Learning Outcomes
By the end of this section, you should be able to:
- 12.2.1 Describe the pathophysiology of migraine headaches.
- 12.2.2 Identify the clinical manifestations related to migraine headaches.
- 12.2.3 Identify the etiology and diagnostic studies related to migraine headaches.
- 12.2.4 Identify the characteristics of drugs used to treat migraine headaches.
- 12.2.5 Explain the indications, action, adverse reactions, and interactions of drugs used to treat migraine headaches.
- 12.2.6 Describe nursing implications of drugs used to treat migraine headaches.
- 12.2.7 Explain the client education related to drug used to treat migraine headaches.
Headaches are a prevalent medical condition that can cause pain or discomfort in the head or neck area. Among the different types of headaches, migraine headaches are a specific and recurring type of headache that can cause significant debilitating symptoms. This chapter will focus specifically on migraine headaches, exploring their causes, symptoms, and common drugs used to alleviate this condition.
Overview of Migraine Headaches
Migraine headaches are a type of headache that can be recurring and are often associated with a range of symptoms that can greatly affect a person’s quality of life. These symptoms will be explored in more detail later in this chapter. Migraine headaches can last for several hours up to several days and can be debilitating, often interfering with daily activities. Some people may experience a warning symptom, known as an aura, which can include visual disturbances such as flashing lights or blind spots. Migraine headaches are a prevalent condition that affects a significant portion of the U.S. population, with an estimated 39 million people experiencing this type of headache (American Migraine Foundation, 2023).
Etiology
Migraines can stem from a range of factors, which may include environmental, potent odors, tobacco use, motion sickness, hormonal fluctuations, flashing lights, inadequate sleep, heightened stress levels, and certain foods such as aged cheeses, aspartame, and monosodium glutamate (MSG), and caffeine withdrawal (American Migraine Foundation, 2023; National Institute of Neurological Disorders and Stroke, 2023).
Pathophysiology
The underlying pathophysiology of migraine headaches is unclear, but a comprehensive theory proposes the involvement of neuronal hyperexcitability, vasodilation of blood vessels—which triggers pain receptors—and inflammation in the brain (American Migraine Foundation, 2023).
Diagnostic Testing
To diagnose migraine headaches, health care providers rely on the client’s report of symptoms, a detailed medical history, and a physical examination. Radiologic imaging, such as an MRI or CT scan, may also be performed to rule out other potential causes of the headaches, such as brain tumors, meningitis, or ischemia (American Migraine Foundation, 2023).
Clinical Manifestations
Clinical manifestations (symptoms) of migraine headaches include:
- Pulsating, throbbing head pain
- Muscle weakness
- Language disturbances
- Pupillary changes
- Visual disturbances
- Mood changes
- Fluid retention
- Increased urinary output
Link to Learning
What Is Migraine Disease?
Nucleus Medical Media presents an educational video on migraine headaches.
Drugs Used to Treat Migraine Headaches
Migraine headaches can be treated through two distinct courses of therapy: abortive and preventive. Abortive therapy aims to relieve the symptoms of a migraine headache through drug administration. On the other hand, preventive therapy involves the use of drugs to prevent the occurrence of migraine headaches altogether.
Triptans
Triptans are serotonin agonists that target the pathophysiological mechanism of migraine headaches, effectively eliminating symptoms. By selectively binding to serotonin receptors 5-HT1B and 5-HT1D, triptans induce vasoconstriction of cranial arteries that are typically dilated during migraines. The vasoconstriction helps to reduce the intensity and duration of migraine headaches.
Table 12.10 lists common triptans and typical routes and dosing for adult clients.
