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Karsan N, Goadsby PJ. Intervening in the Premonitory Phase to Prevent Migraine: Prospects for Pharmacotherapy. CNS Drugs 2024:10.1007/s40263-024-01091-2. [PMID: 38822165 DOI: 10.1007/s40263-024-01091-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2024] [Indexed: 06/02/2024]
Abstract
Migraine is a common brain condition characterised by disabling attacks of headache with sensory sensitivities. Despite increasing understanding of migraine neurobiology and the impacts of this on therapeutic developments, there remains a need for treatment options for patients underserved by currently available therapies. The first specific drugs developed to treat migraine acutely, the serotonin-5-hydroxytryptamine [5-HT1B/1D] receptor agonists (triptans), seem to require headache onset in order to have an effect, while early treatment during mild pain before headache escalation improves short-term and long-term outcomes. Some patients find treating in the early window once headache has started but not escalated difficult, and migraine can arise from sleep or in the early hours of the morning, making prompt treatment after pain onset challenging. Triptans may be deemed unsuitable for use in patients with vascular disease and in those of older age and may not be effective in a proportion of patients. Headache is also increasingly recognised as being just one of the many facets of the migraine attack, and for some patients it is not the most disabling symptom. In many patients, painless symptoms can start prior to headache onset and can reliably warn of impending headache. There is, therefore, a need to identify therapeutic targets and agents that may be used as early as possible in the course of the attack, to prevent headache onset before it starts, and to reduce both headache and non-headache related attack burden. Early small studies using domperidone, naratriptan and dihydroergotamine have suggested that this approach could be useful; these studies were methodologically less rigorous than modern day treatment studies, of small sample size, and have not since been replicated. The emergence of novel targeted migraine treatments more recently, specifically calcitonin gene-related peptide (CGRP) receptor antagonists (gepants), has reignited interest in this strategy, with encouraging results. This review summarises historical and emerging data in this area, supporting use of the premonitory phase as an opportunity to intervene as early as possible in migraine to prevent attack-related morbidity.
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Affiliation(s)
- Nazia Karsan
- Headache Group, Wolfson SPaRC, Institute of Psychiatry, Psychology and Neuroscience, Wellcome Foundation Building, King's College London, Denmark Hill, London, SE5 9PJ, UK
- NIHR King's Clinical Research Facility and SLaM Biomedical Research Centre, King's College Hospital, London, UK
| | - Peter J Goadsby
- Headache Group, Wolfson SPaRC, Institute of Psychiatry, Psychology and Neuroscience, Wellcome Foundation Building, King's College London, Denmark Hill, London, SE5 9PJ, UK.
- NIHR King's Clinical Research Facility and SLaM Biomedical Research Centre, King's College Hospital, London, UK.
- Department of Neurology, University of California, Los Angeles, Los Angeles, CA, USA.
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Giesen S, Rimmele F, Jürgens TP, Scheidt J, Drescher J, Leonhardt AK, Schulze S, Harbeck B, Meyer W, Müller B, Kropp P, Keller A. Relationship between Contingent Negative Variation and afterimage duration in migraine patients. Front Neurol 2024; 15:1401212. [PMID: 38827574 PMCID: PMC11141693 DOI: 10.3389/fneur.2024.1401212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 05/03/2024] [Indexed: 06/04/2024] Open
Abstract
Background Abnormalities in electrocortical parameters and persistence of afterimage after visual stimulation are known to occur in migraine patients. The results of studies on Contingent Negative Variation (CNV) and afterimage persistence in migraine patients suggest a link between these two phenomena and a connection to the pathomechanism of migraine. Objectives To date, no studies have investigated both afterimage duration and CNV parameters in the same subjects. The aim of this study was to investigate the relationship between the early component of CNV (iCNV) and the duration of the afterimage in migraine patients. Methods Sixty seven migraine patients from the headache center of the University of Rostock Medical Center were examined for iCNV amplitude, iCNV habituation and afterimage duration. The subjects also completed questionnaires developed for this study and the MIDAS (Migraine Disability Assessment) questionnaire. Results Associations were found between iCNV amplitude and afterimage duration and between habituation capacity and afterimage duration. A deficit in habituation capacity correlated with a significantly prolonged afterimage duration. Increased iCNV amplitude and prolonged afterimage duration were also significantly correlated. Conclusion Conclusions about the pathophysiology of migraine can be drawn from the results of this study. The results support the hypothesis of cortical hyperexcitability as a consequence of a low pre-activation level, which may be a possible contributory cause of migraine. Furthermore, they allow assessment of whether the afterimage examination, which is easier and quicker to perform than the CNV examination, can be used as a diagnostic tool or as a parameter to monitor the course of therapy in people with migraine.
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Affiliation(s)
- Simeon Giesen
- Institute of Medical Psychology and Medical Sociology, University of Rostock Medical Center, Rostock, Germany
| | - Florian Rimmele
- Department of Neurology, University of Rostock Medical Center, Rostock, Germany
| | - Tim P. Jürgens
- Department of Neurology, University of Rostock Medical Center, Rostock, Germany
- Department of Neurology, KMG Hospital Güstrow, Güstrow, Germany
| | - Jörg Scheidt
- Institute for Informations Systems, University of Applied Sciences, Hof, Germany
| | - Johannes Drescher
- Institute for Informations Systems, University of Applied Sciences, Hof, Germany
| | - Ann-Kristin Leonhardt
- Institute of Medical Psychology and Medical Sociology, University of Rostock Medical Center, Rostock, Germany
| | - Sophia Schulze
- Institute of Medical Psychology and Medical Sociology, University of Rostock Medical Center, Rostock, Germany
| | - Birgit Harbeck
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Amedes Experts, Endocrinology, Hamburg, Germany
| | - Wolfgang Meyer
- Institute of Medical Psychology and Medical Sociology, University of Rostock Medical Center, Rostock, Germany
- Faculty of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Britta Müller
- Institute of Medical Psychology and Medical Sociology, University of Rostock Medical Center, Rostock, Germany
| | - Peter Kropp
- Institute of Medical Psychology and Medical Sociology, University of Rostock Medical Center, Rostock, Germany
| | - Armin Keller
- Institute of Medical Psychology and Medical Sociology, University of Rostock Medical Center, Rostock, Germany
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Karsan N. Pathophysiology of Migraine. Continuum (Minneap Minn) 2024; 30:325-343. [PMID: 38568486 DOI: 10.1212/con.0000000000001412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
OBJECTIVE This article provides an overview of the current understanding of migraine pathophysiology through insights gained from the extended symptom spectrum of migraine, neuroanatomy, migraine neurochemistry, and therapeutics. LATEST DEVELOPMENTS Recent advances in human migraine research, including human experimental migraine models and functional neuroimaging, have provided novel insights into migraine attack initiation, neurochemistry, neuroanatomy, and therapeutic substrates. It has become clear that migraine is a neural disorder, in which a wide range of brain areas and neurochemical systems are implicated, producing a heterogeneous clinical phenotype. Many of these neural pathways are monoaminergic and peptidergic, such as those involving calcitonin gene-related peptide and pituitary adenylate cyclase-activating polypeptide. We are currently witnessing an exciting era in which specific drugs targeting these pathways have shown promise in treating migraine, including some studies suggesting efficacy before headache has even started. ESSENTIAL POINTS Migraine is a brain disorder involving both headache and altered sensory, limbic, and homeostatic processing. A complex interplay between neurotransmitter systems, physiologic systems, and pain processing likely occurs. Targeting various therapeutic substrates within these networks provides an exciting avenue for future migraine therapeutics.
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Yuan H, Silberstein SD. How early can we treat migraine attacks? A perspective based on prodrome. MED 2024; 5:179-180. [PMID: 38460496 DOI: 10.1016/j.medj.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 01/18/2024] [Accepted: 01/18/2024] [Indexed: 03/11/2024]
Abstract
Treating migraine attacks early at the onset of a headache is a common proven strategy. But does this strategy work before headache onset? In the PRODROME trial, Dodick et al. showed that ubrogepant taken during the prodrome can prevent headache attacks and reduce functional disability.1.
