CME

Earn Category I CME credit by reading this article and the article beginning on page 30 and successfully
completing the posttest on page 53. Successful completion is defined as a cumulative score of at least 70%  
correct. This material has been reviewed and is approved for 1 hour of clinical Category I (Preapproved) CME
credit by the AAPA. The term of approval is for 1 year from the publication date of February 2012.

Learning objectives
●● Accurately diagnose migraine headache using the International Headache Classification
●● Differentiate migraine headache from secondary headache
●● Describe the risks and benefits of drug treatments for acute migraine
●● Formulate a prevention plan, including nonpharmacologic and pharmacologic interventions

Management of migraine headache:

An overview of current practice
Using both pharmacologic and nonpharmacologic therapies for acute treatment and as  
preventive therapy can help patients with migraine to avoid debilitating symptoms.

Clay Shugart, PA-C

M
igraine headache is a chronic, genetic,
neurologic disorder involving abnor­
mal sensory processing. Migraines are
often disabling, leading to dramatic
lifestyle changes and limitations for the
migraineur. Clinicians must be confident in their diagnosis
and treatment of migraine headaches if patient outcomes
are to improve.
The pathophysiology of migraine headache has not been
clearly elucidated. Early theories positing that migraine and
migraine aura were solely due to vasodilation and vasocon­
striction of cranial vasculature have been largely disproven.
Recent theories emphasize the importance of close interac­
tions between meningeal/cranial vessels and nerves; neu­
ropeptides; and CNS structures, especially the trigeminal
neurovascular unit and the brainstem.1,2 The migraineur’s
brain most likely has dysfunctional descending pain inhibi­
tion, is hyperexcitable, and has a decreased pain threshold.
Several authors have discussed the pathophysiology of
migraine.1,2
© John Bavosi / Photo Researchers, Inc.

DIAGNOSTIC CRITERIA
The diagnosis of migraine headache is straightforward
and follows the guidelines established by the International
Headache Society (IHS) in its second edition of the Inter­
national Headache Classification (IHCD-2)3 (Table 1).
Migraine headache is often characterized by moderate
to severe unilateral throbbing pain and accompanied by
nausea or vomiting, with sensitivities to lights and sounds.
Note, however, that not all these elements need be present
for a diagnosis of migraine.

