Migraine-specific Medications Research Articles

Which triptan for which patient?

The triptans were developed for the acute treatment of a migraine attack and have revolutionised the treatment of this disorder since their introduction in the early 1990s. Although their mechanisms of actions are similar and based on the stimulation of specific serotonin (5-hydroxytryptamine) receptors including peripheral 1B and central and peripheral 1D subtypes, each triptan has its own distinctive pK properties that result in different profiles of efficacy and tolerability. Triptans work by decreasing neurogenic inflammation peripherally in the meninges, vasoconstriction of meningeal vessels and by modulating secondary-order neurons in the brain stem. Studies of patient attitudes towards their acute care regimens reveal that they are often unhappy with some aspect of their treatment-usually the speed of action, degree of efficacy, presence of adverse events and the need for additional doses due to frequent and/or rapid recurrence. The majority of patients, when asked in a clinical trial performed at tertiary care headache centres, are willing to try another triptan. The aim of this article is to review the pK and clinical characteristics of these acute care, migraine-specific triptan medications and discuss how their individual characteristics lead to their preferred choice in various clinical scenarios. The pK and clinical efficacy data presented are taken from older published studies in which triptans were compared to placebo or each other, but the patients were asked to wait till the headache reached moderate or severe intensity prior to taking study medication. New studies have looked at early treatment paradigms and result in better efficacy data, but are difficult to compare due to different endpoints.

Evaluating the safety and tolerability profile of acute treatments for migraine

Among the medications that have been used as acute treatments for migraine are nonspecific agents, including nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics (either single or combination), and narcotics, as well as migraine-specific medications, including ergot alkaloids and triptans (5-hydroxytryptamine 1B/1D agonists). All of these drugs have side effects that vary in type and severity. Side effects of nonspecific medications, including gastrointestinal (GI) and renal effects with NSAIDs and cognitive effects and the potential for abuse with narcotics and butalbital-containing medications, have been documented over time, as these medications have been used for various indications. Side effects of the migraine-specific medications include GI and vascular symptoms with the ergots; for the triptans, they include chest and neurologic symptoms. Although adverse events are reported fairly frequently in patients receiving triptans, they are usually mild, and few patients discontinue therapy because of them. The most serious adverse events are cardiovascular. Because of potential vasoconstrictor effects--mild and transient increases in blood pressure and mild and transient effects on coronary artery tone--triptans as a class are contraindicated in patients with established or clinically suspected cardiovascular disease, specifically ischemic heart disease and uncontrolled hypertension. Other adverse events, including the potential for drug-drug interactions, are less common. Therefore, consideration should be given to the tolerability and safety of medications before their use as abortive medications for the treatment of migraine headache.

Initiating and optimizing acute therapy for migraine: The role of patient-centered stratified care

Migraine is a chronic, intermittently disabling condition that affects physical, mental, and social aspects of health-related quality of life. Because patients seeking assistance with migraine most often present to primary care providers, these healthcare professionals play critical roles in the diagnosis and treatment process. A comprehensive migraine management plan involves a partnership between the patient and healthcare professional where treatment goals and strategies are established. Elements of such a plan should include preventive strategies to reduce the frequency and effects of future attacks as well as the use of acute treatments to address the immediate need for relief during an attack. Approaches to prevention include education, lifestyle modification, and, often, appropriate medication. Many medications have been used for acute treatment. Nonspecific agents include nonsteroidal anti-inflammatory drugs (NSAIDs), single or combination analgesics (sometimes including antiemetics or caffeine), and narcotics. Migraine-specific medications include ergot alkaloids and triptans (5-hydroxytryptamine(1B/1D) agonists). Various professional organizations have created guidelines to help providers in choosing appropriate management interventions. Clinical approaches to the patient with migraine include step care, whereby all patients begin on a simple or nonspecific treatment, stepping up to the next level of therapy if treatment is unsuccessful; or stratified care, whereby first-line therapy is tailored to the severity of the patient's pattern of headache. Studies have demonstrated that for more disabled headache patients, the stratified-care approach results in more robust headache response with less disability and greater cost-effectiveness than step care. Patient satisfaction studies demonstrate that the use of migraine-specific abortive medications (triptans) is associated with a higher satisfaction rate than over-the-counter preparations, NSAIDs, and analgesic combinations. Patients who initially reported satisfaction with the latter medications also reported a preference for triptan therapy. Healthcare professionals can assist patients, not only by choosing the most appropriate medication but also by assessing whether the level of benefit the patient is currently receiving could be improved.

