B5HT Receptor Agonists Triptans

1. Sumatriptan (Imitrex) is available for subcutaneous self-injection, an oral formulation, and as a nasal spray. A selective serotonin-receptor agonist, it appears to be more effective than ergotamine. The injection and nasal spray begin to produce relief in 10 to 15 minutes, compared to one to two hours with the tablets. A subcutaneous injection produces relief in 70-80%. Sumatriptan nasal spray provides relief in about 60%. Oral sumatriptan is effective in 50-60%.

2. Zolmitriptan (Zomig), naratriptan (Amerge), and rizatriptan (Maxalt). Zolmitriptan and rizatriptan may have a more rapid onset of action than oral sumatriptan. Naratriptan, which has a longer half-life, has a slower onset of action. The rate of recurrence of migraine within 24 hours after treatment with a triptan is 30% to 40%; it may be slightly lower with naratriptan.

Drug

Dosage

NSAIDs

Ibuprofen (Motrin)

400-800 mg, repeat as needed in 4 hr

Naproxen sodium (Anaprox DS)

550-825 mg, repeat as needed in 4 hr

5-HT1 Receptor Agonists ("Triptans")

Naratriptan (Amerge)

1- or 2.5-mg tablet, can be repeated 4 hours later (max 5 mg/24 hours)

Rizatriptan (Maxalt)

5- or 10-mg tablet or wafer (MLT); can be repeated in 2 hours (max 30 mg/24 hours)

Sumatriptan (Imitrex)

6 mg SC; can be repeated in 1 hour (max 2 injections/24 hours)

25, 50 or 100 mg PO; can be repeated in 2 hours (max 200 mg/24 hours) 5 or 20 mg intranasally; can be repeated after 2 hours (max 40 mg/24 hours)

Zolmitriptan (Zomig)

2.5 or 5 mg PO; can be repeated in 2 hours (max 10 mg/24 hours)

Ergot Alkaloids

Dihydroergotamine DHE 45

Migranal Nasal Spray

1 mg IM; can be repeated twice at 1-hour intervals (max 3 mg/attack) 1 spray (0.5 mg)/nostril, repeated 15 minutes later (2 mg/dose; max 3 mg/24 hours)

Ergotamine 1 mg/caffeine 100 mg (Ercaf, Gotamine , Wigraine)

2 tablets PO, then 1 q30min, x 4 PRN (max 6 tabs/attack)

Ergotamine (Ergomar)

2-mg sublingual tablet, can be repeated q30min x 2 PRN (max 3 tabs/attack)

Ergotamine 2 mg/caffeine 100 mg (Cafergot)

One rectal suppository; can be repeated once, 1 hour later

Butalbital combinations

Aspirin 325 mg, caffeine 40 mg, butalbital 50 mg (Fiorinal)

2 tablets, followed by 1 tablet q4-6h as needed

Acetaminophen 325 mg, caffeine 40 mg, butalbital 50 mg (Esgic, Fioricet)

2 tablets, followed by 1 tablet q4-6h as needed

Acetaminophen 325 mg, butalbital 50 mg (Phrenilin)

2 tablets, followed by 1 tablet as q4-6h needed

Drug

Dosage

Isometheptene combination

Isometheptene 65 mg, acetaminophen 325 mg, dichloralphenazone 100 mg (Midrin)

2 tablets, followed by 1 tablet as needed q4-6h prn

Opioid Analgesics

Butorphanol (Stadol NS)

One spray in one nostril; can be repeated in the other nostril in 60-90 minutes; the same two-dose sequence can be repeated in 3 to 5 hours

Drugs for Prevention of Migraine

Drug

Dosage

Propranolol (Inderal)

80 to 240 mg/day, divided bid, tid or qid

Timolol (Blocadren)

10 to 15 mg bid

Divalproex sodium (Depakote)

250 mg bid or tid

Amitriptyline (Elavil)

10-150 mg qhs

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