Clinical experience with patient administered subcutaneous dihydroergotamine mesylate in refractory headaches

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."

Pharmacological Acute Migraine Treatment Strategies: Choosing the Right Drug for a Specific Patient

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.

Dexamethasone prevents relapse after emergency department treatment of acute migraine: a randomized clinical trial

Objective:

To determine whether the addition of intravenous dexamethasone to standard emergency department (ED) migraine therapy would decrease the incidence of severe recurrent headache 24 to 48 hours after initial treatment.

Methods:

Patients aged 19 to 65 years whose headache was severe enough to require parenteral therapy and who met International Headache Society migraine criteria were eligible for this randomized, double-blind trial. The study was conducted in the ED of 2 community hospitals, 1 of which was a tertiary referral centre. Exclusion criteria included pregnancy, focal findings, fever, meningismus, allergy to the study drug, active peptic ulcer disease and diabetes mellitus. Demographic and clinical data, including headache severity, were recorded. After abortive therapy (antiemetics, intravenous nonsteroidal agents, dihydroergotamine or opioids), blinded nurses administered dexamethasone (24 mg intravenously) or placebo. Patients recorded headache severity on a Visual Analogue Scale (VAS) at time T = 0, T = 30 minutes and T = 60 minutes and at discharge. They were contacted 48 to 72 hours later and asked whether they had suffered a recurrence of their headache, categorized as class A (severe, provoking another physician visit), class B (severe, interfering with daily activity but not provoking a physician visit), class C (mild, requiring self-medication but not limiting activity) or class D (mild, requiring no treatment). Results: Two of 100 patients were lost to follow-up, leaving 98 in the study sample. Placebo recipients were more likely to be female; other baseline characteristics were similar between groups. Median VAS pain score was 83 mm on ED arrival, 35 mm after initial treatment and 12 mm on discharge. At follow-up, 65 of 98 patients had suffered headache recurrence. In the placebo versus dexamethasone groups, respectively, the results were 11 versus 0 in class A, 11 versus 9 in class B, 7 versus 11 in class C and 4 versus 12 in class D. Regarding the primary outcome, 9 of 49 dexamethasone patients (18%) and 22 of 49 placebo patients (45%) had severe (classes A and B) recurrent headache (odds ratio 0.28; 95% CI, 0.11 to 0.69;p= 0 .005).

Conclusions:

Migraine recurrence is common after “successful” ED treatment. Inflammation may be a critical factor in migraine genesis. Intravenous dexamethasone decreases the incidence of severe recurrent headache after ED treatment and should be offered to patients thought to be at risk of recurrent headache.

Sleep-related headache and its management

OPINION STATEMENT

Sleep and headache have both generated curiosity within the human mind for centuries. The relationship between headache and sleep disorders is very complex. While Lieving in 1873 first observed that headaches were linked to sleep, Dexter and Weitzman in 1970 described the relationship between headache and sleep stages. Though our understanding of sleep and headache relationship has improved over the years with expanding knowledge in both fields and assessment tools such as polysomnography, it is still poorly understood. Headache and sleep have an interdependent relationship. Headache may be intrinsically related to sleep (migraine with and without aura, cluster headache, hypnic headache, and paroxysmal hemicrania), may cause sleep disturbance (chronic migraine, chronic tension-type headache, and medication overuse headache) or a manifestation of a sleep disorder like obstructive sleep apnea. Headache and sleep disorder may be a common manifestation of systemic dysfunction-like anemia and hypoxemia. Headaches may occur during sleep, after sleep, and in relation to different sleep stages. Lack of sleep and excessive sleep are both considered triggers for migraine. Insomnia is more common among chronic headache patients. Experimental data suggest that there is a common anatomic and physiologic substrate. There is overwhelming evidence that cluster headache and hypnic headaches are chronobiological disorders with strong association with sleep and involvement of hypothalamus. Cluster headache shows a circadian and circannual rhythmicity while hypnic headache shows an alarm clock pattern. There is also a preferential occurrence of cluster headache, hypnic headache, and paroxysmal hemicrania during REM sleep. Silencing of anti-nociceptive network of periaqueductal grey (PAG), locus ceruleus and dorsal raphe nucleus doing REM sleep may explain the preferential pattern. Sleep related headaches can be classified into (1) headaches with high association with obstructive sleep apnea, which includes cluster headache, hypnic headache, and headache related to obstructive sleep apnea; and (2) headaches with high prevalence of insomnia, medication overuse, and psychiatric comorbidity including chronic migraine and chronic tension-type headache. The initial step in the management of sleep related headache is proper diagnosis with exclusion of secondary headaches. Screening for sleep disorders with the use of proper tests including polysomnography and referral to sleep clinic, when appropriate is very helpful. Control of individual episode in less than 2 hours should be the initial goal using measures to abort and prevent a relapse. Cluster headache responds very well to injectable Imitrex and oxygen. Verapamil, steroids and lithium are used for preventive treatment of cluster headache. Intractable cluster headache patients have responded to hypothalamic deep brain stimulation. Hypnic headache patients respond to nightly caffeine, indomethacin, and lithium. Paroxysmal hemicrania responds very well to indomethacin. Early morning headaches associated with obstructive sleep apnea respond to CPAP or BiPAP with complete resolution of headache within a month. Patient education and lifestyle modification play a significant role in overall success of the treatment. Chronic tension-type headache and chronic migraine have high prevalence of insomnia and comorbid psychiatric disorders, which require behavioral insomnia treatment and medication if needed along with psychiatric evaluation. Apart from the abortive treatment tailored to the headache types, - such as triptans and DHE 45 for migraine and nonsteroidal anti-inflammatory medication for chronic tension-type headache, preventive treatment with different class of medications including antiepileptics (Topamax and Depakote), calcium channel blockers (verapamil), beta blockers (propranolol), antidepressants (amitriptyline), and Botox may be used depending upon the comorbid conditions.

