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Ciciarelli MC, Simioni CVDMG, Londero RG. Headaches in adults in supplementary health: management. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2024; 70:e023D701. [PMID: 38511747 PMCID: PMC10941913 DOI: 10.1590/1806-9282.023d701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 11/30/2023] [Indexed: 03/22/2024]
Affiliation(s)
| | | | - Renata Gomes Londero
- Brazilian Academy of Neurology, Porto Alegre Clinical Hospital – Porto Alegre (RS), Brazil
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Santos PSF, Melhado EM, Kaup AO, Costa ATNMD, Roesler CADP, Piovesan ÉJ, Sarmento EM, Theotonio GOM, Campos HCD, Fortini I, Souza JAD, Júnior JAM, Segundo JBA, Carvalho JJFD, Speziali JG, Calia LC, Barea LM, Queiroz LP, Souza MNP, Figueiredo MRCF, Costa MENDM, Peres MFP, Jurno ME, Peixoto PM, Kowacs PA, Rocha-Filho PAS, Filho PFM, Silva-Neto RP, Fragoso YD. Consensus of the Brazilian Headache Society (SBCe) for prophylactic treatment of episodic migraine: part II. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:953-969. [PMID: 36257618 PMCID: PMC10658446 DOI: 10.1055/s-0042-1755320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 04/09/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Migraine affects 1 billion people worldwide and > 30 million Brazilians; besides, it is an underdiagnosed and undertreated disorder. OBJECTIVE The need to disseminate knowledge about the prophylactic treatment of migraine is known, so the Brazilian Headache Society (SBCe, in the Portuguese acronym) appointed a committee of authors with the objective of establishing a consensus with recommendations on the prophylactic treatment of episodic migraine based on articles from the world literature as well as from personal experience. METHODS Meetings were held entirely online, with the participation of 12 groups that reviewed and wrote about the pharmacological categories of drugs and, at the end, met to read and finish the document. The drug classes studied in part II of this Consensus were: antihypertensives, selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, calcium channel blockers, other drugs, and rational polytherapy. RESULTS From this list of drugs, only candesartan has been established as effective in controlling episodic migraine. Flunarizine, venlafaxine, duloxetine, and pizotifen were defined as likely to be effective, while lisinopril, enalapril, escitalopram, fluvoxamine, quetiapine, atorvastatin, simvastatin, cyproheptadine, and melatonin were possibly effective in prophylaxis of the disease. CONCLUSIONS Despite an effort by the scientific community to find really effective drugs in the treatment of migraine, given the large number of drugs tested for this purpose, we still have few therapeutic options.
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Affiliation(s)
- Paulo Sergio Faro Santos
- Instituto de Neurologia de Curitiba, Departamento de Neurologia, Setor de
Cefaleia e Dor Orofacial, Curitiba PR, Brazil.
| | - Eliana Meire Melhado
- Centro Universitário Padre Albino, Faculdade de Medicina, Departamento de
Neurologia, Catanduva SP, Brazil.
| | - Alexandre Ottoni Kaup
- Houston Headache Clinic, Houston TX, USA.
- Universidade Federal de São Paulo, São Paulo SP, Brazil.
- Universidade de Santo Amaro, São Paulo SP, Brazil.
| | | | | | - Élcio Juliato Piovesan
- Universidade Federal do Paraná, Departamento de Clínica Médica, Disciplina de
Neurologia, Curitiba PR, Brazil.
| | | | | | | | - Ida Fortini
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia,
São Paulo SP, Brazil.
| | - Jano Alves de Souza
- Universidade Federal Fluminense, Departamento de Medicina Clínica, Disciplina
de Neurologia, Niterói RJ, Brazil.
| | - Jayme Antunes Maciel Júnior
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Departamento
de Neurologia, Campinas SP, Brazil.
| | | | - João José Freitas de Carvalho
- Unichristus, Curso de Medicina, Disciplina de Neurologia, Fortaleza CE,
Brazil.
- Hospital Geral de Fortaleza, Serviço de Neurologia, Núcleo de Cefaleias,
Fortaleza CE, Brazil.
| | - José Geraldo Speziali
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto,
Departamento de Neurologia, Ribeirão Preto SP, Brazil.
| | - Leandro Cortoni Calia
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo SP,
Brazil.
| | - Liselotte Menke Barea
- Fundação Universidade Federal de Ciências da Saúde de Porto Alegre, Disciplina
de Neurologia, Porto Alegre RS, Brazil.
| | - Luiz Paulo Queiroz
- Universidade Federal de Santa Catarina, Hospital Universitário, Serviço de
Neurologia, Florianópolis SC, Brazil.
| | | | | | | | | | - Mauro Eduardo Jurno
- Fundação José Bonifácio Lafayette de Andrada, Faculdade de Medicina de
Barbacena, Barbacena MG, Brazil.
