Weight change associated with the use of migraine-preventive medications

Revisiting Migraine: The Evolving Pathophysiology and the Expanding Management Armamentarium

Migraine affects about one billion people worldwide yearly and is one of the most common neurologic illnesses, with a high prevalence and morbidity, particularly among young adults and females. Migraine is associated with many comorbidities, including stress, sleep difficulties, and suicidal ideation. Migraine, despite its widespread occurrence, is underdiagnosed and undertreated. Because of the complicated and primarily unknown mechanisms of migraine formation, several social and biological risk factors, such as hormone imbalances, genetic and epigenetic impacts, and cardiovascular, neurological, and autoimmune illnesses, have been proposed. Through the mid-20th century diversion of the now-defunct vascular theory, the pathophysiology of migraine has developed from a historical study of the "humours" to a distinct entity as a neurological disorder. The range of therapeutic targets has broadened significantly, increasing the number of specialized clinical trials. Understanding the biology of migraine through careful research has resulted in the identification of major therapeutic classes: (i) triptans, serotonin 5-HT1B/1D receptor agonists, (ii) gepants, calcitonin gene-related peptide (CGRP) receptor antagonists, (iii) ditans, 5-HT1F receptor agonists, (iv) CGRP monoclonal antibodies, and (v) glurants, mGlu5 modulators, with further targets being explored. This review provides a comprehensive overview of the most recent literature on epidemiology and risk factors and exposes knowledge gaps.

Migraine and obesity: what is the real direction of their association?

INTRODUCTION

In recent decades, studies have addressed the issue of how migraine and obesity are related and have suggested obesity as a risk factor for migraine headache. However, the exact direction of this relationship remains under debate. In this review, the authors summarize the evidence that have suggested migraine as a risk factor for obesity and overweightness.

AREAS COVERED

This article reviews the results of the previous research published on PubMed and Scopus databases (from 2000 to 2020) concerning the association between migraine and obesity to determine the actual direction of their association. Special attention has been given to the common mechanistic pathways involved in the pathophysiology of migraine and obesity.

EXPERT OPINION

The majority of research conducted thus far has considered obesity as a risk factor for migraine. However, because of the cross-sectional design of available research, we cannot be certain of the proposed direction of this association. There is evidence supporting the hypothesis that obesity can serve as a consequence of migraine through the effects of neuropeptides, inflammatory mediators, adipokines, gut microbiota and modifications in eating behavior and lifestyle. However, the real direction of the relationship between migraine and obesity should be further investigated in large prospective studies.

Migraine management: Non-pharmacological points for patients and health care professionals

Migraine is a highly prevalent disorder with an enormous burden on societies. Different types of medications are used for controlling both acute attacks and prevention. This article reviews some non-pharmacological recommendations aiming to manage migraine disorder better and prevent headache attacks. Different triggers of migraine headache attacks, including environmental factors, sleep pattern changes, diet, physical activity, stress and anxiety, some medications, and hormonal changes, are discussed. It is advised that they be identified and managed. Patients should learn the skills to cope with the trigger factors that are difficult to avoid. In addition, weight control, management of migraine comorbidities, lifestyle modification, behavioural treatment and biofeedback, patient education, using headache diaries, and improving patients' knowledge about the disease are recommended to be parts of migraine management. In addition, using neuromodulation techniques, dietary supplements such as riboflavin, coenzyme Q10 and magnesium, and acupuncture can be helpful. Non-pharmacological approaches should be considered in migraine management. Furthermore, the combination of pharmacological and non-pharmacological approaches is more effective than using each separately.

Was it something I ate? Understanding the bidirectional interaction of migraine and appetite neural circuits

