Aura in some patients with familial hemiplegic migraine can be stopped by intranasal ketamine

Migraine aura is probably caused by cortical-spreading depression. No treatment for acute and severe migraine aura has been described previously. The effect of ketamine (25 mg intranasally) was studied in 11 patients with severe, disabling auras resulting from familial hemiplegic migraine. In five patients ketamine reproducibly reduced the severity and duration of the neurologic deficits, whereas in the remaining six patients no beneficial effect was seen. Ketamine offers, for the first time, a possible treatment option for severe and prolonged aura.

[Dexketoprofen trometamol in the treatment of acute migraine attack]

BACKGROUND

Migraine is a common, very disabling pain condition: the occurrence of an acute attack often requires bedrest and prevents from participating in normal activities. Nonsteroidal anti-inflammatory drugs are widely used in the symptomatic treatment of migraine. Aim of this study was to evaluate the efficacy and safety of a potent new formulation, dexketoprofen trometamol (DT), in the treatment of migraine pain.

METHODS

The study enrollment was 42 women (mean age 37.2 +/- 12.2, range 21-65) suffering from migraine, with (n = 6) and without (n = 36) aura, diagnosed according to the International Headache Society criteria. Patients were asked to treat a single attack with a 25 mg dose of DT. The primary efficacy criterion was the change in migraine pain, recorded on a Visual Analogue Scale (VAS) immediately before and at 30, 60, 120, 240 minutes after assumption. The presence of accompanying symptoms and the onset of side effects were also considered.

RESULTS

Pain intensity significantly decreased after drug intake, showing a tendency toward a reduction along the time. The drop in mean VAS values resulted already significant at 30 minutes after DT assumption. Also the reported incidence of accompanying symptoms (nausea, vomiting, photophobia and phonophobia) significantly decreased after treatment. No serious adverse event was reported during the study. All the adverse events recorded were of mild severity and did not require any specific medical treatment.

CONCLUSIONS

DT proved to be an effective and safe oral therapy for the treatment of migraine attack.

Daily migraine with aura: a new migraine variant

The frequency of migraine attacks is not used as a diagnostic criterion, however, it is a very important factor in the evaluation of migraine severity and its treatment. Several studies report the frequency of migraine attacks using the International Headache Society criteria. No investigator, however, has reported daily migraine attacks. In the current report, we present five patients whose headaches transformed from episodic migraine to daily migraine with aura. To the best of our knowledge, this is the first description of this variant of migraine. The symptoms in all the patients described comply strictly with the International Headache Society criteria for the diagnosis of migraine with typical aura. An interesting additional observation concerns the beneficial effect of phenytoin, a drug that has not proved to be effective in migraine but showed some efficacy in our patients.

Effects of the anti-migraine drug sumatriptan on muscle energy metabolism: relationship to side-effects

Sumatriptan succinate (Imitrex) is a 5-HT (5-hydroxytryptamine) agonist used for relief of migraine symptoms. Some individuals experience short-lived side-effects, including heaviness of the limbs, chest heaviness and muscle aches and pains. The effects of this drug on skeletal muscle energy metabolism were studied during short submaximal isometric exercises. We studied ATP flux from anaerobic glycolysis (An Gly), the creatine kinase reaction (CK) and oxidative phosphorylation (Ox Phos) using 31P nuclear magnetic resonance spectroscopy (31P MRS) kinetic data collected during exercise. It was found that side-effects induced acutely by injection of 6 mg sumatriptan succinate s.c. were associated with reduced oxygen storage in peripheral skeletal muscle 5-20 min after injection as demonstrated by a transient reduction in mitochondrial function at end-exercise. These results suggest that mild vasoconstriction in peripheral skeletal muscle is associated with the action of sumatriptan and is likely to be the source of the side-effects experienced by some users. Migraine with aura patients were more susceptible to this effect than migraine without aura patients.

Vasoneuronal coupling in migraineurs after subcutaneous sumatriptan: a TCD study

According to the trigeminovascular model of pain in migraine, sterile neurogenic inflammation of dural vessels stimulates nociceptive fibres of the trigeminal nerve. Sumatriptan, a 5-HT1 receptor agonist, blocks this reaction and mediates vasoconstriction of meningeal arteries. However, it is uncertain, whether sumatriptan also has a vasoconstrictive effect on cerebral arteries, which may influence vasoneuronal coupling and induce secondary cerebral blood flow changes. We studied changes of cerebral blood flow velocity (CBFV) and the pulsatility index (PI) in the posterior cerebral artery (PCA) after stimulus activation before, 10 min and 30 min after subcutaneous application of 6 mg sumatriptan, in order to assess potential vasoactive effects on cerebral circulation. CBFV was recorded from both PCAs simultaneously in 27 migraineurs (twenty women, seven men, mean age 29 years), and arterial blood pressure (BP), heart rate (HR) and respiration rate (RR) were monitored. Although the mean diastolic blood pressure rose significantly from 75 mm Hg to 81 mm Hg (P<0.05) and systolic blood pressure and respiration rates remained constant, average CBFV values remained constant. Similarly, the relative increase of CBFV by visual stimulation, which is clearly higher compared to controls in other studies (55.0% before, 52.6% after 10 min, and 52.4% after 30 min), and absolute mean values for CBFV and PI did not change after visual stimulation. These results provide evidence against the hypothesis that sumatriptan produces vasoconstriction in the intracranial human arterial circulation as a potential risk of cerebral ischemia.