Drugs Used for Headaches

medication overuse headache

• happens after at least 3 months of overuse

• taper

• prophylaxis

what are the 1st, 2nd, 3rd line treatments for tension headache?

1. NSAIDS, aspirin, acetaminophen

2. AAC

3. butabital

butabital + caffeine + acetaminophen

MOA: barbituate + stimulant + analgesic

use: tension headache

SE: drowsiness

warning: abuse potential!! class III schedule, limit less than 5x/mo, not for cardiac defects

first second third line for tension HA prophylaxis

1. amytriptaline

2. mertazepine

3. venlafaxine

combine with stress management

acute migraine mild to moderate treatment

• NSAIDS

• acetaminophen

• AAC (excedrine)

acute migraine moderate to severe treatment

• triptan + NSAID

• triptan + acetaminophen

• antiemetic

if the triptans dont work for migraine, what do you use?

• try a different triptan (sumatriptan)

• CGRP receptor antagonist-gepant

if changing the triptan or CGRP receptor antogonist doesn’t work for acute migraines, what do you use?

• ergot alkaloid (alpha adrenergic blocker)

• lasmiditan (LAST LINE, serotonin receptor agonist)

lasmiditan

• LAST LINE for acute migraines

• driving restriction!

• okay for CAD pts because it does NOT vasoconstrict

sumatriptan

MOA: serotonin agonist, vasoconstriction

use: acute bad migraine with or without aura

dose: take at onset! wait 2 hours between doses

SE: coronary artery vasospasm, MI

drug rxn: serotonin syndrome

DO NOT GIVE IF: brainstem aura, hemiplegic, CAD, CV disease, HTN

what are the most and least effective triptans?

eletriptan, naratriptan

what is the best method to give sumatriptan?

SQ

what are some DONTS for acute migraines?

use opioids or butabital

could cause med overuse headache

CGRP receptor antagonist (rimegepant)

MOA: CGRP receptor antagonist

use: acute migraine with or without aura, prophylaxis (75 mg PA QOD), pts with CAD

warning: med overuse HA

what are first, second, third line treatments for migraine PROPHYLAXIS?

1. amitriptyline, venlafaxine, valproate, metoprolol, propanolol

2. CGRP receptor antagonist, CGRP mab

3. topiramate monotherapy

CGRP monoclonal antibodies (these may become first line)

MOA: binds to CGRP ligand and blocks

types: galcanezumab

use: prophylaxis, episodic cluster HA

if pregnant DO NOT TAKE

• topiramate

• valproate

• atogepant

• rimegepant

• ubrogepant

if pregnant take WITH CAUTION

• metoprolol

• propanolol

• timolol

• sumatriptan

• NSAIDS

cluster HA treatment - acute

• 100% oxygen

• sumatriptan

• CGRP abs

• if none available, intranasal lidocaine, intranasal suma and zoltriptan, oral ergotamine

cluster HA treatment - prophylaxis

• verapamil

• prednisone for short cycles