Subcutaneous Sumatriptan International Study Group. Treatment of migraine attacks with sumatriptan

Refractory migraine and chronic migraine: pathophysiological mechanisms

Migraine is a complex disorder of the brain whose mechanisms are only now being unravelled. It is common, disabling, and economically costly. Brain imaging has suggested a role for the brainstem. While the disorder is almost certainly inherited, the degree to which this contributes to a treatment refractory state is not clear. Indeed, no specific structural or pharmacological explanation can be seen from the data as they have been generated. It is clear that patients with more frequent headache are very likely to go on to even more frequent headache, but again these data are complex. A challenge going forward is to establish the biology of these very challenging patients who undoubtedly have substantial disability.

Triptans: actions and reactions

Subcutaneous sumatriptan is superior to placebo in achieving headache relief. Some commonly reported adverse events are paresthesias, tingling, and transient worsening of headache. Why do patients develop these symptoms? Our unique case may shed light on its actions.

Treatment-emergent CNS symptoms following triptan therapy are part of the attack

If treatment-emergent central nervous system (CNS) symptoms following triptan therapy represent direct pharmacological effects of the drug, they should occur independent of response to active drug. However, if they represent unmasking of neurological symptoms of the migraine attack after pain is relieved, they should be more common in responders both to active drug and to placebo. To explore this issue, we evaluated the relationship between the CNS adverse events and treatment response following triptan or placebo treatment. We used pooled data from seven double-blind, placebo-controlled trials involving eletriptan 20 mg (E20, n = 402), eletriptan 40 mg (E40, n = 1870), eletriptan 80 mg (E80, n = 1393), sumatriptan 100 mg (S100, n = 275) and placebo (Pbo, n = 1024). Somnolence was more prevalent among 2 h headache responders than non-responders for all treatments, including E80 (8.8% vs. 5.0%; P < 0.05), E40 (6.4% vs. 5.0%; NS), E20 (4.0% vs. 2.0%; NS), S100 (4.7% vs. 3.2%; NS) and Pbo (7.6% vs. 3.0%; P < 0.05). Similarly, the incidence of asthenia was higher among patients who responded to treatment compared with those who did not respond to E80 (15.2% vs. 7.8%; P < 0.05), E40 (6.5% vs. 3.6%; P < 0.05), E20 (6.5% vs. 1.0%; P < 0.05), S100 (10.1% vs. 4.7%; NS) and Pbo (4.4% vs. 2.7%; NS). The generally higher rates of somnolence and asthenia in patients who respond to treatment suggests that these treatment-emergent neurological symptoms may represent the unmasking of CNS symptoms associated with the natural resolution of a migraine attack, rather than simply representing drug-related side-effects. The rate of somnolence in placebo responders is comparable to that in responders to E40 and E80, indicating that somnolence is related, at least in some important part, to headache relief and not treatment.

The Discovery of a New Drug Class for the Acute Treatment of Migraine

The history of the scientific ideas and events that led to the discovery of sumatriptan is outlined with personal reminiscences about individuals who influenced the approach. The development of sumatriptan revolutionized the acute treatment of migraine and led to the availability of a number of other triptans. The anti-migraine effects of all the triptans are mediated via 5-HT(1B), and possibly 5-HT(1D) receptors, which transduce their effects via G; proteins. This suggests that agonists at other G(i) protein-coupled receptor types appropriately located (eg, somatostatin sst(2), adenosine A(1)) should be examined for their effects on the trigeminovascular system, Studies on such receptor targets may provide insight into a novel approach towards the design of new anti-migraine drugs.

Efficacy and tolerability of sumatriptan injection for the treatment of morning migraine: two multicenter, prospective, randomized, double-blind, controlled studies in adults

OBJECTIVE

The aim of this study was to assess the efficacy and tolerability of sumatriptan injection in the treatment of morning migraine.

METHODS

In 2 multicenter (20 sites for study 1 and 25 sites for study 2), randomized, double-blind, controlled, parallel-group studies, male and female patients aged 18 to 65 years with migraine meeting International Headache Society criteria received SC sumatriptan succinate injection 6 mg or inactive vehicle (control) for the outpatient treatment of a single morning migraine, defined as migraine with moderate or severe pain on awakening. The primary end point was the percentage of patients who achieved pain-free relief (moderate or severe pain reduced to no pain) at 2 hours after treatment. Tolerability was assessed using spontaneous reporting or noted by a clinician during the studies, assessed at the return visit.

RESULTS

The efficacy analysis included, in the succinate group, 145 patients in study 1, 148 in study 2; control, 152 in study 1, 139 in study 2. The mean (SD) ages in the sumatriptan group were 40.2 (9.7) and 38.8 (10.1) years in studies 1 and 2, respectively; control, 41.4 (10.4) and 39.3 (9.7) years. The majority of patients in the 2 studies were female (sumatriptan, 84% and 93% in studies 1 and 2, respectively; control, 82% and 81%) and white (sumatriptan, 83% and 81%; control, 78% and 89%). Two hours after treatment, 48% and 57% of patients treated with sumatriptan injection compared with 18% and 19% of control patients reported pain-free relief in studies 1 and 2, respectively (both, P < 0.001). Two hours after treatment, 72% and 77% of patients treated with sumatriptan injection reported headache relief (moderate or severe pain reduced to mild or no pain) compared with 32% and 41% of control patients (both, P < 0.001). Onset of efficacy versus control (the first time point with statistical significance of pain relief) was observed beginning 10 minutes postdose (P < 0.05 sumatriptan injection vs placebo across pooled studies). Mean time to efficacy in the sumatriptan group was 10 minutes (P < 0.05 vs controls). The most commonly reported adverse events were nausea (sumatriptan, 6% and 4%; control, 2% and 2%) and injection-site reaction (ie, burning or stinging at the injection site) (sumatriptan, 5 % and 5%; control, 2% and 1%). Injection-site reaction was also the only adverse event considered treatment related and reported in > or =5 % of all patients.

