Efficacy and safety of 6.25 mg t.i.d. feverfew CO2-extract (MIG-99) in migraine prevention--a randomized, double-blind, multicentre, placebo-controlled study

Migraine preventive treatment

Migraine is a chronic neurological disease. Preventive therapy is given in an attempt to reduce the frequency, duration, or severity of attacks. Circumstances that might warrant preventive treatment include recurring migraine attacks that significantly interfere with the patient's daily routines, despite appropriate acute treatment; frequent headaches; contraindication to, failure of, overuse of, or intolerance to acute therapies; patient preference; frequent, very long, or uncomfortable auras; and presence of uncommon migraine conditions. The major medication groups for preventive migraine treatment include beta-adrenergic blockers, antidepressants, calcium channel antagonists, serotonin antagonists, and anticonvulsants. The choice of preventive treatment depends on the individual drug's efficacy and adverse events, the patient's clinical features, frequency, and response to prior treatment, and the presence of any comorbid or coexistent disease.

New drugs for migraine

After the triptans, a calcitonin gene-related peptide blocker (telcagepant) is the first acute medicine that has been developed primarily for treatment of acute migraine. Otherwise, the new drugs have been developed first for other purposes, like anticonvulsants, antihypertensives and antidepressants used for migraine prophylaxis. For acute attacks, a new way to administer a traditional drug like dihydroergotamine is under way, and documentation of efficacy in migraine has been gained for some commonly used painkillers and anti-inflammatory drugs, and for some herbal extracts. Based on insights into the basic pathophysiological mechanisms of the disorder, some drugs have been developed which seem promising in early phase II studies (NOS inhibitors and 5HT1F-receptor agonists). In the future, development and enhancements of existing medicines must be accompanied by increased efforts to develop truly new migraine drugs based on knowledge of the pathophysiology if one wishes to reduce substantially the great burden migraine poses on patients and society.

Complementary and alternative treatments for childhood headaches

Parents frequently ask health care professionals to provide "natural" migraine care for their children and often use herbs, minerals, vitamins, and supplements to treat their children's migraines, thinking that these over-the-counter alternatives are less toxic than prescription medications. The only randomized controlled trial on any alternative treatment for pediatric migraine is for magnesium, and the results were equivocal. Results of two other uncontrolled trials of magnesium, one for migraine and one for episodic tension-type headache, were positive. There is one positive uncontrolled trial each for coenzyme Q10 and Petasites for prevention of pediatric migraine. There are no trials to indicate the safety or efficacy of riboflavin or feverfew for pediatric headache.

Current migraine management - patient acceptability and future approaches

Despite its high prevalence and individual as well as societal burden, migraine remains underdiagnosed and undertreated. In recent years, the options for the management of migraine patients have greatly expanded. A number of drugs belonging to various pharmacological classes and deliverable by several routes are now available both for the acute and the preventive treatments of migraine. Nevertheless, disability and satisfaction remain low in many subjects because treatments are not accessible, not optimized, not effective, or simply not tolerated. There is thus still considerable room for better education, for more efficient therapies and for greater support from national health systems. In spite of useful internationally accepted guidelines, anti-migraine treatment has to be individually tailored to each patient taking into account the migraine subtype, the ensuing disability, the patient's previous history and present expectations, and the co-morbid disorders. In this article we will summarize the phenotypic presentations of migraine and review recommendations for acute and preventive treatment, highlighting recent advances which are relevant for clinical practice in terms of both diagnosis and management.

Gene response of human monocytic cells for the detection of antimigraine activity of feverfew extracts

The herb feverfew is a folk remedy for various conditions, including inflammation, fever, psoriasis, rheumatism, and asthma. Like many herbal medicines, feverfew's mechanisms of action in the human body are largely unknown and its active ingredients remain elusive. Very often, different extraction methods of herb material produce different physical and biochemical properties and variation in clinical efficacy. We identified 3 major methods of extraction for feverfew aerial parts and used microarray technology to test the hypothesis that extracts produced by different methods elicit different gene expression profiles. We have identified approximately 200 genes that are consistently regulated by the 2 presumptive active antimigraine feverfew extracts but not associated with the inactive extract. Our results suggest that the presumptive active feverfew extracts potently stimulate more genes in human cells than the inactive extracts. We also identified several genes as unique signatures for these active extracts. All 3 feverfew extracts exhibited similar blockades on lipopolysaccharide-mediated TNF-alpha (tumor necrosis factor alpha) release, implicating that TNF-alpha is not responsible for the differences in the effects of the 3 feverfew extracts in human cells. In contrast, the active extracts more effectively suppressed CCL2 (also known as monocyte chemoattractant protein 1, MCP-1) than the inactive extracts, suggesting that CCL2 is a potential cellular target for feverfew's antimigraine effects.

