Medications for migraines: Nursing pharmacology

Migraines are a specific type of pounding or pulsating headache that’s typically localized to one side of the head, and is often associated with additional symptoms like photophobia, phonophobia, nausea, or even vomiting.

As preventative therapy, some clients may take beta blockers like metoprolol, antiepileptics like topiramate, or tricyclic antidepressants like amitriptyline.

On the other hand, acute treatment of migraines involves managing the symptoms with abortive agents, which can be broadly divided into four classes; ergot derivatives, triptans, ditans, and calcitonin gene-related peptide or CGRP receptor antagonists, which are also used as preventive therapy.Starting with ergot derivatives, these include ergotamine and dihydroergotamine.

Ergotamine can be administered in sublingual tablets, while dihydroergotamine can be injected intramuscularly or intravenously, or used as a nasal spray.

Once administered, ergot derivatives work by binding to serotonin and alpha-adrenergic receptors on the blood vessels in the brain, causing them to constrict.

And that helps decrease the pain because vasodilation of these blood vessels seems to be a trigger for pain receptors, causing the migraine in the first place.

However, ergot derivatives not only cause vasoconstriction of the blood vessels in the brain, but also blood vessels all around the body, which can cause hypertension.

Vasoconstriction of coronary blood vessels in the heart can also bring about a type of chest pain called angina, which, in severe cases, can get complicated with arrhythmias or even myocardial infarction.

At the same time, ergot derivatives stimulate serotonin receptors in the vomiting center of the brain, so they can trigger nausea, vomiting, or gastrointestinal disturbances.

Itching of the skin, as well as leg weakness, numbness, tingling and muscle pain in arms and legs are also common side effects.Ergot derivatives also stimulate contraction of the smooth muscles of the uterus, which can lead to premature labor or miscarriage in pregnant clients.

Finally, a situation called ergotism happens when clients intoxicate with ergot derivatives; this manifests mainly with spasms, seizures, psychiatric and gastrointestinal symptoms, blood pressure changes, and gangrene in the hands and feet due to vasoconstriction.

It’s also important to point out that overuse of ergot derivatives results in dependence, causing withdrawal symptoms or rebound headaches when discontinued abruptly.Now, ergot derivatives are contraindicated in children and elderly clients, as well as during pregnancy and breastfeeding.

They should also be avoided in clients with cardiovascular disease, hypertension, or peripheral vascular disease, as well as in those with Raynaud phenomenon or Buerger syndrome.

Finally, ergot derivatives should be used with caution in clients with severe hepatic or renal disease.Regarding interactions, ergots have a boxed warning against their use in combination with potent CYP34A inhibitors, such as protease inhibitors or macrolide antibiotics, since they can cause increased levels of ergots, causing vasospasm, peripheral ischemia, and cerebral ischemia.Next, there are triptans and ditans.

Triptans are categorized as serotonin 5-HT 1B/1D receptor agonists, and include sumatriptan, naratriptan, rizatriptan, zolmitriptan, almotriptan, frovatriptan, and eletriptan; on the other hand, ditans are categorized as a serotonin 5-HT1F receptor agonist, and the most common one is lasmiditan.

All of these medications can be taken orally, but this may be impractical for clients who experience nausea or vomiting during the migraine attack.

For these situations, subcutaneous injections or a nasal spray of sumatriptan are available. Similarly to ergot derivatives, both triptans and ditans bind to selective serotonin receptors, namely 1B and 1D for triptans, and 1F for ditans, which are located in blood vessels of the brain and trigeminal nerve, causing vasoconstriction and decreased inflammation.

As a result, these medications help stop the migraine attack and relieve its symptoms. Side effects of triptans and ditans are generally mild, and include fatigue, dizziness, sedation, weakness, and flushing.

In addition, subcutaneous administration can cause mild pain, tingling, numbness, and a cold or burning sensation at the site of injection.

Less commonly, triptans and ditans can also cause gastrointestinal disturbances, as well as discomfort in the mouth, jaw, or throat, chest tightness, hypertension, and even myocardial infarction.

Finally, ditans can cause CNS depression, potentially leading to a decreased mental and physical function; in addition, ditans are also associated with serotonin syndrome.As far as contraindications go, triptans and ditans should not be used in clients with a history of cardiovascular disease or uncontrolled hypertension.

In addition, these medications are contraindicated for intravenous use, as well as for concurrent use with ergot derivatives.

Precautions should be taken during pregnancy and breastfeeding, as well as in children and elderly clients. Additionally, these medications should be used with caution in clients with hypercholesterolemia, obesity, diabetes, and hepatic or renal disease.

Finally, triptans should be used with caution in clients with seizure disorder.Finally, there’s a new class of medications used to treat migraines, called CGRP receptor antagonists.

The most commonly used medications of this group include erenumab, which is a monoclonal antibody that is administered by subcutaneous injection; as well as the medications ubrogepant and rimegepant, which are taken orally.

Once administered, CGRP receptor antagonists target and block either the calcitonin gene-related peptide, or its receptor, which is located on the brain stem.

This peptide is involved in the transmission of sensory impulses like pain, temperature, and touch throughout the trigeminal nerve.

So, basically, CGRP receptor antagonists block these sensory impulses, either preventing or stopping the migraine attack.

CGRP receptor antagonists are quite safe, with mild side effects like pain or redness at the injection site for erenumab.

In addition, these medications may cause severe constipation, especially when combined with medications that decrease gastrointestinal motility, such as antidiarrheal medications and opioids.

Lastly, erenumab may cause hypertension or make existing hypertension worse. Finally, CGRP receptor antagonists should be used with caution in pregnant or breastfeeding clients, as well as in clients with hypertension or risk factors for hypertension, and in those with latex allergy.

