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Robblee J, Hakim SM, Reynolds JM, Monteith TS, Zhang N, Barad M. Nonspecific oral medications versus anti-calcitonin gene-related peptide monoclonal antibodies for migraine: A systematic review and meta-analysis of randomized controlled trials. Headache 2024; 64:547-572. [PMID: 38634515 DOI: 10.1111/head.14693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 02/22/2024] [Accepted: 02/22/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVE To compare calcitonin gene-related peptide monoclonal antibodies (CGRP mAbs) versus nonspecific oral migraine preventives (NOEPs). BACKGROUND Insurers mandate step therapy with NOEPs before approving CGRP mAbs. METHODS Databases were searched for class I or II randomized controlled trials (RCTs) comparing CGRP mAbs or NOEPs versus placebo for migraine prevention in adults. The primary outcome measure was monthly migraine days (MMD) or moderate to severe headache days. RESULTS Twelve RCTs for CGRP mAbs, 5 RCTs for topiramate, and 3 RCTs for divalproex were included in the meta-analysis. There was high certainty that CGRP mAbs are more effective than placebo, with weighted mean difference (WMD; 95% confidence interval) of -1.64 (-1.99 to -1.28) MMD, which is compatible with small effect size (Cohen's d -0.25 [-0.34 to -0.16]). Certainty of evidence that topiramate or divalproex is more effective than placebo was very low and low, respectively (WMD -1.45 [-1.52 to -1.38] and -1.65 [-2.30 to -1.00], respectively; Cohen's d -1.25 [-2.47 to -0.03] and -0.48 [-0.67 to -0.29], respectively). Trial sequential analysis showed that information size was adequate and that CGRP mAbs had clear benefit versus placebo. Network meta-analysis showed no statistically significant difference between CGRP mAbs and topiramate (WMD -0.19 [-0.56 to 0.17]) or divalproex (0.01 [-0.73 to 0.75]). No significant difference was seen between topiramate or divalproex (0.21 [-0.45 to 0.86]). CONCLUSIONS There is high certainty that CGRP mAbs are more effective than placebo, but the effect size is small. When feasible, CGRP mAbs may be prescribed as first-line preventives; topiramate or divalproex could be as effective but are less well tolerated. The findings of this study support the recently published 2024 position of the American Headache Society on the use of CGRP mAbs as the first-line treatment.
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Affiliation(s)
- Jennifer Robblee
- Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Sameh M Hakim
- Department of Anesthesiology, Intensive Care, and Pain Management, Ain Shams University Faculty of Medicine, Cairo, Egypt
| | - John M Reynolds
- The Louis Calder Memorial Library, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Teshamae S Monteith
- Division of Headache, Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Niushen Zhang
- Department of Neurology & Neurological Sciences, Stanford Health Care, Stanford, California, USA
| | - Meredith Barad
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Health Care, Stanford, California, USA
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Tseng PT, Zeng BY, Chen JJ, Kuo CH, Zeng BS, Kuo JS, Cheng YS, Sun CK, Wu YC, Tu YK, Stubbs B, Carvalho AF, Liang CS, Chen TY, Hsu CW, Suen MW, Yang CP, Hsu SP, Chen YW, Shiue YL, Hung CM, Su KP, Lin PY. High Dosage Omega-3 Fatty Acids Outperform Existing Pharmacological Options for Migraine Prophylaxis: A Network Meta-Analysis. Adv Nutr 2024; 15:100163. [PMID: 38110000 PMCID: PMC10808921 DOI: 10.1016/j.advnut.2023.100163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 11/08/2023] [Accepted: 12/13/2023] [Indexed: 12/20/2023] Open
Abstract
Migraine is a highly prevalent neurologic disorder with prevalence rates ranging from 9% to 18% worldwide. Current pharmacologic prophylactic strategies for migraine have limited efficacy and acceptability, with relatively low response rates of 40% to 50% and limited safety profiles. Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are considered promising therapeutic agents for migraine prophylaxis. The aim of this network meta-analysis (NMA) was to compare the efficacy and acceptability of various dosages of EPA/DHA and other current Food and Drug Administration-approved or guideline-recommended prophylactic pharmacologic interventions for migraine. Randomized controlled trials (RCTs) were eligible for inclusion if they enrolled participants with a diagnosis of either episodic or chronic migraine. All NMA procedures were conducted under the frequentist model. The primary outcomes assessed were 1) changes in migraine frequency and 2) acceptability (i.e., dropout for any reason). Secondary outcomes included response rates, changes in migraine severity, changes in the frequency of using rescue medications, and frequency of any adverse events. Forty RCTs were included (N = 6616; mean age = 35.0 y; 78.9% women). Our analysis showed that supplementation with high dosage EPA/DHA yields the highest decrease in migraine frequency [standardized mean difference (SMD): -1.36; 95% confidence interval (CI): -2.32, -0.39 compared with placebo] and the largest decrease in migraine severity (SMD: -2.23; 95% CI: -3.17, -1.30 compared with placebo) in all studied interventions. Furthermore, supplementation with high dosage EPA/DHA showed the most favorable acceptability rates (odds ratio: 1.00; 95% CI: 0.06, 17.41 compared with placebo) of all examined prophylactic treatments. This study provides compelling evidence that high dosage EPA/DHA supplementation can be considered a first-choice treatment of migraine prophylaxis because this treatment displayed the highest efficacy and highest acceptability of all studied treatments. This study was registered in PROSPERO as CRD42022319577.
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Affiliation(s)
- Ping-Tao Tseng
- Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan; Department of Psychology, Collage of Medical and Health Science, Taichung, Asia University, Taiwan; Prospect Clinic for Otorhinolaryngology & Neurology, Kaohsiung City, Taiwan; Institute of Precision Medicine, National Sun Yat-sen University, Kaohsiung City, Taiwan
| | - Bing-Yan Zeng
- Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan; Department of Internal Medicine, E-Da Dachang Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Jiann-Jy Chen
- Prospect Clinic for Otorhinolaryngology & Neurology, Kaohsiung City, Taiwan; Department of Otorhinolaryngology, E-Da Cancer Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Chun-Hsien Kuo
- Department of Psychology, Collage of Medical and Health Science, Taichung, Asia University, Taiwan
| | - Bing-Syuan Zeng
- Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan; Department of Internal Medicine, E-Da Cancer Hospital, I-Shou University, Kaohsiung, Taiwan
| | - John S Kuo
- Neuroscience and Brain Disease Center and Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan
| | - Yu-Shian Cheng
- Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan; Department of Psychiatry, Tsyr-Huey Mental Hospital, Kaohsiung Jen-Ai's Home, Taiwan
| | - Cheuk-Kwan Sun
- Department of Emergency Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan; School of Medicine for International Students, College of Medicine, I-Shou University Kaohsiung, Taiwan
| | - Yi-Cheng Wu
- Department of Sports Medicine, Landseed International Hospital, Taoyuan, Taiwan
| | - Yu-Kang Tu
- Institute of Epidemiology & Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan; Department of Dentistry, National Taiwan University Hospital, Taipei, Taiwan
| | - Brendon Stubbs
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom; Physiotherapy Department, South London and Maudsley NHS Foundation Trust, London, United Kingdom; Positive Ageing Research Institute (PARI), Faculty of Health, Social Care Medicine and Education, Anglia Ruskin University, Chelmsford, United Kingdom
| | - Andre F Carvalho
- Innovation in Mental and Physical Health and Clinical Treatment (IMPACT) Strategic Research Centre, School of Medicine, Barwon Health, Deakin University, Geelong, VIC, Australia
| | - Chih-Sung Liang
- Department of Psychiatry, Beitou Branch, Tri-Service General Hospital, Taipei, Taiwan; School of Medicine, National Defense Medical Center, Taipei, Taiwan; Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Tien-Yu Chen
- Department of Psychiatry, Tri-Service General Hospital, Taipei, Taiwan; School of Medicine, National Defense Medical Center, Taipei, Taiwan; Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Chih-Wei Hsu
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Mein-Woei Suen
- Department of Psychology, Collage of Medical and Health Science, Taichung, Asia University, Taiwan; Gender Equality Education and Research Center, Asia University, Taichung, Taiwan; Department of Medical Research, Asia University Hospital, Asia University, Taichung, Taiwan; Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Chun-Pai Yang
- Department of Neurology, Kuang Tien General Hospital, Taichung, Taiwan; Department of Nutrition, Hungkuang University, Taichung, Taiwan
| | - Shih-Pin Hsu
- Department of Neurology, E-Da hospital, I-Shou University, Kaohsiung, Taiwan; School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Yen-Wen Chen
- Prospect Clinic for Otorhinolaryngology & Neurology, Kaohsiung City, Taiwan
| | - Yow-Ling Shiue
- Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan; Institute of Precision Medicine, National Sun Yat-sen University, Kaohsiung City, Taiwan.
| | - Chao-Ming Hung
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan; Division of General Surgery, Department of Surgery, E-Da Cancer Hospital, I-Shou University, Kaohsiung, Taiwan.
| | - Kuan-Pin Su
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom; Mind-Body Interface Research Center (MBI-Lab), China Medical University Hospital, Taichung, Taiwan; College of Medicine, China Medical University, Taichung, Taiwan; An-Nan Hospital, China Medical University, Tainan, Taiwan.
| | - Pao-Yen Lin
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan; Institute for Translational Research in Biomedical Sciences, Kaohsiung Chang Gung Memorial Hospital.
