Management Of Acute Migraine Research Articles

Triptans in the Acute Migraine Management of Children and Adolescents: An Update.

To summarize recent findings regarding triptan use in the acute treatment of pediatric migraine. Prevalence of pediatric migraine is rising. The American Headache Society and American Academy of Neurology updated guidelines to provide evidence-based recommendations for the treatment of acute migraine in youth. In the setting of a dearth of new randomized controlled trials (RCTs), we review current guidelines, triptan use in the emergency department, and an era of secondary analyses. Measuring the efficacy of triptans in pediatric migraine has been challenged by high placebo response rates. Secondary analyses, combining data from multiple RCTs, support that triptans are safe and effective in the treatment of migraine. Triptans are a vital tool and the only FDA-approved migraine-specific treatment available in pediatrics. There is a need for further studies and funding support in pediatric headache medicine.

Acute Treatment of Migraine: Expert Consensus Statements from the United Arab Emirates (UAE).

Migraine, characterized by recurrent headaches and often accompanied by other symptoms like nausea, vomiting, and sensitivity to light and sound, significantly impacts patients' quality of life (QoL) and daily functioning. The global burden of migraines is reflected not only in terms of reduced QoL but also in the form of increased healthcare costs and missed work or school days. While UAE (United Arab Emirates)-specific consensus-based recommendations for the effective use of preventive calcitonin gene-related peptide (CGRP)-based migraine therapies have been published previously, an absence of such regional guidance on the management of acute migraine represents a gap that needs to be urgently addressed. A task force of eight neurologists from the UAE with expertise in migraine management conducted a comprehensive literature search and developed a set of expert statements on the management of acute migraine that were specific to the UAE context. To ensure diverse perspectives are considered, a Delphi panel comprising 16 neurologists plus the task force members was set up. Consensus was achieved using a modified Delphi survey method. Consensus was predefined as a median rating of 7 or higher without discordance (if > 25% of the Delphi panelists rate an expert statement as 3 or lower on the Likert scale). Expert statements achieving consensus were adopted. The Modified Delphi method was used successfully to achieve consensus on all nine expert statements drafted by the task force. These consensus statements aim to provide a comprehensive guide for UAE healthcare professionals in treating acute migraine. The statements cover all aspects of acute migraine treatment, including what goals to set, the timing of treatment, treatment strategy to use in case of inadequate response to triptans, safety aspects of combining gepants for acute attacks with preventive CGRP-based therapies, special population (pregnant and pediatric patients) considerations, and the management of the most bothersome symptoms (MBS). Adopting these consensus statements on the treatment of acute migraine can help enhance patient care, improve outcomes, and standardize treatment practices in the UAE. The collaborative effort of experts with diverse experiences in developing these consensus statements will strengthen the credibility and applicability of these statements to various healthcare settings in the country.

AKT answer relating to management of acute migraine

AKT answer relating to management of acute migraine

AKT question relating to management of acute migraine

AKT question relating to management of acute migraine

Diagnosis and acute management of migraine.

See related review article at www.cmaj.ca/lookup/doi/10.1503/cmaj.221607 (to be published February 6, 2023) and a first-person account of the difficulty of finding migraine treatment at [www.cmaj.ca/lookup/doi/10.1503/cmaj.221813][1] KEY POINTS Migraine affects about 12% of adults, with a

Efficacy of Sumatriptan/Placebo versus Sumatriptan/Propofol Combination in Acute Migraine; a Randomized Clinical Trial

Introduction:Migraine headaches can cause severe pain for patients and lead them to multiple visits to the emergency department (ED). This study aimed to evaluate the efficacy of propofol + sumatriptan combination in comparison with sumatriptan alone in the management of acute migraine headaches.Methods:This triple-blind clinical trial involved patients who referred to two emergency departments with acute migraine headaches. Patients were randomly assigned to control (sumatriptan and placebo) or intervention (propofol and sumatriptan) groups for comparison of the efficacy and side effects of treatment.Results:In this study, 60 patients were included whose mean age was 31±8.8 years, and headaches were more common among women. After 30 and 60 minutes from the beginning of treatment, the mean pain score reduction in the intervention group was significantly greater than that in the control group (p=0.012, p=0.024). In addition, the rate of chest tightness in the control group was significantly higher than the intervention group. The absolute risk reduction of adverse events (Chest tightness, Bradycardia, hypotension, and etc.), in patients with acute migraine headache taking propofol and sumatriptan treatment, was 32.18% (95% CI: 8.02 – 56.35).Conclusions:This study supports the use of propofol for treatment of acute migraine headaches and shows that combining sumatriptan with propofol is more effective in relieving migraine headaches and the associated symptoms than using sumatriptan alone. However, more studies with longer follow-ups are still needed.

