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Lyu S, Zhang CS, Guo X, Zhang AL, Sun J, Lu C, Xue CC, Luo X. Oral Chinese Herbal Medicine as Prophylactic Treatment for Episodic Migraine in Adults: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2020; 2020:5181587. [PMID: 33424985 PMCID: PMC7781685 DOI: 10.1155/2020/5181587] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 12/07/2020] [Accepted: 12/13/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND The prophylactic effects of Chinese herbal medicine (CHM) for migraine were examined in numerous clinical trials. This review aimed to analyze the effectiveness and safety of CHM as prophylactic treatment of migraine compared to flunarizine. METHODS Nine databases were searched for randomized controlled trials (RCTs) that evaluated effects of CHM for episodic migraine prophylaxis compared to flunarizine, published before March 2019. RESULTS Thirty-five RCTs with 2,840 participants met the inclusion criteria, and 31 of them were included in meta-analyses. The overall meta-analysis indicated that, when compared to flunarizine, CHM reduced the frequency of migraine attacks at the end of treatment (EoT) (21 studies, mean difference (MD) -1.23, 95% confidence interval (CI) (-1.69, -0.76)) and at the end of follow-up (EoFU) (five studies, MD -0.96, 95% CI (-1.70, -0.21)). Subgroup analyses based on the treatment duration, follow-up duration, and the dosage of flunarizine showed that CHM was superior to or comparable with flunarizine in reducing migraine frequency. Similar results were also found for secondary outcomes such as the pain visual analogue scale, migraine duration, responder rate, and acute medication usage. In particular, the studies that used CHM containing herb pairs (Chuan Xiong plus Bai Zhi and Chuan Xiong plus Tian Ma) showed promising results. However, the certainty of this evidence was evaluated as "low" or "very low" using the Grading of Recommendations, Assessment, Development and Evaluations approach. CONCLUSION CHM appeared to be comparable with flunarizine in reducing the frequency of episodic migraine attacks in adults at EoT and EoFU and well-tolerated by participants, regardless of the treatment duration, follow-up duration, and dosage of flunarizine. Due to the low certainty of the evidence, the suggested promising prophylactic outcomes require higher quality evidence from further rigorous RCTs.
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Affiliation(s)
- Shaohua Lyu
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Hospital of Chinese Medicine and Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou 510120, China
- The China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, Royal Melbourne Institute of Technology, Melbourne 3083, Australia
| | - Claire Shuiqing Zhang
- The China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, Royal Melbourne Institute of Technology, Melbourne 3083, Australia
| | - Xinfeng Guo
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Hospital of Chinese Medicine and Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou 510120, China
| | - Anthony Lin Zhang
- The China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, Royal Melbourne Institute of Technology, Melbourne 3083, Australia
| | - Jingbo Sun
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Hospital of Chinese Medicine and Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou 510120, China
| | - Chuanjian Lu
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Hospital of Chinese Medicine and Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou 510120, China
| | - Charlie Changli Xue
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Hospital of Chinese Medicine and Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou 510120, China
- The China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, Royal Melbourne Institute of Technology, Melbourne 3083, Australia
| | - Xiaodong Luo
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Hospital of Chinese Medicine and Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou 510120, China
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Stubberud A, Flaaen NM, McCrory DC, Pedersen SA, Linde M. Flunarizine as prophylaxis for episodic migraine: a systematic review with meta-analysis. Pain 2019; 160:762-772. [PMID: 30699098 DOI: 10.1097/j.pain.0000000000001456] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Based on few clinical trials, flunarizine is considered a first-line prophylactic treatment for migraine in several guidelines. In this meta-analysis, we examined the pooled evidence for its effectiveness, tolerability, and safety. Prospective randomized controlled trials of flunarizine as a prophylaxis against migraine were identified from a systematic literature search, and risk of bias was assessed for all included studies. Reduction in mean attack frequency was estimated by calculating the mean difference (MD), and a series of secondary outcomes-including adverse events (AEs)-were also analyzed. The database search yielded 879 unique records. Twenty-five studies were included in data synthesis. We scored 31/175 risk of bias items as "high," with attrition as the most frequent bias. A pooled analysis estimated that flunarizine reduces the headache frequency by 0.4 attacks per 4 weeks compared with placebo (5 trials, 249 participants: MD -0.44; 95% confidence interval -0.61 to -0.26). Analysis also revealed that the effectiveness of flunarizine prophylaxis is comparable with that of propranolol (7 trials, 1151 participants, MD -0.08; 95% confidence interval -0.34 to 0.18). Flunarizine also seems to be effective in children. The most frequent AEs were sedation and weight increase. Meta-analyses were robust and homogenous, although several of the included trials potentially suffered from high risk of bias. Unfortunately, reporting of AEs was inconsistent and limited. In conclusion, pooled analysis of data from partially outdated trials shows that 10-mg flunarizine per day is effective and well tolerated in treating episodic migraine-supporting current guideline recommendations.
