LW, a 28 year-old female, presents to her primary care physician’s office with complaints of frequent severe, unilateral head pain with accompanying sensitivity to light and sound.  LW states that she has experienced these symptoms on 5 separate occasions during the past 3 months.  She has had minimal relief with Aleve and would like to see if there is something stronger she could try because these attacks are debilitating and throw off her entire day.

Past medical history:

Hypertension: Zestril 40 mg: Take 1 tablet by mouth once a day

Vitals:

Ht: 5’8”

Wt: 152 lbs

BP: 128/72 mmHg

HR: 84 bpm

Temp: 98.6 F

LW’s primary care physician diagnoses her with migraines.  What would be an appropriate choice for the acute treatment of LW’s migraines?

A. Cataflam 50 mg by mouth at onset

B. Imitrex 50 mg by mouth at onset

C. Aimovig 70 mg SQ at onset

D. Nurtec ODT 75 mg by mouth every other day

Answer with rationale:

Matters of the mind can be tricky.  Especially migraines and how to treat them.  The prevalence of migraines peaks at 25-55 years of age, with ¾ of patients reporting the onset of symptoms before the age of 35.  Many patients with migraines report that their migraines interfere with their functions of daily living, causing missed work and decreased productivity.  Typical presentation includes severe, throbbing, unilateral pain that is usually retroorbital.  Accompanying nausea and vomiting as well as sensitivity to light and sound are also common.  Pharmacologic therapy options include acute treatments and prophylactic therapy. Let's work through each of these potential answers to discern the correct one. 

Answer A is incorrect.  Cataflam is the brand name of diclofenac, an NSAID.  NSAIDs are first line for mild-moderate migraine.  LW has severe migraines.  While it is reasonable to use NSAIDs for severe migraines if effective in the past, LW had minimal relief with Aleve previously, so treating her migraines with another NSAID now would not be appropriate.

Answer B is correct.  Imitrex is the brand name of sumatriptan, a serotonin receptor agonist that causes vasoconstriction of the intracranial arteries.  It is one of the first line agents for the acute treatment of severe migraine.  Uncontrolled hypertension is a contraindication to triptans, but since LW’s hypertension is being treated and is within goal (<130/80 mm Hg), it is not an issue in this case.  Therefore, Imitrex would be the most appropriate choice for acute treatment of LW’s migraines.

Answer C is incorrect.  Aimovig is the brand name of erenumab, an injectable calcitonin gene-related peptide (CGRP) monoclonal antibody.  While the dose is appropriate, this answer choice is incorrect because erenumab is used for prophylactic treatment of migraines not acute treatment.  It would not be given as a one time dose, but rather as a monthly injection. Additionally, LW has hypertension and erenumab should also be used with caution in patients with hypertension due to some reports of it causing increased blood pressure after giving the dose.

Answer D is incorrect.  Nurtec is the brand name of rimegepant, a calcitonin gene-related peptide (CGRP) antagonist.  Rimegepant can be used for both acute and prophylactic treatment of severe migraines, but it is typically not considered as an option for acute treatment until after inadequate response to other agents (triptans and ergot derivatives).  This answer choice is incorrect because the dose and directions are for prophylactic treatment not acute treatment, and LW has not attempted to find relief with any of the first line agents for severe migraines.

Brands/generics covered:

Aleve (naproxen), Zestril (lisinopril), Cataflam (diclofenac), Imitrex (sumatriptan), Aimovig (erenumab), Nurtec (rimegepant)

Naplex content domains covered:

1.A.1

Domain 1 Foundational Knowledge for Pharmacy Practice- A. Pharmaceutical Science Principles and Concepts 1. Pharmacology

2.A.1

Domain 2 Medication Use Process- A. Prescriptions and Medication Order Interpretation 1. Drug Names and Therapeutic Classes

2.A.2

Domain 2 Medication Use Process- A. Prescriptions and Medication Order Interpretation 2. Indications, Usage, and Dosing Regimens

3.C.1

Domain 3 Person-Centered Assessment and Treatment Planning- C. Patient Health Conditions, including special populations and medication-related factors 1. Signs, Symptoms, and Findings of Medical Conditions, Etiology of Diseases, or pathophysiology