You want to prescribe an antiemetic to a 19-year-old female who is having a migraine attack. Which one of the following medications is most likely to precipitate extrapyramidal side-effects?
A. Meptazinol
B. Ondansetron
C. Domperidone
D. Cyclizine
E. Metoclopramide
Answer:
E. Metoclopramide
Discussion: Extrapyramidal side-effects are particularly common in children and young adults.
Migraine: management It should be noted that as a general rule 5-HT receptor agonists are used in the acute treatment of migraine whilst 5-HT receptor antagonists are used in prophylaxis.
NICE produced guidelines in 2012 on the management of headache, including migraines.
Acute treatment
first-line: offer combination therapy with an oral triptan and an NSAID, or an oral triptan and paracetamol
for young people aged 12-17 years consider a nasal triptan in preference to an oral triptan
if the above measures are not effective or not tolerated offer a non-oral preparation of metoclopramide or prochlorperazine and consider adding a non-oral NSAID or triptan
Prophylaxis
prophylaxis should be given if patients are experiencing 2 or more attacks per month. Modern treatment is effective in about 60% of patients.
NICE advise either topiramate or propranolol 'according to the person's preference, comorbidities and risk of adverse events'. Propranolol should be used in preference to topiramate in women of child bearing age as it may be teratogenic and it can reduce the effectiveness of hormonal contraceptives
if these measures fail NICE recommend 'a course of up to 10 sessions of acupuncture over 5-8 weeks' or gabapentin
NICE recommend: 'Advise people with migraine that riboflavin (400 mg once a day) may be effective in reducing migraine frequency and intensity for some people'
for women with predictable menstrual migraine treatment NICE recommend either frovatriptan (2.5 mg twice a day) or zolmitriptan (2.5 mg twice or three times a day) as a type of 'mini-prophylaxis'
pizotifen is no longer recommend. Adverse effects such as weight gain & drowsiness are common
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