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Robblee J, Hakim SM, Reynolds JM, Monteith TS, Zhang N, Barad M. Nonspecific oral medications versus anti-calcitonin gene-related peptide monoclonal antibodies for migraine: A systematic review and meta-analysis of randomized controlled trials. Headache 2024; 64:547-572. [PMID: 38634515 DOI: 10.1111/head.14693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 02/22/2024] [Accepted: 02/22/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVE To compare calcitonin gene-related peptide monoclonal antibodies (CGRP mAbs) versus nonspecific oral migraine preventives (NOEPs). BACKGROUND Insurers mandate step therapy with NOEPs before approving CGRP mAbs. METHODS Databases were searched for class I or II randomized controlled trials (RCTs) comparing CGRP mAbs or NOEPs versus placebo for migraine prevention in adults. The primary outcome measure was monthly migraine days (MMD) or moderate to severe headache days. RESULTS Twelve RCTs for CGRP mAbs, 5 RCTs for topiramate, and 3 RCTs for divalproex were included in the meta-analysis. There was high certainty that CGRP mAbs are more effective than placebo, with weighted mean difference (WMD; 95% confidence interval) of -1.64 (-1.99 to -1.28) MMD, which is compatible with small effect size (Cohen's d -0.25 [-0.34 to -0.16]). Certainty of evidence that topiramate or divalproex is more effective than placebo was very low and low, respectively (WMD -1.45 [-1.52 to -1.38] and -1.65 [-2.30 to -1.00], respectively; Cohen's d -1.25 [-2.47 to -0.03] and -0.48 [-0.67 to -0.29], respectively). Trial sequential analysis showed that information size was adequate and that CGRP mAbs had clear benefit versus placebo. Network meta-analysis showed no statistically significant difference between CGRP mAbs and topiramate (WMD -0.19 [-0.56 to 0.17]) or divalproex (0.01 [-0.73 to 0.75]). No significant difference was seen between topiramate or divalproex (0.21 [-0.45 to 0.86]). CONCLUSIONS There is high certainty that CGRP mAbs are more effective than placebo, but the effect size is small. When feasible, CGRP mAbs may be prescribed as first-line preventives; topiramate or divalproex could be as effective but are less well tolerated. The findings of this study support the recently published 2024 position of the American Headache Society on the use of CGRP mAbs as the first-line treatment.
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Affiliation(s)
- Jennifer Robblee
- Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Sameh M Hakim
- Department of Anesthesiology, Intensive Care, and Pain Management, Ain Shams University Faculty of Medicine, Cairo, Egypt
| | - John M Reynolds
- The Louis Calder Memorial Library, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Teshamae S Monteith
- Division of Headache, Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Niushen Zhang
- Department of Neurology & Neurological Sciences, Stanford Health Care, Stanford, California, USA
| | - Meredith Barad
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Health Care, Stanford, California, USA
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Tseng PT, Zeng BY, Chen JJ, Kuo CH, Zeng BS, Kuo JS, Cheng YS, Sun CK, Wu YC, Tu YK, Stubbs B, Carvalho AF, Liang CS, Chen TY, Hsu CW, Suen MW, Yang CP, Hsu SP, Chen YW, Shiue YL, Hung CM, Su KP, Lin PY. High Dosage Omega-3 Fatty Acids Outperform Existing Pharmacological Options for Migraine Prophylaxis: A Network Meta-Analysis. Adv Nutr 2024; 15:100163. [PMID: 38110000 PMCID: PMC10808921 DOI: 10.1016/j.advnut.2023.100163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 11/08/2023] [Accepted: 12/13/2023] [Indexed: 12/20/2023] Open
Abstract
Migraine is a highly prevalent neurologic disorder with prevalence rates ranging from 9% to 18% worldwide. Current pharmacologic prophylactic strategies for migraine have limited efficacy and acceptability, with relatively low response rates of 40% to 50% and limited safety profiles. Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are considered promising therapeutic agents for migraine prophylaxis. The aim of this network meta-analysis (NMA) was to compare the efficacy and acceptability of various dosages of EPA/DHA and other current Food and Drug Administration-approved or guideline-recommended prophylactic pharmacologic interventions for migraine. Randomized controlled trials (RCTs) were eligible for inclusion if they enrolled participants with a diagnosis of either episodic or chronic migraine. All NMA procedures were conducted under the frequentist model. The primary outcomes assessed were 1) changes in migraine frequency and 2) acceptability (i.e., dropout for any reason). Secondary outcomes included response rates, changes in migraine severity, changes in the frequency of using rescue medications, and frequency of any adverse events. Forty RCTs were included (N = 6616; mean age = 35.0 y; 78.9% women). Our analysis showed that supplementation with high dosage EPA/DHA yields the highest decrease in migraine frequency [standardized mean difference (SMD): -1.36; 95% confidence interval (CI): -2.32, -0.39 compared with placebo] and the largest decrease in migraine severity (SMD: -2.23; 95% CI: -3.17, -1.30 compared with placebo) in all studied interventions. Furthermore, supplementation with high dosage EPA/DHA showed the most favorable acceptability rates (odds ratio: 1.00; 95% CI: 0.06, 17.41 compared with placebo) of all examined prophylactic treatments. This study provides compelling evidence that high dosage EPA/DHA supplementation can be considered a first-choice treatment of migraine prophylaxis because this treatment displayed the highest efficacy and highest acceptability of all studied treatments. This study was registered in PROSPERO as CRD42022319577.
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Affiliation(s)
- Ping-Tao Tseng
- Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan; Department of Psychology, Collage of Medical and Health Science, Taichung, Asia University, Taiwan; Prospect Clinic for Otorhinolaryngology & Neurology, Kaohsiung City, Taiwan; Institute of Precision Medicine, National Sun Yat-sen University, Kaohsiung City, Taiwan
| | - Bing-Yan Zeng
- Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan; Department of Internal Medicine, E-Da Dachang Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Jiann-Jy Chen
- Prospect Clinic for Otorhinolaryngology & Neurology, Kaohsiung City, Taiwan; Department of Otorhinolaryngology, E-Da Cancer Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Chun-Hsien Kuo
- Department of Psychology, Collage of Medical and Health Science, Taichung, Asia University, Taiwan
| | - Bing-Syuan Zeng
- Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan; Department of Internal Medicine, E-Da Cancer Hospital, I-Shou University, Kaohsiung, Taiwan
| | - John S Kuo
- Neuroscience and Brain Disease Center and Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan
| | - Yu-Shian Cheng
- Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan; Department of Psychiatry, Tsyr-Huey Mental Hospital, Kaohsiung Jen-Ai's Home, Taiwan
| | - Cheuk-Kwan Sun
- Department of Emergency Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan; School of Medicine for International Students, College of Medicine, I-Shou University Kaohsiung, Taiwan
| | - Yi-Cheng Wu
- Department of Sports Medicine, Landseed International Hospital, Taoyuan, Taiwan
| | - Yu-Kang Tu
- Institute of Epidemiology & Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan; Department of Dentistry, National Taiwan University Hospital, Taipei, Taiwan
| | - Brendon Stubbs
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom; Physiotherapy Department, South London and Maudsley NHS Foundation Trust, London, United Kingdom; Positive Ageing Research Institute (PARI), Faculty of Health, Social Care Medicine and Education, Anglia Ruskin University, Chelmsford, United Kingdom
| | - Andre F Carvalho
- Innovation in Mental and Physical Health and Clinical Treatment (IMPACT) Strategic Research Centre, School of Medicine, Barwon Health, Deakin University, Geelong, VIC, Australia
| | - Chih-Sung Liang
- Department of Psychiatry, Beitou Branch, Tri-Service General Hospital, Taipei, Taiwan; School of Medicine, National Defense Medical Center, Taipei, Taiwan; Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Tien-Yu Chen
- Department of Psychiatry, Tri-Service General Hospital, Taipei, Taiwan; School of Medicine, National Defense Medical Center, Taipei, Taiwan; Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Chih-Wei Hsu
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Mein-Woei Suen
- Department of Psychology, Collage of Medical and Health Science, Taichung, Asia University, Taiwan; Gender Equality Education and Research Center, Asia University, Taichung, Taiwan; Department of Medical Research, Asia University Hospital, Asia University, Taichung, Taiwan; Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Chun-Pai Yang
- Department of Neurology, Kuang Tien General Hospital, Taichung, Taiwan; Department of Nutrition, Hungkuang University, Taichung, Taiwan
| | - Shih-Pin Hsu
- Department of Neurology, E-Da hospital, I-Shou University, Kaohsiung, Taiwan; School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Yen-Wen Chen
- Prospect Clinic for Otorhinolaryngology & Neurology, Kaohsiung City, Taiwan
| | - Yow-Ling Shiue
- Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan; Institute of Precision Medicine, National Sun Yat-sen University, Kaohsiung City, Taiwan.
| | - Chao-Ming Hung
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan; Division of General Surgery, Department of Surgery, E-Da Cancer Hospital, I-Shou University, Kaohsiung, Taiwan.
| | - Kuan-Pin Su
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom; Mind-Body Interface Research Center (MBI-Lab), China Medical University Hospital, Taichung, Taiwan; College of Medicine, China Medical University, Taichung, Taiwan; An-Nan Hospital, China Medical University, Tainan, Taiwan.
| | - Pao-Yen Lin
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan; Institute for Translational Research in Biomedical Sciences, Kaohsiung Chang Gung Memorial Hospital.
