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Flashcards in 35. Migraines Deck (31):
1

Jeff comes into the pharmacy to drop off a prescription for an antibiotic to treat bronchitis. The patient mentions that he has migraine headaches from time-to-time and that his doctor told him to take something over the counter. The patient reports having a severe reaction to acetaminophen. What OTC product would you recommend for this patient?

A. Tylenol
B. Motrin
C. Excedrin Migraine
D. The store brand medication labeled "non aspirin" pain reliever.
E. Axert

B. Some patients with occasional migraines find acceptable relief with OTC products, including NSAIDs or Excedrin Migraine (acetaminophen + aspirin + caffeine). Most stores have a store-brand (less expensive) formulation of this product.

2

Which of the following represent possible "triggers" for migraine attacks and should be avoided, if possible, in susceptible patients? (Select ALL that apply.)

A. Changes in hormone levels
B. Lemon and orange juice
C. Stress
D. Alcohol
E. Bright lights

A, C, D, E. Other triggers include certain foods (including monosodium glutamate, or MSG, and red wine), changes in wake/sleep, and changes in weather. Stress is a major instigator in migraines, as well as hormonal changes in women. Pre-menstrual migraine is the most common type of migraine headache.

Triggers: hormonal changes in women (fluctuations in estrogen; monophasic OC may help reduce migraines; progestin-only OC in migraines with aura), food (alcohol, aged cheeses, chocolate, aspartame, caffeine overuse, MSG, salty foods, processed foods), stress, sensory stimuli (bright light, sun glare, loud sound, scents), changes in wake-sleep pattern, changes in environment (weather or barometric pressure)

3

Dihydroergotamine (DHE) products contain the following boxed warning:
Serious and life threatening peripheral ischemia have been associated with the use of DHE and use of which of the following:

A. Nitrates
B. Calcium channel blocking drugs
C. CYP 3A4 Inhibitors
D. CYP 3A4 Inducers
E. CYP 2D6 Inhibitors

C. Protease inhibitors, macrolides (clarithromycin, erythromycin) and other 3A4 inhibitors are contraindicated with DHE.

Ergotamine Drugs

Primarily used when contraindications to triptans or do not respond to triptans. Stimulates cerebral vasoconstriction and has some effect on serotonin

dihydroergotamine (Migranal): IM/SQ, intranasal. For nasal spray: need to prime 4 times away from face, spray once into each nostril and if needed can repeat after 15 minutes. Boxed warning: peripheral ischemia with potent 3A4 inhibitors. Warnings: cardiac valvular fibrosis (valve thickening), cardiovascular effects (vasospasm, strokes), ischemia (possible gangrene). SE (nasal): rhinitis, dysgeusia (distortion of taste), nausea, dizziness. Pregnancy (X)

4

A pharmacist has a prescription for Migranal Nasal Spray for a patient using the following medications: lisinopril, metformin, atenolol, chlorthalidone and cimetidine. Select the reasonable option/s: (Select ALL that apply.)

A. Do not fill; contact the prescriber.
B. Change the H2RA to Pepcid.
C. Change the prescription to Cafergot.
D. Fill as written.
E. Fill as written after confirming the patient is pregnant.

A, B. The ergot products are pregnancy Category X and contain a boxed warning not to use with strong/moderate CYP 3A4 inhibitors (such as cimetidine) due to the risk of cerebral ischemia with higher drug levels.

5

A patient gave the pharmacist a prescription for Imitrex 50 mg PO at first sign of migraine, repeat x 1 if needed. Which of the following is an appropriate generic substitution for Imitrex?

A. Almotriptan
B. Sumatriptan
C. Rizatriptan
D. Eletriptan
E. Zolmitriptan

B. The generic name of Imitrex is sumatriptan.

sumatriptan (Imitrex, Alsuma): PO, injection, nasal spray, transdermal. PO dosed 25, 50, and 100mg, can repeat x1 after 2 hours (max 200mg/day). Comes in many forms (Sumavel injection; STATdose SC injection; nasal spray; Zecuity transdermal), CI with MAOIs

rizatriptan (Maxalt): PO, ODT. CI with MAOIs

eletriptan (Relpax): PO. CI with strong CYP 3A4 inhibitors (it's a 3A4 substrate)

frovatriptan (Frova): PO, longest half life (26 hours)

naratriptan (Amerge): PO, 2nd longest half life after frovatriptan

almotriptan (Axert): PO

zolmitriptan (Zomig): PO, ODT, nasal spray. CI with MAOIs

6

Which of the following medications is in accordance with the American College of Obstetricians and Gynecologists (ACOG) recommendations to treat pre-menstrual migraine with aura in a female patient? (Select ALL that apply.)

