Fixed drug combinations for the acute treatment of migraine : place in therapy

Evidence-based guidelines for the pharmacological treatment of migraine

We here present evidence-based guidelines for the pharmacological treatment of migraine. These guidelines, created by the Italian Society for the Study of Headache and the International Headache Society, aim to offer clear, actionable recommendations to healthcare professionals. They incorporate evidence-based recommendations from randomized controlled trials and expert-based opinions. The guidelines follow the Grading of Recommendations, Assessment, Development and Evaluation approach for assessing the quality of evidence. The guideline development involved a systematic review of literature across multiple databases, adherence to Cochrane review methods, and a structured framework for data extraction and interpretation. Although the guidelines provide a robust foundation for migraine treatment, they also highlight gaps in current research, such as the paucity of head-to-head drug comparisons and the need for long-term outcome studies. These guidelines serve as a resource to standardize migraine treatment and promote high-quality care across different healthcare settings.

Diagnosis and Treatment of Primary Headache Disorders in Older Adults

OBJECTIVES

To provide a unique perspective on geriatric headache and a number of novel treatment options that are not well known outside of the headache literature.

DESIGN

Review of the most current and relevant headache literature for practitioners specializing in geriatric care.

RESULTS

Evaluation and management of headache disorders in older adults requires an understanding of the underlying pathophysiology and how it relates to age-related physiological changes. To treat headache disorders in general, the appropriate diagnosis must first be established, and treatment of headaches in elderly adults poses unique challenges, including potential polypharmacy, medical comorbidities, and physiological changes associated with aging.

CONCLUSION

The purpose of this review is to provide a guide to and perspective on the challenges inherent in treating headaches in older adults. J Am Geriatr Soc 66:2408-2416, 2018.

Acute Migraine Treatment in Adults

There are many options for acute migraine attack treatment, but none is ideal for all patients. This study aims to review current medical office-based acute migraine therapy in adults and provides readers with an organized approach to this important facet of migraine treatment. A general literature review includes a review of several recent published guidelines. Acetaminophen, 4 nonsteroidal anti-inflammatory drugs (NSAIDs) (ibuprofen, acetylsalicylic acid [ASA], naproxen sodium, and diclofenac potassium), and 7 triptans (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan) have good evidence for efficacy and form the core of acute migraine treatment. NSAID-triptan combinations, dihydroergotamine, non-opioid combination analgesics (acetaminophen, ASA, and caffeine), and several anti-emetics (metoclopramide, domperidone, and prochlorperazine) are additional evidence-based options. Opioid containing combination analgesics may be helpful in specific patients, but should not be used routinely. Clinical features to be considered when choosing an acute migraine medication include usual headache intensity, usual rapidity of pain intensity increase, nausea, vomiting, degree of disability, patient response to previously used medications, history of headache recurrence with previous attacks, and the presence of contraindications to specific acute medications. Available acute medications can be organized into 4 treatment strategies, including a strategy for attacks of mild to moderate severity (strategy one: acetaminophen and/or NSAIDs), a triptan strategy for patients with severe attacks and for attacks not responding to strategy one, a refractory attack strategy, and a strategy for patients with contraindications to vasoconstricting drugs. Acute treatment of migraine attacks during pregnancy, lactation, and for patients with chronic migraine is also discussed. In chronic migraine, it is particularly important that medication overuse is eliminated or avoided. Migraine treatment is complex, and treatment must be individualized and tailored to the patient's clinical features. Clinicians should make full use of available medications and formulations in an organized approach.

Postmarketing migraine survey of frovatriptan: effectiveness and tolerability vs previous triptans, NSAIDs or a combination

OBJECTIVE

Compare the effectiveness and tolerability of current therapy with frovatriptan 2.5-mg tablets (in 1-3 migraines) in patients with migraine previously using other triptans, analgesics/nonsteroidal anti-inflammatory drugs (NSAIDs), or triptans and NSAIDs (T+NSAIDs).

RESEARCH DESIGN AND METHODS

Subanalysis of a postmarketing survey study in patients with migraine managed at primary care facilities in Germany.

MAIN OUTCOME MEASURES

A total of 5025 patients rated the effectiveness and tolerability of previous therapy (triptans; T+NSAIDs; NSAIDs) and current therapy with frovatriptan; physicians rated only frovatriptan effectiveness and tolerability (1 = Very Good, 2 = Good, 3 = Satisfactory, 4 = Poor).