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3
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Raffaelli B, García-Azorín D, Boucherie DM, Amin FM, Deligianni CI, Gil-Gouveia R, Kirsh S, Lampl C, Sacco S, Uluduz D, Versijpt J, MaassenVanDenBrink A, Zeraatkar D, Sanchez-Del-Rio M, Reuter U. European Headache Federation (EHF) critical reappraisal and meta-analysis of oral drugs in migraine prevention - part 3: topiramate. J Headache Pain 2023; 24:134. [PMID: 37814223 PMCID: PMC10563338 DOI: 10.1186/s10194-023-01671-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 09/25/2023] [Indexed: 10/11/2023] Open
Abstract
OBJECTIVE Topiramate is a repurposed first-line treatment for migraine prophylaxis. The aim of this systematic review and meta-analysis is to critically re-appraise the existing evidence supporting the efficacy and tolerability of topiramate. METHODS A systematic search in MEDLINE, EMBASE, Cochrane CENTRAL, and ClinicalTrials.gov was performed for trials of pharmacological treatment in migraine prophylaxis as of August 13, 2022, following the Preferred Reporting Items for Systematic Reviews (PRISMA). Randomized controlled trials in adult patients that used topiramate for the prophylactic treatment of migraine, with placebo as active comparator, were included. Two reviewers independently screened the retrieved studies and extracted all data. Outcomes of interest were the 50% responder rates, the reduction in monthly migraine days, and adverse events leading to treatment discontinuation. Results were pooled and meta-analyzed, with sensitivity analysis based on the risk of bias of the studies, the monthly migraine days at baseline, and the previous use of other prophylactic treatments. Certainty evidence was judged according to the GRADE framework. RESULTS Eight out of 10,826 studies fulfilled the inclusion/exclusion criteria, accounting for 2,610 randomized patients. Six studies included patients with episodic migraine and two with chronic migraine. Topiramate dose ranged from 50 to 200 mg/day, and all studies included a placebo arm. There was a high certainty that topiramate: 1) increased the proportion of patients who achieved a 50% responder rate in monthly migraine days, compared to placebo [relative risk: 1.61 (95% confidence interval (CI): 1.29-2.01); absolute risk difference: 168 more per 1,000 (95% CI: 80 to 278 more)]; 2) was associated with 0.99 (95% CI: 1.41-0.58) fewer migraine days than placebo; 3) and had a higher proportion of patients with adverse events leading to treatment discontinuation [absolute risk difference 80 patients more per 1,000 (95% CI: 20 to 140 more patients)]. CONCLUSIONS There is high-quality evidence of the efficacy of topiramate in the prophylaxis of migraine, albeit its use poses a risk of adverse events that may lead to treatment discontinuation, with a negative effect on patient satisfaction and adherence to care.
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Affiliation(s)
- Bianca Raffaelli
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Clinician Scientist Program, Berlin Institute of Health at Charité (BIH), Berlin, Germany
| | - David García-Azorín
- Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Deirdre M Boucherie
- Department of Internal Medicine, Division of Vascular Medicine and Pharmacology, Erasmus MC Medical Center, Rotterdam, the Netherlands
| | - Faisal Mohammad Amin
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Brain and Spinal Cord Injury, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | | | - Raquel Gil-Gouveia
- Hospital da Luz Headache Center, Neurology Department, Hospital da Luz Lisboa, Lisbon, Portugal
- Center for Interdisciplinary Research in Health, Universidade Católica Portuguesa, Lisbon, Portugal
| | - Sarah Kirsh
- Department of Anesthesia and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Christian Lampl
- Department of Neurology and Stroke Unit, Konventhospital Barmherzige Brüder Linz, Linz, Austria
- Headache Medical Center Linz, Linz, Austria
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Derya Uluduz
- Department of Neurology Istanbul Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Jan Versijpt
- Department of Neurology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Antoinette MaassenVanDenBrink
- Department of Internal Medicine, Division of Vascular Medicine and Pharmacology, Erasmus MC Medical Center, Rotterdam, the Netherlands
| | - Dena Zeraatkar
- Department of Anesthesia and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | | | - Uwe Reuter
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany.
- Universitätsmedizin Greifswald, Greifswald, Germany.
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4
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Lampl C, MaassenVanDenBrink A, Deligianni CI, Gil-Gouveia R, Jassal T, Sanchez-Del-Rio M, Reuter U, Uluduz D, Versijpt J, Zeraatkar D, Sacco S. The comparative effectiveness of migraine preventive drugs: a systematic review and network meta-analysis. J Headache Pain 2023; 24:56. [PMID: 37208596 DOI: 10.1186/s10194-023-01594-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 05/10/2023] [Indexed: 05/21/2023] Open
Abstract
OBJECTIVE While there are several trials that support the efficacy of various drugs for migraine prophylaxis against placebo, there is limited evidence addressing the comparative safety and efficacy of these drugs. We conducted a systematic review and network meta-analysis to facilitate comparison between drugs for migraine prophylaxis. METHODS We searched MEDLINE, EMBASE, CENTRAL, and clinicaltrials.gov from inception to August 13, 2022, for randomized trials of pharmacological treatments for migraine prophylaxis in adults. Reviewers worked independently and in duplicate to screen references, extract data, and assess risk of bias. We performed a frequentist random-effects network meta-analysis and rated the certainty (quality) of evidence as either high, moderate, low, or very low using the GRADE approach. RESULTS We identified 74 eligible trials, reporting on 32,990 patients. We found high certainty evidence that monoclonal antibodies acting on the calcitonin gene related peptide or its receptor (CGRP(r)mAbs), gepants, and topiramate increase the proportion of patients who experience a 50% or more reduction in monthly migraine days, compared to placebo. We found moderate certainty evidence that beta-blockers, valproate, and amitriptyline increase the proportion of patients who experience a 50% or more reduction in monthly migraine days, and low certainty evidence that gabapentin may not be different from placebo. We found high certainty evidence that, compared to placebo, valproate and amitriptyline lead to substantial adverse events leading to discontinuation, moderate certainty evidence that topiramate, beta-blockers, and gabapentin increase adverse events leading to discontinuation, and moderate to high certainty evidence that (CGRP(r)mAbs) and gepants do not increase adverse events. CONCLUSIONS (CGRP(r)mAbs) have the best safety and efficacy profile of all drugs for migraine prophylaxis, followed closely by gepants.
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Affiliation(s)
- Christian Lampl
- Department of Neurology, Konventhospital Barmherzige Brüder Linz, Linz, Austria.
- Headache Medical Center Linz, Linz, Austria.
| | | | | | - Raquel Gil-Gouveia
- Neurology Department, Hospital da Luz Headache Center, Hospital da Luz Lisboa, Lisbon, Portugal
- Center for Interdisciplinary Research in Health, Universidade Católica Portuguesa, Lisbon, Portugal
| | - Tanvir Jassal
- Department of Anesthesia and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | | | - Uwe Reuter
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Derya Uluduz
- Department of Neurology Istanbul Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Jan Versijpt
- Department of Neurology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Dena Zeraatkar
- Department of Anesthesia and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L´Aquila, L'Aquila, Italy
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Tepper SJ, Cirillo J, Kim E, L'Italien G, Tweedie JM, Lodaya K, Riley D, Pathan F, Antaki N, Nathanson BH, McAllister P. The temporal trend of placebo response in migraine prevention from 1990 to 2021: a systematic literature review and meta-analysis with regression. J Headache Pain 2023; 24:54. [PMID: 37193973 DOI: 10.1186/s10194-023-01587-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 04/26/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Migraine affects 1.1 billion people globally and is the second leading cause of disability worldwide. In clinical trials, treatment efficacy is evaluated by comparing the differential responses in the treatment and placebo arms. Although placebo response in preventive migraine trials has been studied, there is limited research examining temporal trends. This study evaluates the trend of placebo response over thirty years in migraine prevention trials and investigates the association of potential confounders, such as patient, treatment, and study characteristics on placebo response using meta-analysis with regression. METHODS We conducted literature searches from January 1990 to August 2021 in bibliographical databases (PubMed, Cochrane Library, and EMBASE). Studies were selected according to PICOS criteria and included randomized, double-blind, placebo-controlled trials evaluating preventive migraine treatments in adult patients diagnosed with episodic or chronic migraine, with or without aura. The protocol was registered with PROSPERO (CRD42021271732). Migraine efficacy outcomes included were either continuous (e.g., monthly migraine days) or dichotomous (e.g., ≥ 50% responder rate (yes/no)). We assessed the correlation of the change in outcome from baseline in the placebo arm, with the year of publication. The relationship between placebo response and year of publication was also assessed after accounting to confounders. RESULTS A total of 907 studies were identified, and 83 were found eligible. For the continuous outcomes, the change from baseline in mean placebo response showed an increase over the years (rho = 0.32, p = 0.006). The multivariable regression analysis also showed an overall increase in placebo response over the years. The correlation analysis of dichotomous responses showed no significant linear trend between publication year and mean placebo response (rho = 0.08, p = 0.596). Placebo response also varied by route of administration. CONCLUSION Placebo response increased over the past 30 years in migraine preventive trials. This phenomenon should be considered when designing clinical trials and conducting meta-analyses.
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Affiliation(s)
- Stewart J Tepper
- Geisel School of Medicine at Dartmouth, Dartmouth Headache Clinic, Hanover, NH, USA.
| | | | - Edward Kim
- Biohaven Pharmaceuticals, New Haven, CT, USA
| | | | | | - Kunal Lodaya
- Boston Strategic Partners Inc, 4 Wellington St., Suite 3, Boston, MA, USA
| | - Dushon Riley
- Boston Strategic Partners Inc, 4 Wellington St., Suite 3, Boston, MA, USA
| | - Farah Pathan
- Boston Strategic Partners Inc, 4 Wellington St., Suite 3, Boston, MA, USA
| | - Nicholas Antaki
- Boston Strategic Partners Inc, 4 Wellington St., Suite 3, Boston, MA, USA
| | | | - Peter McAllister
- New England Institute for Neurology and Headache, Stamford, CT, USA
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Vandervorst F, Van Deun L, Van Dycke A, Paemeleire K, Reuter U, Schoenen J, Versijpt J. CGRP monoclonal antibodies in migraine: an efficacy and tolerability comparison with standard prophylactic drugs. J Headache Pain 2021; 22:128. [PMID: 34696711 PMCID: PMC8547103 DOI: 10.1186/s10194-021-01335-2] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 09/24/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Several drugs are available for the preventive treatment of both episodic and chronic migraine. The choice of which therapy to initiate first, second, or third is not straightforward and is based on multiple factors, including general efficacy, tolerability, potential for serious adverse events, comorbid conditions, and costs. Recently, a new class of migraine preventive drugs was introduced, i.e. monoclonal antibodies against calcitonin gene-related peptide (CGRP) or its receptor. METHODS The present article summarizes the evidence gathered with this new migraine preventive drug class from randomized placebo-controlled clinical trials. It further puts this into perspective next to the evidence gained by the most widely used agents for the prevention of episodic and chronic migraine with an emphasis on efficacy and the robustness with which this efficacy signal was obtained. RESULTS Although being a relatively new class of migraine preventive drugs, monoclonal antibodies blocking the CGRP pathway have an efficacy which is at least comparable if not higher than those of the currently used preventive drugs. Moreover, the robustness of this efficacy signal is substantiated by several randomized clinical trials each including large numbers of patients. In addition, because of their excellent tolerability and with long-term safety data emerging, they seem to have an unprecedented efficacy over adverse effect profile, clearly resulting in an added value for migraine prevention. CONCLUSIONS Balancing the data presented in the current manuscript with additional data concerning long term safety on the one hand and cost issues on the other hand, can be of particular use to health policy makers to implement this new drug class in the prevention of migraine.