Acute and preventive treatment of migraine

PURPOSE OF REVIEW

Migraine remains underdiagnosed and undertreated despite advances in the understanding of its pathophysiology and management. This article focuses on acute and preventive treatment of migraine, including the mechanisms of action, dosing and side effects of medications, and strategies for the most effective care.

RECENT FINDINGS

Best practice suggests that acute migraine treatment should be stratified based on the severity of the individual event, with a goal of returning the patient to full function within 2 hours of treatment. Migraine prevention strategies continue to be underused in the United States. More than 1 in 4 patients with migraines may be candidates for preventive therapy. To obtain the best results from preventive therapy, slow titration to an adequate dose for an adequate timeframe with good documentation of the results is recommended.

SUMMARY

This article reviews several options for managing acute attacks, including information on expected efficacy, dosing, and adverse effects. Strategies for effective application of acute therapies are discussed. Prevention can be added to acute therapy depending on headache characteristics such as frequency, severity, disability, and the presence of comorbid conditions. The mechanisms of action of preventive medications and strategies for their most effective use are discussed.

Acute and preventive treatment of cluster headache and other trigeminal autonomic cephalgias

Patients with cluster headache or any of the trigeminal autonomic cephalalgias (TACs) are often good candidates for preventive treatment as their headaches are frequent and severe. While acute and symptomatic therapies must be used often, they do not alter the course of the cluster period or the duration of the TACs, and they do not usually decrease the frequency of attacks. In this chapter we discuss the aim and the choice of prevention. Verapamil is considered the first choice for prevention of cluster headache, but as with all of the medications to be mentioned, it has various adverse effects to be aware of. Other frequently used preventives for cluster include lithium carbonate, methysergide where available, methylergonovine, clonidine, melatonin, valproate, gabapentin, topiramate, and others. Several other medications can be used as bridge therapy, to decrease the frequency of cluster temporarily, giving time for the preventives to begin to work. The most commonly used bridge therapies are 7-21 days of prednisone at high and then tapering doses and ergots such as ergotamine tartrate and dihydroergotamine. Patients with chronic cluster headache who are unresponsive to all medical therapies can be considered for occipital nerve stimulation and various surgical procedures such as ganglyogliolysis of all three branches of the ipsilateral trigeminal nerve at the root entry zone. A somewhat controversial but highly successful procedure, at least as done by the neurosurgeons in Professor Bussone's group at the Institute of Neurology in Milan, has been deep-brain stimulation of the posterior hypothalamus. Other TACs, such as short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT), can be hard to treat effectively with medications, but the paroxysmal hemicranias and cluster tic respond somewhat better to traditional therapies.

Treatment of status migrainosus

Migraine episodes that persist for at least 3 days despite treatment are termed status migrainosus. Traditionally, these long-lasting migraine episodes were treated with brief in-patient hospitalisations for iv. medication. The full duration of disability associated with these episodes includes both the several days of migraine and the several days of hospital stay. The development of medications that specifically target the mechanism of migraine, such as dihydroergotamine and the triptans, has reduced the number of headache episodes that persist after initial treatment or fail to respond to self-administered therapy.

