Attitudes and Burden of disease among Self-Considered Migraineurs — a Nation-wide Population-based Survey in Sweden

The authors have earlier reported a 1-year prevalence of 13.2 ± 1.9% for migraine in Sweden. This is a subsequent extensive postal survey of the burden of disease and attitudes among migraineurs in a sample ( n = 423, 23% men and 77% women, aged 18-74 years) randomly recruited from all main regions of the country, representative of adults in the general Swedish population with self-considered migraine. Results are presented only from participants who after analysis of symptoms were found to fulfil the International Headache Society's migraine criteria. In order to assess headache duration open-mindedly, the strict time criterion 4-72 h was deliberately disregarded as an inclusion criterion. Individuals who did not consider themselves to have migraine were excluded. Less than half of the group (45%) had received a diagnosis of migraine from a physician. Accordingly, a large number of individuals that would not have come to attention in a clinic-based study have been included. The mean attack frequency was 1.3 per month, and the number of attacks per year in Swedish adults is approximately 10 million. A minority (27%) of sufferers have a majority (68%) of all attacks. The mean attack duration was 19 h. A considerable number of individuals reported attacks < 4 h (15.8%) or > 72 h (6.4%). Less than half of the individuals recovered completely between the attacks. Despite this, only every fourth (27%) participant was currently consulting a physician (6% regularly; 21% occasionally). Most of the migraineurs reported absence from school or work, a negative influence of migraine on the most important aspects of life, and an interest in testing other treatments for migraine during the last year. Of those ( n = 231) migraineurs who had consulted a physician, about 60% were satisfied with information given or treatment offered. This implies, however, that there is still room for improvement in the management of migraine in Sweden.

Subcutaneous Sumatriptan Provides Symptomatic Relief at any Pain Intensity or Time During the Migraine Attack

Over the years the paradigm of treating early during the migraine attack has become well established in clinical practice. It is also recommended that the 5-HT1B/1D agonists be administered early during the migraine attack for efficacy. This is because it has been proposed that most migraineurs are less responsive to delayed treatment, owing to the development of central sensitization of the pain transmission. The main objective of this prospective, cross-over study at a specialist clinic was to evaluate if these recommendations should also apply to the subcutaneous formulation of sumatriptan. Results are based on 20 adult International Headache Society migraineurs. Two attacks ( n = 40) were treated with 6 mg subcutaneous sumatriptan as early as possible after the onset of migraine headache and two attacks ( n = 40) as late as the patients could bear. The median intra-individual difference between the two strategies in time from first occurrence of pain to injection was 5.7 h and the median intra-individual difference in pain intensity at the time of injection was 29 visual analogue units. No significant differences were found in time to freedom from pain, pain severity at 1 and 2 h, area under the curves from injection to pain free or in headache recurrence after injection. At the end of the study, most of the patients claimed that their medication was as effective when given early as when given late in the course of the attack. The discrepancy between our present findings and retrospective analyses of trials on oral triptans probably has more to do with the less disturbed pharmacokinetics early during the migraine attack than with central sensitization. Consequently, we recommend nonoral formulations of triptans, which do not necessarily have to be administered early during the migraine attack to provide efficacy. In conclusion, it is reassuring for migraineurs that it is worthwhile taking their medication in an appropriate formulation even if they have not been able to do so early in the course of the attack.

Evaluation and registration of adverse events in clinical drug trials in migraine

Tolerability of a drug should be regarded as important as its efficacy. In all four phases of drug development evaluation of adverse events is important. Recommendations for assessment of adverse events in acute and prophylactic clinical drug trials in migraine are given. Tolerability may be indirectly assessed using measures of general well-being and eight such tools are presented. Finally, recommendations for reporting of adverse events are given.

The Natural Course of Migraine Attacks. A Prospective Analysis of Untreated Attacks Compared with Attacks Treated with a Triptan

This study was designed to document prospectively and explore scientifically the natural course of untreated migraine attacks in detail. A new, integrated, time-intensity method for self-assessment of the intensity of symptoms was tested on 18 adult International Headache Society migraineurs who volunteered to refrain from treatment during one attack. The area under the curves (AUC) during 72 h of untreated attacks was compared with attacks treated with a triptan. Migraine attacks are heterogeneous both inter- and intra-individually. In untreated attacks, the pain can stabilize and fluctuate around a plateau with a wavelength of hours. In general, the symptoms of each separate migraine attack follow a similar temporal course, with only moderate deviations. In some cases photo- and/or phonophobia (hyperexcitability) were not experienced at all, despite severe pain and nausea. Moreover, there was sometimes no nausea despite severe pain and hyperexcitability. Vomiting does not always correlate to the intensity of nausea and is not always followed by decreased headache intensity. Treatment with a triptan usually only temporarily distorts the basic pattern of attacks. Hyperexcitability can respond before pain to treatment. These genuine findings of the classic symptoms of migraine attacks support the notion of a mutual underlying pathophysiological mechanism.

Role of the needling per se in acupuncture as prophylaxis for menstrually related migraine: a randomized placebo-controlled study

The objectives were to introduce a new method for controlled trials of acupuncture in the field of headache research and to examine the role of needling per se. Women with menstrually related migraine were randomized to three months of treatment with verum or placebo needles. Three standard size casts were moulded to secure the placebo needles in the head. No significant differences were found between the verum group (n=15) and the placebo group (n=13) during treatment or follow up three and six months later, either in the attack frequency or in the number of days per month with migraine, headache intensity or drug-use. The casts held the needles exactly in place despite movements of the head, and are validated as practical, hygienic and extremely durable. This method is satisfactory for controlled studies of acupuncture in headache. It is possible that the positive results in earlier clinical trials on acupuncture in migraine are attributable to other mechanisms than needling of subcutaneous tissue.

