Migraines Flashcards
What are the progression/steps of a migraine attack?
1) Vulnerability (external factors)
2) Start of attack
3) Prodrome
4) Aura (does not always happen)
5) Headache
6) Post-Headache state
Cause of migraines:
Not fully understood. Likely due to vasodilation in cranial blood vessels and/or neurotransmitter imbalances. May be genetic factors.
Patients should identify and avoid “triggers” if possible such as:
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
Migraines can be diagnosed when an adult has at least 5 attacks fulfilling the following criteria:
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)
Non-drug treatments include:
1) Headache diary
2) Massage, applying cold compresses to head
3) Natural products: caffeine, butterbur, feverfew, magnesium, riboflavin, coenzyme Q10, topical peppermint
Acute treatments to treat existing headaches include:
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
Triptans are selective serotonin…
agonists for the 5-HT1 receptor (1B/1D) and cause vasoconstriction of cranial blood vessels, inhibit neuropeptide release, and decrease pain transmission
Triptans should be taken…
at the first sign of a migraine; can repeat dose if it does not help
Which two triptans are available as orally disintegrating tablets (ODTs)? (no water needed)
1) rizatriptan (Maxalt-MLT)
2) zolmitriptan (Zomig)
Which two triptans are available as nasal sprays?
1) sumatriptan (Imitrex)
2) zolmitriptan (Zomig)
Which triptan can be given by SQ injection (preferred site is lateral thigh or upper arm)?
Sumatriptan is available as:
1) a prefilled syringe (contains latex derivative)
2) autoinjector (Imitrex STATdose System, Zembrace SymTouch)
What are contraindications for use of triptans?
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
What are warnings associated with triptans?
Risk of increased BP, serotonin syndrome, cardiac and cerebrovascular events, arrhythmias, medication overuse headache (MOH), seizures (sumatriptan only);
What are side effects for triptans?
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)
sumatriptan + naproxen
Treximet (dispense in the original container and protect from moisture)
Which triptans contain phenylalanine and should not be used in patients with phenylketonuria?
1) rizatriptan (Maxalt-MLT)
2) zolmitriptan (Zomig ZMT ODT)
Which triptans are considered long-acting and have slow onset?
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)
Triptan Drug interactions
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)
Ergotamine drugs may be used in patients with C/I to triptans or for those who do not find benefit with them.
they are nonselective agonists of sertonin receptors
dihydroergotamine
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.
ergotamine + caffeine
1) Cafergot (tablet)
2) Migergol (suppository)
What are contraindications associated with ergotamines?
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
Butalbital-containing products are not recommended for treating acute migraines due to…
dependence issues and lower efficacy. Must be tapered off if used regularly and long-term.
Consider prophylactic treatment if the patient:
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
Choose a prophylactic drug based on patient characteristics and side effect profile, since efficacy data is similar (~50% reduction in headache days).
A full trial should be 2-6 months. Many patients try more than one drug before finding one that works well.
Oral prophylactic therapies include:
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
What are warnings and s/e associated with beta-blockers?
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
divalproex (Depakote, Depakote ER, Depakote Sprinkle)
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
topiramate (Topamax, Topamax Sprinkle); Topiramate ER (Qudexy XR, Trokendi XR)
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
botulinum toxin type A (Botox)
used for ppx, only for chronic migraines (≥ 15 headache days/month)
calcitonin gene-related peptide (CGRP) receptor antagonists are…
human monoclonal antibodies that target high levels of CGRP in the blood
CGRP receptor antagonists include…
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
Aimovig has a warning for…
latex allergy.
Galcancezumab- gnlm (Emgality) is also approved for…
cluster headache prevention
SC injections should be given…
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
Acute treatment should be limited to…
2-3 times/week due to risk of medication overuse headaches (MOH). Counsel patients on this and to d/c the “over-used” medication.
Medication overuse headaches (MOH) are characterized by headaches that occur…
more than 10-15 days/month
How to use sumatriptan nasal powder (Onzetra Xsail)?
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.
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?
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.
Which triptan has the longest duration of action and may be useful in a patient with recurrent migraine?
frovatriptan
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?
ODTs, nasal sprays, and injections
A pharmacist is counseling a new patient on the appropriate use of a triptan nasal spray. What is an important counseling point?
Blow nose gently before use. Zomig and Imitrex nasal sprays only have one dose (unlike others, do not prime them)
Which triptan can be recommended for a 13-year-old female patient with frequent migraines?
rizatriptan tablets, zolmitriptan nasal spray, almotriptan tablets, Treximet tablet
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:
acetaminophen (drug-of-choice in pregnancy). Do not recommend NSAIDs OTC.
