Triptans for acute cluster headache

2023 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline for the Management of Headache

DESCRIPTION

Headache medicine and therapeutics evidence have been rapidly expanding and evolving since the 2020 U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) clinical practice guideline (CPG) for the management of headache. Therefore, the CPG was revised in 2023, earlier than the standard 5-year cycle. This article reviews the 2023 CPG recommendations relevant to primary care clinicians for treatment and prevention of migraine and tension-type headache (TTH).

METHODS

Subject experts from the VA and the DoD developed 12 key questions, which guided a systematic search using predefined inclusion and exclusion criteria. After reviewing evidence from 5 databases published between 6 March 2019 and 16 August 2022, the work group considered the strength and quality of the evidence, patient preferences, and benefits versus harms on critical outcomes before making consensus recommendations.

RECOMMENDATIONS

The revised CPG includes 52 recommendations on evaluation, pharmacotherapy, invasive interventions, and nonpharmacologic interventions for selected primary and secondary headache disorders. In addition to triptans and aspirin-acetaminophen-caffeine, newer calcitonin gene-related peptide (CGRP) inhibitors (gepants) are options for treatment of acute migraine. Medications to prevent episodic migraine (EM) include angiotensin-receptor blockers, lisinopril, magnesium, topiramate, valproate, memantine, the newer CGRP monoclonal antibodies, and atogepant. AbobotulinumtoxinA can be used for prevention of chronic migraine but not EM. Gabapentin is not recommended for prevention of EM. Ibuprofen (400 mg) and acetaminophen (1000 mg) can be used for treatment of TTH, and amitriptyline for prevention of chronic TTH. Physical therapy or aerobic exercise can be used in management of TTH and migraines.

Genetic and Phenotypic Profiling of Triptan Users in a Swedish Cluster Headache Cohort

Up to 25% of individuals who live with cluster headache (CH), an extremely painful primary headache disorder, do not adequately respond to the first-line treatment, triptans. Studies have indicated that genetic variants can play a role in treatment response. Likewise, differences in clinical characteristics can give clues to mechanisms underlying triptan non-response. Our aim was to investigate five genetic variants previously implicated in triptan response and their relation to triptan usage in our Swedish CH cohort and to investigate potential distinctions in clinical characteristics. 545 CH patients were screened for the genetic variants rs1024905, rs6724624, rs4795541, rs5443, and rs2651899 with a case control design based on triptan usage. Analysis of clinical characteristics was based on self-reported questionnaire data from 893 patients. One genetic variant, rs1024905, was significantly associated with triptan non-usage in CH (Pc = 0.010). In addition, multi-allele effector analysis showed that individuals with a higher number of effector variants were less likely to use triptans (P = 0.007). Analysis of clinical characteristics showed that triptan users were more likely to have alcohol as a trigger (57.4% vs 43.4%, P = 0.002), have autonomic symptoms (95.1% vs 88.1%, P = 0.002), and be current smokers (27.0% vs 21.9%, P = 0.033) compared to non-users. These results support the hypothesis that genetic variants can play a role in triptan usage in CH and that patients with a typical CH phenotype are more likely to use triptans.

Health equity, care access and quality in headache - part 2

BACKGROUND

Headache disorders are a global public health concern affecting diverse populations. This review examines headache service organizations in low-, middle-, and high-income countries. It addresses global challenges in pharmacological headache treatment, with a focus on safety, tolerability, reproductive and child health, and outlines disparities in accessing innovative treatments worldwide.

MAIN BODY

Organized headache services are essential due to the wide prevalence and varying severity of headache disorders. The tiered headache service model is globally recognized, although its implementation varies based on financial and workforce considerations. Headache burden affects well-being, causing disability, economic challenges, and work limitations, irrespective of location or income. All nations still require improved diagnosis and treatment, and the majority of countries face obstacles including limited access, awareness, economic barriers, and inadequate health policies. Provided adequate internet availability, telemedicine could help improve health equity by expanding access to headache care, since it can offer patients access to services without lengthy waiting times or extensive travel and can provide healthcare unavailable in underserved areas due to staff shortages. Numerous health disparities restrict global access to many headache medications, especially impacting individuals historically excluded from randomized controlled trials, such as those with cardiovascular and cerebrovascular conditions, as well as pregnant women. Furthermore, despite advancements in researching migraine treatments for young patients, the options for treatment remain limited. Access to headache treatment relies on factors like medication availability, approval, financial coverage, and healthcare provider expertise. Inadequate public awareness leads to neglect by policymakers and undertreatment by patients and healthcare providers. Global access discrepancies are exacerbated by the introduction of novel disease-specific medications, particularly impacting Asian, African, and Latin American nations excluded from clinical trials. While North America and Europe experience broad availability of migraine treatments, the majority of countries worldwide lack access to these therapies.

CONCLUSIONS

Healthcare disparities, treatment access, and medication availability are concerning issues in headache medicine. Variations in national healthcare systems impact headache management, and costly innovative drugs are widening these gaps. Healthcare practitioners and experts should acknowledge these challenges and work towards minimizing access barriers for equitable global headache care in the future.

Clinical characteristics and treatment patterns of patients with episodic cluster headache: results from the United States, United Kingdom and Germany

OBJECTIVE

To describe clinical characteristics and regional treatment patterns of episodic cluster headache (CH).

METHODS

A point-in-time survey of physicians and their patients with CH was conducted in the United States, United Kingdom and Germany in 2017.