CONCLUSION

The results of these 2 randomized, double-blind, controlled studies suggest that sumatriptan injection was effective and well tolerated in the acute treatment of morning migraine in these adults.

Sumatriptan: update and review

Sumatriptan is the first of a novel class of medications referred to as triptans. Since its approval for migraine in the 1990s, six other triptan products have received FDA approval. Despite the proliferation of triptans, sumatriptan remains the most frequently prescribed product in this therapeutic class. Sumatriptan has been instrumental in defining a biological basis for migraine. It is effective in treating migraine with or without aura, well tolerated and, when properly prescribed, safe. Sumatriptan injection is the only member of the triptan class approved for treatment of cluster headache. Studies with sumatriptan have also advanced the therapeutic intervention paradigm that permits patients to treat earlier and avoid substantial disability. Numerous pharmacoeconomic studies have demonstrated that sumatriptan decreases work loss productivity and improves quality of life.

Non-oral formulations of triptans and their use in acute migraine

The introduction of triptans (5-HT (1B/1D) agonists) into clinical practice has expanded the therapeutic options for doctors treating migraine sufferers. The triptans are available in several different formulations such as conventional oral tablets, orally disintegrating wafers, subcutaneous injections, nasal sprays, and suppositories, which provide an excellent opportunity to tailor therapy to individual patients' needs. Although the oral formulations are the most popular with patients, they are not the most appropriate route of administration for drug delivery during the migraine attack. Due to gastrointestinal dysmotility, the intestinal absorption of any triptan administered orally may be impaired and treatment effects become inconsistent. For this reason, triptans preferably should be prescribed in a non-oral formulation (injection, nasal spray, or suppository). Parenteral administration of a triptan is more likely to provide relief of symptoms, even when it is used later in the course of the migraine attack.

EFNS guideline on the drug treatment of migraine - report of an EFNS task force

Migraine is one of the most frequent disabling neurological conditions with a major impact on the patients' quality of life. To give evidence-based or expert recommendations for the different drug treatment procedures of the different migraine syndromes based on a literature search and an consensus in an expert panel. All available medical reference systems were screened for all kinds of clinical studies on migraine with and without aura and on migraine-like syndromes. The findings in these studies were evaluated according to the recommendations of the EFNS resulting in level A,B, or C recommendations and good practice points. For the acute treatment of migraine attacks, oral non-steroidal anti-inflammatory drugs (NSAIDs) and triptans are recommended. The administration should follow the concept of stratified treatment. Before intake of NSAIDs and triptans, oral metoclopramide or domperidon is recommended. In very severe attacks, intravenous acetylsalicylic acid or subcutaneous sumatriptan are drugs of first choice. A status migrainosus can probably be treated by steroids. For the prophylaxis of migraine, betablockers (propranolol and metoprolol), flunarizine, valproic acid, and topiramate are drugs of first choice. Drugs of second choice for migraine prophylaxis are amitriptyline, naproxen, petasites, and bisoprolol.

Migraine: emerging treatment options for preventive and acute attack therapy

This review discusses emerging treatments of migraine in the context of what is now available. At present, patients are treated with a range of acute attack medicines or preventive treatments, with many having significant drawbacks. Important unmet needs are acute attack treatments that act by exclusively neural mechanisms with no vascular effects, and effective, well tolerated preventive medicines. Calcitonin gene-related peptide receptor antagonist, vanilloid receptor antagonists and nitric oxide synthase inhibitors are all in clinical trials for acute migraine. Tonaberset (a gap-junction blocker), an inducible nitric oxide synthase inhibitor and botulinum toxin A are in clinical trials for preventive therapy. Device-based approaches using neurostimulation of the occipital nerve are being studied, although the first study of patent foramen ovale closure for migraine prevention failed.

Migraine with aura: new understanding from clinical epidemiologic studies

PURPOSE OF REVIEW

To discuss the consequences of recent clinical data on migraine with aura for clinical practice and future research in the light of new diagnostic criteria for migraine with aura.

RECENT FINDINGS

Migraine with aura is now distinguished from hemiplegic migraine and from basilar migraine. Migraine with typical aura has an aura consisting of visual, sensory, or speech symptoms. The aura symptoms typically develop gradually over 5 or more minutes, last between 5 and 60 minutes and, when more than one symptom is present, they occur in succession. Half-sidedness is typical of visual and sensory symptoms, whereas speech symptoms are typically aphasic, primarily of the Broca type. A visual aura rating scale with a high sensitivity and specificity has been developed to standardize the diagnosis of visual aura. The new classification, the new criteria, and the new knowledge about clinical features of migraine with aura are important both for routine clinical diagnosis and for future research studies.

SUMMARY

Recent studies of the clinical features of migraine with aura allow a more precise diagnosis and classification than previously possible. A clear distinction between migraine with typical aura, hemiplegic migraine, and basilar migraine is important for genetic and other research studies.

Pain free efficacy of sumatriptan in the early treatment of migraine

BACKGROUND

There is evidence that headache response rates may be higher if triptans are used early when a migraine attack is still mild, as compared to when it is treated after pain has reached moderate or severe intensity.

METHODS

In this randomized, double blind, placebo controlled, parallel group clinical trial, 361 patients took either placebo, sumatriptan 50 mg, or sumatriptan 100 mg in a single attack study. The primary outcome measure was pain-free status at two hours.

RESULTS

In the intention to treat group, two hour pain free rates were 16%, 40%, and 50% in the placebo group, sumatriptan 50 mg group, and the sumatriptan 100 mg group respectively (p < 0.001, active treatment groups vs. placebo).

CONCLUSIONS

Both sumatriptan 50 mg and 100 mg were significantly superior to placebo for the pain-free end point at two hours. The pain-free response rates in this trial where sumatriptan was taken while the headache was still mild were generally higher than in older clinical trials where headache was treated after reaching a moderate or severe intensity.