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Ducros A, de Gaalon S, Roos C, Donnet A, Giraud P, Guégan-Massardier E, Lantéri-Minet M, Lucas C, Mawet J, Moisset X, Valade D, Demarquay G. Revised guidelines of the French headache society for the diagnosis and management of migraine in adults. Part 2: Pharmacological treatment. Rev Neurol (Paris) 2021; 177:734-752. [PMID: 34340810 DOI: 10.1016/j.neurol.2021.07.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 12/21/2022]
Abstract
The French Headache Society proposes updated French guidelines for the management of migraine. This article presents the second part of the guidelines, which is focused on the pharmacological treatment of migraine, including both the acute treatment of attacks and the prophylaxis of episodic migraine as well as chronic migraine with and without medication overuse. The specific situations that can be encountered in women with migraine are also discussed, including pregnancy, menstrual migraine, contraception and hormonal replacement therapy.
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Affiliation(s)
- A Ducros
- Department of neurology, Gui-de-Chauliac hospital, CHU Montpellier, university of Montpellier, 34000 Montpellier, France
| | - S de Gaalon
- Department of neurology, Laënnec hospital, CHU de Nantes, Nantes, France
| | - C Roos
- Emergency headache center (centre d'urgences céphalées), department of neurology, Lariboisière hospital, Assistance publique-Hôpitaux de Paris, Paris, France
| | - A Donnet
- Centre d'évaluation et de traitement de la douleur, FHU INOVPAIN, hôpital de La Timone, Marseille, France
| | - P Giraud
- Department of neurology, Annecy Genevois hospital, Annecy, France
| | | | - M Lantéri-Minet
- Pain department, FHU InovPain, CHU Nice Côte Azur université, Nice, France
| | - C Lucas
- Centre d'évaluation et de traitement de la douleur, service de neurochirurgie, hôpital Salengro, CHRU de Lille, Lille, France
| | - J Mawet
- Emergency headache center (centre d'urgences céphalées), department of neurology, Lariboisière hospital, Assistance publique-Hôpitaux de Paris, Paris, France
| | - X Moisset
- Neuro-Dol, université Clermont Auvergne, CHU de Clermont-Ferrand, INSERM, Clermont-Ferrand, France
| | - D Valade
- Department of neurosurgery, hôpital Pitié-Sapêtrière, Paris, France
| | - G Demarquay
- Neurological hospital, Lyon, neuroscience research center (CRNL), INSERM U1028, CNRS UMR5292, Lyon, France.
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4
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Diener HC, Holle-Lee D, Nägel S, Dresler T, Gaul C, Göbel H, Heinze-Kuhn K, Jürgens T, Kropp P, Meyer B, May A, Schulte L, Solbach K, Straube A, Kamm K, Förderreuther S, Gantenbein A, Petersen J, Sandor P, Lampl C. Treatment of migraine attacks and prevention of migraine: Guidelines by the German Migraine and Headache Society and the German Society of Neurology. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2019. [DOI: 10.1177/2514183x18823377] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In collaboration with some of the leading headache centres in Germany, Switzerland and Austria, we have established new guidelines for the treatment of migraine attacks and the prevention of migraine. A thorough literature research of the last 10 years has been the basis of the current recommendations. At the beginning, we present therapeutic novelties, followed by a summary of all recommendations. After an introduction, we cover topics like drug therapy and practical experience, non-effective medication, migraine prevention, interventional methods, non-medicational and psychological methods for prevention and therapies without proof of efficacy.
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Affiliation(s)
- Hans-Christoph Diener
- Klinik für Neurologie und Westdeutsches Kopfschmerzzentrum, Universitätsklinikum Essen, Essen, Germany
| | - Dagny Holle-Lee
- Klinik für Neurologie und Westdeutsches Kopfschmerzzentrum, Universitätsklinikum Essen, Essen, Germany
| | - Steffen Nägel
- Klinik für Neurologie und Westdeutsches Kopfschmerzzentrum, Universitätsklinikum Essen, Essen, Germany
| | - Thomas Dresler
- Klinik für Psychiatrie und Psychotherapie, Universität Tübingen, Tübingen, Germany
- Graduiertenschule & Forschungsnetzwerk LEAD, Universität Tübingen, Tübingen, Germany
| | - Charly Gaul
- Migräne- und Kopfschmerzklinik Königstein, Königstein im Taunus, Germany
| | | | | | - Tim Jürgens
- Universitätsmedizin Rostock, Zentrum für Nervenheilkunde, Klinik und Poliklinik für Neurologie, Rostock, Germany
| | - Peter Kropp
- Institut für Medizinische Psychologie und Medizinische Soziologie, Universitätsmedizin Rostock, Zentrum für Nervenheilkunde, Rostock, Germany
| | - Bianca Meyer
- Institut für Medizinische Psychologie und Medizinische Soziologie, Universitätsmedizin Rostock, Zentrum für Nervenheilkunde, Rostock, Germany
| | - Arne May
- Institut für Systemische Neurowissenschaften, Universitätsklinikum Hamburg Eppendorf (UKE), Hamburg, Germany
| | - Laura Schulte
- Institut für Systemische Neurowissenschaften, Universitätsklinikum Hamburg Eppendorf (UKE), Hamburg, Germany
| | - Kasja Solbach
- Klinik für Neurologie, Universitätsklinikum Essen, Essen, Germany
| | - Andreas Straube
- Neurologische Klinik, Ludwig-Maximilians-Universität München, Klinikum Großhadern, München, Germany
| | - Katharina Kamm
- Neurologische Klinik, Ludwig-Maximilians-Universität München, Klinikum Großhadern, München, Germany
| | - Stephanie Förderreuther
- Neurologische Klinik, Ludwig-Maximilians-Universität München, Klinikum Großhadern, München, Germany
| | | | - Jens Petersen
- Klinik für Neurologie, Universitätsspital Zürich, Zürich, Swizterland
| | - Peter Sandor
- RehaClinic Bad Zurzach, Bad Zurzach, Swizterland
| | - Christian Lampl
- Ordensklinikum Linz, Krankenhaus der Barmherzigen Schwestern Linz Betriebsgesellschaft m.b.H., Linz, Austria
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Shanmugam S, Karunaikadal K, Varadarajan S, Krishnan M. Memantine Ameliorates Migraine Headache. Ann Indian Acad Neurol 2019; 22:286-290. [PMID: 31359939 PMCID: PMC6613428 DOI: 10.4103/aian.aian_294_18] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background and Objective: A significant number of migraine patients do not find effective and safe treatment to reduce the frequency and severity of their migraine attacks. Hence, a need for newer therapeutic agent exists. In this study, we examined the efficacy and safety of memantine for the treatment of migraine. Materials and Methods: It was a randomized, placebo-controlled, double-blind study including adult patients with 3–12 migraine headache for the last 6 months conducted in India. Patients received memantine (10 mg/day, once a day) or placebo for the period of 24 weeks after a washout period. Migraine frequency per month, the 50% responder rate, rescue medication use, and adverse events were recorded every 4 weeks. Results: Among 81 patients screened, 60 were enrolled for the study. Thirty patients received memantine and other 30 received placebo. Data were analyzed for 28 patients in memantine group and 29 patients in placebo group. At the baseline, all the parameters were similar in both groups. By 24 weeks, migraine frequency/4 weeks was memantine group versus placebo; 2.57 (±0.38) versus 5.07 (±0.69), P = 0.003 and rescue medication use was 0.75 (±0.23) versus 3.72 (±0.63) P = 0.0001. The 50% responder rate was 85.7% versus 51.7% (P = 0.005). Only a few mild adverse events were recorded in both the groups. No severe adverse events and death were recorded during the study. Conclusion: Memantine (10 mg oral, once daily) is effective, well tolerated, and safe for patients with migraine.
