Sumatriptan responsiveness and clinical, psychiatric and psychologic features in migraine patients

Psychological mislabeling of chronic pain: lessons from migraine in the 20th century

Starting with Freud, psychoanalytically oriented practitioners described a complex of unconscious conflicts, desires and personality traits they believed to be the primary cause of a wide range of medical disorders. This was the psychogenic model. With the advance of basic research and pharmacotherapy, the psychogenic model was gradually replaced by a biopsychobehavioral model. This model treats chronic pain as a biologically based disorder that can be influenced by psychological factors and lifestyle. The present paper argues that many patients with chronic pain may not be significantly impacted by psychological factors, and that for those who are, cognitive-behavioral therapy is the treatment of choice.

Clinical-Biochemical Correlates of Migraine Attacks in Rizatriptan Responders and Non-Responders

The present study was aimed at verifying the clinical characteristics of a typical attack in 20 migraine patients, 10 responders and 10 non-responders to rizatriptan, and at investigating any differences in the levels of neuropeptides of the trigeminovascular or parasympathetic systems [calcitonin gene-related peptide (CGRP), neurokinin A (NKA) and vasoactive intestinal peptide (VIP) measured by radio-immunoassay methods in external jugular blood] between responders and nonresponders. In all responders to rizatriptan, pain was unilateral, severe, and pulsating, and in five of them at least one sign suggestive of parasympathetic system activation was recorded. Five patients who were non-responders to rizatriptan referred bilateral and non-pulsating pain, even though severe in most of them. CGRP and NKA levels measured before rizatriptan administration were significantly higher in responders than in non-responders ( P < 0.0001 and P < 0.002, respectively). In the five patients with autonomic signs among rizatriptan responders, detectable VIP levels were found at baseline. One hour after rizatriptan administration, a decrease in CGRP and NKA levels was evident in the external jugular venous blood of rizatriptan responders, and this corresponded to a significant pain relief and alleviation of accompanying symptoms. VIP levels were also significantly reduced at the same time in the five patients with autonomic signs. After rizatriptan administration, CGRP and NKA levels in non-responder patients showed less significant variations at all time points after rizatriptan administration compared with rizatriptan responders. The present study, although carried out on a limited number of patients, supports recent clinical evidence of increased trigeminal activation associated with a better triptan response in migraine patients accompanied by parasympathetic activation in a subgroup of patients with autonomic signs. In contrast, the poor response seems to be correlated with a lesser degree of trigeminal activation, lower variations of trigeminal neuropeptides after triptan administration, and no evidence of parasympathetic activation at baseline.

Sumatriptan fast-disintegrating/rapid-release tablets in the acute treatment of migraine

Sumatriptan is the first serotonin (5-hydroxytryptamine [5-HT](1B/1D)) receptor agonist specifically designed for the acute treatment of migraine. A new sumatriptan fast disintegrating/rapid release tablet (FDT/RRT) using RT technology has been developed to enhance tablet disintegration and dispersion in the stomach with the intention of speeding absorption and onset of effect, hence mitigating the effects on the gastrointestinal dysmotility that typically accompanies the attack. Sumatriptan FDT/RRT is bioequivalent to conventional tablets, although it provides slightly faster absorption during early post-dose interval. Clinical trials indicate that sumatriptan FDT/RRT is rapidly effective in terms of freedom from pain and return to normal activities, both with early and late treatment. The drug is well tolerated. In an oral formulation, which is the patients' preferred dosing route, sumatriptan FDT/RRT may therefore constitute an advance in the management of acute migraine attacks.

Efficacy of almotriptan 12.5 mg in achieving migraine-related composite endpoints: a double-blind, randomized, placebo-controlled study in patients controlled study in patients with previous poor response to sumatriptan 50 mg

BACKGROUND

Triptans are not identical and migraine sufferers respond differently to different triptans. Few studies have evaluated the efficacy of switching triptans in migraine patients who have shown poor response to another agent.

OBJECTIVE

To investigate the efficacy and tolerability of almotriptan 12.5 mg in patients who did not achieve 2-h pain relief with sumatriptan 50 mg.

