Continuous intravenous dihydroergotamine in the treatment of intractable headache

Acute Migraine Treatment

PURPOSE OF REVIEW

Migraine is a disabling disease of attacks of moderate to severe pain with associated symptoms. Every person with migraine requires treatment for acute attacks. Treatments can range from behavioral management and nonspecific medications to migraine-specific medications and neuromodulation. For many with migraine, having a combination of tools allows for effective treatment of all types of attacks.

RECENT FINDINGS

Over the past several years, four neuromodulation devices have been cleared by the US Food and Drug Administration (FDA) for treatment of acute migraine, and three medications with novel mechanisms of action have been FDA approved. They add to the arsenal available to people with migraine and focus on migraine-specific pathways to allow for precise care with fewer side effects.

SUMMARY

This article discusses acute migraine therapy, focusing on best-level evidence.

Preoperative Management of Opioid and Nonopioid Analgesics: Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement

There is a lack of guidelines for preoperative dosing of opioid and nonopioid pain medications for surgical patients, which can lead to suboptimal preoperative pain control. The Society for Perioperative Assessment and Quality Improvement identified preoperative dosing of opioid and nonopioid analgesics as an area in which consensus could improve patient care. The aim of this guideline is to provide consensus that will allow perioperative physicians to make optimal recommendations regarding preoperative pain medication dosing. Six categories of pain medications were identified: opioid agonists, opioid antagonists, opioid agonist-antagonists, acetaminophen, muscle relaxants, and triptans/headache medications. We then used a Delphi survey technique to develop consensus recommendations for preoperative dosing of individual medications in each of these groups.

Inpatient Management of Migraine

Migraine is a frequently disabling neurologic condition which can be complicated by medication overuse headache and comorbid medical disorders, including obesity, anxiety and depression. Although most migraine management takes place in outpatient clinics, inpatient treatment is indicated for migraine refractory to multiple outpatient treatments, with intractable nausea or vomiting, need for detoxification from medication overuse (such as opioids and barbiturates), and significant medical and psychiatric disease. The goals of inpatient treatment include breaking the current cycle of headache pain, reducing the frequency and/or severity of future attacks, monitored detoxification of overused medications, and reducing disability and improving quality of life.

Emergency Department and Inpatient Management of Headache in Adults

PURPOSE OF REVIEW

This article reviews treatment options for patients presenting with headache in the emergency department (ED) and for inpatients, including red flags and status migrainosus (SM).

RECENT FINDINGS

Most patients presenting with headache in the ED will have migraine, but red flags must be reviewed to rule out secondary headaches. SM refractory to home treatment is a common reason for ED presentation or inpatient admission, but high-quality treatment evidence is lacking. Common treatments include intravenous fluids, anti-dopaminergic agents with diphenhydramine, steroids, divalproex, nonsteroidal anti-inflammatory drugs, intravenous dihydroergotamine, and nerve blocks. Other therapies (e.g., ketamine and lidocaine) are used with limited or inconsistent evidence. There is evidence for inpatient behavioral management therapy. This article details red flags to review in the workup of headache presentation in the ED and provides a step-wise approach to ED and inpatient management. However, more studies are needed to better optimize care.

Dihydroergotamine (DHE) - Then and Now: A Narrative Review

OBJECTIVE

To provide a narrative review of clinical development programs for non-oral, non-injectable formulations of dihydroergotamine (DHE) for the treatment of migraine.

BACKGROUND

Dihydroergotamine was one of the first "synthetic drugs" developed in the 20th century for treating migraine. It is effective and recommended for acute migraine treatment. Since oral DHE is extensively metabolized, it must be given by a non-oral route. Intravenous DHE requires healthcare personnel to administer, subcutaneous/intramuscular injection is challenging to self-administer, and the approved nasal spray formulation exhibits low bioavailability and high variability that limits its efficacy. Currently there are several attempts underway to develop non-oral, non-injected formulations of DHE.

