Migraine Flashcards
Patients with migraine with aura are at higher risk for what?
(And what meds should they avoid?)
Stroke
Avoid estrogen-containing contraceptives
Diagnosing migraine
5 attacks which meet the following criteria:
- Headaches last 4-72 hours and recur sporadically
- Headaches have 2 or more of the following characteristics: unilateral location, pulsating, moderate-severe pain and aggravated by routine physical activity
- N/V, photophobia, or phonophobia
Triptans MOA, place in therapy
They are selective agonists for 5-HT1 receptor, cause vasoconstriction of cranial blood vessels, inhibit neuropeptide release, and decrease pain transmission
They are first line for acute treatment
Safety of treating 3-5 headaches/month has not been established
Sumatriptan brands, dosing
Imitrex: PO 25, 50, 100 mg can repeat x 1 after 2 hours
Injection: 4 ot 6 mg, can repeat x 1 after 1 hour
Spray: 5, 10, 20 mg can repeat x 1 after 2 hours
Onzetra Xsail: Intranasal powder, 11 mg in each nostril, can repeat x1 after 2 hours
Zembrace Symtouch injection: 3 mg, can repeat up to 4x/day (min 1 hour between) - max 12 mg/day (4x underlined)
Treximet
Sumatriptan + Naproxen
Tablet only
85-500 mg adult 1 tab can repeat x 1 after 2 hours
10-60 mg child 1 tab can repeat x 1
Contraindications, warnings for triptans
Cerebrovascular disease (stroke/TIA)
Uncontrolled HTN
Ischemic heart disease
Use within 24 hours of another triptan or ergotamine-type medication
Warnings: increased risk of blood pressure
Side effects/counseling for triptans
Triptan sensations: pressure in the chest or heaviness or pressure in the neck region, usually dissipates after administration
Nasal sprays only contain 1 dose so DO NOT prime
Ergotamine MOA, place in therapy
Nonselective agonist of serotonin receptors, so also causes cerebral vasoconstriction
Dihydroergotamine brand, dose, warnings/contraindications
DHE 45, Migranal
DHE 45 is IM/SC/IV: 1 mg at first sign of headache, repeat hourly to max 2 mg/day (IV) or 3 mg/day (IM, SC): max 6 mg/week
Migranal is intranasal: 1 spray (0.5 mg) in each nostril, can repeat after 15 mins up to total of 4 sprays (2 in each nostril, 2 mg total)
Boxd warning: Contraindicated with potent CYP3A4 inhibitors (protease inhibitors, azoles, some macrolide abx) due to LIFE THREATENING peripheral ischemia
Contraindicated in pregnancy, uncontrolled HTN, ischemic heart disease
Warnings: CV effects, avoid in pts w history of CV events or baseline risks; also serious drug interactions
Counsel: prime by pumping 4 times
Fioricet vs Fiorinal
Fioricet: APAP/butalbital/caffeine
Fiorinal: Aspirin/butalbital/caffeine (sched III)
Butalbital-products place in therapy
Not recommended for treatment of acute migraines due to potential for abuse/dependence issues, lower efficacy
If used regularly must taper off
When is prophylactic treatment of migraines indicated?
If patient requires acute treatment > 2 days/week or > 3 days/month
If migraines decrease their quality of life
Or if acute treatments are ineffective or contraindicated
How to select a prophylactic treatment of migraines?
Based on side effect profile of the medications
When are botox injections indicated for prophylaxis?
Chronic migraines only
> 15 headache days/month
Beta blockers for migraine: agents, dosing
Propranolol (Inderal) or metoprolol (Lopressor, Toprol XL)
Propranolol has high CNS absorption bc it is the most lipophilic, dose 80-240 mg q6-8h
Metoprolol dose 100-200 mg daily
Use for prophylaxis only
