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Faisal MM, Gomaa E, Ibrahim AE, El Deeb S, Al-Harrasi A, Ibrahim TM. Verapamil-Loaded Cubosomes for Enhancing Intranasal Drug Delivery: Development, Characterization, Ex Vivo Permeation, and Brain Biodistribution Studies. AAPS PharmSciTech 2024; 25:95. [PMID: 38710921 DOI: 10.1208/s12249-024-02814-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 04/20/2024] [Indexed: 05/08/2024] Open
Abstract
Verapamil hydrochloride (VRP), an antihypertensive calcium channel blocker drug has limited bioavailability and short half-life when taken orally. The present study was aimed at developing cubosomes containing VRP for enhancing its bioavailability and targeting to brain for cluster headache (CH) treatment as an off-label use. Factorial design was conducted to analyze the impact of different components on entrapment efficiency (EE%), particle size (PS), zeta potential (ZP), and percent drug release. Various in-vitro characterizations were performed followed by pharmacokinetic and brain targeting studies. The results revealed the significant impact of glyceryl monooleate (GMO) on increasing EE%, PS, and ZP of cubosomes with a negative influence on VRP release. The remarkable effect of Poloxamer 407 (P407) on decreasing EE%, PS, and ZP of cubosomes was observed besides its influence on accelerating VRP release%. The DSC thermograms indicated the successful entrapment of the amorphous state of VRP inside the cubosomes. The design suggested an optimized formulation containing GMO (50% w/w) and P407 (5.5% w/w). Such formulation showed a significant increase in drug permeation through nasal mucosa with high Er value (2.26) when compared to VRP solution. Also, the histopathological study revealed the safety of the utilized components used in the cubosomes preparation. There was a significant enhancement in the VRP bioavailability when loaded in cubosomes owing to its sustained release favored by its direct transport to brain. The I.N optimized formulation had greater BTE% and DTP% at 183.53% and 90.19%, respectively in comparison of 41.80% and 59% for the I.N VRP solution.
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Affiliation(s)
- Mennatullah M Faisal
- Department of Pharmaceutics, Faculty of Pharmacy, Zagazig University, Zagazig, 44519, Egypt
| | - Eman Gomaa
- Department of Pharmaceutics, Faculty of Pharmacy, Zagazig University, Zagazig, 44519, Egypt
| | - Adel Ehab Ibrahim
- Natural and Medical Sciences Research Center, University of Nizwa, Birkat Al Mauz, P.O. Box 33, Nizwa, 616, Sultanate of Oman.
| | - Sami El Deeb
- Institute of Medicinal and Pharmaceutical Chemistry, Technische Universität Braunschweig, 38106, Brunswick, Germany.
| | - Ahmed Al-Harrasi
- Natural and Medical Sciences Research Center, University of Nizwa, Birkat Al Mauz, P.O. Box 33, Nizwa, 616, Sultanate of Oman
| | - Tarek M Ibrahim
- Department of Pharmaceutics, Faculty of Pharmacy, Zagazig University, Zagazig, 44519, Egypt
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Dominguez Garcia MM, Abejon Gonzalez D, de Diego Gamarra JM, Cánovas Martinez ML, Balboa Díaz M, Hadjigeorgiou I. Symptoms and pathophysiology of cluster headache. Approach to combined occipital and supraorbital neurostimulation. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:83-96. [PMID: 36822404 DOI: 10.1016/j.redare.2021.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 10/05/2021] [Indexed: 02/25/2023]
Abstract
Cluster headache (CH) is included under section 3 - Trigeminal autonomic cephalalgias (TAC) of the International Headache Society (IHS) classification. It is one of the most frequent, painful and disabling primary headaches. Acute and preventive pharmacological treatments are often poorly tolerated and of limited effectiveness. Due to improved understanding of the pathophysiology of CH, neuromodulation devices are now considered safe and effective options for preventive and acute treatment of CH. In this paper, we review the information available to date, and present the case of a patient with disabling cluster headache highly resistant to medical treatment who underwent implantation of a peripheral nerve neurostimulation system to stimulate the supraorbital nerves (SON) and greater occipital nerve (GON) in our Pain Unit. We also review the diagnostic criteria for CH, the state of the knowledge on the pathophysiology of CH, and the role played by neuromodulation in treating this condition.
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Affiliation(s)
- M M Dominguez Garcia
- Hospital Doctor José Molina Orosa de Lanzarote: Hospital Doctor José Molina Orosa Arrecife, Las Palmas, Spain.
| | - D Abejon Gonzalez
- Hospital Doctor José Molina Orosa de Lanzarote: Hospital Doctor José Molina Orosa Arrecife, Las Palmas, Spain
| | - J M de Diego Gamarra
- Hospital Doctor José Molina Orosa de Lanzarote: Hospital Doctor José Molina Orosa Arrecife, Las Palmas, Spain
| | - M L Cánovas Martinez
- Hospital Doctor José Molina Orosa de Lanzarote: Hospital Doctor José Molina Orosa Arrecife, Las Palmas, Spain
| | - M Balboa Díaz
- Hospital Doctor José Molina Orosa de Lanzarote: Hospital Doctor José Molina Orosa Arrecife, Las Palmas, Spain
| | - I Hadjigeorgiou
- Hospital Doctor José Molina Orosa de Lanzarote: Hospital Doctor José Molina Orosa Arrecife, Las Palmas, Spain
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3
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Beduhn B, Roe G, Furst W, Lewno A. Head Pain in the Competitive Aquatic Athlete-An Approach to a Differential Diagnosis and Management. Curr Sports Med Rep 2022; 21:398-404. [PMID: 36342394 DOI: 10.1249/jsr.0000000000001010] [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: 11/09/2022]
Abstract
ABSTRACT Aquatic athletes not only face common headache etiologies similar to the general population and land-based athletes but also experience their own unique pathology. Posture, aquatic pressure, equipment, and even marine animals pose as unique causes to head pain in the aquatic athlete. Common head pain pathologies seen in the aquatic athlete include tension-type headaches, migraines, cluster headaches, and compressive headaches, including supraorbital neuralgia. Creating a thorough but focused differential diagnosis for head pain in the aquatic athlete can be a difficult and overwhelming task for some. We review both the common and not-so-common etiologies of head pain in the aquatic athlete and suggest a simple framework for assessment and treatment to diagnose and treat head pain in this specific population.
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Affiliation(s)
- Benjamin Beduhn
- Swedish Health, Department of Physical Medicine & Rehabilitation, Rehabilitative Performance Medicine, Seattle, WA
| | - Garrett Roe
- Department of Family Medicine, University of Michigan, Ann Arbor, MI
| | - Wendy Furst
- Department of Family Medicine, University of Michigan, Ann Arbor, MI
| | - Adam Lewno
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI
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4
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Medrea I, Christie S, Tepper SJ, Thavorn K, Hutton B. Network meta‐analysis of therapies for cluster headache: Effects of acute therapies for episodic and chronic cluster. Headache 2022; 62:482-511. [DOI: 10.1111/head.14283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 01/19/2022] [Accepted: 02/01/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Ioana Medrea
- University of Ottawa Ottawa Ontario Canada
- SUNY Upstate Medical University Syracuse New York USA
| | - Suzanne Christie
- University of Ottawa Ottawa Ontario Canada
- Ottawa Headache Centre Ottawa Ontario Canada
| | | | - Kednapa Thavorn
- University of Ottawa Ottawa Ontario Canada
- Ottawa Hospital Research Institute Ontario Canada
| | - Brian Hutton
- University of Ottawa Ottawa Ontario Canada
- Ottawa Hospital Research Institute Ontario Canada
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5
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Abstract
Cluster headache, a primary headache disorder, consists of short (15-180 minutes), frequent (up to eight a day), unilateral attacks of facial pain with associated ipsilateral autonomic features and restlessness. The attacks are suspected to be one of the most painful human experiences, and the disorder is associated with a high rate of suicidal ideation. Proper diagnosis is key, as some of the most effective treatments, such as high flow oxygen gas, are rarely used in other headache disorders. Yet diagnostic delay is typically years for this disorder, as it is often confused with migraine and trigeminal neuralgia, and secondary causes may be overlooked. This review covers the clinical, pathophysiologic, and therapeutic features of cluster headache. Recent updates in diagnosis include the redefinition of chronic cluster headache (remission periods lasting less than three months instead of the previous one month), and recent advances in management include new treatments for episodic cluster headache (galcanezumab and non-invasive vagus nerve stimulation).
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Affiliation(s)
- Emmanuelle A D Schindler
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Veterans Health Administration Headache Center of Excellence, Veterans Affairs Connecticut Healthcare System, West Haven, CT
| | - Mark J Burish
- Department of Neurosurgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX, USA
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Comparative Impact of Pharmacological Therapies on Cluster Headache Management: A Systematic Review and Network Meta-Analysis. J Clin Med 2022; 11:jcm11051411. [PMID: 35268502 PMCID: PMC8911224 DOI: 10.3390/jcm11051411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 02/18/2022] [Accepted: 02/24/2022] [Indexed: 12/10/2022] Open
Abstract
It is important to find effective and safe pharmacological options for managing cluster headache (CH) because there is limited evidence from studies supporting the general efficacy and safety of pharmacological therapies. This systematic review and network meta-analysis (NMA) analyzed published randomized controlled trials (RCTs) to evaluate the efficacy and safety of pharmacological treatments in patients with CH. The PubMed and Embase databases were searched to identify RCTs that evaluated the efficacy and safety of pharmacological treatments for CH. Efficacy outcomes included frequency and duration of attacks, pain-free rate, and the use of rescue agents. Safety outcomes were evaluated based on the number of patients who experienced adverse events. A total of 23 studies were included in the analysis. The frequency of attacks was reduced (mean difference (MD) = −1.05, 95% confidence interval (CI) = −1.62 to −0.47; p = 0.0004), and the pain-free rate was increased (odds ratio (OR) = 3.89, 95% CI = 2.76−5.48; p < 0.00001) in the pharmacological treatment group, with a lower frequency of rescue agent use than the placebo group. Preventive, acute, and triptan or non-triptan therapies did not show significant differences in efficacy (p > 0.05). In the NMA, different results were shown among the interventions; for example, zolmitriptan 5 mg was more effective than zolmitriptan 10 mg in the pain-free outcome (OR = 0.40, 95% CI = 0.19−0.82; p < 0.05). Pharmacological treatment was shown to be more effective than placebo to manage CH with differences among types of therapies and individual interventions, and it was consistently shown to be associated with the development of adverse events. Thus, individualized therapy approaches should be applied to treat CH in real-world practice.