RESULTS

Overall, 1012 patients with episodic CH were analyzed. Demographic and clinical findings were generally consistent across regions. Most patients were men (66.6%) and the mean age was 40.9 years. The greatest proportion of patients (38.3%) had ≤1 attack per day. The mean number of attacks per day (APD) was 2.4 and mean number of cluster periods per year was 2.6; the mean cluster period duration was 30.8 days. Most patients (69.3%) did not report a specific or predicable time when cluster periods occurred. Acute treatment was prescribed for 47.6% of patients, 10.3% of patients received preventive treatment, and 37.9% of patients received combined acute and preventive treatment; 4.2% of patients were not receiving treatment. Frequently prescribed acute treatments were sumatriptan, oxygen, and zolmitriptan; oxygen use varied considerably across countries and was prescribed least often in the United States. Frequently prescribed preventive treatments were verapamil, topiramate, and lithium. Lack of efficacy and tolerability were the most common reasons for discontinuing preventive treatment.

CONCLUSIONS

We observed high use of acute treatments, but only half of patients used preventive treatments despite experiencing several cluster periods per year with multiple cluster APD. Further studies about the need for and benefits of preventive treatment for episodic CH are warranted.

A Comprehensive Review of the Mechanism, Efficacy, Safety, and Tolerability of Ubrogepant in the Treatment of Migraine

Ubrogepant is an innovative medication designed for the acute treatment of migraine, a debilitating neurological condition that profoundly impairs quality of life, productivity, and social interactions. This comprehensive review assesses the efficacy, safety, tolerability, and mechanism of action of ubrogepant through a rigorous methodology, including an in-depth literature review from reputable databases like PubMed, Web of Science, Embase, Scopus, and Cochrane. Classified as a calcitonin gene-related peptide (CGRP) receptor antagonist, ubrogepant has emerged as a potential revolutionary medication for migraine treatment. CGRP is a peptide integral to migraine pathophysiology, and its blockade has demonstrated great therapeutic potential. Unlike triptans, known for their cardiovascular risks, ubrogepant lacks vasoconstrictive properties, making it a safer alternative for a broader patient population. Ubrogepant offers significant potential for pain relief, symptom reduction, and restoration of normal function during a migraine attack, and it outperforms placebo in terms of efficacy. It also presents favorable safety, with generally mild adverse drug events (ADEs), such as nausea, dizziness, and somnolence, similar to placebo effects. Consistent results from clinical trials confirm its tolerability, with minor ADEs and no safety alerts for the tested doses, indicating that ubrogepant is a safe and well-tolerated option for migraine treatment. As an effective oral medication, ubrogepant could be an alternative to traditional acute migraine treatments. Its benefits include a unique mechanism of action, rapid onset, and favorable safety profile. However, specific contraindications, such as hypersensitivity, severe hepatic impairment, concurrent use of CYP3A4 inhibitors, pregnancy or breastfeeding, and uncontrolled hypertension, require caution or avoidance of ubrogepant. Despite these limitations, ubrogepant signals a promising new direction in migraine therapeutics.

The HortONS study. Treatment of chronic cluster headache with transcutaneous electrical nerve stimulation and occipital nerve stimulation: study protocol for a prospective, investigator-initiated, double-blinded, randomized, placebo-controlled trial

BACKGROUND

Chronic cluster headache (CCH) is a debilitating primary headache disorder. Occipital nerve stimulation (ONS) has shown the potential to reduce attack frequency, but the occipital paresthesia evoked by conventional (tonic) stimulation challenges a blinded comparison of active stimulation and placebo. Burst ONS offers paresthesia-free stimulation, enabling a blinded, placebo-controlled study. Identification of a feasible preoperative test would help select the best candidates for implantation. This study aims to explore ONS as a preventive treatment for CCH, comparing burst stimulation to tonic stimulation and placebo, and possibly identifying a potential preoperative predictor.

METHODS

An investigator-initiated, double-blinded, randomized, placebo-controlled trial is conducted, including 40 patients with CCH. Eligible patients complete a trial with the following elements: I) four weeks of baseline observation, II) 12 weeks of transcutaneous electrical nerve stimulation (TENS) of the occipital nerves, III) implantation of a full ONS system followed by 2 week grace period, IV) 12 weeks of blinded trial with 1:1 randomization to either placebo (deactivated ONS system) or burst (paresthesia-free) stimulation, and V) 12 weeks of tonic stimulation. The primary outcomes are the reduction in headache attack frequency with TENS and ONS and treatment safety. Secondary outcomes are treatment efficacy of burst versus tonic ONS, the feasibility of TENS as a predictor for ONS outcome, reduction in headache pain intensity (numeric rating scale), reduction in background headache, the patient's impression of change (PGIC), health-related quality of life (EuroQoL-5D), self-reported sleep quality, and symptoms of anxiety and depression (Hospital Anxiety and Depression Scale, HADS). Data on headache attack characteristics are registered weekly. Data on patient-reported outcomes are assessed after each trial phase.

DISCUSSION

The study design allows a comparison between burst ONS and placebo in refractory CCH and enables a comparison of the efficacy of burst and tonic ONS. It will provide information about the effect of burst ONS and explore whether the addition of this stimulation paradigm may improve stimulation protocols. TENS is evaluated as a feasible preoperative screening tool for ONS outcomes by comparing the effect of attack prevention of TENS and tonic ONS.

TRIAL REGISTRATION

The study is registered at Clinicaltrials.gov (trial registration number NCT05023460, registration date 07-27-2023).