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.

Nitrous oxide for the treatment of acute migraine headache

The objective of this study was to determine the efficacy of nitrous oxide in the therapy of acute migraine symptoms in emergency department (ED) patients. This was a prospective, randomized, double blind study of patients presenting to an ED. All eligible patients had a prior diagnosis and symptoms consistent with migraine headache and a normal neurological examination. Patients were randomized to receive either 50% nitrous oxide and 50% oxygen or 100% oxygen over 20 minutes. All patients completed a visual analog pain scale before and immediately after intervention. Initial pain scores and change in pain scores between the two groups were compared. There were 22 patients enrolled, 10 in the nitrous oxide group and 12 in the oxygen group. The groups were similar in age, gender, duration of headache, and initial pain scores. Pain scores decreased significantly in the nitrous oxide group (median change, 69 to 21 mm, P = .02). The oxygen group did not show significant change in pain scores (median change, 78.5 to 72, P = .09). Eighty percent of patients receiving nitrous oxide required no rescue medication at the completion of the intervention, compared with 17% of those receiving 100% oxygen (P = .008). Twenty minutes after termination of intervention, 60% of patients who had received nitrous oxide still required no rescue medication, compared with 8% of those who had received 100% oxygen (P = .02). Nitrous oxide shows efficacy in ED short-term treatment of acute migraine headache.

Medication-induced headache: overview and systematic review of therapeutic approaches

OBJECTIVE

To review medication-induced headache (MIH) through a systematic evaluation of the literature regarding the pharmacologic management of this condition.

METHODOLOGY

To identify and evaluate all pharmacologic interventions for MIH, we conducted a qualitative systematic review of the English-language literature from 1966 to June 1998 using MEDLINE. The following search terms were used: chronic daily headache, transformed migraine, analgesic withdrawal headache, analgesic rebound headache, drug-associated headache, medication-induced headache, detoxification, and dihydroergotamine. In addition, a review of the references from relevant literature was also conducted to collect reports not identified in the MEDLINE search.

RESULTS

Numerous therapies for acute management of MIH have been evaluated, although no rigorously conducted clinical trials were identified. Therapies evaluated include abrupt withdrawal of analgesics, initiation of dihydroergotamine, nonsteroidal antiinflammatory agents, methylergonovine, dihydroergotamine, sumatriptan, amitriptyline, dexamethasone, piracetam, prothipendyl, and valproate. Epidemiology, diagnosis, clinical features, pathophysiology, and long-term prognosis of therapy are discussed and therapeutic guidelines are offered.

CONCLUSIONS

MIH is an underrecognized and difficult condition affecting headache-prone patients. The published literature concerning treatment of patients with MIH is scant and of poor quality, making it difficult for clinicians to decide on appropriate therapy. Recognition and treatment of MIH may lead to a long-term improvement in headache relief for many patients. It appears that complete withdrawal of the medications being overused is required for favorable long-term results.

Double-blind, multicenter trial to compare the efficacy of intramuscular dihydroergotamine plus hydroxyzine versus intramuscular meperidine plus hydroxyzine for the emergency department treatment of acute migraine headache

STUDY OBJECTIVE

To evaluate intramuscular dihydroergotamine in direct comparison with opioid analgesia in the treatment of acute migraine headache.

METHODS

This was a prospective, multicenter, double-blind trial performed in the emergency departments of 11 general hospitals in the United States. One hundred seventy-one patients between the ages of 18 and 60 years who presented to the ED with acute migraine headache were enrolled. Patients were randomly assigned to receive either 1 mg dihydroergotamine (DHE) or 1.5 mg/kg meperidine (MEP) by intramuscular injection. The anti-nauseant hydroxyzine (H) was coadministered in both treatment groups.

RESULTS

One hundred fifty-six patients were evaluable. Treatment groups were comparable in sample size, demographics, and baseline measurements of headache pain. Reduction of headache pain as measured on a 100-mm visual analog scale was 41+/-33 mm (53.5% reduction) for the DHE group, and 45+/-30 mm (55.7% reduction) for the MEP group at 60 minutes after treatment (difference=2.2%; 95% confidence interval [CI] -10%, 14.5%; P=.81). Reduction in the severity of nausea and improvement in functional ability were similar between treatment groups. Central nervous system adverse events were less common in the DHE group (DHE 23.5% versus MEP 37.6%, difference-14.1%: 95% CI -28%, 0%). In particular, dizziness was reported less commonly with DHE than MEP (2% versus 15%, difference=-13%: 95% CI -21%, -5%).

