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Burch R. Acute Treatment of Migraine. Continuum (Minneap Minn) 2024; 30:344-363. [PMID: 38568487 DOI: 10.1212/con.0000000000001402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
OBJECTIVE Most patients with migraine require acute treatment for at least some attacks. This article reviews the approach to the acute treatment of migraine, migraine-specific and nonspecific treatment options, rescue treatment and options for management in the emergency department and inpatient settings, and treatment during pregnancy and lactation. LATEST DEVELOPMENTS Triptans, ergot derivatives, and nonsteroidal anti-inflammatory drugs have historically been the main acute treatments for migraine. The development of new classes of acute treatment, including the small-molecule calcitonin gene-related peptide receptor antagonists (gepants) and a 5-HT1F receptor agonist (lasmiditan), expands available options. These new treatments have not been associated with vasospasm or increased cardiovascular risk, therefore allowing migraine-specific acute treatment for the more than 20% of adults with migraine who are at increased risk of cardiovascular events. Neuromodulation offers a nonpharmacologic option for acute treatment, with the strongest evidence for remote electrical neuromodulation. ESSENTIAL POINTS The number of available migraine treatments continues to expand, although triptans are still the mainstay of migraine-specific acute treatment. There is no one-size-fits-all acute treatment and multiple treatment trials are sometimes necessary to determine the optimal regimen for patients. Switching within and between classes, using the maximum allowed dose, using combination therapy, and counseling patients to treat early are all strategies that may improve patient response to acute treatment.
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Ezzati A, Buse DC, Fanning KM, Reed ML, Martin VT, Lipton RB. Predictors of treatment-response to Acute Prescription Medications in Migraine: Results from the American Migraine Prevalence and Prevention (AMPP) Study. Clin Neurol Neurosurg 2022; 223:107511. [DOI: 10.1016/j.clineuro.2022.107511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 10/21/2022] [Accepted: 11/02/2022] [Indexed: 11/06/2022]
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Villar-Martinez MD, Goadsby PJ. Pathophysiology and Therapy of Associated Features of Migraine. Cells 2022; 11:cells11172767. [PMID: 36078174 PMCID: PMC9455236 DOI: 10.3390/cells11172767] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 08/30/2022] [Accepted: 08/31/2022] [Indexed: 11/16/2022] Open
Abstract
Migraine is a complex and debilitating disorder that is broadly recognised by its characteristic headache. However, given the wide array of clinical presentations in migraineurs, the headache might not represent the main troublesome symptom and it can even go unnoticed. Understanding migraines exclusively as a pain process is simplistic and certainly hinders management. We describe the mechanisms behind some of the most disabling associated symptoms of migraine, including the relationship between the central and peripheral processes that take part in nausea, osmophobia, phonophobia, vertigo and allodynia. The rationale for the efficacy of the current therapeutic arsenal is also depicted in this article. The associated symptoms to migraine, apart from the painful component, are frequent, under-recognised and can be more deleterious than the headache itself. The clinical anamnesis of a headache patient should enquire about the associated symptoms, and treatment should be considered and individualised. Acknowledging the associated symptoms as a fundamental part of migraine has permitted a deeper and more coherent comprehension of the pathophysiology of migraine.