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7
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Petersen AS, Barloese MCJ, Holm P, Jensen RH, Snoer AH. Intranasal treatment of cluster headache: A response. Headache 2022; 62:396-397. [DOI: 10.1111/head.14285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 02/04/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Anja S. Petersen
- Danish Headache Center Department of Neurology Rigshospitalet‐ Glostrup Glostrup Denmark
| | - Mads C. J. Barloese
- Danish Headache Center Department of Neurology Rigshospitalet‐ Glostrup Glostrup Denmark
- Centre for Functional and Diagnostic Imaging and Research Copenhagen University Hospital ‐ Amager and Hvidovre Copenhagen Denmark
| | - Per Holm
- CCH Pharmaceuticals Vanloese Denmark
| | - Rigmor H. Jensen
- Danish Headache Center Department of Neurology Rigshospitalet‐ Glostrup Glostrup Denmark
| | - Agneta H. Snoer
- Danish Headache Center Department of Neurology Rigshospitalet‐ Glostrup Glostrup Denmark
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8
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Medrea I, Christie S, Tepper SJ, Thavorn K, Hutton B. Effects of acute and preventive therapies for episodic and chronic cluster headache: A scoping review of the literature. Headache 2022; 62:329-362. [PMID: 35315067 DOI: 10.1111/head.14284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 01/19/2022] [Accepted: 02/01/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cluster headache is the most common primary headache disorder of the trigeminal autonomic cephalalgias, and it is highly disabling. OBJECTIVE We undertake a scoping review to characterize therapies to prevent and acutely treat cluster headache, characterize trial methodology utilized in studies, and recommend future trial "good practices." We also assess homogeneity of studies and feasibility for future network meta-analyses (NMAs) to compare acute and preventive treatments for cluster headache. METHODS A priori protocol for this scoping review was registered and available on Open Science Forum. We sought studies that enrolled adult patients with cluster headache as identified by accepted diagnostic criteria. Both randomized controlled trials (RCTs) and observational studies (with a control group) were included. The interventions of interest were medications, procedures, devices, surgeries, and behavioral/psychological interventions, whereas comparators of interest were placebo, sham, or other active treatments. Outcomes were predefined; however, we did not exclude studies lacking these outcomes. A systemic search was conducted in Ovid Medline, Embase, and Cochrane. We performed a targeted search for conference abstracts from journals prominent in the field. RESULTS We identified 56 studies: 45 RCTs, four studies only available in clinical trial registries, and seven observational studies. Of the 45 RCTs, 20 focused on acute therapies and 25 on preventive therapies. Overall, we determined that it is feasible to pursue a NMA for acute therapy focusing on 15 or 30-min headache reduction for acute trials, as we identified 11 trials in the combined population of patients with either episodic or chronic cluster headache (2 trials in populations with chronic cluster headache were also found). For preventive therapy of cluster headache, we identified trials with common outcomes that may be considered for NMA, however, as these trials had differences in treatment effect modifiers that could not be corrected, NMAs appear infeasible for this indication. We identified new studies looking at noninvasive vagal nerve stimulation, sphenopalatine ganglion stimulation, prednisone, and oxygen published since the most recent systematic review in the field, although these acute treatments were previously identified as effective. However, for calcitonin gene-related peptide (CGRP) monoclonal antibodies, galcanezumab demonstrated effectiveness in episodic cluster headache, but a lack of effectiveness in chronic cluster headache, and fremanezumab was not effective for episodic nor chronic cluster headache. This finding highlights that CGRP monoclonal antibodies may not show a class effect in cluster headache prevention and need to be considered individually. CONCLUSIONS We describe the treatment landscape of cluster headache for both acute and preventive treatments. Last, we present the NMAs we will undertake in acute therapies of cluster headache.
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Affiliation(s)
- Ioana Medrea
- University of Ottawa Ottawa Ontario Canada
- SUNY Upstate Medical University Syracuse New York USA
| | - Suzanne Christie
- University of Ottawa Ottawa Ontario Canada
- Ottawa Headache Centre Ottawa Ontario Canada
| | | | - Kednapa Thavorn
- University of Ottawa Ottawa Ontario Canada
- Ottawa Hospital Research Institute Ottawa Ontario Canada
| | - Brian Hutton
- University of Ottawa Ottawa Ontario Canada
- Ottawa Hospital Research Institute Ottawa Ontario Canada
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9
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Akhter M, Hashemi M. Intranasal treatment of cluster headache. Headache 2022; 62:395. [DOI: 10.1111/head.14271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 01/05/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Murtaza Akhter
- Department of Emergency Medicine University of Arizona College of Medicine–Phoenix Phoenix Arizona USA
- Department of Emergency Medicine Kendall Regional Medical Center Miami Florida USA
| | - Mani Hashemi
- Department of Emergency Medicine Kendall Regional Medical Center Miami Florida USA
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10
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Petersen AS, Pedersen AS, Barloese MCJ, Holm P, Pedersen O, Jensen RH, Snoer AH. Intranasal ketamine for acute cluster headache attacks-Results from a proof-of-concept open-label trial. Headache 2021; 62:26-35. [PMID: 34806165 DOI: 10.1111/head.14220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To investigate the safety and efficacy of intranasal ketamine for the treatment of a single cluster headache (CH) attack. BACKGROUND Acute treatment options for patients with CH who have an insufficient response to oxygen and triptans are limited. Intranasal ketamine has anecdotally been successful in treating a CH attack. METHODS We conducted an open-label pilot study enrolling 23 patients with chronic CH (International Classification of Headache Disorders, 3rd edition), and of these, 20 patients treated a single CH attack with intranasal ketamine. Under in-hospital observation, patients received 15 mg of intranasal ketamine every 6 min a maximum of five times. The primary endpoint was a 50% reduction in pain intensity within 15 min after initiating treatment. RESULTS The primary endpoint was not met; 15 min after the first ketamine administration, the mean reduction in pain intensity was 1.1 (95% confidence interval [CI]: -0.6 to 2.7, p = 0.188) on the numeric rating scale (NRS), equivalent to a 15% reduction in pain intensity. However, 30 min after the first application, the pain intensity was reduced by 59% on an 11-point NRS (mean difference: 4.3, 95% CI: 2.4-6.2, p < 0.001, N = 16) and 11 out of 16 (69%) scored 4 or below on the NRS. Four patients received rescue medication 15 min after the first ketamine application and were therefore excluded from the analysis at 30 min. Half of the patients preferred ketamine to oxygen and/or sumatriptan injection. No serious adverse events were identified during the trial. CONCLUSION Intranasal ketamine may be an effective acute treatment for CH at 30 min but should be tested in a larger controlled design. Patients and physicians should be conscious of the abuse potential of ketamine.
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Affiliation(s)
- Anja S Petersen
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Glostrup, Denmark
| | - Adam S Pedersen
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Glostrup, Denmark
| | - Mads C J Barloese
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Glostrup, Denmark.,Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital - Amager and Hvidovre, Copenhagen, Denmark
| | - Per Holm
- CCH Pharmaceuticals, Vanloese, Denmark
| | | | - Rigmor H Jensen
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Glostrup, Denmark
| | - Agneta H Snoer
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Glostrup, Denmark
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11
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Plato B, Andrews JS, Rettiganti M, Tockhorn-Heidenreich A, Bardos J, Wenzel R, Kuruppu D, Ambrosini A. Efficacy of galcanezumab in patients with episodic cluster headaches and a history of preventive treatment failure. CEPHALALGIA REPORTS 2021. [DOI: 10.1177/25158163211015654] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Objective: The efficacy of galcanezumab was evaluated in patients with episodic cluster headache and history of preventive treatment failure. Methods: In the randomized, 8-week, double-blind study (CGAL), patients with episodic cluster headache received once-monthly subcutaneous injections of galcanezumab 300 mg or placebo. Patients who completed CGAL and enrolled in an open-label study were queried for preventive treatment history. In a subset of patients with a known history of failure of verapamil or any other prior preventive treatment, a post hoc analysis of least square mean change from baseline in weekly cluster headache attack frequency across Weeks 1 to 3 was assessed. Results: Fifteen patients provided data for known history of prior preventive treatment failure (6 placebo, 9 galcanezumab), of whom 11 failed verapamil. The mean reduction in the weekly frequency of cluster headache attacks was greater with galcanezumab compared to placebo among patients with prior preventive treatment failure (8.2 versus 2.4); mean difference 5.8 (95% confidence interval [CI] 2.0, 13.6) and among patients with verapamil failure (10.1 versus 1.6); mean difference 8.5 (95% CI 0.4, 16.7). Conclusion: In this exploratory analysis of patients with a known history of prior preventive treatment failures, treatment with galcanezumab resulted in greater mean reductions in weekly cluster headache attacks compared with placebo. ClinicalTrials.gov: NCT02397473 (I5Q-MC-CGAL) NCT02797951 (I5Q-MC-CGAR)
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Affiliation(s)
- Brian Plato
- Norton Neuroscience Institute and Norton Headache and Concussion Center, Louisville, KY, USA
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12
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Courault P, Demarquay G, Zimmer L, Lancelot S. Cluster headache: state of the art of pharmacological treatments and therapeutic perspectives. Fundam Clin Pharmacol 2020; 35:595-619. [DOI: 10.1111/fcp.12636] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/13/2020] [Accepted: 12/03/2020] [Indexed: 12/26/2022]
Affiliation(s)
- Pierre Courault
- Lyon Neuroscience Research Center (CRNL) Université de LyonCNRSINSERM Lyon France
- Hospices Civils de Lyon (HCL) Lyon France
| | | | - Luc Zimmer
- Lyon Neuroscience Research Center (CRNL) Université de LyonCNRSINSERM Lyon France
- Hospices Civils de Lyon (HCL) Lyon France
- CERMEP‐Imaging Platform Groupement Hospitalier Est Bron France
- National Institute for Nuclear Science and Technology (INSTN) CEA Saclay France
| | - Sophie Lancelot
- Lyon Neuroscience Research Center (CRNL) Université de LyonCNRSINSERM Lyon France
- Hospices Civils de Lyon (HCL) Lyon France
- CERMEP‐Imaging Platform Groupement Hospitalier Est Bron France
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13
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Primaries non-migraine headaches treatment: a review. Neurol Sci 2020; 41:385-394. [PMID: 33021705 DOI: 10.1007/s10072-020-04762-2] [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: 10/23/2022]
Abstract
In the "headache world," great attention has always been paid to migraine patients, especially for the research and development of new therapies. For the other forms of primary headaches, especially those of Chapters 2 and 3 of the classification, there are however therapies that, even if not specific, can give significant results. Tension-type headache recognizes in NSAIDs the most effective drugs to treat acute attack, while prevention is based on the use of tricyclic antidepressants and muscle relaxants. For TACs, the discussion is more complex: first of all, there are two forms of primary headache that respond absolutely to indomethacin. For these, the main problem is how to manage the possible side effects arising from prolonged treatments and possibly what to use as an alternative. For cluster headaches and short-lasting unilateral neuralgiform headache attacks, we have drugs with good efficacy as regards medical therapy, such as verapamil or lamotrigine, but in recent years, neuromodulation techniques, both surgical and non-invasive, have also been affirming themselves, which represent a more possibility for forms of headache that are often very disabling and resistant to common analgesics.
