A randomized trial of divalproex sodium extended-release tablets in migraine prophylaxis

OBJECTIVE

To evaluate the efficacy and safety of extended-release divalproex sodium compared with placebo in prophylactic monotherapy treatment of migraine headache.

METHODS

This was a double-blind, randomized, placebo-controlled, parallel-group study. Subjects with more than two migraine headache attacks during a 4-week baseline were randomly assigned in a 1:1 ratio at each center to receive either extended-release divalproex sodium or matching placebo once daily for 12 weeks. Subjects initiated treatment on 500 mg once daily for 1 week, and the dose was then increased to 1,000 mg once daily with an option, if intolerance occurred, to permanently decrease the dose to 500 mg during the second week. Reduction from baseline in 4-week migraine headache rate was the primary efficacy variable. Migraine headaches separated by a < 24-hour headache-free interval were counted as single migraines in calculating migraine headache rates. Tolerance and safety were also evaluated.

RESULTS

The mean reductions in 4-week migraine headache rate were 1.2 (from a baseline mean of 4.4) in the extended-release divalproex sodium group and 0.6 (from a baseline mean of 4.2) in the placebo group (p = 0.006); reductions with extended-release divalproex sodium were significantly greater than with placebo in all three 4-week segments of the treatment period. No significant differences were detected between treatment groups in either the overall incidence or in the incidence of any specific treatment-emergent adverse event; 8% of subjects treated with extended-release divalproex sodium and 9% of those treated with placebo discontinued for adverse events.

CONCLUSION

Extended-release divalproex sodium is an efficacious, well-tolerated, safe, and easy-to-use once-a-day prophylactic antimigraine medication.

Triptans in the treatment of basilar migraine and migraine with prolonged aura

OBJECTIVE

To report on the use of triptans in migraine with prominent neurologic symptoms.

BACKGROUND

As stated in their package inserts, the triptans are contraindicated in patients with basilar or familial hemiplegic migraine, and physicians are reluctant to prescribe these drugs to other patients with prominent or prolonged aura.

METHODS

We evaluated 13 patients with basilar migraine, familial hemiplegic migraine, or migraine with prominent or prolonged aura who had received triptans.

RESULTS

Excellent; no adverse events.

CONCLUSION

The contraindication of triptans in basilar migraine should be reconsidered. Similarly, prominent or prolonged aura may not represent a reasonable contraindication to triptan therapy.

A high performance liquid chromatographic method for the estimation of diethylcarbamazine content in medicated salt samples

A simple and reproducible method for the estimation of diethylcarbamazine citrate (DEC) by high performance liquid chromatography (HPLC) in DEC-medicated salt was developed. HPLC analysis was conducted with a mobile phase containing acetonitrile/phosphate buffer (20 mM KH(2)PO(4,) adjusted to pH 3.2 with 10% ortho-phosphoric acid) in the ratio of 1:9 and at a flow rate of 1.5 ml/min. A Phenomenex C8 column (15 cmx4.6 mm) of 5 microm particle size was used for the analysis. Analysis was done at UV 210 nm, 0.02 a.u.f. and 40 degrees C. The coefficient of variation was <10% in the range of 1-25 microg/ml and the minimum detectable level was 0.5 microg/ml. The quality of DEC-medicated salt prepared by two methods was analyzed by using the HPLC method. In spray drying method, 29 and 71% of the samples and in rotating drum method, 9 and 12% of samples were found to contain DEC at 0.15-0.25% and >0.25%, respectively. Thus, this quick and simple HPLC method for the estimation of DEC could play a vital role in checking the quality of the DEC medicated salt used for the control of filariasis.

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.

Laboratory & field evaluation of controlled release formulation of the insect repellents N,N-diethyl-m-toluamide (DEET) & N,N-diethyl phenylacetamide (DEPA) against mosquito vectors

BACKGROUND & OBJECTIVES

Repellents can play a useful role in reducing the man-vector contact and help in interrupting disease transmission. Newer formulations are necessary to improve the efficacy of the repellent on the treated sites for enhanced protection.