A. Alesse
B. Nor-QD
C. Nora-Be
D. Lybrel
E. Camila

B, C, E. If the migraine has aura and a birth control pill will be used to help control the migraines, a progestin-only pill should be chosen as this type of migraine has a higher risk of stroke; estrogen should be avoided.

7

You are counseling a new patient on the appropriate use of a Zomig Nasal Spray. Please select the following counseling point that does not apply?

A. Prime the nasal spray.
B. Blow your nose gently before use.
C. Do not press the plunger until you have put the tip into your nostril.
D. May repeat in 2 hours, if needed.
E. Remove the protective cap.
 

A. Usually nasal sprays are primed since it takes a few sprays to get the medication to come out. With these one-time devices, including the Zomig and Imitrex nasal sprays, if they are primed, the dose is lost.

8

Charles was recently discharged from the hospital for liver failure. His doctor is aware that Charles has a long history of migraine headaches, but he does not want to exacerbate his current liver condition. What agent is the most reasonable option for this patient?

A. Divalproex
B. Felbamate
C. Topiramate
D. Excedrin Migraine
E. Tylenol

C. Felbamate is not used for migraine prophylaxis. It is a drug reserved for refractive epilepsy due to the risk of hepatotoxicity. Topiramate represents the lowest risk among the agents listed.

divalproex (Depakote), valproic acid (Depakene): SE: liver toxicity, pancreatitis, sedation, weight gain, tremor, teratogenicity, thrombocytopenia, alopecia, nausea, polycystic ovarian syndrome, pregnancy (X) for migraine and (D) for others.

topiramate (Topamax): SE: nephrolithiasis, open angle glaucoma, hypohydrosis, depression, metabolic acidosis, weight loss, reduced efficacy of OC, cognitive impairment, pregnancy (D)

9

Dihydroergotamine (DHE) products are generally tried after triptans are found to be ineffective for treating acute migraine headaches. DHE has many warnings, including which of the following?

A. Severe hypotension, including loss of consciousness
B. Severe rash, including risk of SJS/TEN
C. Intense vasoconstriction, resulting in peripheral ischemia and possible gangrene
D. Hypogonadism, including infertility
E. Excessive fertility, including multiple fertilization

C. DHE products can cause pleural fibrosis (primarily with long-term use), cardiovascular events and heart valve fibrosis.

Ergotamine Drugs

Primarily used when contraindications to triptans or do not respond to triptans. Stimulates cerebral vasoconstriction and has some effect on serotonin

dihydroergotamine (Migranal): IM/SQ, intranasal. For nasal spray: need to prime 4 times away from face, spray once into each nostril and if needed can repeat after 15 minutes. Boxed warning: peripheral ischemia with potent 3A4 inhibitors. Warnings: cardiac valvular fibrosis (valve thickening), cardiovascular effects (vasospasm, strokes), ischemia (possible gangrene). SE (nasal): rhinitis, dysgeusia (distortion of taste), nausea, dizziness. Pregnancy (X)

10

What is the pregnancy category of Migranal?

A. Pregnancy category A
B. Pregnancy category B
C. Pregnancy category C
D. Pregnancy category D
E. Pregnancy category X

E. Dihydroergotamine products are contraindicated in pregnancy.

Ergotamine Drugs

Primarily used when contraindications to triptans or do not respond to triptans. Stimulates cerebral vasoconstriction and has some effect on serotonin

dihydroergotamine (Migranal): IM/SQ, intranasal. For nasal spray: need to prime 4 times away from face, spray once into each nostril and if needed can repeat after 15 minutes. Boxed warning: peripheral ischemia with potent 3A4 inhibitors. Warnings: cardiac valvular fibrosis (valve thickening), cardiovascular effects (vasospasm, strokes), ischemia (possible gangrene). SE (nasal): rhinitis, dysgeusia (distortion of taste), nausea, dizziness. Pregnancy (X)

11

Which of the following drugs used for migraine prophylaxis are best avoided in a female of child-bearing age?

