51 Drug Therapy for Migraines

and Other Headaches

LEARNING OBJECTIVES
After studying this chapter, you should be able to:
1 Understand the pathophysiology of migraine headaches.
2 Identify the major manifestations of tension headaches, cluster headaches, migraine
headaches, and menstrual migraine headaches.
3 Identify the prototype and describe the action, use, adverse eects, contraindications,
and nursing implications for nonsteroidal anti-inammatory drugs administered as
abortive therapy for migraines.
4 Describe the action, use, adverse eects, contraindications, and nursing implications
for acetaminophenaspirincaeine combinations administered as abortive therapy for
headaches.
5 Identify the prototypes and describe the action, use, adverse eects, contraindications,
and nursing implications for ergot alkaloids administered as abortive therapy.
6 Identify the prototypes and describe the action, adverse eects, contraindications, and
nursing implications for triptans administered as abortive therapy.
7 Identify the prototype and describe the action, use, adverse eects, contraindications,
and nursing implications for estrogen administered for menstrual migraines.
8 Identify the medications used for the prevention of migraine headaches.
9 Describe the action, use, adverse eects, contraindications, and nursing implications for
antiemetic drugs used in the treatment of migraine headache.
10 Implement the nursing process of care of patients of all ages who suer from migraine
headaches.

Clinical Application Case Study

Tanya Van Art, an 18-year-old young woman, has experienced headaches since she was
13 years old. She has been experiencing headaches with increased severity in the past year.
While at work this past week, she developed a severe headache with nausea and vomiting.
She was admitted to the emergency department. On admission, her blood pressure was
180/90 mm Hg and her pain was 10 on a 10-point scale. In the emergency department, she
received ketorolac tromethamine 30 mg intravenous (IV). The diagnosis was acute migraine
headache.

932
 CHAPTER 51 Drug Therapy for Migraines and Other Headaches 933

KEY TERMS
Abortive therapy: medications administered in the treatment of symptoms of migraine headache

Aura: subjective sensation that immediately precedes a migraine headache, consisting of a breeze, odor, or light

Cluster headache: recurrent, severe, unilateral orbitotemporal headache related to a histamine reaction

Menstrual migraine headache: migraine headache associated with a drop in circulating estrogen that occurs 2 to 3 days
prior to the onset of menses
Migraine headache: unilateral pain in the head that may or may not be accompanied by an aura; may be associated with
vertigo, nausea, vomiting, and photophobia
Preventive therapy: administration of medications to prevent the onset of migraine headaches

Tension headache: headache associated with nervous tension or anxiety, often related to chronic contraction of scalp
muscles
Vascular constriction: narrowing of the blood vessels

Introduction cluster headaches are characterized by hypothalamic activa-

This chapter discusses the various types of headaches, all of
which produce pain. However, the pain experienced by patients
is different with each type of headache. This chapter also consid-
ers the pharmacological treatment of each of these headaches.
Different types of headaches have different symptoms. Cluster
headaches are recurrent, severe, unilateral orbitotemporal head-
aches that are associated with histamine reactions. Tension head-
aches are the result of chronic contraction of the scalp muscles
and are associated with nervous tension or anxiety. Migraine
headaches are unilateral pain in the head that may or may not be
accompanied by an aura. An aura is a subjective sensation that
immediately precedes the migraine headache consisting a breeze,
odor, or light. Menstrual migraine headaches are associated with a
drop in circulating estrogen 2 to 3 days prior to the onset of menses.
Overview of Migraine Headaches
Migraine headaches are common disorders. Annually, they
affect approximately 20% of women and 8% of men. Migraines
demonstrate a familial pattern, and authorities believe that they
are inherited as autosomal dominant traits with incomplete
penetrance. Migraine headaches with an aura are more com-
mon with the genetic inheritance. During childhood, migraine
headaches are evenly distributed between boys and girls; how-
ever, in adulthood, migraines affect women three times more
often than men. Food that precipitate migraine effects include
aged cheeses, fermented foods, aspartame, monosodium gluta-
mate, and chocolate (Solomon & Jamieson, 2009).
Pathophysiology
Cluster Headaches
The pathophysiology of cluster headaches is not completely
understood. One theory, the major one, states that primary
tion with secondary activations of the trigeminal autonomic
reex. Another theory states that neurogenic inamma-
tion of the walls of the cavernous sinus obliterates venous
outow, injuring the transverse sympathetic bers of the
intracranial internal carotid artery and its branches (May,
2010).
Tension Headaches
The pathophysiology of tension headaches is multifacto-
rial. A wide variation exists in the experiences of people
who suffer from tension headaches, but the current theory
of chronic tension headache asserts that a person experi-
ences a sensitization of the dorsal horn neurons related to
increased nociceptive inputs from pericranial myofascial
tissues. Experts believe that this heightened sensitivity of
pain pathways in the central nervous system (CNS) plays
a critical role in the pathogenesis. With a decreased pain
threshold, the person misinterprets incoming signals as pain.
Decreased pain, thermal, and electrical thresholds reported
in patients with chronic tension headaches probably repre-
sent a central misinterpretation of incoming signals (Taylor,
2008).
Migraine Headaches
Authorities have proposed two theories related to the patho-
physiology of migraine headaches. First, at the onset of a
migraine, the trigeminal nerve is stimulated, resulting in the
release of neuropeptides. This leads to painful neurogenic
inammation in the meningeal vasculature characterized
by plasma protein extravasation, vasodilation, and mast cell
degranulation. Second, neurogenic vasodilation of the menin-
geal blood vessels occurs, producing inammation. The acti-
vations of trigeminal sensory bers cause neurogenic dural
vasodilation mediated by the calcitonin gene-related pep-
tide. The calcitonin gene-related peptide is elevated during a
migraine (Porth & Matn, 2009).
934 SECTION 10 Drugs Aecting the Autonomic and Central Nervous System
Clinical Manifestations
Cluster Headaches
Cluster headaches usually occur up to eight times per day, with
severe orbital, supraorbital, or temporal pain accompanied by
autonomic symptoms such as ptosis, miosis, lacrimation, con-
junctival injection, rhinorrhea, and nasal congestion (May,
2010).
Tension Headaches
Characteristic signs and symptoms of tension headaches include
bilateral, nonthrobbing head pain of mild to moderate inten-
sity. Patients may describe pressure, head fullness, or a band-like
sensation around the head, or they may report a feeling like a
heavy weight is on their head or shoulders (Taylor, 2008).
Migraine Headaches
Migraine headaches with an aura have four phases: prodrome,
aura, headache, and recovery. The prodrome phase occurs hours
or days before the onset of a migraine headache. Symptoms
include depression, irritability, feeling cold, cravings, loss of
appetite, alterations in activity, polyuria, diarrhea, and consti-
pation. The aura phase, which occurs only in some patients,
involves an aura lasting 1 hour with focal neurologic symp-
toms, visual disturbances, or vision in only half of the visual
eld. The headache phase is characterized by vasodilation and
a decline in serotonin levels. A throbbing headache becomes
more intense, lasting for several hours. The headache can
become incapacitating, with photophobia, nausea, and vomit-
ing. The recovery phase involves slow subsiding of the pain.
There may be muscle contractions in the neck and scalp, with
localized tenderness, tiredness, and alterations in mood. The
patient may sleep for hours after the recovery phase (Smeltzer,
Bare, Hinkle, & Cheever, 2010).
Chronic migraine headaches may be a problem. The
chronic migraine is diagnosed by the presence of a migraine
headache without an aura for 8 days or more per month for
TABLE 51.1
Drugs Administered for the Treatment of Migraine Headache
Drug Class Prototype
Nonsteroidal Ibuprofen
anti-inammatory drugs (Motrin, Advil)*
Analgesic Aspirinacetaminophencaffeine
(several products)
Ergot alkaloids Ergotamine tartrate
Triptans Sumatriptan
Estrogen Estradiol
*
See Chap. 14 for more information. Naproxen is commonly prescribed for the treatment of migraine headaches.
3 months. The headache is unilateral, pulsating, with moder-
ate to severe intensity, and aggravated by activity (Garza &
Schwedt, 2011).
Drug Therapy
Cluster Headaches
Treatment of cluster headaches involves subcutaneous sumatriptan
and oxygen. It is important to note that although oxygen may
be effective in some patients, repeated or frequent use in a short
period of time should be avoided. Evidence has shown that the
frequency of cluster headaches may increase in some patients with
overuse of oxygen. Ergot derivatives, lidocaine, and octreotide are
also effective in the treatment of acute cluster headaches.
Tension Headaches
Acute therapy for tension headaches entails the use of non-
pharmacological methods such as rest, relaxation techniques, or
stress-reduction strategies as well as medication. Pharmacological
treatment of tension headaches includes acetaminophen, aspi-
rin, and nonsteroidal anti-inammatory agents (see Chap. 14).
Migraine Headaches
There are two specic courses of treatment for migraine head-
aches: abortive and preventive therapy. Abortive therapy is
the administration of medications to treat the symptoms of
migraine headache. Preventive therapy is the administration
of medications to prevent the development of a migraine head-
ache. Medications used in the treatment of migraine headaches
are listed in Table 51.1.
The abortive agents administered for the treatment of migraine
headaches include nonsteroidal anti-inammatory agents, aspi-
rinacetaminophen with caffeine medication, the ergot alka-
loids, and the triptans. According to the American Academy of
Neurology, the pharmacological and nonpharmacological treat-
ment of long-term migraine is to reduce the frequency, severity,
Other Drugs in the Class
Naproxen*
Naproxen sodium (Aleve)*
Ketorolac tromethamine (Toradol)
Dihydroergotamine
Almotriptan (Axert)
Eletriptan (Relpax)
Frovatriptan (Frova)
Naratriptan (Amerge)
Rizatriptan (Maxalt)
Zolmitriptan (Zomig)
 CHAPTER 51 Drug Therapy for Migraines and Other Headaches 935