Ethical aspects of placebo in migraine research

Randomized placebo-controlled clinical trials have been the 'golden standard' during the last decades in the development of new drug therapies. This scientifically valid approach has recently been questioned in the fifth revised version of the Declaration of Helsinki, which states that the use of placebo-controlled clinical trials is only acceptable when no proven treatment exists for the studied disease. The World Medical Association further claims that no national ethical, legal or regulatory requirements should be allowed to reduce or eliminate any of the statements in the declaration. In spite of this, the document is not generally accepted as the world ethical standard, as demonstrated by its lack of adoption by many professional associations. In the evaluation process for a drug to be approved in many countries today, clinical investigators at the hospitals and researchers at the pharmaceutical companies are obliged to use study protocols that would be rejected if the new declaration were to be fully adopted. Adherence to the clinical trial guidelines of the International Headache Society could also mean violation of the new Helsinki declaration of ethics. Some ethics committees have already adopted the new declaration, which has caused concern among clinical investigators, who find this document to be vastly out of the line with common practice. At the moment, the situation is unclear and debated with increasing polarity concerning the scientific and ethical issues regarding the use of placebo in clinical trials.

Eletriptan for the treatment of migraine in patients with previous poor response or tolerance to oral sumatriptan

To determine the tolerability and efficacy of eletriptan in patients who had discontinued oral sumatriptan due to lack of efficacy or intolerable adverse events (AEs) during previous clinical treatment (not a controlled trial). Eletriptan is a potent, selective 5-HT1B/1D receptor agonist with beneficial pharmacokinetic properties compared with sumatriptan. In a double-blind, parallel group, placebo-controlled multicentre study, patients with and without aura (n = 446) were randomized to 40 mg eletriptan (E40, n = 188), 80 mg eletriptan (E80, n = 171) or placebo (n = 87) for treatment of up to three migraine attacks. Two-hour headache response, based on first-dose, first-attack data, was 59% for eletriptan 40 mg, 70% for eletriptan 80 mg, and 30% for placebo (P < 0.0001 for both doses of eletriptan vs. PBO; P < 0.05 for E80 vs. E40). Onset of action was rapid, with 1-h headache response rates significantly superior for E40 and E80 vs. placebo (40%, 48%, 15%; P < 0.0005). Both E40 and E80 were significantly superior to placebo, based on first-dose, first-attack data, for 2-h pain-free response (35%, 42%, and 7%; P < 0.0001). Both E40 and E80 demonstrated significant consistency of response, with headache relief rates at 2 h on at least two of three attacks in 66% and 72% vs. 15% on placebo (P < 0.001). AEs were mild to moderate in severity and dose related. The most commonly reported AEs included nausea, vomiting, asthenia, and chest symptoms. E40 and E80 produce an effective response in patients who had previously discontinued treatment with sumatriptan due to lack of efficacy or side-effects.

Efficacy, safety and tolerability of oral eletriptan in the acute treatment of migraine: results of a phase III, multicentre, placebo-controlled study across three attacks

The efficacy, safety and tolerability of the 5-HT1B/D receptor agonist eletriptan (40 mg and 80 mg) in acute treatment of migraine was evaluated in a multinational, randomized, double-blind, parallel-group, placebo-controlled, three-attack study treating 1153 patients. In the initial attack, significantly more eletriptan patients reported headache relief and complete pain relief at 2 h vs. placebo (40 mg 62% and 32%, 80 mg 65% and 34%, placebo 19% and 3%; P < 0.0001). Headache relief occurred faster after eletriptan, with more patients at both doses reporting relief 30 min (P < 0.01) and 1 h (P < 0.0001) after treatment than after placebo. There was a significantly lower recurrence rate with eletriptan 80 mg compared with placebo (P < 0.01). Adverse events for all treatments were generally mild or moderate and self-limiting. Eletriptan 40 mg and eletriptan 80 mg both appear to be effective and well-tolerated acute migraine treatments.

Dose finding, placebo-controlled study of oral almotriptan in the acute treatment of migraine

OBJECTIVE

To assess the efficacy and tolerability of oral almotriptan, a selective serotonin receptor (5-HT1B/1D) agonist, when used at different doses in the treatment of acute migraine.

METHODS

This was a placebo controlled, double-blind, parallel-group, dose-finding study. Patients satisfying International Headache Society criteria for acute migraine were randomized to a single dose of placebo or oral almotriptan 2, 6.25, 12.5, or 25 mg at the onset of moderate or severe pain. Patients graded pain intensity on a 4-point verbal scale from 0 (no pain) to 3 (severe pain) and recorded adverse events. The primary efficacy variable was headache response at 2 hours. Data were analyzed on an intent-to-treat basis.

RESULTS

Nine hundred and three patients were randomized, and 742 were included in the evaluation of the efficacy and tolerability. Headache response at 2 hours was 32.5% with placebo, and 30%, 56.3%, 58.5%, and 66.5% with almotriptan 2, 6.25, 12.5, and 25 mg doses (p < 0.05 for 6.25, 12.5, and 25 mg vs placebo). A dose-dependent decrease in the incidence of migraine-associated symptoms and the need for escape medication was observed. The incidence of adverse events with the almotriptan 2-mg, 6.25-mg, and 12.5-mg groups was comparable to that with the placebo group.

CONCLUSION

Almotriptan 12.5 mg demonstrated the most favorable ratio between efficacy and tolerability, offering equivalent efficacy and better tolerability compared with the 25 mg dose. The minimum effective dose of almotriptan was 6.25 mg.

One-year prevalence of migraine in Sweden: a population-based study in adults

A randomly selected sample of 1668 individuals (782 women and 886 men) aged 18-74 years was interviewed by telephone using a standardized questionnaire including the International Headache Society (IHS) criteria for migraine. The survey was performed by SIFO, the national public opinion poll agency. The results obtained demonstrate that 21% of the Swedish population had suffered from severe headaches during the past year. A majority of these headache sufferers (61%) fulfilled the IHS-criteria for migraine. The 1-year prevalence of migraine in Sweden was found to be 13.2 +/- 1.9% (16.7% among women and 9.5% among men). The prevalence of migraine in this Swedish population did not differ between the northern, middle and southern part of Sweden, or between urban and rural areas or different income groups. Only about half (49%) of the migraineurs had been diagnosed by a physician. Among the individuals who fulfilled the IHS criteria for migraine the mean attack-frequency was 1.3 per month and the mean attack-duration was 19 h. If the duration of the attack was disregarded as a strict criterion for migraine (attacks < 4 h and > 72 h were included), the prevalence increased to 17.0 +/- 1.9% without affecting the sex distribution. With this amendment, 92% of those who considered their headaches to be migraine or migraine-like in fact fulfilled the alternative criteria for migraine. However, only 76% of those who believed that they had migraine or migraine-like headaches fulfilled the strict IHS criteria for migraine. An extension of the time window from 4 to 72 h may be reasonable both from a pragmatic and from a rational clinical point of view.