Impact of an Educational Intervention on the Opioid Knowledge and Prescribing Behaviors of Resident Physicians.

Objectives: The opioid epidemic is a multifactorial issue, which includes pain mismanagement. Resident physician education is essential in addressing this issue. We aimed to analyze the effects of an educational intervention on the knowledge and potential prescribing habits of emergency medicine (EM), general surgery (GS), and internal medicine residents (IM).Methods: Resident physicians were provided with educational materials and were given pre-tests and post-tests to complete. Descriptive statistics were used to analyze pre-test and post-test responses. Chi-squared analysis was used to identify changes between the pre-tests and post-tests. A p < 0.05 value was considered statistically significant. Results: Following the educational intervention, we observed improvement in correct prescribing habits for acute migraine management among emergency medicine residents (from 14.8% to 38.5%). Among general surgery residents, there was a significant improvement in adherence to narcotic amounts determined by recent studies for sleeve gastrectomy (p= 0.01) and laparoscopic cholecystectomy (p= 0.002). Additionally, we observed a decrease in the number of residents who would use opioids as a first-line treatment for migraines, arthritic joint pain, and nephrolithiasis.Discussion: Resident physicians have an essential role in combating the opioid epidemic. There was a significant improvement in various aspects of opioid-related pain management among emergency medicine, internal medicine, and general surgery residents following the educational interventions. We recommend that medical school and residency programs consider including opioid-related pain management in their curricula.

Propofol + Granisetron vs. Propofol + Metoclopramide in Symptom Management of Acute Migraine Headache; a Double-Blind Randomized Clinical Trial.

Introduction:Acute headache is one of the most common reasons for emergency department (ED) visits. This study aimed to compare the combination of propofol and granisetron with propofol and metoclopramide in symptom management of acute migraine headache.Methods:In this double-blind randomized clinical trial, 60 adult patients with acute migraine headache who referred to ED were randomly divided into two groups of propofol + metoclopramide and propofol + granisetron. Pain and nausea/vomiting severity as well as blood pressure were compared between groups 30, 45, and 60 minutes after treatment. Results:The two groups had similar situation regarding mean age (p = 0.606), sex distribution (p = 0.793), baseline severity of pain (p = 0.642), frequency of nausea/vomiting (p = 0.488), and vital signs (p > 0.05). The severity of pain was similar in the two groups 30 (p = 0.731), 45 (p = 0.460), and 60 (p = 0.712) minutes after treatment. The number of patients with resistant nausea and vomiting 60 minutes after treatment was significantly higher in metoclopramide group (30.0% versus 10.0%; p = 0.033). Diastolic pressure 60 minutes after treatment (81.43 ±8.94 vs. 74.97 ± 4.8; p = 0.001) and heart rate 30 minutes after treatment (68.87 ±6.52 vs. 73.57± 7.62; p = 0.013) had statistically significant differences between the groups. Conclusion:The combination of propofol and granisetron was superior to propofol and metoclopramide in case of controlling nausea and vomiting of cases with acute migraine headache; meanwhile, no differences were observed in case of pain relief and hemodynamic status between the two groups.

POSC202 Estimated Migraine Patient Population in England Progressing Beyond First-Line Acute Management

In England, NICE clinical guidelines on acute management of migraine recommend first-line use of an oral triptan, followed by a non-oral triptan if first-line treatment is ineffective or not tolerated.[1] NHS formularies further suggest trial of tablet formulations before orodispersible tablets and oral lyophilisates.[2-3] New acute therapies with novel mechanisms of action may offer relief for patients who progress beyond first-line triptan tablets.[4] This study aimed to assess the size of this patient population, using recent triptan prescription data for England.

Non-invasive neuromodulation in the acute treatment of migraine: a systematic review and meta-analysis of randomized controlled trials.

