Influence of physiologic hormonal modification and of hormonal treatment in a patient with a history of migraine with aura

We present the case of 48-year-old woman suffering from migraine with aura (MA) since menarche. During her life the patient frequently presented catamenial MA attacks with an increasing frequency during pregnancy in particular in the second and third trimesters, and then during breast-feeding. Treatment with oral contraceptive (OC) for endometriosis and later with cyclophosphamide, methotrexate, fluorouracil (CMF) for breast cancer produced a higher number of attacks. Instead, she referred an improvement with gonadotropin releasing hormone agonist (GnRH-a) for the treatment of endometriosis and then with tamoxifen as hormonal therapy after mastectomy and chemotherapy for breast cancer. We highlight the importance of physiological hormonal modification and hormonal therapies on the course of MA.

Hemiplegic migraine: hyperperfusion and abortive therapy with intravenous verapamil

A 20-year-old female with hemiplegic migraine was treated during an acute attack with intravenous verapamil, which reproducibly resolved the headache within 20 min but did not affect her hemiplegia. Magnetic resonance (MR) and computed tomographic (CT) angiography and perfusion performed during the attack showed vasodilation and hyperperfusion. Cerebral hyperperfusion concurrent with hemiplegia suggests a dissociation between cerebral perfusion and neuronal function in hemiplegic migraine. The beneficial effect of verapamil on headache but not hemiplegia suggests a distinct mechanism for pain and neuronal dysfunction in hemiplegic migraine, with the beneficial effect on pain not due to vasodilation.

Treatment of hemiplegic migraine with triptans

The objective of this study was to investigate the efficacy, safety and tolerability of triptans in patients who suffer from familial or sporadic hemiplegic migraine. Seventy-six subjects had used triptans at least once as an abortive treatment. Average triptan response was 6.9 (SD +/-3.1) and adverse event severity 4.9 (SD +/-3.3) on a scale from 0 to 10 (no response or side effect 0, excellent response or unbearable side effects 10). None of the patients had an ischaemic stroke or a heart attack. One patient reported prolonged neurological symptoms, related to a single dose of rizatriptan, but there were no pathological findings in several MRI-scans. Triptans seem to be safe and effective treatment for most hemiplegic migraine patients.

Basilar-type migraine responsive to lamotrigine: three case reports

Basilar-type migraine (BM) has been recognised in the revised International Classification of Headache Disorders as a distinct clinical entity (subtype of migraine with aura), characterised by disturbing migraine aura clearly originating from the brainstem or from both hemispheres simultaneously affected. It differs from familial and sporadic hemiplegic migraines by the absence of motor deficit. Lamotrigine has been shown to be effective in preventing migraine aura symptoms in typical aura and in some cases of BM. We tried lamotrigine in three female cases of BM.

Efficacy of sumatriptan tablets in migraineurs self-described or physician-diagnosed as having sinus headache: a randomized, double-blind, placebo-controlled study

BACKGROUND

Many patients and physicians interpret episodic headache in the presence or absence of nasal symptoms as "sinus' headache, while ignoring the possible diagnosis of migraine.

OBJECTIVE

The purpose of this study was to assess the efficacy and tolerability of sumatriptan succinate 50-mg tablets in patients with migraine presenting with "sinus" headache.

METHODS

A randomized, double-blind, placebo-controlled, multicenter study was conducted in adult (aged 18-65 years) migraine patients presenting with self-described or physician-diagnosed "sinus" headache. From November 2001 to March 2002, patients meeting International Headache Society criteria for migraine (with > or =2 of the following: unilateral location, pulsating quality, moderate or severe intensity, aggravation by moderate physical activity; and > or =1 of: phonophobia and phonophobia, nausea and/or vomiting) and with no evidence of bacterial rhinosinusitis were enrolled and randomized in a 1:1 ratio via computer-generated randomization schedule to receive either 1 sumatriptan 50-mg tablet or matching placebo tablet. The primary efficacy end point was headache response (moderate or severe headache pain reduced to mild or no headache pain) at 2 hours after administration. The presence or absence of migraine-associated symptoms and sinus and nasal symptoms was also measured. Tolerability was assessed through patient-reported adverse events (AEs).