The efficacy and safety of sc alniditan vs. sc sumatriptan in the acute treatment of migraine: a randomized, double-blind, placebo-controlled trial

This double-blind, placebo-controlled, parallel-group, multicentre, multinational, phase-III trial was designed to assess the efficacy and safety of a single subcutaneous injection of placebo, 2 doses of alniditan (1.4 mg and 1.8 mg) and 6 mg of sumatriptan in subjects with acute migraine. A total of 114 investigators from 13 different countries screened 2021 subjects. In total 924 patients were treated with placebo (157), alniditan 1.4 mg (309), alniditan 1.8 mg (141) and sumatriptan 6 mg (317). The lower number of subjects in the alniditan 1.8 mg group is due to the termination of this trial arm after the incidence of a serious adverse event and a subsequent protocol amendment. The number of subjects who were pain free at 2 h (primary endpoint) was: 22 (14.1%) with placebo, 174 (56.3%) with alniditan 1.4 mg, 87 (61.7%) with alnditan 1.8 mg and 209 (65.9%) with sumatriptan 6 mg. Alniditan 1.4 mg was significantly better (P < 0.001) than placebo and sumatriptan was significantly better (P = 0.015) than alniditan 1.4 mg. The number of responders (reduction of headache severity from moderate or severe headache before treatment to mild or absent at 2 h), was 59 (37.8%) on placebo, 250 (80.9%) on alniditan 1.4 mg, 120 (85.1%) on alniditan 1.8 mg, and 276 (87.1%) on sumatriptan. Response was significantly higher (P < 0.001) with alniditan 1.4 mg than with placebo, and significantly lower (P = 0.036) with alniditan 1.4 mg than with sumatriptan. Recurrence rates were: 22 (37.3%) with placebo, 87 (34.8%) with alniditan 1.4 mg, 35 (29.2%) with alniditan 1.8 mg and 108 (39.1%) with sumatriptan. Adverse events occurred in 577/924 (62.4%) subjects, i.e. in 62/157 (39.5%) with placebo, 214/309 (69.3%) with alniditan 1.4 mg, 91/141 (64.5%) with alniditan 1.8 mg and 210/317 (66.2%) with sumatriptan 6 mg. Sumatriptan was significantly better than alniditan 1.4 mg for pain free at 2 h. The difference, however, was small and clinically not important. For alniditan, a dose-dependent adverse event relationship was seen. The safety profile of alniditan 1.4 mg was similar to that of sumatriptan.

[A vicious circle when headache medication is the cause of chronic headache. A well-planned ambulatory detoxication can result in dramatic improvement]

Chronic daily headache is a commonly encountered syndrome. Typically affected are persons who as a result of recurrent attacks of migraine or tension-type headache have used medications regularly during an earlier stage. Based on clinical experience it is concluded that outpatient drug-withdrawal should be a first-line treatment for patients with chronic daily headache and frequent long-term drug-use. If there is no improvement treatment with a tricyclic drug is recommended.

Withdrawal therapy improves chronic daily headache associated with long-term misuse of headache medication: a retrospective study

Chronic daily headache (CDH) associated with long-term misuse of headache medication is a common clinical problem which is refractory to most treatments. The present study is a retrospective analysis of the effect of drug withdrawal therapy in patients with CDH and frequent long-term use of headache symptomatic medication. One hundred and one adult patients (74 women and 27 men, aged between 16 and 72 years, mean age 43 years) were evaluated 1-3 months after drug withdrawal therapy had been initiated. The mean headache frequency at baseline was 26.9+/-4.0 days per month. Fifty-seven (56%) patients were significantly improved (defined as at least 50% reduction in number of headache days) after a period of drug withdrawal therapy. Based on the outcome of the drug withdrawal therapy, the patients were divided into three categories: group I, those who had between 0 and 10 headache days per month (n = 41), group II, those who had 11-20 days (n = 37), and group III, those who had 21-30 days (n = 23). The mean headache frequencies in groups I, II and III were 5.6+/-2.8 days, 15.7+/-2.5 days and 28.7+/-2.4 days, respectively. Treatment with amitriptyline was offered to patients in whom no improvement had been achieved. Ten of those 22 patients (36%) experienced a significant (> or = 50%) reduction of headache days. It is concluded that out-patient drug withdrawal therapy is the treatment of choice in patients with CDH and frequent long-term use of headache symptomatic medication, and that about one quarter of these CDH patients do not respond to drug withdrawal therapy only.

Efficacy of naratriptan tablets in the acute treatment of migraine: a dose-ranging study. Naratriptan S2WB2004 Study Group

OBJECTIVE

This study sought to compare the efficacy of several doses of naratriptan tablets with that of sumatriptan tablets and placebo in the acute treatment of a single migraine attack.

METHODS

This was a randomized, double-blind, placebo-controlled, parallel-group, dose-ranging study. Patients received either naratriptan tablets (1, 2.5, 5, 7.5, or 10 mg), sumatriptan tablets (100 mg), or placebo.

RESULTS

A total of 643 patients took part in the study. Two hours after dosing, headache relief was reported by significantly more patients treated with any dose of naratriptan (52%-69%) or sumatriptan (60%) than with placebo (31%) (P < 0.05). Four hours after dosing, headache relief was reported by significantly more patients treated with any dose of naratriptan (63%-80%) or sumatriptan (80%) than with placebo (39%) and by significantly more patients treated with sumatriptan 100 mg (80%) than with naratriptan 1 mg (64%), 2.5 mg (63%), or 5 mg (65%) (P < 0.05). Twenty-four-hour overall efficacy (headache relief maintained through 24 hours postdose with no worsening, no use of rescue medication, and no recurrence) was reported by more patients treated with any dose of naratriptan (39%-58%) or sumatriptan (44%) than with placebo (22%). Headache recurrence was reported in 17% to 32% of naratriptan-treated patients, 44% of sumatriptan-treated patients, and 36% of placebo recipients. The overall incidence of adverse events was similar in patients treated with naratriptan 1 mg (20%), naratriptan 2.5 mg (21%), and placebo (23%). For naratriptan 5, 7.5, and 10 mg, the incidence of adverse events was 32%, 37%, and 35%, respectively, and for sumatriptan 100 mg it was 26%.