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Affiliation(s)
- Fenne Vandervorst
- Department of Neurology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Laura Van Deun
- Department of Neurology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Annelies Van Dycke
- Department of Neurology, General Hospital Sint-Jan Bruges, Bruges, Belgium
| | - Koen Paemeleire
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Uwe Reuter
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jean Schoenen
- Headache Research Unit, Dept of Neurology-Citadelle Hospital, University of Liège, Liège, Belgium
| | - Jan Versijpt
- Department of Neurology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium.
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7
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Hu C, Zhang Y, Tan G. Advances in topiramate as prophylactic treatment for migraine. Brain Behav 2021; 11:e2290. [PMID: 34472696 PMCID: PMC8553310 DOI: 10.1002/brb3.2290] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 06/09/2021] [Accepted: 07/04/2021] [Indexed: 01/13/2023] Open
Abstract
It is well-known that topiramate as a kind of antiepileptic drug has been proved effective for migraine prevention in North America and Europe. However, topiramate is still viewed as an off-label medication for migraine treatment in China, partly because of the limited evidence in Chinese patients. We summarize the effects of topiramate on the frequency, severity, quality-of-life, and adverse event among migraine patients, including children and adolescent in this review, so as to provide reference for Chinese doctors.
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Affiliation(s)
- Chuan Hu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yixin Zhang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ge Tan
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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8
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Frank F, Ulmer H, Sidoroff V, Broessner G. CGRP-antibodies, topiramate and botulinum toxin type A in episodic and chronic migraine: A systematic review and meta-analysis. Cephalalgia 2021; 41:1222-1239. [PMID: 34130525 PMCID: PMC8506070 DOI: 10.1177/03331024211018137] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Background The approval of monoclonal antibodies for prevention of migraine has revolutionized treatment for patients. Oral preventatives are still considered first line treatments as head-to-head trials comparing them with antibodies are lacking. Methods The main purpose of this study was to provide a comparative overview of the efficacy of three commonly prescribed migraine preventative medication classes. For this systematic review and meta-analysis, we searched the databases CENTRAL, EMBASE, and MEDLINE until 20 March 2020. We included RCTs reporting the 50% response rates for topiramate, Botulinum Toxin Type A and monoclonal antibodies against CGRP(r). Studies were excluded if response rates were not reported, treatment allocation was unclear, or if study quality was insufficient. Primary outcome measure were the 50% response rates. The pooled odds ratios with 95% confidence intervals were calculated with the random effects model. The study was registered at PROSPERO (CRD42020222880). Findings We identified 6552 reports. Thirty-two were eligible for our review. Studies assessing monoclonal antibodies included 13,302 patients and yielded pooled odds ratios for the 50% response rate of 2.30 (CI: 2.11–2.50). Topiramate had an overall effect estimate of 2.70 (CI: 1.97–3.69) with 1989 included patients and Botulinum Toxin Type A achieved 1.28 (CI: 0.98–1. 67) with 2472 patients included. Interpretation Topiramate, botulinum toxin type A and monoclonal antibodies showed higher odds ratios in achieving a 50% response rate compared to placebo. Topiramate numerically demonstrated the greatest effect size but also the highest drop-out rate.
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Affiliation(s)
- Florian Frank
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - Hanno Ulmer
- Department of Medical Statistics, Informatics, and Health Economics, Innsbruck Medical University, Innsbruck, Austria
| | - Victoria Sidoroff
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - Gregor Broessner
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
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Evans K, Romero H, Spierings EL, Katz N. The relation between the placebo response, observed treatment effect, and failure to meet primary endpoint: A systematic review of clinical trials of preventative pharmacological migraine treatments. Cephalalgia 2020; 41:247-255. [PMID: 32960658 DOI: 10.1177/0333102420960020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To evaluate the association between the degree of response to placebo in migraine studies and the observed difference between drug and placebo across studies of preventative treatments for migraine. METHODS A systematic review was performed using MEDLINE and the Cochrane Central Register of Controlled Clinical Trials from January 1988 to June 2019. Randomized, double-blind, parallel-group, placebo-controlled trials on oral or injection preventative treatments for migraine were included. Single- and multi-variable linear regression analyses were performed on the placebo-subtracted response rate (i.e. placebo responders subtracted from active responders), and the proportion of placebo responders. Fisher's exact tests were performed on the level of placebo response and the success in meeting the study's primary endpoint. RESULTS After adjusting for route of administration and number of randomized subjects, there was a statistically significant association between the proportion of patients who were placebo responders and the placebo-subtracted response rate (b = -0.27, p = 0.02). There was a statistically significant difference in trial success rate (60%) between studies with ≤20% placebo responders and studies with > 30% placebo responders (p = 0.03). CONCLUSION Considering the detrimental impact that high placebo response can have on clinical trials, it is imperative to find effective solutions to decrease the placebo response and increase assay sensitivity.
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Affiliation(s)
| | | | | | - Nathaniel Katz
- WCG Analgesic Solutions, Wayland, MA, USA.,Tufts University School of Medicine, Boston, MA, USA
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Tseng PT, Yang CP, Su KP, Chen TY, Wu YC, Tu YK, Lin PY, Stubbs B, Carvalho AF, Matsuoka YJ, Li DJ, Liang CS, Hsu CW, Chen YW, Shiue YL. The association between melatonin and episodic migraine: A pilot network meta-analysis of randomized controlled trials to compare the prophylactic effects with exogenous melatonin supplementation and pharmacotherapy. J Pineal Res 2020; 69:e12663. [PMID: 32347977 DOI: 10.1111/jpi.12663] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 04/07/2020] [Accepted: 04/21/2020] [Indexed: 01/03/2023]
Abstract
Although exogenous melatonin supplementation has been suggested to be effective for episodic migraine prophylaxis, there is no conclusive evidence comparing the efficacy of exogenous melatonin supplementation to the other FDA-approved pharmacotherapy for episodic migraine prophylaxis. The aim of the current network meta-analysis (NMA) was to compare the efficacy of exogenous melatonin supplementation in patients with episodic migraine. The randomized placebo-controlled trials or randomized controlled trials (RCTs) incorporating a placebo in the study designs were included in our analyses. All of the NMA procedures were conducted under the frequentist model. The primary outcome was changes in frequency of migraine days and response rate after migraine prophylaxis with melatonin supplementation or pharmacological interventions. We included 25 RCTs in total with 4499 patients (mean age = 36.0 years, mean female proportion = 78.9%). The NMA demonstrated that migraine prophylaxis with oral melatonin 3 mg/d (immediate-release) at bedtime was associated with the greatest improvement in migraine frequency [mean difference = -1.71 days, 95% confidence interval (CI): -3.27 to -0.14 days compared to placebo] and the second highest response rate (odds ratio = 4.19, 95% CI = 1.46 to 12.00 compared to placebo). Furthermore, oral melatonin 3 mg (immediate-release) at bedtime was the most preferred pharmacological intervention among all of the investigated interventions when improvements in migraine frequency, response rate, dropout rate, and rates of any adverse events were taken into account. This pilot NMA suggests the potential prophylactic role of exogenous melatonin supplementation in patients with episodic migraine.
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Affiliation(s)
- Ping-Tao Tseng
- WinShine Clinics in Specialty of Psychiatry, Kaohsiung, Taiwan
- Prospect Clinic for Otorhinolaryngology & Neurology, Kaohsiung, Taiwan
- Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Chun-Pai Yang
- Department of Neurology, Kuang Tien General Hospital, Taichung, Taiwan
- Department of Nutrition, Huang-Kuang University, Taichung, Taiwan
| | - Kuan-Pin Su
- Department of Psychiatry & Mind-Body Interface Laboratory (MBI-Lab), China Medical University Hospital, Taichung, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
| | - Tien-Yu Chen
- Department of Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan
| | - Yi-Cheng Wu
- Department of Sports Medicine, Landseed International Hospital, Taoyuan, Taiwan
| | - Yu-Kang Tu
- Institute of Epidemiology & Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Department of Dentistry, National Taiwan University Hospital, Taipei, Taiwan
| | - Pao-Yen Lin
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Institute for Translational Research in Biomedical Sciences, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Brendon Stubbs
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Physiotherapy Department, South London and Maudsley NHS Foundation Trust, London, UK
- Faculty of Health, Social Care Medicine and Education, Positive Ageing Research Institute (PARI), Anglia Ruskin University, Chelmsford, UK
| | - Andre F Carvalho
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Centre for Addiction & Mental Health (CAMH), Toronto, ON, Canada
| | - Yutaka J Matsuoka
- Department of Psychiatry & Mind-Body Interface Laboratory (MBI-Lab), China Medical University Hospital, Taichung, Taiwan
- Division of Health Care Research, Center for Public Health Sciences, National Cancer Center Japan, Tokyo, Japan
| | - Dian-Jeng Li
- Department of Addiction Science, Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung City, Taiwan
| | - Chih-Sung Liang
- Department of Psychiatry, Beitou branch, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Chih-Wei Hsu
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yen-Wen Chen
- Prospect Clinic for Otorhinolaryngology & Neurology, Kaohsiung, Taiwan
| | - Yow-Ling Shiue
- Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan
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He A, Song D, Zhang L, Li C. Unveiling the relative efficacy, safety and tolerability of prophylactic medications for migraine: pairwise and network-meta analysis. J Headache Pain 2017; 18:26. [PMID: 28220376 PMCID: PMC5318356 DOI: 10.1186/s10194-017-0720-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 01/06/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A large number patients struggle with migraine which is classified as a chronic disorder. The relative efficacy, safety and tolerability of prophylactic medications for migraine play a key role in managing this disease. METHODS We conducted an extensive literature search for popular prophylactic medications that are used for migraine patients. Pairwise meta-analysis and network meta-analysis (NMA) were carried out sequentially for determining the relative efficacy, safety and tolerability of prophylactic medications. Summary effect for migraine headache days, headache frequency, at least 50% reduction in headache attacks, all-adverse events, nausea, somnolence, dizziness, withdrawal and withdrawal due to adverse events were produced by synthesizing both direct and indirect evidence. RESULTS Patients with three interventions exhibited significantly less average migraine headache days compared with those treated by placebo (topiramate, propranolol, divalproex). Moreover, topiramate and valproate exhibited a significantly increased likelihood of at least 50% reduction in migraine headache attacks compared to placebo. Patients with topiramate and propranolol also exhibited significantly reduced headache frequency compared to those with placebo. On the other hand, patients with divalproex exhibited significantly higher risk of nausea compared to those with placebo, topiramate, propranolol, gabapentin and amitriptyline. Finally, divalproex was associated with an increased risk of withdrawal compared to placebo and propranolol. CONCLUSIONS Topiramate, propranolol and divalproex may be more efficacious than other prophylactic medications. Besides, the safety and tolerability of divalproex should be further verified by future studies.