METHODS

This double-blind, placebo-controlled study recruited patients with IHS-defined migraine and at least 2 previous unsatisfactory responses to sumatriptan. Those who did not achieve pain relief (moderate or severe pain decreasing to mild or no pain) 2 h after taking oral sumatriptan 50 mg on an open-label basis for the treatment of their first migraine attack during this trial (Attack 1) were randomized to receive either oral almotriptan 12.5 mg or placebo for the treatment of their next migraine attack (Attack 2).

RESULTS

Of 302 patients receiving sumatriptan 50 mg for the treatment of their first migraine attack, 221 (73%) did not achieve 2-h pain relief and were randomized to almotriptan 12.5 mg or placebo for the treatment of Attack 2. The majority (70%) of randomized patients treating their headache in Attack 2 reported severe pain at baseline characterizing this as a difficult-to-treat population. In the intent-to-treat population (n = 198), significantly more patients in the almotriptan group compared with the placebo group achieved 2-h complete relief (free from pain and migraine-associated symptoms) at 2 h (17.1% vs. 4.4%; p < 0.05) and sustained pain free (20.9% vs. 9.0%; p < 0.05). Adverse events of mild-to-moderate intensity occurred in 7.1% of patients in the almotriptan group compared to 5.1% in the placebo group (not statistically different).

CONCLUSION

Almotriptan is more effective than placebo and similarly well-tolerated for the acute treatment of migraine in patients who responded poorly to oral sumatriptan.

Psychiatric perspectives on headache and facial pain

For a subset of headache patients, an understanding of psychological antecedents and interpersonal difficulties is an important part of the headache evaluation. This subset includes patients with chronic headache, frequent headache, treatment-refractory headache, analgesic misuse problems, and serious compliance issues. Inadequate coping with stress is central to the persistence of headache in many such patients. Other patients present to the headache specialist but actually suffer from a serious comorbid psychiatric disorder, such as major depression, panic disorder, substance abuse, or personality disorder. For successful treatment of headache, it is important that these related problems be detected and either treated (as outlined here) or referred to a specialist for treatment.

Single use of sumatriptan: a patient interview study

OBJECTIVE

To investigate the possible reasons associated with the use of a single prescription of sumatriptan.

BACKGROUND

A few population-based studies concerning the usage patterns of sumatriptan have revealed a relatively high incidence (approximately 40%) of sumatriptan users who utilize only a single prescription of the drug.

DESIGN AND METHODS

Using automated prescription data from 11 community pharmacies, we identified single and multiple sumatriptan prescription recipients. The data were collected from May 1, 1998, to April 30, 2000. Several patient- and medication-related variables possibly associated with single recipiency of sumatriptan were analyzed. In addition, single recipients of sumatriptan were invited for an interview and asked a number of questions related to their clinical status and their experience with the medication.

RESULTS

Four hundred ninety-five, first-time users of sumatriptan were identified during the patient selection period, of whom 38% were single recipients of sumatriptan. Of the latter, 102 patients were considered eligible for interview. Reasons for terminating treatment after only 1 prescription included: inefficacy and/or occurrence of side effects, 78% (n=79); uncertain diagnosis of migraine, 39.2% (n=40); and reduction in headache frequency, 33.3% (n=34). Almost half of the population had terminated treatment without having consulted their physician. More than half relied upon the use of over-the-counter (OTC) analgesics after having tried sumatriptan. Compared to multiple users of sumatriptan, single recipients were far less likely to have used another form of migraine treatment prior to (odds ratio, 0.35; [95% confidence interval, 019 to 0.67]) and after (odds ratio, 0.34 [95% confidence interval, 0.19 to 0.63]) initiating sumatriptan. Furthermore, single recipients had demonstrated an increased tendency towards benzodiazepine use prior to receiving sumatriptan (odds ratio, 1.80 [95% confidence interval, 1.00 to 3.28]).

CONCLUSIONS

Single use of a sumatriptan prescription reveals some issues that may impact negatively the provision of effective migraine management. These include: rapidly developing dissatisfaction with the treatment provided and a lower tendency to seek out medical care. Our results also suggest that the drug may be used (inappropriately) as a diagnostic tool.