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Affiliation(s)
- Hsiangkuo Yuan
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA 19107, USA.
| | - Stephen D Silberstein
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA 19107, USA
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Karsan N, Goadsby PJ. Neuroimaging in the pre-ictal or premonitory phase of migraine: a narrative review. J Headache Pain 2023; 24:106. [PMID: 37563570 PMCID: PMC10416375 DOI: 10.1186/s10194-023-01617-x] [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: 06/05/2023] [Accepted: 06/20/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND The premonitory phase, or prodrome, of migraine, provides valuable opportunities to study attack initiation and for treating the attack before headache starts. Much that has been learned about this phase in recent times has come from the outcomes of functional imaging studies. This review will summarise these studies to date and use their results to provide some feasible insights into migraine neurobiology. MAIN BODY The ability to scan repeatedly a patient without radiation and with non-invasive imaging modalities, as well as the recognition that human experimental migraine provocation compounds, such as nitroglycerin (NTG) and pituitary adenylate cyclase activating polypeptide (PACAP), can trigger typical premonitory symptoms (PS) and migraine-like headache in patients with migraine, have allowed feasible and reproducible imaging of the premonitory phase using NTG. Some studies have used serial scanning of patients with migraine to image the migraine cycle, including the 'pre-ictal' phase, defined by timing to headache onset rather than symptom phenotype. Direct observation and functional neuroimaging of triggered PS have also revealed compatible neural substrates for PS in the absence of headache. Various imaging methods including resting state functional MRI (rsfMRI), arterial spin labelling (ASL), positron emission tomography (PET) and diffusion tensor imaging (DTI) have been used. The results of imaging the spontaneous and triggered premonitory phase have been largely consistent and support a theory of central migraine attack initiation involving brain areas such as the hypothalamus, midbrain and limbic system. Early dysfunctional pain, sensory, limbic and homeostatic processing via monoaminergic and peptidergic neurotransmission likely manifests in the heterogeneous PS phenotype. CONCLUSION Advances in human migraine research, including the use of functional imaging techniques lacking radiation or radio-isotope exposure, have led to an exciting opportunity to study the premonitory phase using repeated measures imaging designs. These studies have provided novel insights into attack initiation, migraine neurochemistry and therapeutic targets. Emerging migraine-specific therapies, such as those targeting calcitonin gene-related peptide (CGRP), are showing promise acutely when taken during premonitory phase to reduce symptoms and prevent subsequent headache. Therapeutic research in this area using PS for headache onset prediction and early treatment is likely to grow in the future.
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Affiliation(s)
- Nazia Karsan
- Headache Group, NIHR King's Clinical Research Facility and SLaM Biomedical Research Centre, The Wolfson Sensory, Pain and Regeneration Research Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 9PJ, UK.
| | - Peter J Goadsby
- Headache Group, NIHR King's Clinical Research Facility and SLaM Biomedical Research Centre, The Wolfson Sensory, Pain and Regeneration Research Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 9PJ, UK
- Department of Neurology, University of California, Los Angeles, USA
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Fischer-Schulte LH, Peng KP. Migraine prodromes and migraine triggers. HANDBOOK OF CLINICAL NEUROLOGY 2023; 198:135-148. [PMID: 38043958 DOI: 10.1016/b978-0-12-823356-6.00014-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
Migraine is characterized by a well-defined premonitory phase occurring hours or even days before the headache. Also, many migraineurs report typical triggers for their headaches. Triggers, however, are not consistent in their ability to precipitate migraine headaches. When looking at the clinical characteristics of both premonitory symptoms and triggers, a shared pathophysiological basis seems evident. Both seem to have their origin in basic homeostatic networks such as the feeding/fasting, the sleeping/waking, and the stress response network, all of which strongly rely on the hypothalamus as a hub of integration and are densely interconnected. They also influence the trigeminal pain processing system. Additionally, thalamic and hormonal mechanisms are involved. Activity within all those networks is influenced by various endogenous and external factors and might even cyclically change dependent on physiological internal rhythms. This might affect the threshold for the generation of migraine headaches. Premonitory symptoms thus appear as the result of an already ongoing alteration within those networks, whereas triggers might in this special situation only be able to further stress the system over the threshold for attack generation as catalysts of a process already in motion.
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Affiliation(s)
- Laura H Fischer-Schulte
- Clinic and Policlinic of Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Kuan-Po Peng
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Førland-Schill A, Berring-Uldum A, Debes NM. Migraine Pathophysiology in Children and Adolescents: A Review of the Literature. J Child Neurol 2022; 37:642-651. [PMID: 35607281 DOI: 10.1177/08830738221100888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Although migraine in adult and pediatric patients are overall very similar to each other, differences in prevalence, presentation, and treatment efficacy may reflect slight differences in the pathophysiological processes underlying migraine in these patient groups, perhaps because of ongoing development of the nervous system during childhood and adolescence. Although major gains have been made in understanding the pathophysiology of migraine in adults in recent years, equivalent research on migraine in pediatric patients continues to lag behind. In this review, we will describe the current state of migraine research in pediatric patients with regard to presentation and frequency of prodromal and postdromal symptoms, ictal and interictal calcitonin gene-related peptide elevation, and evidence for cortical spreading depression, thus covering all phases of migraine, and discuss how the findings seen here may relate to possible underlying pathophysiological mechanisms of migraine. We aim to elucidate possible differences between migraine in children and adults, and the need for further research specific to pediatric patients with migraine in order to improve treatment in this patient group.
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Gago-Veiga A, Vivancos J, Sobrado M. The premonitory phase: a crucial stage in migraine. NEUROLOGÍA (ENGLISH EDITION) 2021. [DOI: 10.1016/j.nrleng.2017.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Wang X, Yin Z, Lian Y, Xu Y, Li Y, Liu J, Gu Q, Yan F, Ge Z, Lian Y, Hu D, Chen S, Wang R, Chen X, Liu J, Zhang M, Ran Y, Zhou P, Ma J, Lv X, Dong Z, Yu S. Premonitory symptoms in migraine from China: A multi-clinic study of 4821 patients. Cephalalgia 2021; 41:991-1003. [PMID: 33631964 DOI: 10.1177/0333102421997850] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To observe the prevalence and characteristics of premonitory symptoms in Chinese migraineurs and explore their associations with migraine-related factors. METHOD Migraineurs who visited a tertiary headache clinic and one of nine neurology clinics between May 2014 and November 2019 were studied. RESULT Among the 4821 patients meeting the migraine criteria (International Classification of Headache Disorders, 3rd edition), 1038 (21.5%) patients experienced at least one premonitory symptom. The most common premonitory symptoms were neck stiffness, dizziness, yawning and drowsiness. The logistic regression analysis demonstrated that aura, photophobia, aggravation by routine physical activity, triggers, family history, depression, coffee consumption and physical exercise were associated with an increased probability of experiencing premonitory symptoms (p ≤ 0.001). The premonitory symptoms of migraine with and without aura differ in prevalence and most common symptoms. The cluster analysis revealed pairwise clustering of the following premonitory symptoms: Photophobia/phonophobia, concentration change/dysesthesia, loquacity/overactivity, yawning/drowsiness, fatigue/dizziness, and mood change/irritability. The correlation analysis of triggers and premonitory symptoms revealed that temperature change, environment change, sleep disorder, activity and stress were related to multiple premonitory symptoms, and that food, light, menstruation, alcohol and odor were related to special premonitory symptoms (p ≤ 0.001). CONCLUSION The prevalence of premonitory symptoms among migraineurs in China is 21.5%. Some factors influence the probability of experiencing premonitory symptoms. Paired premonitory symptoms in the clustering analysis may share similar origins. Certain triggers associated with multiple premonitory symptoms may induce brain dysfunction; however, other triggers that overlap with corresponding special premonitory symptoms may be premonitory symptoms or a form of premonitory symptom.
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Affiliation(s)
- Xiaolin Wang
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Ziming Yin
- School of Medical Instrument and Food Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Yajun Lian
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Yanmei Xu
- Department of Neurology, Dingyuan General Hospital, Anhui, China
| | - Yajie Li
- Diagnostic Ultrasound Centre, The Centre Hospital of Jilin city, Jilin, China
| | - Jiale Liu
- Department of Neurology, The Centre Hospital of Jilin city, Jilin, China
| | - Qun Gu
- Department of Neurology, Huzhou First People's Hospital, Zhejiang, China
| | - Fanhong Yan
- Department of Neurology, Linyi Jinluo Hospital, Shandong, China
| | - Zhaoli Ge
- Department of Neurology, Shenzhen Second People's Hospital, Guangdong, China
| | - Yu Lian
- Department of Neurology, Inner Mongolia Xing'an League People's Hospital, Inner Mongolia, China
| | - Dongmei Hu
- Department of Neurology, The Second Affiliated Hospital of Shandong First Medical University, Shandong, China
| | - Sufen Chen
- Department of Neurology, Changsha Central Hospital affiliated to University of South China, Hunan, China
| | - Rongfei Wang
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Xiaoyan Chen
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jing Liu
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Mingjie Zhang
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Ye Ran
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Ping Zhou
- School of Applied Sciences, Beijing Information Science and Technology University, Beijing, China
| | - Jingyi Ma
- School of Statistics and Mathematics, Central University of Finance and Economics, Beijing, China
| | - Xudong Lv
- College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China
| | - Zhao Dong
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Shengyuan Yu
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
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Cho S, Cho SJ, Lee MJ, Park JW, Chu MK, Moon HS, Chung PW, Sohn JH, Kim BS, Kim D, Kim JM, Chung JM, Oh K, Ahn JY, Chung CS, Kim BK. Clinical characteristics of pre-attack symptoms in cluster headache: A large series of Korean patients. Cephalalgia 2020; 41:227-236. [PMID: 33086875 DOI: 10.1177/0333102420966983] [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: 11/16/2022]
Abstract
BACKGROUND Previous studies have reported notable differences in demographic and clinical features of cluster headache between Western and Asian populations, including lower prevalence of the chronic type and in women. Recently, prodromal symptoms of migraine and pre-attack symptoms of cluster headache have drawn attention regarding their potential pathophysiological implications and pre-emptive treatment. However, pre-attack symptoms of cluster headache have not been studied in the Asian population. METHODS A total of 136 patients with cluster headache (21 first-onset, 110 episodic, and five chronic cases) were recruited in this multi-center study between October 2018 and December 2019. We evaluated the characteristics of pre-attack symptoms in a current bout using a structured questionnaire. Univariable and multivariable logistic regression analyses were performed to evaluate the factors associated with presence of pre-attack symptoms. RESULTS Pre-attack symptoms were reported in 71.3% of our patients with cluster headache. When present, pre-attack symptoms occurred at a median of 20 minutes (range 1-120) before the attack. The prevalence of local and painful, local and painless sensory, autonomic, and general symptoms was 58.8%, 14.7%, 11.0%, and 30.1%, respectively. Multivariable logistic regression analysis revealed that higher number of bouts was associated with higher prevalence of pre-attack symptoms (OR = 1.464, p = 0.044). CONCLUSIONS Pre-attack symptoms were frequently observed in Korean patients with cluster headache, which was consistent with previous Western studies.
