|
Drug Class/Drug
|
Drug
|
Dose Range
|
Notes
|
| Nonsteroidal anti-inflammatory drugs |
Ibuprofen Naproxen Diclofenac Diclofenac epolamine Tolfemanic acid Dexletoprofen
|
900-100 mg 400-600 mg 275-825 mg 50-100 mg 65 mg 200 mg 120 mg 50 mg
| All NSAIDs have similar efficacy |
| Non-opioid analgesic |
|
| Acute-life threatening hepatotoxicity at > 4 g/d |
|
Serotonin 1b/1d agonists (triptans)
(Sumatriptan)*[67]
|
Sumatriptan (intranasal solution) [68]
|
6 mg as a single dose, may repeat dose (usually same as the first dose) after ≥1 hour if symptoms persist or return, or lesser dosage if 6 mg was not tolerated, maximum dose: 6 mg/dose; 12 mg/d
|
All formulations of triptans are contraindicated in severe hepatic impairment.
Contraindicated in patients with cardiovascular illness as prolonged QT interval on ECG and subsequent ventricular arrhythmias, including torsades de pointes (TdP) and ventricular fibrillation, are reported.
It may also cause dizziness, lethargy, tremor, vertigo, akathisia, dystonia, and pathological laughter.
Other vasospasm-related events include peripheral ischemia, ischemic colitis, splenic infarction, and Raynaud disease.
It should be avoided in patients with uncontrolled hypertension and pregnancy.
Ocular side effects include transient and permanent blindness and significant partial vision loss.
The use of concomitant serotonergic drugs may cause serotonin syndrome.
Unpleasant taste is lower with intranasal zolmitriptan as compared to intranasal sumatriptan.
Patients who do not respond to one triptan may respond to another.
Naratriptan and frovatriptan have a slower onset and lower efficacy.
|
|
Serotonin 1b/1d agonists (triptans)
(Naratriptan)
|
|
|
Use within 24 hours of an ergotamine preparation or a different triptan is not advised.
Contraindicated with severe renal impairment (CrCl <15 mL/minute).
|
|
Serotonin 1b/1d agonists (triptans)
(Zolmitriptan)
|
|
2.5 mg as a single dose; may repeat dose after ≥2 hours; maximum dose: 5 mg/dose; 10 mg/d [70]
| Refer to the section on sumatriptan above for the side effects of triptans. |
|
Serotonin 1b/1d agonists (triptans)
(Frovatriptan)
|
|
| Slower onset |
|
Serotonin 1b/1d agonists (triptans)
(Almotriptan)
|
|
12.5 mg as a single dose; may repeat dose after ≥2 hours when needed; maximum dose: 12.5 mg/dose; 25 mg/d [71]
| Reduce dose to half with hepatic impairment |
|
Serotonin 1b/1d agonists (triptans)
(Rizatriptan)
|
|
| Propranolol increases rizatriptan levels by 70%. So the dose of rizatriptan must be adjusted downward in these patients. |
|
Serotonin 1b/1d agonists (triptans)
(Eletriptan)
|
|
| Primarily metabolized by cytochrome P-450 enzyme CYP3A4. Not advised within at least 72 hours of treatment with other drugs that are potent CYP3A4 inhibitors: itraconazole, ketoconazole, clarithromycin, nefazodone, troleandomycin, ritonavir, and nelfinavir. |
|
Antiemetics
|
Metoclopramide (IV, IM, oral) [73]
|
| IV route is preferred for metoclopramide. Pretreat with diphenhydramine to prevent akathisia and other acute dystonic reactions. |
| Calcitonin-gene-related peptide (CGRP) antagonists |
|
|
Administration early in the course of a migraine attack may improve response to treatment.
Second-line therapy when triptans are contraindicated, poorly tolerated, or ineffective.
More studies are needed to establish efficacy and safety.
|
| Serotonin 5-HT1F receptor agonist |
|
|
Administration early in the course of a migraine attack may improve response to treatment.
Second-line therapy when triptans are contraindicated, poorly tolerated, or ineffective.
A major side effect is dizziness (9% to 17%). Wait for at least 8 hours between dosing and driving or operating heavy machinery.
It may enhance the CNS depressant effect of alcohol.
|
| Ergot derivative |
|
IM: 1 mg as a single dose; may repeat hourly as required; maximum dose: 3 mg/d, 6 mg/week IV: 1 mg as a single dose; may repeat hourly as required; maximum dose: 2 mg/d, 6 mg/week SUBQUT: 1 mg as a single dose; may repeat every 2 hours as required; maximum dose: 3 mg/d, 6 mg/week Intranasal: 0.5 mg per spray: 1 spray (0.5 mg) into each nostril; repeat after 15 minutes (total of 4 sprays per dose); maximum dose: 4 sprays (1 dose)/d
|
Use is contraindicated in severe hepatic or renal impairment and pregnancy or breastfeeding.
Also contraindicated in patients with hypertension or ischemic heart disease.
It should not be used within 24 hours of triptans or ergot-like agents.
Use with potent inhibitors of CYP3A4 (including azole antifungals, protease inhibitors, and some macrolide antibiotics) is also avoided.
|