METHOD

A systematic search of MEDLINE/PubMed and ClinicalTrials.gov databases, then narrative review of identified reports, focusing on those published in the last 10 years.

RESULTS

Of 1881 references to DHE from a MEDLINE/PubMed search, 164 were from the last 10 years and were the focus of this review. Further cross reference was made to ClinicalTrials.gov for 19 clinical studies, of which some results have not yet been published, or are studies that are currently underway. Three nasal DHE products are in clinical development, reawakening interest in this route of delivery for migraine. Other routes of DHE administration have been, or are being, explored.

CONCLUSION

There is renewed appreciation for DHE and the need for non-oral, non-injected delivery is now being addressed.

Is the Generally Held View That Intravenous Dihydroergotamine Is Effective in Migraine Based on Wrong "General Consensus" of One Trial? A Critical Review of the Trial and Subsequent Quotations

BACKGROUND

The claim that parenteral dihydroergotamine (DHE) is effective in migraine is based on one randomized, placebo-controlled, crossover trial from 1986. The aim of this review was to critically evaluate the original article. It was also found to be of interest to review quotes concerning the results in the more than 100 articles subsequently referring to the article.

METHODS

The correctness of the stated effect of intravenous DHE in the randomized clinical trial (RCT) was first critically evaluated. Then, Google Scholar was searched for references to the article and these references were classified as to whether they judged the reported RCT as positive or negative.

RESULTS

The design of the RCT, with a crossover within one migraine attack, only allows evaluation of the results for the first period and the effect of DHE and placebo were quite comparable. About 151 references were found for the article in Google scholar. Among the 95 articles with a judgment on the efficacy of intravenous DHE in the RCT, 90 stated that DHE was effective or likely effective whereas only 5 articles stated that DHE was ineffective.

CONCLUSIONS

Despite a "negative" RCT, authors of subsequent articles on the efficacy of parenteral DHE overwhelmingly reported this RCT as "positive." This is probably due to the fact that the authors concluded in the abstract that DHE is effective, and to a kind of "wrong general consensus."

Management of Primary Headache in the Emergency Department and Inpatient Headache Unit

Migraine is a chronic disorder with debilitating exacerbations throughout the lifetime of migraineurs. Children and adolescents are significantly affected. The prevalence of migraine in this age group is higher than predicted in the last decade. Fortunately, this chronic disease is getting more attention and recognition, and better treatments are now being offered to these patients. Different medications are available, mostly for the outpatient management of an attack and include the use of over-the-counter anti-inflammatory medications as well as prescribed medications like the triptans group. These therapies do sometime fail and the exacerbations can last days to weeks. Early aggressive intravenous treatment can be very effective in breaking the attack and allowing the child to be functional faster and sometimes may prevent chronification of an attack.

Update of Inpatient Treatment for Refractory Chronic Daily Headache

Chronic daily headache (CDH) is a group of headache disorders, in which headaches occur daily or near-daily (>15 days per month) and last for more than 3 months. Important CDH subtypes include chronic migraine, chronic tension-type headache, hemicrania continua, and new daily persistent headache. Other headaches with shorter durations (<4 h/day) are usually not included in CDH. Common comorbidities of CDH are medication overuse headache and various psychiatric disorders, such as depression and anxiety. Indications of inpatient treatment for CDH patients include poor responses to outpatient management, need for detoxification for overuse of specific medications (particularly opioids and barbiturates), and severe psychiatric comorbidities. Inpatient treatment usually involves stopping acute pain, preventing future attacks, and detoxifying medication overuse if present. Multidisciplinary integrated care that includes medical staff from different disciplines (e.g., psychiatry, clinical psychology, and physical therapy) has been recommended. The outcomes of inpatient treatment are satisfactory in terms of decreasing headache intensity or frequency, withdrawal from medication overuse, reducing disability, and improving life quality, although long-term relapse is not uncommon. In conclusion, inpatient treatment may be useful for select patients with refractory CDH and should be incorporated in a holistic headache care program.

