT be taking MAO inhibitors while using or after discontinuing MAO inhibitor within the last 2 weeks, increase risk of Serotonin syndrome.
Side Effects:
Nausea,
nasal spray: dysgeusia (altered sense in taste), rhinitis, dizziness
Monitoring:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Nurtec ODT
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
rimegepant
class: (CGRP) Calcitonin Gene-Related Peptide receptor antagonist
Indication: FDA approved for acute (abortive) treatment AND prevention (prophylaxis) of migraine
MOA: “We believe that with migraine, there is activation of the trigeminal nerve leading to release of CGRP along with some other neurotransmitters & neuropeptides”. CGRP contributes to neurogenic inflammation and vasodilation, both of which are components to migraine pain. These drugs block the CGRP receptors, which reduces or eliminates inflammation and vasodilation. And this will lessen or eliminate pain & other symptoms.
Dosage forms: Oral Disintegrating tablet
Dosing: 75mg PO once
Max dose: 75mg/24hrs
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Only Drug Approved for both Acute Tx and prevention of migraine attacks**
**Needs to be renally and hepatically dose adjusted
Drug-Drug/Food interactions:
Ubrelvy
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
ubrogepant
class: (CGRP) Calcitonin Gene-Related Peptide receptor antagonist
Indication: FDA approved for acute treatment of migraine
MOA: “We believe that with migraine, there is activation of the trigeminal nerve leading to release of CGRP along with some other neurotransmitters & neuropeptides”. CGRP contributes to neurogenic inflammation and vasodilation, both of which are components to migraine pain. These drugs block the CGRP receptors, which reduces or eliminates inflammation and vasodilation. And this will lessen or eliminate pain & other symptoms.
Dosage forms: Oral tablet
Dosing: 50-100mg PO, can repeat for 1 dose after 2 hours for additional relief
Max dose: 200mg/24hrs
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Is the only medication in its class (CGRP antagonist) that can be repeated for 1 dose if there was some partial relief with the first dose they took
Drug-Drug/Food interactions:
Reyvow
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
lasmiditan C-V
class: selective serotonin 5-HT1F receptor agonist
“cousin to the Triptans”
Indication: FDA approved for acute treatment of migraine
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
- CNS depression, including driving impairment; use caution if patient is taking other CNS depressants.
- May cause Serotonin Syndrome with or without other serotonergic drugs.
Side Effects:
Monitoring:
Pearls/Notes:
- First of its class**
-Not contraindicated in patients with CVD**
- Doesn’t cause vasoconstriction**
- patients should not drive or operate heavy machinery for 8 hours after taking dose.
- Is a strong inhibitor of P-gp, SO should not be used with other drugs that are substrates for P-gp.
Drug-Drug/Food interactions:
Fioricet
class:
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
acetaminophen/butalbital/caffeine
class:
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Not good drugs at treating migraine.
NOT Recommended
Drug-Drug/Food interactions:
Fiorinal
class:
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
aspirin/butalbital/caffeine C-III
class:
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Not good drugs at treating migraine.
NOT Recommended
Drug-Drug/Food interactions:
Fioricet w/ Codeine
acetaminophen/butalbital/caffeine/codeine C-III
class:
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Not good drugs at treating migraine.
NOT Recommended
Drug-Drug/Food interactions:
Fiorinal w/ Codeine
aspirin/butalbital/caffeine/codeine C-III
class:
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Not good drugs at treating migraine.
NOT Recommended
Drug-Drug/Food interactions:
Butalbital is a ______
barbiturate
Qulipta
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
atogepant
class: (CGRP) Calcitonin Gene-Related Peptide receptor antagonist
Indication: FDA approved for ONLY migraine prevention (prophylaxis) in adults
MOA: “We believe that with migraine, there is activation of the trigeminal nerve leading to release of CGRP along with some other neurotransmitters & neuropeptides”. CGRP contributes to neurogenic inflammation and vasodilation, both of which are components to migraine pain. These drugs block the CGRP receptors, which reduces or eliminates inflammation and vasodilation. And this will lessen or eliminate pain & other symptoms.
Dosage forms: oral tablet
Dosing: 10, 30, 60mg PO daily
** Dose adjustments depend on concurrent use with Strong CYP3A4 inhibitors or inducers or OATP inhibitors**
Max dose:
Contraindications:
Warnings:
Side Effects: nausea, somnolence
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Nurtec ODT
class:
Indications: Approved for BOTH migraine abortive treatment AND prevention
MOA:
Dosage forms: oral disintegrating tablet
Dosing: 75mg once daily for Tx of migraine or 75mg (QOD) every other day for prevention of migraine
Max dose: 75mg/24hrs
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Vyepti
class:
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Eptinezumab-jjmr
class: (CGRP) Calcitonin Gene-Related Peptide receptor antagonist
monoclonal antibodies
Indication: FDA approved for migraine prevention (prophylaxis)
MOA: “We believe that with migraine, there is activation of the trigeminal nerve leading to release of CGRP along with some other neurotransmitters & neuropeptides”. CGRP contributes to neurogenic inflammation and vasodilation, both of which are components to migraine pain. These drugs block the CGRP receptors, which reduces or eliminates inflammation and vasodilation. And this will lessen or eliminate pain & other symptoms.
