Use Of Triptans Research Articles

Management of migraine by hospital emergency departments: a retrospective observational study carried out at the Hospital Universitario Virgen del Rocio

Migraine is the second most common type of primary headache disorder in Europe, accounting for 2.8% of visits to emergency departments. Some studies have shown that emergency departments may approach the disorder in ways that may be insufficient or inadequate. A retrospective observational study was conducted of patients with migraine who were discharged from the adult emergency department of the Hospital Universitario Virgen del Rocio in 2020. Variables related to their healthcare were analysed. 73.9% were women, with a mean age of 38 years. They were not asked about the frequency of their migraines. The mean length of time patients spent in the emergency department before receiving initial medical care was 45 minutes (standard deviation: 41). Computed tomography scans were requested for 27.4% of the patients, and these were not pathological. Nonsteroidal anti-inflammatory drugs were the most commonly used treatment for the symptoms. Opioids were also used. Preventive treatments were prescribed in 6% of cases. Management of migraines by emergency departments is limited, and as such continuous and updated training is important. The use of triptans and occipital nerve blocks should be encouraged, and the use of opioids, among other drugs, should cease.

Cost of illness and labour market disaffiliation among patients with migraine discontinuing triptan treatment: A Danish nationwide register study from 1995 to 2021.

Migraine presents significant health and economic challenges. Despite the widespread use of triptans, some patients discontinue them because of insufficient relief or adverse effects. Using national registers, the present study investigates the excess costs and labour market disaffiliation of Danish patients discontinuing triptan treatment. The study included all individuals ≥18 years ("patients") who discontinued redemption of triptan prescriptions between 1998 and 2019. They were categorized by number of distinct triptans redeemed before discontinuation: one, two or three or more. A control group was established from the general population without triptan redemptions, three per patient, matched by year of birth, sex and region of residence. We estimated excess direct and indirect costs from 5 years prior ("year -5") to 10 years post ("year 10") the first triptan redemption. We identified 211,026 patients who discontinued triptan redemption, 82% after one, 14% after two and 4% after three or more distinct triptans. Over the period from year -5 to year 10, average excess healthcare costs per patient in these cohorts were EUR 9,554, EUR 10,942 and EUR 12,812 respectively. Over the same period, these patients earned EUR 27,964, EUR 35,920 and EUR 50,076 less than their respective controls, and received higher public transfer payments of EUR 20,181, EUR 23,264 and EUR 26,459. Triptan discontinuers, who appear to have exhausted all current treatment avenues, face high direct and very high indirect excess costs attributable to migraine, and experience substantial increased labour market disaffiliation.

Triptan non-response in a London tertiary headache centre: What can we learn? A retrospective study.

Triptans revolutionized the acute treatment of migraine; however, varied responses to triptans, as a result of poor efficacy and tolerability, are reported. A standardized definition of triptan non-response was recently proposed by the European Headache Federation (EHF). There is currently limited data available on the prevalence of triptan non-response. We used clinic letters over a two-year duration to evaluate the triptan response and triptan efficacy or tolerability failure, or both, in a London-based tertiary headache service. In total, 419 adult migraine patients (females: 83.8%, age: 46 ± 18years, chronic migraine: 88.5%) were included in a service evaluation. In line with the EHF definitions, "triptan non-response" was seen in 63.8% of patients (264/414), whereas 37.7% of patients (156/414) had failed at least two triptans (EHF "triptan resistant") and 4.6% of patients (19/414) had failed at least three triptans, including a subcutaneous formulation (EHF "triptan refractory"). Notably, 21.3% of patients (88/414) had failed at least three triptans inclusive and exclusive of subcutaneous triptan use. Advancing age (p < 0.001) and the presence of medication overuse (p = 0.006) increased the probability of triptan response, whereas an increased number of failed preventives (p < 0.001) and the use of calcitonin gene-related peptide monoclonal antibodies (p = 0.022) increased the probability of triptan non-response. The largest proportion of patients responded to eletriptan (49.5%), followed by nasal zolmitriptan (44.4%) and rizatriptan (35.7%). Our findings highlight an alarming prevalence of triptan non-response among adult migraineurs receiving treatment in a London-based tertiary headache service. It is imperative for clinicians to explore methods to optimize acute medication efficacy, whether this comprises changing to a triptan with a superior response rate, advocating for early intervention or considering alternative acute medication classes, such as gepants or ditans.

