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Tepper SJ, Ailani J, Ray S, Hirman J, Shrewsbury SB, Aurora SK. Variability in recurrence rates with acute treatments for migraine: why recurrence is not an appropriate outcome measure. J Headache Pain 2022; 23:148. [PMID: 36414952 PMCID: PMC9682643 DOI: 10.1186/s10194-022-01519-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 09/07/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Headache recurrence is a common feature of acute therapies, whether approved or still in development, and continues to be a significant problem for both the patient and the clinician. Further complicating this issue is lack of standardization in definitions of recurrence used in clinical trials, as well as disparity in patient characteristics, rendering a comparison of different acute medications challenging. Recurrence has serious clinical implications, which can include an increased risk for new-onset chronic migraine and/or development of medication overuse headache. The aim of this review is to illustrate variability of recurrence rates depending on prevailing definitions in the literature for widely used acute treatments for migraine and to emphasize sustained response as a clinically relevant endpoint for measuring prolonged efficacy. BODY: A literature search of PubMed for articles of approved acute therapies for migraine that reported recurrence rates was performed. Study drugs of interest included select triptans, gepants, lasmiditan, and dihydroergotamine mesylate. An unpublished post hoc analysis of an investigational dihydroergotamine mesylate product that evaluated recurrence rates using several different definitions of recurrence common in the literature is also included. Depending on the criteria established by the clinical trial and the definition of recurrence used, rates of recurrence vary considerably across different acute therapies for migraine, making it difficult to compare results of different trials to assess the sustained (i.e., over a single attack) and the prolonged (i.e., over multiple attacks) efficacy of a particular study medication. CONCLUSION A standardized definition of recurrence is necessary to help physicians evaluate recurrence rates of different abortive agents for migraine. Sustained pain relief or freedom may be more comprehensive efficacy outcome measures than recurrence. Future efficacy studies should be encouraged to use the recommended definition of sustained pain freedom set by the International Headache Society.
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Affiliation(s)
| | - Jessica Ailani
- MedStar Georgetown University Hospital, Washington, DC, USA
| | | | - Joe Hirman
- Pacific Northwest Statistical Consulting, Inc, Woodinville, WA, USA
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Tfelt-Hansen P. Pharmacological strategies to treat attacks of episodic migraine in adults. Expert Opin Pharmacother 2020; 22:305-316. [PMID: 33003955 DOI: 10.1080/14656566.2020.1828347] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Migraine patients prioritize early complete relief of headache and associated symptoms, sustained freedom of pain, and good tolerability. One major obstacle for the successful use of drug treatment of migraine attack is that the speed of action of triptans, 5-HT1B/1D receptor agonists, is delayed. AREAS COVERED In this review, the author discusses the following features of acute migraine drugs: pharmacology; pharmacokinetics, and absorption of drugs during migraine attacks. Next, dose-response curves for effect; and the delayed onset of action is reviewed. In the more clinical part of the review, the following items are discussed: overall clinical judgments; comparison of triptans; comparison of triptans with NSAIDs; early intervention with triptans; medication-overuse headache; comments on the effect of gepants; and the general principle of acute migraine therapy. EXPERT OPINION The delay in the onset of effect of acute migraine drugs is likely due to a complex antimigraine system involving more than one site of action. Investigations into the mechanisms of the delay should have a high priority, both in studies with animals, migraine models, and in migraine patients during attacks. Non-oral administration of antimigraine drugs resulting in early absorption of drugs should be developed as they possibly also can increase Emax.
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Affiliation(s)
- Peer Tfelt-Hansen
- From Danish Headache Center, Department of Neurology, Rigshospital Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen , Glostrup, Denmark
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Zhou L, Chen P, Liu L, Zhang Y, Liu X, Wu Y, Jiang L, Cheng D, Huang W, Pettigrew JC, Yi D. Systematic Review and Meta-Analysis of Traditional Chinese Medicine in the Treatment of Migraines. THE AMERICAN JOURNAL OF CHINESE MEDICINE 2013; 41:1011-25. [DOI: 10.1142/s0192415x13500687] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Migraine is a chronic disorder characterized by recurrent moderate to severe headaches often in association with a number of autonomic nervous system symptoms. It is a common disease and incidence has increased yearly. Chinese medical treatments are popularly used in Asian countries, although they vary in effectiveness. In this study, we applied a systematic review method and combined meta-regression with meta-subgroup analysis to explore heterogeneity of clinical therapeutic efficacy upon meta-analysis of randomized controlled Chinese medical treatments for migraine. We also aimed to provide a more effective Chinese prescription and to advance the knowledge in evaluating validity of preventing or alleviating migraine symptoms with Chinese medical treatments. Twenty randomized migraine control trails, including 2246 patients, were collected from online databases: PubMed, MEDLINE, EMBASE, CENTRAL of Cochrane Library, CBM, integrated version of CMCI/CMCC, TCM online, CDFD, and CMFD from January 2000 to December 2011. The results showed that the major factors influencing therapeutic efficacy were either the specific medicine form of or its prescription type (p < 0.05). The use of TCM decoctions, especially those that condition the viscera, treat from the perspective of "wind", and target the Shaoyang gateway, could be the best migraine treatment in clinical TCM practice (RR > 1.30).
