Migraine

Question 1

Triptans

Answer 1

1. Triptan
2. Acute relief of migraine
3. Rizatriptan (Maxalt) - 10mg ASAP after h/ache onset. Repeat after at least 2 hours if migraine recurs. Max 30mg.
   Eletriptan (Relpax) - Age >17: 40mg ASAP. Max single 80mg, max daily 160mg
   Naratriptan (Naramig) - 2.5mg ASAP. Dose may be repeated after at least 4 hours if migraine recurs. Max 5mg.
   Sumatriptan (Imigran) - 50-100mg. Max 300mg.
   Zolmitriptan (Zomig) - 2.5mg ASAP. Repeat at 5mg if 2.5mg tolerated but ineffective in previous attack. Max. 10mg.
4. Exclude other causes of h/ache.
   - Medication-overuse headache
   - frequency of migraine
   - frequency of use

C/I in uncontrolled HTN and PVD, and if there is a history of MI, ischaemic heart disease, coronary vasospasm (eg Prinzmetal’s angina), cerebrovascular accident or TIA.
Potent inhibitors of CYP3A4 (ketoconazole) can inhibit the metabolism of eletriptan, resulting in increased serum concentrations and possibly, adverse effects of eletriptan. Coadministration w/in 72hrs is not recommended.
prolonged QT interval (Zolmitriptan)
transient burning sensation in the nose or throat, taste disturbance (nasal spray) (Sumatriptan)
dyspnoea (Sumatriptan, Rizatriptan)
Eletriptan and naratriptan MAO substrates

Refer: new onset pts >50 years, or large △ in h/ache pattern.

5. Well tolerated and safe.
   - improve associated symptoms such as nausea, vomiting, photophobia and phonophobia.
   - effective in relieving h/ache w/in 30-60mins of oral administration (longer with naratriptan)
   - Triptans are most effective if taken when the headache is beginning to develop, and not earlier (eg during aura) or later (when headache is more severe).
   - if one triptan is ineffective another may be effective
   - 2 or more severe migraine attacks/month and do not respond well to tx taken acutely
   - LABEL 1, 16?
   - If there is no improvement with the first dose, do not repeat.
   - Dependence may occur with overuse resulting in recurrent and/or rebound headaches and withdrawal syndrome.
   S/Es:
   sensations of tingling, heat, pain, heaviness or tightness in any part of the body including chest and throat, flushing, dizziness, drowsiness, weakness, myalgia, fatigue, nausea, vomiting, dry mouth, transient increase in BP

NON-PHARM

• Drugs can cause headache: as an adverse effect, following withdrawal, or secondary to overuse (see Medication-overuse headache).
• Rest or sleep in a dark and quiet room.
• Maintain fluid intake, if possible.
• Identify/manage triggers eg; missing meals, stress, irregular sleep habits, alcohol, bright lights, overwork. Often no obvious cause.
• Relaxation, behavioural therapy and/or acupuncture may help.

Question 2

First-line drug treatment for mild-to-moderate acute migraine is…

Answer 2

paracetamol, aspirin or another NSAID. If these are consistently ineffective (eg for 3 attacks) or if migraine is severe, use a triptan at the onset of the headache.
Consider adding an antiemetic for nausea and vomiting.

Question 3

First-line and second-line drug treatment for prevention of migraine is…

Answer 3

First-line drugs are beta-blockers, amitriptyline or topiramate; valproate is considered second line.

Other agents, eg botulinum toxin, erenumab, are usually reserved for use under specialist supervision.

Question 4

Pizotifen

Answer 4

serotonin antagonist antimigraine agent Prevention of recurrent migraine or cluster headache 0.5-4.5mg daily at night. Clinical effect- if not effective another medication may be suitable
Migraine occurrences
Cause of migraine- medication overuse h/ache?
Compliance

When stopping treatment, withdraw gradually to avoid withdrawal symptoms (e.g. depression, tremor, nausea, anxiety, malaise, dizziness, sleep disorder).
Rarely, hypersensitivity reactions, angioedema, depression, agitation, hallucinations, insomnia, rash, myalgia, hepatitis. Labels: 1
This medicine is used to prevent or reduce the frequency of migraine
attacks. It will not stop an attack once it has started.
You should take this medicine every day as prescribed.
Pizotifen may make you feel drowsy especially when you first start to take it and may increase the effects of alcohol; do not drive or operate machinery if you are affected.

Your appetite may increase when taking this medicine and you may need to pay more attention to your diet to avoid weight gain.
S/Es= increased appetite, weight gain, nausea, dizziness, dry mouth, constipation and fatigue.
If you develop yellowing of the eyes or skin, unusual tiredness or loss of appetite, tell your doctor immediately.