Migraine headache in patients with spontaneous coronary artery dissection: A report of the iSCAD Registry.

Spontaneous coronary artery dissection (SCAD) is a nonatherosclerotic cause of myocardial infarction. Migraine headache has been reported to be common among patients with SCAD, but the degree of migraine-related disability has not been quantified. Clinical data and headache variables were obtained from the baseline assessment of the prospective, multicenter iSCAD Registry. Migraine-related disability was quantified using the self-reported Migraine Disability Assessment (MIDAS). Demographic, clinical, psychosocial, and medical characteristics from data entry forms were compared between patients with and without migraine. Of the 773 patients with available data, 46% reported previous or current migraines. Those with migraines were more likely to be women (96.9% vs 90.3%, p = 0.0003). The presence of underlying carotid fibromuscular dysplasia was associated with migraine (35% vs 27%, p = 0.0175). There was not a significant association with carotid artery dissection and migraine. Current migraine frequency was less than monthly (58%), monthly (24%), weekly (16%), and daily (3%). Triptan use was reported in 32.5% of patients, and 17.5% used daily migraine prophylactic medications. Using the MIDAS to quantify disability related to migraine, 60.2% reported little or no disability, 14.4% mild, 12.7% moderate, and 12.7% severe. The mean MIDAS score was 9.9 (mild to moderate disability). Patients with SCAD had higher rates of depression and anxiety (28.2% vs 17.7% [p = 0.0004] and 35.3% vs 26.7% [p = 0.0099], respectively). Migraines are common, frequent, and a source of disability in patients with SCAD. The association between female sex, anxiety, and depression may provide some insight for potential treatment modalities.

Cardiovascular safety of dihydroergotamine mesylate delivered by precision olfactory delivery (INP104) for the acute treatment of migraine.

To report the cardiovascular (CV) safety of dihydroergotamine mesylate (DHE) administered by precision olfactory delivery (INP104) from two clinical trials. Although the absolute risk is low, migraine is associated with an increased risk of CV events. DHE is a highly effective acute treatment for migraine, but due to its theoretical risk of promoting arterial vasoconstriction, DHE is contraindicated in patients with CV disease or an unfavorable risk factor profile. The INP104 is a novel drug-device combination product approved for acute treatment of migraine that delivers DHE to the upper nasal space using precision olfactory delivery (POD®). The STOP 101 was a Phase 1 open-label study that assessed the safety, tolerability, and bioavailability of INP104 1.45 mg, intravenous DHE 1.0 mg, and MIGRANAL (nasal DHE) 2.0 mg in healthy participants. The STOP 301 was a pivotal Phase 3, open-label study that assessed the safety, tolerability, and exploratory efficacy of INP104 1.45 mg over 24 and 52 weeks in patients with migraine. In both studies, active or a history of CV disease, as well as significant CV risk factors, were exclusion criteria. In STOP 101, 36 participants received one or more doses of investigational product. Treatment with intravenous DHE, but not INP104 or nasal DHE, resulted in clinically relevant changes from baseline in systolic blood pressure (BP; 11.4 mmHg, 95% confidence interval [CI] 7.9-15.0) and diastolic BP (13.3 mmHg, 95% CI 9.4-17.1) at 5 min post-dose, persisting up to 30 min post-dose for systolic BP (6.3 mmHg; 95% CI 3.0-9.5) and diastolic BP (7.9 mmHg, 95% CI 3.9-11.9). None of the treatments produced any clinically meaningful electrocardiogram (ECG) changes. In STOP 301, 354 patients received one or more doses of INP104. Over 24 weeks, five patients (1.4%) experienced a non-serious, vascular treatment-emergent adverse event (TEAE). Minimal changes were observed for BP and ECG parameters over 24 or 52 weeks. Off-protocol concomitant use of triptans and other ergot derivatives did not result in any TEAEs. In two separate studies, INP104 demonstrated a favorable CV safety profile when used in a study population without CV-related contraindications.

