The triptan formulations : how to match patients and products

Efficacy and tolerability of frovatriptan in acute migraine treatment: systematic review of randomized controlled trials

OBJECTIVE

To evaluate the efficacy and tolerability of frovatriptan in acute migraine treatment.

METHODS

Systematic review and meta-analysis of randomized controlled trials. Clinical trials of frovatriptan were systematically identified through electronic searches and historical searches up until February 2005. Studies were included if they were (i) double-blind, randomized, placebo controlled trials that evaluated frovatriptan 2.5 mg in acute migraine treatment and (ii) reporting the efficacy data in terms of pain-free, headache response, headache recurrence, or relief of migraine-associated symptoms. Two authors extracted data independently. Disagreements were resolved through discussion. The efficacy was estimated using risk ratio (RR), risk difference, and number needed to treat together with 95% confidence intervals.

RESULTS

Five trials involving a total of 2,866 patients were included. Frovatriptan 2.5 mg was more effective than placebo in rendering patient pain-free (RR 3.70, 95% CI 2.59-5.29, P < 0.0001 at 2 h and 2.67, 95% CI 2.21-3.22, P < 0.0001 at 4 h post-dose). It was also superior to placebo in reducing headache severity. The pooled RR was 1.66 (95% CI 1.48-1.88, P < 0.0001) and 1.83 (95% CI 1.66-2.00, P < 0.0001), respectively, at 2 and 4 h after treatment. In those whose headache was relieved at 4 h, the risk of headache recurrence within 24 h was reduced by 26% with frovatriptan (RR 0.74, 95% CI 0.59-0.93, P = 0.009). Frovatriptan was also superior to placebo in improving symptoms associated with migraine. At 2 h after dosing, frovatriptan reduced the risk of nausea by 14% (95% CI 6-20%, P = 0.0005), photophobia 17% (95% CI 12-22%, P < 0.0001), and phonophobia 14% (95% CI 17-20%, P < 0.0001). The corresponding numbers at 4 h after dosing were 37% (95% CI 30-43%, P < 0.0001), 34% (95% CI 29-39%, P < 0.0001) and 30% (95% CI 23-36%, P < 0.0001), respectively. Frovatriptan caused more adverse events than did placebo (RR 1.31, 95% CI 1.07-1.62, P = 0.01).

CONCLUSION

The available evidence suggests that frovatriptan is more effective but may cause more adverse events than placebo in the treatment of acute moderate to severe migraine. It is effective in providing pain relief and reducing the risk of recurrence. However, its effectiveness relative to other more established agents needs to be better defined by appropriate head to head trials.

Almotriptan in Migraine Patients Who Respond Poorly to Oral Sumatriptan: A Double-Blind, Randomized Trial

OBJECTIVE

To investigate the efficacy and tolerability of almotriptan 12.5 mg in migraine patients who respond poorly to sumatriptan 50 mg.

BACKGROUND

Poor response to sumatriptan therapy for acute migraine attacks has been documented in the literature, but few controlled trials have investigated the efficacy of an alternative triptan in this subgroup of patients.

METHODS

Patients with an International Headache Society diagnosis of migraine who self-described as experiencing at least two unsatisfactory responses to sumatriptan treated their first migraine attack with open-label sumatriptan 50 mg. Patients who did not achieve 2-hour pain relief (improvement of headache from moderate/severe to mild/no headache) were then randomized to treat their second attack with almotriptan 12.5 mg or placebo under double-blind conditions.

RESULTS

In the first attack, 221 of 302 participants (73%) did not achieve 2-hour pain relief with sumatriptan and were randomized to treatment of their second attack with almotriptan 12.5 mg or placebo. Of the 198 sumatriptan nonresponders who treated their second attack (99 almotriptan; 99 placebo), 70% had severe headache pain at baseline. Two-hour pain-relief rates were significantly higher with almotriptan compared to placebo (47.5% vs 23.2%; P<.001). A significant treatment effect for almotriptan was also seen in pain-free rates at 2 hours (33.3% vs 14.1%; P<.005) and sustained freedom from pain (20.9% vs 9.0%; P<.05). In the second attack, 7.1% of patients in the almotriptan group experienced adverse events compared to 5.1% in the placebo group (P=.77).