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Affiliation(s)
- Anker Stubberud
- Department of Neuromedicine and Movement Sciences, NTNU Norwegian University of Science and Technology, Trondheim, Norway
| | - Nikolai Melseth Flaaen
- Department of Neuromedicine and Movement Sciences, NTNU Norwegian University of Science and Technology, Trondheim, Norway
| | - Douglas C McCrory
- Duke Evidence Synthesis Group, Duke Clinical Research Institute, Durham, NC, United States.,Department of Medicine, Duke University School of Medicine, Durham, NC, United States.,Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, United States
| | - Sindre Andre Pedersen
- Library Section for Medicine and Health Sciences, NTNU University Library, NTNU Norwegian University of Science and Technology, Trondheim, Norway
| | - Mattias Linde
- Department of Neuromedicine and Movement Sciences, NTNU Norwegian University of Science and Technology, Trondheim, Norway.,Norwegian Advisory Unit on Headaches, St. Olavs Hospital, Trondheim, Norway
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Jiang L, Yuan DL, Li M, Liu C, Liu Q, Zhang Y, Tan G. Combination of flunarizine and transcutaneous supraorbital neurostimulation improves migraine prophylaxis. Acta Neurol Scand 2019; 139:276-283. [PMID: 30428122 DOI: 10.1111/ane.13050] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 10/07/2018] [Accepted: 11/09/2018] [Indexed: 01/03/2023]
Abstract
OBJECTIVE This study is aimed to access the efficacy and safety of combination therapy of flunarizine plus transcutaneous supraorbital neurostimulation (tSNS) compared with either flunarizine or tSNS alone for migraine prophylaxis. METHODS Patients with episodic migraine were enrolled and randomized into 3 groups. Flunarizine 5 mg per day, or tSNS for 20 minutes daily or combination of both were prescribed consecutively for 3 months. The primary outcome measures were changes in migraine days and 50% responder rate of monthly migraine days. Secondary outcome measures were the changes in migraine intensity and intake of rescue medication. Finally, satisfaction to treatment and adverse effect were evaluated as well. RESULTS A total of 154 were randomized and included in the analysis. After 3 months, the monthly migraine days were decreased in 3 groups and more significant in the combination group. The 50% responder rate was significantly higher (78.43%) in the combination therapy than monotherapy of flunarizine (46.15%) or tSNS (39.22%) alone. Greater reduction of migraine intensity and intake of rescue medication was observed in combination group. There was no difference of adverse events between flunarizine group and combination group (P = .89). CONCLUSION Adding tSNS to flunarizine can improve the therapeutic efficacy of migraine prophylaxis without increasing the adverse effects. In addition, tSNS is effective and safe for migraine treatment and can be a valid option for migraineurs who are reluctant to take oral medications or for patients who experience a low-migraine frequency and/or intensity that prophylactic therapy is not indicated but desire to acquire medical intervention.
