Intravenous dipyrone in the acute treatment of migraine without aura and migraine with aura: a randomized, double blind, placebo controlled study

BACKGROUND

Dipyrone (Metamizol) has been used in the acute treatment of migraines in Brazil. Some investigators have found it to be a highly effective medication for migraine pain and associated symptoms.

OBJECTIVE

To conduct a randomized, placebo controlled, double blind study to assess the effect of dipyrone on the pain and symptoms associated with migraine without aura or with aura and the adverse effect profile of this medication.

METHODS

For the migraine without aura group, 44 patients were assigned at random to receive 1 g intravenous dipyrone, and 30 patients received 10 mL 0.9% physiological saline. For the migraine with aura group, 30 patients received both dipyrone or placebo. We used seven parameters of analgesic evaluation and an analog scale to assess nausea, photophobia, and phonophobia.

RESULTS

Patients receiving dipyrone demonstrated a statistically superior improvement (P<.05 and P<.01) in pain and all associated symptoms compared with control subjects.

CONCLUSIONS

Dipyrone is an effective drug for the relief of acute migraine pain and associated symptoms.

Intravenous chlorpromazine in the emergency department treatment of migraines: a randomized controlled trial

The aim of this study is to assess, in a double blind randomized clinical trial, the effect of chlorpromazine (CPZ) on the pain and associated symptoms in patients with migraine. Sixty patients with migraine with aura and 68 patients with migraine without aura were assigned at random to receive IV 0.1 mg/Kg CPZ or placebo. We assessed pain intensity, nausea, photophobia, and phonophobia at baseline, 30 min, and 60 min post-IV administration. End-point efficacy at 60 min was used to calculate the number needed to treat (NNT). We also recorded adverse effects, need for rescue medication at 24 h, and recurrence of headache at 24 h. We found clinically and statistically significant (p < 0.01) improvement associated with CPZ in pain scores, nausea, photophobia, phonophobia, and need for rescue medication, all at 60 min, and in rate of recurrence at 24 h, both in patients with and without aura. NNT = 2. Those allocated to CPZ had less nausea and dyspepsia, but more drowsiness and postural hypotension than those receiving placebo. CPZ is an excellent option for the treatment of migraines, with and without aura, in the Emergency Department.

Intravenous magnesium sulphate in the acute treatment of migraine without aura and migraine with aura. A randomized, double-blind, placebo-controlled study

Magnesium sulphate has been used in the acute treatment of migraines; some studies found it to be a highly effective medication in the acute control of migraine pain and associated symptoms. This randomized, double-blind, placebo-controlled study assesses the effect of magnesium sulphate on the pain and associated symptoms in patients with migraine without aura and migraine with aura. Sixty patients in each group were assigned at random to receive magnesium sulphate, 1000 mg intravenously, or 0.9% physiological saline, 10 ml. We used seven parameters of analgesic evaluation and an analogue scale to assess nausea, photophobia and phonophobia. In the migraine without aura group there was no statistically significant difference in the patients who received magnesium sulphate vs. placebo in pain relief. The analgesic therapeutic gain was 17% and number needed to treat was 5.98 at 1 h. There was also no statistical difference in relief of nausea. We did observe a significant lower intensity of photophobia and phonophobia in patients who received magnesium sulphate. In the migraine with aura group patients receiving magnesium sulphate presented a statistically significant improvement of pain and of all associated symptoms compared with controls. The analgesic therapeutic gain was 36.7% at 1 h. A smaller number of patients continued to have aura in the magnesium sulphate group compared with placebo 1 h after the administration of medication. Our data support the idea that magnesium sulphate can be used for the treatment of all symptoms in migraine with aura, or as an adjuvant therapy for associated symptoms in patients with migraine without aura.

[Efficacy of three drugs in the treatment of migrainous aura: a randomized placebo-controlled study]

In spite of the enormous amount of research regarding classification, epidemiology, diagnosis, pathophysiology and treatment of migraines, aura, one of its hallmarks, stays much less studied. The objective of this study is, therefore, to evaluate the evolution of aura in patients submitted to placebo and three different drugs available in Brazilian public health units. We studied 86 patients during an acute migrainous attack, with aura at the moment of the evaluation. Patients were randomized to receive one of the following substances, in a parenteral route: placebo, dipyrone, chlorpromazine and magnesium sulphate. Magnesium sulphate was superior to placebo (p <0,05) 30 and 60 minutes after its administration. Dipyrone and chlorpromazine reduced the duration of the aura, when compared to placebo, 60 minutes following their administration. Our findings make possible some speculations about the pathophysiology of migraine, as well as about the therapeutic approach of patients presenting migrainous aura.