CONCLUSIONS

Almotriptan 12.5 mg is an effective and well-tolerated alternative for patients who respond poorly to sumatriptan 50 mg. A poor response to one triptan does not predict a poor response to other agents in that class.

Almotriptan in migraine patients who respond poorly to oral sumatriptan: a double-blind, randomized trial

OBJECTIVE

To investigate the efficacy and tolerability of almotriptan 12.5 mg in migraine patients who respond poorly to sumatriptan 50 mg.

BACKGROUND

Poor response to sumatriptan therapy for acute migraine attacks has been documented in the literature, but few controlled trials have investigated the efficacy of an alternative triptan in this subgroup of patients.

METHODS

Patients with an International Headache Society diagnosis of migraine who self-described as experiencing at least two unsatisfactory responses to sumatriptan treated their first migraine attack with open-label sumatriptan 50 mg. Patients who did not achieve 2-hour pain relief (improvement of headache from moderate/severe to mild/no headache) were then randomized to treat their second attack with almotriptan 12.5 mg or placebo under double-blind conditions.

RESULTS

In the first attack, 221 of 302 participants (73%) did not achieve 2-hour pain relief with sumatriptan and were randomized to treatment of their second attack with almotriptan 12.5 mg or placebo. Of the 198 sumatriptan nonresponders who treated their second attack (99 almotriptan; 99 placebo), 70% had severe headache pain at baseline. Two-hour pain-relief rates were significantly higher with almotriptan compared to placebo (47.5 vs. 23.2%; p < 0.001). A significant treatment effect for almotriptan was also seen in pain-free rates at 2 h (33.3 vs. 14.1%; p < 0.005) and sustained freedom from pain (20.9 vs. 9.0%; p < 0.05). In the second attack, 7.1% of patients in the almotriptan group experienced adverse events compared to 5.1% in the placebo group (p = 0.77).

CONCLUSIONS

Almotriptan 12.5 mg is an effective and well-tolerated alternative for patients who respond poorly to sumatriptan 50 mg. A poor response to one triptan does not predict a poor response to other agents in that class.

The Economic and Psychosocial Impact of Migraine before and after Diagnosis and Treatment

Background:

Migraine headache is associated with significant costs. Many patients with migraine do not receive appropriate care. Correct diagnosis of migraine is often elusive, which may impact patient care.

Objective:

To determine the economic and disability burdens that patients with migraine experience before treatment and after diagnosis and treatment.

Methods:

This survey was administered to patients in a community pharmacy. Eligible patients were 18–40 years of age with diagnosed migraine who had prescriptions for an ergotamine, triptan, or combination product containing acetaminophen, isometheptene, and dichloralphenazone. Main outcome measures included pre- and postdiagnostic comparison of patient disability measures, migraine medication use, migraine-related patient costs, and physician office visit characteristics and diagnostic testing.

Results:

Forty-nine patients completed the study (mean ± SD age 38 ± 14 y, 90% female). The average age of symptom onset was 24 ± 13 years, with first presentation to physician at age 28 ± 12 and diagnosis made at age 31 ± 12 years. The mean number of physicians visited was 2.3 ± 4.7, comprising 5.3 ± 7.8 office visits before diagnosis. After diagnosis and treatment, significantly fewer patients experienced attacks lasting ≥16 hours and reported missing ≥5 days of work/month from migraine symptoms. Patients also reported significantly increased effectiveness at work when experiencing symptoms after diagnosis and treatment.

Conclusions:

This study demonstrated that migraine often eludes formal diagnosis and diagnosis is difficult for the primary care physician to make without expensive tests and/or consultation. Patient outcomes were greatly improved after a formal diagnosis followed by appropriate treatment.

Migraine headache: Options for acute treatment

The optimal acute treatment of migraine requires recognition of the multitude of migraine presentations, the frequency of total attacks, and number of days of headache disability. These initial diagnostic steps are initiated in the waiting room, but phase-specific and stratified treatment selection requires having mutual understanding, trust, and belief through extensive discussion. The imperative acute treatment goal must be to treat early, but not too often, a fact represented by a 75% or better occurrence of pain freedom at 2 hours with two or fewer drug doses averaging 2 or fewer days a week. Migraine-specific therapy best wins the race against time and allodynia. Employing this formulary, multiple triptan formulations and phase and stratified patient-centered therapy creates success.