48 JAAPA • february 2012 • 25(2) • www.jaapa.com
 Migraine aura can occur in up to 30% of persons with
migraine headache.4 An aura is a stereotypical, reversible
neurologic event that may occur either prior to or during a
migraine headache. The aura can be visual, auditory, sen­
sory, motor, or a combination of these. The most common
aura is visual; the second most common is sensory. Visual
auras include seeing light or dark spots, unformed flashes
of light, or expanding zigzag lines, or they can manifest as
tunnel vision. First-time visual loss or monocular visual
loss warrants further investigation to rule out other neuro­
logic problems, such as amaurosis fugax in the setting of a
transient ischemic attack (TIA). Sensory auras are typically
experienced either as tingling or numbness in the face or
extremities or as a “sensory march,” which begins with sen­
sory symptoms in the hand that may then progress upward
along the arm or shoulder. A motor aura causes weakness,
usually in an extremity, and may need further evaluation
during a first-time event.
In addition to migraine with and without aura, there are
four other subclassifications of migraine: childhood periodic
syndromes that are commonly precursors of migraine, retinal
migraine, complications of migraine, and probable migraine.
Migraine with aura includes the following subtypes: typi­
cal aura with migraine headache, typical aura with nonmi­
graine headache, typical aura without headache, basilar-type
migraine, familial hemiplegic migraine, and sporadic hemiple­
gic migraine.3 The complications of migraine subclassification
include chronic migraine and status migrainosus. Chronic
migraine headache is a migraine headache that occurs on 15
or more days per month for at least 3 months.
Migraine headaches are often misdiagnosed. Migraineurs
are frequently told they have sinus headache, toothache,
“allergy headache,” or tension headache. By applying IHS-
ICHD-2 migraine criteria, performing a thorough examina­
tion, and bearing in mind the cranial and cervical anatomy
(particularly the three divisions of the trigeminal nerve), the
clinician can correctly diagnose migraine.
SECONDARY HEADACHES
In most patients, the diagnosis of migraine is straightforward
and additional testing or imaging is not needed. However, cer­
tain headache patterns or features are more ominous and may
reflect serious underlying abnormalities requiring immediate
attention. Some of these red-flag patterns include headache with
rapid onset and peak (seconds to minutes); a first or worst head­
ache; headache with abnormal neurologic symptoms or signs;
headache accompanied by a change in level of consciousness;
headache associated with fever/chills or a stiff neck; headache
following trauma (particularly head trauma); new-onset head­
ache in a patient older than 50 years; headaches in patients who
are immunosuppressed, have a malignancy, or are HIV-positive;
headache during pregnancy or postpartum; and headache
caused by exertion, sexual intercourse, or Valsalva maneuver.5,6
Various medical conditions are frequently accompanied
by headaches, and it is important to remember that patients
may have more than one headache disorder. Taking into
TABLE 1. International Headache Society guidelines for
diagnosing migraine headaches3
Migraine without aura
At least five headaches that meet the criteria below
Duration of 4-72 h (untreated or successfully treated)
Must demonstrate two of the following:
•Unilateral location
•Pulsation
•Moderately to severely intense pain
•Exacerbation with routine physical activity, eg, walking or
climbing stairs or causing the patient to avoid such activity
Must be accompanied by
•Either nausea or vomiting OR
•Photophobia and phonophobia
Note: If neither nausea nor vomiting is present, the patient must
have both photophobia and phonophobia.
Headache and symptoms must not be attributable to another
disorder.
Typical aura with migraine headache
The headache must meet all the criteria for migraine without
aura, that is, the patient must have had a total of at least five
headaches and at least two of those headaches had to be ac-
companied by aura.
The headache must begin during the aura or within 60 min fol-
lowing the aura.
Aura cannot be accompanied by motor weakness and must
consist of at least one of the following:
•Reversible visual symptoms, including positive and negative
features
•Fully reversible sensory symptoms
•Fully reversible dysphasic speech disturbance
Aura must include at least two of the following:
•Homonymous visual symptoms and/or unilateral sensory
symptoms
•At least one symptom that sets in gradually over ≥5 min, and/or
different aura symptoms that occur in succession over ≥5 min
•Each symptom lasts 5-60 min
Symptoms must not be attributable to another disorder.
consideration systemic symptoms, neurologic symptoms,
onset timing, onset after age 50 years, and pattern change
in the patient with a history of headaches will help identify
the cause of secondary headaches (Table 2). The mnemonic
SNOOP4 is a helpful tool for this purpose.
The evaluation of a secondary headache disorder depends
on the clinical presentation. The diagnostic evaluation
may include brain imaging (CT, MRI, magnetic resonance
angiography [MRA], magnetic resonance venography
[MRV]) with or without IV contrast enhancement; lumbar
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CME Migraine headache
puncture; serum testing, including ESR; and assessment for
malignancies or an immunosuppressed state. Not all testing
is needed for all patients.
MIGRAINE TREATMENT
Migraine treatment is divided into preventive and acute
therapies. The treatment plan will depend on headache
frequency, severity, and associated disability for the patient.
The plan should involve both nonpharmacologic and phar­
macologic management.
Begin by addressing lifestyle issues and headache trig­
gers with all patients. The three most common triggers for
migraine headaches are poorly managed stress, hormonal
