12.2 Migraine Headaches and Migraine Headache Drugs
4 min read•june 18, 2024
are complex neurological disorders involving the . They're characterized by phases of symptoms, from to , with triggers ranging from stress to dietary factors. Understanding these mechanisms is crucial for effective management.
Pharmacological treatment of migraines includes preventive and acute medications. and are key players in acute treatment, working on receptors to relieve symptoms. Each drug class has specific side effects and contraindications that nurses must consider when administering treatment.
Pathophysiology and Symptoms of Migraine Headaches
Mechanisms of migraine headaches
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- Neurological disorder involving the trigeminovascular system
- Trigeminal nerve innervates the meninges and cerebral blood vessels
- Activation of trigeminal nerve releases vasoactive peptides (, ) causing vasodilation and
- (CSD) wave of neuronal and glial depolarization followed by suppression of neural activity associated with symptoms and activation of trigeminal nerve
- Serotonergic dysfunction: imbalance in serotonin levels may contribute to migraine pathogenesis by increasing pain sensitivity and vasodilation
Triggers and symptoms of migraines
- Common triggers include stress and anxiety, hormonal changes (menstrual cycle, menopause), sleep disturbances (insomnia, oversleeping), dietary factors (alcohol, caffeine, certain foods), and environmental factors (bright lights, loud noises, strong odors)
- Symptoms occur in phases:
- Prodrome (hours to days before headache) characterized by fatigue, mood changes, food cravings, neck stiffness
- (occurs in some patients, usually before headache) involves visual disturbances (flashing lights, blind spots), sensory disturbances (tingling, numbness), and language disturbances (difficulty speaking)
- Headache phase presents with unilateral, pulsating pain of moderate to severe intensity aggravated by physical activity along with nausea, vomiting, , and
- Postdrome (after headache resolves) characterized by fatigue, cognitive difficulties, mood changes
Pharmacological Management of Migraine Headaches
Classes of migraine medications
- Preventive medications () taken regularly to reduce frequency and severity of migraines include beta-blockers (, ), antidepressants (, venlafaxine), anticonvulsants (topiramate, ), and CGRP antagonists (, )
- Acute treatment medications () taken at the onset of a migraine to relieve symptoms include (, ), ergotamines (, ), NSAIDs (ibuprofen, naproxen), and combination analgesics (acetaminophen/aspirin/caffeine)
Pharmacology of triptans vs ergotamines
- Triptans are selective serotonin (5-HT) receptor agonists primarily targeting and receptors causing of dilated cranial blood vessels, inhibition of vasoactive peptide release (CGRP, substance P), reduction of neurogenic inflammation and pain transmission
- Ergotamines are nonselective serotonin receptor agonists with affinity for 5-HT1B, 5-HT1D, and receptors causing vasoconstriction of cranial blood vessels, inhibition of trigeminal nerve activation and pain transmission, and reduction of neurogenic inflammation
Side effects of migraine drugs
- Triptans side effects include , chest tightness, fatigue, dizziness, nausea and are contraindicated in patients with cardiovascular disease, uncontrolled hypertension, or with drug interactions involving , ergotamines, ,
- Ergotamines side effects include nausea, vomiting, abdominal pain, muscle cramps, paresthesia and are contraindicated in patients with cardiovascular disease, uncontrolled hypertension, or pregnancy with drug interactions involving triptans, macrolide antibiotics, protease inhibitors
- Beta-blockers side effects include fatigue, dizziness, hypotension, bradycardia, sexual dysfunction and are contraindicated in patients with asthma, heart block, or severe peripheral vascular disease with drug interactions involving calcium channel blockers, antiarrhythmics, insulin
- Anticonvulsants side effects include drowsiness, dizziness, weight changes, cognitive impairment with drug interactions involving oral contraceptives, valproic acid, carbamazepine
Nursing considerations for migraine treatment
- Assessment involves obtaining a thorough headache history including triggers, frequency, severity and assessing for contraindications and drug interactions before administering medications
- Administration ensures proper dosing and route of administration for each medication and educates patients on the proper use of acute treatment medications (take at onset of migraine)