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Affiliation(s)
- Maria Dolores Villar-Martinez
- Headache Group, Wolfson CARD, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London WC2R 2LS, UK
- NIHR King’s Clinical Research Facility, SLaM Biomedical Research Centre, King’s College Hospital, London SE5 9RS, UK
| | - Peter J. Goadsby
- Headache Group, Wolfson CARD, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London WC2R 2LS, UK
- NIHR King’s Clinical Research Facility, SLaM Biomedical Research Centre, King’s College Hospital, London SE5 9RS, UK
- Department of Neurology, University of California, Los Angeles, CA 90095, USA
- Correspondence:
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Ezzati A, Fanning KM, Buse DC, Pavlovic JM, Armand CE, Reed ML, Martin VT, Lipton RB. Predictive models for determining treatment response to nonprescription acute medications in migraine: Results from the American Migraine Prevalence and Prevention Study. Headache 2022; 62:755-765. [PMID: 35546653 DOI: 10.1111/head.14312] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 04/05/2022] [Accepted: 04/07/2022] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To identify predictors of acute treatment response for nonprescription (over-the-counter [OTC]) medications among people with migraine and develop improved models for predicting treatment response. BACKGROUND Pain freedom and sustained pain relief are important priorities in the acute treatment of migraine. OTC medications are widely used for migraine; however, it is not clear which treatment works best for each patient without going through the trial and error process. METHODS A prediction model development study was completed using the 2006 American Migraine Prevalence and Prevention Study survey, from participants who were aged ≥18, met criteria and headache day frequency for episodic migraine, did not take prescription medication for migraine, and used ≥1 of the following acute migraine medication classes: acetaminophen, aspirin, NSAIDs, or caffeine containing combination products (CCP). Two items from the Migraine Treatment Optimization Questionnaire were used to evaluate treatment response, adequate 2-h pain freedom (2hPF) and 24-h pain relief (24hPR), which were defined by a response to treatment ≥half the time at 2 h and 24 h post treatment, respectively. We identified predictors of adequate treatment response and developed models to predict probability of treatment response to each medication class. RESULTS The sample included 3852 participants (3038 [79.0%] females) with an average age of 45.0 years (SD = 12.8). Only 1602/3852 (41.6%) and 1718/3852 (44.6%) of the participants reported adequate 2hPF and 24hPR, respectively. Adequate treatment-response was significantly predicted by lower average headache pain intensity, less cutaneous allodynia, and lower depressive symptom scores. Lower migraine symptom severity was predictive of adequate 2hPF and fewer monthly headache days was predictive of adequate 24hPR. Among participants reporting OTC monotherapy (n = 2168, 56.3%) individuals taking CCP were more likely to have adequate 2hPF (OR = 1.55, 95% CI 1.23-1.95) and 24hPR (OR = 1.79, 95% CI 1.18-1.88) in comparison with those taking acetaminophen. Predictive models were modestly predictive of responders to OTC medications (c-statistics = 0.65; 95% CI 0.62-0.68). CONCLUSION These results show that response to acute migraine treatments is not optimized in the majority of people with migraine treating with OTC medications. Predictive models can improve our ability to choose the best therapeutic option for individuals with episodic migraine and increase the proportion of patients with optimized response to treatments.
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Affiliation(s)
- Ali Ezzati
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Dawn C Buse
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jelena M Pavlovic
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Cynthia E Armand
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Vincent T Martin
- University of Cincinnati Headache and Facial Pain Center, Cincinnati, Ohio, USA
| | - Richard B Lipton
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
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Wu JW, Lai PY, Chen YL, Wang YF, Lirng JF, Chen ST, Lai KL, Chen WT, Wu YT, Wang SJ. The Use of Neuroimaging for Predicting Sumatriptan Treatment Response in Patients With Migraine. Front Neurol 2022; 13:798695. [PMID: 35173673 PMCID: PMC8841861 DOI: 10.3389/fneur.2022.798695] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 01/07/2022] [Indexed: 01/14/2023] Open
Abstract
Objectives To identify the neuroimaging predictors for the responsiveness of patients to sumatriptan and use an independent cohort for external validation. Methods Structuralized headache questionnaire and 3-Tesla brain magnetic resonance imaging were performed in migraine patients. Regional brain volumes were automatically calculated using FreeSurfer version 6.0, including bilateral amygdala, anterior cingulated cortex, caudate, putamen, precuneus, orbitofrontal cortex, superior frontal gyri, middle frontal gyri, hippocampus, and parahippocampus. A sumatriptan-responder was defined as headache relief within 2 h after the intake of sumatriptan in at least two out of three treated attacks. We constructed a prediction model for sumatriptan response using the regional brain volume and validated it with an independent cohort of migraine patients. Results A total of 105 migraine patients were recruited, including 73 sumatriptan responders (69.5%) and 32 (30.5%) non-responders. We divided the migraine patients into derivation (n = 73) and validation cohorts (n = 32). In the derivation cohort, left hippocampal volume was larger in sumatriptan responders (responders vs. non-responders: 3,929.5 ± 403.1 vs. 3,611.0 ± 389.9 mm3, p = 0.002), and patients with a larger left hippocampal volume had a higher response rate to sumatriptan (>4,036.2 vs. ≤4,036.2 mm3: 92.0 vs. 56.3%, p = 0.001). Based on the findings, we constructed a prediction model using the cutoff value of 4,036.2 mm3, and we found that patients with a left hippocampal volume >4,032.6 mm3 had a higher response rate to sumatriptan than those with a left hippocampal volume ≤4,032.6 mm3 (84.6 vs. 42.1%, odds ratio [OR] = 7.6 [95% confidence interval = 1.3–44.0], p = 0.013) in the validation cohort. Conclusion Our study showed that left hippocampal volume is helpful to identify sumatriptan non-responders. This proof-of-concept study shows that left hippocampal volume could be used to predict the treatment response to sumatriptan in migraine patients.