Dosage forms: (IV) intravenous injection
Dosing:100mg IV once every 3 months; some patients benefit from 300mg
Max dose:
Contraindications:
Warnings:
Side Effects: injection site reactions, antibody development, constipation
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Aimovig
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Erenumab-aooe
class:(CGRP) Calcitonin Gene-Related Peptide receptor antagonist
monoclonal antibodies
Indication: FDA approved for migraine prevention (prophylaxis)
MOA: “We believe that with migraine, there is activation of the trigeminal nerve leading to release of CGRP along with some other neurotransmitters & neuropeptides”. CGRP contributes to neurogenic inflammation and vasodilation, both of which are components to migraine pain. These drugs block the CGRP receptors, which reduces or eliminates inflammation and vasodilation. And this will lessen or eliminate pain & other symptoms.
Dosage forms: SC autoinjector
Dosing: 70mg SC once monthly; some patients benefit from two 70mg injections
Max dose:
Contraindications:
Warnings: Latex Allergy
Side Effects: injection site reactions, antibody development, constipation
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Ajovy
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Fremanezumab
class: (CGRP) Calcitonin Gene-Related Peptide receptor antagonist
monoclonal antibodies
Indication: FDA approved for migraine prevention (prophylaxis)
MOA: “We believe that with migraine, there is activation of the trigeminal nerve leading to release of CGRP along with some other neurotransmitters & neuropeptides”. CGRP contributes to neurogenic inflammation and vasodilation, both of which are components to migraine pain. These drugs block the CGRP receptors, which reduces or eliminates inflammation and vasodilation. And this will lessen or eliminate pain & other symptoms.
Dosage forms: prefilled syringe
Dosing: 225mg SC once monthly or 625mg SC every 3 months
Max dose:
Contraindications:
Warnings:
Side Effects: injection site reactions, antibody development, constipation
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Emgality
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Galcancezumab-gnlm
class: (CGRP) Calcitonin Gene-Related Peptide receptor antagonist
monoclonal antibodies
Indication: FDA approved for migraine prevention (prophylaxis)
also approved for cluster headache prevention
MOA: “We believe that with migraine, there is activation of the trigeminal nerve leading to release of CGRP along with some other neurotransmitters & neuropeptides”. CGRP contributes to neurogenic inflammation and vasodilation, both of which are components to migraine pain. These drugs block the CGRP receptors, which reduces or eliminates inflammation and vasodilation. And this will lessen or eliminate pain & other symptoms.
Dosage forms: SC auto injector, prefilled syringe
Dosing: 240mg SC as a loading dose, then 120mg SC once monthly
Max dose:
Contraindications:
Warnings:
Side Effects: injection site reactions, antibody development, constipation
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Dihydroergotamine is available in what dosage forms?
IM injection, SQ injection, IV, nasal spray
remember ** for Strong CYP3A4 inhibitors: G <3 PACMAN**
Grapefruit Juice
<3
Protease inhibitors: ritonavir especially but many PI are potent.
Azole antifungals: fluconazole, itraconazole, ketoconazole, posaconazole, voriconazole, and isavuconazole
Cyclosporine & Cobicistat
Macrolides: Clarithromycin & Erythromycin
Amiodarone & Dronedarone
Non-DHP CCBs: Diltiazem & Verapamil
Do the ergotamine nasal sprays need to be Primed?
Yes, Prime before first use
what class are the -gepant medications?
(CGRP) Calcitonin Gene-Related Peptide receptor antagonist
What are the common classes & drugs in those that are substrates for the P-gp?
-
-
-
-
-
Anticoagulants: (apixaban, rivaroxaban), edoxaban, dabigatran
Cardiovascular drugs: (digoxin, diltiazem, verapamil) carvedilol, ranolazine
Immunosuppressants: (cyclosporine, tacrolimus), sirolimus
HCV drugs: dasabuvir, ombitasvir, paritaprevir, sofosbuvir
Others: (colchicine), atazanavir, dolutegravir, posaconazole, raletegravir, saxagliptin
Prophylactic Migraine Drug Treatment
Drugs that are taken on a regular basis to prevent migraine attacks
Abortive Treatment =
treating an in-progress migraine attack
- taken only as needed
- will not prevent future attacks
Preventive Treatment =
reduces attack frequency, severity.
- taken regularly
- will not treat current attacks
However, there is one exception. There is a drug that is FDA approved for both treating Acute migraine attacks and used for preventative treatment.
