You are in: eMedicine Specialties > Ophthalmology > NEUROLOGIC DISORDERS Headache, MigraineArticle Last Updated: Aug 28, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Ronald Braswell, MD, Assistant Professor, Department of Ophthalmology, University of Alabama-Birmingham Ronald Braswell is a member of the following medical societies: American Academy of Ophthalmology and North American Neuro-Ophthalmology Society Editors: Edsel Ing, MD, FRCSC, Assistant Professor, Department of Ophthalmology & Vision Sciences, University of Toronto: Consulting Staff, Toronto East General Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Brian R Younge, MD, Professor of Ophthalmology, Mayo Clinic School of Medicine; Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri; James P Gills, MD, Founder, St Luke's Cataract and Laser Institute; Professor, Department of Ophthalmology, University of South Florida College of Medicine Author and Editor Disclosure Synonyms and related keywords: migraine headache, migraines, aura, ophthalmoplegic migraine, retinal migraine, migrainous disorder, 5-hydroxytryptamine, 5-HT, dihydroergotamine, DHE, selective serotonin reuptake inhibitor, SSRI, monoamine oxidase inhibitor, MAOI, headache disorder INTRODUCTIONSection 2 of 10
  BackgroundThis complex, recurrent headache disorder is one of the most common complaints in medicine today. The term migraine is derived from the Greek word hemikrania. Later, this term was corrupted into low Latin as hemigranea, which eventually was accepted by the French translation as migraine. A typical episode is characterized by unilateral head pain that may be preceded by various prodromal symptoms. Other focal neurologic symptoms, collectively known as an aura, may also precede or coincide with the onset of a headache. Although many more headache types are listed in the International Classification of Headache Disorders (ICHD) by the International Headache Society (IHS), the following are the most often encountered in practice, with migraine being the most challenging:
PathophysiologyHistorically, migraine has been associated with fluctuations in cerebral perfusion. Investigations show areas of hypoperfusion preceding the onset of a headache, followed by a period of reactive hyperperfusion and eventual normalization of flow. Current theories advocate a primarily neurogenic phenomenon related to changes in neuropeptide levels of serotonin and dopamine. Certain symptomatic and prophylactic agents are effective in part through binding at specific serotonin (5-hydroxytryptamine [5-HT]) binding sites. Signs and symptoms (eg, anorexia, nausea, vomiting, pallor, yawning) respond to dopaminergic antagonists. The concept of an altered migrainous threshold in individual patients has been advocated. Imbalances in inhibitory and excitatory neuronal pathways may sensitize the trigeminovascular system and provoke a migraine event. FrequencyUnited StatesRecent epidemiologic studies indicate that 23 million Americans, approximately 18% of females and 6% of males, will have one or more migraine headaches per year. Migraine accounts for 64% of all females and 43% of all males with severe headache. Mortality/MorbidityMigraine continues to be a major health problem.
Race
SexMigraine with aura: Incidence or age of onset appears to peak in patients aged 4-5 years (6.6 per 1000 person-years).
AgeIn patients younger than 10 years, prevalence appears to be higher in males than in females. After the onset of puberty, migraine is considerably more common in females than in males (3:1). CLINICALSection 3 of 10
HistoryThe migraine headache is typically a unilateral and throbbing pain, but the features often vary. Migraineurs often experience a bilateral event. The pain can be felt anywhere around the head or neck.
PhysicalEvidence of autonomic nervous system involvement can be helpful, although most patients with migraine may exhibit little or no findings. Serial neurologic examinations are recommended.
