Acute migraine treatment with droperidol: A randomized, double-blind, placebo-controlled trial

BACKGROUND

The treatment of a migraine attack can be difficult when first-line medication is unsuccessful and options for parenteral "rescue" therapy are limited.

METHODS

A randomized, double-blind, placebo-controlled, dose-ranging, multicenter study was conducted to assess the efficacy and tolerability of droperidol 0.1 mg, 2.75 mg, 5.5 mg, and 8.25 mg for the acute treatment of moderate to severe migraine headache in adults.

RESULTS

A total of 331 patients were enrolled; 305 were treated. Headache response at 2 hours was better (p < 0.002) in the treatment groups receiving droperidol IM at doses of 2.75 mg (87%), 5.5 mg (81%), and 8.25 mg (85%) compared with placebo (57%). The percent of patients achieving a pain-free response at 2 hours after treatment was significantly greater than placebo for the droperidol 2.75-mg, 5.5-mg, and 8.25-mg dose groups. The frequency of headache recurrence (within 24 hours) for patients initially responding by 2 hours was lower in patients treated with droperidol than placebo, but differences failed to reach significance. A significantly greater percentage of patients receiving droperidol 2.75 mg reported the elimination of migraine-associated symptoms (nausea, vomiting, photophobia, and phonophobia) than those who received placebo. Although most adverse events were of mild or moderate intensity, anxiety, akathisia, and somnolence were rated as severe in 30% of patients who experienced those symptoms. Hypotension was uncommon. No patient had QT prolongation.

Fatigue in chronic migraine patients

Fatigue is a common symptom frequently reported in many disorders including headaches, but little is known about its nature. The objective was to determine the prevalence of fatigue in chronic migraine (CM) patients, to define its subtypes and its relationship with other conditions comorbid with CM. Sixty-three CM patients were analysed. The Fatigue Severity Scale (FSS), the Chalder fatigue scale and the CDC diagnostic criteria for chronic fatigue syndrome (CFS) were used. Fifty-three (84.1%) patients had FSS scores greater than 27. Forty-two (66.7%) patients met the CDC criteria for CFS. Thirty-two patients (50.8%) met the modified CDC criteria (without headache). Beck depression scores correlated with FSS, mental and physical fatigue scores. Trait anxiety scores also correlated with fatigue scales. Women had higher FSS scores than men, P < 0.05. Physical fatigue was associated with fibromyalgia, P < 0.05. Fatigue as a symptom and CFS as a disorder are both common in CM patients. Therapeutic interventions include a graded aerobic exercise program, cognitive behavioural therapy and antidepressants. Identification of fatigue and its subtypes in headache disorders and recognition of headaches in CFS patients has implications for the pathophysiology, diagnosis and treatment of these disorders.

Topiramate: a case series study in migraine prophylaxis

We reviewed the electronic records of 74 migraine patients treated with topiramate for more than 6 weeks. Twenty-four patients had episodic migraine and 50 had chronic (transformed) migraine. Most (81%) started treatment at 25 mg per day and reached a dose of 100 mg twice a day (mean dose on the last follow-up visit was 208 mg). The mean headache frequency decreased from 20.6 days to 13.6 days per month (P<0.0001) for all headaches (9.9-5.1 (P<0.0001) and 25.7-17.7 (P<0.001) for episodic migraine and chronic migraine, respectively). The percentage of patients whose headache frequency was reduced by > or =50% was 44.6% for all patients; 58.3 for episodic migraine and 38.0 for chronic migraine. For all patients mean headache severity (10-point scale) was reduced from 6.2 to 4.8 (P<0.0001). Patients on monotherapy (20%) and polytherapy (80%) had similar reductions in headache frequency. Adverse events were usually mild to moderate and were seen in 58.1% (paresthesias in 25%, cognitive difficulties 14.9%). Mean weight loss was 3.1 +/- 4 kg (3.8% of total body weight).

Is muscle power related to running speed with changes of direction?

BACKGROUND

The purpose of this study was to identify the relationships between leg muscle power and sprinting speed with changes of direction.

METHODS

EXPERIMENTAL DESIGN

the study was designed to describe relationships between physical qualities and a component of sports performance.

SETTING

testing was conducted in an indoor sports hall and a biomechanics laboratory.

PARTICIPANTS

15 male participants were required to be free of injury and have recent experience competing in sports involving sprints with changes of direction.

MEASURES

subjects were timed in 8 m sprints in a straight line and with various changes of direction. They were also tested for bilateral and unilateral leg extensor muscle concentric power output by an isokinetic squat and reactive strength by a drop jump.

