Pharmacy & Therapeutics- July 2008 - (Page 406) CONTINUING EDUCATION CREDIT Table 1 Medications Used in the Abortive Management of Migraine ASA, numerous generics 650–1,000 mg q 4–6 hours (maximum 4,000 mg daily) APAP (e.g., Tylenol) 325–1,000 mg q 4–6 hours (maximum 4,000 mg daily) Some combination OTC products • Anacin (ASA) 400 mg, caffeine 32 mg) • Bayer Extra Strength (APAP 500 mg, caffeine 32.5 mg) • Excedrin Extra Strength and Excedrin Migraine* (APAP 250 mg, ASA 250 mg, caffeine 65 mg) • Vanquish (APAP 194 mg, ASA 227 mg, caffeine 33 mg) Serotonin receptor agonists (triptans) • Sumatriptan (Imitrex) Intranasal, Oral, SQ • Rizatriptan (Maxalt) Oral, MLT (dissolving product) • Zolmitriptan (Zomig) Oral, ZMT (dissolving product), Nasal • Naratriptan (Amerge) Oral • Almotriptan (Axert) Oral • Frovatriptan (Frova) Oral • Eletriptan (Relpax) Oral Ergot alkaloids • Dihydroergotamine mesylate (DHE) injection/1 mg/mL Nasal Spray (Migranol) • Ergotamine tartrate (numerous brands with various contents, including belladonna alkaloids, caffeine, and phenobarbital) Sympathomimetics* • Isometheptene 65 mg, dichloralphenazone 100 mg, APAP 325 mg (Midrin) Barbiturate combinations* • Butalbital and ASA/caffeine (Fiorinal) 1–2 tablets q 4–6 hours (also available with codeine) • Butalbital and APAP/caffeine (Fioricet) 1–2 tablets q 4–6 hours (also available with codeine) Restrict use to avoid rebound; 4 tablets daily; not more than 2 days per week Opiate combinations* • Propoxyphene with APAP (Darvocet) • Codeine with APAP (Tylenol #3) • Oxycodone with APAP or ASA (Percocet, Percodan) • Butorphanol nasal spray (Stadol) one spray in one nostril (1 mg); may repeat in 1 hour; maximum four sprays daily NSAIDs • Ibuprofen 200–400 mg q 4–6 hours (maximum 1,200 mg daily OTC) • Advil Migraine Liqui-Gels • Advil Migraine • Naproxen sodium 220 mg q 6–8 hours (maximum 660 mg daily), OTC Aleve • Numerous other products: diclofenac potassium (Cataflam), ketorolac (Toradol) Phenothiazines: prochlorperazine (Compazine), chlorpromazine (Thorazine), metoclopramide (Reglan) Anticonvulsants: IV valproate (Depacon) APAP = acetaminophen; ASA = aspirin; IV = intravenous; NSAID = nonsteroidal anti-inflammatory drug; OTC = over the counter; SQ = subcutaneous. * Regular weekly usage requires medical evaluation and determining the need for preventative therapy. Adapted from references 10, 36, 41, 42, and 46. others. In some cases, the use of more than one of these agents in combination may be necessary to relieve a migraine attack.10,35,36,41–45 Obtaining a patient’s headache history, including responses to previous therapies, onset of effect, and recurrent patterns, may also be helpful in selecting an appropriate abortive therapy. Patients’ input and acceptance of their therapeutic plan is an important but often overlooked component of migraine management.40,44,45 alone or in combination. • NSAIDs. Two other commonly used analgesic classes include barbiturate and opiate combination products containing aspirin or acetaminophen.41,42,46,47 Simple Analgesics Limited clinical data support the role of APAP as monotherapy in the acute management of migraine. One placebocontrolled trial reported benefits with 1,000 mg in mild-tomoderate migraine,48 although comparison trials with NSAIDs reported greater efficacy with NSAIDs.49,50 APAP’s mechanism of action is probably achieved through a central mechanism related to central prostaglandin inhibition.46 A trial of acetaminophen may be considered in mild-to-moderate migraine, especially in patients who do not tolerate NSAIDs,36 although most patients will have already tried simple an- Analgesic Agents Analgesics for the management of migraine include three general classes. They can be used as monotherapy or in various combinations (see Table 1). The simple analgesics include: • acetaminophen (APAP). • aspirin (acetylsalicylic acid, ASA), which can be used 406 P&T® • July 2008 • Vol. 33 No. 7
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