CONCLUSIONS

Our results suggest that the 2.5-mg dose of naratriptan tablets offers the optimal efficacy-to-tolerability ratio at the dose range between 1 and 10 mg. Although naratriptan 2.5 mg was less effective than sumatriptan 100 mg at 4 hours after dosing, the 2 medications showed similar efficacy at 24 hours.

Ergotamine in the acute treatment of migraine: a review and European consensus

Ergotamine has been used in clinical practice for the acute treatment of migraine for over 50 years, but there has been little agreement on its place in clinical practice. An expert group from Europe reviewed the pre-clinical and clinical data on ergotamine as it relates to the treatment of migraine. From this review, specific suggestions for the patient groups and appropriate use of ergotamine have been agreed. In essence, ergotamine, from a medical perspective, is the drug of choice in a limited number of migraine sufferers who have infrequent or long duration headaches and are likely to comply with dosing restrictions. For most migraine sufferers requiring a specific anti-migraine treatment, a triptan is generally a better option from both an efficacy and side-effect perspective.

Sumatriptan nasal spray in the acute treatment of migraine: a review of clinical studies

Sumatriptan nasal spray is a single-dose device that delivers 5 mg, 10 mg, or 20 mg of sumatriptan (dosage availability dependent upon country) in a 0.1 ml aqueous solution to one nostril. The efficacy and tolerability of sumatriptan nasal spray have been assessed in a number of studies. It has been demonstrated that administering sumatriptan as a divided dose in both nostrils confers no advantage over administration in a single nostril. It appears from these studies that sumatriptan nasal spray is rapidly effective (with an onset of efficacy as early as 15 min postdose). The 20 mg dose is superior to the lower doses (5 mg, 10 mg) in terms of both time to onset of efficacy and the extent of migraine symptom relief. Sumatriptan nasal spray is consistently effective in the treatment of multiple migraine attacks (with 67% of patients treated with the 20 mg dose responding in at least two of three treated attacks) and with long-term use for up to 1 year. Apart from a bitter taste, the adverse event profile of sumatriptan nasal spray is comparable to that of placebo.

Long-term effects of diltiazem and atenolol on blood glucose, serum lipids, and serum urate in hypertensive patients. Swedish-Finnish Study Group

The purpose of this long-term treatment study was to evaluate health-related quality of life by comparing the effects of diltiazem and atenolol on some important metabolic parameters.

SUBJECTS, MATERIAL AND METHODS

In a Swedish-Finnish long-term multicenter study 256 patients with mild to moderate hypertension were randomized to treatment with diltiazem retard (D) (n = 127) or atenolol (A) (n = 129). Doses could be increased and additional captopril medication be given to achieve adequate blood pressure (BP) reduction. The treatment in group D lasted for two years while group A was treated for 1 year and then was given D for another 2 years.

RESULTS

After 1 year BP was significantly reduced in both groups and to a similar degree. The BP reduction was maintained during the rest of the study. After 1 and 2 years, HDL had increased significantly (p < 0.001) in group D. There was a corresponding significant reduction of the LDL/HDL ratio. In group A there were no changes after 1 year regarding lipoprotein levels. After the switch to D, group A showed similar improvements regarding HDL and the LDL/HDL ratio as the original D group.

CONCLUSION

It is concluded that D and A are equally effective in lowering BP. However, long-term treatment with D, but not with A, has a favorable effect on HDL concentrations and the LDL/HDL ratio. According to these findings D affects the risk factor profile in hypertension.

Sumatriptan nasal spray (20 mg/dose) in the acute treatment of cluster headache

Subcutaneous injection of sumatriptan is an effective treatment for attacks of cluster headache with a short onset of action. This open, randomized study evaluates whether sumatriptan nasal spray at its highest commercially available dose (20 mg/dose) is equally effective. In 26 patients, four consecutive attacks were treated alternately with nasal spray and subcutaneous injection. Treatment was given within 5 min of onset of pain, and the time interval for the start and completeness of pain relief, provided these occurred within 15 min of administration, were recorded by the patient. After completion of the study, the patients were also asked to indicate which treatment they preferred, based on efficacy, side effects, and handling of the preparation. Forty-nine of the 52 treatments with injection resulted in complete relief of pain within 15 min, with a mean of 9.6 min. The remaining three attacks were reduced by a mean of 86.7% at 15 min. Only 7 of the 52 treatments with nasal spray in the nostril ipsilateral to pain resulted in complete relief within this time period, with a mean of 13.0 min. In 18 of these treatments pain was reduced by a mean of 42.2% at 15 min, whereas no effect on pain was obtained at this time in the remaining 27 treatments. The effect was almost identical when the nasal spray was administered in the nostril on the non-painful side. As an overall judgement, only 2 of the 26 patients preferred nasal spray to injection. We conclude that sumatriptan nasal spray 20 mg/dose is less effective than subcutaneous injection in relieving pain in the great majority of cluster headache sufferers.

Prevalence of perceived symptoms of dry mouth in an adult Swedish population--relation to age, sex and pharmacotherapy

The aim of the study was to evaluate the prevalence of subjective perception of dry mouth in an adult population and to determine the prevalence of pharmacotherapy in this population. An additional aim was to assess a possible co-morbidity between symptoms of dry mouth and continuing pharmacotherapy. Four-thousand-two-hundred persons were selected at random from the national census register of the adult population of the southern part of the province of Halland, Sweden. The sample was stratified according to age and sex, and 300 men and an equal number of women aged 20, 30, 40, 50, 60, 70 and 80, were included. A newly developed questionnaire was mailed to each individual. In addition to questions about subjective perception of dry mouth, the subjects were asked to report on present diseases and continuing pharmacotherapy. Three-thousand-three-hundred and thirteen (80.5%) evaluable questionnaires were returned. The estimated prevalence of xerostomia in the population was 21.3% and 27.3% for men and women, respectively. This difference between the sexes was statistically significant. In non-medicated subjects, women tended to report a higher prevalence of xerostomia compared with men, 18.8% vs. 14.6%, and also among medicated subjects the estimated prevalence of dry mouth was higher for women than for men, 32.5% vs. 28.4%. There was a strong association between xerostomia and increasing age and also between xerostomia and continuing pharmacotherapy. The average prevalence of dry mouth among medicated and non-medicated subjects was 32.1% and 16.9%, respectively, the difference being statistically significant. There was also a strong association between xerostomia and the number of medications. In a logistic regression, the probability of reporting mouth dryness was significantly greater in older subjects and in women, and the probability increased with the number of medications taken. In conclusion, this epidemiological survey of an adult population has demonstrated that women, independent of age, do report a higher prevalence of xerostomia than men and that the symptom of dry mouth is strongly associated with age and pharmacotherapy. It is, however, not possible to discriminate between disease and pharmacotherapy as causal factors.