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Affiliation(s)
- Soohyun Cho
- Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea
| | - Soo-Jin Cho
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Mi Ji Lee
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Wook Park
- Department of Neurology, Uijeongbu St. Mary's Hospital, Catholic University of Korea College of Medicine, Uijeongbu, Korea
| | - Min Kyung Chu
- Department of Neurology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Heui-Soo Moon
- Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Pil-Wook Chung
- Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong-Hee Sohn
- Department of Neurology, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
| | - Byung-Su Kim
- Department of Neurology, Bundang Jesaeng General Hospital, Daejin Medical Center, Seongnam, Korea
| | - Daeyoung Kim
- Department of Neurology, Chungnam National University College of Medicine, Daejeon, Korea
| | - Jae-Moon Kim
- Department of Neurology, Chungnam National University College of Medicine, Daejeon, Korea
| | - Jae Myun Chung
- Department of Neurology, Inje University College of Medicine, Seoul, South Korea
| | - Kyungmi Oh
- Department of Neurology, Korea University College of Medicine, Seoul, Korea
| | - Jin-Young Ahn
- Department of Neurology, Seoul Medical Center, Seoul, Korea
| | - Chin-Sang Chung
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byung-Kun Kim
- Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea
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Termini SD, Wöber C, Brannath W. Early use of acute medication for preventing migraine attacks: Results from a diary-based cohort study. CEPHALALGIA REPORTS 2020. [DOI: 10.1177/2515816320944928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Treating migraine attacks early may improve outcome. The aim of this analysis was to investigate whether certain premonitory symptoms could be indicators for taking acute medication. Methods: We analyzed 3-month diary data recorded by 271 patients with episodic migraine and looked at all migraine-free intervals. For investigating the interaction between acute medication and neck discomfort associated with sensitivity to lights, noises, or odors, we used a marginal structural model and a Cox regression analysis adjusted for moderate or severe headache. Results: The patients (mean age 43 ± 15.4 years, 88% women) recorded a total of 20,219 diary days without migraine. In the marginal structural model analysis, the risk for occurrence of a migraine attack on the subsequent day was reduced when acute medication was used in the presence of neck discomfort associated with sensitivity to lights (hazard ratio 0.4; 95% confidence interval 0.2–0.7), noises (0.4; 0.3–0.7), or odors (0.2; 0.1–0.4). The marginal structural model showed lower risk of migraine attacks than the Cox regression analysis adjusted for moderate or severe headache in the majority of the cases. Conclusion: Migraine attacks may be prevented when acute medication is used in the presence of neck discomfort associated with sensitivity to lights, noises, or odors. The results of this study may stimulate further prospective trials.
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Affiliation(s)
- Susanna Di Termini
- Competence Center for Clinical Trials, University of Bremen, Bremen, Germany
| | - Christian Wöber
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Werner Brannath
- Competence Center for Clinical Trials, University of Bremen, Bremen, Germany
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Roesch A, Dahlem MA, Neeb L, Kurth T. Validation of an algorithm for automated classification of migraine and tension-type headache attacks in an electronic headache diary. J Headache Pain 2020; 21:75. [PMID: 32532222 PMCID: PMC7291668 DOI: 10.1186/s10194-020-01139-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 05/27/2020] [Indexed: 02/06/2023] Open
Abstract
Background This study evaluates the accuracy of an automated classification tool of single attacks of the two major primary headache disorders migraine and tension-type headache used in an electronic headache diary. Methods One hundred two randomly selected reported headache attacks from an electronic headache-diary of patients using the medical app M-sense were classified by both a neurologist with specialisation in headache medicine and an algorithm, constructed based on the ICHD-3 criteria for migraine and tension-type headache. The level of agreement between the headache specialist and the algorithm was compared by using a kappa statistic. Cases of disagreement were analysed in a disagreement validity assessment. Result The neurologist and the algorithm classified migraines with aura (MA), migraines without aura (MO), tension-type headaches (TTH) and non-migraine or non-TTH events. Of the 102 headache reports, 86 cases were fully agreed on, and 16 cases not, making the level of agreement unweighted kappa 0.74 and representing a substantial level of agreement. Most cases of disagreement (12 out of 16) were due to inadvertent mistakes of the neurologist identified in the disagreement validity assessment. The second most common reason (3 out of 16) was insufficient information for classification by the neurologist. Conclusions The substantial level of agreement indicates that the classification tool is a valuable instrument for automated evaluation of electronic headache diaries, which can thereby support the diagnostic and therapeutic clinical processes. Based on this study’s results, additional diagnostic functionalities of primary headache management apps can be implemented. Finally, future research can use this classification algorithm for large scale database analysis for epidemiological studies.
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Affiliation(s)
- Aaron Roesch
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | | | - Lars Neeb
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Tobias Kurth
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
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Abstract
PURPOSE OF REVIEW The premonitory phase of migraine is defined as the presence of nonpainful symptomatology occurring hours to days before the onset of headache. Symptoms can include neck stiffness, yawning, thirst, and increased frequency of micturition. Clinical recognition of these symptoms is important to ensure early and effective attack management. Further understanding of the clinical phenotype and neurobiological mediation of these symptoms is important in the advancement of therapeutics research in both acute and preventive treatments of migraine. RECENT FINDINGS Since 2014, functional imaging studies have been conducted during the premonitory stage of migraine and have provided novel insights into the early neurobiology and anatomy of the earliest stage of the migraine attack. These studies have shown early involvement of subcortical brain areas including the hypothalamus, substantia nigra, dorsal pons, and various limbic cortical areas, including the anterior cingulate cortex during the premonitory phase. More recent work has revealed altered hypothalamic-brainstem functional connectivity during migraine, which starts before the onset of pain. These exciting findings have provided functional correlation of the symptoms experienced by patients and changes seen on functional brain imaging. SUMMARY This article focuses on the prevalence, phenotype, and proposed neurobiology of premonitory symptomatology in migraineurs as well as the scope of future research.
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Cuvellier JC. Pediatric vs. Adult Prodrome and Postdrome: A Window on Migraine Pathophysiology? Front Neurol 2019; 10:199. [PMID: 30930831 PMCID: PMC6423905 DOI: 10.3389/fneur.2019.00199] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 02/15/2019] [Indexed: 01/03/2023] Open
Abstract
Few studies have been conducted on the prodromal and postdromal phases of the migraine attack in children and adolescents. Using a questionnaire, we found that 67% of 103 children and adolescents with migraine reported at least one prodromal symptom, with a mean number per subject of 1.8 (median 2.2). The most frequently reported prodromal symptoms were face changes, fatigue and irritability. In pediatric patients selected as having prodrome, fatigue, mood change and neck stiffness were the most frequently reported prodromal symptoms. Using a different design, Laurell et al. found that 71% of 137 pediatric patients reported at least one prodromal symptom with a mean number per subject of 1.9 ± 2.0. Studying postdrome was fraught with unexpected difficulties as our preliminary research showed. Patients reported 2 groups of symptoms occurring during the resolution phase of the headache: symptoms whose onset was before headache cessation and were persisting after it, and symptoms whose onset was after headache cessation. We referred to the former as persistent symptoms and to the latter as true postdromes. Ninety-one per cent of patients reported persistent symptoms, with a mean of 6.0 and a median of 2, asthenia, pallor, cognitive difficulties, anorexia, somnolence, and nausea being the more frequently reported. True postdromes were reported by 82% of patients, with a mean of 2.6 and a median of 2, thirst, somnolence, visual disturbances, food craving, paraesthesias, and ocular pain being the most frequent reported. Interestingly, several prodromal and postdromal symptoms are also encountered during the aura classic and/or accompany the headache phase. Functional imaging in migraine has showed that the activations in areas such as hypothalamus or brainstem may begin before headache onset and/or persist after headache relief. Thus, one may wonder whether prodromal and postdromal symptoms may indicate the involvement of the limbic system, dopaminergic pathways, the hypothalamus and the brainstem. Differences between children, adolescents and adults might contribute to the understanding of migraine neurobiology.