and disability. The initial pharmacotherapy for acute treatment
of migraine is the administration of triptans (serotonin receptor
[5-HT1B and 5-HT1D] agonists). Patients who experience nausea
and vomiting may receive intranasal or subcutaneous sumatriptan.
Women who experience menstrual migraines take estrogen
preparations. People who suffer from migraines take preventive
medications, which are discussed later in this chapter.
Clinical Application 51-1
What does the nurse teach Ms. Van Art about the
pathophysiology of acute migraine?
Thus, naproxen or naproxen sodium (Aleve) is the
prototype described in detail in this chapter.
Pharmacokinetics
There are two types of naproxen: naproxen and naproxen sodium.
Naproxen has an onset of action of 1 hour, a peak of action of
2 to 4 hours, and duration of action of 7 hours or less. Naproxen
sodium has an onset of action of 1 hour, a peak of action of 1 to
2 hours, and the same duration of action as naproxen. Metabolism
of both agents occurs in the liver, and they have a half-life of
12 to 15 hours. Excretion is in the urine. Naproxen and naproxen
sodium cross the placental barrier and enter the breast milk.

NCLEX Success Action

Naproxen is a nonselective inhibitor of cyclo-oxygenase result-
1. A patient is admitted to the emergency department with a
ing in the inhibition of prostaglandin synthesis of COX-1 and
severe headache with nausea and vomiting. She receives
COX-2. Naproxen sodium improves the solubility of naproxen
a diagnosis of an acute migraine headache. Which of the
through faster absorption and rapid onset of action (Suthisisang,
following medications assists in decreasing the nausea
Poolsup, Suksomboon, Lertpipopmetha, & Tepwitukgid, 2010).
and vomiting related to the acute migraine episode?
A. intravenous ketorolac
B. intranasal sumatriptan Use
C. inhaled albuterol Prescribers order naproxen sodium to reduce the pain resulting
D. oral diclofenac from an acute migraine headache. Table 51.2 presents dosage
information for naproxen and related drugs.
2. Which of the following medications are administered
for preventive therapy in the treatment of migraine? Use in Older Adults
A. beta blockers Older people should not take more than 200 mg of naproxen
B. nonsteroidal anti-inammatory agents sodium every 12 hours.
C. ergot alkaloids
D. analgesics Use in Patients With Renal Impairment
Caution is necessary with the administration of naproxen
sodium in patients with renal disease because the renal system
excretes the drug.
Nonsteroidal Anti-Inammatory Agents
Use in Patients With Hepatic Impairment
Ibuprofen is the prototype of the nonsteroidal anti-inamma- Caution is warranted with the administration of naproxen
tory agents (see Chap. 14). However, naproxen sodium is more sodium in patients with hepatic impairment because the site of
commonly prescribed for the treatment of migraine headaches. metabolism is the liver.

TABLE 51.2
DRUGS AT A GLANCE: Nonsteroidal Anti-Inammatory Drugs*
Drug Pregnancy Category Routes and Dosages