METHODS

To determine the comparative efficacy, 20 per cent liposphere lotion formulation and 20 per cent alcohol solution of two insect repellents DEET and DEPA were evaluated for the extent of protection on rabbits against Aedes aegypti during the day in the laboratory and on human volunteers during the night against Culex quinquefasciatus in the urban areas of Pondicherry, India.

RESULTS

In the laboratory, the lotion formulations of DEPA and DEET were found to enhance the repellency by 1.5 (4.00 to 6.00 h) and 1.25 (4.00 to 5.00 h) times respectively compared to the alcohol solution of the repellents against Ae. aegypti at the application rate of 0.5 mg/cm2. In the field, the lotion formulation of DEPA at 0.3 mg/cm2 could increase the protection time from 6.30 to 8.36 h (1.3 times) whereas the lotion formulation of DEET at 0.3 mg/cm2 could increase the protection time from 6.54 to 8.42 h (1.2 times).

INTERPRETATION & CONCLUSION

In laboratory and field tests, the lotion formulations of both repellents were found to give a higher protection compared to alcohol solution. The lotion formulations of DEET and DEPA were found to be equally effective.

Effects of a juvenoid, DPE-28, on biology and behaviour of Culex quinquefasciatus, the human filariasis vector

Studies on the effect of a juvenoid, DPE-28 (2,4-dinitrophenyl-2',6'-di-tertiarybutyl phenyl ether) on biology and behaviour of Cx. quinquefasciatus showed that the developmental duration, sex ratio, mating success and blood feeding were considerably affected by the exposure of larvae and pupae to the compound. Exposure of fourth instar larvae to 0.007 (EI90) and 0.0019 (EI50) ppm of DPE-28 prolonged the duration of pupation by 58.6 and 52.4 hr and delayed the adult emergence by 35.4 and 17.7 hr in males and 36.8 and 21.1 hr in females respectively. Exposure of freshly ecdysed pupae to 10 and 5 ppm delayed the adult emergence with respect to the control by 54.3 and 32.4 hr in males and 55.2 and 33.2 hr in females respectively. The sex ratio of the adults emerged from treated larvae and pupae was also affected. The female mosquitoes that survived from the exposed fourth instar larvae and pupae exhibited a low blood engorgement ratio. This depression in blood feeding was more pronounced in adults emerged from treated pupae than that of treated fourth instar larvae. A significant proportion of adults emerged from treated larvae and pupae were able to feed only partially. Mating success of the treated populations declined considerably when crosses were made between the males and females emerged from treated fourth instar larvae and pupae. The adults emerged from treated larvae and pupae showed a significant reduction in the oviposition.

Botulinum toxin type A as a migraine preventive treatment. For the BOTOX Migraine Clinical Research Group

OBJECTIVE

To assess the safety and efficacy of botulinum toxin type A (BOTOX; Allergan, Inc) in the prevention of migraine.

BACKGROUND

Current migraine preventive therapies are often unsatisfactory because of their limited efficacy, adverse effects, and drug interactions. Botulinum toxin type A injections often reduce the pain associated with conditions such as cervical dystonia, achalasia, rectal fissures, and myofascial pain syndrome. An open-label, noncontrolled study of botulinum toxin type A suggested benefits for patients with migraine.

DESIGN AND METHODS

This was a double-blind, vehicle-controlled study of 123 subjects with a history of two to eight moderate-to-severe migraine attacks per month, with or without aura. Participants were randomized to receive single administrations of vehicle or botulinum toxin type A, 25 U or 75 U, injected into multiple sites of pericranial muscles at the same visit. During a 1-month baseline period and for 3 months following injection, subjects kept daily diaries in which they recorded migraine frequency, migraine severity, and the occurrence of migraine-associated symptoms.

