EFNS guideline on the drug treatment of migraine - report of an EFNS task force

Do antithrombotic drugs have a role in migraine prevention? A systematic review

OBJECTIVES

To explore the available evidence on the role of antithrombotics as migraine preventive medication.

BACKGROUND

In clinical practice, the use of antithrombotic drugs in individuals with migraine is sometimes considered, especially in the case of frequent auras, association with patent foramen ovale, or prothrombotic states. This paper systematically reviews evidence on antithrombotic agents' efficacy for migraine prevention.

METHODS

We performed a systematic literature search on PubMed and Scopus including observational and interventional studies focused on antiplatelets or anticoagulants as preventive treatments for migraine. The search included studies published until June 30th, 2024. Ongoing trials on Clinicaltrials.org were also explored. Quality assessment used the Cochrane Risk of Bias 2 (RoB-2) tool for randomized controlled trials (RCTs) and the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) for observational studies. The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO identifier CRD42024501531).

RESULTS

Out of 1854 records, we found 12 RCTs and 8 observational studies investigating the impact of antithrombotic drugs in migraine prevention. Due to heterogeneity of data, a meta-analysis was not feasible. RCTs tested acetylsalicylic acid (ASA) alone (seven), ASA in combination with other preventive treatments (two), clopidogrel (one), dual antiplatelet treatment (one), and vitamin K antagonists (one). Observational studies tested ASA (three), vitamin K antagonists (three), and clopidogrel (two). No clear evidence of efficacy was found for the overall population of individuals with migraine. Limited evidence from old RCTs-not specifically addressing the role of antithrombotic drugs for migraine prevention-and observational studies showed a potential improvement of migraine with the use of antiplatelet agents, mostly ASA, in special populations, including males, individuals with migraine with aura, and those with patent foramen ovale.

CONCLUSIONS

Evidence supporting the effectiveness of antithrombotic drugs as a preventive treatment for patients with migraine is insufficient. As preliminary data show potential improvements in special populations in whom those agents act indirectly by ameliorating vascular function, RCTs are worth conducting.

Effects of Dietary Interventions in Patients With Migraine: A Systematic Review

CONTEXT

Migraine is a disabling neurological disorder. Diet may be a factor to consider because measures of diet quality have been linked to both frequency and severity of attacks.

OBJECTIVES

To investigate the effects of dietary interventions on the clinical symptoms of migraine, quality of life, and body composition of patients with migraine.

DATA SOURCES

The MEDLINE, Embase, and Web of Sciences databases were searched since database inception to February 13, 2024. We included articles on randomized clinical trials that assessed the effect dietary interventions on clinical symptoms of migraines and the quality of life and body composition of individuals with migraine.

DATA EXTRACTION

Data from the included articles were independently extracted by 2 researchers; another independent reviewer further verified the extractions. The Cochrane risk-of-bias tool was used to evaluate the risk of bias of selected studies, and the Physiotherapy Evidence Database scale was used to assess the methodological quality.

RESULTS

Eight articles were included in this review. Of these, 3 reported on studies that assessed the ketogenic diet (KD), 2 reported on the Dietary Approaches to Stop Hypertension (DASH), and 3 reported on studies of other dietary strategies. Strong evidence exists regarding the effectiveness of the KD and DASH in reducing the frequency of migraine attacks, whereas their efficacy in improving patients' quality of life was supported only by limited evidence. There also is strong evidence regarding the effectiveness of DASH in reducing migraine's severity and patients' body weight. Insufficient evidence was found regarding the effectiveness of the other dietary interventions on all variables.

CONCLUSIONS

The DASH and KD may help reduce migraine frequency and severity. However, more high-quality studies are needed to confirm their effectiveness.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO No. CRD42024516161.

Practice guidelines for the treatment of acute migraine and chronic knee osteoarthritis with paracetamol: an expert appraisal on evolution over time between scientific societies

BACKGROUND

Paracetamol is the commonest analgesic worldwide in primary care. Despite evidence-based recommendations for management of acute and chronic pain with paracetamol, practices seem to vary considerably in its modalities of use, with or without restrictions, between renowned scientific societies and over time.

OBJECTIVE

Qualitative assessment of similarities, differences, and changes over time in guidelines for paracetamol use in acute and chronic pain.

METHODS

We focused on two common pain conditions for which paracetamol is widely used: acute migraine and chronic knee osteoarthritis (OA). In 19 guidelines (10 for acute migraine, 9 for chronic knee OA) from 10 scientific societies (AAN/AHS, ACR/AF, CHS, EFNS, EHF/LTB, ESCEO, EULAR, SFEMC, SRF, OARSI) published between 1997 and 2021, methods, results and conclusions were compared, between guidelines and over time.

RESULTS

In acute migraine, there was a shift from no recommendation for paracetamol or recommendation only for mild attacks to recommendation for mild to moderate attacks in updated guidelines, without restriction for use for four of the five scientific societies. In knee OA, although updated guidelines generally used the GRADE system, recommendations remained heterogeneous between scientific societies: recommendation without or with restrictions, or not recommended. Consensus is lacking regarding long-course safety and efficacy in acute pain and pain at mobilization.

CONCLUSIONS

Most migraine guidelines now recommend paracetamol for mild to moderate pain. Knee OA guidelines vary on the use of paracetamol: a more holistic approach is needed for this condition, considering patient profile, disease stage, and pain management during physical activity to clarify its appropriate use.

Primary headache and migraine in headache specialists – does personal history of doctors matter?

Objective

Migraine is a common disorder affecting more than 10% of the population. The prevalence of migraine among physicians and, in particular, among headache specialists is widely unknown as is the impact of suffering from migraine on the attitudes towards migraine and on treatment recommendations of physicians. We designed a survey among headache specialists and neurologists and compared the results to general pain specialists and general practitioners.

Methods

A standardized interview in randomly selected samples of these four groups of physicians was performed. The interview included data on the prevalence of migraine and other primary headache disorders in the physician groups, self-report on their own treatment, attitudes towards migraine, and treatment recommendations for migraine. The prevalence rates were also compared to an age- and sex-matched German general population sample.

