Dr neil jaddou m. D board certified and professor of family medicine



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Tx of Acute Migraine

Drugs

Trade/Brand Name

Dosage

Simple Analgesic







Acetaminophen, aspirin, caffeine

Excedrin Migraine

2 tabs or caps q6h (max 8 per day)

NSAIDS







Naproxen

Aleve, Anaprox, generic

220-550mg PO bid

Ibuprofen

Advil, Motrin, Nuprin, generic

400mg PO q3-4h

Tolfenamic acid

Clotam Rapid

200mg PO. May repeat x1 after 1-2 h

5-HT1 Agonist







Oral







Ergotamine

Ergomar

One 2mg sublingual tab at onset & q1/2h (max 3 per day, 5 per week)

Ergotamine 1 mg,

caffeine 100mg



Ercaf Wigraine

1 or 2 tab at onset, then 1 tab q1/2h (max 6 per day, 10 per week)

Naratriptan

Amerge

2.5mg tab at onset, may repeat once after 4h

Rizatriptan

Maxalt

Maxalt-MLT



5-10mg tab at onset, may repeat after 2h (max 30mg/dl)

Sumatriptan

Imitrex

50-100mg tab at onset; may repeat after 2h (max 200mg/dl)

Frovatriptan

Frova

2.5mg tab at onset, may repeat after 2h(max 5mg/dl)

Almotriptan

Axert

12.5mg tab at onset, may repeat after 2h(max 25mg/dl)

Eletriptan

Relpax

40 or 80mg

Zolmitriptan

Zomig

Zomig Rapimelt



2.5mg tab at onset, may repeat after 2h(max 10mg/dl)

Nasal







Dihydroergotamine

Migraine Nasal Spray

1 spray(0.5mg) is administered, followed in 15min by a second spray

Sumitriptan

Imitrex Nasal Spry

5-20 intranasal spary as 4 sprays of 5mg or a single 20mg spray (may repeat once after 2 h, not to exceed a dose of 40mg/dl)

Zolmitriptan

Zomig

5mg intranasal spray as one spray( may repeat once after 2h, not to exceed a dose of 10mg/dl)

Parenteral







Dihydroergotamine

DHE-45

1mg IV, IM or SC at onset & q1h (max 3mg/dl, 6mg per week)

Sumatriptan

Imitrex injection

6mg SC at onset(may repeat once after 1 h for max of 2 doses in 24h)

Dopamine Antagonists







Oral







Metoclopramide

Reglan,

5-10mg/d

Prochlorperazide

Compazine

1-25mg/d

Parenteral







Chlorpromazine




0.1mg/kg IV at 2mg/min; max 35mg/d

Metoclopramide

Reglan

10mg IV

Prochlorperazine

Compazine

10mg IV

Other







Oral







Actaminophen, 325mg, plus dichloralphenazone 100mg, plus isometheptene, 65mg

Midrin, Duradin

2 caps at onset followed by 1 cap q1h(max 5 capsules)

Nasal







Butorphanol

Stadol

1mg(1 spray in nostril), may repeat if necessary in 1-2h

Parenteral







Narcotics




Multiple preparation and dosage


Clinical Stratification of Acute Specific Migraine Treatments

Clinical Situation

Treatment Options

Failed NSAIDS/ Analgesics

First Tier

  • Sumatriptan 50mg or 100mg PO

  • Almotriptan 12.5mg PO

  • Rizatriptan 10mg PO

  • Eletriptan 40mg PO

  • Zolmitriptan 2.5mg PO

Slower Effect/better tolerability

  • Naratriptan 2.5mg PO

  • Frovatriptan 2.5mg PO

Infrequent Headache

  • Ergotamine 1-2mg PO

  • Dihydroergotamine nasal spray 2mg

Early Nausea or difficulties taking tablets

  • Zolmitriptan 5mg nasal spray

  • Sumatriptan 20mg nasal spray

  • Rizatriptan 10mg MLT wafer

Headache recurrence

  • Ergotamine 2mg(most effective PR/usually with Caeffeine)

  • Naratriptan 2.5 mg PO

  • Almotriptan 12.5mg PO

  • Eletriptan 40mg

Tolerating acute treatments poorly

  • Naratriptan 2.5 mg

  • Almotriptan 12.5mg

Early vomiting

  • Zolmitriptan 5mg Nasal Spray

  • Sumitriptan 25mg PR

  • Sumitriptan 6mg SC

Menses-related Headache

Prevention

  • Ergotamine PO at night

  • Estrogen Patches

Treatment

  • Triptans

  • Dihydroergotamine nasal spray

Very Rapidly developing symptoms

  • Zolmitriptan 5mg Nasal Spray

  • Sumatriptan 6mg SC

  • Dihydroergotamine 1mg IM


Preventive Treatments in Migraine

Drug

Dose

Selected Side Effects

Pizotifen

0.5-2 mg qd

  • Weight Gain

  • Drowsiness

Beta blocker







Propanolol

40-120 mg BID

  • Reduced energy

  • Tiredness

  • Contraindicated in Asthma

Tricyclics







Amitriptyline

10-75mg at night

Drowsiness

Dothiepin

25-75mg at night




Nortriptyline

25-75mg at night

Note: Some pt many only need a total dose of 10mg, although1-1.5mg/kg body weight is required

Anticonvulsants







Topiramate

25-200mg/dl

  • Paresthesias

  • Cognitive Symptoms

  • Weight loss

  • Glaucoma

  • Caution with nephrolithiasis

Valproate

400-600 mg BID

  • Drowsiness

  • Weight gain

  • Tremor

  • Hair loss

  • Fetal abnormalities

  • Hematologic or liver abnormalaties

Gabapentin

900-3600 mg qd

  • Dizziness

  • Sedation

Serotonergic drugs







Methysergide

1-4mg dq

  • Drowsiness

  • Leg cramps

  • Hair loss

  • Retroperitoneal Fibrosis

Flunarizine

5-15mg qd

  • Drowsiness

  • Weight gain

  • Depression

  • Parkinsonism


Natural treatments for migraine include riboflavin (vitamin B2), magnesium, coenzyme Q10, and butterbur.
Board Pearls:


  • Withdrawal from Decongestants can Precipitate Migraines.




  • Cortical spreading depression (CSD) a main culprit behind migraine attacks.




  • Genetic mutations leads to defective NA+ and CA++ channels which are linked to migraine.

  • A migraine lasting longer than 72 hours is termed Status Migrainous.




  • Rx acute attacks of migraines : Rizatriptan




  • Rx for acute attack of migraines lasting longer than 48 hours or that are frequently recurrent : Ergotamine

  • Migraine is most common in women and has a strong genetic component.


Difference between sinus headache and migraine:

Parameters

Sinus headache

Migrane

Face pain

+



Infection

+



Upper Respiratory Problems

+



Fever, purulent discharge and post nasal drip

+



Pale or Pink nasal mucosa

+

+ /—

Significant sinus fluid levels

+





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