Migraine

(Family disorder)
(recurrent attacks) (unilateral) (associated symptoms)

1.classical migraine (migraine with aura)

- phase
migraine attack
- prodromal phase
(Flickering Scotoma)
- hemicranial headache
2.common migraine (migraine without aura)

(throbbing or hollow )

- (stress) (exertion) (excitement)
(anxiety) (fatigue)
- hormone

-
- vasoactive amine chocolate cheese
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migraine
1. Neuronal hypothesis :

2. Vascular hypothesis : 3
-
-
- exudate transudate (pia)
3. Humoral hypothesis : neurotransmitters serotonin
biological amine noradrenaline
adrenaline dopamine histamine

4. Platelet hypothesis :

aura cortical spreading depression (CSD) cortical hyperexcitability

depolarization wave brain cortex transient depression sapontaneous evoked neuronal
activity depression wave CSD brain ion homeostasis
visual cortex aura

trigeminovascular system
dura mater (meningeal blood vessels)
pial vessel innervated sensory afferent fiber
trigeminal nerve nociceptive information terminate trigeminal
nucleus caudalis (TNC) lower brainstem upper cervical cord relay nociceptive information
quintothalomic tract thalamus cortical pain areas
trigeminovascular system CSD
depolarization trigeminal ganglion, trigeminal nucleus caudalis blood vessel wall
antidromic stimulation
retrograde stimulation trigeminal nerve innervate calcitonin-gene
related peptide (CGRP) trigeminal A- fiber substance P/neurokinin A trigeminal C-fiber neurotransmitters
vasodilation plasma extravasation neurogenic inflammation
sensitizing nerve fiber innocuous stimuli ( ) vessel pulsation veneous
pressure change neurogenic inflammation

 neurogenic inflammation orthodromic transmission impulses

trigeminal nucleus caudalis (TNC) neuron higer center
TNC superior salivatory neurons (SuS) shphenoplalatine
ganglion (SPG) parasympathetic fiber innervate trigeminovascular system SPG acetylcholine,
vasoactive intestinal peptides neurotransmitter SPG modulate cranial inflammatory
process
trigeminal nerve cranial vascular smooth muscle 5-HT receptor subtype 1
5-HT1D trigeminal nerve 5-HT1B human cerebral blood vessel
receptor neuronal inflammation
Acute attack
- analgesic : prostaglandins ASA, Paracetamol, Ibuprofen, Naproxen
NSAIDs nacrotic analgesics codeine
- antiemetic : Metoclopramide, Domperidone
gastric emptying)
- sedative : benzodiazepine


Ergot alkaloids
1 agonist vasoconstriction
nonselective 5-HT1B/1D receptor agonist ergotamine
caffeine ergotamine


12 1-2
1-2 6 10 3
5 2

1. (Ergotamine tartate) (Cafergot) 1
1 . (Caffeine) 100 .
2. (Dihydroergotamine) 1 . 1 . (1
.) (Dihydergot)


(peripheral gangrene)
non selective vasodilator sodium nitoprusside

- ergotamine
-
Angina pectoris ( preload afterload)
- Triptans
Generic name

Brand name

Ergotamine

Ergosia

Ergotamine and caffeine

AVAMIGRAN
CAFERGOT
DEGRAN
POLIGOT-CF
POLYGOT

Dihydroergotamine (DHE)
ergotamine
Triptan family
Sumatriptan ( BBB ), Zolmitriptan, Naratriptan, Rizatriptan, Eletriptan, Almotriptan,
Alnitidan Fravotriptan selective 5-HT1B/1D agonist

ergotamine
Sumatriptan
: (paresthesia)
ergotamine, MAOI,
lithium, 5-HT reuptake inhibitor
Carbon dioxide inhalation
(cerebral vasodilation)
aura ( cortical vasoconstriction)

Acute attack 2
attack acute attack

 4-6

Aspirin
prostaglandin thromboxane
prostacyclin
Beta blocker
membrane stabilizing effect propanolol 80-320 mg/day, atenolol, metoprolo,l nadolol
timolol beta-blocker (fatigue)
ergotamine

5-HT2 receptor blocker

Pizotifen 0.5 mg 1 3-6 3

Cyproheptadine
Methysergide ( 5-HT1 receptor ) pizotifen
retroperitoneal fibrosis 1 4-6
0.5 mg

1-2

mg

Calcium channel antagonist
beta-blocker Calcium channel blockers
verapamil 40 mg tid, flunarizine 10 mg/day
Antidepressants amitriptyline, nortriptyline, and doxepin
Anticonvulsants valproic acid 10
promising agents Gabapentin 900-2400 mg/day Topiramate 25-200 mg/day