Migraine attacks can involve changes of appetite: while fasting or skipping meals are often reported triggers in susceptible individuals, hunger or food craving are reported in the premonitory phase. Over the last decade, there has been a growing interest and recognition of the importance of studying these overlapping fields of neuroscience, which has led to novel findings. The data suggest additional studies are needed to unravel key neurobiological mechanisms underlying the bidirectional interaction between migraine and appetite. Herein, we review information about the metabolic migraine phenotype and explore migraine therapeutic targets that have a strong input on appetite neuronal circuits, including the calcitonin gene-related peptide (CGRP), the pituitary adenylate cyclase-activating polypeptide (PACAP) and the orexins. Furthermore, we focus on potential therapeutic peptide targets that are involved in regulation of feeding and play a role in migraine pathophysiology, such as neuropeptide Y, insulin, glucagon and leptin. We then examine the orexigenic - anorexigenic circuit feedback loop and explore glucose metabolism disturbances. Additionally, it is proposed a different perspective on the most reported feeding-related trigger - skipping meals - as well as a link between contrasting feeding behaviors (skipping meals vs food craving). Our review aims to increase awareness of migraine through the lens of appetite neurobiology in order to improve our understanding of the earlier phase of migraine, encourage better studies and cross-disciplinary collaborations, and provide novel migraine-specific therapeutic opportunities.

InterMiG: international differences in the therapeutic approach to migraine patients in specialized headache centers

Background

There is currently a wide therapeutic arsenal for migraine patients, without a single first-line preventive drug and we choose the different available alternatives taking into account comorbidities, national guidelines, previous treatments and personal experiences.

Our objective was to evaluate the differences in the use of migraine treatments between neurologists from different countries.

Methods

This is a multi-centre observational study carried out by neurologists from specialized headache units in seven countries, retrospective with consecutive inclusion of all patients presenting with a migraine diagnosis, over a period of three months.

Results

A total of 734 patients were recruited but only 600 were considered in the analysis in order to homogenize the patient cohorts from countries: 200 Spain (ES), 100 Italy (IT), 85 Russia (RUS), 80 Germany (DE), 60 Portugal (PT), 45 Poland (PL) and 30 Australia (AU). 85.4 % of patients were women with a mean age of 42.6 ± 11.8 years. Considering previous and current preventive treatment, the order of use was: antidepressants (69.3 %), antiepileptic drugs (54.7 %), beta-blockers and antihypertensive drugs (49.7 %), OnabotulinumtoxinA (44.0 %) and others (36.2 %).

Statistically significant differences were found between all pharmacological classes: antidepressants were commonly used in all countries, with the exception of Poland (AU: 76.7 %, IT: 71.0 %, DE: 60.0 %, PL: 31.1 %, PT: 71.7 %, RUS: 70.6 %, ES: 78.5 %; p < 0.0001); antiepileptic drugs were more frequently prescribed in Portugal, Australia and Spain (AU: 73.3 %, IT: 40.0 %, DE: 37.5 %, PL: 48.9 %, PT: 85.0 %, RUS: 29.4 % and ES: 69.0 %; p < 0.0001); beta-blockers and antihypertensive drugs were frequently used in all countries except Italy (AU: 60.0 %, IT: 14.0 %, DE: 53.8 %, PL: 48.9 %, PT: 68.3 %, RUS: 49.4 % and ES: 59.0 %; p < 0.0001); BTX-A were predominately used in Spain, Italy and Australia (AU:56.7 %, IT:58.0 %, DE:20.0 %, PL: 42.2 %, PT: 26.7 %, RUS: 24.7 % and ES: 58.5 %; p < 0.0001) and others were most frequently used in Poland (AU: 0.0 %, IT: 19.0 %, DE: 42.5 %, PL: 95.6 %, PT: 31.7 %, RUS: 3.5 % and ES: 49.5 %; p < 0.0001). If only patients without comorbidities are considered (200/600), statistically differences between countries persist in all preventive treatments.

Conclusions

There is heterogeneity in the choice of preventive treatment between different countries. Prospective comparative studies of the different oral and subcutaneous alternatives would help to create a global therapeutic algorithm that would guarantee the best option for our patients.

The Relationship Between Major Dietary Patterns and Disease Severity Among Migraine Patients

