Therapie und Versorgung bei chronischer Migräne: Expertenempfehlung der Deutschen Migräne- und Kopfschmerzgesellschaft/Deutsche Gesellschaft für Neurologie sowie der Österreichischen Kopfschmerzgesellschaft/Schweizerischen Kopfwehgesellschaft

Rizatriptan as an Over-the-Counter Triptan in the Treatment of Migraine Attacks

Around 91% of migraine patients use over-the-counter medicines to treat attacks, often without further treatment or medical consultation. This therapeutic principle is established in most countries, regardless of how the healthcare system is otherwise structured or financed. Using Germany as an example, the basis for an expansion of attack therapy with rizatriptan as an over-the-counter triptan is described. To achieve the best possible tolerability and safety in the context of self-medication, the lowest possible dose should be selected to provide the most favourable tolerability and safety profile in the context of self-medication through low dosages. The lowest approved dose of rizatriptan is 5 mg. This was investigated in three randomized controlled trials with 752 patients. The results show that rizatriptan at a dose of 5 mg is more effective than the triptans naratriptan 2.5 mg, almotriptan 12.5 mg and sumatriptan 50 mg, which were previously available for self-medication in Germany. There was no significant difference in the frequency of adverse events with rizatriptan 5 mg compared to placebo. Rizatriptan 5 mg does not have a higher side effect potential than sumatriptan 50 mg, which is already exempt from the prescription requirement. The reasons given show that rizatriptan in a dose of 5 mg for the treatment of acute migraine attacks fulfils the requirements for a transfer from prescription to pharmacy-only status at least as well as sumatriptan 50 mg, naratriptan 2.5 mg and almotriptan 12.5 mg. From a clinical care perspective, it is desirable for affected patients to have other options available for self-medication. Non-responders to other substances also have a further treatment option with rizatriptan 5 mg, with the same or even better risk-benefit profile, to treat migraine attacks safely, effectively and in a tolerable manner as part of self-medication.

Peppermint and menthol: a review on their biochemistry, pharmacological activities, clinical applications, and safety considerations

In this manuscript, we conducted a comprehensive review of the diverse effects of peppermint on human health and explored the potential underlying mechanisms. Peppermint contains three main groups of phytochemical constituents, including essential oils (mainly menthol), flavonoids (such as hesperidin, eriodictyol, naringenin, quercetin, myricetin, and kaempferol), and nonflavonoid phenolcarboxylic acids. Peppermint exhibits antimicrobial, antioxidant, anti-inflammatory, immunomodulatory, anti-cancer, anti-aging, and analgesic properties and may be effective in treating various disorders, including gastrointestinal disorders (e.g., irritable bowel syndrome, dyspepsia, constipation, functional gastrointestinal disorders, nausea/vomiting, and gallbladder stones). In addition, peppermint has therapeutic benefits for psychological and cognitive health, dental health, urinary retention, skin and wound healing, as well as anti-depressant and anti-anxiety effects, and it may improve memory. However, peppermint has paradoxical effects on sleep quality and alertness, as it has been shown to improve sleep quality in patients with fatigue and anxiety, while also increasing alertness under conditions of monotonous work and relaxation. We also discuss its protective effects against toxic agents at recommended doses, as well as its safety and potential toxicity. Overall, this review provides the latest findings and insights into the properties and clinical effects of peppermint/menthol and highlights its potential as a natural therapeutic agent for various health conditions.

Medication overuse headache: Updating of the French recommendations regarding the treatments strategies

Regular and frequent use of analgesics and acute antimigraine drugs can increase the frequency of headache, and induce the transition from episodic to chronic migraine or medication-overuse headache (MOH). The one-year prevalence of this condition is between 1% and 2% in Europe, provoking substantial burden. MOH is more prevalent in people with comorbid depression, anxiety, and other chronic pain conditions. This paper aims at presenting an updating of French recommendations regarding treatments strategies. Prior French recommendations, published in 2014, were written in French. A literature search in the major medical databases including the terms "medication overuse headache", "symptomatic medication overuse", published between 2010 and 2020 was carried out. Three main strategies can be recommended and conducted in parallel: education and explanations about the negative consequences of overusing acute antimigraine drugs, discontinuation of the overused medication, and finally, preventive drug therapy and non-pharmacological prevention. Medication overuse headache remains a debated problem and evidence for the most effective treatment strategy is needed.

Hints on Diagnosing and Treating Headache

BACKGROUND

Headache, like dizziness, is one of the more common presenting complaints in outpatient care and in the emergency room. More than 200 varieties of headache have been described, and the false impression may arise that the diagnosis and treatment of these syndromes is a highly challenging task.

