A prospective, open-label study of milnacipran in the prevention of headache in patients with episodic or chronic migraine

Serotonin–norepinephrine reuptake inhibitors for the prevention of migraine and vestibular migraine: a systematic review and meta-analysis

Background and objectives

The role of serotonin–norepinephrine reuptake inhibitors (SNRIs) in migraine prophylaxis has not been completely established. Current treatments for vestibular migraine (VM) are based on scarce evidence. We aimed to perform an updated review focusing on the efficacy and tolerability of SNRIs for migraine and VM prevention.

Methods

We searched the PubMed, Web of Science, and Cochrane Library databases for relevant studies. The primary outcome was migraine frequency. In the case of VM, the Dizziness Handicap Inventory (DHI) scores and Vertigo Severity Scores (VSSs) were extracted.

Results

Six randomized controlled trials involving 418 patients were analyzed. Patients receiving SNRIs had fewer migraine days than those receiving a placebo (standardized mean difference −0.38, 95% CI −0.76 to −0.01, p=0.04). The effects of SNRIs and other active drugs were comparable. In patients with VM, venlafaxine had a significant advantage over other active drugs in decreasing the VSS (weighted mean difference (MD) −1.45, 95% CI −2.11 to −0.78, p<0.0001) and the emotional domain score of the DHI (MD −2.64, 95% CI −4.97 to −0.31, p=0.03). We found no significant difference in the rate of withdrawals due to any reason or withdrawals due to side effects between SNRIs and active drugs and between SNRIs and a placebo.

Conclusions

SNRIs were clinically safe and effective for migraine and VM prophylaxis, were better than a placebo, and not inferior to other active drugs. SNRIs may be a preferable choice for patients with VM with psychiatric disorders.

An Association of Serotonin with Pain Disorders and Its Modulation by Estrogens

Ovarian hormones play an important role in pain perception, and are responsible, at least in part, for the pain threshold differences between the sexes. Modulation of pain and its perception are mediated by neurochemical changes in several pathways, affecting both the central and peripheral nervous systems. One of the most studied neurotransmitters related to pain disorders is serotonin. Estrogen can modify serotonin synthesis and metabolism, promoting a general increase in its tonic effects. Studies evaluating the relationship between serotonin and disorders such as irritable bowel syndrome, fibromyalgia, migraine, and other types of headache suggest a clear impact of this neurotransmitter, thereby increasing the interest in serotonin as a possible future therapeutic target. This literature review describes the importance of substances such as serotonin and ovarian hormones in pain perception and illustrates the relationship between those two, and their direct influence on the presentation of the aforementioned pain-related conditions. Additionally, we review the pathways and receptors implicated in each disorder. Finally, the objective was to stimulate future pharmacological research to experimentally evaluate the potential of serotonin modulators and ovarian hormones as therapeutic agents to regulate pain in specific subpopulations.

Antidepressants for Preventive Treatment of Migraine

PURPOSE OF REVIEW

This review describes the pharmacology of each antidepressant class as it applies to migraine prevention, summarizes the evidence base for each medication, and describes relevant side effects and clinical considerations. Use of antidepressants for migraine prevention in clinical practice is also discussed.

RECENT FINDINGS

Antidepressants are commonly used as migraine preventives. Amitriptyline has the best evidence for use in migraine prevention. Nortriptyline is an alternative in patients who may not tolerate amitriptyline. The sedating effect of TCAs can be beneficial for patients with comorbid insomnia. SNRIs including venlafaxine and duloxetine also have evidence for efficacy and may be the most effective treatments in patients with comorbid depression and migraine. SSRIs including fluoxetine are not effective for most patients. The side effect burden of antidepressants can be substantial. Patients should be particularly counseled about the possibility of a withdrawal effect from SNRIs. Antidepressants are an important option for preventive treatment of migraine. Further research on the efficacy and tolerability of SNRIs as migraine preventives is needed.

Chronic migraine: risk factors, mechanisms and treatment

Chronic migraine has a great detrimental influence on a patient's life, with a severe impact on socioeconomic functioning and quality of life. Chronic migraine affects 1-2% of the general population, and about 8% of patients with migraine; it usually develops from episodic migraine at an annual conversion rate of about 3%. The chronification is reversible: about 26% of patients with chronic migraine go into remission within 2 years of chronification. The most important modifiable risk factors for chronic migraine include overuse of acute migraine medication, ineffective acute treatment, obesity, depression and stressful life events. Moreover, age, female sex and low educational status increase the risk of chronic migraine. The pathophysiology of migraine chronification can be understood as a threshold problem: certain predisposing factors, combined with frequent headache pain, lower the threshold of migraine attacks, thereby increasing the risk of chronic migraine. Treatment options include oral medications, nerve blockade with local anaesthetics or corticoids, and neuromodulation. Well-defined diagnostic criteria are crucial for the identification of chronic migraine. The International Headache Society classification of chronic migraine was recently updated, and now allows co-diagnosis of chronic migraine and medication overuse headache. This Review provides an up-to-date overview of the classification of chronic migraine, basic mechanisms and risk factors of migraine chronification, and the currently established treatment options.