Migraine

Question 0

Triptans

Answer 0

5HT1 receptor agonists: blood vessels in the brain become dilated during an migraine attack and the triptans, by binding to 5HT-1 receptors, cause cranial vessel constriction, inhibiting neuropeptide release and decreasing pain transmission

Contraindications: patients with cerebrovascular disease or uncontrolled hypertension and contraindicated with MAOIs

Side effects: some boots, nausea, paresthesias, throat and neck pressure, dizziness, hot and cold sensations, chest pain and tightness (triptans sensations are those pressures and then neck and chest)

Formulations:

1. All are available and tablet formulation
2. Rizatriptan and zolmitriptan also have disintegrating tablets (better for nausea)
3. Sumatriptan is available in a tablet, nasal spray, and SC injection
4. Zolmitriptan also has a nasal spray

Duration of action:

1. Longest half-life is with frovatriptan and naratriptan
2. Fastest onset however is with almotriptan, eletriptan, rizatriptan, sumatriptan, and zolmitriptan

Question 1

Acute Treatment

Answer 1

Triptans, NSAIDS, Excedrin Migraine or generics

Question 2

Naratriptan

Answer 2

Brand: Amerge

Question 3

Almotriptan

Answer 3

Brand: Axert

Question 4

Frovatriptan

Answer 4

Brand: Frova

Question 5

Sumatriptan

Answer 5

Brand: Imitrex, Alsuma

Other: Imitrex STATdose SC injection and Imitrex nasal spray

Combo: sumatriptan plus naproxen (treximet)

Question 6

Rizatriptan

Answer 6

Brand: Maxalt, Maxalt – MLT(disintegrating tablets)

Question 7

Eletriptan

Answer 7

Brand: Relpax

Question 8

Zolmitriptan

Answer 8

Brand: Zomig, Zomig-ZMT disintegrating tablets, and Zomig nasal spray

Question 9

Triptan drug interactions

Answer 9

Avoid with serotonergic drugs such as SSRIs and SNRIs due to risk of serotonin syndrome (watch for restlessness, sweating, poor coordination, confusion and hallucinations)

Imitrex, Maxalt and Zomig are contraindicated with MAOIs

Question 10

Counseling Triptans

Answer 10

If nausea: recommend dissolvable tablet, injection or nasal spray

If migraine comes on very quickly: nasal spray or SC injection will provide quicker relief

Caution in patients with a previous cardiovascular event

If having to take more than twice a week may need a prophylactic drug

Question 11

Imitrex injection counseling using the STATdose system

Answer 11

1. Inject SC as soon as symptoms appear
2. System includes a case and two syringes
3. Open the case, pull off the tamperproof packaging, load the pen by inserting it into the cartridge and turning it clockwise until it will no longer turn
4. Then gently pull the loaded pen out of the carrying case the blue button on the side triggers the injection and cannot be injected unless it is against your skin
5. Hold the pen to your skin and push the blue button on the side of the pen and hold for five seconds
6. Return the pen to the cartridge and turn counterclockwise to remove needle and Store in carrying case

Question 12

Zomig nasal spray counseling

Answer 12

1. Blow your nose gently before use
2. Remove protective And hold sprayer device gently with fingers but do not prime as there is only one dose
3. Insert into knows about half an inch close your mouth press the plunger keep head level for 10/22 and gently breath through your mouth

Question 13

Other product

Answer 13

1. Fioricet (acetaminophen/butalbital/caffeine)

2. Ergotamine products: pregnancy category X

Question 14

Migraine prophylaxis

Answer 14

May need if using acute treatments more than twice a week or if migraines decrease the quality-of-life or the patient

Works in approximately 50% of cases but should be tried for 2 to 6 months

Question 15

First-line therapies for migraine prophylaxis and adults

Answer 15

1. First line: beta blockers (propranolol or Inderal, Timolol, metoprolol, valproate, topiramate or Topamax
2. If menstrual: extended cycle oral contraceptives or start NSAIDs or triptans two days prior to menses and continue for 5 to 7 days
3. Second line: other beta blockers, Ace inhibitors, antidepressants, birth-control, Botox or botulinum toxin type A

Question 16

Propranolol (Inderal)

Answer 16

Nonselective beta blocker and should not be used in COPD, asthma, emphysema

Side effects: fatigue, decreased heart rate, possible depression

Question 17

Timolol (blocadren)

Answer 17

Nonselective beta blocker

do not use and COPD, emphysema

Question 18

Metoprolol (lopressor, Lopressor XL and Toprol XL)

Answer 18

Beta-1 selective

Decrease heart rate, monitor for hypertension, dizziness

Question 19

Topiramate or Topamax

Answer 19

Pregnancy category D

Side effects: open angle glaucoma, hyperhydrosis, depression, metabolic acidosis, 6 to 8% weight loss, reduced efficacy of oral contraceptives, cognitive and

Question 20

Rebound or medication overuse headaches

Answer 20

To cut down on this, educate patients to limit the acute treatment medications to 2-3 times per week at the most and the most important thing is to stop the overused medication. If the drug is an opioid or containing butalbital such as Fioricet or Fiorinal they will require a slow taper to discontinue