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Affiliation(s)
- Aijie He
- Department of Neurosurgery, the Affiliated Yantai Yuhuangding Hospital of Qingdao University, 264000, Yantai, Shandong, China
| | - Dehua Song
- Department of Radiotherapy, the Affiliated Yantai Yuhuangding Hospital of Qingdao University, 264000, Yantai, Shandong, China
| | - Lei Zhang
- Department of Pharmacy, Yantai Hospital of Traditional Chinese Medicine, 264000, Yantai, Shandong, China
| | - Chen Li
- Department of Anesthesia, Yantai Hospital of Traditional Chinese Medicine, No. 39 Xingfu Road, Zhifu Disctrict, 264000, Yantai, Shandong, China.
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Jelinski SE, Becker WJ, Christie SN, Giammarco R, Mackie GF, Gawel MJ, Eloff AG, Magnusson JE. Clinical Features and Pharmacological Treatment of Migraine Patients Referred to Headache Specialists in Canada. Cephalalgia 2016; 26:578-88. [PMID: 16674767 DOI: 10.1111/j.1468-2982.2005.01077.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We set out to examine selected clinical characteristics of migraine patients referred to neurologists specializing in headache in Canada, and to document their pharmacological therapy both before and after consultation with the neurologist. Demographic, clinical and pharmacotherapy data were collected at the time of consultation for 606 patients referred to five headache clinics and who were given a migraine diagnosis by the neurologist. Data were analysed as part of the Canadian Headache Outpatient Registry and Database (CHORD) Project. The mean age of the migraine patients was 39.7 years; and 82.5% were female. The majority of patients suffered severe impact from their headaches. Prior to consultation, 48.7% were taking a triptan; after consultation, 97.2% were on a triptan. Before consultation, 30.9% were on a prophylactic drug; after consultation, 70.4% were. 20.8% of patients were medication overusers. Of these medication overusers, 42.4% were overusing an opiate, usually in combination with other analgesics; 21.6% were overusing a triptan. Medication changes made by the neurologists at consultation included a large increase in the use of both triptans and prophylactic medications. Medication overuse, particularly opiate overuse, remains a significant problem in patients with migraine in Canada.
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Affiliation(s)
- S E Jelinski
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, and Richmond Hospital, British Columbia, Canada
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13
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Abstract
July 2015: This review has been split and updated in a series of four new reviews (Linde 2013a; Linde 2013b; Linde 2013c; Linde 2013d). Readers are referred to those reviews for updated results. This review will not be updated. May 2016: This review has now been withdrawn as it has been replaced by the four new titles listed above. The editorial group responsible for this previously published document have withdrawn it from publication.
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Affiliation(s)
- Edward P Chronicle
- University of Hawaii at Manoa(Deceased) Department of PsychologyManoaUSA
| | - Wim M Mulleners
- Canisius Wilhelmina ZiekenhuisDepartment of NeurologyPO Box 9015NijmegenNetherlands6500 GS
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14
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Abstract
BACKGROUND Migraine is a chronic debilitating disorder. Selected antiepileptic drugs (AEDs) are proposed as preventives for migraine. Clinical efficacy and side effects of these AEDs are discussed. SUMMARY OF REVIEW The American Academy of Neurology and the American Society of Headache classify topiramate (TPM) and divalproex sodium (DVPX) as Level-A medications and recommend offering them to patients for migraine prophylaxis. Their mechanism(s) of actions remains not entirely known. Their recognized action as sodium channel blockers may affect the neural component of migraine pain. TPM or DVPX can be considered an obvious choice for those patients with a concomitant seizure disorder. Care must be taken to plan their treatment with their psychiatrist if a mood disorder is present. DVPX tends not to be prescribed as first/second choice due to its potential for weight gain and hepatotoxicity. TPM is generally first choice, but bears severe contraindications. Both medications require education on teratogenesis in childbearing women. Consideration of gabapentin, acetazolamide, leviteracetam, zonisamide, and carbamazipine may be given later as empiric options and in selected patients. Patients must be made aware that there is insufficient scientific support for their use in migraine. CONCLUSIONS Available AEDs to prophylactically treat migraine are few but of robust clinical efficacy. Special care needs to be exerted with respect to their side effects. Future research is needed for a better understanding of their mechanisms of action in migraine. Such research has the potential of providing some insight into the pathophysiology of migraine.
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Affiliation(s)
| | - Janine Good
- Department of Neurology, University of Vanderbilt, Nashville, TN, USA
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15
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Mulleners WM, McCrory DC, Linde M. Antiepileptics in migraine prophylaxis: an updated Cochrane review. Cephalalgia 2014; 35:51-62. [PMID: 25115844 DOI: 10.1177/0333102414534325] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The efficacy of several antiepileptics in the preventive treatment of episodic migraine in adults has been systematically reviewed. Because many trial reports have been published since then, an updated systematic review was warranted. METHODS We searched the Cochrane Central Register of Controlled Trials, PubMed/MEDLINE (1966 to January 15, 2013), MEDLINE In-Process (current week, January 15, 2013), and EMBASE (1974 to January 15, 2013) and hand-searched Headache and Cephalalgia through January 2013. Prospective, controlled trials of antiepileptics taken regularly to prevent the occurrence of migraine attacks, to improve migraine-related quality of life, or both, were selected. RESULTS Mean headache frequency on topiramate and sodium valproate is significantly lower than placebo. Likewise, topiramate and divalproex demonstrated favorable results for the proportion of subjects with ≥ 50% reduction of migraine attacks. For topiramate, 100 mg and 200 mg outperformed 50 mg, but this was paralleled by a higher adverse event rate. For valproate/divalproex, a dose-effect correlation could not be established. There was no unequivocal evidence of efficacy for any of the other antiepileptics. CONCLUSION Topiramate, sodium valproate and divalproex are effective prophylactic treatments for episodic migraine in adults. In contrast to previous reports, there is insufficient evidence to further support the use of gabapentin.
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Affiliation(s)
- Wim M Mulleners
- Department of Neurology, Canisius Wilhelmina Ziekenhuis, The Netherlands
| | - Douglas C McCrory
- Department of Medicine, Duke University Medical Center, NC, USA Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, NC, USA
| | - Mattias Linde
- Department of Neuroscience, Norwegian University of Science and Technology (NTNU), Norway Norwegian National Headache Centre, St. Olavs University Hospital, Norway
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Chiossi L, Negro A, Capi M, Lionetto L, Martelletti P. Sodium channel antagonists for the treatment of migraine. Expert Opin Pharmacother 2014; 15:1697-706. [DOI: 10.1517/14656566.2014.929665] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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17
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van Passel L, Arif H, Hirsch LJ. Topiramate for the treatment of epilepsy and other nervous system disorders. Expert Rev Neurother 2014; 6:19-31. [PMID: 16466308 DOI: 10.1586/14737175.6.1.19] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Initially synthesized as an oral hypoglycemic agent, topiramate was approved for use as an anticonvulsant in 1996. Its broad spectrum efficacy in epilepsy, including as monotherapy and in children, is well established. Topiramate has also been used in the management of nonepileptic neurologic and psychiatric conditions, including migraine prophylaxis (with firmly established efficacy), obesity (with some evidence of long-term maintenance of weight loss), substance dependence, bipolar disorder and neuropathic pain, and it has been investigated as a possible neuroprotective agent. Paresthesias and cognitive side effects are the most common troublesome adverse effects. Recent trends towards lower doses may help achieve the best combination of efficacy and tolerability.
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Affiliation(s)
- Leonie van Passel
- Comprehensive Epilepsy Center, Neurological Institute, Columbia University, Box NI-135, New York, NY 10032, USA.
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18
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Shamliyan TA, Choi JY, Ramakrishnan R, Miller JB, Wang SY, Taylor FR, Kane RL. Preventive pharmacologic treatments for episodic migraine in adults. J Gen Intern Med 2013; 28:1225-37. [PMID: 23592242 PMCID: PMC3744311 DOI: 10.1007/s11606-013-2433-1] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Revised: 12/10/2012] [Accepted: 03/15/2013] [Indexed: 01/13/2023]
Abstract
OBJECTIVES Systematic review of preventive pharmacologic treatments for community-dwelling adults with episodic migraine. DATA SOURCES Electronic databases through May 20, 2012. ELIGIBILITY CRITERIA English-language randomized controlled trials (RCTs) of preventive drugs compared to placebo or active treatments examining rates of ≥50 % reduction in monthly migraine frequency or improvement in quality of life. STUDY APPRAISAL AND SYNTHESIS METHODS We assessed risk of bias and strength of evidence and conducted random effects meta-analyses of absolute risk differences and Bayesian network meta-analysis. RESULTS Of 5,244 retrieved references, 215 publications of RCTs provided mostly low-strength evidence because of the risk of bias and imprecision. RCTs examined 59 drugs from 14 drug classes. All approved drugs, including topiramate (9 RCTs), divalproex (3 RCTs), timolol (3 RCTs), and propranolol (4 RCTs); off-label beta blockers metoprolol (4 RCTs), atenolol (1 RCT), nadolol (1 RCT), and acebutolol (1 RCT); angiotensin-converting enzyme inhibitors captopril (1 RCT) and lisinopril (1 RCT); and angiotensin II receptor blocker candesartan (1 RCT), outperformed placebo in reducing monthly migraine frequency by ≥50 % in 200-400 patients per 1,000 treated. Adverse effects leading to treatment discontinuation (68 RCTs) were greater with topiramate, off-label antiepileptics, and antidepressants than with placebo. Limited direct evidence as well as frequentist and exploratory network Bayesian meta-analysis showed no statistically significant differences in benefits between approved drugs. Off-label angiotensin-inhibiting drugs and beta-blockers were most effective and tolerable for episodic migraine prevention. LIMITATIONS We did not quantify reporting bias or contact principal investigators regarding unpublished trials. CONCLUSIONS Approved drugs prevented episodic migraine frequency by ≥50 % with no statistically significant difference between them. Exploratory network meta-analysis suggested that off-label angiotensin-inhibiting drugs and beta-blockers had favorable benefit-to-harm ratios. Evidence is lacking for long-term effects of drug treatments (i.e., trials of more than 3 months duration), especially for quality of life.