[Intramuscular diclofenac in the acute treatment of migraine: a double-blind placebo controlled study]

The aim of this study is to assess, in a double blind fashion, the effect of diclofenac on the pain and associated symptoms in patients with acute migraine. 60 patients with migraine with aura and 60 patients with migraine without aura were assigned at random to receiving intramuscular diclofenac, 75 mg associated to intravenous physiological saline, 10 ml, or physiological saline alone. We used 3 parameters of analgesic evaluation and an analogical scale to asses associated symptoms. We also observed the recurrence and rescue medication percentiles. Patients receiving diclofenac showed a statistically significant improvement of pain 60 minutes after the administration in two of the three parameters(migraine without aura) and in all parameters (migraine with aura). They did not present difference, compared to placebo, on the intensity of associated symptoms. We observed a reduction on the recurrence and rescue medication utilization. Despite being an option to treat migraines attacks in the emergency room settings, diclofenac has a slow onset action and no effects on the associated symptoms.

Hereditary haemochromatosis in two cousins with cluster headache

A 60-year-old woman with secondary chronic cluster headache had increased serum ferritin and serum transferrin saturation and was homozygous for the C282Y mutation in the HFE gene, which is indicative of hereditary haemochromatosis. Treatment with venesection that normalized her iron stores led to a radical improvement of her headache complaints that had been daily for several years. Later, the headache returned to some degree in spite of normal serum ferritin levels. Her cousin, a 33-year-old man who had had episodic cluster headache for several years, also had increased transferrin saturation and was compound heterozygous for two mutations, a genotype known to be associated with a slightly increased frequency of haemochromatosis. This is the first report of a headache disorder in a patient with hereditary haemochromatosis. The coexistence of the two disorders may be a mere coincidence, but the temporary improvement of headache from depletion of iron stores may indicate a causal relation, possibly mediated by iron deposits in pain-modulating centres in the brainstem.

Hemicrania continua with aura

Hemicrania continua is a primary headache disorder that is characterized by a continuous unilateral headache of moderate severity, exacerbations of severe pain and complete responsiveness to indomethacin. We report four patients with a unique variant of hemicrania continua: visual auras that precede or accompany the pain exacerbations.

Use of rescue medication in trials of almotriptan versus placebo in the treatment of acute migraine

BACKGROUND

Almotriptan malate is a recently marketed triptan for the treatment of acute migraine. Results from controlled clinical trials demonstrate efficacy superior to placebo and an adverse event rate comparable to that with placebo.

OBJECTIVE

The goal of this study was to assess the effect of oral almotriptan on the use of rescue medication in the treatment of acute migraine attacks.

METHODS

Three Phase II and III, placebo-controlled, randomized, double-blind studies of almotriptan used as the basis for regulatory approval of the drug were included in the analysis. Two studies (1 single dose, 1 multiple dose) assessed almotriptan 6.25 mg and 12.5 mg and a third compared almotriptan 12.5 mg and sumatriptan 100 mg. Primary results from all 3 trials were previously published. Rescue medication was permitted if migraine pain had not decreased to mild severity or to no pain at 2 hours after study medication. The primary end point of this analysis was use of rescue medication.

RESULTS

A total of 1777 patients were included in the analysis. Mean patient age ranged from 39.4 to 44.0 years; approximately 87% were women, and >98% were white. Patients were well matched for demographic characteristics. Overall, use of rescue medication was significantly lower with almotriptan 6.25 mg and 12.5 mg compared with placebo (P < or = 0.05 for each group). No significant difference was noted between the almotriptan 12.5-mg and sumatriptan 100-mg groups. In 2 of the studies, patients with moderate or severe baseline pain used significantly less rescue medication in the almotriptan groups compared with placebo.

CONCLUSIONS

Oral almotriptan 6.25 mg or 12.5 mg significantly reduced use of rescue medication compared with placebo among patients with acute migraine. Use of rescue medication was comparable with almotriptan 12.5 mg and sumatriptan 100 mg.

