Migraine

DOSING (ADULTS):
Oral: Adults: Migraine: Initial: 6.25-12.5 mg in a single dose; if the headache returns, repeat the dose after 2 hours; no more than 2 doses in 24-hour period
Note: If the first dose is ineffective, diagnosis needs to be re-evaluated. Safety of treating more than 4 migraines/month has not been established.

Dosage adjustment in renal impairment: Initial: 6.25 mg in a single dose; maximum daily dose: </= 12.5 mg

Dosage adjustment in hepatic impairment: Initial: 6.25 mg in a single dose; maximum daily dose: </= 12.5 mg

SUPPLIED:
Tablet, as malate: 6.25 mg, 12.5 mg

Two theories have been proposed to explain the efficacy of 5-HT receptor agonists in migraine. One theory suggests that activation of 5-HT1 receptors located on intracranial blood vessels, including those on the arteriovenous anastomoses, leads to vasoconstriction, which is correlated with the relief of migraine headache. The other hypothesis suggests that activation of 5-HT1 receptors on sensory nerve endings in the trigeminal system results in the inhibition of pro-inflammatory neuropeptide release

INDICATIONS AND USAGE
RELPAX is indicated for the acute treatment of migraine with or without aura in adults.

RELPAX is not intended for the prophylactic therapy of migraine or for use in the management of hemiplegic or basilar migraine (see package insert for CONTRAINDICATIONS). Safety and effectiveness of RELPAX Tablets have not been established for cluster headache, which is present in an older, predominantly male population

DOSING (ADULTS):
Oral: Acute migraine: 20-40 mg; if the headache improves but returns, dose may be repeated after 2 hours have elapsed since first dose; maximum 80 mg/day.
Note: If the first dose is ineffective, diagnosis needs to be re-evaluated. Safety of treating >3 headaches/month has not been established.

Dosage adjustment in renal impairment: No dosing adjustment needed; monitor for increased blood pressure

Dosage adjustment in hepatic impairment:
Mild to moderate impairment: No adjustment necessary
Severe impairment: Use is contraindicated

SUPPLIED:
Tablet, as hydrobromide [film coated]: 20 mg, 40 mg

Frovatriptan is believed to act on extracerebral, intracranial arteries and to inhibit excessive dilation of these vessels in migraine. In anesthetized dogs and cats, intravenous administration of frovatriptan produced selective constriction of the carotid vascular bed and had no effect on blood pressure (both species) or coronary resistance (in dogs).

INDICATIONS AND USAGE
FROVA is indicated for the acute treatment of migraine attacks with or without aura in adults.

FROVA is not intended for the prophylactic therapy of migraine or for use in the management of hemiplegic or basilar migraine (see package insert for CONTRAINDICATIONS). The safety and effectiveness of FROVA have not been established for cluster headache, which is present in an older, predominately male, population

DOSING (ADULTS):
Oral: Migraine: 2.5 mg; if headache recurs, a second dose may be given if first dose provided some relief and at least 2 hours have elapsed since the first dose (maximum daily dose: 7.5 mg)
Dosage adjustment in renal impairment: No adjustment necessary

Dosage adjustment in hepatic impairment: No adjustment necessary in mild to moderate hepatic impairment; use with caution in severe impairment

SUPPLIED:
Tablet, as base: 2.5 mg

DOSING (ADULTS): Oral: 1-2.5 mg at the onset of headache; it is recommended to use the lowest possible dose to minimize adverse effects. If headache returns or does not fully resolve, the dose may be repeated after 4 hours; do not exceed 5 mg in 24 hours.

Elderly: Not recommended for use in the elderly

Dosing in renal impairment:
Clcr: 18-39 mL/minute: Initial: 1 mg; do not exceed 2.5 mg in 24 hours
Clcr: <15 mL/minute: Do not use

Dosing in hepatic impairment: Contraindicated in patients with severe liver failure; maximum dose: 2.5 mg in 24 hours for patients with mild or moderate liver failure; recommended starting dose: 1 mg

SUPPLIED:
Tablet: 1 mg, 2.5 mg

Note: For orally-disintegrating tablets (Maxalt-MLT™): Patient should be instructed to place tablet on tongue and allow to dissolve. Dissolved tablet will be swallowed with saliva.

