Treatment Of Migraine Attacks Research Articles

The iontophoretic transdermal system formulation of sumatriptan as a new option in the acute treatment of migraine: a perspective.

An iontophoretic transdermal system (ITS) (skin patch) formulation of sumatriptan for the acute treatment of migraine attacks was approved by the US Food and Drug Administration in January 2013. This transdermal system bypasses the gastrointestinal tract, as it uses low electrical current to move sumatriptan transdermally into the subcutaneous tissue. Randomized, double-blind, controlled clinical trials have demonstrated minimal triptan-related side effects and superior efficacy versus placebo, comparable with other sumatriptan formulations. Sumatriptan ITS can be applied successfully during a mild or severe migraine attack. According to pharmacokinetic properties and clinical data, sumatriptan ITS may be a good choice for people with migraine and severe nausea, vomiting or gastroparesis, those with intolerable triptan-related adverse events and those not responding optimally to oral medications.

Triptan use among hospital workers affected by migraine

Triptans represent the most specific and effective treatment for migraine attacks. Nevertheless, in clinical practice, they are often underused. Hospital workers, in particular physicians, are expected to be more aware of the correct use of specific drugs, especially for a very common disease such as migraine. Aim of this study was to evaluate whether different hospital workers affected by migraine are able to correctly manage the most suitable therapy for their migraine attacks. During a 1-year period, we submitted hospital employees to a structured interview with a questionnaire to investigate the presence of headache and its characteristics. In particular, in the subpopulation of subjects affected by migraine, we took information regarding their usual treatment for the control of attacks. The type of drug and the category of the working activity were synthesized as two different ordinal variables. Difference in the distribution of the different drug categories was evaluated with Chi squared test. Statistics was performed with SPSS 13.0 for Windows systems. We enrolled 1250 consecutive subjects: 20.3 % of the population (254 patients) was affected by migraine. Triptans use was significantly lower than that of non-steroidal anti-inflammatory drugs. The distribution of the use of the drugs was significantly different (p < 0.0001) at Chi squared test. Among migraineur physicians, only 10.7 % used triptans. Even in this subgroup, we observed a significant difference (p < 0.0001) in the distribution of the use of the drugs at Chi squared test. Our findings show a reduced use of triptans among hospital workers. These data reflect the unsatisfactory dissemination of knowledge regarding the correct management of migraine attacks and the advantages of treatment with triptans. An incorrect therapeutic approach to migraine contributes to the risk of the most important complications, such as drugs abuse or illness chronicization. These findings suggest that an insufficient awareness of migraine-related therapeutic options also involves hospital workers, including physicians.

Early (≤ 1-h) vs. late (>1-h) administration of frovatriptan plus dexketoprofen combination vs. frovatriptan monotherapy in the acute treatment of migraine attacks with or without aura: a post hoc analysis of a double-blind, randomized, parallel group study.

The early use of triptan in combination with a nonsteroidal anti-inflammatory drug after headache onset may improve the efficacy of acute migraine treatment. In this retrospective analysis of a randomized, double-blind, parallel group study, we assessed the efficacy of early or late intake of frovatriptan 2.5 mg + dexketoprofen 25 or 37.5 mg (FroDex 25 and FroDex 37.5) vs. frovatriptan 2.5 mg alone (Frova) in the acute treatment of migraine attacks. In this double-blind, randomized parallel group study 314 subjects with acute migraine with or without aura were randomly assigned to Frova, FroDex 25, or FroDex 37.5. Pain free (PF) at 2-h (primary endpoint), PF at 4-h and pain relief (PR) at 2 and 4-h, speed of onset at 60, 90, 120 and 240-min, and sustained pain free (SPF) at 24-h were compared across study groups according to early (≤1-h; n = 220) or late (>1-h; n = 59) intake. PF rates at 2 and 4-h were significantly larger with FroDex 37.5 vs. Frova (early intake, n = 71 FroDex 37.5 and n = 75 Frova: 49 vs. 32 % and 68 vs. 52 %, p < 0.05; late intake, n = 20 Frodex 37.5, and n = 18 Frova: 55 vs. 17 %, p < 0.05 and 85 vs. 28 %, p < 0.01). Also with FroDex 25, in the early intake group (n = 74) PF episodes were significantly higher than Frova. PR at 2 and 4-h was significantly better under FroDex 37.5 than Frova (95 % vs. 50 %, p < 0.001, 100 % vs. 72 %, p < 0.05) in the late intake group (n = 21). SPF episodes at 24-h after early dosing were 25 % (Frova), 45 % (FroDex 25) and 41 % (FroDex 37.5, p < 0.05 combinations vs. monotherapy), whereas they were not significantly different with late intake. All treatments were equally well tolerated. FroDex was similarly effective regardless of intake timing from headache onset.