Medication overuse headache: history, features, prevention and management strategies

Medication overuse headache (MOH) is a daily, or almost daily, headache form that arises from overuse of one or more classes of migraine-abortive or analgesic medication. The main classes of drugs that cause MOH are opioids, butalbital-containing mixed analgesics, triptans, ergotamine tartrate derivatives, simple analgesics (except for plain aspirin), and perhaps non-steroidal anti-inflammatory drugs. MOH can be debilitating and results from biochemical and functional brain changes induced by certain medications taken too frequently. At this time, migraine and other primary headache disorders in which migraine or migraine-like elements occur seem exclusively vulnerable to the development of MOH. Other primary headache disorders are not currently believed to be vulnerable. The treatment of MOH consists of discontinuation of the offending drug(s), acute treatment of the withdrawal symptoms and escalating pain, establishing a preventive treatment when necessary, and the implementation of educational and behavioral programs to prevent recidivism. In most patients, MOH can be treated in the outpatient setting but, for the most difficult cases, including those with opioid or butalbital overuse, or in patients with serious medical or behavioral disturbances, effective treatment requires a multidisciplinary, comprehensive headache program, either day-hospital with infusion or an inpatient hospital setting.

DHE repression of ATP-mediated sensitization of trigeminal ganglion neurons

OBJECTIVE

To investigate the mechanism by which adenosine triphosphate (ATP) causes sensitization of trigeminal neurons and how dihydroergotamine (DHE) represses this modulatory effect.

BACKGROUND

Dihydroergotamine is an effective treatment of migraine. The cellular mechanisms of action of DHE in treating migraine attacks remain unclear.

METHODS

In this study, neonatal rat trigeminal ganglia cultures were used to investigate effects of ATP, alpha, beta-methyl ATP (α,β-meATP), and DHE on intracellular calcium levels and calcitonin gene-related peptide (CGRP) secretion.

RESULTS

Pretreatment with ATP or α,β-meATP caused sensitization of neurons, via P2X(3) receptors, such that a subthreshold amount of potassium chloride (KCl) significantly increased intracellular calcium levels and CGRP secretion. Pretreatment with DHE repressed increases in calcium and CGRP secretion in response to ATP-KCl or α,β-meATP-KCl treatment. Importantly, these inhibitory effects of DHE were blocked with an α(2) -adrenoceptor antagonist and unaffected by a 5HT(1B/D) receptor antagonist. DHE also decreased neuronal membrane expression of the P2X(3) receptor.

CONCLUSIONS

Our findings provide evidence for a novel mechanism of action for DHE that involves blocking ATP-mediated sensitization of trigeminal neurons, repressing stimulated CGRP release, and decreasing P2X(3) membrane expression via activation of α(2) -adrenoceptors.

Chronic daily headaches

Chronic Daily Headache is a descriptive term that includes disorders with headaches on more days than not and affects 4% of the general population. The condition has a debilitating effect on individuals and society through direct cost to healthcare and indirectly to the economy in general. To successfully manage chronic daily headache syndromes it is important to exclude secondary causes with comprehensive history and relevant investigations; identify risk factors that predict its development and recognise its sub-types to appropriately manage the condition. Chronic migraine, chronic tension-type headache, new daily persistent headache and medication overuse headache accounts for the vast majority of chronic daily headaches. The scope of this article is to review the primary headache disorders. Secondary headaches are not discussed except medication overuse headache that often accompanies primary headache disorders. The article critically reviews the literature on the current understanding of daily headache disorders focusing in particular on recent developments in the treatment of frequent headaches.

Effectiveness of nonnarcotic protocol for the treatment of acute exacerbations of chronic nonmalignant pain

INTRODUCTION

Emergency department (ED) overcrowding is a growing problem. Frequent visits for chronic pain are a significant subset of patients. The use of narcotics in these patients is controversial. The purpose of this study was to test a strict nonnarcotic protocol in reducing need for and number of ED visits for chronic pain while at the same time addressing their pain.