A. Propranolol
B. Timolol
C. Valproic acid
D. Topiramate
E. Amitryptiline

C. Of the list above, valproic acid is the most teratogenic and should not be used in this patient population; many pregnancies were not planned at the time of conception.

divalproex (Depakote), valproic acid (Depakene): SE: liver toxicity, pancreatitis, sedation, weight gain, tremor, teratogenicity, thrombocytopenia, alopecia, nausea, polycystic ovarian syndrome, pregnancy (X) for migraine and (D) for others.

topiramate (Topamax): SE: nephrolithiasis, open angle glaucoma, hypohydrosis, depression, metabolic acidosis, weight loss, reduced efficacy of OC, cognitive impairment, pregnancy (D)

12

A patient is using ibuprofen for acute migraine treatment. He reports that it works fine. He told his doctor that he has occasional migraines which he self-treats with an over-the-counter medicine. His physician is not a good listener, and when the patient left the doctor’s appointment he found that the physician had left a prescription for sumatriptan for him at the front desk. Choose the correct statement:

A. Some patients find acceptable treatment for migraines with OTC products such as NSAIDs or acetaminophen-aspirin-caffeine combo drugs.
B. Aspirin-butalbital-caffeine is considered the first-line agent for acute migraines.
C. All patients receive higher efficacy with the use of prescription agents-these are considered first-line.
D. He should use naproxen instead of ibuprofen since ibuprofen lasts too long.
E. All of the above.

A. Some patients are treated well using triptan therapy. Others require both an NSAID and a triptan for adequate pain relief. OTC agents, in some patients, are the best option. Naproxen has a longer duration of action (Q12H) than ibuprofen.

13

Samantha has 2-3 migraines monthly. They reduce her ability to function for 2-3 days. Her daily medications include fosinopril for hypertension and a multivitamin. Choose the correct statement:

A. She should start daily therapy with sumatriptan.
B. She should start daily therapy with rizatriptan.
C. She should begin prophylaxis therapy to reduce her migraine incidence.
D. She does not need a daily prophylactic agent since she uses fosinopril.
E. She should begin daily therapy with Fiorinal.

C. If a patient uses acute treatment more than twice weekly, or has severe symptoms, or requests prophylaxis, an agent can be used to decrease migraine frequency. These agents can be antidepressants, anticonvulsants, vitamins or natural products, and are tried at a reasonable dose for 2-6 months. Female patients who have pre-menstrual migraines may find benefit with an oral contraceptive.

14

A pharmacist will help a patient identify common migraine triggers. Which of the following could be contributing to a migraine? (Select ALL that apply.)

A. Too much sleep
B. Too little sleep
C. Stress
D. Spicy foods, hot red pepper
E. Tomatoes

A, B, C.

Triggers: hormonal changes in women (fluctuations in estrogen; monophasic OC may help reduce migraines; progestin-only OC in migraines with aura), food (alcohol, aged cheeses, chocolate, aspartame, caffeine overuse, MSG, salty foods, processed foods), stress, sensory stimuli (bright light, sun glare, loud sound, scents), changes in wake-sleep pattern, changes in environment (weather or barometric pressure)

15

A pharmacist is dispensing eletriptan to a patient who has not used a triptan previously. She should counsel her on the likelihood of this side effect:

A. Electric shock sensations
B. Chest pressure/heaviness
C. Alopecia with chronic use
D. Activation/insomnia
E. Rash, with hives possible

B. Side effects from triptans: somnolence (sleepiness, not activation), nausea, paresthesias (tingling/numbness), throat/neck pressure, dizziness, hot/cold sensations, chest pain/tightness.

Triptans

MoA: Triptans are serotonin-receptor agonists (5HT-1 receptor agonists) causing vasoconstriction of cranial blood vessels, inhibiting neuropeptide release and decreasing pain transmission.

CI: cerebrovascular events (rare), cerebrovascular disease or uncontrolled hypertension, MAOIs (with Imitrex, Maxalt, Zomig only), caution with concurrent serotonergic agents (counsel patients to report restlessness, sweating, poor coordination, confusion, hallucinations when used with other serotonergic agents)

SE: somnolence, nausea, paresthesias (tingling/numbness), throat/neck pressure, dizziness, hot/cold sensations, chest pain/tightness. Triptan sensations include pressure in the chest or heaviness or pressure in the neck region and usually dissipate after administration

16

India comes to your pharmacy with a prescription for phenelzine (Nardil) to treat her depression. She wants to refill an old prescription on file to help alleviate her migraine symptoms. India cannot recall the name of the migraine medication but she knows that it is a triptan. Which medication can India safely take with phenelzine?