- Monitoring assesses for effectiveness of treatment and any adverse effects and monitors vital signs, especially in patients taking ergotamines or triptans
- Patient education teaches patients about the importance of avoiding triggers and maintaining a healthy lifestyle and instructs patients on the proper use, storage, and disposal of medications while encouraging patients to keep a headache diary to track triggers, symptoms, and treatment effectiveness
Patient education for migraine management
- Lifestyle modifications include stress management techniques (relaxation, meditation, exercise), maintaining a regular sleep schedule, avoiding known triggers (certain foods, alcohol, caffeine), staying hydrated and eating a balanced diet
- Proper use of medications involves taking preventive medications as prescribed even when feeling well, using acute treatment medications at the onset of a migraine not exceeding recommended dosage, and avoiding medication overuse which can lead to
- Tracking migraines and treatment effectiveness by keeping a headache diary to record triggers, symptoms, and response to medications and sharing the diary with healthcare providers to optimize treatment plan
- Follow-up care schedules regular check-ups with healthcare providers to monitor progress and adjust treatment as needed and reports any adverse effects or changes in migraine patterns to healthcare providers
- Support and resources include joining a migraine support group or seeking counseling to cope with the impact of migraines on daily life and utilizing reputable online resources (American Migraine Foundation, National Headache Foundation) for additional information and support
Key Terms to Review (60)
5-HT1B: 5-HT1B is a subtype of serotonin (5-hydroxytryptamine or 5-HT) receptors that is involved in the regulation of various physiological processes, including migraine headaches and the mechanism of action of certain migraine headache drugs.
5-HT1D: 5-HT1D is a subtype of the 5-hydroxytryptamine (5-HT) or serotonin receptor. It is primarily involved in the regulation of migraine headaches and the mechanism of action of certain migraine headache drugs.
5-HT1F: 5-HT1F is a subtype of serotonin (5-hydroxytryptamine) receptors that is involved in the pathophysiology and treatment of migraine headaches. This receptor is a G protein-coupled receptor that mediates the effects of serotonin in the central and peripheral nervous systems.
Abortive therapy: Abortive therapy is a treatment aimed at stopping the progression of a migraine headache once it begins. It focuses on immediate relief of symptoms rather than prevention.
Abortive Therapy: Abortive therapy refers to the use of medications or interventions aimed at stopping or aborting the progression of a migraine headache attack. The goal of abortive therapy is to provide rapid relief of migraine symptoms and prevent the attack from worsening or becoming debilitating.
Alpha-adrenergic blockers: Alpha-adrenergic blockers are medications that inhibit the action of alpha-adrenergic receptors, leading to vasodilation and decreased blood pressure. They are often used to manage conditions like hypertension and can be beneficial in treating certain types of migraines.
Amitriptyline: Amitriptyline is a tricyclic antidepressant medication that is also used to treat various types of chronic pain, including migraine headaches and certain urinary conditions. It works by altering the balance of neurotransmitters in the brain to improve mood and reduce pain perception.
Aura: An aura is a sensory disturbance experienced before a migraine or seizure, often manifesting as visual changes, sensory changes, or other neurological symptoms. It typically serves as a warning sign that the main episode is about to occur.
Aura: An aura is a transient sensory phenomenon that often precedes or accompanies certain neurological and medical conditions, particularly epilepsy and migraine headaches. It is a subjective experience that can manifest as visual, auditory, or other sensory disturbances, signaling the onset of a seizure or a migraine attack.
Cafergot: Cafergot is a combination medication containing ergotamine and caffeine used to treat migraine headaches. It works by constricting blood vessels in the brain and reducing inflammation.
Calcitonin gene related peptide (CGRP) receptor antagonists: Calcitonin gene-related peptide (CGRP) receptor antagonists are a class of medications used to prevent and treat migraine headaches. They work by blocking the action of CGRP, a neuropeptide involved in migraine pathophysiology.
