Migraines

Question 1

What are the progression/steps of a migraine attack?

Answer 1

1) Vulnerability (external factors)
2) Start of attack
3) Prodrome
4) Aura (does not always happen)
5) Headache
6) Post-Headache state

Question 2

Cause of migraines:

Answer 2

Not fully understood. Likely due to vasodilation in cranial blood vessels and/or neurotransmitter imbalances. May be genetic factors.

Question 3

Patients should identify and avoid “triggers” if possible such as:

Answer 3

1) Hormonal changes in women (ex. menstrual-associated migraines). Can be treated with oral contraceptives, the estradiol patch, or creams.
2) Foods
3) Stress
4) Sensory stimuli (ex. bright lights, smells)
5) Changes in sleep-wake pattern
6) Changes in the environment

Question 4

Migraines can be diagnosed when an adult has at least 5 attacks fulfilling the following criteria:

Answer 4

1) Headaches last 4-72 hours and recur sporadically
2) Have ≥ 2 of the following characteristics: unilateral location, pulsating, moderate-severe pain and aggravated by (or causing avoidance of) routine physical activity
3) One of the following occurs during the headache: nausea and/or vomiting, photophobia (sensitivity to light), and phonophobia (sensitivity to sound)

Question 5

Non-drug treatments include:

Answer 5

1) Headache diary
2) Massage, applying cold compresses to head
3) Natural products: caffeine, butterbur, feverfew, magnesium, riboflavin, coenzyme Q10, topical peppermint

Question 6

Acute treatments to treat existing headaches include:

Answer 6

1) OTC or Rx NSAIDs
2) acetaminophen
3) Excedrin Migraine (aspirin, acetaminophen, caffeine)
4) Triptans
5) Ergotamine
6) may benefit from antiemetic for N/V

Question 7

Triptans are selective serotonin…

Answer 7

agonists for the 5-HT1 receptor (1B/1D) and cause vasoconstriction of cranial blood vessels, inhibit neuropeptide release, and decrease pain transmission

Question 8

Triptans should be taken…

Answer 8

at the first sign of a migraine; can repeat dose if it does not help

Question 9

Which two triptans are available as orally disintegrating tablets (ODTs)? (no water needed)

Answer 9

1) rizatriptan (Maxalt-MLT)

2) zolmitriptan (Zomig)

Question 10

Which two triptans are available as nasal sprays?

Answer 10

1) sumatriptan (Imitrex)

2) zolmitriptan (Zomig)

Question 11

Which triptan can be given by SQ injection (preferred site is lateral thigh or upper arm)?

Answer 11

Sumatriptan is available as:

1) a prefilled syringe (contains latex derivative)
2) autoinjector (Imitrex STATdose System, Zembrace SymTouch)

Question 12

What are contraindications for use of triptans?

Answer 12

Cerebrovascular disease (stroke/TIA), uncontrolled hypertension, ischemic heart disease, peripheral vascular disease, history of hemiplegic or basilar migraine, use within 24 hours of another triptan or ergotamine-type medication

Question 13

What are warnings associated with triptans?

Answer 13

Risk of increased BP, serotonin syndrome, cardiac and cerebrovascular events, arrhythmias, medication overuse headache (MOH), seizures (sumatriptan only);

Question 14

What are side effects for triptans?

Answer 14

Paresthesia (tingling/numbness), dizziness, hot/cold sensations, chest pain/tightness, dry mouth, somnolence, nausea. May feel pressure or heaviness in the chest and/or neck (should improve)

Question 15

sumatriptan + naproxen

Answer 15

Treximet (dispense in the original container and protect from moisture)

Question 16

Which triptans contain phenylalanine and should not be used in patients with phenylketonuria?

Answer 16

1) rizatriptan (Maxalt-MLT)

2) zolmitriptan (Zomig ZMT ODT)

Question 17

Which triptans are considered long-acting and have slow onset?

Answer 17

1) frovatriptan (Frova); half-life is 26 hours
2) naratriptan (Amerge)
* Note: can be a good option if headache recurs after dosing, lasts a long time, or can be anticipated in advance (e.g.MAM)

Question 18

Triptan Drug interactions

Answer 18

1) risk of serotonin syndrome with SSRIs and SNRIs
2) Sumatriptan, rizatriptan and zolmitriptan are contraindicated with MAO inhibitors (or within 2 weeks of stopping)
3) Eletriptan is C/I with strong CYP3A4 inhibitors (reduce dose of almotriptan)

Question 19

Ergotamine drugs may be used in patients with C/I to triptans or for those who do not find benefit with them.

Answer 19

they are nonselective agonists of sertonin receptors

Question 20

dihydroergotamine

Answer 20

1) D.H.E. 45 Injection (IM/SC/IV)
2) Migranal (nasal spray)
Note: Prime nasal spray by pumping 4 times. Do not inhale deeply. 1 spray (0.5 mg) into each nostril, can repeat after 15 minutes, up to a total of 4 sprays.

Question 21

ergotamine + caffeine

Answer 21

1) Cafergot (tablet)

2) Migergol (suppository)

Question 22

What are contraindications associated with ergotamines?

Answer 22

1) Use with strong CYP3A4 inhibitors due to serious and life-threatening peripheral ischemia
2) Uncontrolled HTN
3) Pregnancy (category X)
4) ischemic heart disease
5) angina/MI
6) Peripheral vascular disease
7) Hemiplegic or basilar migraine
8) Sepsis
9) Use with pressors/vasoconstrictive drugs

Question 23

Butalbital-containing products are not recommended for treating acute migraines due to…

Answer 23

dependence issues and lower efficacy. Must be tapered off if used regularly and long-term.