TRIPTANS: HOPE FOR THE BEST, PREPARE FOR THE WORST

Abstract The estimated prevalence of headaches in the population is 66%. According to recent guidelines, basic analgesics, nonsteroidal anti–inflammatory drugs (NSAIDs), or acetaminophen are frequently used as first–line treatment for mild migraine attacks. A triptan is added when analgesic–resistant attacks occur. So these drugs are used as a second–line medication for mild migraines and a first–line medication for moderate to severe headaches. A correlation between spontaneous coronary artery dissection (SCAD) and triptans has already been reported in the literature. If myocardial infarction is more common in patients with cardiovascular risk factors, SCAD seems more frequent in young and smoker females. What is interesting is the speculation of the pathophysiological mechanisms of SCAD after triptans use. A possible option may consist in the fact that the dissection of the anterior descending artery is due to circumferential shear stress caused by these drugs, combined with smoking habits and estrogen deprivation. These latters influence the immune system and the circulating progenitor cells, which are reduced and less active to replace senescent endothelial cells. That is why an intimal flap is formed so that the blood would enter the media and the dissection would be perpetuated. The suspension of the drug is necessary to prevent the vasoconstriction of the vessel from exacerbating the wall stress caused by smoke and sexual hormones deficiency.

Triptan use in elderly over 65 years and the risk of hospitalization for serious vascular events

BackgroundSeveral studies have focused on the use of triptan and the risk of acute vascular events but the existence of such association is still debated and has never been quantified in patients over 65 years. To assess whether triptan use among older is associated with an increased risk of hospitalization for acute vascular events.MethodsA propensity score-matched cohort study was designed using the French national health insurance database linked to hospital stays. Patients aged ≥ 65 years, newly treated by triptans between 2011 and 2014, were included… The primary event was hospitalization for an acute ischemic vascular event within de 90 days following triptan initiation. Association with triptan exposure was investigated through cox regression model, considering exposure at inclusion, and with exposure as a time-varying variable A case-crossover (CCO) and a self-controlled case series (SCCS) analyses were also conducted to address potential residual confounding.ResultsThe cohort included 24, 774 triptan users and 99 096 propensity matched controls (mean (SD) age: 71 years (5.9), 74% of women). Within 90 days after cohort entry, 163 events were observed in the triptan group, and 523 in the control group (0.66% vs. 0.53%, adjusted hazard ratio (aHR) exposed/not exposed 1.25 95%CI [1.05–1.49]; aHR time−varying 8.74 [5.21–14.66]). The association was significant (CCO) for all events (adjusted odds ratio (aOR1.63 [1.22–2.19]) with a more consistent association with cerebral events (aOR 2.14 [1.26–3.63]). The relative incidence (RI) for all events was 2.13 [1.76–2.58] in the SCCS, for cardiac (RI: 1.67 [1.23–2.27]) and for cerebral events (RI: 3.20, [2.30–4.45]).ConclusionThe incidence of acute vascular events was low among triptan users. We found that triptan use among older may be associated with a low increased risk for acute vascular events, which may be more marked for cerebral events such as stroke, than for cardiac events.

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.

Breastfeeding-Related Adverse Drug Reactions of Triptans: A Descriptive Analysis Using Four Pharmacovigilance Databases.