CausesNo specific etiology is known. Various precipitants of migraine events have been identified, as follows:
DIFFERENTIALSSection 4 of 10
Giant Cell Arteritis Idiopathic Intracranial Hypertension Trigeminal Neuralgia
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| Drug Name | Sumatriptan (Imitrex); frovatriptan (Frova); eletriptan (Relpax); naratriptan (Amerge, Naramig) |
|---|---|
| Description | Vascular 5-HT1 receptor subtypes (to which these agents bind selectively and through which they presumably exert antimigrainous effects) have been shown to be excellent first-line therapy for acute migraine events. Naratriptan has a duration of action of up to 24 hours with low headache recurrence rate. Useful for patients with slow onset, prolonged migraine (eg, menstrual migraine). Frovatriptan possesses long half-life (ie, 26-30 h), decreasing recurrence of migraine within 24 h after treatment. Eletriptan has half-life of 18 h. |
| Adult Dose | Sumatriptan: 6 mg SC injection; if no response, repeat after 1 h; not to exceed 2 doses in 24 h 25-100 mg PO single dose; repeat at intervals of at least 2 h; not to exceed 200 mg/d (100 mg/d if injection) 5-20 mg intranasally; reevaluate if no response; may repeat once after 2 h; not to exceed 40 mg/d Frovatriptan: 2.5 mg PO once at onset of migraine attack Eletriptan: 20-40 mg/dose PO at onset of migraine; if initial dose ineffective, may repeat dose once after 2 h; not to exceed 80 mg/d Naratriptan: 1-2.5 mg PO initially PO q4h; not to exceed 5 mg/d |
| Pediatric Dose | Not recommended |
| Contraindications | Documented ischemic cardiac, cerebrovascular, or peripheral vascular syndromes; vasospastic coronary artery disease; uncontrolled hypertension; basilar or hemiplegic migraine; within 24 h of ergot-type drugs (eg, methysergide, dihydroergotamine) or other 5-HT1 agonists; during or within 2 wk after discontinuing MAOIs |
| Interactions | Toxicity may increase when used within 24 h of ergotamines or other 5-HT agonists; coadministration with SSRIs may cause weakness, hyperreflexia, or incoordination; CYP450-3A4 inhibitors (eg, ketoconazole, itraconazole, ritonavir, erythromycin) may increase plasma concentration and subsequent toxicity |
| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus |
| Precautions | Confirm diagnosis; avoid excessive use; exclude underlying cardiovascular disease, supervise first dose, and consider monitoring ECG in patients with a likelihood of unrecognized coronary artery disease (eg, postmenopausal women, those with hypercholesterolemia, men >40 y, patients with hypertension, those with a strong family history, and patients who are obese, diabetic, or smoke); hepatic or renal dysfunction |
| Drug Name | Zolmitriptan (Zomig, Zomig-ZMT); almotriptan (Axert); rizatriptan (Maxalt, Maxalt-MLT) |
|---|---|
| Description | Selective agonists for serotonin 5-HT1 receptors in cranial arteries and suppress the inflammation associated with migraine headaches. |
| Adult Dose | Zolmitriptan: 2.5 mg PO initially; repeat dose after 2 h if headache returns; not to exceed 10 mg/24h Almotriptan: 6.25-12.5 mg PO at onset of migraine; may repeat once, not to exceed 25 mg/d Rizatriptan: 5-10 mg intranasally initially; repeat after 2 h; not to exceed 30 mg/d; concomitant administration of 5 mg/dose PO propranolol; not to exceed 3 doses/d |
| Pediatric Dose | Not recommended |
| Contraindications | Documented hypersensitivity; documented ischemic cardiac, cerebrovascular, or peripheral vascular syndromes; vasospastic coronary artery disease; uncontrolled hypertension; basilar or hemiplegic migraine; within 24 h of ergot-type drugs (eg, methysergide, dihydroergotamine) or other 5-HT1 agonists; during or within 2 wk after discontinuing MAOIs |
| Interactions | Toxicity may increase when used within 24 h of ergotamines or other 5-HT agonists; coadministration with SSRIs may cause weakness, hyperreflexia, or incoordination; CYP450-3A4 inhibitors (eg, ketoconazole, itraconazole, ritonavir, erythromycin) may increase plasma concentration and subsequent toxicity |
| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus |
| Precautions | Confirm diagnosis; not recommended in Wolff-Parkinson-White syndrome or arrhythmias that are associated with other cardiac accessory conduction pathway disorders; exclude underlying cardiovascular disease, supervise first dose, and consider monitoring ECG in patients with likelihood of unrecognized coronary artery disease (eg, postmenopausal women, hypercholesterolemia, men >40 y, hypertension, those with strong family history, and patients who are obese, diabetic, or smoke); hepatic or renal dysfunction |
The first combination product of a 5HT receptor agonist and an NSAID, Treximet, was approved by the US Food and Drug Administration in April 2008. Efficacy was demonstrated in 2 randomized, double-blind, multicenter, parallel-group trials comparing the combination product to placebo and each individual active component (ie, sumatriptan and naproxen sodium). The percentage of patients remaining pain free without use of other medications through 24 hours postdose was significantly greater (p<0.01) among patients receiving a single dose of Treximet (25% and 23%) compared with placebo (8% and 7%) or either sumatriptan (16% and 14%) or naproxen sodium (10%) alone.1
