Escitalopram and venlafaxine for the prophylaxis of migraine headache without mood disorders

Efficacy and safety of venlafaxine versus nortriptyline for the preventive treatment of migraine: A double-blind randomized clinical trial

OBJECTIVE

Migraine, as a primary headache disorder, stands as one of the primary causes of disability worldwide. Consequently, prophylactic treatments are highly recommended for individuals experiencing recurrent migraine episodes. Our study aimed to compare the efficacy and safety profiles of venlafaxine and nortriptyline in the prophylactic management of migraine.

METHODS

In this single-center, randomized, double-blind clinical trial, 210 migraine patients were allocated into two groups in a 1:1 ratio. One group received venlafaxine (37.5 mg, orally twice daily), while the other group administered nortriptyline (25 mg, orally once daily). A neurologist documented (1) headache intensity using the Visual Analog Scale (VAS) and 6-point Behavioral Rating Scale (BRS-6), (2) headache frequency (per month), and (3) headache duration (in hours) of participants on days 0, 45, and 90 of the intervention.

RESULTS

Following the 90-day intervention, a significant decrease was observed in VAS, BRS-6, frequency, and duration of headaches within both groups (all with p-values <0.001). No difference in VAS, BRS-6, or headache durations was observed between the two groups after 45 and 90 days of treatment (all p-values > 0.05). Although the headache frequency exhibited no difference between the groups after 45 days (p-value = 0.097), a significantly lower frequency in the venlafaxine group was observed at day 90 of the intervention (p-value = 0.011). The reductions in attack parameters in the 0-45- and 0-90-day intervals did not meet statistical significance between the two groups (p-values > 0.05). 77.0 % of the participants in the venlafaxine group and 79.2 % in the nortriptyline group experienced a minimum of 50 % improvement in all attack parameters. Venlafaxine demonstrated a statistically significant lower incidence of adverse reactions in comparison to nortriptyline (p-value = 0.005). A total of 33 adverse drug reactions were documented in the venlafaxine group and 53 in the nortriptyline group, with insomnia observed in the former and xerostomia in the latter as the most prevalent side effects.

CONCLUSIONS

Venlafaxine and nortriptyline demonstrate clinically significant and comparable therapeutic efficacy for migraine patients in reducing the intensity, frequency, and duration of headache attacks. Venlafaxine may be preferred to nortriptyline in the context of migraine preventive treatment under comparable conditions due to its lower incidence of adverse effects.

Clinical efficacy of escitalopram combined with botulinum toxin A in patients with generalized anxiety disorder and comorbid headache

BACKGROUND

Generalized anxiety disorder (GAD) is a common mental disorder that happens comorbidly with other diseases. Headache is a common anxiety comorbidity. Previous reports have shown that the selection of therapeutic drugs for GAD patients and comorbid headache is challenging. Therefore, our study aimed to investigate the clinical efficacy of escitalopram combined with botulinum toxin A (BoNT/A) in patients with GAD and comorbid headache and seek an alternative treatment strategy for the comorbidity of GAD and headache.

METHODS

A prospective, randomized controlled, double-blind study was performed. The eligible GAD patients with comorbid headache were randomly assigned to the BoNT/A group and the placebo group. All the patients were given oral escitalopram therapy (10-20 mg/day) for the whole duration of the study. The BoNT/A group was given local injections of BoNT/A (50 U per person), whereas the placebo group was given local saline (0.9% NaCl) injections at the beginning and 3 months after the experiments. All participants were followed up for 6 months and relevant information was collected at months 0, 1, 2, 3, and 6. Primary outcomes included the following: (1) the Generalized Anxiety Disorder 7 (GAD-7); (2) the Self-rating Anxiety Scale (SAS); (3) the Hamilton Anxiety Rating Scales (HAMA); (4) days with headache per month; (5) visual analogue scale (VAS).

