Unit II D:

Anti Migraine and drugs for Trigeminal neuralgia

By: Muhammad Aurangzeb

Lecturer-INS/KMU
 Objectives

By the completion of this session learners will be able to:

• Discuss the action, contraindication and side effects of

Antimigraine and Trigeminal neuralgia Drugs
• Identify most commonly used drugs for migraine and
Trigeminal neuralgia
• State the major nursing care if client is using drugs for
migraine and Trigeminal neuralgia.
• Calculate the drug dosage accurately for oral anti migraine
and drugs for trigeminal neuralgia.
 Migraine

• “Migraine is a familial disorder characterized by recurrent

attacks of headache widely variable in intensity, frequency
and duration.
• A pulsating headache, which comes in attacks lasting 2 - 72
hours
• Attacks are commonly unilateral and are usually associated
with anorexia, nausea and vomiting”.
Simplified Diagnostic Criteria for Migraine

Repeated attacks of headache lasting 2–72 h in patients with a normal

physical examination, no other reasonable cause for the headache, and:

At Least 2 of the Following Features: Plus at Least 1 of the Following

Features:
Unilateral pain Nausea/vomiting

Throbbing pain Photophobia and Phonophobia

Aggravation by movement

Moderate or severe intensity

 Types of Migraine

Two Types:-

1. Migraine with aura (classical migraine) :-headache

preceded by visual or other neurological symptoms

2. Migraine without aura(common migraine)

Migraine without aura (Common Migraine)

• Migraine without aura, is a severe, unilateral, pulsating

headache that typically lasts from 2 to 72 hours.
• These headaches are often aggravated by physical activity and
are accompanied by nausea, vomiting, photophobia
(hypersensitivity to light), and phonophobia (hypersensitivity
to sound).
• The majority of patients with migraine do not have aura.
 Migraine with aura (Classical Migraine)

• Migraine with aura, the headache is preceded by neurologic

symptoms called auras, which can be visual, sensory, and/or
cause speech or motor disturbances.
• Most commonly, these prodromal symptoms are visual
(flashes, zigzag lines, and glare), occurring approximately 20
to 40 minutes before headache pain begins.
• In the 15% of migraine patients whose headache is preceded
by an aura
 4 Stages of Migraine

1.Prodrome

2. Aura

3. Headache

4. Postdrome
 Prodrome
Vague premonitory symptoms that begin from 12 to 36 hours
before the aura and headache.
• Symptoms:
– Yawning
– Excitation
– Depression
– Lethargy
– Craving or distaste for various foods
• Duration: 15 to 20 min.
 Aura

Aura is a warning or signal before onset of headache.

• Symptoms:
– Flashing of lights
– Zigzag lines
– Difficulty in focusing
• Duration: 15-30 min.
 Headache

• Headache is generally unilateral and is associated with

SYMPTOMS like:
– Anorexia
– Nausea
– Vomiting
– Photophobia
– Phonophobia
– Tinnitus
• Duration: 4-72 hrs. 8
 Postdrome

• Following headache, patient complains of -

– Fatigue
– Depression
– Severe exhaustion
– Some patients feel unusually fresh
• Duration: Few hours or up to 2 days.

9
 Pathophysiology of Migraine

• Increased excitability of CNS (Cortical Spreading Depression)

• Meningeal blood vessel dilation
• Activation of perivascular sensory trigeminal nerves
• Pain impulses and inflammation due to neuropeptides
• Vasoactive neuropeptides contain:
• Substance P
• Calcitonin gene-related peptide (CGRP)
• Neurokinin A
• Combination of increased pain sensitivity, tissue and vessel
swelling, and inflammation
 Theories about Pathophysiology:

Vascular Theory:-
• Intracranial/Extra-cranial blood vessel vasodilation –
headache.
• Intracerebral blood vessel vasoconstriction – aura.
Serotonin Theory:-
• Decreased serotonin levels linked to migraine.
• Specific serotonin receptors found in blood vessels of brain.
Hunter Area Toxicology
Service
 Classification

