Migraine Headache

Topiramate.

TOPAMAX. Most extensively studied anticonvulsant used in migraine prophylaxis. Can cause paresthesias, fatigue, anorexia, diarrhea, weight loss, memory problems, language problems, taste perversion, and nausea. Should be used with caution in patients with a history of kidney stones. Pregnancy category D.

Sumatriptan & naproxen.

TREXIMET. 5HT1 agonist and NSAID.

What is a cluster headache?

Uncommon headache produced by decreased sympathetic/increased parasympathetic activity, as well as vasoactive neuropeptide release and neurogenic inflammation.

What is the clinical presentation of a cluster headache?

Unilateral, severe, intermittent, sharp/stabbing pain, parasympathetic symptoms (lacrimation, rhinorrhea, sweating), occurring at night, patients are restless, and generally lasts less than 10 minutes but repeats during the day.

What are therapeutic considerations with triptans?

First line for moderate to severe pain as rescue therapy after a non-specific agent (most effective, least nauseating). Most effective when pain is caught early.

What constitutes the diagnosis of chronic migraine headaches?

Five or more attacks fulfilling the criteria.

Describe the use of opioids in migraine treatment.

Oxycodone, codeine, and hydromorphone can be used as rescue therapy if there is no relief from other options or contraindications to the other options. Risk of dependency and overuse HA.

What are the adverse reactions of triptans?

Parasthesias, fatigue, dizziness, flushing, warmth, somnolence, chest tightness, and local side effects with SQ or intranasal formulations.

Who should not use triptans?

Patients with ischemic heart disease, Prinzmetal's angina, previous MI, hemiplegic/basilar migraine (puts patient at higher risk for stroke), uncontrolled HTB, TIA/CVS, or PVD. Should not be taken within 14 days of taking MAOI or within 24 hours of ergotamine derivatives. Should be taken with caution in people with high risk for CAD or on a current SSRI/TCA.

Who should not take ergotamines?

Patients with renal/hepatic failure, cardiac disease (CAD, CVA/TIA, PVD), uncontrolled HTN, CYP3A4 inhibitors, use within 2 weeks of MAOIs, use within 24 hours of triptans, and pregnant women (category X).

Who should not use tricyclic antidepressants?

People with BPH or glaucoma. Pregnancy category C.

Eletriptan.

RELPAX. Comes as oral tablets. 5HT1 agonist.

What are the goals of therapy for migraine headaches?

Reduce frequency and severity of attacks, improve quality of life, reduce medication escalation, treat attacks rapidly to restore normal level of functioning, optimize self-care to maximize cost effectiveness and decrease ER visits, and minimize adverse effects.

What is the mechanism of action of analgesics?

Reduce inflammatory prostaglandin production and prevent inflammation in trigeminovascular system.

What triptans are cleared renally?

Almotriptan and naratriptan.

What is the first line of treatment for migraines?

Analgesics are generally effective, less expensive, and cause less side effects. Should be used for mild to moderate pain, or pain that has previously responded to this therapy.

What are the adverse events associated with tricyclic antidepressants?

Anticholinergic side effects, increased appetite/weight gain, orthostatic hypotension, and cardiac toxicity.

What is the mechanism of action of triptans?

5HT1 agonists that increase vasoconstriction, inhibit peripheral neurons, and inhibit transmission of the trigeminocervical complex.

What is the mechanism of action of ergotamines?

5HT1A1 agonists.

Almotriptan.

AXERT. Comes as oral tablets. 5HT1 agonist.

What is the treatment strategy for a patient with tension headaches?

Acute treatment- self-care with analgesics and NSAIDs. OTC APAP and NSAIDs are first line. Other options include Rx NSAIDs, butalbital or codeine.

Injectible botulinum neurotoxin type A.

BOTOX. Injections given every 12 weeks for the prevention of chronic migraine in adults who have headaches more than 15 days/month that last more than 4 hours/day. Inhibits substance P, CGRP, and glutamate release. Can cause pain at injection site, neck stiffness, and respiratory distress. Pregnancy category C.

What place do beta blockers hold in migraine therapy?

Beneficial in patients with comorbid conditions that may benefit from BB or healthy patients.

What are adverse effects of beta blockers?

Bradycardia, hypotension, drowsiness, fatigue, sleep/memory disturbances, depression, and impotence.

What is the last line of therapy for migraines?

Burophanol nasal spray.

What pregnancy category are triptans?

Category C.

What pregnancy class are antiemetics that are used in migraines?

Category C.

What is the place in migraine therapy for antidepressants?

Comorbid depression or insomnia.

When can NSAIDs be used in the prevention of migraines?

Could be considered acutely for predictable migraine patterns (like menstrual migraines). Give 1-2 days prior to expected onset, but avoid continued use.

Frovatriptan.

FROVA. Comes are oral tablets. 5HT1 agonist.

What is the treatment strategy for a patient with cluster headaches?

First line for acute treatment is 100% oxygen via mask. Other options are ergotamines and triptans. Prophylaxis includes verapamil, lithium, ergotamine, and steroids.

Dexamethasone.

DECADRON. Used as an adjunct to abortive therapies during an acute attack and status migrainosus. IV injection can be used to prevent migraine recurrence in the next 72 hours (reduces recurrence by 26% with no effect on pain).

Valproic acid/divalproex sodium.

DEPAKOTE. Anticonvulsant used in migraine prophylaxis. Can cause nausea, vomiting, alopecia, tremor, somnolence, weight gain, and hepatotoxicity. Should not be used in patients with pancreatitis or chronic liver disease. Pregnancy category X for migraines. No definitive blood level for migraine prevention.

