Tolfenamic acid and caffeine: a useful combination in migraine

Pyridoxine, folate and cobalamin for migraine: A systematic review

There is a possible relationship between migraine and hypercoagulability inducing factors, such as hyperhomocysteinemia. In this context, homocysteine (Hcy)-lowering vitamins (B6-folate-B12) may prove beneficial in the management-prophylaxis of migraine. We performed a systematic literature search in order to retrieve studies assessing the supplementation of B6, folate and B12 (alone or as adjunctive therapies) to migraine patients, as well as patients suffering from other primary headache disorders. MEDLINE, EMBASE, CENTRAL, Google Scholar, trial registries and OpenGrey were searched. Twelve relevant articles were retrieved. The management of acute migraine attacks with Hcy-lowering vitamins has not provided promising results (one randomized controlled trial-RCT-and one prospective uncontrolled trial). On the contrary, significant benefits were registered for the use of B6 alone, in combination with folate and in combination with folate and B12 in the prophylaxis of migraine with aura (MA) in adults compared to placebo (five RCTs, only one did not obtain significant results). Folate supplementation alone was not more efficacious than placebo (one RCT). Limited data for the prophylaxis of migraine without aura (MO) in children (two prospective uncontrolled trials) and adults (two prospective uncontrolled trials involving both MA and MO participants) impede the extraction of safe conclusions. An overall attractive safety profile was exhibited with gastrointestinal adverse events being the most common. Overall, a potential beneficial effect regarding the administration of B6, folate and/or B12 in the prophylaxis of MA in adults was indicated. Additional high-quality RCTs that will investigate MO in adults as well as MO and MA in children are warranted.

12: Clinical Aspects of Prostaglandins and Leukotrienes in Migraine

Clinical, pathophysiological, pharmacological, and biochemical evidence support the concept that the prostanoid system may be involved in migraine. As a local defence system prostaglandins may best be linked with hyperalgesia and vascular events. The response to potent inhibitors of PG-synthesis like tolfenamic acid further supports the involvement of prostaglandins in the “inflammatory-like” aspects of migraine pain. The prostanoid system may be closely coupled with the monoaminergic mechanism; e.g. in stress reactions plasma thromboxane correlates with adrenaline levels. The possible participation of leukotrienes in migraine is only speculative. However, in cerebral hypoxia lipid peroxidation is increased and leukotrienes might participate in the cerebrovascular reactions. Prostaglandins may inhibit the formation of free radicals, antagonize some actions of leukotrienes and protect the tissues. The interplay between leukotrienes and prostaglandins may give new aspects to some cerebrovascular abnormalities in migraine.

Tolfenamic acid downregulates BACE1 and protects against lead-induced upregulation of Alzheimer's disease related biomarkers

Environmental exposure to lead (Pb) early in life results in a latent upregulation of genes and products associated with Alzheimer's disease (AD), particularly the plaque forming protein amyloid beta (Aβ). Furthermore, animals exposed to Pb as infants develop cognitive decline and memory impairments in old age. Studies from our lab demonstrated that tolfenamic acid lowers the levels of the amyloid β precursor protein (APP) and its aggregative cleavage product Aβ by inducing the degradation of the transcription factor specificity protein 1 (Sp1). These changes were accompanied by cognitive improvement in transgenic APP knock-in mice. In this study, we examined the effects of tolfenamic acid on beta site APP cleaving enzyme 1 (BACE1) which is responsible for Aβ production and tested its ability to reverse Pb-induced upregulation in the amyloidogenic pathway. Mice were administered tolfenamic acid for one month and BACE1 gene expression as well as its enzymatic activity were analyzed in the cerebral cortex. Tolfenamic acid was also tested for its ability to reverse changes in Sp1, APP and Aβ that were upregulated by Pb in vitro. Differentiated SH-SY5Y neuroblastoma cells were either left unexposed, or sequentially exposed to Pb followed by tolfenamic acid. Our results show that tolfenamic acid reduced BACE1 gene expression and enzyme activity in mice. In neuroblastoma cells, Pb upregulated Sp1, APP and Aβ, while tolfenamic acid lowered their expression. These results along with previous data from our lab provide evidence that tolfenamic acid, a drug that has been used for decades for migraine, represents a candidate which can reduce the pathology of AD and may mitigate the damage of environmental risk factors associated with this disease.

NSAIDs in the Acute Treatment of Migraine: A Review of Clinical and Experimental Data

Migraine is a common disabling neurological disorder with a serious socio-economical burden. By blocking cyclooxygenase nonsteroidal anti-inflammatory drugs (NSAIDs) decrease the synthesis of prostaglandins, which are involved in the pathophysiology of migraine headaches. Despite the introduction more than a decade ago of a new class of migraine-specific drugs with superior efficacy, the triptans, NSAIDs remain the most commonly used therapies for the migraine attack. This is in part due to their wide availability as over-the-counter drugs and their pharmaco-economic advantages, but also to a favorable efficacy/side effect profile at least in attacks of mild and moderate intensity. We summarize here both the experimental data showing that NSAIDs are able to influence several pathophysiological facets of the migraine headache and the clinical studies providing evidence for the therapeutic efficacy of various subclasses of NSAIDs in migraine therapy. Taken together these data indicate that there are several targets for NSAIDs in migraine pathophysiology and that on the spectrum of clinical potency acetaminophen is at the lower end while ibuprofen is among the most effective drugs. Acetaminophen and aspirin excluded, comparative trials between the other NSAIDs are missing. Since evidence-based criteria are scarce, the selection of an NSAID should take into account proof and degree of efficacy, rapid GI absorption, gastric ulcer risk and previous experience of each individual patient. If selected and prescribed wisely, NSAIDs are precious, safe and cost-efficient drugs for the treatment of migraine attacks.