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Affiliation(s)
- Jean-Christophe Cuvellier
- Division of Pediatric Neurology, Department of Pediatrics, Lille Faculty of Medicine and Children's Hospital, Lille, France
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Karsan N, Goadsby PJ. Biological insights from the premonitory symptoms of migraine. Nat Rev Neurol 2018; 14:699-710. [DOI: 10.1038/s41582-018-0098-4] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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16
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Grazzi L, Tassorelli C, de Tommaso M, Pierangeli G, Martelletti P, Rainero I, Geppetti P, Ambrosini A, Sarchielli P, Liebler E, Barbanti P. Practical and clinical utility of non-invasive vagus nerve stimulation (nVNS) for the acute treatment of migraine: a post hoc analysis of the randomized, sham-controlled, double-blind PRESTO trial. J Headache Pain 2018; 19:98. [PMID: 30340460 PMCID: PMC6742918 DOI: 10.1186/s10194-018-0928-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 10/03/2018] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND The PRESTO study of non-invasive vagus nerve stimulation (nVNS; gammaCore®) featured key primary and secondary end points recommended by the International Headache Society to provide Class I evidence that for patients with an episodic migraine, nVNS significantly increases the probability of having mild pain or being pain-free 2 h post stimulation. Here, we examined additional data from PRESTO to provide further insights into the practical utility of nVNS by evaluating its ability to consistently deliver clinically meaningful improvements in pain intensity while reducing the need for rescue medication. METHODS Patients recorded pain intensity for treated migraine attacks on a 4-point scale. Data were examined to compare nVNS and sham with regard to the percentage of patients who benefited by at least 1 point in pain intensity. We also assessed the percentage of attacks that required rescue medication and pain-free rates stratified by pain intensity at treatment initiation. RESULTS A significantly higher percentage of patients who used acute nVNS treatment (n = 120) vs sham (n = 123) reported a ≥ 1-point decrease in pain intensity at 30 min (nVNS, 32.2%; sham, 18.5%; P = 0.020), 60 min (nVNS, 38.8%; sham, 24.0%; P = 0.017), and 120 min (nVNS, 46.8%; sham, 26.2%; P = 0.002) after the first attack. Similar significant results were seen when assessing the benefit in all attacks. The proportion of patients who did not require rescue medication was significantly higher with nVNS than with sham for the first attack (nVNS, 59.3%; sham, 41.9%; P = 0.013) and all attacks (nVNS, 52.3%; sham, 37.3%; P = 0.008). When initial pain intensity was mild, the percentage of patients with no pain after treatment was significantly higher with nVNS than with sham at 60 min (all attacks: nVNS, 37.0%; sham, 21.2%; P = 0.025) and 120 min (first attack: nVNS, 50.0%; sham, 25.0%; P = 0.018; all attacks: nVNS, 46.7%; sham, 30.1%; P = 0.037). CONCLUSIONS This post hoc analysis demonstrated that acute nVNS treatment quickly and consistently reduced pain intensity while decreasing rescue medication use. These clinical benefits provide guidance in the optimal use of nVNS in everyday practice, which can potentially reduce use of acute pharmacologic medications and their associated adverse events. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02686034 .
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Affiliation(s)
- Licia Grazzi
- Neuroalgology Unit, Carlo Besta Neurological Institute and Foundation, Milan, Italy
- Department of Fondazione IRCCS Istituto Neurologico C. Besta, U.O. Neurologia III – Cefalee e Neuroalgologia, Via Celoria 11, 20133 Milan, Italy
| | - Cristina Tassorelli
- Headache Science Centre, IRCCS C. Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Marina de Tommaso
- Neurophysiology and Pain Unit, University of Bari Aldo Moro, Bari, Italy
| | - Giulia Pierangeli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | | | | | | | - Paola Sarchielli
- Neurologic Clinic, Santa Maria della Misericordia Hospital, Perugia, Italy
| | | | - Piero Barbanti
- Headache and Pain Unit, IRCCS San Raffaele Pisana, Rome, Italy
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Gago-Veiga AB, Pagán J, Henares K, Heredia P, González-García N, De Orbe MI, Ayala JL, Sobrado M, Vivancos J. To what extent are patients with migraine able to predict attacks? J Pain Res 2018; 11:2083-2094. [PMID: 30310310 PMCID: PMC6166762 DOI: 10.2147/jpr.s175602] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Purpose Premonitory symptoms (PSs) of migraine are those that precede pain in a migraine attack. Previous studies suggest that treatment during this phase may prevent the onset of pain; however, this approach requires that patients be able to recognize their PSs. Our objectives were to evaluate patients’ actual ability to predict migraine attacks based on their PSs and analyze whether good predictors meet any characteristic profile. Patients and methods This prospective, observational study included patients with migraine with and without aura. Patients’ baseline characteristics were recorded. During a 2-month follow-up period, patients used a mobile application to record what they believed to be PSs and later to record the onset of pain, if this occurred. When a migraine attack ended, patients had to complete a form on the characteristics of the episode (including the presence of PSs not identified prior to the attack). Results Fifty patients were initially selected. A final total of 34 patients were analyzed, recording 229 attacks. Of whom, 158 (69%) were accompanied by PSs and were recorded prior to the pain onset in 63 (27.5%) cases. A total of 67.6% of the patients were able to predict at least one attack, but only 35.3% were good predictors (>50% of attacks). There were only 11 cases in which a patient erroneously reported their PSs (positive predictive value: 85.1%). Good predictors were not differentiated by any specific clinical characteristic. However, a range of symptoms were particularly predictive; these included photophobia, drowsiness, yawning, increased thirst, and blurred vision. Conclusion A large majority of patients with migraine experienced a PS and were able to predict at least one attack. Besides, only a small percentage of patients were considered as good predictors; however, they could not be characterized by any specific profile. Nonetheless, when patients with migraine believed that they were experiencing PSs, they were frequently correct.
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Affiliation(s)
- Ana B Gago-Veiga
- Headache Unit, Department of Neurology, Instituto de Investigación Sanitaria Hospital, Universitario de la Princesa, Madrid, Spain,
| | - Josué Pagán
- Department of Electronic Engineering, Universidad Politécnica de Madrid, Madrid, Spain.,Center for Computational Simulation, Universidad Politécnica de Madrid, Madrid, Spain
| | - Kevin Henares
- Department of Electronic Engineering, Universidad Politécnica de Madrid, Madrid, Spain.,Department of Computer and Automation Architecture, Universidad Complutense de Madrid, Madrid, Spain
| | - Patricia Heredia
- Headache Unit, Department of Neurology, Instituto de Investigación Sanitaria Hospital, Universitario de la Princesa, Madrid, Spain,
| | | | - María-Irene De Orbe
- Department of Computer and Automation Architecture, Universidad Complutense de Madrid, Madrid, Spain
| | - Jose L Ayala
- Center for Computational Simulation, Universidad Politécnica de Madrid, Madrid, Spain.,Department of Computer and Automation Architecture, Universidad Complutense de Madrid, Madrid, Spain
| | - Mónica Sobrado
- Headache Unit, Department of Neurology, Instituto de Investigación Sanitaria Hospital, Universitario de la Princesa, Madrid, Spain,
| | - Jose Vivancos
- Headache Unit, Department of Neurology, Instituto de Investigación Sanitaria Hospital, Universitario de la Princesa, Madrid, Spain,
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Gago-Veiga AB, Vivancos J, Sobrado M. The premonitory phase: A crucial stage in migraine. Neurologia 2017; 36:298-304. [PMID: 29277522 DOI: 10.1016/j.nrl.2017.09.014] [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] [Received: 08/13/2017] [Revised: 09/25/2017] [Accepted: 09/28/2017] [Indexed: 10/18/2022] Open
Abstract
INTRODUCTION The premonitory phase comprises a wide range of symptoms that precede the onset of pain in a migraine episode by up to 48hours. Premonitory symptoms are often not recognised by patients but do have a significant impact on their quality of life. As these symptoms represent the first stage of a migraine attack, they are crucial in improving our understanding of the key points of the origin of migraine. DEVELOPMENT This paper uses a question-answer format to review the main clinical studies analysing premonitory symptoms, their predictive capacity, the relationship between these symptoms and the biology of migraine, and the role of neuroimaging in the premonitory phase. Finally, we discuss the relevance of these symptoms as potential therapeutic targets in the future. CONCLUSIONS This study of the premonitory phase has demonstrated that the hypothalamus plays an essential role in the origin of migraine attacks. We should consider the search for new targets in acute migraine treatment in order to act before the onset of the pain. This would imply a radical change in the lives of patients with migraine.