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Affiliation(s)
- Li Jiang
- Department of Neurology The First Affiliated Hospital of Chongqing Medical University Chongqing China
| | - Dong Li Yuan
- Institute of Medical Information Chongqing Medical University Chongqing China
| | - Maolin Li
- Department of Neurology The First Affiliated Hospital of Chongqing Medical University Chongqing China
| | - Chaoyang Liu
- Department of Neurology The First Affiliated Hospital of Chongqing Medical University Chongqing China
| | - Qing Liu
- Department of Neurology The First Affiliated Hospital of Chongqing Medical University Chongqing China
| | - Yixin Zhang
- Department of Neurology The First Affiliated Hospital of Chongqing Medical University Chongqing China
| | - Ge Tan
- Department of Neurology The First Affiliated Hospital of Chongqing Medical University Chongqing China
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Yoon MS, Savidou I, Diener HC, Limmroth V. Evidence-based medicine in migraine prevention. Expert Rev Neurother 2014; 5:333-41. [PMID: 15938666 DOI: 10.1586/14737175.5.3.333] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Migraine headache is a chronic, painful, disabling and potentially progressive, condition primarily occurring in early and middle adulthood. For many patients, daily activities are impaired by the sudden and unpredictable occurrence of migraine attacks. In recent years, significant progress has been made in the field of migraine treatment. For the acute treatment of migraine attacks, 5-hydroxytryptophan(1B/D) agonists (so called triptans), were the most innovative development, successfully aborting attacks in less than 1 h. The search for innovative drugs usable for migraine prevention, however, was less successful, mainly due to the lack of reliable and predictive animal models. Recently, neuromodulators such as valproic acid and topiramate, initially developed as anticonvulsants, have been shown in large clinical trials to be effective in the prevention of migraine. As for the acute treatment of migraine attacks more than 10 years ago, large clinical trial programs are now setting new standards for evidence-based medicine in migraine prevention. This review summarizes the current options in migraine prevention with special emphasis on clinical trial design and new developments such as topiramate.
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Affiliation(s)
- Min-Suk Yoon
- University Hospital Essen, Department of Neurology, Hufelandstrasse 55, 45122 Essen, Germany
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Bostani A, Rajabi A, Moradian N, Razazian N, Rezaei M. The effects of cinnarizine versus sodium valproate in migraine prophylaxis. Int J Neurosci 2013; 123:487-93. [DOI: 10.3109/00207454.2013.765419] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Evers S, Afra J, Frese A, Goadsby PJ, Linde M, May A, Sándor PS. EFNS guideline on the drug treatment of migraine - revised report of an EFNS task force. Eur J Neurol 2009; 16:968-81. [PMID: 19708964 DOI: 10.1111/j.1468-1331.2009.02748.x] [Citation(s) in RCA: 459] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- S Evers
- Department of Neurology, University of Münster, Münster, Germany.
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Evers S, Afra J, Frese A, Goadsby PJ, Linde M, May A, Sándor PS. EFNS guideline on the drug treatment of migraine - report of an EFNS task force. Eur J Neurol 2006; 13:560-72. [PMID: 16796580 DOI: 10.1111/j.1468-1331.2006.01411.x] [Citation(s) in RCA: 129] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Migraine is one of the most frequent disabling neurological conditions with a major impact on the patients' quality of life. To give evidence-based or expert recommendations for the different drug treatment procedures of the different migraine syndromes based on a literature search and an consensus in an expert panel. All available medical reference systems were screened for all kinds of clinical studies on migraine with and without aura and on migraine-like syndromes. The findings in these studies were evaluated according to the recommendations of the EFNS resulting in level A,B, or C recommendations and good practice points. For the acute treatment of migraine attacks, oral non-steroidal anti-inflammatory drugs (NSAIDs) and triptans are recommended. The administration should follow the concept of stratified treatment. Before intake of NSAIDs and triptans, oral metoclopramide or domperidon is recommended. In very severe attacks, intravenous acetylsalicylic acid or subcutaneous sumatriptan are drugs of first choice. A status migrainosus can probably be treated by steroids. For the prophylaxis of migraine, betablockers (propranolol and metoprolol), flunarizine, valproic acid, and topiramate are drugs of first choice. Drugs of second choice for migraine prophylaxis are amitriptyline, naproxen, petasites, and bisoprolol.