A systematic review and meta-analysis was performed to determine the efficacy of non-invasive neuromodulation modalities for the treatment of acute migraine. Although pharmacological treatments are the gold standard for the management of acute migraine, some patients may require non-pharmacological treatment options. Non-invasive neuromodulation may provide an alternative, and techniques include transcranial magnetic stimulation (TMS), non-invasive vagal nerve stimulation (nVNS), non-painful remote electrical stimulation (NRES), and external trigeminal nerve stimulation (e-TNS). This systematic review and meta-analysis was performed following PRISMA guidelines. We searched PUBMED, EMBASE, ClinicalTrials.gov, Cochrane Center Register of Controlled Trials, and LILACS databases. We included randomized controlled clinical trials studying patients with migraine treated with any form of non-invasive neuromodulation. Primary outcome was pain freedom within 2h post-treatment. Secondary outcomes were pain relief within 2-h post-treatment and sustained pain freedom and sustained pain relief 48h post-treatment. Pooled analysis demonstrated a significant effect of non-invasive neuromodulation on pain-free rates within 2h (RR, 1.66; 95% CI, 1.35 to 2.05; P < 0.00001) and pain relief rates within 2h (RR, 1.52; 95% CI, 1.13 to 2.05; P = 0.005) post-treatment. Non-invasive neuromodulation had no significant effect on sustained pain freedom at 48h (RR, 1.56; 95% CI, 0.68 to 3.59; P = 0.29) or sustained pain relief at 48h (RR, 1.47; 95% CI, 0.57 to 3.77; P = 0.43) after administration. Neuromodulation has demonstrated some efficacy in acute migraine management and may be considered in the treatment paradigm of acute migraine in patients with contraindications to pharmacological therapies.

COMPLICATED MIGRAINE

Migraine is a chronic paroxysmal neurological disease characterized by attacks of moderate or severe headache accompanied by reversible neurologic and systemic symptoms. Although not life threatening, migraine can cause disability in the productive population. Migraine sufferers generally have a family history of migraine so that migraine is considered a genetic disease. Endogenous psychological factors such as stress or fatigue are the main triggers for migraine. Migraine pathophysiology involves various parts of the brain so that migraine symptoms are complex. Management of acute migraine can be done pharmacologically and non-pharmacologically. Migraine preventive management is needed if the patient has a chronic migraine or does not respond to abortive treatment.

Percutaneous Interventional Strategies for Migraine Prevention: A Systematic Review and Practice Guideline.

To systematically evaluate the efficacy and effectiveness of percutaneous interventional treatments for prevention of migraine through a qualitative and (when possible) quantitative analysis. An expert panel was asked to develop recommendations for the multidisciplinary preventive treatment of migraine, including interventional strategies. The committee conducted a systematic review and (when evidence was sufficient) a meta-analytic review by using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria and the modified Cochrane Risk of Bias analysis available in the Covidence data management program. Clinical questions addressed adults with migraine who should be offered prevention. Examined outcomes included headache days, acute medication use, and functional impairment. Acute management of migraine was outside the scope of this guideline. The committee screened 1,195 studies and assessed 352 by full text, yielding 16 randomized controlled trials that met the inclusion criteria. As informed by evidence related to the preselected outcomes, adverse event profile, cost, and values and preferences of patients, onabotulinumtoxinA received a strong recommendation for its use for chronic migraine prevention and a weak recommendation against its use for episodic migraine prevention. Greater occipital nerve blocks received a weak recommendation for their use for chronic migraine prevention. For greater occipital nerve block, steroid received a weak recommendation against its use vs the use of local anesthetic alone. Occipital nerve with supraorbital nerve blocks, sphenopalatine ganglion blocks, cervical spine percutaneous interventions, and implantable stimulation all received weak recommendations for their use for chronic migraine prevention. The committee found insufficient evidence to assess trigger point injections in migraine prevention and highly discouraged the use of intrathecal medication.

Update on Management of Acute Migraine

Update on Management of Acute Migraine

Ubrogepant in the Acute Management of Migraine: A Narrative Review.

