Podcast 883: Migraine Treatment in Cardiovascular Disease - The Emergency Medical Minute

Podcast 883: Migraine Treatment in Cardiovascular Disease

Contributor: Jorge Chalit, OMS II

Educational Pearls:

  • Migraine pathophysiology

    • Primarily mediated through the trigeminovascular system

    • Serotonin, dopamine, and calcitonin gene-related peptide (CGRP)

    • Trigeminovascular system is linked to the trigeminal nucleus caudalis, which relays pain to the hypothalamus and cerebral cortex

  • One effective treatment for acute migraines is -triptan medications

    • 5-HT1D/1B agonists such as sumatriptan

    • Often combined with NSAIDs and dopamine antagonists (as antiemetics) in migraine cocktails

  • Diphenhydramine (Benadryl) was shown to be ineffective in a randomized controlled trial comparing it with placebo and a dopamine antagonist antiemetic.

  • The -triptan medications carry significant risk for peripheral vasoconstriction and are therefore avoided in cardiovascular disease

  • One serotonin agonist specifically approved for use in vascular disease

    • Lasmiditan – 5-HT1F agonist

    • Slightly different mechanism of action avoids peripheral vasoconstriction

  • CGRP antagonists are also used in patients who are unresponsive to -triptans

References

1. Friedman WB, Cabral L, Adewunmi V, et al. Diphenhydramine as adjuvant therapy for acute migraine. An ED-based randomized clinical trial. Ann Emerg Med. 2016;67(1):32-39.e3. doi:doi:10.1016/j.annemergmed.2015.07.495

2. Lasmiditan (Reyvow) and ubrogepant (Ubrelvy) for acute treatment of migraine. (2020). The Medical letter on drugs and therapeutics, 62(1593), 35–39.

3. Robbins MS. Diagnosis and Management of Headache: A Review. JAMA – J Am Med Assoc. 2021;325(18):1874-1885. doi:10.1001/jama.2021.1640

4. Vanderpluym JH, Halker Singh RB, Urtecho M, et al. Acute Treatments for Episodic Migraine in Adults: A Systematic Review and Meta-analysis. JAMA – J Am Med Assoc. 2021;325(23):2357-2369. doi:10.1001/jama.2021.7939

Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII

 

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