Acute Migraine Treatment in Adults.

There are many options for acute migraine attack treatment, but none is ideal for all patients. This study aims to review current medical office-based acute migraine therapy in adults and provides readers with an organized approach to this important facet of migraine treatment. A general literature review includes a review of several recent published guidelines. Acetaminophen, 4 nonsteroidal anti-inflammatory drugs (NSAIDs) (ibuprofen, acetylsalicylic acid [ASA], naproxen sodium, and diclofenac potassium), and 7 triptans (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan) have good evidence for efficacy and form the core of acute migraine treatment. NSAID-triptan combinations, dihydroergotamine, non-opioid combination analgesics (acetaminophen, ASA, and caffeine), and several anti-emetics (metoclopramide, domperidone, and prochlorperazine) are additional evidence-based options. Opioid containing combination analgesics may be helpful in specific patients, but should not be used routinely. Clinical features to be considered when choosing an acute migraine medication include usual headache intensity, usual rapidity of pain intensity increase, nausea, vomiting, degree of disability, patient response to previously used medications, history of headache recurrence with previous attacks, and the presence of contraindications to specific acute medications. Available acute medications can be organized into 4 treatment strategies, including a strategy for attacks of mild to moderate severity (strategy one: acetaminophen and/or NSAIDs), a triptan strategy for patients with severe attacks and for attacks not responding to strategy one, a refractory attack strategy, and a strategy for patients with contraindications to vasoconstricting drugs. Acute treatment of migraine attacks during pregnancy, lactation, and for patients with chronic migraine is also discussed. In chronic migraine, it is particularly important that medication overuse is eliminated or avoided. Migraine treatment is complex, and treatment must be individualized and tailored to the patient's clinical features. Clinicians should make full use of available medications and formulations in an organized approach.

Efficacy of frovatriptan as compared to other triptans in migraine with aura.

BackgroundThe treatment of migraine attacks with aura by triptans is difficult since triptans most probably are not efficacious when taken during the aura phase. Moreover, there are insufficient data from randomised studies whether triptans are efficacious in migraine attacks with aura when taken during the headache phase. In this metaanalysis, we aimed to compare the efficacy of frovatriptan versus rizatriptan, zolmitriptan, and almotriptan.MethodsFive double-blind, randomized, controlled crossover trials were pooled. All trials had an identical design. Patients were asked to treat three consecutive migraine attacks with frovatriptan 2.5 mg and three consecutive migraine attacks with a comparative triptan (rizatriptan 10 mg; zomitriptan 2.5 mg; almotriptan 12.5 mg).ResultsIn this analysis, 117 migraine attacks with aura could be included (intention-to-treat population). The mean headache intensity after 2 hours was 1.2 +/- 1.0 for frovatriptan and 1.6 +/- 1.0 for the other triptans (p<0.05); all triptans showed significant improvement of headache. Frovatriptan resulted in significantly lower relapse rates at 24 hours and 48 hours when taken in migraine attacks with aura.ConclusionsOur data suggest that frovatriptan is efficacious and even superior in some endpoints also when taken during the headache phase in migraine attacks with aura. This is of particular importance for those many patients who have migraine attacks both without and with aura.