Ubrogepant is a small-molecule calcitonin gene-related peptide (CGRP) receptor antagonist that received Food and Drug Administration (FDA) approval for the acute treatment of migraine with and without aura in adults. The ACHIEVE I and ACHIEVE II Phase III clinical trials showed that ubrogepant was superior to placebo for pain freedom and freedom of the most bothersome migraine-associated symptom at 2 hours after medication intake. The 52-week open label extension of the Phase III trials demonstrated safety of ubrogepant. A real-world study conducted at a tertiary headache center also confirmed the efficacy and safety of ubrogepant. Adverse event rates were higher in the real-world population. Studies are needed to evaluate its long-term efficacy and safety, especially in the setting of co-administration with other CGRP modulating therapies such as the CGRP monoclonal antibodies.

Acute migraine management in the emergency department: experience from a large Spanish tertiary hospital.

To assess the characteristics of the management of patients with migraine who present to the emergency department (ED) with a migraine attack. Retrospective, observational study analyzing demographic, clinical, diagnostic and therapeutic characteristics of patients with migraine diagnosis presenting to ED for a migraine attack between 2016 and 2019. We reviewed the clinical records of 847 cases. 82.2% were women with mean age of 34.9years. 87.2% had episodic migraine and 12.2% chronic migraine. 62.3% (528/847) had taken analgesics before visiting the ED [non-steroidal-anti-inflammatory drugs (NSAIDs) (300/528; 56.9%) and triptans (261/528; 49.5%)]. 25.4% (215/847) received blood testing and 6.4% (55/847) received cranial CT. Medication was administered in 77.2% cases (654/847). The median time-to-treatment was 70min (IQR 42-120). NSAIDs (81%, 530/654), antiemetics (43.1%, 282/654) and metamizole (39% 255/654) were the most used. Triptans were administered in 7 cases (1.1%) and opioids in 84 (12.8%). At discharge, preventive treatment was prescribed or modified in 8.2% of cases (69/839) and triptans were prescribed in 129 cases (15.3%). 70.5% (592/839) were instructed to follow-up with their primary care provider (PCP), 21.5% (181/839) with a general neurologist and 7.9% (66/839) with a headache specialist. The majority of migraine patients were not receiving the recommended acute migraine-specific medication, both in the outpatient and in the ED setting, being especially remarkable the rare use of triptans in the ED. Furthermore, we found an elevated use of urgent complementary tests, mainly blood tests.

“Establishment of an acute headache infusion clinic as an alternative for emergency department care”

ObjectivesNumerous patients receive acute migraine care in the Emergency Department (ED) setting. A shift of this care to the outpatient Neurology Clinic and outpatient Infusion Center setting has the potential to optimize clinical management while decreasing resource utilization. MethodsClinicians and administrators collaborated on the operationalization of an Acute Headache Infusion Clinic run through the outpatient Neurology Clinic. Data was collected on all patients treated in the Acute Headache Infusion Clinic from 9/2018–12/2019. Duration of the outpatient visit, cost per visit, and pre- and post-treatment pain scores were collected. Comparison was made to similar care administered at our institution's Emergency Department. ResultsResults from 133 patients were obtained. The outpatient encounter was 3.73 h shorter than the ED encounter and was associated with a cost savings of ~$9400/patient. Patients experienced a substantial decrease in their pain scores with treatment in the outpatient setting. ConclusionsThe transition of acute migraine management requiring infusion therapies can successfully be transitioned from the ED to the outpatient setting. This can be associated with shorter clinical encounters with more optimal resource utilization while still providing adequate headache relief. Classification of evidenceThis study provides Class III evidence for an outpatient infusion clinic for saving costs and clinical care time for patients with acute migraines requiring infusion therapies.

Acute Migraine: Can the New Drugs Clinically Outpace?