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Affiliation(s)
- Jr-Wei Wu
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Pi-Yi Lai
- Institute of Biophotonics, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yung-Lin Chen
- Institute of Biophotonics, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yen-Feng Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jiing-Feng Lirng
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shu-Ting Chen
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Kuan-Lin Lai
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wei-Ta Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yu-Te Wu
- Institute of Biophotonics, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- *Correspondence: Shuu-Jiun Wang ;
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Viana M, Sances G, Terrazzino S, Zecca C, Goadsby PJ, Tassorelli C. Predicting the response to a triptan in migraine using deep attack phenotyping: A feasibility study. Cephalalgia 2020; 41:197-202. [PMID: 32955929 PMCID: PMC7859670 DOI: 10.1177/0333102420959786] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Triptans, specific symptomatic medications for migraine, are not effective in
a proportion of patients, or in all attacks, hence the importance of
identifying predictors of response. Our aim was to investigate the
association between the efficacy of oral frovatriptan 2.5 mg and clinical
characteristics of migraine attacks. Methods We enrolled 29 consecutive patients affected by migraine without aura at the
Headache Center of “Mondino” Institute of Pavia. Each patient was given a
diary and asked to record prospectively the features of three consecutive
migraine attacks while using frovatriptan. A generalized estimating
equations approach was used to determine phenotypic features associated with
the pain free response at 2 hours. Results Participants provided complete data for 85 attacks. Thirty of these (34%)
patients reported being pain free 2 hours after taking frovatriptan 2.5 mg
intake. Unilateral pain, presence of phonophobia, presence of one or more
cranial autonomic symptoms and presence of one or more premonitory symptom
were each associated with being pain free at 2 hours. Conclusions The response to frovatriptan was associated with particular features of the
migraine attack, either before or during the pain phase of attacks. The data
support larger studies to explore detailed attack phenotyping, with
particular attention to early signs, to enable individualized treatment in
migraine.
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Affiliation(s)
- Michele Viana
- Headache Group, Department of Basic and Clinical Neurosciences, King's College London, London, UK.,Neurocenter of Southern Switzerland, Neurology clinic, Headache Center, Lugano, Switzerland.,Headache Science Center, IRCCS Mondino Foundation, Pavia, Italy
| | - Grazia Sances
- Headache Science Center, IRCCS Mondino Foundation, Pavia, Italy
| | - Salvatore Terrazzino
- Department of Pharmaceutical Sciences, University of Piemonte Orientale, Novara, Italy
| | - Chiara Zecca
- Neurocenter of Southern Switzerland, Neurology clinic, Headache Center, Lugano, Switzerland.,Faculty of biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Peter J Goadsby
- Headache Group, Department of Basic and Clinical Neurosciences, King's College London, London, UK.,NIHR-Wellcome Trust Clinical Research Facility, King's College Hospital, London, UK
| | - Cristina Tassorelli
- Headache Science Center, IRCCS Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy
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7
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Peterson OJ, Cornelison LE, Durham PL. Neuroprotective Effect of Enriched Chicken Bone Broth as a Dietary Supplement in a Model of Migraine Mediated by Early Life Stress. J Med Food 2020; 23:1259-1265. [PMID: 32326809 DOI: 10.1089/jmf.2019.0312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Early life stress is a risk factor for development of migraine, a prevalent painful neurological disease characterized by sensitization and activation of trigeminal neurons. Secondary early life stress was previously shown to cause increased expression of neuronal proteins implicated in peripheral and central sensitization. Recently, dietary supplementation of chicken bone broth was shown to attenuate trigeminal nociception in an orofacial pain model. Accordingly, the focus of this study was to determine the effects of early life stress and dietary inclusion of bone broth on trigeminal nociceptor sensitization and activation in a model of episodic migraine. Adult Sprague-Dawley male sender rats subjected to primary traumatic stress were placed next to breeding or pregnant female rats that served as receiver rats (secondary traumatic stress) and in proximity to the offspring until weaning. Unstressed and stressed young adult offspring were tested for mechanical nocifensive response after exposure to a pungent odor known to be a migraine trigger, and in response to daily supplementation of bone broth. Early life stress promoted a primed state of trigeminal nociceptors that were activated by the pungent odor in both genders. Female animals exhibited a higher basal sensitization level and prolonged nociception compared with males. Supplementation of bone broth beginning at the time of weaning inhibited basal and triggered trigeminal mechanical sensitivity. Early life stress caused development of a sensitized trigeminal system that is implicated in migraine pathology and dietary supplementation with bone broth suppressed trigeminal sensitization, and thus may provide neuroprotective activity for reducing migraine risk.