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Affiliation(s)
- Sundar Shanmugam
- Department of Neurology, Sri Ramachandra Medical College, Chennai, Tamil Nadu, India
| | - Kranthi Karunaikadal
- Department of Pharmacology, Sri Ramachandra Medical College, Chennai, Tamil Nadu, India
| | | | - Muthuraj Krishnan
- Department of Neurology, SRM Medical College, Chennai, Tamil Nadu, India
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Meyers S, Claire Simon K, Bergman-Bock S, Campanella F, Marcus R, Mark A, Freedom T, Rubin S, Semenov I, Lai R, Hillman L, Tideman S, Pham A, Frigerio R, Maraganore DM. Structured Clinical Documentation to Improve Quality and Support Practice-Based Research in Headache. Headache 2018; 58:1211-1218. [DOI: 10.1111/head.13348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 04/23/2018] [Accepted: 05/12/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Steven Meyers
- Department of Neurology; NorthShore University HealthSystem; Evanston IL USA
| | - Kelly Claire Simon
- Department of Neurology; NorthShore University HealthSystem; Evanston IL USA
| | - Stuart Bergman-Bock
- Department of Neurology; NorthShore University HealthSystem; Evanston IL USA
| | - Franco Campanella
- Department of Neurology; NorthShore University HealthSystem; Evanston IL USA
| | - Revital Marcus
- Department of Neurology; NorthShore University HealthSystem; Evanston IL USA
| | - Angela Mark
- Department of Neurology; NorthShore University HealthSystem; Evanston IL USA
| | - Thomas Freedom
- Department of Neurology; NorthShore University HealthSystem; Evanston IL USA
| | - Susan Rubin
- Department of Neurology; NorthShore University HealthSystem; Evanston IL USA
| | - Irene Semenov
- Department of Neurology; NorthShore University HealthSystem; Evanston IL USA
| | - Rebekah Lai
- Health Information Technology, NorthShore University HealthSystem; Evanston IL USA
| | - Laura Hillman
- Health Information Technology, NorthShore University HealthSystem; Evanston IL USA
| | - Samuel Tideman
- Department of Neurology; NorthShore University HealthSystem; Evanston IL USA
| | - Anna Pham
- Department of Neurology; NorthShore University HealthSystem; Evanston IL USA
| | - Roberta Frigerio
- Department of Neurology; NorthShore University HealthSystem; Evanston IL USA
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Abstract
BACKGROUND Migraine, ranked as the 7th-highest specific cause of disability worldwide, has caused an enormous burden on the economy and society. Tricyclic antidepressant (TCA) is one of the most commonly drugs for migraine prevention. However, evidence about the efficacy and tolerability of TCAs in the prophylaxis of migraine in adults is somewhat confusing. METHODS A computerized literature search of the PubMed, Embase, Cochrane, and Web of Science databases from inception to July 2016 was conducted. We reviewed all randomized controlled trials that assigned adults with a clinical diagnosis of migraine to TCAs or other treatments (placebo or other antidepressants). Reduction in migraine frequency or index and response rates to treatment were defined as the efficacy outcomes. Rates of dropout due to adverse effects were defined as the tolerability outcomes. RESULTS In total 12 trials consisting of 1006 participants were identified: 9 trials compared TCAs with placebo, and the other 3 compared amitriptyline with selective serotonin reuptake inhibitors (SSRIs) or serotonin norepinephrine reuptake inhibitors (SNRIs). A significant advantage of TCAs compared with placebo in the prevention of migraine in adults was observed (standardized mean difference [SMD] = -.75; 95% confidence interval [CI] = -1.05 to -.46; P < .00001). Participants receiving TCAs were more likely to experience an ≥50% reduction in their headache burden than those receiving placebo (risk ratio [RR] =1.40; 95% CI = 0.89-2.20; P = .14). In addition, the efficacy between amitriptyline and SSRIs or SNRIs did not differ for migraine prevention in adults (SMD = -.01; 95% CI = -0.31 to 0.28; P = .94) based on the available limited trials. However, TCAs were less well tolerated than placebo (RR = 1.73; 95% CI = 1.00-2.99; P = .05) and SSRI or SNRI (RR = 2.85; 95% CI = 0.97-8.41; P = .06) on account of adverse events. CONCLUSIONS This research reveals that TCAs were more effective than placebo, but no more than SSRI or SNRI in ameliorating the headache burden in adults with migraine. However, TCAs appeared to be less tolerated than placebo and SSRIs or SNRIs for some side effects.
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Affiliation(s)
- Xiao-min Xu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University
- Chongqing Key Laboratory of Neurobiology, Chongqing, China
| | - Yang Liu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University
- Chongqing Key Laboratory of Neurobiology, Chongqing, China
| | - Mei-xue Dong
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University
- Chongqing Key Laboratory of Neurobiology, Chongqing, China
| | - De-zhi Zou
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University
- Chongqing Key Laboratory of Neurobiology, Chongqing, China
| | - You-dong Wei
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University
- Chongqing Key Laboratory of Neurobiology, Chongqing, China
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8
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Xu XM, Yang C, Liu Y, Dong MX, Zou DZ, Wei YD. Efficacy and feasibility of antidepressants for the prevention of migraine in adults: a meta-analysis. Eur J Neurol 2017; 24:1022-1031. [PMID: 28557171 DOI: 10.1111/ene.13320] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 04/06/2017] [Indexed: 01/03/2023]
Affiliation(s)
- X.-M. Xu
- Department of Neurology; First Affiliated Hospital of Chongqing Medical University; Chongqing China
- Chongqing Key Laboratory of Neurobiology; Chongqing China
| | - C. Yang
- Department of Burn and Plastic Surgery; First Affiliated Hospital of Chongqing Medical University; Chongqing China
| | - Y. Liu
- Department of Neurology; First Affiliated Hospital of Chongqing Medical University; Chongqing China
- Chongqing Key Laboratory of Neurobiology; Chongqing China
| | - M.-X. Dong
- Department of Neurology; First Affiliated Hospital of Chongqing Medical University; Chongqing China
- Chongqing Key Laboratory of Neurobiology; Chongqing China
| | - D.-Z. Zou
- Department of Neurology; First Affiliated Hospital of Chongqing Medical University; Chongqing China
- Chongqing Key Laboratory of Neurobiology; Chongqing China
| | - Y.-D. Wei
- Department of Neurology; First Affiliated Hospital of Chongqing Medical University; Chongqing China
- Chongqing Key Laboratory of Neurobiology; Chongqing China
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9
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Abstract
BACKGROUND Propranolol is one of the most commonly prescribed drugs for migraine prophylaxis. OBJECTIVES We aimed to determine whether there is evidence that propranolol is more effective than placebo and as effective as other drugs for the interval (prophylactic) treatment of patients with migraine. SEARCH METHODS Potentially eligible studies were identified by searching MEDLINE/PubMed (1966 to May 2003) and the Cochrane Central Register of Controlled Trials (Issue 2, 2003), and by screening bibliographies of reviews and identified articles. SELECTION CRITERIA We included randomised and quasi-randomised clinical trials of at least 4 weeks duration comparing clinical effects of propranolol with placebo or another drug in adult migraine sufferers. DATA COLLECTION AND ANALYSIS Two reviewers extracted information on patients, methods, interventions, outcomes measured, and results using a pre-tested form. Study quality was assessed using two checklists (Jadad scale and Delphi list). Due to the heterogeneity of outcome measures and insufficient reporting of the data, only selective quantitative meta-analyses were performed. As far as possible, effect size estimates were calculated for single trials. In addition, results were summarised descriptively and by a vote count among the reviewers. MAIN RESULTS A total of 58 trials with 5072 participants met the inclusion criteria. The 58 selected trials included 26 comparisons with placebo and 47 comparisons with other drugs. The methodological quality of the majority of trials was unsatisfactory. The principal shortcomings were high dropout rates and insufficient reporting and handling of this problem in the analysis. Overall, the 26 placebo-controlled trials showed clear short-term effects of propranolol over placebo. Due to the lack of studies with long-term follow up, it is unclear whether these effects are stable after stopping propranolol. The 47 comparisons with calcium antagonists, other beta-blockers, and a variety of other drugs did not yield any clear-cut differences. Sample size was, however, insufficient in most trials to establish equivalence. AUTHORS' CONCLUSIONS Although many trials have relevant methodological shortcomings, there is clear evidence that propranolol is more effective than placebo in the short-term interval treatment of migraine. Evidence on long-term effects is lacking. Propranolol seems to be as effective and safe as a variety of other drugs used for migraine prophylaxis.
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Affiliation(s)
- Klaus Linde
- Centre for Complementary Medicine Research, Department of Internal Medicine II, Technical University Munich, Munich, Germany
| | - Karin Rossnagel
- Institute of Social Medicine & Epidemiology, Charité University Hospital, Humboldt University, Berlin, Germany, 10098
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Doyle Strauss L, Weizenbaum E, Loder EW, Rizzoli PB. Amitriptyline Dose and Treatment Outcomes in Specialty Headache Practice: A Retrospective Cohort Study. Headache 2016; 56:1626-1634. [PMID: 27775149 DOI: 10.1111/head.12987] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To characterize treatment patterns and real world outcomes in headache patients treated with amitriptyline in an academic headache center. DESIGN AND METHODS A retrospective chart review identified 178 patients in our center who were given a new prescription for amitriptyline in treatment of headache, and who were seen in follow-up within one year. Charts were reviewed to identify dosing patterns (initial and maximum dose) and persistence, patient-reported headache benefit, and reported side effects. Variables assessed in relation to medication use were comorbid psychiatric disease, headache characteristics, and prior use of a preventive medication. RESULTS We followed patients for an average of 6.5 months. Initial and maximum prescribed amitriptyline doses were characterized as: "very low" (≤10 mg daily), "low" (11-25 mg daily), and "traditional" (≥25 mg daily). The initial dose of amitriptyline ranged from 2.5 to 50 mg daily, though most patients were started on a dose of 10 mg daily (112/178, 63%). Approximately 3/4 of the patients were found to have improvement (134/178) and 85% (129/151) were still taking amitriptyline at the last follow-up appointment. Maximum dosing ranged from 2.5 to 100 mg daily with most patients taking 10-25 mg (86/146, 58%). The most commonly reported adverse effect was daytime fatigue (17/151, 11%). There did not appear to be any effect from gender, ethnicity, race, diagnosis of sleep apnea, chronicity of migraine, presence of aura on our outcome measures. CONCLUSION Our study supports the common clinical practice of using low doses of amitriptyline to treat chronic headache disorders and suggests that it was effective and well tolerated at doses lower than those used in many clinical trials. Use of low dosage amitriptyline may also improve medication persistence, an important clinical consideration in the management of this common and chronic condition. A subgroup of patients may experience a dramatic benefit from amitriptyline and this could warrant further investigation.
