Headache LOs

• Role of serotonin in pathophysiology of migraines

  • There are receptors for serotonin throughout the brainstem and cortex, serotonin leads to vasoconstriction and plays a role in pain
  • In migraine pt, serotonin levels are decreased at baseline but elevated at onset and during migraine
  • Brain cells are extra sensitive to sudden increases in serotonin
• Role of CGRP in pathophysiology of migraines

  • CGRP and prostaglandins cause inflammation and vasodilation of cerebral and meningeal blood vessels
  • The inflammation and edema activate peripheral meningeal pain receptors called nociceptors
  • Nociceptors transmit signals to the trigeminal ganglion and the TNC
  • Stimulating trigeminal nerve leads to release of more CGRP
• Explain the pharmacologic advantage of triptans versus ergotamine alkaloids

  Triptans have better specificity, developed to cause vasoconstriction in the brain and avoid systemic vasoconstriction
• Describe pharmacologic differences between triptans and CGRP antagonists

  CGRP antagonists avoid the vascular side effects that we see with triptans
• What meds are used for tx of acute migraine

  Ergotamine alkaloids, Acetaminophen, NSAIDs, Triptans, CGRP Antagonist (Ubrogepant), 5-HT1F Agonist
• What meds are used for prevention of migraine

  CGRP monoclonal antibodies, CGRP antagonist (atogepant, rimegepant), Antiepileptic, Antidepressants, Antihypertensives
• Counseling points and clinical pearls for the use of triptans

  1. Majority are available oral
  2. Sumatriptan also subcutaneous (faster onset) and intranasal
  3. Zolmitriptan also nasal
  4. Headache may reoccur within 24-48 hours after single dose, usually the second dose is effective for aborting HA
  5. If one not effective, another within the class may be more effective