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Affiliation(s)
- Liang Zhou
- Department of Health Statistics, College of Preventive Medicine, Third Military Medical University, Chongqing 400038, China
| | - Pinyi Chen
- Department of Health Statistics, College of Preventive Medicine, Third Military Medical University, Chongqing 400038, China
| | - Ling Liu
- Department of Health Statistics, College of Preventive Medicine, Third Military Medical University, Chongqing 400038, China
| | - Yanqi Zhang
- Department of Health Statistics, College of Preventive Medicine, Third Military Medical University, Chongqing 400038, China
| | - Xiaoyu Liu
- Department of Health Statistics, College of Preventive Medicine, Third Military Medical University, Chongqing 400038, China
| | - Yazhou Wu
- Department of Health Statistics, College of Preventive Medicine, Third Military Medical University, Chongqing 400038, China
| | - Lei Jiang
- Department of Rehabilitation and Physiotherapy, Xinqiao Hospital, Third Military Medical University, Chongqing 400038, China
| | - Dixiang Cheng
- Soft College, Chongqing University of Posts and Telecommunications, Chongqing 400065, China
| | - Wenquan Huang
- Department of Rehabilitation and Physiotherapy, Xinqiao Hospital, Third Military Medical University, Chongqing 400038, China
| | - Julia Christine Pettigrew
- Department of Biological Sciences and Department of Asian Language and Literature, University of Washington, School of Arts and Sciences, Snohomish, WA 98290, USA
| | - Dong Yi
- Department of Health Statistics, College of Preventive Medicine, Third Military Medical University, Chongqing 400038, China
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Tfelt-Hansen PC. Triptans and ergot alkaloids in the acute treatment of migraine: similarities and differences. Expert Rev Neurother 2013; 13:961-3. [PMID: 23980649 DOI: 10.1586/14737175.2013.832851] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Peer C Tfelt-Hansen
- Department of Neurology, Danish Headache Center, University of Copenhagen, Glostrup Hospital, Glostrup, Denmark +45 3863 3050 +45 3863 2639
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Tfelt-Hansen P, Hougaard A. Sumatriptan: a review of its pharmacokinetics, pharmacodynamics and efficacy in the acute treatment of migraine. Expert Opin Drug Metab Toxicol 2012; 9:91-103. [PMID: 23228070 DOI: 10.1517/17425255.2013.744394] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Sumatriptan was developed more than 20 years ago as a 5-HT1B/1D receptor agonist, the first drug in a new class of specific anti-migraine drugs, the triptans. A large amount of information and experience has been gained from the clinical trials undertaken as well the various formulations of sumatriptan used over this period of time. AREAS COVERED This evaluation specifically reviews the pharmacokinetics, pharmacodynamics, clinical efficacy, and safety of different formulations and dosages of sumatriptan used for the acute treatment of migraines. Special clinical trials of the timing of dosage and sumatriptan in combination with other triptans as well as non-triptan drugs are also included. EXPERT OPINION Oral sumatriptan is effective, but not in a convincing majority (60%) of patients in clinical trials. Sumatriptan has failed to show superiority over more standard and cheaper treatment such as aspirin or aspirin plus metoclopramide. In addition, migraine patients want to quickly become pain free, and to remain pain free, but oral sumatriptan at 100 mg managed to keep patients pain free for 24 h is only 20% of cases. Even though sumatriptan has been a major step forward in providing a new specific therapy for the treatment of migraines, there are still are limitations in its use. There is still an unmet need to develop new non-triptan, anti-migraine drugs which act as effective treatment for those who suffer with migraines.
