6- Migraines Pharm

Front 1

Headache
phys

Back 1

Referred pain to the surface of the head from other areas
Stretching of the dura
Stretching of the vessels of the dura
Stretching of the venous sinuses
Muscle spasm
Irritation of the nasal mucosa and/or sinuses
Eye strain

Front 2

Migraine

Back 2

Recurrent attacks of headache
Pain most often occurring on one side of head
May be accompanied by nausea, vomiting, sensitivity to light and sound
Routine activity of slight head movement makes pain worse
Pain lasts hours to days and may be disabling
Pain may migrate around head and from head to neck and/or shoulder
Scalp tenderness

Front 3

Triggers of Migraines

Back 3

Exposure to bright lights or loud noises
Exhaustion
Hormonal changes-can be hard to deal with (OCT)
Diet
Foods such as chocolate and cheese
Additives such as nitrites, nitrates and monosodium glutamate (MSG)
Alcoholic beverages (wine and beer)-tyramine can be prob
Stress

Front 4

Migraine Aura

Back 4

Neurological disturbance that occurs before a migraine headache begins
Visual
Flashing lights, small blind spots
Auditory
Ringing in the ears
Tactile
Numbness of extremities or digits

Front 5

Causes of Migraines

Back 5

1)Abnormal cerebral blood flow
Intracerebral vasoconstriction (aura) followed by vasodilatation(THE migraine event)(this we drug)(central v-constrictors help-some say caffeine my dilate periph./constrict central)
2)Spreading depression of cortical electrical activity
Decreased cortical function reduces cerebral blood flow
(like a reverse epilepsy)
(thus anticonvulsants)

Front 6

Treatment of Migraine
general

Back 6

Headache diary
Identify triggers
Nonpharmacological treatments
Drug Treatment
Analgesics
Ergot alkaloids
Serotonin-1 Receptor Agonists (DOC)

Front 7

Non-pharmacological Treatment of Migraines

Back 7

Identification of migraine triggers(DIARY)
Behavioral interventions
Relaxation therapy, (massage)biofeedback, cognitive therapy
Application of ice to forehead, sleep/rest in a dark, quiet place

Front 8

Analgesics-
in migraines
combos

Back 8

Nonsteroidal anti-inflammatory drugs
Aspirin, acetaminophen, ibuprofen (FIRST START FIRST LINE)
Often in combination
Acetaminophen, aspirin and caffeine (cerebral vasoconstrictor) (Excedrin Migraine)
Acetaminophen, caffeine, butalbital (barbiturate sedative) (Fioricet, Esgic)
Acetaminophen, isomeheptene (sympathomimetic) and dichoralphenazone (chloral hydrate-like sedative) (Midrin)
Butorphanol (Stadol) nasal spray
Often used for mild migraines
Occasional throbbing headache
Moderate nausea
Antiemetics or non-oral routes of administration may be necessary
Short duration

Front 9

Ergot Alkaloids

Back 9

2nd line
-Ergotamines
Cafergot (ergotamine and caffeine)
Ergomar
Dihydroergotamine
D.H.E. 45
Migranal nasal spray (good in nausea

Front 10

Ergot Alkaloids
moA

Back 10

1)PRIMARY MECH ****Nonspecific serotonin agonists
Vasoconstrictor of dilated cerebral vessels
Sympathetic vasoconstrictor
Partial agonists/antagonist of serotonin, dopamine and alpha-adrenergic receptors at various locations
Stimulates alpha-receptors at therapeutic doses with small elevation in blood pressure (watch HTN)
Acute treatment of migraines
Prolonged use results in rebound headaches (NOT RECOMENDED FOR CHRONIC)
also accumulate sympathetics causing HTN.....can't repeat dosing

Front 11

Ergot Alkaloids
adverse Rx

Back 11

Nausea and vomiting
Myocardial infarction-(SNS)
Vascular constriction**** and occlusion
Pain, numbness and tingling of digits, weakness
Hypothermia
Necrosis and gangrene-(V-CONStrict)
Portal hypertension
Drug dependence-rebound headache hypotension

Front 12

Ergot Alkaloids
CIs

Back 12

Cardiac or vascular disease-(sns)
Obesity-(HTN, CVD a bigger problem)
Hepatic or biliary tract disease
Pregnancy (category X) (bad V-constrict) and breastfeeding
Renal disease-----(decr RBF)

Front 13

Sertonin-1 Agonist
named

Back 13

(THE TRIPTANS)
Naratriptan (Amerge)
oral
Rizatriptan (Maxalt, Maxalt MLT)
Oral, and orally disintegrating tablet
Sumatriptan (Imitrex)
Oral, nasal, subcutaneous
Zolmitriptan (Zomig, Zomig ZMT)
Oral and orally disintegrating tablet

Front 14

Naratriptan
moA

Back 14

superior
Specific agonists of Serotonin-1 B/D receptors*****
Presynaptic stimulation inhibits dural vessel vasodilatation and inflammation
Inhibit nociceptive***** (decrease pain) transmission
Vasoconstriction of dilated intracranial extracerebral vessels
LACK SYMP. of ergots very good

Front 15

Sertonin-1 Agonist
p-kinetic

Back 15

Biotransformed by
cytochrome P450 system for naratriptan********
********Monoamine oxidase for all others********(WATCH MAOIs)they don't play nice
Dosage adjustment needed in patients with renal or hepatic disease

Front 16

the triptans
Adverse effects

Back 16

looks bad but better than ergots-usually in OD
these drugs do have a MAOI inhibition type deal leading to incr-DA,EPI,NE!!!!
-Cardiac effects
Angina, infarction, arrhythmias
Chest pressure syndrome
Hypertension and stroke
Peripheral vascular disease
Ischemia and necrosis
Muscle pain and tightness
Tingling, flushing, dizziness and drowsiness
almost all from MAOI scene

Front 17

the triptans
CIs

Back 17

Cardiac or vascular disease
Hypertension-prob ok if controlled (not ergots)
Monoamine oxidase inhibitor use with 14 days
Selective Serotonin Reuptake Inhibitor (additive -can get 5-ht syndrome(autonimic,hypertherm, muscle rigid)
Ergot use with 24 hours
Other “triptans” within 24 hours (both 5-HT agonists)
be sure-it's a migraine should not be used repeatedly-will get rebound headaches

Front 18

migraine
Prophylaxis

Back 18

Beta-adrenergic blockers
Inhibit vasodilation, renin release, lipolysis (cheep, can be used chronically -if no asthm,DM)
Valproate (anticonvulse)good TOUCHY drug
Inhibits cortical depression?
Calcium channel blockers
Inhibit vasculature contraction preceding migraine
(takes away early constrict pre dilation headache

Front 19

migraines
drug Recommendations
use
missuse

Back 19

Analgesic for mild to moderate migraine
Triptan or dihydroergotamine for moderate to severe headache
Nasal and injectable sumatriptan may have faster onset
Beta-adrenergic blocker is agent of choice for prevention
******Overuse of these agents(ergots / triptans) may result in chronic dull headaches
Frequent long term use may increase frequency of migraines