SUPPLIED:
Tablet, as benzoate (Maxalt®): 5 mg, 10 mg
Tablet, orally-disintegrating, as benzoate (Maxalt-MLT®): 5 mg, 10 mg.

The vascular 5-HT1 receptor subtype to which sumatriptan binds selectively, and through which it presumably exerts its antimigrainous effect, is present on cranial arteries in both dog and primate, on the human basilar artery, and in the vasculature of the isolated dura mater of humans. In these tissues, sumatriptan activates this receptor to cause vasoconstriction, an action in humans correlating with the relief of migraine and cluster headache. In the anesthetized dog, sumatriptan selectively reduces the carotid arterial blood flow with little or no effect on arterial blood pressure or total peripheral resistance. In the cat, sumatriptan selectively constricts the carotid arteriovenous anastomoses while having little effect on blood flow or resistance in cerebral or extracerebral tissues.

INDICATIONS AND USAGE
IMITREX Injection is indicated for 1) the acute treatment of migraine attacks with or without aura and 2) the acute treatment of cluster headache episodes.

IMITREX Injection is not for use in the management of hemiplegic or basilar migraine (see package insert for CONTRAINDICATIONS)

Drug UPDATES: ZECUITY ® (sumatriptan iontophoretic transdermal system)
Initial U.S. Approval: 1992
[Drug information  /  PDF]  
Dosing:  Click (+) next to Dosage and Administration section (drug info link)

INDICATIONS AND USAGE:  ZECUITY is a serotonin (5HT) 1b/1d receptor agonist (triptan) indicated for the acute treatment of migraine with or without aura in adults
Limitations of Use:
Use only after a clear diagnosis of migraine has been established
Not indicated for the prevention of migraine attacks

DOSING (ADULTS):
Oral: A single dose of 25 mg, 50 mg, or 100 mg (taken with fluids). If a satisfactory response has not been obtained at 2 hours, a second dose may be administered. Results from clinical trials show that initial doses of 50 mg and 100 mg are more effective than doses of 25 mg, and that 100 mg doses do not provide a greater effect than 50 mg and may have increased incidence of side effects. Although doses of up to 300 mg/day have been studied, the total daily dose should not exceed 200 mg. The safety of treating an average of >4 headaches in a 30-day period have not been established.

Intranasal: A single dose of 5 mg, 10 mg, or 20 mg administered in one nostril. A 10 mg dose may be achieved by administering a single 5 mg dose in each nostril. If headache returns, the dose may be repeated once after 2 hours, not to exceed a total daily dose of 40 mg. The safety of treating an average of >4 headaches in a 30-day period has not been established.

SubQ: 6 mg; a second injection may be administered at least 1 hour after the initial dose, but not more than 2 injections in a 24-hour period. If side effects are dose-limiting, lower doses may be used.

Dosage adjustment in renal impairment: Dosage adjustment not necessary

Dosage adjustment in hepatic impairment: Bioavailability of oral sumatriptan is increased with liver disease. If treatment is needed, do not exceed single doses of 50 mg. The nasal spray has not been studied in patients with hepatic impairment, however, because the spray does not undergo first-pass metabolism, levels would not be expected to alter. Use of all dosage forms is contraindicated with severe hepatic impairment.

Administration
Oral: Should be taken with fluids as soon as symptoms appear.
Injection solution: For SubQ administration; do not administer I.V.; may cause coronary vasospasm.

SUPPLIED:
Note: Expressed as sumatriptan base
Injection, solution, as succinate: 12 mg/mL (0.5 mL)
Intranasal spray: 5 mg (100 uL unit dose spray device); 20 mg (100 uL unit dose spray device)
Tablet, as succinate: 25 mg, 50 mg, 100 mg
Iontophoretic transdermal system: Delivers 6.5 mg of sumatriptan over 4 hours

Drug UPDATES:  ONZETRA ™ Xsail ™ ( sumatriptan nasal powder )
[Drug information  /  PDF]  
Package insert - Dosing:  Click (+) next to Dosage and Administration section (drug info link)

Initial U.S. Approval:  2016

Mechanism of Action:
Sumatriptan binds with high affinity to human cloned 5-HT1B/1D receptors. Sumatriptan presumably exerts its therapeutic effects in the treatment of migraine headache through agonist effects at the 5-HT1B/1D receptors on intracranial blood vessels and sensory nerves of the trigeminal system, which result in cranial vessel constriction and inhibition of pro-inflammatory neuropeptide release.