- Fundação Hospitalar do Estado de Minas Gerais, Hospital Regional de Barbacena
Dr. José Américo, Barbacena MG, Brazil.
| | | | - Pedro André Kowacs
- Instituto de Neurologia de Curitiba, Serviço de Neurologia, Curitiba PR,
Brazil.
- Universidade Federal do Paraná, Complexo Hospital de Clínicas, Serviço de
Neurologia, Curitiba PR, Brazil.
| | - Pedro Augusto Sampaio Rocha-Filho
- Universidade Federal de Pernambuco, Centro de Ciências Médicas, Área de
Neuropsquiatria, Recife PE, Brazil.
- Universidade de Pernambuco, Hospital Universitário Oswaldo Cruz, Ambulatório de
Cefaleias, Recife PR, Brazil.
| | - Pedro Ferreira Moreira Filho
- Universidade Federal Fluminense, Hospital Universitário Antônio Pedro,
Departamento de Medicina Clínica, Niterói RJ, Brazil.
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Acupuncture versus propranolol in migraine prophylaxis: an indirect treatment comparison meta-analysis. J Neurol 2019; 267:14-25. [DOI: 10.1007/s00415-019-09510-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 08/12/2019] [Accepted: 08/13/2019] [Indexed: 01/21/2023]
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Stubberud A, Flaaen NM, McCrory DC, Pedersen SA, Linde M. Flunarizine as prophylaxis for episodic migraine: a systematic review with meta-analysis. Pain 2019; 160:762-772. [PMID: 30699098 DOI: 10.1097/j.pain.0000000000001456] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Based on few clinical trials, flunarizine is considered a first-line prophylactic treatment for migraine in several guidelines. In this meta-analysis, we examined the pooled evidence for its effectiveness, tolerability, and safety. Prospective randomized controlled trials of flunarizine as a prophylaxis against migraine were identified from a systematic literature search, and risk of bias was assessed for all included studies. Reduction in mean attack frequency was estimated by calculating the mean difference (MD), and a series of secondary outcomes-including adverse events (AEs)-were also analyzed. The database search yielded 879 unique records. Twenty-five studies were included in data synthesis. We scored 31/175 risk of bias items as "high," with attrition as the most frequent bias. A pooled analysis estimated that flunarizine reduces the headache frequency by 0.4 attacks per 4 weeks compared with placebo (5 trials, 249 participants: MD -0.44; 95% confidence interval -0.61 to -0.26). Analysis also revealed that the effectiveness of flunarizine prophylaxis is comparable with that of propranolol (7 trials, 1151 participants, MD -0.08; 95% confidence interval -0.34 to 0.18). Flunarizine also seems to be effective in children. The most frequent AEs were sedation and weight increase. Meta-analyses were robust and homogenous, although several of the included trials potentially suffered from high risk of bias. Unfortunately, reporting of AEs was inconsistent and limited. In conclusion, pooled analysis of data from partially outdated trials shows that 10-mg flunarizine per day is effective and well tolerated in treating episodic migraine-supporting current guideline recommendations.
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Affiliation(s)
- Anker Stubberud
- Department of Neuromedicine and Movement Sciences, NTNU Norwegian University of Science and Technology, Trondheim, Norway
| | - Nikolai Melseth Flaaen
- Department of Neuromedicine and Movement Sciences, NTNU Norwegian University of Science and Technology, Trondheim, Norway
| | - Douglas C McCrory
- Duke Evidence Synthesis Group, Duke Clinical Research Institute, Durham, NC, United States.,Department of Medicine, Duke University School of Medicine, Durham, NC, United States.,Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, United States
| | - Sindre Andre Pedersen
- Library Section for Medicine and Health Sciences, NTNU University Library, NTNU Norwegian University of Science and Technology, Trondheim, Norway
| | - Mattias Linde
- Department of Neuromedicine and Movement Sciences, NTNU Norwegian University of Science and Technology, Trondheim, Norway.,Norwegian Advisory Unit on Headaches, St. Olavs Hospital, Trondheim, Norway
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Jackson JL, Kuriyama A, Kuwatsuka Y, Nickoloff S, Storch D, Jackson W, Zhang ZJ, Hayashino Y. Beta-blockers for the prevention of headache in adults, a systematic review and meta-analysis. PLoS One 2019; 14:e0212785. [PMID: 30893319 PMCID: PMC6426199 DOI: 10.1371/journal.pone.0212785] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 02/10/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Headaches are a common source of pain and suffering. The study's purpose was to assess beta-blockers efficacy in preventing migraine and tension-type headache. METHODS Cochrane Register of Controlled Trials; MEDLINE; EMBASE; ISI Web of Science, clinical trial registries, CNKI, Wanfang and CQVIP were searched through 21 August 2018, for randomized trials in which at least one comparison was a beta-blocker for the prevention of migraine or tension-type headache in adults. The primary outcome, headache frequency per month, was extracted in duplicate and pooled using random effects models. DATA SYNTHESIS This study included 108 randomized controlled trials, 50 placebo-controlled and 58 comparative effectiveness trials. Compared to placebo, propranolol reduced episodic migraine headaches by 1.5 headaches/month at 8 weeks (95% CI: -2.3 to -0.65) and was more likely to reduce headaches by 50% (RR: 1.4, 95% CI: 1.1-1.7). Trial Sequential Analysis (TSA) found that these outcomes were unlikely to be due to a Type I error. A network analysis suggested that beta-blocker's benefit for episodic migraines may be a class effect. Trials comparing beta-blockers to other interventions were largely single, underpowered trials. Propranolol was comparable to other medications known to be effective including flunarizine, topiramate and valproate. For chronic migraine, propranolol was more likely to reduce headaches by at least 50% (RR: 2.0, 95% CI: 1.0-4.3). There was only one trial of beta-blockers for tension-type headache. CONCLUSIONS There is high quality evidence that propranolol is better than placebo for episodic migraine headache. Other comparisons were underpowered, rated as low-quality based on only including single trials, making definitive conclusions about comparative effectiveness impossible. There were few trials examining beta-blocker effectiveness for chronic migraine or tension-type headache though there was limited evidence of benefit. REGISTRATION Prospero (ID: CRD42017050335).
