An oral nonopioid analgesic is often sufficient for acute treatment of mild to moderate migraine pain without severe nausea or vomiting. A triptan is the drug of choice for treatment of moderate to severe migraine in most patients without vascular disease. Treatment of pain when it is still mild to moderate in intensity improves headache response and reduces the risk of recurrence.

The FDA has approved Gimoti (Evoke), a nasal spray formulation of the dopamine-2 (D₂) receptor antagonist metoclopramide, for relief of symptoms in adults with acute and recurrent diabetic gastroparesis. Metoclopramide (Reglan, and generics) has been available for years in conventional and orally-disintegrating tablets and in an injectable formulation. It is the only drug that is FDA-approved for treatment of diabetic gastroparesis.

An oral nonopioid analgesic is often sufficient for acute treatment of mild to moderate migraine headache without severe nausea or vomiting. A triptan is the drug of choice for treatment of moderate to severe migraine headache pain in most patients without vascular disease. Early treatment of pain when it is still mild to moderate in intensity improves headache response and reduces the risk of recurrence.

The FDA has approved valbenazine (Ingrezza – Neurocrine Biosciences), a vesicular monoamine transporter 2 (VMAT2) inhibitor, for treatment of tardive dyskinesia in adults. It is the first drug to be approved in the US for this indication; two other VMAT2 inhibitors, tetrabenazine (Xenazine, and generics) and deutetrabenazine (Austedo), were approved earlier for treatment of chorea associated with Huntington's disease.

An oral nonopioid analgesic may be sufficient for treatment of mild to moderate migraine without severe nausea or vomiting. A triptan is the drug of choice for treatment of moderate to severe migraine. Use of a triptan early in an attack when pain is still mild to moderate in intensity improves headache response and reduces recurrence rates.

The FDA has approved Diclegis (Duchesnay), a fixed-dose, delayed-release combination of the H₁-antihistamine doxylamine and the vitamin B₆ analog pyridoxine, for treatment of nausea and vomiting of pregnancy in women who do not respond to conservative management. It is only available by prescription. Doxylamine and pyridoxine, both currently available over the counter, were previously available by prescription in a fixed-dose combination (Bendectin) for morning sickness. Bendectin was voluntarily withdrawn in the US in 1983 because of claims of teratogenicity that have since been disproven. The combination has continued to be available in Canada as Diclectin.

Drugs for treatment of migraine are listed in Table 2 on page 9. Drugs for prevention of migraine are listed in Table 3 on page 10. Treatment of migraine in the emergency room, which may involve use of intravenous drugs, is not included here.

Many drugs can cause psychiatric symptoms, but a causal connection is often difficult to establish. Psychiatric symptoms that emerge during drug treatment could also be due to the underlying illness, previously unrecognized psychopathology, or psychosocial factors. The withdrawal of some drugs can cause symptoms such as anxiety, psychosis, delirium, agitation or depression.

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Peptic ulcers caused by treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) are mainly gastric ulcers. Most duodenal and other gastric ulcers are caused by the gram-negative bacillus Helicobacter pylori. Gastroesophageal reflux disease (GERD) is caused by gastric acid reflux into the esophagus. Drugs that suppress gastric acid production are the primary treatment for GERD and peptic ulcers.

Some drugs for treatment of migraine attacks are listed in table 2 on page 18. Drugs for prevention of migraine are listed in table 3 on page 20. Treatment of migraine in the emergency room, which may involve use of intravenous drugs, is not included here.

The FDA has reported that 5106 elderly patients with dementia treated with atypical (second generation) antipsychotics in 17 randomized controlled trials had a higher mortality rate (4.5% vs. 2.6%) than those receiving placebo. Most of the deaths were due to cardiovascular and infectious causes (such as pneumonia). The drugs used in the trials were aripiprazole (Abilify), olanzapine (Zyprexa), quetiapine (Seroquel), and risperidone (Risperdal). As the increase in mortality was considered a class effect, the FDA advisory also included ziprasidone (Geodon), clozapine (Clozaril) and the olanzapine/fluoxetine combination (Symbyax). The manufacturers of all of these drugs will be required to add a "black box" warning to their labeling.

Apomorphine (Apokyn - Mylan/Bertek), an injected non-ergot dopamine agonist, was recently approved by the FDA for intermittent subcutaneous (SC) treatment of hypomobility ("off" episodes) in patients with advanced Parkinson's disease. It has been available in Europe for many years.

Drugs for treatment of migraine attacks are listed in the table on page 64. All of the oral drugs are most effective if taken early in an attack when the pain is mild (H Christoph-Diener et al, Neurology 2004; 63:520). Drugs for prevention of migraine are listed in the table on page 65. Treatment of migraine in the emergency room, which may involve use of intravenous drugs, is not included here.