Question 24

Consider prophylactic treatment if the patient:

Answer 24

1) requests it
2) uses acute treatments ≥2 days/week or ≥3 times per month
3) or if the migraines decrease their quality of life or if acute treatments are ineffective or contraindicated

Question 25

Choose a prophylactic drug based on patient characteristics and side effect profile, since efficacy data is similar (~50% reduction in headache days).

Answer 25

A full trial should be 2-6 months. Many patients try more than one drug before finding one that works well.

Question 26

Oral prophylactic therapies include:

Answer 26

1) Beta-blockers (best evidence with propranolol, timolol, and metoprolol)
2) Antiepileptic drugs (topiramate and valproic acid)
3) Tricyclic antidepressants at lower doses (most evidence with amitriptyline, venlafaxine)
4) MAM: monophasic and extended-cycle oral contraceptives can be used (if no aura). With aura, use progestin-only pills. NSAIDs or a triptan can be started before menses and continued for 5-7 days.
5) Natural products

Question 27

What are warnings and s/e associated with beta-blockers?

Answer 27

Use caution with bronchospastic disease (e.g. asthma, COPD), especially with non-selective propranolol and timolol
Side effects: bradycardia, fatigue, hypotension, dizziness, depression (more so with propranolol, the most lipophilic), impotence, cold extremities

Question 28

divalproex (Depakote, Depakote ER, Depakote Sprinkle)

Answer 28

Dose: 250-500 mg BID
BBW: Fetal harm, liver failure, pancreatitis
Warnings and s/es: weight gain, thrombocytopenia, increased ammonia, alopecia, N/V, somnolence, tremor, polycystic ovarian syndrome

Question 29

topiramate (Topamax, Topamax Sprinkle); Topiramate ER (Qudexy XR, Trokendi XR)

Answer 29

Dose: Start 25 mg QHS, titrate to 50 mg BID
Warnings: fetal harm, metabolic acidosis, nephrolithiasis, increased ammonia, open-angle glaucoma, reduced sweating
S/Es: weight loss (6-13%), somnolence, cognitive impairment, paresthesia, reduced efficacy of oral contraceptives

Question 30

botulinum toxin type A (Botox)

Answer 30

used for ppx, only for chronic migraines (≥ 15 headache days/month)

Question 31

calcitonin gene-related peptide (CGRP) receptor antagonists are…

Answer 31

human monoclonal antibodies that target high levels of CGRP in the blood

Question 32

CGRP receptor antagonists include…

Answer 32

1) eptinezumab-jjmr (Vyepti); IV injection
2) erenumab-aooe (Aimovig); SC autoinjector
3) fremanezumab-vfrm (Ajovy); prefilled syringe
4) galcancezumab-gnlm (Emgality); SC autoinjector, prefilled syringe
5) rimegepant (Nurtec); ODT

Question 33

Aimovig has a warning for…

Answer 33

latex allergy.

Question 34

Galcancezumab- gnlm (Emgality) is also approved for…

Answer 34

cluster headache prevention

Question 35

SC injections should be given…

Answer 35

in the abdomen, thigh or upper arm; store refrigerated in the original carton before use; allow the injection to sit at room temperature for at least 30 min before injecting

Question 36

Acute treatment should be limited to…

Answer 36

2-3 times/week due to risk of medication overuse headaches (MOH). Counsel patients on this and to d/c the “over-used” medication.

Question 37

Medication overuse headaches (MOH) are characterized by headaches that occur…

Answer 37

more than 10-15 days/month

Question 38

How to use sumatriptan nasal powder (Onzetra Xsail)?

Answer 38

1) Open the pouch and remove the first nosepiece
2) Insert the nosepiece into the device until you hear it click
3) Press and release the white button to pierce the capsule
4) Insert the nosepiece deeply into the nostril. Rotate the device to place the mouthpiece into your mouth.
5) Blow into the device with your mouth for 2-3 seconds to deliver medication into your nose.
6) Press the clear tab to remove the first noisepiece. Check the capsule to be sure the medication is gone. Throw out the first nosepiece.
7) Insert the second nosepiece into the device and repeat the steps above using the second nostril.

Question 39

A patient takes one dose of generic sumatriptan injection (4mg/0.5 mL). About 90 minutes later, her migraine is partially relieved but she still has a “pounding” pain in her head. What should she do?

Answer 39

She can use a second SQ dose now. Injectable sumatriptan can be repeated 1 hour after the first dose, if needed and only if there is some response to the first dose.

Question 40

Which triptan has the longest duration of action and may be useful in a patient with recurrent migraine?

Answer 40

frovatriptan

Question 41

RD has significant nausea during her migraine headaches and cannot tolerate swallowing any pills. She vomits them right back up. Which formulations might offer benefit?

Answer 41

ODTs, nasal sprays, and injections

Question 42

A pharmacist is counseling a new patient on the appropriate use of a triptan nasal spray. What is an important counseling point?

Answer 42

Blow nose gently before use. Zomig and Imitrex nasal sprays only have one dose (unlike others, do not prime them)

Question 43

Which triptan can be recommended for a 13-year-old female patient with frequent migraines?

Answer 43

rizatriptan tablets, zolmitriptan nasal spray, almotriptan tablets, Treximet tablet

Question 44

BC is 20 weeks pregnant with her first child. She has been having frequent headaches. The pharmacist can recommend the occasional use of the following:

Answer 44

acetaminophen (drug-of-choice in pregnancy). Do not recommend NSAIDs OTC.