European Academy of Neurology guidelines on the treatment of cluster headache

BACKGROUND AND PURPOSE

Cluster headache is a relatively rare, disabling primary headache disorder with a major impact on patients' quality of life. This work presents evidence-based recommendations for the treatment of cluster headache derived from a systematic review of the literature and consensus among a panel of experts.

METHODS

The databases PubMed (Medline), Science Citation Index, and Cochrane Library were screened for studies on the efficacy of interventions (last access July 2022). The findings in these studies were evaluated according to the recommendations of the European Academy of Neurology, and the level of evidence was established using GRADE (Grading of Recommendations Assessment, Development, and Evaluation).

RECOMMENDATIONS

For the acute treatment of cluster headache attacks, there is a strong recommendation for oxygen (100%) with a flow of at least 12 L/min over 15 min and 6 mg subcutaneous sumatriptan. Prophylaxis of cluster headache attacks with verapamil at a daily dose of at least 240 mg (maximum dose depends on efficacy and tolerability) is recommended. Corticosteroids are efficacious in cluster headache. To reach an effect, the use of at least 100 mg prednisone (or equivalent corticosteroid) given orally or at up to 500 mg iv per day over 5 days is recommended. Lithium, topiramate, and galcanezumab (only for episodic cluster headache) are recommended as alternative treatments. Noninvasive vagus nerve stimulation is efficacious in episodic but not chronic cluster headache. Greater occipital nerve block is recommended, but electrical stimulation of the greater occipital nerve is not recommended due to the side effect profile.

A Rare Case of Cluster Headache Occurring Exclusively During Sleep Without Autonomic Symptoms and Agitation: A Case Report and Literature Review

As a primary headache disorder, cluster headache (CH) is a severe unilateral headache that recurs at certain times of the year, such as during season changes. It is characterized by autonomic symptoms, such as ipsilateral lacrimal and nasal discharge, as well as an inability to stay still during headache attacks. We report a rare case of CH in a 67-year-old male who presented with a severe right-sided headache lasting 30 minutes to one hour and occurring only during sleep. The headache resolved within five minutes after the subcutaneous injection of sumatriptan and was not accompanied by any autonomic symptoms or clear agitation.

Management of Trigeminal Autonomic Cephalalgias Including Chronic Cluster: A Review

Importance

Trigeminal autonomic cephalalgias (TACs) comprise a unique collection of primary headache disorders characterized by moderate or severe unilateral pain, localized in in the area of distribution of the first branch of the trigeminal nerve, accompanied by cranial autonomic symptoms and signs. Most TACs are rare diseases, which hampers the possibility of performing randomized clinical trials and large studies. Therefore, knowledge of treatment efficacy must be based only on observational studies, rare disease registries, and case reports, where real-world data and evidence play an important role in health care decisions.

Observations

Chronic cluster headache is the most common of these disorders, and the literature offers some evidence from randomized clinical trials to support the use of pharmacologic and neurostimulation treatments. Galcanezumab, a monoclonal antibody targeting the calcitonin gene-related peptide, was not effective at 3 months in a randomized clinical trial but showed efficacy at 12 months in a large case series. For the other TACs (ie, paroxysmal hemicrania, hemicrania continua, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing, and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms), only case reports and case series are available to guide physicians in everyday management.

Conclusions and Relevance

The accumulation of epidemiologic, pathophysiologic, natural history knowledge, and data from case series and small controlled trials, especially over the past 20 years from investigators around the world, has added to the previously limited evidence and has helped advance and inform the treatment approach to rare TACs, which can be extremely challenging for clinicians.

Cluster headache polygenetic risk and known functional variants of CYP3A4 are not associated with treatment response

BACKGROUND AND PURPOSE

The response to cluster headache treatments has a high interindividual variation. To date, treatment response has only been assessed by a candidate gene approach and no investigations into metabolic pathways have been performed. Our aim was to investigate the association between the polygenetic risk of cluster headache and treatment response to first-line cluster headache treatments as well as known functional variants of CYP3A4 and the response to verapamil. Further, it was aimed to replicate previous single nucleotide polymorphisms found to be associated with treatment response in cluster headache and/or migraine.

METHODS

In, 508 cluster headache patients diagnosed according to the International Classification of Headache Disorders were genotyped and participated in a semi-structured interview to evaluate treatment response. Polygenetic risk scores were calculated by the effect retrieved from a meta-analysis of the latest two genome-wide association studies on cluster headache.

RESULTS

Inferior treatment response to oxygen, triptans and verapamil is associated with chronicity of cluster headache were confirmed but no evidence was found that a response could be predicted by a high genetic risk of cluster headache. Likewise, verapamil response was not associated with functional variants of CYP3A4. No support of the genetic variants previously reported to be associated with treatment response to triptans or verapamil was found.

CONCLUSION

The clinically relevant variation in treatment response for cluster headache was not influenced by genetic factors in the present study.