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Affiliation(s)
- Jeffrey L. Jackson
- Department of Medicine, Zablocki VA Medical Center, Milwaukee, WI, United States of America
| | - Akira Kuriyama
- Department of General Medicine, Kurashiki Central Hospital, Okayama, Japan
| | | | - Sarah Nickoloff
- Department of Medicine, Zablocki VA Medical Center, Milwaukee, WI, United States of America
| | - Derek Storch
- Department of Medicine, Zablocki VA Medical Center, Milwaukee, WI, United States of America
| | - Wilkins Jackson
- Department of Biology, University of Wisconsin-Milwaukee, Milwaukee, WI, United States of America
| | - Zhi-Jiang Zhang
- Department of Epidemiology and Biostatistics, School of Health Sciences, Wuhan University, Wuhan, China
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Karsan N, Palethorpe D, Rattanawong W, Marin JC, Bhola R, Goadsby PJ. Flunarizine in migraine-related headache prevention: results from 200 patients treated in the UK. Eur J Neurol 2018. [PMID: 29512871 DOI: 10.1111/ene.13621] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND PURPOSE For over 20 years, as a group we have been using flunarizine in primary headache disorders. Flunarizine is widely used in Europe, but not licensed in the UK. In September 2014, the National Institute for Clinical Excellence published supportive guidelines for flunarizine use in migraine, based on randomized controlled evidence that it is as effective as propranolol and topiramate in adults. METHODS We reviewed a cohort of adult patients (n = 200) treated with flunarizine from our practice. The clinical information of these patients, i.e. diagnosis, dose, efficacy, side effects and duration of treatment, was collected. RESULTS The most common indication for flunarizine use was chronic migraine, followed by migraine with aura, sporadic hemiplegic migraine, familial hemiplegic migraine and new daily persistent headache with migrainous features. Flunarizine was generally effective, with only 24% (n = 47) of patients reporting no clinical effect. The most common dose used was 10 mg per day. Duration of treatment information was available for 39% (n = 78) of patients. Of these patients, 64% (n = 50) continued treatment for more than 1 year. Doses up to 15 mg were generally well tolerated, with only 10.5% (n = 21) of patients stopping treatment due to adverse effects. The most common adverse events were tiredness, mood change and weight gain. CONCLUSION The data provide supportive evidence from tertiary headache practice in the UK for the use of flunarizine in migraine. The data encourages development of future guidance regarding flunarizine use in headache centres in countries where its use is not routine.