Background: Migraine is a chronic medical problem and sometimes progressive disorder characterized by recurrent episodes of headache. Nutritional factors can reduce and prevent the severity and frequency of migraine. Objectives: This study aimed to assess the relationship between major dietary patterns and disease severity among migraine patients. Methods: This cross-sectional study included 266 females (18 - 50 years old) who attend neurology clinics of Sina and Khatam Alanbia hospitals, and a professional headache clinic, both in Tehran, Iran, for episodic migraine diagnosis in 2016. The participants’ data was gathered using a general questionnaire and medical history. Dietary intake was assessed using a 147-item semi-quantitative food frequency questionnaire (FFQ). Anthropometric measurements were taken for all cases. visual analog scale (VAS) and migraine disability assessment (MIDAS) questionnaires were used by a neurologist for assessing migraine disability and pain severity, respectively. Also, principal component analysis (PCA) was used to identify major dietary patterns. The association between dietary patterns and disease severity was evaluated using multinomial logistic regression. Results: Using the PCA, two major dietary patterns, including the healthy and unhealthy diet, were identified. More adherence to the healthy dietary pattern (high in fruits, fruit juices, and dried fruits, vegetables, whole grains, liquid oil, brains, beans, low-fat dairy, and white meat) was associated with a lower VAS score after adjusting for energy intake, BMI, water intake, and increased salt intake (OR = 1.82, 95% CI = 0.96 - 3.44, P-trend < 0.005). The intensity of migraine headache increased by 82% in the lowest adherence to this pattern compared to the most adherence. There was no significant association between healthy and unhealthy dietary patterns with MIDAS before and after controlling for confounding variables. Conclusions: This study showed that adherence to a healthy dietary pattern reduces the severity of pain in migraine patients. However, further studies are needed to evaluate the relationship between the unhealthy dietary pattern and the severity of migraine symptoms.

Propranolol for Treatment of Infantile Hemangioma: Efficacy and Effect on Pediatric Growth and Development

Purpose

Propranolol has been successful in treating problematic infantile hemangiomas (IH) but concerns regarding its effect on normal growth and development have been raised. This study examines physical growth, developmental milestones, and human growth hormone (hGH) levels in infants receiving propranolol for problematic IH.

Method

Monthly heights and weights of children undergoing propranolol therapy for IH were prospectively collected and tabulated. Data analysis and comparison to World Health Organization (WHO) weight-for-age and weight-to-length z-scores was performed. Questionnaires regarding milestones, efficacy, and guardian satisfaction were performed, and a combination of both chart results and phone conducted surveys was tabulated. Serum from a small representative cohort of age-matched children with IH treated and not treated with propranolol was collected.

Results

A total of 185 children receiving propranolol therapy between 2008 and 2013 for IH were assigned to this study. The children were divided into two cohorts based on the presence of comorbidities or risk factors that may affect growth and development (n = 142 no comorbidities, n = 43 with comorbidities). Neither cohort demonstrated deviation from normal weight in comparison to WHO normative data. There was a significant deviation for BMI-for-age and weight-for-age z-scores in our population, especially in patients on propranolol for more than 7 months. Based on data from participants, via either completed questionnaires or chart results, most children met their developmental milestones at or before target ages, regardless of the presence of comorbidities. Eighty percent of guardians noticed clinical improvement of the IH, with 91% either happy about or neutral to using the medication. hGH levels were higher in patients receiving propranolol therapy, but not significantly different.

Conclusion

Propranolol therapy is effective and well tolerated in the treatment of infantile hemangiomas. This study suggests that propranolol does not impair growth and has no impact on normal pediatric development.

Tolerability of eptinezumab in overweight, obese or type 1 diabetes patients

Introduction

In addition to its role in the pathogenesis of migraine, calcitonin gene-related peptide (CGRP) is implicated in the regulation of insulin secretion. However, there are limited data on the use of CGRP inhibitor monoclonal antibodies in individuals who are overweight/obese and those with diabetes.

Methods

Two randomized, double-blind, placebo-controlled trials were conducted to assess the safety and metabolic effects of eptinezumab in non-migraine overweight/obese patients (study 1) and patients with type 1 diabetes (T1D; study 2). The primary end-point in overweight/obese patients was safety and changes in basal metabolic rate (BMR), defined as the energy expenditure during the fasting and resting states. In patients with T1D, the primary end-points were safety and insulin sensitivity as assessed by the bodyweight and insulin concentration corrected glucose infusion rate (M/I).

Results

A total of 24 patients were enrolled in study 1, and 21 patients were enrolled in study 2. In overweight/obese patients, there was no significant difference in the least squares (LS) mean change in BMR between the eptinezumab- and placebo-treated patients from baseline to day 7 (6.4 vs -25.2 Kcal/day; LS mean difference 31.6 [95% confidence interval -90.6, 153.8]). In patients with T1D, there was no significant difference in insulin sensitivity between the eptinezumab and placebo groups. Eptinezumab was well tolerated in both studies with a similar rate of adverse events between treatment groups, and no new safety signals were identified.