CONCLUSION

In this prospective, double-blind trial of a convenience sample of ED patients randomly assigned to one of two treatment regimens, DHE and MEP were comparable therapies for acute migraine. The use of DHE avoids several problems associated with opioid analgesia, including dizziness.

Headaches

Headaches are a common problem that can be disabling. The clinical features and treatment of migraine, cluster, and tension headaches are presented in this article. Emphasis is placed on the newer drugs available for acute and prophylactic treatment of these headaches. Features of headaches associated with intracranial aneurysms, temporal arteritis, cerebrovascular accidents, brain tumors, and temporomandibular disorders are also discussed.

Intravenous versus rectal prochlorperazine in the treatment of benign vascular or tension headache: a randomized, prospective, double-blind trial

STUDY OBJECTIVE

To compare the effectiveness of i.v. and PR prochlorperazine for treatment of acute benign vascular or tension headache.

DESIGN

Prospective, randomized, double-blind trial.

SETTING

University emergency department with 50,000 annual census.

PARTICIPANTS

Forty-five adult patients enrolled on 46 visits.

INTERVENTIONS

Patients received 10 mg prochlorperazine i.v. and placebo suppository or 25 mg prochlorperazine PR and placebo injection. Pain assessment was made using a 10-cm visual-analog scale; scores were analyzed using Wilcoxon/Kruskal-Wallis rank-sum tests (alpha of .01).

RESULTS

Mean 60-minute pain scores for i.v. and PR groups were 0.6 and 3.5, respectively (P = .0002). Two patients (8.7%) in the i.v. group and six patients (26.1%) in the PR group required rescue analgesia (P = .12).

CONCLUSION

i.v. prochlorperazine appears to provide more effective relief than PR prochlorperazine for benign vascular or tension headaches.

Emergency department treatment of migraine, tension, and mixed-type headache

The complaint of headache is frequently encountered in the emergency department, but most patients with cephalalgia have a benign etiology for their pain. At least 90% of patients presenting with headache are diagnosed as suffering from benign vascular or muscle-tension (for example, migraine, tension, or mixed-type) headache. There is no consensus on the ideal therapeutic approach to these patients. Classically utilized narcotic therapy suffers from problems with efficacy, relapse, and potential for abuse and addiction. However, other agents have successively proved to be imperfect as well, despite the many therapeutic approaches that have been suggested in the medical literature. While no one drug has emerged as clearly superior for treatment of acute benign headache, recent investigations have clarified the role of certain therapies. This review is intended to familiarize emergency physicians with the latest information on most recommended therapeutic approaches to the patient with headache.

Recent advances in the acute management of migraine and cluster headaches

I have discussed the pharmacokinetics, efficacies, and side effects of the various nonnarcotic drugs available for the treatment of patients who have headache. Sumatriptan, the newest one, is expensive but may be cost-effective for those who have failed traditional migraine treatment, who visit the ER frequently, who have potential for drug abuse, or who have to miss time from school or work due to the headache. Studies are in progress to compare sumatriptan with other available drugs such as DHE-45 and to determine its possible role in the prophylaxis of migraine. A new 5-HT1D receptor agonist with more efficacy and fewer side effects may be developed in the future. When sumatriptan and DHE-45 are contraindicated due to hypertension or coronary artery disease, other drugs such as metoclopramide, ketorolac, and butorphanol can be used as alternatives.

Diagnosis and treatment of cluster headache

Cluster headache (CH) is a rare form of headache occurring in both episodic and chronic forms. The painful attacks are short-lived, occur unilaterally, and are associated with signs and symptoms of autonomic involvement. Attacks frequently occur at night and can be precipitated by ingestion of alcohol. In the episodic form, attacks occur daily for some weeks followed by a period of remission. In the chronic form, attacks can continue for years. Inheritance is not a factor in CH. Treatment can be symptomatic or prophylactic. Agents used to treat individual attacks include inhalation of oxygen, rapidly acting forms of ergotamine and dihydroergotamine, and sumatriptan. Prophylactic treatment employs calcium-channel-blocking agents, methysergide, lithium, and corticosteroids. Surgical modalities, notably thermocoagulation of the gasserian ganglion, can provide relief in those who are resistant to medical management.