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Affiliation(s)
- Peer Tfelt-Hansen
- University of Copenhagen, Glostrup Hospital, Danish Headache Center, Department of Neurology, Glostrup, Denmark.
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Gentile G, Borro M, Simmaco M, Missori S, Lala N, Martelletti P. Gene polymorphisms involved in triptans pharmacokinetics and pharmacodynamics in migraine therapy. Expert Opin Drug Metab Toxicol 2010; 7:39-47. [DOI: 10.1517/17425255.2011.538680] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Gentile G, Borro M, Lala N, Missori S, Simmaco M, Martelletti P. Genetic polymorphisms related to efficacy and overuse of triptans in chronic migraine. J Headache Pain 2010; 11:431-5. [PMID: 20652353 PMCID: PMC3452274 DOI: 10.1007/s10194-010-0241-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2010] [Accepted: 07/02/2010] [Indexed: 11/29/2022] Open
Abstract
Migraine is a common type of headache and its most severe attacks are usually treated with triptans, the efficacy of which is extremely variable. Several SNPs in genes involved in metabolism and target mechanisms of triptans have been described. To define an association between genetic profile and triptan response, we classified a migrainous population on the basis of triptan response and characterized it for polymorphisms in the genes coding for monoamine oxidase A, G protein β3 and the cytochrome CYP1A2. Analysis of the association between genotypic and allelic frequencies of the analyzed SNPs and the grade of response to triptan administration showed a significant correlation for MAOA uVNTR polymorphism. Further stratification of patients in abuser and non-abuser groups revealed a significant association with triptan overuse and, within the abusers, with drug response to the CYP1A2*1F variant.
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Affiliation(s)
- Giovanna Gentile
- Department of Biochemical Sciences, Advanced Molecular Diagnostic Unit, 2nd School of Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Via di Grottarossa 1035, Rome, Italy.
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Treating headache recurrence after emergency department discharge: a randomized controlled trial of naproxen versus sumatriptan. Ann Emerg Med 2010; 56:7-17. [PMID: 20303198 DOI: 10.1016/j.annemergmed.2010.02.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2009] [Revised: 01/26/2010] [Accepted: 02/03/2010] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVE Multiple parenteral medications are used to treat migraine and other acute primary headaches in the emergency department (ED). Regardless of specific headache diagnosis, no medication eliminates the frequent recurrence of primary headache after ED discharge. It is uncertain which medication primary headache patients should be given on discharge from an ED. The aim of this study is to compare the efficacy of oral sumatriptan with naproxen for treatment of post-ED recurrent primary headache. METHODS This was a randomized, double-blind efficacy trial. We randomized patients to either naproxen 500 mg or sumatriptan 100 mg for headache recurrence after ED discharge. Patients were eligible if they received parenteral therapy for an acute exacerbation of a primary headache in the ED. Patients who met established criteria for migraine without aura were designated a priori as a homogenous subgroup of interest. We followed all patients by telephone 48 hours after ED discharge. The primary endpoint was the between-group difference in change in pain intensity during the 2-hour period after ingestion of either 500 mg naproxen or 100 mg sumatriptan. This difference was measured on a validated 11-point (0 to 10) verbal numeric rating scale (NRS). Satisfaction with the medication and adverse effects were also assessed. Patients who met criteria for migraine without aura were analyzed twice according to a priori design: once as a homogenous subgroup and then again combined with all other primary headaches. RESULTS Of 410 patients randomized, 383 (93%) had outcome data available for analysis. Two hundred eighty (73%; 95% confidence interval [CI] 68% to 77%) reported headache post-ED discharge and 196 (51%; 95% CI 44% to 58%), including 88 with migraine, took the investigational medication provided to them. The naproxen group improved by a mean of 4.3 NRS points, whereas the sumatriptan group improved by 4.1 points (95% CI for difference of 0.2 points: -0.7 to 1.1 points). Findings were virtually identical among the migraine subset (4.3 versus 4.2 NRS points; 95% CI for difference of 0.1 points: -1.3 to 1.5 points). Seventy-one percent (95% CI 62% to 80%) of naproxen patients and 75% (95% CI 66% to 84%) of sumatriptan patients would want to take the same medication the next time. Adverse effect profiles were also comparable. CONCLUSION In this trial, nearly three quarters of patients reported headache recurrence within 48 hours of ED discharge. Naproxen 500 mg and sumatriptan 100 mg taken orally relieve post-ED recurrent primary headache and migraine comparably. Clinicians should be guided by medication costs, contraindications, and a patient's previous experience with the medication.
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