Antimigraine drug

Examples of specific antimigraine drug classes include triptans (first line option), ergot alkaloids, ditans and gepants. Migraines can also be treated with unspecific analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen. Opioids are not recommended for treatment of migraines. Triptans The triptan drug class includes 1st generation sumatriptan (which has poor bioavailability), and second generation zolmitriptan. Due to their safety, efficacy and selectivity, triptans are considered first line agents for abortion of migraines. Triptans use is limited to less than ten times per month in order to reduce medication overuse headache (MOH). Their lack of selectivity leads to more adverse effects, making them second line compared to triptans. Adverse effects include nausea, vomiting, paresthesia, and ergotism. Ditans Ditans (eg. lasmiditan) are a new group of anti migraine drugs which were developed due some of the concerns with the 1st line triptans (eg. adverse effects, concern with use in cardiovascular disease, use of less than 10x per month to reduce MOH). Ditans are 5-HT1F receptors agonists. Lasmiditan has been suggested to have less pain relief when compared to the triptans at the 2 hour mark post taking the medication. Lasmiditan was shown to have higher adverse events (dizziness, fatigue and nausea) than the triptans or another novel medication class, CGRP antagonists. Similar to the triptans and ergots alkaloids, their use should be limited to less than 10x per month to reduce MOH. Acetaminophen is an analgesic that can also be used, but NSAIDS should be tried first due to their anti-inflammatory properties. However, acetaminophen would be considered first line in pregnant patients. Combination therapy of an NSAID with a triptan can be used when either medication is insufficient alone for migraine relief or recurrence . Long term NSAID use has risks including nephrotoxicity and cardiotoxicity, and long term acetaminophen use is associated with hepatoxicity. If warranted, an antiemetic can be used in combination with an NSAID. Opioids Opioids are not recommended for treatment of acute migraines due to their significant side effect profile, including twice the risk of medication overuse headache when compared to NSAIDS, acetaminophen or triptans. In addition, their strength of efficacy has shown to be low or insufficient for pain relief of migraines. Importantly, there is also risk of addiction and opioid use disorder. == Prevention ==

For patients who require preventive therapy with symptoms such as more than 4 migraines per month or migraines lasting longer than 12 hours, first-line drugs for the prevention of migraine attacks include beta blockers, antidepressants, and anti convulsants. Serotonin antagonists Non-selective serotonin receptor antagonists like methysergide, pizotifen, and cyproheptadine are used to prevent migraines. Their antimigraine effects may be due specifically to serotonin 5-HT2B receptor blockade. The timeframe to effectiveness in generally within 3 months. The exact mechanism of action is unknown but seems to be related to serotonin's impact on migraine. They are well tolerated short term, but should be monitored during long term therapy because of risks of pancreatitis, liver failure and teratogenicity. Valproate should not be used in females of childbearing age because studies suggest that children exposed to valproate in the prenatal period are associated with having lower IQ scores. It is a safe medication but should be used in caution in females of childbearing ages because it is suggested to cause birth defects. CGRP is a neuropeptide which is thought to induce migraines via vasodilation of cranial arteries. Melatonin There have been some studies suggesting the benefit of using melatonin for prophylaxis of migraine, however, there is a lack of strength of evidence due to a low number of studies as well as conflicting results. Melatonin has a good safety profile but there have been rare instances of serious side effects. More studies are needed in order to suggest the therapeutic use of melatonin for prophylaxis of migraine. == Prophylaxis in pediatric patients ==

There is not a strong degree of evidence for the use of anti migraine drugs prophylactically in children and adolescence. It is highly important to consider risk vs benefit when considering their use in the paediatric population. ==See also==