Objective: Migraine attacks are common in women of reproductive age. Although attacks are often less severe and less frequent during pregnancy, they regularly reoccur shortly after delivery. When first-line analgesic treatment is insufficient, triptans may be used for acute treatment of migraine attacks. Milk levels of occasional triptan use have shown to be low, and no adverse effects in breastfed infants have been reported. However, the available knowledge on the safety of triptans during breastfeeding is still limited. Methods: Four (inter)national pharmacovigilance databases were searched for breastfeeding related adverse drug reactions of triptans. These included the Dutch Pregnancy Drug Register and three databases of spontaneous reports (Netherlands Pharmacovigilance Centre Lareb, the European Medicines Agency [EudraVigilance], and the World Health Organization [VigiBase]). Results: A total of 26 reports on 27 breastfeeding related adverse drug reactions were identified (one report involved two separate adverse drug reactions). These involve three main complaints: painful breasts and/or nipples, painful milk ejection reflex, and a decrease in milk production. Discussion and Conclusion: The hypothesized pharmacological mechanism relates to the serotonin-receptor agonistic properties of triptans. These may lead to vasoconstriction in the breasts and nipples, including the vasculature surrounding the milk ducts and alveoli, and may also influence the hormonal function and levels of prolactin. The reported adverse drug reactions do not negatively impact the overall compatibility of triptans with breastfeeding. However, breastfeeding women may experience them as unsettling. Awareness of these potential adverse drug reactions is essential and should be weighed against the potential adverse effects of (untreated) symptoms of migraine attacks.

Risk of Stroke and Myocardial Infarction Among Initiators of Triptans

Triptans are contraindicated in patients with ischemic heart disease or previous myocardial infarction, and caution is advised when prescribing these drugs to patients with vascular risk factors. However, controlled observational studies have either shown no association or an apparent lower risk, possibly owing to a channeling of triptans to individuals at low risk of cardiovascular outcomes, and it remains unclear whether avoiding triptan treatment for these patients is meaningful. To establish whether an association between triptans and ischemic events could be demonstrated using a self-controlled design because this type of design is robust to the previously mentioned type of confounding. All people in nationwide Danish registries who were initiating triptans and all the ischemic events that they experienced were identified. A case-crossover design was used to estimate odds ratios (OR) for associations between first-ever triptan use and ischemic outcomes, comparing triptan exposure in the 2-week period up to the event with four 2-week reference periods. Data were obtained for the period January 1995 to August 2022. Included from the population of Denmark were individuals redeeming a prescription for any triptan and experiencing at least 1 of 3 predefined ischemic outcomes. No one was excluded. Initiation of any triptan. Acute myocardial infarction, ischemic stroke, or nonspecified stroke. Identified were a total of 429 612 individuals (median [IQR] age, 38 [28-48] years; 325 687 female [75.8%]) who redeemed a first prescription for a triptan in the study period. Of these patients, 11 (0.003%) had a myocardial infarction with the first triptan prescription in either a focal or referent window (odds ratio [OR], 3.3; 95% CI, 1.0-10.9), 18 (0.004%) had ischemic stroke (OR, 3.2; 95% CI, 1.3-8.1), and 35 (0.008%) had ischemic/nonspecified stroke (OR, 3.0; 95% CI, 1.5-5.9). Case patients had a median age of approximately 60 years and had a high-risk cardiovascular profile. Results of this case-crossover study suggest that triptan initiation was associated with higher risk of ischemic stroke and myocardial infarction. For the individual patient with low background cardiovascular risk, the risk of an ischemic event after triptan initiation was very low.

Serotonin Syndrome With the Concomitant Use of Triptans and SSRIs/Serotonergic Medications: Is It Time to Revisit FDA Warning?

Serotonin Syndrome With the Concomitant Use of Triptans and SSRIs/Serotonergic Medications: Is It Time to Revisit FDA Warning?

Switching anti-CGRP monoclonal antibodies in chronic migraine: real-world observations of erenumab, fremanezumab and galcanezumab

ObjectivesThe anti-calcitonin gene-related peptide monoclonal antibodies (anti-CGRP-mAb) are effective in migraine; however, few studies have examined the benefit of switching from one anti-CGRP-mAb to another. In order to better inform...

Trends in Triptan Usage in Korea: A Population-Based Cohort Study.