Results

The lifetime prevalence of migraine was higher in headache specialists (53.0%) than in general neurologists (43.0%), pain specialists (21.7%), general practitioners (19.3%), and in the general age- and sex-matched population (16.8%). Cluster headache prevalence was high in neurologists (1.9%) and in headache specialists (1.3%); episodic tension-type headache prevalence was significantly lower in general practitioners (19.5%). One reason, among others, was that being a migraine (or cluster headache) patient more often prompted the sufferers to become a specialist in neurology. Physicians with migraine rated the biopsychosocial concept of lower importance for migraine than did physicians without migraine. The self-treatment of migraine in physicians differs from the treatment recommendations to the patients. For example, only 36.4% of the headache specialists with migraine take triptans whereas 94.4% recommend triptans to their patients.

Conclusions

We conclude that being a headache specialist or a neurologist is associated with an increased migraine or cluster headache prevalence. This personal history of migraine leads to a more somatic view of migraine as a disorder and to different treatment recommendations as compared to self-treatment.

A high-throughput LC-MS/MS method for determination of flunarizine in human plasma: Pharmacokinetic study with different doses

A high-throughput and sensitive liquid chromatography-tandem mass spectrometry (LC-MS/MS) method has been developed and validated for the determination of flunarizine in human plasma. Liquid-liquid extraction under acidic conditions was used to extract flunarizine and flunarizine-d8 from 100 μL human plasma. The mean extraction recovery obtained for flunarizine was 98.85% without compromising the sensitivity of the method. The chromatographic separation was performed on Hypersil Gold C₁₈ (50 × 2.1 mm, 3 μm) column using methanol-10 mm ammonium formate, pH 3.0 (90:10, v/v) as the mobile phase. A tandem mass spectrometer (API-5500) equipped with an electrospray ionization source in the positive ion mode was used for detection of flunarizine. Multiple reaction monitoring was selected for quantitation using the transitions, m/z 405.2 → 203.2 for flunarizine and m/z 413.1 → 203.2 for flunarizine-d8. The validated concentration range was established from 0.10 to 100 ng/mL. The accuracy (96.1-103.1%), intra-batch and inter-batch precision (CV ≤ 5.2%) were satisfactory and the drug was stable in human plasma under all tested conditions. The method was used to evaluate the pharmacokinetics of 5 and 10 mg flunarizine tablet formulation in 24 healthy subjects. The pharmacokinetic parameters C_max and AUC were dose-proportional.

Cognitive impairment in patients with migraine: causes, principles of effective prevention and treatment

Cognitive impairment (CI) is common in patients with migraine; its causes and pathogenesis continue to be discussed. Some authors consider that migraine proper does not lead to decreased cognitive functions, neuroimaging changes in the brain white matter are asymptomatic in migraine; and CI in patients with this condition is caused by comorbidities (depression, anxiety disorder) and/or concurrent cerebrovascular and neurodegenerative diseases. Other authors report the pathogenetic role of migraine in the development of CI and the importance of the frequency of headache attacks and neuroimaging changes in the brain matter in migraine. The paper reviews clinical trials dealing with the prevalence, causes, and pathogenesis of CI in patients with migraine. It sets forth the current principles of prevention and treatment of CI in patients with this condition.

Migraine

Migraine is a chronic paroxysmal neurological disorder characterised by multiphase attacks of head pain and a myriad of neurological symptoms. The underlying genetic and biological underpinnings and neural networks involved are coming sharply into focus. This progress in the fundamental understanding of migraine has led to novel, mechanism-based and disease-specific therapeutics. In this Seminar, the clinical features and neurobiology of migraine are reviewed, evidence to support available treatment options is provided, and emerging drug, device, and biological therapies are discussed.

Headache Outcomes After Coil Embolization in Patients with Unruptured Intracranial Aneurysms: Do They Get Better or Worse? A Prospective Analysis

BACKGROUND

To investigate the association between headache outcomes and coil embolization and to identify potential factors associated with different headache outcomes in patients with unruptured intracranial aneurysms (UIAs) after treatment with coil embolization.

METHODS

A prospective study of patients with planned coil embolization for UIAs was conducted. The changes in headache patterns, headache-related disability, and depression were assessed before coil embolization and at 3 days and 2 and 6 weeks after coil embolization. All variables were analyzed to identify factors associated with different headache outcomes.

RESULTS

Fifty-nine (72%) of 82 patients reported headaches before coil embolization. Of these, improvements in the severity of headaches were reported by 42 patients (71%). In addition to a significant reduction in headache severity, significant reductions in headache-related disability and depression scores also were observed. Demographic factors, aneurysmal characteristics, or procedural factors were not found to be significantly associated with improvement in the severity of headaches after coil embolization. In addition, the number of microemboli on diffusion-weighted imaging was not significantly associated with improvement of headaches after coil embolization. Twenty-three patients reported no headaches before coil embolization, and 3 (13%) patients reported new-onset headaches after coil embolization. All new-onset headaches were mild and dull in nature without combined symptoms in the temporal area.

CONCLUSIONS

Our study suggested that regardless of headache characteristics, the aneurysm size (even those <5 mm in diameter), technique used (stent-assisted or not stent-assisted), and coil embolization of UIAs resulted in headache improvement in most patients with pretreatment headaches.

Economic analysis of acupuncture for migraine prophylaxis

BACKGROUND

Acupuncture has become a viable option for migraine prophylaxis in Europe; however, despite its wide use, more data on the short- and long-term cost-effectiveness are needed when considering the perspectives of a paying third-party, the patient, and of society in general. The aim was to evaluate the cost and effectiveness of adjuvant acupuncture to pharmacologic treatment vs pharmacologic treatment alone in migraine patients after a 3-month acupuncture course and a 6-month follow-up from all perspectives.