Conclusion

Eptinezumab was well tolerated and not associated with adverse metabolic effects in patients who were overweight/obese or had T1D, providing ongoing support for the use of eptinezumab in these subgroups of patients with migraine.

Headache in Children: Selected Factors of Vascular Changes Involved in Underlying Processes of Idiopathic Headaches

Headaches are common complaints in children. The International Classification of Headache Disorders, 3^rd edition (beta version), defines more than 280 types of headaches. Primary headaches refer to independent conditions that cause pain and include migraine, tension-type headaches (TTH), and trigeminal autonomic cephalalgias (TACs). Several agents are involved in the pathogenesis of headaches. The factors associated with predisposition to atherosclerosis seem to be particularly important from the clinical point of view. The influence of obesity on the incidence of headaches has been well established. Moreover, idiopathic headaches, especially migraine, are thought to be one of the first signs of disorders in lipid metabolism and atherosclerosis. The risk of migraine increases with increasing obesity in children. Another factor that seems to be involved in both obesity and headaches is the adiponectin level. Recent data also suggest new potential risk factors for atherosclerosis and platelet aggregation such as brain-derived neurotrophic factor (BDNF), sCD40L (soluble CD40 ligand), serpin E1/PAI I (endothelial plasminogen activator inhibitor), and vascular endothelial growth factor (VEGF). However, their role is controversial because the results of clinical studies are often inconsistent. This review presents the current knowledge on the potential markers of atherosclerosis and platelet aggregation, which may be associated with primary headaches.

Antidepressants for Preventive Treatment of Migraine

PURPOSE OF REVIEW

This review describes the pharmacology of each antidepressant class as it applies to migraine prevention, summarizes the evidence base for each medication, and describes relevant side effects and clinical considerations. Use of antidepressants for migraine prevention in clinical practice is also discussed.

RECENT FINDINGS

Antidepressants are commonly used as migraine preventives. Amitriptyline has the best evidence for use in migraine prevention. Nortriptyline is an alternative in patients who may not tolerate amitriptyline. The sedating effect of TCAs can be beneficial for patients with comorbid insomnia. SNRIs including venlafaxine and duloxetine also have evidence for efficacy and may be the most effective treatments in patients with comorbid depression and migraine. SSRIs including fluoxetine are not effective for most patients. The side effect burden of antidepressants can be substantial. Patients should be particularly counseled about the possibility of a withdrawal effect from SNRIs. Antidepressants are an important option for preventive treatment of migraine. Further research on the efficacy and tolerability of SNRIs as migraine preventives is needed.

Pediatric Obesity Algorithm: A Practical Approach to Obesity Diagnosis and Management

Childhood obesity is a growing global health problem. Despite the highest rates of childhood obesity in the United States and other developed countries over the last 30 years, there is still no clear treatment strategy. Practitioners often do not know where to turn to find guidance on managing the nearly one third of their population who present for medical care either with obesity that coexists with other medical problems or because of obesity. The Pediatric Obesity Algorithm is an evidence based roadmap for the diagnosis and management of children with obesity. In this article, we summarize topics from the Pediatric Obesity Algorithm pertaining to pediatric obesity diagnosis, evaluation, and management including assessment, differential diagnosis, review of systems, diagnostic work up, physical exam, age specific management, comorbidities, use of medications and surgery, and medication associated weight gain. Identifying and treating children with obesity as early as possible is important, as is identifying comorbid conditions. Earlier and more comprehensive management through resources such as the Pediatric Obesity Algorithm serve to help guide health care practitioners with a practical and evidence based approach to the diagnosis and management of children with obesity, and provide families with the tools needed for a healthy future.

Headache and obesity in the pediatric population

Childhood obesity and headache are both significant health concerns that often have a marked impact both personally and socially, that if not addressed can carry over into adulthood. For many individuals, these effects may be magnified when obesity and headache are seen in conjunction. It is this overlap between obesity and headache in children, as well as similarities in the known mechanism of action for feeding and headache, which led to a suspected association between the two. Unfortunately, although recent studies have supported this association, only a limited number have been conducted to directly address this. Furthermore, despite rising rates of childhood obesity and headache, the associated medical comorbidities, and the significant financial cost for these conditions, there is a relative void in studies investigating treatment options that address both underlying conditions of obesity and headache in children.