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Affiliation(s)
- Orion J Peterson
- Jordan Valley Innovation Center - Center for Biomedical and Life Sciences, Missouri State University, Springfield, Missouri, USA
| | - Lauren E Cornelison
- Jordan Valley Innovation Center - Center for Biomedical and Life Sciences, Missouri State University, Springfield, Missouri, USA
| | - Paul L Durham
- Jordan Valley Innovation Center - Center for Biomedical and Life Sciences, Missouri State University, Springfield, Missouri, USA
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8
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Pascual J, Vila C. Almotriptan: a review of 20 years' clinical experience. Expert Rev Neurother 2019; 19:759-768. [PMID: 30845850 DOI: 10.1080/14737175.2019.1591951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Introduction: Almotriptan (ALT), a serotonin 5-HT1B/1D agonist has been used in the acute treatment of migraine with or without aura for 20 years, accumulating data on more than 15,000 patients in studies and from an estimated >150 million treated migraine attacks in daily clinical practice. The last major review of ALT was written almost 10 years ago. The current narrative review provides an overview of the experience gained with almotriptan over that time, and highlights data published in the last decade. Areas covered: Randomized clinical trials, observational studies, postmarketing studies and meta-analyses involving ALT for the treatment of acute migraine identified through a systematic literature search. Expert opinion: Triptans are a mainstay of anti-migraine treatment. Findings with ALT over the last 10 years have reinforced the positive efficacy and tolerability results that were reported during the first 10 years following its introduction. In particular, more recent clinical results have confirmed its efficacy in women with menstrual migraine, the usefulness of early intervention, long-term benefit in adults, and also its efficacy and safety in adolescents. Overall, ALT can be considered an optimal choice for managing acute migraine resistant to first-line drugs.
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Affiliation(s)
- Julio Pascual
- a Neurology Service , University Hospital Marqués de Valdecilla and IDIVAL , Santander , Spain
| | - Carlos Vila
- b Global Medical Affairs , Almirall S.A , Barcelona , Spain
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9
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Diener HC, Holle-Lee D, Nägel S, Dresler T, Gaul C, Göbel H, Heinze-Kuhn K, Jürgens T, Kropp P, Meyer B, May A, Schulte L, Solbach K, Straube A, Kamm K, Förderreuther S, Gantenbein A, Petersen J, Sandor P, Lampl C. Treatment of migraine attacks and prevention of migraine: Guidelines by the German Migraine and Headache Society and the German Society of Neurology. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2019. [DOI: 10.1177/2514183x18823377] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In collaboration with some of the leading headache centres in Germany, Switzerland and Austria, we have established new guidelines for the treatment of migraine attacks and the prevention of migraine. A thorough literature research of the last 10 years has been the basis of the current recommendations. At the beginning, we present therapeutic novelties, followed by a summary of all recommendations. After an introduction, we cover topics like drug therapy and practical experience, non-effective medication, migraine prevention, interventional methods, non-medicational and psychological methods for prevention and therapies without proof of efficacy.