METHODS

The study involved an open-label randomized clinical trial of patients receiving acupuncture (n=42), and a waiting list control group (n=44). The number of migraine days during the last 28 days, as well as direct and indirect costs were considered. The trial was registered under DRKS00009803.

RESULTS

The total cost per patient reached €696 vs €285 after 3 months of acupuncture and €66 vs €132 in the acupuncture and control groups after a 6-month follow-up, respectively (P=0.071). The trends observed in effectiveness and costs from all perspectives are discussed.

CONCLUSION

The inclusion of acupuncture in health care results beneficial mainly for its observed trend in reduced losses of productivity and income, with the latter often exceeding the costs of acupuncture treatment. As such, acupuncture may be recommended as an adjuvant treatment in migraine prophylaxis to standard pharmacotherapy.

The effectiveness of aspirin for migraine prophylaxis: a systematic review

CONTEXT AND OBJECTIVE:

Many researchers have suggested that aspirin prevents migraines. However, the evidence is unclear. The aim of this study was to analyze the available evidence on the effect of aspirin as a migraine prophylactic.

DESIGN AND SETTING:

Systematic review, conducted at the Pontifícia Universidade Católica do Paraná, Brazil, and at the University of São Paulo, Brazil.

METHODS:

We performed electronic searches in the databases of MEDLINE/PubMed, Embase, WEB OF SCIENCE, the World Health Organization, CENTRAL and OpenGrey, and we also searched manually for interventional studies published before April 2016 that compared the effects of aspirin with a control, in adults. Two authors independently extracted data on the publication, population recruited, intervention (aspirin dosage, follow-up and combined treatment) and main outcomes (frequency, severity and duration of migraine). We evaluated the quality of the studies using the Cochrane risk-of-bias tool.

RESULTS:

Our search retrieved 1,098 references, of which 8 met the selection criteria for this systematic review. The total population was 28,326 participants (18-64 years old); most (96%) were men. The dosage varied from 50 to 650 mg/day across the studies. The risk of bias was generally low or unclear. The only outcome for which most of the studies included (6/8) reported a significant reduction was frequency of migraine, which was reduced at an aspirin dosage of at least 325 mg/day.

CONCLUSION:

Aspirin can reduce the frequency of migraines. However, the optimal dosage is unclear.

Comorbidity of Migraine and Headache Associated With Sexual Activity

In order to investigate the comorbidity of migraine and headache associated with sexual activity (HSA), we performed a case-control study based on migraine patients. By means of a questionnaire and a personal interview, 100 migraine patients and 100 control subjects were examined regarding a diagnosis of HSA. In five subjects from the migraine group vs. none from the control group, a diagnosis of HSA could be established ( P = 0.021). Previous studies that have demonstrated comorbidity of migraine and HSA were all based on HSA patients. Thus, it can now be concluded that the association between the two headache disorders is bilateral. In addition, the prevalence of HSA in the general population can be estimated to average around at least 0.9%, which concurs with previously published data.

Sumatriptan iontophoretic transdermal system for acute treatment of episodic migraine

Migraine is a common and debilitating condition affecting approximately nearly one in four women in the USA and Europe. Episodic attacks can be associated with a number of symptoms, with nausea and/or vomiting being among the most frequent and distressing. Sumatriptan is widely used for acute treatment of migraine and is available in several formulations. The efficacy of oral sumatriptan is well-established. However, patients who experience migraine-associated nausea and/or vomiting can have difficulty swallowing tablets and may delay taking anti-migraine medication. In addition, absorption of oral sumatriptan can be reduced by migraine-associated gastroparesis. Non-oral formulations of sumatriptan are recommended for patients with nausea and/or vomiting, but their use may be limited by adverse effects and patient acceptance. A new transdermal formulation of sumatriptan has recently become available in the USA for acute treatment of migraine in adults. In this article, we review the properties of the sumatriptan iontophoretic transdermal patch and discuss the evidence to support its use in clinical practice.

Primary Headache Disorders: Focus on Migraine

Migraine is the most common disabling headache disorder.Most patients with disabling tension-type headache are likely to have migraine and accordingly respond to treatments efficacious in migraine.Individuals are genetically predisposed to experiencing recurrent migraine.Evidence supports migraine to be a primarily neural and not vascular mediated disorder.1-2% of the population have chronic daily headache associated with acute-relief medication overuse; the majority are migraineurs.The presence of acute-relief medication overuse renders preventative medication less adequately efficacious.

Introduction to the Guideline, and General Principles of Acute Migraine Management

Objectives:

To provide an overview of the objectives and target population of the guideline, and to review the general principles of acute pharmacological migraine therapy.

Methods:

A general literature review and several consensus groups were used to formulate an expert consensus for the general use of acute migraine medications.

Results:

The objective of the guideline is to assist the physician in choosing an appropriate acute migraine medication for an individual with migraine, and thereby to reduce migraine-related disability. The target population includes adults with episodic migraine (patients with migraine headache < 15 days/month). This guideline is intended primarily for physicians who treat patients with migraine. Other health professionals may also find this guideline helpful. Acute migraine therapy should be considered for the great majority of patients with migraine. A specific acute medication is chosen based on evidence for efficacy, tolerability, migraine attack severity, patient preference, and on the presence of co-existing disorders. General principles of acute migraine therapy include that the response of a patient to any given medication cannot be predicted with certainty, and that treatment early in the attack is generally more effective than treatment later once the migraine attack is fully developed. A suitable treatment approach (stratified or stepped approaches) and drug formulation (injection, tablet, wafer, powdered formulation, or nasal spray) should be chosen based on patient clinical features. Excessively frequent use of acute medications (medication overuse) should be avoided. Two or more acute medications can be combined if necessary.

Conclusions:

This guideline provides evidence-based advice on the use of acute medications for migraine, and should provide useful guidance for acute migraine therapy to both health professionals and patients.