Migraine is associated with chest symptoms but not cardiac events

The association between migraine and coronary heart disease (CHD) is important for at least two reasons. As a common disorder of early and middle adult life, if migraine were a risk factor for CHD, it could account for a high proportion of CHD in these age groups. Second, because currently available migraine-specific medications constrict coronary arteries, if patients with migraine were at risk for CHD, greater caution in selecting patients for triptans might be warranted. The relationship between headaches in general and migraine in particular with the risk of CHD has been debated for many years. Case reports and clinical data suggest an association between angina, especially variant angina, and migraine. Epidemiologic studies have produced conflicting results. Two large investigations with cohort design and with diagnosis of CHD verified through medical records have been published. In the Kaiser Permanente study in Northern California, a retrospective cohort of ∼80,000 subjects showed that migraine was associated with self-reported chest pain but was not associated with an increased risk of myocardial infarction (MI) with the exception of women who had both a diagnosis …

Migraine Therapy: A Survey of Pharmacists' Knowledge, Attitudes, and Practice Patterns

Study pharmacists' knowledge, attitudes, and practice patterns with regard to migraine therapy. Pharmacists interact with headache sufferers at least 53,000 times daily, thus are well positioned to improve the less than optimal medication management of these disorders. Methods.-Two hundred self-administered surveys, distributed at a migraine symposium, assessing pharmacists' demographic characteristics and level of agreement or disagreement with treatment approaches were conducted. A total of 171 useable surveys (86%) were received. Of the sample, 35% were community pharmacists, 29% were hospital pharmacists, and the remainder were from other work environments. Exclusively among community pharmacists, 80% feel that headache is an important part of their practice, 85% make between one and five over-the-counter (OTC) headache product suggestions per day, and 12% make six or more daily OTC recommendations. Among all the sample's pharmacists, more than half feel migraine patients should try OTC drugs prior to prescription medications, only half ask patients about headache-related morbidity, and one-third feel migraine-specific medications should be reserved only for patients who initially fail nonspecific drugs. Few pharmacists utilize published migraine treatment guidelines. Approximately two-thirds of pharmacists do not feel migraine is a neurobiological illness. The majority is comfortable with their ability to identify people needing a physician referral. Our results show pharmacists, particularly those in community pharmacies, interact with headache sufferers multiple times daily. Most pharmacists were neither familiar with nor practice migraine therapies endorsed by evidence-based guidelines. Further training of pharmacists is warranted.

Cost considerations of acute migraine treatment.