Intercepting migraine: Results of early therapy with nonspecific and migraine-specific agents

Migraine is a pervasive neurologic disorder characterized by recurrent attacks of disabling headache. Despite significant morbidity with impact that may be physical, emotional, social, and economic, treatment of these attacks is often delayed. Patients frequently delay therapy until the more severe or "textbook" symptoms arise, often mistaking the earliest stages as representative of "tension" or "sinus" headaches. Clinicians may recommend deferral of treatment until the more severe levels of pain are seen, perhaps in a misguided attempt to conserve pharmaceutical resources. Patients and clinicians seem more comfortable with perspectives of "being sure it's a migraine" and "not wasting the medication on milder headaches." Therefore, patients and clinicians must learn the latest lessons in migraine: 1) mild migraine usually progresses to more severe levels if left untreated, 2) early treatment is more effective than delayed treatment, 3) early treatment may result in lower rates of adverse events and headache recurrence, and 4) early treatment is cost effective. As clinicians advocate the early treatment of migraine in its mild phase, evidence to support this recommendation has finally become available. I educate my migraineurs to consider each typical headache to be a version of migraine. Most patients with migraine will experience "little" headaches that they often mislabel as tension, sinus, regular, stress, or normal headaches. Instead of these terms, I have them consider their attacks as "small migraines" and "big migraines," with the smaller headaches often evolving into the bigger episodes. Given such a foundation, I advise them to treat at the beginning of the headache, perhaps earlier than they would have previously identified it as a migraine. They must capture the attack while it "whispers migraine" instead of delaying until the attack "shouts migraine." Early treatment of migraine is successful for most patients. However, there are situations in which treatment of the mild phase is not advisable or possible. In patients with frequent or daily migraine, treatment must be reserved for the most disabling attacks. We must advise treatment as soon as the migraine becomes moderate to severe. Certain patients, or certain headaches in some patients, may not progress through a mild phase, perhaps because of rapid escalation or because migraine is already severe upon awakening. Here we encourage migraineurs to treat as soon as possible, often with parenteral formulations of medication. The reaction of the patient (speed of dosing) and the action of the medication (speed of onset of the drug) will ultimately play roles in the successful interception of each attack.

Zolmitriptan Intranasal: A Review of the Pharmacokinetics and Clinical Efficacy

Migraine is a common disabling neurological disorder, associated with headache, nausea, and on occasions vomiting. Zolmitriptan is a widely available serotonin 5HT(1B/1D) receptor agonist with a long track record in clinical studies and in the treatment of acute migraine. A nasal formulation has been developed that has clear evidence for local absorption, resulting in plasma drug concentrations within 2 minutes of dosing, central nervous system penetration 3 minutes later, and a significant efficacy benefit versus placebo 10 to 15 minutes after dosing. Intranasal zolmitriptan offers advantages to migraineurs, particularly those seeking a more rapid onset of effect without wishing to self-inject, or those with gastrointestinal upset. The comparison of pharmacokinetic and clinical data available from different formulations of zolmitriptan contributes both to the understanding of its mode of action and the characteristics required of an acute migraine treatment if it is to meet patient needs.

Fixed drug combinations for the acute treatment of migraine : place in therapy

Fixed drug combinations (FDCs) combine standardised doses of two or more drugs in a single tablet, injection, nasal spray or suppository. FDCs may improve treatment compliance, efficacy or tolerability through a variety of mechanisms. At present, FDCs are commonly used in migraine treatment, and more are in development. This systematic review identified 43 prospective trials of FDCs in use for the acute treatment of migraine. Quantitative combination and analysis of the data were not possible, but results of the review support the following qualitative conclusions. First, many FDCs in use for the acute treatment of migraine are older drugs. In these cases, clinical trial evidence that the FDC is efficacious or has important advantages over its treatment components is lacking. The benefits assumed for some common FDC ingredients such as caffeine and metoclopramide are not clearly confirmed in these trials. Secondly, the use of barbiturate-containing FDCs for the acute treatment of migraine is not evidence based, and these drugs are frequently implicated in the development of dependence or medication-induced headache syndromes. Thirdly, studied opioid-containing FDCs are generally superior to placebo, but evidence regarding the safety and tolerability of their repeated use in the treatment of migraine is lacking; clinical experience dictates caution in the use of these agents. Fourthly, ergotamine-containing FDCs are generally superior to placebo, but perform poorly in comparison with single-agent selective serotonin 5-HT(1B/1D) receptor agonists ('triptans'), NSAIDs or even isometheptene or opioid comparators, and are less well tolerated. Fifthly, the most consistent and impressive evidence of benefit is for NSAID-containing FDCs. These invariably outperform placebo and are equivalent or superior to active comparators. Finally, with renewed interest in the use of FDCs for the acute treatment of migraine, high-quality evidence of a benefit for such treatments is emerging. An FDC containing a triptan and NSAID seems most likely to provide efficacy and tolerability benefits in the acute treatment of migraine. Such an FDC is in development but not yet approved for use.

Cost-effectiveness analysis of rizatriptan and sumatriptan versus Cafergot in the acute treatment of migraine

BACKGROUND

Both ergotamine and selective serotonin 5-HT(1B/1D) receptor agonists ('triptans') are currently used in the treatment of moderate to severe migraine. Ergotamine is a traditional therapy with a lower drug acquisition cost compared with triptans. It has been shown that triptans are more efficacious than ergotamine, but the higher acquisition costs and shorter duration of action are disadvantages of triptans compared with ergotamine.

OBJECTIVE

The purpose of this study was to provide a comparison of the cost-effectiveness of rizatriptan 10 mg and sumatriptan 50 mg tablets with that of a fixed-dose combination of ergotamine tartrate plus caffeine (Cafergot) in the treatment of an acute migraine attack. The cost-effectiveness of rizatriptan in comparison with sumatriptan was also assessed.

METHODS

Three separate decision tree models were developed (model 1: rizatriptan vs Cafergot; model 2: sumatriptan vs Cafergot; model 3: rizatriptan vs sumatriptan). The time horizon was 1 year. Cost-effectiveness analysis was conducted from the societal perspective using cost and effectiveness estimates from the literature. All costs were converted to US dollars (2003). The cost-effectiveness ratio was expressed as incremental cost per quality-adjusted life-year (QALY) gained.