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Affiliation(s)
- Lauren Doyle Strauss
- Pediatric Neurology, Wake Forest Baptist Health Medical Center, Winston-Salem, NC, USA
| | - Emma Weizenbaum
- Department of Neurology, Brigham and Women's Faulkner Hospital, Research Assistant, John R. Graham Headache Center, Boston, MA, USA
| | - Elizabeth W Loder
- Division of Headache and Pain, Department of Neurology, Brigham and Women's Faulkner Hospital, Boston, MA, USA
| | - Paul B Rizzoli
- John R. Graham Headache Center, Department of Neurology, Brigham and Women's Faulkner Hospital, Boston, MA, USA
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Lavenstein B. A Comparative Study of Cyproheptadine, Amitriptylins, and Propranolol in the Treatment of pre Adolescent Migraine. Cephalalgia 2016. [DOI: 10.1177/0333102491011s1166] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Gooriah R, Nimeri R, Ahmed F. Evidence-Based Treatments for Adults with Migraine. PAIN RESEARCH AND TREATMENT 2015; 2015:629382. [PMID: 26839703 PMCID: PMC4709728 DOI: 10.1155/2015/629382] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Accepted: 12/09/2015] [Indexed: 01/03/2023]
Abstract
Migraine, a significantly disabling condition, is treated with acute and preventive medications. However, some individuals are refractory to standard treatments. Although there is a host of alternative management options available, these are not always backed by strong evidence. In fact, most of the drugs used in migraine were initially designed for other purposes. Whilst effective, the benefits from these medications are modest, reflecting the need for newer and migraine-specific therapeutic agents. In recent years, we have witnessed the emergence of novel treatments, of which noninvasive neuromodulation appears to be the most attractive given its ease of use and excellent tolerability profile. This paper reviews the evidence behind the available treatments for migraine.
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Affiliation(s)
| | - Randa Nimeri
- Department of Neurology, Hull Royal Infirmary, Hull, UK
| | - Fayyaz Ahmed
- Department of Neurology, Hull Royal Infirmary, Hull, UK
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Jackson JL, Cogbill E, Santana-Davila R, Eldredge C, Collier W, Gradall A, Sehgal N, Kuester J. A Comparative Effectiveness Meta-Analysis of Drugs for the Prophylaxis of Migraine Headache. PLoS One 2015; 10:e0130733. [PMID: 26172390 PMCID: PMC4501738 DOI: 10.1371/journal.pone.0130733] [Citation(s) in RCA: 146] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Accepted: 05/24/2015] [Indexed: 01/03/2023] Open
Abstract
Objective To compare the effectiveness and side effects of migraine prophylactic medications. Design We performed a network meta-analysis. Data were extracted independently in duplicate and quality was assessed using both the JADAD and Cochrane Risk of Bias instruments. Data were pooled and network meta-analysis performed using random effects models. Data Sources PUBMED, EMBASE, Cochrane Trial Registry, bibliography of retrieved articles through 18 May 2014. Eligibility Criteria for Selecting Studies We included randomized controlled trials of adults with migraine headaches of at least 4 weeks in duration. Results Placebo controlled trials included alpha blockers (n = 9), angiotensin converting enzyme inhibitors (n = 3), angiotensin receptor blockers (n = 3), anticonvulsants (n = 32), beta-blockers (n = 39), calcium channel blockers (n = 12), flunarizine (n = 7), serotonin reuptake inhibitors (n = 6), serotonin norepinephrine reuptake inhibitors (n = 1) serotonin agonists (n = 9) and tricyclic antidepressants (n = 11). In addition there were 53 trials comparing different drugs. Drugs with at least 3 trials that were more effective than placebo for episodic migraines included amitriptyline (SMD: -1.2, 95% CI: -1.7 to -0.82), -flunarizine (-1.1 headaches/month (ha/month), 95% CI: -1.6 to -0.67), fluoxetine (SMD: -0.57, 95% CI: -0.97 to -0.17), metoprolol (-0.94 ha/month, 95% CI: -1.4 to -0.46), pizotifen (-0.43 ha/month, 95% CI: -0.6 to -0.21), propranolol (-1.3 ha/month, 95% CI: -2.0 to -0.62), topiramate (-1.1 ha/month, 95% CI: -1.9 to -0.73) and valproate (-1.5 ha/month, 95% CI: -2.1 to -0.8). Several effective drugs with less than 3 trials included: 3 ace inhibitors (enalapril, lisinopril, captopril), two angiotensin receptor blockers (candesartan, telmisartan), two anticonvulsants (lamotrigine, levetiracetam), and several beta-blockers (atenolol, bisoprolol, timolol). Network meta-analysis found amitriptyline to be better than several other medications including candesartan, fluoxetine, propranolol, topiramate and valproate and no different than atenolol, flunarizine, clomipramine or metoprolol. Conclusion Several drugs good evidence supporting efficacy. There is weak evidence supporting amitriptyline’s superiority over some drugs. Selection of prophylactic medication should be tailored according to patient preferences, characteristics and side effect profiles.
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Affiliation(s)
- Jeffrey L. Jackson
- General Internal Medicine, Zablocki VA Medical Center, Milwaukee, Wisconsin, United States of America
- * E-mail:
| | - Elizabeth Cogbill
- Department of Medicine, Western Michigan School of Medicine, Kalamazoo, Michigan, United States of America
| | - Rafael Santana-Davila
- Division of Hematology and Oncology, University of Washington, Seattle, Washington, United States of America
| | - Christina Eldredge
- Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - William Collier
- Department of Pharmacology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Andrew Gradall
- School of Health Sciences, Gollis University, Hergaisa, Somaliland
| | - Neha Sehgal
- Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Jessica Kuester
- General Internal Medicine, Zablocki VA Medical Center, Milwaukee, Wisconsin, United States of America
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Abstract
All physicians will encounter patients with headaches. Primary headache disorders are common, and often disabling. This paper reviews the principles of drug therapy in headache in adults, focusing on the three commonest disorders presenting in both primary and secondary care: tension-type headache, migraine and cluster headache. The clinical evidence on the basis of which choices can be made between the currently available drug therapies for acute and preventive treatment of these disorders is presented, and information given on the options available for the emergency parenteral treatment of refractory migraine attacks and cluster headache.
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Affiliation(s)
- Mark W Weatherall
- Princess Margaret Migraine Clinic, Charing Cross Hospital, London, UK
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15
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Fan W, Lv Y, Ying G, Li W, Zhou J. Pilot study of amitriptyline in the prophylactic treatment of medication-overuse headache: a 1-year follow-up. PAIN MEDICINE 2014; 15:1803-10. [PMID: 25159678 DOI: 10.1111/pme.12517] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE This study aims to evaluate the long-term efficacy of low-dose amitriptyline combined with abrupt withdrawal in outpatients of medication-overuse headache (MOH) in an open-label design. METHODS We evaluated the effectiveness of early introduction of low-dose amitriptyline combined with abrupt withdrawal in outpatients with MOH over a 1-year observational period. The primary outcome measures were the reduction in number of headache days and days with use of acute headache medication after 3 months and after 12 months. A number of secondary outcome measures, as well as safety and tolerability, were assessed. The responders were defined as patients with ≥50% reduction in headache frequency from baseline and being without medication overuse. RESULTS Thirty-three patients completed the study. Significant reductions in headache frequency and medication consumption were observed at both months 3 and 12, compared to baseline (P < 0.05 for all). Neither the primary nor the secondary endpoints differed significantly between months 3 and 12. At the 12-month follow-up, 58% of the patients were considered as responders (N = 19); 73% remained cured of MOH (N = 24); 64% had reverted to episodic headaches (N = 21); 27% had relapsed into MOH (N = 9). CONCLUSION Given these results, early introduction of low-dose amitriptyline combined with abrupt withdrawal could be considered as a choice for patients with MOH.
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Affiliation(s)
- Wen Fan
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Pietrini U, De Luca M, Del Bene E, De Cesaris F, Bertinotti L, Colangelo N, Moggi Pignone A. Prophylactic activity of increasing doses of intravenous histamine in refractory migraine: Retrospective observations of a series of patients with migraine without aura. Curr Ther Res Clin Exp 2014; 65:70-8. [PMID: 24936105 DOI: 10.1016/s0011-393x(04)90006-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2003] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Histamine is thought to play a pivotal role in the modulation of peripheral and central pain. The administration of increasing doses of histamine may lead to desensitization of receptors of histamine types 1 and 2, causing meningeal vasodilation, and to depletion of neuropeptides in the trigeminal ganglion, thus inhibiting the initiation of migraine. OBJECTIVE In this study, the efficacy and tolerability of increasing doses of IV histamine in migraine prophylaxis were investigated. METHODS This single-center, open-label, retrospective, controlled study was conducted at the Headache Center (Department of Internal Medicine, University of Florence, Villa Monna Tessa, Italy). Patients included in the study had 3 to 6 migraines without aura per month that were refractory to common symptomatic and prophylactic agents in the 6 months preceding the study. Patients were treated with IV histamine hydrochloride for 21 days starting with a dosage of 0.5 mg/d and increasing to 4.0 mg/d. To assess the efficacy of the treatment, these patients were matched for age; sex; and frequency, duration, and severity of attacks with untreated migraineurs. Clinical benefit was defined as ⩽ 1 migraine of mild intensity per month. Tolerability was assessed during the hospitalization period, and patients were instructed to contact the Headache Center to report any adverse effects after hospital discharge. RESULTS The histamine group comprised 47 patients (40 women, 7 men; mean [SD] age, 42.0 [8.6] years) and the control group comprised 23 patients (20 women, 3 men; mean [SD] age, 38.8 [8.4] years). The histamine-treated patients showed a clinical benefit lasting for a mean of 10.4 (4.2) months, while the patients in the control group showed a clinical benefit of 3.8 (1.9) months. The difference in the duration of the clinical benefit between the 2 groups was 6.6 months (95% CI, 5.15-7.99). Adverse effects consisted of flushing, heat sensation during infusion, headache, and palpitations. CONCLUSIONS In this study, histamine showed lasting prophylactic efficacy in migraineurs. If further research confirms this preliminary finding, histamine could be considered when established prophylactic drugs, such as betablockers, calcium antagonists, antidepressants, and antiepileptics, have not been effective.