Migraine presents a significant global health problem that emphasizes the need for efficient acute treatment options. Triptans, introduced in the early 1990s, have substantially advanced migraine management owing to their effectiveness compared to that of traditional medications. However, data on triptan use in migraine management from Asian countries, where migraines tend to have milder symptoms than those in European and North American countries, are limited. This study aimed to identify the trends in triptan usage in Korea. This retrospective cohort study used data from the Korean National Health Insurance Service-National Sample Cohort spanning from 2002 to 2019. Patients with migraine were identified using the International Classification of Diseases 10th revision codes, and triptan prescriptions were evaluated annually in terms of quantity, pills per patient, and associated costs. The distribution of triptan prescriptions across different medical specialties was also examined. Factors contributing to the odds of triptan use were analyzed using multivariable logistic regression. From 2002 to 2019, the total number of triptan tablets, prescriptions, and patients using triptans increased by 24.0, 17.1, and 13.6 times, respectively, with sumatriptan being the most frequently prescribed type of triptan. Additionally, the number of prescriptions and related costs have consistently increased despite stable pricing because of government regulation. By 2019, only approximately one-tenth of all patients with migraines had been prescribed triptans, although there was a notable increase in prescriptions over the study period. These prescription patterns varied according to the physician's specialty. After adjusting for patient-specific factors including age and sex, the odds of prescribing triptans were higher for neurologists than for internal medicine physicians (odds ratio 2.875, P < 0.001), while they were lower for general practitioners (odds ratio 0.220, P < 0.001). The findings revealed an increasing trend in triptan use among individuals with migraines in Korea, aligning with global usage patterns. Despite these increases, the overall prescription rate of triptans remains low, indicating potential underutilization and highlighting the need for improved migraine management strategies across all medical fields. Further efforts are necessary to optimize the use of triptans in treating migraines effectively.

Patients with episodic migraine without aura have an increased rate of delayed discounting.

This study aimed to explore decision-making impulsivity and its neural mechanisms in patients with episodic migraine without aura (EMoA). Previous evidence indicates increased impulsivity and altered reward processing in patients with chronic migraine and medication overuse; however, whether the same holds true for those with EMoA is unclear. Patients newly diagnosed with EMoA (n=51) and healthy controls (HC, n=45) were recruited. All participants completed delay discounting task, cognitive assessments, a questionnaire for headache profile, and resting-state function magnetic resonance imaging scans. Resting-state functional connectivity (RSFC) between the regions of interest and the entire brain was explored. Patients with EMoA showed a steeper subjective discount rate than HCs (F=4.74, p=.032), which was positively related to a history of migraines (r=.742, p<.001). RSFC among the ventral striatum (vSTR), ventromedial prefrontal cortex, and occipital cortex was lower in patients with EMoA than in control groups, which was correlated with history (r'=.294, p=.036) and subjective discount rate (r'=.380, p=.006). Additionally, discounting rates and RSFC between the vSTR and occipital regions were significantly abnormal in the triptan group than the non-triptan group. Mediating effect analysis indicated a significant mediating effect in the change in RSFC between the vSTR and occipital status, history of triptan use, and subjective discount rate. This study further elucidated that an increase in delayed discounting rate exists in patients with EMoA and is related to the abnormality of the value processing network.

Acute medications' intake for migraine: a one-year report in patients undergoing first evaluation at a third level Italian headache center.