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Krymchantowski AV, Moreira Filho PF. [Update on migraine prophylactic treatment]. ARQUIVOS DE NEURO-PSIQUIATRIA 1999; 57:513-9. [PMID: 10450363 DOI: 10.1590/s0004-282x1999000300027] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Among the primary headaches, patients with migraine are those that seek for medical help the most. Its prevalence is estimated in 12% of the population being more common in women with a prevalence of 18 to 20%, 6% of the men and 4 to 8% of the children. Its economic impact in the productivity and leisure is significant, and the headache attacks may incapacitate the patients for the usual activities. With a complex and still unknown pathophysiology, migraine may present with intermittent and peculiar episodes of intense headache. The most efficient approach for the treatment includes the avoidance of the trigger factors, preventive treatment, rescue treatment for the moments of pain and the accessory or non drug treatment. For the preventive treatment, scope of this update, various classes of substances are used and include the beta blockers, tricyclic antidepressants (and recently the selective serotonin reuptake inhibitors), calcium antagonists, serotonin antagonists, anticonvulsants and others. Even though its mechanisms of action in the treatment of migraine are unknown, it seems that all of the drugs influence the central serotonergic, noradrenergic and gabaergic functions. New proposals for the mechanisms of action of some of these drugs, also include the inhibition of the synthesis of nitric oxide and the modulation of the neuronal cationic channels. When individualized and correctly used, these preventive medications have been held responsible for important reductions in the frequency and intensity of migraine episodes, decreasing this way, the marathon of suffering and doubtful approaches, that these patients are usually submitted.
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Affiliation(s)
- A V Krymchantowski
- Centro de Avaliação e Tratamento da Dor de Cabeça do Rio de Janeiro, Brasil.
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Bell KR, Kraus EE, Zasler ND. Medical management of posttraumatic headaches: pharmacological and physical treatment. J Head Trauma Rehabil 1999; 14:34-48. [PMID: 9949245 DOI: 10.1097/00001199-199902000-00006] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Posttraumatic headache can be a very difficult syndrome to manage, especially if chronic. As with most other types of headache, medications are the primary treatment modality, although there is very limited evidence-based data to support any given approach. A number of physical interventions also are available to be used in conjunction with medication, particularly for headaches with a musculoskeletal component. This article will review the general principles of pharmacological treatment for headache and the physical approach to treatment of headaches and head and facial pain. The major categories of medications commonly used for treatment of many varieties of headache will be discussed. In addition, the problems encountered in diagnosing and treating chronic daily headache and analgesic rebound headache are addressed. The approach to treatment of such syndromes as myofascial pain, cervico-zygapophyseal joint pain, neuritic pain, and craniocervical somatic pain are outlined.
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Affiliation(s)
- K R Bell
- Department of Rehabilitation Medicine, University of Washington, Seattle 98195, USA
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Fullerton T. Recent Advances in the Understanding and Treatment of Migraine. J Pharm Pract 1993. [DOI: 10.1177/089719009300600602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Migraine is a disorder that afflicts more than 23 million individuals in the United States alone. The disorder is characterized by paroxysmally recurring attacks, which are moderately to severely disabling. The migraine attack is typified by a severe, usually unilateral headache, which is pulsatile in quality, and by one or more concomitant symptoms, such as nausea, vomiting, photophobia, and/or phonophobia. Because of its debilitating nature, migraine causes significant morbidity among sufferers, including lost time from work or school, and inability to perform other normal daily activities during attacks. The precise pathogenesis of migraine remains to be elucidated. However, the attack may be initiated and perpetuated by both neural and vascular mechanisms. The trigeminovascular system appears to be particularly involved. Treatment of migraine consists of avoidance of trigger factors, acute or abortive pharmacotherapy, and prophylactic pharmacotherapy. A plethora of endogenous and exogenous migraine triggers have been identified, some of which can be avoided or controlled in order to reduce attack frequency. The ergots represent the accepted standard for the treatment of the acute attack, though significant toxicity and the potential for rebound headache with overuse limit the usefulness of these agents. Simple and combination analgesics are also limited by their inherent propensity to cause a rebound phenomenon when overused. Sumatriptan is a selective serotonin receptor agonist that is now available for abortive treatment of migraine. It has been shown to be highly effective in treating the acute attack. Beta-blocking drugs are the agents of choice for migraine prophylaxis, though anti-depressant compounds, calcium channel antagonists, non-steroidal anti-inflammatory drugs, cyproheptadine, and methysergide are also used. Non-pharmacological therapy may be tried, but is rarely effective by itself.
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Affiliation(s)
- Terence Fullerton
- Division of Neuropharmacology, The Dent Neurologic Institute, Millard Fillmore Hospital
- Department of Clinical Pharmacy Research, University at Buffalo, School of Pharmacy, Buffalo, NY
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