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Affiliation(s)
- A B Gago-Veiga
- Unidad de Cefaleas, Servicio de Neurología, Instituto de Investigación Sanitaria Princesa, Hospital Universitario de la Princesa, Madrid, España.
| | - J Vivancos
- Unidad de Cefaleas, Servicio de Neurología, Instituto de Investigación Sanitaria Princesa, Hospital Universitario de la Princesa, Madrid, España
| | - M Sobrado
- Unidad de Cefaleas, Servicio de Neurología, Instituto de Investigación Sanitaria Princesa, Hospital Universitario de la Princesa, Madrid, España
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Jay GW, Barkin RL. Primary Headache Disorders Part I- Migraine and the Trigeminal Autonomic Cephalalgias. Dis Mon 2017; 63:308-338. [DOI: 10.1016/j.disamonth.2017.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Karsan N, Prabhakar P, Goadsby PJ. Characterising the premonitory stage of migraine in children: a clinic-based study of 100 patients in a specialist headache service. J Headache Pain 2016; 17:94. [PMID: 27770403 PMCID: PMC5074936 DOI: 10.1186/s10194-016-0689-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 10/11/2016] [Indexed: 01/03/2023] Open
Abstract
Background The premonitory stage of migraine attacks, when symptomatology outside of pain can manifest hours to days before the onset of the headache, is well recognised. Such symptoms have been reported in adults in a number of studies, and have value in predicting an impending headache. These symptoms have not been extensively studied in children. We aimed to characterise which, if any, of these symptoms are reported in children seen within a Specialist Headache Service. Methods We reviewed clinic letters from the initial consultation of children and adolescents seen within the Specialist Headache Service at Great Ormond Street Hospital between 1999 and 2015 with migraine in whom we had prospectively assessed clinical phenotype data. We randomly selected 100 cases with at least one premonitory symptom recorded in the letter. For these patients, the age at headache onset, presence of family history of headache, headache diagnosis, presence of episodic syndromes which may be associated with headache, developmental milestones, gestation at birth, mode of delivery and presence of premonitory symptoms occurring before or during headache were recorded. Results Of the 100 patients selected, 65 % were female. The age range of the patients was 18 months to 15 years at the time of headache onset. The most common diagnosis was chronic migraine in 58 %, followed by episodic migraine (29 %), New Daily Persistent Headache with migrainous features (8 %) and hemiplegic migraine (5 %). A history of infantile colic was noted in 31 % and was the most common childhood episodic syndrome associated with migraine. The most common premonitory symptoms recorded were fatigue, mood change and neck stiffness. The commonest number of reported premonitory symptoms was two. Conclusion Premonitory symptoms associated with migraine are reported in children as young as 18 months, with an overall clinical phenotype comparable to adults. Better documentation of this stage will aid parents and clinicians to better understand the phenotype of attacks, better recognise migraine and thus initiate appropriate management. Larger studies with a broader base are warranted to understand the extent and implications of these symptoms for childhood and adolescent migraine.
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Affiliation(s)
- N Karsan
- Headache Group, Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - P Prabhakar
- Department of Paediatric Neurology, Great Ormond Hospital for Children NHS Foundation Trust, London, UK
| | - P J Goadsby
- NIHR-Wellcome Trust King's Clinical Research Facility, King's College Hospital, London, SE5 9PJ, UK.
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Premonitory symptoms in migraine: A cross-sectional study in 2714 persons. Cephalalgia 2016; 36:951-9. [DOI: 10.1177/0333102415620251] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 10/04/2015] [Indexed: 01/03/2023]
Abstract
Aim To describe the frequency and number of premonitory symptoms (PS) in migraine, the co-occurrence of different PS, and their association with migraine-related factors. Methods In this cross-sectional study, a validated questionnaire was sent to Finnish migraine families between 2002 and 2013 to obtain data on 14 predefined PS, migraine diagnoses, demographic factors, and migraine characteristics. The estimated response rate was 80%. Results Out of 2714 persons, 2223 were diagnosed with migraine. Among these, 77% reported PS, with a mean number of 3.0 symptoms compared to 30% ( p < 0.001) and 0.5 symptoms ( p < 0.001) among 491 persons with non-migraine headaches. Yawning was the most commonly reported symptom (34%) among migraineurs. Females reported PS more frequently than males (81 versus 64%, p < 0.001) and experienced a higher number of different symptoms (mean 3.3 versus 1.8, p < 0.001). All measures of migraine severity were associated with a higher burden of PS. Light and sound sensitivity showed the highest co-occurrence (kappa = 0.51, 95% CI 0.47–0.55). In a generalized linear model, age, gender, higher frequency, duration and intensity of headache, reduced working capacity, most aura symptoms, and associated symptoms of the headache phase were significantly associated with an increased in the number of PS. Conclusion PS are experienced by a majority of migraineurs. More severe migraine is associated with a higher burden of PS. Since the material was not entirely representative of the general population of migraineurs, caution should be exercised in generalizing the results.
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Quintela E, Castillo J, Muñoz P, Pascual J. Premonitory and Resolution Symptoms in Migraine: A Prospective Study in 100 Unselected Patients. Cephalalgia 2016; 26:1051-60. [PMID: 16919055 DOI: 10.1111/j.1468-2982.2006.01157.x] [Citation(s) in RCA: 121] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The nosology of migraine premonitory (PS) and resolution (RS) symptoms was studied in 100 migraineurs consulting their general physician. They were asked to fill in, for three attacks, a PS and RS questionnaire. ‘True’ PS/RS were those experienced the day before (or the day after) the headache had started only if they were not present in a questionnaire completed in a pain-free period. True PS and RS were experienced by 84± and 80±, respectively, of subjects for the first attack. The mean and range (per patient) of PS were 6.8 and 0–21 and of RS 4.7 and 0–15. Anxiety, phonophobia, irritability, unhappiness and yawning were the commonest PS, whereas asthenia, tiredness, somnolence and concentration difficulties were the most common RS. Gender, age and Migraine Disability Assessment scores did not influence PS and RS. Both PS and RS were more frequent in migraine with aura subjects. Patients on preventatives showed a decreased frequency of PS and, to a lesser degree, of RS. Severity of headache was associated with a higher frequency of RS. Individual RS and especially PS were quite consistent after three attacks. Almost two-thirds of the symptoms were noticed in at least two out of three attacks, while more than a half of PS and more than a quarter of RS repeated in three out of three attacks. In conclusion, around 80± of unselected migraineurs experience RS and PS. Migraine with aura and severe pain are risk factors for experiencing PS and RS, while preventatives were protective, especially for PS.
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Affiliation(s)
- E Quintela
- Health Centre of Astillero, University Hospital, Salamanca, Spain
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Abstract
For the last quarter of a century, triptans have been available for acute treatment of migraine but with little guidance on which of the different triptan products to use for which patient or which attack of migraine. In this article, we propose a structured approach to analysis of individual migraine attacks and patient characteristics as a means of defining and optimizing acute intervention. Assessment of patient and attack profiles includes the "5-Ps": pattern, phenotype, patient, pharmacology, and precipitants. Attending to these five components of information can assist in developing an individualized behavioral, pharmacological, and nonpharmacological comprehensive treatment plan for most migraine patients. This clinical approach is then focused on frovatriptan because of its unique molecular signature and potential novel clinical applications. Frovatriptan like all triptans is indicated for acute treatment of migraine but its role has been explored in management of several unique migraine phenotypes. Frovatriptan has the longest half-life of any triptan and consequently is often promoted for acute treatment of migraine of longer duration. It has also been studied as a short-term preventive treatment in women with menstrual-related migraine. Given that 60% of female migraineurs suffer from menstrual-related migraine, this population is the obvious group for continued study. Small studies have also explored frovatriptan's use in treating migraine predicted by premonitory symptoms as a preventive for the headache phase of migraine. By identifying patient and attack profiles, clinicians may effectively determine the viability of frovatriptan as an effective pharmacological intervention for migraine.
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Pharmacological Acute Migraine Treatment Strategies: Choosing the Right Drug for a Specific Patient. Can J Neurol Sci 2015. [DOI: 10.1017/s0317167100118979] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ABSTRACT:Background:In our targeted review (Section 2), 12 acute medications received a strong recommendation for use in acute migraine therapy while four received a weak recommendation for use. Strong recommendations were made to avoid use of two other medications, except for exceptional circumstances. Two anti-emetics received strong recommendations for use as needed.Objective:To organize the available acute migraine medications into acute migraine treatment strategies in order to assist the practitioner in choosing a specific medication(s) for an individual patient.Methods:Acute migraine treatment strategies were developed based on the targeted literature review used for the development of this guideline (Section 2), and a general literature review. Expert consensus groups were used to refine and validate these strategies.Results:Based on evidence for drug efficacy, drug side effects, migraine severity, and coexistent medical disorders, our analysis resulted in the formulation of eight general acute migraine treatment strategies. These could be grouped into four categories: 1) two mild-moderate attack strategies, 2) two moderate-severe attack or NSAID failure strategies, 3) three refractory migraine strategies, and 4) a vasoconstrictor unresponsive-contraindicated strategy. In addition, strategies were developed for menstrual migraine, migraine during pregnancy, and migraine during lactation. The eight general treatment strategies were coordinated with a “combined acute medication approach” to therapy which used features of both the “stratified” and the “step care across attacks” approaches to acute migraine management.Conclusions:The available medications for acute migraine treatment can be organized into a series of strategies based on patient clinical features. These strategies may help practitioners make appropriate acute medication choices for patients with migraine.
