BJ is a 31-year-old female who presents to your pharmacotherapy clinic for follow-up of migraine headaches. The patient visited the pharmacotherapy clinic months ago and her PCP prescribed Imitrex after failing OTC therapy. The patient explains that her symptoms have not resolved since her last appointment, and she’s had difficulty sleeping. Her most recent migraine episode was this morning for which she took a dose of Imitrex. She reports that her current regimen is no longer effective and asks you if there is anything else she can try immediately before going back to work as a machine operator.
Medications: Imitrex 50mg
- Na: 137mg/dL, K: 3.6meq/L, Cl: 97 meq/L, BUN: 9mg/dL, WBC: 9.4K, Scr: 0.8mg/dL, Glucose: 87mg/dL, AST: 25U/L ALT:22U/L
- Vitals: BP: 120/76, HR 98, RR 13, Temp 98.7°F
- Weight – 85kg Height 67 inches
- Pregnancy test (-) hCG
Which of the following would be appropriate options to initiate in this patient today? Select all that apply.
C. Nurtec ODT
Brands/Generics covered: Imitrex (sumatriptan), Ubrelvy (ubrogepant), Cafergot (ergotamine tartrate/caffeine), Nurtec ODT (rimegepant), Reyvow (lasmiditan), Migranal (dihydroergotamine mesylate)
Correct answers with rationale:
The correct answers are A, C
Migraines are characterized by severe, throbbing, unilateral pain that usually last 4-72hrs and recur sporadically. Acute drug treatment includes OTC analgesics (e.g. acetaminophen) NSAIDs (e.g. aspirin, ibuprofen), Serotonin receptor agonists/triptans(e.g. sumatriptan), ergot derivatives (e.g. ergotamine tartrate), calcitonin gene-related peptide (CGRP) receptor antagonists (e.g. ubrogepant) and 5-HT1F receptor agonists (lasmiditan).
Answer choice A is correct. BJ has failed OTC therapies and a serotonin receptor agonist. BJ does not have any contraindications to CGRP receptor antagonists therefore Ubrelvy would be an appropriate option in this patient. In 2019, the FDA approved Ubrelvy for the acute (immediate) treatment of migraine with or without aura in adults.
Answer choice B is incorrect. The use of ergot derivates with, or within 24 hours of triptans is contraindicated. Both serotonin receptor agonists (triptans) and ergot derivates exert vasoconstrictive effects and their combined use may result in additive vasoconstrictive effects. BJ took her last dose of Imitrex (sumatriptan) this morning and therefore, Cafergot (ergotamine tartrate/caffeine), an ergot derivative would be inappropriate to initiate in this patient.
Answer choice C is correct. BJ has failed OTC therapies and a serotonin receptor agonist. BJ does not have any contraindications to CGRP receptor antagonists therefore Nurtec ODT would be an appropriate option in this patient. In 2020, the FDA approved Nurtec ODT for the acute (immediate) treatment of migraine with or without aura in adults and for the preventative treatment of episodic migraine in adults.
Answer choice D is incorrect. Patients are advised not to drive or operate machinery until 8 hours after taking each dose of Reyvow (Lasmiditan). BJ would like to start therapy immediately before going back to work. Therefore, Reyvow would be inappropriate to start in this patient.
Answer choice E is incorrect. The use of ergot derivates with, or within 24 hours of triptans is contraindicated. Both serotonin receptor agonists (triptans) and ergot derivates exert vasoconstrictive effects and their combined use may result in additive vasoconstrictive effects. BJ took her last dose of Imitrex (sumatriptan) this morning and therefore, Migranal (dihydroergotamine mesylate), an ergot derivative would be inappropriate to initiate in this patient. Ergot alkaloids are rarely used in clinical practice due to significant vasoconstrictive side effects. Even if 24 hours had passed after Imitrex therapy, in most circumstances this would be a last line option.
In general, CGRP receptor antagonists are not as effective as triptans which remain first-line abortive therapies. Another option not listed here would be to attempt a different triptan to see if the patient would respond to it or even increase the sumatriptan dose to 100mg as both of these would also be appropriate options in clinical practice. This question focused on known contraindications with migraine therapies.
NAPLEX Competencies Covered: Area 2 (Identify Drug Characteristics), 2.1 Pharmacology, mechanism of action, or therapeutic class; 2.2 Commercial availability; prescription or non-prescription status; brand, generic, or biosimilar names; physical descriptions; or how supplied; Area 3 (Develop or Manage Treatment Plans), drug dosing or dosing adjustments; duration of therapy; 3.6 drug contraindications, allergies, or precautions
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