Sex-related differences in migraine

This paper reviews sex-related differences in migraine epidemiology, symptoms, natural history and co-morbid disorders. Migraine is more than twice as common in females as in males, and women experience more frequent, longer lasting and more painful attacks, have more disability and a risk of transition from episodic to chronic migraine greater than men, but the mechanisms behind these differences are still poorly understood. The role of sex hormones, genes, and the differences in brain function and structure are discussed. Finally, we evaluate the many gender-related questions about treatment of migraine in women. In future research data should be analyzed separately for men and women to ensure that differences between the sexes could be identified.

Migraine in pregnancy and lactation

Migraine headache is a significant health problem affecting women more than men. In women, the hormonal fluctuations seen during pregnancy and lactation can affect migraine frequency and magnitude. Understanding the evaluation of headache in pregnancy is important, especially given the increased risk of secondary headache conditions. Pregnancy and lactation can complicate treatment options for women with migraine because of the risk of certain medications to the fetus. This review includes details of the workup and then provides treatment options for migraine during pregnancy and lactation.

A proposed roadmap for inpatient neurology quality indicators

BACKGROUND/PURPOSE

In recent years, there has been increasing pressure to measure and report quality in health care. However, there has been little focus on quality measurement in the field of neurology for conditions other than stroke and transient ischemic attack. As the number of evidence-based treatments for neurological conditions grows, so will the demand to measure the quality of care delivered. The purpose of this study was to review essential components of hospital performance measures for neurological disease and propose potential quality indicators for commonly encountered inpatient neurological diagnoses.

METHODS

We determined the most common inpatient neurological diagnoses at a major tertiary care medical center by reviewing the billing database. We then searched PubMed and the National Guidelines Clearinghouse to identify treatment guidelines for these conditions. Guideline recommendations with class I/level A evidence were evaluated as possible quality indicators.

RESULTS

We found 94 guidelines for 14 inpatient neurological conditions other than stroke and transient ischemic attack. Of these, 36 guidelines contained at least 1 recommendation with class I evidence. Based on these, potential quality indicators for intracerebral hemorrhage, subarachnoid hemorrhage, pneumococcal meningitis, coma following cardiac arrest, encephalitis, Guillain-Barre syndrome, multiple sclerosis, and benign paroxysmal positional vertigo are proposed.

CONCLUSIONS

There are several inpatient neurological conditions with treatments or diagnostic test routines supported by high levels of evidence that could be used in the future as quality indicators.

A case of migraine without aura that was successfully treated with an herbal medicine

OBJECTIVE

Migraine is a common neurologic condition characterized by the disabling effects it has on the patient. Despite recent progress in drug development, better pharmacotherapies against migraine are still needed. This report describes an herbal medicine that has a strong pain-relieving effect against migraine.

PATIENT

This case involved a 49-year-old woman with a 16-year history of headaches. Migraine without aura had been diagnosed at age 47 years. Despite taking antiepileptic drugs as prophylaxis, she had migraines almost three times a week, especially in the morning. As a result, 3 months before her visit to the study clinic she was prescribed sumatriptan, which she had to take for each attack. However, sumatriptan sometimes failed to work as a painkiller, and the patient did not want to continue taking it because she was worried about overuse.

INTERVENTION AND OUTCOME

According to traditional Japanese (Kampo) and Chinese herbal medicine, the patient was prescribed an oral sanno-shashin-to (Xie Xin Tang) extract formula to take at night to prevent her migraines. Soon after she started taking the formula, the intensity of her morning headaches markedly decreased, to the extent that triptans were no longer needed. Furthermore, her residual headaches quickly disappeared after the additional administration of the formula in the morning.

CONCLUSIONS

Sanno-shashin-to might have both prophylactic and therapeutic effects against migraine without aura. Although the underlying mechanism behind the effectiveness of this herbal medicine against migraine has not been fully elucidated, it is a possible option for the treatment of this type of headache.

Preventive treatment for migraine in primary care, a population-based study in the Netherlands

Background

Preventive treatment of migraine contributes to reducing the impact of migraine but its extent of use in routine care is unknown.

Objective

The objective of this article is to assess current use, previous use, duration and course of preventive treatment of migraine in Dutch general practice.

Methods

We conducted a retrospective cohort study, for the period between 1997 and 2007, in the Interdisciplinary Processing of Clinical Information (IPCI) database, a GP research database in the Netherlands (source population of more than half a million subjects). All prevalent and incident migraine patients ( N = 7367) were included.

Results

About 13% of all migraine patients currently use preventive therapy and almost half of migraine patients have prior use. Of those starting with preventive treatment, 56% (95% CI: 54.3–64.7) still used it after nine months. There was a long delay between migraine diagnosis and preventive treatment start. Forty-four percent (95% CI 43.0–45.7) started preventive therapy in the study period.

Conclusion

This large primary-care database study shows that a limited number of patients are current users of preventive treatment, but many patients have prior use. After diagnosis there is often an extended time before preventive treatment is applied. Also there is often only one attempt. The continuation in time seems appropriate. Preventive therapy in migraine still deserves focus.

Randomized, double-blind, placebo-controlled, phase II trial of gabapentin enacarbil for migraine prophylaxis

Objective

The objective of this article is to evaluate the efficacy and safety of gabapentin enacarbil (GEn) for migraine prophylaxis.

Methods

In this randomized, double-blind, parallel-group study, patients with International Headache Society-defined migraine who met criteria suggesting the need for prophylactic therapy were randomized 2:1:2:2:1 to one of the following five groups, designated according to target daily dose of study medication during the 20-week treatment period: placebo, GEn 1200 mg, GEn 1800 mg, GEn 2400 mg, or GEn 3000 mg.

Results

The intent-to-treat population included 523 patients ( n = 128 placebo, n = 66 GEn 1200 mg, n = 134 GEn 1800 mg, n = 133 GEn 2400 mg, n = 62 GEn 3000 mg). No statistically significant difference between active treatment (the average of 1800 mg and 2400 mg treatment groups) and placebo was found for change from baseline in the number of migraine headache days during the last four weeks of treatment prior to taper (the primary endpoint). Results of analyses of the primary endpoint using the per protocol population, analyses using imputation methods different from those of the primary analysis, and nonparametric analyses were consistent with the primary analysis in showing no difference between active treatment and placebo. The pattern of results was similar for the secondary efficacy endpoints. Pharmacokinetic data demonstrate that patients had adequate estimated exposure to GEn. The adverse event profile of GEn was consistent with that in previous studies.