RESULTS

Base case evaluation showed that both rizatriptan and sumatriptan dominated Cafergot. The net annual saving associated with use of rizatriptan was US dollars 622.98 per patient, with an incremental QALY of 0.001. Use of sumatriptan resulted in a saving of US dollars 620.90 and an increase in QALY. The cost-effective ratios were not sensitive to changes in key variables such as efficacy, utility, drug costs, hospitalisation cost and patient preference over alternative therapies. The study further showed that rizatriptan is more cost effective than sumatriptan, as evidenced by its lower cost and greater effectiveness. Sensitivity analysis showed that the cost-effectiveness ratios were sensitive to moderate changes in drug efficacy.

CONCLUSION

Rizatriptan and sumatriptan were less costly and more effective than Cafergot in the treatment of an acute migraine attack. Rizatriptan was somewhat less costly and more effective than sumatriptan. Additional quality-of-life studies are needed to confirm the benefits of using triptans in the management of migraine.

Sumatriptan and Naproxen Sodium for the Acute Treatment of Migraine

OBJECTIVE

To evaluate the efficacy and tolerability of treatment with a combination of sumatriptan 50 mg (encapsulated) and naproxen sodium 500 mg administered concurrently in the acute treatment of migraine.

BACKGROUND

The pathogenesis of migraine involves multiple peripheral and central neural mechanisms that individually have been successful targets for acute (abortive) and preventive treatment. This suggests that multi-mechanism therapy, which acts on multiple target sites, may confer improved efficacy and symptom relief for patients with migraine.

DESIGN AND METHODS

This was a multicenter, randomized, double-blind, double-dummy, placebo-controlled, four-arm study. Participants (n = 972) treated a single moderate or severe migraine attack with placebo, naproxen sodium 500 mg, sumatriptan 50 mg, or a combination of sumatriptan 50 mg and naproxen sodium 500 mg. In the latter two treatment arms, the sumatriptan tablets were encapsulated in order to achieve blinding of the study.

RESULTS

In the sumatriptan plus naproxen sodium group, 46% of subjects achieved 24-hour pain relief response (primary endpoint), which was significantly more effective than sumatriptan alone (29%), naproxen sodium alone (25%), or placebo (17%) (P < .001). Two-hour headache response also significantly favored the sumatriptan 50 mg plus naproxen sodium 500 mg therapy (65%) versus sumatriptan (49%), naproxen sodium (46%), or placebo (27%) (P < .001). A similar pattern of between-group differences was observed for 2-hour pain-free response and sustained pain-free response (P < .001). The incidence of headache recurrence up to 24 hours after treatment was lowest in the sumatriptan plus naproxen sodium group (29%) versus sumatriptan alone (41%; P = .048), versus naproxen sodium alone (47%; P= .0035), and versus placebo (38%; P= .08). The incidences of the associated symptoms of migraine were significantly lower at 2 hours following sumatriptan 50 mg plus naproxen sodium 500 mg treatment versus placebo (P < .001). The frequencies and types of adverse events reported did not differ between treatment groups, with dizziness and somnolence being the most common.

CONCLUSIONS

This is among the first prospective studies to demonstrate that multi-mechanism acute therapy for migraine, combining a triptan and an analgesic, is well tolerated and offers improved clinical benefits over monotherapy with these selected standard antimigraine treatments. Specifically, sumatriptan 50 mg (encapsulated) and naproxen sodium 500 mg resulted in significantly superior pain relief as compared to monotherapy with either sumatriptan 50 mg (encapsulated) or naproxen sodium 500 mg for the acute treatment of migraine. Because encapsulation of the sumatriptan for blinding purposes may have altered its pharmacokinetic profile and thereby decreased the efficacy responses, additional studies are warranted that do not involve encapsulation of the active treatments and assess the true onset of action of multi-mechanism therapy in migraine. This study did show that the combination of sumatriptan and naproxen sodium was well tolerated and that there was no significant increase in the incidence of adverse events compared to monotherapy.

Can we Develop Neurally Acting Drugs for the Treatment of Migraine?

Serotonin (5-HT)(1B/1D) receptor agonists, which are also known as triptans, represent the most important advance in migraine therapeutics in the four millennia that the condition has been recognized. The vasoconstrictive activity of triptans produced a small clinical penalty in terms of coronary vasoconstriction but also raised an enormous intellectual question: to what extent is migraine a vascular problem? Functional neuroimaging and neurophysiological studies have consistently developed the theme of migraine as a brain disorder and, therefore, demanded that the search for neurally acting antimigraine drugs should be undertaken. The prospect of non-vasoconstrictor acute migraine therapies, potential targets for which are discussed here, offers a real opportunity to patients and provides a therapeutic rationale that places migraine firmly in the brain as a neurological problem, where it undoubtedly belongs.

Migraine and other headaches: associations with Rose angina and coronary heart disease

OBJECTIVE

To examine the association between a lifetime history of migraines and other headaches with and without aura and Rose angina and coronary heart disease (CHD).

METHODS

Participants were 12,409 African American and white men and women from the Atherosclerosis Risk in Communities Study, categorized by their lifetime history of headaches lasting > or =4 hours (migraine with aura, migraine without aura, other headaches with aura, other headaches without aura, no headaches). Gender-specific associations of headaches with Rose angina and CHD, adjusted for sociodemographic and cardiovascular disease risk factors, were evaluated using Poisson regression.

