Migraine Meds

Question 1

3 categories of H/As?

Answer 1

tension
cluster
migraine

Question 2

majority of H/As are caused by what state of vessels?

Answer 2

vasodilation

Question 3

what hormone appears to play a vital role in migraines and how so?

Answer 3

serotonin
receptors appear to account for potential of either vasoconstriction or dilation being elicited by serotonin
serotonin 1 receptors elicit constriction
serotonin 2 receptors elicit dilation
also has been found that higher levels of serotonin cause constriction whereas lower levels cause dilation
serotonin may also alter the threshold of pain perception

Question 4

prophylactic migraine med options?

Answer 4

beta-blockers (propanolol/inderal or metoprolol/lopressor)
CCBs (verapamil/isoptin)
methysergide
tricyclic antidepressants (nortyptylene/aventyl)
erogtamine
anti-seizure meds

Question 5

prodromal phase migraine tx option?

Answer 5

triptans

Question 6

actual migraine H/A phase meds?

Answer 6

analgesics

anti-emetics

Question 7

class of propranolol/inderal? indications? MOA? how to rx propranolol? problem that can occur dt non-selectivity?

Answer 7

class: non-selective BB
indications: HTN, angina, AMI, panic attacks, migraines
MOA: blocks adrenergic stimulation which serves to decrease HR and myocardial O2 demand and also decreases renin release
rx: PO 10-100 mg/d
SE: non-selective means it might cause bronchoconstriction via antagonism of B2 nerves

Question 8

SEs of propranolol/inderal? abrupt discont can cause what?

Answer 8

bronchoconstriction, hypotension, bradycardia, fatigue, impotence
abrupt discont can cause rebound HTN, tachycardia w/subsequent increase in myocardial O2 demand, increases risk of arrhythmias, stroke, angina and MI

Question 9

class of amitriptyline/elavil? indications? MOA? how to rx?

Answer 9

class: tricyclic antidepressant
indications: migraine/tension H/A, chronic pn, bipolar d/o, depression
MOA: CNS modulation of both serotonin and NE (inhibits reuptake)
rx: PO or IM, usu taken at bedtime to minimize SEs of drowsiness and dizziness

Question 10

SEs of amitriptyline/elavil? do not use in combo with what?

Answer 10

SEs: dizziness, marked drowsiness, Ach effects such as anti-SLUD + blurred vision
do not use with monoamine oxidase inhibitors!

Question 11

class of topiramate/topamax? indications? MOA?

Answer 11

class: anticonvulsant
indications: anticonvulsant approved in use of epilepsy and prophylaxis of migraines, off-label use for bipolar d/o
MOA: block voltage dependent Na channels in CNS, augmenting the activity of GABA at some subtypes of GABA-A receptor

Question 12

how to rx topiramate/topamax? SEs?

Answer 12

rx: PO tablets, also available capsules or sprinkle form for peds
SEs: fatigue, dizziness, vision changes, acute angle glaucoma, nausea, constipation

Question 13

class of methysergide/sansert? indications? MOA?

Answer 13

class: ergot derivative, serotonin 2 receptor antagonist
indications: prophylaxis migraine and cluster H/A
MOA not fully understood but appears to be serotonin receptor 2 antagonist which = vasoconstriction

Question 14

how to rx methysergide/sansert? do not use w/in 24 hrs of what other drug?

Answer 14

give PO, should never use beyond 6 mos w/o a drug free interval; dosage must be tapered to avoid rebound
do not use w/in 24 hrs of triptan b/c of increased risk of vasoconstrictive spasm

Question 15

SEs of methysergide/sansert? use is usu reserved for tx’ing what?

Answer 15

HTN
thrombophlebitis
N/V
pulmonary fibrosis and retroperitoneal fibrosis (potentially life-threatening)
heart valve thickening
C/I in PG and in pts w/peripheral vascular dz
all these potential SEs make its use a less attractive choice
use is reserved for cases refractive to other meds and tx modalities

Question 16

class of sumatriptan/imitrex? indications? MOA? how to rx?

Answer 16

class: serotonin agonist
indication: migraines and cluster H/As
MOA: serotonin agonist at 5-HT 1D and 1B receptors, found in small, peripheral nerves that innervate the intracranial vasculature; acts to reduce the vascular inflammation assoc w/migraines
take PO/SQ/nasal spray

Question 17

onset of action of sumatriptan/imitrex? max dose in 24 hrs? SEs? what category?