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Affiliation(s)
- N Karsan
- Headache Group, Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London.,NIHR-Wellcome Trust King's Clinical Research Facility, King's College Hospital, London, UK
| | - D Palethorpe
- Headache Group, Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London.,NIHR-Wellcome Trust King's Clinical Research Facility, King's College Hospital, London, UK
| | - W Rattanawong
- Headache Group, Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London.,NIHR-Wellcome Trust King's Clinical Research Facility, King's College Hospital, London, UK
| | - J C Marin
- Headache Group, Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London.,NIHR-Wellcome Trust King's Clinical Research Facility, King's College Hospital, London, UK
| | - R Bhola
- Headache Group, Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London.,NIHR-Wellcome Trust King's Clinical Research Facility, King's College Hospital, London, UK
| | - P J Goadsby
- Headache Group, Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London.,NIHR-Wellcome Trust King's Clinical Research Facility, King's College Hospital, London, UK
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Abstract
BACKGROUND Propranolol is one of the most commonly prescribed drugs for migraine prophylaxis. OBJECTIVES We aimed to determine whether there is evidence that propranolol is more effective than placebo and as effective as other drugs for the interval (prophylactic) treatment of patients with migraine. SEARCH METHODS Potentially eligible studies were identified by searching MEDLINE/PubMed (1966 to May 2003) and the Cochrane Central Register of Controlled Trials (Issue 2, 2003), and by screening bibliographies of reviews and identified articles. SELECTION CRITERIA We included randomised and quasi-randomised clinical trials of at least 4 weeks duration comparing clinical effects of propranolol with placebo or another drug in adult migraine sufferers. DATA COLLECTION AND ANALYSIS Two reviewers extracted information on patients, methods, interventions, outcomes measured, and results using a pre-tested form. Study quality was assessed using two checklists (Jadad scale and Delphi list). Due to the heterogeneity of outcome measures and insufficient reporting of the data, only selective quantitative meta-analyses were performed. As far as possible, effect size estimates were calculated for single trials. In addition, results were summarised descriptively and by a vote count among the reviewers. MAIN RESULTS A total of 58 trials with 5072 participants met the inclusion criteria. The 58 selected trials included 26 comparisons with placebo and 47 comparisons with other drugs. The methodological quality of the majority of trials was unsatisfactory. The principal shortcomings were high dropout rates and insufficient reporting and handling of this problem in the analysis. Overall, the 26 placebo-controlled trials showed clear short-term effects of propranolol over placebo. Due to the lack of studies with long-term follow up, it is unclear whether these effects are stable after stopping propranolol. The 47 comparisons with calcium antagonists, other beta-blockers, and a variety of other drugs did not yield any clear-cut differences. Sample size was, however, insufficient in most trials to establish equivalence. AUTHORS' CONCLUSIONS Although many trials have relevant methodological shortcomings, there is clear evidence that propranolol is more effective than placebo in the short-term interval treatment of migraine. Evidence on long-term effects is lacking. Propranolol seems to be as effective and safe as a variety of other drugs used for migraine prophylaxis.
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Affiliation(s)
- Klaus Linde
- Centre for Complementary Medicine Research, Department of Internal Medicine II, Technical University Munich, Munich, Germany
| | - Karin Rossnagel
- Institute of Social Medicine & Epidemiology, Charité University Hospital, Humboldt University, Berlin, Germany, 10098
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Jackson JL, Cogbill E, Santana-Davila R, Eldredge C, Collier W, Gradall A, Sehgal N, Kuester J. A Comparative Effectiveness Meta-Analysis of Drugs for the Prophylaxis of Migraine Headache. PLoS One 2015; 10:e0130733. [PMID: 26172390 PMCID: PMC4501738 DOI: 10.1371/journal.pone.0130733] [Citation(s) in RCA: 146] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Accepted: 05/24/2015] [Indexed: 01/03/2023] Open
Abstract
Objective To compare the effectiveness and side effects of migraine prophylactic medications. Design We performed a network meta-analysis. Data were extracted independently in duplicate and quality was assessed using both the JADAD and Cochrane Risk of Bias instruments. Data were pooled and network meta-analysis performed using random effects models. Data Sources PUBMED, EMBASE, Cochrane Trial Registry, bibliography of retrieved articles through 18 May 2014. Eligibility Criteria for Selecting Studies We included randomized controlled trials of adults with migraine headaches of at least 4 weeks in duration. Results Placebo controlled trials included alpha blockers (n = 9), angiotensin converting enzyme inhibitors (n = 3), angiotensin receptor blockers (n = 3), anticonvulsants (n = 32), beta-blockers (n = 39), calcium channel blockers (n = 12), flunarizine (n = 7), serotonin reuptake inhibitors (n = 6), serotonin norepinephrine reuptake inhibitors (n = 1) serotonin agonists (n = 9) and tricyclic antidepressants (n = 11). In addition there were 53 trials comparing different drugs. Drugs with at least 3 trials that were more effective than placebo for episodic migraines included amitriptyline (SMD: -1.2, 95% CI: -1.7 to -0.82), -flunarizine (-1.1 headaches/month (ha/month), 95% CI: -1.6 to -0.67), fluoxetine (SMD: -0.57, 95% CI: -0.97 to -0.17), metoprolol (-0.94 ha/month, 95% CI: -1.4 to -0.46), pizotifen (-0.43 ha/month, 95% CI: -0.6 to -0.21), propranolol (-1.3 ha/month, 95% CI: -2.0 to -0.62), topiramate (-1.1 ha/month, 95% CI: -1.9 to -0.73) and valproate (-1.5 ha/month, 95% CI: -2.1 to -0.8). Several effective drugs with less than 3 trials included: 3 ace inhibitors (enalapril, lisinopril, captopril), two angiotensin receptor blockers (candesartan, telmisartan), two anticonvulsants (lamotrigine, levetiracetam), and several beta-blockers (atenolol, bisoprolol, timolol). Network meta-analysis found amitriptyline to be better than several other medications including candesartan, fluoxetine, propranolol, topiramate and valproate and no different than atenolol, flunarizine, clomipramine or metoprolol. Conclusion Several drugs good evidence supporting efficacy. There is weak evidence supporting amitriptyline’s superiority over some drugs. Selection of prophylactic medication should be tailored according to patient preferences, characteristics and side effect profiles.