changes, and poor sleep patterns, so educating the patient
in these areas is essential. Proper diet and exercise are also
important. Many patients with frequent migraines are
overusing caffeine products and OTC analgesics. Narcotic
use is also common in these patients. All these products
have been implicated in migraine progression and can con­
tribute to medication overuse headaches (MOHs), which
make chronic migraines more resistant to treatment. (See
“Medication overuse headaches.”) A key approach to
therapy is to have patients taper off and/or discontinue use
of caffeine, OTC analgesics, and narcotics. Inform them
that they may feel worse before they begin to improve while
they are discontinuing these products.
“A stepped-care approach has been
shown to be time-consuming and
ineffectual overall, and it often
worsens the migraine condition.”
Preventive therapy Patients with three or more disabling
headaches per month may benefit by using a preventive medi­
cation.7 When choosing an agent, consider a medication’s
efficacy and side-effect profile as well as the patient’s comorbid
conditions. Table: Medications for prevention of migraine
headache (available online) lists the most commonly used
preventives. Other agents include onabotulinum toxin type
A injections (Botox), magnesium, riboflavin, and butterbur
(an herb of the genus Petasites). While numerous preventative
Key Points
■■ Migraine headache is often characterized by moderate to severe unilateral, throbbing pain and accompanied by nausea or vomiting,
with sensitivities to lights and sounds.
■■ The three most common triggers for migraine headaches are poorly managed stress, hormonal changes, and poor sleep patterns.
■■ While numerous preventive treatments are available, the treating clinician should become comfortable with using two to three medica-
tions and be aware of other options that are available if needed.
■■ The triptans treat associated migraine symptoms as well as the migraine pain.
50 JAAPA • february 2012 • 25(2) • www.jaapa.com
Medication overuse headaches8
Medication overuse headaches (MOHs) are considered
secondary headaches and are caused by the chronic
overuse of symptomatic headache medications, such as
analgesics, triptans, ergots, and opioids. The complex bio-
chemical nature of MOH is not known at this time; how-
ever, these headaches impose a hurdle that must be over-
come before successful treatment of chronic migraine
headaches can be achieved. Abrupt cessation of the
offending medication is usually recommended. However,
withdrawal of the overused medications can also lead to
headaches and other symptoms that include worsening
migraine headaches, anxiety, nausea and vomiting, sleep
disturbances, and hypotension. Treatment of MOH ranges
from preventive medication and nerve blocks to admis-
sion to an outpatient unit where the patient receives IV
corticosteroids along with IV hydration.
treatments are available, the treating clinician should become
comfortable with using two to three medications and be aware
of other options that are available if needed.
Patients often do not notice benefit with a particular preven­
tive medication for at least 6 weeks, and the medication fre­
quently needs to be titrated to higher doses before it is effective.
Educating the patient about this fact and providing the proper
support is crucial to successful therapy. Other, nonmedicinal
treatment options include biofeedback, meditation, physical
and massage therapy, acupuncture, exercise, and counseling.
Acute treatment There are both pharmacologic and
nonpharmacologic treatments for an acute migraine head­
ache. In the past, patients were often treated acutely using
a stepped-care approach, starting with the least effective,
“weakest,” or least intrusive treatment and then adding or
changing treatments when the current treatment proved
suboptimal. This has been shown to be a time-consuming
and, overall, ineffectual approach, and it often worsens the
migraine headache condition. A stratified-care approach has
proven to be much more successful in a shorter amount of
time. In this situation, the patient with a known diagnosis
of migraine headache is started on disease-specific treat­
ments for his or her individual acute headache. Here again,
treating headaches acutely without working on headache
TABLE 2. Recognizing the causes of secondary headaches—(SNOOP4 mnemonic)5
Symptom category Symptoms Causes
Systemic symptoms/ Fever, chills, night sweats, myalgias, weight loss Giant cell arteritis, infection, malignancy
signs/disease
History of malignancy, immunocompromised state,   Metastatic disease, opportunistic CNS infection
HIV infection
Neurologic symptoms Focal or global neurologic symptoms or signs, including Neoplasia, inflammation, infection, vascular CNS
or signs changes in behavior or personality; diplopia; transient disease
visual obscurations; and pulsatile tinnitus, especially in
obese patients (idiopathic intracranial hypertension)
Onset, sudden  Sudden onset means split second and out of the blue.   Vascular crises (stroke, subarachnoid hemor-
(thunderclap headache) Ask a quantitative question: “How quickly did your pain   rhage, cerebral venous sinus thrombosis, revers-
go from 0 to 10 on a 10-point scale?” ible cerebral vasoconstriction syndrome, arterial
dissection)
Onset after age 50 ya Neoplasia, inflammation, infectious CNS disease,
giant cell arteritis
Pattern change (if previous history)
Progressive headache Loss of headache-free periods
Precipitated by   Valsalva maneuver worsens most headaches; all head- Chiari malformation, structural lesions that
Valsalva maneuver aches that are precipitated by the Valsalva maneuver obstruct CSF flow, CSF leak
require imaging for secondary headache. Certain primary
headaches are precipitated by the Valsalva maneuver, eg,
primary cough headache.
Postural aggravation Headache worse when standing or lying down  Intracranial hypotension from CSF leaks,  
  intracranial hypertension 