INDICATIONS AND USAGE:
ONZETRA Xsail is a serotonin 5-HT1B/1D receptor agonist (triptan) indicated for the acute treatment of migraine with or without aura in adults (1).

Limitations of Use:
Use only if a clear diagnosis of migraine headache has been established (1)
Not indicated for the prophylactic therapy of migraine attacks (1)
Not indicated for the treatment of cluster headache (1)

DOSAGE AND ADMINISTRATION:
Recommended dose: 22 mg, administered by use of one nosepiece (11 mg) in each nostril (2.1)
Maximum dose in a 24-hour period should not exceed two doses (44 mg) separated by at least 2 hours (2.1)

HOW SUPPLIED:
DOSAGE FORMS AND STRENGTHS
Capsule in disposable nosepiece: 11 mg sumatriptan as the succinate salt.
For use with the Xsail breath-powered delivery device only.

Current theories proposed to explain the etiology of migraine headache suggest that symptoms are due to local cranial vasodilatation and/or to the release of sensory neuropeptides (vasoactive intestinal peptide, substance P and calcitonin gene-related peptide) through nerve endings in the trigeminal system. The therapeutic activity of zolmitriptan for the treatment of migraine headache can most likely be attributed to the agonist effects at the 5-HT1B/1D receptors on intracranial blood vessels (including the arterio-venous anastomoses) and sensory nerves of the trigeminal system which result in cranial vessel constriction and inhibition of pro-inflammatory neuropeptide release.

INDICATIONS AND USAGE:
ZOMIG is indicated for the acute treatment of migraine with or without aura in adults.

ZOMIG is not intended for the prophylactic therapy of migraine or for use in the management of hemiplegic or basilar migraine (see package insert for CONTRAINDICATIONS). Safety and effectiveness of ZOMIG have not been established for cluster headache, which is present in an older, predominantly male population.

DOSING (ADULTS):
Migraine:
Tablet: Initial: </= 2.5 mg at the onset of migraine headache; may break 2.5 mg tablet in half.

Orally-disintegrating tablet: Initial: 2.5 mg at the onset of migraine headache.

Nasal spray: Initial: 1 spray (5 mg) at the onset of migraine headache.

Note: Use the lowest possible dose to minimize adverse events. If the headache returns, the dose may be repeated after 2 hours; do not exceed 10 mg within a 24-hour period. Controlled trials have not established the effectiveness of a second dose if the initial one was ineffective

Elderly: No dosage adjustment needed but elderly patients are more likely to have underlying cardiovascular disease and should have careful evaluation of cardiovascular system before prescribing.

Dosage adjustment in renal impairment: No dosage adjustment recommended. There is a 25% reduction in zolmitriptan's clearance in patients with severe renal impairment (Clcr 5-25 mL/minute)

Dosage adjustment in hepatic impairment: Administer with caution in patients with liver disease, generally using doses <2.5 mg. Patients with moderate-to-severe hepatic impairment may have decreased clearance of zolmitriptan, and significant elevation in blood pressure was observed in some patients.

Administration
Administer as soon as migraine headache starts.
Tablet: May be broken

Orally-disintegrating tablet: Must be taken whole; do not break, crush or chew; place on tongue and allow to dissolve; administration with liquid is not required

Nasal spray: Blow nose gently prior to use. After removing protective cap, instill device into nostril. Block opposite nostril; breathe in gently through nose while pressing plunger of spray device. One dose (5 mg) is equal to 1 spray in 1 nostril.

SUPPLIED:
Solution, nasal spray [single dose] (Zomig®): 5 mg/0.1 mL (0.1 mL).
Tablet (Zomig®): 2.5 mg, 5 mg.
Tablet, orally-disintegrating (Zomig-ZMT™): 2.5 mg, 5 mg.

Caffeine, also a cranial vasoconstrictor, is added to further enhance the vasoconstrictive effect without the necessity of increasing ergotamine dosage.