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Linde M, Mulleners WM, Chronicle EP, McCrory DC. Topiramate for the prophylaxis of episodic migraine in adults. Cochrane Database Syst Rev 2013; 2013:CD010610. [PMID: 23797676 PMCID: PMC7388931 DOI: 10.1002/14651858.cd010610] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Some antiepileptic drugs but not others are useful in clinical practice for the prophylaxis of migraine. This might be explained by the variety of actions of these drugs in the central nervous system. The present review is part of an update of a Cochrane review first published in 2004, and previously updated (conclusions not changed) in 2007. OBJECTIVES To describe and assess the evidence from controlled trials on the efficacy and tolerability of topiramate for preventing migraine attacks in adult patients with episodic migraine. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library 2012, Issue 12), PubMed/MEDLINE (1966 to 15 January 2013), MEDLINE In-Process (current week, 15 January 2013), and EMBASE (1974 to 15 January 2013) and handsearched Headache and Cephalalgia through January 2013. SELECTION CRITERIA Studies were required to be prospective, controlled trials of topiramate taken regularly to prevent the occurrence of migraine attacks, to improve migraine-related quality of life, or both. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies and extracted data. For headache frequency data, we calculated mean differences (MDs) between topiramate and comparator (placebo, active control, or topiramate in a different dose) for individual studies and pooled these across studies. For dichotomous data on responders (patients with ≥ 50% reduction in headache frequency), we calculated odds ratios (ORs) and, in select cases, risk ratios (RRs); we also calculated numbers needed to treat (NNTs). We calculated MDs for selected quality of life instruments. Finally, we summarised data on adverse events from placebo-controlled trials and calculated risk differences (RDs) and numbers needed to harm (NNHs). MAIN RESULTS Twenty papers describing 17 unique trials met the inclusion criteria. Analysis of data from nine trials (1737 participants) showed that topiramate reduced headache frequency by about 1.2 attacks per 28 days as compared to placebo (MD -1.20; 95% confidence interval (CI) -1.59 to -0.80). Data from nine trials (1190 participants) show that topiramate approximately doubled the proportion of responders relative to placebo (RR 2.02; 95% CI 1.57 to 2.60; NNT 4; 95% CI 3 to 6). Separate analysis of different topiramate doses produced similar MDs versus placebo at 50 mg (-0.95; 95% CI -1.95 to 0.04; three studies; 520 participants), 100 mg (-1.15; 95% CI -1.58 to -0.71; six studies; 1620 participants), and 200 mg (-0.94; 95% CI -1.53 to -0.36; five studies; 804 participants). All three doses significantly increased the proportion of responders relative to placebo; ORs were as follows: for 50 mg, 2.35 (95% CI 1.60 to 3.44; three studies; 519 participants); for 100 mg, 3.49 (95% CI 2.23 to 5.45; five studies; 852 participants); and for 200 mg, 2.49 (95% CI 1.61 to 3.87; six studies; 1025 participants). All three doses also significantly improved three or more domains of quality of life as compared to placebo. Meta-analysis of the three studies that included more than one dose of topiramate suggests that 200 mg is no more effective than 100 mg. With regard to mean headache frequency and/or responder rate, seven trials using active comparators found (a) no significant difference between topiramate and amitriptyline (one study, 330 participants); (b) no significant difference between topiramate and flunarizine (one study, 83 participants); (c) no significant difference between topiramate and propranolol (two studies, 342 participants); (d) no significant difference between topiramate and relaxation (one study, 61 participants); but (e) a slight significant advantage of topiramate over valproate (two studies, 120 participants). Relaxation improved migraine-specific quality of life significantly more than topiramate. In trials of topiramate against placebo, seven adverse events (AEs) were reported by at least three studies. These were usually mild and of a non-serious nature. Except for taste disturbance and weight loss, there were no significant differences in the frequency of AEs in general, or of the seven specific AEs, between placebo and topiramate 50 mg. AEs in general and all of the specific AEs except nausea were significantly more common on topiramate 100 mg than on placebo, with NNHs varying from 3 to 25, and the RDs versus placebo were even higher for topiramate 200 mg, with NNHs varying from 2 to 17. AUTHORS' CONCLUSIONS Meta-analysis demonstrates that topiramate in a 100 mg/day dosage is effective in reducing headache frequency and reasonably well-tolerated in adult patients with episodic migraine. This provides good evidence to support its use in routine clinical management. More studies designed specifically to compare the efficacy or safety of topiramate versus other interventions with proven efficacy in the prophylaxis of migraine are needed.
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Affiliation(s)
- Mattias Linde
- Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway.
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Abstract
Migraine headaches are among the most common headache disorders seen in various practices. The prevalence of migraine headaches is 18% in women and 6% in men. While millions of Americans suffer from migraine headaches, roughly 3%-13% of identified migraine patients are on preventive therapy, while an estimated 38% actually need a preventive agent. The challenge among physicians is not only when to start a daily preventive agent but which preventive agent to choose. Circumstances warranting prevention have been described in the past, and in 2012, a new set of guidelines with an evidence review on preventive medications was published. A second set of guidelines provided evidence on nonsteroidal anti-inflammatory drugs, herbs, minerals, and vitamins for prevention of episodic migraine. This article describes the updated US guidelines for the prevention of migraines and also outlines the major studies from which these guidelines were derived.
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Affiliation(s)
- E Estemalik
- Cleveland Clinic, Neurological Center for Pain, Cleveland, Ohio, USA
| | - S Tepper
- Cleveland Clinic, Neurological Center for Pain, Cleveland, Ohio, USA
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Silberstein SD, Holland S, Freitag F, Dodick DW, Argoff C, Ashman E. Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 2012; 78:1337-45. [PMID: 22529202 DOI: 10.1212/wnl.0b013e3182535d20] [Citation(s) in RCA: 536] [Impact Index Per Article: 44.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To provide updated evidence-based recommendations for the preventive treatment of migraine headache. The clinical question addressed was: What pharmacologic therapies are proven effective for migraine prevention? METHODS The authors analyzed published studies from June 1999 to May 2009 using a structured review process to classify the evidence relative to the efficacy of various medications available in the United States for migraine prevention. RESULTS AND RECOMMENDATIONS The author panel reviewed 284 abstracts, which ultimately yielded 29 Class I or Class II articles that are reviewed herein. Divalproex sodium, sodium valproate, topiramate, metoprolol, propranolol, and timolol are effective for migraine prevention and should be offered to patients with migraine to reduce migraine attack frequency and severity (Level A). Frovatriptan is effective for prevention of menstrual migraine (Level A). Lamotrigine is ineffective for migraine prevention (Level A).
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Affiliation(s)
- S D Silberstein
- Thomas Jefferson University, Jefferson Headache Center, Philadelphia, PA, USA
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22
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Abstract
Migraine is among the 10 most disabling disorders worldwide. It is characterized by episodes of moderate or severe headaches with various degree of disability, resulting in a considerable health burden upon the sufferers and their family. The objective of this article is to review the use of prophylaxis with antiepileptic drugs. Particular focus is given to their mechanism of action, metabolism, pharmacokinetics, safety profile, efficacy and to provide a summary of the most relevant clinical studies and patient preference.
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Affiliation(s)
- R Shahien
- Department of Neurology, Ziv Medical Center, affiliated to Bar Ilan University, Safed 13100, Israel
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23
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Macedo A, Baños JE, Farré M. Placebo response in the prophylaxis of migraine: A meta-analysis. Eur J Pain 2012; 12:68-75. [PMID: 17451980 DOI: 10.1016/j.ejpain.2007.03.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2006] [Revised: 02/13/2007] [Accepted: 03/04/2007] [Indexed: 11/29/2022]
Abstract
BACKGROUND Migraine constitutes a good model for the study of placebo response. It is a well-defined disease, affects a large population and a great number of clinical trials have been performed, which have given homogeneous outcomes. AIM The aim of this meta-analysis is to evaluate the placebo response rate in migraine prophylaxis in all published clinical trials since 1988 and to estimate the influence of study design in response variability. METHODS A computer-based information search was conducted on the Medline database. The outcomes studied were patients who improved (reduction in migraine attacks of 50% or more); attacks per month, and patients with adverse events. Study design and countries in which the study was carried out were also analysed. The meta-analysis was computed using the Mantel-Haenszel test. RESULTS In the final analysis, 32 papers were considered. The pooled estimate of the placebo response (patients who improved) was 21%. The placebo response rates were significantly higher in studies with a parallel design than those in cross-over studies (p<0.01). This response was also higher in European studies than in those performed in North America (p<0.001). Adverse events occurred in 30% of the patients who took a placebo, and the percentage of patients with adverse events was significantly higher in the North American studies than in those conducted in Europe (p<0.01). CONCLUSION These data reinforce the need to consider the placebo effect when ascertaining the true therapeutic effect of any drug, as well as to design any clinical trial in the prophylaxis of migraine.