Современные подходы к фармакотерапии мигрени

Статья посвящена одной из разновидностей головной боли — мигрени. Приведены этапы и критерии успешного лечения приступов мигрени. Лекарственными средствами выбора для терапии приступа мигрени легкой или средней тяжести признаны нестероидные противовоспалительные препараты (НПВП). Одним из наиболее эффективных НПВП для лечения и профилактики мигрени является напроксен натрия (Налгезин форте). Если приступы не удается купировать с помощью НПВП, назначают препараты с более выраженным специфическим действием (триптаны). Лекарственная профилактическая терапия оправданна при частых (не менее 3 раз в месяц) тяжелых приступах мигрени, а также при наличии коморбидных нарушений.

Cefalea (II). Migraña

Migraine is the second most common primary headache after tension headaches. Sometimes cause significant alteration of the quality of life of sufferers. Diagnosis and treatment of the crisis abortive and prophylactic treatment of them is essential. For proper management will have to individualize treatment depending on age, sex and other comorbidities experienced by the migraine sufferer. The treatment of migraine attacks and prophylactic, should be applied to the required dose or in synergistic combinations, to improve effectiveness and prevent side effects. For handling not only drug treatment will be considered, but also the avoidance of triggers or enhancers factors. There are certain types of migraines less frequent occurrence, but if you do not think they can make the patient suffer wrong, and even dangerous treatment unneccesary and request unnecessary tests. Always before a migraine sufferer will have to make an accurate medical history and neurological examination to detect signs or warning signs that make us a test of neuroimaging or referral to a neurologist.

Population pharmacokinetic analysis of the multiple peaks phenomenon in sumatriptan

+ The first two authors contributed equally to this work. The objective of this study was to develop a population pharmacokinetic (PK) model for sumat - riptan, which frequently shows an atypical absorption profile with multiple peaks. Sumatriptan, a selective agonist for the vascular serotonin (5-HT1) receptor that causes vasoconstriction of the cerebral arteries, is used for the acute treatment of migraine attack with or without aura. Despite its relatively high between-subject variability, few reports have addressed PK modeling of sumatriptan. Plasma data obtained after a single 50-mg oral dose of sumatriptan in 26 healthy Korean male sub - jects were used. Blood samples were collected 0 (predose), 0.25, 0.5, 0.75, 1, 1.5, 2, 2.5, 3, 4, 6, 8, 10, and 12 h after dosing. Plasma sumatriptan concentrations were analyzed using UPLC/MS/MS. Pop - ulation PK analysis was performed using plasma concentration data for sumatriptan with NON- MEM (ver. 7.2). A total of 364 concentrations of sumatriptan were captured by a one-compartment model with first-order elimination, and a combined transit compartment model and first-order absorption with lag time was successful in describing the PK with multiple peaks in the absorption phase of sumatriptan. The creatinine clearance as a covariate significantly ( P < 0.01) influenced the absorption fraction (f ). The final model was validated through a visual predictive check and boot - strapping with no serious model misspecification.

The acute treatment of migraine in adults: the american headache society evidence assessment of migraine pharmacotherapies.