RESULTS

A total of 101 patients (the sex ratio of female to male: 3.39:1) were finally included. Compared with the placebo group, the BoNT/A group showed a significant decrease in GAD-7 scores, SAS scores, HAMA scores, days with headache per month, and VAS scores at months 1, 2, 3, and 6 of follow-up (all p < 0.05). The average time to complete remission of anxiety symptoms (HAMA< 7 points) in the BoNT/A group was less than the placebo group (2 months vs. 3 months). At the same time, the results of the survival analysis showed a clear beneficial effect of BoNT/A relative to placebo on the time to remission of anxiety (log-rank test, p < 0.001). Mean daily doses of escitalopram at the sixth month in the BoNT/A group was smaller than the placebo group (12.5 mg vs. 16.04 mg, p < 0.001). The number of patients who relapsed (HAMA total score ≥ 14 points) at 6 months of follow-up in the BoNT/A group was less than the placebo group (2.2% vs. 14.9%, p < 0.05). The rates of response (HAMA subtraction rate ≥ 50%) were 93.8% for the BoNT/A group and 75.5% for the placebo group (p < 0.05), and the rates of remission (HAMA < 7 points) were 87.5% for the BoNT/A group and 64.2% for the placebo group (p < 0.01) at the sixth month.

CONCLUSION

The combination of escitalopram with BoNT/A is a significantly effective intervention in improving clinical efficacy and reducing the recurrence in patients with GAD and comorbid headache, and we believe that this approach will be an additional treatment strategy for future treatment of comorbid headache in GAD. Therefore, we recommend that escitalopram combined with BoNT/A should be given as early as possible in GAD patients and comorbid headache.

Approach to headache disorders and the management of migraine: consensus guidelines from the Headache Society of Singapore, first edition (2023)

Headache disorders, particularly migraine, are one of the most common and disabling neurological disorders. There is a need for high-quality, accessible care for patients with headache disorders across all levels of the healthcare system in Singapore. The role of the Headache Society of Singapore is to increase awareness and advance the understanding of these disorders and to advocate for the needs of affected patients. In this first edition of local consensus guidelines, we focus on treatment approaches for headaches and provide consensus recommendations for the management of migraine in adults. The recommendations in these guidelines can be used as a practical tool in routine clinical practice by primary care physicians, neurologists and other healthcare professionals who have a common interest in headache disorders.

Off-label Uses of Selective Serotonin Reuptake Inhibitors (SSRIs)

Psychiatric drugs have primacy for off-label prescribing. Among those, selective serotonin reuptake inhibitors (SSRIs) are highly versatile and, therefore, widely prescribed. Moreover, they are commonly considered as having a better safety profile compared to other antidepressants. Thus, when it comes to off-label prescribing, SSRIs rank among the top positions. In this review, we present the state of the art of off-label applications of selective serotonin reuptake inhibitors, ranging from migraine prophylaxis to SARS-CoV-2 antiviral properties. Research on SSRIs provided significant evidence in the treatment of premature ejaculation, both with the on-label dapoxetine 30 mg and the off-label paroxetine 20 mg. However, other than a serotoninergic syndrome, serious conditions like increased bleeding rates, hyponatremia, hepatoxicity, and post-SSRIs sexual dysfunctions, are consistently more prominent when using such compounds. These insidious side effects might be frequently underestimated during common clinical practice, especially by nonpsychiatrists. Thus, some points must be addressed when using SSRIs. Among these, a psychiatric evaluation before every administration that falls outside the regulatory agencies-approved guidelines has to be considered mandatory. For these reasons, we aim with the present article to identify the risks of inappropriate uses and to advocate the need to actively boost research encouraging future clinical trials on this topic.

Acute and Preventive Management of Migraine during Menstruation and Menopause

Migraine course is influenced by female reproductive milestones, including menstruation and perimenopause; menstrual migraine (MM) represents a distinct clinical entity. Increased susceptibility to migraine during menstruation and in perimenopause is probably due to fluctuations in estrogen levels. The present review provides suggestions for the treatment of MM and perimenopausal migraine. MM is characterized by long, severe, and poorly treatable headaches, for which the use of long-acting triptans and/or combined treatment with triptans and common analgesics is advisable. Short-term prophylaxis with triptans and/or estrogen treatment is another viable option in women with regular menstrual cycles or treated with combined hormonal contraceptives; conventional prevention may also be considered depending on the attack-related disability and the presence of attacks unrelated to menstruation. In women with perimenopausal migraine, hormonal treatments should aim at avoiding estrogen fluctuations. Future research on migraine treatments will benefit from the ascertainment of the interplay between female sex hormones and the mechanisms of migraine pathogenesis, including the calcitonin gene-related peptide pathway.