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Affiliation(s)
- Hans-Christoph Diener
- Klinik für Neurologie und Westdeutsches Kopfschmerzzentrum, Universitätsklinikum Essen, Essen, Germany
| | - Dagny Holle-Lee
- Klinik für Neurologie und Westdeutsches Kopfschmerzzentrum, Universitätsklinikum Essen, Essen, Germany
| | - Steffen Nägel
- Klinik für Neurologie und Westdeutsches Kopfschmerzzentrum, Universitätsklinikum Essen, Essen, Germany
| | - Thomas Dresler
- Klinik für Psychiatrie und Psychotherapie, Universität Tübingen, Tübingen, Germany
- Graduiertenschule & Forschungsnetzwerk LEAD, Universität Tübingen, Tübingen, Germany
| | - Charly Gaul
- Migräne- und Kopfschmerzklinik Königstein, Königstein im Taunus, Germany
| | | | | | - Tim Jürgens
- Universitätsmedizin Rostock, Zentrum für Nervenheilkunde, Klinik und Poliklinik für Neurologie, Rostock, Germany
| | - Peter Kropp
- Institut für Medizinische Psychologie und Medizinische Soziologie, Universitätsmedizin Rostock, Zentrum für Nervenheilkunde, Rostock, Germany
| | - Bianca Meyer
- Institut für Medizinische Psychologie und Medizinische Soziologie, Universitätsmedizin Rostock, Zentrum für Nervenheilkunde, Rostock, Germany
| | - Arne May
- Institut für Systemische Neurowissenschaften, Universitätsklinikum Hamburg Eppendorf (UKE), Hamburg, Germany
| | - Laura Schulte
- Institut für Systemische Neurowissenschaften, Universitätsklinikum Hamburg Eppendorf (UKE), Hamburg, Germany
| | - Kasja Solbach
- Klinik für Neurologie, Universitätsklinikum Essen, Essen, Germany
| | - Andreas Straube
- Neurologische Klinik, Ludwig-Maximilians-Universität München, Klinikum Großhadern, München, Germany
| | - Katharina Kamm
- Neurologische Klinik, Ludwig-Maximilians-Universität München, Klinikum Großhadern, München, Germany
| | - Stephanie Förderreuther
- Neurologische Klinik, Ludwig-Maximilians-Universität München, Klinikum Großhadern, München, Germany
| | | | - Jens Petersen
- Klinik für Neurologie, Universitätsspital Zürich, Zürich, Swizterland
| | - Peter Sandor
- RehaClinic Bad Zurzach, Bad Zurzach, Swizterland
| | - Christian Lampl
- Ordensklinikum Linz, Krankenhaus der Barmherzigen Schwestern Linz Betriebsgesellschaft m.b.H., Linz, Austria
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Akerman S, Karsan N, Bose P, Hoffmann JR, Holland PR, Romero-Reyes M, Goadsby PJ. Nitroglycerine triggers triptan-responsive cranial allodynia and trigeminal neuronal hypersensitivity. Brain 2019; 142:103-119. [PMID: 30596910 PMCID: PMC6308314 DOI: 10.1093/brain/awy313] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/26/2018] [Accepted: 10/23/2018] [Indexed: 12/29/2022] Open
Abstract
Cranial allodynia associated with spontaneous migraine is reported as either responsive to triptan treatment or to be predictive of lack of triptan efficacy. These conflicting results suggest that a single mechanism mediating the underlying neurophysiology of migraine symptoms is unlikely. The lack of a translational approach to study cranial allodynia reported in migraine patients is a limitation in dissecting potential mechanisms. Our objective was to study triptan-responsive cranial allodynia in migraine patients, and to develop an approach to studying its neural basis in the laboratory. Using nitroglycerine to trigger migraine attacks, we investigated whether cranial allodynia could be triggered experimentally, observing its response to treatment. Preclinically, we examined the cephalic response properties of central trigeminocervical neurons using extracellular recording techniques, determining changes to ongoing firing and somatosensory cranial-evoked sensitivity, in response to nitroglycerine followed by triptan treatment. Cranial allodynia was triggered alongside migraine-like headache in nearly half of subjects. Those who reported cranial allodynia accompanying their spontaneous migraine attacks were significantly more likely to have symptoms triggered than those that did not. Patients responded to treatment with aspirin or sumatriptan. Preclinically, nitroglycerine caused an increase in ongoing firing and hypersensitivity to intracranial-dural and extracranial-cutaneous (noxious and innocuous) somatosensory stimulation, reflecting signatures of central sensitization potentially mediating throbbing headache and cranial allodynia. These responses were aborted by a triptan. These data suggest that nitroglycerine can be used as an effective and reliable method to trigger cranial allodynia in subjects during evoked migraine, and the symptom is responsive to abortive triptan treatments. Preclinically, nitroglycerine activates the underlying neural mechanism of cephalic migraine symptoms, central sensitization, also predicting the clinical outcome to triptans. This supports a biological rationale that several mechanisms can mediate the underlying neurophysiology of migraine symptoms, with nitrergic-induced changes reflecting one that is relevant to spontaneous migraine in many migraineurs, whose symptoms of cranial allodynia are responsive to triptan treatment. This approach translates directly to responses in animals and is therefore a relevant platform to study migraine pathophysiology, and for use in migraine drug discovery.
