Migrane Medicaitions

Question 1

Triptans

Answer 1

• serotonin receptor agonists (5-HT1B and 5-HT1D)
• 1st line for mild-severe
• rescue for when NSAIDs/analgesics don’t work
• Sumatriptan, zolmitriptan, almotriptan, frovatriptan, eletriptan, naratriptan, rizatriptan
• frova and nara have slower onsers and reduced efficacy, longest t1/2
• MOA: by engaging receptors–> normalization of dilated intracranial arteries via vasoconstriction. —-> inhibition of vasoactive peptide release from perivascult trigem neurons. —–> inhibition of transmisison via 2nd order neuron ascending through thalamus
• Adverse effects: paresthesias, dizziness, fatigue, flushing, sleepy. Tightness in chest, neck, throat
• Contraindication: hx of ischemic heart disease, uncontrolled HTN, CVD, ppl using SSRIs or SNRIs because serotonin syndrome can occur

Question 2

Ergot Alkaloids

Answer 2

• moderate-severe migraine
• MOA: non-selective 5-HT1 receptors. Causes constriction of intracranial BVs and inhibit development of neurogenic inflammation in trigeminovascular system. Central inhibition of trigeminovascular pathway.
• Adverse affects: nausea and vomiting, abdominal pain, weakness, fatigue, paresthesias, muscle pain, diarrhea, chest tightness
• Contraindication: renal or hepatic failure, coronary/cerebral/peripheral vascular disease, uncontrolled HTN, sepsis, pregnancy, nursing

Question 3

B-Blockers

Answer 3

• prophylaxis
• Metoprolol, propanolol, timolol
• adverse effects: drowsiness, fatigue, sleep disturbances, vivid dreams, memory disturbance, depression, impotence, brady, hypoTN.
• Contraindicated in CHF, PVD, asthma, depression, DM

Question 4

Antidepressants

Answer 4

-Prophylaxis
Tricyclic: amitriptyline
SNRI: venlafaxine
-good for pts with comorbid depression or insomnia
-MOA is thought to be related to downreg of central 5-HT2 receptors and increased levels of synaptic norepi and enhanced endogenous opioid receptor actions.
-Adverse effects: anticholinergic with amitriptyline, increased appetite/weight gain. Venlafaxine: nausea, vomiting, drowsiness
-Contraindications: BPH, glaucoma

Question 5

Anticonvulsants

Answer 5

• Prophylaxis
• valproate, divalproex, topiramate
• good for pts comorbid seizure disorder or bipolar
• titrate up
• benefits of topamax seen as early as 2 weeks after initiation, significant reduciton in migraines after 1 month
• MOA: enhancement of GABA-mediated inhibition, modulation glutamate, inhibition of Na/Ca ion channel activity
• Adverse effects: nausea, vomiting, alopecia, tremor, asthenia, sleepy, weight gain. Valproate: hepatotox, so baseline AST/ALT important for initiation of monotherapy. Topamax: paresthesia, fatigue, anorexia, diarrhea, memory issues, language problems, taste perversion.
• Contraindications of topamax: hx of kidney stones or cog impairment

Question 6

Prophylactic NSAIDs or Triptans

Answer 6

• useful to prevent menstrual migraines bc predictable.
• take meds at time of vulnerability, 1-2 days before expected onset of headache and continue during period of vulnerability