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14
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Joshi S. Peptides, MAbs, Molecules, Mechanisms, and More: Taking a Stab at Cluster Headache. Headache 2020; 60:1871-1877. [DOI: 10.1111/head.13909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 06/29/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Shivang Joshi
- Dent Neurologic Institute Amherst NY USA
- University of Buffalo School of Pharmacy Buffalo NY USA
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15
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Arca KN, Smith JH, Chiang CC, Starling AJ, Robertson CE, Halker Singh RB, Schwedt TJ, Kissoon NR, Garza I, Rozen TD, Boes CJ, Whealy MA, VanderPluym JH. COVID-19 and Headache Medicine: A Narrative Review of Non-Steroidal Anti-Inflammatory Drug (NSAID) and Corticosteroid Use. Headache 2020; 60:1558-1568. [PMID: 32648592 PMCID: PMC7404408 DOI: 10.1111/head.13903] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/18/2020] [Accepted: 06/18/2020] [Indexed: 12/17/2022]
Abstract
Objective To summarize the current literature on non‐steroidal anti‐inflammatory drug and corticosteroid use during the coronavirus disease 2019 (COVID‐19) pandemic, recognizing that these are commonly used treatments in the field of headache medicine. Background The use of non‐steroidal anti‐inflammatory drugs and corticosteroids in patients during the COVID‐19 pandemic has been a controversial topic within the medical community and international and national health organizations. Lay press and social media outlets have circulated opinions on this topic despite the fact that the evidence for or against the use of these medications is sparse. In the field of headache medicine, these medications are used commonly and both patients and clinicians may have questions or hesitations pertaining to their use during the COVID‐19 pandemic. Methods A detailed search of the scientific and popular literature was performed. Results There is limited literature pertaining to the safety of non‐steroidal anti‐inflammatory drugs and corticosteroids during the COVID‐19 pandemic. To date, there are no clear scientific data that preclude the use of non‐steroidal anti‐inflammatory drugs in the general population who may acquire COVID‐19 or in those acutely infected with the virus. Several health organizations have concluded that treatment with corticosteroids during active infection should be avoided due to concerns of prolonged viral shedding in the respiratory tract and the lack of survival benefit based on the data from past coronaviruses and influenza virus; specific exceptions exist including treatment for underlying asthma or chronic obstructive pulmonary disease, septic shock, and acute respiratory distress syndrome. Conclusion Scientific information regarding the COVID‐19 pandemic is constantly evolving, and limited or contradictory information can lead to confusion for both patients and clinicians. It is recommended that prior to prescribing non‐steroidal anti‐inflammatory drugs and steroids for the treatment of headache, clinicians have open discussions with their patients about the potential risks and benefits of using these medications during the COVID‐19 pandemic. This manuscript summarizes the currently available evidence and understanding about these risks and benefits to help clinicians navigate such discussions.
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Affiliation(s)
- Karissa N Arca
- Department of Neurology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Jonathan H Smith
- Department of Neurology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Chia-Chun Chiang
- Department of Neurology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Amaal J Starling
- Department of Neurology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | | | | | - Todd J Schwedt
- Department of Neurology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | | | - Ivan Garza
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Todd D Rozen
- Department of Neurology, Mayo Clinic Florida, Jacksonville, FL, USA
| | | | - Mark A Whealy
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
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16
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D'Amico D, Raggi A, Grazzi L, Lambru G. Disability, Quality of Life, and Socioeconomic Burden of Cluster Headache: A Critical Review of Current Evidence and Future Perspectives. Headache 2020; 60:809-818. [DOI: 10.1111/head.13784] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 02/06/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Domenico D'Amico
- Neuroalgology Unit and Headache Center Fondazione IRCCS Istituto Neurologico Carlo Besta Milan Italy
| | - Alberto Raggi
- Neurology, Public Health and Disability Unit Fondazione IRCCS Istituto Neurologico Carlo Besta Milan Italy
| | - Licia Grazzi
- Neuroalgology Unit and Headache Center Fondazione IRCCS Istituto Neurologico Carlo Besta Milan Italy
| | - Giorgio Lambru
- Guy's and St Thomas' NHS Foundation Trust King's College London London UK
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Xie S, Fan W, He H, Huang F. Role of Melatonin in the Regulation of Pain. J Pain Res 2020; 13:331-343. [PMID: 32104055 PMCID: PMC7012243 DOI: 10.2147/jpr.s228577] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 01/20/2020] [Indexed: 12/15/2022] Open
Abstract
Melatonin is a pleiotropic hormone synthesized and secreted mainly by the pineal gland in vertebrates. Melatonin is an endogenous regulator of circadian and seasonal rhythms. Melatonin is involved in many physiological and pathophysiological processes demonstrating antioxidant, antineoplastic, anti-inflammatory, and immunomodulatory properties. Accumulating evidence has revealed that melatonin plays an important role in pain modulation through multiple mechanisms. In this review, we examine recent evidence for melatonin on pain regulation in various animal models and patients with pain syndromes, and the potential cellular mechanisms.
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Affiliation(s)
- Shanshan Xie
- Department of Pediatric Dentistry, Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-sen University, Guangzhou, People's Republic of China.,Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, People's Republic of China
| | - Wenguo Fan
- Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, People's Republic of China.,Department of Anesthesiology, Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Hongwen He
- Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, People's Republic of China.,Department of Oral Anatomy and Physiology, Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Fang Huang
- Department of Pediatric Dentistry, Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-sen University, Guangzhou, People's Republic of China.,Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, People's Republic of China
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Empiric use of oxygen for acute atraumatic, unilateral, retro-orbital headaches. JAAPA 2020; 33:25-27. [DOI: 10.1097/01.jaa.0000651724.17784.e1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Abstract
Headache is the most common neurologic symptom and affects nearly half the world's population at any given time. Although the prevalence declines with age, headache remains a common neurologic complaint among elderly populations. Headaches can be divided into primary and secondary causes. Primary headaches comprise about two-thirds of headaches among the elderly. They are defined by clinical criteria and are diagnosed based on symptom pattern and exclusion of secondary causes. Primary headaches include migraine, tension-type, trigeminal autonomic cephalalgias, and hypnic headache. Secondary headaches are defined by their suspected etiology. A higher index of suspicion for a secondary headache disorder is warranted in older patients with new-onset headache. They are roughly 12 times more likely to have serious underlying causes and, frequently, have different symptomatic presentations compared to younger adults. Various imaging and laboratory evaluations are indicated in the presence of any "red flag" signs or symptoms. Head CT is the procedure of choice for acute headache presentations, and brain MRI for those with chronic headache complaints. Management of headache in elderly populations can be challenging due to the presence of multiple medical comorbidities, polypharmacy, and differences in drug metabolism and clearance.
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Affiliation(s)
- Robert G Kaniecki
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.
| | - Andrew D Levin
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
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Petersen AS, Barloese MCJ, Snoer A, Soerensen AMS, Jensen RH. Verapamil and Cluster Headache: Still a Mystery. A Narrative Review of Efficacy, Mechanisms and Perspectives. Headache 2019; 59:1198-1211. [DOI: 10.1111/head.13603] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2019] [Indexed: 01/04/2023]
Affiliation(s)
- Anja S. Petersen
- Department of Neurology, Danish Headache Center Rigshospitalet‐Glostrup Glostrup Denmark
| | - Mads C. J. Barloese
- Department of Neurology, Danish Headache Center Rigshospitalet‐Glostrup Glostrup Denmark
- Department of Clinical Physiology and Nuclear Medicine, Center for Functional and Diagnostic Imaging Hvidovre Hospital Hvidovre Denmark
| | - Agneta Snoer
- Department of Neurology, Danish Headache Center Rigshospitalet‐Glostrup Glostrup Denmark
| | - Anne Mette S. Soerensen
- Department of Clinical Pharmacology Bispebjerg and Frederiksberg Hospital Copenhagen Denmark
| | - Rigmor H. Jensen
- Department of Neurology, Danish Headache Center Rigshospitalet‐Glostrup Glostrup Denmark
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21
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Effect of Melatonin on Blood Loss After Cesarean Section: A Prospective Randomized Double-Blind Trial. J Obstet Gynaecol India 2019; 69:436-443. [PMID: 31598047 DOI: 10.1007/s13224-019-01205-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 02/05/2019] [Indexed: 01/17/2023] Open
Abstract
Background and Objectives The similarities between the melatonin and oxytocin signaling could lead to increased contractility of myometrium. We designed this randomized double-blind, placebo-controlled trial to evaluate the efficacy of melatonin in reduction of blood loss during and after the lower segment cesarean section. Methods One hundred and twenty patients who had been scheduled for cesarean section under spinal anesthesia were enrolled in the study. We randomly allocated them to one of the three following groups to receive either melatonin 3 mg (M3), melatonin 6 mg (M6), or placebo (P) sublingually 20 min before the surgery. The hemoglobin levels before and 12 h after surgery, the mean weight of the materials used in the operation time, the need for additional oxytocic therapy, and the incidence of adverse effects were probed and recorded. Results There was a significant difference between the group M6 and both M3 and P in the mean weight of the materials (p = .024 and .041, respectively) and between M6 and P groups in terms of mean decrease in hemoglobin during 12 h after cesarean section (p = .029). Conclusion Using 6 mg melatonin, sublingually, as a premedication in patients undergoing cesarean section with spinal anesthesia could statistically reduce the amount of blood loss after the lower segment cesarean section, although it may not be clinically meaningful.Registration number: ACTRN12612000117819 and ClinicalTrials.gov Identifier: NCT01572805.