RESULTS

Of 7107 patients initially surveyed, 5025 were identified for this subanalysis as previously using NSAIDs (n = 2890), triptans (n = 1418) or T + NSAIDs (n = 717). The mean (SD) age was 42.3 (11.9) years. At baseline, patients who previously used NSAIDs reported significantly fewer migraines per month, lower migraine severity, shorter migraine duration, and poorer ratings for effectiveness and tolerability versus responses from patients previously using triptans or T + NSAIDs (P < 0. 001 for each). Patient effectiveness ratings of Very Good or Good for previous therapy occurred in 49% (n = 691 of 1411) of patients using triptans, 27% (n = 195 of 716) of patients using T + NSAIDs, and 11% (n = 303 of 2866) of patients using NSAIDs (P < 0.04 between each group). Most patients rated current therapy with frovatriptan as Very Good or Good for effectiveness (86%, triptans; 83%, T + NSAIDs; 94%, NSAIDs) and tolerability (95%; 95%; 97%). Most physicians rated frovatriptan as Very Good or Good for effectiveness (87%; 86%; 95%) and tolerability (96%; 96%; 98%). Within-patient comparisons confirmed that frovatriptan had improved effectiveness (P < 0.001) and tolerability ratings (P < 0.001) in all three groups versus previous therapies.

CONCLUSIONS

Intrapatient comparisons showed that most patients with migraine reported significantly improved effectiveness and tolerability ratings with frovatriptan versus previous acute therapies.

Synthesis and investigations of double-pharmacophore ligands for treatment of chronic and neuropathic pain

Acids 9a-f as possible bivalent ligands designed as a structural combination of opioid mu-agonist (Fentanyl) and NSAID (Indomethacin) activities and produced compounds which were tested as analgesics. The obtained series of compounds exhibits low affinity and activity both at opioid receptors and as cyclooxygenase (COX) inhibitors. One explanation of the weak opioid activity could be stereochemical peculiarities of these bivalent compounds which differ significantly from the fentanyl skeleton. The absence of significant COX inhibitory properties could be explained by the required substitution of an acyl fragment in the indomethacin structure for 4-piperidyl.

Acute migraine treatment with oral triptans and NSAIDs in a managed care population

OBJECTIVE

To describe the use of oral triptans with or without nonsteroidal anti-inflammatory drugs (NSAIDs) for acute migraine treatment in a managed care population and its potential impact on functionality.

BACKGROUND

Prescription or over-the-counter NSAIDs with or without oral triptans are commonly used for treatment of acute migraine pain. Little is known about patients' treatment strategy when they have had experiences using NSAIDs and oral triptan cotherapy and the relationship between treatment strategy and migraine symptoms and functionality.

METHOD

Migraineurs identified from an administrative claims database were surveyed for their use of oral triptans and NSAIDs during their last attack in the screening phase and during the subsequent migraine attack in the follow-up phase of the study. Treatment regimens were classified into 6 categories: simultaneous coadministration of triptans and NSAIDs (T and N); triptans first followed by NSAIDs (T N); NSAIDs first followed by triptans (N T); triptans only (TRP only); NSAIDs only (NSAID only); and others. Headache experience, reasons for treatment regimens, and treatment satisfaction were cross-tabulated by treatment regimens. The log-rank test was used for the analysis of time-to-event data.

RESULTS

Among 8440 oral triptan users surveyed during the screening phase, 2307 (27%) reported using triptans and NSAIDs combination therapy during their last migraine attack. Of those, 1502 experienced a subsequent migraine attack and completed the follow-up survey; 38% of these 1502 patients who used triptans and NSAIDs cotherapy during their last migraine attack continued to use combination therapy for their next attack. The most common treatment regimen, excluding "others" (n = 354, 24%), was TRP only (n = 403, 27%), followed by N T (n = 345, 23%), NSAID only (n = 170, 11%), T&N (n = 152, 10%), and T N (n = 75, 5.0%). More TRP only patients became nausea-free within 1 h after an initial dosing. TRP only, T&N, and N T had significantly shorter median hours of suffering from migraine and limited functioning, as compared with other treatment regimens. Substantially more patients taking TRP only (34.7%) were very satisfied with their current treatment regimen than other regimens.

CONCLUSIONS

Migraine patients frequently change their treatment regimens in response to headache profiles. For patients with migraine associated nausea symptom, combination of therapy with triptan and NSAIDs appears to be less effective in relieving nausea than triptan monotherapy. Triptan montherapy remains a common and an effective migraine treatment strategy.