Comparative Impact of Pharmacological Therapies on Cluster Headache Management: A Systematic Review and Network Meta-Analysis

It is important to find effective and safe pharmacological options for managing cluster headache (CH) because there is limited evidence from studies supporting the general efficacy and safety of pharmacological therapies. This systematic review and network meta-analysis (NMA) analyzed published randomized controlled trials (RCTs) to evaluate the efficacy and safety of pharmacological treatments in patients with CH. The PubMed and Embase databases were searched to identify RCTs that evaluated the efficacy and safety of pharmacological treatments for CH. Efficacy outcomes included frequency and duration of attacks, pain-free rate, and the use of rescue agents. Safety outcomes were evaluated based on the number of patients who experienced adverse events. A total of 23 studies were included in the analysis. The frequency of attacks was reduced (mean difference (MD) = −1.05, 95% confidence interval (CI) = −1.62 to −0.47; p = 0.0004), and the pain-free rate was increased (odds ratio (OR) = 3.89, 95% CI = 2.76−5.48; p < 0.00001) in the pharmacological treatment group, with a lower frequency of rescue agent use than the placebo group. Preventive, acute, and triptan or non-triptan therapies did not show significant differences in efficacy (p > 0.05). In the NMA, different results were shown among the interventions; for example, zolmitriptan 5 mg was more effective than zolmitriptan 10 mg in the pain-free outcome (OR = 0.40, 95% CI = 0.19−0.82; p < 0.05). Pharmacological treatment was shown to be more effective than placebo to manage CH with differences among types of therapies and individual interventions, and it was consistently shown to be associated with the development of adverse events. Thus, individualized therapy approaches should be applied to treat CH in real-world practice.

Pharmacogenetics in Primary Headache Disorders

Primary headache disorders, such as migraine, tension-type headache (TTH), and cluster headache, belong to the most common neurological disorders affecting a high percentage of people worldwide. Headache induces a high burden for the affected individuals on the personal level, with a strong impact on life quality, daily life management, and causes immense costs for the healthcare systems. Although a relatively broad spectrum of different pharmacological classes for the treatment of headache disorders are available, treatment effectiveness is often limited by high variances in therapy responses. Genetic variants can influence the individual treatment success by influencing pharmacokinetics or pharmacodynamics of the therapeutic as investigated in the research field of pharmacogenetics. This review summarizes the current knowledge on important primary headache disorders, including migraine, TTH, and cluster headache. We also summarize current acute and preventive treatment options for the three headache disorders based on drug classes and compounds taking important therapy guidelines into consideration. Importantly, the work summarizes and discusses the role of genetic polymorphisms regarding their impact on metabolism safety and the effect of therapeutics that are used to treat migraine, cluster headache, and TTH exploring drug classes such as nonsteroidal anti-inflammatory drugs, triptans, antidepressants, anticonvulsants, calcium channel blockers, drugs with effect on the renin-angiotensin system, and novel headache therapeutics such as ditans, anti-calcitonin-gene-related peptide antibodies, and gepants. Genetic variants in important phase I-, II-, and III-associated genes such as cytochrome P450 genes, UGT genes, and different transporter genes are scrutinized as well as variants in genes important for pharmacodynamics and several functions outside the pharmacokinetic and pharmacodynamic spectrum. Finally, the article evaluates the potential and limitations of pharmacogenetic approaches for individual therapy adjustments in headache disorders.

[Perioperative analgesia with nonopioid analgesics : Joint interdisciplinary consensus-based recommendations of the German Pain Society, the German Society of Anaesthesiology and Intensive Care Medicine and the German Society of Surgery]

BACKGROUND

Nonopioid analgesics are frequently used for perioperative analgesia; however, insufficient research is available on several practical issues. Often hospitals have no strategy for how to proceed, e.g., for informing patients or for the timing of perioperative administration of nonopioid analgesics.

METHODS

An expert panel representing the German national societies of pain, anaesthesiology and intensive care medicine and surgery developed recommendations for the perioperative use of nonopioid analgesics within a formal, structured consensus process.

RESULTS

The panel agreed that nonopioid analgesics shall be part of a multimodal analgesia concept and that patients have to be informed preoperatively about possible complications and alternative treatment options. Patients' history of pain and analgesic intake shall be evaluated. Patients at risk of severe postoperative pain and possible chronification of postsurgical pain shall be identified. Depending on the duration of surgery, nonopioid analgesics can already be administered preoperatively or intraoperatively so that plasma concentrations are sufficient after emergence from anesthesia. Nonopioid analgesics or combinations of analgesics shall be administered for a limited time only. An interdisciplinary written standard of care, comprising the nonopioid analgesic of choice, possible alternatives, adequate dosing and timing of administration as well as surgery-specific policies, have to be agreed upon by all departments involved. At discharge, the patient's physician shall be informed of analgesics given and those necessary after discharge. Patients shall be informed of possible side effects and symptoms and timely discontinuation of analgesic drugs.

CONCLUSION

The use of nonopioid analgesics as part of a perioperative multimodal concept should be approved and established as an interdisciplinary and interprofessional concept for the adequate treatment of postoperative pain.

[Perioperative analgesia with nonopioid analgesics : Joint interdisciplinary consensus-based recommendations of the German Pain Society, the German Society of Anaesthesiology and Intensive Care Medicine and the German Society of Surgery]

BACKGROUND

Nonopioid analgesics are frequently used for perioperative analgesia; however, insufficient research is available on several practical issues. Often hospitals have no strategy for how to proceed, e.g., for informing patients or for the timing of perioperative administration of nonopioid analgesics.

METHODS

An expert panel representing the German national societies of pain, anaesthesiology and intensive care medicine and surgery developed recommendations for the perioperative use of nonopioid analgesics within a formal, structured consensus process.

