Migraines Flashcards
Migraine prophylaxis if > 3 migraine per month
Prevention of migraine NOT for tx
• BB - Metoprolol, propranolol , timolol - ( FDA approved for migraines propranolol and timolol )
• Verapamil
•amitriptyline, Venlafaxine ext release ( Effexor XR )
•divalproex sodium ( depakote ) - teratogenic, N/V , weight gain, alopecia, hepatotoxicity, pancreatitis
• topamax - teratogenic
• amitriptyline
•botulinum toxin
•dietary supplements : butterbur, feverfew
Tx for acute attacks
• asa
• Asa or apap with caffeine ( all 3 : excedrin migraine )
•NSAIDs : ketoralac, naproxen, indomethacin , diclofenac, ibuprofen
• Nodolor : isomethaptene + dichloralphenazone + apap
•butalbital compounds - tension or muscle contraction HA
• triptans — INCREASES serotonin and are Vasoconstrictors
• ergot alkaloids
•for nausea : metoclopramide ( reglan )- decreases dopamine ( cant use for parkinsons patients ) , prochloperazine, chlorpromazine
Treximet
Sumatriptan - naproxen
Oral formulation that works well
Naratriptan
Amerge
Oral tabs
The only triptan the patient has to wait 4 hours between doses. ( other triptans you only have to wait 2 )
Also it takes 1 to 3 hours to work. Slow onset
Rizatriptan
Maxalt / Maxalt -MLT
Oral and odt
2 hours between each dose.
Onset 30 mins.
Sumatriptan
Imitrex
Alsuma- subq initial dose 6 mg
Sumavel - subq initial dose 6mg
Zembrace - subq initial dose 3 mg
Onzetra - nasal formulation ( second quickest after sub q form)
Tabs subQ nasal
Only Triptan that comes subq
2 hours between doses. ( for subq only have to wait one hour between doses )
Onset 30-60 min
Max dose of 200 mg in 24 hours
Zolmitriptan
Zomig; zomig zmt
Oral, odt, nasal
Almotriptan
Axert
Frovatriptan
For a
Eletriptan
Relpax
TRIPTANS MOA
SE
Contraindications
MOA: 5HT receptor agonists
SE: N headache recurrence, chest tightness, dizziness, sleepiness, parathesias ( numbness or tingling )
Contraindications: uncontrolled HTN, vasospastic angina ( prinzmetal), ischemic stroke, ischemic heart disease
Pregnancy category C
Kids 6- 11 recommend Maxalt tabs or imitrex nasal
Contraindicated with ergots and MAOI’s ( linezolid , tedizolid )
DDI with TRIPTANS
Triptans increase 5HT ( watch for additive ): ssri, SNRI,
Watch for MAOI: selegiline : EMSAM MAOI watch for high doses.
Almotriptan
Axert
All triptans pregnancy category C
Only tabs
2 hours between dose
Onset 30-60 mins
Frovatriptan
Frova
Only comes in 2.5 mg tabs
2 hrs between doses.
Longest elimination half life 24 hours
But slow onset about 2 hours
Eletriptan
Relpax
Only tabs
Max 80mg/day
Works in 30 to 60 mins
DDI: cyp3a4 substrate. Do not use withing 72 hours of strong inhibitors ( keto, itra, voriconazole, posconazole, erythromycin, clarithromycin, verapamil, diltiazem, any protease inhibitor, strongest is Ritonavir ) and grapefruit juice too ( 3a4 inhibitor )
SubQ formulation works faster than other formulations
T and sumatriptan is the only fast formulation.
ODT formulations of triptans
Maxalt and zomig
Trexemet
Sumatriptan and naproxen
Ergot alkaloids
Major vasoconstrictors ( much more than triptans). They increase 5HT, increase NE, dopamine.
Pregnancy category X.
Indication: Migraine / one for cluster headache
• dihydroergotamine mesylate
Migranal - nasal spray
D.H.E. 45 : IV IM SQ
• ergotamine Tartrate
( ergomar ) SL Tabs
•ergotamine + caffeine
Cafergot ( Tabs ) and Migergot( suppository )
Butalbutal / Caffeine / APAP
Fioricet - cet for apap
Fiorinal - ASA instead of apap. C3 bc it has increased CNS effects
Nodolor
Isomethptene + Dichloralphenazone + acetaminophen
Isometheptene is a vasoconstrictor
Dichloralphenazone : sedating analgesic effect
Apap :
Max 5 caps in 12 hours
DDI : maoi’s
Excedrin migraine
OTC
Apap + ASA + Caffeine
Pregnancy category D: aspiring component
New migraine medications
Prevention: monoclonal abs ( mabs) : all refrigerated. Dont shake them.
• Erenumab ( Aimovig ) SQ
• Fremanezumab ( Ajovy ) SQ
•Galcanezumab ( Emgality ) SQ
•Eptinezumab ( Vyepti ) IV
Treatment:
Calcitonin gene related peptide ( CGRP ) antagonists
( Gepant’s ) - all are cyp3a4 substrates
Remegepant ( Nurtec ODT ) - cyp3a4 substrate
Uborgepant ( Ubrelvy ) -cryp3a4 substrate
Selective serotonin 5-HT1 F agonists : Lasmiditan ( Reyvow)
Rimegepant
Nurtec ODT
CGRP antagonist for the tx of migraine
Max 75 mg /24 hours
Dose : 75 mg odt as a single dose
Wait 48 hours if on a moderate cyp3a4. Avoid if on strong cyp3a4
Inhibitors will increase it. And inducers will decrease it.
Strong cyp3a4 inhibitors
GPAC
Grapefruit juice
Protease Inhibitors - strongest is Ritonavir
Azoles and amiodarone
Clarithromycin and erythromycin and CCB ( verapamil and diltiazem )
Strong Cyp3a4 inducers
SRCOP
St. John’s wort
Rifampin ( major inducer )
Carbamazepine,
oxcarbazepine,
phenytoin, phenobarbital
Ubrogepant
Ubrelvy
1 hour onset ( Nurtec was 2 )
Lasmiditan
reyVow: this is CV C5
SE: major sedation. Hullicinations euphoria. Dont drive or operate ( at least 8 hours)
Benefit: unlike triptans this does not cause vasoconstriction.
DDI : watch for serotonin syndrome
What drugs increase seratonin?
SSRIs, SNRIs
MAOIs linezolid ( zyvox) tedizolid ( Sivextro ) , phenelzine
Pain: tramadol, nucenta ( tapendatol ) , fentanyl, methadone, meperidine
TCAs
Cyclobenzaprine ( structurally like TCA and carabamazepine )
Cluster headaches
Very painful. Usually on one side of the face for patient.
Need tx that works fast. ( SQ sumatriptan is fastest)
Prophylaxis : verapamil 240 mg /day in divided doses
