Migraine prophylaxis: what is new and what we need?

Consensus of the Brazilian Headache Society (SBCe) for the Prophylactic Treatment of Episodic Migraine: part I

The Brazilian Headache Society (Sociedade Brasileira de Cefaleia, SBCe, in Portuguese) nominated a Committee of Authors with the aim of establishing a consensus with recommendations regarding prophylactic treatment for episodic migraine based on articles published in the worldwide literature, as well as personal experience. Migraine affects 1 billion people around the world and more than 30 million Brazilians. In addition, it is an underdiagnosed and undertreated disorder. It is well known within the medical community of neurologists, and especially among headache specialists, that there is a need to disseminate knowledge about prophylactic treatment for migraine. For this purpose, together with the need for drug updates and to expand knowledge of the disease itself (frequency, intensity, duration, impact and perhaps the progression of migraine), this Consensus was developed, following a full online methodology, by 12 groups who reviewed and wrote about the pharmacological categories of the drugs used and, at the end of the process, met to read and establish conclusions for this document. The drug classes studied were: anticonvulsants, tricyclic antidepressants, monoclonal anti-calcitonin gene-related peptide (anti-CGRP) antibodies, beta-blockers, antihypertensives, calcium channel inhibitors, other antidepressants (selective serotonin reuptake inhibitors, SSRIs, and dual-action antidepressants), other drugs, and polytherapy. Hormonal treatment and anti-inflammatories and triptans in minimum prophylaxis schemes (miniprophylaxis) will be covered in a specific chapter. The drug classes studied for part I of the Consensus were: anticonvulsants, tricyclic antidepressants, monoclonal anti-CGRP antibodies, and beta-blockers.

Exercise in Treatment of Migraine Including Chronic Migraine

PURPOSE OF REVIEW

With this review, we aimed to investigate the effect of exercise on migraine and explored the possibility of exercise as a treatment option for migraine.

RECENT FINDINGS

A close association of physical activity and exercise with migraine has been reported in clinical and population-based studies. Recent randomized controlled trials investigating the effect of aerobic exercise as a migraine-preventive treatment have revealed a notable improvement in migraine symptoms. Data on the effect of anaerobic exercise and exercise for flexibility, coordination, and relaxation on migraine are currently insufficient to make any recommendations. Possible pathways for the attenuation of migraine by exercise include the endogenous opioid and cannabinoid systems, brain-derived neurotrophic factor, inflammation, and behavioral/psychological factors. Regarding efficacy, side effects, and health benefits, aerobic exercise is a potentially beneficial strategy in the preventive treatment of migraine. Further studies are needed to delineate an evidence-based exercise program for migraine treatment.

Real-world insights on the management of migraine patients: an Italian nationwide study

Objectives: Understanding migraine management using data from a sample of patients representative of the Italian general adult population.Methods: Retrospective analysis on IQVIA Italian Longitudinal Patient Database. Two cohorts were created. (a) The triptan user cohort included patients with triptan prescriptions between November 2015 and October 2016. Migraine days were estimated counting triptan and indometacin/caffeine/prochlorperazine (ICP) pills prescribed during the 6 months following first triptan prescription. Patients were categorized as having episodic (EM) or chronic (CM) migraine based on the number of migraine days following International Classification of Headache Disorders criteria. (b) The migraine preventive treatment (MPT) user cohort included patients with MPT prescriptions during the period June 2016-May 2017. MPTs considered included beta-blockers, calcium-channel blockers, antiepileptics, antidepressants and antiserotoninergics. Migraine days experienced by MPTs users were estimated counting triptan and ICP pills prescribed during the 6 months following the most recent MPT prescription, while the number of MPT switches was estimated based on MPT prescriptions during the previous two years.Results: There were 9461 patients with triptan prescriptions to treat migraine acute attacks, which accounted yearly for 0.8% of general adult population. CM patients accounted for 3% of triptan users. There were 2004 patients prescribed with MPTs, which accounted for 0.16% of general adult population. Overall, among MPT users, 291 (15%) were still experiencing at least four migraine days/month, with this proportion increasing with the increase in the number of MPT switches.Conclusions: Results from this study suggest an unmet need in the management of migraine: too many patients did not receive MPTs, with this potentially due to several reasons requiring further investigations. Furthermore, even among patients receiving MPTs, disease control level with now available drugs seems to be sub-optimal.