Headache worse with certain neck movements/positions Cervicogenic headache

Papilledema Transient visual obscurations, diplopia, and field defects Possible intracranial hypertension
Primary headache disorders beginning after the age of 50 years are highly unusual.
a

prevention often leads to MOH that can evolve and become
chronic migraine.
Individual acute treatments include limiting the use of
oral OTC medications while judiciously prescribing anal­
gesics, prescription muscle relaxers, prescription triptans,
prescription antiemetics, and prescription “rescue” medica­
tions, along with performing trigger point injections (TPIs)
and nerve blocks. Probably the most important recent addi­
tion to acute migraine therapy has been the introduction of
the triptan medications. The triptans are migraine-specific,
treat associated migraine symptoms as well as the migraine
pain, and are available in multiple brands and routes of
administration (Table 3).
Most triptans have the same instructions for use, but clini­
cians should become familiar with the several triptans they
usually prescribe. All are contraindicated in patients with car­
diovascular disease, peripheral vascular disease, uncontrolled
hypertension, basilar-type migraine, migraine with prolonged
aura, and hemiplegic migraine. Patients with cardiovascular
risk factors, such as obesity, hypertension, hypercholester­
olemia, diabetes mellitus, sleep apnea, and estrogen use, and
those who smoke may not be good candidates for treatment
with a triptan, especially if they have multiple risk factors.
Additionally, all triptans are dosed so that the patient takes
one tablet as early as possible during the onset of headache.
For most medications, another dose can be taken after 2
hours if the headache persists. Exceptions to that schedule
include having to wait 4 hours to take a second dose of
Amerge; Sumavel DosePro can be repeated in 1 hour. The
patient should try a specific triptan with at least two to three
headaches before deciding if it works or not. Two different
triptans should not be used within 24 hours of one another.
Additionally, triptan use should be limited to 1 to 2 days a
week, as more frequent use can lead to MOH.
Neuroleptic drugs, such as metoclopramide (Reglan, gener­
ics), chlorpromazine, and olanzapine (Zyprexa generics), are also
effective for migraine headaches. Some practices avoid using
chlorpromazine because of an increased risk of cardiac arrhyth­
mias. Neuroleptic drugs can be used when NSAIDs or triptans
are contraindicated or as rescue medications.
Treatment summary At the patient’s initial visit to our
practice, we often administer a series of nerve blocks and