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McLean A, Becker WJ, Vujadinovic Z. Making a new-patient headache education session more patient-centered: what participants want to know. Disabil Rehabil 2019; 42:1462-1473. [PMID: 30689453 DOI: 10.1080/09638288.2018.1526337] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Purpose: To describe the new-patient Education Session provided by the Calgary Headache Assessment and Management Program, analyze patient evaluations, and generate potential patient-centered improvements based on themes in patient feedback.Materials and Methods: Between 2008 and 2012, 1873 new patients attended the Education Session, and 913 evaluations were completed. Session objectives ratings were analyzed. Open-ended questions regarding most- and least-helpful components and suggestions for improvement were examined using thematic analysis.Results: Eighty-seven percent of respondents indicated they would recommend the session to others with headache. Median objectives ratings ranged from 9.0-10.0 out of 10 and were stable over time. Most-helpful themes included medication, types of headache, our program's multi-faceted management approach, medication overuse, triggers, and not feeling alone. Most respondents left the least-useful and suggestions sections blank or commented "nothing" or "not applicable". Least-useful themes included migraine overemphasis, insufficient or excessive medication content, participant over-disclosure, and lack of practical trigger management strategies.Conclusion: Most attendees found the Education Session useful. Those who did not provided valuable input that will allow us to modify the content. Our findings may benefit other headache programs seeking to implement or improve patient education programing. Implications for RehabilitationHeadache is a common and debilitating condition.Education is an important part of headache treatment, and has been associated with decreases in headache frequency, intensity, and disability, as well as increases in self-efficacy.A new-patient Education Session is a practical and inexpensive way to provide evidence-based medical and behavioral headache information.Quantitative and qualitative analysis of patient evaluations can help gauge relevance and direct content changes.
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Affiliation(s)
- Allison McLean
- Calgary Headache Assessment and Management Program, Alberta Health Services, Calgary Canada
| | - Werner J Becker
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Zorana Vujadinovic
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
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Vukovic Cvetkovic V, Jensen RH. Neurostimulation for the treatment of chronic migraine and cluster headache. Acta Neurol Scand 2019; 139:4-17. [PMID: 30291633 DOI: 10.1111/ane.13034] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 09/17/2018] [Accepted: 10/02/2018] [Indexed: 12/17/2022]
Abstract
Small subsets of patients who fail to respond to pharmacological treatment may benefit from alternative treatment methods. In the last decade, neurostimulation is being explored as a potential treatment option for the patients with chronic, severely disabling refractory primary headaches. To alleviate pain, specific nerves and brain areas have been stimulated, and various methods have been explored: deep brain stimulation, occipital nerve stimulation, and sphenopalatine ganglion stimulation are among the more invasive ones, whereas transcranial magnetic stimulation and supraorbital nerve stimulation are noninvasive. Vagal nerve stimulation can be invasive or noninvasive, though this review included only data for noninvasive VNS. Most of these methods have been tested in small open-label patient series; recently, more data from randomized, controlled, and blinded studies are available. Although neurostimulation treatments have demonstrated good efficacy in many studies, it still has not been established as a standard treatment in refractory patients. This review analyzes the available evidence regarding efficacy and safety of different neurostimulation modalities for the treatment of chronic migraine and cluster headache.
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24
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Seeger S. Cluster Headache and Other Trigeminal Autonomic Cephalalgias. Pain 2019. [DOI: 10.1007/978-3-319-99124-5_122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Wei J, Robbins MS. Greater Occipital Nerve Injection versus Oral Steroids for Short Term Prophylaxis of Cluster Headache: A Retrospective Comparative Study. Headache 2018; 58:852-858. [DOI: 10.1111/head.13334] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2018] [Indexed: 01/03/2023]
Affiliation(s)
- Jerry Wei
- Department of Neurology; Montefiore Headache Center; Bronx NY USA
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26
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Choong CK, Ford JH, Nyhuis AW, Joshi SG, Robinson RL, Aurora SK, Martinez JM. Clinical Characteristics and Treatment Patterns Among Patients Diagnosed With Cluster Headache in U.S. Healthcare Claims Data. Headache 2017; 57:1359-1374. [PMID: 28581025 PMCID: PMC5655925 DOI: 10.1111/head.13127] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 04/05/2017] [Accepted: 04/21/2017] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To characterize demographics, clinical characteristics, and treatment patterns of patients with cluster headache (CH). BACKGROUND CH is an uncommon trigeminal autonomic cephalalgia with limited evidence-based treatment options. Patients suffer from extremely painful unilateral headache attacks and autonomic symptoms with episodic and chronic cycles. DESIGN/METHODS This retrospective analysis used insurance claims from Truven Health Analytics MarketScan® research databases from 2009 to 2014. Two cohorts were compared: CH patients (with ≥2 CH claims) were propensity score matched with 4 non-headache controls, all with continuous enrollment for 12 months before and after the date of first CH claim or matched period among controls. RESULTS CH patients (N = 7589) were mainly male (57.4%) and 35-64 years old (73.2%), with significantly more claims for comorbid conditions vs controls (N = 30,341), including depressive disorders (19.8% vs 10.0%), sleep disturbances (19.7% vs 9.1%), anxiety disorders (19.2% vs 8.7%), and tobacco use disorders (12.8% vs 5.3%), with 2.5 times greater odds of suicidal ideation (all P < .0001). Odds of drug dependence were 3-fold greater among CH patients (OR = 2.8 [95% CI 2.3-3.4, P < .0001]). CH patients reported significantly greater use of prescription medications compared with controls; 25% of CH patients had >12 unique prescription drug claims. Most commonly prescribed drug classes for CH patients included: opiate agonists (41%), corticosteroids (34%), 5HT-1 agonists (32%), antidepressants (31%), NSAIDs (29%), anticonvulsants (28%), calcium antagonists (27%), and benzodiazepines (22%). Only 30.4% of CH patients received recognized CH treatments without opioids during the 12-month post-index period. These patients were less likely to visit emergency departments or need hospitalizations (26.8%) as compared to CH patients with no pharmacy claims for recognized CH treatments or opioids (33.6%; P < .0001). CONCLUSIONS The burden of CH is associated with significant co-morbidity, including substance use disorders and suicidal ideation, and treatment patterns indicating low use of recognized CH treatments.
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Affiliation(s)
| | | | | | - Shivang G. Joshi
- Community Neuroscience Services, Westborough, and MCPHS UniversityWorcesterMAUSA .
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Tepper SJ, Duplin J, Nye B, Tepper DE. Prescribing Oxygen for Cluster Headache: A Guide for the Provider. Headache 2017; 57:1428-1430. [PMID: 28857152 DOI: 10.1111/head.13180] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 08/07/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Oxygen is the standard of care for acute treatment of cluster headache. CMS, the US Centers for Medicaid and Medicare Services, has made the indefensible decision to not cover oxygen for cluster headache for patients with Medicaid and Medicare insurance, despite the evidence and professional guidelines. Commercial insurance generally covers oxygen for cluster headache. OBJECTIVE This is a "how-to" guide for successfully prescribing oxygen in the US. SUMMARY Prescription information is provided that can be incorporated as dot phrases, smart sets, or other standard templates for prescribing oxygen for cluster patients. In many states, oxygen is affordable and can be prescribed for Medicaid and Medicare patients who wish to pay cash. Welding or nonmedical grade industrial oxygen is almost the same cost as medical oxygen. However, it is less pure, lacks the same inspection of tanks, and is delivered without regulators to provide appropriate flow rates. Patients who pay cash should be strongly encouraged to buy medical oxygen.