Answer 17

onset of action: 10-60 misn, max 2 doses in 24 hrs
SEs: dizziness, tingling, facial flushing, weakness, chest tightness or pn, arrythmias, HTN, use w/caution in pts w/HTN and in pts w/angina
category C drug that is well controlled, should probably not be used in PG

Question 18

what is serotonin syndrome?

Answer 18

uncommon potential SE of all triptans
ssxs: agitation, tremor, ataxia, fever, chills, diarrhea
frequent use can cause rebound H/As

Question 19

nonsteroidal analgesics that can be used during migraine?

Answer 19

NSAIDs: aspirin, ibuprofen, naproxen, acetaminophen

caffeine often added to analgesic and increases effectiveness in tx’ing H/A

Question 20

MOA of NSAIDs?

Answer 20

inhibit synth of prostaglandins

Question 21

what do prostaglandins promote?

Answer 21

inflammation, pain, fever, support clotting fxn of platelets and protect lining of the stomach from damaging effects of stomach acid

Question 22

what enzyme is primarily involved in the production of prostaglandins?

Answer 22

COX-1, which NSAIDs prevent the formation of

Question 23

class of ibuprofen/motrin, advil? indications? MOA? how to rx?

Answer 23

class: NSAID
indications: inflammation, pn, fever
MOA: reversible inhibition of COX-1, COX-2 enzymes; anti-inflam, analgesic effect largely dt blockade of prostaglandin synth at target tissues
rx: PO, PR, no increased risk for Reye’s syndrome noted

Question 24

class of codeine? indications? MOA? how to rx? SEs? DOA?

Answer 24

class: opioid analgesic
indications: pain relief, antitussive
MOA: opioid agonist, much weaker analgesic than morphine
rx PO, IV, IM, SQ- lower abuse potential- effective antitussive
SEs: sedation, constipation
DOA: 4-6 hrs

Question 25

class of butorphanol/stadol? indications? MOA?

Answer 25

class: opioid analgesic
indications: migraine that is refractory to triptans and to other agents as well as less potent analgesics
MOA: mixed agonist-antagonist of opioid receptors

Question 26

how to rx butorphanol/stadol? SEs?

Answer 26

rx nasal spray or IM, usu dosed as 1 spray in nostrils every 3-5 hrs as needed for control of severe pn, marked dependency exists
SEs: nasal irritation, drowsiness, dysphoria, N/V, withdrawal sxs can be precipitated in pts w/underlying addiction to opiates

Question 27

5 main anti-emetics used to tx migraines? given how?

Answer 27

diphenhydramine (benadryl), prochlorperazine (compazine), promethazine (phenergan), hydroxyzine (vistaril), these antihistamines are very effective in alleviating nausea
all give PO, PR, IV

Question 28

when are cannabinoids used?

Answer 28

pts w/cachexia, cytotoxic nausea, vomiting or those who are unresponsive to other agents

Question 29

how to 5-HT3 receptor antagonists work to alleviate nausea?

Answer 29

block serotonin receptors in the CNS and GI which prevents nausea

Question 30

class of prochlorperazine/compazine? indications? MOA?

Answer 30

class: typical neuroleptic
indications: anti-emetic particularly when assoc w/migraine, vertigo, anti-psychotic
MOA: primarily H1 histamine receptor antagonist, also D2 dopaminergic receptor antagonist and alpha-adrenergic receptor antagonist

Question 31

how to rx prochlorperazine/compazine? SEs?

Answer 31

give PO, PR, IM, IV
SEs: drowsiness, dry mouth, constipation, urinary retention, lowers seizure threshold, extrapyramidal SEs genearly seen when given in higher doses after a longer period of time (tardive dyskinesia, pseudoparkinsonism, dystonic rxns, akathisia)

Question 32

category of ondansetron/zofran? indications? MOA? how to rx? SEs?

Answer 32

category: antiemetic
indication: severe nausea
MOA: block serotonin (5HT3) receptor sites resulting in significant anti-nausea effects
give PO, IV
SEs: dizziness, H/A, generally well tolerated

Question 33

additional non-pharm tx options?

Answer 33

B2, riboflabin 400 mg/d
Mg 600-2000 mg/d
biofeedback 
acupuncture
botulinum toxin (botox) injxn has shown promise