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Affiliation(s)
- Ana Macedo
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
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Seeburger JL, Cady RK, Winner P, MacGregor A, Valade D, Ge Y, Zhang Y, Hustad CM, Strickler N, Schaefer E, Connor KM, Ho TW. Rizatriptan for Treatment of Acute Migraine in Patients Taking Topiramate for Migraine Prophylaxis. Headache 2011; 52:57-67. [DOI: 10.1111/j.1526-4610.2011.02027.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Afshari D, Rafizadeh S, Rezaei M. A Comparative Study of the Effects of Low-Dose Topiramate Versus Sodium Valproate in Migraine Prophylaxis. Int J Neurosci 2011; 122:60-8. [DOI: 10.3109/00207454.2011.626908] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Varkey E, Cider A, Carlsson J, Linde M. Exercise as migraine prophylaxis: a randomized study using relaxation and topiramate as controls. Cephalalgia 2011; 31:1428-38. [PMID: 21890526 PMCID: PMC3236524 DOI: 10.1177/0333102411419681] [Citation(s) in RCA: 160] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Revised: 05/10/2011] [Accepted: 07/16/2011] [Indexed: 01/07/2023]
Abstract
AIM Scientific evidence regarding exercise in migraine prophylaxis is required. Therefore this study aimed to evaluate the effects of exercise in migraine prevention. METHODS In a randomized, controlled trial of adults with migraine, exercising for 40 minutes three times a week was compared to relaxation according to a recorded programme or daily topiramate use, which was slowly increased to the individual's highest tolerable dose (maximum 200 mg/day). The treatment period lasted for 3 months, and migraine status, quality of life, level of physical activity, and oxygen uptake were evaluated. The primary efficacy variable was the mean reduction of the frequency of migraine attacks during the final month of treatment compared with the baseline. RESULTS Ninety-one patients were randomized and included in the intention-to-treat analysis. The primary efficacy variable showed a mean reduction of 0.93 (95% confidence interval (CI) 0.31-1.54) attacks in the exercise group, 0.83 (95% CI 0.22-1.45) attacks in the relaxation group, and 0.97 (95% CI 0.36-1.58) attacks in the topiramate group. No significant difference was observed between the groups (p = 0.95). CONCLUSION Exercise may be an option for the prophylactic treatment of migraine in patients who do not benefit from or do not want to take daily medication.
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Ferrari A, Tiraferri I, Neri L, Sternieri E. Clinical pharmacology of topiramate in migraine prevention. Expert Opin Drug Metab Toxicol 2011; 7:1169-81. [PMID: 21756204 DOI: 10.1517/17425255.2011.602067] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Migraine is a widespread disorder. Migraine patients experience worse health-related quality of life than the general population. The availability of effective and tolerable treatments for this disorder is an important medical need. This narrative review focuses on the clinical pharmacology of topiramate, an antiepileptic drug that was approved for the prophylaxis of migraine where it should act as a neuromodulator. AREAS COVERED A PubMed database search (from 2000 to 24 January 2011) and a review of the human studies published on topiramate and migraine was conducted. EXPERT OPINION Topiramate is an important option for the prophylaxis of migraine and is of proven efficacy and tolerability. It has also been studied in chronic migraine with encouraging results, even in patients with medication overuse. However, in migraine prevention its efficacy is comparable to the other first-line drugs and there are no published trials with a superiority design which can establish topiramate's role in the available therapeutic armamentarium.
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Affiliation(s)
- Anna Ferrari
- University of Modena and Reggio Emilia, Headache and Drug Abuse Inter-Dep. Research Centre, Division of Toxicology and Clinical Pharmacology, Modena, Italy.
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Are the current IHS guidelines for migraine drug trials being followed? J Headache Pain 2010; 11:457-68. [PMID: 20931348 PMCID: PMC3476229 DOI: 10.1007/s10194-010-0257-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2010] [Accepted: 09/12/2010] [Indexed: 11/18/2022] Open
Abstract
In 2000, the Clinical Trials Subcommittee of the International Headache Society (IHS) published the second edition of its guidelines for controlled trials of drugs in migraine. The purpose of this publication was to improve the quality of such trials by increasing the awareness amongst investigators of the methodological issues specific to this particular illness. Until now the adherence to these guidelines has not been systematically assessed. We reviewed all published controlled trials of drugs in migraine from 2002 to 2008. Eligible trials were scored for compliance with the IHS guidelines by using grading scales based on the most essential recommendations of the guidelines. The primary efficacy measure of each trial was also recorded. A total of 145 trials of acute treatment and 52 trials of prophylactic treatment were eligible for review. Of the randomized, double-blind trials, acute trials scored an average of 4.7 out of 7 while prophylactic trials scored an average of 5.6 out of 9 for compliance. Thirty-one percent of acute trials and 72% of prophylactic trials used the recommended primary efficacy measure. Fourteen percent of the reviewed trials were either not randomized or not double-blinded. Adherence to international guidelines like these of IHS is important to ensure that only high-quality trials are performed, and to provide the consensus that is required for meta analyses. The primary efficacy measure for trials of acute treatment should be “pain free” and not “headache relief”. Open-label or non-randomized trials generally have no place in the study of migraine drugs.
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Luykx JJ, Carpay JA. Nervous system adverse responses to topiramate in the treatment of neuropsychiatric disorders. Expert Opin Drug Saf 2010; 9:623-31. [PMID: 20367527 DOI: 10.1517/14740331003739196] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
IMPORTANCE OF THE FIELD Nervous system adverse drug reactions (NS-ADRs), such as cognitive complaints and paresthesia, are among the most frequent and clinically important ADRs of topiramate. Studying ADR profiles across disorders is clinically relevant because treatment decision-making in neuropsychiatry is highly guided by ADR profiles. AREAS COVERED IN THIS REVIEW We used medline searches (until July 2009) to review the NS-ADRs of topiramate across the most investigated topiramate indications: alcohol dependence, essential tremor, binge-eating disorder, bulimia nervosa, migraine and epilepsy. We compared NS-ADRs between these disorders but did not carry out meta-analysis. WHAT THE READER WILL GAIN ADR profiles greatly differed between disorders. Drop-outs due to ADRs highly varied between disorders: from 2% in the bulimia nervosa group to 29% in the migraine group. Paresthesia was the most common NS-ADR for all disorders but frequencies also differed between disorders. Cognitive complaints were frequent and were reported in comparable proportions. TAKE HOME MESSAGE When prescribing topiramate in neuropsychiatry, physicians should be aware that NS-ADR profiles have been found to differ between disorders. Differences in drop-out rates due to ADRs and in frequencies of specific NS-ADRs across disorders must be taken into account when evaluating the potential harm of topiramate in clinical practice.
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Affiliation(s)
- Jurjen J Luykx
- University Medical Center Utrecht, Department of Psychiatry, p/a Jurjen Luykx, PO Box 85500, 3508 GA Utrecht HP B01.206, The Netherlands.
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Abstract
Although the triptan drugs provide effective relief from migraine for many patients, a substantial number of affected individuals are unresponsive to these compounds, and such therapy can also lead to a range of adverse effects. Telcagepant represents a new class of antimigraine drug-the calcitonin gene-related peptide receptor blockers. This compound exerts its effects by blocking receptors for the calcitonin-gene-related peptide at several sites in the trigeminal and central nervous systems, resulting in pain relief. Telcagepant does not cause vasoconstriction, a major limitation in the use of triptans. Comparisons with triptans in clinical trials for acute treatment of migraine attacks revealed clinical effects similar to those of triptans but better than those of placebo. Telcagepant might provide hope for those who have a poor response to, or are unable to use, older drugs. In patients who need prophylaxis because of frequent attacks of migraine, topiramate is a first-line drug for migraine prevention in many countries; it is generally safe and reasonably well tolerated. Data suggest that topiramate could aid reversion of chronic migraine to episodic migraine.
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Affiliation(s)
- Lars Edvinsson
- Department of Internal Medicine, University Hospital, Lund, Sweden.
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Affiliation(s)
- Tamara Pringsheim
- Department of Clinical Neurosciences, University of Calgary, Calgary Headache Assessment and Management Program, Foothills Medical Centre, 1403-29th St. NW, Calgary AB T2N 2T9.
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Abstract
Migraine is a common neurological disease affecting about 12% of the population in Western Europe and North America, and causing a considerable burden both to migraineurs and to society. Severe, frequent and disabling migraine attacks, as well as those poorly responsive to acute care medication, require preventive treatment, which is often under-utilized. Antiepileptic drugs are used in the prevention of migraine. We performed a literature search of PubMed through June 2008 for controlled trials of antiepileptic drugs in the prevention of migraine. The search identified 70 papers for a full-text review. The majority of these papers referred to valproate and topiramate, and showed that these drugs are effective and well tolerated in migraine prevention and are suitable for first-line clinical use. On the other hand, acetazolamide, lamotrigine, oxcarbazepine and vigabatrin have been shown to be not effective and gabapentin requires further evaluation. For the rest of the antiepileptic drugs, no data from controlled trials are available.
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Affiliation(s)
- Michail Vikelis
- Headache Outpatient Clinic, Athens Naval Hospital, Athens, Greece.
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Abstract
In the US, it is estimated that up to 10% of men and 25% of women, particularly those aged 25-55 years, experience debilitating migraines, such that the condition presents an enormous economic burden for patients, health systems, employers and society. Migraine headache is a particularly prevalent condition associated with major reductions in patients' quality of life. From a payer perspective, the implementation of relevant programmes of migraine prophylaxis is highly desirable. Consistent evidence exists, from several randomized, controlled studies, of the efficacy of amitriptyline, divalproex sodium, propranolol, timolol and topiramate in migraine prophylaxis. Considering resource utilization, various studies suggest that migraine prophylaxis with antiepileptics, antidepressants, beta-blockers or calcium channel antagonists markedly reduces triptan use and visits to physician offices and emergency departments (EDs), without compromising quality of care or treatment outcomes. Over recent years, the effects of topiramate in reducing resource utilization in patients with migraine have been relatively widely studied. In US claims database analyses involving >4000 patients with migraine, topiramate significantly reduced triptan use by up to 20% in the 12-month period after starting treatment. Reductions were also noted in the numbers of ED visits, diagnostic procedures, hospital admissions and migraine-related hospitalization days. These long-term benefits of topiramate manifested without any increase in overall headache-related costs. Furthermore, in detailed modelling analyses based on UK and US data, topiramate-induced savings in acute medical services were estimated to offset about one-quarter of the monthly per patient cost of the topiramate regimen, which was shown to be a dominant cost-effective intervention relative to no preventive therapy: cost-effectiveness ratios were calculated as pound 5728 per quality-adjusted life-year (QALY) [2005 costings] and $US10 888 per QALY (2002 costings), respectively. Overall, there is a need to improve quality of care in migraine, and prophylactic therapy appears to be an effective option, particularly with respect to decreasing resource use and improving productivity. For both health-plan payers and employers, topiramate appears to be a cost-effective intervention for preventing migraine.