| Drug Name | Sumatriptan and naproxen (Treximet) |
|---|---|
| Description | Combination product containing sumatriptan, a selective 5-hydroxytryptamine (5-HT1) receptor agonist, and naproxen sodium, an arylacetic acid nonsteroidal anti-inflammatory drug (NSAID). Fixed combination contains sumatriptan 85 mg and naproxen sodium 500 mg. Indicated for acute migraine. Sumatriptan mediates vasoconstriction of the basilar artery and vasculature of dura mater, which correlates with migraine relief. Naproxen provides analgesic, anti-inflammatory, and antipyretic properties. Decreases activity of cyclooxygenase, thereby interrupting prostaglandin synthesis. |
| Adult Dose | 1 tab PO at onset of migraine; do not exceed 2 tab/24 h; if second dose administered, do not administer until at least 2 h after first dose |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity; ischemic heart disease (eg, stable angina, vasospastic forms of angina, myocardial infarction, silent myocardial ischemia); uncontrolled hypertension; cerebrovascular or peripheral vascular disease; history of coronary artery bypass graft (CABG) surgery; peptic ulcer disease; recent GI bleeding or perforation; renal (CrCl <30 mL/min) or hepatic insufficiency; coadministration with MAOIs or within 2 wk of discontinuing MAOI; hemiplegic or basilar migraine; patients in whom aspirin or other NSAIDs induce asthma, rhinitis, nasal polyps, or urticaria |
| Interactions | Do not split, crush, or chew tab Sumatriptan: Do not administer within 24 h of ergotamine-containing or ergot-type drugs (eg, dihydroergotamine, methysergide); coadministration with selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) may increase risk for serotonin syndrome; coadministration with MAOIs or within 2 wk of discontinuing MAOIs may increase sumatriptan levels (see Contraindications) Naproxen: Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus |
| Precautions | Sumatriptan may increase risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke Naproxen may increase risk of serious GI adverse events (eg, bleeding, ulceration, stomach or intestinal perforation); acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug; preexisting asthma |
May alleviate migraine pain by inhibiting prostaglandin synthesis, reducing serotonin release and blocking platelet aggregation. Although effects of NSAIDs in treatment of migraine pain tend to be patient specific, ibuprofen is usually DOC for initial therapy. Other options include naproxen, ketoprofen, and ketorolac.
| Drug Name | Ibuprofen (Ibuprin, Motrin, Advil) |
|---|---|
| Description | For acute treatment of mild-to-moderate migraine headaches. |
| Adult Dose | 400 mg PO q4-6h, 600 mg q6h, or 800 mg q8h while symptoms persist; not to exceed 3.2 g/d |
| Pediatric Dose | 20-70 mg/kg/d PO divided tid/qid; start at lower end of dosing range and titrate; not to exceed 2.4 g/d |
| Contraindications | Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding |
| Interactions | Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals |
| Precautions | Category D in third trimester of pregnancy; caution in CHF, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy |
| Drug Name | Ketorolac (Toradol) |
|---|---|
| Description | Inhibits prostaglandin synthesis by decreasing the activity of the enzyme, cyclooxygenase, which results in decreased formation of prostaglandin precursors. |
| Adult Dose | 30-60 mg IM initially, followed by 15-30 mg q6h prn; not to exceed 5 d of treatment |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding; do not administer into CNS |
| Interactions | Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals |
| Precautions | Category D in third trimester of pregnancy; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; low WBC counts (rare) usually return to normal during ongoing therapy; discontinue therapy if persistent leukopenia, granulocytopenia, or thrombocytopenia occur |
| Drug Name | Aspirin (Bayer Aspirin, Ascriptin, Anacin) |
|---|---|
| Description | Treats mild to moderate pain and headache. Inhibits prostaglandin synthesis, which prevents formation of platelet-aggregating thromboxane A2. |
| Adult Dose | 1.3 g/d PO divided bid/qid |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity; liver damage; hypoprothrombinemia; vitamin K deficiency; bleeding disorders; asthma; due to association of aspirin with Reye syndrome, do not use in children ( <16 y) with flu |
| Interactions | Effects may decrease with antacids and urinary alkalinizers; corticosteroids decrease salicylate serum levels; additive hypoprothrombinemic effects and increased bleeding time may occur with coadministration of anticoagulants; may antagonize uricosuric effects of probenecid and increase toxicity of phenytoin and valproic acid; doses > 2 g/d may potentiate glucose-lowering effect of sulfonylurea drugs |
| Pregnancy | D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus |
| Precautions | May cause transient decrease in renal function and aggravate chronic kidney disease; avoid use in patients with severe anemia, with history of blood coagulation defects, or taking anticoagulants |
Initial therapy for patients with infrequent migraines can be treated with simple analgesics.