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Robust and Accurate Modeling Approaches for Migraine Per-Patient Prediction from Ambulatory Data. SENSORS 2015; 15:15419-42. [PMID: 26134103 PMCID: PMC4541837 DOI: 10.3390/s150715419] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 06/23/2015] [Accepted: 06/26/2015] [Indexed: 11/18/2022]
Abstract
Migraine is one of the most wide-spread neurological disorders, and its medical treatment represents a high percentage of the costs of health systems. In some patients, characteristic symptoms that precede the headache appear. However, they are nonspecific, and their prediction horizon is unknown and pretty variable; hence, these symptoms are almost useless for prediction, and they are not useful to advance the intake of drugs to be effective and neutralize the pain. To solve this problem, this paper sets up a realistic monitoring scenario where hemodynamic variables from real patients are monitored in ambulatory conditions with a wireless body sensor network (WBSN). The acquired data are used to evaluate the predictive capabilities and robustness against noise and failures in sensors of several modeling approaches. The obtained results encourage the development of per-patient models based on state-space models (N4SID) that are capable of providing average forecast windows of 47 min and a low rate of false positives.
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Pavlovic JM, Buse DC, Sollars CM, Haut S, Lipton RB. Trigger Factors and Premonitory Features of Migraine Attacks: Summary of Studies. Headache 2014; 54:1670-9. [DOI: 10.1111/head.12468] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2014] [Indexed: 12/13/2022]
Affiliation(s)
- Jelena M. Pavlovic
- Department of Neurology; Albert Einstein College of Medicine; Bronx NY USA
- Montefiore Headache Center; Bronx NY USA
| | - Dawn C. Buse
- Department of Neurology; Albert Einstein College of Medicine; Bronx NY USA
- Montefiore Headache Center; Bronx NY USA
| | - C. Mark Sollars
- Department of Neurology; Albert Einstein College of Medicine; Bronx NY USA
- Montefiore Headache Center; Bronx NY USA
| | - Sheryl Haut
- Department of Neurology; Albert Einstein College of Medicine; Bronx NY USA
- Montefiore Headache Center; Bronx NY USA
| | - Richard B. Lipton
- Department of Neurology; Albert Einstein College of Medicine; Bronx NY USA
- Department of Epidemiology and Population Health; Albert Einstein College of Medicine; Bronx NY USA
- Montefiore Headache Center; Bronx NY USA
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Pharmacological Acute Migraine Treatment Strategies: Choosing the Right Drug for a Specific Patient. Can J Neurol Sci 2014. [DOI: 10.1017/s0317167100017844] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Abstract
OBJECTIVE The objective was to determine, through a literature review, whether treatment during the premonitory phase of migraine is a potentially useful migraine management strategy. METHODS A general literature review was done with regard to the nature of migraine premonitory symptoms, their frequency, their reliability in predicting migraine attacks, and the effectiveness of medication treatment when given during the premonitory phase. RESULTS Many different symptoms have been reported as premonitory symptoms that occur before migraine attacks. Up to 87% of patients with migraine may experience premonitory symptoms, although some studies have provided estimates as low as 33%. In selected patients, premonitory symptoms may be relatively reliable predictors of a migraine attack to follow. Both naratriptan (open-label study) and domperidone (double-blind, randomized, placebo-controlled study) have been reported to be effective when given during the premonitory phase. CONCLUSIONS More research is needed, but there is some evidence that medication treatment during the premonitory phase has the potential to be helpful in selected patients with migraine.
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Affiliation(s)
- Werner J Becker
- Division of Neurology, University of Calgary and Alberta Health Services, Canada
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Delestras S, Roustit M, Bedouch P, Minoves M, Dobremez V, Mazet R, Lehmann A, Baudrant M, Allenet B. Comparison between two generic questionnaires to assess satisfaction with medication in chronic diseases. PLoS One 2013; 8:e56247. [PMID: 23437104 PMCID: PMC3577836 DOI: 10.1371/journal.pone.0056247] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Accepted: 01/07/2013] [Indexed: 11/19/2022] Open
Abstract
Objective The objective of this work was to compare two generic questionnaires assessing patients’ satisfaction with medication. In addition we tested whether satisfaction can predict adherence to medication regimens in patients with chronic diseases, and which dimensions of satisfaction are most involved. Methods This prospective, observational study was conducted over one year in a heterogeneous population of patients with various chronic diseases. Satisfaction with medication was assessed by using the TSQM® vII and the SatMed-Q® questionnaires, and adherence to treatment was assessed with the Morisky-Green questionnaire. Clinical pharmacists interviewed patients to collect clinical, demographic and therapeutic data. Results 190 patients were enrolled. Both questionnaires showed excellent reliability and correlation was high (R = 0.70; p<0.001). Adherence was correlated with satisfaction with medication whether assessed with the SatMed-Q® (R = 0.23; p = 0.002) or the TSQM® (R = 0.17; p = 0.02). Among different dimensions of satisfaction, convenience of use and side effects are prominent predictors of adherence. Conclusion Adherence is related to the patient’s satisfaction with medication whether assessed with the TSQM® vII or the SatMed-Q®. Therefore, these simple questionnaires could be used as predictive tools to identify patients whos’ adherence needs to be improved.
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Affiliation(s)
- Stéphanie Delestras
- Department of Pharmacy, Grenoble University Hospital, Grenoble, France
- TIMC UMR CNRS 5525, Grenoble, France
| | - Matthieu Roustit
- Clinical Research Centre, Inserm CIC003, Grenoble University Hospital, Grenoble, France
- Joseph Fourier University, Grenoble, France
- * E-mail:
| | - Pierrick Bedouch
- Department of Pharmacy, Grenoble University Hospital, Grenoble, France
- TIMC UMR CNRS 5525, Grenoble, France
- Joseph Fourier University, Grenoble, France
| | - Mélanie Minoves
- Department of Pharmacy, Grenoble University Hospital, Grenoble, France
| | - Valérie Dobremez
- Department of Pharmacy, Grenoble University Hospital, Grenoble, France
| | - Roseline Mazet
- Department of Pharmacy, Grenoble University Hospital, Grenoble, France
| | - Audrey Lehmann
- Department of Pharmacy, Grenoble University Hospital, Grenoble, France
| | - Magalie Baudrant
- Department of Pharmacy, Grenoble University Hospital, Grenoble, France
- TIMC UMR CNRS 5525, Grenoble, France
| | - Benoît Allenet
- Department of Pharmacy, Grenoble University Hospital, Grenoble, France
- TIMC UMR CNRS 5525, Grenoble, France
- Joseph Fourier University, Grenoble, France
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Marcus DA, Bhowmick A. Survey of migraine sufferers with dogs to evaluate for canine migraine-alerting behaviors. J Altern Complement Med 2012; 19:501-8. [PMID: 23210467 DOI: 10.1089/acm.2012.0234] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Anecdotal reports suggest that changes in dog behavior might be used to predict impending migraine episodes. This survey was designed to investigate how companion dogs react to migraines that occur in their owners. DESIGN Online survey was available from January 4-31, 2012. SETTINGS/LOCATION Survey was conducted through SurveyMonkey, with links to the survey posted at Migraine.com and promoted through social media. SUBJECTS Adults ≥18 years old who experience migraine episodes and live with a dog were eligible to participate. INTERVENTIONS AND OUTCOME MEASURES Participants completed an 18-question online survey that asked about participant demographics, migraines, and their dog's behavior before or during migraine episodes. RESULTS The survey was completed by 1029 adult migraineurs (94.9% women), with migraines typically occurring ≤8 days per month in 63.4% of participants. A recognized change in the dog's behavior prior to or during the initial phase of migraine was endorsed by 552 participants (53.7%), most commonly unusual attentiveness to the owner (39.9%). Among the 466 participants providing details about their dog's behavior with their migraines, 57.3% were able to identify dog alerting behavior before symptoms of a migraine attack would typically begin, with changes usually noticed within 2 hours before the onset of initial migraine symptoms. The dog's behavior was considered to be often or usually linked with the development of a migraine for 59.2% of migraineurs, and 35.8% of migraineurs endorsed beginning migraine treatments after the dog's behavior was recognized and before migraine symptoms had started. Participant demographics, migraine frequency, and breed of dog in the home were similar between the 470 participants with no alerting behavior endorsed and the 466 participants providing detailed alerting information. CONCLUSIONS About one in four migraineurs living with a companion dog endorsed recognizing a change in their dog's behavior before recognizing initial symptoms of a migraine attack.