Evidence of new-onset depression among persons with migraine after discontinuing antidepressants

Antidepressants have been hypothesized to cause tardive dysphoria-the delayed development of negative emotional symptoms. We assessed the risk of tardive dysphoria in a cohort of persons with migraine taking anti-migraine antidepressants with no known diagnosis of any mood or anxiety disorder. We included all outpatient encounters in a university hospital system for migraine from January 2008 through October 2018, excluding subjects with prior psychiatric diagnoses. Kaplan-Meier survival curves and multivariable Cox proportional hazards analyses were conducted. 13,048 subjects were included; 1191 took an antidepressant; 402 discontinued an antidepressant. In multivariable analyses examining the first year after exposure, antidepressant use was not significantly associated with risk of a depression, any mood disorder (including depression, mania, and other mood disorders), or anxiety. Antidepressant discontinuation was significantly associated with increased risk of depression, but not any mood disorder or anxiety. Among persons with migraine with no known psychiatric diagnosis, antidepressants did not appear to be associated with indicators of tardive dysphoria. Antidepressant discontinuation, however, was associated with increased risk of a depression diagnosis.

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.

Migraine: navigating the hormonal minefield

Migraine affects 959 million people worldwide,1 with the highest prevalence being in women of childbearing age. The interplay between female hormones and migraine can be a challenging area to navigate since issues relating to pregnancy, contraception and the menopause are often out of the neurology comfort zone. This review aims to help the neurologist to manage women with migraine, from menarche to menopause.

Botulinum Toxin a Valuable Prophylactic Agent for Migraines and a Possible Future Option for the Prevention of Hormonal Variations-Triggered Migraines

BACKGROUND

In 1989, Botulinum toxin (BoNT) was accepted by the FDA for the management of some ophthalmic disorders. Although it was initially considered a lethal toxin, in recent times, Botulinum toxin A (BoNT-A), which is the more used serotype, has expanded to cover different clinical conditions, primarily characterized by neuropathic pain, including migraines and headaches. Evidence suggests that migraines are influenced by hormonal factors, particularly by estrogen levels, but very few studies have investigated the prevalence and management strategies for migraines according to the hormonal status. The effects of several therapeutic regimens on migraines have been investigated, but the medications used varied widely in proven efficacies and mechanisms of action. BoNT-A is increasingly used in the management of migraine and several placebo-controlled trials of episodic and chronic migraine are currently underway. This paper is a review of the recently published data concerning the administration of BoNT-A in the prevention of chronic migraines. Considering the lack of population-based studies about the effectiveness of BoNT-A in the alleviation of premenstrual and perimenopausal migraines, this study proposes a new perspective of the therapeutic approach of migraine syndrome associated with menopausal transition and the premenstrual period.

METHODS

We selected the reviewed papers from CrossRef, PubMed, Medline, and GoogleScholar, and a total of 21 studies met our inclusion criteria.

RESULTS

To date, no specific preventive measures have been recommended for menopausal women with migraines. BoNT-A often reduces the frequency and intensity of migraine attacks per month; the treatment is well tolerated and does not exhibit a significantly higher rate of treatment-related side effects. No population-based studies were conducted in order to highlight the role of BoNT-A in menopause-related migraines, neither in menstrual migraines.

CONCLUSION

There is a need for further research in order to quantify the real burden of menstrual and perimenopausal migraines and to clarify if BoNT-A could be used in the treatment of refractory postmenopausal and premenstrual migraines.