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Affiliation(s)
- Miguel J A Láinez
- Department of Neurology, Hospital Clínico Universitario, Universidad de Valencia, 46010 Valencia, Spain.
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Evers S, Afra J, Frese A, Goadsby PJ, Linde M, May A, Sándor PS. EFNS guideline on the drug treatment of migraine - revised report of an EFNS task force. Eur J Neurol 2009; 16:968-81. [PMID: 19708964 DOI: 10.1111/j.1468-1331.2009.02748.x] [Citation(s) in RCA: 459] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- S Evers
- Department of Neurology, University of Münster, Münster, Germany.
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Patient-reported cognitive side effects of antiepileptic drugs: predictors and comparison of all commonly used antiepileptic drugs. Epilepsy Behav 2009; 14:202-9. [PMID: 19010446 DOI: 10.1016/j.yebeh.2008.10.017] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2008] [Revised: 10/14/2008] [Accepted: 10/15/2008] [Indexed: 11/23/2022]
Abstract
Subjective cognitive side effects (CSEs) are common in patients taking antiepileptic drugs (AEDs). The objective of this study was to predict which patients are at risk for CSEs, and compare the CSE profiles of all commonly used AEDs. In this nonrandomized retrospective study, medical records of 1694 adult outpatients with epilepsy seen at our center over a 5-year period who had taken one or more AEDs were examined. Non-AED predictors of CSEs were investigated, and rates of AED-related CSEs were compared in 1189 patients (546 on monotherapy) newly started on an AED at our center. The average rate of AED-related intolerable CSEs (leading to dosage change or discontinuation) was 12.8%. On multivariate analysis, no significant non-AED predictors of CSEs were found. Significantly more intolerable CSEs were attributed to topiramate (21.5% of 130 patients) than to most other AEDs, including carbamazepine (9.9%), gabapentin (7.3%), levetiracetam (10.4%), lamotrigine (8.9%), oxcarbazepine (11.6%), and valproate (8.3%). CSE rates with zonisamide (14.9%) were significantly higher than those for gabapentin and lamotrigine. After exclusion of CSEs during the first 8 weeks of therapy, rates of CSEs were lower, but relative differences remained unchanged. In monotherapy, significantly more intolerable CSEs occurred with topiramate (11.1% of 18 patients) than with carbamazepine or valproate, and both phenytoin and zonisamide were associated with more CSEs than valproate. From this study, it can be concluded that intolerable patient-reported CSEs are most common with topiramate, followed by zonisamide, phenytoin, and oxcarbazepine. They are least likely to be reported with gabapentin, valproate, lamotrigine, carbamazepine, and levetiracetam.
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Luykx J, Mason M, Ferrari MD, Carpay J. Are Migraineurs at Increased Risk of Adverse Drug Responses?: A Meta-Analytic Comparison of Topiramate-Related Adverse Drug Reactions in Epilepsy and Migraine. Clin Pharmacol Ther 2008; 85:283-8. [DOI: 10.1038/clpt.2008.203] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Abstract
Advances in our understanding of the pathophysiology of migraine have resulted in important breakthroughs in treatment. For example, understanding of the role of serotonin in the cerebrovascular circulation has led to the development of triptans for the acute relief of migraine headaches, and the identification of cortical spreading depression as an early central event associated wih migraine has brought renewed interest in antiepileptic drugs for migraine prophylaxis. However, migraine still remains inadequately treated. Indeed, it is apparent that migraine is not a single disease but rather a syndrome that can manifest itself in a variety of pathological conditions. The consequences of this may be that treatment needs to be matched to particular patients. Clinical research needs to be devoted to identifying which sort of patients benefit best from which treatments, particularly in the field of prophylaxis. We propose four patterns of precipitating factors (adrenergic, serotoninergic, menstrual, and muscular) which may be used to structure migraine prophylaxis. Finally, little is known about long-term outcome in treated migraine. It is possible that appropriate early prophylaxis may modify the long-term course of the disease and avoid late complications.
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Affiliation(s)
- Michel Dib
- Fédération du système nerveux central, Hôpital de la Salpêtrière, Assistance Publique- Hôpitaux de Paris, France
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Abstract
Several trials have asserted that some anticonvulsant drugs seem to be useful for the prophylaxis of migraine, but systematic reviews are sparse. We independently searched PubMed, EMBASE and the Cochrane Central Register of Controlled Trials until 2005, as well as Headache and Cephalalgia through April 2006, for prospective, controlled trials of anticonvulsant drugs. Data were calculated and pooled across studies and expressed as standardized mean differences, odds ratios and numbers-needed-to-treat. Anticonvulsants, considered as a class, reduce migraine frequency by about 1.3 attacks per 28 days compared with placebo, and more than double the number of patients for whom migraine frequency is reduced by ≥50% relative to placebo. Sodium valproate/divalproex sodium and topiramate were better than placebo, whereas acetazolamide, clonazepam, lamotrigine and vigabatrin were not; gabapentin, in particular, needs further evaluation. Trials designed with sufficient power to compare different drugs are also necessary.
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Affiliation(s)
- WM Mulleners
- Department of Neurology, Canisius Wilhelmina Ziekenhuis, Nijmegen, the Netherlands
| | - EP Chronicle
- Department of Psychology, University of Hawaii at Manoa, Honolulu, HI, USA
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Gupta P, Singh S, Goyal V, Shukla G, Behari M. Low-dose topiramate versus lamotrigine in migraine prophylaxis (the Lotolamp study). Headache 2007; 47:402-12. [PMID: 17371357 DOI: 10.1111/j.1526-4610.2006.00599.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the efficacy and safety of topiramate and lamotrigine for prophylaxis in patients with frequent migraine as compared to each other and to placebo. METHODS Sixty patients with frequent migraine (more than 4 attacks per month) from the headache clinic at a tertiary referral centre in India were randomized to receive 50 mg topiramate/lamotrigine or matching placebo for 1 month each in 2 divided doses in 4 phases in a crossover manner with a washout period of 7 days in between. Primary efficacy measure was responder rate (50% decrease in mean migraine frequency/intensity). Secondary efficacy measures included reduction in mean monthly frequency, intensity, duration, rescue medication use, migraine associated symptoms, and adverse events. STATISTICAL ANALYSIS Analysis was on intention to treat basis. Data were analyzed as correlated data. Generalized estimation equation was used to compute overall mean standard deviation and 95% confidence intervals for each of the outcome variables. Bonferroni's correction done for multiple comparisons. P value of < .017 was taken as significant. RESULTS Fifty-seven patients comprised the intent-to-treat population. Four patients withdrew from the study at various phases, none because of the side effects. Responder rate for frequency was significantly higher for topiramate versus placebo (63% vs 30%, P < .001), and versus lamotrigine (63% vs 46 %, P = .02). For intensity of headache also a responder rate of topiramate versus placebo (50% vs 10%, P < .001), and versus lamotrigine (50% vs 41%, P = .01) was observed. Topiramate showed statistically significant benefits (P < .017) in most of the secondary efficacy measures while lamotrigine was beneficial for reduction in headache frequency, and migraine associated symptoms. Adverse events were similar. CONCLUSION Low-dose topiramate is efficacious in migraine prophylaxis as compared to both placebo and lamotrigine. Lamotrigine in low doses might be beneficial for headache frequency; however, longer trials are required to establish its efficacy on the intensity and frequency of migraine.
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Affiliation(s)
- Praveen Gupta
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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Evers S, Afra J, Frese A, Goadsby PJ, Linde M, May A, Sándor PS. EFNS guideline on the drug treatment of migraine - report of an EFNS task force. Eur J Neurol 2006; 13:560-72. [PMID: 16796580 DOI: 10.1111/j.1468-1331.2006.01411.x] [Citation(s) in RCA: 129] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Migraine is one of the most frequent disabling neurological conditions with a major impact on the patients' quality of life. To give evidence-based or expert recommendations for the different drug treatment procedures of the different migraine syndromes based on a literature search and an consensus in an expert panel. All available medical reference systems were screened for all kinds of clinical studies on migraine with and without aura and on migraine-like syndromes. The findings in these studies were evaluated according to the recommendations of the EFNS resulting in level A,B, or C recommendations and good practice points. For the acute treatment of migraine attacks, oral non-steroidal anti-inflammatory drugs (NSAIDs) and triptans are recommended. The administration should follow the concept of stratified treatment. Before intake of NSAIDs and triptans, oral metoclopramide or domperidon is recommended. In very severe attacks, intravenous acetylsalicylic acid or subcutaneous sumatriptan are drugs of first choice. A status migrainosus can probably be treated by steroids. For the prophylaxis of migraine, betablockers (propranolol and metoprolol), flunarizine, valproic acid, and topiramate are drugs of first choice. Drugs of second choice for migraine prophylaxis are amitriptyline, naproxen, petasites, and bisoprolol.
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Mei D, Ferraro D, Zelano G, Capuano A, Vollono C, Gabriele C, Di Trapani G. Topiramate and Triptans Revert Chronic Migraine With Medication Overuse to Episodic Migraine. Clin Neuropharmacol 2006; 29:269-75. [PMID: 16960472 DOI: 10.1097/01.wnf.000022888.49044.99] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This is a randomized, double-blind versus placebo study aimed at evaluating the efficacy of topiramate (TPM) in reducing the number of days with headache and the amount of acute medication taken monthly in patients with chronic migraine with medication overuse. We also studied the efficacy of single triptans available in Italy in interrupting headache crises during preventive treatment. METHODS The studied sample was made up of 50 subjects: 30 patients were randomized for treatment with TPM, 100 mg/d, and 20 for placebo. Subjects treated with TPM were further randomized to evaluate, in double-blind versus placebo, the efficacy of single triptans available in Italy. The double-blind phase consisted of a titration phase (4 weeks) and of a maintenance phase (8 weeks). OUTCOME MEASURES The reduction in the number of days with headache per 28 days and the reduction in the amount of acute medication taken per 28 days throughout the clinical trial in the TPM group were compared with those of the placebo group; the number of patients who were pain-free at 2 hours after the triptan intake and the headache recurrence rate in the 22 hours after the pain-free condition in the triptan group were compared with those of the placebo group. We also looked at tolerability profile. RESULTS The group treated with TPM had a significant reduction in the number of days with headache (P < 0.0001 vs placebo) and in the mean amount of acute medication taken (P < 0.0001 vs placebo); all triptans were superior to placebo; there were no significant differences between different triptans; the analgesic effect of triptans increased throughout the trial. CONCLUSIONS Topiramate proved to be well tolerated and effective in reverting chronic migraine with medication overuse to episodic migraine.