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Affiliation(s)
- Dawn A Marcus
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
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Cady RK, Voirin J, Farmer K, Browning R, Beach ME, Tarrasch J. Two center, randomized pilot study of migraine prophylaxis comparing paradigms using pre-emptive frovatriptan or daily topiramate: research and clinical implications. Headache 2011; 52:749-64. [PMID: 22188311 DOI: 10.1111/j.1526-4610.2011.02054.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To compare the efficacy and clinical benefit of 2 paradigms of migraine prevention using pre-emptive frovatriptan and daily topiramate. The study compares the paradigms of pre-emptive use of frovatriptan, a drug approved for acute migraine, and the daily use of topiramate, a Federal Drug Administration-approved and -accepted standard for migraine prophylaxis. BACKGROUND Traditionally, preventive treatment of migraine required daily medication. However, recent studies suggest that pre-emptive prophylaxis may be beneficial to those migraineurs who can predict an attack of migraine based on premonitory symptoms and treat during that phase. METHODS A total of 76 adult subjects with a diagnosis of migraine were screened for the study. During a 1-month baseline period, subjects demonstrated through a daily diary that they predicted at least 50% of migraine attacks during the premonitory phase and treated with their usual medication. Of these, 55 were randomized to either Group A (daily topiramate) or Group B (frovatriptan during premonitory symptoms); 44 completed the study. The treatment period lasted 2 months. The subjects answered the Migraine-Specific Quality of Life Questionnaire at randomization, and at Weeks 4 and 8. The revised Patient Perception of Migraine Questionnaire was answered 24 hours after taking frovatriptan (Group A, for break-through headaches; Group B, treatment during premonitory symptoms). RESULTS The number of migraine attacks and headache days per month decreased significantly from baseline for both Groups A and B. Subjects in Group A had considerably more adverse events leading to study withdrawal than in Group B (18% vs 4%). Though this study was not powered to directly compare the efficacy of the 2 drugs, topiramate showed superiority over frovatriptan at Month 2 in reduction of headache days, which was a secondary end point in the study (P = .036). CONCLUSIONS This pilot study demonstrated that statistical benefit for reduction of headache days over baseline for both pre-emptive frovatriptan and daily topiramate. Subjects utilizing pre-emptive frovatriptan experienced fewer adverse events leading to study withdrawal. Subjects utilizing daily topiramate had fewer headache days at Month 2.
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Affiliation(s)
- Roger K Cady
- Headache Care Center, 3805 S. Kansas Expressway, Springfield, MO 65807, USA.
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Affiliation(s)
- Michael A Moskowitz
- Stroke and Neurovascular Regulation Laboratory, Departments of Radiology and Neurology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA 02129, USA.
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Cuvellier JC, Mars A, Vallée L. The Prevalence of Premonitory Symptoms in Paediatric Migraine: A Questionnaire Study in 103 Children and Adolescents. Cephalalgia 2009; 29:1197-201. [DOI: 10.1111/j.1468-2982.2009.01854.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The prevalence and characterization of premonitory symptoms have not been rigorously studied in children and adolescents. Using a questionnaire, we retrospectively studied the prevalence of 15 predefined premonitory symptoms in a clinic-based population. In 103 children and adolescents fulfilling the International Classification of Headache Disorders, 2nd edn criteria for paediatric migraine, at least one premonitory symptom was reported by 69 (67%). The most frequently reported premonitory symptoms were face changes, fatigue and irritability. The mean number of premonitory symptoms reported per subject was 1.8 (median 2.2). Age, migraine subtype (with or without aura) and mean attack frequency per month had no effect on the mean number of premonitory symptoms reported per subject. In conclusion, premonitory symptoms are frequently reported by children and adolescents with migraine. Face changes seem to be a premonitory symptom peculiar to paediatric migraine.
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Affiliation(s)
- J-C Cuvellier
- Division of Paediatric Neurology, Department of Paediatrics, Lille Faculty of Medicine and Children's Hospital, Lille, France
| | - A Mars
- Division of Paediatric Neurology, Department of Paediatrics, Lille Faculty of Medicine and Children's Hospital, Lille, France
| | - L Vallée
- Division of Paediatric Neurology, Department of Paediatrics, Lille Faculty of Medicine and Children's Hospital, Lille, France
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Cady RK, Martin VT, Géraud G, Rodgers A, Zhang Y, Ho AP, Hustad CM, Ho TW, Connor KM, Ramsey KE. Rizatriptan 10-mg ODT for Early Treatment of Migraine and Impact of Migraine Education on Treatment Response. Headache 2009; 49:687-96. [DOI: 10.1111/j.1526-4610.2009.01412.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Buzzi MG. Triptan efficacy in migraine attacks: from appropriate diagnosis to metabolic profiles and pharmacogenomics. Drug Dev Res 2007. [DOI: 10.1002/ddr.20197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Dowson AJ, Mathew NT, Pascual J. Review of clinical trials using early acute intervention with oral triptans for migraine management. Int J Clin Pract 2006; 60:698-706. [PMID: 16805756 DOI: 10.1111/j.1742-1241.2006.00981.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Most of the data on triptan use are from clinical trials in which patients were instructed to wait until migraine headache pain was moderate/severe in intensity. In the real world, patients may hesitate to use a triptan until headache pain is moderate/severe because of the cost of these agents or limited supply allowed by their health service organisation. However, accumulating data indicate that early intervention with an oral triptan when headache pain is still mild may be the most effective acute treatment strategy. Economic analyses also support early triptan intervention in migraine attacks. Tolerability is expected to be particularly important in early intervention, as patients treating mild migraine pain may be more reluctant to risk adverse events. Thus, an agent selected for use as early intervention should have both a demonstrated efficacy in treating mild migraine headache and placebo-like tolerability. This article reviews retrospective and prospective clinical trials which investigated the use of triptans for early acute migraine therapy.
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Affiliation(s)
- A J Dowson
- King's Headache Services, King's College Hospital, London, UK.
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Abstract
The basic CNS neuropharmacology of naratriptan is reviewed here. Naratriptan is a second-generation triptan antimigraine drug, developed at a time when CNS activity was thought not to be relevant to its therapeutic effect in migraine. It was, however, developed to be a more lipid-soluble, more readily absorbed and less readily metabolized variant on preexisting triptans and these variations conferred on it a higher CNS profile. Naratriptan is a 5-HT(1B/1D) receptor agonist with a highly selective action on migraine pain and nausea, without significant effect on other pain or even other trigeminal pain. Probable sites of therapeutic action of naratriptan include any or all of: the cranial vasculature; the peripheral terminations of trigeminovascular sensory nerves; the first-order synapses of the trigeminovascular sensory system; the descending pain control system; and the nuclei of the thalamus. Naratriptan may prevent painful dilatation of intracranial vessels or reverse such painful dilatation. Naratriptan can prevent the release of sensory peptides and inhibit painful neurogenic vasodilatation of intracranial blood vessels. At the first order synapse of the trigeminal sensory system, naratriptan can selectively suppress neurotransmission from sensory fibers from dural and vascular tissue, while sparing transmission from other trigeminal fibers, probably through inhibition of neuropeptide transmitter release. In the periaqueductal gray matter and in the nucleus raphe magnus, naratriptan selectively activates inhibitory neurons which project to the trigeminal nucleus and spinal cord and which exert inhibitory influences on trigeminovascular sensory input. Naratriptan has also a therapeutic effect on the nausea of migraine, possibly exerting its action at the level of the nucleus tractus solitarius via the same mechanisms by which it inhibits trigeminovascular nociceptive input. The incidence of naratriptan-induced adverse effects in the CNS is low and it is not an analgesic for pain other than that of vascular headache. In patients receiving selective serotonin uptake inhibitors (SSRIs) naratriptan may cause serotonin syndrome-like behavioral side effects. The mechanism of action involved in the production of behavioral and other CNS side effects of naratriptan is unknown.
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Affiliation(s)
- Geoffrey A Lambert
- Institute of Neurological Sciences, The Prince of Wales Hospital, Randwick NSW 2031, Australia.
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Kaniecki R. Intercepting migraine: Results of early therapy with nonspecific and migraine-specific agents. Curr Treat Options Neurol 2006; 8:3-10. [PMID: 16343356 DOI: 10.1007/s11940-996-0019-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Migraine is a pervasive neurologic disorder characterized by recurrent attacks of disabling headache. Despite significant morbidity with impact that may be physical, emotional, social, and economic, treatment of these attacks is often delayed. Patients frequently delay therapy until the more severe or "textbook" symptoms arise, often mistaking the earliest stages as representative of "tension" or "sinus" headaches. Clinicians may recommend deferral of treatment until the more severe levels of pain are seen, perhaps in a misguided attempt to conserve pharmaceutical resources. Patients and clinicians seem more comfortable with perspectives of "being sure it's a migraine" and "not wasting the medication on milder headaches." Therefore, patients and clinicians must learn the latest lessons in migraine: 1) mild migraine usually progresses to more severe levels if left untreated, 2) early treatment is more effective than delayed treatment, 3) early treatment may result in lower rates of adverse events and headache recurrence, and 4) early treatment is cost effective. As clinicians advocate the early treatment of migraine in its mild phase, evidence to support this recommendation has finally become available. I educate my migraineurs to consider each typical headache to be a version of migraine. Most patients with migraine will experience "little" headaches that they often mislabel as tension, sinus, regular, stress, or normal headaches. Instead of these terms, I have them consider their attacks as "small migraines" and "big migraines," with the smaller headaches often evolving into the bigger episodes. Given such a foundation, I advise them to treat at the beginning of the headache, perhaps earlier than they would have previously identified it as a migraine. They must capture the attack while it "whispers migraine" instead of delaying until the attack "shouts migraine." Early treatment of migraine is successful for most patients. However, there are situations in which treatment of the mild phase is not advisable or possible. In patients with frequent or daily migraine, treatment must be reserved for the most disabling attacks. We must advise treatment as soon as the migraine becomes moderate to severe. Certain patients, or certain headaches in some patients, may not progress through a mild phase, perhaps because of rapid escalation or because migraine is already severe upon awakening. Here we encourage migraineurs to treat as soon as possible, often with parenteral formulations of medication. The reaction of the patient (speed of dosing) and the action of the medication (speed of onset of the drug) will ultimately play roles in the successful interception of each attack.
