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First-Line Abortive Migraine Medication: Addendum
Lawrence Robbins, M.D.
Posted July 2002
 


FROVATRIPTAN (FROVA)

Frova was released in the United States in June, 2002. Frova is very well tolerated. The long (26 hours) half-life is advantageous for those with prolonged migraines. Mean maximal blood concentrations are seen approximately 2 to 4 hours after a dose of Frova. Frova has been particularly useful for those with slower-onset moderate or moderate to severe migraines.

Who Should Use Frova?

Frova is most useful for migraines that are of slower-onset; if one awakens with a very severe migraine with severe nausea, Frova may not be the optimal choice. It is common for migraineurs to experience prolonged moderate or moderate to severe migraines. Menstrual migraines are often of long duration. Frova, with itís extended duration of action, is an ideal triptan for these patients. As with any migraine abortive, early intervention with the medication is best. Frova is an outstanding first-line choice as a migraine abortive medication.

Who Should Not Use Frova?

As with other triptans, the following conditions should mitigate against the use of Frova: 1. hypertension that is not well controlled; 2. past history of a stroke; 3. history of heart disease; 4. circulatory problems; and 5. basilar or hemiplegic migraine. Any triptan can cause a transient increase in blood pressure.

How to Use Frova Tablets

Frova is available in 2.5 mg. tablets. Frova tablets are less expensive than most of the other available triptans. The usual dose is 2.5 mg. every 2 to 4 hours, as needed, 3 tablets in 24 hours at most.

Frova With Other Medications

As with other triptans, Frova may be used in conjunction with most other medications, such as nsaids or analgesics. At times, I do suggest to patients that they combine an nsaid (such as naproxen) with a triptan, in an attempt to prevent headache recurrence. Antiemetics are safe with Frova.

Frova should not be used in the same day as other triptans (Imitrex, Amerge, Axert, Zomig, Maxalt). If an ergotamine or methysergide (Sansert) has been ingested in the previous 24 hours, Frova should not be utilized.

Side Effects

Frova has been exceptionally well tolerated. As with other triptans, certain patients will experience 20 to 30 minutes of mild side effects. These include dizziness, paresthesias, flushing, and fatigue. In addition, feelings of hot or cold, dyspepsia, skeletal pains, dry mouth, or (brief) headache may occur. All triptans may provoke chest pain, which is rarely of cardiac origin.

The serious side effects of triptans, as a class, include myocardial infarction and stroke. Over 25 million patients have taken triptans, and serious adverse events are extremely rare. Prior to triptan use, patients should be screened for risk factors associated with coronary artery disease or spasm. If moderate to severe chest pain does occur after the use of any triptan, it is prudent to discontinue use, at least until appropriate cardiac evaluation is accomplished.

Frova With Pregnancy or Nursing

Frova should not be used during pregnancy (it is category C). Frova should not be used by a woman who is nursing.

Sample Case: Menstrual Migraine (Utilizing Frova)

Ginnie is a 38 year old woman with a moderate migraine lasting 3 days, occurring just prior to or during menses. Her headaches have a slow, rambling onset, gradually building over 2 to 4 hours. She has mild nausea and photophobia with her migraine. Other than hormonal changes, Ginnie describes her headache triggers as undersleeping and weather changes. Ginnie also has twice weekly tension headache, relieved by ibuprofen and caffeine. Ginnie has 2 young children and cannot afford to give up 3 days to the headache. She has had mild relief from naproxen, and butalbital (Fiorinal) overly sedated her. Zomig relieved Ginnieís migraine, but she complained of side effects: paresthesias in her jaw, and fatigue. Daily nsaids (prior to and with menses) have not been helpful as preventatives for Ginnie.

Ginnie was given Frova tablets, and instructed to take one at an early point in the menstrual migraine. She felt that the Frova began to take effect in one hour, and relief lasted the entire day. She did need to re-dose the next day, and the 3rd day as well. However, she noted no adverse effects, and Ginnie was able to work and care for her children during the migraine days.

Alternative possibilities for Ginnie included adding naproxen (500mg) to the Frova (in an attempt to limit recurrence), utilizing other triptans, or adding small doses of cortisone (Prednisone, dexamethasone) the first day of the migraine. The very long duration of action of Frova rendered it an ideal migraine abortive for the long, moderate menstrual migraine described by Ginnie.

ALMOTRIPTAN (AXERT)

Axert was released in the United States in 2001. Axert is a well-tolerated triptan, combining good efficacy with minimal side effects. Axert is well absorbed, with an absolute bioavailability of 70%. The mean half-life is 3 to 4 hours, with peak plasma levels 1 to 3 hours post-dose. Axert is less expensive than most other triptans.

Who Should Use Axert?

Axert has demonstrated a high efficacy in migraine; it is best suited for those who can swallow a tablet during the migraine. Due to a low incidence of side effects, Axert is well-suited for those who are sensitive to the usual side effects of triptans. Many patients tolerate one triptan and not another, and Axert offers good efficacy with minimal adverse events.

Who Should Not Use Axert?

As with other triptans, the following conditions should mitigate against the use of Axert: 1. hypertension that is not well controlled; 2. past history of stroke; 3. history of heart disease; 4. circulation problems; and 5. basilar or hemiplegic migraine. Any triptan can cause a transient increase in blood pressure.

How To Use Axert Tablets

Axert is available in 6.25 mg. and 12.5 mg. tablets. The usual dose is one 12.5 mg. tablet every 2 to 4 hours, as needed, 2 tablets in 24 hours at most. As with other migraine abortives, early intervention with Axert is desirable.

Axert With Other Medications

As with other triptans, Axert may be used in conjunction with most other medications, such as analgesics or nsaids. Occasionally, I will suggest that a patient combine an nsaid (such as naproxen) with a triptan, in an attempt to prevent headache recurrence. Antiemetics are safe to use in conjunction with Axert. Axert should not be used in the same day as other triptans (Imitrex, Frova, Amerge, Zomig, Maxalt). If patients have taken ergotamines or Sansert in the previous 24 hours, Axert should not be given.

Side Effects

Axert is usually very well tolerated. As with other triptans, some patients do experience 20 to 30 minutes of mild side effects. These include nausea, somnolence, headache, paresthesias, and dry mouth. All triptans may provoke chest pain, which is rarely of cardiac origin.

The serious side effects of triptans, as a class, include myocardial infarction and stroke. Over 25 million patients have taken triptans, and serious adverse events are extremely rare. Prior to triptan use, patients should be screened for risk factors associated with coronary artery disease or spasm. If moderate to severe chest pain does occur after the use of any triptan, it is prudent to discontinue use, at least until appropriate cardiac evaluation is accomplished.

Axert With Pregnancy or Nursing

Axert should not be used during pregnancy, and should not be utilized by a woman who is nursing.

Sample Case: Moderate Migraine Utilizing Axert

Kerri is a 43 year old woman with 3 moderate migraines per month, each lasting 8 to 24 hours. They are associated with minimal nausea. Kerri notes triggers of stress, weather, and hormonal changes. She has 3 children, works full time, and needs to function during the day of a migraine. Kerri had no relief from otcís or nsaids, and analgesics were overly sedating. Amerge was helpful for her headache, but she felt that it took too long (1.5 hours) to become effective. Kerri was given Axert, and finds that it usually relieves the headache within 45 minutes. For most of her migraines, Kerri only needs one Axert; she occasionally re-doses with another tablet later in the day. Kerri experiences no adverse events from the Axert. Other considerations for Kerri would include other triptans, or DHE. On occasion, patients find that one triptan may lose itís efficacy, and switching (at least temporarily) to another triptan may be necessary.




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