Adults Children

Naproxen C 375500 mg PO 2 times per day 10 mg/kg PO in two divided

Naproxen sodium
(Aleve)
Ketorolac tromethamine
(Acular LS, Acular PF)
*
Drugs used in headache treatment.
doses
C 275550 mg PO 2 times per day Safety has not been established
May increase to 1.65 g/d for a
limited period
C (second and third 30 mg IV every 6 h to a 216 y: 0.5 mg/kg IV up to a
trimester) maximum of 120 mg/d maximum of 15 mg
D (third trimester)
936 SECTION 10 Drugs Aecting the Autonomic and Central Nervous System
Adverse Eects
The most severe adverse effects of naproxen sodium include bron-
chospasm and anaphylaxis. Gastrointestinal (GI) adverse effects
include GI bleeding, nausea, dyspepsia, and GI pain. U.S. Food
and Drug Administration (FDA) has issued a BLACK BOX
WARNING stating that naproxen sodium may put patients
at increased risk for cardiovascular events and GI bleeding.
Contraindications
Contraindications to naproxen or naproxen sodium include a
known allergy to aspirin or other nonsteroidal anti-inammatory
drugs as well as pregnancy and lactation. It is important to admin-
ister the medication cautiously to patients with asthma, cardio-
vascular dysfunction, hypertension, GI bleeding, and peptic ulcer.
Nursing Implications
Preventing Interactions
The administration of naproxen sodium with lithium results in
increased lithium levels and the risk of lithium toxicity.
Assessing for Therapeutic Eects
Following the administration of naproxen or naproxen sodium,
the patient should exhibit diminished pain. The nurse assesses
the patients pain level using a pain scale.
Assessing for Adverse Eects
The nurse assesses the patient for GI upset, dyspepsia, or bleed-
ing. He or she also assesses pulmonary function and lung sounds
for bronchospasm or anaphylactic reaction.
Patient Teaching
Box 51.1 identies patient teaching guidelines for naproxen
sodium.
Other Drugs in the Class
Migraine sufferers often seek treatment in the emergency
department when the more commonly used abortive thera-
pies are ineffective. In the emergency setting, ketorolac
tromethamine is the most frequently administered intravenous
BOX 51.1 Patient Teaching Guidelines
for Naproxen Sodium
testinal
Take the medication with meals to prevent gastroin-
upset.
Take medication as prescribed.
Do not cut, crush, or chew tablets.
occurs.
Do not operate machinery if dizziness or drowsiness
changes,
Report sore throat, fever, rash, itching, edema, visual
and black, tarry stools to your health care
provider.
medication for migraine sufferers who have not responded to
oral abortive therapy.
Clinical Application 51-2
What is the rationale for administering ketorolac
to Ms. Van Art?
Acetaminophen, Aspirin, and Caeine
The combination of acetaminophen, aspirin, and
caeine may be effective for the treatment of headaches. In the
United States, brand names include Anacin Advanced Headache
Formula, Excedrin Extra Strength, Excedrin Migraine, Goodys
Extra Strength, and Vanquish Extra Strength Pain Reliever.
Pharmacokinetics
To understand the pharmacokinetics of acetaminophen,
aspirin, and caffeine, it is important to review each medica-
tion individually. Acetaminophen reaches a peak of action in
0.5 to 2 hours and possesses a 1- to 3-hour half-life. It crosses
the placental barrier and enter the breast milk. The drug is
metabolized in the liver and excreted in the urine. Aspirin
has an onset of action of 5 to 30 minutes, reaches a peak of
action in 15 to 120 minutes, and has a duration of action of
3 to 6 hours. The half-life of aspirin is 15 minutes to 12 hours.
The drug is absorbed in the stomach and metabolized in the
liver. Caffeine has an onset of action of 15 minutes and reaches
a peak of action in 15 to 45 minutes. It readily crosses the
placental barrier and enters breast milk. Like acetaminophen
and aspirin, metabolism of caffeine takes place in the liver and
elimination occurs in the kidneys.
Action
Acetaminophen may act as an analgesic, and its mechanism of
action is unknown. Aspirin has the ability to inhibit the syn-
thesis of prostaglandins, which are a mediator of inammation.
Caffeine increases calcium permeability in the sarcoplasmic
reticulum to promote the accumulation of cyclic adenosine
monophosphate (cAMP) and block the adenosine receptors,
stimulating the CNS, cardiac activity, gastric acid secretion,
and diuresis. It causes constriction of the blood vessels, which
is known as vascular constriction. Migraine headaches result
from the vasodilation of blood vessels. In addition, caffeine
increases the effectiveness of acetaminophen and aspirin by
approximately 40%.
Use
Acetaminophenaspirincaffeine products are administered to
reduce pain related to migraine or tension headache. Table 51.3
presents oral dosage of information for these combination
products.
 CHAPTER 51 Drug Therapy for Migraines and Other Headaches 937

TABLE 51.3
DRUGS AT A GLANCE: AspirinAcetaminophenCaeine Combinations
Drug Pregnancy Category Routes and Dosages

Adults Children

Acetaminophen/Aspirin/Caeine B 500 mg PO Adult dosing is

(Anacin Advanced Headache Formula, Excedrin D 500 mg PO administered to
Extra Strength, Excedrin Migraine, Goodys Extra C 130 mg PO children >12 years
Strength, and Vanquish Extra Strength Pain
Reliever)

Use in Children
Children older than 12 years of age may receive the adult dose
of the combination agent.
Use in Patients With Hepatic Impairment
People with hepatic impairment should not receive this com-
bination agent on an ongoing basis. They may not metabolize
acetaminophen in this combined medication effectively, lead-
ing to hepatotoxicity.
Adverse Eects
Each component of the combination medication has adverse
effects, which will be addressed individually. Acetaminophen
may result in headache, chest pain, dyspnea, myocardial dam-
age with doses of 5 to 8 g/day, and hepatic impairment. Aspirin
may lead to GI effects such as dyspepsia, heartburn, and epigastric
discomfort as well as hematologic effects such as occult blood loss
and hemostatic defects. Aspirin toxicity involves respiratory alka-
losis, tachypnea, hemorrhage, excitement, confusion, seizures,
tetany, cardiovascular collapse, and metabolic acidosis. Caffeine
may result in excitement, insomnia, restlessness, tremors, head-
aches, and lightheadedness, as well as cardiovascular effects such
as tachycardia, hypertension, extrasystole, and palpitations.
Contraindications
Contraindications to acetaminophen include a known allergy
to the drug. Caution is necessary in impaired hepatic function,
chronic alcoholism, pregnancy, and lactation. Contraindications
to aspirin includes a known hypersensitivity to the drug or other
anti-inammatory agents. Vigilance is warranted with renal
impairment. Contraindications to caffeine include duodenal
ulcers, diabetes, and lactation. Caution is essential in pregnancy,
renal and hepatic impairment, and cardiovascular disease.
Nursing Implications
People most commonly take the acetaminophenaspirincaf-
feine in the home setting. It is important to be familiar with
all aspects of each medication to maintain medication safety.
Preventing Interactions
Several drugdrug interactions may occur with acetami-
nophenaspirincaffeine combinations. Box 51.2 names the
specic medications that increase or decrease the effects of
each of the medications in the combined drug. Other drug
drug interactions include the following:
Oral anticoagulants combined with acetaminophen
increase hypothrombinemic effects.
Aspirin combined with sulfonylureas and insulin results
in greater glucose-lowering effects.
Valproic acid combined with aspirin puts patients at risk
for seizure activity secondary to protein receptor site
displacement.
Spironolactone or furosemide combined with aspirin
leads to decreased diuretic effects.
Theophylline or clozapine combined with caffeine
increases the serum levels of theophylline or clozapine.
The concomitant administration of caffeine and guarana, ma
huang, and ephedra with caffeine is not recommended.
BOX 51.2 Drug Interactions:
Acetaminophen, Aspirin,
and Caeine
Drugs That Increase the Eects of Acetaminophen
rifampin,
Alcohol, barbiturates, carbamazepine, hydantoins,
sulnpyrazone
Increase the risk of hepatotoxicity
Drugs That Increase the Eects of Aspirin
anti-in
Alcohol, anticoagulants, nonsteroidal
ammatory agents
Increase the bleeding risk
Carbonic anhydrase inhibitors
Increase the risk of salicylate toxicity
Drugs That Increase the Eects of Caeine
cipro
Cimetidine, hormonal contraceptive, disulram,
oxacin, mexiletine
Increase the central nervous system eects
Drugs That Decrease the Eects of Aspirin
Acetazolamide, methazolamide, antacids, alkalinizers
Decrease the salicylate levels
Drugs That Decrease the Eects of Caeine
Nicotine
Produces vasoconstriction
938 SECTION 10 Drugs Aecting the Autonomic and Central Nervous System

