<prompt> Drug of choice in acute severe migraine is:ErgotamineSumatriptanDihydroergotaminePropranol  <response>: MIGRAINE Severe, throbbing, pulsating headache usually unilateral headache few hours to a few days in duration Associated with nausea, vomiting, sensitivity to light and sound, flashes of light, loose motion and others Types: -Classical with aura -Without aura common Pathophysiology: -Pulsatile dilatation of temporal or ceain cranial vessels -Vascular theory: initial vasoconstriction or shunting of blood through carotid aerio-venous anastomosis causing cerebral ischaemia -Neurogenic theory: depression of coical electrical activity followed by depression Migraine attack associated with based on histological studies: sterile neurogenic perivascular edema inflammation clinically effective antimigraine medication reduce perivascular inflammation SUMATRIPTAN Selective agonist of 5-HT1B1D receptor No interaction with other 5-HT receptors No interaction with adrenergic, dopaminergic and cholinergic receptors, GABA MOA: Blockade of 5-HT1D1B mediated constriction of dilated extracerebral blood vessel Constriction of aeriovenous shunt of carotid aery Inhibition of release of 5-HT and inflammatory neuropeptides around the affected vessels - supression of neurogenic inflammation Supression of impulse transmission in trigeminovascular system Kinetics: Poorly absorbed from GIT, bioavailability - 10 - 15 only Complete absorption after subcutaneous administration Metabolized by MAO-A and excreted in urine, t12 is 2-3 Hrs Administration Doses: -Onset of acute attack -Better tolerated than ergotamine -50 to 100 mg as initial dose and repeated after 24 Hrs if required -Should not be given is first dose fails -SC dose - 12 mg 1 ml stat and repeated if required Adverse effects: Dose-related - Tightness of chest, feeling of heat, paresthesia of limbs, dizziness, and weakness sho lasting - common with SC route -Risk of MI and seizure and death Contraindications: IHD, epilepsy, hypeension, pregnancy, hepatic and renal impairment Ref: KD tripathi 8th ed 