RESULTS

The panel agreed that nonopioid analgesics shall be part of a multimodal analgesia concept and that patients have to be informed preoperatively about possible complications and alternative treatment options. Patients' history of pain and analgesic intake shall be evaluated. Patients at risk of severe postoperative pain and possible chronification of postsurgical pain shall be identified. Depending on the duration of surgery, nonopioid analgesics can already be administered preoperatively or intraoperatively so that plasma concentrations are sufficient after emergence from anesthesia. Nonopioid analgesics or combinations of analgesics shall be administered for a limited time only. An interdisciplinary written standard of care, comprising the nonopioid analgesic of choice, possible alternatives, adequate dosing and timing of administration as well as surgery-specific policies, have to be agreed upon by all departments involved. At discharge, the patient's physician shall be informed of analgesics given and those necessary after discharge. Patients shall be informed of possible side effects and symptoms and timely discontinuation of analgesic drugs.

CONCLUSION

The use of nonopioid analgesics as part of a perioperative multimodal concept should be approved and established as an interdisciplinary and interprofessional concept for the adequate treatment of postoperative pain.

Mesenchymal stem cells as a multimodal treatment for nervous system diseases

Neurological disorders are a massive challenge for modern medicine. Apart from the fact that this group of diseases is the second leading cause of death worldwide, the majority of patients have no access to any possible effective and standardized treatment after being diagnosed, leaving them and their families helpless. This is the reason why such great emphasis is being placed on the development of new, more effective methods to treat neurological patients. Regenerative medicine opens new therapeutic approaches in neurology, including the use of cell-based therapies. In this review, we focus on summarizing one of the cell sources that can be applied as a multimodal treatment tool to overcome the complex issue of neurodegeneration-mesenchymal stem cells (MSCs). Apart from the highly proven safety of this approach, beneficial effects connected to this type of treatment have been observed. This review presents modes of action of MSCs, explained on the basis of data from vast in vitro and preclinical studies, and we summarize the effects of using these cells in clinical trial settings. Finally, we stress what improvements have already been made to clarify the exact mechanism of MSCs action, and we discuss potential ways to improve the introduction of MSC-based therapies in clinics. In summary, we propose that more insightful and methodical optimization, by combining careful preparation and administration, can enable use of multimodal MSCs as an effective, tailored cell therapy suited to specific neurological disorders.

A narrative review of the potential pharmacological influence and safety of ibuprofen on coronavirus disease 19 (COVID-19), ACE2, and the immune system: a dichotomy of expectation and reality

The coronavirus disease 19 (COVID-19) pandemic is currently the most acute healthcare challenge in the world. Despite growing knowledge of the nature of Severe Acute Respiratory Syndrome coronavirus-2 (SARS-CoV-2), treatment options are still poorly defined. The safety of non-steroidal anti-inflammatory drugs (NSAIDs), specifically ibuprofen, has been openly questioned without any supporting evidence or clarity over dose, duration, or temporality of administration. This has been further conflicted by the initiation of studies to assess the efficacy of ibuprofen in improving outcomes in severe COVID-19 patients. To clarify the scientific reality, a literature search was conducted alongside considerations of the pharmacological properties of ibuprofen in order to construct this narrative review. The literature suggests that double-blind, placebo-controlled study results must be reported and carefully analysed for safety and efficacy in patients with COVID-19 before any recommendations can be made regarding the use of ibuprofen in such patients. Limited studies have suggested: (i) no direct interactions between ibuprofen and SARS-CoV-2 and (ii) there is no evidence to suggest ibuprofen affects the regulation of angiotensin-converting-enzyme 2 (ACE2), the receptor for COVID-19, in human studies. Furthermore, in vitro studies suggest ibuprofen may facilitate cleavage of ACE2 from the membrane, preventing membrane-dependent viral entry into the cell, the clinical significance of which is uncertain. Additionally, in vitro evidence suggests that inhibition of the transcription factor nuclear factor-κB (NF-kB) by ibuprofen may have a role in reducing excess inflammation or cytokine release in COVID-19 patients. Finally, there is no evidence that ibuprofen will aggravate or increase the chance of infection of COVID-19.

Emerging Novel Pharmacological Non-opioid Therapies in Headache Management: a Comprehensive Review

PURPOSE OF REVIEW

Chronic headache is a significant worldwide problem despite advances in treatment options. Chronic headaches can have significant a detrimental impact on the activities of daily living.

RECENT FINDINGS

Patients who do not obtain relief from chronic head and neck pain from conservative treatments are commonly being managed with interventional treatments. These interventional treatment options include botulinum toxin A, injections, local occipital nerve anesthetic and corticosteroid infiltration, occipital nerve subcutaneous stimulation and occipital nerve pulsed radiofrequency (PRF), sphenopalatine ganglion block, and radiofrequency techniques. Recently, evidence has emerged to support non-opioid-based drug and interventional approaches. Overall, more research is necessary to clarify the safety and efficacy of interventional treatments and to better understand the pathogenesis of chronic headache pain.

Endogenous Neurostimulation and Physiotherapy in Cluster Headache: A Clinical Case

OBJECTIVE

The aim of this paper is to describe the progressive changes of chronic cluster headaches (CHs) in a patient who is being treated by a multimodal approach, using pharmacology, neurostimulation and physiotherapy.

SUBJECT

A male patient, 42 years of age was diagnosed with left-sided refractory chronic CH by a neurologist in November 2009. In June 2014, the patient underwent a surgical intervention in which a bilateral occipital nerve neurostimulator was implanted as a treatment for headache.

METHODS

Case report.