Assessing for Therapeutic Eects Ergot Alkaloids

Following the administration of the acetaminophenaspirin
caffeine combination, the patient should exhibit diminished The ergotamine preparations are administered for abortive
pain. The nurse assesses for pain using a pain scale. therapy for migraine headaches. The prototype medication is
ergotamine tartrate (Ergomar). It is an alpha-adrenergic
Assessing for Adverse Eects antagonist.
The nurse assesses for hepatotoxicity, allergic reaction, uid
and electrolyte imbalance, hypoglycemia, agitation, and car-
diovascular effects. Pharmacokinetics
Ergotamine has a variable rate of absorption and onset of
Patient Teaching action. The peak of action is 0.5 to 3 hours. The half-life of
ergotamine is 2 hours, but the effects of the medication can
Box 51.3 identies patient teaching guidelines for acetami- continue for 24 hours. The medication is metabolized by the
nophenaspirincaffeine combinations. cytochrome P450 enzyme CYP3A4 in the liver and excreted
in the bile. Ergotamine is excreted in the breast milk and may
cause vomiting, diarrhea, and changes in heart rate and blood
NCLEX Success pressure in the nursing infant. It has caused fetal growth retar-
3. A patient is taking naproxen sodium for headache and dation in animal studies.
lithium for manic depression. Which of the following
effects occurs when the naproxen is administered in
Action
combination with lithium?
A. increased risk of lithium toxicity Ergotamine produces stimulation of the cranial and peripheral
B. increase in creatinine clearance vascular smooth muscles while depressing the effects of the
C. hepatotoxicity central vasomotor centers. It is a partial agonist and antago-
D. potential GI effects nist that acts against tryptaminergic, dopaminergic, and alpha-
adrenergic receptors to constrict the cranial and peripheral
4. A teenage girl is suffering from migraine headaches. blood vessels.
Her health care provider orders a combination of
acetaminophen, aspirin, and caffeine. Prior to the
administration of the medication, it is necessary to
Use
assess for which of the following? Prescribers order ergotamine individually or in combination
A. anxiety and depression with caffeine to prevent or stop migraine, cluster, or vascular
B. history of smoking headaches. Children as well as people with renal or hepatic
C. family history of migraines impairment should not take ergotamine. Table 51.4 gives dos-
D. antacid use age information for the ergot alkaloids.

Use in Older Adults

It is necessary to administer ergotamine cautiously in older
adults because of the drugs vasoconstrictive properties and car-
BOX 51.3 Patient Teaching Guidelines diovascular adverse effects.
for AcetaminophenAspirin
Caeine Combinations
Adverse Eects
ophenaspirinca
Never exceed the recommended dosage of acetamin-
eine combinations. The cardiovascular adverse effects of ergotamine include
forms of medications that contain and
Avoid the use of over-the-counter prescription
acetaminophen.
absence of pulse, bradycardia, cardiac valvular brosis, cya-
nosis, edema, heart rhythm changes, gangrene, hypertension,
Keep the medication out of the reach of children. ischemia, precordial distress, chest pain, tachycardia, and
Take the drug with food or after meals if possible. vasospasm. Musculoskeletal adverse effects include muscle
Do not stop caeine abruptly. pain, numbness, paresthesia, and weakness. Other side effects
Do not consume foods high in caeine. may include vertigo, nausea, vomiting, itching, pulmonary
provider:
Report the following conditions to your health care brosis, and genitourinary retroperitoneal brosis.

Any signs and symptoms of bleeding Contraindications

nal
Ringing in the ears, dizziness, confusion, abdomi-
pain, dyspnea, nausea, and vomiting
Abnormal heart rate and palpitations.
Contraindications of ergotamine include a known hypersensitiv-
ity reaction to the drug or its components. Additional contrain-
dications are the existence of peripheral vascular disease, hepatic
 CHAPTER 51 Drug Therapy for Migraines and Other Headaches 939

TABLE 51.4
DRUGS AT A GLANCE: Ergot Alkaloids
Drug Pregnancy Category Routes and Dosages

Adults Children

Ergotamine X 12 mg sublingual followed by 12 mg every 30 min Safety and efcacy have

tartrate until headache abates or until max dosage of not been established
(Ergomar) 6 mg/24 h or 10 mg/wk
Dihydroergotamine X 1 mg may be repeated at 1 h intervals to a total of 3 mg Safety and efcacy have
mesylate IM or 2 mg IV or Sub-Q (max dosage: 6 mg/wk) not been established
1 spray (0.5 mg) in each nostril, may repeat with addi-
tional spray in 15 min if no relief (max of 4 sprays/
attack); wait 68 h before treating another attack
(max of sprays 8 sprays/24 h, 24 sprays/wk)

and renal disease, coronary artery disease, hypertension, and sepsis.
The FDA has issued a BLACK BOX WARNING stating that
ergotamine is contraindicated with potent inhibitors of CYP3A4
medications. These medications include the protease inhibitors,
azole antifungals, and some macrolide antibiotics. Concomitant
use of these medications results in ergot toxicity. Pregnancy and
lactation are also contraindications to the use of ergotamine.
Nursing Implications
Preventing Interactions
Many medications and foods interact with ergotamine, increas-
ing its effect (Boxes 51.4 and 51.5).
Administering the Medication
Administration of ergotamine is sublingual, and the tablet
should be dissolved under the tongue. It is important that
tablets not be crushed, chewed, or swallowed whole. Patients
should not drink, eat, or smoke while the medication is in place.
Assessing for Therapeutic Eects
The nurse assesses for a decrease in headache pain.
Assessing for Adverse Eects
Following administration of ergotamine, the nurse assesses for
cardiovascular adverse effects. Measurement of the pulse and
blood pressure is essential. The nurse also assesses for vertigo,
muscle pain, numbness, paresthesia, and weakness, as well as
for signs and symptoms of a hypersensitivity reaction to ergot-
amine. It is important to assess the patients uid and electro-
lyte status if the patient is suffering from nausea and vomiting.
In addition, the nurse assesses the patients urinary elimination
due to the adverse effect of retroperitoneal brosis in which the
patient develops an obstruction of the ureters.

