Migraine

Question 1

migraine: gender in US

Answer 1

18 million women>6 million men

Question 2

Migraine ddx

Answer 2

Migraine
Cluster HA
tension type

Question 3

Migraine location and duration

Answer 3

(U) unilateral

2-72 hours per episode

Question 4

Common migraine vs. classic migraine

Answer 4

common migraine=NO aura
classic migraine=WITH AURA
-aura:visual, sensory and/or sleep disturbances
-due to reduced blood flow of the posterior part of the brain

Question 5

what causes the pain in migraine

Answer 5

in both types: due to extracranial & intracranial arterial dilation & release of neuroactive molecules such as substance P

Question 6

2 phases in migraine

Answer 6

first: VASOCONSTRICTION
2nd: VASODILATION & pulsation

Question 7

Sumatriptan (Imitrex): use, MOA, half-life, how does it work

Answer 7

symptomatic tx for migraine HA
expensive, reserved for when nothing else works
PO or SC, 2hr half-life
HA recurs in 24-48hrs,2nd dose needed

5-HT1D agonist on small peripheral nerves:

• (P) suppresses release of sensory neuropeptides
• vasoconstriction is not as strong as w/ergotamine

Question 8

Sumatriptan (Imitrex) toxicities

Answer 8

coronary artery vasospasm, cardiac arrhythmias, angina, transient MI, MI, cardiac arrest

cerebral vasospasm resultin in intractanial bleeding, subarachnoid hemorrhage, strokes, seizures

BOWEL ISCHEMIA& periph. vasc ischemia

abdominal pain, bloody diarrhea & cramping

dizziness, lightheadedness, weakness, myalgia or muscle cramps

Question 9

Sumatriptan (Imirex) contraindications

Answer 9

breast-feeding
cardiac dz
CAD, DM, cerebrovasc. dz, HTN, IV admin, periph vasc dz, prego, renal impairment, seizures, tobacco smoking

Question 10

Other “triptan”s similar to sumatriptan (5)

Answer 10

FRENZ
Frovatriptan (Miguard)
Risatriptan (Maxalt)
Eletriptan (Relpax)
Naratriptan (Amerge)
Zomatriptan (Zomag)

Question 11

Ergotamine (Ergomar)
used for:
acts on/effectiveness:
admin:
intrxns:

Answer 11

• used for migraines
• acts on 5-HT receptors
• less specific than sumatriptan, effective in 50% of pts
• oral, sublingual, rectal, nasal
• caffeine ↑absorption, potentiates effect

Question 12

Ergotamine (Ergotamar) SEs:
Acute:
Chronic:

Answer 12

acute: diarrhea, N/V, cardiovascular toxicity (sim. to sumatriptan)
chronic: ergotism-vasoconstriction+CNS [St. Anthony’s fire: hallucinations (devil), gangrene, pain, death]

Question 13

Dihydroergotamine (Microgranan)

Answer 13

used for migraines
similar to ergotamine
administered IV
efficacy similar to sumatriptan
nausea is a common SE

Question 14

Analgesics used in migraine

Answer 14

aspirin, acetaminophen, naproxen, etc.

-if possible avoid opioids in gout or migraine HAs

Question 15

Drugs/classes used for prophylaxis (8 classes, 9 drugs)

Answer 15

1. Beta-blockers: propranolol (Inderal)
2. CCBs: Verapamil (Calan, Isoptin)
3. Antidepressants:
   - Amitriptyline (Elavil, Endep)
   - Fluoxetine
4. Clonidine (Catapres)
5. Valproic Acid (Depakane)
6. Topiramate (Topomax)
7. Botulinum Toxin Type A & B
8. Angiotensin II receptor blockers

Question 16

Drugs used in ACUTE migraine

Answer 16

at start: Triptans (such as Sumatriptan)
at prodrome: Dihydroergotamine
HA phase: Analgesics