A. Imitrex
B. Maxalt
C. Relpax
D. Zomig
E. Alsuma

C. Imitrex, Maxalt, and Zomig are contraindicated with MAO Is, the other triptans are not.

sumatriptan (Imitrex, Alsuma): PO, injection, nasal spray, transdermal. PO dosed 25, 50, and 100mg, can repeat x1 after 2 hours (max 200mg/day). Comes in many forms (Sumavel injection; STATdose SC injection; nasal spray; Zecuity transdermal), CI with MAOIs

rizatriptan (Maxalt): PO, ODT. CI with MAOIs

eletriptan (Relpax): PO. CI with strong CYP 3A4 inhibitors (it's a 3A4 substrate)

frovatriptan (Frova): PO, longest half life (26 hours)

naratriptan (Amerge): PO, 2nd longest half life after frovatriptan

almotriptan (Axert): PO

zolmitriptan (Zomig): PO, ODT, nasal spray. CI with MAOIs

17

Dihydroergotamine is a popular migraine drug that can be administered by the following routes and delivery methods: (Select ALL that apply.)

A. Oral
B. Intramuscular
C. Subcutaneous
D. Transdermal
E. Nasal

B, C, E. The shot is 1 mg initially and can be repeated twice (hourly, if still needed, up to a max of 3 mg in 24 hours. The nasal spray is given one spray into each nostril, and can be repeated after 15 minutes for a total of 4 sprays. Each spray provides 0.5 mg, and the max total dose is 2 mg.

Ergotamine Drugs

Primarily used when contraindications to triptans or do not respond to triptans. Stimulates cerebral vasoconstriction and has some effect on serotonin

dihydroergotamine (Migranal): IM/SQ, intranasal. For nasal spray: need to prime 4 times away from face, spray once into each nostril and if needed can repeat after 15 minutes. Boxed warning: peripheral ischemia with potent 3A4 inhibitors. Warnings: cardiac valvular fibrosis (valve thickening), cardiovascular effects (vasospasm, strokes), ischemia (possible gangrene). SE (nasal): rhinitis, dysgeusia (distortion of taste), nausea, dizziness. Pregnancy (X)

18

A patient gave the pharmacist a prescription for Maxalt 5 mg PO at first sign of migraine, can repeat x 1 if migraine pain persists. Which of the following is an appropriate generic substitution for Maxalt?

A. Almotriptan
B. Sumatriptan
C. Rizatriptan
D. Eletriptan
E. Zolmitriptan

C. The generic name of Maxalt is rizatriptan.

sumatriptan (Imitrex, Alsuma): PO, injection, nasal spray, transdermal. PO dosed 25, 50, and 100mg, can repeat x1 after 2 hours (max 200mg/day). Comes in many forms (Sumavel injection; STATdose SC injection; nasal spray; Zecuity transdermal), CI with MAOIs

rizatriptan (Maxalt): PO, ODT. CI with MAOIs

eletriptan (Relpax): PO. CI with strong CYP 3A4 inhibitors (it's a 3A4 substrate)

frovatriptan (Frova): PO, longest half life (26 hours)

naratriptan (Amerge): PO, 2nd longest half life after frovatriptan

almotriptan (Axert): PO

zolmitriptan (Zomig): PO, ODT, nasal spray. CI with MAOIs

19

Bonnie is expecting her first child and has been complaining of frequent headaches. She comes into your pharmacy and she states that she is 20 weeks into the pregnancy and would like to find some relief. You can recommend occasional use of the following product:

A. Aspirin
B. Excedrin Migraine
C. Aleve
D. Acetaminophen
E. Motrin

D. Acetaminophen is the analgesic/antipyretic drug-of-choice (DOC) during pregnancy although, if possible, drugs are avoided in pregnancy. They are used when the benefit outweighs any possible risk. NSAIDs pose risk in pregnancy and although they may come in on a prescription, they should not be recommended OTC.

20

A patient takes one dose of Imitrex injection. About 90 minutes later, her migraine is partially relieved but she still has "pounding" pain in her head. She wishes to use a second dose. Choose the correct statement:

A. She can use a second dose now; two doses are the maximum.
B. She can use up to three doses at any time.
C. She can use up to four doses at any time.
D. She cannot use any additional headache medication after the dose she has taken.
E. She can supplement with an NSAID, but not use more of the triptan-drug.

