Which treatment should be started in all patient for migraine?
Limit stimuli (i.e., light, loud noises) and activity.
Start abortive treatment as soon as possible. [19]
Treat nausea and vomiting, if present.
IV fluids
Parenteral antiemetics: e.g., metoclopramide, prochlorperazine
What is the first line treatment for mild/moderate headache in migraine (I.e., pain does not interfere with usual activities or causes some interference but does not prevent the patient from engaging in them)
First-line treatment consists of NSAIDs, acetaminophen, acetylsalicylic acid, or combinations including caffeine.
If tolerating PO, consider one of the following:
Ibuprofen
Aspirin
Acetaminophen
Acetaminophen/aspirin/caffeine
If nausea/vomiting are present, consider one of the following:
Ketorolac
Diclofenac
Second-line: Treat as “Moderate to severe headache.”
Children: ibuprofen and family counseling
What is the treatment for moderate/severe headache? I.e., usual activities must be adjusted or suspended because of pain.
Trial a parenteral antidopaminergic agent OR start a migraine-specific agent.
Parenteral antidopaminergics
Metoclopramide
Prochlorperazine PLUS diphenhydramine [15][20]
Migraine-specific agents: triptans (e.g., sumatriptan) OR ergotamine; do not combine these agents! [21]
First-line: oral or parenteral triptans
Sumatriptan-naproxen
Zolmitriptan
If nausea/vomiting are present or there is a higher analgesic requirement, consider one of the following:
Sumatriptan
Second-line: consider a parenteral ergotamine (e.g., dihydroergotamine)
Short-term recurrence prevention: Consider IV dexamethasone. [22]
Refractory headache: See “Status migrainosus.”
What is the mechanism of aciton of triptans (Sumatriptan, zolmitriptan, almotriptan, rizatriptan)
5-HT1B/1D receptor agonists that cause:
Vasoconstriction of (dilated) cranial and basilar arteries
Inhibition of trigeminal nerve nociception
Inhibition of vasoactive peptide secretion
Most effective if taken at the onset of headache
List indications for triptans.
Migraine headaches
Cluster headaches
List side effects of triptans.
Vasospasm of coronary vessels → coronary ischemia (rare)
Paresthesia and sensation of cold in the extremities
Serotonin syndrome (if taken with other 5-HT agonists)
Temporary blood pressure increase (very common)
Dizziness, malaise, flashes
Frequent intake (≥ 10 x/month) can lead to headaches.
Hypertension
List contraindications for triptans.
Coronary artery disease
Vasospastic angina
Peripheral artery disease
What is the mechanism of action of Ergotamines (Ergotamine Dihydroergotamine)
Vasoconstriction by binding to 5-HT1B/1D serotonin receptors and alpha-adrenergic receptors [23]
Indication for ergotamine?
Vascular headaches (i.e., migraine and variants, histaminic cephalalgia)
List side effects of ergotamines.
ECG changes
Ischemia
Nausea/vomiting
Numbness, paresthesia, myalgia, weakness
Ergot toxicity
An intoxication that causes convulsive (e.g., fasciculations, paresthesias, and seizures) and/or gangrenous symptoms (e.g., peripheral necrosis)
Historically, it occurred from consumption of ergot alkaloids produced by fungi (e.g., contaminated rye).
Nowadays, it is only rarely seen due to overdosing or pharmacological interactions with ergot-derived drugs (e.g., ergotamine).
List contraindications for ergotamines.
Pregnancy
Peripheral vascular disease
Pharmacologic interactions
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