Headache disorders, particularly primary headaches like migraine and tension-type headache, still remain underdiagnosed and undertreated despite their high prevalence and significant impact on quality of life. In recent years, several specific medications targeting key pathways in the pathophysiology of migraine have been developed. Despite this advancement, numerous studies indicate that non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics remain the most commonly used drugs. This study focused on the use of NSAIDs and simple analgesics as acute treatments for migraine among patients at a tertiary headache center. A retrospective observational study was conducted at the Fondazione Policlinico Universitario Campus Bio-Medico throughout 2022. Data were collected on the type and frequency of headaches, the usage and dosage of NSAIDs and other medications, and changes in their use at follow-up visits. Statistical analyses were performed to evaluate the efficacy and determinants of NSAID consumption and headache frequency changes. Two hundred and eightythree patients diagnosed with migraine undergoing their first examination at our center were enrolled. Initially, 58.7% of patients used NSAIDs or simple analgesics, which decreased to 46.6% 3 months after, while triptan use increased from 65.1 to 72.8%. Changes in prophylactic therapies were significantly associated with a decrease in NSAID intake (W = 834.000, p = 0.004) and in headache frequency (W = 5960.5, p = 0.003). Specifically, the addition of topiramate or amitriptyline was associated with a reduction in NSAID use and headache frequency. Even pain freedom after the intake of NSAIDs improved from 55.2 to 79.4% of cases at follow-up. The study highlights the importance of appropriate diagnosis and tailored treatment strategies in the management of primary headaches. It underscores the need for specialized care to enhance treatment efficacy and patient outcomes, demonstrating that adjustments in prophylactic therapy can significantly reduce NSAID intake and improve headache care. This reinforces the role of tertiary headache centers in providing specialized care that can adapt treatments to individual patient needs and improve overall headache management.

Comparative retention and effectiveness of migraine preventive treatments: A nationwide registry-based cohort study.

Little is known about the comparative effects of migraine preventive drugs. We aimed to estimate treatment retention and effectiveness of migraine preventive drugs in a nationwide registry-based cohort study in Norway between 2010 and 2020. We assessed retention, defined as the number of uninterrupted treatment days, and effectiveness, defined as the reduction in filled triptan prescriptions during four 90-day periods after the first preventive prescription, compared to a 90-day baseline period. We compared retention and efficacy for different drugs against beta blockers. Comparative retention was estimated with hazard ratios (HRs), adjusted for covariates, using Cox regression, and effectiveness as odds ratios (ORs) using logistic regression, with propensity-weighted adjustment for covariates. We identified 104,072 migraine patients, 81,890 of whom were female (78.69%) and whose mean (standard deviation) age was 44.60 (15.61) years. Compared to beta blockers, botulinum toxin (HR 0.43, 95% confidence interval [CI] 0.42-0.44) and calcitonin gene-related peptide pathway antibodies (CGRPabs; HR 0.63, 95% CI 0.59-0.66) were the least likely to be discontinued, while clonidine (HR 2.95, 95% CI 2.88-3.02) and topiramate (HR 1.34, 95% CI 1.31-1.37) were the most likely to be discontinued. Patients on simvastatin, CGRPabs, and amitriptyline were more likely to achieve a clinically significant reduction in triptan use during the first 90 days of treatment, with propensity score-adjusted ORs of 1.28 (95% CI 1.19-1.38), 1.23 (95% CI 0.79-1.90), and 1.13 (95% CI 1.08-1.17), respectively. We found a favorable effect of CGRPabs, amitriptyline, and simvastatin compared with beta blockers, while topiramate and clonidine were associated with poorer outcomes.

Triptans utilization in Italian population: A real-life study in community pharmacies.

The term Headache Disorders (HD) refers to a number of nervous system pathologies characterised by recurrent headaches. Despite the serious impact HD have on the health system, society, and the economy, these are an underestimated, underdiagnosed, and, hence, undertreated phenomenon. Triptans are the first-line therapy for the acute treatment of moderate to severe migraine but their utilization is still inadequate, perhaps also because in Italy no triptan can be bought without a medical prescription. In this article, the data from a 2016-2017 study has been further analysed with the aim of evaluating any associations between the use of triptans and the other series of variables identified in the questionnaire. This further analysis has been connected to the role that community pharmacies could play on this issue. The questionnaire was administered to 4,424 pharmacy users by 610 purposely trained pharmacists working in 514 pharmacies. The survey was carried out in 19 of the 20 Italian regions. The data shows that only 25% of patients suffering from HDs are prescribed triptans. Older patients, those with definite migraines, and those with a chronic disorder resort more frequently to this class of pharmaceuticals, as do those patients in care at a specialist headache centre. The multivariable analysis also confirmed these results. Our study, which performed a direct detection, in real life, on patients requesting pharmacological treatment for a migraine headache, therefore confirmed the need to investigate the reasons behind the low use and prescription of triptans in the Italian population. Moreover, any future studies should take advantage of community pharmacies, plan actions that would allow a series of evaluations over time of the requirements of migraineurs, and establish a process to put these patients under the care of the pharmacy to ensure adherence to therapy.