[Migraine in women: clinical and therapeutical aspects]

Migraine is one of the most common neurological disorders, affecting women. Physiological changes in the hormonal status can modulate the functional status of pain and analgesic systems of the brain and, by involving different pathophysiological mechanisms, change the course of migraine. In addition to an analysis of epidemiological data, the review provides current views on the clinical features of the disease in women population at different periods of life, particular attention was focused on menstrual migraine. It has certain features, such as acute and long attacks and treatment difficulties. One of main issues is the use of oral contraceptives in women with migraine according to the ratio of potential benefit to cardiovascular risk. The problems of treatment headaches in pregnant and breastfeeding women are also considered. An influence of migraine on the course and outcome of pregnancy was shown. The authors analysed the results of the studies on the course of migraine during perimenopause and postmenopause and recommendations for women with migraine attacks and climacteric syndrome. The data presented in the review are useful for clinicians, because this information represents new views on pathogenetic mechanisms, clinical features and treatment of migraine in women.

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.

Meta-analysis: Second generation antidepressants and headache

BACKGROUND

To assess the risk of headache associated with commonly prescribed antidepressant medications and to examine the impact of medication class, pharmacodynamics and dosage on risk of headache.

METHODS

We searched PubMed to identify all randomized, double-blind, placebo-controlled trials examining the efficacy of second generation antidepressant medications in the treatment of adults with depression, anxiety or obsessive-compulsive disorders. We used a fixed-effect meta-analysis to examine the pooled risk ratio of headache reported as a side-effect in adults treated with second generation antidepressants compared to placebo. We used stratified subgroup analysis and meta-regression to examine the effects of medication type, class, dosage, indication, and receptor affinity profile on the measured risk of headache.

RESULTS

SSRIs were associated with a significantly increased risk of headache (RR = 1.06, 95%CI = 1.00-1.13, z = 2.0, p = 0.045) when compared to placebo. There was no significant difference (test for subgroup differences χ² = 2.2, df = 1, p = 0.14) in the risk of headache between SSRIs and SNRIs (RR = 0.97, 95%CI = 0.88-1.06, p = 0.63). There was no significant difference in the relative risk of headache with second generation antidepressants based on diagnostic indication, pharmacological properties and dosage of medications. The only antidepressants that were found to be significantly associated with increased risk of headache compared to placebo were bupropion (RR = 1.22, 95%CI = 1.06-1.41, z = 2.73, p = 0.006) and escitalopram (RR = 1.18, 95%CI = 1.01-1.37, z = 2.11, p = 0.04).

LIMITATIONS

The small number of studies that examined side effects within fixed-dose trials may have limited the power to examine the association between medication dosing and risk of headache. Additionally, reporting bias could potentially occur non-randomly across agents and therefore effect meta-analysis results.

CONCLUSIONS

Headaches reported after the initiation of second generation antidepressant medications are more likely to be coincidental than a treatment-emergent side effect of these medications.

Current Treatment Options: Headache Related to Menopause-Diagnosis and Management

PURPOSE OF REVIEW

Menopause is a life-changing event in numerous ways. Many women with migraine hold hope that the transition to the climacteric state will coincide with a cessation or improvement of migraine. This assumption is based mainly on common lay perceptions as well as assertions from many in the healthcare community. Unfortunately, evidence suggests this is far from the rule. Many women turn to a general practitioner or a headache specialist for prognosis and management. A natural instinct is to manipulate the offending agent, but in some cases, this approach backfires, or the concern for adverse events outweighs the desire for a therapeutic trial, and other strategies must be pursued. Our aim was to review the frequency and type of headache syndromes associated with menopause, to review the evidence for specific treatments for headache associated with menopause, and to provide management recommendations and prognostic guidance.