A multinational investigation of the impact of subcutaneous sumatriptan. I: Design, methods and clinical findings

This report describes the design, methods and clinical results of a prospective sequential multinational (5 countries) study conducted to evaluate the effects of subcutaneous sumatriptan on health-related quality of life, workplace productivity, clinical parameters and patient satisfaction. Adult patients with moderate to severe migraine initially received customary therapy for migraine episodes for 12 weeks, followed by 24 weeks' treatment with self-administered subcutaneous sumatriptan 6 mg. Demographic, baseline, health-related quality of life and patient satisfaction rating data were collected during visits to the clinic. Data relating to migraine symptoms, migraine therapy, work productivity and non-work activity time were collected on diary cards filled out by the patients. 749 patients were recruited to the study and 637 received at least 1 dose of sumatriptan. Overall, 75.5% of migraines were successfully treated within 2 hours with sumatriptan compared with 31.9% with customary therapy; 36% of patients reported complete relief at 2 hours with sumatriptan treatment compared with 1% of patients receiving customary therapy. 69% of patients successfully treated 70% of their migraines with sumatriptan within 2 hours, compared with 12% of patients with customary therapy. No serious adverse events were reported; 50% of patients reported an adverse event during the 12-week customary therapy phase and 89% of patients during the 24-week sumatriptan phase. These clinical results, which are consistent with those reported in randomised blinded studies of subcutaneous sumatriptan, suggest that relief of migraine symptoms occurs more often, and in less time, in patients receiving subcutaneous sumatriptan rather than customary therapy as their primary medication.

A multinational investigation of the impact of subcutaneous sumatriptan. IV: Patient satisfaction

This report describes the patient satisfaction results from a prospective, sequential, multinational study. The study was conducted to concurrently evaluate the effects of sumatriptan, compared with customary therapy, on clinical parameters, health-related quality of life, productivity and patient satisfaction in adult patients with moderate to severe migraine. Patients treated migraine attacks for 12 weeks with their customary therapy, followed by 24 weeks' treatment with subcutaneous sumatriptan 6 mg. A questionnaire was conducted at the end of each study phase, or retrospectively at the end of the study, to assess patient satisfaction with customary therapy and sumatriptan. Sumatriptan was considered by most patients (67 to 85%) to be dependable and fast-acting, and to have a long duration of effect, allowing a quick return to normal activities. By comparison, 15 to 32% of patients considered that their customary therapy possessed the same attributes. However, customary therapy was considered to be easy/very easy to use by 82% of patients compared with 62% for subcutaneous sumatriptan. 89% of patients indicated that they would use sumatriptan again in the future. This study demonstrates that treatment of migraine attacks with subcutaneous sumatriptan for 24 weeks is associated with greater patient satisfaction as regards specific drug attributes than customary therapy.

A multinational investigation of the impact of subcutaneous sumatriptan. III: Workplace productivity and non-workplace activity

This report presents the workplace productivity and non-workplace activity results of a multinational study of the effects of subcutaneous sumatriptan 6 mg in the acute treatment of migraine compared with patient's customary therapy. Patients diagnosed with migraine treated their symptoms for 24 weeks with subcutaneous sumatriptan after a 12-week period of treating symptoms with their customary (non-sumatriptan) therapy. Patients used diary cards to record information concerning the effects of migraine on workplace productivity and non-workplace activity time. The average workplace productivity time lost was 23.4 hours per patient during 12 weeks of customary therapy, compared with 7.2 and 5.8 hours per patient during the first and second 12-week periods of sumatriptan therapy, respectively. An average of 9.3 hours of non-workplace activity time was lost per patient during the customary therapy phase, compared with 3.2 and 2.8 hours during the first and second 12-week periods of sumatriptan therapy, respectively. Treatment of migraine with subcutaneous sumatriptan compared with customary therapy was associated with an average gain per patient of approximately 16 hours of workplace productivity time and 6 hours of non-workplace activity time, over a 3-month period.

A multinational investigation of the impact of subcutaneous sumatriptan. II: Health-related quality of life

The aim of this prospective sequential multinational (5 countries) study was to concurrently evaluate the effects of subcutaneous sumatriptan on clinical parameters, health-related quality-of-life (HRQOL) measures, workplace productivity and patient satisfaction. This report presents the HRQOL results. 582 patients (aged 18 to 65 years) with moderate to severe migraine received their customary antimigraine therapy for 12 weeks and then subcutaneous sumatriptan for 24 weeks. The Short Form-36 Health Survey and the Migraine-Specific Quality of Life Questionnaire were completed at a screening visit (base-line), at the end of the 12-week customary therapy phase, and at 12 and 24 weeks of the sumatriptan phase. Scores for most of the Short Form-36 dimensions improved significantly (p < 0.05) after 12 and 24 weeks of sumatriptan therapy compared with 12 weeks of customary therapy, in each country. Similarly, scores on all Migraine-Specific Quality of Life Questionnaire dimensions were significantly (p < 0.05; paired t-test) improved after 12 weeks (in all countries) and 24 weeks (in 4 of 5 countries) of sumatriptan therapy compared with 12 weeks of customary therapy. This study demonstrates that, in 5 countries, treatment of migraine attacks with subcutaneous sumatriptan compared with customary therapy was associated with improvements in HRQOL, as measured by both general health status and disease-specific instruments.