A. Sumatriptan is the most commonly used agent and is tier 1 on most formularies. Sumatriptan dosing: 

PO: 25, 50 & 100 mg, can repeat x 1 after 2 hours. 
Nasal Spray: 5, 20 mg, can repeat x 1 after 2 hours. 
SC inj: 4, 6 mg, can repeat x 1 after 1 hour. Use injectable or nasal for either faster onset, or if nausea is present.

21

Agnes is hospitalized for a diabetic foot infection. Her current medications include insulin glargine 50 units BID, insulin glulisine as-directed, sertraline 100 mg daily, Zyban 150 mg BID and linezolid 600 mg twice daily. Agnes has been told that she will lose her left foot. The stress has induced a migraine headache. The doctor orders sumatriptan 50 mg x 1 now. Choose the correct statement:

A. Do not fill; replace with eletriptan.
B. This is the safest triptan to use and is first-line, but do not use any others; acceptable to fill as-written.
C. Do not fill any triptan at present.
D. She should use atenolol instead.
E. She should use duloxetine instead.

C. The FDA has a warning about combining triptans with serotonergic drugs. Most often, the patient is using an SSRI or SNRI that triggers the computer alert. If you do fill a prescription for a combination of two serotonergic drugs at reasonable doses, be sure to counsel the patient to report restlessness, sweating, poor coordination and confusion or hallucinations.

Triptans

MoA: Triptans are serotonin-receptor agonists (5HT-1 receptor agonists) causing vasoconstriction of cranial blood vessels, inhibiting neuropeptide release and decreasing pain transmission.

CI: cerebrovascular events (rare), cerebrovascular disease or uncontrolled hypertension, MAOIs (with Imitrex, Maxalt, Zomig only), caution with concurrent serotonergic agents (counsel patients to report restlessness, sweating, poor coordination, confusion, hallucinations when used with other serotonergic agents)

SE: somnolence, nausea, paresthesias (tingling/numbness), throat/neck pressure, dizziness, hot/cold sensations, chest pain/tightness. Triptan sensations include pressure in the chest or heaviness or pressure in the neck region and usually dissipate after administration

22

A patient gave the pharmacist a prescription for Fiorinal. Choose the correct statement concerning Fiorinal:

A. It contains butalbital (a barbiturate)
B. It is a C-IV agent
C. Physiological dependence risk is low
D. It is a C-II agent
E. It is the preferred treatment for migraine prophylaxis

A. This agent has risk for physiological dependence. It is scheduled as C III.

acetaminophen/butalbital/caffeine (Fioricet), aspirin/butabital/caffeine (Fiorinal): not recommended for migraines due to dependence risk

23

Choose the correct mechanism of action of sumatriptan:

A. Serotonin receptor antagonist
B. Serotonin receptor agonist
C. Dopamine receptor antagonist
D. Dopamine receptor agonist
E. Serotonin-Dopamine receptor agonists

B. The triptans are serotonin receptor agonists. Blood vessels in the brain become dilated during a migraine attack and the triptans, by binding to serotonin (5HT-1) receptors, cause cranial vessel constriction.

Triptans

MoA: Triptans are serotonin-receptor agonists (5HT-1 receptor agonists) causing vasoconstriction of cranial blood vessels, inhibiting neuropeptide release and decreasing pain transmission.

CI: cerebrovascular events (rare), cerebrovascular disease or uncontrolled hypertension, MAOIs (with Imitrex, Maxalt, Zomig only), caution with concurrent serotonergic agents (counsel patients to report restlessness, sweating, poor coordination, confusion, hallucinations when used with other serotonergic agents)

SE: somnolence, nausea, paresthesias (tingling/numbness), throat/neck pressure, dizziness, hot/cold sensations, chest pain/tightness. Triptan sensations include pressure in the chest or heaviness or pressure in the neck region and usually dissipate after administration

24

Shira is an 18 year-old patient with asthma, iron-deficiency anemia, heavy menstrual bleeding and monthly migraines (without aura) that occur right before her period. Shira is in misery when she has a migraine. Choose a reasonable prophylactic option to help control the migraines:

ASumatriptan
BPropranolol
CAlesse
DBetaxolol
EFioricet

C. A birth control pill could reduce or even eliminate the pre-menstrual migraine that many women experience. In this case, it would also provide benefit in reducing blood loss and hopefully eliminating the anemia.