RECENT FINDINGS

We reviewed both clinic- and population-based studies assessing headache associated with menopause. Headache in menopause is less common than headache at earlier ages but can present a unique challenge. Migraine phenotype predominates, but presentations can vary or be due to secondary causes. Other headache types, such as tension-type headache (TTH) and cluster headache (CH) may also be linked to or altered by hormonal changes. There is a lack of well-defined diagnostic criteria for headache syndromes associated with menopause. Women with surgical menopause often experience a worse course of disease status than those with natural menopause. Hormonal replacement therapy (HRT) often results in worsening of migraine and carries potential for increased cardiovascular and ischemic stroke risk. Estrogen replacement therapy (ERT) in patients with migraine with aura (MA) may increase the risk of ischemic stroke; however, the effect is likely dose-dependent. Some medications used in the prophylaxis of migraine may be useful in ameliorating the vasomotor and mood effects of menopause, including venlafaxine, escitalopram, paroxetine, and gabapentin. Other non-medication strategies such as acupuncture, vitamin E, black cohosh, aerobic exercise, and yoga may also be helpful in reducing headache and/or vasomotor symptoms associated with menopause. The frequency and type of headache associated with menopause is variable, though migraine and TTH are most common. Women may experience a worsening, an improvement, or no change in headache during the menopausal transition. Treatment may be limited by vascular risks or other medical and psychiatric factors. We recommend using medications with dual benefit for migraine and vasomotor symptoms including venlafaxine, escitalopram, paroxetine, and gabapentin, as well as non-medication strategies such as acupuncture, vitamin E, black cohosh, aerobic exercise, and yoga. If HRT is pursued, continuous (rather than cyclical) physiological doses should be used, transdermal route of administration is recommended, and the patient should be counseled on the potential for increased risk of adverse events (AEs). Concomitant use of a progestogen decreases the risk of endometrial hyperplasia with ERT. Biological mechanisms are incompletely understood, and there is a lack of consensus on how to define and classify headache in menopause. Further research to focus on pathophysiology and nuanced management is desired.

Comorbidity of Migraine, Major Depressive Disorder, and Generalized Anxiety Disorder in Adolescents and Young Adults

PURPOSE

Depression and anxiety are highly comorbid psychiatric conditions and both are common in adult patients with migraine. This study aims to examine the unique associations between major depressive disorder (MDD) and generalized anxiety disorder (GAD) in a well-characterized group of older adolescents and college-age individuals with migraine.

METHOD

Participants (N =  227), between 15 and 20 years old, who were unmedicated or within 1 month of beginning antidepressant treatment underwent a comprehensive psychiatric assessment to establish the presence of MDD and GAD, according to the Diagnostic and Statistical Manual, Fourth Edition, Text Revision, and to rate their symptom severity using the Longitudinal Interval Follow-up Evaluation for Adolescents (A-LIFE). They then completed the ID-Migraine. The Student's t test and chi-square test were used to compare continuous and categorical variables, respectively, across participants with vs. without migraine. Logistic regression analysis examined the association between the presence of migraine and psychopathology.

RESULTS

A diagnosis of MDD was associated with significantly increased risk of having migraine. Moreover, more severe and persistent ratings of depression were associated with an even higher likelihood of having migraine. A diagnosis of GAD was also significantly associated with the presence of migraine. The prevalence of comorbid MDD and GAD was significantly higher in participants with migraine than those without migraine (55 vs. 22%, p < 0.0001). When examined concurrently, GAD remained significantly associated with migraine, with a statistical trend for MDD to be associated with it.

CONCLUSION

The comorbidity of migraine, MDD, and GAD has important clinical and research implications. Patients who suffer from any of these problems should be screened for all three in order to receive comprehensive care. Shared psychological and biological vulnerabilities may be involved in the three conditions. Greater understanding of the shared vulnerabilities can lead to unified treatments.