Treatment pattern and health care resource utilization for Taiwanese patients with migraine: a population-based study.

Given the substantial disease burden, appropriate and effective management of migraine is a public health priority. To gain insights into real-world migraine management practices in Taiwan, current treatment patterns, costs, and health care resource use were assessed. This was a retrospective, longitudinal study using the Taiwan National Health Insurance Research Database. Included patients had an initial diagnosis of migraine (defined using International Classification of Diseases codes) between 1 January 2013 and 31 December 2017. Data analyzed included demographics; the use, number, and type of acute and preventive medications; and drug and medical services costs. Data were stratified according to migraine type (chronic [CM] or episodic [EM] migraine). A total of 312,718 patients were included in the analyses: 53,992 (17.3%) had CM and 258,726 (82.7%) had EM. Most patients (81.7%) had used acute and/or preventive medications; acute medications used more frequently than preventive medications (78.0% vs. 20.2%). Acute medications were used by 81.6 and 77.3% of patients with CM and EM, respectively. Commonly used acute medications were acetaminophen (68.8%), ergots (49.4%), and non-steroidal anti-inflammatory drugs (38.4%); the use of triptans (6.0%), tramadol (3.1%), and other opioids (0.2%) was less common. A total of 28.6 and 18.5% of patients with CM and EM, respectively, used preventive medications. Flunarizine (68.9%), propranolol (40.7%), and topiramate (16.0%) were the most commonly used preventive medications. Most patients had used 1-2 acute or preventive medications, with the use of ≥3 acute or preventive medications more common in patients with CM than EM. Average total medical cost per annum was 4,169 New Taiwan Dollars (NTDs) per CM patient and 2,928 NTDs per EM patient, with CM patients having higher costs associated with medical service utilization and acute medication use. These real-world data suggest unmet needs for Taiwanese patients with migraine, including under-utilization of preventive medications and greater costs and health care resource use for patients with CM versus EM. These findings provide important information on treatment patterns, cost, and health care resource use for patients with migraine in Taiwan.

Are Women with COVID-19 and Migraine Prone to AMN Type 2?

Purpose: To describe 3 cases of acute macular neuroretinopathy (AMN) type 2 associated with SARS-CoV-2 viral infection and migraine. Methods: Observational case series and literature review. Results: The three patients, which were all women in their reproductive years with a mean age of 31 (range, 22-43), were diagnosed with AMN type 2 after presenting with acute onset of uni- or bilateral persisting paracentral scotomata. On multi-modal imaging with near-infrared (NIR) reflectance imaging, wedge-shaped dark-gray lesions were discernable in a perifoveal petaloid configuration. SD-OCT through the lesions revealed initial hyperreflectivity at the level of the outer retina, beneath the OPL (outer plexiform layer) and comprising the ONL (outer nuclear layer), with disruption of the inner segment/outer segment (IS/OS) band, eventually evolving into thinning of the ONL with or without persisting disruption of the photoreceptor complex. Anterior segment, fundoscopic, angiographic and electrophysiologic examinations were unremarkable. Conclusion: All three cases were diagnosed with a concurrent viral upper respiratory tract infection caused by the SARS-CoV-2 virus. While AMN is considered to be a rare disease, a worldwide surge in the incidence of AMN has recently been reported and the largest case series to date have been described during the latest SARS-CoV-2 viral pandemic. Thus, COVID-19 could be considered a potential risk factor for the development of AMN type 2. Two of our cases were associated with migraine, one of which experienced the onset of AMN symptoms in the immediate setting of a migraine attack and the use of triptans. This association between migraine, triptans and AMN type 2 should be considered in the context of a seemingly persisting visual aura, particularly in the presence of additional risk factors, such as female gender and oral contraceptive use. Summary statement An increased incidence of acute macular neuroretinopathy (AMN) type 2 is observed in the context of SARS-CoV-2 viral infection. The presently described association between AMN, migraine, and triptans should be considered when examining a patient with seemingly persisting visual aura, in particular negative scotomata, in the context of migraine.