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Affiliation(s)
- Simon Akerman
- Headache Group-Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
- Department of Oral and Maxillofacial Pathology, Radiology and Medicine, New York University College of Dentistry, New York, NY, USA
- Department of Neural and Pain Sciences, University of Maryland Baltimore, Baltimore, Maryland, MD, USA
| | - Nazia Karsan
- Headache Group, Department of Basic and Clinical Neuroscience, Institute of Psychology, Psychiatry and Neuroscience, King’s College London, London, UK
- NIHR-Wellcome Trust King’s Clinical Research Facility, King’s College Hospital, London, UK
| | - Pyari Bose
- Headache Group, Department of Basic and Clinical Neuroscience, Institute of Psychology, Psychiatry and Neuroscience, King’s College London, London, UK
- NIHR-Wellcome Trust King’s Clinical Research Facility, King’s College Hospital, London, UK
| | - Jan R Hoffmann
- Headache Group-Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
- Headache Group, Department of Basic and Clinical Neuroscience, Institute of Psychology, Psychiatry and Neuroscience, King’s College London, London, UK
| | - Philip R Holland
- Headache Group, Department of Basic and Clinical Neuroscience, Institute of Psychology, Psychiatry and Neuroscience, King’s College London, London, UK
| | - Marcela Romero-Reyes
- Department of Oral and Maxillofacial Pathology, Radiology and Medicine, New York University College of Dentistry, New York, NY, USA
- Department of Neural and Pain Sciences, University of Maryland Baltimore, Baltimore, Maryland, MD, USA
| | - Peter J Goadsby
- Headache Group-Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
- Headache Group, Department of Basic and Clinical Neuroscience, Institute of Psychology, Psychiatry and Neuroscience, King’s College London, London, UK
- NIHR-Wellcome Trust King’s Clinical Research Facility, King’s College Hospital, London, UK
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11
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Cha MJ, Kim BK, Moon HS, Ahn JY, Oh K, Kim JY, Kim BS, Sohn JH, Chung JM, Song TJ, Kim J, Seo JG, Chu MK, Cho SJ. Stress Is Associated with Poor Outcome of Acute Treatment for Chronic Migraine: A Multicenter Study. PAIN MEDICINE 2018; 19:1832-1838. [PMID: 29106663 DOI: 10.1093/pm/pnx269] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background Chronic migraine (CM) is associated with severe psychological symptoms and disabilities. Information on the relationship between stress and the outcomes of acute CM treatment is limited. Methods We evaluated the clinical presentation and stress levels of patients with CM who visited the neurology departments of 14 hospitals between September and December 2015. The patients were divided into stress and reference groups on the basis of the Korean version of the Brief Encounter Psychosocial Instrument (BEPSI-K). Quality of life was evaluated using EuroQol Five Dimension Questionnaire Three-Level. The Migraine Assessment of Current Therapy questionnaire was used to assess the outcomes of acute treatment. Results This study included 186 CM patients. On the basis of the BEPSI-K score, 79 and 107 patients were assigned to the stress and reference groups, respectively. The stress group had more patients with poor outcomes of acute treatment than the reference group (67.1% vs 40.2%, P < 0.001). In a multivariate analysis, female gender (odds ratio [OR] = 3.266, 95% confidence interval [CI] = 1.172-9.103, P = 0.024), the number of headache-free days per month (OR = 0.932, 95% CI = 0.883-0.985, P = 0.012), and BEPSI-K score (OR = 1.667, 95% CI = 1.051-2.643, P = 0.030) predicted poor outcomes of acute treatment. Conclusions High levels of stress were reported by 42.5% of patients with CM. The association between stress and the outcomes of acute treatment suggests that stress is an important clinical variable for improving the management of CM.