All right, when a client has been diagnosed with migraines, they could be prescribed a selective serotonin receptor agonist like sumatriptan.

Before administering this medication, be sure to review their chart, checking for any active cardiovascular disease like angina or uncontrolled hypertension.

Then, perform a focused baseline assessment, including a description of their migraine, its location, time of onset and frequency, severity and type of pain, as well as presence of aura, and any additional symptoms like photophobia, phonophobia, nausea, or vomiting.

Also, ask your client if there are any known triggers for the migraine. Lastly, review their most recent laboratory test results, including renal and hepatic function, and for clients of childbearing age, be sure to confirm they are not pregnant.Next, explain to your client that sumatriptan can resolve their active migraine symptoms by constricting blood vessels in the brain that are dilated and spasming.

Be sure your client understands the importance of taking their medication as soon as they begin to feel any migraine symptoms.Now, if your client is prescribed the needleless subcutaneous form of sumatriptan, demonstrate the proper administration technique using the medication delivery device.

Teach them to pinch about two inches of skin on their thigh or lower abdomen, keeping at least two inches away from their navel.

Remind them to rotate injection sites and avoid areas with bruising, tenderness, or open wounds. Then, show them how to press the device straight down against their skin until they hear a whooshing sound and feel a burst of air, which means the medication has been delivered and it is okay for them to remove the device.

Also explain that, after removing the device, they could see a small drop of blood where the medication was administered.

If this occurs, instruct them to gently press a cotton ball or clean gauze on the site without rubbing. Then, instruct them to properly dispose of the device.

Lastly, if your client feels they need a second dose, let them know that they can take it after one hour has passed; and caution them that they should not take more than two doses of the medication within a 24 hour period.

On the flip side, if your client is taking their migraine medication orally, teach them to swallow the pill whole and drink a full glass of water afterwards.

If they need a second dose, let them know that they should wait two hours after the initial dose before taking it. In contrast, when your client is prescribed sumatriptan in an intranasal powder or nasal spray form, demonstrate the correct technique to promote safe medication self-administration.

Once your client has taken their medication, recommend they rest in a cool, quiet, dark room to further help alleviate their migraine symptoms.

Discuss relaxation techniques that may be helpful, as well as methods of avoiding or controlling triggers that bring on their migraine.

If your client requires sumatriptan more than ten days per month, prompt them to consult with their health care provider.Next, teach your client to monitor for common side effects of sumatriptan, such as numbness or tingling, which can happen when their blood vessels constrict as a result of the medication.

If your client experiences shortness of breath, dizziness, chest pain or pressure, advise them to seek emergency medical treatment right away.

Lastly, remind your client to use reliable birth control methods while using sumatriptan.Now, if your client is prescribed a CGRP receptor antagonist like erenumab, first perform a focused assessment; be sure to confirm your client does not have hypertension or a latex allergy, since parts of the autoinjector contain dry natural rubber, which may cause a reaction in latex sensitive clients.

Then, explain how erenumab prevents migraines by blocking pain impulses in the brain, and teach them to take their medication once each month at the same time of the day.

Instruct your client to keep the medication in the refrigerator, in its original container, protected from light. Before using it, instruct them to allow it to sit at room temperature for 30 minutes prior to administration, and to avoid shaking the autoinjector.

Then, demonstrate proper subcutaneous technique using the autoinjector, as well as its proper disposal into a sharps container.

Next, be sure to let your client know about common side effects they could experience, such as injection site reactions.

Emphasize the importance of preventing constipation by drinking plenty of fluids, increasing their daily intake of fiber-rich foods, and including physical activity in their daily routine.

Also, prompt them to report symptoms that might indicate a rise in blood pressure, such as a headache or feeling of lightheadedness or dizziness.

Then, advise your client to keep track of how often their migraines occur, and to contact their health care provider if they experience severe side effects or if the medication is ineffective in preventing migraines.

Lastly, remind your client to keep their follow-up appointments so they can be monitored. Finally, when caring for a client taking medication to treat migraines, monitor them closely for the development of side effects, as well as the desired therapeutic effect of migraine prevention and symptom management.Alright, as a quick recap… Migraines are a specific type of pulsating headache usually occurring on one side of the head, often associated with additional symptoms like photophobia, phonophobia, nausea, and vomiting.

As preventative therapy, some clients may take beta blockers, antiepileptics, tricyclic antidepressants, or calcitonin gene-related peptide or CGRP receptor antagonists.

On the other hand, acute treatment of migraines involves abortive agents, which include ergot derivatives, triptans, ditans, and CGRP receptor antagonists.

Ergot derivatives relieve migraines by binding to serotonin and alpha-adrenergic receptors on the blood vessels in the brain, causing them to constrict.

Side effects include angina, arrhythmias, myocardial infarction, gastrointestinal disturbances, or ergotism. Triptans are serotonin 5-HT 1B/1D receptor agonists, while ditans are serotonin 5-HT1F receptor agonists; both triptans and ditans bind to their specific serotonin receptors located in blood vessels of the brain and trigeminal nerve, causing vasoconstriction and decreased inflammation.

Side effects include fatigue, flushing, numbness or tingling. Lastly, CGRP antagonists work to either prevent or stop active migraines by blocking the calcitonin gene-related peptide or its receptor, which is located on the brain stem, ultimately blocking sensory impulses.

Side effects include injection site reactions, severe constipation, and hypertension. When caring for clients prescribed medications to treat migraines, nursing considerations include assessing migraine symptoms, monitoring for side effects, and assessing for the therapeutic effect of migraine prevention and symptom management.

Client education is focused on safe self-administration techniques, as well as learning about side effects that should be