METHODS

This was a prospective observational study. We identified patients with more than 10 ED visits for exacerbations of chronic nonmalignant pain in the last 12 calendar months. Each patient and their physician were sent letters informing them of the concern of frequent ED use and the use of opioids for rescue therapy. Furthermore, the patient would receive medications other than narcotics in subsequent ED visits, and follow-up with the primary physician for alternatives was encouraged. Use of the ED for pain-related visits was then monitored for the subsequent 12-month period. Clinic use and outpatient medication uses were also monitored.

RESULTS

Fifteen patients were identified for the initial study. These patients averaged 19 ED visits per 12 months for pain-related complaints. All of them had a regular physician. After notification of the new protocol, ED visits decreased to an average of 2 visits per year. Visits with primary care physicians also dropped from an average of 19 visits per year to 7 visits. There were 7 patients who had been weaned off narcotic medications, 4 who had been converted to methadone maintenance, and 1 who had been switched to a fentanyl patch.

CONCLUSIONS

Initiation of a strict nonnarcotic protocol for treatment of patients with frequent ED visits for chronic nonmalignant pain results in a significant drop in the number of pain-related visits to the ED. These visits were not offset by a significant elevation in the number of clinic visits for pain complaints, and many were weaned off narcotics. Nonnarcotic protocols for acute exacerbations of chronic nonmalignant pain may be a viable alternative for reducing frequent pain-related ED visits in a select population.

Medication overuse headache

Medication overuse headache may complicate any type of headache and occurs in young people, adults, and even elderly patients. Overuse of acute medications may change intermittent or self-limited headaches into chronic daily headache. Migraineurs seem particularly prone to analgesic rebound headache/ transformed migraine/chronic migraine. Prophylactic therapies are often ineffective in the setting of medication overuse. Recognition of this condition allows appropriate clinical intervention that includes cessation of the offending medications.

Inpatient Treatment of Headache: An Evidence-Based Assessment

OBJECTIVE

To evaluate inpatient treatment of headache in the United States.

PARTICIPANTS

Participants were selected by the meeting chairpersons, Drs. Diamond and Silberstein as well as Dr. Freitag. Criteria for selection included participation in an inpatient treatment program, headache specialists not affiliated with an inpatient treatment program, clinician with interest in headache but not affiliated with a dedicated headache treatment program. The single meeting held in New York was by invitation only. All invitees were provided with opportunity to present their views and participate in the recommendations of the Consortium. The list of participants at the meeting were: Harvey Blumenthal, MD, Roger Cady, MD, James Couch, MD, Seymour Diamond, MD, Frederick G. Freitag, DO, R. Michael Gallagher, DO, Al Lake III, PhD, Richard Lipton, MD, NinanMathew,MD, Alan Rapoport, MD, Jay Rosenberg, MD, Joel Saper, MD, Stephen Silberstein, MD. Funding for theproject was provided by the US Headache Guidelines Consortium Project through the American Academy of Neurology and the National Headache Foundation.

EVIDENCE

Each of the authors were part of the writing committee each with specific areas that they were responsible for conducting the literature reviews and submitting a portion of the original document for editing and review. Dr. Freitag coordinated this process and assembled the first draft of the article for circulation and review among the authors and chairpersons. In the absence of class I evidence consensus expert opinion was fundamental to the process.