Visual cortex excitability in migraine before and after valproate prophylaxis: a pilot study using TMS

We examined the effect of standard migraine prophylaxis with sodium valproate on repeated measures of occipital excitability using transcranial magnetic stimulation (TMS). We predicted that, comparing pre- and post-treatment assessments, a reduction in clinical migraine parameters would be paralleled by a decrease in excitability measurements.A total of 31 migraine patients enrolled in the study, for assessment prior to and 1 month after commencement of sodium valproate prophylaxis. At each assessment, we used a standardized protocol to stimulate the occipital cortex with a 90-mm circular (coil A) and 70 mm figure-of-eight (coil B) coil. We recorded the threshold stimulation intensity at which subjects just perceived phosphenes. Subjects kept detailed records of headache parameters 1 month before and also during the study period. Valproate therapy significantly improved headache indexes, as expected. In MA subjects assessed with coil B, phosphene thresholds were significantly higher post-treatment than pre-treatment, but those for MO did not change. Modest correlations were observed in MA patients between increase in phosphene threshold and decrease in headache index. Although preliminary, the findings with coil B lend some support to the notion that effective migraine prophylaxis may be achieved through lowering cortical excitability by gamma-aminobutyric acid (GABA)-ergic intervention. Further investigation of the effect of sodium valproate or other similarly acting substances on cortical excitability in migraine is warranted.

Migraines

A 26-year-old woman is evaluated for headaches, which began when she was 14 years old. She states that she initially sees bright zig-zag bands, which expand in the shape of a horseshoe in her right visual field. Twenty minutes later, she develops a throbbing headache over the left frontal area, associated with photophobia and nausea. The headaches last 1-3 days and they occur once a month. There is no medical history, and she takes only multivitamin supplements. Her sister has been diagnosed with migraines. Her examination is normal, including equal and reactive pupils, full extraocular movements, and normal strength and sensation. A magnetic resonance scan of the brain shows no abnormalities.

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.

[Evaluation of placebo use in migraine without aura, migraine with aura and episodic tension-type headache acute attacks]

This study presents an evaluation of placebo response in the acute treatment of migraine with or without aura and episodic tension type headache. We studied patients admitted between March 1st,1997 and November 31st,1999 in two Emergency Room Units. Three groups had been defined, each one with 30 participants: migraine without aura (MWOA), migraine with aura (MWA) and episodic tension-type headache (ETTH). Patients were participating of a randomized study to evaluate efficacy of 4 different drugs; those randomized to receive placebo were included. We evaluated pain and associated symptoms. After one hour of placebo administration, 50% of MWOA patients, 23.3% of MWA and 26.7% of ETTH had presented pain relief. The mean of this relief, evaluated by the numerical pain scale, was 41.6%, 23.1% and 36%, respectively. Use of placebo is essential in evaluating the therapeutic role of drugs used in the treatment of acute headache.

Persistent migrainous visual phenomena might be responsive to lamotrigine

Two patients with migraine reported having experienced persistent auralike visual phenomena for months to years. All laboratory investigations were normal except for occipital hypoperfusion on the brain single photon emission computed tomography. After lamotrigine treatment for 2 weeks, they both had a resolution of the visual symptoms. Persistent migrainous visual phenomena are potentially benign and probably a status of spontaneous aura.

[Role of arterial hypertension in comorbidity of chronic headaches]

INTRODUCTION

The literature concerning the association between headache and arterial hypertension is very scarce, mostly prior to the actual IHS classification and based on very diverse methods, being therefore difficult to interpret.

OBJECTIVES

To analyse the association between arterial hypertension and two types of chronic headache and to determine, if and how arterial hypertension may affect the outcome of prophylactic therapy for chronic headaches.

PATIENTS AND METHODS

Sixty four files of our headache outpatient clinic, chosen randomly among patients suffering from migraine or tensional type headache (TTH), were analysed retrospectively. Patients were considered hypertensive, if blood pressure was higher than normal several times without an acute crisis present. Resistance to treatment was defined as lack of benefit concerning number and/or intensity of crisis.

RESULTS

Age varied between 18 and 80 years, the mean age being 42,9 (SD 13,86) years. Eighty six percent were females. Twenty nine patients suffered from TTH and 35 from migraine. Prevalence of hypertension was 35,9% among all patients, 28,5% among migraine patients, 44,8% among patients with TTH. The prevalence of resistance to treatment was 39,8%, 34,3% and 41,3%, respectively. Of the patients resistant to treatment 60% were hypertensive and 62,5% of the hypertensive patients showed resistance to therapy.