CGRP: CGRP, or calcitonin gene-related peptide, is a potent vasodilator and neuropeptide that plays a crucial role in the pathophysiology of migraine headaches. It is released from sensory nerve endings and triggers a cascade of events that lead to the development of migraine pain.
Cortical Spreading Depression: Cortical spreading depression (CSD) is a wave of depolarization that slowly propagates across the cerebral cortex, temporarily disrupting normal neuronal activity. This phenomenon is closely linked to the pathophysiology of migraine headaches and serves as a key target for migraine headache drugs.
Dihydroergotamine: Dihydroergotamine is a semisynthetic ergot alkaloid derivative that is used primarily in the treatment and prevention of migraine headaches. It is structurally similar to the neurotransmitter serotonin and acts on various serotonin receptors in the brain and blood vessels to produce its therapeutic effects.
Eletriptan: Eletriptan is a medication used to treat acute migraine headaches. It works by narrowing blood vessels around the brain and reducing substances that trigger headache pain.
Erenumab: Erenumab is a monoclonal antibody medication used for the preventive treatment of migraine headaches. It works by blocking the activity of the calcitonin gene-related peptide (CGRP) receptor, which plays a crucial role in the pathophysiology of migraine.
Ergot alkaloids: Ergot alkaloids are a group of compounds derived from the ergot fungus, used primarily to treat migraine headaches by constricting blood vessels and reducing inflammation. They interact with serotonin receptors in the brain to alleviate symptoms.
Ergotamine: Ergotamine is a vasoconstrictor drug derived from the ergot fungus that is primarily used in the treatment of migraine headaches. It acts on serotonin (5-HT) receptors in the brain and blood vessels to constrict blood vessels and reduce the inflammation and pain associated with migraines.
Ergotamines: Ergotamines are a class of alkaloid compounds derived from the ergot fungus that have potent effects on the vascular and nervous systems. They are particularly important in the context of migraine headache treatment and management.
Fremanezumab: Fremanezumab is a monoclonal antibody medication used for the preventive treatment of migraine headaches. It works by targeting and inhibiting the activity of calcitonin gene-related peptide (CGRP), a protein that plays a key role in the pathophysiology of migraine attacks.
Hemiplegic Migraine: Hemiplegic migraine is a rare and severe type of migraine headache that is accompanied by temporary paralysis or weakness on one side of the body. It is classified as a subtype of migraine with aura, where the aura includes neurological symptoms that precede or accompany the migraine pain.
Imitrex: Imitrex is a brand name for sumatriptan, a medication used to treat acute migraine headaches. It works by narrowing blood vessels around the brain and reducing substances that trigger headache pain, nausea, and sensitivity to light and sound.
Lasmiditan: Lasmiditan is a serotonin receptor agonist used to treat acute migraine headaches. It works by targeting the 5-HT1F receptor, reducing migraine symptoms without causing vasoconstriction.
MAO Inhibitors: MAO inhibitors (MAOIs) are a class of medications that work by inhibiting the activity of the enzyme monoamine oxidase (MAO), which is responsible for the breakdown of certain neurotransmitters in the brain. This action leads to increased levels of these neurotransmitters, which can have therapeutic effects in the context of various medical conditions, including migraine headaches, central nervous system (CNS) stimulant and nonstimulant disorders, and shock states.
Maxalt: Maxalt is a brand name for rizatriptan, a medication used to treat acute migraine headaches. It belongs to the class of drugs called triptans, which work by narrowing blood vessels around the brain and reducing substances in the body that can trigger migraine symptoms.
Medication Overuse Headache: Medication overuse headache (MOH) is a condition characterized by the development of a chronic and disabling headache disorder due to the overuse of acute or symptomatic headache medications. It is a significant problem that can arise in the context of migraine headaches and the use of migraine headache drugs.
Metoprolol: Metoprolol is a beta-adrenergic blocking agent, commonly known as a beta-blocker, that is primarily used to treat various cardiovascular conditions, including hypertension, angina, and certain types of arrhythmias. It works by selectively blocking the beta-1 receptors in the heart, reducing the heart's workload and oxygen demand.