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Affiliation(s)
- Stewart J Tepper
- Dartmouth Headache Center, Neurology Department, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Jessica Duplin
- Dartmouth Headache Center, Neurology Department, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Barbara Nye
- Dartmouth Headache Center, Neurology Department, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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28
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O'Brien M, Ford JH, Aurora SK, Govindan S, Tepper DE, Tepper SJ. Economics of Inhaled Oxygen Use as an Acute Therapy for Cluster Headache in the United States of America. Headache 2017; 57:1416-1427. [DOI: 10.1111/head.13167] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 05/25/2017] [Accepted: 05/25/2017] [Indexed: 01/03/2023]
Affiliation(s)
| | | | | | | | | | - Stewart J. Tepper
- Geisel School of Medicine at Dartmouth; Hanover NH, USA (S.J. Tepper)
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29
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Robbins MS, Starling AJ, Pringsheim TM, Becker WJ, Schwedt TJ. Treatment of Cluster Headache: The American Headache Society Evidence-Based Guidelines. Headache 2017; 56:1093-106. [PMID: 27432623 DOI: 10.1111/head.12866] [Citation(s) in RCA: 144] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 05/10/2016] [Indexed: 01/03/2023]
Abstract
BACKGROUND Cluster headache (CH), the most common trigeminal autonomic cephalalgia, is an extremely debilitating primary headache disorder that is often not optimally treated. New evidence-based treatment guidelines for CH will assist clinicians with identifying and choosing among current treatment options. OBJECTIVES In this systematic review we appraise the available evidence for the acute and prophylactic treatment of CH, and provide an update of the 2010 American Academy of Neurology (AAN) endorsed systematic review. METHODS Medline, PubMed, and EMBASE databases were searched for double-blind, randomized controlled trials that investigated treatments of CH in adults. Exclusion and inclusion criteria were identical to those utilized in the 2010 AAN systematic review. RESULTS AND RECOMMENDATIONS For acute treatment, sumatriptan subcutaneous, zolmitriptan nasal spray, and high flow oxygen remain the treatments with a Level A recommendation. Since the 2010 review, a study of sphenopalatine ganglion stimulation was added to the current guideline and has been administered a Level B recommendation for acute treatment. For prophylactic therapy, previously there were no treatments that were administered a Level A recommendation. For the current guidelines, suboccipital steroid injections have emerged as the only treatment to receive a Level A recommendation with the addition of a second Class I study. Other newly evaluated treatments since the 2010 guidelines have been given a Level B recommendation (negative study: deep brain stimulation), a Level C recommendation (positive study: warfarin; negative studies: cimetidine/chlorpheniramine, candesartan), or a Level U recommendation (frovatriptan). CONCLUSIONS This AHS guideline can be utilized for understanding which therapies have superiority to placebo or sham treatment in the management of CH. In clinical practice, these recommendations should be considered in concert with other variables including safety, side effects, patient preferences, clinician experience, cost, and the invasiveness of the intervention. Given the lack of Class I evidence and Level A recommendations, particularly for a number of commonly used preventive therapies, further studies are warranted to demonstrate safety and efficacy for established and emerging therapies.
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Affiliation(s)
- Matthew S Robbins
- Montefiore Headache Center, Albert Einstein College of Medicine, Bronx, NY, USA
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30
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Tepper SJ, Caparso A. Sphenopalatine Ganglion (SPG): Stimulation Mechanism, Safety, and Efficacy. Headache 2017; 57 Suppl 1:14-28. [PMID: 28387016 DOI: 10.1111/head.13035] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 12/14/2016] [Accepted: 12/15/2016] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To describe the history of and available data on sphenopalatine ganglion (SPG) neuromodulation in the treatment of headache up to the present. BACKGROUND The SPG has been a therapeutic target to treat primary headache disorders for over 100 years. Multiple destructive lesions have also been tried with variable rate and duration of success. Neurostimulation of the SPG for cluster headache was first described in 2007. METHODS This is not a systematic review. The authors review the anatomy and pathophysiology of the SPG and cluster headache and the important clinical trials, relating a history of how SPG neuromodulation reached the current state of approval in the European Union (EU) and pivotal registration study for cluster headache in the US. RESULTS The EU approved SPG stimulation for cluster headache with a CE Mark in February of 2012. Since then, several EU countries have elected to reimburse implantation for cluster headache, and over 300 patients have been implanted worldwide. CONCLUSIONS Success rates for implanted SPG neuromodulation in the experimental phase of the European randomized controlled trial, in the open label extension trial, and in the registry of patients implanted outside of the trial remain at about two-thirds of patients implanted being responders, defined as being able to terminate at least 50% of attacks or having at least a 50% decrease in attack frequency or both. A US pivotal registration study is underway to confirm these results and obtain FDA approval for this treatment for cluster headache patients. Further studies in migraine are also underway.
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Affiliation(s)
- Stewart J Tepper
- Department of Neurology, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
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Silberstein SD, Mechtler LL, Kudrow DB, Calhoun AH, McClure C, Saper JR, Liebler EJ, Rubenstein Engel E, Tepper SJ. Non-Invasive Vagus Nerve Stimulation for the ACute Treatment of Cluster Headache: Findings From the Randomized, Double-Blind, Sham-Controlled ACT1 Study. Headache 2017; 56:1317-32. [PMID: 27593728 PMCID: PMC5113831 DOI: 10.1111/head.12896] [Citation(s) in RCA: 164] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 05/11/2016] [Accepted: 06/10/2016] [Indexed: 01/03/2023]
Abstract
Objective To evaluate non‐invasive vagus nerve stimulation (nVNS) as an acute cluster headache (CH) treatment. Background Many patients with CH experience excruciating attacks at a frequency that is not sufficiently addressed by current symptomatic treatments. Methods One hundred fifty subjects were enrolled and randomized (1:1) to receive nVNS or sham treatment for ≤1 month during a double‐blind phase; completers could enter a 3‐month nVNS open‐label phase. The primary end point was response rate, defined as the proportion of subjects who achieved pain relief (pain intensity of 0 or 1) at 15 minutes after treatment initiation for the first CH attack without rescue medication use through 60 minutes. Secondary end points included the sustained response rate (15‐60 minutes). Subanalyses of episodic cluster headache (eCH) and chronic cluster headache (cCH) cohorts were prespecified. Results The intent‐to‐treat population comprised 133 subjects: 60 nVNS‐treated (eCH, n = 38; cCH, n = 22) and 73 sham‐treated (eCH, n = 47; cCH, n = 26). A response was achieved in 26.7% of nVNS‐treated subjects and 15.1% of sham‐treated subjects (P = .1). Response rates were significantly higher with nVNS than with sham for the eCH cohort (nVNS, 34.2%; sham, 10.6%; P = .008) but not the cCH cohort (nVNS, 13.6%; sham, 23.1%; P = .48). Sustained response rates were significantly higher with nVNS for the eCH cohort (P = .008) and total population (P = .04). Adverse device effects (ADEs) were reported by 35/150 (nVNS, 11; sham, 24) subjects in the double‐blind phase and 18/128 subjects in the open‐label phase. No serious ADEs occurred. Conclusions In one of the largest randomized sham‐controlled studies for acute CH treatment, the response rate was not significantly different (vs sham) for the total population; nVNS provided significant, clinically meaningful, rapid, and sustained benefits for eCH but not for cCH, which affected results in the total population. This safe and well‐tolerated treatment represents a novel and promising option for eCH. ClinicalTrials.gov identifier: NCT01792817.
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Affiliation(s)
| | - Laszlo L Mechtler
- Department of Neurology and Neuro-Oncology, Dent Neurologic Headache Center, Amherst, NY, USA
| | - David B Kudrow
- California Medical Clinic for Headache, Santa Monica, CA, USA
| | | | | | - Joel R Saper
- Michigan Head Pain and Neurological Institute, Ann Arbor, MI, USA
| | - Eric J Liebler
- Department of Scientific, Medical and Governmental Affairs, electroCore, LLC, Basking Ridge, NJ, USA
| | | | - Stewart J Tepper
- Department of Neurology, Geisel School of Medicine at Dartmouth, Hanover, NH, USA.,Dr. Tepper was at Cleveland Clinic Headache Center, Cleveland, OH, at the time of study completion
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Gaul C, Magis D, Liebler E, Straube A. Effects of non-invasive vagus nerve stimulation on attack frequency over time and expanded response rates in patients with chronic cluster headache: a post hoc analysis of the randomised, controlled PREVA study. J Headache Pain 2017; 18:22. [PMID: 28197844 PMCID: PMC5309191 DOI: 10.1186/s10194-017-0731-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 02/07/2017] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND In the PREVention and Acute treatment of chronic cluster headache (PREVA) study, attack frequency reductions from baseline were significantly more pronounced with non-invasive vagus nerve stimulation plus standard of care (nVNS + SoC) than with SoC alone. Given the intensely painful and frequent nature of chronic cluster headache attacks, additional patient-centric outcomes, including the time to and level of therapeutic response, were evaluated in a post hoc analysis of the PREVA study. FINDINGS After a 2-week baseline phase, 97 patients with chronic cluster headache entered a 4-week randomised phase to receive nVNS + SoC (n = 48) or SoC alone (n = 49). All 92 patients who continued into a 4-week extension phase received nVNS + SoC. Compared with SoC alone, nVNS + SoC led to a significantly lower mean weekly attack frequency by week 2 of the randomised phase; the attack frequency remained significantly lower in the nVNS + SoC group through week 3 of the extension phase (P < 0.02). Attack frequencies in the nVNS + SoC group were significantly lower at all study time points than they were at baseline (P < 0.05). Response rates were significantly greater with nVNS + SoC than with SoC alone when response was defined as attack frequency reductions of ≥25%, ≥50%, and ≥75% from baseline (≥25% and ≥50%, P < 0.001; ≥75%, P = 0.009). The 100% response rate was 8% with nVNS + SoC and 0% with SoC alone. CONCLUSIONS Prophylactic nVNS led to rapid, significant, and sustained reductions in chronic cluster headache attack frequency within 2 weeks after its addition to SoC and was associated with significantly higher ≥25%, ≥50%, and ≥75% response rates than SoC alone. The rapid decrease in weekly attack frequency justifies a 4-week trial period to identify responders to nVNS, with a high degree of confidence, among patients with chronic cluster headache.