Serotonin and Norepinephrine Reuptake Inhibitors

This chapter covers antidepressants that fall into the class of serotonin (5-HT) and norepinephrine (NE) reuptake inhibitors. That is, they bind to the 5-HT and NE transporters with varying levels of potency and binding affinity ratios. Unlike the selective serotonin (5-HT) reuptake inhibitors (SSRIs), most of these antidepressants have an ascending rather than a flat dose-response curve. The chapter provides a brief review of the chemistry, pharmacology, metabolism, safety and adverse effects, clinical use, and therapeutic indications of each antidepressant. Venlafaxine, a phenylethylamine, is a relatively weak 5-HT and weaker NE uptake inhibitor with a 30-fold difference in binding of the two transporters. Therefore, the drug has a clear dose progression, with low doses predominantly binding to the 5-HT transporter and more binding of the NE transporter as the dose ascends. Venlafaxine is metabolized to the active metabolite O-desmethylvenlafaxine (ODV; desvenlafaxine) by CYP2D6, and it therefore is subject to significant inter-individual variation in blood levels and response dependent on variations in CYP2D6 metabolism. The half-life of venlafaxine is short at about 5 h, with the ODV metabolite being 12 h. Both parent compound and metabolite have low protein binding and neither inhibit CYP enzymes. Therefore, both venlafaxine and desvenlafaxine are potential options if drug-drug interactions are a concern, although venlafaxine may be subject to drug-drug interactions with CYP2D6 inhibitors. At low doses, the adverse effect profile is similar to an SSRI with nausea, diarrhea, fatigue or somnolence, and sexual side effects, while venlafaxine at higher doses can produce mild increases in blood pressure, diaphoresis, tachycardia, tremors, and anxiety. A disadvantage of venlafaxine relative to the SSRIs is the potential for dose-dependent blood pressure elevation, most likely due to the NE reuptake inhibition caused by higher doses; however, this adverse effect is infrequently observed at doses below 225 mg per day. Venlafaxine also has a number of potential advantages over the SSRIs, including an ascending dose-antidepressant response curve, with possibly greater overall efficacy at higher doses. Venlafaxine is approved for MDD as well as generalized anxiety disorder, social anxiety disorder, and panic disorder. Desvenlafaxine is the primary metabolite of venlafaxine, and it is also a relatively low-potency 5-HT and NE uptake inhibitor. Like venlafaxine it has a favorable drug-drug interaction profile. It is subject to CYP3A4 metabolism, and it is therefore vulnerable to enzyme inhibition or induction. However, the primary metabolic pathway is direct conjugation. It is approved in the narrow dose range of 50-100 mg per day. Duloxetine is a more potent 5-HT and NE reuptake inhibitor with a more balanced profile of binding at about 10:1 for 5HT and NE transporter binding. It is also a moderate inhibitor of CYP2D6, so that modest dose reductions and careful monitoring will be needed when prescribing duloxetine in combination with drugs that are preferentially metabolized by CYP2D6. The most common side effects identified in clinical trials are nausea, dry mouth, dizziness, constipation, insomnia, asthenia, and hypertension, consistent with its mechanisms of action. Clinical trials to date have demonstrated rates of response and remission in patients with major depression that are comparable to other marketed antidepressants reviewed in this book. In addition to approval for MDD, duloxetine is approved for diabetic peripheral neuropathic pain, fibromyalgia, and musculoskeletal pain. Milnacipran is marketed as an antidepressant in some countries, but not in the USA. It is approved in the USA and some other countries as a treatment for fibromyalgia. It has few pharmacokinetic and pharmacodynamic interactions with other drugs. Milnacipran has a half-life of about 10 h and therefore needs to be administered twice per day. It is metabolized by CYP3A4, but the major pathway for clearance is direct conjugation and renal elimination. As with other drugs in this class, dysuria is a common, troublesome, and dose-dependent adverse effect (occurring in up to 7% of patients). High-dose milnacipran has been reported to cause blood pressure and pulse elevations. Levomilnacipran is the levorotary enantiomer of milnacipran, and it is pharmacologically very similar to the racemic compound, although the side effects may be milder within the approved dosing range. As with other NE uptake inhibitors, it may increase blood pressure and pulse, although it appears to do so less than some other medications. All medications in the class can cause serotonin syndrome when combined with MAOIs.

Migraine, menopause and hormone replacement therapy

Perimenopause marks a period of increased migraine prevalence in women and many women also report troublesome vasomotor symptoms. Migraine is affected by fluctuating estrogen levels with evidence to support estrogen 'withdrawal' as a trigger of menstrual attacks of migraine without aura, while high estrogen levels can trigger migraine aura. Maintaining a stable estrogen environment with estrogen replacement can benefit estrogen-withdrawal migraine particularly in women who would also benefit from relief of vasomotor symptoms. In contrast to contraceptive doses of ethinylestradiol, migraine aura does not contraindicate use of physiological doses of natural estrogen. In women with migraine with or without aura, using only the lowest doses of transdermal estrogen necessary to control vasomotor symptoms minimizes the risk of unwanted side effects. Cyclical progestogens can have an adverse effect on migraine so continuous progestogens, as provided by the levonorgestrel intrauterine system or in continuous combined transdermal preparation, are preferred. There are no data on the effect of micronized progesterone on migraine, either cyclical or continuous. Non-hormonal options for both conditions are limited but there is evidence of efficacy for escitalopram and venflaxine.