Safety of Concomitant Triptan and INP104 Use From the Phase 3 STOP 301 Study in Migraine Patients (P14-12.011)

<h3>Objective:</h3> To report safety in migraine patients who used a triptan within 24 hours of INP104 administration. <h3>Background:</h3> INP104 is a combination of dihydroergotamine mesylate (DHE) and Precision Olfactory Delivery approved for the acute treatment of migraine. DHE and triptans act on 5-HT_1B/1D receptor subtypes, which contributes to their vasoconstrictive effects; therefore, administering 5-HT₁ agonists (eg, sumatriptan) within 24 hours of DHE use is contraindicated. <h3>Design/Methods:</h3> STOP 301 was a Phase 3 open-label study assessing the safety, tolerability, and exploratory efficacy of INP104 in migraine patients. Eligible patients were provided INP104 to nasally self-administer (1.45 mg) with self-recognized migraine attacks over 24 weeks, with a subset continuing to 52 weeks. Only non-ergot, non-triptan acute therapies for migraine were allowed as rescue medication within 2 hours of INP104 administration. <h3>Results:</h3> Over 24 weeks, 354 patients self-administered ≥1 dose of INP104. Despite being instructed NOT to take triptans during the treatment period, 10 patients used triptans within 24 hours of INP104 use on ≥1 occasion. Seven of the 10 patients reported 15 treatment-emergent adverse events (TEAEs); only 2 TEAEs occurred within 24 hours of concomitant triptan/INP104 use. These included nasal congestion (possibly INP104 related) on the day of INP104 administration, which resolved before subsequent triptan use on the following day (~6 hours later) and epistaxis 2 days after concomitant triptan and INP104 use (unlikely related to INP104 or INP104/triptan use because epistaxis is not anticipated for either product). The remaining 5 patients had various TEAEs that were not temporally related to triptan/INP104 use. No TEAEs related to blood pressure, pulse, or electrocardiogram parameters were reported, and any variance was within normal clinical limits. <h3>Conclusions:</h3> Although in a small population, the safety of concomitant triptan/INP104 use was reported, which is an important topic for the patient/physician dialogue. <b>Disclosure:</b> Dr. Feoktistov has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Upsher-Smith. Dr. Feoktistov has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Abbvie. Dr. Feoktistov has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Eli Lilly. Dr. Feoktistov has received personal compensation in the range of $5,000-$9,999 for serving on a Speakers Bureau for Amgen. Dr. Feoktistov has received personal compensation in the range of $5,000-$9,999 for serving on a Speakers Bureau for Lundbeck. Dr. Feoktistov has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Biohaven. Dr. Feoktistov has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Impel. Dr. Vann has received personal compensation for serving as an employee of Impel Neuropharma. Dr. Vann has received personal compensation for serving as an employee of Biogen. Dr. Gutierrez has received personal compensation for serving as an employee of Impel Pharmaceuticals. Dr. Gutierrez has stock in Impel Pharmaceuticals. Dr. Ray has received personal compensation for serving as an employee of Impel Pharmaceuticals. Dr. Ray has stock in Impel Pharmaceuticals. Dr. Shrewsbury has received personal compensation for serving as an employee of Impel NeuroPharma. Dr. Shrewsbury has received stock or an ownership interest from Impel NeuroPharma. Dr. Aurora has received personal compensation for serving as an employee of Impel Neuropharma. Dr. Aurora has stock in Impel Neurpharma.