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Affiliation(s)
- Jeffrey L. Jackson
- General Internal Medicine, Zablocki VA Medical Center, Milwaukee, Wisconsin, United States of America
- * E-mail:
| | - Elizabeth Cogbill
- Department of Medicine, Western Michigan School of Medicine, Kalamazoo, Michigan, United States of America
| | - Rafael Santana-Davila
- Division of Hematology and Oncology, University of Washington, Seattle, Washington, United States of America
| | - Christina Eldredge
- Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - William Collier
- Department of Pharmacology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Andrew Gradall
- School of Health Sciences, Gollis University, Hergaisa, Somaliland
| | - Neha Sehgal
- Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Jessica Kuester
- General Internal Medicine, Zablocki VA Medical Center, Milwaukee, Wisconsin, United States of America
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Shivarkar NA, Dudhe PB, Nagras MA. Development and Validation of a HPTLC Method for Simultaneous Quantitation of Flunarizine Dihydrochloride and Propranolol Hydrochloride in Capsule Dosage Form. Indian J Pharm Sci 2013; 75:364-8. [PMID: 24082355 PMCID: PMC3783757 DOI: 10.4103/0250-474x.117418] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Revised: 04/08/2013] [Accepted: 04/15/2013] [Indexed: 11/04/2022] Open
Abstract
A simple, precise, accurate, and rapid high-performance thin layer chromatographic method has been developed and validated for the simultaneous quantitation of flunarizine dihydrochloride and propranolol hydrochloride in a combined capsule dosage form. The method was carried out on precoated silica gel 60 F254 TLC aluminum plate, (20×10 cm(2)). The solvent system was ethyl acetate:methanol:glacial acetic acid in the proportion of 8:1:1, (v/v/v). R f value for flunarizine dihydrochloride and propranolol hydrochloride was found to be 0.62±0.02 and 0.18±0.02, respectively. The linearity regression analysis for calibration showed 0.999 and 0.999 for flunarizine dihydrochloride and propranolol hydrochloride with respect to peak area and height in the concentration range of 50-350 ng/spot and 500-3500 ng/spot, respectively. Accuracy of recovery studies was found to be 98-100.28 and 99.11-99.45% for flunarizine dihydrochloride and propranolol hydrochloride, respectively. The amounts of drug in marketed formulation were 100.5 and 101.25% of flunarizine dihydrochloride and propranolol hydrochloride, respectively. The method developed can be used for routine analysis in bulk drug and capsule dosage form.
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Affiliation(s)
- N A Shivarkar
- Department of Pharmaceutical Chemistry, Sinhgad College of Pharmacy, Vadgaon (Bk), Pune-411 041, India
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Li F, Qiu E, Dong Z, Liu R, Wu S, Yu S. Protection of flunarizine on cerebral mitochondria injury induced by cortical spreading depression under hypoxic conditions. J Headache Pain 2011; 12:47-53. [PMID: 21350793 PMCID: PMC3055997 DOI: 10.1007/s10194-011-0300-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Accepted: 11/25/2010] [Indexed: 10/27/2022] Open
Abstract
A rat cortical spreading depression (CSD) model was established to explore whether cerebral mitochondria injury was induced by CSD under both normoxic and hypoxic conditions and whether flunarizine had a protective effect on cerebral mitochondria. SD rats, which were divided into seven groups, received treatment as follows: no intervention (control Group I); 1 M NaCl injections (Group II); 1 M KCl injections (Group III); intraperitoneal flunarizine (3 mg/kg) 30 min before KCl injections (Group IV); 14% O(2) inhalation before NaCl injections (Group V); 14% O(2) inhalation followed by KCl injections (Group VI); 14% O(2) inhalation and intraperitoneal flunarizine followed by KCl injections (Group VII). Following treatment, brains were removed for the analysis of mitochondria transmembrane potential (MMP) and oxidative respiratory function after recording the number, amplitude and duration of CSD. The duration of CSD was significantly longer in Group VI than that in Group III. The number and duration of CSD in Group VII was significantly lower than that in Group VI. MMP in Group VI was significantly lower than that in Group III, and MMP in Group VII was significantly higher than that in Group VI. State 4 respiration in Group VI was significantly higher than that in Group III, and state 3 respiration in Group VII was significantly higher than that in Group VI. Respiration control of rate in Group VII was also significantly higher than that in Group VI. Thus, we concluded that aggravated cerebral mitochondria injury might be attributed to CSD under hypoxic conditions. Flunarizine can alleviate such cerebral mitochondria injury under both normoxic and hypoxic conditions.