Regulation of Cellular Metabolism and Cytokines by the Medicinal Herb Feverfew in the Human Monocytic THP-1 Cells

The herb feverfew is a folk remedy for various symptoms including inflammation. Inflammation has recently been implicated in the genesis of many diseases including cancers, atherosclerosis and rheumatoid arthritis. The mechanisms of action of feverfew in the human body are largely unknown. To determine the cellular targets of feverfew extracts, we have utilized oligo microarrays to study the gene expression profiles elicited by feverfew extracts in human monocytic THP-1 cells. We have identified 400 genes that are consistently regulated by feverfew extracts. Most of the genes are involved in cellular metabolism. However, the genes undergoing the highest degree of change by feverfew treatment are involved in other pathways including chemokine function, water homeostasis and heme-mediated signaling. Our results also suggest that feverfew extracts effectively reduce Lipopolysaccharides (LPS)-mediated TNF-alpha and CCL2 (MCP-1) releases by THP-1 cells. We hypothesize that feverfew components mediate metabolism, cell migration and cytokine production in human monocytes/macrophages.

Use of Herbal Supplements and Vitamins in Plastic Surgery: A Practical Review

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Explain what governmental regulations control the labeling and distribution of herbal supplements. 2. List the more commonly used supplements and their reported benefits. 3. List the possible postoperative complications from consumption of the more commonly used herbal supplements. 4. Explain the preoperative management of patients using herbal supplements. 5. Know additional resources to consult when unanswered questions arise.

BACKGROUND

The American public spends over $5 billion per year on herbal supplements, and approximately 20 percent of all Americans use prescription medications concurrently with herbal supplements. As the number of people who take alternative medicines rises, there is growing awareness among health care providers of the need to become educated and to educate their patients on the effects that such supplementation may have on their health. As plastic surgeons, we have an added responsibility to become informed because of potential adverse interactions with other medications and anesthesia in the elective surgical patient.

METHODS

Literature regarding commonly encountered herbal supplements and vitamins was reviewed and summarized to include reported indications for use and potential adverse effects and interactions specific to the perioperative patient.

RESULTS

Abundant literature exists regarding herbal supplementation, but very little scientific evidence exists to advocate the use of the majority of supplements available on the market. In addition, little is known about the positive and negative interactions that these supplements are capable of producing, and those interactions that are known are based on case reports.

CONCLUSIONS

With the lack of quality scientific studies to support the efficacy of most herbal products available and the limited regulation of these products by the government, health care providers are faced with a significant public health dilemma. This article provides a brief overview of information published on commonly encountered herbal supplements and vitamins taken by plastic surgery patients.

Effectiveness and tolerability of acupuncture compared with metoprolol in migraine prophylaxis

OBJECTIVES

In a randomized controlled multicenter trial extending over 24 weeks, we investigated whether acupuncture is as effective and safe as metoprolol in the prophylactic treatment of migraine under conditions similar to routine care.

METHODS

One hundred fourteen migraine patients could be randomized to treatment over 12 weeks either with acupuncture (8 to 15 sessions) or metoprolol (100 to 200 mg daily). Main outcome measure was the difference in the number of migraine days between baseline and the weeks 9 to 12 after randomization (derived from a headache diary).

RESULTS

Two of 59 patients randomized to acupuncture withdrew prematurely from the study compared to 18 of 55 randomized to metoprolol. The number of migraine days decreased by 2.5 +/- 2.9 days (baseline 5.8 +/- 2.5 days) in the acupuncture group compared to 2.2 +/- 2.7 days (baseline 5.8 +/- 2.9 days) in the metoprolol group (P= .721). The proportion of responders (reduction of migraine attacks by > or =50%) was 61% for acupuncture and 49% for metoprolol. Both physicians and patients reported fewer adverse effects in the acupuncture group.

CONCLUSIONS

Due to missing the recruitment target (480 patients) and the high drop-out in the metoprolol group the results must be interpreted with caution. Still, they suggest that acupuncture might be an effective and safe treatment option for patients unwilling or unable to use drug prophylaxis.