RESULTS

Primary findings included a decreased frequency of CH which lasted up to 2 months and sometimes even without pain. Besides this, there were decreased levels of anxiety, helplessness (PCS subscale) and a decreased impact of headache (HIT-6 scale). Bilateral pressure pain thresholds (PPTs) were improved along with an increase in strength and motor control of the neck muscles. These improvements were present at the conclusion of the treatment and maintained up to 4 months after the treatment.

CONCLUSIONS

A multimodal approach, including pharmacology, neurostimulation and physiotherapy may be beneficial for patients with chronic CHs. Further studies such as case series and clinical trials are needed to confirm these results.

[Oxycodone, piritramide and tramadol for the management of postoperative pain : A registry study on use and effectiveness in clinical routine]

BACKGROUND

In the context of improving perioperative pain management and shortening hospital stays, potent oral analgesics, such as slow release opioids, are gaining increasingly in importance.

OBJECTIVE

The aim of this study was to compare the use and effectiveness of different opioids in postoperative pain treatment in Germany.

MATERIALS AND METHODS

Using data from the QUIPS database, the records of 5249 patients were evaluated. The total study population was divided into four groups: group 1 (10 mg oxycodone with or without naloxone 5 mg), group 2 (20 mg oxycodone with or without naloxone 10 mg), group 3 (piritramide) and group 4 (tramadol). Maximum pain intensity, pain-related interference with sleep and respiration, vomiting, postoperative fatigue, desire for more pain treatment and satisfaction with pain management were evaluated.

RESULTS AND DISCUSSION

The differences in pain intensity were statistically significant between groups. Patients with piritramide reported more pain, more interference with sleep and respiration and more fatigue compared to those from the other groups. In the group with 10 mg oxycodone, the desire for additional pain medication was the lowest. Postoperative vomiting and satisfaction with pain management differed significantly between the four groups. Procedure-specific analysis has shown that differences between sub-groups were also significant following cholecystectomy and total knee arthroplasty.

CONCLUSIONS

In summary, our findings suggest that postoperative pain treatment with slow release oral oxycodone does not show disadvantages compared to tramadol or piritramide with regard to pain-related impairments and opioid-induced side effects. This hypothesis needs to be further analyzed in controlled studies.

Population-Based Analysis of Cluster Headache-Associated Genetic Polymorphisms

Cluster headache is a disorder with increased hereditary risk. Associations between cluster headache and polymorphism rs2653349 of the HCRTR2 gene have been demonstrated. The less common allele (A) seems to reduce disease susceptibility. The polymorphism rs5443 of the GNB3 gene positively influences triptan treatment response. Carriers of the mutated T allele are more likely to respond positively compared to C:C homozygotes, when treated with triptans. DNA was extracted from buccal swabs obtained from 636 non-related Southeastern European Caucasian individuals and was analyzed by real-time PCR. Gene distribution for the rs2653349 was G:G = 79.1%, G:A = 19.2%, and A:A = 1.7%. The frequency of the wild-type G allele was 88.7%. The frequencies for rs5443 were C:C = 44.0%, C:T = 42.6%, and T:T = 13.4%. The frequency of the wild-type C allele was 65.3%. The frequency distribution of rs2653349 in the Southeastern European Caucasian population differs significantly when compared with other European and East Asian populations, and the frequency distribution of rs5443 showed a statistically significant difference between Southeastern European Caucasian and African, South Asian, and East Asian populations. For rs2653349, a marginal statistically significant difference between genders was found (p = 0.080) for A:A versus G:G and G:A genotypes (OR = 2.78), indicating a higher representation of male homozygotes for the protective mutant A:A allele than female. No statistically significant difference was observed between genders for rs5443. Cluster headache pathophysiology and pharmacotherapy response may be affected by genetic factors, indicating the significant role of genotyping in the overall treatment effectiveness of cluster headaches.

Chronic cluster-like headache in a patient with a macroprolactinoma presenting with falsely low prolactin levels: bromocriptine versus cabergoline?

Cluster‐like headache may be associated with pituitary tumors, mostly prolactinomas. Pituitary imaging and prolactin measurement should be assessed in patients presenting with cluster‐like headaches with atypical features or unsatisfactory response to treatment. Furthermore, large pituitary adenomas with moderate increase in prolactin levels should prompt prolactin dilutions to avoid “hook effect”.

Non-Invasive Vagus Nerve Stimulation for the ACute Treatment of Cluster Headache: Findings From the Randomized, Double-Blind, Sham-Controlled ACT1 Study

Objective

To evaluate non‐invasive vagus nerve stimulation (nVNS) as an acute cluster headache (CH) treatment.

Background

Many patients with CH experience excruciating attacks at a frequency that is not sufficiently addressed by current symptomatic treatments.

Methods

One hundred fifty subjects were enrolled and randomized (1:1) to receive nVNS or sham treatment for ≤1 month during a double‐blind phase; completers could enter a 3‐month nVNS open‐label phase. The primary end point was response rate, defined as the proportion of subjects who achieved pain relief (pain intensity of 0 or 1) at 15 minutes after treatment initiation for the first CH attack without rescue medication use through 60 minutes. Secondary end points included the sustained response rate (15‐60 minutes). Subanalyses of episodic cluster headache (eCH) and chronic cluster headache (cCH) cohorts were prespecified.