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Affiliation(s)
- Umberto Pietrini
- Headache Center, Department of Intemal Medicine, University of Florence, Villa Monna Tessa, Italy ; Department of Internal Medicine, Clinica Medica IV, Villa Monna Tessa, Italy
| | - Massimo De Luca
- Headache Center, Department of Intemal Medicine, University of Florence, Villa Monna Tessa, Italy ; Department of Internal Medicine, Clinica Medica IV, Villa Monna Tessa, Italy
| | - Enrico Del Bene
- Headache Center, Department of Intemal Medicine, University of Florence, Villa Monna Tessa, Italy ; Department of Internal Medicine, Clinica Medica IV, Villa Monna Tessa, Italy
| | - Francesco De Cesaris
- Headache Center, Department of Intemal Medicine, University of Florence, Villa Monna Tessa, Italy ; Department of Internal Medicine, Clinica Medica IV, Villa Monna Tessa, Italy
| | - Luca Bertinotti
- Department of Internal Medicine, Clinica Medica IV, Villa Monna Tessa, Italy
| | - Nicola Colangelo
- Department of Internal Medicine, Clinica Medica IV, Villa Monna Tessa, Italy
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Tuchin PJ, Pollard H. Does classic migraine respond to manual therapy – a case series. PHYSICAL THERAPY REVIEWS 2013. [DOI: 10.1179/ptr.1998.3.3.149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Abbar JC, Lamani SD, Nandibewoor ST. Ruthenium(III) Catalyzed Oxidative Degradation of Amitriptyline-A Tricyclic Antidepressant Drug by Permanganate in Aqueous Acidic Medium. J SOLUTION CHEM 2011. [DOI: 10.1007/s10953-011-9655-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Yamada K, Moriwaki K, Oiso H, Ishigooka J. High prevalence of comorbidity of migraine in outpatients with panic disorder and effectiveness of psychopharmacotherapy for both disorders: a retrospective open label study. Psychiatry Res 2011; 185:145-8. [PMID: 20546930 DOI: 10.1016/j.psychres.2009.08.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2008] [Revised: 06/16/2009] [Accepted: 08/13/2009] [Indexed: 11/18/2022]
Abstract
We investigated the comorbidity rate of migraine in outpatients with panic disorder, and the efficacy of pharmacotherapy for both disorders. Fifty-four patients who met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria for panic disorder were recruited in the study. Forty-three patients were female, and their age ranged from 20 to 71 (38.8±11.2; mean±S.D.) years. Forty-one patients had agoraphobia. In these patients, we diagnosed migraine and other types of headache, using the International Classification of Headache Disorders, Second Edition (ICHD-II). Forty-three (79.6%) patients were diagnosed as having some type of headache; 33 (61.1%) migraine, 32 tension-type headache, and one cluster headache. In patients with migraine, treatment for panic disorder also improved their migraine in 19 (57.6%) patients. The mean onset age of panic disorder in patients with migraine was statistically significantly younger than that in non-migraine patients. The Clinical Global Impression Improvement (CGI-I) score of panic disorder was statistically significantly correlated with the CGI-I score of migraine. A high comorbidity rate (61.1%) of migraine was observed in outpatients with panic disorder, and our result suggests that treatment with antidepressants for panic disorder may also be effective for prophylaxis of migraine.
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Affiliation(s)
- Kazuo Yamada
- Department of Psychiatry, Tokyo Women's Medical University, Medical Center East, Tokyo, Japan.
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22
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Abstract
OBJECTIVE AND BACKGROUND Amitriptyline is one of the most commonly used medications in migraine prophylaxis. There have been relatively few placebo-controlled studies of amitriptyline in migraine prophylaxis or in treatment of chronic daily headache (CDH). This report deals with a large placebo-controlled trial of amitriptyline vs placebo of 20 weeks duration that included subjects with intermittent migraine (IM) as well as CDH. The study was carried out between 1976 and 1979; however, results have never been fully reported. METHODS Patients with a history of migraine as defined by the 1962 Ad Hoc Committee report were recruited for this study. Subjects had at least 2 headaches per month, and no limit was placed on the number of headaches per month that could be experienced. The study format included a 4-week baseline period (Period A) in which all subjects received placebo in a dose of 2 pills per day for one week, 3 pills per day for one week and then 4 pills per day for 2 weeks. Subjects with at least 2 migraine headaches in this period were then entered into Period B and randomized into either amitriptyline or placebo tracks. Medication consisted of identical tablets containing either 25 mg amitriptyline or placebo. Period B was 4 weeks in duration with dose titration identical to Period A. The dose could be reduced if necessary to reduce side effects. The minimum dose was one pill per day. Period C was a 12-week maintenance or stabilization period in which the patient continued the dose established by week 8 with visits at weeks 12, 16, and 20. Patients kept a headache calendar that was used for data collection. Headache frequency (per month), severity, and duration (hours) were the primary measurement parameters employed for data analysis. RESULTS For the entire group, 391 subjects were entered into Period A, 338 were randomized into Period B, 317 (81%) subjects completed the first post-randomization visit (8 weeks), 255 (65%) completed week 12, 210 (54%) completed week 16, and 186 (48%) completed week 20. Using headache frequency and evaluating parameters of (a) improvement, (b) no change, or (c) worsening relative to baseline, there was a significant improvement in headache frequency for amitriptyline over placebo at 8 weeks (P = .018) but not at 12, 16, or 20 weeks. When amitriptyline and placebo patients were compared for headache frequency at 8, 12, 16, and 20 weeks to their own placebo stabilization period at 4 weeks, statistically significant improvement vs worsening was seen in headache frequency at each evaluation point for both amitriptyline and placebo groups (P ≤ .01) reaching 50% reporting a decrease in frequency in each group and approximately 10% reporting worsening by week 20. There were no significant differences in headache severity or duration between amitriptyline and placebo groups at anytime during the study. Within the study sample, there were 36 amitriptyline and 22 placebo subjects who had headaches ≥ 17 days/month that fit the current definition of CDH by the Silberstein-Lipton criteria. These were analyzed separately as a subgroup for comparison of amitriptyline vs placebo using a metric of (1) no change or worsening; (2) up to a 50% improvement; and (3) ≥ 50% improvement in headache frequency. Amitriptyline was superior to placebo in number with improvement in frequency of ≥ 50% at 8 weeks (25% vs 5% [P = .031]) and at 16 weeks (46% vs 9% [P = .043]). There was a trend for amitriptyline to be superior to placebo at 12 and 20 weeks but this did not reach significance. CONCLUSIONS In this study, using headache frequency as the primary metric, for the entire group, amitriptyline was superior to placebo in migraine prophylaxis at 8 weeks but, because of a robust placebo response, not at subsequent time points. For the subgroup with CDH, amitriptyline was statistically significantly superior to placebo at 8 weeks and 16 weeks with a similar but nonsignificant trend at 12 and 20 weeks. Compared with placebo amitriptyline is effective in CDH. Amitriptyline was also significantly effective in IM compared intragroup to its own baseline; however, placebo was equally effective in the same analysis. The reason for the robust placebo response in the IM group is not clear, but has been occasionally reported.