RESULTS

Participants with a history of migraines and other headaches were more likely to have a history of Rose angina than those without headaches. The associations were stronger for migraine and other headaches with aura (prevalence ratio [PR] = 3.0, 95% CI = 2.4, 3.7 and PR = 2.0, 95% CI = 1.5, 2.7 for women; PR = 2.2, 95% CI = 1.2, 3.9 and PR = 2.4, 95% CI = 1.4, 3.9 for men) than for migraine and other headaches without aura (PR = 1.5, 95% CI = 1.2, 1.9 and PR = 1.3, 95% CI = 1.1, 1.6 for women; PR = 1.9, 95% CI = 1.2, 2.9 and OR = 1.4, 95% CI = 1.0, 1.8 for men). In contrast, migraine and other headaches were not associated with CHD, regardless of the presence of aura.

CONCLUSIONS

The lack of association of migraines with coronary heart disease suggests that the association of migraine with Rose angina is not related to coronary artery disease. Future research assessing other common underlying pathologic mechanisms is warranted.

Intranasal zolmitriptan

Intranasal zolmitriptan has recently been launched in the US and Canada and is a novel formulation of the antimigraine drug zolmitriptan. This drug has been used extensively in its oral formulation. The intranasal formulation offers a more rapid onset of action. Pharmacokinetic studies have demonstrated that it is absorbed rapidly into the systemic circulation and traces can be seen in the brain within 5 min. The onset of efficacy in the Real Life Intranasal Zolmitriptan Exposure (REALIZE) study was measurable at 10 min and at 15 min in the US 22 study, which demonstrates rapid absorption and effect at the 5-HT(1B/1D) receptors. This article reviews the initial studies of intranasal zolmitriptan; three of the most recent studies will be examined in detail.

Should We Advise Patients to Treat Migraine Attacks Early: Methodologic Issues

In clinical trials of triptans in acute migraine, patients have traditionally been required to take their medication only when their pain reached moderate or severe intensity. This methodology better ensured that migraine attacks rather than nonmigraine headaches were treated, minimized the placebo response and simplified comparison of improvement as all patients start from the same baseline pain level. In clinical practice, patients do not take medication in this way, and there is some theoretical evidence that early treatment might be beneficial. There are increasing numbers of reports claiming advantages of 'early' treatment, when the pain is mild, over 'late' treatment, when pain is moderate or severe, but these studies raise significant methodologic issues. Treating 'early' may equate with treating 'mild' in slowly progressing attacks only but this may not always be the case in rapidly progressing attacks; these two types of migraine attacks should be distinguished carefully and investigated separately. Trials should be placebo-controlled, blinded, assess the therapeutic gain versus placebo rather than the absolute rates, and use the sustained pain-free endpoint. Early treatment may also increase the risk of medication overuse headaches. At present, there is no scientific support to advise patient to treat early. Patients should be advised to take their medication as soon as they are sure they are developing a migraine headache, but not during the aura phase.

Pilot Study Evaluating Preference for 3‐mg Versus 6‐mg Subcutaneous Sumatriptan

BACKGROUND

Subcutaneous sumatriptan (6 mg) is undeniably an excellent treatment of migraine. However, some patients have avoided using 6 mg sumatriptan because of unpleasant or unwanted side effects.

OBJECTIVE

To evaluate the efficacy of subcutaneous sumatriptan (3 mg) during a moderate or severe migraine attack.

METHODS

Thirty subcutaneous sumatriptan-naive patients with a history of migraine with and without aura treated their next two moderate or severe migraines with either 3-mg or 6-mg sumatriptan injection. The primary endpoint was whether patients preferred the low-dose (3 mg) or the high-dose (6 mg) subcutaneous sumatriptan. Other objectives included percentage of patients pain free at 15 and 30 minutes, 1 and 2 hours; a pain-free response lasting between 2 and 24 hours, patient satisfaction, and acceptability of formulation. A new combination endpoint (efficacy and lack of significant side effects) was also evaluated.

RESULTS

Eighty percent of patients preferred 3-mg over 6-mg subcutaneous sumatriptan. At 1 hour postdose 57% of patients were pain free with 3 mg and 53% with 6 mg. At 2 hours postdose 87% were pain free with 3 mg and 80% with 6 mg. A sustained pain-free response was obtained by 70 to 80% of patients. When combining a pain-free response at 2 hours and a sustained pain-free response at 24 hours with no significant side effects, more patients met the endpoint with 3 mg (63 to 67%) than with 6 mg (33 to 50%).

CONCLUSIONS

Combining efficacy and tolerability endpoints may be clinically meaningful and reflective of real-world expectations. In some patients, a lower dose of sumatriptan injection may be beneficial.

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

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

Octreotide is not effective in the acute treatment of migraine

The aim of this study was to determine whether subcutaneous octreotide is effective for the treatment of acute migraine. Patients with migraine with and without aura as classified by the International Headache Society were recruited to a double-blind placebo-controlled crossover study. Patients were instructed to treat two attacks of at least moderate pain severity, with at least a 7 day interval, using subcutaneous 100 microg octreotide or matching placebo. The primary endpoint was the headache response defined as: severe or moderate pain becomes mild or nil, at 2 h. The primary endpoint was analysed using a Multilevel Analysis approach. Secondary end-points included associated symptoms and a four-point functional disability score. The study was powered to detect a 30% difference at an alpha of 0.05 and a beta of 0.8. A total of 51 patients were recruited, of whom 42 provided efficacy data on an attack treated with octreotide and 41 with placebo. Modelling the headache response as a binomial determined by treatment, using the patient as the level 2 variable, and considering a possible period effect, and sex and migraine type as other variables of interest, subcutaneous octreotide was not significantly superior to placebo. The two hour headache response rates were 20% for placebo and 14% for octreotide, whilst the two hour pain free rates were 7% and 2%, respectively. Subcutaneous octreotide 100 microg is not effective in the acute treatment of migraine when compared to placebo.

Correlation Between Lipophilicity and Triptan Outcomes

BACKGROUND

It has been suggested that triptans achieving higher central nervous system (CNS) levels should have an advantage in efficacy, if central actions are important. Objective.-Our aim was to correlate the efficacy and tolerability results of triptans with their lipophilicity.