Dietary considerations in migraine management: does a consistent diet improve migraine?

The clinical expression of migraine is significantly impacted by dietary and gastrointestinal issues. This includes gut dysfunction during and between attacks, food triggers, increase in migraine with obesity, comorbid GI and systemic inflammation influenced by diet, and specific food allergies such as dairy and gluten. Practitioners often encourage migraineurs to seek consistency in their lifestyle behaviors, and environmental exposures, as a way of avoiding sudden changes that may precipitate attacks. However, rigorous evidence linking consistency of diet with improvement in migraine is very limited and is, at best, indirect, being based mainly on the consistency of avoiding suspected food triggers. A review of current data surrounding the issue of dietary consistency is presented from the perspective of migraine as an illness (vulnerable state), as a disease (symptom expression traits), and with a view toward the role of local and systemic inflammation in its genesis. Firm recommendations await further investigation.

Obesity and headache: Part II--potential mechanism and treatment considerations

Obesity and headache are both associated with a substantial personal and societal impact, and epidemiologic studies have consistently identified a positive association between obesity and headache in general, as well as obesity and migraine specifically (see part I). In the current manuscript, we will discuss the potential mechanisms for the migraine-obesity association, with a focus on the central and peripheral pathophysiological pathways which overlap between migraine and those modulating the drive to feed. We then discuss surgical, behavioral, and pharmacological treatment considerations for overweight and obese migraineurs as well as for those with idiopathic intracranial hypertension. We close by briefly discussing where future research may be headed in light of this data.

Metabolic syndrome and migraine

Migraine and metabolic syndrome are highly prevalent and costly conditions. The two conditions coexist, but it is unclear what relationship may exist between the two processes. Metabolic syndrome involves a number of findings, including insulin resistance, systemic hypertension, obesity, a proinflammatory state, and a prothrombotic state. Only one study addresses migraine in metabolic syndrome, finding significant differences in the presentation of metabolic syndrome in migraineurs. However, controversy exists regarding the contribution of each individual risk factor to migraine pathogenesis and prevalence. It is unclear what treatment implications, if any, exist as a result of the concomitant diagnosis of migraine and metabolic syndrome. The cornerstone of migraine and metabolic syndrome treatments is prevention, relying heavily on diet modification, sleep hygiene, medication use, and exercise.

The young brain and concussion: imaging as a biomarker for diagnosis and prognosis

Concussion (mild traumatic brain injury (mTBI)) is a significant pediatric public health concern. Despite increased awareness, a comprehensive understanding of the acute and chronic effects of concussion on central nervous system structure and function remains incomplete. Here we review the definition, epidemiology, and sequelae of concussion within the developing brain, during childhood and adolescence, with current data derived from studies of pathophysiology and neuroimaging. These findings may contribute to a better understanding of the neurological consequences of traumatic brain injuries, which in turn, may lead to the development of brain biomarkers to improve identification, management and prognosis of pediatric patients suffering from concussion.

Nonpharmacologic treatment of migraine with low-dose propranolol or amitriptyline

This study evaluated the effectiveness of nonpharmacologic measures combined with low-dose propranolol or amitriptyline for treating severe pediatric migraine. Data were collected from the medical files of 118 patients (mean age, 12.54 ± 3.14 years S.D.). All were treated with nonpharmacologic measures. In addition, 93 children received propranolol (mean initial dose, 0.4 ± 0.17 mg/kg/day S.D.), and 25 received amitriptyline (mean initial dose, 0.26 ± 0.1 mg/kg/day S.D.). Twenty patients were switched from propranolol to amitriptyline during treatment. In both groups, headache frequency was reduced by >50% per month in ~80% of patients. Patients without aura responded significantly better to propranolol than patients with aura (P = 0.02). No significant difference was evident in response to pharmacologic treatment by migraine frequency or type (episodic chronic). No significant difference was evident in response to amitriptyline between patients with or without aura. The response rate was higher than previously reported for placebo. Low-dose propranolol and low-dose amitriptyline, when combined with nonpharmacologic measures, are equally effective in reducing the frequency of migraine in children. Propranolol is preferred because of its lower risk of side effects. An additive effect of nonpharmacologic measures may allow for a reduction in drug dose.