Many migraine patients experience excessive nausea and vomiting during attacks, making it impossible for them to retain any oral medication. In such cases, therefore, the only practical means of medication is through the rectal route where medication may reach the cranial vessels directly, evading the splanchnic vasculature and the liver.

INDICATIONS AND USAGE
CAFERGOT® (ergotamine tartrate and caffeine)
Indicated as therapy to abort or prevent vascular headache, e.g., migraine, migraine variants or so-called “histaminic cephalalgia”.

DOSING (ADULTS):
Oral: Two tablets at onset of attack; then 1 tablet every 30 minutes as needed; maximum: 6 tablets per attack; do not exceed 10 tablets/week.

Rectal: One suppository rectally at first sign of an attack; follow with second dose after 1 hour, if needed; maximum: 2 per attack; do not exceed 5/week.

SUPPLIED:
Suppository, rectal (Cafergot®): Ergotamine tartrate 2 mg and caffeine 100 mg (12s)
Tablet (Cafergot®, Wigraine®): Ergotamine tartrate 1 mg and caffeine 100 mg

The therapeutic activity of dihydroergotamine in migraine is generally attributed to the agonist effect at 5-HT1D receptors. Two current theories have been proposed to explain the efficacy of 5-HT1D receptor agonists in migraine. One theory suggests that activation of 5-HT1D receptors located on intracranial blood vessels, including those on arterio-venous anastomoses, leads to vasoconstriction, which correlates with the relief of migraine headache. The alternative hypothesis suggests that activation of 5-HT1D receptors on sensory nerve endings of the trigeminal system results in the inhibition of pro-inflammatory neuropeptide release.

In addition, dihydroergotamine possesses oxytocic properties.

INDICATIONS AND USAGE
Dihydroergotamine mesylate injection is indicated for the acute treatment of migraine headaches with or without aura and the acute treatment of cluster headache episodes.

DOSING (ADULTS):
I.M., SubQ: 1 mg at first sign of headache; repeat hourly to a maximum dose of 3 mg total; maximum dose: 6 mg/week

I.V.: 1 mg at first sign of headache; repeat hourly up to a maximum dose of 2 mg total; maximum dose: 6 mg/week

Intranasal: 1 spray (0.5 mg) of nasal spray should be administered into each nostril; if needed, repeat after 15 minutes, up to a total of 4 sprays. Note: Do not exceed 3 mg (6 sprays) in a 24-hour period and no more than 8 sprays in a week.

Elderly: Patients >65 years of age were not included in controlled clinical studies

Dosing adjustment in renal impairment: Contraindicated in severe renal impairment

Dosing adjustment in hepatic impairment: Dosage reductions are probably necessary but specific guidelines are not available; contraindicated in severe hepatic dysfunction

SUPPLIED:
Injection, solution, as mesylate (D.H.E. 45®): 1 mg/mL (1 mL) [contains ethanol 94%]
Solution, intranasal spray, as mesylate (Migranal®): 4 mg/mL [0.5 mg/spray] (1 mL) [contains caffeine 10 mg/mL]

*Based on a review of this drug (isometheptene mucate) by the National Academy of Sciences-National Research Council and/or other information, FDA has classified the other indication as "possibly" effective in the treatment of migraine headache. Final classification of the less-than-effective indication requires further investigation.

CLINICAL PHARMACOLOGY
Isometheptene Mucate, a sympathomimetic amine, acts by constricting dilated cranial and cerebral arterioles, thus reducing the stimuli that lead to vascular headaches. Dichloralphenazone, a mild sedative, reduces the patient's emotional reaction to the pain of both vascular and tension headaches. Acetaminophen raises the threshold to painful stimuli, thus exerting an analgesic effect against all types of headaches.

DOSAGE AND ADMINISTRATION
FOR RELIEF OF MIGRAINE HEADACHE: The usual adult dosage is two capsules at once, followed by one capsule every hour until relieved, up to 5 capsules within a twelve hour period.

FOR RELIEF OF TENSION HEADACHE: The usual adult dosage is one or two capsules every four hours up to 8 capsules a day.

SUPPLIED:
Each red capsule contains Isometheptene Mucate USP, 65 mg, Dichloralphenazone USP, 100 mg, and Acetaminophen USP, 325 mg.