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Affiliation(s)
- Daniele Mei
- Department of Neuroscience, Headache Centre, Catholic University, Rome, Italy.
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Abstract
Migraine is a costly, recurrent condition that affects 28 million individuals in the United States yet remains underdiagnosed and undertreated. In 2004, the U.S. Food and Drug Administration approved topiramate for the prevention of migraine in adults, joining three other agents with this indication: divalproex sodium, propranolol, and timolol. We evaluated the role of topiramate in the treatment of migraine based on published literature and our clinical experiences. A qualitative systematic search of the literature from January 1966-December 2004 was conducted by using MEDLINE, and other pertinent literature was reviewed. Three large, randomized, placebo-controlled trials of topiramate for migraine prevention in individuals experiencing 3-12 attacks/month have been published, as have several small studies and a comparator trial with propranolol. Based on the results of these studies, 100 mg/day is the optimum topiramate dosage in terms of efficacy and tolerability. Using that dosage, the number of migraine attacks/month decreased by approximately two. Several other secondary outcome measures were also significantly reduced including the number of days/month with migraine and the use of acute treatment/attack. Suboptimal efficacy was shown with 50 mg/day, whereas 200 mg/day caused considerably more tolerability issues. Paresthesia was dose related and the most common cause of attrition. Cognitive dysfunction and weight loss were also commonly reported. The reduction by two migraines/month demonstrated with topiramate in clinical trials is similar to the published results for other preventive agents, though most of those studies were small, antiquated, and poorly designed. In contrast, the topiramate trials enrolled a larger number of patients and closely adhered to the International Headache Society research recommendations, strengthening the quality of results. Topiramate 100 mg/day is an effective option in adults who require migraine prophylaxis. Although the published efficacy results of the various migraine preventive agents are comparable, the superior study design of the topiramate trials warrants consideration of topiramate as an agent of choice for migraine prevention. Future studies of any preventive agent should include more refined quality-of-life outcomes.
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Affiliation(s)
- Richard G Wenzel
- Diamond Headache Clinic Inpatient Unit, Chicago, Illinois 60613, USA.
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Abstract
Migraine is a chronic, neurological disorder generally manifesting itself in attacks with severe headache, nausea and an increased reactivity to sensory stimuli. A low migraine threshold is set by genetic factors, although the phenotype also modulates the manifestations. The 1-year prevalence is approximately 13% and is higher among women. Patients usually experience neuropsychological dysfunction, and sometimes also reversible focal neurological symptoms. The trajectories of the characteristic symptoms of acute migraine usually follow a similar time course, indicating a reciprocal underlying mechanism. A central nervous system hyperexcitability has been demonstrated in neurophysiological studies. The dibilitating effects of migraine are not confined to the attacks per se. Many individuals do not recover completely between the attacks and most report a negative impact on the most important life domains, and an interest in testing other treatments. Young persons have a higher frequency of attacks. Acute treatment should routinely be initiated with an analgesic plus a prokinetic anti-emetic. Triptans must not be provided early during the attack to ensure their efficacy. The natural course of attacks is commonly only temporarily altered by acute treatment. Non-pharmacological treatment and drugs may be equally viable in prophylaxis for migraine. In more complicated cases, conjoint therapy should be considered. New strategies to improve adherence with existing therapeutic regimens might yield greater benefits than will new pharmacological agents.
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Affiliation(s)
- M Linde
- Cephalea Headache Centre and Institute of Neuroscience and Physiology, Sahlgrenska Academy, Göteborg University, Gothenburg, Sweden.
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44
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Shaygannejad V, Janghorbani M, Ghorbani A, Ashtary F, Zakizade N, Nasr V. Comparison of the Effect of Topiramate and Sodium Valporate in Migraine Prevention: A Randomized Blinded Crossover Study. Headache 2006; 46:642-8. [PMID: 16643559 DOI: 10.1111/j.1526-4610.2006.00413.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Topiramate and sodium valporate are anticonvulsants, demonstrated to be effective as monotherapy for migraine prevention in placebo-controlled trials. OBJECTIVES To compare the relative efficacy of topiramate and sodium valporate in the prevention of migraine. PATIENTS AND METHODS A 24-week, randomized, double-blind, crossover, clinical trial was conducted from October 2003 to September 2004. A total of 64 patients with migraine headache, aged 14 to 57 years, were randomly allocated to the 2 treatment groups. The first group received topiramate (25 mg daily increment over 1 week to 50 mg) for a total of 2 months. The second group received sodium valporate (200 mg daily increment over 1 week to 400 mg) for 2 months. Response to treatment was assessed at 0, 1, 8, 16, and 24 weeks after start of therapy. RESULTS Topiramate appeared to be equivalent in efficacy and safety to sodium valporate. A significant decrease in duration, monthly frequency, and intensity of headache occurred in both groups. Of the 32 patients treated with sodium valporate, the mean standard deviation (SD) of monthly migraine frequency decreased from 5.4 (2.5) to 4.0 (2.8) episode per month, headache intensity from 7.7 (1.2) to 5.8 (1.7) by visual analog scale (VAS), and headache duration from 21.3 (14.6) to 12.3 (10.7) hours (P < .001). Correspondingly, in the 32 patients treated with topiramate, the mean SD of monthly headache frequency decreased from 5.4 (2.0) to 3.2 (1.9) per month, headache intensity from 6.9 (1.2) to 3.7 (1.3), and headache duration from 17.3 (8.4) to 3.9 (2.7) hours (P < .001). CONCLUSION This study demonstrates that treatment with topiramate and sodium valporate both significantly reduce migraine headache. This effect of topiramate and sodium valporate has previously been shown to reduce migraine headache, and we postulate that treatment with topiramate and sodium valporate may have a similar benefit.
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Affiliation(s)
- Vahid Shaygannejad
- Department of Neurology, Isfahan University of Medical Sciences and Health Services, Isfahan, Iran
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Abstract
The past two decades have contributed a large body of preclinical work that has assisted in our understanding of the underlying pathophysiological mechanisms that cause chronic pain. In this context, it has been recognized that effective treatment of pain is a priority and that treatment often involves the use of one or a combination of agents with analgesic action. The current review presents an evidence-based approach to the pharmacotherapy of chronic pain. Medline searches were done for all agents used as conventional treatment in chronic pain. Published papers up to June 2005 were included. The search strategy included randomized, controlled trials, and where available, systematic reviews and meta-analyses. Further references were found in reference sections of papers located using the above search strategy. Agents for which there were no controlled trials supporting efficacy in treatment of chronic pain were not included in the present review, except in cases where preclinical science was compelling, or where initial human work has been positive and where it was thought the reader would be interested in the scientific evidence to date.
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Affiliation(s)
- Mary E Lynch
- Department of Psychiatry, Dalhousie University, Halifax, Canada.
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46
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Abstract
BACKGROUND Anticonvulsant drugs seem to be useful in clinical practice for the prophylaxis of migraine. This might be explained by a variety of actions of these drugs in the central nervous system that are probably relevant to the pathophysiology of migraine. OBJECTIVES To describe and assess the evidence from controlled trials on the efficacy and tolerability of anticonvulsants for preventing migraine attacks in adult patients with migraine. SEARCH STRATEGY We searched MEDLINE (from 1966 on) and the Cochrane Central Register of Controlled Trials (CENTRAL). Date of most recent search: April 2003. Additional information was gained from hand-searching specialist headache journals; correspondence with pharmaceutical companies, authors of reports, and experts in the field; and a wide variety of review articles and book chapters. SELECTION CRITERIA Studies were required to be prospective, controlled trials of self-administered drug treatments taken regularly to prevent the occurrence of migraine attacks and/or to reduce the intensity of those attacks. DATA COLLECTION AND ANALYSIS Studies were selected and data extracted by two independent reviewers. For migraine frequency data, standardized mean differences (SMDs) were calculated for individual studies and pooled across studies. For dichotomous data on significant reduction in migraine frequency, odds ratios (ORs) and numbers-needed-to-treat (NNTs) were similarly calculated. Adverse events were analyzed by calculating numbers-needed-to-harm (NNHs) for studies using similar agents. MAIN RESULTS Fifteen papers were included in the review. Of these, 14 reported trials comparing anticonvulsants with placebo, as follows: four trials of divalproex sodium, three trials of topiramate, two trials of sodium valproate, two trials of gabapentin, and one trial each of carbamazepine, clonazepam, and lamotrigine. One paper reported a trial of sodium valproate versus an active comparator, flunarizine, and one trial of divalproex sodium versus placebo included a comparison against propranolol, also an active comparator. Data from 2024 patients were considered. Analysis of data from eight trials (n = 841) demonstrates that anticonvulsants, considered as a class, reduce migraine frequency by about 1.4 attacks per 28 days as compared to placebo (SMD -0.60; 95% confidence interval [CI] -0.93 to -0.26). Data from 10 trials (n = 1341) show that anticonvulsants, considered as a class, also more than double the number of patients for whom migraine frequency is reduced by 50% or more, relative to placebo (OR 3.90; 95% CI 2.61 to 5.82; NNT 3.8; 95% CI 3.2 to 4.6). For seven trials of sodium valproate and divalproex sodium, NNHs for five clinically important adverse events ranged from 6.6 to 16.3. For the three trials of topiramate, NNHs for eight adverse events (100-mg dose) ranged from 2.4 to 32.9. REVIEWERS' CONCLUSIONS Anticonvulsants appear to be both effective in reducing migraine frequency and reasonably well tolerated. There is noticeable variation among individual agents, but there are insufficient data to know whether this is due to chance or variation in true efficacy. Neither clonazepam nor lamotrigine was superior to placebo (one trial each). Relatively few robust trials are available for agents other than sodium valproate/divalproex sodium. Two recently published and large trials of topiramate demonstrated reasonable efficacy, and one further trial of this agent is anticipated in the near future.
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Affiliation(s)
- E Chronicle
- Department of Psychology, University of Hawaii at Manoa, 2430 Campus Road, Honolulu, Hawaii, USA, 96822
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