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Affiliation(s)
- Myoung-Jin Cha
- Department of Neurology, National Police Hospital, Seoul, Korea
| | - Byung-Kun Kim
- Department of Neurology, Eulji Hospital, Eulji University, Seoul, Korea
| | - Heui-Soo Moon
- Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin-Young Ahn
- Department of Neurology, Seoul Medical Center, Seoul, Korea
| | - Kyungmi Oh
- Department of Neurology, Korea University Guro Hospital, Korea University School of Medicine, Seoul, Korea
| | - Jee Young Kim
- Department of Neurology, Myongji Hospital, Seonam University College of Medicine, Goyang, Korea
| | - Byung-Su Kim
- Department of Neurology, Bundang Jesaeng General Hospital, Daejin Medical Center, Seongnam, Korea
| | - Jong-Hee Sohn
- Department of Neurology, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
| | - Jae-Myun Chung
- Department of Neurology, Inje University Seoul Paik Hospital, Seoul, Korea
| | - Tae-Jin Song
- Department of Neurology, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Jiyoung Kim
- Department of Neurology, Bio Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Jong-Geun Seo
- Department of Neurology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Min Kyung Chu
- Department of Neurology, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Soo-Jin Cho
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
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Orr SL, Kabbouche MA, O’Brien HL, Kacperski J, Powers SW, Hershey AD. Paediatric migraine: evidence-based management and future directions. Nat Rev Neurol 2018; 14:515-527. [DOI: 10.1038/s41582-018-0042-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Abstract
Context The classification of headache disorders has improved over the years, but further work is needed to develop and improve headache diagnosis within headache subtypes. The present review is a call for action to implement laboratory tests in the classification and management of primary and some secondary headaches. Background In this narrative review we present and discuss published tests that might be useful in phenotyping and/or diagnosis of long-lasting headache disorders such as migraine, tension-type headache, trigeminal autonomic cephalalgias, trigeminal neuralgia and persisting secondary headaches. Aim The palpometer test, quantitative sensory testing, nociceptive blink reflex and autonomic tests may be valuable to phenotype and/or diagnose subforms of migraine, tension-type headache, cluster headache, trigeminal neuralgia and medication-overuse headache. Provocation tests with glyceryl trinitrate (GTN) and calcitonin gene-related peptide (CGRP) may be valuable in subclassification of migraine and cluster headache. Lumbar pressure monitoring and optical coherence tomography may valuable tools to diagnose and follow patients with chronic headache and raised intracranial pressure. Finding A number of laboratory tests in headache research are presently available, but have primarily been performed in single research studies or a few studies that differ in methods and patient groups. At present, there is no evidence-based strategy for implementing diagnostic tests, but this could be achieved if well-reputed tertiary headache centers commence developing and implementing laboratory tests in order to improve the classification and treatment of headache patients.
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Affiliation(s)
- Henrik Winther Schytz
- University of Copenhagen, Danish Headache Centre, Department of Neurology at Glostrup Hospital, Denmark
| | - Jes Olesen
- University of Copenhagen, Danish Headache Centre, Department of Neurology at Glostrup Hospital, Denmark
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14
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Pharmacological Acute Migraine Treatment Strategies: Choosing the Right Drug for a Specific Patient. Can J Neurol Sci 2015. [DOI: 10.1017/s0317167100118979] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ABSTRACT:Background:In our targeted review (Section 2), 12 acute medications received a strong recommendation for use in acute migraine therapy while four received a weak recommendation for use. Strong recommendations were made to avoid use of two other medications, except for exceptional circumstances. Two anti-emetics received strong recommendations for use as needed.Objective:To organize the available acute migraine medications into acute migraine treatment strategies in order to assist the practitioner in choosing a specific medication(s) for an individual patient.Methods:Acute migraine treatment strategies were developed based on the targeted literature review used for the development of this guideline (Section 2), and a general literature review. Expert consensus groups were used to refine and validate these strategies.Results:Based on evidence for drug efficacy, drug side effects, migraine severity, and coexistent medical disorders, our analysis resulted in the formulation of eight general acute migraine treatment strategies. These could be grouped into four categories: 1) two mild-moderate attack strategies, 2) two moderate-severe attack or NSAID failure strategies, 3) three refractory migraine strategies, and 4) a vasoconstrictor unresponsive-contraindicated strategy. In addition, strategies were developed for menstrual migraine, migraine during pregnancy, and migraine during lactation. The eight general treatment strategies were coordinated with a “combined acute medication approach” to therapy which used features of both the “stratified” and the “step care across attacks” approaches to acute migraine management.Conclusions:The available medications for acute migraine treatment can be organized into a series of strategies based on patient clinical features. These strategies may help practitioners make appropriate acute medication choices for patients with migraine.