METHODS

This review is based on pertinent articles retrieved by a selective search in PubMed.

RESULTS

In primary headache, the headache is not a symptom but a disease in its own right. There are four types of primary headache: migraine, tension headache, trigeminal autonomic cephalalgia, and other primary headache disorders. By definition, the physical examination is normal, including the neurological examination. Secondary headache, in contrast, is a symptom of another disease (e.g., a tumor or cerebral hemorrhage). Triptans and nonsteroidal anti-inflammatory drugs (NSAID) are the drugs usually given for the acute treatment and prophylaxis of migraine. In tension headache, NSAID are given acutely, and tricyclic drugs for prophylaxis. There are various options for the treatment of trigeminal autonomic cephalalgia syndromes such as cluster headache and paroxysmal hemicrania. For group 4 headaches (other primary headache disorders), the treatment must be chosen on an individual basis; indomethacin is often effective.

CONCLUSION

If the patient is clearly suffering from none of the four types of primary headache, the problem must be a headache of a secondary nature, potentially reflecting a dangerous underlying disease. The treatment of headache is usually successful and thus highly rewarding for physicians of all medical specialties.

[Treatment of chronic migraine with botulinum neurotoxin A : Expert recommendations of the German Migraine and Headache Society]

BACKGROUND

Injection of botulinum neurotoxin A (BoNT-A) according to the PREEMPT (Phase 3 REsearch Evaluating Migraine Prophylaxis Therapy) paradigm has been approved for the treatment of refractory chronic migraine in Germany in 2011.

OBJECTIVE

The practical application raises some questions, such as the choice of dose and injection intervals during the course of the treatment, and the appropriate time point for discontinuation of BoNT-A treatment.

MATERIAL AND METHODS

Taking into account the existing literature, the German Migraine and Headache Society (Deutsche Migräne- und Kopfschmerzgesellschaft, DMKG) gives recommendations for the treatment of chronic migraine with BoNT-A.

RESULTS

Treatment is usually started with a dose of 155 U BoNT-A. During the first year of treatment, 3‑month injection intervals are recommended. Goal of the treatment is an improvement of migraine by ≥30%. If needed, dose escalation up to 195 U can be used to reach this goal. If improvement by ≥30% is not reached after the third injection cycle, the treatment is usually considered to be insufficiently efficient and discontinuation is recommended. If a stable success is reached during the first year of treatment, prolongation of injection intervals to 4 months can be considered. If success continues to be stable for at least two 4‑month intervals, discontinuation of BoNT-A treatment can be tried.

CONCLUSION

The literature on these points is insufficient for recommendations at the guideline level. The present recommendations are based on an expert consensus of the DMKG for the structured approach to the treatment of chronic migraine with BoNT-A.

[Relaxation techniques and behavioural therapy for the treatment of migraine : Guidelines from the German Migraine and Headache Society]

Besides pharmacological and interventional possibilities nonpharmacological options, deriving from behavioural approaches may be helpful in the treatment of migraine. Already consulting a patient reduces frequency of attacks. Relaxation (especially progressive muscle relaxation), endurance sports, and biofeedback as well as cognitive behavioural therapy are effective in treatment of migraine. The combination of these treatment options also with pharmacological treatment increase the positive effects.

An update on behavioral treatments in migraine - current knowledge and future options

INTRODUCTION

Besides pharmacological and interventional treatments a variety of non-medical therapeutic options exist for migraine, which has largely been derived from behavioral therapy. Areas covered: For our update we collected available studies via PubMed searches. This review highlights that already consulting of the patient is able to reduce the frequency of migraine attacks. Relaxation techniques, especially progressive muscle relaxation, and various types of biofeedback are effective, as is the implementation of cognitive behavioral therapy. However, recent reviews also point to some existing inconsistencies and methodological limitations. The advent of modern information technology based approaches (e.g. online therapy, smartphone applications) further advanced the arsenal of behavioral treatment regimes. The combination of behavioral treatment options and the combination with pharmacotherapy lead to additive effects. In modern multidisciplinary treatment approaches, behavioral therapy is an indispensable component. Expert commentary: Behavioral treatment in prophylaxis of migraine is as effective as pharmacological treatment with additional effects when pharmacological and behavioral treatment is applied in combination. Novel treatment approaches using online technology and electronic devices offer interesting options that will spread more in the future.