CONCLUSIONS

Arterial hypertension was more prevalent in the study sample than would be expected in an equivalent sample of the general population. Hypertension was significantly more prevalent among patients resistant to therapy, as was resistance to treatment among hypertensive patients. We therefore conclude that there is a relevant comorbidity between chronic headache and hypertension and that arterial hypertension complicates the control of chronic headaches.

Oral almotriptan vs. oral sumatriptan in the abortive treatment of migraine: a double-blind, randomized, parallel-group, optimum-dose comparison

BACKGROUND

Almotriptan malate is a novel, selective serotonin(1B/D) agonist, or triptan, developed for the abortive treatment of migraine. In double-blind, placebo-controlled studies, it has been shown to be effective, well tolerated, and safe.

OBJECTIVE

To compare the efficacy, tolerability, and safety of almotriptan with that of the "standard triptan," sumatriptan succinate. The power calculation of the study was based on 24-hour headache recurrence, an efficacy measure in the abortive treatment of migraine, and on the occurrence of adverse events.

SUBJECTS AND METHODS

Subjects, aged between18 and 65 years, with migraine with or without aura but otherwise healthy, were randomized to take orally either almotriptan malate, 12.5 mg, or sumatriptan succinate, 50 mg. The medications were provided in identical-looking capsules to ensure blinding and were taken for the treatment of moderate or severe headache. Efficacy was determined in terms of (1) headache relief-a decrease in pain intensity to mild or no pain; (2) headache freedom-a decrease to no pain; (3) use of rescue medications, allowed after 2 hours; and (4) headache recurrence-moderate or severe pain returning within 24 hours after headache relief at 2 hours. Adverse events were collected for 96 hours after treatment and for safety evaluation, vital signs, blood tests, and electrocardiograms were performed at the screening and exit visits.

RESULTS

Seventy-five investigators enrolled 1255 subjects of whom 1173 were treated (591 with almotriptan and 582 with sumatriptan). At 2 hours, almotriptan treatment provided headache relief in 58.0% of the subjects and sumatriptan treatment in 57.3%; headache freedom was provided by the medications in 17.9% and 24.6%, respectively (P =.005). Rescue medications were taken by 36.7% of the subjects in the almotriptan-treated group and by 33.2% in the sumatriptan-treated group; headaches returned to moderate or severe intensity in 27.4% and 24.0%, respectively. Treatment-emergent adverse events occurred in 15.2% of the subjects in the almotriptan-treated group and in 19.4% in the sumatriptan-treated group (P =.06); treatment-related adverse events occurred in 9.1% and 15.5% of the subjects, respectively (P =.001), including chest pain, which occurred in 0.3% and 2.2%, respectively (P =.004).

CONCLUSIONS

Almotriptan and sumatriptan are similarly effective in the abortive treatment of moderate or severe migraine headache; they are also similarly well tolerated and safe.

Experimental models of migraine

Experimental models have been developed to study various aspects of migraine. Here we describe the most commonly used models--mostly animal models--which led to the development of a pathophysiological concept of migraine. We focus on activation studies of the trigeminovascular system, the sphenopalatine ganglion, the superior sagittal sinus, the dura mater as well as blood vessels. The most common consequences of activation are noted and include protein extravasation, neuropeptide release, rCBF and diameter changes, c-fos expression and electrical neuronal activity. In addition, we briefly summarize the results of cortical spreading depression studies, as they relate to the human migraine aura. These models will continue to be useful to elucidate migraine pathophysiology and explore drug mechanisms.

Ergotamine-induced acute vascular insufficiency of the lower limb--a case report

Ergotamine-containing drugs are widely used in the treatment of acute migraine attacks. Spastic vasoconstriction is one of the possible side effects usually affecting the lower extremities and sometimes leading to gangrene. A 28-year-old woman was hospitalized for severe acute arterial insufficiency of the limbs. The initial surgical approach was not successful since the diagnosis was missed. Overuse of ergotamine derivative was acknowledged by the patient, who had a long history of migraine headaches. Therefore, the patient was treated conservatively with intravenous heparin and prostaglandin infusion and sympatheticolysis via epidural catheter. The vascular complications, angiographic findings, and different modalities of treatment of ergotamine-induced peripheral vascular insufficiency of the lower limb are reviewed.