25

A pharmacist has a prescription for sumatriptan for a patient using the following medications: rosuvastatin, clopidogrel, aspirin, nitroglycerin SL, metoprolol and irbesartan. Her patient has checked his blood pressure on the store’s machine. It is currently 178/102. Should the pharmacist dispense the sumatriptan?

A. Yes, the patient could have high blood pressure from a migraine.
B. No, the patient cannot use sumatriptan with metoprolol.
C. No, the patient cannot use sumatriptan with rosuvastatin.
D. No, the patient cannot use sumatriptan with irbesartan.
E. No, the patient cannot use sumatriptan with this degree of hypertension.

E. Serious but rare cerebrovascular and cardiovascular events can occur; because of this, triptans are contraindicated in patients with cerebrovascular disease or uncontrolled hypertension. She has both.

Triptans

MoA: Triptans are serotonin-receptor agonists (5HT-1 receptor agonists) causing vasoconstriction of cranial blood vessels, inhibiting neuropeptide release and decreasing pain transmission.

CI: cerebrovascular events (rare), cerebrovascular disease or uncontrolled hypertension, MAOIs (with Imitrex, Maxalt, Zomig only), caution with concurrent serotonergic agents (counsel patients to report restlessness, sweating, poor coordination, confusion, hallucinations when used with other serotonergic agents)

SE: somnolence, nausea, paresthesias (tingling/numbness), throat/neck pressure, dizziness, hot/cold sensations, chest pain/tightness. Triptan sensations include pressure in the chest or heaviness or pressure in the neck region and usually dissipate after administration

26

A patient gave the pharmacist a prescription for Relpax 20 mg PO at first sign of migraine, repeat x 1 if needed. Which of the following is an appropriate generic substitution for Relpax?

A. Almotriptan
B. Sumatriptan
C. Rizatriptan
D. Eletriptan
E. Zolmitriptan

D. The generic name of Relpax is eletriptan.

sumatriptan (Imitrex, Alsuma): PO, injection, nasal spray, transdermal. PO dosed 25, 50, and 100mg, can repeat x1 after 2 hours (max 200mg/day). Comes in many forms (Sumavel injection; STATdose SC injection; nasal spray; Zecuity transdermal), CI with MAOIs

rizatriptan (Maxalt): PO, ODT. CI with MAOIs

eletriptan (Relpax): PO. CI with strong CYP 3A4 inhibitors (it's a 3A4 substrate)

frovatriptan (Frova): PO, longest half life (26 hours)

naratriptan (Amerge): PO, 2nd longest half life after frovatriptan

almotriptan (Axert): PO

zolmitriptan (Zomig): PO, ODT, nasal spray. CI with MAOIs

27

A patient gave the pharmacist a prescription for Fiorinal. This medicine is used for acute migraine pain, along with some other pain conditions. It contains the following medications: (Select ALL that apply.)

A. Aspirin
B. Acetaminophen
C. Butalbital
D. Caffeine
E. Codeine

A, C, D. Fiorinal also comes with codeine. Fioricet ends in -cet and contains butalbital and caffeine, but includes acetaminophen instead of the aspirin.

acetaminophen/butalbital/caffeine (Fioricet), aspirin/butabital/caffeine (Fiorinal): not recommended for migraines due to dependence risk

28

Amanda complains of frequent migraines at least twice a month. She takes propranolol daily to prevent migraine attacks, but still she reports not having any relief when she has an acute migraine attack. Her doctor prescribed Imitrex STATdose to provide relief at the onset of her migraine symptoms. What is the correct route of administration and the usual injection site?

A. SC, deltoid
B. SC, upper outside arm
C. SC, gluteus maximus
D. NS, nasal passage
E. SL, underside of tongue

B. Imitrex injections can be administered by prefilled SC syringe, or commonly using the STAT dose injection device. Inject the medication just below the skin (always SC, never IM or IV) as soon as symptoms of a migraine appear. Patients often inject into the front of the thigh or upper outside arm.

sumatriptan (Imitrex, Alsuma): PO, injection, nasal spray, transdermal. PO dosed 25, 50, and 100mg, can repeat x1 after 2 hours (max 200mg/day). Comes in many forms (Sumavel injection; STATdose SC injection; nasal spray; Zecuity transdermal), CI with MAOIs

rizatriptan (Maxalt): PO, ODT. CI with MAOIs

eletriptan (Relpax): PO. CI with strong CYP 3A4 inhibitors (it's a 3A4 substrate)

frovatriptan (Frova): PO, longest half life (26 hours)

naratriptan (Amerge): PO, 2nd longest half life after frovatriptan

almotriptan (Axert): PO

zolmitriptan (Zomig): PO, ODT, nasal spray. CI with MAOIs

29

Rosemarie has significant nausea when she is having a migraine headache and cannot tolerate swallowing any pills. She vomits them right back up. Which of the following formulations might provide benefit? (Select ALL that apply.)