Many drugs can cause psychiatric symptoms, but a causal connection is often difficult to establish. Psychiatric symptoms that emerge during drug treatment may also be due to the underlying illness, previously unrecognized psychopathology, or psychosocial factors. The withdrawal of some drugs can cause symptoms such as anxiety, psychosis, delirium, agitation or depression.

A fixed-dose combination of atovaquone and proguanil hydrochloride has been approved by the FDA for oral prophylaxis and treatment of malaria due to Plasmodium falciparum, including choloroquine-resistant strains.

Older patients are especially susceptible to drug-induced cognitive impairment. They are more likely to be taking multiple drugs, to have higher blood levels of those drugs because of renal or hepatic dysfunction, and to have pre-existing cognitive problems that make it difficult to detect the role of drugs causing new symptoms or making old ones worse.

Three new 5-HT1 receptors agonissts ('triptans') have been marketed recently for treatment of migraine. Some drugs for prevention of migraine are listed in the table on page 99. Treatment of migraine in the emergency room, which may involve use of intravenous drugs, is not included here.

Pramipexole (Mirapex - Pharmacia & Upjohn) and ropinirole (Requip - SmithKline Beecham), two new dopamine agonists, have been approved by the US Food and Drug Administration (FDA) for treatment of both early (without levodopa) and advanced (with levodopa) Parkinson's disease. Bromocriptine (Parlodel) and pergolide (Permax) are older dopamine agonists marketed in the USA for adjunctive use with levodopa.

Drugs are used both to prevent and treat migraine symptoms. The effectiveness of such use can be difficult to evaluate, even with double-blind controlled trials, because migraine is episodic, response to placebo is frequent, and patients vary in response to a given agent (KMA Welch, N Engl J Med, 329:1476, 1993; SD Silberstein and RB Lipton, Neurology, 44 suppl 7:S6, Oct 1994).

Granisetron, a serotonin (5-HT) antagonist similar to ondansetron, was recently approved by the US Food and Drug Administration for prevention of nausea and vomiting due to cancer chemotherapy. Although available in an oral formulation in other countries, granisetron is available here only for intravenous (IV) use.

Several currently available antiemetic drugs can prevent vomiting caused by cancer chemotherapy. Anticancer drugs that cause vomiting are listed in the table below.

Sumatriptan (soo ma trip' tan; Imitrex - Glaxo), a serotonin (5-HT) agonist, is now available in Canada and may soon be available in the USA for oral or parenteral treatment of migraine headache. The parenteral formulation is designed for patients to inject themselves subcutaneously. Sumatriptan is not recommended for prophylactic use.

Ondansetron (on dan' se tron; Zofran - Glaxo), a serotonin (5-hydroxytryptamine) antagonist, was recently marketed in the USA for intravenous use to prevent nausea and vomiting due to cancer chemotherapy. An oral formulation is available in many other countries.

Levodopa combined with carbidopa (Sinemet) is the treatment of choice for Parkinson's disease (Medical Letter, 30:113, 1988). After prolonged treatment, however, the symptoms of the disease often become difficult to manage. The benefit from each dose becomes shorter (the 'wearing-off' effect), sudden fluctuations occur between mobility and immobility (the 'on-off' phenomenon), and abnormal involuntary movements (dyskinesias) may become frequent. The dopamine agonist bromocriptine (Parlodel) can ameliorate some of these effects. Two new drugs, pergolide (Permax - Lilly), another dopamine agonist, and selegiline (Eldepryl - Somerset), a selective type B monoamine oxidase (MAO) inhibitor previously known as deprenyl, were recently approved by the US Food and Drug Administration for use with levodopa-carbidopa in patients with difficult-to-manage Parkinson's disease.

Nabilone (Cesamet - Lilly), a synthetic cannabinoid chemically related to tetrahydrocannabinol (THC), the main active ingredient in marijuana, was recently marketed in the USA for oral treatment of nausea and vomiting associated with cancer chemotherapy. Oral THC itself, known generically as dronabinol (Marinol), is also commercially available as an antiemetic for cancer patients (Medical Letter, 27:97, 1985). Other drugs used for this purpose include metoclopramide (Reglan - Medical Letter, 24:67, 1982), prochlorperazine (Compazine; and others), haloperidol (Haldol; and others), and corticosteroids. Benzodiazepines, such as lorazepam (Ativan; and others), are used to treat anticipatory nausea and vomiting that occurs before chemotherapy begins.