Migraines

• what is the receptor and location for sumatriptan?


  5-HT 1B1D

  intercranial BV and sensory nerves on trigeminal system
• what is the MOA of sumatriptan?

  vasoconstriction and reduces neurogenic inflammation with antidromoic neuronal transmission
• what is the dose, max dose, onset, and half life of sumatriptan?

  50-100mg

  max: 200

  onset: 30min

  half-life: 2 hours
• what are side effects of sumatriptan?

  bad taste

  chest symptoms

  coronary vasospasm

  teratogensis
• contraindications for sumatriptan


  pregnancy

  heart diseas

  gertiatric

  liver disease

  use of MAOI in the last 2 weeks
• Triggers for migraines


  additives, alcohol (red wine), artificial sweetner

  caffeine - overconsumption or acute from withdrawal

  delayed or skip meals, exercise

  foods: chocolate or soft cheese

  light, mensus, odors, oral contraceptives

  sleep disturbances, smoke, stress

  weather
• what migraine medications are not contraindicated with MAOIs?

  Almotriptan, Eletriptan, Frovatriptan, Naratriptan
• Eletriptan has a contraindications for what drugs?

  Clithromycin

  Itraconazole

  Ketoconazole

  Nelfinavir

  Ritonavir (CYP3A4 inhibitors)
• Each tripan better for what

  Almotriptan: better tolerated and better than oral sumatriptan

  Eletriptan: bioavailability increased with high fat meal, balance between onset and long duration, better efficacy and low recurrence rate

  Frovatriptan: better for pts with hx of recurrence,

  Rizatriptan: most consistency effective
• Lasmiditan uses what receptor and has what issues with Serotonin Syndrome risk

  receptor: 5-HT1F

  Serotonin syndrome risk: given with SSRI, SNRI, RCA, MAOI, Dextromethorphan, st. johns wort,

  caution with p-glycoprotien substrates
• What is the receptor for Gepants?

  Calcitonin gene-related peptide receptor antagonist

  does not cause rebound headaches
• what happens when a pt is overusing preventative migraine medication?

  may require escalation in preventative dose or a change in acute or preventative therapy

  may need a second preventative treatment
• oral preventative medications for migrane


  candesartan, divalproex sodium, frovatriptan, metoprolol, propranolol, timolol, valporate sodium
• what triptans would you give for menstrual migraine?

  Frovatriptan, Naratiptan, Zolmatriptan
• Parenteral preventable efficacy for migraine

  Eptinezumab

  Erenumab

  Fremanezumab

  Galcanezumab

  Onabotulinumtoxin A
• what are non-specific established efficacy for treatment of migraines

  NSAIDs: ASA, celecoxib oral solution, diclofenac, ibuprofen, naproxen

  combination analgesic: acetaminophen+ ASA + caffeine
• what are probable NSAIDs to treat migraines?

  flubiprofen, ketoprofen, IV and IM ketorolac
• what are probable effective treatments for migraines?

  IV mag

  Isometheptene-containing compounds

  antiemetics: chlopromazine, droperidol, metoclopramide, prochlorperazine, promethazine
• what is the dose and max dose of sumatriptan intranasal?


  5mg, 10, 20,

  max: 40mg
• what is the dose and max dose of sumatriptan powder?


  22mg - 11 mg in each capsule

  max: 44mg
• what is the dose and max dose of sumatriptan subQ?


  4mg or 6mg

  max is 12mg

  may repeat in 1 hour
• what is the dose and max dose of sumatriptan nasal spray?


  10mg

  max: 30mg

  may repeat after 1 hour
• Almotripan dose, max dose, onset, half life?

  - Dose: 12.5-25 mg - Max dose: 25 mg - Onset: 60-90 minutes - Half-life: 1-3 hours
• what lab test should you monitor for Almotriptan

  LFTs and Creatine clearance
• Eletriptan dose, max dose, onset, half life?

  Dose: 20-40mg

  max dose: 80mg

  onset: 60min

  half life: 4 hours
• How is Eletriptan better than Sumatriptan?

  bioavailablity increased with high fat meal

  good balance between onset and long duration

  better 2 hour efficacy and lower recurrence rate than oral sumatriptan
• Frovatriptan dose, max dose, onset, half life?

  dose: 2.5mg

  max: 7.5mg

  onset: 120-180min

  half-life: 26 hours
• How is Frovatriptan different?

  longest half-life and slow onset

  better for recurrence pts

  better tolerated and low recurrence

  does not benefit from second dose
• Naratriptan dose, max dose, onset, half life?

  Dose: 1-2.5mg

  max dose: 5mg

  onset: 60-180min

  half-life: 6 hours
• Rizatriptan dose, max dose, onset, half life?

  dose: 5-10mg

  max: 30mg

  onset: 30-120min

  half-life: 2-3 hours
• What are the Ergot Alkaloids?

  Dihydroergotamine (DHE)

  Erogtamine

  Ergotamine plus caffeine
• Ergotamine dose, max dose, onset, half life?

  dose: 1mg subling every 30min

  max: 10mg per week

  half-life: 2 hours

  effects are observed after 24 hours
• What are adverse effects of Ergotamine?

  muscle pain, paresthesia, cold extremities, N/V, physical dependence, vasospasm, cardiac valvular fibrosis
• What is the side effect Ergotism?


  intense vasoconstriction resulting in peripheral vascular ischemia dn possible gangrene
• contraindications for Ergotamine


  hepatic or renal impairment, CAD, PVD, pregnancy
• Lasmiditan MOA?


  5-HT1F agononist: associated with inhibition of plasma extravasation in dura

  decreases stimulation of trigeminal system and treats migraine pain without causing vasconstriction
• Lasmiditian adverse effects


  CNS: dizziness, fatigue, paresthesia, drowsiness, nausea, muscle weakness

  severe: cognitive changes, decrease in pulse and BP

  can cause overuse and habit forming

  should not drive 8 hours after taking medication
• Rimegepant can be used as acute or preventative?

  both acute and preventative
• what medications are probably effective against migraines?


  amitrptyline

  atenolol

  lisinopril

  memantine

  nadolol

  venlafaxine
• what is the treatment plan for migraine prevention?

  start low and titrate every 2-4 weeks until effective

  full benefits may take 2-6 months

  8 weeks or max or if intolerable, try different first line

  try 2nd line if not effective

  consider second line therapy