www.jaapa.com • february 2012 • 25(2) • JAAPA 51
CME Migraine headache
TABLE 3. Medications for the acute treatment of migraine TPIs to help break the current headache cycle. (See “Nerve
headaches9 blocks and trigger point injections.”) In addition, the
patient is usually started on a preventive medication and
Brand name Generic Form Dose
given a muscle relaxer or rescue medication to treat acute
Triptans headaches. At a follow-up appointment 2 weeks later, we
Amerge Naratriptan PO 2.5 mga perform the second of a series of three nerve blocks/TPIs.
We further reinforce positive lifestyle choices, adjust medi­
Axert Almotriptan PO 12.5 mg
cations when needed, and answer any questions the patient
Frova Frovatriptan PO 2.5 mg may have. This process is repeated in 2 more weeks. The
Imitrex Sumatriptan SC 4 and 6 mg next appointment is scheduled 6 to 8 weeks later. Patients
NS 20 mg do better if they are seen more frequently at first, after
PO
which they can spread out their appointments as their con­
100 mg
dition improves.
Maxalt Rizatriptan PO, orally 10 mg CONCLUSION
disintegrating Patients who suffer from migraine headaches often have
tablet comorbid conditions, including obesity, fibromyalgia,
Relpax Eletriptan PO 40 mg insomnia, sleep apnea, depression, and anxiety. Recognizing
Sumavel Sumatriptan SC, needle- 6 mg
these comorbid conditions is important, as treating them
DoseProb free system
often results in improvement of the migraine headaches.
Patients benefit from a coordinated effort from their various
Treximet Sumatriptan/ PO 85 mg/500 health care providers.
naproxen mg Once patients have been given a diagnosis of migraine
Zomig Zolmitriptan NS 5 mg headache, proactive treatment should be started immediate­
PO 5 mg ly. Discussing and reviewing lifestyle changes is an impor­
orally disinte- 5 mg
tant key to treatment. Regular follow-up is also important,
grating tablet
and patients are usually willing to come in more frequently
if they see that the provider cares and that they are making
Nontriptan medication—ergotamines progress. A patient who notes a change in headache pat­
Cafergot Ergotamine +   PO 1 mg/100 tern, worsening headaches, or new neurologic symptoms
caffeine mgc may require further evaluation. JAAPA
Migranal Dihydroergotamine NS 0.5 mgc
When this article was written, Clay Shugart practiced at the Headache
Key: NS, nasal spray; PO, orally; SC, subcutaneously.
a
Patients must wait 4 h before taking a second dose of Amerge.
Wellness Center, Greensboro, North Carolina. He currently practices at
b
Second dose of Sumavel DosePro can be taken after 1 h. Crossroads Psychiatric Group in Greensboro, where he sees both psychiatric
c
See package insert for dosing of nontriptan medications. and headache patients. The author has indicated no relationships to disclose
relating to the content of this article.

Nerve blocks and trigger point injections
For nerve blocks and trigger point injections (TPIs), we
use a mixture of lidocaine, marcaine, and dexametha-
sone in a 2:2:1 ratio. Injections are typically given in the
areas of the greater and lesser occipital nerves, bilateral
supraorbital nerves, bilateral suprascapular nerves, bi-
lateral paraspinal muscles at the level of C7-T1, paracer-
vical muscles, and bilateral posterior superior trapezius
muscles. Other nerve blocks can be administered on an
as-indicated basis. A number of articles on nerve blocks
and TPIs have been published in the medical literature.1-3
1. Ashkenazi A, Blumenfeld A, Napchan U, et al. Peripheral nerve blocks and trigger
point injections in headache management—a systematic review and suggestions for
future research. Headache. 2010;50(6):943-952.
2. Blumenfeld A, Ashkenazi A. Nerve blocks trigger point injections and headache.
Headache. 2010;50(6):953-954.
3. Tobin J, Flitman S. Occipital nerve blocks: when and what to inject? Headache.
2009;49(10):1521-1533.
Acknowledgment: The author wishes to thank Marshall C. Freeman, MD,
director of the Headache Wellness Center, for his help in editing this article.
REFERENCES
1. Goadsby PJ, Oshinsky ML. Pathophysiology of headache. In: Silberstein SD, Lipton RB, Dodick
DW, eds. Wolff’s Headache and Other Head Pain. 8th ed. New York, NY: Oxford University Press;
2008:105-112.
2. Levy D. Migraine pain and nociceptor activation—where do we stand? Headache. 2010;50(5):
909-916.
3. Headache Classification Subcommittee of the International Headache Society. The International
Classification of Headache Disorders: 2nd edition. Part I. The primary headaches. Cephalalgia.
2004;24(suppl 1):24-29.
4. Rasmussen BK, Olesen J. Migraine with aura and migraine without aura: an epidemiological
study. Cephalalgia. 1992;12(4):221-228.
5. Saper J, Silberstein S, Gordon CD, et al. Handbook of Headache Management: A Practical Guide
to Diagnosis and Treatment of Head, Neck, and Facial Pain. 2nd ed. Baltimore, MD: Lippincott
Williams & Wilkins; 1999:57.
6. Dodick DW. Pearls: headache. Semin Neurol. 2010;30(1):74-81.
7. Loder E, Biondi D. General principles of migraine management: the changing role of prevention.
Headache. 2005;45(suppl 1):S33-S47.
8. Trucco M, Meineri P, Ruiz, L, et al. Medication overuse headache: withdrawal and prophylactic
therapeutic regimen. Headache. 2010;50(6):989-997.
9. Migraine and headache. In: Ernst D, Lee A, eds. Physician Assistants’ Prescribing Reference. New
York, NY: Haymarket Media; Winter 2010-2011;17(4):270-275.