The effect of aerobic exercise on the number of migraine days, duration and pain intensity in migraine: a systematic literature review and meta-analysis

BACKGROUND

In patients with frequent migraine, prophylactic treatments are used. Patients often request non-pharmacological alternatives. One treatment option can be aerobic exercise. The value of aerobic exercise as prophylactic treatment however needs to be determined.

METHODS

A systematic review and meta-analysis was performed to investigate the result of aerobic exercise on the number of migraine days, duration and pain intensity in patients with migraine. After screening three online databases, PubMed, Cochrane library and Web of Science, using predefined in- and exclusion criteria, six studies were retained. Pooling of data was performed when possible.

RESULTS

Significant reductions in the number of migraine days after aerobic exercise treatment were found with a mean reduction of 0.6 ± 0.3 migraine days/month. Other outcomes were too variable to pool due to heterogeneity of outcome measurements. Unpooled data revealed small to moderate reductions in attack duration (20-27%) and pain intensity (20-54%) after aerobic exercise intervention. Various exercise intensities are applied.

CONCLUSION

There is moderate quality evidence that in patients with migraine aerobic exercise therapy can decrease the number of migraine days. No conclusion for pain intensity or duration of attacks can be drawn. Effect sizes are small due to a lack of uniformity. For future studies, we recommend standardized outcome measures and sufficiently intense training programs.

TRIAL REGISTRATION

CRD42018091178 .

Redox Mechanisms in Migraine: Novel Therapeutics and Dietary Interventions

SIGNIFICANCE

Migraine represents the third most prevalent and the seventh most disabling human disorder. Approximately 30% of migraine patients experience transient, fully reversible, focal neurological symptoms (aura) preceding the attack. Recent Advances: Awareness of the hypothesis that migraine actually embodies a spectrum of illnesses-ranging from episodic to chronic forms-is progressively increasing and poses novel challenges for clarifying the underlying pathophysiological mechanisms of migraine as well as for the development of novel therapeutic interventions. Several theories have evolved to the current concept that a combination of genetic, epigenetic, and environmental factors may play a role in migraine pathogenesis, although their relative importance is still being debated.

CRITICAL ISSUES

One critical issue that deserves a particular attention is the role of oxidative stress in migraine. Indeed, potentially harmful oxidative events occur during the migraine attack and long-lasting or frequent migraine episodes may increase brain exposure to oxidative events that can lead to chronic transformation. Moreover, a wide variety of dietary, environmental, physiological, behavioral, and pharmacological migraine triggers may act through oxidative stress, with clear implications for migraine treatment and prophylaxis. Interestingly, almost all current prophylactic migraine agents exert antioxidant effects.

FUTURE DIRECTIONS

Increasing awareness of the role of oxidative stress and/or decreased antioxidant defenses in migraine pathogenesis and progression to a chronic condition lays the foundations for the design of novel prophylactic approaches, which, by reducing brain oxidative phenomena, could favorably modify the clinical course of migraine. Antioxid. Redox Signal. 28, 1144-1183.

The effects of Maras powder use on patients with migraine

BACKGROUND

It is accepted that smoking often triggers migraine. However, studies evaluating the relationship between the use of smokeless tobacco and migraine are limited, and there is no clear consensus on the subject. In this study, it was aimed to evaluate the relationship between migraine and Maras powder, which is the most common smokeless tobacco in Turkey.