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Pharmacological Acute Migraine Treatment Strategies: Choosing the Right Drug for a Specific Patient. Can J Neurol Sci 2014. [DOI: 10.1017/s0317167100017844] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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16
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Lambert GA, Hoskin KL, Michalicek J, Panahi SE, Truong L, Zagami AS. Stimulation of dural vessels excites the SI somatosensory cortex of the cat via a relay in the thalamus. Cephalalgia 2013; 34:243-57. [DOI: 10.1177/0333102413508239] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Aim We carried out experiments in cats to determine the thalamo-cortical projection sites of trigeminovascular sensory neurons. Methods 1) We stimulated the middle meningeal artery (MMA) with C-fibre intensity electrical shocks and made field potential recordings over the somatosensory cortical surface. 2) We then recorded neurons in the ventroposteromedial (VPM) nucleus of the thalamus in search of neurons which could be activated from the skin, MMA and superior sagittal sinus. 3) Finally, we attempted to antidromically activate the neurons found in stage 2 by stimulating the responsive cortical areas revealed in stage 1. Results VPM neurons received trigeminovascular input, input from the V1 facial skin and could also be activated by electrical stimulation of the somatosensory cortex. VPM neurons activated from the cortex responded with short and invariant latencies (6.7 ± 7.7 msec mean and SD). They could follow high rates of stimulation and sometimes showed collision with orthodromic action potentials. Conclusions We conclude that somatosensory (SI) cortical stimulation excites trigeminovascular VPM neurons antidromically. In consequence, these VPM neurons project to the somatosensory cortex. These findings may help to explain the ability of migraineurs with headache in the trigeminal distribution to localise their pain to a particular region in this distribution.
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Affiliation(s)
| | - Karen L Hoskin
- Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, Australia
| | - Jan Michalicek
- Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, Australia
| | - Seyed E Panahi
- Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, Australia
| | - Linda Truong
- Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, Australia
| | - Alessandro S Zagami
- Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, Australia
- Institute of Neurological Sciences, Prince of Wales Hospital, Australia
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Viana M, Genazzani AA, Terrazzino S, Nappi G, Goadsby PJ. Triptan nonresponders: do they exist and who are they? Cephalalgia 2013; 33:891-6. [PMID: 23564209 DOI: 10.1177/0333102413480756] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Triptans represent the best treatment option for most migraine attacks, although this is not as well studied as it might be in controlled trials. Their efficacy and tolerability vary, both between agents, and from patient to patient, with about 30%-40% of patients not responding adequately to therapy. As yet unexplained, the failure of one triptan does not predict failure with another, and therefore triptan nonresponders cannot be defined as individuals who have failed a single triptan. Five clinical studies provide evidence that switching from a triptan that is ineffective to a second one can result in effective treatment in a proportion of patients. Systematic studies investigating whether there are patients who do not respond to all triptans in all formulations are lacking. METHODS Here we discuss the importance of identifying triptan nonresponders, the literature supporting their existence, and the issues to be resolved to design trials to investigate this. CONCLUSION So far, no scientific data about the presence of a triptan nonresponder population are available. We propose a pragmatic study design to assess the existence of this subpopulation, recognizing the complexity of the question and the likelihood that more than one issue is at play in nonresponders.
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Affiliation(s)
- Michele Viana
- Headache Science Center, C. Mondino National Institute of Neurology Foundation, IRCCS, Pavia, Italy.
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Tepper SJ, Kori SH, Borland SW, Wang MH, Hu B, Mathew NT, Silberstein SD. Efficacy and Safety of MAP0004, Orally Inhaled DHE in Treating Migraines With and Without Allodynia. Headache 2011; 52:37-47. [DOI: 10.1111/j.1526-4610.2011.02041.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Symptomatic Treatment of Migraine: When to Use NSAIDs, Triptans, or Opiates. Curr Treat Options Neurol 2010; 13:15-27. [DOI: 10.1007/s11940-010-0107-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Affiliation(s)
- Elizabeth Loder
- Division of Headache and Pain, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA.
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Pharmacokinetics and tolerability of sumatriptan after single-dose administration of a fixed-dose combination tablet of sumatriptan/naproxen sodium 85/500 mg followed two hours later by subcutaneous sumatriptan 4- or 6-mg injection: A randomized, open-label, three-period crossover study in healthy volunteers. Clin Ther 2010; 32:1165-77. [DOI: 10.1016/j.clinthera.2010.06.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2010] [Indexed: 11/17/2022]
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