RESULTS

Two hundred sixteen patients with self-described or physician-diagnosed "sinus" headache received a migraine diagnosis and treated 1 migraine attack with sumatriptan 50 mg. The efficacy (intent-to-treat) analysis included 215 patients treated with sumatriptan 50 mg (n = 108; mean [SD] age, 39.6 [12.3] years; mean [SD] weight, 77.7 [17.7] kg; sex, 71% female; race, 69% white) or placebo (n = 107; mean [SD] age, 41.0 [11.3] years; mean [SD] weight 80.7 [20.9] kg; sex, 69% female; race, 64% white). Significantly more patients treated with sumatriptan 50 mg achieved a positive headache response at 2 and 4 hours after administration compared with those treated with placebo (69% vs 43% at 2 hours and 76% vs 49% at 4 hours, respectively; both, P < 0.001). Significantly more sumatriptan-treated patients were free from sinus pain compared with placebo recipients at 2 hours (63% vs 49% placebo, P = 0.049) and 4 hours (77% vs 55%, P = 0.001). All treatments were generally well tolerated. The most common drug-related AEs reported in the sumatriptan and placebo groups, respectively, were dizziness (5% vs < 1%), nausea (3% vs 2%), other pressure/tightness (defined as sense of heaviness; heaviness of upper body, upper extremities; jaw tension; neck tension) (4% vs 0%), and temperature sensations (defined as warm feeling of back of neck, or flushing) (2% vs 0%). No patients experienced any serious AEs.

CONCLUSIONS

Sumatriptan 50-mg tablets were effective and generally well tolerated in the treatment of these patients presenting with migraine headaches that were self-described or physician-diagnosed as sinus headaches.

Cessation of Hemiplegic Migraine Auras With Greater Occipital Nerve Blockade

Prolonged migraine auras can be disabling and potentially can cause permanent neurologic deficits. Several medicinal agents have shown some efficacy in aborting prolonged auras, but results are inconsistent. Greater occipital nerve blockade can alleviate the pain of migraine and in 1 case report the migraine aura. Hemiplegic migraine attacks are marked by motor weakness that can last for minutes to days. Two case patients with a history of hemiplegic migraine with prolonged auras are presented, who both had complete alleviation of their aura symptoms with GON blockade. A hypothesis on how GON blockade may inhibit cortical spreading depression is also presented.

The efficacy of sodium valproate and a MRA finding in confusional migraine

Confusional migraine (CM) is recognized as a kind of pediatric migraine equivalent. We report that a 10-year-old girl had repeated attacks of confusional state and of migraine with aura. She suffered from total of six CM attacks and migraine attacks with aura almost once a month. Therefore, sodium valproate (VPA) was initiated to prevent these attacks. They have been controlled after increasing her dosage to 600mg/day. The intracranial magnetic resonance angiography (MRA) during the last CM attack indicated narrowing of left middle and posterior cerebral arteries. However, MRA during the attack free period at 41-day follow-up showed normal vessels. Electroencephalograms showed severe slowing without seizure discharges during the CM attacks. This case indicates that VPA is an effective treatment for the prophylaxis of CM and migraine with aura. MRA is considered helpful for the diagnosis of this kind of migraine in children because of noninvasive neuroimaging.

Acute treatment for migraine headache

Migraine headaches can be frequent and disabling. Effective acute treatment can improve the quality of life for migraineurs. The migraine attack is made up of phases, which include the prodrome, aura and the headache itself. Not every migraineur experiences each phase. Each phase, however, has its own distinct pathogenesis and its own unique acute therapy. This review article will help to define the treatment strategies for the various phases of the migraine attack. It will discuss some general principles of acute migraine treatment, specific acute medications and some unique clinical situations (treatment of the prolonged aura and treating when pain is mild versus moderate/severe). It should be very apparent that a better understating of migraine pathogenesis has led to improved and more effective acute therapies for migraine.