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Affiliation(s)
- Robert Kaniecki
- The Headache Center at University of Pittsburgh, 120 Lytton Avenue, Suite 300, Pittsburgh, PA 15213, USA.
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Cady R, Schreiber C. Frovatriptan: clinical review and future directions. FUTURE NEUROLOGY 2006. [DOI: 10.2217/14796708.1.1.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Triptan medications are selective serotonin receptor (5-HT1B/D) agonists approved for the treatment of acute migraine attacks. Among the currently available triptans, frovatriptan is unique with a long half-life (~26 h), metabolism by multiple pathways and a low side-effect profile. Clinical trial data demonstrates efficacy for frovatriptan across multiple doses, with the 2.5 mg dose selected for lower side effects. Frovatriptan is approved for use in the conventional treatment of an ongoing migraine attack, as are the other currently available triptan medications. The long half-life of frovatriptan has led to the initiation of studies of frovatriptan for the short-term prevention of menstrually related migraine attacks, during which patients are often difficult to treat. This newly investigated treatment approach for patients with predictable menstrually related migraine may, in the future, lead to treatment paradigms that benefit those patients with migraine attacks that are difficult to manage.
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Evans RW, Seifert T, Mathew NT. Are Triptans Effective and Safe When Taken During the Aura Phase of Migraine? Headache 2005; 45:601-3. [PMID: 15953281 DOI: 10.1111/j.1526-4610.2005.05116.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
The optimal acute treatment of migraine requires recognition of the multitude of migraine presentations, the frequency of total attacks, and number of days of headache disability. These initial diagnostic steps are initiated in the waiting room, but phase-specific and stratified treatment selection requires having mutual understanding, trust, and belief through extensive discussion. The imperative acute treatment goal must be to treat early, but not too often, a fact represented by a 75% or better occurrence of pain freedom at 2 hours with two or fewer drug doses averaging 2 or fewer days a week. Migraine-specific therapy best wins the race against time and allodynia. Employing this formulary, multiple triptan formulations and phase and stratified patient-centered therapy creates success.
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Affiliation(s)
- Frederick R Taylor
- Headache Clinic and Research Center, Park Nicollet Health Services, 6490 Excelsior Boulevard, Minneapolis, MN 55426, USA.
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Abstract
OBJECTIVES This study of premonitory symptoms in migraine was performed to document the frequency, duration, and types of symptoms in a large group of migraine patients. BACKGROUND Prodrome importance continues to be debated. Intervention early in the migraine attack is assuming more importance and necessitates better knowledge of the prodrome. METHODS A total of 893 migraine patients (IHS 1.1-1.7) were evaluated at first visit. Prodrome frequency, duration, and characteristics were analyzed in the total migraine population IHS 1.1-1.7 and IHS 1.1-1.6 migraine. RESULTS A total of 32.9% of IHS migraine 1.1-1.6 patients reported prodrome symptoms with an average of 9.42 hours. IHS 1.1-1.7 migraine reported 29.7% and 6.8 hours, respectively. The most commonest symptoms were tiredness, mood change, and gastrointestinal symptoms; all three of these symptoms were present together in 17% of the patients with prodrome. The duration of prodrome was less than 1 hour in 45.1%, 1-2 hours in 13.6%, 2-4 hours in 15.0%, 4-12 hours in 13.1%, and greater than 12 hours in 13.2%. IHS 1.1-1.7 patients showed similar findings. IHS 1.1-1.6 patients with prodrome differed from patients without prodrome in having more triggers as a whole (P <.01), more individual triggers including alcohol (P <.01), hormones (P <.01), light (P <.001), not eating (P <.05), perfume (P <.01), stress (P <.01), and weather changes (P <.05), a longer duration of aura (P <.05), longer time between aura and headache (P <.05), more aura with no headache (P <.05), longer time to peak of headache (P <.05), longer time to respond to triptan (P <.05), longer maximum duration of headache (P <.05), and more headache associated nausea (P <.05), more headache associated running of the nose or tearing of the eyes (P <.05), more postdrome syndrome (P <.05), and longer duration of postdrome syndrome (P <.001). CONCLUSIONS This study provides a portrait of prodrome in a large cohort of patients. It highlights differences between patients with prodrome and patients not having prodrome, and it draws attention to the potential of preventing the headache phase of the acute migraine attack.
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Abstract
The triptans represent a relatively new class of compounds effective in the treatment of migraine. The safety and tolerability of these drugs have been extensively investigated since the first triptan (sumatriptan) became commercially available. A report on a very large population of patients tested during clinical trials and in postmarketing studies, confirms that these drugs are safe and well tolerated when correctly used. Adverse events are frequently reported, but are usually mild and only a few patients discontinue therapy because of them. These adverse events include, in particular, the so-called 'triptan symptoms' (tingling, sensation of warmth, etc.). The exact mechanism of chest symptoms reported by 20% of patients with migraine treated with triptans remains unclear, but are exceptionally related to a cardiac mechanism. CNS adverse events (i.e. somnolence) are also reported, but it is a matter of debate whether they are related to the pharmacological properties (i.e. lipophilicity) of the drug or are symptoms of the disease itself. The potential risk for drug overuse must be taken into account when the triptans are given to patients with a high frequency of migraine attacks. Clinical interaction of triptans with other drugs metabolised in the liver may theoretically influence the incidence of adverse events, but there is little evidence to support this assumption. There is no evidence of a teratogenic risk of triptans in pregnant women taking these drugs.
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Affiliation(s)
- Giuseppe Nappi
- University Centre for Adaptive Disorders and Headache, IRCCS C. Mondino Foundation, University of Pavia, Italy.
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Abstract
OBJECTIVE To analyze the cost-effectiveness of antiepileptics in migraine prophylaxis. METHODS A cost-effectiveness analysis was performed using efficacy data from three recent, double-blind, placebo-controlled, clinical trials of antiepileptic drugs studied for migraine prevention and cost data. Two measures of cost-effectiveness were used: cost per headache prevented and the cost-equivalent number. RESULTS In the double-blind, placebo-controlled, clinical trials evaluated, three antiepileptic drugs were shown to be effective in migraine prevention. All three antiepileptic drugs had high costs per migraine reduced. Gabapentin was the most costly at dollars 138.00 per migraine prevented, whereas the cost per migraine prevented with topiramate was US dollars 114.80 and with divalproex sodium was US dollars 48.00. For migraine prevention divalproex sodium became cost-effective with 10 migraines per month, whereas gabapentin and topiramate required considerably more migraines per month to be cost-effective. CONCLUSIONS Antiepileptic drugs have proven effectiveness in migraine prophylaxis. However, in patients responsive to their acute care medications, the antiepileptic drugs are only cost-effective for those patients with a high frequency of migraines and those with comorbid diseases. Future studies should be done with antiepileptic drugs in patients exhibiting a migraine frequency of 10 or more headaches per month.
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Affiliation(s)
- James U Adelman
- Headache Wellness Center, Greensboro, North Carolina, 27401, USA.
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Phillips LJ, Leicester SB, O'Dwyer LE, Francey SM, Koutsogiannis J, Abdel-Baki A, Kelly D, Jones S, Vay C, Yung AR, McGorry PD. The PACE Clinic: identification and management of young people at "ultra" high risk of psychosis. J Psychiatr Pract 2002; 8:255-69. [PMID: 15985888 DOI: 10.1097/00131746-200209000-00002] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Over the past decade, both clinical and research interest in the early stages of psychotic disorders has grown. This has been associated with research suggesting that early intervention in these disorders may limit their impact on the life of the affected individual and his or her family. It has also been recognized that the biological and psychological changes underpinning the development of psychotic disorders may already be active in the prepsychotic or prodromal phase. It has been suggested that efforts to prevent psychotic disorders should be focused on this phase of emerging illness. In this article, the authors review work conducted at the PACE Clinic in Melbourne, Australia since 1994. This clinical research program was established to develop strategies for identifying young people at high risk for developing a psychotic disorder within a short period. The program has also investigated biological and psychological processes thought to underlie the development of psychosis and evaluated potential preventive interventions.
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Affiliation(s)
- R Cady
- Headache Care Centre, Primary Care Network, Springfield, MO, USA
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