Drugs for Migraine

Question 1

What is Status migraineus ?

Answer 1

intractable migraine for >72 hours

Question 2

What is chronic migraine ?

Answer 2

Migraine > 15 days

Question 3

What are the important pathological mediators of migraine ?

Answer 3

• 5-hydroxytryptamine or 5-HT
• calcitonin gene-related peptide 0r CGRP
• Dopamine.

Question 4

What are the COX-inhibitors used in Migraine ?

Answer 4

aspirin, ibuprofen, naproxen, diclofenac, celecoxib, paracetamol

Question 5

What is the most effective way to administer COX- inhibitors in migraine ?

Answer 5

Combination treatments- eg. paracetamol-aspirin-caffeine

Question 6

What is the MOA of Migraine-specific agents : Triptans ?

Answer 6

They act by promoting vasoconstriction, inhibiting the release of CGRP, and block brainstem pain pathways. They are administered in combination example: Sumatriptan and Naproxen.

Question 7

What is the pharmacokinetics of triptans ?

Answer 7

• All triptans can be given orally
• Sumatriptan can be given subcut for rapid action.
• Zolmitriptan and Sumatriptan can also be given as nasal spray.

Question 8

Contraindication for triptans ?

Answer 8

It is still recommended that triptans be avoided in patients with hemiplegic migraine, basilar migraine, ischemic stroke, ischemic heart disease, Prinzmetal’s angina, uncontrolled hypertension, and pregnancy

Question 9

What are the most commonly used anti-emetics which act as dopamine receptor antagonists in Migraine ?

Answer 9

i.v. metoclopramide or i.v/i.m prochlorperazine. They reduce migraine headache and sensitisation.

Question 10

What are the Monoclonal antibodies against CGRP used for migraine prevention?

Answer 10

Rimgepant and ubrogepant

Question 11

What are Ergots ?

Answer 11

They are 5-HT 1b/d partial agonists (similar to Triptans) and also Alpha adrenergic agonist. They promote vasoconstriction and blocks trigeminal nerve transmission. Examples are Ergotamine, dihydroergotamine.

Question 12

What are the contraindications for ergots ?

Answer 12

• HTN and concomitant triptan’s therapy.

Question 13

What is the action of Lasmiditan ?

Answer 13

It is 5-HT 1F agonist which lacks vasoconstriction activity of triptans. Can cause dizziness. It is sometimes used in migraine.

Question 14

What is the last resort in migraine ?

Answer 14

Opioids and barbiturates

Question 15

What is the indication for dexamethasone in migraine ?

Answer 15

It is indicated to reduce the frequency of migraine in the long run.

Question 16

What is the optimal time for pharmacological intervention in Migraine ?

Answer 16

It is best to treat early at around the onset of aura or prodromal symptoms.

Question 17

Who are the candidates for migraine preventive therapy ?

Answer 17

• People with migraine episodes of >4 per month or lasting >12hours despite treatment.
• If attacks cause significant disability or reduction in QoL
• Menstrual migraine
• Start low dose and the effects takes 4 weeks to 6 months.

Question 18

What are the anti-hypertensives used to treat headaches ?

Answer 18

• CCBs
• ACEI and ARBS
• Beta blockers.

Question 19

What is the TCA of choice in migraine ?

Answer 19

Amitriptyline

Question 20

What are the anti-convulsants used in migraine ?

Answer 20

Topiramate

Sodium valproate

Gabapentin

Question 21

What is the management of Status migrainosus: >72 hour headache
?

Answer 21

*iv fluids + dopamine R block ketorolac
*Other drugs by non-oral route

Question 22

What is the management of Chronic migraine: >15 migraine days / month?

Answer 22

*First line: propranolol, amitriptyline, topiramate
*Second line: Botulinum toxin, CGRP antagonist, other