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Affiliation(s)
- James R Couch
- University of Oklahoma Medical School, Oklahoma City, OK 73104, USA
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Jackson JL, Shimeall W, Sessums L, Dezee KJ, Becher D, Diemer M, Berbano E, O'Malley PG. Tricyclic antidepressants and headaches: systematic review and meta-analysis. BMJ 2010; 341:c5222. [PMID: 20961988 PMCID: PMC2958257 DOI: 10.1136/bmj.c5222] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/09/2010] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To evaluate the efficacy and relative adverse effects of tricyclic antidepressants in the treatment of migraine, tension-type, and mixed headaches. DESIGN Meta-analysis. DATA SOURCES Medline, Embase, the Cochrane Trials Registry, and PsycLIT. Studies reviewed Randomised trials of adults receiving tricyclics as only treatment for a minimum of four weeks. DATA EXTRACTION Frequency of headaches (number of headache attacks for migraine and number of days with headache for tension-type headaches), intensity of headache, and headache index. RESULTS 37 studies met the inclusion criteria. Tricyclics significantly reduced the number of days with tension-type headache and number of headache attacks from migraine than placebo (average standardised mean difference -1.29, 95% confidence interval -2.18 to -0.39 and -0.70, -0.93 to -0.48) but not compared with selective serotonin reuptake inhibitors (-0.80, -2.63 to 0.02 and -0.20, -0.60 to 0.19). The effect of tricyclics increased with longer duration of treatment (β=-0.11, 95% confidence interval -0.63 to -0.15; P<0.0005). Tricyclics were also more likely to reduce the intensity of headaches by at least 50% than either placebo (tension-type: relative risk 1.41, 95% confidence interval 1.02 to 1.89; migraine: 1.80, 1.24 to 2.62) or selective serotonin reuptake inhibitors (1.73, 1.34 to 2.22 and 1.72, 1.15 to 2.55). Tricyclics were more likely to cause adverse effects than placebo (1.53, 95% confidence interval 1.11 to 2.12) and selective serotonin reuptake inhibitors (2.22, 1.52 to 3.32), including dry mouth (P<0.0005 for both), drowsiness (P<0.0005 for both), and weight gain (P<0.001 for both), but did not increase dropout rates (placebo: 1.22, 0.83 to 1.80, selective serotonin reuptake inhibitors: 1.16, 0.81 to 2.97). CONCLUSIONS Tricyclic antidepressants are effective in preventing migraine and tension-type headaches and are more effective than selective serotonin reuptake inhibitors, although with greater adverse effects. The effectiveness of tricyclics seems to increase over time.
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Affiliation(s)
- Jeffrey L Jackson
- General Medicine Division, Walter Reed Army Medical Center, Washington, DC, USA.
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Li XL, Fang YN, Gao QC, Lin EJ, Hu SH, Ren L, Ding MH, Luo BN. A diffusion tensor magnetic resonance imaging study of corpus callosum from adult patients with migraine complicated with depressive/anxious disorder. Headache 2010; 51:237-45. [PMID: 20946428 DOI: 10.1111/j.1526-4610.2010.01774.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the possible microstructural abnormalities of the corpus callosum (CC) in adult patients with migraine without aura complicated with depressive/anxious disorder. BACKGROUND Emotional disorders, especially depression and anxiety, are with relatively higher incidence in migraine population. However, the mechanism of migraine complicated with depressive/anxious disorder remains unclear. METHODS Diffusion tensor magnetic resonance imaging was carried out in 12 adult patients with simple migraine (without aura and without depressive/anxious disorder) (S-M group), 12 adult patients with complicated migraine (without aura but complicated with depressive/anxious disorder) (Co-M group), and 12 age- and sex-matched healthy subjects (Control group). Fractional anisotropy (FA) and apparent diffusion coefficient were measured at genu, body, and splenium of the CC, respectively. RESULTS There were significant differences in FA values at all locations of the CC among the 3 groups. The FA values from both the SM and Co-M groups were significantly lower than the control (P < .05 and P < .01, respectively). The FA values from Co-M group were significantly lower than the SM group (P < .01). The apparent diffusion coefficient values of the above regions had no significant differences among these groups (P > .05). There were negative correlations between FA value of genu of the CC and disease course as well as FA value of genu and body of the CC and headache frequency (P < .05). Negative correlations were also found between FA values at all locations of the CC and Hamilton anxiety and Hamilton depression scores (both P < .05). CONCLUSIONS There might be an integrity change of neurofibrotic microstructures existing as a possible neuroanatomical basis in the CC of migraine patients complicated with depressive/anxious disorder.
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Affiliation(s)
- Xian L Li
- Department of Neurology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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Holroyd KA, Cottrell CK, O'Donnell FJ, Cordingley GE, Drew JB, Carlson BW, Himawan L. Effect of preventive (beta blocker) treatment, behavioural migraine management, or their combination on outcomes of optimised acute treatment in frequent migraine: randomised controlled trial. BMJ 2010; 341:c4871. [PMID: 20880898 PMCID: PMC2947621 DOI: 10.1136/bmj.c4871] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine if the addition of preventive drug treatment (β blocker), brief behavioural migraine management, or their combination improves the outcome of optimised acute treatment in the management of frequent migraine. DESIGN Randomised placebo controlled trial over 16 months from July 2001 to November 2005. SETTING Two outpatient sites in Ohio, USA. PARTICIPANTS 232 adults (mean age 38 years; 79% female) with diagnosis of migraine with or without aura according to International Headache Society classification of headache disorders criteria, who recorded at least three migraines with disability per 30 days (mean 5.5 migraines/30 days), during an optimised run-in of acute treatment. INTERVENTIONS Addition of one of four preventive treatments to optimised acute treatment: β blocker (n=53), matched placebo (n=55), behavioural migraine management plus placebo (n=55), or behavioural migraine management plus β blocker (n=69). MAIN OUTCOME MEASURE The primary outcome was change in migraines/30 days; secondary outcomes included change in migraine days/30 days and change in migraine specific quality of life scores. RESULTS Mixed model analysis showed statistically significant (P≤0.05) differences in outcomes among the four added treatments for both the primary outcome (migraines/30 days) and the two secondary outcomes (change in migraine days/30 days and change in migraine specific quality of life scores). The addition of combined β blocker and behavioural migraine management (-3.3 migraines/30 days, 95% confidence interval -3.2 to -3.5), but not the addition of β blocker alone (-2.1 migraines/30 days, -1.9 to -2.2) or behavioural migraine management alone (-2.2 migraines migraines/30 days, -2.0 to -2.4), improved outcomes compared with optimised acute treatment alone (-2.1 migraines/30 days, -1.9 to -2.2). For a clinically significant (≥50% reduction) in migraines/30 days, the number needed to treat for optimised acute treatment plus combined β blocker and behavioural migraine management was 3.1 compared with optimised acute treatment alone, 2.6 compared with optimised acute treatment plus β blocker, and 3.1 compared with optimised acute treatment plus behavioural migraine management. Results were consistent for the two secondary outcomes, and at both month 10 (the primary endpoint) and month 16. CONCLUSION The addition of combined β blocker plus behavioural migraine management, but not the addition of β blocker alone or behavioural migraine management alone, improved outcomes of optimised acute treatment. Combined β blocker treatment and behavioural migraine management may improve outcomes in the treatment of frequent migraine. TRIAL REGISTRATION Clinical trials NCT00910689.
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Valguarnera F, Tanganelli P. The efficacy of withdrawal therapy in subjects with chronic daily headache and medication overuse following prophylaxis with topiramate and amitriptyline. Neurol Sci 2010; 31 Suppl 1:S175-7. [PMID: 20464616 DOI: 10.1007/s10072-010-0319-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Management of patients affected by chronic daily headache (CDH) with medication overuse constitutes one of the most important unresolved problems. The uncertainty regarding the classification and the prophylaxis are a remarkable part of this problem. Objectives are to: (1) to evaluate the efficacy of withdrawal therapy following prophylaxis with topiramate and amitriptyline in a population affected by CDH and medication overuse with follow-up at 1 (T1), 3 (T2) and 6 (T3) months; (2) to identify which group of the Silberstein's CDH classification (1994) may benefit from this protocol. Inclusion criteria are patients with CDH (headache for more >15 days/month for at least 3 consecutive months) and medication overuse according with IHS second edition (8.2 group); exclusion criteria are patients with secondary headache. All patients included in the study were hospitalized for 1 week. Type of overuse: combination of medications, 38%; analgesics, 29%; triptans, 29%; opioids, 2%; ergotamines, 2%. During hospitalization the following protocol was applied: desametasone 4 mg i.v./day for 1 week, diazepam 6 mg/day for 10 days and prophylaxis with amitriptylin plus topiramate. This prophylaxis was protracted for at least 6 months. The dosages assumed ranged for amitriptylin from 10 to 20 mg/day and for topiramate from 50 to 100 mg/day. In the last 4 years 105 patients with CDH (age 24-89 years; f 96; m 9) were admitted to the hospital. The protocol was applied in 52 patients (age, 29-65 years; f 49; m 3). At T1, 89% of the patients did not fall again into medication overuse; at T2, 64%; and at T3,45% of the patients remained free from overuse. According to the Silberstein' proposal at T1, 93% of the subjects was affected by transformed migraine; and 7% by tension-type headache. At T3, all the patients free from overuse were affected by transformed migraine. Our data suggest that the patients affected by CDH and medication overuse benefit from withdrawal therapy performed during hospitalization plus prophylaxis with amitriptyline plus topiramate. This combination seems a good pharmacological solution to reduce the risk of relapse.
