Migraine

Question 1

Fast acting triptans?

Answer 1

Ele, suma, almo, riza

Question 2

Quickest onset Tristan?

Answer 2

Non-PO : suma

Nasal: suma, zolmi

Question 3

Longest duration?

Answer 3

Frova, nara

Question 4

ODT formulation?

Answer 4

Riza, zolm

Question 5

Propranolol DDI with triptans?

Answer 5

Riza ajust dose to 5 mg dose/15 max total

Question 6

MAOI DDI w/ triptans?

Answer 6

Suma, riza, zolmi

Question 7

Ditan and gpants place in therapy for acute tx?

Answer 7

No vasoconstriction
Can be used in cardio disease
Advantage over triptans and ergotamines

Lasmiditan (Rayvow) CV
- ditan: selective 5ht-1F agonist 
- no renal hepatic dose adj needed 
-newest rimegepant.
Ubrogepant ( Ubrevly) 
- small molecule CGRP receptor antagonis
- renal hepatic drug adjustment needed
-

Question 8

Prevention of migraine rx options?

Standards of care and antiCGRP mAbs

Answer 8

Antiepileptics:

• divalproex sod*
• Topi*
• Carba

Antihypertensives:

• propranolol *
• metoprolol*
• candesartan
• lisinopril

Antidepressants:

• amitriptyline^ avoid in elderly
• venlafaxine^

Other:
Feverfew^
Mag^
Riboflavin ^
Onabotulinum toxin A- chronic migraine only 

• level A
  ^ level B

6-8 weeks on target dose=adécuate trial
Goal reduction by 30-50%

Question 9

AntiCGRP mAbs?

Answer 9

All sub Q
Monthly or quarterly
Used if failed adequate trial of at least 2 other level A/B preventive medications

Erenumab- Aimovig- GI CEs
Fremanezumab- Ajovy- monthly or quarterly q3mo
Galcanezumab-Emgality- prophylaxis and episodic cluster

Pros:
no PK DIs, quick effect seen as soon as 4 weeks
Super responders seen in trials: no migraine in a month
Cons:
Expensive, no head to head trials,