52 JAAPA • february 2012 • 25(2) • www.jaapa.com
TABLE. Medications for prevention of migraine headache6,9
Drugs Dosage range (mg/d) Contraindications/cautions Side effects Comments
Antiepileptics
Monitor for abrupt mood changes and suicidal tendencies with all drugs in this class
Divalproex sodium   500-1,500 Liver disease, bleeding Hair loss, weight gain, Used in seizure therapy;
(Depakote ER, generics) disorders—monitor liver hepatotoxicity, cogni- not used frequently
function, platelet count, tive changes, polycystic because of its hair loss,
bleeding times; FDA   ovary syndrome, hemor- weight gain, and hepato-
pregnancy category D rhagic pancreatitis; in- toxicity effects
teracts with many other
medications
Gabapentin (Neurontin, 300-3,600 Fatigue, dizziness,   Adjunct in seizure
generics) sleepiness, cognitive therapy; can improve
dysfunction sleep; used for  
neuropathic pain and
restless legs syndrome
Lamotrigine   50-200 Titrate and taper slowly; Rare likelihood of Adjunct in seizure
(Lamictal, generics)  discontinue at first sign of Stevens-Johnson therapy; used in treat-
(use for migraine   rash unless it is clearly not syndrome; sleepiness, ment of bipolar disorder,
with aura) drug-related cognitive dysfunction; depressed state
can interfere with other
medications, including
oral contraceptives
Topiramate   50-400 Use with caution in patients Paresthesia, cognitive Seizure therapy; can  
(Topamax, generics) with glaucoma dysfunction, weight loss, result in significant
renal stones, anorexia, weight loss
angle-closure glaucoma;
can interfere with oral
contraceptives
Zonisamide   50-400 Sulfa allergy; titrate and Rare chance of Stevens- Adjunct in seizure
(Zonegran, generics) taper slowly; discontinue at Johnson syndrome, therapy
first sign of rash unless it is sleepiness, cognitive
clearly not drug-related dysfunction
Antidepressants
All antidepressants carry an increased risk of depression and suicide, especially in teens and adults up to age 28 y  
Contraindicated during or within 14 d of using MAOIs
Serotonin-norepinephrine reuptake inhibitors (SNRIs)
Venlafaxine 50-200 Mania/hypomania, heart Nausea, insomnia, de- Used for depression
Venlafaxine extended- 75-300 disease, increased intraocu- creased libido, elevated and anxiety; venlafax-
release (Effexor)a lar pressure, seizures; added BP, abnormal dreams, ine sometimes used to
cautions with duloxetine: serotonin syndrome, hot treat night sweats in
Duloxetine (Cymbalta) 60-120
severe renal impairment, flushes menopausal women;
hepatic insufficiency Cymbalta also approved
for diabetic neuropathy,
fibromyalgia, chronic
musculoskeletal pain
Tricyclic antidepressants (TCAs)
Amitriptyline 25-150 Use caution during the All have similar side Can be helpful for  
Imipramine (Surmontil, 25-150 period immediately post MI, effects: dry mouth, anxiety and depression;
Tofranil, generics) with history of glaucoma, constipation, sleepiness, help with allergies, sleep
seizures, urinary reten- weight gain, elevated BP,
Desipramine   25-150
tion, cardiac arrhythmias cardiac dysrhythmias
(Norpramin, generics)
or cardiovascular disease, Drug-specific side
Doxepin 10-100
