Migraine

Question 1

Patients with migraine with aura are at higher risk for what?
(And what meds should they avoid?)

Answer 1

Stroke

Avoid estrogen-containing contraceptives

Question 2

Diagnosing migraine

Answer 2

5 attacks which meet the following criteria:

1. Headaches last 4-72 hours and recur sporadically
2. Headaches have 2 or more of the following characteristics: unilateral location, pulsating, moderate-severe pain and aggravated by routine physical activity
3. N/V, photophobia, or phonophobia

Question 3

Triptans MOA, place in therapy

Answer 3

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

Question 4

Sumatriptan brands, dosing

Answer 4

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)

Question 5

Treximet

Answer 5

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

Question 6

Contraindications, warnings for triptans

Answer 6

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

Question 7

Side effects/counseling for triptans

Answer 7

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

Question 8

Ergotamine MOA, place in therapy

Answer 8

Nonselective agonist of serotonin receptors, so also causes cerebral vasoconstriction

Question 9

Dihydroergotamine brand, dose, warnings/contraindications

Answer 9

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

Question 10

Fioricet vs Fiorinal

Answer 10

Fioricet: APAP/butalbital/caffeine
Fiorinal: Aspirin/butalbital/caffeine (sched III)

Question 11

Butalbital-products place in therapy

Answer 11

Not recommended for treatment of acute migraines due to potential for abuse/dependence issues, lower efficacy

If used regularly must taper off

Question 12

When is prophylactic treatment of migraines indicated?

Answer 12

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

Question 13

How to select a prophylactic treatment of migraines?

Answer 13

Based on side effect profile of the medications

Question 14

When are botox injections indicated for prophylaxis?

Answer 14

Chronic migraines only

> 15 headache days/month

Question 15

Beta blockers for migraine: agents, dosing

Answer 15

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

Question 16

Antiepileptic drugs for migraine: agents, dosing, counseling

Answer 16

Divalproex (Depakote), Valproic acid (Depakene): 250-500 mg twice daily
Worry about liver toxicity, pancreatitis, weight gain, teratogenicity, thrombocytopenia

Topiramate (Topamax): 25 mg HS, titrate to 50 mg BID
Weight loss, paresthesia, cognitive impairment

Question 17

Antidepressant agents for migraine

Answer 17

Most evidence with amitriptyline, TCAs are used at lower doses for prophylaxis

Venlafaxine may also be effective

Question 18

How to prevent medication over-use headaches?

Answer 18

Limit acute treatment to 2-3 times per week at most

Question 19

Caution for patients with phenylketonuria

Answer 19

Orally disintegrating tablets have sweetener in them so they should not be used (Maxalt-MLT, Zomig-ZMT)

(Rizatriptan ODT)