Mild Moderate Severe

Less than one attack a One or more attacks per 2-3 attacks or more
Month Month every month

Lasting up to 8 hours 6-24 hours 12-48 hours

Throbbing but tolerable Intense throbbing Intense throbbing

headache headache with nausea and headache with
vomiting nausea and vomiting,
vertigo, GIT
instability, fatigue,
photophobia
 Antimigraine agents

• Antimigraine agents are drugs used to treat migraine

headaches
• Pharmacological treatment of migraine includes
– Acute (abortive) treatment
– Preventive (prophylaxis) treatment
 Classification of drugs used to treat
migraine headache
Specific Treatment Non-specific Treatment PROPHYLACTIC AGENTS
TRIPTANS NSAIDs • Anticonvulsants
• Almotriptan AXERT • Aspirin BAYER,
• Beta-blockers
• Eletriptan RELPAX BUFFERIN, ECOTRIN
• Frovatriptan FROVA • Ibuprofen ADVIL, • Calcium channel
• Rizatriptan MAXALT MOTRIN blockers
• Naratriptan AMERGE • Indomethacin INDOCIN • Tricyclic
• Sumatriptan IMITREX, • Ketorolac TORADOL
antidepressants
ALSUMA • Naproxen ALEVE,
• Zolmitriptan ZOMIG ANAPROX, NAPROSYN
ERGOTS Anti-emetics
• Dihydroergotamine
MIGRANAL, VARIOUS
 Management of Migraine

• Mild migraine: Analgesics with or without antiemetic.

• Moderate migraine: NSAIDs combinations / a triptan/ergot
alkaloids (+antiemetic)
• Severe migraine: A triptan/ergot akaloids (+antiemetic) +
prophylaxis
 Acute Treatment: Step 1
• Simple oral analgesic ± anti-emetic:
• Soluble Aspirin 600-900mg orally STAT OR Ibuprofen 400mg (Maximum
of 4 doses over 24 hours) AND/OR Paracetamol 1g orally every 4 hours
(Maximum of 4 g over 24 hours) for non-incapacitating headache
• Efficacy of analgesia may be improved by giving a pro-kinetic anti-
emetic to promote gastric emptying with:
– Metoclopramide 10-20mg orally
– Domperidone 10-20mg orally.
• For nausea and vomiting (if required): Prochlorperazine 5mg orally
or Prochlorperazine 25mg suppository
• Domperidone 10mg-20mg orally. If unable to tolerate either of the
above due to prominent nausea and vomiting: Metoclopramide 10-
20mg IM or IV STAT
 Step 2 Acute Treatment:

• Prescription NSAID (± anti-emetic as described in step 1)

Naproxen 500mg-750mg with a further 250mg- 500mg in 6 hours
if required (Maximum dose=1250mg/day)
• OR Diclofenac 50-100mg (maximum 200mg /day).
• Diclofenac 100mg suppository (maximum 100mg BD )

• Analgesics inhibit release of prostaglandin release due to

neurogenic inflammation .
• Metoclopramide besides being antiemetic enhances
absorption of analgesics
 Pharmacology of specific antimigraine drugs:

• Triptans: Selective 5-HT1B/1D agonists

• Triptan includes-Sumatriptan, naratriptan, rizatriptan,

eletriptan, zolmitriptan, almotriptan & frovatriptan
• Therapeutic Action: Triptans is a relatively new antimigraine
agent that causes cranial vascular constriction and relief of
migraine headache pain. They do this by binding to serotonin
receptors.
• Indications: Triptans are indicated for the treatment of acute
migraine and are not used for prevention of migraines.
Role of serotonin in migraine: Various studies have
implicated serotonin in the pathogenesis
of migraine. Serotonin vasoconstricts the nerve endings and
blood vessels and in this way affects nociceptive pain.
Comings43 postulated that low serotonin levels dilate blood
vessels and initiate migraine
 Adverse Effects and Contraindications of
Triptans
• Coronary artery vasospasm, transient myocardial ischemia,
atrial and ventricular arrhythmias, MI
• Irritation at the site of injection. The most common side
effect of sumatriptan nasal spray is a bitter taste.
• Contraindicated- coronary artery disease , history of stroke
or transient ischemic attacks, cerebrovascular or peripheral
vascular disease
 Ergotamine