A clinical study of migraine evolution

BACKGROUND

The buildup time of migraine headaches has not been well delineated in publications to date and we are aware of patients whose migraines last well over 72 hours. More concentration on these factors in the assessment of patients might lead to more appropriate therapeutic choices.

METHOD

Prospective ascertainment of such data through a questionnaire completed by 253 informed and willing patients with IHS migraine with or without aura consulting Canadian headache specialists. Data were electronically sent to a central computer from each center, tabulated and analyzed using standard statistical parameters.

RESULTS

In 253 patients with migraine ascertained using applied IHS criteria, nausea was a feature in over 90% of cases, especially in those with aura. This inhibited the ingestion of oral medications in about a quarter of all subjects. The time to build from no pain to moderate/severe pain was shorter in subjects with auras and was less than 2 hours in 97% of those with and 86% of those without auras. However, we also identified a group of subjects with migraine (over 10% of all) in whom the build time to maximum pain is delayed for over 2 hours. Nausea was experienced by 91.7% of subjects, slightly but significantly later in those without auras. While most headaches in each group lasted from 4 to 72 hours, 24.3% of those with and 20.6% of those without aura expected to experience pain for more than 72 hours, while in untreated cases disability due to pain, nausea, or malaise usually persisted for over 3 days in 24.3% and 16.7% of those with and without aura, respectively. One-fifth of migraineurs may be in pain and/or disabled by accompanying symptoms for over 3 days in a typical migraine attack. Over half of our subjects reported that their medications worked well or excellently.

CONCLUSIONS

Attacks of migraine in real-life clinical situations vary somewhat from the IHS criteria in that they are more often associated with nausea that interferes with oral therapy; can persist for over 72 hours; may have slow (>2 hours) buildup to maximum pain in 10% of cases; and may cause disability for over 3 days. Nevertheless, current therapeutic regimens (including prescribed medications) work well for a substantial majority.

Recent advances in understanding migraine mechanisms, molecules and therapeutics

Migraine is a complex, disabling disorder of the brain that manifests itself as attacks of often severe, throbbing head pain with sensory sensitivity to light, sound and head movement. There is a clear familial tendency to migraine, which has been well defined in a rare autosomal dominant form of familial hemiplegic migraine (FHM). FHM mutations so far identified include those in CACNA1A (P/Q voltage-gated Ca(2+) channel), ATP1A2 (N(+)-K(+)-ATPase) and SCN1A (Na(+) channel) genes. Physiological studies in humans and studies of the experimental correlate--cortical spreading depression (CSD)--provide understanding of aura, and have explored in recent years the effect of migraine preventives in CSD. Therapeutic developments in migraine have come by targeting the trigeminovascular system, with the most-recent being the proof-of-principle study of calcitonin gene-related peptide (CGRP) receptor antagonists in acute migraine. To understand the basic pathophysiology of migraine, brain imaging studies have firmly established reproducible changes in the brainstem in regions that include areas that are involved in sensory modulation. These data lead to the view that migraine is a form of sensory dysmodulatio--a system failure of normal sensory processing.

Effectiveness and Satisfaction with Zolmitriptan 5mg Nasal Spray for??Treatment of Migraine in??Real-Life Practice

OBJECTIVE

Addressing the needs of migraineurs by actively seeking patient feedback on disease-related disability and treatment satisfaction may lead to improved management and treatment outcomes. Patient feedback can be collected in postmarketing surveillance (PMS) studies. The objective of this PMS study was to evaluate the efficacy and tolerability of zolmitriptan 5 mg nasal spray in the acute treatment of migraine attacks.