Migraine headaches: Migraine headaches are severe, recurring headaches often accompanied by nausea, vomiting, and sensitivity to light and sound. They can last from a few hours to several days and severely impact daily activities.
Neurogenic Inflammation: Neurogenic inflammation is a complex inflammatory response triggered by the activation of sensory nerves, leading to the release of pro-inflammatory neuropeptides and the subsequent vasodilation, plasma extravasation, and mast cell degranulation. This process is a key feature in the pathophysiology of migraine headaches and the mechanism of action of certain migraine drugs.
Nurtec: Nurtec (rimegepant) is an orally administered calcitonin gene-related peptide (CGRP) receptor antagonist used for the acute treatment of migraine headaches. It helps alleviate migraine pain and associated symptoms such as nausea, phonophobia, and photophobia.
Paresthesia: Paresthesia refers to a burning, prickling, or tingling sensation on the skin that is not caused by actual stimulation of the skin. This abnormal sensation can occur in various medical conditions, including neurological disorders, metabolic disturbances, and certain medications.
Phonophobia: Phonophobia is an abnormal and irrational fear or aversion to loud sounds. It is a type of specific phobia that can be a common symptom associated with migraine headaches and is an important consideration in the context of migraine headache drugs.
Photophobia: Photophobia is an abnormal sensitivity or intolerance to light. It is a common symptom associated with various medical conditions, particularly migraine headaches, and can significantly impact a person's quality of life.
Postdrome: The postdrome is the final phase of a migraine attack, which occurs after the headache has subsided. It is characterized by a period of recovery and lingering symptoms that can last for hours or even days after the migraine pain has resolved.
Preventive therapy: Preventive therapy involves the use of medications or lifestyle changes to prevent the onset of disease symptoms. Specifically, it aims to reduce the frequency and severity of conditions like migraine headaches.
Prodrome: A prodrome is an early symptom or set of symptoms that can signal the onset of a disease or condition, often occurring before the main symptoms become apparent. In the context of migraine headaches and migraine headache drugs, the prodrome refers to the initial phase of a migraine attack.
Prophylaxis: Prophylaxis refers to the measures taken to prevent the occurrence or development of a disease or condition. It is a proactive approach to healthcare aimed at reducing the risk of illness or infection.
Propranolol: Propranolol is a beta-adrenergic blocking agent, commonly known as a beta-blocker, that is primarily used to treat a variety of cardiovascular and neurological conditions. It works by blocking the effects of the neurotransmitter norepinephrine, which is responsible for the body\'s fight-or-flight response, making it a versatile medication with applications in the nervous system, migraine treatment, and cardiac dysrhythmia management.
Rebound Headaches: Rebound headaches, also known as medication overuse headaches, are a type of chronic headache that can develop as a result of the overuse or overreliance on pain medication used to treat other headache disorders, such as migraines. This cyclical pattern of headache relief followed by a rebound effect can lead to a worsening of the original headache condition.
Relpax: Relpax (eletriptan) is a medication used to treat migraine headaches by narrowing blood vessels around the brain and reducing substances that trigger headache pain. It belongs to a class of drugs known as triptans.
Reyvow: Reyvow (lasmiditan) is a medication used for the acute treatment of migraine headaches in adults. It acts as a serotonin (5-HT1F) receptor agonist to alleviate migraine symptoms.
Rimegepant: Rimegepant is a calcitonin gene-related peptide (CGRP) receptor antagonist used for the acute treatment of migraine headaches. It works by blocking the CGRP receptors to alleviate migraine symptoms.
Rizatriptan: Rizatriptan is a selective serotonin receptor agonist used to treat acute migraine headaches. It works by narrowing blood vessels around the brain and reducing substances in the body that trigger migraine pain, nausea, and sensitivity to light and sound.
Selective serotonin receptor agonists: Selective serotonin receptor agonists are drugs that specifically target and activate serotonin receptors in the brain to alleviate migraine headaches. They primarily work by narrowing blood vessels and reducing inflammation.