METHODS

Data for response and pain free at 2 hours, recurrence, adverse events (AE), CNS AE, and chest symptoms taken from Ferrari et al's meta-analysis publications for the recommended doses of oral triptans were correlated with their lipophilicity coefficients (logD(pH)7.4 = -2.1 almotriptan < -1.5 sumatriptan < -1.0 zolmitriptan < -0.7 rizatriptan < -0.2 naratriptan < 0.5 eletriptan).

RESULTS

We found no significant correlation between lipophilicity coefficients and any of the analyzed parameters. There was, however, some correlation between lipophilicity and CNS AE (P = .09, r = 0.74) and, to a lesser degree, with a reduction in recurrence rate (r = -0.36). The r values for response and pain free with placebo correction ranged from 0.04 to 0.34, suggesting almost no correlation between lipophilicity and efficacy variables.

CONCLUSIONS

According to this analysis, a higher lipophilicity does not seem crucial to improve triptan efficacy. This physico-chemical property, however, correlates with higher CNS AE and, possibly, lower recurrence rates.

New drugs for the prevention and treatment of migraine: topiramate and BIBN 4096 BS

Migraine is one of the leading causes of disability. Topiramate has multiple mechanisms and may reduce neurotransmission through the trigeminocervical complex to prevent migraine. In clinical trials for the prevention of migraine, the mean monthly migraine frequency decreased from 5.6 to 4.5 in the placebo group and larger decreases were observed with topiramate (100 mg/day, 5.8 to 3.5; 200 mg/day, 5.1 to 3.0). However, topiramate use is associated with a high incidence of adverse events (paraesthesia, fatigue, anorexia, diarrhoea), which may limit the willingness of patients to use topiramate for the prevention of migraine. BIBN 4096 BS is a non-peptide calcitonin gene-related peptide-receptor antagonist that has recently been trialled in migraine attacks. The primary efficacy end point was the reduction of severe or moderate headache prior to treatment to mild or no headache at 2 h. This endpoint was achieved in 21 of 32 (66%) patients with BIBN 4096 BS 2.5 mg, compared to 27% of patients given placebo. Although BIBN 4096 BS is a non-peptide, it is still administered intravenously, which will probably limit its use to medical centres.

Coronary Vasospasm and Myocardial Infarction Induced by Oral Sumatriptan

Coronary vasospasm is well documented as a side effect of injectable subcutaneous forms of sumatriptan; only one such case has been reported so far with oral ingestion of sumatriptan in a patient with underlying coronary artery disease. This report describes a case of coronary vasospasm induced by oral sumatriptan even in normal coronary arteries. Physicians and patients should be aware of a small and unpredictable risk of the serious cardiac side effects of this drug.

Calcitonin gene-related peptide receptor antagonist BIBN 4096 BS for the acute treatment of migraine

BACKGROUND

Calcitonin gene-related peptide (CGRP) may have a causative role in migraine. We therefore hypothesized that a CGRP-receptor antagonist might be effective in the treatment of migraine attacks.

METHODS

In an international, multicenter, double-blind, randomized clinical trial of BIBN 4096 BS, a highly specific and potent nonpeptide CGRP-receptor antagonist, 126 patients with migraine received one of the following: placebo or 0.25, 0.5, 1, 2.5, 5, or 10 mg of BIBN 4096 BS intravenously over a period of 10 minutes. A group-sequential adaptive treatment-assignment design was used to minimize the number of patients exposed.

RESULTS

The 2.5-mg dose was selected, with a response rate of 66 percent, as compared with 27 percent for placebo (P=0.001). The BIBN 4096 BS group as a whole had a response rate of 60 percent. Significant superiority over placebo was also observed with respect to most secondary end points: the pain-free rate at 2 hours; the rate of sustained response over a period of 24 hours; the rate of recurrence of headache; improvement in nausea, photophobia, phonophobia, and functional capacity; and the time to meaningful relief. An effect was apparent after 30 minutes and increased over the next few hours. The overall rate of adverse events was 25 percent after the 2.5-mg dose of the drug and 20 percent for the BIBN 4096 BS group as a whole, as compared with 12 percent for placebo. The most frequent side effect was paresthesia. There were no serious adverse events.

CONCLUSIONS

The CGRP antagonist BIBN 4096 BS was effective in treating acute attacks of migraine.

Newer formulations of the triptans: advances in migraine management

Migraine is a common, frequently incapacitating, headache disorder that imposes a substantial burden on both the individual patient and society. The last two decades have witnessed an explosion in our understanding of the pathophysiology of migraine, and in our development of an efficacious and diverse therapeutic armamentarium. There are several routes of drug administration available to patients with migraine. All the serotonin 5-HT(1B/1D) receptor agonists (triptans) are available as oral tablets (sumatriptan, rizatriptan, zolmitriptan, naratriptan, almotriptan, frovatriptan and eletriptan). Only sumatriptan is available as a subcutaneous injection. Some triptans are also available via newer routes of administration, including orally disintegrating tablets (rizatriptan and zolmitriptan), rectal suppositories (sumatriptan) and intranasal sprays (sumatriptan and zolmitriptan). Oral disintegrating tablets and other non-oral triptan routes (subcutaneous, intranasal, rectal) are a useful alternative to conventional oral tablets for patients who have difficulty swallowing pills or prefer not to do so, and for patients whose nausea and/or vomiting precludes swallowing tablets and/or makes the likelihood of complete absorption unpredictable. This is important because epidemiological studies in migraine reveal that the vast majority of patients (>90%) have experienced nausea during a migraine attack and more than 50% have nausea with the majority of attacks. Similarly, most (almost 70%) have vomited at some time during an attack and of these patients, almost one-third vomit in the majority of attacks. The newer formulations, rapidly dissolving tablets and intranasal sprays, afford patients the opportunity to use abortive therapy without the need for liquids, at anytime and anywhere, at the onset of a migraine attack. Furthermore, the intranasal sprays are absorbed rapidly and have a prompt onset of action allowing for significant pain free rates versus placebo as early as 15 minutes post administration. The ability to administer treatment early in a migraine attack and have a rapid onset of action is particularly important in acute migraine treatment in order to prevent the development of central sensitisation. While many patients and physicians choose conventional oral tablets because of familiarity and ease of administration, the newer formulations, oral disintegrating tablets and intranasal sprays, should be given consideration as first-line agents in selected patients.

