Drugs Used In Migraine And Headache

Question 1

Sumatriptan

Answer 1

• Mechanism of Action: 5-HT1B/1D receptor agonist, causing vasoconstriction in cranial arteries and reducing neurogenic inflammation.
• Indications: Acute treatment of migraine or cluster headaches.
• Contraindications: Ischemic heart disease, cerebrovascular syndromes, peripheral vascular disease, uncontrolled hypertension, hepatic impairment, use within 2 weeks of MAO inhibitor.
• Caution: Sulfa allergies, seizure history, Serotonin Syndrome.
• Adverse Effects: Chest pain, pressure sensations in the chest, neck, throat, and jaw, dizziness, malaise.
• Dosage: 50 mg at onset of severe headache, may repeat in 1-2 hours if needed. If needs to repeat every headache, increase to 100 mg at onset.

Question 2

Dihydroergotamine

Answer 2

• Mechanism of Action: Ergot alkaloid, acts as a 5-HT1 receptor agonist, causing vasoconstriction, and also affects alpha-adrenergic receptors and dopamine receptors.
• Indications: Acute treatment of migraine headaches, particularly severe cases.
• Contraindications: Pregnancy, coronary artery disease, peripheral vascular disease.
• Adverse Effects: Nausea, vomiting.
• Dosage: Intravenous or intranasal administration.

Question 3

Topiramate

Answer 3

• Mechanism of Action: Anticonvulsant, thought to block sodium channels in neurons, enhancing GABA activity and blocking glutamate activity.
• Indications: FDA approved for prevention of episodic migraines. Investigational use for neuropathic pain, migraine, and cluster headaches.
• Contraindications: History of kidney stones.
• Adverse Effects: Somnolence, dizziness, nausea, memory impairment, word finding difficulty, weight loss, renal stones.
• Dosage: Start 25 mg q HS or BID, titrate to 100 mg (MAX) BID.

Question 4

Amitriptyline

Answer 4

• Mechanism of Action: Tricyclic antidepressant, increases synaptic concentrations of serotonin and norepinephrine by inhibiting their reuptake.
• Indications: Antidepressant. Unlabeled/investigational uses include analgesic for chronic and neuropathic pain, and prophylaxis against migraine headaches.
• Contraindications: Use of MAO inhibitors within the past 14 days, acute recovery phase after MI, pregnancy.
• Adverse Effects: Drowsiness, sedation.
• Dosage: Start 10 mg at bedtime for one week, then 20 mg at bedtime

Question 5

Gabapentin

Answer 5

• Mechanism of Action: Anticonvulsant, exact mechanism unknown.
• Indications: Adjunct for treatment of seizures. Unlabeled use for chronic pain, migraine, and cluster headaches.
• Contraindications: Hypersensitivity.
• Adverse Effects: Renal disease, sedation, withdrawal syndrome.
• Dosage: Start 300 mg q HS, titrate up to 600-900 mg TID.

Question 6

Prazosin

Answer 6

• Mechanism of Action: Alpha-1 adrenergic receptor antagonist (alpha blocker).
• Indications: Treatment of HTN. Unlabeled use for management of nightmares, headache prophylaxis.
• Contraindications: Hypersensitivity to quinazolines.
• Adverse Effects: Orthostatic hypotension, syncope.
• Dosage: Start 1 mg at bedtime for one week, then 2 mg at bedtime for one week, titrate to 4 to 6 mg, may increase dose to 10-15 mg.

Question 7

Propranolol

Answer 7

• Mechanism of Action: Non-selective beta-adrenergic blocker.
• Indications: HTN, tachycardia, arrhythmias, migraine headaches.
• Contraindications: CHF, bradycardia, asthma, COPD, pregnancy.
• Adverse Effects: Hepatic dysfunction, PVD, exercise intolerance.
• Dosage: Start 10 mg twice daily. If helping, change to 60 mg LA daily.

Question 8

Botulinum toxin type A (Botox)

Answer 8

• Mechanism of Action: Neurotoxin that blocks acetylcholine release at neuromuscular junctions, causing muscle paralysis.
• Indications: FDA approved for preventive treatment of chronic migraine (15 or more headache days a month, each lasting 4 hours or more).
• Contraindications: None specific to headache treatment, but general contraindications apply.
• Adverse Effects: Localized muscle weakness, pain at injection site.
• Dosage: Injections into multiple facial muscles, every 3 months.

Question 9

Medication Overuse Headache (MOH)

Answer 9

• Definition: Chronic headache due to overuse of analgesic medications (more than 3 days/week).
• Causes: Often occurs in patients with chronic migraine or tension-type headaches.
• Characteristics: Rebound headaches, typically bilateral, non-throbbing, mild, and able to continue activity.
• Management: Avoid narcotics and benzodiazepines due to high risk of dependence and rebound headaches.

Question 10

Serotonin Syndrome

Answer 10

• Definition: A potentially life-threatening condition caused by excessive serotonin activity in the body.
• Symptoms: Confusion, agitation, restlessness, sweating, tremor, muscle rigidity, fever, diarrhea, and seizures.
• Causes: Interaction between serotonin-enhancing medications, such as SSRIs, SNRIs, TCAs, and triptans.
• Management: Discontinue offending medications, supportive care, and potentially serotonin receptor antagonists.

Question 11

Headache Triggers

Answer 11

• Common Headache Triggers:
• Stress
• Bright lights
• Lack of sleep
• Foods (nitrites, nitrates, aged cheese, MSG, raw onions, chocolate, caffeine)

Question 12

Headache Journal-

Answer 12

Purpose: To help patients track their headaches, identify triggers, and monitor the effectiveness of treatment.

• Elements to Include:
• Date and time of headache
• Intensity of headache
• Preceding symptoms
• Triggers
• Medications taken
• Relief achieved