Migraine Drugs

Question 1

What is the hallmark of a migraine?

Answer 1

Disabling headache associated with

–nausea and/or light and sound sensitivity

Question 2

What are the drugs used for mild to moderate attacks?

Answer 2

Acetaminophen and NSAIDs

—attacks not associated with vomiting or severe nausea

Question 3

Triptans (Sumatriptan) are the drugs used for moderate to severe migraine attacks. what are some features?

Answer 3

Drug of choice for treatment of moderate to severe migraine
–selective agonists at 5-HT1D and 5-HT1B
Combo of Sumatriptan and naproxen provides better pain relief than either agent alone
SQ is faster acting (sumatriptan)

Question 4

What are adverse effects of Triptans?

Answer 4

Tingling, flushing, dizziness, drowsiness, fatigue and feeling of heaviness, tightness, or pressure in chest. Angina, MI, cardiac arrhythmia, stroke and death

Question 5

Triptans are contraindicated in whom?

Answer 5

In patients with coronary, cerebrovascular or other arterial disease or uncontrolled HTN
–used in caution in diabetics

Question 6

The other drug class used for acute migraine attacks are the Ergot Alkaloids, Ergotamine and Dihydroergotamine. What are some features?

Answer 6

Agonist at alpha androreceptors, 5-HT receptors (HT1B/D) and dopamine D2 receptors

Question 7

What are adverse effects of the Ergot Alkaloid?

Answer 7

Nausea and Vomiting are common
–but can be prevented with metoclopramide
Overdose: vascular occlusion and gangrene
Dihydroergotamine is a weaker vasoconstrictor than ergotamine so fewer side effects
Do not use in arterial disease or uncontrolled hypertension

Question 8

Moving on to the drugs for prevention of migraines. No single drug has emerged as a clear treatment of choice. What are the first line agents?

Answer 8

1. Beta Blockers: Propranolol, Timolol, Metoprolol, Nadolol and Atenolol (80% of pts achieve complete or partial response)
2. Anti-epileptics:
   –Valproate: used for tx of manic episodes of bipolar, epileptic seizures and prophylaxis of migraines. Inhibits voltage gated Na channels and T type Ca channels
   —-Topiramate: tx of epileptic seizures and prophylaxis of migraines. Inhibits voltage gated Na channels and a GABA receptor agonist and antagonist at glutamate receptors
   (dont use either of these drugs in pregos: teratogenic)

Question 9

The last set of drugs to cover are the second and third line drugs for prevention of migraines. The first are the Antidepressants. What are they?

Answer 9

1. TCAs (amitriptyline, nortriptyline and Imipramine)
   - –can be used in combo with propranolol to increase efficacy and decrease adverse effects.
   - -inhibit NE and serotonin reuptake
   - -adverse effects: sedation, dry mouth and weight gain
2. Venlafaxine (SNRIs)
   - -adverse effects: nausea, constipation, insomnia, headaches and sexual dysfunction

Question 10

The next second and third line drugs used for prevention of migraines are calcium channel blocker, Verpamil. What are some features?

Answer 10

Evidence for their effectiveness is weak

–only CCB with evidence of efficacy

Question 11

The next second and third line drug used are antiepileptic, Gabapentin. what are some features?

Answer 11

Decreases glutamate release: this effect is a consequence of blockage of presynaptic voltage gated Ca channels
Adverse effects: sleepiness, dizziness and fatigue

Question 12

What are the last three types of second and third line drugs used?

Answer 12

ACEIs and ARBS: lisinopril and candesartan reduce migraine by 30%
Botulinum Toxin: injection shown to be marginally effective for prophylaxis of headaches
NSAIDs: naproxen and ibuprofen