Results

The intent‐to‐treat population comprised 133 subjects: 60 nVNS‐treated (eCH, n = 38; cCH, n = 22) and 73 sham‐treated (eCH, n = 47; cCH, n = 26). A response was achieved in 26.7% of nVNS‐treated subjects and 15.1% of sham‐treated subjects (P = .1). Response rates were significantly higher with nVNS than with sham for the eCH cohort (nVNS, 34.2%; sham, 10.6%; P = .008) but not the cCH cohort (nVNS, 13.6%; sham, 23.1%; P = .48). Sustained response rates were significantly higher with nVNS for the eCH cohort (P = .008) and total population (P = .04). Adverse device effects (ADEs) were reported by 35/150 (nVNS, 11; sham, 24) subjects in the double‐blind phase and 18/128 subjects in the open‐label phase. No serious ADEs occurred.

Conclusions

In one of the largest randomized sham‐controlled studies for acute CH treatment, the response rate was not significantly different (vs sham) for the total population; nVNS provided significant, clinically meaningful, rapid, and sustained benefits for eCH but not for cCH, which affected results in the total population. This safe and well‐tolerated treatment represents a novel and promising option for eCH. ClinicalTrials.gov identifier: NCT01792817.

Noninvasive vagus nerve stimulation in the management of cluster headache: clinical evidence and practical experience

The efficacy of invasive vagal nerve stimulation as well as other invasive neuromodulatory approaches such as deep brain stimulation, occipital nerve stimulation, and ganglion sphenopalatine stimulation has been shown in the treatment of headache disorders in several studies in the past. However, these invasive treatment options were quite costly and often associated with perioperative and postoperative side effects, some severe. As such, they were predominantly restricted to chronic and therapy refractory patients. Transcutaneous vagal nerve stimulation now offers a new, noninvasive neuromodulatory treatment approach. Recently published studies showed encouraging results of noninvasive vagus nerve stimulation (nVNS), especially with respect to cluster headache, with high tolerability and a low rate of side effects; however, randomized controlled trials are needed to prove its efficacy. Further data also indicate therapeutic benefits regarding treatment of migraine and medication overuse headache. This review summarizes current knowledge and personal experiences of nVNS in the treatment of cluster headache.

Normobaric and hyperbaric oxygen therapy for the treatment and prevention of migraine and cluster headache

BACKGROUND

Migraine and cluster headaches are severe and disabling. Migraine affects up to 18% of women, while cluster headaches are much less common (0.2% of the population). A number of acute and prophylactic therapies are available. Hyperbaric oxygen therapy (HBOT) is the therapeutic administration of 100% oxygen at environmental pressures greater than one atmosphere, while normobaric oxygen therapy (NBOT) is oxygen administered at one atmosphere. This is an updated version of the original Cochrane review published in Issue 3, 2008 under the title 'Normobaric and hyperbaric oxygen for migraine and cluster headache'.

OBJECTIVES

To examine the efficacy and safety of normobaric oxygen therapy (NBOT) and hyperbaric oxygen therapy (HBOT) in the treatment and prevention of migraine and cluster headache.

SEARCH METHODS

We updated searches of the following databases up to 15 June 2015: CENTRAL (the Cochrane Library), MEDLINE, EMBASE, and CINAHL. For the original review we searched the following databases up to May 2008: CENTRAL, MEDLINE, EMBASE, CINAHL, DORCTIHM, and reference lists from relevant articles. We handsearched relevant journals and contacted researchers to identify trials.

SELECTION CRITERIA

Randomised controlled trials comparing HBOT or NBOT with one another, other active therapies, placebo (sham) interventions, or no treatment in participants with migraine or cluster headache.

DATA COLLECTION AND ANALYSIS

Three review authors independently extracted data and assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

In this update, we included 11 trials with 209 participants. Five trials (103 participants) compared HBOT versus sham therapy for acute migraine, three trials compared NBOT to sham therapy or ergotamine tartrate for cluster headache (145 participants), two trials evaluated HBOT for cluster headache (29 participants), and one trial (56 participants) compared NBOT to sham for a mixed group of headache. The risk of bias varied considerably across these trials but in general trial quality was poor to moderate. One trial may not have been truly randomised and two included studies were reported as abstracts only. Seven trials did not indicate allocation concealment or randomisation method. Notably, 10 of the 11 trials used a sham comparator therapy and masked the outcome assessor to allocation.We pooled data from three trials, which suggested that HBOT was effective in relieving migraine headaches compared to sham therapy (risk ratio (RR) 6.21, 95% CI 2.41 to 16.00; 58 participants, three trials). The quality of evidence was low, having been downgraded for small crossover studies with incomplete reporting. There was no evidence that HBOT could prevent migraine episodes, reduce the incidence of nausea and vomiting, or reduce the requirement for rescue medication. There was no evidence that HBOT was effective for the termination of cluster headache (RR 11.38, 95% CI 0.77 to 167.85; P = 0.08) (one trial), but this trial had low power.NBOT was effective in terminating cluster headache compared to sham in a single small study (RR 7.88, 95% CI 1.13 to 54.66), but not superior to ergotamine administration in another small trial (RR 1.17, 95% CI 0.94 to 1.46; P = 0.16). A third trial reported a statistically significant difference in the proportion of attacks successfully treated with oxygen (117 of 150 attacks were successfully treated with NBOT (78%) versus 30 of 148 attacks treated with NBOT (20%)). The proportion of responders was consistent across these three trials, and suggested more than 75% of headaches were likely to respond to NBOT.No serious adverse events during HBOT or NBOT were reported.