Negative feelings (discontent) predict progress of intima-media thickness of the common carotid artery in treated hypertensive men at high cardiovascular risk

A number of psychosocial factors have been identified as cardiovascular risk factors. The purpose of the present study was to examine, in a prospective study, whether quality of life, as measured by the minor symptoms evaluation profile, was associated with progression of the intima-media thickness in the common carotid artery in a group of treated hypertensive men at high risk of cardiovascular disease (n = 97). Patients with any cardiovascular disease (myocardial infarction, angina pectoris, intermittent claudication, or stroke) at entry felt significantly more discontent, compared with patients without signs or symptoms of cardiovascular disease. The change in maximum intima-media thickness during the follow-up period was associated with discontent at entry (r = 0.23, P = .03). The relationship between the change in maximum intima-media thickness and discontent at entry remained significant (P = .02) after adjusting for serum-cholesterol and concomitant cardiovascular disease. In conclusion, discontent in treated hypertensive men at high cardiovascular risk was significantly and independently associated with an increase in maximum intima-media thickness in the common carotid artery. This finding suggests that the experience of well-being may influence the atherosclerotic process.

Effects on salivary flow rate and composition of withdrawal of and re-exposure to the beta 1-selective antagonist metoprolol in a hypertensive patient population

Secretion rates and composition of unstimulated and chewing-stimulated whole saliva and 3% citric acid stimulated parotid and submandibular-sublingual secretions were studied in 12 hypertensive patients during withdrawal of and re-exposure to antihypertensive pharmacotherapy. All the patients' blood pressures were well controlled by monotherapy with metoprolol, a beta 1-selective adrenoceptor antagonist. Blood pressure measurements and saliva sampling were performed at about 9:30 a.m., 2 h after intake of breakfast, on days 0 (medicated baseline), 7, 14, 28 (nonmedicated experimental values and nonmedicated baseline) and 35 (medicated experimental values). A significant increase in unstimulated whole saliva secretion rate was observed when metoprolol was withdrawn and a corresponding decrease when the drug was reintroduced. A positive correlation was found between diastolic blood pressure levels and chewing-stimulated whole saliva secretion rates. In unstimulated whole saliva and 3% citric acid stimulated submandibular-sublingual secretion, the output of total protein, amylase, potassium, calcium and phosphate was significantly increased during the withdrawal period and decreased when metoprolol was reintroduced. For chewing-stimulated whole saliva, the corresponding changes were restricted to output of total protein and amylase, while for citric acid stimulated parotid secretion, no changes in salivary composition were observed. Finally, in all secretions one or both of the ratios hexosamine/total protein and sialic acid/total protein were affected, indicating a possible effect of beta-adrenoceptor antagonists on salivary protein synthesis.

A randomized study of quality of life during multiple risk factor intervention in treated hypertensive men at high cardiovascular risk

OBJECTIVE

To examine the effect on quality of life in hypertensive men of a multiple risk factor intervention programme compared with that of usual care.

DESIGN

A prospective, open, randomized, parallel-group study with allocation either to a comprehensive multiple risk factor modification programme or to usual care.

SETTING

An outpatient clinic in a city hospital.

PATIENTS

Five hundred and eight treated hypertensive men, aged 50-72 years, with at least one of the following: serum cholesterol > or = 6.5 mmol/l, smoking habit or diabetes mellitus.

INTERVENTION

Nutritional advice, behavioural treatment principles and drug therapy.

MAIN OUTCOME MEASURES

Minor symptoms evaluation profile (MSEP) was used to measure change in quality of life.

RESULTS

The intervention programme led to sustained effects on lifestyle-related variables such as hypercholesterolaemia, body mass index and smoking habits, whereas diastolic blood pressure and HbA1c remained unchanged. The change in the MSEP during follow-up did not differ between the intervention and the usual care groups. There was a close relationship between the measurements of the three MSEP dimensions at baseline and at follow-up (P < 0.0001). None of the potential risk factors measured at entry was significantly associated with change in the three MSEP dimensions during follow-up.

CONCLUSION

The multiple risk factor intervention programme directed towards smoking habits, hypercholesterolaemia and the metabolic control of diabetes mellitus in treated hypertensive men at high cardiovascular risk was not associated with an impaired quality of life compared with that in a control group. The method used, the MSEP, has previously been found to be a reliable method with good validity, and this study's results provide further evidence of its validity.

Quality of life is not negatively affected by diet and exercise intervention in healthy men with cardiovascular risk factors

Health-related quality of life was assessed in a diet and exercise intervention study among 157 healthy men aged 35-60 years (mean +/- s.d.; 46.2 +/- 5.0) with moderately raised cardiovascular risk factors. The men were randomized to four groups, diet (D, n = 40), exercise (E, n = 39), diet plus exercise (DE, n = 39), and no active intervention (controls (C) n = 39). Quality of life was measured with two self-administered questionnaires; Subjective Symptoms Assessment Profile and Minor Symptom Evaluation Profile, at baseline and after 1.5, 3 and 6 months. Cardiovascular risk factors were investigated at baseline and after 6 months. As a result of changes in dietary habits and physical exercise in the three intervention groups, several important cardiovascular risk factors were significantly reduced. The quality of life/well-being did not differ between the four groups and did not change significantly in any of the groups during the study. There was, however, a tendency towards fewer gastrointestinal symptoms in group D and fewer cardiac symptoms in group DE. We conclude that advice on lifestyle changes in the form of diet and exercise reduce risk factors in middle-aged men without negative effects on their quality of life.

Clinical experiences from Sweden on the use of subcutaneously administered sumatriptan in migraine and cluster headache

This article reviews, from the practitioner's point of view, more than 1 year of clinical experience of the use of subcutaneously administered sumatriptan succinate in the short-term treatment of migraine and cluster headache with regard to advantages and disadvantages of the drug. In accordance with the results of clinical trials, subcutaneous sumatriptan, also in the practitioner's hands, was found to relieve migraine headaches and all other symptoms associated with migraine in most patients and within a reasonable period. Adverse events, however, are common and were perceived by about 70% of the patients. The most common adverse events were pressure/stiffness in the neck and throat (32%), general tiredness (22%), pressure/tightness over the chest (21%), injection site reactions (16%), and tingling sensations in the head and arms (14%). Headache recurrence within 24 hours is a clinical problem not only for the patient but also for the prescribing physician. About every second (53%) migraineur using subcutaneous sumatriptan reports headache recurrence. Headache recurrence appears to be effectively treated by a second injection. Pending valid information about effects, adverse events, headache recurrence, and how to handle the autoinjector, the compliance and tolerability of subcutaneous sumatriptan appear to be most satisfactory among eligible patients with migraine.