Treating depression in multiple sclerosis with antidepressants: A brief review of clinical trials and exploration of clinical symptoms to guide treatment decisions

Depression is a common comorbidity in patients with multiple sclerosis (MS). Those with MS and concurrent depression have poorer quality of life and are also less likely to be compliant with disease-modifying treatment, which may ultimately affect their MS disease course. Treating depression in MS with pharmacological agents can improve not only depression, but may also impact the MS disease course. However, no guidelines exist around treating depression in MS. Few randomized-controlled trials using antidepressants in MS exist. Here, we briefly review trials using antidepressant medications to treat depression in MS. We also propose individualizing treatment of depression in MS, as the depressive symptoms and MS symptoms and disease course differ significantly between patients. We explore the heterogeneity in presentation of depression through different comorbid symptoms in MS, and discuss which antidepressant options would be appropriate in each situation. We propose that future clinical trials should incorporate differences in issues between those with depression (e.g. sexual dysfunction, urinary incontinence) into analysis. As MS is incredibly heterogeneous, treating concurrent depression on a case-by-case basis may enable for improving quality of life and the MS disease course.

Chronic Daily Headache: Mechanisms and Principles of Management

Primary headache is a common malady that is often under-recognized and frequently inadequately managed in spite of the fact that it affects up to 95 % of the population in a lifetime. Many forms of headache, including episodic tension and migraine headaches, if properly diagnosed, are reasonably amenable to treatment, but a smaller, though not insignificant, percent of the population suffer daily from a chronic, intractable form of headache that destroys one's productivity and quality of life. These patients are frequently seen in neurological practices at a point when treatment options are limited and largely ineffective. In the following review, we will discuss mechanisms drawn from recent studies that address the transition from acute to chronic pain that may apply to the transformation from episodic to chronic daily headaches which may offer opportunities for preempting headache transformation.

General lack of use of placebo in prophylactic, randomised, controlled trials in adult migraine. A systematic review

Background

The Clinical Trials Subcommittee of the International Headache Society (IHS) recommends that a placebo arm is included in comparative randomised clinical trials (RCTs) of multiple prophylactic drugs due to the highly variable placebo response in migraine prophylaxis studies. The use of placebo control in such trials has not been systematically assessed.

Methods

We performed a systematic review of all comparative RCTs of prophylactic drug treatment of migraine published in English from 2002 to 2014. PubMed was searched using the Cochrane Highly Sensitive Search Strategy for identifying reports of RCTs.

Results

A placebo arm was used in <10% (three of 31) of prophylactic RCTs in migraine. In only 7.1% (two of 28) of the comparative RCTs without placebo was one drug superior to another drug. Thus in 26 RCTs, including one study requiring more than 75,000 patient days, no difference was identified across treatment arms and conclusions regarding drug superiority could not be drawn.

Conclusions

The majority of comparative, prophylactic migraine RCTs do not include a placebo arm. Failure to include a placebo arm may result in failure to demonstrate efficacy of potentially effective migraine-prophylactic agents. In order to benefit current and future patients, the current strong tendency to omit placebo-controls in these RCTs should be replaced by adherence to the guidelines of the IHS.

Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) for the prevention of migraine in adults

BACKGROUND

This is an updated version of the original Cochrane review published in 2005 on selective serotonin reuptake inhibitors (SSRIs) for preventing migraine and tension-type headache. The original review has been split in two parts and this review now only regards migraine prevention. Another updated review is under development to cover tension-type headache.Migraine is a common disorder. The chronic forms are associated with disability and have a high economic impact. In view of discoveries about the role of serotonin and other neurotransmitters in pain mechanisms, selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have been evaluated for the prevention of migraine.