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Affiliation(s)
- Fengpeng Li
- Department of Neurology, Chinese PLA General Hospital, Beijing, 100853 China
| | - Enchao Qiu
- Department of Neurology, Chinese PLA General Hospital, Beijing, 100853 China
| | - Zhao Dong
- Department of Neurology, Chinese PLA General Hospital, Beijing, 100853 China
| | - Ruozhuo Liu
- Department of Neurology, Chinese PLA General Hospital, Beijing, 100853 China
| | - Shiwen Wu
- Department of Neurology, Chinese PLA General Hospital, Beijing, 100853 China
| | - Shengyuan Yu
- Department of Neurology, Chinese PLA General Hospital, Beijing, 100853 China
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Domingues RB, Silva ALPD, Domingues SA, Aquino CCH, Kuster GW. A double-blind randomized controlled trial of low doses of propranolol, nortriptyline, and the combination of propranolol and nortriptyline for the preventive treatment of migraine. ARQUIVOS DE NEURO-PSIQUIATRIA 2009; 67:973-7. [PMID: 20069203 DOI: 10.1590/s0004-282x2009000600002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2009] [Accepted: 08/03/2009] [Indexed: 11/22/2022]
Abstract
Few trials have evaluated combination of two or more drugs in the preventive treatment of migraine. In this study three therapeutic regimens were compared: (a) propranolol, at a dose of 40 mg per day, (b) nortriptyline, at a dose of 20 mg per day, and (c) the combination of these two drugs in these dosages. The groups were matched according to age, gender, and frequency of migraine attacks prior to treatment. The period of treatment was two months and the frequency and intensity of headache attacks of the 30 days pre-treatment period were compared with the frequency of headaches in the treatment period. Fourteen patients in groups A and B and sixteen patients in group C have completed the study. Treatment with propranolol, alone or in combination, was shown to be effective. Treatment with nortriptyline alone was not effective. All three therapeutic regimens were safe and side effects were minimal. The frequency of discontinuation of the study was the same in the 3 groups but no patient left the study due to adverse reactions. The combined therapy proved to be as safe as the monotherapy. Further studies evaluating this and other possible combinations of drugs in higher doses and for longer periods, should more clearly elucidate the role of combined therapy in the treatment of migraine.
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Affiliation(s)
- Renan B. Domingues
- Escola Superior de Ciências da Saúde de Vitória, Brazil; Federal University of Minas Gerais, Brazil
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Unalp A, Uran N, Oztürk A. Comparison of the effectiveness of topiramate and sodium valproate in pediatric migraine. J Child Neurol 2008; 23:1377-81. [PMID: 19073842 DOI: 10.1177/0883073808318547] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Frequent migraine headaches can have a significant impact on disability, prompting the need for early recognition and treatment. The objective of this study is to compare the efficacy of topiramate and sodium valproate for the prevention of pediatric migraine, retrospectively. Mean monthly migraine frequency, intensity, and duration in the 28 patients treated with topiramate decreased from 15.3 +/- 10.1 to 4.4 +/- 5.5 episode, from 6.8 +/- 1 to 3.2 +/- 1, and from 10.2 +/- 9.4 to 2.4 +/- 3.1 hours, respectively. Headache disability improved with a reduction of Pediatric Migraine Disability Assessment score from 36 +/- 29.5 to 4.6 +/- 6.5 (P < .05). Similarly, mean monthly headache frequency, headache intensity, headache duration, and Pediatric Migraine Disability Assessment score in the 20 patients treated with sodium valproate decreased from 20.1 +/- 10.2 to 6.6 +/- 8.6, from 7.1 +/- 1 to 3.4 +/- 2.1, from 7 +/- 12 to 1.4 +/- 2.5 hours, and from 20.5 +/- 16.1 to 5.5 +/- 9.2, respectively (P < .05). In conclusion, valproate and topiramate seem to be able to manage successfully childhood migraine without substantial differences in efficacy.
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Affiliation(s)
- Aycan Unalp
- Department of Pediatrics, Division of Pediatric Neurology, Behcet Uz Child Disease and Pediatric Surgery Training and Research Hospital, Izmir, Turkey.
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15
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Abstract
Advances in our understanding of the pathophysiology of migraine have resulted in important breakthroughs in treatment. For example, understanding of the role of serotonin in the cerebrovascular circulation has led to the development of triptans for the acute relief of migraine headaches, and the identification of cortical spreading depression as an early central event associated wih migraine has brought renewed interest in antiepileptic drugs for migraine prophylaxis. However, migraine still remains inadequately treated. Indeed, it is apparent that migraine is not a single disease but rather a syndrome that can manifest itself in a variety of pathological conditions. The consequences of this may be that treatment needs to be matched to particular patients. Clinical research needs to be devoted to identifying which sort of patients benefit best from which treatments, particularly in the field of prophylaxis. We propose four patterns of precipitating factors (adrenergic, serotoninergic, menstrual, and muscular) which may be used to structure migraine prophylaxis. Finally, little is known about long-term outcome in treated migraine. It is possible that appropriate early prophylaxis may modify the long-term course of the disease and avoid late complications.
