Here's a crash course on the new acute migraine treatment options along with a memory trick that's too stupid to forget.
In fact this memory trick is so great, it will knock your PANTS off, BRO.... RIMshot (ba dmm, tss) for the dad joke! That's because their names are uBROgePANT and RIMegepant. Now that you are done audibly groaning, what do you need to know about these for your CCFP exam? These are both antagonists of the CGRP receptor, a neuropeptide that is involved in migraine pathophysiology, contributing to pain and inflammation during a migraine attack. Not only can they relieve migraine pain, but they can also alleviate other symptoms such as light sensitivity and nausea. NOTE - these are indicated for acute migraine, NOT prevention. See our blog post on The 5 As to see some other medications that target the same receptor but are used for migraine prevention. PROS:
Can be used in patients who have a contraindication to triptans such as cardiovascular disease (though these patients were excluded from the trials)
May have fewer side effects than other options
Taken orally
Safe in studies with 1-year follow-up (we are still awaiting data beyond 1 year)
CONS:
New drugs are generally pricier
No head-to-head trials comparing these with triptans. A meta-analysis showed most triptans were "more strongly associated with freedom from pain at 2 hours" than the gepants.
Some patients still have side effects from gepants, such as nausea, dizziness, dry mouth and dyspepsia
OTHER OPTIONS:
Know about triptans, adjuncts (see below), NSAIDs & acetaminophen as other migraine treatment options. As well, at The Review Course we cover the sphenopalatine ganglion block as another option for your ER patients with migraine.
EXAM TIP:
Medications such as Metoclopramide, domperidone are considered adjunct medications rather than migraine treatments because they treat the other side effects, not the migraine pain
SUMMARY:
Most triptans likely work better, with more side effects
Dad jokes are painful but can help you ace your exam
Source: CMAJJanuary 30, 2023 195 (4) E153-E158; https://www.cmaj.ca/content/195/4/E153
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