PATIENTS AND METHODS

Patients received zolmitriptan 5 mg nasal spray to treat migraine attacks of any severity and were followed up after a maximum of 4 months. Patients evaluated the efficacy and tolerability of zolmitriptan nasal spray, and were asked whether they wished to continue using zolmitriptan nasal spray and their preference compared with previous treatments. Physicians also assessed the efficacy and tolerability of zolmitriptan nasal spray.

RESULTS

A total of 1838 patients (84.8% females) participated in the study. Within 30 minutes of administration of zolmitriptan nasal spray, 85.0% of patients reported improvements in headache pain, with 25.1% reporting an improvement within 10 minutes. At 1 hour post-dose, 57.9% of patients were pain free and 61.7% were able to resume usual daily activities. Most patients (72.9%) rated zolmitriptan nasal spray as 'better' than previous therapy. The majority (88.8%) expressed a wish to continue using zolmitriptan nasal spray. Physicians evaluated the efficacy of zolmitriptan nasal spray as 'excellent' or 'good' in 89.4% of patients. Tolerability was evaluated as 'excellent' or 'good' in 91.6% of patients.

CONCLUSIONS

Zolmitriptan 5 mg nasal spray provides favourable efficacy and tolerability in the acute treatment of migraine attacks. Most patients assessed zolmitriptan nasal spray as 'better' than previous treatment, with nearly all wishing to continue using it.

Migraine with aura following atrial septostomy for pulmonary arterial hypertension

BACKGROUND

A 34-year-old woman with known familial pulmonary arterial hypertension presented with syncope. Despite medical therapy with an endothelin-receptor antagonist and a phosphodiesterase inhibitor, the patient had NYHA class III symptoms, with exertional dyspnea. Right heart catheterization revealed severe pulmonary hypertension (right atrial pressure 15 mmHg, right ventricular pressure 80/15 mmHg, pulmonary artery pressure 80/35 mmHg, mean pulmonary artery pressure 52 mmHg). The patient underwent balloon atrial septostomy, creating a right-to-left shunt. Although she had no history of headaches or migraine attacks, the patient developed a migraine headache with aura on the third day after the procedure. Migraine attacks recurred for the next 2 days, but symptoms were relieved with simple analgesia.

INVESTIGATIONS

Physical examination, electrocardiography, laboratory testing, 6-min-walk test, right heart catheterization, chest radiography, transesophageal echocardiography, transthoracic echocardiography.

DIAGNOSIS

Migraine with aura following atrial septostomy.

MANAGEMENT

Bosentan, sildenafil, furosemide, spironolactone and warfarin therapy, atrial septostomy, and paracetamol therapy for migraine.

Side-shifting hemicrania continua with aura (migraine with aura with autonomic symptoms responsive to indomethacin?)

Atypical features of hemicrania continua (HC), including both visual aura and side shifting, have been reported previously. However, auras and variable unilaterality have never been reported together in HC. We report two patients with side-shifting HC with aura. These patients' symptoms are unilateral headaches, visual aura, autonomic features, throbbing pain, nausea and photo/phonophobia. One could speculate that the unilaterality and/or the autonomic symptom modules are indomethacin responsive. The patients can also be classified as chronic migraine with aura, with autonomic symptoms, responsive to indomethacin. Neither migraine subtype nor side-shifting HC with aura is included in the current International Headache Society (IHS) classification, so these patients are not classifiable. Side-shifting HC with aura implies the need to revisit the traditional IHS categorization of headaches into unique diagnostic groups. The modular headache theory may be a tool for the understanding of these rare and complex cases.

Could statins be useful in the treatment of patients with migraine?