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Affiliation(s)
- Michel Dib
- Fédération du système nerveux central, Hôpital de la Salpêtrière, Assistance Publique- Hôpitaux de Paris, France
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When should "chronic migraine" patients be considered "refractory" to pharmacological prophylaxis? Neurol Sci 2008; 29 Suppl 1:S55-8. [PMID: 18545898 DOI: 10.1007/s10072-008-0888-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Patients with chronic headache forms evolving from a previous episodic migraine ('chronic migraine') are often difficult to treat. In this paper we focus attention on aspects we believe important for producing a definition of "refractory" in relation to this headache form. We propose a "chronic migraine" patient should be considered "refractory" to pharmacological prophylaxis when adequate trials of preventive therapies at adequate doses have failed to reduce headache frequency and improve headache-related disability and, in patients with medication overuse, reduce the consumption of symptomatic drugs. However before a definition of "refractory" chronic migraine can become established, generally accepted diagnostic criteria and treatment guidelines for this condition need to be developed.
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Krymchantowski AV, Bigal ME. Polytherapy in the preventive and acute treatment of migraine: fundamentals for changing the approach. Expert Rev Neurother 2006; 6:283-9. [PMID: 16533132 DOI: 10.1586/14737175.6.3.283] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The pathophysiology of migraine is complex and involves multiple neurophysiological pathways. Monotherapeutic approaches for migraine are the rule but many patients discontinue their medications owing to lack of efficacy. Polytherapy may provide a rational strategy for some of these individuals. Herein, we review the basis of polytherapy treatment for migraine. We suggest that refractory patients, with previous failure to single agents, may benefit from the use of a two- or three-drug regimen combining medications that target different neurotransmitter systems. In addition, those patients with high recurrence rates or not presenting pain free at 2 h and/or sustained pain free at 24 h may also respond better to combination therapy suited to their individual profile, which must include nonsteroidal anti-inflammatory agents plus a triptan or a gastrokinetic drug. The three-drug regimen may also be considered. Finally, changing the time medicine is taken (before the development of central sensitization and allodynia cutanea) and switching the choice of formulations to non-oral potentially achieves a better response and can be determined individually. Although highly speculative, these hypotheses could stimulate further controlled studies to support changing the current paradigm of monotherapeutic migraine treatment in some patients.
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Benito-León J, Morales-González JM, Collar JM. Tratamiento farmacológico preventivo de la migraña. Med Clin (Barc) 2006; 126:467-72. [PMID: 16620735 DOI: 10.1157/13086327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Julián Benito-León
- Servicio de Neurología, Hospital General de Móstoles, Móstoles, Madrid, Spain.
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19
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Krymchantowski AV, Bigal ME. Rizatriptan versus rizatriptan plus rofecoxib versus rizatriptan plus tolfenamic acid in the acute treatment of migraine. BMC Neurol 2004; 4:10. [PMID: 15222892 PMCID: PMC449711 DOI: 10.1186/1471-2377-4-10] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2004] [Accepted: 06/28/2004] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Rizatriptan is an effective and fast acting drug for the acute treatment of migraine. Some nonsteroidal anti-inflammatory drugs (NSAID) have also demonstrated efficacy in treating migraine attacks. There is evidence that the combination of a triptan and a NSAID decreases migraine recurrence in clinical practice. The primary aim of this randomized open label study was to assess the recurrence rates in migraine sufferers acutely treated with rizatriptan (RI) alone vs. rizatriptan plus a COX-2 enzyme inhibitor (rofecoxib, RO) vs. rizatriptan plus a traditional NSAID (tolfenamic acid, TO). We were also interested in comparing the efficacy rates within these three groups. METHODS We assessed 45 patients from a headache clinic in Rio de Janeiro (35 women and 10 men, ages 18 to 65 years, mean 37 years). Patients with IHS migraine were randomized to one out of 3 groups, where they had to treat 6 consecutive moderate or severe attacks in counterbalanced order. In group 1, patients treated the first two attacks with 10 mg RI, the third and fourth attacks with RI + 50 mg RO and the last attacks with RI + 200 mg of TA. In group 2, we began with RI + TA, followed by RI, and RI + RO. Group 3 treated in the following order: RI + RO, RI + TA, RI alone. The presence of headache, nausea and photophobia at 1, 2 and 4 hours, as well as recurrence and side effects were compared. RESULTS A total of 33 patients finished the study, treating 184 attacks. The pain-free rates at 1 hour were: RI: 15.5%; RI + RO: 22.6%; RI + TA: 20.3%(NS). Pain-free rates at 2 h were: RI: 37.9%; RI + RO: 62.9%, and RI + TA: 40.6% (p = 0.008 for RI vs. RI + RO; p = 0.007 for RI + RO vs. RI + TA, NS for RI vs RI + TA). At 4 h, pain-free rates were: RI: 69%; RI + RO: 82.3%; RI + TA: 78.1% (NS for all comparisons). The combination of RI + RO was superior to RI and to RI + TA in regard of the absence of nausea and photophobia at 4 hours. Recurrence (after being pain-free at 2 h) was observed in 50% of patients treated with RI, in 15,4% of those treated with RI + RO, and in 7,7% of those treated with RI + TA. CONCLUSIONS Despite the methodological limitations of this study, the combination of RI and RO revealed a higher response rate at 2 hours. Recurrence was also clearly decreased with both combinations in relation to the use of RI alone. Controlled studies are necessary to provide additional evidence.