RESULTS

The correlations between concentric power and straight sprinting speed were non-significant whereas the relationships between reactive strength and straight speed were statistically significant. Correlations between muscle power and speed while changing direction were generally low and non-significant for concentric leg power with some moderate and significant (p<0.05) coefficients found for reactive strength. The participants who turned faster to one side tended to have a reactive strength dominance in the leg responsible for the push-off action.

CONCLUSIONS

The relationships between leg muscle power and change-of-direction speed were not consistent. Reactive strength as measured by the drop jump appears to have some importance for lateral change-of-direction speed, possibly because of similar push-off actions. It was concluded that reactive strength of the leg extensor muscles has some importance in change-of-direction performance but the other technical and perceptual factors than influence agility performance should also be considered.

Greater occipital nerve blockade for cluster headache

Cluster headache is perhaps the most painful of the primary headache disorders. Its treatment includes acute, transitional, and preventive therapy. Despite the availability of many treatments, cluster headache patients can still be difficult to treat. We treated 14 cluster headache patients with greater occipital nerve block as transitional therapy (treatment initiated at the same time as preventive therapy). The mean number of headache-free days was 13.1 + 23.6. Four patients (28.5%) had a good response, five (35.7%) a moderate, and five (35.7%) no response. The greater occipital nerve block was well tolerated with no adverse events. Headache intensity, frequency and duration were significantly decreased comparing the week before with the week after the nerve block (P < 0.003, P = 0.003, P < 0.005, respectively). Greater occipital nerve blockade is a therapeutic option for the transitional treatment of cluster headache.

Intravenous propofol in the treatment of refractory headache

We analyzed the results of treating patients who had chronic daily headaches that were refractory to standard medications with repetitive low-dose boluses of intravenous propofol (2,6-diisopropylphenol). Patients were treated over a 1-year period at Thomas Jefferson University Hospital. A total of 18 patients were treated a total of 21 times. Over 90% of patients had at least some headache relief after treatment. The headache cycle was broken in eight patients. There were no complications. Intravenous propofol is safe and effective when used under monitored conditions and should be considered for patients who have refractory chronic daily headache and have failed other interventions.

Olanzapine in the treatment of refractory migraine and chronic daily headache

BACKGROUND

Olanzapine, a thienobenzodiazepine, is a new "atypical" antipsychotic drug. Olanzapine's pharmacologic properties suggest it would be effective for headaches, and its propensity for inducing acute extrapyramidal reactions or tardive dyskinesia is relatively low. We thus decided to assess the value of olanzapine in the treatment of chronic refractory headache.

METHODS

We reviewed the records of 50 patients with refractory headache who were treated with olanzapine for at least 3 months. All previously had failed treatment with at least four preventative medications. The daily dose of olanzapine varied from 2.5 to 35 mg; most patients (n = 19) received 5 mg or 10 mg (n = 17) a day.

RESULTS

Treatment resulted in a statistically significant decrease in headache days relative to baseline, from 27.5 +/- 4.9 before treatment to 21.1+/-10.7 after treatment (P <.001, Student t test). The difference in headache severity (0 to 10 scale) before treatment (8.7+/-1.6) and after treatment (2.2 +/- 2.1) was also statistically significant (P <.001).

CONCLUSION

Olanzapine may be effective for patients with refractory headache, including those who have failed a number of other prophylactic agents. Olanzapine should receive particular consideration for patients with refractory headache who have mania, bipolar disorder, or psychotic depression or whose headaches previously responded to other neuroleptic medications.

Should butalbital-containing analgesics be banned? Yes

In the United States analgesic-overuse headache is often caused by butalbital-containing analgesics. These agents can cause physical and psychological dependency, and dangerous withdrawal syndromes. Butalbital-containing analgesics have already been banned in several European countries. They are proven effective in tension-type headache, but not in migraine; there are many alternative treatments for migraine and tension-type headache. In the 20 years since analgesic overuse headache was widely recognized, butalbital overuse has remained distressingly common. It is time to ban these agents.

Modular headache theory: a new approach

Many people experience headaches that do not fulfill the International Headache Society's criteria for a specific headache disorder, yet behave biologically like that disorder. Others fulfill criteria for one headache disorder but have features of another. To explain these observations, we propose that groups of neurons, called modules, become activated to produce each symptom of a primary headache disorder, and that each module is linked to other modules that together produce an individual's headache. Headaches develop phenotypic stability through a process referred to as learned stereotypy. This theory has implications for the classification, research, and treatment of primary and secondary headache patients.

