Prevention and Treatment of Migraines CAITLIN BARNES, PHARM.D. CANDIDATE AMBULATORY CARE JOE CAMMILLERI, PHARM.D. NATOHYA MALLORY, PHARM.D.

Transcription

1 Prevention and Treatment of Migraines CAITLIN BARNES, PHARM.D. CANDIDATE AMBULATORY CARE JOE CAMMILLERI, PHARM.D. NATOHYA MALLORY, PHARM.D.

2 Objectives Present patient case Review epidemiology/pathophysiology of headaches Assess and evaluate treatment options Assess and evaluate prophylaxis management Review primary literature Revisit patient case

3 Patient Case 69 y/o AAF CC: frequent headaches, pain on both sides of the neck, nausea/vomiting PMH: classic migraine with aura, DM, DPN, GERD, HTN, HLD, low back pain, OSA, asthma

4 Patient Case Vitals BP 159/71, HR 69, RR 16 Labs Na 139 meq/l Glu 111 mg/ dl K 3.5 meq/l BUN 8 mg/ dl Cl 104 meq/ L CO 2 27 meq/l SCr 0.72 mg/dl Mg 2.1 mg/ dl Phos 3.8 mg/dl WBC 5.7 x 10 3 /mm 3 Hg 11.6 g/dl Hct 36.7% Plt 232 x 10 3 /mm 3 Medications Amlodipine 10 mg daily Baclofen 10 mg QHS Carvedilol 6.25 mg BID Fluticasone 50 mcg 2 sprays in each nostril daily Fluticasone/Salmeterol puff BID Gabapentin 300 mg TID HCTZ 25 mg daily Lisinopril 40 mg BID Metformin 1,000 mg BID Omeprazole 40 mg daily Pravastatin 40 mg QHS ProAir 108 mcg 2 puffs q6h prn Montelukast 10 mg daily Tramadol 50 mg TID prn

5 Epidemiology and Pathophysiology Most prevalent neurological disorders Episodic instability of the neurovascular system Available 5-HT might be diminished Trigeminal nerve becomes hyperactive

6 Types of Headaches Primary headaches Migraine (with or without aura) Tension-type Cluster Secondary headaches Head and/or neck trauma Cranial or cervical vascular disorder Non-vascular intracranial disorder Substance or its withdrawal Infection Disorder of homeostasis Pyschiatric disorder

7 Migraines With aura Fully reversible aura symptoms Attacks last 4-72 hours Unilateral location Pulsating quality Moderate-severe intensity Aggravation by routine physical activity Associated with nausea/vomiting and/or photophobia or phonophobia

8 Treatment Goals Reduce attack frequency, severity, and disability Improve quality of life Educate and enable patients to manage their disease to enhance personal control of their migraine Reduce headache-related distress and physiological symptoms

9 Migraine Treatment Institute for Clinical Systems Improvement. Diagnosis and Treatment of Headache, 11 th edition. 2013

10 Migraine Treatment Treatment APAP NSAIDs Ergot derivatives Triptans Prophylaxis Beta-blockers Anticonvulsants Antidepressants

11 Mild to Moderate Treatment -- Analgesics Acetaminophen Caution in renal/hepatic impairment Stevens-Johnson Syndrome & toxic epidermal necrolysis NSAIDs Caution in patients with a history of ulcers & GI bleeds

12 Moderate Treatment -- Ergot Derivatives MOA: inhibits reuptake of NE & stimulates α receptors causing increased vasoconstriction Use is limited Renal/hepatic contraindicated Pregnancy - contraindicated

13 Triptans Mild to severe MOA-A elimination (sumatriptan, zolmitriptan, rizatriptan, almotriptan) Renal elimination (naratriptan) CYP 1A2/3A4 (frovatriptan, eletriptan) Interactions Serotonin syndrome

14 Migraine Prophylaxis -- Beta-Blockers Metoprolol, propranolol, timolol Selection based on patient specifics Hepatic impairment

15 Migraine Prophylaxis -- Anticonvulsants Valproate Contraindicated in hepatic impairment Category X Pancreatitis Topiramate Nephrolithiasis Oligohydrosis Caution in renal/hepatic impairment

16 Migraine Prophylaxis -- Antidepressants TCA s Anticholinergic effects Caution in hepatic impairment/elderly SNRI s Nausea Take in the AM Monitor changes in blood pressure Caution in hepatic impairment

17 Meta-Analysis of Oral Triptan Therapy Randomized, double-blind, placebo-controlled trials Outcome: Percentage of patients who were pain free within 2 hours Results: Rivatriptan 10 mg & zolmitriptan 5 mg were the most clinically effective

18 Amitriptyline vs. Divalproate in Migraine Prophylaxis Randomized, prospective Outcome: more than 50% reduction in headache frequency & one or more grade reduction in severity Results: divalproate had more significant reductions by 3 months, no difference at 6 months

19 Patient Case 69 y/o female diagnosed with migraines with aura Recommendation Initiate divalproex 250 mg BID and titrate dose Reassess in 6-12 months

20 References 1. Headache Classification Committee of the International Headache Society. The International Classification of headache Disorders, 3 rd edition. Cephalgia ;(9): Institute for Clinical Systems Improvement. Diagnosis and Treatment of Headache, 11 th edition Available from: 3. National Institute for Health and Clinical Excellence. Diagnosis and management of headaches in young people and adults Available from: 4. Loder E, Burch R, Rizzoli P. The 2012 AHS/AAN Guidelines for Prevention of Episodic Migraine: A Summary and Comparison With Other Recent Clinical Practice Guidelines. Headache : Tfelt-Hansen P, De Vries P, Saxena P. Triptans in Migraine. Drugs ;(6): Adelman J, Belsey J. Meta-analysis of Oral Triptan Therapy for Migraine: Number Needed to Treat and Relative Cost to Achieve Relief Within 2 hours. Journal of Managed Care Pharmacy (1): Rolan P. Drug Interactions with Triptans. CNS Drugs : Kalita J, Bhoi SK, Misra UK. Amitriptyline vs divalproate in migraine prophylaxis: a randomized controlled trial. Acta Neurol Scand :65-72.

21 Questions?