Calibration of an item pool for assessing the burden of headaches: an application of item response theory to the headache impact test (HIT)

BACKGROUND

Measurement of headache impact is important in clinical trials, case detection, and the clinical monitoring of patients. Computerized adaptive testing (CAT) of headache impact has potential advantages over traditional fixed-length tests in terms of precision, relevance, real-time quality control and flexibility.

OBJECTIVE

To develop an item pool that can be used for a computerized adaptive test of headache impact.

METHODS

We analyzed responses to four well-known tests of headache impact from a population-based sample of recent headache sufferers (n = 1016). We used confirmatory factor analysis for categorical data and analyses based on item response theory (IRT).

RESULTS

In factor analyses, we found very high correlations between the factors hypothesized by the original test constructers, both within and between the original questionnaires. These results suggest that a single score of headache impact is sufficient. We established a pool of 47 items which fitted the generalized partial credit IRT model. By simulating a computerized adaptive health test we showed that an adaptive test of only five items had a very high concordance with the score based on all items and that different worst-case item selection scenarios did not lead to bias.

CONCLUSION

We have established a headache impact item pool that can be used in CAT of headache impact.

Investigation of the effects of naratriptan, rizatriptan, and sumatriptan on jugular venous oxygen saturation in anesthetized pigs: implications for their mechanism of acute antimigraine action

The effects of naratriptan, rizatriptan, and sumatriptan on arteriovenous oxygen saturation difference and carotid hemodynamics were compared in the anesthetized pig. Oxygen and carbon dioxide partial pressures in systemic arterial and jugular venous blood as well as hemoglobin oxygen saturation were determined by conventional blood gas analysis. Vehicle (n = 19) or naratriptan, rizatriptan, or sumatriptan (0.63, 2.5, 10, 40, 160, 630, and 2,500 microg/kg i.v.; n = 7/group) were infused cumulatively. In naratriptan-, rizatriptan-, and sumatriptan-treated animals, jugular venous oxygen saturation decreased dose dependently (geometric mean ED50 values of 3.1, 17.9, and 16.0 microg/kg, respectively) concomitantly with increases in carotid vascular resistance. Rizatriptan significantly and dose dependently, from 160 microg/kg, increased PvCO2 (P < 0.05 versus vehicle). Naratriptan and sumatriptan also tended to increase PvCO2 albeit nonstatistically significantly. All three triptans consistently evoked quantitatively similar carotid vasoconstriction, whereas decreases in jugular venous oxygen saturation (VOS) and increases in PvCO2 had different magnitudes and occurred only in around one-half of the animals studied. Maximal variations in PvCO2 were found to correlate highly with those in PvO2 (P = 0.002), but maximal variations in carotid resistance failed to correlate with those in PvCO2 (P = 0.76) or PvO2 (P = 0.28). The results demonstrate that the triptans investigated robustly produced carotid vasoconstriction, but elicited less consistent decreases in VOS and increases in jugular PvCO2, possibly suggestive of distinct mechanisms. Collectively, the data suggest that triptan-induced increases in arteriovenous oxygen saturation difference and carbon dioxide partial pressure in venous blood draining the head are class effects.

The triptan formulations : how to match patients and products

The 5-HT(1B/1D) receptor agonists (the 'triptans') are migraine-specific agents that have revolutionised the treatment of migraine. They are usually the drugs of choice to treat a migraine attack in progress. Different triptans are available in various strengths and formulations, including oral tablets, orally disintegrating tablets, nasal sprays and subcutaneous injections. In Europe, sumatriptan is also available as a suppository. Specific differences among the triptans exist, as evidenced by different pharmacological profiles including half-life, time to peak plasma concentrations, peak plasma concentrations, area under the concentration-time curve, metabolism and drug-drug interaction profiles. How or whether these differences translate to clinical efficacy and tolerability advantages for one agent over another is not well differentiated. However, delivery systems may play an important role in onset of action. Given that the clinical distinctions among these agents are subtle, identification of the most appropriate triptan for an individual patient requires consideration of the specific characteristics of the patient and knowledge of patient preference, an accurate history of the efficacy of previous acute-care medications and individual features of the drug being considered. The selection of an acute antimigraine drug also depends upon the stratification of the patient's migraine attack by peak intensity, time to peak intensity, level of associated symptoms such as nausea and vomiting, time to associated symptoms, comorbid diseases and concomitant treatments that might cause drug-drug interactions. Individual patient response to the triptans seems to be idiosyncratic and possibly genetically determined. Therefore, a set of specific questions can be used to determine whether a currently used triptan is optimally effective, whether the dose needs to be increased or whether another triptan should be tried. The clinician has in his/her armamentarium an ever-expanding variety of triptans, available in multiple formulations and dosages, which have good safety and tolerability profiles. Continued clinical use will yield familiarity with the various triptans, and it should become possible for the interested physician to match individual patient needs with the specific characteristics of a triptan to optimise therapeutic benefit. Use of the methods outlined in this review in choosing a triptan for an individual patient is probably more likely to lead to migraine relief than making an educated guess as to which triptan is most appropriate.

The genetics of migraine: implication for treatment approaches

Migraine is a paroxysmal neurological disorder affecting up to 12% of males and 24% of females in the general population, demonstrated to have a strong, but complex, genetic component. Genetic investigation of migraine bears great promise in providing new targets for drug development and optimization of individual specific therapy. Better, preferably prophylactic, treatment of migraine patients is desired because the presently used drugs are not effective in all patients, allow recurrence of the headache in a high percentage of patients and sometimes have severe adverse side effects. With the recent identification of the brain-specific P/Q-type calcium channel gene CACNA1A in the pathogenesis of migraine, the first step has been taken to identify primary biochemical pathways leading to migraine. Here, we summarize the current knowledge about the genetics of migraine and focus on the implication for treatment approaches.

