Which of the triptans to have the lowest incidence of chest discomfort?

By | May 13, 2012

Which of the following triptans appears to have the lowest incidence of chest discomfort?

A. Almotriptan (Axert)

B. Subcutaneous sumatriptan (Imitrex)

C. Intranasal zolmitriptan (Zomig)

D. Oral sumatriptan (Imitrex)

E. Eletriptan (Relpax)

The answer is A. Chest discomfort, presumably related to pulmonary vasoconstriction and/or esophageal spasm, is lowest in oral triptan formulations. The tolerability of almotriptan (Axert) 12.5 mg is close to that of placebo, with a low incidence of central nervous system (CNS) side effects and chest symptoms. Chest discomfort is in the range of <3% of patients with oral sumatriptan (Imitrex) and <1% of patients given almotriptan. (Dahlof, Dodick, Dowson, et al., Headache 2002; Dodick, Sandrini, & Williams, CNS Drugs 2007)

What of the following is a plausible mechanism of action for botulinum toxin in the treatment of migraine?

A. Relaxation of muscles of the neck and face

B. Prevention of release of nociceptive neuropeptides

C. Reduced anxiety about wrinkles

D. Ca2 channel inhibition

E. All of the above

The answer is B. Botulinum toxin blocks acetylcholine release from motor nerve terminals and other cholinergic synapses and may reduce the release of neuropeptides involved in pain perception, including substance P and glutamate. Botulinum toxin injections have been studied in patients with TTH, chronic migraine, and CDH (chronic daily headache). Multiple randomized, double-blind, placebo-controlled trials of botulinum toxin used to treat headaches have been published with variable results. Botulinum toxin type A and placebo injections have been equally effective in some studies, and its role in the prevention of multiple headache types continues to be investigated. (Schulte-Mattler & Leinisch, Transm 2007; Ramadan, Headache 2007)

Which of the following characteristics of evoked potentials is seen in patients with migraine?

A. Lack of habituation

B. Decreased amplitude

C. Increased amplitude

D. Decreased latencies

E. Increased latencies

The answer is A. Information processing, as measured by visual and auditory evoked responses, is abnormal in migraineurs who show lack of interictal habituation. Habituation may be a protective mechanism to conserve energy and to prevent the brain from experiencing sensory overload. This habituation pattern may be a familial trait marker that can be used to predict migraine risk. Interictal lack of habituation has been found on blink response (a trigeminofacial brainstem reflex) on electromyogram. Latencies and amplitudes on evoked response testing are not reliably abnormal in patients with migraine. (Gantenbein & Sandor, Headache 2006)

Tension-type headache:

A. Has a lifetime prevalence of about 80%.

B. Is the most common form of headache.

C. Is more common in younger, than in older, individuals.

D. Is more prevalent in women.

E. All of the above

The answer is E. Tension-type headache (TTH) is the most common type of headache, but patients with episodic tension-type headache consult with a doctor infrequently and the diagnosis is made in less than a quarter of patients treated in a headache practice. Patients with tension-type headaches may self-diagnose and self-treat, often to excess, with over-the-counter medication. The lifetime prevalence is about 80%, with 3% of patients experiencing tension-type headaches for >15 days a month for more than 3 months (chronic TTH). The prevalence of tension-type headaches is higher in women, and declines with age in both genders. (Fumal & Schoenen, Lancet Neurol 2008)