Neurology/Migraine & headache drugs

Migraine & headache drugs

also: sumatriptan · triptan · propranolol · topiramate · cluster headache

Overview

Acute and preventive migraine therapy, plus cluster headache and the medication-overuse trap.

Mechanism

Triptans are 5-HT₁B/₁D agonists → cranial vasoconstriction + inhibit trigeminal neuropeptide release (abort migraine). Prophylactics (propranolol, topiramate, amitriptyline) reduce attack frequency by various central mechanisms.

Indications

Acute migraine
Migraine prophylaxis
Cluster headache
Trigeminal neuralgia (carbamazepine — cross-ref epilepsy)

The agents

Acute: sumatriptan + NSAID/paracetamol ± antiemeticabortive

oral/SC/nasal

Triptan CONTRAINDICATED in ischaemic heart disease / uncontrolled HTN (vasoconstrictor).

Propranololprophylaxis

First-line prophylaxis; good in women of childbearing potential.

Topiramateprophylaxis

TERATOGENIC + reduces contraceptive efficacy — avoid in women of childbearing potential.

Amitriptylineprophylaxis

Also helps tension-type headache + sleep.

Cluster: high-flow O₂ + SC sumatriptan; verapamil prophylaxiscluster

Oxygen 100% is the acute treatment; verapamil prevents.

Adverse effects

Triptans: chest tightness, paraesthesiacommon

Topiramate: weight loss, paraesthesia, cognitive slowing, teratogenicityserious

Medication-overuse headacheclassic

Regular analgesic/triptan use >10–15 days/month — withdraw the analgesic.

Cautions & contraindications

Triptans in IHD / uncontrolled hypertension / previous strokeall

Coronary/cerebral vasoconstriction.

Topiramate in pregnancy / women of childbearing potentialpregnancy

Combined oral contraceptive in migraine WITH auraall

Stroke risk (cross-ref O&G).

Interactions

Triptan + SSRI/SNRI → serotonin syndrome (caution)

Monitoring & kinetics

Headache diary; review prophylaxis at ~3 months

Acute treatments PRN; prophylaxis daily.

Source: NICE CKS — Migraine / cluster · BNF — Antimigraine drugs