Patient Teaching
Box 51.6 identies patient teaching guidelines for ergotamine.
BOX 51.4 Drug Interactions:
Ergotamine
Other Drugs in the Class
Drugs That Increase the Eect of Ergotamine
Dihydroergotamine mesylate reduces the rate of serotonin-
Beta-adrenergic blockers, sympathomimetics
induced platelet aggregation and has a weaker vasoconstrictive
Have additive vasoconstrictive eects
action than ergotamine. It has a greater adrenergic blocking
Erythromycin, troleandomycin
activity to relieve migraine headaches.
Increase the risk of peripheral vasospasm
Rizatriptan, sumatriptan, zolmitriptan
Increase the risk of coronary ischemia
BOX 51.5 Herb and Dietary
amine,
Azole antifungals, nefazodone, uoxetine, uvox-
amprenavir, delavirdine, efavirenz, indinavir,
Interactions: Ergotamine
nelnavir, ritonavir, saquinavir Foods That Increase the Eect of Ergotamine
Inhibit ergotamine metabolism and increase toxicity
Sibutramine, dexfenuramine, nefazodone,
Cola
uvoxamine Coee
Increase the risk of muscle rigidity also known as Tea
serotonin rigidity Grapefruit juice
940 SECTION 10 Drugs Aecting the Autonomic and Central Nervous System
BOX 51.6 Patient Teaching Guidelines
for Ergotamine
the
Take ergotamine or ergot alkaloids at the onset of
migraine headache.
more frequently
Notify the prescriber if the migraine attacks occur
or are not relieved.
medication.
Rest in a dark room for 2 to 3 hours after taking the
Provide information on adverse eects and notify the
prescriber if muscle pain, weakness of extremities,
changes in heart rate, nausea, or vomiting develops.
Never crush, swallow, or chew tablets.
prescriber.
Do not increase dose unless indicated by the
NCLEX Success
5. A patient with migraine headaches receives a prescrip-
tion for an ergot alkaloid as abortive therapy. Which
of the following is a priority intervention for patient
education?
A. Notify the prescriber if an aura precedes the migraine
headache.
B. Administer the medication with food.
C. Seek emergency help if cardiac changes occur.
D. Administer the medication with caffeinated bever-
ages.
6. A 32-year-old woman has been taking ergotamine
tartrate as abortive therapy for migraine headache for
many years. For which of the following adverse effects
does the nurse assess?
A. hypotension
B. muscle weakness
C. hypoventilation
D. valvular brosis
Triptans
Triptans are serotonin 5-HT1B and 5-HT1D agonists that affect the
pathophysiologic mechanism of migraine or cluster headaches,
thus relieving the associated symptoms. The advantage of the
administration of triptans over the ergot alkaloids is that these
medications can be easily taken by patients during their daily
lives. The prototype triptan is sumatriptan (Imitrex).
Pharmacokinetics
The oral preparation of sumatriptan has an onset of action of
60 to 90 minutes and a peak of action of 2 to 4 hours. The
onset of action of intranasal sumatriptan is rapid, with a peak
of action of 90 minutes. The onset of action of subcutaneous
sumatriptan varies, with a peak of action of 5 to 20 minutes.
Sumatriptan is widely distributed and is 10% to 20% protein
bound. Its therapeutic half-life is 115 minutes. Metabolism
occurs in the liver. Excretion is in the urine, with excretion
of the oral preparation in the feces. Sumatriptan crosses the
placenta and enters the breast milk.
Action
Sumatriptan binds to the serotonin receptors 5-HT1D, produc-
ing vascular constriction of the cranial blood vessels and reliev-
ing the pain of a migraine headache. It also relieves the nausea,
vomiting, photophobia, and phonophobia that accompany the
migraine headache.
Use
Health care providers use sumatriptan to treat acute migraine
headache pain with or without an aura. They also use it to treat
cluster headaches. Older adults should not take sumatriptan
and other triptans. Table 51.5 gives dosage information for the
triptans.
Use in Patients With Renal Impairment
Caution is necessary when administering sumatriptan to
patients with impaired renal function because elimination
takes place in the renal system.
Use in Patients With Hepatic Impairment
Caution is also warranted when administering sumatriptan to
patients with impaired hepatic function because metabolism
takes place in the liver.
Adverse Eects
CNS adverse effects of all sumatriptan preparations are dizzi-
ness, vertigo, headache, anxiety, malaise, myalgia, and fatigue.
Cardiovascular adverse effects include alterations in blood pres-
sure and chest pain as well as the most severe cardiovascular
adverse effect, shock. The nasal administration of sumatriptan
produces nausea, nasal and throat irritation, and a bad taste in
the mouth. The injectable form of the drug may cause injection
site discomfort.
Contraindications
Contraindications include a history of hypersensitivity reac-
tions to the drug. Other contraindications are existing cerebro-
vascular or peripheral vascular syndromes.
Nursing Implications
Preventing Interactions
QSEN Safety Alert
It is important to ask the patient about recent
administration ergot alkaloids. The ergot alkaloids
should not be given within 24 hours of the adminis-
tration of triptans.
 CHAPTER 51 Drug Therapy for Migraines and Other Headaches 941

TABLE 51.5
DRUGS AT A GLANCE: Triptans
Pregnancy
Drug Category Routes and Dosages

Adults Children

Sumatriptan C 25, 50, or 100 mg PO additional doses may be Safety and efcacy have not
(Imitrex) repeated in 2 h or more (max dosage 200 mg/d) been established
6 mg Sub-Q may be repeated in 1 h; (max dosage
12 mg/24 h)
5, 10, or 20 mg intranasal into one nostril or 10 mg
divided doses of 5 mg one in each nostril, may be
repeated after 2 h (max dosage 40 mg/24 h)
Almotriptan C 6.2512.5 mg PO repeat after 2 h if necessary Safety and efcacy have not
(Axert) (max, 2 doses/24 h) been established
Eletriptan C 2040 mg PO as a single dose, repeat after 2 h Safety and efcacy have not
(Relpax) if necessary (max dose, 80 mg/d) been established
Frovatriptan C 2.5 mg PO; repeat after 2 h if necessary Safety and efcacy have not
(Frova) (max dose, 7.5 mg) been established
Naratriptan C 12.5 mg PO as a single dose; repeat in 4 h if Safety and efcacy have not
(Amerge) necessary (max dose, 5 mg/d) been established
Rizatriptan C 510 mg PO as a single dose; repeat after 2 h if Safety and efcacy have not
(Maxalt) necessary (max dose, 30 mg/d) been established
Zolmitriptan C 1.252.5 mg PO as a single dose; may repeat after Safety and efcacy have not
(Zomig) 2 h if necessary (max dose, 10 mg/d) been established
0.5, 1, 2.5, or 5 mg intranasal by unit-dose spray
device (max dose, 10 mg/d)
Orally disintegrating tablets (Zomig-ZMT) 2.5
5 mg as a single dose; may repeat after 2 h if
necessary (max dose, 10 mg/d)
Sumatriptan C 1 tablet (sumatriptan 85 mg and naproxen 500 mg) Safety and efcacy have not
and naproxen PO; if migraine is not relieved in 2 h, a second been established
(Treximet) dose may be administered
(max dose, 2 tablets/24 h)