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Affiliation(s)
- Fabio Valguarnera
- Department Head-Neck, ASL 3 Genovese, P.A. Micone Hospital, Largo N. Rosso 2, 16154, Genoa, Italy
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Smitherman TA, Walters AB, Maizels M, Penzien DB. The use of antidepressants for headache prophylaxis. CNS Neurosci Ther 2010; 17:462-9. [PMID: 21951370 DOI: 10.1111/j.1755-5949.2010.00170.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The focus of this review is on the efficacy of antidepressants as preventive treatments for migraine and chronic tension-type headache (TTH). Pharmacologic prophylaxis may be indicated for patients with frequent headaches, who respond insufficiently to acute therapies, or for whom medication overuse is a concern. The well-documented efficacy of the tricyclic antidepressant amitriptyline, both for migraine and chronic TTH, has been followed by widespread use of other antidepressants for headache prophylaxis. Although antidepressants in general share comparable efficacy for the treatment of depressive disorders, their efficacy as headache preventives varies widely. Evidence supporting use of the selective serotonin reuptake inhibitors as headache preventives is poor; their use should be reserved for treating comorbid depression in a patient who also has a headache disorder. Small randomized trials of venlafaxine indicate preliminary efficacy both for migraine and tension-type headache. Evidence for other antidepressants is lacking. Although antidepressants are often prescribed to headache patients under the assumption that the prescribed agent also will be effective in reducing symptoms of comorbid depression, the majority of studies have failed to find a strong relationship between depression symptoms and headache improvement. Suggestions for future research are discussed.
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Affiliation(s)
- Todd A Smitherman
- Department of Psychology, University of Mississippi, Oxford, MS, USA.
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Affiliation(s)
- Tamara Pringsheim
- Department of Clinical Neurosciences, University of Calgary, Calgary Headache Assessment and Management Program, Foothills Medical Centre, 1403-29th St. NW, Calgary AB T2N 2T9.
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Evers S, Afra J, Frese A, Goadsby PJ, Linde M, May A, Sándor PS. EFNS guideline on the drug treatment of migraine - revised report of an EFNS task force. Eur J Neurol 2009; 16:968-81. [PMID: 19708964 DOI: 10.1111/j.1468-1331.2009.02748.x] [Citation(s) in RCA: 459] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- S Evers
- Department of Neurology, University of Münster, Münster, Germany.
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30
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Lampl C, Huber G, Adl J, Luthringshausen G, Franz G, Marecek S, Weber J, Baumhackl U, Mueller T. Two different doses of Amitriptyline ER in the prophylaxis of migraine: long-term results and predictive factors. Eur J Neurol 2009; 16:943-8. [DOI: 10.1111/j.1468-1331.2009.02631.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Migraine headache is a debilitating disorder that affects millions of people in the United States and worldwide. The diagnosis of migraine can significantly affect quality of life, health care costs, and daily productivity. Hundreds of trials and many guidelines have documented various approaches to migraine management, whether via acute treatment or chronic migraine prophylaxis. Acute or abortive migraine management encompasses specific and nonspecific migraine therapeutics, including nonopioid and opioid analgesics, triptans, and ergotamines. Prophylactic migraine management data span the pharmacological spectrum from antiepileptic and antihypertensive agents to botulinum toxin type A. Special considerations for migraine management also must be applied in various populations, including children, pregnant women, and the elderly. The following review serves as an introduction to current therapeutic approaches for acute migraine treatment and provides an overview of available literature for pharmacological prophylaxis.
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Affiliation(s)
- Kimberly A. Pesaturo
- Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences, Worcester, Massachusetts,
| | - Fae G. Wooding
- Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences, Worcester, Massachusetts
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33
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Evers S. Alternativen zu Betablockern in der Migräneprophylaxe. DER NERVENARZT 2008; 79:1135-6, 1138-40, 1142-3. [DOI: 10.1007/s00115-008-2522-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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35
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Schürks M, Diener HC, Goadsby P. Update on the prophylaxis of migraine. Curr Treat Options Neurol 2008; 10:20-9. [DOI: 10.1007/s11940-008-0003-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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37
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Eine klinische Herausforderung. Schmerz 2008; 22 Suppl 1:11-6. [DOI: 10.1007/s00482-007-0608-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Abstract
Chronic pain represents one of the most important public health problems and, in addition to classical analgesics, antidepressants are an essential part of the therapeutic strategy. This article reviews available evidence on the efficacy and safety of antidepressants in major chronic pain conditions; namely, neuropathic pain, headaches, low back pain, fibromyalgia, irritable bowel syndrome (IBS) and cancer pain. Studies, reviews and meta-analyses published from 1991 to March 2008 were retrieved through MEDLINE, PsycINFO and the Cochrane database using numerous key words for pain and antidepressants. In summary, evidence supports the use of tricyclic antidepressants in neuropathic pain, headaches, low back pain, fibromyalgia and IBS. The efficacy of the newer serotonin and norepinephrine reuptake inhibitors is less supported by evidence, but can be recommended in neuropathic pain, migraines and fibromyalgia. To date, evidence does not support an analgesic effect of serotonin reuptake inhibitors, but beneficial effects on well-being were reported in several chronic pain conditions. These results are discussed in the light of current insights in the neurobiology of pain, the reciprocal relationship between pain and depression, and future developments in this field of research.
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Affiliation(s)
- Bénédicte Verdu
- Department of Psychiatry, University Hospital Center and University of Lausanne, Lausanne, Switzerland
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Samsam M, Coveñas R, Ahangari R, Yajeya J, Narváez J. Role of neuropeptides in migraine: where do they stand in the latest expert recommendations in migraine treatment? Drug Dev Res 2007. [DOI: 10.1002/ddr.20193] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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40
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Evers S, Afra J, Frese A, Goadsby PJ, Linde M, May A, Sándor PS. EFNS guideline on the drug treatment of migraine - report of an EFNS task force. Eur J Neurol 2006; 13:560-72. [PMID: 16796580 DOI: 10.1111/j.1468-1331.2006.01411.x] [Citation(s) in RCA: 129] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Abstract
Migraine is a chronic, neurological disorder generally manifesting itself in attacks with severe headache, nausea and an increased reactivity to sensory stimuli. A low migraine threshold is set by genetic factors, although the phenotype also modulates the manifestations. The 1-year prevalence is approximately 13% and is higher among women. Patients usually experience neuropsychological dysfunction, and sometimes also reversible focal neurological symptoms. The trajectories of the characteristic symptoms of acute migraine usually follow a similar time course, indicating a reciprocal underlying mechanism. A central nervous system hyperexcitability has been demonstrated in neurophysiological studies. The dibilitating effects of migraine are not confined to the attacks per se. Many individuals do not recover completely between the attacks and most report a negative impact on the most important life domains, and an interest in testing other treatments. Young persons have a higher frequency of attacks. Acute treatment should routinely be initiated with an analgesic plus a prokinetic anti-emetic. Triptans must not be provided early during the attack to ensure their efficacy. The natural course of attacks is commonly only temporarily altered by acute treatment. Non-pharmacological treatment and drugs may be equally viable in prophylaxis for migraine. In more complicated cases, conjoint therapy should be considered. New strategies to improve adherence with existing therapeutic regimens might yield greater benefits than will new pharmacological agents.
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Affiliation(s)
- M Linde
- Cephalea Headache Centre and Institute of Neuroscience and Physiology, Sahlgrenska Academy, Göteborg University, Gothenburg, Sweden.
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Ozyalcin SN, Talu GK, Kiziltan E, Yucel B, Ertas M, Disci R. The Efficacy and Safety of Venlafaxine in the Prophylaxis of Migraine. Headache 2005; 45:144-52. [PMID: 15705120 DOI: 10.1111/j.1526-4610.2005.05029.x] [Citation(s) in RCA: 120] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of venlafaxine in the prophylaxis of migraine. BACKGROUND The efficacy of venlafaxine, which is selectively effective on the serotonergic and noradrenergic mechanisms, on various headaches and chronic pain syndromes has been demonstrated. To our knowledge, this is the first placebo-controlled, double-blind, randomized study of two different doses of venlafaxine for migraine treatment. METHODS In this prospective study, 60 migraine patients without aura were randomly assigned to venlafaxine XR 75 mg, venlafaxine XR 150 mg, or placebo. The frequency of headache attacks, the severity and the duration of attacks, and analgesic use were monitored every 2 weeks for 2 months. Adverse events and patient satisfaction were also evaluated during these visits. At the end of the 2 months, global efficacy and tolerance were investigated. RESULTS A significant difference was observed between the venlafaxine 150 mg and placebo groups in the number of headache attacks (P= .006). According to patient satisfaction comparisons, the active drug groups were significantly different when compared with placebo (P= .001 at visit 2 and visit 6). When the global efficacy was considered, 80% of patients in the 75-mg group and 88.2% of the patients in the 150-mg group evaluated treatment benefits as either good or very good. CONCLUSIONS Venlafaxine was more effective than placebo and is safe and well tolerated as migraine prophylaxis.
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Eftedal OS, Lydersen S, Helde G, White L, Brubakk AO, Stovner LJ. A randomized, double blind study of the prophylactic effect of hyperbaric oxygen therapy on migraine. Cephalalgia 2004; 24:639-44. [PMID: 15265052 DOI: 10.1111/j.1468-2982.2004.00724.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
In a double blind, placebo-controlled study to assess the prophylactic effect of hyperbaric oxygen therapy on migraine, 40 patients were randomly assigned to a treatment group receiving three sessions of hyperbaric oxygen, or a control group receiving three hyperbaric air treatments. The patients were instructed to keep a standardized migraine diary for eight weeks before and after the treatment. Thirty-four patients completed the study. Our primary measure of efficacy was the difference between pre- and post-treatment hours of headache per week. The results show a nonsignificant reduction in hours of headache for the hyperbaric oxygen group compared to the control group. Levels of endothelin-1 in venous blood before and after treatment did not reveal any difference between the hyperbaric oxygen and control groups. We conclude that the tested protocol does not show a significant prophylactic effect on migraine and does not influence the level of endothelin-1 in venous blood.
