Pharmacology-Migraine Therapy

Question 1

A patient presents with throbbing one-sided headaches one a month. They are very painful, made worse by alcohol, menstrual cycle and stress. She says light makes it worse. Her mother had a similar condition. Excedrin is no longer working for her. What may be causing her symptoms?

Answer 1

She is experiencing migraines. The core event in development of migraines is activation of the trigeminal vascular output. This can be caused by with peripheral nerve inflammatory messengers or CNS sensitization.

Question 2

Treatment for patients with migraines that don’t need to see the doctor?

Answer 2

NSAIDs, Tylenol, Anti-emetics.

Question 3

Treatment for patients who only need medications for migraine attacks?

Answer 3

Triptans (abortive). Make sure you know Sumatriptan for the exam.

Question 4

Treatment for patients who require prophylactic migraine medication?

Answer 4

Beta blockers (propranolol), anti-seizure (topiramate), anti-depressants (amitryptyline), Ca channel blockers (Verapamil), NSAIDs (Ibuprofen), neurotoxins (BONT)

Question 5

What should you try if Sumatriptan does not help your patient abort her migraines?

Answer 5

Another triptan. Just because on triptan didn’t work doesn’t mean the whole class won’t work.

Question 6

How do triptans work?

Answer 6

They are 5-HT1 receptor agonists. These are presynaptic inhibitory receptors that decrease adenylyl cyclase activity. This reduces the amount of serotonin released.

Question 7

What are contraindications for use of triptans?

Answer 7

Ischemic heart disease, uncontrolled HTN and cerebrovascular disease. These drugs can worsen these symptoms due to vasoconstriction. They should not be used with MAO-I because MAO metabolizes Sumatriptan.

Question 8

Why might other triptans have better efficacy than Sumatriptan?

Answer 8

Sumatriptan cannot cross the BBB.

Question 9

Why do ergotamines have more side effects than triptans?

Answer 9

They act as agonists & antagonists at alpha-adrenergic, serotonergic and dopamine receptors.

Question 10

When are ergots contraindicated?

Answer 10

Pregnancy (causes uterine smooth muscle contraction), coronary heart disease (vasoconstriction) and impaired liver function.

Question 11

CGRP antagonists

Answer 11

Gepants.