The study aims to provide an updated assessment of the evidence for individual pharmacological therapies for acute migraine treatment. Pharmacological therapy is frequently required for acutely treating migraine attacks. The American Academy of Neurology Guidelines published in 2000 summarized the available evidence relating to the efficacy of acute migraine medications. This review, conducted by the members of the Guidelines Section of the American Headache Society, is an updated assessment of evidence for the migraine acute medications. A standardized literature search was performed to identify articles related to acute migraine treatment that were published between 1998 and 2013. The American Academy of Neurology Guidelines Development procedures were followed. Two authors reviewed each abstract resulting from the search and determined whether the full manuscript qualified for review. Two reviewers studied each qualifying full manuscript for its level of evidence. Level A evidence requires at least 2 Class I studies, and Level B evidence requires 1 Class I or 2 Class II studies. The specific medications - triptans (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan [oral, nasal spray, injectable, transcutaneous patch], zolmitriptan [oral and nasal spray]) and dihydroergotamine (nasal spray, inhaler) are effective (Level A). Ergotamine and other forms of dihydroergotamine are probably effective (Level B). Effective nonspecific medications include acetaminophen, nonsteroidal anti-inflammatory drugs (aspirin, diclofenac, ibuprofen, and naproxen), opioids (butorphanol nasal spray), sumatriptan/naproxen, and the combination of acetaminophen/aspirin/caffeine (Level A). Ketoprofen, intravenous and intramuscular ketorolac, flurbiprofen, intravenous magnesium (in migraine with aura), and the combination of isometheptene compounds, codeine/acetaminophen and tramadol/acetaminophen are probably effective (Level B). The antiemetics prochlorperazine, droperidol, chlorpromazine, and metoclopramide are probably effective (Level B). There is inadequate evidence for butalbital and butalbital combinations, phenazone, intravenous tramadol, methadone, butorphanol or meperidine injections, intranasal lidocaine, and corticosteroids, including dexamethasone (Level C). Octreotide is probably not effective (Level B). There is inadequate evidence to refute the efficacy of ketorolac nasal spray, intravenous acetaminophen, chlorpromazine injection, and intravenous granisetron (Level C). There are many acute migraine treatments for which evidence supports efficacy. Clinicians must consider medication efficacy, potential side effects, and potential medication-related adverse events when prescribing acute medications for migraine. Although opioids, such as butorphanol, codeine/acetaminophen, and tramadol/acetaminophen, are probably effective, they are not recommended for regular use.

Current therapies in episodic migraine management

Migraine is a common neurological disease characterized by severe, recurrent episodes of throbbing, unilateral, headache. Non-pharmacologic migraine treatment refers to the patient behavioral modification in order to avoid trigger. Current therapies in migraine attack treatment are non-specific drugs (non-steroidal anti-inflammatory drugs, aspirin, antiemetics) and specific antimigraine drugs (ergot alkaloids, serotonin 5-HT1B/1D receptor agonists – triptans). For migraine prophylaxis are recommended beta-blockers (metoprolol, propranolol), calcium channel blockers (flunarizine), antiepileptic drugs (valproic acid, topiramate), antidepressants (amitriptilyne, fluoxetine).

How to effectively treat migraine attacks

How to effectively treat migraine attacks

Practical implications of the migraine cardio- and cerebrovascular association: unmet needs of patients.

Numerous studies have described a relationship between migraine and stroke, and there is emerging evidence that migraine is also associated with cardiovascular disease. The combination of migraine and both cerebrovascular and cardiovascular disease has implications for therapy. We conducted a review of the modifications in medical therapy in patients with comorbid migraine and cardio- and cerebrovascular disorders based on publications from the last 15 years. Some drugs are contraindicated to treat migraine attacks (ergots, triptans) or for migraine prevention in patients after transient ischemic attack (TIA)/ischemic stroke. Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated in patients with cerebral bleeding. Some drugs for the treatment of acute migraine attacks are contraindicated in patients with symptomatic coronary heart disease. Given the large number of patients with comorbid migraine and cardiovascular as well as cerebrovascular disease, there is an unmet need to treat these patients.

EHMTI-0368. Treatment of migraine attacks as suggested by Dr. John R. Graham in 1955. A historical analysis with current implications

In 1955 Dr. John R. Graham, an astute clinician, published 3 influential papers on migraine theories and mainly on treatment of migraine in the New England Journal of Medicine [1,2,3]. Many of Dr. Graham’s clinical observations remain relevant to current methods of treating migraine attacks and some of his examples of suggestions are shown below. Examples of suggestions on ergot therapy: 1. The patient should be checked regarding to diagnosis of migraine and possible contraindications to ergot therapy. 2. The ergot dose should be carefully selected as the minimally effective dose. 3. The patient should be instructed to use ergot as early in the attack as he can make the diagnosis of “one of his migraine.” 4. He should be urged to use the selected amount of ergot at the start rather than to distribute it over several hours. 5. Ergot derivatives should not be considered a failure until ergotamine tartrate has been given, early in an attack, by the parenteral route.

EHMTI-0036. Gammacore device for treatment of migraine attack: preliminary report

despite the several options for treatment of migraine attack , sometimes pain episodes remain unresolved and often patients ask for non pharmacological methods for aborting attack which can be a valid alternative to the use of medications.