Heterogeneity of prejunctional neuropeptide Y receptors inhibiting noradrenaline overflow in the portal vein of freely moving rats

The effects of intraportal infusions of different doses of neuropeptide Y, its selective neuropeptide Y Y1 receptor analogue, [Leu31,Pro34]neuropeptide Y, and the Y2-selective C-terminal fragment, neuropeptide Y-(18-36), on basal and electrically evoked noradrenaline overflow in the portal vein as well as on mean arterial pressure and heart rate were investigated in permanently instrumented freely moving rats. Neuropeptide Y dose dependently (2-2000 ng/kg/min) attenuated the electrically evoked noradrenaline overflow and almost complete blockade was reached at the highest dose used. [Leu31,Pro34]Neuropeptide Y also dose dependently (20-20,000 ng/kg/min) attenuated the evoked overflow, reaching a maximum of 55% inhibition at the highest dose (20,000 ng/kg/min). Neuropeptide Y-(18-36) attenuated the evoked release only at 20,000 ng/kg/min (by 46%). Only at the highest dose did neuropeptide Y (2000 ng/kg/min) and [Leu31,Pro34]neuropeptide Y (20,000 ng/kg/min) significantly enhance mean arterial pressure and decrease heart rate and basal plasma noradrenaline levels, the latter two effects being due to the baroreceptor reflex. Neuropeptide Y-(18-36) did not influence these parameters at all doses used. The results indicate the presence of prejunctional neuropeptide Y Y1 receptors, and possibly the coexistence of Y1 and Y2 receptors, in the portal vein of freely moving rats, which in conjunction are able to inhibit markedly electrically evoked noradrenaline overflow. Postjunctional neuropeptide Y receptors mediating an increase in blood pressure in the freely moving rat are solely of the Y1 subtype.

Effects of the beta-adrenoceptor antagonists atenolol and propranolol on human unstimulated whole saliva flow rate and protein composition

The effects of 1-wk medication with two beta-adrenoceptor antagonists on unstimulated whole saliva flow rate and protein composition were evaluated in 11 healthy young men in a randomized, double-blind, placebo-controlled, cross-over study. Unstimulated whole saliva was collected before each treatment period and then again after 7 days. The saliva was assessed for flow rate, total protein, and hexosamine and sialic acid concentrations and for amylase activity. No significant effect on saliva secretion rate was found. A statistically significant reduction of salivary total proteins was registered during atenolol medication. The amylase activity decreased significantly during treatment with both atenolol and propranolol. Significant changes of the calculated ratios of sialic acid/hexosamine and hexosamine/total protein indicated an alteration in glandular protein synthesis after atenolol treatment.

Intranasal sumatriptan for the acute treatment of migraine. International Intranasal Sumatriptan Study Group

Two double-blind, placebo-controlled, randomised, multicentre, multinational, parallel-group studies were carried out to identify the optimum dose of intranasal sumatriptan for the acute treatment of migraine. Study medication was taken as a single dose through one nostril in the first study, and as a divided dose through two nostrils in the second study. Totals of 245 and 210 patients with a history of migraine were recruited into the one- and two-nostril studies, respectively. In both studies, headache severity had significantly improved at 120 min after doses of 10-40 mg sumatriptan compared to placebo (P < 0.05) and the greatest efficacy rates were obtained with 20 mg sumatriptan. With 20 mg sumatriptan 78% and 74% of patients experienced headache relief in one- and two-nostril studies respectively. Sumatriptan was generally well tolerated, the most frequently reported event being taste disturbance. The results of the two studies are similar and indicate that administering sumatriptan as a divided dose via two nostrils confers no significant advantage over single-nostril administration.

Tetrodotoxin-sensitive release of adrenaline, noradrenaline and neuropeptide Y-like immunoreactivity in the pithed guinea-pig in the absence of electrical preganglionic nerve stimulation

The effect of tetrodotoxin (TTX) on plasma noradrenaline (NA), adrenaline (A) and neuropeptide Y-like immunoreactivity (NPY-LI) levels was evaluated in the pithed guinea pig, in the absence of electrical stimulation and following preganglionic nerve stimulation (PNS). Blood samples for determination of NA, A and NPY-LI were collected 5 min before and 5 min after injection of saline (control group, n = 6) or TTX (13 micrograms/kg, i.v., TTX-treated group, n = 8), respectively. In both groups, blood samples were collected 20 s and 40 s after initiation of PNS. In the absence of electrical stimulation, TTX reduced the plasma NA level by 66%, NPY-LI level by 42%, whereas the plasma A level was not significantly altered by the neurotoxin. In the control group, PNS elicited a 27-fold increase of plasma NA, a 60-fold increase of plasma A and enhanced the NPY-LI levels by 13%. Pretreatment with TTX completely blocked this release of sympathetic transmitters. The present results suggest that a certain degree of spontaneous nerve activity is present in the pithed animal model, also during baseline conditions, since TTX significantly reduced NA and NPY-LI in the absence of electrical stimulation. This spontaneous nerve activity is probably a consequence of local mechanical activity of the pithing rod capable of eliciting action potentials at the preganglionic level of the sympathetic nerve terminals.

Pre- and postganglionic stimulation-induced noradrenaline overflow is markedly facilitated by a prejunctional beta 2-adrenoceptor-mediated control mechanism in the pithed rat

The aim of the study was to further explore the prejunctional beta-adrenoceptor-mediated control mechanism of noradrenaline release from sympathetic nerves in response to preganglionic nerve stimulation (PNS) and local nerve stimulation of the portal vein, respectively, in the pithed rat. Baseline values as well as the increments of mean arterial blood pressure (delta-BP), heart rate (delta-HR) and plasma noradrenaline levels (delta-NA) in response to four PNS episodes (0.8 Hz, 3 ms, 75 V for 45 s at 20 min intervals), respectively, were evaluated. Fenoterol administration (0.25 mg/kg, i.v.) reduced significantly the basal blood pressure but did not alter delta-BP in response to PNS. Basal heart rate markedly increased after fenoterol without any further change in heart rate induced by PNS. The beta 1-selective antagonist CGP 20712A attenuated delta-BP in response to PNS and prevented the fenoterol-induced increase in basal heart rate. The beta 2-selective antagonist ICI 118,551 per se did not change the blood pressure and heart rate values, but antagonized the fenoterol-induced decrease in basal blood pressure. Fenoterol enhanced plasma delta-NA in response to PNS by 105% in comparison to the corresponding control value. This effect of fenoterol could be blocked by pretreatment with ICI 118,551 but not with CGP 20712A (a selective beta 1-adrenoceptor antagonist) which per se did not significantly change plasma delta-NA. Repeated local stimulation of the portal vein (S1-S3, 2 Hz, 3 ms, 10 mA, for 120 s at 30 min intervals) increased portal plasma noradrenaline without changing mean blood pressure and heart rate in pithed rats.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of the beta-adrenoceptor antagonists atenolol and propranolol on human parotid and submandibular-sublingual salivary secretion