Pediatric headache

Migraine is very treatable in children and adolescents. Principles of treatment include early intervention, elimination of triggers, involvement of parents and schools, and judicious use of medicines. Although there is no pediatric indication in the United States, triptans are safe and effective in this age group. Prophylactic drugs should be used when significant disability from migraine exists. Choice of drug is based upon comorbidity. Nonpharmacologic treatment has an important role.

New and future migraine therapy

Modern neuroscience advanced our understanding of putative migraine mechanisms, which led to improved therapeutics. Indeed, mechanism-based acute migraine therapy gained steam in the early 1990s after the introduction of the triptans (5-HT1B,D agonists). Post-triptans, novel targets such as calcitonin gene-related peptide (CGRP) antagonists, inhibitors of excitatory glutamatergic receptors, and nitric oxide synthase (NOS) inhibitors are leading the pack in this exploding field of discovery research. In contrast, novel therapeutic targets for migraine prevention are lacking despite a hugely unmet need. To date, migraine prophylactic drugs are advanced based on expanded indications for already approved pharmaceuticals (e.g., topiramate, valproate, propranolol, and timolol). An improved understanding of the predisposition to an attack, genomic discoveries, valid and reliable biomarkers and surrogates, and predictive preclinical models likely will unravel the neuronal substrates for central hyperexcitability and nociceptive dysmodulation, hopefully leading us to better mechanism-based targets for prevention, and ultimately yielding drugs with optimal therapeutic ratios or indices.

A reproductive screening test of feverfew: is a full reproductive study warranted?

Feverfew is currently used in the treatment of migraine and arthritis. It is traditionally contraindicated in pregnancy but there are no studies confirming this warning. An in vivo and in vitro preliminary screen was performed using a rat model: five female rats were orally dosed with 839 mg/kg feverfew daily on either gestation days (GD) 1-8 or 8-15. On GD20, rats were sacrificed and fetuses, placentae and ovaries were collected. The fetuses were weighed and examined for malformations. While maternal weight gain appeared to be reduced, ANCOVA analysis suggested that the difference was due to litter size, rather than treatment. Pre-implantation loss appeared increased but this was not statistically significant in the feverfew GD1-8 group. Fetuses exposed to feverfew from GD8-15 were smaller than ethanol controls perhaps as a result of the increased frequency of runts in treated litters. Feverfew induced toxicity when GD10.5 embryos were cultured for 26 h in rat serum to which extract was added. The results of the present preliminary study suggest that a comprehensive reproductive study of feverfew is warranted.

Tanacetum parthenium and Salix??alba??(Mig-RL??) Combination in??Migraine Prophylaxis

BACKGROUND

Tanacetum parthenium (feverfew) has been used traditionally to treat migraine, and although its mechanism of action is not fully understood, serotonin 5-HT receptor blocking effects have been suggested. T. parthenium and Salix alba (white willow) either alone or in combination (Mig-RL) were recently shown to inhibit binding to 5-HT(2A/2C) receptors; T. parthenium failed to recognise 5-HT(1D) receptors, whereas S. alba or the combination did. It was hypothesised that S. alba in combination with T. parthenium may provide superior migraine prophylactic activity compared with T. parthenium alone.

METHODS

A prospective, open-label study was performed in 12 patients diagnosed with migraine without aura. Twelve weeks' treatment with T. parthenium 300 mg plus S. alba 300 mg (Mig-RL) twice daily was administered to determine the effects of therapy on migraine attack frequency (primary efficacy criterion), intensity and duration (secondary efficacy criteria), and quality of life, together with tolerability for patients.

RESULTS

Attack frequency was reduced by 57.2% at 6 weeks (p < 0.029) and by 61.7% at 12 weeks (p < 0.025) in nine of ten patients, with 70% patients having a reduction of at least 50%. Attack intensity was reduced by 38.7% at 6 weeks (p < 0.005) and by 62.6% at 12 weeks (p < 0.004) in ten of ten patients, with 70% of patients having a reduction of at least 50%. Attack duration decreased by 67.2% at 6 weeks (p < 0.001) and by 76.2% at 12 weeks (p < 0.001) in ten of ten patients. Two patients were excluded for reasons unrelated to treatment. Self-assessed general health, physical performance, memory and anxiety also improved by the end of the study. Mig-RL treatment was well tolerated and no adverse events occurred.

CONCLUSION

The remarkable efficacy of Mig-RL in not only reducing the frequency of migraine attacks but also their pain intensity and duration in this trial warrants further investigation of this therapy in a double-blind, randomised, placebo-controlled investigation involving a larger patient population.