(rimegepant) Nurtec ODT
Who should get medication for Migraine prevention prophylaxis?
Generally speaking: A patient may be considered a candidate if,
- they are using an Acute Therapy greater than or equal to 2 times a week OR greater than or equal to 3 times a month
- if their migraines are decreasing their quality of life
- or if Acute treatments are ineffective or contraindicated
- patient is a candidate if they request it too
An appropriate full trial for a prophylactic treatment for migraines is __________
2-6 months
- it takes time to work
What are the options for Migraine Prophylaxis Drugs?
-Antihypertensives:
-Antiepileptic drugs:
-Antidepressants:
-Oral Contraceptives:
-CGRP antagonists:
- (propranolol/metoprolol/timolol)
- (valproic acid/ topiramate)
- (amitriptyline/venlafaxine)
- IF NO AURA & for menstrually associated migraine (monophasic or extended cycle)
- atogepant/rimegepant/eptinezumab/erenumab/fremanezumab/ galcancezumab (used for prophylaxis only)
Remember, patients that have a Migraine with aura SHOULD NOT take _______________
estrogen containing contraceptives because of the increased risk of stroke!!
which CGRP antagonist is approved for both treating and preventing migraine attacks?
rimegepant
Inderal
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
propranolol
Class: Non-selective beta blocker antagonist
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings: Use Caution with bronchospastic diseases (asthma, COPD), especially with non-selective agents
Side Effects:
- bradycardia, fatigue, hypotension, dizziness, depression (more with propranolol, the most lipophilic), impotence, cold extremities (can exacerbate Raynaud’s).
- since it is the most lipophilic in the group, it has the best penetration through the blood brain barrier.
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Inderal LA
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
propranolol XL
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
- Propranolol XL formulations (Inderal XL, InnoPran XL) are NOT FDA-approved for migraine prophylaxis.
- since it is the most lipophilic in the group, it has the best penetration through the blood brain barrier.
Drug-Drug/Food interactions:
Lopressor
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
metoprolol tartrate
Class: Beta-1 selective blocker antagonist
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Toprol XL
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
metoprolol succinate
Class: Beta-1 selective blocker antagonist
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Divalproex
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Boxed Warnings: Cause Fetal harm. Hepatic failure, pancreatitis
Contraindications:
Warnings&SE: (weight gain, thrombocytopenia, increased ammonia, alopecia), N/V, somnolence, tremor, polycystic ovarian syndrome
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Depakote ER
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Boxed Warning: Cause Fetal harm. Hepatic failure, pancreatitis
Contraindications:
Warnings&SE: (weight gain, thrombocytopenia, increased ammonia, alopecia), N/V, somnolence, tremor, polycystic ovarian syndrome
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Depakote Sprinkle
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Boxed Warnings: Cause Fetal harm. Hepatic failure, pancreatitis
Contraindications:
Warnings&SE: (weight gain, thrombocytopenia, increased ammonia, alopecia), N/V, somnolence, tremor, polycystic ovarian syndrome
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Valproic Acid
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Boxed Warnings: Cause Fetal harm. Hepatic failure, pancreatitis
Contraindications:
Warnings&SE: (weight gain, thrombocytopenia(low plts), increased ammonia, alopecia “hair loss”), N/V, somnolence, tremor, polycystic ovarian syndrome
Side Effects:
Monitoring:
Pearls/Notes:
- the valproic acid products are formulated as valproate sodium OR divalproex sodium, and these terms are all used interchangeably.
Drug-Drug/Food interactions:
Topamax
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Boxed Warnings:
Contraindications:
Warnings: Cause Fetal Harm, metabolic acidosis, nephrolithiasis (kidney stones), increased ammonia, open angle glaucoma and visual field defects, oligohidrosis (reduced ability to sweat)
Side Effects: weigh loss (in up to 6-13% of patients), somnolence, cognitive impairment, paresthesia, Reduced Efficacy of Oral Contraceptives
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Topamax Sprinkle
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Boxed Warnings:
Contraindications:
Warnings: Cause Fetal Harm, metabolic acidosis, nephrolithiasis (kidney stones), increased ammonia, open angle glaucoma and visual field defects, oligohidrosis (reduced ability to sweat)
Side Effects: weigh loss (in up to 6-13% of patients), somnolence, cognitive impairment, paresthesia, reduced efficacy of oral contraceptives
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Which of the CGRP antagonists is administered (IV) intravenously?
eptinezumab (Vyepti)
OATP inhibitors
Which CGRP antagonists are given once monthly for prophylactic of migraines?
Aimovig, Ajovy, Emgality,
Which CGRP antagonists are given every 3 months?
Vyepti, Ajovy
Which CGRP antagonist requires a Loading dose when initiating?
Emgality, a loading dose of 240mg SC, then 120mg monthly