Triptan Nonresponder Studies: Implications for Clinical Practice

The maximum absolute response rate with oral triptans, as measured in clinical trials by the incidence of relief from migraine pain at 2 hours after taking medication, is approximately 70%. Therefore around 30% of patients fail to respond to a particular triptan. Nonresponse is likely to be due to a variety of factors, including low and inconsistent absorption, use of the medication late in an attack, inadequate dosing, and variability in individual response. Evidence from recent clinical trials, however, confirms the common clinical observation that patients with a poor response to one triptan can benefit from subsequent treatment with a different triptan. Two-hour pain-relief rates of 25% to 81% using alternative triptans (naratriptan, almotriptan, eletriptan, zolmitriptan, and rizatriptan) have been reported in patients who were described as poor responders to sumatriptan. Physicians should remain vigilant in assessing the response to acute therapy and take advantage of simple clinical questionnaires that have been developed to facilitate the recognition of those patients who require and may benefit from a change in acute therapy.

Part I: what do patients really need and want from migraine treatment?

Migraine is characterised by recurrent episodes of head pain, often accompanied by other symptoms, such as nausea and vomiting. In addition to migraine impairing a patient's ability to function normally during an attack, fear of the next attack can detract from quality of life between attacks. Of those migraineurs who consult a physician for headache, the minority are prescribed migraine-specific triptans and many are dissatisfied with current therapy. Clinical trials have shown that triptans are capable of providing rapid and effective relief of headache pain, which is what patients primarily desire from acute migraine therapies. Patients generally prefer to administer acute migraine therapies orally, but conventional tablets do not suit all patients and situations. Some patients dislike swallowing tablets, nausea can make swallowing difficult and can be exacerbated by fluid intake, and attacks can easily strike when fluids are not readily available, especially as many young migraineurs lead busy, active lives. Patients need a treatment that enables any migraine attack to be treated promptly and effectively in any given situation. Tablets that dissolve rapidly on the tongue without a requirement for extra fluid intake are a popular alternative to conventional tablets, allowing discreet, convenient and early treatment of migraine anywhere and anytime it strikes. Several triptans are currently on the market in conventional tablet form, but some are available in other formulations, such as orally disintegrating tablets or nasal sprays, making it possible to prescribe rapidly effective migraine treatments in formulations that suit individual patient preferences, lifestyles and attack characteristics.

Menstrual migraine

The initial treatment of menstrual migraine (MM) should be the same as that of migraine that occurs at any other time during the month and should include lifestyle modifications and the use of appropriate acute therapies aimed at decreasing attack symptoms, duration, and disability. If results of acute therapy are incomplete or unsatisfactory, then preventive strategies may be required. Comorbidities may, however, influence choice of preventive therapy or accelerate initiation of preventive therapy. Comorbid dysmenorrhea, menometrorrhagia, and endometriosis argue for early use of hormonal therapies. Hormonal strategies may be appropriate because the premenstrual decline in estradiol concentration predictably precipitates MM, and targeting and preventing this decline can decrease headache occurrence. Continuous combined hormonal contraceptives can reduce hormone fluctuations and, for some MM sufferers, can deliver more than contraceptive benefits. Nonsteroidal anti-inflammatory drugs are appropriate for treatment of co-occurring dysmenorrhea or when hormonal strategies are contraindicated; their efficacy may be caused partly by the role of prostaglandins in MM and dysmenorrhea. As with the use of hormonal therapy, use of nonsteroidal anti-inflammatory drugs allows for treatment of breakthrough headache with triptans. Results of clinical trials suggest that daily use of triptans in the menstrual window may bring about as much as 50% reduction in headache frequency, but such use still requires acute treatment of breakthrough headache and adherence to daily triptan limits. Use of this strategy requires that headache occurrence be highly predictable.

Assessment of Adverse Events Associated With Triptans—Methods of Assessment Influence the Results

BACKGROUND

A recent study conducted in triptan-naive migraine patients showed that tolerability was the second most important attribute of an acute treatment. However, the proportion of patients reporting side effects after any acute treatment may vary with regard to the method of assessment.

