MIGRAINE Flashcards
MIGRAINE
- a common EPISODIC disorder
- disabling headache generally associated with NAUSEA and/or LIGHT + SOUND SENSITIVITY
- most migraine suffereres require pharmacologic treatment
DRUGS FOR MILD-MODERATE ATTACKS
either = DOC
1) ACETAMINOPHEN
2) NSAIDS
–> for mild-moderate attacks NOT ASSOCIATED with vomiting/severe nausea
TRIPTANS
drugs used for MODERATE-SEVERE ATTACKS
TRIPTANS = DOC for moderate-severe migraines
-Triptans are selective agonists at 5-HT1D and 5-HT1B receptors
Combination of sumatriptan and naproxen provides better pain relief than either drug alone.
SC sumatriptan is the fastest-acting and most effective triptan formulation.
ADVERSE EFFECTS:
1) tingling, flushing, dizziness, fatigue
2) Chest tightness
3) RARE: angina, MI, arrhythmia, stroke, and death
CONTRAINDICATIONS:
-in coronary, cerebrovascular, or other arterial disease, or uncontrolled HTN
ERGOTAMINE
DIHYDROERGOTAMINE
ERGOT ALKALOIDS: DRUGS USED TO TREAT MODERATE-SEVERE ATTACKS
ER GROSS AMINE –> agonist at a few receptors, but can cause GANGRENE (er gross) d/t vascular occlusion (contraindicated in arterial disease or uncontrolled HT)
-Ergotamine acts as an agonist at α-adrenoceptors, 5-HT and D2 receptors
• The agonist actions of ergot alkaloids at 5-HT1B/1D receptors likely mediate their anti-migraine effects.
ADVERSE EFFECTS:
1) Nausea and vomiting. Can be prevented with an antiemetic such as metoclopramide.
2) Serious adverse effects: vascular occlusion and gangrene. Rare. Usually associated with overdosage.
3) Dihydroergotamine is a weaker vasoconstrictor than ergotamine and causes fewer AE.
CONTRAINDICATIONS:
1) arterial disease or 2) uncontrolled hypertension.
DRUGS FOR PREVENTOIN OF MIGRAINE
- Patients with frequent or severe disabling migraine headaches should receive prophylactic treatment.
- The mechanisms of action of drugs used for migraine prophylaxis are diverse.
- No single drug has emerged as a clear treatment of choice.
FIRST LINE AGENTS: BETA BLOCKERS, VALPROATE, TOPIRAMATE (Val’s at the top with Beta) –> they are the top of the prophylatic choices
SECOND LINE AGENTS: Tricyclic AntiD’s, SNRI’s, Calcium Channel Blockers, Gabapentin, ACEIs/ARBs, Botulinum Toxin, NSAIDS
BETA BLOCKERS
FIRST LINE AGENTS FOR PREVENTION OF MIGRAINS
PROPANOLOL, TIMOLOL, METOPROLOL, NADOLOL, ATENOLOL
–> for continuous prophylaxis, beta blockers are commonly used
VALPROATE
FIRST LINE AGENT FOR PREVENTION OF MIGRAINE
Val (james’s girlfriend) may be a little crazy (biopolar, epilepsy), but she sometimes gives him a headache –> she inhibits Na and Ca from his diet –> can strangle him also and give him THROMBOCYTOPENIA
- indicated for BIPOLAR DISORDER, EPILSEPY, + MIGRAINE PROPHYLAXIS
- valproate inhibits voltage gated Na+ channels and T-type Ca2+ channels
ADVERSE EFFECTS:
-GI side effects, Thrombocytopenia, rarely hepatotoxicity, teratogenic
TOPIRAMATE
FIRST LINE AGENT FOR PREVENTION OF MIGRAINE
Like Val, also used for epilepsy, also blocks Na+ but is a GABA AGONIST, Glut antagonist (unlike val, who works out) –> affects your Top ie your Two eyes –> acute myopia, glaucoma
- indicated for 1) EPILEPSY and 2) MIGRAINE PROPHYLAXIS
- inhibits voltage-gated Na+ channels
- GABAA receptor agonist and glutamate receptor antagonist.
AE: Somnolence, fatigue, cognitive slowing, nervousness, confusion. Acute myopia (nearsightednes) , glaucoma. Hyperthermia, renal stones. Teratogenic.
AMITRIPTYLINE
NORTRIPTYLINE
IMIPRAMINE
TRICYCLIC ANTI-D’S: 2ND OR 3RD LINE AGENTS
-are TCAs that inhibit NE or Serotonin reuptake
AE: sedation, dry mouth, weight gain
VENLAFAXINE
SEROTONIN NE RUPTUAKE INHIBITOR (SNRI’s): 2nd-3rd line agent
AE: nausea, constipation, insomnia, headaches, sexual dysfunction
VERAPAMIL
CALCIUM CHANNEL BLOCKER (2ND OR 3RD LINE AGENT)
- are used for prevention of migraine, but evidence for their effectiveness is WEAK
- Verapamil is the CCB with the most evidence of efficacy
GABAPENTIN
-gabapentin decreases glutamate release by blocking presynaptic voltage-gated Ca2+ channels
GABAPENT –> makes a tent in the presynaptic cleft and BLOCKS the GLUTAMATE RELEASE
AE: sleepiness, dizziness, fatigue (B/C IN A TENT)
LISINOPRIL
CANDESARTAN
2nd/3rd line ACEI’s or ARBs
Lisinopril and Candesartan have reduced migrine fequency by about 30%
BOTULINUM TOXIN
2nd-3rd line prophylactic agent
-pericranial injections of botulinum toxin is marginaly fffective for prophylaxis of headaches in adult patients with chronic migraine (patients with 15 or more headache days/month)
NAPROXEN
IBUPROFEN
2ND/3RD LINE AGENT: PROPHYLACTIC USE NSAIDS
1) NAPROXEN
2) IBUPROFEN
–> have been used for short-term pervention of migraine