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Affiliation(s)
- O S Eftedal
- Department of Circulation and Imaging, Norwegian University of Science and Technology, Trondheim, Norway
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45
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Abstract
BACKGROUND Propranolol is one of the most commonly prescribed drugs for migraine prophylaxis. OBJECTIVES We aimed to determine whether there is evidence that propranolol is more effective than placebo and as effective as other drugs for the interval (prophylactic) treatment of patients with migraine. SEARCH STRATEGY Potentially eligible studies were identified by searching MEDLINE/PubMed (1966 to May 2003) and the Cochrane Central Register of Controlled Trials (Issue 2, 2003), and by screening bibliographies of reviews and identified articles. SELECTION CRITERIA We included randomised and quasi-randomised clinical trials of at least 4 weeks duration comparing clinical effects of propranolol with placebo or another drug in adult migraine sufferers. DATA COLLECTION AND ANALYSIS Two reviewers extracted information on patients, methods, interventions, outcomes measured, and results using a pre-tested form. Study quality was assessed using two checklists (Jadad scale and Delphi list). Due to the heterogeneity of outcome measures and insufficient reporting of the data, only selective quantitative meta-analyses were performed. As far as possible, effect size estimates were calculated for single trials. In addition, results were summarised descriptively and by a vote count among the reviewers. MAIN RESULTS A total of 58 trials with 5072 participants met the inclusion criteria. The 58 selected trials included 26 comparisons with placebo and 47 comparisons with other drugs. The methodological quality of the majority of trials was unsatisfactory. The principal shortcomings were high dropout rates and insufficient reporting and handling of this problem in the analysis. Overall, the 26 placebo-controlled trials showed clear short-term effects of propranolol over placebo. Due to the lack of studies with long-term follow up, it is unclear whether these effects are stable after stopping propranolol. The 47 comparisons with calcium antagonists, other beta-blockers, and a variety of other drugs did not yield any clear-cut differences. Sample size was, however, insufficient in most trials to establish equivalence. REVIEWERS' CONCLUSIONS Although many trials have relevant methodological shortcomings, there is clear evidence that propranolol is more effective than placebo in the short-term interval treatment of migraine. Evidence on long-term effects is lacking. Propranolol seems to be as effective and safe as a variety of other drugs used for migraine prophylaxis.
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Affiliation(s)
- K Linde
- Centre for Complementary Medicine Research, Department of Internal Medicine II, Technische Universität, Kaiserstr. 9, München, Germany, 80801
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46
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Abstract
The term migraine is derived from the ancient Greek word hemicrania introduced by Galen in approximately 200 AD. However, descriptions of "sick headache" have been found dating back to as far as 3000 BC. Despite this, migraine is a condition that still remains underdiagnosed and undertreated. The development of effective abortive agents, such as the triptans, have had a significant impact on migraine management, but there still remains a substantial proportion of migraineurs in whom further medication is required in the form of preventatives. These have the potential to transform the lives of many migraine sufferers.
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Affiliation(s)
- Shazia Afridi
- Headache Group, Institute of Neurology, Queen Square, London WC1N 3BG, UK.
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Bigal ME, Rapoport AM, Bordini CA, Tepper SJ, Sheftell FD, Speciali JG. Burden of migraine in Brazil: estimate of cost of migraine to the public health system and an analytical study of the cost-effectiveness of a stratified model of care. Headache 2003; 43:742-54. [PMID: 12890129 DOI: 10.1046/j.1526-4610.2003.03132.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The search for rationality in health expenses in developing countries collides with the lack of effectively conducted epidemiologic studies. PURPOSE To present an estimate of the impact and costs of migraine in the Brazilian public health system and to estimate the impact on these costs and the effectiveness of a model of stratified care in the management of migraine. METHODS An analytical model of utilization of the Brazilian public health system was constructed. Data refer to 1999 and were obtained in accordance with the following steps: (1) Brazilian demographic characteristics; (2) characteristics of the public health system related to its 3 hierarchical levels-primary, secondary, and tertiary care, the last being subdivided into emergency department and hospital care; and (3) estimation of the number of migraine consultations at each complexity level. In Brazil, migraineurs seen in the public health system are most often discharged with an acute treatment, usually a nonspecific medication. We compared this treatment with a proposed stratified care model that uses a triptan as an acute care medication. We have made the following assumptions: (1) 15% of the patients would fall into the Migraine Disability Assessment (MIDAS) grade I category, 25% would fall into the MIDAS grade II category, 30% into the grade III category, and 30% into the MIDAS grade IV category; (2) the mean number of migraine attacks per year are: MIDAS I, 7.49; MIDAS II, 8.02; MIDAS III, 12.22; and MIDAS IV, 27.01. The annual costs of the treatment were calculated according to the following equation: AC = P x N x C + P x Cp + P x Cat x AMA, where P is the number of patients; N, the number of consultations per patient; C, the cost of consultation per level; Cp, the cost of preventive drugs; Cat, the cost of acute therapy drugs; and AMA is the number of migraine attacks per year. Results.-The public health system resources included 55 735 ambulatory units (primary and secondary) and 6453 emergency department and public hospital units, with a corresponding budget of US $2 820 899 621.26. The estimated cost of a consultation on the primary care level was US $11.53; on the secondary care level, US $22.18; in the emergency department, $34.82; and for hospitalization, US $217.93. The total estimated public health system expenses for migraine were US $140 388 469.60. The proposed model would imply a cost reduction of 6.2% (US $7 514 604.40) with an improvement in the quality of the public health system from the actual 18.2% to an estimated 84.5%. CONCLUSION Migraine seems to pose a huge burden on the Brazilian public health system. The implementation of a stratified care model of treatment that would include specific acute migraine therapies could result in a dramatic increase in the quality of migraine care and a significant reduction in cost.
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Affiliation(s)
- Marcelo E Bigal
- Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
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48
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Abstract
Antidepressants, particularly tricyclic antidepressants, have been a mainstay in the prophylactic therapy of migraine. The tricyclic antidepressants amitriptyline, nortriptyline, and doxepin have been the major agents for prophylactic treatment of migraine. These cause significant side effects in some patients. The high-affinity selective serotonin reuptake inhibitors and other newer antidepressants have been disappointing and much less effective in the treatment of migraine. In patients who are depressed with severe migraine, a tricyclic antidepressant may treat both conditions; however, the addition of a newer atypical antidepressant may be needed.
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Affiliation(s)
- Nestor C Punay
- The University of Oklahoma Health Sciences Center, Department of Neurology, 711 S.L. Young Boulevard, Oklahoma City, OK 73104, USA.
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49
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Abstract
Migraine is a common episodic headache disorder. A comprehensive headache treatment plan includes acute attack treatment to relieve pain and impairment and long-term preventive therapy to reduce attack frequency, severity, and duration. Circumstances that might warrant preventive treatment include: (i) migraine that significantly interferes with the patient's daily routine despite acute treatment; (ii) failure, contraindication to, or troublesome side-effects from acute medications; (iii) overuse of acute medications; (iv) special circumstances, such as hemiplegic migraine; (v) very frequent headaches (more than two a week); or (vi) patient preference. Start the drug at a low dose. Give each treatment an adequate trial. Avoid interfering, overused, and contraindicated drugs. Re-evaluate therapy. Be sure that a woman of childbearing potential is aware of any potential risks. Involve patients in their care to maximize compliance. Consider co-morbidity. Choose a drug based on its proven efficacy, the patient's preferences and headache profile, the drug's side-effects, and the presence or absence of coexisting or co-morbid disease. Drugs that have documented high efficacy and mild to moderate adverse events (AEs) include beta-blockers, amitriptyline, and divalproex. Drugs that have lower documented efficacy and mild to moderate AEs include selective serotonin reuptake inhibitors (SSRIs), calcium channel antagonists, gabapentin, topiramate, riboflavin, and non-steroidal anti-inflammatory drugs.
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Affiliation(s)
- S D Silberstein
- Jefferson Headache Center, and Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA.
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50
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Abstract
Migraine is a recurrent clinical syndrome characterised by combinations of neurological, gastrointestinal and autonomic manifestations. The exact pathophysiological disturbances that occur with migraine have yet to be elucidated; however, cervico-trigemino-vascular dysfunctions appear to be the primary cause. Despite advances in the understanding of the pathophysiology of migraine and new effective treatment options, migraine remains an under-diagnosed, under-treated and poorly treated health condition. Most patients will unsuccessfully attempt to treat their headaches with over-the-counter medications. Few well designed, placebo-controlled studies are available to guide physicians in medication selection. Recently published evidence-based guidelines advocate migraine-specific drugs, such as serotonin 5-HT(1B/1D) agonists (the 'triptans') and dihydroergotamine mesylate, for patients experiencing moderate to severe migraine attacks. Additional headache attack therapy options include other ergotamine derivatives, phenothiazines, nonsteroidal anti-inflammatory agents and opioids. Preventative medication therapy is indicated for patients experiencing frequent and/or refractory attacks.
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Affiliation(s)
- Seymour Diamond
- Diamond Inpatient Headache Unit, Diamond Headache Clinic, St. Joseph Hospital, and Finch University of Health Sciences/The Chicago Medical School, North Chicago, Chicago, Illinois 60614, USA
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