Symptomatic pharmacotherapy of migraine

Evaluation of the efficacy of intravenous acetaminophen in the treatment of acute migraine attacks: a double-blind, placebo-controlled parallel group multicenter study

The efficacy of intravenous acetaminophen (1000mg) in the treatment of acute migraine attacks as an alternative to parenteral application of lysine acetylsalicylate or triptans was investigated, using a multi-center, randomized, double-blind, placebo controlled study design. Migraine diagnosis was made according to the International Headache Society Classification. Sixty patients were included in three headache outpatient centers (Neurology Departments of the Universities of Regensburg, Münster and München). In the acute migraine attack patients were treated intravenously with either 1000mg paracetamol (acetaminophen) or placebo. The primary end point was pain-free after 2h. Secondary efficacy criteria were pain-free after 24h or pain relief after 2hours and after 24hours. With regard to the efficacy criteria, 37% of patients reported pain relief or painfree after two hours, 12 patients after treatment with acetaminophen and 10 patients after treatment with placebo. Out of these, 3 patients in the acetaminophen and 4 patients in the placebo group were painfree. After 24hours 86% of the patients reported pain relief: 24 treated with acetaminophen and 27 treated with placebo. The results indicate, that 1000mg intravenous acetaminophen is not superior to placebo in treating severe acute migraine attacks.

Characterization of lipophilicity and antiproliferative activity of E-2-arylmethylene-1-tetralones and their heteroanalogues

A molecular library based on E-2-arylmethylene-1-tetralone has been designed and synthesized. A reversed phase high performance liquid chromatographic (RP-HPLC) method has been developed and applied to separate them and to characterize their lipophilicity. The chromatographic method applied here was suitable to separate the structural (ortho and para) isomers of compounds and was sensitive enough to differentiate their lipophilicities. The measured (k') and computer calculated (CLOGP) lipophilicity values has been compared. Good linear correlation has been found in the case of these structurally related molecules. In vitro biological assay has been performed with Methylene blue dying to investigate the antiproliferative potency of the compounds synthesized in this work. The measured (k') and calculated (CLOGP) lipophilicities of the compounds were compared with the antiproliferative activities and an optimum value of lipophilicity has been found for these compounds.

Productivity cost benefit to employers of treating migraine with rizatriptan: a specific worksite analysis and model

Employers in the United States might not be aware of the productivity costs of migraine or the extent to which those costs can be reduced by optimal treatment. An economic model was developed to enable employers to estimate the productivity costs of migraine to their company and the savings that will accrue if those patients who suffer from migraine are treated with rizatriptan. Analyses were run for both a major financial services corporation and a representative U.S. company. The major financial services corporation, with 87,821 employees, is projected to lose 538 person-years annually, at an estimated cost of 23.8 million dollars. A representative U.S. company with 10,000 employees is projected to lose 46.0 person-years of productive effort annually as a result of migraine, valued at approximately 1.94 million dollars. The value of the annual work loss avoided if migraine is treated with rizatriptan is projected at 10.3 million dollars for the financial services corporation and 841,000 dollars for the representative U.S. company. There is a substantial productivity cost burden of migraine from a U.S. employer perspective. These productivity costs can be reduced significantly by treating migraine headaches with rizatriptan.

Rizatriptan: an update of its use in the management of migraine

Rizatriptan is an orally active serotonin 5-HT(1) receptor agonist that potently and selectively binds to 5-HT(1B/1D) subtypes. Earlier clinical trials demonstrated that rizatriptan 5 or 10mg is more effective than placebo at providing pain relief and a pain-free state, relieving associated symptoms of migraine, normalising functional ability and improving patient quality of life, and showed that rizatriptan provides faster freedom from pain and reduces nausea to a greater extent than oral sumatriptan. More recently, rizatriptan 10mg was shown to be more effective than zolmitriptan 2.5mg or naratriptan 2.5mg at producing a pain-free state 2 hours postdose. Furthermore, compared with naratriptan, significantly more patients who received rizatriptan were pain free or had pain relief from 1 hour onwards. The number of patients with normal functional ability at 2 hours was significantly higher after rizatriptan than after naratriptan or zolmitriptan. Rizatriptan was also generally more effective than zolmitriptan or naratriptan at relieving migraine-associated symptoms. Rizatriptan is generally well tolerated and adverse events are usually mild and transient. The most common adverse events associated with rizatriptan in recent randomised trials were asthenia/fatigue, dizziness, somnolence and nausea. There was a trend towards a lower incidence of adverse events with rizatriptan compared with zolmitriptan (31.2 vs 38.8%). However, rizatriptan was associated with a significantly higher incidence of adverse events than naratriptan (39 vs 29%). The incidence of chest pain was similar after the administration of rizatriptan, zolmitriptan or naratriptan (2 to 4%).