Open label trial of coenzyme Q10 as a migraine preventive

The objective was to assess the efficacy of coenzyme Q10 as a preventive treatment for migraine headaches. Thirty-two patients (26 women, 6 men) with a history of episodic migraine with or without aura were treated with coenzyme Q10 at a dose of 150 mg per day. Thirty-one of 32 patients completed the study; 61.3% of patients had a greater than 50% reduction in number of days with migraine headache. The average number of days with migraine during the baseline period was 7.34 and this decreased to 2.95 after 3 months of therapy, which was a statistically significant response (P < 0.0001). Mean reduction in migraine frequency after 1 month of treatment was 13.1% and this increased to 55.3% by the end of 3 months. Mean migraine attack frequency was 4.85 during the baseline period and this decreased to 2.81 attacks by the end of the study period, which was a statistically significant response (P < 0.001). There were no side-effects noted with coenzyme Q10. From this open label investigation coenzyme Q10 appears to be a good migraine preventive. Placebo-controlled trials are now necessary to determine the true efficacy of coenzyme Q10 in migraine prevention.

Hemiplegic cluster

We report four cases of a new variant of cluster headache associated with hemiparesis. Clinical similarities with hemiplegic migraine suggest that hemiplegic cluster, too, may be a channelopathy. One of our patients had a family history suggestive of an autosomal dominant inheritance.

Korean American health insurance and health services utilization

The purpose of this ethnic group study was to describe the unique pattern of Korean Americans, as compared with the aggregate of Asian Americans, for: (a) the predisposing, enabling, and need factors for health service utilization, focusing specifically on the role of health insurance coverage; and (b) predictors of health insurance coverage. Using the behavioral model for health service utilization, data were selected from the 1992 National Health Insurance Survey (NHIS, 1994) for Korean Americans (n = 345) and Asian Americans (n = 3,059). Results differed between the Korean American group and the Asian American group. Health insurance coverage was the strongest predictor of Korean American utilization, and need factors lacked significance, suggesting that uninsured Korean Americans have less access regardless of need. For the aggregate Asian American group, need factors tempered the influence of health insurance on utilization. Results of this type of study may be helpful for designing and implementing health care services tailored for specific ethnic at-risk markets.

Fibromyalgia is common in patients with transformed migraine

Fibromyalgia (FM) and transformed migraine (TM) are common chronic pain disorders. The authors estimated the prevalence of FM in 101 patients with TM, and analyzed its relationship to depression, anxiety, and insomnia. FM was diagnosed in 35.6% of cases. Patients with FM had more insomnia, were older, and had headaches that were more incapacitating than patients without FM. Insomnia and depression predicted FM in patients with TM.

Modular headache theory

Many people experience headaches that do not fulfil the International Headache Society's criteria for a specific headache disorder yet behave biologically like that disorder. Others fulfil criteria for one headache disorder and yet have features of another disorder. To explain these observations, we propose that groups of neurones called modules become activated to produce each symptom of a primary headache disorder, and that each module is linked to other modules that together produce an individual's headache. This theory has implications for the classification, research and treatment of primary and secondary headache patients.

Hemicrania continua is not that rare

BACKGROUND

Hemicrania continua is an indomethacin-responsive headache disorder characterized by a continuous, moderate to severe, unilateral headache. More than 90 cases of hemicrania continua have been reported, but there is still uncertainty about its clinical features.

METHODS

The authors compared 34 new cases (24 women, 10 men) with previously reported cases. All the patients met Goadsby and Lipton's proposed criteria. The authors compared baseline (continuous background headache) and exacerbation (attacks of severe periods of headaches).

RESULTS

The baseline headache was typically mild to moderate in intensity and usually not associated with severe disability. In contrast, the headache exacerbations were severe and associated with photophobia, phonophobia, nausea, and disability. At least one autonomic symptom was present in 25 patients (74%). Jabs and jolts were present in 14 patients (41%). The mean indomethacin dose was 136.7 +/- 60 mg (range 25 to 225 mg). Twenty-four patients (70.6%) met International Headache Society criteria for migraine in their exacerbation period. Occipital tenderness was observed in 23 patients (67.6%). The temporal pattern was remitting in four patients (11.8%), continuous from onset in 18 (52.9%), and continuous evolving from remitting in 12 (35.3%).

CONCLUSION

Hemicrania continua is not a rare disorder. All cases of chronic unilateral daily headaches should receive an indomethacin trial early if not first in treatment.

Optimization of a screening lead for factor VIIa/TF

The structure-based design and progression of a screening lead to a 3nM factor VIIa/TF inhibitor with improved selectivity versus related enzymes is described.