What precautions exist with beta blockers?

Depression, asthma, and diabetes. Pregnancy category C.

What is the mechanism of action of antidepressants?

Downregulation of central 5HT3 receptors, increased synaptic NE, and enhanced endogenous opioid receptor activity.

Amitriptyline.

ELAVIL. Tricyclic antidepressant used in migraine prophylaxis.

Ergotamine.

ERGOMAR. Formulated as an oral tablet with caffeine, a SL tablet, and a rectal suppository. 5HT1A1 agonist.

Acetaminophen/aspirin/caffeine.

EXCEDRIN. NSAID shown to be superior to ibuprofen and fast acting.

What is the treatment strategy for a patient with migraine headaches?

Educate patient, assess for prophylaxis, treat N/V, assess pain (mild, moderate, severe?). If mild to moderate, analgesics, combo products, triptans or ergotamine if ineffective. If severe, triptans or ergotamine, opioid plus analgesic or nasal butorphanol if ineffective.

What is the mechanism of action of anticonvulsants?

Enhancement of GABA activity, modulation of excitatory neurotransmitters, sodium/calcium ion channel inhbition.

What are common triggers for a migraine headache?

Exertion, menstruation, lights, noise, smells, tobacco smoke, sleep extremes, caffeine/withdrawal, dairy products, fatty foods, chocolate tyramines, and alcohol.

Propranolol.

INDERAL. Beta-blocker used in migraine prophylaxis.

What does it mean that there is not class effect with triptans?

If one agent is ineffective, you can try another one. (Just because one does not work doesn't mean they all won't work).

What are non-pharmacological treatments for patients with migraines?

Keep a headache diary (track triggers, frequency, severity, and response to treatment), behavioral interventions (relaxation therapy, biofeedback, cognitive-based therapy), environmental control (rest in quiet, dark area; use ice packs), and healthy lifestyle (regular sleep, exercise, smoking cessation, and limited caffeine).

Rizatriptan.

MAXALT. Comes as oral tablets and ODT. 5HT1 agonist.

Dihydroergotamine.

MIGRANAL. Formulated as an IM, IV, or SQ injection and a nasal spray. 5HT1A1 agonist.

What is the mechanism of action of beta blockers?

May alter serotonin neurotransmission.

What antiemetics are often used to treat the nausea and vomiting associated with migraines?

Metoclopramide (IV/IM/PO), prochlorperazine (IV/IM/PR/PO), and chlorpromazine (IV/PO).

What is the clinical presentation of a tension headache?

Mild to moderate severity, nonpulsating, band-like pressure or tightness, bilateral pain, no systemic symptoms, and lasts less than 4 hours.

What are indications for migraine prophylaxis?

More than 2 migraines/week, significant interference with daily life, problems with acute therapy, patient preference, unusual presentation of migraines, and predictable pattern.

What is a tension headache?

Most common headache disorder (most patients don't present for care) that is influenced by environmental factors. Usually caused by muscle contraction and central sensitization to pain.

What treatment considerations should be analyzed when looking at acute treatment?

Most effective if initiated in the first hour of symptom onset, non-specific agents for mild to moderate attacks, migraine-specific therapies for severe attacks, oral routes may be less effective, and medication overuse headache (limit acute options to 2d/week to prevent rebound HA).

Naratriptan.

NARAMIG. Comes as oral tablets. 5HT1 agonist.

What are the adverse effects of ergotamines?

Nausea, vomiting, abdominal pain, diarrhea, weakness, fatigue, paresthesias, muscle pain, chest tightness, and peripheral ischemia (vasoconstrictor effects).

Butorphanol nasal spray.

STADOL NS. Last line of therapy for migraines. Alternative to injection. Mixed opioid agonist/antagonist with established risk of overuse and dependence.

What precautions should be taken with SNRIs?

Serotonin syndrome can occur with concomitant triptan use.

What is the clinical presentation of a migraine headache?

Severe enough pain to interfere with daily activities. Can present with or without aura (flickering lights, spots, wavy lines, partial loss of vision, numbness, parasthesias, and speech deficits). Pain worsens with activity, is unilateral, and is pulsating. Patient also has at least 2 of the following: nausea, vomiting, photophobia, phonophobia, and osmophobia.

What is a migraine headache?

Severe headache caused by extracranial vasodilation, activation of trigeminal sensory nerves causing release of vasoactive neuropeptides, and sensitization of CNS sensory neurons.

When should effects from migraine prophylactic treatment be seen?

Should see effects within a month, but 2-6 months are necessary to evaluate the efficacy.

SUMAVEL DOSEPRO.

Sumatriptan (SQ inject). 5HT1 agonist.

IMITREX.

Sumatriptan (tablets, nasal spray). 5HT1 agonist.

Why can antiemetics be used in the treatment of migraines?

Treatment of nausea/vomiting is important- may allow for PO treatment options that the patient would not otherwise be able to tolerate.

What is the place in migraine therapy for anticonvulsants?

Useful in prophylaxis with concomitant seizure disorder or psychiatric disorders.

What is considered the first line of therapy for migraine prophylaxis?

Valproic acid, topiramate, amitriptyline, propranolol, metoprolol, and timolol.

What drugs are FDA approved for migraine prevention?

Valproic acid, topiramate, propranolol, and timolol.

Zolmitriptan.

ZOMIG. Comes as tablets, ODT, and nasal spray. 5HT1 agonist.