THERAPEUTICS

Brands

• Zomig, Zomig MLT

Generic?

• Yes

Class

• Triptan

Commonly Prescribed for

(FDA approved in bold)

• Acute treatment of migraine with or without aura in adults

• Acute treatment of migraine with or without aura in adolescents (nasal spray)

• Cluster headache (nasal spray)

How the Drug Works

• Selective 5-HT1B/1D/1F receptor agonist. In addition to vasoconstriction on meningeal vessels, its antinociceptive effect is likely due to blocking the transmission of pain signals at trigeminal nerve terminals (preventing the release of inflammatory neuropeptides) and synapses of second-order neurons in trigeminal nucleus caudalis

How Long Until It Works

• 1 hour or less

If It Works

• Continue to take as needed. Patients taking acute treatment more than 2 days/week are at risk for medication-overuse headache, especially if they have migraine

If It Doesn't Work

• Treat early in the attack – triptans are less likely to work after the headache become severe, regardless of cutaneous allodynia, which is a marker of central sensitization

• For patients with partial response or reoccurrence, other rescue medications include NSAIDs (e.g., ketorolac, naproxen), antiemetics (e.g., prochlorperazine, metoclopramide), neuroleptics (e.g., haloperidol, chlorpromazine), or corticosteroids

• Change to another triptan or another administration route

Best Augmenting Combos for Partial Response or Treatment-Resistance

• NSAIDs or antiemetics/neuroleptics are often used to augment response

Tests

• None required

ADVERSE EFFECTS (AEs)

How the Drug Causes AEs

• Direct effect on systemic serotonin receptors (e.g., 5-HT1B agonism on vasoconstriction)

Notable AEs

• Paresthesias, dizziness, sensation of pressure (chest or jaw), palpitation

Life-Threatening or Dangerous AEs

• Serotonin syndrome. Rare cardiac events including acute myocardial infarction, cardiac arrhythmias, and coronary artery vasospasm have been reported with zolmitriptan

Weight Gain

• Unusual

Sedation

• Unusual

What to Do About AEs

• In most cases, only reassurance is needed. Lower dose, change to another triptan, or use an alternative headache treatment

Best Augmenting Agents to Reduce AEs

• Treatment of nausea with antiemetics is acceptable. Other AEs decrease with time