Conclusion

GEn did not significantly differ from placebo for migraine headache prophylaxis. A high placebo effect should be considered when interpreting these results.

Knowledge about and use of pharmacological and non-pharmacological headache therapies

OBJECTIVE

To analyse knowledge and use of pharmacological and non-pharmacological therapies in headache patients referred to a tertiary headache centre.

METHODS

We included 114 consecutive patients referred by a neurologist and asked them to fill out a comprehensive questionnaire immediately before their first appointment at our outpatient headache clinic. The questionnaire covered 23 compounds for acute treatment, 21 prophylactic drugs, and 30 complementary and alternative treatments.

RESULTS

The proportion of patients who knew at least one acute therapy stood at 92 %; 62 % knew at least one pharmaco-prophylaxis and 80 % knew at least one non-pharmacological treatment. Even though 87 % of the patients with migraine had ³ 4 disabling headache days per month, only 41 % had used triptans and not more than 19 % had taken drugs of first choice for migraine prophylaxis for at least 3 months. In contrast, 75 % had used complementary or alternative treatments. Univariate analyses showed several predictors for the use of pharmaco-prophylaxis and non-pharmacological treatment, of which only knowledge about pharmaco-prophylaxis predicted use of alternative treatments in multivariate analysis.

CONCLUSION

In Austria, a significant proportion of patients suffering from frequent recurrent headaches or migraines who are referred to a tertiary headache centre do not know and do not use triptans and pharmacological prophylaxis, while there is obviously broad acceptance and frequent use of mostly questionable alternative treatments. Improvement of primary and secondary care as well as patient education is desirable.

Acute treatment of migraines

Migraine is a prevalent and disabling brain disorder that costs billions of dollars annually in direct healthcare costs, and school and work absenteeism and presenteeism. The objective of acute treatment is a cost-effective, rapid restoration of functional ability, with minimal recurrence and adverse effects. The acute treatment of migraine includes specific drugs, which currently all have vasoconstrictive effects (dihydroergotamine and triptans), and nonspecific drugs that include paracetamol (acetaminophen), combination analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), dopamine antagonists, narcotics and corticosteroids. NSAIDs have both peripheral and central effects on reversing migraine, and so may represent the best alternative for patients who cannot use triptans and ergots due to vascular contraindications. Narcotics and habituating medications should be avoided in the acute treatment of migraine, as the risk for transformation to chronic daily headache is excessively high at a relatively infrequent rate of exposure.

Migrainous infarction: aspects on risk factors and therapy

Migraine and stroke are related in more than one way. Migraine with aura is a risk factor for ischemic stroke in women under age 45 years, particularly when combined with other risk factors such as smoking and oral contraceptives. Further, individuals with migraine with aura seem to have more white matter lesions and ischemic infarctions than control patients. Migraine has been correlated to cervical artery dissection, the symptoms of which can mimic migraine. Correspondingly, migraine with aura sometimes is mistaken for stroke. Migrainous infarction is a rare but specific type of ischemic stroke developing during an attack of migraine with aura. It is important to recognize this unusual complication of migraine because the management probably is important. In this review, we will discuss the present knowledge of migrainous infarction, the clinical picture, possible mechanisms, and potential prevention and treatment.

Neuroimaging and other investigations in patients presenting with headache

Headache is very common. In the United Kingdom, it accounts for 4.4% of primary care consultations, 30% of referrals to neurology services and 0.5-0.8% of alert patients presenting to emergency departments. Primary headache disorders account for the majority of patients and most patients do not require investigation. Warning features (red flags) in the history and on examination help target those who need investigation and what investigations are required. This article summarizes the typical presentations of the common secondary headaches and what neuroimaging and other investigations are appropriate for each headache type.

The acute and preventative treatment of episodic migraine

Episodic migraine is a common debilitating condition with significant worldwide impact. An effective management plan must include acute treatment to relieve the pain and potential disability associated with the attacks and may also include preventative treatments with an aim of decreasing attack frequency and severity in the longer term. Acute treatments must be limited to a maximum of 2-3 days a week to prevent medication overuse headache and focus on simple analgesia, non-steroidal anti-inflammatory drugs and triptans. Preventative treatments are numerous and should be considered when migraine attacks are frequent and or disabling, acute medication is failing, in special circumstances such as hemiplegic migraines or if the patient requests them. All preventative medications must be given at therapeutic doses for at least 6-8 weeks before an adequate trial can be judged ineffective. The most important factor in choosing drugs is the patient and the clinical features of their attack and treatment should be tailored to these. Relative co-morbidities will influence drug choice, as will the side effect profile and the efficacy of the drug. First line preventative drugs include ß-blockers, amitriptyline and anti-epileptic drugs such as topiramate and valproate. Drugs with lower efficacy or poorer side effect profiles include selective serotonin reuptake inhibitors (SSRIs), calcium channel antagonists, gabapentin and herbal medicines.

Results of a 2-year retrospective cohort study of newly prescribed triptan users in European nationwide practice databases

Objective: This study was conducted to characterize prescription refill patterns for triptans among European patients with new prescriptions of triptans.

Background: Persistency with prescriptions of triptan monotherapy for migraine headache among newly prescribed users in European primary-care practices has not been well described.

Methods: Using electronic medical databases in the UK ( N = 3618), France ( N = 2051) and Germany ( N = 954), we conducted a retrospective cohort analysis to identify refill patterns over 2 years among migraineurs receiving new prescriptions of triptan monotherapy in 2006.

