Migraine is characterized by moderate to severe unilateral throbbing headache, which lasts from four hours to three days if untreated. A migraine attack can be accompanied by nausea, sensitivity to light (photophobia) or sound (phonophobia). Vomiting is also rare.
Migraine without aura (typical) occurs episodicly and is not associated with focal brain or brainstem disorders. Most patients experience a prodromal phase characterized by changes in mood or energy levels in the form of depression. There may be euphoria, yawning, thirst or increased desire for food. A migraine attack may wake up the patient. At this stage, the headache is one-sided in the supra-orbital area, but it may be felt in the whole head. By lowering the head, the headache becomes more throbbing and by going to a dark room, it becomes less. Sensitivity to smell (osmophobia) and anorexia may be accompanied by migraine headache, which is even more common than nausea, blurred vision is common in all types of migraine. In migraine with aura (classic migraine), there is visual, sensory, motor, speech disorder or focal brain symptoms. Migraine with Aura includes about 15% of migraines.
Visual impairment is more common, which is seen as a bright halo of white or colored light in one half of the field of vision. The scotoma may be negative or positive in the form of zigzag lines. Fortification spectrum photopsia is also one of the visual disorders in migraine with aura.
Migraine pathogenesis
The pathogenesis of migraine is still not well understood. Dilation of scalp arteries increases scalp blood flow. Radioactive studies have shown that the blood flow of areas of the cortex decreases during migraine. There is an increase in external carotid blood flow during the headache phase. During a migraine attack, plasma serotonin increases. Serotonin causes contraction of large arteries and expansion of arterioles and capillaries and is the most important neurotransmitter in the pathogenesis of migraine.
The performance of ergot compounds is complex, their effect depends on the dosage and resting phase tone of target vessels. External carotid vessels are constricted by ergot compounds, and there is no evidence that internal carotid vessels are affected in the same way. Ergot compounds act through agonistic effects on 5-HT in migraine.
If more than 6 mg of ergotamine per week is needed, other combinations should be used. Ergotamine should be used with caution in people over 40 years of age and in peripheral vascular disease and high blood pressure, and in coronary artery disease and pregnant women, ergotamine is prohibited.
Nausea is a common side effect of ergot compounds and it is recommended to use it in combination with an anti-nausea drug. It should be mentioned that dihydrovargotamine is available in 2.5 mg, the form of Sumatriptan tablets specifically affects 5-HT receptors.
Stimulation of 5-HT receptors causes contraction of cranial vessels and inhibition of the release of sensory neuropeptides from perivascular trigeminal afferents. The central nervous system is relatively impenetrable to sumatriptan, therefore most of its action is concentrated on peripheral vessels.
There are seven types of triptans available, and all of them have a beneficial effect on nausea, photophobia, and phonophobia, and make the patient return to his normal function. In Iran, sumatriptan is also available in tablet form and in combination with naproxen, and its preparation It is easy. In a small number of patients, taking sumatriptan causes an unpleasant feeling of heaviness or pressure on the neck and chest. which rarely lasts more than a few minutes or is not accompanied by other evidence of myocardial ischemia changes. Anyway, because sumatriptan causes changes in the diameter of the coronary artery and causes it to decrease, it should be used with caution in patients who have important risk factors for coronary artery disease, and in patients with any history of coronary artery disease. It is not recommended.
Sumatriptan should not be prescribed in patients with untreated high blood pressure or those taking ergot compounds, in pregnancy and breastfeeding, and in basilar or hemiplegic migraine.
Side effects of all triptans are similar to sumatriptan. If sumatriptan is used, it is forbidden to use another type of triptan or any combination of ergotamine during the next 24 hours.
Sumatriptan or ergotamines?
If the headache has started in patients with classic and normal migraines, it is better to treat it with triptans (one of the most common and less complicated ones is sumatriptan, which can be combined with naproxen to help reduce inflammation). be used In most published studies, it has been reported that sumatriptan has a better effect than ergot alkaloids in patients with migraine.
Researchers’ studies showed that oral sumatriptan is more effective than ergotamine in the treatment of acute migraine attacks.
The researchers announced in a research that although ergot alkaloids are available as a specific first-line treatment for migraine, but with the introduction of sumatriptan, their use has decreased and the effect of ergotamine is 100%.
In another study, it was shown that dihydroergotamine should not be used daily due to induced headache and it is less effective than sumatriptan.
Medical suggestion
Patients who take dihydroergotamine suffer from nausea and gastrointestinal complications, which are often associated with the use of metoclopramide tablets, and also have the limitation of use for people over 40 years old, as well as the complication of vascular spasms that may lead to gangrene of organs. On the other hand, the induced headache caused by ergot alkaloids and the fact that more than 6 mg of ergotamine per week is not allowed has created problems for patients regarding the use of dihydroergotamine, it is recommended that sumatriptan be used as a single drug regimen or It should be used with naproxen (better effectiveness of sumatriptan).