OBJECTIVES

To determine the efficacy and tolerability of SSRIs and SNRIs compared to placebo and other active interventions in the prevention of episodic and chronic migraine in adults.

SEARCH METHODS

For the original review, we searched MEDLINE (1966 to January 2004), EMBASE (1994 to May 2003), the Cochrane Central Register of Controlled Trials (CENTRAL 2003, Issue 4), and Headache Quarterly (1990 to 2003). For this update, we applied a revised search strategy to reflect the broader type of intervention (SSRIs and SNRIs). We searched CENTRAL (2014, Issue 10), MEDLINE (1946 to November 2014), EMBASE (1980 to November 2014), and PsycINFO (1987 to November 2014). We also checked the reference lists of retrieved articles and searched trial registries for ongoing trials.

SELECTION CRITERIA

We included randomised controlled trials comparing SSRIs or SNRIs with any type of control intervention in participants 18 years and older of either sex with migraine.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data (migraine frequency, index, intensity, and duration; use of symptomatic/analgesic medication; days off work; quality of life; mood improvement; cost-effectiveness; and adverse events) and assessed the risk of bias of trials. The primary outcome of this updated review is migraine frequency.

MAIN RESULTS

The original review included eight studies on migraine. Overall, we now include 11 studies on five SSRIs and one SNRI with a total of 585 participants. Six studies were placebo-controlled, four compared a SSRI or SNRI to amitriptyline, and one was a head-to-head comparison (escitalopram versus venlafaxine). Most studies had methodological or reporting shortcomings (or both): all studies were at unclear risk of selection and reporting bias. Follow-up rarely extended beyond three months. The lack of adequate power of most of the studies is also a major concern.Few studies explored the effect of SSRIs or SNRIs on migraine frequency, the primary endpoint. Two studies with unclear reporting compared SSRIs and SNRIs to placebo, suggesting a lack of evidence for a difference. Two studies compared SSRIs or SNRIs versus amitriptyline and found no evidence for a difference in terms of migraine frequency (standardised mean difference (SMD) 0.04, 95% confidence interval (CI) -0.72 to 0.80; I(2) = 72%), or other secondary outcomes such as migraine intensity and duration.SSRIs or SNRIs were generally more tolerable than tricyclics. However, the two groups did not differ in terms of the number of participants who withdrew due to adverse advents or for other reasons (one study, odds ratio (OR) 0.39, 95% CI 0.10 to 1.50 and OR 0.42, 95% CI 0.13 to 1.34).We did not find studies comparing SSRIs or SNRIs with pharmacological treatments other than antidepressants (e.g. antiepileptics and anti-hypertensives).

AUTHORS' CONCLUSIONS

Since the last version of this review, the new included studies have not added high quality evidence to support the use of SSRIs or venlafaxine as preventive drugs for migraine. There is no evidence to consider SSRIs or venlafaxine as more effective than placebo or amitriptyline in reducing migraine frequency, intensity, and duration over two to three months of treatment. No reliable information is available at longer-term follow-up. Our conclusion is that the use of SSRIs and SNRIs for migraine prophylaxis is not supported by evidence.

Italian guidelines for primary headaches: 2012 revised version

The first edition of the Italian diagnostic and therapeutic guidelines for primary headaches in adults was published in J Headache Pain 2(Suppl. 1):105-190 (2001). Ten years later, the guideline committee of the Italian Society for the Study of Headaches (SISC) decided it was time to update therapeutic guidelines. A literature search was carried out on Medline database, and all articles on primary headache treatments in English, German, French and Italian published from February 2001 to December 2011 were taken into account. Only randomized controlled trials (RCT) and meta-analyses were analysed for each drug. If RCT were lacking, open studies and case series were also examined. According to the previous edition, four levels of recommendation were defined on the basis of levels of evidence, scientific strength of evidence and clinical effectiveness. Recommendations for symptomatic and prophylactic treatment of migraine and cluster headache were therefore revised with respect to previous 2001 guidelines and a section was dedicated to non-pharmacological treatment. This article reports a summary of the revised version published in extenso in an Italian version.