Results: Of all patients, >33% of migraineurs with new triptan prescriptions received ≥1 refill of their index triptan prescriptions (UK, 44.3%; France, 34.2%; Germany, 37.7%). More than 50% never received index-triptan refill prescriptions (UK, 55.7%; France, 65.8%; Germany, 63.3%). Small proportions of patients (<7.0%) switched to alternative triptans, and even fewer switched to different prescription-medication classes (UK and Germany, 2.3%; France, 4.0%). More than 48% of patients received no further prescriptions for migraine after index prescriptions (UK, 48.5%; France, 54.9%; Germany, 54.7%). After the second year, >83.0% of patients in each country had no further prescriptions for migraine medications, <14.0% remained persistent with index prescriptions, <4.0% switched to other triptans, and <3.0% switched to alternative medication classes.

Conclusions: In migraine patients who received new prescriptions of triptan monotherapy from their primary-care physicians, poor triptan prescription refill frequency was observed in Europe. Although consistent with potential clinical challenges in migraine management, our findings should be interpreted with caution given certain inherent limitations associated with the database study design. Further research is warranted to confirm our findings and to identify reasons for, or predictors of, triptan discontinuation.

Prophylactic treatment of migraine by GPs: a qualitative study

BACKGROUND

Despite the considerable impact of migraine, the use of preventive medication in primary care is limited. Only about 5% of migraine patients who qualify for prophylaxis actually receive it, and adherence is far from optimal.

AIM

To explore the opinions of GPs regarding preventive medication for migraine.

DESIGN AND SETTING

A qualitative focus group study in Dutch general practice.

METHOD

Four focus groups (six GPs each) were formed. GPs were purposively sampled to acquire a range of participants, reflecting the more general GP population.

RESULTS

GPs perceived patients' concerns about the impact of migraine and the potential benefits of prophylaxis. However, some were hesitant to start prescribing prophylaxis due to doubts about effectiveness, potential side effects, and the risk of developing drug dependency. GPs' decisions were often based on considerations other than those presented in national guidelines, for example, the patient's need to control their own problem. Many GPs placed responsibility for initiating prophylaxis with the patient.

CONCLUSION

Various considerations hamper GPs from managing migraine with preventive medication, and various patient-related concerns cause GPs to deviate from national headache guidelines.

The characteristics and risk factors of headache development after the coil embolization of an unruptured aneurysm

BACKGROUND AND PURPOSE

Development of a headache after aneurysm coil embolization is not uncommon but has received little attention. The authors prospectively analyze the characteristics and risk factors of a headache after coiling in patients treated for an unruptured cerebral aneurysm.

MATERIALS AND METHODS

Ninety patients treated for an unruptured cerebral aneurysm over a period of 1 year, and without a headache history within a month before coiling, were enrolled in this study. All coilings were successfully performed without neurologic complications. After coiling, headache development and intensities were recorded.

RESULTS

Fifty (55.6%) patients experienced a headache (VAS score, 4.5 ± 2.02) at 7.9 (range, 0-72) hours, on average, after coiling, and all headaches resolved within an average of 73.0 (range, 3-312) hours. Univariate analysis showed that the following were significantly associated with the development of a headache: age ≤ 50 years (OR 4.636, 95% CI, 1.414-15.198), hypertension (OR 0.232, 95% CI, 0.095-0.571), a packing attenuation of >25% (OR 3.619, 95% CI, 1.428-9.174), and a previous headache history (OR 2.769, 95% CI, 1.120-6.849). However, binary logistic regression showed that only a packing attenuation of >25% (P = .013, adjusted OR 3.774, 95% CI, 1.320-10.790) and no history of hypertension (P = .019, adjusted OR 3.515, 95% CI, 1.233-10.021) were independently associated with the development of a headache.

CONCLUSIONS

A headache frequently developed after the coiling of unruptured aneurysms. However, headaches were relatively benign and resolved within several days. The present study shows that no hypertension history and a packing attenuation of >25% are risk factors of headache development.

Emerging migraine treatments and drug targets

Migraine has a 1-year prevalence of 10% and high socioeconomic costs. Despite recent drug developments, there is a huge unmet need for better pharmacotherapy. In this review we discuss promising anti-migraine strategies such as calcitonin gene-related peptide (CGRP) receptor antagonists and 5-hydroxytrypamine (5-HT)(1F) receptor agonists, which are in late-stage development. Nitric oxide antagonists are also in development. New forms of administration of sumatriptan might improve efficacy and reduce side effects. Botulinum toxin A has recently been approved for the prophylaxis of chronic migraine. Tonabersat, a cortical spreading depression inhibitor, has shown efficacy in the prophylaxis of migraine with aura. Several new drug targets such as nitric oxide synthase, the 5-HT(1D) receptor, the prostanoid receptors EP(2) and EP(4), and the pituitary adenylate cyclase receptor PAC1 await development. The greatest need is for new prophylactic drugs, and it seems likely that such compounds will be developed in the coming decade.

Migrainous infarction: a Nordic multicenter study

BACKGROUND AND PURPOSE

Migrainous infarction (MI), i.e., an ischemic stroke developing during an attack of migraine with aura is rare and the knowledge of its clinical characteristics is limited. Previous case series using the International Classification of Headache Disorders (ICHD) included <10 cases which make conclusions less valid. This study aimed to describe characteristics and outcome of MI in a larger sample.

METHODS

We analyzed demographic data, risk factors, migraine medication, stroke localization, symptoms, and outcome in a sample of 33 patients with MI according to second edition of the ICHD criteria collected from seven Nordic headache clinics.

RESULTS

Amongst 33 patients with MI, there were 20 (61%) women and 13 (39%) men with the median age for stroke of 39 (range 19-76) years. Traditional risk factors for stroke were rare compared with Scandinavian young ischemic stroke populations. During the acute phase, 12 (36%) patients used ergotamines or triptans. Stroke was located in the posterior circulation in 27 (82%) patients and cerebellum was involved in 7 (21%). Except in two patients with brainstem infarctions, the outcome was favorable with total recovery or limited residual symptoms.

CONCLUSIONS

The prevalence of traditional risk factors was low and the infarctions were predominantly located in posterior circulation territory, supporting theories of migraine specific mechanisms. The outcome was in general favorable.