[Peppermint oil in the acute treatment of tension-type headache]

Tension-type headache is the most frequent form of headache. The local topical treatment with peppermint oil (oleum menthae piperitae) has proven to be significantly more effective than placebo in controlled studies. Peppermint oil targets headache pathophysiology in multiple ways. The efficacy is comparable to that of acetylsalicylic acid or paracetamol. Solutions of 10 % peppermint oil in ethanol are licensed for the treatment of tension-type headache in adults and children above 6 years. It is included in treatment recommendations and guidelines by the respective professional societies and is regarded as a standard treatment for the acute therapy of tension-type headaches.

[Botulinum toxin type A in headache treatment : Established and experimental indications]

In recent years botulinum toxin type A has been used increasingly more in the treatment of specific headache disorders. Especially regarding chronic migraine with and without combined medication overuse, convincing randomized studies have proven the efficacy of this treatment option and have led to approval for this indication. Regarding other headache entities, such as episodic migraine, tension-type headache, trigeminal autonomic cephalalgia (TAC), neuralgic, neuropathic and myofascial pain, currently available scientific data on the efficacy of botulinum toxin type A are scarce and often ambiguous. The exact underlying mechanisms of the influence of botulinum toxin type A on the pathophysiology of headache are not completely clear but an influence on the release of calcitonin gene-related peptide (CGRP) seems to play a crucial role. This article summarizes the most important studies as well as experiences of treatment with botulinum toxin type A regarding different headache entities.

Botulinum toxin in the management of chronic migraine: clinical evidence and experience

Chronic migraine (CM) is a severely disabling neurological condition characterized by episodes of pulsating unilateral or bilateral headache. The United States Food and Drug Administration (FDA) approved onabotulinumtoxinA (Botox®) for the prophylactic treatment of CM in 2010. It has been shown that onabotulinumtoxinA is effective in the reduction of headache frequency and severity in patients with CM. Treatment is well tolerated by the patients. This review reports on the history of botulinum neurotoxin (BoNT) in CM and presents the current clinical evidence for the use of onabotulinumtoxinA in the treatment of CM.

Comparative effectiveness of onabotulinumtoxinA versus oral migraine prophylactic medications on headache-related resource utilization in the management of chronic migraine: Retrospective analysis of a US-based insurance claims database

BACKGROUND

Migraine, especially chronic migraine (CM), causes substantial disability; however, health care utilization has not been well characterized among patients receiving different migraine prophylactic treatments.

METHODS

Using a large, US-based, health care claims database, headache-related health care utilization was evaluated among adults with CM treated with onabotulinumtoxinA or oral migraine prophylactic medications (OMPMs). Headache-related health care utilization was assessed at six, nine, and 12 months pre- and post-treatment. The primary endpoint was the difference between pre- and post-index headache-related health care utilization. A logistic regression model was created to test the difference between onabotulinumtoxinA and OMPM-treated groups for headache-related emergency department (ED) visits and hospitalizations.

RESULTS

Baseline characteristics were comparable between groups. The proportion of patients with ED visits or hospitalizations for a headache-related event decreased after starting onabotulinumtoxinA, but increased after starting an OMPM, for all three cohorts. Regression analyses showed that the odds of having a headache-related ED visit were 21%, 20%, and 19% lower and hospitalization were 47%, 48%, and 56% lower for the onabotulinumtoxinA group compared to the OMPM group for the six-month, nine-month, and 12-month post-index periods, respectively.

CONCLUSIONS

When compared with similar patients who initiated treatment with OMPM, onabotulinumtoxinA was associated with a significantly lower likelihood of headache-related ED visits and hospitalizations.

[Classification and therapy of medication-overuse headache: impact of the third edition of the International Classification of Headache Disorders]

The diagnosis of medication-overuse headache (MOH) is of central importance because this secondary headache disorder can be treated very effectively and patients do not usually respond to headache prophylaxis as long as MOH persists. The article describes important changes in the diagnostic criteria of different MOH subtypes after publication of the International Classification of Headache Disorders (ICHD-3beta) in 2013. The new classification has a crucial and direct impact on prevention and treatment of MOH. In addition interactions exist with the new criteria of chronic migraine. With a controlled medication intake scheme according to the 10-20 rule and using a medication break, MOH usually remits in most patients. If patient education and advice does not lead to remission of MOH, a specialized managed medication break or withdrawal treatment becomes necessary. This can be done on an outpatient, day clinic or inpatient basis. In uncomplicated cases, the results of these three treatment settings do not differ. From a cost-effectiveness standpoint, the outpatient treatment should be given priority. In complicated cases, a fully inpatient withdrawal treatment using a multimodal treatment concept is significantly superior.