| Drug Name | Acetaminophen (Tylenol, Feverall, Aspirin-Free Anacin) |
|---|---|
| Description | DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants. |
| Adult Dose | 325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity; known G-6-P deficiency |
| Interactions | Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity |
| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals |
| Precautions | Hepatotoxicity possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; APAP is contained in many OTC products and combined use with these products may result in cumulative APAP doses exceeding recommended maximum dose |
For use in acute treatment of migraine.
| Drug Name | Dihydroergotamine (DHE 45, Migranal) |
|---|---|
| Description | Alpha-adrenergic blocking agent with direct stimulating effect on smooth muscle of peripheral and cranial blood vessels. Depresses central vasomotor centers. Indicated to abort or prevent vascular headache when rapid control needed or when other routes of administration not feasible. |
| Adult Dose | 1 mL IV/IM at attack's onset, then 1 mL after 1 h, if needed; not to exceed 2 mL IV or 3 mL IM per attack, 6 mL/wk Premedicate with metoclopramide (10 mg IV/IM) or another antiemetic Intranasal administration: Spray once in each nostril, then repeat 15 min later; not to exceed 6 sprays/24 h and 8 sprays/wk |
| Pediatric Dose | Not recommended |
| Contraindications | Documented hypersensitivity; coronary or peripheral vascular disease; hypertension; impaired hepatic or renal function; sepsis; breastfeeding |
| Interactions | Increases effects of heparin and toxicity of nitroglycerin, propranolol, erythromycin, and clarithromycin |
| Pregnancy | X - Contraindicated; benefit does not outweigh risk |
| Precautions | Caution in angina, hypertension, impaired renal or hepatic function, or peripheral vascular disease |
For use in acute and prophylactic treatment of migraine
Agents that interact with the GABA-ergic system, seem to have a positive effect in reducing migraine attacks. Valproate and topiramate are most commonly used.
| Drug Name | Topiramate (Topamax) |
|---|---|
| Description | Sulfamate-substituted monosaccharide with broad spectrum of antiepileptic activity that may have state-dependent sodium channel blocking action, potentiates inhibitory activity of neurotransmitter GABA. In addition, may block glutamate activity. Not necessary to monitor plasma concentrations to optimize therapy. |
| Adult Dose | 50 mg/d PO; titrate by 50 mg/d at 1-wk intervals to target dose of 200 mg bid; not to exceed 1600 mg/d |
| Pediatric Dose | <2 years: Not established 2-16 years: 1-3 mg/kg PO initially; not to exceed 25 mg/d, then titrate dose upward by 1-3 mg/kg/d divided bid (not to exceed dosage increases of 25 mg) q1-2wk until total daily dose is 5-9 mg/kg/d divided bid >16 years: Administer as in adults |
| Contraindications | Documented hypersensitivity |
| Interactions | Phenytoin, carbamazepine and valproic acid can significantly decrease topiramate levels; topiramate reduces digoxin and norethindrone levels, when administered concomitantly; concomitant use with carbonic anhydrase inhibitors may increase risk of renal stone formation and should be avoided; use topiramate with extreme caution when administering concurrently with CNS depressants since may have an additive effect in CNS depression, as well as other cognitive or neuropsychiatric adverse events |
| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus |
| Precautions | Risk of developing a kidney stone formation is increased 2-4 times that of untreated population; risk may be reduced by increasing fluid intake; caution in renal or hepatic impairment; patients taking topiramate should seek immediate medical attention if they experience blurred vision or periorbital pain; continued usage after symptoms develop, can lead to glaucoma; primary treatment is discontinuation of topiramate; if left untreated, serious sequelae, including permanent vision loss, may occur; oligohidrosis and hyperthermia has been reported predominantly in children during vigorous exercise or exposure to warm environmental temperatures (ensure proper hydration prior and during activity and warm temperatures); may cause hyperchloremic, non-anion gap metabolic acidosis acute or chronic metabolic acidosis resulting in hyperventilation, and nonspecific symptoms, such as fatigue and anorexia, or more severe adverse effects including cardiac arrhythmias or stupor; chronic, untreated metabolic acidosis may increase nephrolithiasis or nephrocalcinosis risk, osteomalacia (ie, rickets in pediatric patients), or osteoporosis with an increased risk for bone fractures; chronic metabolic acidosis in pediatric patients may also reduce growth rates; measure baseline and periodic serum bicarbonate |
