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Migraine Definition
Decreased in serotonin -> release of neuropeptides -> vasodilation
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Common Migraine Triggers
- Hormonal changes
- Foods (beer, red wine, aged cheese, chocolate)
- Stress
- Sensory Stimuli (bright lights, sun, loud sounds)
- Missing Sleep
- Changing weather
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Natural Products for Tx
- Butterbur
- Coenzyme Q10
- Feverfew
- Fish Oils
- Guarana
- Magnesium
- Riboflavin
- Willow bark (salicylate)
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Triptans
- Acute Tx for migraines
- 5HT1 Receptor Agonists
- constriction of vessels, ihibits neuropeptide release, dec pain transmission
- S/E: triptan sensations, hot/cold sensations, paresthesia, nausea, dizziness
- CI: cerebrovascular d(x), uncontrolled HTN, MAOI, serotonergics, phenylketonuria
- Naratriptan (Amerge)
- Frovatriptan (Frova)
- Almotriptan (Avert)
- Sumatriptan (Imitrex)
- Rizatriptan (Maxalt, Maxalt XLT)
- Eletriptan (Relpax)
- Zomitriptan (Zomig, Zomig ZMT)
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Naratriptan
- AMERGE-5HT1 Receptor Agonists
- :LONG ACTING
- :Acute Tx for migraines
- :constriction of vessels, inhibits neuropeptide release, dec pain transmission
- S/E: triptan sensations, hot/cold sensations, paresthesia, nausea, dizziness
- CI: cerebrovascular d(x), uncontrolled HTN, MAOI, serotonergics, phenylketonuria
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Frovatriptan
- FROVA-5HT1 Receptor Agonists
- LONG ACTING
- Acute Tx for migraines
- constriction of vessels, inhibits neuropeptide release, dec pain transmission
- S/E: triptan sensations, hot/cold sensations, paresthesia, nausea, dizziness
- CI: cerebrovascular d(x), uncontrolled HTN, MAOI, serotonergics, phenylketonuria
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Almotriptan
- AXERT- 5HT1 Receptor AgonistSHORT ACTING
- Acute Tx for migraines
- constriction of vessels, inhibits neuropeptide release, dec pain transmission
- S/E: triptan sensations, hot/cold sensations, paresthesia, nausea, dizziness
- CI: cerebrovascular d(x), uncontrolled HTN, MAOI, serotonergics, phenylketonuria
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Sumatriptan
- IMITREX- 5HT1 Receptor Agonist
- SHORT ACTING
- PO - 25, 50, 100mg (Can repeat 1x after 2hr)
- Injection - 4, 6mg (can repeat 1x after 1hr)
- Nasal Spray - 5, 20mg (can repeat 1x after 2hr)
- Acute Tx for migraines
- constriction of vessels, inhibits neuropeptide release, dec pain transmission
- S/E: triptan sensations, hot/cold sensations, paresthesia, nausea, dizziness
- CI: cerebrovascular d(x), uncontrolled HTN, MAOI, serotonergics, phenylketonuria
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Rizatriptan
- MAXALT, MAXALT XLT - 5HT1 Receptor Agonist
- SHORT ACTING
- Acute Tx for
migraines - PO - 5, 10 mg (can repeat 1x after 2 hr)
- Disinteg. tab. - 5mg (no water needed)
- constriction of vessels, inhibits neuropeptide release, dec pain transmission
- S/E: triptan sensations, hot/cold sensations, paresthesia, nausea, dizziness
- CI: cerebrovascular d(x), uncontrolled HTN, MAOI, serotonergics, phenylketonuria
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Eletriptan
- RELPAX - 5HT1 Receptor Agonist
- SHORT ACTING
- Acute Tx for migraines
- PO - 20, 40mg (can repeat 1x after 2hr)
- constriction of vessels, inhibits neuropeptide release, dec pain transmission
- S/E: triptan sensations, hot/cold sensations, paresthesia, nausea, dizziness
- CI: cerebrovascular d(x), uncontrolled HTN, MAOI, serotonergics, phenylketonuria
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Zolmitriptan
- ZOMIG, ZOMIG ZMT - 5HT1 Receptor Agonist
- SHORT ACTING
- Acute Tx for migraines
- PO - 2.5, 5mg (can repeat after 2hr)
- Nasal Spray - 5mg (can repeat after 2hr)
Disinteg. tab. - 2.5, 5mg (no water needed) - constriction of vessels, inhibits neuropeptide release, dec pain transmission
- S/E: triptan sensations, hot/cold sensations, paresthesia, nausea, dizziness
- CI: cerebrovascular d(x), uncontrolled HTN, MAOI, serotonergics, phenylketonuria
- Nasal Spray Counseling:
- blow nose gently before use
- do not prime nasal spray
- do not press plunger until tip is in nostril
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Fioricet / Fioricet w/Codeine
- APAP/Butalbital/Caffeine Acute Migraine Tx
- Must taper off or worsening of HA
- Do NOT mix with alcohol
- Do NOT exceed 4g of APAP in 1 day
- S/E: N/V, abdominal pain, sedation
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Fiorinal / Fiorinal w/Codeine
- ASA/Butalbital/Caffeine
- Acute Migraine Tx
- Must taper off or worsening of HA
- Do NOT mix with alcohol
- S/E: Somnolence
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Ergotamines
- ERGOMAR
- ERGOSTAT
- CAFERGOT (ergotamine w/caffeine)
- DIHYDROERGOTAMINE (DHE-45, Migranal nasal spray)
- Pregnancy X
- BBW: Do NOT use with CYP3A4 Inhibitors ->risk of cerebral ischemia
- S/E: N/V, muscle pain, angina, tachy/bradycardia, leg weakness
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Migraine Prophylaxis
- ~50 % reduction in migraines
- Use if >1 migraine/mo
- Use if severe migraines
- May have to try 1+ agent b4 finding one that works for that pt.
- Try for 2-6mo before switching
- 1st line: Propranolol, Timolol, Topiramate, Na Valproate, Amitriptyline, Divalproex
- 2nd line: ACE, Antidepressants, BCPs, Botulinum toxin A inj.
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Rebound HA
- Medication overuse
- NSAIDs
- Narcotics
- Analgesic combination products
- Triptans
- Ergotamines (except DHE)
- Limit acute treatment meds to 2-3x/wk
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