Transient minor improvement of high altitude headache by sumatriptan

High-altitude headache often fulfills the criteria of migraine. Therefore, we hypothesized that sumatriptan, a 5-HT1 receptor agonist specifically effective for treatment of migraine, would also alleviate high altitude headache. A randomized, placebo-controlled double-blind trial was performed on 29 mountaineers with at least moderate headache on the day of arrival at 4559 m. Fourteen subjects received 100 mg sumatriptan orally and 15 subjects received placebo. Before treatment there were no significant differences between groups regarding rate of ascent, duration and severity of headache, and acute mountain sickness score. All 6 female subjects were randomly assigned to placebo. Absolute values and the reduction of headache scores 1, 3, and 12 h after the administration of sumatriptan did not differ between treatment groups, but headache scores tended to be lower with sumatriptan after 1 or 3 h when compared with placebo. Considering only male mountaineers, there was a significant decrease of headache scores after 1 and 3 h. Because there was only a minor transient amelioration of high altitude headache with sumatriptan, we conclude that 5-HT1 receptors do not play a major role in the pathophysiology of high altitude headache.

Drug therapy of neurovascular disease

Recent advances in the prevention and pharmacotherapy of cerebrovascular disease have provided more favorable clinical outcomes. For the treatment of an acute ischemic stroke, the early use of thrombolytic agents can reduce the degree of brain damage while improving functional outcomes. However, trials evaluating various classes of other neuroprotective agents have not shown benefit to date. For the prevention of second stroke, the use of antiplatelet drugs, HMG-CoA reductase inhibitors, and angiotensin-converting enzyme inhibitors with a diuretic have shown benefit in reducing new events. In patients with underlying heart disease or atrial fibrillation, warfarin appears to be the drug of choice in preventing stroke. Early treatment of hemorrhagic stroke with calcium channel blockers can improve the functional outcome. Innovative therapies are now available for the treatment of migraine and vascular dementia. Primary prevention of stroke remains the optimal therapeutic strategy and includes treatment of systemic hypertension and hypercholesterolemia.

Efficacy, safety, and tolerability of oral eletriptan for treatment of acute migraine: a multicenter, double-blind, placebo-controlled study conducted in the United States

OBJECTIVE

To investigate the efficacy, consistency, safety, and tolerability of oral eletriptan in the acute treatment of three migraine attacks.

BACKGROUND

Eletriptan is a selective 5-HT1B/1D agonist member of a class of agents known to be effective in the acute treatment of migraine.

METHODS

Thirteen hundred thirty-four patients were randomized to 20 mg, 40 mg, or 80 mg of eletriptan, or placebo and could treat up to three attacks. The primary efficacy endpoint was 2-hour headache response for the first attack. Secondary endpoints included associated symptom relief, and pain-free, sustained pain-free, and consistency of response.

RESULTS

Eletriptan 20 mg, 40 mg, and 80 mg achieved significantly (P <.0001) better headache response rates than placebo at 2 hours (47%, 62%, and 59%, respectively, versus 22%) and 4 hours (64%, 76%, and 79%, respectively, versus 25%). Headache response was observed to be rapid, showing improvement at 0.5 hour and 1 hour. Two-hour pain-free response rates for eletriptan 20 mg, 40 mg, and 80 mg were 14%, 27%, and 27%, respectively, compared with 4% for placebo. Sustained pain-free response rates were significantly (P <.001) better for eletriptan 20 mg (10%), 40 mg (20%), and 80 mg (18%) compared with placebo (3%). Eletriptan had a higher consistency of intrapatient response than placebo in two of three (68% to 82%) and three of three attacks (32% to 60%) versus 16% and 8%, respectively. All eletriptan doses yielded significant functional improvement at 2 hours. Adverse events were generally mild or moderate and transient, with eletriptan 20 mg having an adverse event profile comparable to placebo.

CONCLUSIONS

Eletriptan is efficacious, displaying high consistency of response over multiple attacks, and is well tolerated for the acute treatment of migraine.

Application of the 1988 International Headache Society diagnostic criteria in nine Italian headache centers using a computerized structured record

BACKGROUND

The actual application of the current International Headache Society (IHS) diagnostic criteria in clinical practice has not been investigated thoroughly.

OBJECTIVES

To develop a computerized, structured, medical record based exclusively on the IHS classification system.

DESIGN AND METHOD

We tested the computerized structured record by entering and analyzing data reported on the case sheets of 500 consecutive patients attending nine headache centers in Italy. All clinical diagnoses in the study were made according to current IHS criteria. The rate of concordance between the diagnosis provided by the computerized structured record and that reported by clinicians on the case sheets was calculated, and reasons for any discrepancies between the two diagnoses were analyzed.

RESULTS

Concordance between the two diagnoses was found in 345 of 500 cases examined (69%). In the remaining 155 cases, diagnoses reached with the computerized structured record and case sheets were impossible or discordant with respect to the diagnoses made by the clinician. In 144 of these cases (28.8%), this was due to missing information or errors in the diagnosis recorded by the clinicians on the patient case sheet. In particular, the diagnosis could not be reached using the computerized structured record in 105 cases (20.6%) because of a lack of one or more data needed in formulating a correct diagnosis according to the IHS operational criteria for one of the primary headache disorders. In the remaining 41 cases some data were missing, but the data available were sufficient to reach a diagnosis according to the IHS criteria. Moreover, the diagnoses reached using the computerized structured record were not in agreement with those made by the clinicians in another 39 cases (7.9%) due to an incorrect interpretation by the clinicians of the data reported on the patients' case sheets. In only 2.2% of the cases (n = 11) misdiagnoses were due to errors of the program that were promptly corrected.

CONCLUSIONS

The present study suggests that incorrect application of IHS criteria for the diagnosis of primary headache may occur in as many as one third of patients attending headache centers and that use of a computerized structured record based exclusively on current IHS criteria may overcome this deficiency.