Practical considerations for the treatment of elderly patients with migraine

Treatment of migraine presents special problems in the elderly. Co-morbid diseases may prohibit the use of some medications. Moreover, even when these contraindications do not exist, older patients are more likely than younger ones to develop adverse events. Managing older migraine patients, therefore, necessitates particular caution, including taking into account possible pharmacological interactions associated with the greater use of drugs for concomitant diseases in the elderly. Paracetamol (acetaminophen) is the safest drug for symptomatic treatment of migraine in the elderly. Use of selective serotonin 5-HT(1B/1D) receptor agonists ('triptans') is not recommended, even in the absence of cardiovascular or cerebrovascular risk, and NSAID use should be limited because of potential gastrointestinal adverse effects. Prophylactic treatments include antidepressants, beta-adrenoceptor antagonists, calcium channel antagonists and antiepileptics. Selection of a drug from one of these classes should be dictated by the patient's co-morbidities. Beta-adrenoceptor antagonists are appropriate in patients with hypertension but are contraindicated in those with chronic obstructive pulmonary disease, diabetes mellitus, heart failure and peripheral vascular disease. Use of antidepressants in low doses is, in general, well tolerated by elderly people and as effective, overall, as in young adults. This approach is preferred in patients with concomitant mood disorders. However, prostatism, glaucoma and heart disease make the use of tricyclic antidepressants more difficult. Fewer efficacy data in the elderly are available for selective serotonin reuptake inhibitors, which can be tried in particular cases because of their good tolerability profile. Calcium channel antagonists are contraindicated in patients with hypotension, heart failure, atrioventricular block, Parkinson's disease or depression (flunarizine), and in those taking beta-adrenoceptor antagonists and monoamine oxidase inhibitors (verapamil). Antiepileptic drug use should be limited to migraine with high frequency of attacks and refractoriness to other treatments. Promising additional strategies include ACE inhibitors and angiotensin II type 1 receptor antagonists because of their effectiveness and good tolerability in patients with migraine, particularly in those with hypertension. Because of its favourable compliance and safety profile, botulinum toxin type A can be considered an alternative treatment in elderly migraine patients who have not responded to other currently available migraine prophylactic agents. Pharmacological treatment of migraine poses special problems in regard to both symptomatic and prophylactic treatment. Contraindications to triptan use, adverse effects of NSAIDs, and unwanted reactions to some antiemetics reduce the list of drugs available for the treatment of migraine attacks in elderly patients. The choice of prophylactic treatment (beta-adrenoceptor antagonists, calcium channel antagonists, antiepileptics, and more recently, some antihypertensive drugs) is influenced by co-morbidities and should be directed at those drugs that are believed to have fewer adverse effects and a better safety profile. Unfortunately, for most of these drugs, efficacy studies are lacking in the elderly.

Optimizing migraine therapy: evidence-based and patient-centered care

Migraine is a chronic, intermittently debilitating neurovascular condition that affects the physical, mental and social aspects of health-related quality of life. Primary care provider interactions with migraine sufferers are common, highlighting the need for clinicians to provide optimal therapy. A comprehensive therapy plan should encompass the whole patient, via a patient-physician partnership where goals and strategies are mutually established. Key treatments include nondrug approaches, such as education and lifestyle modifications, to reduce the occurrence of attacks, as well as acute medications to address the immediate need for relief during an attack. Routine assessment and adjustment of therapy based on data recorded by patient diaries is paramount. Clinical trials support the use of triptans and dihydroergotamine for moderate-to-severe migraine and nonsteroidal anti-inflammatory drugs (alone or in combination with antiemetics or caffeine) for mild-to-moderate migraine, as the treatments of choice to reduce pain and disability time in a cost-effective manner. Published evidence also endorses stratified care, where medication selection is geared towards disease severity, instead of step care, where nonspecific mediations are given to all patients. Thus, patients with significant migraine-induced debilitation, as assessed by tools, such as the Migraine Disability Assessment Scale or the Headache Impact Test, are prescribed migraine-specific agents from the onset of therapy, thereby avoiding the inherent failures of step care. For individuals experiencing a high frequency of attacks or routine debilitation, preventive medications are warranted.

Hyperbaric oxygen in the treatment of patients with cerebral stroke, brain trauma, and neurologic disease

Hyperbaric oxygen (HBO) therapy has been used to treat patients with numerous disorders, including stroke. This treatment has been shown to decrease cerebral edema, normalize water content in the brain, decrease the severity of brain infarction, and maintain blood-brain barrier integrity. In addition, HBO therapy attenuates motor deficits, decreases the risks of sequelae, and prevents recurrent cerebral circulatory disorders, thereby leading to improved outcomes and survival. Hyperbaric oxygen also accelerates the regression of atherosclerotic lesions, promotes antioxidant defenses, and suppresses the proliferation of macrophages and foam cells in atherosclerotic lesions. Although no medical treatment is available for patients with cerebral palsy, in some studies, HBO therapy has improved the function of damaged cells, attenuated the effects of hypoxia on the neonatal brain, enhanced gross motor function and fine motor control, and alleviated spasticity. In the treatment of patients with migraine, HBO therapy has been shown to reduce intracranial pressure significantly and abort acute attacks of migraine, reduce migraine headache pain, and prevent cluster headache. In studies that investigated the effects of HBO therapy on the damaged brain, the treatment was found to inhibit neuronal death, arrest the progression of radiation-induced neurologic necrosis, improve blood flow in regions affected by chronic neurologic disease as well as aerobic metabolism in brain injury, and accelerate the resolution of clinical symptoms. Hyperbaric oxygen has also been reported to accelerate neurologic recovery after spinal cord injury by ameliorating mitochondrial dysfunction in the motor cortex and spinal cord, arresting the spread of hemorrhage, reversing hypoxia, and reducing edema. HBO has enhanced wound healing in patients with chronic osteomyelitis. The results of HBO therapy in the treatment of patients with stroke, atherosclerosis, cerebral palsy, intracranial pressure, headache, and brain and spinal cord injury are promising and warrant further investigation.