The combination of ergot-containing drugs and the triptans
results in cardiac ischemia. Also, administration of monoam-
ine oxidase (MAO) inhibitors leads to increased serum levels
of sumatriptan and sumatriptan toxicity. Two weeks after an
MAO inhibitor has been discontinued, it is permissible to give
sumatriptan in combination with the MAO inhibitor. In addi-
tion, administration of the herb St. Johns wort with triptans
results in triptan toxicity.
Administering the Medication
It is important to administer sumatriptan at the onset of migraine
symptoms. Administration of a second dose of the oral prepara-
tion when symptoms return is acceptable but not earlier than
2 hours after the rst tablet. Dosages should not exceed 100 mg
in a single dose or 200 mg/d. It is necessary to administer the
oral preparation with uids and the intranasal preparation as a
single dose of one spray in each nostril. With the subcutane-
ous preparation, administration just below the skin as soon as
symptoms develop is best. If relief does not occur or if symptoms
reappear, a second injection may follow 1 hour or longer after
the rst one. A person may have two injections in 24 hours.
With the administration of all sumatriptan preparations, it is
necessary to monitor the blood pressure for hypertension.
Assessing Therapeutic Eects
The nurse assesses for diminished pain and ultimate relief of
migraine headaches.
Assessing for Adverse Eects
The nurse assesses for increased blood pressure, as well as chest
pain, shock, dizziness, and vertigo. With subcutaneous admin-
istration, the nurse also assesses for irritation at the injection
site.
Patient Teaching
Box 51.7 identies patient teaching guidelines for sumatriptan.
942 SECTION 10 Drugs Aecting the Autonomic and Central Nervous System
BOX 51.7 Patient Teaching Guidelines
for Sumatriptan
cutaneous
Provide instruction about the administration of sub-
sumatriptan or use of the autoinjector.
24
Do not administer more than two injections in
hours.
noted.just below the skin as soon as symptoms are
Inject
needles.
Properly dispose of the autoinjector, syringes, and
necessary
Administer nasal spray as a single dose; repeat if
in 2 hours.
pregnant.
Do not administer the medication if you are
sumatriptan.
Do not operate machinery after the administration of
Report symptoms of hypersensitivity such as heat,
ushing, tiredness, and feeling sick to your health
care provider.
Other Drugs in the Class
Almotriptan (Axert) is similar in action to other triptans; how-
ever, it can be administered with MAO inhibitors. After oral
administration, it has a variable onset of action and a peak of
action of 1 to 3 hours. Prior to administering almotriptan, it is
necessary to determine whether the patient has received any
ergot alkaloids in the past 24 hours.
Eletriptan (Relpax) has a rapid onset of action with a 1.5
to 2 hour peak of action. It is administered orally in 20- or
40-mg doses. It is important to ensure the patient has not taken
an ergot-containing compound within 24 hours and to control
the environment for light and sound. The drug is usually well
tolerated and causes no major harm; however, any elevation
in blood pressure or chest pain requires discontinuation of the
medication.
Frovatriptan (Frova) has a variable onset of action and
reaches the peak of action in 2 to 4 hours. It interacts unfa-
vorably with selective serotonin reuptake inhibitors such as
uoxetine, uvoxamine, paroxetine, and sertraline, produc-
ing weakness, hyperreexia, and diminished CNS effects
such as alertness. Frovatriptan may lead to serotonin syn-
drome, and is a potentially life-threatening reaction that
may occur when two drugs that affect serotonin levels in the
body are taken concurrently. Other symptoms of serotonin
syndrome include restlessness, hallucinations, fever, loss
of consciousness, tachycardia, and a rapid change in blood
pressure.
Naratriptan (Amerge) has a slow onset of action. Contraindi-
cations include a creatinine clearance less than 15 mL/min
or severe hepatic impairment. Women of childbearing age
should use barrier contraceptives due to the risk of serious birth
defects.
Rizatriptan (Maxalt) is an oral preparation that can be swal-
lowed or administered in a melt-away (orally disintegrating)
formulation. It is effective in the treatment of acute migraine.
Studies have shown that the 10-mg dosage is more effective
than the 5-mg dose. The most common adverse effects are diz-
ziness, fatigue, nausea, and somnolence.
Zolmitriptan (Zomig) is a triptan that may be administered
orally or intranasally. The onset of action of the oral drug is
variable, whereas that of the intranasal preparation is 15 min-
utes. Two large studies have found that zolmitriptan is effective
for acute migraine therapy, with an optimal starting dose of
2.5 mg. The most commonly reported adverse effects were diz-
ziness, nausea, somnolence, paresthesia, fatigue, and tightness
of the throat or chest.
Sumatriptannaproxen sodium (Treximet) is a combination
drug that is administered orally. Patients should not divide,
chew, or crush the tablets. This combination is effective in
treating acute migraine and decreasing photophobia. The FDA
has issued two BLACK BOX WARNINGS : (1) cardiovas-
cular risk from sumatriptan, with an increased risk of adverse
thrombotic events, including myocardial infarction and stroke,
and (2) GI risk due to naproxen sodium, with an increased
risk of GI irritation, inammation, ulceration, bleeding, and
perforation.
NCLEX Success
7. A 50-year-old woman has a subarachnoid bleed. She
has received treatment for migraine headaches in the
past. Which of the following patient teaching guide-
lines is a priority on her discharge from the rehabilita-
tion facility?
A. Take estrogen to prevent a menstrual migraine.
B. Take gabapentin (Neurontin) for neuropathic pain.
C. Do not take sumatriptan (Imitrex) for migraine
headache.
D. Take zolmitriptan (Zomig) because it has a more
rapid onset of action.
8. A patient has taken sumatriptannaproxen sodium
(Treximet) for an acute migraine. She has also taken
over-the-counter ibuprofen (Motrin) for menstrual
cramps. Which of the following adverse effects is she
at risk for developing?
A. bronchospasm
B. urinary retention
C. edema
D. GI bleed
Clinical Application 51-3
Ms. Van Art is discharged from the emergency de-
partment following an acute migraine headache.
Her prescriber orders sumatriptan (Imitrex), to be
administered subcutaneously at the onset of an
acute migraine headache.
What education should Ms. Van Art receive prior
to discharge?
What medications are contraindicated with the
administration of sumatriptan?
 CHAPTER 51 Drug Therapy for Migraines and Other Headaches 943

Estrogen BOX 51.8 Drug Interactions:

Estradiol
Estrogen in the form of estradiol is a treatment for
menstrual migraines, which are most likely 2 days prior to Drugs That Increase the Eects of Estradiol
menses through the third day of bleeding (Calhoun, 2011). Cyclosporine, theophylline, tricyclic antidepressants
Perimenstrual estrogen supplementation is based on evidence Increase serum levels
that the natural decline in estrogen in the late luteal phase of Drugs That Decrease the Eects of Estradiol
the menstrual cycle, prior to menstruation, is associated with
the increased risk of migraine (MacGregor, 2010).
Phenytoin and rifampin
Decrease serum levels
Nicotine
Pharmacokinetics Reduces or cancels ecacy

Metabolism of estradiol occurs in the liver. Excretion takes

place in the urine. The drug crosses the placenta and enters
the breast milk.
Action
Estradiol binds to intracellular receptors to form a complex
that stimulates synthesis of proteins responsible for estrogenic
effects. Prophylactic administration minimizes the premen-
strual decline in estrogen that precipitates the development of
the migraine headache (Calhoun, 2011).
Nursing Implications
Preventing Interactions
Some drugs interact with estradiol, increasing or decreasing its
effects (Box 51.8). In addition, the combination of estradiol
and bromocriptine interferes with the effects of bromocriptine.
Administering the Medication
Prior to applying the transcutaneous preparation, it is neces-
sary to clean and dry the skin area. It is important to apply the
preparation to the trunk.

