IC5- Tx of migraine Flashcards
(37 cards)
What are the acute Tx goals? (6)
- Rapid and consistent freedom from pain and associated symptoms, especially the most bothersome symptom, without recurrence
- Restored ability to function
- Minimal need for repeat dosing or rescue medications
- Optimal self-care and reduced subsequent use of resources (e.g., emergency room visits, diagnostic imaging, clinician and ambulatory infusion center visits).
- Minimal or no adverse events
- Cost-effective treatment
How soon do we give medications for acute Tx of migraine?
Why? (can just read through)
As early as possible.
Effective acute treatment is associated with a significant beneficial response within 2 h from the time of administration, confers a sustained pain-free response over 24 h and reIduces disability quickly during attacks
Is stratified approach (guided by pain severity) or step by step approach (starting with mildest medication first) preferred for migraine Tx?
Stratified approach → better clinical outcomes & cost effective
If migraine pts also have n/v SSx, what type of migraine medications can you prescribe them?
Anti-emetics
How can we choose appropriate formulations and dosage forms for pts?
- E.g. nausea exacerbated with drinking water > orally disintergrating tablet
- E.g. severe nausea vomiting / fullblown symptoms at outstart > parenteral formulation
What are the different migraine-specific medications?
State the ones with established efficacy (4), and ones that are probably effective (2)
Established efficacy:
-triptans
- Ergotamine derivatives
- Gepants
- Lasmiditan
Probably effective:
- Ergotamine
- Other forms of dihydroergotamine
What are the different non-specific medications for migraine?
State the ones with established efficacy (2), and ones that are probably effective (4)
Established efficacy:
- NSAIDs: aspirin, celecoxib oral solution, diclofenac, ibuprofen, naproxen
- Combination analgesic: acetaminophen + aspirin + caffeine
Probably effective:
- NSAIDs: flurbiprofen, ketoprofen, IV/ IM ketorolac
- IV magnesium
- Isometheptene-containing compounds
- Antiemetics: chlorpromazine, droperidol, metoclopramide, prochlorperazine, promethazine
What type of migraine attacks are NSAIDs used for?
Mild-to-moderate migraine attacks
MOA of NSAIDs in migraine?
Inhibit PG synthesis → prevent neurogenically mediated inflammation in trigeminovascular system
ADEs of NSAIDs in migraine?
- Hypersensitivity
- GI (dyspepsia, n/v/d)
- CNS: somnolence (drowsiness), dizziness
- Upper GI effects
NSAIDs- use with caution in which type of patients? (4)
- Hx of PUD
- Renal disease
- Severe CVD
- Hypersensitivity to aspirin
Name some -triptans
Eletriptan, Sumatriptan, Zolmitriptan
MOA of triptans?
Selective agonist at 5-HT1B and 5-HT1D receptors:
- Vasoconstriction of intracranial extracerebral blood vessels
- Inhibition of vasoactive peptide release by trigeminal neurons
- Inhibition of nociception neurotransmission within trigeminocervical complex
What should we do if a pt does not respond to a triptan? Do we change to another medication class?
No. We try another triptan
What is something to note about recurrent migraines when taking triptans?
~20-50% of pts experience recurrent migraine within 48h of first dose of triptan → additional dose of triptan will be effective
What are some common SEs of triptans? (3)
- Pressure sensation on chest
- Nausea
- Distal paraesthesia and fatigue
What are some contraindications of triptans for migraines? (pre-existing conditions- 7; drug: 2)
Pre-existing conditions:
- Stroke/ TIA
- Ischemic coronary artery disease
- Coronary artery vasospasm
- Uncontrolled HTN
- Peripheral vascular disease
- GI ischaemia
- Hx of hemiplegic or basilar migraine
Drugs:
- Concomitant use of ergotamine-containing/ ergot-type medication (eg. dihydroergotamine) within 24 hours
- Concomitant administration of MAO-A inhibitors/ use within 2w of discontinuation of MAO-A inhibitor therapy
MOA of ergotamine in Cafergot?
- Agonist of 5-HT-1B/1D on intracranial vessels → induce vasoconstriction
- Inhibit norepinephrine uptake and alpha-adrenoreceptors: leads to prolonged vasoconstriction
MOA of caffeine in Cafergot?
- Adenosine A1, A2A, and A2B receptors antagonist: vasoconstrict cerebral vasculature
- May enhance GI absorption of ergotamine by ↑ solubility of ergotamine & decrease gastric pH
Common SEs of Ergotamines & Dihydroergotamines? (4)
- N/V
- Cramps
- Insomnia
- Transient (temporary) lower limb muscle pain
When do we use -gepants & -ditans for migraine Tx?
Either of the following:
- Contraindications to or inability to tolerate triptans
- Inadequate response to ≥ 2 oral triptans by: (1) validated acute Tx patient-reported outcome questionnaire, (2) clinician attestation
What are some contraindications of Ergotamines & Dihydroergotamines for migraines? (pre-existing conditions- 7; drug: 2)
Pre-existing conditions:
- Stroke/ TIA
- Ischemic coronary artery disease
- Coronary artery vasospasm
- Uncontrolled HTN
- Peripheral vascular disease
- GI ischaemia
- Hx of hemiplegic or basilar migraine
Drugs:
- Concomitant use of triptans within 24h
- Potent CYP3A4 inhibitors (eg. protease inhibitors and macrolides)
Should we use opioids for migraine Tx?
No
What are the preventative Tx goals for migraine? (8)
- Reduce attack frequency, severity, duration, and disability
- Improve responsiveness to and avoid escalation in use of acute treatment.
- Improve function and reduce disability.
- Reduce reliance on poorly tolerated, ineffective, or unwanted acute treatments.
- Reduce overall cost associated with migraine treatment.
- Enable patients to manage their own disease to enhance a sense of personal control.
- Improve health-related quality of life (HRQoL).
- Reduce headache-related distress and psychological symptoms.