CONCLUSION

Rizatriptan is an effective drug for the acute treatment of moderate or severe migraine. Oral rizatriptan 5 and 10mg have shown greater efficacy than placebo in providing pain relief, an absence of pain, relief from associated symptoms, normal functional ability and an improvement in patient quality of life. Earlier results showed that rizatriptan provides faster freedom from pain and reduces nausea to a greater extent than oral sumatriptan. More recent studies have shown that rizatriptan 10mg provides faster pain relief and a higher percentage of patients with an absence of pain and normal functional ability at 2 hours than naratriptan 2.5mg or zolmitriptan 2.5mg. The efficacy of rizatriptan is retained when used in the long term and the drug is generally well tolerated. Although well designed studies comparing rizatriptan with almotriptan, eletriptan and frovatriptan would further define the position of rizatriptan, current data suggest rizatriptan should be considered as a first-line treatment option in the management of migraine.

Current options for the prevention and treatment of migraine

BACKGROUND

Migraine is a common condition affecting approximately 18% of women and 6% of men in the United States. The goals of managing migraine are 2-fold: to prevent attacks from occurring and to effectively and rapidly end them when they do occur.

OBJECTIVE

This article reviews the acute and prophylactic treatment of migraine.

METHODS

Information for inclusion in this review was identified through a search of MEDLINE from 1995 to the present. Search terms included migraine, acute treatment, prophylactic treatment, preventive treatment, and individual drug names.

RESULTS

Preventive measures for migraine include lifestyle changes (eg, avoiding migraine triggers and maintaining regular sleep, eating, and work habits) and drug therapy. Beta-blockers, calcium channel blockers, tricyclic antidepressants, and anticonvulsants are among the more common drug classes used for migraine prophylaxis, but preventive therapy must be individualized, taking into account efficacy, potential adverse effects, co-existing medical conditions, and drug costs. Many medications are available for the acute treatment of migraine, including over-the-counter analgesics and prescription drugs. Of the latter, the 5-hydroxytryptamine(1B/1D)-receptor agonists, or triptans, are the most recently introduced class. Each of the 4 available triptans (sumatriptan, zolmitriptan, naratriptan, and rizatriptan) is effective in ending a migraine attack, but comparative trials have shown differences between individual drugs in the time to pain relief and the percentage of patients who obtain pain relief.

CONCLUSIONS

Medications to prevent or reduce the frequency of migraine tend to be less specific and effective than medications for the acute treatment of migraine. As a class, triptans are generally well tolerated and may be considered drugs of choice for the acute treatment of moderate to severe migraine.

The trigeminovascular system in bacterial meningitis

Headache as a cardinal symptom of acute meningitis reflects activation of trigeminal afferents from the meninges. With their perivascular endings, these fibers form the so-called trigeminovascular system (TVS), which releases proinflammatory neuropeptides upon nociceptive stimulation. In the present article, we review a role of the TVS in enhancing the early inflammatory response of bacterial meningitis. Furthermore, we discuss inhibition of neuropeptide release from the TVS using 5HT(1B/D) agonists as a potential new anti-inflammatory treatment strategy for early bacterial meningitis.

Hypofunctionality of Gi proteins as aetiopathogenic mechanism for migraine and cluster headache

The involvement of Gi proteins in the modulation of pain perception has been widely established, and mutations in G-proteins have already been identified as the aetiopathological cause of human diseases. The aim of the present study was to determine whether a deficiency or a hypofunctionality of the Gi proteins occurred in primary headache. The functionality and the level of expression of Gi proteins were investigated in lymphocytes from migraine without aura, migraine with aura and cluster headache sufferers. A reduced capability to inhibit forskolin-stimulated adenylyl cyclase activity in headache patients was observed. Migraine patients also showed basal adenosine cAMP levels about four times higher than controls. The reduced activity of Gi proteins seems not to be related to a reduction of protein levels since no significant reduction of the Gialpha subunits was observed. These results indicate Gi protein hypofunctionality as an aetiopathogenic mechanism in migraine and cluster headache.