Migraine Therapy
Medication
Anaigesics
Acetaminophen

Dosage

Comments

1000 mg at onset; repeat every 4-6 h

as needed
2 tablets at onset and every 6 h

Maximum daily dose is 4 g

Acetaminophen 250 mg/aspirin 250

mg/caffeine 65 mg
Aspirin or Acetaminophen with
1-2 tablets every 4-6 h
butalbital, caffeine
Isometheptene 65
2 capsules at onset; repeat 1 capsule
mg/dicloralphenazone 100
every hour as needed
mg/acetaminophen 325 mg(Midrin)
Nonsteroidal Anti-inflammatory Drug
Aspirin
500-100 mg every 4-6 h
Ibuprofen
200-800 mg every 6 h
Naproxen sodium
550-825 mg at onset; may repeat 220
mg in 3-4 h
Diclofenac potassium
50-100 mg at onset; may repeat 50 mg
in 8 h
Ergotamine Tartrate
Oral tablet (1 mg) with caffeine 100 2 mg at onset; then 1-2 mg every 30
mg
min as needed
Sublingual tablet (2 mg) rectal
suppository (2 mg) with caffeine 100
mg
dihydroergotamine
Injection 1 mg/ml
Nasal spray

Serotonin Agonists (Triptans)

Insert to 1 suppository at onset;

repeat after 1 h as needed

0.25-1 mg at onset IM or SQ; repeat

every hour as needed
One spray (0.5 mg) in each nostril at
onset; repeat sequence 15 min later
(total dose is 2 mg or 4 sprays)

Available over-the-counter as
Excedrin Migraine
Limit dose to 4 tablets/day and usage
to 2 days/week
Maximum of 6 capsules/day and 20
capsules/mounth

Maximum daily dose is 4 g

Avoid dose > 2.4 g/day
Avoid dose > 1.375 g/day
Avoid dose > 150 mg/day

Maximum dose is 6 mg/day or 10

mg/wk; consider pretreatment an
antiemetic
Maximum dose is 4 mg/day or 10
mg/wk; consider pretreatment an
antiemetic
Maximum dose is 3 mg/day or 20
mg/wk
Maximum dose is 3 mg/day; prime
sprayer 4 times before using; do not
tilt head back or inhale through nose
while spraying; discard open
ampoules after 8 h

Sumatriptan
Injection
Oral tablets
Nasal spray

zolmitrilptan

Naratriptan
Rizatriptan

Almotriptan
Frovatriptan
Eletriptan
Miscellaneous
Butorphanol nasal spray

6 mg SC at onset; may repeat after 1 h

if needed
25, 50, or 100 mg at onset; may repeat
after 2 h if needed
5, 10, or 20 mg at onset; may repeat
after 2 h if needed

Maximum daily dose is 12 mg

1 spray in 1 nostril (1 mg) at onset;

repeat in 1 h if needed

Limit to 4 sprays/day; consider use

only when nonopioid therapies are
ineffective or not tolerated
Useful for acute relief in the office or
emergency department setting
Useful for acute relief in the office or
emergency department setting

Optimal dose is 50-100 mg; maximum

daily dose is 200 mg
Optimal dose is 20 mg; maximum
daily dose is 40 mg; single-dose
device delivering 5 or 20 mg;
administer one spray in one nostril
2.5 or 5 mg at onset as regular or
Optimal dose is 2.5 mg; maximum
orally disintegrating tablet; may repeat daily dose is 10 mg/day
after 2 h if needed
Do not divide ODT dosage form
1 or 2.5 mg at onset; may repeat after Optimal dose is 2.5 mg; maximum
4 h if needed
daily dose is 5 mg
5 or 10 mg at onset as regular or
Optimal dose is 10 mg; maximum
orally disintegrating tablet; may repeat daily dose is 300 mg; onset of effect is
after 2 h if needed
similar with standard and orally
disintegrating tablets; use 5-mg dose
(15 mg/day max) in patients receiving
propranolol
6.25 or 12.5 mg at onset; may repeat Optimal dose is 12.5 mg; maximum
after 2 h if needed
daily dose is 25 mg
2.5 or 5 mg at onset; may repeat after Optimal dose is 2.5-5 mg; maximum
2 h if needed
daily dose is 7.5 mg (3 tablets)
20 or 40 mg at onset; may repeat after Maximum single dose is 40 mg;
2 h if needed
maximum daily dose is 80 mg

Metoclopramide

10 mg IV at onset

Prochloperazine

10 mg IV or IM at onset

Prophylactic Migraine Therapy

Medication
Beta-blocker
Atenolol
Metoprolol
Nadolol
Propanolol
Timolol
Antidepressants
Amitriptyline
Doxepin
Imipramine
Nortriptyline
Protriptyline
Fluoxetine
Phenelzine
Valproic acid
Verapamil
Methysergide
Nonsteroidal Anti-inflammatory Drugs
Aspirin
Ketoprofen
Naproxen sodium
Vitamin B2

Dose
25-100 mg/day
50-300 mg/day in divided doses
80-240 mg/day
80-240 mg/day in divided doses
20-60 mg/day in divided doses
25-150 mg at bedtime
10-200 mg at bedtime
10-200 mg at bedtime
10-150 mg at bedtime
5-30 mg at bedtime
10-80 mg/day
15-60 mg/day in divided doses
500-1500 mg/day in divided doses
240-360 mg/day in divided doses
2-8 mg/day in divided doses with food
1300 mg/day in divided doses
150 mg/day in divided doses
550-1100 mg/day in divided doses
400 mg/day