L9.5 Migraine

No warning sign before onset; 70-80% of migraine patients

Common migraine

Warning “aura” signs in 20-30% of patients

Migraine with Aura

Blindness of an eye for < 1hr associated with HA

Retinal migraine

Occasional intense period of vomiting

Childhood periodic syndrome

Scotoma

• Visual field disturbances

  • Zig-zag structure, Negative/Positive, one-sided loss of perception

temporary visual disturbance of shimmering, flickering, or jagged blind spot

Scintillating Scotoma

Factors that contribute to migraine development

Vascular or Neurological

Migraine mechanism

• Cerebral vasodilation and subsequent activation of pain fibers via transmitters released

  • Vasoactive intestinal peptide (VIP)

  • Substance P

  • Calcitonin gene related peptide (CGRP)

Systems affected by migraines

• Trigeminal nerves

  • Relays sensations of pain/touch from face, head, & jaw to brainstem

• Trigeminovascular system

  • Nerves of meninges

Serotonin mediation of migraine

• low levels during migraine

• 5-HT1D in trigeminal nerves of meningeal blood vessels

• 5-HT1B in vascular endothelial & smooth muscle cells, and trigeminal nerves

Triptans MOA

• Serotonin RA

  • 5-HT1B → vasoconstriction of dilated extra cerebral vessels

  • 5-HT1D → inhibits neuropeptide release

Sumatriptan (Imitrex) formulations

SQ, Oral, Nasal inhalation, Transdermal

Triptans indication

• First line for mod-severe migraines

• Rapid onset & short half life

• Reduce sensory activation in periphery & nociceptive transmission in brainstem trigeminal nucleus

• Diminish central sensitization

Triptans Contraindications

Causes vasoconstriction & → avoid Coronary heart disease and Uncontrolled HTN

Triptans AEs

• Coronary artery vasospasm

• Transient MI

• Atrial / Ventricular arrhythmias

List of CGRP receptor antagonists

Ubrogepant

Rimegepant

Atogepant

Zavegepant

Ubrogepant indication

Acute migraine ± aura in adults

Rimegepant indications

• acute migraine

• preventative migraine Tx

Atogepant indication

Prevent episodic migraines

Zavegepant

Acute migraine — nasal spray

CGRP receptor antag AEs

Hypersensitivity, Nausea

List of CGRP Antibodies

Erenumab-aooe (Aimovig)

Galcanezumab-gnlm (Ajovy)

Fremanezumab (Emgality)

Eptinezumab (VYEPTI)

CGRP Antibody indications

• Chronic migraine

• Preventative Tx of cluster HA

CGRP Antibody AEs

Hypersensitivity, CVD

Botox indication

Prophylactic Tx for Chronic Migraine

Botox MOA

• Heavy chain binds presynaptic botulinum neurotoxin receptors for neurotoxin entry

• Neurotoxin cleaves SNARE proteins → blocks AChE release into synaptic cleft

Botox AEs

• Muscle weakness

• Double / Blurred vision

• Drooping eyelids

Verapamil MOA & AEs

• Calcium channel blockers → up to 8 weeks for effects seen

• Hypotension, Constipation

Other options for migraine medications

• Antiemetics, Opioids, Caffeine

• Combo: Indomethacin, Prochlorperazine (antiemetic), & Caffeine