Combined treatment of pancreatic cancer with mithramycin A and tolfenamic acid promotes Sp1 degradation and synergistic antitumor activity

Mithramycin (MIT) and tolfenamic acid (TA) inhibit the activity of the transcription factor Sp1. In the present study, we investigated whether pancreatic cancer treatment with a combination of these compounds has a synergistic effect on Sp1 activity, tumor growth, and their underlying response mechanisms. Treatment of pancreatic tumor xenografts with MIT and TA produced dose-dependent antitumor activity, and significant antitumor activity of either compound alone was directly associated with systemic side effects. Combination treatment with nontoxic doses of both compounds produced synergistic antitumor activity, whereas treatment with a nontoxic dose of either compound alone lacked a discernible antitumor effect. Synergistic therapeutic effects correlated directly with synergistic antiproliferation and antiangiogenesis in vitro. Moreover, combination treatment resulted in Sp1 protein degradation, drastically downregulating expression of Sp1 and vascular endothelial growth factor. Our findings established that Sp1 is a critical target of TA and MIT in human pancreatic cancer therapy, rationalizing clinical studies to determine the effect of existing pancreatic cancer therapy regimens on Sp1 signaling in tumors and normal pancreatic tissue, and the ability of Sp1-targeting strategies to modify cancer responses.

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

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

A prospective, double-blind study of metoclopramide hydrochloride for the control of migraine in the emergency department

STUDY OBJECTIVE

To determine the effectiveness of IV metoclopramide as sole therapy for relieving the pain of acute migraine in the emergency department.

DESIGN

Prospective study. Fifty patients were divided randomly into subjects and placebo controls with blinding of the treating physician and the patient.

PARTICIPANTS

Patients presenting to the ED with migraine requiring parenteral treatment.

INTERVENTIONS

Subjects received 10 mg IV metoclopramide and controls received IV normal saline; patient assessment of relief was followed by means of a numerical scale.

MEASUREMENTS AND MAIN RESULTS

Sixty-seven percent of subjects compared with 19% of controls had effective pain relief within one hour (P less than .001). Subjects achieved mean relief scores of 2.46 compared with 1.69 for controls (P less than .02). No significant side effects were observed.

CONCLUSION

IV metoclopramide as a single agent is effective and safe therapy for migraine in the ED.

Tolfenamic acid, metoclopramide, caffeine and their combinations in the treatment of migraine attacks

Tolfenamic acid is a fenamate which inhibits prostaglandin (PG) biosynthesis and may act as a PG antagonist as well. Caffeine and metoclopramide are used in combination with analgesics and ergotamine in the treatment of migraine attacks, but controlled clinical studies on fixed combinations with analgesics are rare. The effects of orally given tolfenamic acid (200 mg), caffeine (100 mg), metoclopramide (10 mg), tolfenamic acid + caffeine (200 mg + 100 mg), tolfenamic acid + metoclopramide (200 mg + 10 mg) and placebo were studied in 49 migraine patients (3 men, 46 women) in a double-blind randomized cross-over study comprising 482 migraine attacks. The patients were allowed to take either one or two capsules of each preparation for an attack. Additional drugs were allowed after 3 h. Parameters characterizing the effects and side-effects of the drugs were registered. Tolfenamic acid and its combinations were found to be effective in the treatment of acute migraine, but caffeine and metoclopramide alone did not differ from placebo. Combination with metoclopramide was better than tolfenamic acid alone as judged by the smaller dose needed and the intensity of attack. Between tolfenamic acid alone and its caffeine combination there were no statistically significant differences.

Effects of migraine attack and metoclopramide on the absorption of tolfenamic acid

The effect of acute migraine attack and rectally given metoclopramide on the absorption of orally given tolfenamic acid (300 mg) was investigated in seven female patients in a crossover study consisting of four phases, two without migraine and two during migraine. Metoclopramide hydrochloride (20 mg) or placebo was given double-blind. Migraine attacks delayed the absorption of tolfenamic acid. Serum concentrations of tolfenamic acid 1.5 and 2 h after drug administration remained smaller, the peak serum concentration (tmax) occurred later and the area under the serum concentration-time curve between zero and 2 h (AUC0-2 h) remained decreased during migraine. Metoclopramide pretreatment in migraine attacks increased the serum concentration of tolfenamic acid at 1.5 h, but its peak concentration, time to peak concentration and the AUC0-5 h remained unchanged as compared with the values obtained with tolfenamic acid alone. Between the absorption of tolfenamic acid without migraine and after metoclopramide pretreatment during migraine no significant differences existed. When the patients were studied without migraine the serum concentrations of tolfenamic acid 45 min and 60 min after its administration were higher after metoclopramide than after placebo pretreatment. During migraine attacks the serum concentrations and the AUC0-5.5 h of metoclopramide were slightly lowered. The impairment of drug absorption by migraine was not related to the duration or severity of the attack. The observed changes in drug absorption during migraine attacks are obviously due to the delay in gastric emptying. Rectally administered metoclopramide accelerates the absorption of orally given tolfenamic acid.