Migraine is a common and disabling neurological disorder. Studies have shown that patients with migraine (especially those with typical aura with migraine) have an unfavorable cardiovascular risk profile and an increased risk of early-onset (<45 years) ischemic stroke. Statins are effective hypolipidemic drugs that reduce cardiovascular-related morbidity and death in patients with or without established atherosclerotic vascular disease. We report a patient whose frequent attacks of typical aura with migraine completely resolved after the initiation of treatment with a statin. In this context, we comment on the possible effects of statins on the pathophysiology of migraine. We suggest that statins may be useful drugs in the treatment of migraine because they could reduce the increased cardiovascular risk in these patients and also attenuate migraine attacks. Only a randomized prospective study in this population could provide a definite answer to these speculations.

Hypomania as an aura in migraine

We report a 19-year-old man presenting to the department of Psychiatry for the evaluation of prominent behavioral symptoms associated with episodic headaches, with normal inter-episodic periods. A diagnosis of classic migraine with hypomanic aura was made. Other possible co-morbid or causative illnesses were excluded and preventive therapy with valproate was started due to the prominent affective symptoms as a part of the migranous aura. With this the frequency of headaches gradually decreased over the next four months. He was followed up for 2 years when he was found to be symptom-free. Recent research into the mechanisms of migraine has identified that the cortical hyperexcitability and an imbalance between neuronal inhibition and excitement mediated by gamma-aminobutyric acid and excitatory amino acids respectively may be the underlying mechanism. The high rate of affective disorders in patients with migraine, association of migraine with an aura comprising of mood symptoms and good response to treatment with mood-stabilisers might give newer insights into the pathophysiology of mood disorder as well.

[Migraine therapy in general practice 2006]

Migraine therapy consists of two elements, prophylaxis and abortive treatment, for each of which both drug and nondrug strategies are available. To stop mild migraine attacks, analgesics and antiemetics are employed; for severe attacks, triptans are necessary. Triptans differ in their efficacy, tolerance, speed of onset of effect and duration of effect. Moreover, there are different pharmaceutical forms. Triptans are contraindicated for coronary, cerebral and peripheral vascular diseases and, likewise, during pregnancy. They are not suitable for emergency treatment.

Treatment of aura: solving the puzzle

Migraine with aura (MwA) sufferers, at times, need specific treatments. This is the case when the auras are frequent, prolonged and cause anxiety and distress. Abnormal release of glutamate, which may trigger auras, and abnormal platelet behaviour, which constitutes a possible predisposing factor to MwA, are possible targets for MwA-specific prophylactic therapy. Here we present results obtained using lamotrigine (two open trials), an agent known to inhibit glutamate release, and picotamide, an antiplatelet drug, in the prophylactic treatment of MwA sufferers. Lamotrigine significantly reduced the frequency of MwA attacks, and picotamide together with lamotrigine reduced the duration and/or the occurrence of auras. In comparison to lamotrigine, the therapy with picotamide may have some advantages such as the use of the therapeutic dose from the first day of treatment (lamotrigine needs one month or more to reach such a dose) and the possibility to prevent cerebral ischaemic events and migraine stroke, a rare but severe complication of MwA attacks.

Use of a Pine Bark Extract and Antioxidant Vitamin Combination Product as Therapy for Migraine in Patients Refractory to Pharmacologic Medication

OBJECTIVE

To evaluate the potential benefit of a pine bark extract and antioxidant vitamin combination product in the treatment of migraine headache.

BACKGROUND

This was an uncontrolled preliminary study to investigate the potential of an antioxidant formulation as therapy for migraine headache.

METHODS

Twelve patients with a long-term history of migraine with and without aura who had failed to respond to multiple treatments with beta-blockers, antidepressants, anticonvulsants, and 5-hydroxytryptamine receptor agonists were selected for the study. They were treated with 10 capsules of an antioxidant formulation of 120 mg pine bark extract, 60 mg vitamin C, and 30 IU vitamin E in each capsule daily for 3 months. Following enrollment patients completed a migraine disability assessment (MIDAS) questionnaire to give a baseline measure of migraine impact on work, school, domestic, and social activities over the previous 3 months. Patients were then treated for 3 months with the antioxidant formulation while continuing to receive existing pharmacologic medications. A second MIDAS was given at the conclusion of the treatment period.