Improved patient satisfaction and pain evolution with almotriptan in migraine: a primary care study

BACKGROUND/OBJECTIVE

The START study was a large general practice observational study involving 400 patients with migraine. Given the large sample size, a sub-analysis was planned to ascertain whether any patient characteristics/behaviors might help predict/explain the responses observed in this study, which demonstrated that almotriptan administered early when pain was mild significantly improved pain-related outcomes compared with non-early/non-mild treatment.

METHODS

This pre-planned sub-analysis assessed the impact of predictors of patient satisfaction, medication history, delayed drug intake, etc. on the primary pain endpoints of the START study.

RESULTS

Patients had previously tried an average of 2.5 drugs for migraine relief and were currently taking a mean of 1.4 drugs. Almotriptan had been tried by 21% of the sample and was still being used by 83% of this sub-group. Treatment satisfaction was higher in the subset of patients taking almotriptan than in almotriptan-naїve individuals (p < 0.001) and this may explain why this group had the highest continuation rate of all drugs evaluated. On completion of the study, patient satisfaction was higher in the early/mild treatment group than the non-early/non-mild group (p = 0.049). Many patients delayed taking almotriptan, despite being instructed otherwise. Patients reported that this was primarily because they believed that they should only take the medication in the case of a severe migraine attack and/or to ensure that the symptoms were definitely due to migraine headache. The limitations of the trial include its open, observational design, and the small number of individuals who managed to treat their migraine attack within 1 hour when it was still mild.

CONCLUSIONS

Almotriptan was associated with increased patient satisfaction, particularly when taken early. Further action is required to increase patient compliance with early treatment regimens to improve clinical outcomes.

Protection of flunarizine on cerebral mitochondria injury induced by cortical spreading depression under hypoxic conditions

A rat cortical spreading depression (CSD) model was established to explore whether cerebral mitochondria injury was induced by CSD under both normoxic and hypoxic conditions and whether flunarizine had a protective effect on cerebral mitochondria. SD rats, which were divided into seven groups, received treatment as follows: no intervention (control Group I); 1 M NaCl injections (Group II); 1 M KCl injections (Group III); intraperitoneal flunarizine (3 mg/kg) 30 min before KCl injections (Group IV); 14% O(2) inhalation before NaCl injections (Group V); 14% O(2) inhalation followed by KCl injections (Group VI); 14% O(2) inhalation and intraperitoneal flunarizine followed by KCl injections (Group VII). Following treatment, brains were removed for the analysis of mitochondria transmembrane potential (MMP) and oxidative respiratory function after recording the number, amplitude and duration of CSD. The duration of CSD was significantly longer in Group VI than that in Group III. The number and duration of CSD in Group VII was significantly lower than that in Group VI. MMP in Group VI was significantly lower than that in Group III, and MMP in Group VII was significantly higher than that in Group VI. State 4 respiration in Group VI was significantly higher than that in Group III, and state 3 respiration in Group VII was significantly higher than that in Group VI. Respiration control of rate in Group VII was also significantly higher than that in Group VI. Thus, we concluded that aggravated cerebral mitochondria injury might be attributed to CSD under hypoxic conditions. Flunarizine can alleviate such cerebral mitochondria injury under both normoxic and hypoxic conditions.

Prophylaxis of migraine with melatonin: a randomized controlled trial

BACKGROUND

A previous open-label study of melatonin, a key substance in the circadian system, has shown effects on migraine that warrant a placebo-controlled study.

METHOD

A randomized, double-blind, placebo-controlled crossover study was carried out in 2 centers. Men and women, aged 18-65 years, with migraine but otherwise healthy, experiencing 2-7 attacks per month, were recruited from the general population. After a 4-week run-in phase, 48 subjects were randomized to receive either placebo or extended-release melatonin (Circadin®, Neurim Pharmaceuticals Ltd., Tel Aviv, Israel) at a dose of 2 mg 1 hour before bedtime for 8 weeks. After a 6-week washout treatment was switched. The primary outcome was migraine attack frequency (AF). A secondary endpoint was sleep quality assessed by the Pittsburgh Sleep Quality Index (PSQI).

RESULTS

Forty-six subjects completed the study (96%). During the run-in phase, the average AF was 4.2 (±1.2) per month and during melatonin treatment the AF was 2.8 (±1.6). However, the reduction in AF during placebo was almost equal (p = 0.497). Absolute risk reduction was 3% (95% confidence interval -15 to 21, number needed to treat = 33). A highly significant time effect was found. The mean global PSQI score did not improve during treatment (p = 0.09).

CONCLUSION

This study provides Class I evidence that prolonged-release melatonin (2 mg 1 hour before bedtime) does not provide any significant effect over placebo as migraine prophylaxis.

CLASSIFICATION OF EVIDENCE

This study provides Class I evidence that 2 mg of prolonged release melatonin given 1 hour before bedtime for a duration of 8 weeks did not result in a reduction in migraine frequency compared with placebo (p = 0.497).

Triptan persistency among newly initiated users in a pharmacy claims database

Objective

Our study was conducted to describe prescription refill patterns among patients newly treated with triptans.

Background

Although triptans are efficacious in treating migraine headache, the persistency of triptan use among newly initiated users has not been well described.

Methods

From a US pharmacy claims database, we identified patients receiving new triptan monotherapy prescriptions from 2001 to 2005. Prescription refill information was gathered for two years for each patient. Persistency was defined as sustained refills of the index triptan prescription, regardless of duration between refills.

Results

Of 40,892 patients receiving a new triptan prescription, 53.8% (N=22031) did not persistently refill their index triptan. Of these, 25.5% discontinued prescription migraine therapy, 7.4% switched to a different triptan, and 67.1% switched to a non-triptan migraine medication at the time of their first refill. Only 46.2% of patients received at least one persistent refill.

