Pharmacy & Therapeutics- July 2008 - (Page 404) CONTINUING EDUCATION CREDIT The Pharmacological Management Of Migraine, Part 1 Overview and Abortive Therapy George DeMaagd, PharmD, BCPS Educational Objectives After reviewing this article, readers should be able to: I Describe, in general terms, the epidemiology, pathophysiology, and public health implications associated with migraine. I Identify the comorbidities and risk factors associated with migraine. I Recognize the clinical presentations of migraine. I Identify nonpharmacological treatments used in the management of migraine. I Describe the abortive therapies used in the pharmacological treatment of migraine, including the risks and benefits of these agents. I Understand the etiology and management of medicationoveruse headache. approximately $1 billion annually, and the indirect costs of lost time at work, school, and home result in an estimated $5.6 billion to $17.2 billion per year.1,4–5 The pharmacotherapy of migraine is complex, and the appropriate use of abortive agents and preventative medications requires an understanding of the various medications available and when they are best used in migraine management. Pathophysiology Migraine is best described as a neuronal event that may be caused by a hereditary susceptibility of the brain and various environmental triggers. It may occur in patients who have a genetically sensitive nervous system. The pathophysiology of migraine continues to be studied, and numerous theories have been proposed. The most recent and widely studied theory involves the trigeminovascular system, which—under the influence of a variety of external and internal triggers—results in the release of various inflammatory peptides, including calcitonin generelated peptide (CGRP), substance P, neurokinin A, and nitric oxide. The resultant perivascular inflammatory response influences the trigeminal nucleus caudalis in the brainstem (the migraine generator) and cervical cord area, transferring pain data to the upper areas of the brain, including the thalamus and cortex. This leads to a state of hyperexcitability or cortical sensitization, resulting in the pain of migraine and associated features, including gastrointestinal (GI) and visual changes.6,7 Although other neurotransmitters may be involved in the pathophysiology of migraine, the serotonergic (serotonin, or 5-hydroxytriptamine [5-HT]) system may have significant involvement. Documented changes in 5-HT processing and metabolism during a migraine attack suggest that migraine is a result of a central neurochemical imbalance secondary to dysfunction of the serotonergic system. Although the exact series of events involved is not fully understood, low levels of 5-HT appear to cause activation of the trigeminovascular system.8 This is part 1 of a two-part series. Preventative therapy and treatment of special populations will be presented as part 2 in the August issue of P&T. Introduction Although tension headache is the most common headache type, migraine is the most common headache complaint in clinical practice. Migraine affects approximately 13% of adults in the U.S., and its prevalence ranges between 12% and 20% in various countries around the world.1 Migraine is more common in females than males, with a prevalence of 19% and 7%, respectively. Approximately 80% of patients report a family history.1–3 Because migraine affects people during their most productive years (the 25- to 50-year-old age group), direct and indirect costs have a significant impact on society. The direct costs are Dr. DeMaagd is Professor and Associate Dean of Academic Administration at Union University School of Pharmacy in Jackson, Tennessee. Clinical Presentation and Diagnosis The clinical presentation of migraine may vary from patient to patient, and even within the same individual, it may vary from one attack to another. The proper diagnosis may require Accepted for continuing education credit April 10, 2008. 404 P&T® • July 2008 • Vol. 33 No. 7
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