Amy R. Dunleavy, PharmD, highlights various drug therapies used for the acute treatment of migraine and provides recommendations for appropriate use.
Mark Percifield, PharmD: Amy, if we could stick with you, could you briefly discuss the different drug classes used for the acute treatment of migraine based on mechanisms of action and efficacy?
Amy R. Dunleavy, PharmD: For our acute treatment of migraine, we have a number of drug therapies we tend to use. One of these categories are nonspecific drug agents: things such as NSAIDs [nonsteroidal anti-inflammatory drugs] and acetaminophen, which are targeting that inflammatory process of the migraine. These are items that can be found over the counter and are really 1 of the first places we start when treating migraine headaches. We also tend to find that antiemetics—so our antinausea agents—can be used to treat those undesirable symptoms of the migraine. We tend to find that IV [intravenous] metoclopramide and IV prochlorperazine are used as monotherapy in the acute setting of a migraine and our oral antiemetic agents tend to be used as an adjunct therapy for our individuals using abortive therapies such as the NSAIDs and triptans at home. Triptans are another class of medications you’ll often find used in the treatment of migraine. These tend to be used more for those with severe pain due to migraine and act via the 5-HT1 receptor. They’re an agonist of that receptor. These triptans include medications you commonly see in the pharmacy, such as sumatriptan, rizatriptan, naratriptan, and a few others. They all share that common mechanism of action at the 5-HT1 receptor. The big difference is that they do have different routes of administration. It may be that, for a patient who experiences significant nausea and vomiting, an alternative route like oral may be a better option.
We tend to see, with things such as sumatriptan, that subcutaneous administration route or the intranasal administration route. These avoid some of the adverse effects of that nausea. It tends to have a bit of a quicker onset and can hopefully help to resolve that migraine a bit quicker. With the subcutaneous route of sumatriptan, we tend to find a few more of those adverse effects. We see injection site reactions. Patients often report a bit of a chest heaviness or pressure. Sometimes our patients have that flushing. We tend to find that those adverse effects resolve spontaneously, sometimes within about 30 minutes of the administration. The intranasal sumatriptan tends not to have quite as much of those adverse effects but still has that relatively quick onset of action. Most frequently, individuals are reporting that they may be having a bit of an unpleasant taste, some nasal discomfort, or throat irritation. Other medications we sometimes use are the class of medications called ergots. Some of the common medications in that class are dihydroergotamine, or DHE, and ergotamine or Ergomar. These, like the triptans, bind to that 5-HT1 receptor and have a variety of administration routes as well. In general, acute treatment tends to be most effective if given within 15 minutes or so of that pain onset and when that pain is mild.
With these different abortive therapies, you should limit treatment to 2 to 3 days per week to prevent the development of rebound headaches. As you may have noticed, 1 of the medications you’ll often see in the community setting is opioids. You may notice this was not on our list of medications, and that’s really for a good reason. We tend to see, in the emergency department, that things like narcotics are used to help with managing that pain. Really, they don’t have a place in therapy. They tend to be potentially ineffective, and they tend to result in longer emergency department stays. They can lead to some dangerous things, especially as we think about the opioid epidemic and the unnecessary overutilization of drugs.
Transcript edited for clarity.