Therapeutic Action:
• Partial agonist at α-adrenoceptors . Partial agonist at
serotonergic receptors. Constricts all peripheral arteries.
• Ergotamine was the drug of choice for migraines before
triptans were developed.
Dose: Oral/ sublingual route is preferred,1mg is given at half
hours intervals till relief is obtained or total of 6mg is given
 Adverse Effects and Contraindications of
Ergot Alkaloids
• Nausea and vomiting, due to a direct effect on CNS emetic
center.
• Ergotism: repeated doses cause cumulative toxicity, Severe
peripheral vasoconstriction, hypertension, gangrene of
extremities, anginal pain.
• Contraindicated in pregnant, peripheral vascular disease,
coronary artery disease, hypertension, impaired hepatic or
renal function.
• In contrast to triptans, the contractile effect of ergotamine in
the human isolated coronary artery is long- lasting and
persists even after repeated washings
 Migraine Prophylaxis to reduce
Frequency
• Raising the threshold to migraine activation by stabilizing a
more reactive nervous system

• Enhancing antinociception

• Inhibiting CSD

• Blocking neurogenic inflammation

Drugs Used For Prophylaxis of Migraine
 Trigeminal Neuralgia

• Sudden, usually unilateral Brief, stabbing , electric shock like

recurrent pain
• Pain is limited to the sensory distribution of trigeminal nerve
that includes middle face (maxillary division)– being most
frequently involved, lower (mandibular division) & upper
(ophthalmic division)– being least frequently involved
 TN symptoms

• Pain in areas supplied by CN V

– Usually unilateral
– Sharp, stabbing, electric shock like pain
– Lasts for few seconds to minutes
– This transient attack may be repeated in matter of minutes
or hours
 1st step of treatment Pharmacotherapy
(Medical management of TN)
• Trigeminal neuralgia is usually treated with drugs called anti-
convulsants which include:
– Carbamazepine (drug of choice) (400 1000mg/day)
– Phenytoin (300mg/day)
– Oxycarbazepine
– Gabapentin (600-1200mg/day)
– Baclofen, lamotrigine, clonazepam
 Non Pharmacological Measures

There are some things that a patient can do to minimize

the frequency and intensity of TN attacks:
1. Apply ice packs. Cold often numbs the area and will reduce
the pain
2. Get adequate rest in normal rest cycles
3. Manage your stress well and keep stress levels low
4. Avoid foods that may act as nerve stimulants, such as coffee,
tea, and foods that are high in sugar
5. Maintain adequate hydration and electrolyte levels
6. Practice healthy living principles such as diet and exercise
 Nursing Role

• Assess aforementioned cautions and contraindications (e.g.

drug allergy, history of myocardial infarction and CAD,
hepatic-renal dysfunction, etc.) to prevent complications.
• Administer drug to relieve acute migraines (at first sign of
headache)
• Monitor for complaints of extremity numbness and tingling to
identify effects on vascular constriction.
 Nursing Role

• Educate client on drug therapy to promote understanding and

compliance.
• Monitor patient response to therapy (relief of acute migraine
headache).
• Monitor for adverse effects (e.g. CV changes, arrhythmias,
hypertension, etc).
• Monitor patient compliance to drug therapy.
 References

• Karch, A. M., & Karch. (2011). Focus on nursing pharmacology. Wolters

Kluwer Health/Lippincott Williams & Wilkins.
• Katzung, B. G. (2017). Basic and clinical pharmacology. McGraw-Hill
Education.
• Lehne, R. A., Moore, L. A., Crosby, L. J., & Hamilton, D. B. (2004).
Pharmacology for nursing care.
• Smeltzer, S. C., & Bare, B. G. (1992). Brunner & Suddarth’s textbook of
medical-surgical nursing. Philadelphia: JB Lippincott