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Affiliation(s)
- Charly Gaul
- Department of Headache and Facial Pain, Migraine and Headache Clinic, Ölmühlweg 31, Königstein im Taunus, 61462, Germany.
| | - Delphine Magis
- Headache Research Unit, University Department of Neurology, Centre Hospitalier Régional de la Citadelle, Boulevard du 12ème de Ligne 1, 4000, Liège, Belgium
| | - Eric Liebler
- electroCore, LLC, 150 Allen Road, Suite 201, Basking Ridge, 07920, NJ, USA
| | - Andreas Straube
- Department of Neurology, Ludwig-Maximilian University, Marchioninistr 15, Munich, D81377, Germany
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Koppen H, Stolwijk J, Wilms EB, van Driel V, Ferrari MD, Haan J. Cardiac monitoring of high-dose verapamil in cluster headache: An international Delphi study. Cephalalgia 2016; 36:1385-1388. [DOI: 10.1177/0333102416631968] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 01/04/2016] [Accepted: 01/07/2016] [Indexed: 11/16/2022]
Abstract
Background In many patients, high-dose verapamil (HDV) is the only effective prophylactic treatment for cluster headache. Although cardiac adverse events and EKG abnormalities are relatively common, evidence-based guidelines for screening and monitoring patients on HDV are lacking. Goal and methods Using the Delphi approach, we interviewed 22 international clinical experts in cardiac rhythm disorders to formulate EKG guidelines for the pretreatment screening and monitoring of cluster headache patients using HDV. Results The panel agreed only on performing pretreatment EKG to screen for pre-existing cardiac arrhythmia. Pretreatment EKG was deemed not necessary by most panel members for patients who did not have cardiac adverse events during a previous period of cluster headache attacks treated with HDV. Half the panel advised Holter EKG for patients on verapamil ≥ 480 mg/day. The highest recommended daily doses varied between 240 and 960 mg. Contraindications for use of verapamil largely followed FDA guidelines. Discussion Experts in cardiac rhythm disorders agreed on pretreatment EKG monitoring, but no consensus was reached on EKG monitoring during HDV treatment and around dose adjustments.
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Affiliation(s)
- H Koppen
- Department of Neurology, Haga Hospital, The Netherlands
| | - J Stolwijk
- Department of Neurology, Haga Hospital, The Netherlands
| | - EB Wilms
- Department of Clinical Pharmacy, Haga Hospital, The Netherlands
| | - V van Driel
- Department of Cardiology Haga Hospital, The Netherlands
| | - MD Ferrari
- Department of Neurology, Leiden University Medical Center, The Netherlands
| | - J Haan
- Department of Neurology, Rijnland Hospital Leiderdorp and Leiden University Medical Center, The Netherlands
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de Andrés F, Lionetto L, Curto M, Capi M, Cipolla F, Negro A, Martelletti P. Acute, transitional and long-term cluster headache treatment: pharmacokinetic issues. Expert Opin Drug Metab Toxicol 2016; 12:1011-20. [DOI: 10.1080/17425255.2016.1201067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Fernando de Andrés
- CICAB Clinical Research Centre, Extremadura University Hospital and Medical School, Badajoz, Spain
| | - Luana Lionetto
- Advanced Molecular Diagnostics Unit, IDI-IRCCS, Rome, Italy
| | - Martina Curto
- Department of Molecular Medicine, Sant’Andrea Medical Center, Sapienza University of Rome, Rome, Italy
- Regional Referral Headache Center, Sant’Andrea Hospital, Rome, Italy
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Matilde Capi
- NESMOS Department, Sapienza University of Rome, Rome, Italy
| | | | - Andrea Negro
- Department of Molecular Medicine, Sant’Andrea Medical Center, Sapienza University of Rome, Rome, Italy
- Regional Referral Headache Center, Sant’Andrea Hospital, Rome, Italy
| | - Paolo Martelletti
- Department of Molecular Medicine, Sant’Andrea Medical Center, Sapienza University of Rome, Rome, Italy
- Regional Referral Headache Center, Sant’Andrea Hospital, Rome, Italy
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Morris J, Straube A, Diener HC, Ahmed F, Silver N, Walker S, Liebler E, Gaul C. Cost-effectiveness analysis of non-invasive vagus nerve stimulation for the treatment of chronic cluster headache. J Headache Pain 2016; 17:43. [PMID: 27102120 PMCID: PMC4840129 DOI: 10.1186/s10194-016-0633-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 04/07/2016] [Indexed: 01/03/2023] Open
Abstract
Background Cluster headache (CH) is a debilitating condition that is generally associated with substantial health care costs. Few therapies are approved for abortive or prophylactic treatment. Results from the prospective, randomised, open-label PREVA study suggested that adjunctive treatment with a novel non-invasive vagus nerve stimulation (nVNS) device led to decreased attack frequency and abortive medication use in patients with chronic CH (cCH). Herein, we evaluate whether nVNS is cost-effective compared with the current standard of care (SoC) for cCH. Methods A pharmacoeconomic model from the German statutory health insurance perspective was developed to estimate the 1-year cost-effectiveness of nVNS + SoC (versus SoC alone) using data from PREVA. Short-term treatment response data were taken from the clinical trial; longer-term response was modelled under scenarios of response maintenance, constant rate of response loss, and diminishing rate of response loss. Health-related quality of life was estimated by modelling EQ-5D™ data from PREVA; benefits were defined as quality-adjusted life-years (QALY). Abortive medication use data from PREVA, along with costs for the nVNS device and abortive therapies (i.e. intranasal zolmitriptan, subcutaneous sumatriptan, and inhaled oxygen), were used to assess health care costs in the German setting. Results The analysis resulted in mean expected yearly costs of €7096.69 for nVNS + SoC and €7511.35 for SoC alone and mean QALY of 0.607 for nVNS + SoC and 0.522 for SoC alone, suggesting that nVNS generates greater health benefits for lower overall cost. Abortive medication costs were 23 % lower with nVNS + SoC than with SoC alone. In the alternative scenarios (i.e. constant rate of response loss and diminishing rate of response loss), nVNS + SoC was more effective and cost saving than SoC alone. Conclusions In all scenarios modelled from a German perspective, nVNS was cost-effective compared with current SoC, which suggests that adjunctive nVNS therapy provides economic benefits in the treatment of cCH. Notably, the current analysis included only costs associated with abortive treatments. Treatment with nVNS will likely promote further economic benefit when other potential sources of cost savings (e.g. reduced frequency of clinic visits) are considered. Trial registration Clinicaltrials.gov identifier NCT01701245, 03OCT2012.
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Affiliation(s)
- James Morris
- Cogentia Healthcare Consulting Ltd., Richmond House, 16-20 Regent Street, Cambridge, CB2 1DB, UK.
| | - Andreas Straube
- Ludwig Maximilian University of Munich, Marchioninistr 15, Munich, D81377, Germany
| | - Hans-Christoph Diener
- Department of Neurology and Headache Center, University Hospital Essen, Hufelandstrasse 55, 45122, Essen, Germany
| | - Fayyaz Ahmed
- Hull and Yorkshire Hospitals, Hull Royal Infirmary, Anlaby Road, Hull, HU3 2JZ, UK
| | - Nicholas Silver
- The Walton Centre for Neurology and Neurosurgery, Lower Lane, Liverpool, L9 7LJ, UK
| | - Simon Walker
- Cogentia Healthcare Consulting Ltd., Richmond House, 16-20 Regent Street, Cambridge, CB2 1DB, UK
| | - Eric Liebler
- electroCore, LLC, 150 Allen Road, Suite 201, Basking Ridge, NJ, 07920, USA
| | - Charly Gaul
- Department of Neurology and Headache Center, University Hospital Essen, Hufelandstrasse 55, 45122, Essen, Germany.,Migraine and Headache Clinic Königstein, Ölmühlweg 31, 61462, Königstein im Taunus, Germany
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Tariq N, Estemalik E, Vij B, Kriegler JS, Tepper SJ, Stillman MJ. Long-Term Outcomes and Clinical Characteristics of Hypnic Headache Syndrome: 40 Patients Series From a Tertiary Referral Center. Headache 2016; 56:717-24. [DOI: 10.1111/head.12796] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Nauman Tariq
- Michigan Headache & Neurological Institute; Ann Arbor MI USA (N. Tariq); the Cleveland Clinic, Cleveland, OH, USA (E. Estemalik, B. Vij, J.S. Kriegler, M.J. Stillman); Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA (S.J. Tepper)
| | - Emad Estemalik
- Michigan Headache & Neurological Institute; Ann Arbor MI USA (N. Tariq); the Cleveland Clinic, Cleveland, OH, USA (E. Estemalik, B. Vij, J.S. Kriegler, M.J. Stillman); Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA (S.J. Tepper)
| | - Brinder Vij
- Michigan Headache & Neurological Institute; Ann Arbor MI USA (N. Tariq); the Cleveland Clinic, Cleveland, OH, USA (E. Estemalik, B. Vij, J.S. Kriegler, M.J. Stillman); Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA (S.J. Tepper)
| | - Jennifer S. Kriegler
- Michigan Headache & Neurological Institute; Ann Arbor MI USA (N. Tariq); the Cleveland Clinic, Cleveland, OH, USA (E. Estemalik, B. Vij, J.S. Kriegler, M.J. Stillman); Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA (S.J. Tepper)
| | - Stewart J. Tepper
- Michigan Headache & Neurological Institute; Ann Arbor MI USA (N. Tariq); the Cleveland Clinic, Cleveland, OH, USA (E. Estemalik, B. Vij, J.S. Kriegler, M.J. Stillman); Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA (S.J. Tepper)
| | - Mark J. Stillman
- Michigan Headache & Neurological Institute; Ann Arbor MI USA (N. Tariq); the Cleveland Clinic, Cleveland, OH, USA (E. Estemalik, B. Vij, J.S. Kriegler, M.J. Stillman); Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA (S.J. Tepper)
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Holle-Lee D, Gaul C. Noninvasive vagus nerve stimulation in the management of cluster headache: clinical evidence and practical experience. Ther Adv Neurol Disord 2016; 9:230-4. [PMID: 27134678 DOI: 10.1177/1756285616636024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The efficacy of invasive vagal nerve stimulation as well as other invasive neuromodulatory approaches such as deep brain stimulation, occipital nerve stimulation, and ganglion sphenopalatine stimulation has been shown in the treatment of headache disorders in several studies in the past. However, these invasive treatment options were quite costly and often associated with perioperative and postoperative side effects, some severe. As such, they were predominantly restricted to chronic and therapy refractory patients. Transcutaneous vagal nerve stimulation now offers a new, noninvasive neuromodulatory treatment approach. Recently published studies showed encouraging results of noninvasive vagus nerve stimulation (nVNS), especially with respect to cluster headache, with high tolerability and a low rate of side effects; however, randomized controlled trials are needed to prove its efficacy. Further data also indicate therapeutic benefits regarding treatment of migraine and medication overuse headache. This review summarizes current knowledge and personal experiences of nVNS in the treatment of cluster headache.