| Drug Name | Valproic acid (Depakote) |
|---|---|
| Description | There is no evidence that valproic acid is useful in the acute treatment of migraine headaches. The mechanism of action is unknown. |
| Adult Dose | 250 mg PO bid initially; not to exceed 1 g/d |
| Pediatric Dose | <16 years: Not established >16 years: Administer as in adults |
| Contraindications | Documented hypersensitivity; hepatic disease/dysfunction |
| Interactions | Coadministration with cimetidine, salicylates, felbamate, and erythromycin may increase toxicity; rifampin may significantly reduce valproate levels; in pediatric patients, protein binding and metabolism of valproate decrease when taken concomitantly with salicylates; coadministration with carbamazepine may result in variable changes of carbamazepine concentrations with possible loss of seizure control; valproate may increase diazepam and ethosuximide toxicity (monitor closely); valproate may increase phenobarbital and phenytoin levels while either one may decrease valproate levels; valproate may displace warfarin from protein binding sites (monitor coagulation tests); may increase zidovudine levels in HIV seropositive patients |
| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus |
| Precautions | Thrombocytopenia and abnormal coagulation parameters have occurred; the risk of thrombocytopenia increases significantly at total trough valproate plasma concentrations >110 mcg/mL in females and 135 mcg/mL in males; at periodic intervals and prior to surgery, determine platelet counts and bleeding time before initiating therapy; reduce dose or discontinue therapy if hemorrhage, bruising, or a hemostasis/coagulation disorder occur; hyperammonemia may occur, resulting in hepatotoxicity; monitor patients closely for appearance of malaise, weakness, facial edema, anorexia, jaundice, and vomiting; may cause drowsiness |
For acute treatment of mild-to-moderate migraine headaches.
| Drug Name | Isometheptene, dichloralphenazone, acetaminophen (Midrin, Midchlor, Isocom) |
|---|---|
| Description | Acetaminophen/aspirin combinations are indicated for initial migraine events. Isometheptene acts by constricting dilated cranial and cerebral arterioles, reducing stimuli that lead to vascular headaches. Acetaminophen raises threshold to painful stimuli, thus exerting an analgesic effect against all types of headaches. |
| Adult Dose | 2 cap PO initially, followed by 1 cap PO q1h until desired response obtained; not to exceed 5 cap per 12 h |
| Pediatric Dose | Not recommended |
| Contraindications | Documented hypersensitivity; glaucoma, hypertension, organic heart disease, severe renal disease, or hepatic disease; do not administer within 2 wk of taking MAOI |
| Interactions | Concurrent use of MAOIs with isometheptene may result in severe headache, hypertension, and hyperpyrexia, which in turn may result in hypertensive crisis |
| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus |
| Precautions | Caution in hypertension, peripheral vascular disease, and recent cardiovascular injuries |
| Drug Name | Butalbital, acetaminophen, caffeine (Fioricet); butalbital, aspirin; caffeine (Fiorinal) |
|---|---|
| Description | Drug combination for tension headaches. Barbiturate component has generalized depressant effect in CNS. |
| Adult Dose | 1-2 tab or cap PO q4h prn; not to exceed 6 doses/d |
| Pediatric Dose | Not recommended |
| Contraindications | Documented hypersensitivity; porphyria; varicella or influenza in teenagers; bleeding or coagulation disorders; peptic ulcer; third trimester pregnancy |
| Interactions | Effects decreased by coadministration of phenothiazines, quinidine, tricyclic antidepressants, theophylline, haloperidol, chloramphenicol, ethosuximide, corticosteroids, warfarin, doxycycline, and beta-blockers; effects are increased with coadministration of CNS depressants, methylphenidate, valproic acid, propoxyphene, and benzodiazepines; aspirin may increase effect of anticoagulants |
| Pregnancy | D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus |
| Precautions | Caution in patients with history of substance abuse; impaired hepatic or renal function; acute abdomen; depression; suicidal tendencies; asthma; bleeding disorders; gastritis; monitor blood pressure, BUN, and uric acid levels; elderly persons; those who are debilitated |
Are effective in prophylactic therapy, possibly by blocking vasodilators, decreasing platelet adhesiveness and aggregation, stabilizing the membrane, and increasing the release of oxygen to tissues.