The aim of the study was to evaluate the effects of a beta 1-selective (atenolol 50 mg q.d.) and a non-selective (propranolol 80 mg b.i.d.) beta-adrenoceptor antagonists on human stimulated parotid and submandibular-sublingual (SM-SL) gland secretion. A randomized double-blind, placebo-controlled cross-over ("Latin square") design was used in 19 healthy male volunteers. Stimulated parotid and SM-SL saliva were sampled immediately before and 7 days after the start of each treatment period. Stimulation of salivary secretion was achieved by use of a 3% citric acid solution. Plasma concentrations of propranolol and atenolol were determined from blood samples. The salivary secretion of both glands was assessed for flow rate, amylase, lysozyme, and salivary peroxidase activity and for concentrations of total protein, hexosamine, sialic acid, Ca2+, Cl-, K+, Mg2+, Na+, and PO4(3-). In both parotid and SM-SL secretions, the total protein and phosphate concentrations and amylase activity were significantly decreased during the two active treatment periods. In SM-SL gland secretion, there were significant changes in potassium and calcium concentrations during active treatment as compared with baseline, with potassium showing a decreased and calcium an increased concentration. During atenolol treatment, salivary peroxidase activity decreased significantly in SM-SL secretion. In parotid secretion, the hexosamine/total protein ratio decreased and the sialic acid/hexosamine ratio increased during atenolol treatment, which may indicate an effect on protein synthesis. No significant effects on salivary secretion rates were disclosed.

Assessment of health-related quality of life in migraine

Assessment of HQL has become an important complement to the traditional methods that are used for objective registration of physiological, structural or biochemical processes during an illness. A generally applicable definition of HQL includes both subjective perception of one's life situation and objectively registrable health factors. This manner of evaluating quality of life perhaps will achieve further acceptance and thereby facilitate both reporting and evaluation of quality-of-life measurements. To document changes in HQL more precisely, reliable and valid test instruments with sufficient sensitivity to detect clinically relevant changes are essential. Available data indicate that the individual's personality, the migraine attack or its treatment or both can influence the patient's HQL. At present it is unclear which of the available acute treatments for migraine attacks produces the best general well-being or highest quality of life. It is probable that, as in other therapeutic areas, an optimal treatment result can only be achieved with an individualized therapeutic strategy.

A modified device for collection and flow-rate measurement of submandibular-sublingual saliva

The aims of the present study were to measure stimulated submandibular-sublingual (SM-SL) salivary flow rate with a modified Block-Brottman collection device, and, further, to evaluate the reliability of measurements of stimulated SM-SL salivary flow rate by means of this modified Block-Brottman device, as compared to measurements of parotid flow rate using modified Carlson-Crittenden cups. Twenty-nine healthy female volunteers, aged 36 +/- 7 yr, were included. Saliva stimulation was achieved by application of a 3% citric acid solution to the rims of the tongue four times/min, for 3 s every 15 s. On 3 consecutive days, stimulated parotid and SM-SL salivas were collected for 2 min at 07.30, before breakfast (morning value), and at 10.00, 2 h after a standard breakfast (lunchtime values). SM-SL saliva was also collected on one occasion for 2 min x 3. For parotid and SM-SL saliva, the mean stimulated flow rates were in the morning, 1.50 +/- 0.83 and 2.25 +/- 1.12 ml/min, and at lunchtime, 1.71 +/- 1.16 and 2.54 +/- 1.01 ml/min, respectively. For both salivas, lunchtime values were significantly higher than morning values by about 13-14%. Comparing parotid and SM-SL saliva flow rates, we found the SM-SL saliva flow rate to exceed the parotid flow rate by about 50% both in the morning and at lunchtime. Variations in flow rate were analyzed by means of ANOVA. Interindividual variance and variance between measurement days and times of day made up 88% of parotid and 83% of SM-SL total variance.(ABSTRACT TRUNCATED AT 250 WORDS)

Placebo-controlled clinical trials with ergotamine in the acute treatment of migraine

Although oral ergotamine alone or in combination with caffeine is widely used for the acute treatment of migraine, there is little evidence that it is significantly more effective than placebo. There are no placebo-controlled data to support the use of aerosol or suppository formulations. In addition, the recommended doses of ergotamine cannot be justified. Each formulation of ergotamine now should be tested in clinical studies performed according to the IHS criteria for trial design and in migraine patients fulfilling the diagnostic criteria of the IHS. Until these clinical data are available, no clear recommendations can be given for the use of ergotamine in the acute treatment of migraine.

Diclofenac-K (50 and 100 mg) and placebo in the acute treatment of migraine

The aim of the present study was to assess the efficacy and tolerability of single oral doses of 50 mg and 100 mg of diclofenac-K compared to placebo in migraine sufferers during three attacks. The study was conducted in a double-blind, randomized, placebo-controlled, three-period, within-patient comparative trial; 72 migraine patients were treated with diclofenac-K (50 mg or 100 mg) or placebo at six centres (1 in Sweden and 5 in Finland). The primary efficacy end-point was the change in pain intensity assessed on a 100 mm Visual Analogue Scale (VAS) at 120 min after taking the study medication. We found that 50 mg and 100 mg of diclofenac-K reduced the pain intensity significantly better than placebo (p = 0.003 and p = 0.001, respectively), without difference between the doses; 100 mg diclofenac-K was significantly better than placebo in improving phonophobia, photophobia, working ability and need for rescue medication. Diclofenac-K 50 mg or 100 mg is an effective and well-tolerated acute treatment for migraine headache and its associated symptoms. The higher dose of diclofenac-K was only marginally more effective than the lower dose.