To provide medication price data and cost-reducing strategies for the acute treatment of migraine. Retail prices for common acute care medications were found at http://www.drugstore.com. Cost-reduction tactics were obtained from literature searches and clinical experience. Several strategies can reduce cost without sacrificing treatment outcome. In mild to moderate migraine, low-priced nonsteroidal anti-inflammatory drugs can be used as first-line medications due to their proven efficacy and favorable tolerability. For patients with more severe migraine, implementing a stratified care approach-using migraine-specific medications early in acute treatment-is cost-effective for most patients. Stratified care not only improves outcome and decreases disability, but also reduces cost. Pill splitting and early administration of triptans within an attack enhance their value. Supplying rescue medications, such as opioids, sedatives, and phenothiazines, can prevent emergency department visits. Minimizing multiple dosing of triptans and reducing utilization of expensive health care resources are key factors in reducing the cost of effective migraine treatment. An important affordability factor for patients with co-payments is the number of triptan pills per package. Sumatriptan, naratriptan, and frovatriptan each contain 9 tablets per package, while most other triptan packages contain 6. Current triptan retail prices (per unit) include: Amerge 1 and 2.5 mg, 17.78 dollars; Axert 6.25 and 12.5 mg, 16.31 dollars; Frova 2.5 mg, 13.89 dollars; Imitrex 50 mg, 14.96 dollars; Imitrex 100 mg, 14.41 dollars; Imitrex Nasal Spray 20 mg, 21.61 dollars; Imitrex SQ 6 mg, 50.26 dollars; Maxalt 5 and 10 mg, 15 dollars; Maxalt-MLT 5 and 10 mg, 15 dollars; Relpax 40 mg, 13.58 dollars; Zomig 2.5 mg, 13.67 dollars; Zomig 5 mg, 15.89 dollars; Zomig-ZMT 2.5 mg, 13.67 dollars; and Zomig-ZMT 5 mg, 15.89 dollars. Practitioners can optimize the use of health care dollars without compromising quality of care through awareness of cost-saving treatment strategies, as well as price variations among medications.

Initial Abortive Treatments for Migraine Headache.

Stratify care by choosing the optimal medication for a migraine. Severe pain, significant disability, and associated features such as nausea or vomiting necessitate early treatment with specific, high efficacy therapy. Migraine patients may have a spectrum of headache presentations ranging from tension-type headaches to migraine headaches with or without aura. Mild headache types may respond to simple analgesics, though there is evidence that migraineurs will respond to migraine-specific medications such as the triptans for a range of headache phenotypes. Physicians should provide patients with medication to treat nausea and vomiting. They may be infrequent accompaniments, but medication such as a neuroleptic may avoid a trip to the emergency room. Provide rescue medication for an occasional failure of usual treatment to avoid further disability or emergency room visits. Avoid medication overuse by matching treatment to patient needs. A cycle of repetitive and escalating medication use can lead to transformation of migraine into chronic daily headache with analgesic-dependent rebound.

Menstrual migraine

An association between migraine and menstruation can be ascertained by use of a diary for a minimum of three cycles. The pathophysiological and clinical peculiarities of menstrual migraine indicate that its management should differ from that of non–menstrual migraine. NSAIDS or migraine-specific medications (e.g. triptans) are often effective for the acute management of menstrual migraine. Preventive treatment is indicated when the attacks are long–lasting, severe and disabling and do not respond to acute treatments. Short–term prophylaxis (at the time of headache vulnerability) employs standard drugs such as magnesium, ergotamine or NSAIDs; triptans are currently being evaluated for short–term prophylaxis. If severe menstrual migraine attacks cannot be controlled by these, hormone therapy (percutaneous or transdermal estrogen) may be indicated. Antiestrogen agents (danazol, tamoxifen) are indicated only in rare resistant cases.

Migraine: Diagnosis and Treatment.

Migraine is a genetically determined recurrent pain syndrome accompanied by neurological and gastrointestinal features, involving interaction of external triggers and internal pathophysiology and the cause of considerable disability to sufferers.This article discusses the pathophysiology and diagnosis of migraine and outlines a patient centred approach to management.Establishing the correct diagnosis is essential for success. Discussing a structured approach ("a puff, a gust, and a gale") in the recognition of a developing migraine attack can assist patients in appropriate self management. A "stepped care" approach to management of acute migraine involves initial nonpharmacological methods followed by antiemetics and simple analgesics or nonsteroidal anti-inflammatory medications. Moderate episodes are treated with antiemetics and migraine specific medications. More severe migraines often require parenteral medications and sometimes intravenous fluids. Prophylaxis involves adoption of a chronic disease model, identifying and avoiding triggers and causative factors for migraine, nonpharmacological methods such as dietary modification and biofeedback, and for some patients, pharmacological prophylaxis.