SUBJECTS AND METHODS

The study included a total of 600 subjects, consisting of 300 patients (aged >18 years) diagnosed with a migraine according to the International Headache Society (IHS-ICHD-3 Beta) criteria after presenting at Sütçü Imam University Medical Faculty Neurology Policlinic with the complaint of headache between July 2016 and December 2016 and a control group of 300 individuals with similar features of age, gender, and educational level. A questionnaire was administered to each patient to record the status of smoking or using Maras powder.

RESULTS

In the migraine patient group, 16.4% smoked and 9.7% used Maras powder. In the control group, the rate of smoking was 8.5% and the rate of Maras powder use was 11.86%. In males diagnosed with a migraine, the use of Maras powder was found to be at a higher rate than smoking (p<0.001). The Visual Pain Score and the headache frequency values were higher in those who smoked or used Maras powder than in non-users (p<0.001). The Fagerström Test for Nicotine Dependence Smokeless Tobacco results of the patients diagnosed with migraine and who used Maras powder were found to be higher than of those who smoked (Fagerström Test for Nicotine Dependence; p<0.001). When patients were evaluated according to the Migraine Disability Assessment Scale, the majority of migraine patients were seen to be at stages 1 and 2, and one in every three patients who used Maras powder cigarette and one in every two patients who smoked had headaches of a severity which affected their daily activities (p<0.001).

CONCLUSION

Smoking or the use of Maras powder increases the frequency and severity of migraines in a similar way. Therefore, Maras powder must be included in the scope of the fight against tobacco and people should be warned about this issue.

Effects of Coriandrum sativum Syrup on Migraine: A Randomized, Triple-Blind, Placebo-Controlled Trial

Background:

Migraine is one of the most common and debilitating neurological problems. Although numerous preventive drugs are used to treat migraine, their complications are unavoidable. Application of herbal medicine, especially well-known medicinal plants, to treatment of chronic diseases, like migraine, could be effective. Coriandrum sativum L. (C. sativum) fruit is one of the most commonly prescribed herbs in Persian medicine, which has been used to treat headache.

Objectives:

This study was designed to evaluate the effects of C. sativum syrup on duration, severity and frequency of migraine.

Patients and Methods:

A total of 68 migraineurs, who had the eligibility criteria, according to international headache society diagnostic criteria, were randomly assigned to intervention group (n = 34) or control group (n = 34). In addition to 500 mg of sodium valproate per day, in intervention group, they received 15 mL of Coriander fruit syrup and 15 mL of placebo syrup, in control group, three times a day, during a month. The subjects were followed for clinical efficacy at weeks 1, 2, 3 and 4. The number of migraine attacks per week, as well as the duration and severity of attacks, were evaluated.

Results:

Of 68 patients randomized, 66 were included in analysis. The generalized estimating equations analysis showed that the Coriander fruit syrup decreased duration, severity and frequency of migraine, in the intervention group (P < 0.001). To be more precise, the mean migraine duration, severity and frequency, in the intervention group, were 5.7 hours, 3.65 units and about 50% less than control group, respectively.

Conclusions:

Results of this study showed that C. sativum fruit is efficient in reduction of the duration and frequency of migraine attacks and in diminishing pain degree.

Progesterone receptor gene (PROGINS) polymorphism correlates with late onset of migraine

Progesterone influences central neuronal excitability, a key event in migraine pathophysiology. Progesterone receptor gene (PGR) rs1042838 (G/T - Val660Leu) variant is indicative of PROGINS haplotype and associated to a reduced PGR activity. With the aim of investigating whether any type of association existed between this genetic variant and migraine pathophysiology, genotyping was performed in 380 consecutive migraine patients and 185 age-, sex-, and race-ethnicity-matched healthy controls from Interinstitutional Multidisciplinary BioBank (BioBIM) of IRCCS San Raffaele Pisana, Rome, Italy. rs1042838 genotypes did not correlate with demographics or clinical migraine features. However, TT (Leu) genotype was significantly associated with a later age of migraine onset: Patients affected by migraine with aura showed a linear relationship between copy number of the T allele carried by the individual and the age of migraine onset. Our data suggest that the PROGINS PGR polymorphism does not directly predispose to migraine but significantly delays migraine onset probably via a reduction in brain neuronal excitability.