EHMTI-0052. Efficacy of early vs. late use of frovatriptan combined with dexketoprofen vs. frovatriptan alone in the acute treatment of migraine attacks with or without aura

EHMTI-0052. Efficacy of early vs. late use of frovatriptan combined with dexketoprofen vs. frovatriptan alone in the acute treatment of migraine attacks with or without aura

Pharmacological and non-pharmacological treatment of pediatric primary headaches

Primary headaches represent highly prevalent diseases in childhood and adolescence. Unlike in adulthood, in children the most common primary headache is migraine, while tension-type headache (TTH) is less diffused, especially up to 10 years of age. Cluster headache is to be considered exceptional, showing a prevalence of 0.1%. While in TTH painful attacks are often of weak intensity and do not require particular treatment, migraine attacks often impair child’s quality of life and need to be interrupted. The first choice drug for the migrainous attack treatment should be ibuprofen. In case of failure, paracetamol and other NSAIDs should be considered. Triptans, which are the most effective drugs for the migraine attack treatment in adults, are not authorized in children, with the exclusion of sumatriptan 10 mg spray. Whether migraine attacks become too frequent or they do not respond to symptomatic treatment, a prophylactic therapy should be considered. Among drugs used for migraine prophylaxis, only flunarizine and topiramate have solid evidence of effectiveness, although there are also some data in favor of valproate and amitriptyline. It should be underlined that the practice to use minerals or herbs for migraine prophylaxis does not have any scientific support. Non-pharmacological treatments have also been proposed for pediatric migraine. Cognitive treatment, associated with amitriptyline, has proved useful in chronic migraine. In different painful syndrome, acupuncture was demonstrated to have an analgesic effect. Although a specific demonstration of acupuncture efficacy in pediatric migraine is lacking, this non-pharmacological intervention should be considered, especially in drug resistant cases.

Zolmitriptan for acute migraine attacks in adults.

Migraine is a common, disabling condition and a burden for the individual, health services, and society. Zolmitriptan is an abortive medication for migraine attacks, belonging to the triptan family. These medicines work in a different way to analgesics such as paracetamol and ibuprofen. To determine the efficacy and tolerability of zolmitriptan compared to placebo and other active interventions in the treatment of acute migraine attacks in adults. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and the Oxford Pain Relief Database, together with three online databases (www.astrazenecaclinicaltrials.com, www.clinicaltrials.gov, and apps.who.int/trialsearch) for studies to 12 March 2014. We also searched the reference lists of included studies and relevant reviews. We included randomised, double-blind, placebo- or active-controlled studies, with at least 10 participants per treatment arm, using zolmitriptan to treat a migraine headache episode. Two review authors independently assessed trial quality and extracted data. We used numbers of participants achieving each outcome to calculate risk ratios and numbers needed to treat for an additional beneficial effect (NNT) or harmful effect (NNH) compared with placebo or a different active treatment. Twenty-five studies (20,162 participants) compared zolmitriptan with placebo or an active comparator. The evidence from placebo-controlled studies was of high quality for all outcomes except 24 hour outcomes and serious adverse events where only limited data were available. The majority of included studies were at a low risk of performance, detection and attrition biases, but did not adequately describe methods of randomisation and concealment.Most of the data were for the 2.5 mg and 5 mg doses compared with placebo, for treatment of moderate to severe pain. For all efficacy outcomes, zolmitriptan surpassed placebo. For oral zolmitriptan 2.5 mg versus placebo, the NNTs were 5.0, 3.2, 7.7, and 4.1 for pain-free at two hours, headache relief at two hours, sustained pain-free during the 24 hours postdose, and sustained headache relief during the 24 hours postdose, respectively. Results for the oral 5 mg dose were similar to the 2.5 mg dose, while zolmitriptan 10 mg was significantly more effective than 5 mg for pain-free and headache relief at two hours. For headache relief at one and two hours and sustained headache relief during the 24 hours postdose, but not pain-free at two hours, zolmitriptan 5 mg nasal spray was significantly more effective than the 5 mg oral tablet.For the most part, adverse events were transient and mild and were more common with zolmitriptan than placebo, with a clear dose response relationship (1 mg to 10 mg).High quality evidence from two studies showed that oral zolmitriptan 2.5 mg and 5 mg provided headache relief at two hours to the same proportion of people as oral sumatriptan 50 mg (66%, 67%, and 68% respectively), although not necessarily the same individuals. There was no significant difference in numbers experiencing adverse events. Single studies reported on other active treatment comparisons but are not described further because of the small amount of data. Zolmitriptan is effective as an abortive treatment for migraine attacks for some people, but is associated with increased adverse events compared to placebo. Zolmitriptan 2.5 mg and 5 mg benefited the same proportion of people as sumatriptan 50 mg, although not necessarily the same individuals, for headache relief at two hours.

