How Do I Choose Acute Treatment Medication Options for Migraine Patients?

Laura Xanders, FNP-BC Maureen Moriarty, DNP, APRN, FAHS, FAANP Step 1: Conduct a history of present illness (HPI)

What is their migraine frequency? • What is the frequency of the paent’s moderate to severe migraine aacks? • What associated symptoms do they experience with their migraine aacks? • Are their migraine aacks rapid or gradual in onset? What do they currently take? • Do they get complete relief? • How oen do they take it? • Can they tolerate oral medicaon during a migraine aack?

What have they tried in the past that has or has not worked? Step 2: Determine any comorbid condions or concurrent medicaons that may be a contraindicaon to an acute migraine medicaon.

A patient with a history of stomach A patient with a history of Pregnancy/lactation status ulcer may not be a good candidate cardiovascular disease or could impact safe or approved for an oral NSAID uncontrolled hypertension use of a medication may not be a good candidate for a triptan Step 3: Review the available acute medicaon opons. 1. NSAIDs • Faster onset: diclofenac powder, ketorolac IM, ketorolac NS • Slower onset: naproxen, ibuprofen, diclofenac, indomethacin 2. Triptans • Short half life: sumatriptan, rizatriptan, eletriptan, almotriptan, zolmitriptan • Long half life: naratriptan, frovatriptan • Non-PO: sumatriptan NS, zolmitriptan NS, sumatriptan SQ 3. Acute CGRP antagonists (gepants) • ubrogepant • rimegepant 4. Ditans • lasmiditan 5. An-emecs* • metoclopramide • prochlorperazine • promethazine • ondansetron

* Metoclopramide, prochlorperazine and promethazine have addional direct an-migraine effect but may be sedang, and ondansetron has no direct an-migraine effect but is not sedang. Step 4: Make a treatment acon plan

If the patient always experiences severe attacks, and fewer than 8 days/month, they may do best with a migraine- specific agent at onset of all attacks.

If frequency is more than 8 days/month, or there is a mix of moderate and severe attacks, use a stratified care and combination approach.

When there is significant nausea use non-oral treatment or add an anti-emetic. Step 5: Clarify medicaon limits

Medicaon limits exist for safety and to prevent acute medicaon overuse.

SUGGESTED LIMITS • If a paent is using only simple analgesics, usage up to 15 days/month is considered reasonable. If a paent uses other agents in addion, the limit should be 10 days/month. This recommendaon is to reduce the chances of medicaon toxicity and rebound headache. Note: Some common side effects or cauons

• Triptans - jaw/throat/chest ghtness, palpitaons, ngling, nausea, temporary increase in blood pressure, sedaon • Gepants - medicaon interacons (see med insert) • Ditans - sedaon, dizziness • NSAIDs - stomach upset • metoclopromide/phenothiazines - tardive dyskinesia, akathisia, sedaon, anxiety Acute Medicaons for Migraine Medicaon Class Frequency of Treatment/Limits Most Common Side effects Consideraons Triptans All triptans can be repeated once in 2 hours with -Dizziness Can contribute to increased headache Sumatriptan PO, NS, SQ the following excepons: -Drowsiness frequency if overused Eletriptan PO -Heaviness Frovatriptan PO • Sumatriptan SQ can be repeated in 1 hour Naratriptan PO • Naratriptan can be repeated in 4 hours -Neck/jaw ghtness Contraindicated in paents with or at Rizatriptan PO, ODT -Elevated Blood Pressure risk for vascular disease Zolmitriptan PO, NS, ODT Almotriptan PO NSAIDs Every 6-12 hours -Abdominal pain Contraindicated in history of Aspirin PO -Conspaon gastrointesnal bleed, decreased Ibuprofen PO -Diarrhea kidney funcon and/or abnormal liver Naproxen PO Limit to 12-15 days or less per month Diclofenac PO -Nausea/Voming funcon with overuse Indomethacin PO *limit to 4 days per month -Heartburn Nabumetone PO *Ketorolac IM, NS Celecoxib PO Gepants U- 1 dose followed by 2nd as needed in 2 hours -Drowsiness (U) Limited long-term data Ubrogepant PO R- limit to 1 dose in 24 hrs -Nausea (U, R) Should not be used in paents with Rimegepant ODT -Dry mouth (U) acve vascular disease

Ditans Limit to 1 dose in 24hrs -Sedaon Limited long-term data Lasmidan PO -Dizziness Controlled substance -Numbness/Tingling 8 hour driving restricon Should not be used in paents with acve vascular disease Neurolepcs Up to 3 mes a day -Drowsiness Metoclopramide safe in pregnancy Metoclopramide PO Limit to 10 days per month -Tardive dyskinesi Prochlorperazine PO, PR Promethazine PO, PR

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