Development of serine protease inhibitors displaying a multicentered short (<2.3 A) hydrogen bond binding mode: inhibitors of urokinase-type plasminogen activator and factor Xa

Novel scaffolds that bind to serine proteases through a unique network of short hydrogen bonds to the catalytic Ser195 have been developed. The resulting potent serine protease inhibitors were designed from lead molecule 2-(2-hydroxyphenyl)1H-benzoimidazole-5-carboxamidine, 6b, which is known to display several modes of binding. For instance, 6b can recruit zinc and bind in a manner similar to that reported by bis(5-amidino-2-benzimidazolyl)methane (BABIM) (Nature 1998, 391, 608-612).(1) Alternatively, 6b can bind in the absence of zinc through a multicentered network of short (<2.3 A) hydrogen bonds. The lead structure was optimized in the zinc-independent binding mode toward a panel of six human serine proteases to yield optimized inhibitors such as 2-(3-bromo-2-hydroxy-5-methylphenyl)-1H-indole-5-carboxamidine, 22a, and 2-(2-hydroxybiphenyl-3-yl)-1H-indole-5-carboxamidine, 22f. Structure-activity relationships determined that, apart from the amidine function, an indole or benzimidazole and an ortho substituted phenol group were also essential components for optimal potency. The affinities (K(i)) of 22a and 22f, for example, bearing these groups ranged from 8 to 600 nM toward a panel of six human serine proteases. High-resolution crystal structures revealed that the binding mode of these molecules in several of the enzymes was identical to that of 6b and involved short (<2.3 A) hydrogen bonds among the inhibitor hydroxyl oxygen, Ser195, and a water molecule trapped in the oxyanion hole. In summation, novel and potent trypsin-like serine protease inhibitors possessing a unique mode of binding have been discovered.

Specificity of sprint and agility training methods

The purpose of this study was to determine if straight sprint training transferred to agility performance tests that involved various change-of-direction complexities and if agility training transferred to straight sprinting speed. Thirty-six males were tested on a 30-m straight sprint and 6 agility tests with 2-5 changes of direction at various angles. The subjects participated in 2 training sessions per week for 6 weeks using 20-40-m straight sprints (speed) or 20-40-m change-of-direction sprints (3-5 changes of 100 degrees) (agility). After the training period, the subjects were retested, and the speed training resulted in significant improvements (p < 0.05) in straight sprinting speed but limited gains in the agility tests. Generally, the more complex the agility task, the less the transfer from the speed training to the agility task. Conversely, the agility training resulted in significant improvements in the change-of-direction tests (p < 0.05) but no significant improvement (p > 0.05) in straight sprint performance. We concluded that straight speed and agility training methods are specific and produce limited transfer to the other. These findings have implications for the design of speed and agility training and testing protocols.

Development of potent and selective factor Xa inhibitors

The development of potent and selective small molecule inhibitors of factor Xa is described.

Neutral inhibitors of the serine protease factor Xa

A neutral inhibitor of the serine protease factor Xa was identified via a high-throughput screen of a commercial library. The initial lead 1 demonstrated reversible and competitive inhibition kinetics for factor Xa and possessed a high degree of selectivity versus other related serine proteases. Initial modeling efforts and the generation of a series of analogues of 1 are described.

Dibasic inhibitors of human mast cell tryptase. Part 3: identification of a series of potent and selective inhibitors containing the benzamidine functionality

A survey of charged groups and linkers for a series of symmetrical and unsymmetrical dibasic inhibitors is described, leading to several classes of potent and selective inhibitors. In particular, the benzamidine functionality was identified as the most potent charged group investigated.

Quality-of-life differences between patients with episodic and transformed migraine

OBJECTIVE

To determine whether there are any differences in health-related quality of life between patients with migraine and those with transformed migraine.

BACKGROUND

There are no published reports comparing the health-related quality of life between patients with migraine and patients with transformed migraine.

METHODS

We conducted a retrospective analysis examining the health-related quality of life of patients with transformed migraine and migraine seen at a specialty headache clinic. Data collected included the Short Form-36 (SF-36) and the Migraine Disability Assessment questionnaires as well as demographic information. Both of these forms are part of the initial evaluation at the headache clinic. A t test with Bonferroni correction was used to test for significant differences in the SF-36 domains between the groups.

RESULTS

Data were collected for 90 patients, 46 with transformed migraine and 44 with migraine. There were no significant differences between groups with respect to sex, race, or age. Over the last 90 days prior to their first visit, patients with transformed migraine reported having a headache an average of 69 days compared with patients with migraine who averaged 18 days with headache (P<.05). Compared with patients with migraine, patients with transformed migraine had statistically (P<.05) and clinically significant (difference >5 points) lower mean scores on seven of the eight SF-36 domains and both the mental and physical summary scores of the SF-36.

CONCLUSIONS

The results of this study suggest that patients with transformed migraine have a lower health-related quality of life than patients with migraine. These findings indicate that the headache chronicity associated with transformed migraine has a significant influence on quality of life. The results highlight the importance of effective management of headaches to avoid the progression of migraine to the more disabling transformed migraine.