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Affiliation(s)
- Dagny Holle-Lee
- Department of Neurology and Westgerman Headache Center Essen, University Hospital Essen, Hufelandstr. 55, 45127 Essen, Germany
| | - Charly Gaul
- Migräne- und Kopfschmerzklinik Königstein, Ölmühlweg 31, 61462 Königstein im Taunus, Germany
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Bennett MH, French C, Schnabel A, Wasiak J, Kranke P, Weibel S. Normobaric and hyperbaric oxygen therapy for the treatment and prevention of migraine and cluster headache. Cochrane Database Syst Rev 2015; 2015:CD005219. [PMID: 26709672 PMCID: PMC8720466 DOI: 10.1002/14651858.cd005219.pub3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Migraine and cluster headaches are severe and disabling. Migraine affects up to 18% of women, while cluster headaches are much less common (0.2% of the population). A number of acute and prophylactic therapies are available. Hyperbaric oxygen therapy (HBOT) is the therapeutic administration of 100% oxygen at environmental pressures greater than one atmosphere, while normobaric oxygen therapy (NBOT) is oxygen administered at one atmosphere. This is an updated version of the original Cochrane review published in Issue 3, 2008 under the title 'Normobaric and hyperbaric oxygen for migraine and cluster headache'. OBJECTIVES To examine the efficacy and safety of normobaric oxygen therapy (NBOT) and hyperbaric oxygen therapy (HBOT) in the treatment and prevention of migraine and cluster headache. SEARCH METHODS We updated searches of the following databases up to 15 June 2015: CENTRAL (the Cochrane Library), MEDLINE, EMBASE, and CINAHL. For the original review we searched the following databases up to May 2008: CENTRAL, MEDLINE, EMBASE, CINAHL, DORCTIHM, and reference lists from relevant articles. We handsearched relevant journals and contacted researchers to identify trials. SELECTION CRITERIA Randomised controlled trials comparing HBOT or NBOT with one another, other active therapies, placebo (sham) interventions, or no treatment in participants with migraine or cluster headache. DATA COLLECTION AND ANALYSIS Three review authors independently extracted data and assessed the quality of the evidence using the GRADE approach. MAIN RESULTS In this update, we included 11 trials with 209 participants. Five trials (103 participants) compared HBOT versus sham therapy for acute migraine, three trials compared NBOT to sham therapy or ergotamine tartrate for cluster headache (145 participants), two trials evaluated HBOT for cluster headache (29 participants), and one trial (56 participants) compared NBOT to sham for a mixed group of headache. The risk of bias varied considerably across these trials but in general trial quality was poor to moderate. One trial may not have been truly randomised and two included studies were reported as abstracts only. Seven trials did not indicate allocation concealment or randomisation method. Notably, 10 of the 11 trials used a sham comparator therapy and masked the outcome assessor to allocation.We pooled data from three trials, which suggested that HBOT was effective in relieving migraine headaches compared to sham therapy (risk ratio (RR) 6.21, 95% CI 2.41 to 16.00; 58 participants, three trials). The quality of evidence was low, having been downgraded for small crossover studies with incomplete reporting. There was no evidence that HBOT could prevent migraine episodes, reduce the incidence of nausea and vomiting, or reduce the requirement for rescue medication. There was no evidence that HBOT was effective for the termination of cluster headache (RR 11.38, 95% CI 0.77 to 167.85; P = 0.08) (one trial), but this trial had low power.NBOT was effective in terminating cluster headache compared to sham in a single small study (RR 7.88, 95% CI 1.13 to 54.66), but not superior to ergotamine administration in another small trial (RR 1.17, 95% CI 0.94 to 1.46; P = 0.16). A third trial reported a statistically significant difference in the proportion of attacks successfully treated with oxygen (117 of 150 attacks were successfully treated with NBOT (78%) versus 30 of 148 attacks treated with NBOT (20%)). The proportion of responders was consistent across these three trials, and suggested more than 75% of headaches were likely to respond to NBOT.No serious adverse events during HBOT or NBOT were reported. AUTHORS' CONCLUSIONS Since the last version of this review, two new included studies have provided additional information to change the conclusions. There was some evidence that HBOT was effective for the termination of acute migraine in an unselected population, and some evidence that NBOT was similarly effective in cluster headache. Given the cost and poor availability of HBOT, more research should be done on patients unresponsive to standard therapy. NBOT is cheap, safe, and easy to apply, so will probably continue to be used despite the limited evidence in this review.
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Affiliation(s)
- Michael H Bennett
- Prince of Wales Clinical School, University of NSWDepartment of AnaesthesiaSydneyNSWAustralia
| | - Christopher French
- University of MelbourneDepartment of Medicine (RMH)MBC Neurosciences BuildingParkvilleMelbourneVictoriaAustralia
| | - Alexander Schnabel
- University of WürzburgDepartment of Anaesthesia and Critical CareOberduerrbacher Str. 6WürzburgGermany
| | - Jason Wasiak
- The Epworth HospitalDepartment of Radiation Oncology89 Bridge RdRichmondAustralia3121
| | - Peter Kranke
- University of WürzburgDepartment of Anaesthesia and Critical CareOberduerrbacher Str. 6WürzburgGermany
| | - Stephanie Weibel
- University of WürzburgDepartment of Anaesthesia and Critical CareOberduerrbacher Str. 6WürzburgGermany
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Abstract
Cluster headache (CH), one of the most painful syndromes known to man, is managed with acute and preventive medications. The brief duration and severity of the attacks command the use of rapid-acting pain relievers. Inhalation of oxygen and subcutaneous sumatriptan are the two most effective acute therapeutic options for sufferers of CH. Several preventive medications are available, the most effective of which is verapamil. However, most of these agents are not backed by strong clinical evidence. In some patients, these options can be ineffective, especially in those who develop chronic CH. Surgical procedures for the chronic refractory form of the disorder should then be contemplated, the most promising of which is hypothalamic deep brain stimulation. We hereby review the pathogenesis of CH and the evidence behind the treatment options for this debilitating condition.
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Affiliation(s)
- Rubesh Gooriah
- Department of Neurology, Hull Royal Infirmary, Kingston upon Hull, UK
| | - Alina Buture
- Department of Neurology, Hull Royal Infirmary, Kingston upon Hull, UK
| | - Fayyaz Ahmed
- Department of Neurology, Hull Royal Infirmary, Kingston upon Hull, UK
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Gaul C, Diener HC, Silver N, Magis D, Reuter U, Andersson A, Liebler EJ, Straube A. Non-invasive vagus nerve stimulation for PREVention and Acute treatment of chronic cluster headache (PREVA): A randomised controlled study. Cephalalgia 2015; 36:534-46. [PMID: 26391457 PMCID: PMC4853813 DOI: 10.1177/0333102415607070] [Citation(s) in RCA: 163] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 08/27/2015] [Indexed: 12/21/2022]
Abstract
Background Chronic cluster headache (CH) is a debilitating disorder for which few well-controlled studies demonstrate effectiveness of available therapies. Non-invasive vagus nerve stimulation (nVNS) was examined as adjunctive prophylactic treatment of chronic CH. Methods PREVA was a prospective, open-label, randomised study that compared adjunctive prophylactic nVNS (n = 48) with standard of care (SoC) alone (control (n = 49)). A two-week baseline phase was followed by a four-week randomised phase (SoC plus nVNS vs control) and a four-week extension phase (SoC plus nVNS). The primary end point was the reduction in the mean number of CH attacks per week. Response rate, abortive medication use and safety/tolerability were also assessed. Results During the randomised phase, individuals in the intent-to-treat population treated with SoC plus nVNS (n = 45) had a significantly greater reduction in the number of attacks per week vs controls (n = 48) (−5.9 vs −2.1, respectively) for a mean therapeutic gain of 3.9 fewer attacks per week (95% CI: 0.5, 7.2; p = 0.02). Higher ≥50% response rates were also observed with SoC plus nVNS (40% (18/45)) vs controls (8.3% (4/48); p < 0.001). No serious treatment-related adverse events occurred. Conclusion Adjunctive prophylactic nVNS is a well-tolerated novel treatment for chronic CH, offering clinical benefits beyond those with SoC.
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Affiliation(s)
- Charly Gaul
- Migraine and Headache Clinic, Königstein, Germany
| | | | | | | | - Uwe Reuter
- Department of Neurology, Charité University Hospital, Berlin, Germany
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Abstract
Many animal models of migraine have been described. Some of them have been useful in the development of new therapies. All of them have their shortcomings. Animal models of chronic migraine have been relatively less frequently described. Whether a rigid distinction between episodic and chronic migraine is useful when their underlying pathophysiology is likely to be the same and that migraine frequency probably depends on complex polygenic influences remains to be determined. Any model of chronic migraine must reflect the chronicity of the disorder and be reliable and validated with pharmacological interventions. Future animal models of chronic migraine are likely to involve recurrent activation of the trigeminal nociceptive system. Valid models would provide a means for investigating pathophysiological mechanism of the transformation from episodic to chronic migraine and may also be used to test the efficacy of potential preventive medications.