Migraine preventive drug-induced weight gain may be mediated by effects on hypothalamic peptides: the results of a pilot study

AIMS

This study was aimed to verify changes in the levels of hypothalamic neuropeptides in migraineurs under preventive treatment with amitryptiline and flunarizine. Thirty-nine migraine patients with a body mass index <25 kg/m(2) and without endocrinological or metabolic diseases were assigned to two treatment groups, one receiving amitryptiline, the other flunarizine, for 3 months. Orexin-A, orexin-B and neuropeptide-Y plasma levels were measured at the basal time, at the 1st, 2nd and 3rd months of preventive treatment.

RESULTS

A statistically significant reduction in plasma orexin-A and orexin-B levels emerged in both groups. Conversely, plasma neuropeptide-Y levels were markedly increased, with the highest levels at the 2nd and 3rd months, in both patient groups. Orexin-A levels were also negatively correlated to weight gain in both groups during the treatment period.

CONCLUSIONS

These results suggest that changes in the levels of hypothalamic orexinergic peptides may contribute to body weight increase occurring in migraineurs during amitryptiline or flunarizine prophylactic treatment.

Reverse causation and illness-related weight loss in observational studies of body weight and mortality

In studies of weight and mortality, the construct of reverse causation has come to be used to imply that the exposure-outcome relation is biased by weight loss due to preexisting illness. Observed weight-mortality associations are sometimes thought to result from this bias. Evidence for the occurrence of such bias is weak and inconsistent, suggesting that either the analytical methods used have been inadequate or else illness-related weight loss is not an important source of bias. Deleting participants has been the most frequent approach to control possible bias. As implemented, this can lead to deletion of almost 90% of all deaths in a sample and to deletion of more overweight and obese participants than participants with normal or below normal weight. Because it has not been demonstrated that the procedures used to adjust for reverse causation increase validity or have large or systematic effects on relative risks, it is premature to consider reverse causation as an important cause of bias. Further research would be useful to elucidate the potential effects and importance of reverse causation or illness-related weight loss as a source of bias in the observed associations between weight and mortality in cohort studies.

New drugs in migraine treatment and prophylaxis: telcagepant and topiramate

Although the triptan drugs provide effective relief from migraine for many patients, a substantial number of affected individuals are unresponsive to these compounds, and such therapy can also lead to a range of adverse effects. Telcagepant represents a new class of antimigraine drug-the calcitonin gene-related peptide receptor blockers. This compound exerts its effects by blocking receptors for the calcitonin-gene-related peptide at several sites in the trigeminal and central nervous systems, resulting in pain relief. Telcagepant does not cause vasoconstriction, a major limitation in the use of triptans. Comparisons with triptans in clinical trials for acute treatment of migraine attacks revealed clinical effects similar to those of triptans but better than those of placebo. Telcagepant might provide hope for those who have a poor response to, or are unable to use, older drugs. In patients who need prophylaxis because of frequent attacks of migraine, topiramate is a first-line drug for migraine prevention in many countries; it is generally safe and reasonably well tolerated. Data suggest that topiramate could aid reversion of chronic migraine to episodic migraine.

Drugs and nutrition: how side effects can influence nutritional intake

There are many factors that can influence nutritional intake. Food availability, physical capability, appetite, presence of gastrointestinal symptoms and perception of food are examples. Drug therapy can negatively influence nutritional intake through their effect on these factors, predominantly due to side effects. This review aims to give a brief overview of each of these factors and how drug therapy can affect them. Specific examples are given for each section and an indication of the impact on nutritional status. This article aims to assist the clinician in the identification of the effects of drug therapy on nutritional intake and provides advice on appropriate intervention. A drug history and side effect review should form an integral part of nutritional assessment. Early identification and effective therapeutic use of alternative drug therapy can also positively influence nutritional intake.

Prevention of episodic migraine with topiramate: a prospective 24-week, open-label, flexible-dose clinical trial with optional 24 weeks follow-up in a community setting

OBJECTIVE

To explore efficacy and safety outcomes of topiramate for episodic migraine prevention in community practice.

RESEARCH DESIGN AND METHODS

Open-label, multicenter, flexible-dose clinical trial consisting of a 4-week baseline phase, 24-week core phase and an optional 24-week follow-up phase in patients (18-80 years) with episodic migraine treated in community practices outside tertiary care centers.