RESULTS

There was a significant mean improvement in MIDAS score of 50.6% for the 3-month treatment period compared with the 3 months prior to baseline (P < .005). The treatment was also associated with significant reductions in number of headache days and headache severity score. Mean number of headache days was reduced from 44.4 days at baseline (95% CI 28.9 to 59.8) to 26.0 days (95% CI 5.3 to 46.7; P < .005) after 3 months' therapy and mean headache severity was reduced from 7.5 of 10 (95% CI 6.7 to 8.4) to 5.5 (95% CI 4.1 to 7.0; P < .005).

CONCLUSION

These data suggest that the antioxidant therapy used in this study may be beneficial in the treatment of migraine possibly reducing headache frequency and severity. Further clinical investigation into the efficacy of antioxidant as therapy for chronic migraine is warranted.

Early intervention in migraine with sumatriptan tablets 50 mg versus 100 mg: a pooled analysis of data from six clinical trials

BACKGROUND

In clinical trials evaluating sumatriptan in the treatment of moderate or severe migraine pain, the 50- and 100-mg doses have been comparably effective and well tolerated.

OBJECTIVE

To assess the dose-efficacy relationship of sumatriptan tablets given early for mild pain, data from 6 randomized, double-blind, placebo-controlled, early-intervention studies of sumatriptan tablets 50 mg and 100 mg (5 of which have been published) were pooled for analysis. These constitute all the studies conducted to date of sumatriptan tablets prospectively given early for mild pain.

METHODS

The primary efficacy end point in all the studies was the proportion of patients reporting a pain-free result (ie, mild, moderate, or severe pain reduced to none) 2 hours postdose. Other efficacy end points included the proportion of patients who were migraine free (ie, no pain and no associated symptoms of nausea, vomiting, photophobia, or phonophobia) 2 hours postdose; the proportion reporting worsening of pain (ie, moderate or severe pain) 2 hours postdose; and the proportion with a sustained pain-free result (ie, pain free from 2-24 hours postdose with no use of a second dose of study medication or of rescue medication). Tolerability was assessed by evaluating the incidence of individual adverse events. The investigators assessed each adverse event's relationship to study medication.

RESULTS

The number of patients in the intent-to-treat population was 2297 (771 sumatriptan 50 mg, 759 sumatriptan 100 mg, 767 placebo). Patients' mean age ranged from 39.4 to 39.8 years across groups, and most patients were female (90%-92%) and white (89%-90%). A pain-free result 2 hours post dose was reported by significantly more patients who took either dose of sumatriptan tablets compared with placebo and by significantly more patients who took the 100-mg dose compared with the 50-mg dose (50 mg, 49%; 100 mg, 58%; placebo, 24%; P < 0.001, both sumatriptan doses vs placebo, and 100 mg vs 50 mg). A similar pattern was observed for migraine-free results 2 hours postdose (50 mg, 42%; 100 mg, 47%; placebo, 20%; P < 0.05, both sumatriptan doses vs placebo, and 100 mg vs 50 mg), worsening of pain 2 hours postdose (50 mg, 26%; 100 mg, 21%; placebo, 46%; P < 0.05, both sumatriptan doses vs placebo, and 100 mg vs 50 mg), and sustained pain-free results from 2 through 24 hours postdose (50 mg, 30%; 100 mg, 35%; placebo, 12%; P < 0.05, both sumatriptan doses vs placebo, and 100 mg vs 50 mg). Both doses of sumatriptan were well tolerated, and no dose-related trends in the incidence of individual drug-related adverse events were observed.

CONCLUSIONS

In this analysis of pooled data from 6 clinical trials, sumatriptan tablets 50 mg and 100 mg administered early in a migraine attack while the pain was mild were well tolerated and significantly more effective than placebo. The 100-mg dose of sumatriptan was significantly more effective than the 50-mg dose.