| Drug | Routes and Dosage Ranges |
|---|---|
| Eletriptan (Relpax) |
Single doses of 20–40 mg orally once. If the migraine does not resolve within 2 hours or returns after transient improvement, a second dose may be administered at least 2 hours after the first dose. Maximum daily dose should not exceed 80 mg. |
| Rizatriptan (Maxalt) |
The recommended starting dose is either 5 mg or 10 mg orally once, for acute treatment of migraines in adults. May repeat dose after at least 2 hours if headache returns. Maximum daily dose should not exceed 30 mg. |
| Sumatriptan (Imitrex) | The recommended daily doses are 25 mg, 50 mg, or 100 mg orally. If the migraine has not resolved by 2 hours after taking sumatriptan or returns after a transient improvement, a second dose may be administered at least 2 hours after the first dose. Maximum daily dose is 200 mg in 24 hours. Subcutaneous dosing: 6 mg with a maximum dose of 12 mg/day. Maximum dosing should be 2–6 mg injections separated at least 1 hour apart. Intranasal doses: 5 mg, 10 mg, and 20 mg given as a single spray in one nostril. The maximum daily dose is 40 mg in a 24-hour period. |
| Zolmitriptan (Zomig) |
The recommended starting dose is 1.25 mg or 2.5 mg. The maximum recommended single dose is 5 mg. If the migraine has not resolved by 2 hours after taking zolmitriptan or returns after a transient improvement, a second dose may be administered at least 2 hours after the first dose. Maximum daily dose is 10 mg in a 24-hour period. |
Adverse Effects and Contraindications
Adverse effects of triptans include dizziness, nausea, flushing, tingling, neck pain, chest tightness, and paresthesia. Triptans are contraindicated in clients with a history of myocardial infarction, coronary artery disease, stroke, uncontrolled hypertension, and peripheral vascular disease (Nicholas & Nicholas, 2023).
Table 12.11 is a drug prototype table for triptans featuring sumatriptan. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
| Drug Class Serotonin agonists Mechanism of Action Selectively binds to serotonin receptors 5-HT1B and 5-HT1D and induces vasoconstriction of cranial arteries |
Drug Dosage The recommended daily doses are 25 mg, 50 mg, or 100 mg orally. If the migraine has not resolved by 2 hours after taking sumatriptan or returns after a transient improvement, a second dose may be administered at least 2 hours after the first dose. Maximum daily dose is 200 mg in 24 hours. Subcutaneous dosing: 6 mg with a maximum dose of 12 mg/day. Maximum dosing should be 2–6 mg injections separated at least 1 hour apart. Intranasal doses: 5 mg, 10 mg, and 20 mg given as a single spray in one nostril. The maximum daily dose is 40 mg in a 24-hour period. |
| Indications To treat migraine headaches To treat cluster headaches Therapeutic Effects Reduces migraine and cluster headaches |
Drug Interactions Ergot-containing drugs Monoamine oxidase inhibitors Selective serotonin reuptake inhibitors Serotonin and norepinephrine reuptake inhibitors Tricyclic antidepressants Food Interactions No significant interactions |
| Adverse Effects Paresthesia Flushing Vertigo Malaise Hypotension Dystonia |
Contraindications Hypersensitivity Ischemic coronary disease Stroke Peripheral vascular disease Uncontrolled hypertension Pregnancy Caution: Monitor closely for arrhythmias including ventricular tachycardia and ventricular fibrillation, which can lead to death |
FDA Black Box Warning
Sumatriptan
There is cardiovascular risk from sumatriptan with an increased risk of adverse thrombotic events, including myocardial infarction and stroke.
Ergot Alkaloids
Ergot alkaloids are alpha-adrenergic blockers, a class of drug that directly stimulates vascular smooth muscle, thereby causing vasoconstriction. These alpha-adrenergic blockers are used in the treatment of migraine and vascular headaches as well as other medical conditions such as hypertension. Adverse effects include coronary and peripheral ischemia, muscle pains, nausea, vomiting, paresthesias, vertigo, weakness, and itching. Ergot alkaloids are contraindicated in hypersensitivity to the drug or any of its components, peripheral vascular disease, coronary heart disease, hypertension, impaired hepatic or renal function, and sepsis.
The most common ergot alkaloid used in the treatment of migraine headaches is ergotamine tartrate (Cafergot). Table 12.12 is a drug prototype table for ergot alkaloids featuring ergotamine tartrate. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
| Drug Class Ergot alkaloid and alpha-adrenergic blocker Mechanism of Action Inhibits norepinephrine and directly stimulates vascular smooth muscle, causing vasoconstriction |
Drug Dosage Starting dose: 1–2 mg sublingually at the first sign of a migraine and 1 mg additional sublingually every ½ hour, if needed for full relief. Maximum dose: 6 mg in 24 hours. Also available in suppository form and in tablets with caffeine. |
| Indications To treat migraine and vascular headaches Therapeutic Effects Reduces headache symptoms |
Drug Interactions Ritonavir Indinavir Erythromycin Clarithromycin Troleandomycin Food Interactions No significant interactions |
| Adverse Effects Paresthesia Nausea Vomiting Weakness Vertigo Transient tachycardia or bradycardia Hypertension |
Contraindications Hypersensitivity Vasoconstrictive conditions such as peripheral vascular disease and coronary heart disease Renal insufficiency Hepatic insufficiency Myocardial ischemia/infarction Caution: Monitor closely in clients who have bronchial asthma |
FDA Black Box Warning
Ergotamine
Ergotamine is contraindicated with potent inhibitors CYP3A4 drugs. Concomitant use of these drugs may result in serious vasospasm producing cerebral limb ischemia.