Conclusions

Migraine patients were more likely to discontinue their triptan after their index prescription than at any other time in their prescription refill history. The majority of patients did not persistently refill triptans, but filled prescriptions for non-specific migraine therapies such as opioids and non-steroidal anti-inflammatory drugs. Reasons for triptan discontinuation warrant further investigation.

Efficacy of combined topiramate/thioctic acid therapy in migraine prophylaxis

Migraine cannot be cured and the aim, shared with the patient, is to minimise the impact of the illness on the patient's life and lifestyle. The aim of prophylaxis is to reduce the number of migraine attacks. Prophylaxis should be considered when appropriately used acute management gives inadequate control of symptoms. The efficacy and safety of topiramate 50 mg/d and thioctic acid (α-lipoic acid) 300 mg/d either as monotherapy or in combination were investigated as migraine prophylactic agents. Forty secondary school migraineur girls were enrolled in the study. The study was conducted in two phases, a prospective baseline phase and 1-month treatment phase. Combined topiramate/thioctic acid therapy was more effective than either topiramate or thioctic acid monotherapy as a migraine-preventive treatment. Combined topiramate/thioctic acid therapy decreased the mean monthly migraine frequency from 5.86 ± 1.2 to 2.6 ± 0.98 (p ⩽ 0.05), topiramate (50 mg/d) from 5.71 ± 1.4 to 4.75 ± 1.5 and thioctic acid (300 mg/d) from 5.68 ± 1.6 to 5.22 ± 1.8. Reduction in mean monthly migraine days was also significantly greater in the group receiving combined topiramate/thioctic acid (from 12.32 ± 1.85 to 5.74 ± 1.1) compared to those receiving either topiramate 50 mg/d (from 12.7 ± 1.34 to 11.85 ± 1.35) or thioctic acid 300 mg/d (from 12.5 ± 1.72 to 11.65 ± 1.44). The responder rate (% of patients showing ⩾50% reduction in monthly migraine frequency) was 85% in patients receiving combined topiramate/thioctic acid therapy compared to 30% and 20% in patients receiving either topiramate or thioctic acid, respectively. The incidence of adverse events was higher in patients receiving topiramate (50 mg/d) monotherapy. The most common adverse events were nausea, fatigue, paraesthesia and taste perversion. We conclude that combined topiramate/thioctic acid therapy is more effective and better tolerated than topiramate monotherapy. The combination has lower monthly medication costs compared to the traditionally used topiramate 100 mg monotherapy.

Treatment response and tolerability of frovatriptan in patients reporting short- or long-duration migraines at baseline

OBJECTIVES

Compare migraine duration with frovatriptan (versus baseline) in migraineurs reporting long- (24-72 h) or short-duration (<24 h) migraines at baseline.

METHODS

Post hoc analysis of two postmarketing surveillance studies of migraineurs in German primary care clinics using frovatriptan (2.5 mg) to treat a single migraine attack. Using case-report forms, physicians recorded migraine characteristics at baseline (aura, duration, frequency, severity) and with frovatriptan (duration, severity, and recurrence). Patients and physicians rated frovatriptan effectiveness and tolerability versus previous therapy; physicians recorded adverse reactions. The primary analysis was change in migraine duration with frovatriptan versus baseline.

RESULTS

At baseline, 44.2% (7178/16 253) and 55.8% (9075/16 253) of patients reported short- and long-duration migraines, respectively; long-duration migraines were more often frequent (> or =3/months; 55.5% [4893/8811] vs. 30.6% [2132/6973]; p < 0.001; 95% CI, 23.5-26.5%), severe (61.7% [5584/9047] vs. 33.9% [2427/7156]; p < 0.001; 95% CI, 26.3-29.3%), and accompanied by aura (46.8% [4199/8977] vs. 31.3% [2215/7088]; p < 0.001; 95% CI, 14.0-17.0%). Mean (SD) onset of frovatriptan effect was <1 h; 72.3% (11 592/16 040) of patients required only one frovatriptan tablet. With frovatriptan, patients were 26.8-fold more likely to experience decreased versus increased headache duration (p < 0.001; 95% CI, 23.5-30.2) and 76.5% of patients reporting long-duration migraines at baseline experienced short-duration migraines. Most patients (87-90%) and physicians (70-75%) rated frovatriptan more effective and tolerable than previous therapies.

CONCLUSION

Patients with more severe migraine characteristics at baseline were more likely to have attacks lasting > or =24 h. When using frovatriptan, patients were 26.8-fold more likely to experience decreased versus increased headache duration. Frovatriptan might be a good option for patients with long-duration or recurrent migraine attacks. The post hoc design and analysis of a single migraine attack are possible study limitations.

Prevention of medication overuse in patients with migraine

This multi-center study compared the therapeutic effect of a cognitive-behavioral minimal contact program (MCT) to the effect of a brochure (bibliotherapy) for the prevention of medication overuse headache (MOH) in migraine patients. Seven German headache centers recruited 182 migraine patients with high triptan or analgesic intake frequency. Patients were randomly allocated to either the MCT-group, receiving both an MCT program and an educational brochure or to the biblio-group receiving only the brochure. All participants continued usual medical treatment. Course of headaches, intake of analgesics or triptans after training, 3 months post-training as well as 1-2 years (mean 15.7 months) later and psychological variables were defined as outcome variables. A significant decline was observed in the number of headache days (11.0-8.8), migraine days (7.3-5.7) and medication intake days (7.4-6.1) from pre to post in the MCT-group (p<0.001 each) and in the biblio-group (p<0.001 each). The pre-to-post-improvements were maintained from pre- to short- and from pre- to long-term follow-up (p<0.001 each) in both groups. Both groups improved significantly from pre to post in psychological variables, e.g. pain acceptance: p<0.001; pain catastrophizing: p<0.001; functional pain coping: p<0.001; and pain related internal control beliefs: p<0.01. Psychological improvements remained stable in both groups at short- and long-term follow-up. During the study, none of the patients developed an MOH. MCT- and bibliotherapy are useful in migraine patients to prevent medication overuse headache or the transition of episodic to chronic headache.