A. Maxalt MLT
B. Sumatriptan injection
C. Sumatriptan nasal spray
D. Zomig ZMT
E. Eletriptan immediate release

A, B, C, D. Rizatriptan and zolmitriptan also have disintegrating tablets that dissolve on the tongue: these can be useful if nausea or dysphagia is present. Sumatriptan has a nasal spray and a SC injection-these provide fast onset for migraines that come on quickly, and avoids oral route. Zolmitriptan has an intranasal spray and disintegrating tablet.

sumatriptan (Imitrex, Alsuma): PO, injection, nasal spray, transdermal. PO dosed 25, 50, and 100mg, can repeat x1 after 2 hours (max 200mg/day). Comes in many forms (Sumavel injection; STATdose SC injection; nasal spray; Zecuity transdermal), CI with MAOIs

rizatriptan (Maxalt): PO, ODT. CI with MAOIs

eletriptan (Relpax): PO. CI with strong CYP 3A4 inhibitors (it's a 3A4 substrate)

frovatriptan (Frova): PO, longest half life (26 hours)

naratriptan (Amerge): PO, 2nd longest half life after frovatriptan

almotriptan (Axert): PO

zolmitriptan (Zomig): PO, ODT, nasal spray. CI with MAOIs

30

A patient came into the pharmacy and asked for a refill on her Imitrex. The patient states that this headaches really "wipe me out" and reports that although she has them approximately once monthly, when a migraine occurs, she has to miss work and feels terrible for 2-3 days. Is this patient a candidate for migraine prophylaxis treatment?

A. No, she needs to have 3 or more migraines weekly.
B. No, she needs to have 3 or more migraines monthly.
C. No, she needs to have 4 or more migraines weekly.
D. No, she needs to have 4 or more migraines monthly.
E. Yes, she is a candidate for prophylactic treatment.

E. She is a candidate due to the decrease in her quality of life.

Migraine Px

Px indication: uses acute treatments more than twice a week, or if migraines decrease quality of life

1st line: beta-blockers best evidence with propranolol (Inderal), timolol (Blocadren), metoprolol (Lopressor, Toprol XL), valproic acid, topiramate (Topamax). Extended-cycle OC if premenstrual migraine, or start NSAIDs or triptans 2 days prior to menses, continue for 5-7 days.

2nd line: other beta blockers, ACE inhibitors, antidepressants, natural products (feverfew, willow bark (a salicylate), butterbur, magnesium, riboflavin)

divalproex (Depakote), valproic acid (Depakene): SE: liver toxicity, pancreatitis, sedation, weight gain, tremor, teratogenicity, thrombocytopenia, alopecia, nausea, polycystic ovarian syndrome, pregnancy (X) for migraine and (D) for others.

topiramate (Topamax): SE: nephrolithiasis, open angle glaucoma, hypohydrosis, depression, metabolic acidosis, weight loss, reduced efficacy of OC, cognitive impairment, pregnancy (D)

31

Which triptan has the longest duration of action and may be useful in a patient with recurrent migraine?

A. Sumatriptan
B. Eletriptan
C. Almotriptan
D. Frovatriptan
E. Rizatriptan

D.

sumatriptan (Imitrex, Alsuma): PO, injection, nasal spray, transdermal. PO dosed 25, 50, and 100mg, can repeat x1 after 2 hours (max 200mg/day). Comes in many forms (Sumavel injection; STATdose SC injection; nasal spray; Zecuity transdermal), CI with MAOIs

rizatriptan (Maxalt): PO, ODT. CI with MAOIs

eletriptan (Relpax): PO. CI with strong CYP 3A4 inhibitors (it's a 3A4 substrate)

frovatriptan (Frova): PO, longest half life (26 hours)

naratriptan (Amerge): PO, 2nd longest half life after frovatriptan

almotriptan (Axert): PO

zolmitriptan (Zomig): PO, ODT, nasal spray. CI with MAOIs

Decks in Pharmacy Class (61):