Selective Serotonin Receptor Agonists
Selective serotonin receptor agonists are a novel drug class that is used in the treatment of migraine headaches. It is scentrally and peripherally acting 5-HT1F receptor agonist that decreases the release of neuropeptides and the neurotransmitter glutamate, thereby inhibiting neuronal firing. Adverse effects include paresthesia, fatigue, drowsiness, nausea, vomiting, muscle weakness, and hypertension. They are contraindicated in hypersensitivity to the drug or its components (Berger et al., 2020).
The most prescribed selective serotonin receptor agonist for migraine headaches is lasmiditan (Reyvow). Table 12.13 is a drug prototype table for selective serotonin receptor agonists featuring lasmiditan. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
| Drug Class Selective serotonin receptor agonist Mechanism of Action Decreases the release of neuropeptides and the neurotransmitter glutamate, inhibiting neuronal firing |
Drug Dosage Recommended dose is 50–200 mg taken orally, as needed. No more than 1 dose should be taken in 24 hours. |
| Indications To treat migraine and cluster headaches Therapeutic Effects Reduces migraine and cluster headache symptoms |
Drug Interactions Selective serotonin reuptake inhibitors Serotonin and norepinephrine reuptake inhibitors Tricyclic antidepressants Food Interactions No significant interactions |
| Adverse Effects Paresthesia Drowsiness/sedation Nausea and vomiting Muscle weakness Fatigue Serotonin syndrome |
Contraindications Hypersensitivity Caution: Monitor closely in clients who are taking other drugs associated with serotonin syndrome because coadministration of lasmiditan with these drugs can cause serotonin syndrome Monitor closely for central nervous system depression/impaired driving |
Calcitonin Gene Related Peptide (CGRP) Receptor Antagonists
Calcitonin gene related peptide (CGRP) receptor antagonists are a novel drug class used in the treatment of migraine headaches. They block CGRP receptors and inhibit the biological activity of CGRP neuropeptides. Adverse effects include nausea, rash, and dyspnea. Contraindications include hypersensitivity to the drug or its constituents (Rashid & Manghi, 2022).
The most prescribed CGRP receptor antagonist is rimegepant (Nurtec). Table 12.14 is a drug prototype table for CGRPs featuring rimegepant. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
| Drug Class CGRP receptor antagonist Mechanism of Action Binds to CGRP receptors, decreasing inflammation in the meninges of the brain |
Drug Dosage Recommended dose is 75 mg orally as needed. Maximum dose: 75 mg in a 24-hour period. |
| Indications To treat migraine headaches Therapeutic Effects Reduces migraine headaches |
Drug Interactions Ritonavir Indinavir Amiodarone Cyclosporine Quinidine Food Interactions No significant interactions |
| Adverse Effects Nausea Rash Shortness of breath |
Contraindications Hypersensitivity Caution: Monitor closely in clients with hepatic insufficiency |
Nursing Implications
The nurse should do the following for clients who are taking migraine headache drugs:
- Assess the client’s medical history, current drug list, and allergies.
- Assess client’s baseline symptoms, vital signs, and pain level.
- Ensure the drug is prepared appropriately using aseptic technique and verify dosage before administration.
- Monitor the client’s response to the drug, including any changes in pain level, neurological status, and vital signs.
- Maintain a dark, calm, and quiet environment.
- Provide client teaching regarding the drug and when to call the health care provider. See below for client teaching guidelines.
Client Teaching Guidelines
The client taking a migraine headache drug should:
- Get adequate sleep and rest.
- Keep a journal of symptoms, the presence or non-presence of an aura, and improved or worsening symptoms.
- Take migraine drugs as prescribed.
- Identify food triggers, environmental triggers, hormonal triggers, and stress triggers.
- Report worsening of symptoms such as visual changes and uncontrolled head pain to the health care provider immediately because these manifestations can be debilitating.
The client taking a migraine headache drug should not:
- Drink alcohol or smoke as these can precipitate symptoms of migraine headaches.
- Operate heavy equipment or machinery while taking migraine headache drugs.