| Drug Name | Propranolol (Inderal) |
|---|---|
| Description | Indicated for prophylaxis of migraine headache. |
| Adult Dose | 80 mg/d PO divided tid/qid initially; may increase to 160-240 mg/d PO |
| Pediatric Dose | Not recommended |
| Contraindications | Documented hypersensitivity; asthma; sinus bradycardia; second- or third-degree AV block; overt heart failure; cardiogenic shock |
| Interactions | Potentiated by alcohol, CNS depressants, other antihypertensives, antithyroid drugs, haloperidol, chlorpromazine, and cimetidine; bradycardia with catecholamine-depleting drugs; antagonized by NSAIDs, barbiturates, rifampin, and phenytoin; may increase cardiac effects of calcium channel blockers, digitalis, and lidocaine; potentiates theophylline, antipyrine, and lidocaine; may block epinephrine; may interfere with glaucoma screening tests |
| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus |
| Precautions | CHF, Wolff-Parkinson-White syndrome; renal or hepatic dysfunction; bronchospastic disease and COPD; diabetes; hyperthyroidism; surgery; SLE; avoid abrupt cessation; discontinue if results are poor after 4-6 wk of therapy |
Used for prophylaxis (mechanism of action is independent of antidepressant effect, but unknown). Inhibits activity of such diverse agents as histamine, 5-HT, and acetylcholine.
| Drug Name | Amitriptyline (Elavil) |
|---|---|
| Description | Analgesic for certain chronic and neuropathic pain. Mechanism of action in migraine headaches unknown. |
| Adult Dose | 10-300 mg PO qd in divided doses or hs; titrate dose to alleviate symptoms |
| Pediatric Dose | Not recommended |
| Contraindications | Documented hypersensitivity; during or within 14 d of MAOIs; acute post-MI |
| Interactions | Hyperpyretic crisis, convulsions, death with MAOIs; potentiates alcohol; CNS stimulation with reserpine; antagonized by barbiturates, carbamazepine, and phenytoin; paralytic ileus, hyperpyrexia with anticholinergics; blocks guanethidine; potentiated by hepatic enzyme inhibitors; monitor serum levels with cimetidine |
| Pregnancy | D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus |
| Precautions | Caution in cardiac conduction disturbances and history of hyperthyroidism, renal or hepatic impairment; avoid using in elderly persons |
| Drug Name | Nortriptyline (Pamelor, Aventyl HCl) |
|---|---|
| Description | Has demonstrated effectiveness in the treatment of chronic pain. Mechanism of action in the treatment of migraine headaches unknown. By inhibiting the reuptake of serotonin and/or norepinephrine by the presynaptic neuronal membrane this drug increases the synaptic concentration of these neurotransmitters in the central nervous system. Pharmacodynamic effects such as the desensitization of adenyl cyclase and down-regulation of beta-adrenergic receptors and serotonin receptors also appear to play a role in its mechanisms of action. |
| Adult Dose | 10-125 mg PO qd in divided doses or hs; titrate dose to alleviate symptoms |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity; narrow-angle glaucoma; do not administer to patients that have taken MAOIs in past 14 d |
| Interactions | Cimetidine may increase nortriptyline levels when used concurrently; nortriptyline may increase prothrombin time in patients stabilized with warfarin |
| Pregnancy | D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus |
| Precautions | Caution in cardiac conduction disturbances and history of hyperthyroidism, renal or hepatic impairment; due to pronounced effects in cardiovascular system, best to avoid in elderly persons |
Article Last Updated: Aug 28, 2008