Migraine Attack Treatment : A Tailor-made Suit, Not One Size Fits All

About 15% of people in the world suffer migraine attacks. Migraine can induce a great impact in the quality of life, and the costs of medical care and loss of productivity can be also high. Non-steroidal anti-inflammatory drugs (NSAIDs) are the best treatment in mild-to-moderate migraine attacks and triptans are the first line option in the acute treatment of moderate-to-severe migraine attacks. At present, there are seven marketed triptans: sumatriptan, rizatriptan, zolmitriptan, eletriptan, naratriptan, almotriptan and frovatriptan. Obviously, every drug presents different pharmacokinetic and pharmacodynamics properties and, moreover, some triptans have several formulations. The prescription of one of these seven triptans for a specified patient is based in the drug profile: efficacy, safety, pharmacokinetics and pharmacodynamics. Other data to take account in the final prescription are clinical characteristics of the migraine attack (speed of onset, intensity of pain, lasting of the attack) and patient characteristics as working habits, life style or medical history. It is therefore mandatory to perform an individualization of the treatment of migraine attack. In recent years, several new patents of drugs have been registered in the treatment of migraine attack, although most of these are already known drugs that only provide new routes of administration. We present an update on the treatment of the migraine attack.

Tackling chronic migraine: current perspectives.

In the last decade, several diagnostic criteria and definitions have been proposed for chronic migraine (CM). The third edition of the International Classification of Headache Disorders–3 beta, published in 2013, has revised CM diagnostic criteria. CM is defined as “headache occurring on 15 or more days per month for more than 3 months, which has the features of migraine headache on at least 8 days per month.” Patients who meet the criteria for CM and for medication-overuse headache should be given both diagnoses. Worldwide, CM prevalence ranges 1%–3%, and its incidence has been estimated to be 2.5% per year. CM is associated with disability and poor quality of life. Modifiable risk factors include (among others): migraine progression (defined as an increase in frequency and severity of migraine attacks); medication and caffeine overuse; obesity; stressful life events; and snoring. CM patients have a significantly higher frequency of some comorbid conditions, including chronic pain, psychiatric disorders, respiratory illness, and some vascular risk factors. Management includes identification and control of comorbidities and risk factors that predispose to CM; treatment and prevention for medication overuse; early treatment for migraine attacks; and an adequate preventive therapy for CM. Several randomized controlled clinical trials have shown the efficacy of topiramate, amitriptyline, onabotulinumtoxinA, and cognitive-behavioral therapy in CM.

Opioids in Headache

Opioid analgesics have long been used to treat head pain of various types. This has been increasing to a significant degree over the past 25 years because of a trend for more liberal use of opioids in non-malignant pain. Opioid treatment for acute headache, as well as prophylactically for refractory chronic headache, is controversial. There are a number of adverse effects associated with acute and chronic opioid treatment. Tolerance, dependence, and addiction are prominent issues. This article attempts to analyze the benefits and disadvantages for opioids in the management of migraine and other headache disorders, relying on known properties of this class of medication as well as clinical data. It will mainly focus on 2 topics: the use of opioid medication for the acute treatment of migraine attacks and continuous prophylactic use for refractory chronic migraine.