The objective of this article is to discuss and compare the latest approved drugs (lasmiditan, ubrogepant, and rimegepant) for the management of acute migraine in a clinically relevant manner, emphasizing on their efficacy, safety, as well as cost benefits. A PubMed, clincialtrials.gov , and USFDA literature search (2013–2019) was conducted using the following keywords: Lasmiditan; Ubrogepant; Rimegepant; Acute Migraine; 5HT1F; CGRP. We included only English language articles which discussed the efficacy, safety, and tolerability of newly approved drugs for acute migraine. Triptans and NSAIDs have constitutively been the go-to drugs for the management of acute attack of migraine. These three latest drugs (lasmiditan, ubrogepant, and rimegepant) approved by USFDA may prove to be a game-changer, especially for those migraineurs who have accompanying cardiovascular diseases or have been dissatisfied with the existing therapeutic options. Migraine is a chronic debilitating disease for which the therapeutic options are already available, but for a proportion of patients, these options get either contraindicated, or prove to be clinically ineffective, or crop-out as ill-suited due to the adverse effects. In such conditions, the recently approved three drugs by USFDA stand a chance to fulfill the unmet needs. But due to the paucity of head-on trials between different groups of drugs, it is still difficult to comment about which group may clinically outpace by providing better therapeutic gain.

Ubrogepant: The First Gepant to Pass Food and Drug Administration for Acute Migraine

Migraine is one of the most common and disabling forms of primary headache disorders. It is characterized by the presence of unilateral pulsatile headache associated commonly with nausea, vomiting, photophobia, and phonophobia lasting for about 4–72 h. Currently, nonsteroidal anti-inflammatory drugs, ergot alkaloids, and triptans are the most commonly used drugs to abort an acute attack of migraine. Management of acute migraine is becoming a challenging task to physicians and patients due to several drawbacks faced with the use of aforementioned drugs. This lacuna is being filled up by developing drugs against novel targets such as calcitonin gene-related peptide (CGRP) and pituitary adenylate cyclase-activating peptide. In December 2019, the US Food and Drug Administration (FDA) approved ubrogepant for the treatment of acute migraine with or without aura in adults. Ubrogepant belongs to a new class of drugs called “Gepants” which are small molecules targeted against the CGRP receptor. The recommended initial dose is 50 mg or 100 mg orally. It follows first-order kinetics and is metabolized to a major extent by CYP3A4-mediated mechanisms. Compared to placebo, ubrogepant causes significant and rapid freedom from headache, pain and absence of migraine-associated most bothersome symptoms. Nausea, vomiting, and dry mouth are some of its common adverse effects. Ubrogepant with advantages such as good oral bioavailability, lack of vasoconstrictor action, and lack of hepatotoxicity might emerge as a promising drug for terminating an acute attack of migraine in the future. However, long-term clinical studies are needed to ascertain its safety profile.

The Traffic Light of Headache: Simplifying Acute Migraine Management for Physicians and Patients Using the Canadian Headache Society Guidelines.

Migraine is a disabling neurological condition and it is well described that early treatment is more effective and less likely to lead to headache recurrence. While it would seem intuitive for a migraine sufferer to treat early, despite well-established guidelines by the Canadian Headache Society, many sufferers continue to treat late. As a result, acute therapy is less effective, resulting in higher associated disability and a longer lasting attack. Pain scales can help patients determine how to treat; however, we propose a simple, easily recalled traffic light system to help patients determine which drug to use based upon how they feel. The traffic light system is based on the associated disability of the migraine attack, with green being a "I can still go" headache, a yellow being a "I have to slow down" headache, and a red being a "I have to stop" headache. The traffic light system leads to earlier more effective treatment with a reduction in migraine-associated disability.

The Evidence for the Role of Nutraceuticals in the Management of Pediatric Migraine: a Review.

Nutraceuticals are a form of complementary and alternative medicine that is commonly used by children and adolescents with migraine. In this review, observational studies, randomized controlled trials, systematic reviews, and meta-analyses on the efficacy and safety of single compound nutraceuticals for the management of migraine in children and adolescents were identified through a literature search of MEDLINE, Embase, and EBM Reviews-Cochrane Central Register of Controlled Trials. Twenty-one studies were reviewed, of which 11 were observational studies, 7 were randomized controlled trials, and 3 were systematic reviews. Six different nutraceuticals were included in the review: vitamin D, riboflavin, coenzyme Q10, magnesium, butterbur, and polyunsaturated fatty acids. All but three of the studies assessed the role of nutraceuticals in migraine prevention, while three studies evaluated the role of intravenous magnesium for acute migraine management. Overall, the quality and size of the studies were limited. Due to low quality evidence and limited studies, no definite conclusions can be drawn on the efficacy of nutraceuticals for the treatment of pediatric migraine. Future studies are warranted in order to establish evidence upon which to define the role of nutraceuticals in this patient population.