THERAPEUTICS

Brands

• Axert, Almogran

Generic?

• Yes

Class

• Triptan

Commonly Prescribed for

(FDA approved in bold)

• Acute treatment of migraine in adults and adolescents (> 12 years old)

• Menstrual migraine

How the Drug Works:

• Selective 5-HT1B/1D/1F receptor agonist. In addition to vasoconstriction on meningeal vessels, its antinociceptive effect is likely due to blocking the transmission of pain signals at trigeminal nerve terminals (preventing the release of inflammatory neuropeptides) and synapses of second-order neurons in trigeminal nucleus caudalis. Although it generally does not penetrate BBB, it has been postulated that transient permeability may occur during a migraine attack

How Long Until It Works

• 1–2 hours or less

If It Works

• Continue to take as needed. Patients taking acute treatment more than 2 days/week are at risk for medication-overuse headache, especially if they have migraine

If It Doesn't Work

• Treat early in the attack – triptans are less likely to work after the headache becomes moderate or severe, regardless of cutaneous allodynia, which is a marker of central sensitization

• Address life style issues (e.g., stress, sleep hygiene), medication use issues (e.g., compliance, overuse), and other underlying medical conditions

• Change to higher dosage, another triptan, another administration route, or combination of other medications. Add preventive medication when needed

• For patients with partial response or reoccurrence, other rescue medications include NSAIDs (e.g., ketorolac, naproxen), antiemetic (e.g., prochlorperazine, metoclopramide), neuroleptics (e.g., haloperidol, chlorpromazine), ergots, antihistamine, or corticosteroid

Best Augmenting Combos for Partial Response orTreatment-Resistance

• NSAIDs or antiemetics/neuroleptics are often used to augment response

Tests

• None required

ADVERSE EFFECTS (AEs)

How the Drug Causes AEs

• Direct effect on systemic serotonin receptors (e.g., 5-HT1B agonism on vasoconstriction)

Notable AEs

• Tingling, flushing, sensation of burning, vertigo, sensation of pressure, heaviness, nausea

Life-Threatening or Dangerous AEs

• Serotonin syndrome. Rare cardiac events including acute myocardial infarction and vasospasm have been reported with almotriptan. Life-threatening cardiac arrhythmias have been reported with other triptans