Selective serotonin reuptake inhibitors (SSRIs): Selective serotonin reuptake inhibitors (SSRIs) are a class of drugs used primarily to treat depression by increasing serotonin levels in the brain. They work by blocking the reabsorption (reuptake) of serotonin into neurons, making more serotonin available.
Serotonin: Serotonin is a neurotransmitter that plays a crucial role in regulating various physiological and psychological processes in the body. It is involved in the functioning of the nervous system, the regulation of mood, sleep, appetite, and other important bodily functions.
Serotonin agonists: Serotonin agonists are drugs that activate serotonin receptors, mimicking the effects of serotonin. They are commonly used to treat migraine headaches by constricting blood vessels and inhibiting pain pathways.
Serotonin norepinephrine reuptake inhibitors (SNRIs): Serotonin norepinephrine reuptake inhibitors (SNRIs) are a class of antidepressants that increase the levels of serotonin and norepinephrine in the brain by inhibiting their reabsorption (reuptake) into neurons. They are commonly prescribed for major depressive disorder, anxiety disorders, and certain chronic pain conditions.
SNRIs: SNRIs, or Serotonin-Norepinephrine Reuptake Inhibitors, are a class of medications primarily used as antidepressants and for the management of various other conditions, such as chronic pain, migraine headaches, and anxiety disorders. These drugs work by inhibiting the reuptake of both serotonin and norepinephrine, two important neurotransmitters in the brain, leading to increased levels and improved signaling between neurons.
SSRIs: SSRIs, or Selective Serotonin Reuptake Inhibitors, are a class of medications primarily used to treat depression and other mental health conditions. They work by selectively inhibiting the reuptake of the neurotransmitter serotonin, which is believed to play a crucial role in regulating mood, sleep, appetite, and other physiological processes.
Substance P: Substance P is a neuropeptide that acts as a neurotransmitter and neuromodulator in the central and peripheral nervous systems. It is involved in the transmission of pain signals and plays a crucial role in the pathophysiology of migraine headaches and the regulation of nausea and vomiting.
Sumatriptan: Sumatriptan is a medication used to treat migraine headaches by narrowing blood vessels around the brain and reducing substances in the body that can trigger headache pain, nausea, sensitivity to light and sound. It belongs to a class of drugs called triptans.
Tartrate: Tartrate is a salt or ester of tartaric acid, often used in medications to improve stability and absorption. In pharmacology, tartrate compounds are utilized for their role in drug formulations.
Trigeminovascular System: The trigeminovascular system is a complex neurological pathway that plays a crucial role in the pathophysiology of migraine headaches. It involves the trigeminal nerve, which is responsible for transmitting sensory information from the face, head, and meninges (the protective membranes surrounding the brain and spinal cord) to the central nervous system.
Triptans: Triptans are a class of medications specifically used to treat acute migraine attacks. They work by stimulating serotonin receptors, leading to the constriction of blood vessels in the brain and reducing inflammation.
Triptans: Triptans are a class of drugs primarily used for the acute treatment of migraine headaches. They work by selectively binding to and activating serotonin 5-HT1B and 5-HT1D receptors, which helps to constrict dilated blood vessels and reduce inflammation in the brain, effectively relieving migraine symptoms.
Valproic Acid: Valproic acid is a medication primarily used to treat epilepsy, migraine headaches, and mood disorders. It is an anticonvulsant drug that works by stabilizing electrical activity in the brain, reducing the frequency and severity of seizures, and modulating neurotransmitter levels to alleviate symptoms associated with various neurological and psychiatric conditions.
Vasoconstriction: Vasoconstriction is the narrowing or constriction of blood vessels, specifically the arteries and arterioles, which leads to a decrease in blood flow and blood pressure. This physiological process is an important mechanism in the regulation of blood flow and blood pressure throughout the body.
Zolmitriptan: Zolmitriptan is a medication used to treat acute migraine headaches. It belongs to the class of drugs known as triptans, which help narrow blood vessels around the brain and reduce substances that trigger headache pain.
Zomig: Zomig is a medication used to treat migraine headaches. It belongs to a class of drugs called triptans, which work by narrowing blood vessels around the brain and reducing substances that trigger migraine symptoms.