Pharmacy & Therapeutics- July 2008 - (Page 411) CONTINUING EDUCATION CREDIT lized by the MAO-A pathway (see Table 2), when used concurrently with propranolol, should be avoided. This interaction will be detailed in part 2 of this series next month.207–210 Clinical Recommendations To select the appropriate triptan for each patient, prescribers should consider the past efficacy and tolerability of migraineabortive medications, the characteristics of the patient’s migraine, and the patient’s preference.211 The various triptans and their available dosage forms allow for alternative delivery methods and flexibility in administration (see Table 2). The SQ and intranasal formulations are excellent options for patients who are experiencing GI effects, who prefer a faster onset, or who have a history of poor response to oral therapies (see Table 2).212–216 The oral dissolution tablets, available with some formulations (see Table 2), can be placed directly on the tongue. These products are an option for patients experiencing GI effects, although they offer only a perception of faster onset; they may actually be more slowly absorbed than the regular oral formulation. Some oral formulations, particularly frovatriptan (Frova), have a slower onset, compared with others (e.g., rizatriptan); this may be a consideration for some patients.151,153,217 The triptans are reported to be effective in 50% to 90% of patients with moderate-to-severe migraine attacks, and they are indicated as a first-line agent or as an alternative in patients who have not responded to or who are intolerant of simple analgesics or NSAIDs. Early use is recommended in the preheadache phase. Failure to respond to one agent warrants a trial of another medication but not within the same 24-hour period. Although limited evidence supports medication-overuse headache with triptan use, appropriate monitoring and usage are important. When dispensing triptans, pharmacists play a major role in monitoring and educating patients about their appropriate use, potential side effects, and expected efficacy.36,169,218–222 Other Abortive Agents The phenothiazines, butyrophenones, and metoclopramide (Reglan) have shown clinical efficacy in the abortive management of migraine. The antiemetic properties of these agents, along with their IV and rectal dosage formulations, are options for patients with significant nausea and vomiting. The proposed mechanism of these agents may result from their dopamine antagonist properties and the dopamine hypersensitivity reported during a migraine.41,42 IV prochlorperazine (Compazine, GlaxoSmithKline), chlorpromazine (Thorazine, GlaxoSmithKline), promethazine (Phenergan, Wyeth), droperidol (Inapsine, Janssen), and haloperidol decanoate (Haldol, Ortho-McNeil) have shown efficacy as migraine-abortive drugs in clinical trials. 223–236 The antiemetic metoclopramide has been effective,237,238 with one trial reporting efficacy similar to that of sumatriptan when used in high doses in persistent migraine.185 Using metoclopramide in combination with the triptans or ergots may provide additional efficacy as well as antiemetic benefits.238,239 The side effects and toxicities of these agents are well documented elsewhere; however, when these medications are given intravenously, they must be administered cautiously because of concerns about potential hypotension, arrhythmias (an electrocardiogram should be performed before the dose is given), or dystonic reactions. These agents should be considered an alternative in the abortive management of migraine if they are administered in the proper setting in patients who do not respond to triptans or ergot derivatives.36 Other agents that may be used in the abortive management of migraine include IV valproic acid (Depacon, Abbott). This anticonvulsant was found to be more effective than placebo, and it had comparative efficacy with DHE in refractor y cases.240–244 Case reports have shown efficacy for Pfizer’s IV verapamil (e.g., Calan) and sublingual nifedipine (Procardia) in complicated migraine.245,246 Tramadol (Ultram, Ortho-McNeil), a dual-mechanism analgesic, had efficacy similar to that of the NSAID diclofenac potassium (Cataflam, Novartis).247 Other agents and supplements that may have a role in the abortive management of migraine include corticosteroids and herbal supplements (e.g., feverfew and magnesium sulfate).248–250 Table 3 Common Drugs with Serotonergic Properties Monoamine oxidase inhibitors Phenelzine (Nardil) Selegiline (Zelapar, Eldepryl, Emsam) Isocarboxazid (Marplan) Tranylcypromine (Parnate) Tricyclics: amitriptyline, others SSRIs: fluoxetine (Prozac), others Miscellaneous: nefazodone (Serzone*), trazodone (Desyrel), venlafaxine (Effexor), bupropion ( Wellbutrin) Buspirone (BuSpar) Dextromethorphan Lithium Amantadine (Symmetrel) Cocaine Conclusion In selecting the most appropriate pharmacotherapy for the abortive management of migraine, prescribers must consider the severity of the pain. Patients with mild-to-moderate migraine attacks can often be treated with simple analgesics or NSAIDs, with the triptans or ergots reserved for moderateto-severe pain. Other options may have a role in refractory migraine or when contraindications exist for first-line agents.36 Combination therapy may be necessary for some patients, and triptans or ergots combined with NSAIDs or other potential agents may provide additional benefits in refractor y migraine.35,36,41,42,84,189 Preventative pharmacotherapy may also be necessary for many patients.251,252 Prophylaxis will be covered in part 2 of this two-part series in the next issue of P&T. Antidepressants Others SSRI = selective serotonin reuptake inhibitor. * Serzone has been discontinued, but generic brands are available. Adapted from references 204–208. Vol. 33 No. 7 • July 2008 • P&T® 411
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