AUTHORS' CONCLUSIONS

Since the last version of this review, two new included studies have provided additional information to change the conclusions. There was some evidence that HBOT was effective for the termination of acute migraine in an unselected population, and some evidence that NBOT was similarly effective in cluster headache. Given the cost and poor availability of HBOT, more research should be done on patients unresponsive to standard therapy. NBOT is cheap, safe, and easy to apply, so will probably continue to be used despite the limited evidence in this review.

Non-invasive vagus nerve stimulation for PREVention and Acute treatment of chronic cluster headache (PREVA): A randomised controlled study

Background

Chronic cluster headache (CH) is a debilitating disorder for which few well-controlled studies demonstrate effectiveness of available therapies. Non-invasive vagus nerve stimulation (nVNS) was examined as adjunctive prophylactic treatment of chronic CH.

Methods

PREVA was a prospective, open-label, randomised study that compared adjunctive prophylactic nVNS (n = 48) with standard of care (SoC) alone (control (n = 49)). A two-week baseline phase was followed by a four-week randomised phase (SoC plus nVNS vs control) and a four-week extension phase (SoC plus nVNS). The primary end point was the reduction in the mean number of CH attacks per week. Response rate, abortive medication use and safety/tolerability were also assessed.

Results

During the randomised phase, individuals in the intent-to-treat population treated with SoC plus nVNS (n = 45) had a significantly greater reduction in the number of attacks per week vs controls (n = 48) (−5.9 vs −2.1, respectively) for a mean therapeutic gain of 3.9 fewer attacks per week (95% CI: 0.5, 7.2; p = 0.02). Higher ≥50% response rates were also observed with SoC plus nVNS (40% (18/45)) vs controls (8.3% (4/48); p < 0.001). No serious treatment-related adverse events occurred.

Conclusion

Adjunctive prophylactic nVNS is a well-tolerated novel treatment for chronic CH, offering clinical benefits beyond those with SoC.

Drug therapy in headache

All physicians will encounter patients with headaches. Primary headache disorders are common, and often disabling. This paper reviews the principles of drug therapy in headache in adults, focusing on the three commonest disorders presenting in both primary and secondary care: tension-type headache, migraine and cluster headache. The clinical evidence on the basis of which choices can be made between the currently available drug therapies for acute and preventive treatment of these disorders is presented, and information given on the options available for the emergency parenteral treatment of refractory migraine attacks and cluster headache.

The Neuropharmacology of Cluster Headache and other Trigeminal Autonomic Cephalalgias

Trigeminal autonomic cephalalgias (TACs) are a group of primary headaches including cluster headache (CH), paroxysmal hemicrania (PH) and short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT). Another form, hemicrania continua (HC), is also included this group due to its clinical and pathophysiological similarities. CH is the most common of these syndromes, the others being infrequent in the general population. The pathophysiology of the TACs has been partly elucidated by a number of recent neuroimaging studies, which implicate brain regions associated with nociception (pain matrix). In addition, the hypothalamic activation observed in the course of TAC attacks and the observed efficacy of hypothalamic neurostimulation in CH patients suggest that the hypothalamus is another key structure. Hypothalamic activation may indeed be involved in attack initiation, but it may also lead to a condition of central facilitation underlying the recurrence of pain episodes. The TACs share many pathophysiological features, but are characterised by differences in attack duration and frequency, and to some extent treatment response. Although alternative strategies for the TACs, especially CH, are now emerging (such as neurostimulation techniques), this review focuses on the available pharmacological treatments complying with the most recent guidelines. We discuss the clinical efficacy and tolerability of the currently used drugs. Due to the low frequency of most TACs, few randomised controlled trials have been conducted. The therapies of choice in CH continue to be the triptans and oxygen for acute treatment, and verapamil and lithium for prevention, but promising results have recently been obtained with novel modes of administration of the triptans and other agents, and several other treatments are currently under study. Indomethacin is extremely effective in PH and HC, while antiepileptic drugs (especially lamotrigine) appear to be increasingly useful in SUNCT. We highlight the need for appropriate studies investigating treatments for these rare, but lifelong and disabling conditions.

Bi-allelic and tri-allelic 5-HTTLPR polymorphisms and triptan non-response in cluster headache

Background

Triptans are only effective in terminating cluster headache (CH) attacks in 70-80% of patients. Pharmacogenetic aspects of the serotonin metabolism, specifically variation in the 5-HTTLPR may be involved.

Methods

Genetic association study in a well-defined cohort of 148 CH patients with information on drug response to triptans. CH was diagnosed according to the criteria of the International Headache Society. Genotypes of the 43-bp insdel (rs4795541) and A > G (rs25531) polymorphisms in the 5-HTTLPR promoter region were detected by restriction fragment length polymorphism analysis. We used logistic regression analysis to investigate the association between bi-allelic and tri-allelic genotypes and triptan non-response with genotype models.

Results

Mean age at study entry among patients was 44.6 ± 10.5 years, 77.7% were men. The genotype distribution both for the bi-allelic and the tri-allelic polymorphism was in Hardy-Weinberg equilibrium. We did not find an association of the bi-allelic polymorphism with triptan non-response. While the effect estimates for the S variant of the tri-allelic polymorphisms suggested increased odds of triptan non-response in CH patients (multivariable-adjusted odds ratio [95% confidence interval]: L*L* genotype—reference; L*S* genotype—1.33 [0.53-3.32]; S*S* genotype—1.46 [0.54-3.98]), the results were not statistically significant.

Conclusions

Data from our study do not indicate a role of bi-allelic and tri-allelic genotypes of the 5-HTTLPR polymorphism in triptan non-response in CH.