and prostatic hypertrophy; effects: desipramine
decrease seizure threshold typically does not cause
weight gain; doxepin
is most sedating and
causes more weight gain
Antihypertensives
Doses are often limited by hypotension at higher doses
Atenolol (Tenormin, 25-200; dose typi- Sinus bradycardia, second-
generics) cally ≤100 mg/d and third-degree heart
Can dose once daily block, overt heart failure,
cardiogenic shock; caution
with bronchospastic disease,
diabetes, hyperthyroidism,
ischemic heart disease,
peripheral circulatory disor-
ders, renal dysfunction
Propranolol (Inderal, In- 60-320; typically Asthma, sinus bradycardia,
nopran, generics) needs to be dosed second- and third-degree
twice daily atrioventricular block, overt
heart failure, cardiogenic
shock; caution with WPW
syndrome, bronchospastic
disease, liver or renal failure
Verapamil 90-360; use   Multiple cardiac issues
(used to treat migraine extended-release to avoid, including heart
with aura) form; can often dose failure, cardiac conduction
once daily block, hypotension; cau-
tion with renal or hepatic
dysfunction; interacts with
numerous medications and
grapefruit juice
Drugs that act on 5-hydroxytryptamine receptor mechanisms
Cyproheptadine (used in 4-12 MAOI use within 14 d; angle-
children) closure glaucoma
Methylergonovine   0.2-0.4 mg 3 to 4 Coronary artery disease,
(Methergine, generics) times daily; 1-mo drug peripheral vascular disease,
holiday after 6 mo cerebrovascular disease,
of use uncontrolled hypertension,
deep venous thrombosis,
pregnancy, significant renal
and hepatic disease, basilar-
type migraine, and brain-
stem-related neurologic
symptoms, prolonged aura,
migraine-related stroke,  
pulmonary fibrotic disorders
Key: MAOI, monoamine oxidase inhibitor; WPW, Wolff-Parkinson-White.
a
Extended-release venlafaxine is usually preferred over the immediate-release formulation because the latter has fewer side effects and once-daily dosing.
Dizziness, fatigue, de-
pression, orthostatic hy-
potension, heart failure,
MI; exacerbates Raynaud
disease
Hypotension, brady-
cardia, bronchospasm,
dizziness, depression,
rash (could be Stevens-
Johnson syndrome)
Constipation, dizzi-
ness, fatigue, periph-
eral edema, palpitations,
hypotension
Sedation, weight gain
Retroperitoneal or   Ergot derivatives should
pleuropulmonary
fibrosis, coronary or
peripheral vasoconstric-
tion resulting in MI or
extremity claudication;
muscle aches
Used to treat hyperten-
sion; low doses are used
to treat stage fright or
mild anxiety; atenolol
is cardioselective, so it
should have less effect
on bronchospasm, pe-
ripheral vasospasm, and
hypoglycemia
Used to treat hyperten-
sion and mild anxiety;
propranolol is not car-
dioselective; does have
high lipid solubility
Treat hypertension; treat
symptoms of Raynaud
disease; immediate-  
release form is used to
treat cluster headaches
Strong antihistaminic
effects and used to treat
allergic rhinitis and urti-
caria in adults; also used
as appetite stimulant
be administered by a
provider experienced
in treating resistant
headaches and thor-
oughly familiar with the
drugs; patients at this
point should be seeing a
headache specialist