Use Assessing for Therapeutic Eects

Transcutaneous administration of estradiol increases the
estrogen levels in the late luteal phase of the menstrual
cycle that contribute to the development of menstrual
migraine headaches. Table 51.6 gives dosage information for
estradiol.
Adverse Eects
The major adverse effect associated with the administration of
estrogen preparations is thromboembolic disorders. Menstrual
irregularity can occur because of the suppression of endogenous
estrogen during treatment.
Contraindications
Contraindications include incomplete bone growth, which
occurs in adolescents. Other contraindications are the pres-
ence of neoplasms, breast cancer, thromboembolic disorders,
broids, endometriosis, thyroid disease, and pregnancy.
TABLE 51.6
DRUGS AT A GLANCE: Estradiol
Pregnancy Routes and
Drug Category Dosages
The nurse assesses for the development of migraine headache
in the later luteal phase of the menstrual cycle. If a headache
does not develop, the dose is adequate.
Assessing for Adverse Eects
The nurse assesses for the development of leg pain or chest pain
indicative of the development of thromboembolism. He or she
also assesses for breakthrough bleeding.
Patient Teaching
Box 51.9 identies patient teaching guidelines for estradiol.
Preventive Therapy for
Migraine Headaches
Many medications are administered for the prevention of migraine
headaches. These medications are primarily administered for the
treatment of other conditions and are thoroughly covered in
other chapters. Their use in the prevention of migraines medica-
tions is discussed briey. For complete information about these
drugs, one may review the information in the chapters indicated.
BOX 51.9 Patient Teaching Guidelines
for Estradiol

Adults Children scriber.

Take estradiol transdermal as ordered by the pre-

Estradiol X 100-mcg
patch or
Safety and efcacy
have not been
breakthrough
Notify your health care provider of intermittent
bleeding, spotting, or unexplained
1.5-mg gel established pain, especially calf or chest pain.
944 SECTION 10 Drugs Aecting the Autonomic and Central Nervous System
Carboxylic Acid Derivative
Valproic acid (see Chap. 52) is a carboxylic acid derivative that
is most commonly administered to control seizures. However,
it has proved effective in the prevention of migraine head-
aches. Valproic acid is available in two forms. The dosage for
valproic acid tablets is 250 mg orally two times per day, with
a maximum dosage of 1000 mg. The dosage of the extended-
release preparation is 500 mg orally once per day. Researchers
have found that valproic acid is safe for children younger than
18 years of age. According to a study by Apostol et al. (2008),
the administration of extended-release valproic acid was asso-
ciated with a 75% decrease in median 4-week headache days
between the rst and fourth months of the study. The most
common adverse effects with the administration of valproic
acid were nausea, vomiting, weight gain, nasopharyngitis,
migraine, and upper respiratory infection. Ten percent of sub-
jects stated that the migraine headache worsened. According
to this study, extended-release valproic acid is well tolerated by
adolescents with migraine headaches.
Gamma-Aminobutyric Acid
Gabapentin (Neurontin) (see Chap. 52) is a gamma-aminobu-
tyric acid medication commonly administered to control neu-
ropathic pain and as an adjunctive agent for control of seizures.
Studies have shown that gabapentin is effective in reducing the
frequency of migraines. At the end of 12 weeks, 46% of patients
who received 2400 mg/d had a 50% reduction in the 4-week
rate of migraine. The most commonly reported adverse effects
were dizziness and somnolence.
Sulfamate-Substituted Monosaccharide
Topiramate (Topamax) is a sulfamate-substituted monosaccha-
ride agent used most commonly as an antiepileptic agent (see
Chap. 52). It has been approved for the prevention of migraine
with an initial dose of 25 mg PO in the evening during week 1,
then 25 mg PO two times per day during week 2, then 25 mg
PO in the morning and 50 mg PO in the evening during week
3, and 50 mg in the morning and evening during week 4. The
most commonly reported adverse effects include paresthesia,
fatigue, anorexia, diarrhea, weight loss, altered memory, dif-
culty concentrating, and nausea.
Beta-Adrenergic Blocking Agents
The most common administered beta-adrenergic blocking
agent administered prophylactically for migraine headaches
is propranolol (Inderal) (see Chap. 28). The recommended
dosage is 80 mg/d, either in (1) sustained-release capsules, (2)
extended-release tablets, or (3) divided doses. The mainte-
nance dosage may be increased to 160 to 240 mg/d. Studies
have shown that propranolol is effective in reducing migraine
frequency.
Other beta blockers used for migraine prophylaxis
include timolol, metoprolol, nadolol, and atenolol. It takes
several weeks for the beta blockers to become effective, and
it is necessary to titrate the dose for at least 3 months to
ascertain effectiveness. A concern related to the use of beta
blockers is the increased risk of stroke and other cardiovas-
cular events.
Calcium Channel Blockers
Verapamil is the calcium channel blocker of choice for migraine
prophylaxis. It takes several weeks for benets of the medica-
tion to be noted. It seems to be the most effective calcium
channel blocker for migraine prevention. It is necessary to take
120 mg in three divided doses.
Studies have also noted that tolerance may develop with
calcium channel blockers. Tolerance to the medication can be
overcome by increasing the dosage or switching to a different
calcium channel blocker. Calcium channel blocking agents
such as nifedipine (Procardia) (see Chap. 26) have been used
for prevention of migraine headache. However, studies have
shown that this class is not as effective as other agents.
Angiotensin-Converting Enzyme Inhibitors
As Chap. 28 points out, enalapril maleate is the prototype
angiotensin-converting enzyme (ACE) inhibitor, but stud-
ies have shown that lisinopril seems to be more effective in
the prevention of migraine headaches. A study has shown
that a dose of 10 mg/d for 1 week and then 20 mg/d reduced
the number of hours and days with headache and headache
severity compared to a placebo. An adverse effect is the
development of the ACE cough. (The cough is a result of
an interference with bradykinin, substance P, or tachykinin
metabolism.)
Angiotensin II Receptor Blockers
Angiotensin II receptor blockers (see Chap. 28) can be effec-
tive in the prevention of migraine headache. Studies on the
effectiveness of candesartan have revealed that it produces
favorable results in the prevention of migraine headaches. It
is necessary to inform women of childbearing age that barrier
contraceptives are required with this medication. The FDA has
issued a BLACK BOX WARNING stating that fetal injury
and death have been reported with candesartan.
Olmesartan is effective and well tolerated as a migraine
prophylactic agent for patients with comorbid hypertension
and prehypertension. Researchers have studied patients with
hypertension and prehypertension to determine the effective-
ness of this medication (Charles, Jotkowitz, & Byrd, 2006).
Tricyclic Antidepressants
Imipramine (Tofranil) and other tricyclic antidepressants (see
Chap. 53) are effective in the prevention of migraine and ten-
sion headaches. Amitriptyline (Elavil) 10 to 50 mg at bedtime
is also effective for migraine prophylaxis. Tricyclic antidepres-
sants have a sedative effect, and to minimize this, it helps to
administer the drugs at bedtime. Other side effects of tricyclic
antidepressants include dry mouth, constipation, tachycardia,
palpitations, orthostatic hypotension, weight gain, and urinary
retention.
 CHAPTER 51
Antidepressants in Long-term Migraine
Prevention
by HORST J. KOCH, TIM P. JRGENS
Drugs
2009, 69(1), 119
The rate of depression and migraine headache is 20%
to 30%. Clinical studies have identied tricyclic antide-
pressants to be benecial in the prophylactic treatment
of migraine. Amitriptyline is considered the antide-
pressant of choice for the prophylactic treatment of
migraine. In a study of 279 children with a mean age of
12 years, amitriptyline showed a reduction in the num-
ber of migraine attacks per month by 62%. Current
data have shown that uoxetine, a selective serotonin
reuptake inhibitor, is also benecial in the treatment
of migraine, but the number of patients in the study
was small in number, requiring further research. The
authors also identied various herbal remedies such
as St. Johns wort, used in treatment of depression,
and butterbur root and feverfew, used in treatment
of migraine. St. Johns wort can increase the risk of
adverse effects if taken together with an antidepressant.
Butterbur root has been associated with hepatotoxicity.
IMPLICATIONS FOR NURSING PRACTICE: It is imperative that
the nurse interviews the patient and discovers any com-
plementary or alternative therapies taken by the patient.
This knowledge reduces the potential adverse effects that
can result from the combination with antidepressants.
Herbal Supplements
People with migraines may use herbal supplements to treat
these headaches (Box 51.10).
NCLEX Success
9. A 14-year-old girl is diagnosed with menstrual migraines.
Which of the following factors prevents the use of es-
tradiol for the treatment of menstrual migraines?
A. breakthrough bleeding
B. leg pain
C. incomplete long bone growth
D. anxiety
10. A 16-year-old girl develops migraine headaches. Which
of the following medications is safe and effective for
the treatment of migraine headaches?
A. antiepileptic agents
B. triptans
C. ergot alkaloids
D. opioids
Drug Therapy for Migraines and Other Headaches 945
BOX 51.10 Herbal Supplements Used
in the Treatment of
Headaches
Feverfew is an herbal medicine with some evidence of
eectiveness in treatment of migraines, especially in
reducing incidence and severity. Authorities think that the
main active ingredient of feverfew is parthenolide. Some
people believe that this agent inhibits platelet aggregation,
prostaglandin synthesis, and the release of inammatory
mediators such as histamine, but its exact mechanism
in migraine prophylaxis is unknown. Contraindications
include pregnancy and lactation.
In general, it is necessary to encourage patients to try
standard methods of preventing and treating migraine
before taking products with uncertain benets and risks.
For example, commercial preparations of feverfew are not
standardized and may contain dierent amounts of parthe-
nolide. The usual recommended dose is 25 to 50 mg daily
with food, but more studies are needed.
Adverse eects include hypersensitivity reactions in
people with allergies to ragweed, asters, chrysanthemums,
or daisies. Stopping the preparation abruptly can result in
withdrawal symptoms of pain and stiness. No reported
interactions with over-the-counter or prescription drugs
have occurred, but there is a potential for increased risks
of bleeding in patients taking an antiplatelet drug (e.g.,
aspirin) or an anticoagulant (e.g., warfarin).
Adjuvant Medications for
Migraine Headaches
Adjuvant medications administered for severe migraine head-
aches include antiemetics and opioids. Antiemetic agents are
adjuvant medications administered to control the symptoms
of nausea and vomiting related to migraine, tension, and clus-
ter headaches. Table 51.7 gives dosage information for the
antiemetics. Opioid use is controversial because these agents
can contribute to the development of chronic daily headache
and interference with preventive therapy (Bajwa & Sabahat,
2010). They are not discussed in this section.
Antiemetic agents may be useful for treatment of symp-
toms related to migraine headache. Chlorpromazine
hydrochloride (Thorazine) (see Chap. 55) is a pheno-
thiazine that has been shown to be effective in treating both
the headache itself and the associated nausea and vomiting.
Investigators have also shown that antiemetic drugs decrease
the photophobia and phonophobia that may accompany the
migraine headache. The mechanism of action involved in the
decrease of nausea and vomiting is related to the suppression
of the chemoreceptor zone. Besides chlorpromazine, related
antiemetics include metoclopramide and prochlorperazine.
Parenteral preparations of these drugs appear more effective
than oral preparations. When administering the antiemetic
agents, it is necessary to assess the patient for relief of head-
ache, nausea, and vomiting. Chlorpromazine also depresses
the CNS, so it is important to assess the patients level of
consciousness.
946 SECTION 10 Drugs Aecting the Autonomic and Central Nervous System