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Affiliation(s)
- Abouch Valenty Krymchantowski
- Department of Neurology, Universidade Federal Fluminense, Niterói, Brazil
- Headache Outpatient Unit, Instituto de Neurologia Deolindo Couto, Rio de Janeiro, Brazil
- Headache Center of Rio, Rio de Janeiro, Brazil
| | - Marcelo Eduardo Bigal
- Department of Neurology, The Albert Einstein College of Medicine, Bronx, NY, USA
- Research Department, The New England Center for Headache, Stamford, CT, USA
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Abstract
BACKGROUND Propranolol is one of the most commonly prescribed drugs for migraine prophylaxis. OBJECTIVES We aimed to determine whether there is evidence that propranolol is more effective than placebo and as effective as other drugs for the interval (prophylactic) treatment of patients with migraine. SEARCH STRATEGY Potentially eligible studies were identified by searching MEDLINE/PubMed (1966 to May 2003) and the Cochrane Central Register of Controlled Trials (Issue 2, 2003), and by screening bibliographies of reviews and identified articles. SELECTION CRITERIA We included randomised and quasi-randomised clinical trials of at least 4 weeks duration comparing clinical effects of propranolol with placebo or another drug in adult migraine sufferers. DATA COLLECTION AND ANALYSIS Two reviewers extracted information on patients, methods, interventions, outcomes measured, and results using a pre-tested form. Study quality was assessed using two checklists (Jadad scale and Delphi list). Due to the heterogeneity of outcome measures and insufficient reporting of the data, only selective quantitative meta-analyses were performed. As far as possible, effect size estimates were calculated for single trials. In addition, results were summarised descriptively and by a vote count among the reviewers. MAIN RESULTS A total of 58 trials with 5072 participants met the inclusion criteria. The 58 selected trials included 26 comparisons with placebo and 47 comparisons with other drugs. The methodological quality of the majority of trials was unsatisfactory. The principal shortcomings were high dropout rates and insufficient reporting and handling of this problem in the analysis. Overall, the 26 placebo-controlled trials showed clear short-term effects of propranolol over placebo. Due to the lack of studies with long-term follow up, it is unclear whether these effects are stable after stopping propranolol. The 47 comparisons with calcium antagonists, other beta-blockers, and a variety of other drugs did not yield any clear-cut differences. Sample size was, however, insufficient in most trials to establish equivalence. REVIEWERS' CONCLUSIONS Although many trials have relevant methodological shortcomings, there is clear evidence that propranolol is more effective than placebo in the short-term interval treatment of migraine. Evidence on long-term effects is lacking. Propranolol seems to be as effective and safe as a variety of other drugs used for migraine prophylaxis.
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Affiliation(s)
- K Linde
- Centre for Complementary Medicine Research, Department of Internal Medicine II, Technische Universität, Kaiserstr. 9, München, Germany, 80801
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Limmroth V, Michel MC. The prevention of migraine: a critical review with special emphasis on beta-adrenoceptor blockers. Br J Clin Pharmacol 2001; 52:237-43. [PMID: 11560555 PMCID: PMC2014548 DOI: 10.1046/j.0306-5251.2001.01459.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2001] [Accepted: 06/01/2001] [Indexed: 11/20/2022] Open
Abstract
Migraine is one of the most frequent neurological disorders affecting up to 15% of the general population. Many patients require not only management of individual migraine episodes but also prophylactic treatment. beta-adrenoceptor blockers, flunarizine and valproic acid have been established as first-line agents for the prophylaxis of migraine attacks. Among the beta-adrenoceptor blockers propranolol and metoprolol are best documented and hence deserve preferential use. On the other hand, it appears that other beta-adrenoceptor blockers, perhaps with the exception of those with intrinsic sympathomimetic activity, can be equally effective. Uncertainties regarding the relative merits of various treatment modalities are largely caused by lack of adherence to specific requirements for clinical trials on migraine prophylaxis. Therefore, this article reviews internationally recommended conditions for reliable studies on migraine prophylaxis and appraises individual agents in the light of these criteria.
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Affiliation(s)
- V Limmroth
- Department of Neurology, University of Essen, Germany
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