DRUG THERAPY FOR MIGRAINE

1. Drug therapy of migraine

2. Migraine
• Migraine is a mysterious disorder characterized by pulsating
headache, restricted to one side which comes in attacks lasting 4-
48hrs and is often associated with nausea, vomiting, sensitivity to
sound and light, flashes of light vertigo..
Types :
Migraine with aura
Migraine without aura

3. Cause of migraine
• Increased excitability of cns
• Meningeal blood vessel dilation
• Activation of perivascular sensory trigeminal nerves
• Pain impulse
• Vasoactive neuropeptide contain
• Substance P
• Calcitonin gene related peptide
• Neurokinin A

4. Pathophysiology
VASCULAR THEORY : intracrenial /extracranial blood vessel
vasodilation –headache
Intracerebral blood vessels vasoconstriction –aura
SEROTONIN THEORY : decreased serotonin level linked to migraine
Specific serotonin receptors found in blood vessels in brain

6. Classification
Mild
Less than one attack a
month
Lasting up to 8 hrs
Throbbing but tolerable
headache
Moderate
One or more headache per
month
6-24 hrs
Intense throbbing headache
with nausea and vomiting
Severe
2-3 attacks or more per
month
12-48 hrs
Intense throbbing headache
with nausea and vomiting,
vertigo, git instability,
fatigue, photo phobia

8. Mild migraine
• Simple analgesic: paracetamol 0.5-1 gm, aspirin300-600mg,
repeated 4-6 hourly
• NSAIDS : IBUPROFEN 400-800 MG 8hourly DICLOFENEC 50 MG 6-8
HOURLY
• Antiemetics – metoclopramide 10 mg Oral /I.m. Domperidone 10-
20 mg

9. • Moderate migraine-
• Stronger nsaids or their combination
• Ergot preparation or sumatriptans
• Severe migraine-
• Ergot alkaloid, sumatriptans

10. Ergotamine
• It is a amino acid alkaloid. It acts as a partial agonist and antagonist at
a adrenergic and all subtypes of 5ht1and 5ht2 receptors, but does not
interact with 5ht3 or dopamine receptors sustained vasoconstriction,
visceral smooth muscle contraction, vasomotor depression are produced
and the action of na and 5ht on smooth muscle is antagonized
• Oral bioavailability is poor less than 1%
• A/E nausea vomiting cramps weakness paresthesia coronary and other
vascular spasm
• C/I sepsis ,ischaemic heart disease, pvd, hypertension pregnancy, liver
disease
• Dose 1-3mg oral / sublingual 6mg max in a day
• 0.25 -0. 5 mg i. M Or sc.

11. Selective 5ht 1b /1d receptors agonist
• Sumatriptans: administered at onset of migraine
• It has been ascribed to 5ht1b1d receptors mediated constriction of
dilated cranial blood vessels especially the av shunt in carotid
artery
• It reduce 5ht and inflammatory neuropeptide release around the
affected vessels, reduce extra vacation of plasma proteins across
dural vessels
• Reduce inflammatory mediators release CGRP, NKO, SP
• Suppression of impulse transmission in trigemino vascular pathway
• P/k bioavailability 15%
• absorbtion is fast after nasal spray

12. Advantage over ergotamine
• Better tolerated
• faster relief lesser rebound headache
• Also prevent nauseater photophobia etc
• S/E
• Tightness in head and chest
• Feeling of heat paresthtin limbs
• Dizzimess weakness
• Rare ; bradycardia coronary vasospasm Mi
• Seizure hypersensitivity reaction
•

13. Prophylaxis
• B blockers : propranolol is common ly used drug reduce frequently
and severity of attack
• Effect seen in 4weeks 40 mg bd increasing upto 160 mg bd
• Tricyclic anti depressants ; amitriptyline 25-50 mg at bed time
• Calcium channel blocker : verapamil
• Flunarizine –weak ca channel blocker That also inhibits
Na+channels
• Anticonvulsamts valproic acid 400-1200 mg/day gabapentin 300-
1200 mg/ day 5ht antagonist: methysergide, cyproheptadine