OBJECTIVES

To contrast two methods of assessing adverse events (prompted and unprompted) in those with headache using triptans.

METHODS

This study was conducted in two sites, a headache center in the United States, and a neurology office focusing on headache in Italy. We prospectively surveyed 415 adults with headache, who had been using the same triptan for at least 3 months. Participants were asked about their headache and treatment history. Subjects then completed a standardized questionnaire, assessing adverse events in two different ways. First, subjects were asked if they had any adverse events when using the triptan. After returning the first part of the questionnaire, subjects received a second form, where 49 possible adverse events were listed. We contrasted and correlated both sets of answers.

RESULTS

Most patients (U.S.=74.9%, Italy=65.5%) reported no side effects in the unprompted questionnaire. However, most of them (U.S.=62.9%, Italy=54.1%) reported at least one side effect in the prompted questionnaire. Most patients that reported side effects in the unprompted questionnaire said they had just one adverse event, while most reported two or more side effects in the prompted questionnaire. Both in the unprompted and in the prompted questionnaires, most side effects were rated as mild or moderate. Interestingly, 31 (7.5%) subjects (pooling data from both sites together) graded their adverse events as severe in the prompted questionnaire, but had not self-reported them.

CONCLUSIONS

(1) When assessing adverse events, the method of data collection may dramatically influence the results. (2) From those subjects who did not self-report adverse events after using a triptan, most of them will report positively if presented with a list of side effects.

The Medical Management of Migraine

Migraine is a common, chronic neurologic disorder that affects 11% of the adult population in Western countries. In this article, we review the current approaches to the pharmacologic treatment of migraine. Once migraine is diagnosed, and illness severity has been assessed, clinicians and patients should work together to develop a treatment plan based on the patient needs and preferences. The goals of the treatment plan usually include reducing attack frequency, intensity, and duration; minimizing headache-related disability; improving health-related quality of life; and avoiding headache escalation and medication misuse. Medical treatments for migraine can be divided into preventive drugs, which are taken on a daily basis regardless of whether headache is present, and acute drugs taken to treat individual attacks as they arise. Acute treatments are further divided into nonspecific and migraine-specific treatments. The US Headache Consortium Guidelines recommend stratified care based on the level of disability to help physicians individualize treatment. Simple analgesics are appropriate as first-line acute treatments for less disabled patients; if simple analgesics are unsuccessful, treatment is escalated. For those with high disability levels, migraine-specific acute therapies, such as the triptans, are recommended as the initial treatment, with preventive drugs in selected patients. A variety of behavioral interventions are helpful. The clinicians have in their armamentariums an ever-expanding variety of medications. With experience, clinicians can match individual patient needs with the specific characteristics of a drug to optimize therapeutic benefit.

Acute Treatment of Migraine Headache

Migraine is a common, chronic neurologic disorder that affects approximately 12% of the adult population in Western countries. Once migraine is diagnosed, illness severity must be assessed. Clinicians and patients should then work together to develop a treatment plan based on patient needs and preferences. The goals of treatment usually include reducing the intensity and duration of acute attacks, minimizing the frequency of attacks, minimizing headache-related disability and maximizing health-related quality of life, and avoiding headache escalation and medication misuse. Management of migraine is divided into pharmacologic and nonpharmacologic approaches. Pharmacologic approaches are subdivided into preventive treatment, taken on a daily basis whether or not headache is present, and acute drugs taken to treat individual attacks as they arise. Acute treatments are further divided into nonspecific agents, which work for all types of pain, and migraine-specific treatments. The US Headache Consortium Guidelines recommend stratified care based on the level of disability to help physicians individualize treatment. Using this approach means that simple analgesics are appropriate as first-line acute treatments for less-disabled patients; if simple analgesics are unsuccessful, treatment is escalated for high-end therapies (eg, triptans). For those with high disability levels, migraine-specific acute therapies, such as the triptans, are recommended as the initial treatment, with preventive drugs in selected patients. A variety of behavioral interventions are helpful. The clinician has an armamentarium of ever-expanding variety of medications. With experience, clinicians can match individual patient needs with the specific characteristics of a drug to optimize therapeutic benefit.