TABLE 51.7
DRUGS AT A GLANCE: Antiemetics Used for the Treatment of Headaches
Pregnancy
Drug Category Routes and Dosages

Adults Children

Chlorproma- C 1025 mg PO every 46 h; 50- to 100-mg >6 mo: 0.55 mg/kg PO every 46 h PRN up
zinve hydro- suppository rectally every 68 h; 25 to 500 mg/d
chloride 50 mg IM/IV every 46 h >6 mo: 0.55 mg/kg IM/IV every 68 h
(Thorazine)

Metoclopramide B 1020 mg IM/IV 2 mg/kg IM/IV

(Reglan)
Prochlorperazine C 510 mg PO 34 2/d sustained release; 2.5 mg PO or per rectum 13 times per day or
(Compazine) 1015 mg every 12 h; 510 mg IM 5 mg 2 times per day (max dose, 15 mg/d;
every 34 h (max dose, 40 mg); 2.5 0.13 mg/kg IM every 34 h)
10 mg IV every 34 h (max dose, 40
mg); 25 mg per rectum 2 times per day

Metoclopramide (Reglan) is a GI stimulant that is effective Planning/Goals

in reducing headache, nausea, and vomiting. It is less effective
than chlorpromazine in reducing symptoms. Metoclopramide
is a potent central dopamine receptor antagonist that increases
esophageal sphincter tone and elevates the chemoreceptor
zone threshold.
Prochlorperazine (Compazine) has the same antiemetic
action as chlorpromazine and metoclopramide. When taking
prochlorperazine orally, it is important to swallow it whole and
not chew or crush the tablets. When administering the medica-
tion parenterally, it is necessary to give it intramuscularly (deep)
and never subcutaneously. When administering metoclopramide
and prochlorperazine, it is necessary to assess the patient for signs
and symptoms of dystonia, which is indicative of a hypersensi-
tivity reaction. If the patient develops dystonia, it is necessary
to administer diphenhydramine (Benadryl) to counteract this
reaction. With all of these medications, the patient should be
assessed for urinary retention due to the anticholinergic effects.
The Nursing Process
Assessment
Assess the severity, patterns, and occurrences of cluster,
tension, or migraine headaches.
The patient will
Take medications routinely to prevent headache
Take medications to treat acute migraine with the onset
of symptoms or aura
Avoid trigger factors that contribute to headache symptoms
Experience fewer and less severe attacks of migraine, tension,
or cluster headaches
Nursing Interventions
The nurse will
Implement measures to minimize and prevent the symp-
toms of headache
Instruct the patient on medications to treat acute migraine
headache pain
Instruct the patient on the trigger points related to
migraine and strategies to decrease trigger points
Instruct the patient on medications to prevent migraine
headaches
Administer medications to treat acute migraine head-
aches
Administer medications to prevent migraine headaches
Administer antiemetic agents to reduce nausea and vom-
iting during acute episodes

Nursing Diagnosis Evaluation

Acute pain Interview and observe patient for relief of symptoms.
Fluid volume decit Interview and observe patients ability to provide self-care.
Activity intolerance related to pain Interview and observe patient regarding safe, effective use
Decient knowledge: therapeutic and adverse effects of of the medications for the acute and preventive treatment.
commonly administered medications Interview and assess patient for medication compliance.