Migraine Meds

Question 1

Migraine HA have association with serotonin receptors. Serotonin 1 (5 HT-1) and Serotonin 2 (5 HT-2). Explain.

Answer 1

Serotonin 1 (5 HT-1): elicit vasoconstriction

Serotonin 2 (5 HT-2): elicit vasodilation

Question 2

Which migraine medication is best for the prodromal phase?

Answer 2

Triptans

Question 3

Which drugs are best for prophylaxis?

Answer 3

Propanolol/Inderal
Amitriptyline/Elavil
Methysergie/Sansert
Topiramate/Topamax

Question 4

Propanolol
Class:
Ind:
MOA:
Char:

Answer 4

Propanolol
Class: Non-selective beta blocker
Ind: HTN, angina, AMI, panic attacks, migraine
MOA: Blocks adrenergic stimulation decreasing HR and oxygen demand, decreases renin release
Char: PO, 10 to 100 mg/day

Question 5

Propanolol SE

Answer 5

Bronchoconstriction (non-selective beta blocker), hypotension, bradycardia, fatigue, impotence

Question 6

Amitriptyline/Elavil
Class:
Ind:
MOA:
Char:

Answer 6

Amitriptyline/Elavil
Class: Tricyclic antidepressant TCA
Ind: Migraine/tension HA, chronic pain, bipolar disorder, depression
MOA: CNS modulation of serotonin and norepinephrine
Char: PO and IM, taken at bedtime to minimize SE of drowsiness and dizziness

Question 7

Which drug is indicated for both migraine and bipolar disorder?

Answer 7

Amitriptyline/Elavil

Question 8

When is Amitriptyline/Elavil CI?

Answer 8

CI with MONOAMINE OXIDASE inhibitors

(MAO - blunt production of enzymes that break down neurotransmitters)

+ effects take days to weeks
- effects noted within first several days

Question 9

Amitriptyline/Elavil SE

Answer 9

Dizziness and drowsiness (do not take at night), dry mouth, constipation, urinary hesitancy, blurred vision

Question 10

Topiramate/Topamax
Class:
Ind:
MOA:

Answer 10

Topiramate/Topamax
Class: Anticonvulsant
Ind: Tx epilepsy and prophylaxis of migraine HA, off label use for bipolar disorder
MOA: block voltage-dependent sodium channels in the CNS, augmenting activity of GABA

Question 11

Topiramate SE

Answer 11

Fatigue, dizziness, vision changes, acute angle glaucoma, nausea, constipation

Question 12

Methysergide/Sansert
Class:
Ind:
MOA:

Answer 12

Methysergide/Sansert
Class: Ergot derivative - serotonin 2 receptor antagonist
Ind: Prophylaxis of migraine and cluster HA
MOA: maybe a serotonin 2 receptor antagonist resulting in vasoconstrictor effect

Question 13

Methysergide/Sansert

Char

Answer 13

Methysergide/Sansert
Char: PO
SHOULD NEVER BE USED BEYOND 6 MO W/O A DRUG FREE INTERVAL

Do not use within 24 hours of triptan because of increased risk of vasoconstrictive spasm

Question 14

Methysergide/Sansert

SE

Answer 14

Methysergide/Sansert
SE:
(1) PULMONARY FIBROSIS and RETROPERITONEAL FIBROSIS, HTN, thrombophlebitis, N/V
(2) Heart valve thickening

Question 15

When is Methysergide/Sansert CI?

Answer 15

Pregnancy (Category X)

Patients with peripheral vascular disease

Question 16

Sumatriptan/Imitrex
Class:
Ind:
MOA:
Char:

Answer 16

Sumatriptan/Imitrex
Class: Serotonin agonist (Triptan - Prodromal phase tx)
Ind: Migraine, cluster HA
MOA: Serotonin agonist at 5-HT 1D and 1B receptors in periperhal nerves that innervate the intracranial vasculature
Char: PO/SQ/Nasal spray (aborts or reduces severity of migraines)

Question 17

Sumatriptan/Imitrex

Char:

Answer 17

Sumatriptan/Imitrex

Char: Onset between 10-60 min. MAXIMUM of 2 doses in 24 Hrs.

Question 18

Sumatriptan/Imitrex

SE:

Answer 18

Sumatriptan/Imitrex

SE: dizziness, tingling, facial flushing, weakness, chest tightness

Question 19

What is an uncommon SE of all triptans and what are the symptoms?

Answer 19

Serotonin syndrome: agitation, tremor, ataxia, fever, chills and diarrhea.

Question 20

What is the maximum dose of Sumatriptan/Imitrex?

Answer 20

2 to 3 doses/ 24 hour

12 - 18 dose max/month

Question 21

Ibuprofen/Motrin, Advil
Ind:
MOA:
Char:

Answer 21

Ibuprofen/Motrin, Advil
Ind: Inflammation, pain, fever
MOA: REVERSIBLE inhibition of COX-1 and COX-2 enzymes
Char: PO, PR, no risk for Reye’s

Question 22

Codeine
Class:
Ind:
MOA:
Char:
SE:

Answer 22

Codeine
Class: Opioid analgesic 
Ind: Pain relief, antitussive
MOA: opioid agonist
Char: PO, IV, IM, SQ
SE: sedation, constipation

Question 23

Butorphanol/Stadol
Class:
Ind:
MOA:

Answer 23

Butorphanol/Stadol
Class: Opiod analgesic
Ind: Migraine HA that is refractory to triptans
MOA: agonist/antagonist of opioid receptors

Question 24

Butorphanol/Stadol

SE

Answer 24

Marked dependency potential exists.

SE: nasal irritation, drowsiness, dysphoria, N/V, withdrawal symptoms can be precipitated in patients with underlying addiction to opiates.

Question 25

What are the anti-emetic’s typically given for migraine HA?

Answer 25

Benadryl
Compazine
Phenergan
Vistaril

Question 26

Prochlorperazine/Compazine
Class:
Ind:
MOA:

Answer 26

Prochlorperazine/Compazine
Class: Typical neuroleptic
Ind: Anti-emetic particularly when associated with migraine HA, vertigo, anti-psychotic
MOA: H1-histamine receptor antagonist and D2 dopaminergic receptor antagonist

Question 27

Prochlorperazine/Compazine
Char:
SE:

Answer 27

Prochlorperazine/Compazine
Char: PO, PR, IM, IV
SE: Drowsiness, dry mouth, constipation, urinary retention, lowers seizure threshold.

Extrapyramidal SE seen when it is given at high doses over long periods.

Question 28

Ondansetron/Zofran
Class:
MOA:
Ind:
Char:
SE:

Answer 28

Ondansetron/Zofran
Class: Antiemetic
MOA: Blockade of serotonin 5HT3 receptor sites
Ind: Severe nausea
Char: PO, IV
SE: Dizziness, HA

Question 29

Additional migraine HA tx options.

Answer 29

Vitamin B2 (Riboflavin) - 400 mg/day
Mg 600-2000 mg/day