CONCLUSIONS

The treatment of headache is commonly delivered in the outpatient office environment. There exists a group of patients who have been refractive to outpatient treatment and in whom in patient care may be appropriate. The factors that determine the optimal treatment setting, the methodology of the treatment and the results of such treatment have come under increasing scrutiny secondary to the cost of treatment in the hospital. The US Headache Consortium guidelines project in conjunction with the national headache foundation believed that the need existed to objectively examine the issues surrounding inpatient treatment. The epidemiology of chronic headache is important to understand in this context since essentially all patients that are treated in hospital have high frequency headache often associated with significant disability. This severity of illness produces both health care costs but also is responsible for significant impact on businesses and the economy. The method of treatment of headache in the hospital environment can follow several paths based on the accessibility of the resources specific to headache treatment. While there exist these differing paths of treatment only treatment in a dedicated headache treatment unit has been investigated in depth here in the US though reports from other countries that do not have dedicated inpatient treatment lends support to options in headache treatment. Some have suggested that inpatient treatment is not required even in recidivist patients and limited reports have examined aggressive outpatient treatment as an option in headache management. None of the studies reported to date provide class one evidence for efficacy either inpatient or outpatient. Recommendations are made to assess headache treatment in patients with high frequency headaches to garner better scientific evidence for differing treatment approaches.

Repetitive intravenous prochlorperazine treatment of patients with refractory chronic daily headache

OBJECTIVES

To investigate the efficacy and long-term outcome of intravenous prochlorperazine for the treatment of refractory chronic daily headache.

BACKGROUND

Unlike dihydroergotamine, the treatment results of intravenous neuroleptics as first-line agents for refractory chronic daily headache have rarely been reported.

METHODS

We retrospectively analyzed the data of inpatients with refractory chronic daily headache who received intravenous repetitive prochlorperazine treatment from November 1996 to March 1999. A semistructured telephone follow-up interview was done in September 1999.

RESULTS

A total of 135 patients (44 men, 91 women) were recruited, including 95 (70%) with analgesic overuse. After intravenous prochlorperazine treatment, 121 (90%) achieved a 50% or greater reduction of headache intensity, including 85 (63%) who became headache-free. The mean hospital stay was 6.2 +/- 2.7 days, and mean total prochlorperazine used was 98 +/- 48 mg. Acute extrapyramidal symptoms occurred in 21 patients (16%). One hundred twenty-four patients (92%) were successfully followed up, with a mean duration of 14.3 +/- 7.5 months. Compared with pretreatment status, 93 patients (75%) considered their headache intensity decreased, and 86 patients (69%) considered their headache frequency decreased, although 40 (32%) still had a daily headache. Of the 87 patients with analgesic overuse who could be followed, 61 (70%) no longer overused analgesics. Poor response to prochlorperazine treatment (relative risk, 1.8) and presence of major depression (relative risk, 1.8) were predictors of persistent chronic daily headache at follow-up.

CONCLUSIONS

Prochlorperazine was effective and safe in the treatment of patients with refractory chronic daily headache with or without analgesic overuse. Compared with dihydroergotamine, prochlorperazine seemed less effective at achieving "freedom from headache" during hospitalization, but had a similar outcome at follow-up.

Prophylactic pharmacological treatment of chronic daily headache

OBJECTIVE

To review all the prophylactic pharmacological treatments for chronic daily headache from the past decade.

BACKGROUND

Chronic daily headache is among the most common diagnoses seen in specialized headache centers. Prior to 1988, there were no criteria for the diagnosis of chronic tension-type headache and chronic daily headache. An expanded chronic daily headache classification has been proposed.

METHODS

A MEDLINE search was performed using the following key words: chronic daily headache, intractable headache, transformed migraine, chronic tension headache, and chronic tension-type headache. We limited our review to those studies published in English in the last decade, including published abstracts and letters to the editor. Double-blind studies carried out prior to 1988 were also included.

RESULTS

Pharmacological treatments for chronic daily headache include antidepressants (tricyclics, tetracyclics, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors), anticonvulsants, muscle relaxants, 5-HT1 agonists, ergots, 5-HT2 antagonists, antianxiety agents, and miscellaneous drugs. Many of these reports are anecdotal, and most are open rather than double-blind studies.

CONCLUSIONS

There is a great variety of pharmacological treatments available for chronic daily headache. Only the antidepressants have been extensively studied. Other medications may be used if these fail. Recommendations based on our experience at the Headache Unit of the Montefiore Medical Center are outlined here.