RESULTS

Compared with vehicle treatment, subjects in the 25-U botulinum toxin type A treatment group showed significantly fewer migraine attacks per month, a reduced maximum severity of migraines, a reduced number of days using acute migraine medications, and reduced incidence of migraine-associated vomiting. Both the 25-U and 75-U botulinum toxin type A groups were significantly better than the vehicle group on subject global assessment. Botulinum toxin A treatment was well tolerated, with only the 75-U treatment group exhibiting a significantly higher rate of treatment-related adverse events than vehicle.

CONCLUSIONS

Pericranial injection of botulinum toxin type A, 25 U, was found to be a safe treatment that significantly reduced migraine frequency, migraine severity, acute medication usage, and associated vomiting.

Concomitant administration of antiemetics is not necessary with intramuscular dihydroergotamine

The influence of concomitant administration of an antiemetic agent on the course of nausea was assessed in a field trial of intramuscular dihydroergotamine for the treatment of acute migraine. Of 311 migraine patients enrolled onto the study, 62% (191 of 311) experienced nausea at the outset; 38% (119 of 311) did not. Of those with nausea at the outset, 54% (103 of 191) received an antiemetic. Of those without nausea at the outset, 25% (30 of 119) received an antiemetic. Thus, a total of 43% (133 of 311) of patients received a concomitant antiemetic, whereas 57% (177 of 311) received dihydroergotamine alone. When changes in the incidence of nausea were compared at 30 and 60 minutes after dihydroergotamine, an antiemetic effect was discerned in patients treated with or without a concomitant antiemetic. Antiemetic treatment yielded no significant difference in the percentage of patients experiencing nausea during the study. At baseline, 50% (88 of 177) of patients who received dihydroergotamine alone experienced nausea compared with 77% (103 of 133) of those who received an antiemetic. At the 30-minute point, 35% (61 of 173) of patients who received dihydroergotamine alone still experienced nausea versus 47% (62 of 133) of patients who received an antiemetic. At the 60-minute point, only 24% (42 of 174) of those given dihydroergotamine alone had nausea, compared with 38% (50 of 132) given concomitant antiemetic. Ongoing nausea seems to be a manifestation of the migraine process rather than an adverse effect associated with intramuscular dihydroergotamine.(ABSTRACT TRUNCATED AT 250 WORDS)

Office-based treatment of acute migraine with dihydroergotamine mesylate

The Regional Migraine Field Trial assessed the efficacy and safety of dihydroergotamine mesylate (D.H.E. 45) for migraine in the office setting. Patients were admitted to the study provided they met the International Headache Society definition of migraine with or without aura. Thirty-eight neurologists enrolled 311 patients (274 women and 37 men) between the ages of 13 and 70 years in this open-design study. Ninety-five percent of the patients had moderate or severe headache pain at entry, and 62% had nausea. All patients received a single intramuscular injection of D.H.E. 45 1 mg. A second intramuscular injection of 1 mg was given 60 minutes after the first injection, if needed. An antiemetic was administered concomitantly with D.H.E. 45, if needed. Rescue therapy was given at the investigators' discretion. Efficacy was judged by the relief of pain, patients' ability to function, need for a second injection, need for rescue medication, and need for an antiemetic. At 30 and 60 minutes, 46% and 72% of patients had only mild or no head pain, respectively. At 24 hours, 77% of all patients had mild or no head pain. D.H.E. 45 also improved functional ability. At 30 and 60 minutes, 58% and 75% of patients had only mild or no disability, respectively. At 24 hours, 81% had mild or no impairment. Nausea was present in 62% of patients at the outset, 40% of patients at 30 minutes, and 30% at 60 minutes. An antiemetic was given to 43% of patients at the outset. The presence of nausea was similar whether or not patients received an antiemetic.(ABSTRACT TRUNCATED AT 250 WORDS)