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Costa M, Squassina A, Piras IS, Pisanu C, Congiu D, Niola P, Angius A, Chillotti C, Ardau R, Severino G, Stochino E, Deidda A, Persico AM, Alda M, Del Zompo M. Preliminary Transcriptome Analysis in Lymphoblasts from Cluster Headache and Bipolar Disorder Patients Implicates Dysregulation of Circadian and Serotonergic Genes. J Mol Neurosci 2015; 56:688-95. [DOI: 10.1007/s12031-015-0567-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 04/14/2015] [Indexed: 12/22/2022]
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Dach F, Éckeli ÁL, Ferreira KDS, Speciali JG. Nerve block for the treatment of headaches and cranial neuralgias - a practical approach. Headache 2015; 55 Suppl 1:59-71. [PMID: 25644836 DOI: 10.1111/head.12516] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Several studies have presented evidence that blocking peripheral nerves is effective for the treatment of some headaches and cranial neuralgias, resulting in reduction of the frequency, intensity, and duration of pain. OBJECTIVES In this article we describe the role of nerve block in the treatment of headaches and cranial neuralgias, and the experience of a tertiary headache center regarding this issue. We also report the anatomical landmarks, techniques, materials used, contraindications, and side effects of peripheral nerve block, as well as the mechanisms of action of lidocaine and dexamethasone. CONCLUSIONS The nerve block can be used in primary (migraine, cluster headache, and nummular headache) and secondary headaches (cervicogenic headache and headache attributed to craniotomy), as well in cranial neuralgias (trigeminal neuropathies, glossopharyngeal and occipital neuralgias). In some of them this procedure is necessary for both diagnosis and treatment, while in others it is an adjuvant treatment. The block of the greater occipital nerve with an anesthetic and corticosteroid compound has proved to be effective in the treatment of cluster headache. Regarding the treatment of other headaches and cranial neuralgias, controlled studies are still necessary to clarify the real role of peripheral nerve block.
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Affiliation(s)
- Fabíola Dach
- Headache Clinic, University Hospital of School of Medicine, University of Sao Paulo, Ribeirao Preto, SP, Brazil
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Mitsikostas DD, Edvinsson L, Jensen RH, Katsarava Z, Lampl C, Negro A, Osipova V, Paemeleire K, Siva A, Valade D, Martelletti P. Refractory chronic cluster headache: a consensus statement on clinical definition from the European Headache Federation. J Headache Pain 2014; 15:79. [PMID: 25430992 PMCID: PMC4256964 DOI: 10.1186/1129-2377-15-79] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 11/12/2014] [Indexed: 12/31/2022] Open
Abstract
Chronic cluster headache (CCH) often resists to prophylactic pharmaceutical treatments resulting in patients’ life damage. In this rare but pragmatic situation escalation to invasive management is needed but framing criteria are lacking. We aimed to reach a consensus for refractory CCH definition for clinical and research use. The preparation of the final consensus followed three stages. Internal between authors, a larger between all European Headache Federation members and finally an international one among all investigators that have published clinical studies on cluster headache the last five years. Eighty-five investigators reached by email. Proposed criteria were in the format of the International Classification of Headache Disorders III-beta (description, criteria, notes, comments and references). Following this evaluation eight drafts were prepared before the final. Twenty-four (28.2%) international investigators commented during two rounds. Refractory CCH is described in the present consensus as a situation that fulfills the criteria of ICHD-3 beta for CCH with at least three severe attacks per week despite at least three consecutive trials of adequate preventive treatments. The condition is rare, but difficult to manage and invasive treatments may be needed. The consensus addresses five specific clinical and paraclinical diagnostic criteria followed by three notes and specific comments. Although refractory CCH may be not a separate identity these specific diagnostic criteria should help clinicians and investigators to improve patient’s quality of life.
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Affiliation(s)
- Dimos D Mitsikostas
- Athens Naval Hospital, Neurology Department, 77A Vas, Sofias Avenue, 11521 Athens, Greece.
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Schürks M, Frahnow A, Diener HC, Kurth T, Rosskopf D, Grabe HJ. Bi-allelic and tri-allelic 5-HTTLPR polymorphisms and triptan non-response in cluster headache. J Headache Pain 2014; 15:46. [PMID: 25043824 PMCID: PMC4112603 DOI: 10.1186/1129-2377-15-46] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 07/13/2014] [Indexed: 12/16/2022] Open
Abstract
Background Triptans are only effective in terminating cluster headache (CH) attacks in 70-80% of patients. Pharmacogenetic aspects of the serotonin metabolism, specifically variation in the 5-HTTLPR may be involved. Methods Genetic association study in a well-defined cohort of 148 CH patients with information on drug response to triptans. CH was diagnosed according to the criteria of the International Headache Society. Genotypes of the 43-bp insdel (rs4795541) and A > G (rs25531) polymorphisms in the 5-HTTLPR promoter region were detected by restriction fragment length polymorphism analysis. We used logistic regression analysis to investigate the association between bi-allelic and tri-allelic genotypes and triptan non-response with genotype models. Results Mean age at study entry among patients was 44.6 ± 10.5 years, 77.7% were men. The genotype distribution both for the bi-allelic and the tri-allelic polymorphism was in Hardy-Weinberg equilibrium. We did not find an association of the bi-allelic polymorphism with triptan non-response. While the effect estimates for the S variant of the tri-allelic polymorphisms suggested increased odds of triptan non-response in CH patients (multivariable-adjusted odds ratio [95% confidence interval]: L*L* genotype—reference; L*S* genotype—1.33 [0.53-3.32]; S*S* genotype—1.46 [0.54-3.98]), the results were not statistically significant. Conclusions Data from our study do not indicate a role of bi-allelic and tri-allelic genotypes of the 5-HTTLPR polymorphism in triptan non-response in CH.
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Affiliation(s)
- Markus Schürks
- Department of Neurology, University Hospital Essen, Hufelandstrasse 55, 45122 Essen, Germany.
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Benemei S, Fusi C, Trevisan G, Geppetti P. The TRPA1 channel in migraine mechanism and treatment. Br J Pharmacol 2014; 171:2552-67. [PMID: 24206166 PMCID: PMC4008999 DOI: 10.1111/bph.12512] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 10/31/2013] [Accepted: 11/04/2013] [Indexed: 01/07/2023] Open
Abstract
Migraine remains an elusive and poorly understood disease. The uncertainty is reflected by the currently unsatisfactory acute and prophylactic treatments for this disease. Genetic and pharmacological information points to the involvement of some transient receptor potential (TRP) channels in pain mechanisms. In particular, the TRP vanilloid 1 (TRPV1) and TRP ankyrin 1 (TRPA1) channels seem to play a major role in different models of pain diseases. Recent findings have underscored the possibility that TRP channels expressed in the nerve terminals of peptidergic nociceptors contribute to the migraine mechanism. Among this channel subset, TRPA1, a sensor of oxidative, nitrative and electrophilic stress, is activated by an unprecedented series of irritant and pain-provoking exogenous and endogenous agents, which release the pro-migraine peptide, calcitonin gene-related peptide, through this neuronal pathway. Some of the recently identified TRPA1 activators have long been known as migraine triggers. Furthermore, specific analgesic and antimigraine medicines have been shown to inhibit or desensitize TRPA1 channels. Thus, TRPA1 is emerging as a major contributing pathway in migraine and as a novel target for the development of drugs for pain and migraine treatment.
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Affiliation(s)
- S Benemei
- Clinical Pharmacology Unit, Department of Health Sciences, University of FlorenceFlorence, Italy
- Headache Centre, Department of Health Sciences, University of FlorenceFlorence, Italy
| | - C Fusi
- Clinical Pharmacology Unit, Department of Health Sciences, University of FlorenceFlorence, Italy
| | - Gabriela Trevisan
- Clinical Pharmacology Unit, Department of Health Sciences, University of FlorenceFlorence, Italy
| | - Pierangelo Geppetti
- Headache Centre, Department of Health Sciences, University of FlorenceFlorence, Italy
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48
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Mariani R, Capuano A, Torriero R, Tarantino S, Properzi E, Vigevano F, Valeriani M. Cluster headache in childhood: case series from a pediatric headache center. J Child Neurol 2014; 29:62-5. [PMID: 23307881 DOI: 10.1177/0883073812470735] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Childhood-onset cluster headache is an excruciatingly painful and distressing condition. A retrospective study was conducted on charts of patients referring to our Headache Center. Those diagnosed as cluster headache were selected. We identified 11 children (6 males and 5 females). The mean age of cluster headache onset was 10 years (range: 5-16). All children had episodic cluster headache. All children had unilateral orbital pain; 7 patients had throbbing pain, whereas 4 children complained stabbing pain. The mean duration of the attack was 86 minutes (ranging from 30 to 180 minutes). The frequency of episodes was between 1 and 4 per day. All children had the typical cluster headache autonomic features, such as lacrimation, conjunctival injection, ptosis, and nostril rhinorrhea. Steroids showed a good clinical efficacy in interrupting cluster headache recurrence. As symptomatic drugs, acetaminophen as well as ibuprofen were ineffective; indomethacin was effective in 1 case.
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Affiliation(s)
- Rosanna Mariani
- 1Headache Centre, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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49
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Tepper SJ, Stillman MJ. Cluster Headache: Potential Options for Medically Refractory Patients (When All Else Fails). Headache 2013; 53:1183-90. [DOI: 10.1111/head.12148] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Stewart J. Tepper
- Headache Center, Neurological Center for Pain; Cleveland Clinic; Cleveland; OH; USA
| | - Mark J. Stillman
- Headache Center, Neurological Center for Pain; Cleveland Clinic; Cleveland; OH; USA
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Becker WJ. Cluster headache: conventional pharmacological management. Headache 2013; 53:1191-6. [PMID: 23773141 DOI: 10.1111/head.12145] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2013] [Indexed: 11/28/2022]
Abstract
Cluster headache pain is very intense, usually increases in intensity very rapidly from onset, and attacks are often frequent. These clinical features result in significant therapeutic challenges. The most effective pharmacological treatment options for acute cluster attack include subcutaneous sumatriptan, 100% oxygen, and intranasal zolmitriptan. Subcutaneous or intramuscular dihydroergotamine and intranasal sumatriptan are additional options. Transitional therapy is applicable mainly for patients with high-frequency (>2 attacks per day) episodic cluster headache, and options include short courses of high-dose oral corticosteroids, dihydroergotamine, and occipital nerve blocks with local anesthetic and steroids. Prophylactic therapy is important both for episodic and chronic cluster headache, and the main options are verapamil and lithium. Verapamil is drug of first choice but may cause cardiac arrhythmias, and periodic electrocardiograms (EKGs) during dose escalation are important. Many other drugs are also in current use, but there is an insufficient evidence base to recommend them.
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Affiliation(s)
- Werner J Becker
- Department of Clinical Neurosciences, University of Calgary and Alberta Health Services, Calgary, AB, Canada
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