Association between migraine and ACE gene (insertion/deletion) polymorphism: the BioBIM study

AIM

In the present case-control study, we investigated the correlation between the common ACE insertion/deletion (I/D) polymorphism and migraine.

MATERIALS & METHODS

Genotyping of the ACE I/D variant was performed in 502 Caucasian patients with migraine and 323 age-, sex- and race/ethnicity-matched healthy controls. We investigated associations between ACE genetic variants and sociodemographic and/or clinical features of migraineurs.

RESULTS

We found a significant association between ACE insertion/insertion (I/I) polymorphism and lower use of pharmacological prophylaxis in migraine patients with aura and in those with chronic migraine. Moreover, ACE I/I polymorphism was significantly more common in migraine patients with aura who had a negative family history of migraine.

CONCLUSION

Our data suggest that although the ACE I/D polymorphism is not a direct risk factor for migraine, the ACE I/I genotype may influence the clinical feature of this disease being associated with reduced use of prophylactic agents in patients with migraine with aura and in those with chronic migraine.

Atenolol in the prophylaxis of chronic migraine: a 3-month open-label study

Background

Chronic migraine (CM) is a type of chronic daily headache. CM presents a challenge to primary care physicians and neurologists. Any new treatment showing efficiency would therefore be of great importance. Atenolol together with other beta-blockers is a first-line choice in episodic migraine prophylaxis. Clinical findings support the efficacy of atenolol in doses of 50 to 200 mg/day.

Methods

Here I present an open-label study the aim of which is to evaluate the efficacy and tolerability of atenolol (50 mg o.d) for the prevention of CM. 19 patients affected by CM were studied.

Results

Following a one-month run-in period, the patients took atenolol for 3 months. Mean numbers of headache days per month were reduced from 20.1 ± 2.4 during the run-in period to 7.8 ± 6.1 by month 1.5 and to 7.1 ± 5.7 by the 3rd month of treatment (p < 0.0003). There was a significant difference between 1.5 months and the 3rd month (p < 0.006). The severity of attacks was reduced from a mean 2.3 ± 0.6 to 1.4 ± 1.1 (p < 0.010) at 1.5 months. In this, there was no difference between 1.5 months and the 3rd month. In 5 (29%) of the17 patients who completed the study, CM was totally gone during the 3rd month of treatment. No patient was totally unresponsive to the drug. Among the patients who completed the study, the treatment was well tolerated and the compliance was good.

Conclusion

Atenolol seems to be a safe and effective treatment for CM. Controlled trials are needed to confirm the observed results.

[Gap junctional intercellular communication: a new mechanism in pathophysiology of migraine with aura. Therapeutic applications]

Migraine is a common, recurrent and disabling primary headache disorder, which affects up to 20% of the population. About a third of patients with migraine have attacks with aura, a focal neurological disturbance that manifests itself as visual, sensitive or motor symptoms. Cortical spreading depression, a wave of electrical activity that moves across the cerebral cortex through neuronal-glial cell gap junctions, would be involved in the triggering of migraine aura. Moreover, cortical spreading depression activates perivascular trigeminal afferents in the neocortex, that through central and peripheral reflex, cause inflammatory reaction in the meninges to generate the headache. Tonabersat, a novel benzopyran compound, was selected for clinical trial on the basis of its inhibitory activity on cortical spreading depression and neurogenic inflammation in animal models of migraine. Moreover, tonabersat inhibited trigeminal ganglion neuronal-glial cell gap junctions, suggesting that this compound could prevent peripheral sensitization within the ganglion. In clinical trial, tonabersat showed a preventive effect on attacks of migraine with aura but had no efficacy on non-aura attacks and in the acute treatment of migraine. In conclusion, neuronal-glial cell gap junctional intercellular communication seems to be involved in the pathophysiology of migraine with aura and is emerging as a new promising therapeutic target for prophylactic treatment of patients with chronic attacks.