MAIN OUTCOME MEASURES

The primary efficacy endpoint was the change in the number of migraine days/28 days (baseline vs. the last 4 weeks of core treatment) Secondary efficacy parameters included aspects of quality of life (QoL) and subjective patient ratings.

RESULTS

A total of 360 patients entered the core phase (ITT population); 37.6% (97 patients) discontinued prematurely, mainly due to adverse events (AEs; 23.6%). Mean topiramate dosage was 90 mg/day. Migraine days decreased from 8.30/28 days to 5.65/28 days and QoL (HIT-6 and MIDAS) was improved. Efficacy, tolerability and satisfaction were rated as 'good' or better by 56, 61 and 63% of patients, respectively. A total of 321 of 364 patients (88.2%) reported at least one treatment emergent AE, and the most common during the core phase were paraesthesia (46.4% of 364 patients), fatigue (17.0%), nausea (15.4%), dizziness (12.9%), viral infection (12.9%), weight decrease (12.6%) and impaired concentration (10.2%). Of 227 patients completing the core phase, 199 (88%) participated in the follow-up phase. A total of 187 patients received topiramate and 38 (20.3%) of these stopped treatment prematurely due to insufficient efficacy (6.4%), AEs (4.8%) or other reasons (10.2%). Reduction in migraine days and improvements in QoL (HIT-6) were maintained or improved (MIDAS) during follow-up, and 84% rated their satisfaction with topiramate therapy as 'good to very good'.

CONCLUSIONS

This community practice study showed that long-term treatment with topiramate in the prevention of episodic migraine was effective and well-tolerated, and it was associated with clinically relevant improvements in several aspects of QoL.

Topiramate in the prevention and treatment of migraine: efficacy, safety and patient preference

Migraine is a very common disorder characterized by the combination of typical headache with associated autonomic symptoms and/or the presence of aura. Considerable advances have been made in recent years to understand the pathophysiology of migraine, which has led to improved treatment options for the acute migraine attack as well as migraine prophylaxis. Unfortunately, preventive treatment is often insufficient to decrease migraine frequency substantially or is not well tolerated. Topiramate is an antipileptic drug with a complex mode of action which has proven its efficacy and safety in the prophylactic treatment of episodic migraine in a number of randomized controlled clinical trials. Topiramate is also effective in treating patients with chronic migraine. It has little pharmacological interaction with other drugs and is generally well tolerated by patients.

A double-blind randomized controlled trial of low doses of propranolol, nortriptyline, and the combination of propranolol and nortriptyline for the preventive treatment of migraine

Few trials have evaluated combination of two or more drugs in the preventive treatment of migraine. In this study three therapeutic regimens were compared: (a) propranolol, at a dose of 40 mg per day, (b) nortriptyline, at a dose of 20 mg per day, and (c) the combination of these two drugs in these dosages. The groups were matched according to age, gender, and frequency of migraine attacks prior to treatment. The period of treatment was two months and the frequency and intensity of headache attacks of the 30 days pre-treatment period were compared with the frequency of headaches in the treatment period. Fourteen patients in groups A and B and sixteen patients in group C have completed the study. Treatment with propranolol, alone or in combination, was shown to be effective. Treatment with nortriptyline alone was not effective. All three therapeutic regimens were safe and side effects were minimal. The frequency of discontinuation of the study was the same in the 3 groups but no patient left the study due to adverse reactions. The combined therapy proved to be as safe as the monotherapy. Further studies evaluating this and other possible combinations of drugs in higher doses and for longer periods, should more clearly elucidate the role of combined therapy in the treatment of migraine.

Prophylatic treatment of migraine and migraine clinical variants with topiramate: an update

Migraine and migraine variants are common, chronic and incapacitating neurovascular disorders with a high impact on health resources. There is an extensive evidence base provided by double-blind, placebo-controlled trials showing that topiramate is a safe, effective and well tolerated drug in the management of migraine and its variants, being especially promising in the management of migraine-vertigo syndrome. Models both in the US and the UK have also shown that it offers a cost benefit when direct and indirect costs are evaluated, by reducing work loss, improving quality of life and reducing the use of increasingly scarce health resources.