Effectiveness of lamotrigine in the prophylaxis of migraine with aura: an open pilot study

Visual Disturbances Spectrum in Pediatric Migraine

Migraine is a complex neurological disorder with partially unknown pathophysiological mechanisms. The prevalence in childhood ranges from 7.7% to 17.8%, thus representing the most frequent primary headache. In half of the cases, migraine is accompanied or preceded by various neurological disturbances, among which the visual aura is the best known. In literature, other conditions, such as Alice in Wonderland Syndrome and Visual Snow syndrome, are characterized by visual manifestations and are often associated with migraine. The aim of this narrative review is to describe the spectrum of visual disturbances in pediatric migraine and their pathophysiological mechanisms.

Antiseizure Medications for the Prophylaxis of Migraine during the Anti- CGRP Drugs Era

Migraine and epilepsy are fundamentally distinct disorders that can frequently coexist in the same patient. These two conditions significantly differ in diagnosis and therapy but share some widely- used preventive treatments. Antiseizure medications (ASMs) are the mainstay of therapy for epilepsy, and about thirty different ASMs are available to date. ASMs are widely prescribed for other neurological and non-neurological conditions, including migraine. However, only topiramate and valproic acid/valproate currently have an indication for migraine prophylaxis supported by high-quality evidence. Although without specifically approved indications and with a low level of evidence or recommendation, several other ASMs are used for migraine prophylaxis. Understanding ASM antimigraine mechanisms, including their ability to affect the pro-migraine calcitonin gene-related peptide (CGRP) signaling pathway and other pathways, may be instrumental in identifying the specific targets of their antimigraine efficacy and may increase awareness of the neurobiological differences between epilepsy and migraine. Several new ASMs are under clinical testing or have been approved for epilepsy in recent years, providing novel potential drugs for migraine prevention to enrich the treatment armamentarium and drugs that inhibit the CGRP pathway.

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.

Updated review on the link between cortical spreading depression and headache disorders

INTRODUCTION

Experimental animal studies have revealed mechanisms that link cortical spreading depression (CSD) to the trigeminal activation mediating lateralized headache. However, conventional CSD as seen in lissencephalic brain is insufficient to explain some clinical features of aura and migraine headache.

AREAS COVERED

The importance of CSD in headache development including dysfunction of the thalamocortical network, neuroinflammation, calcitonin gene-related peptide, transgenic models, and the role of CSD in migraine triggers, treatment options, neuromodulation and future directions are reviewed.

EXPERT OPINION

The conventional understanding of CSD marching across the hemisphere is invalid in gyrencephalic brains. Thalamocortical dysfunction and interruption of functional cortical network systems by CSD, may provide alternative explanations for clinical manifestations of migraine phases including aura. Not all drugs showing CSD blocking properties in lissencephalic brains, have efficacy in migraine headache and monoclonal antibodies against CGRP ligand/receptors which are effective in migraine treatment, have no impact on aura in humans or CSD properties in rodents. Functional networks and molecular mechanisms mediating and amplifying the effects of limited CSD in migraine brain remain to be investigated to define new targets.

May lamotrigine be an alternative to topiramate in the prevention of migraine with aura? Results of a retrospective study

Background

Evidence suggests that lamotrigine could be effective in reducing aura frequency and duration. However, studies comparing lamotrigine to other, first-line prophylactic agents solely involving patients suffering from migraine with aura are still lacking. The aim of this study was to compare the efficacy of lamotrigine and topiramate for the preventive treatment of migraine with aura.

Methods

Fifty-three patients suffering from migraine with aura treated with lamotrigine or topiramate for at least 6 months were included. Pre- and post-treatment clinical data regarding monthly aura frequency and duration, monthly migraine frequency, days of headache and rescue medication used per month were collected.

Results

Responder rates were similar between the two treatment groups at 6-month follow-up. Interestingly, responder rates for aura frequency and duration were higher in the lamotrigine group compared with the topiramate group (88% vs 79% and 73% vs 54%). Moreover, 50% of the lamotrigine-treated patients reported a complete disappearance of migraine aura compared with 37% of topiramate-treated patients. Side effects were more frequent in topiramate group compared with lamotrigine group (p=0.004).

Conclusions

Lamotrigine should be considered in clinical practice for the preventive treatment of migraine with aura especially for patients reporting prolonged aura and who do not respond, have contraindications or discontinue topiramate treatment due to side effects.

Headache in the elderly

Headache is the most common neurologic symptom and affects nearly half the world's population at any given time. Although the prevalence declines with age, headache remains a common neurologic complaint among elderly populations. Headaches can be divided into primary and secondary causes. Primary headaches comprise about two-thirds of headaches among the elderly. They are defined by clinical criteria and are diagnosed based on symptom pattern and exclusion of secondary causes. Primary headaches include migraine, tension-type, trigeminal autonomic cephalalgias, and hypnic headache. Secondary headaches are defined by their suspected etiology. A higher index of suspicion for a secondary headache disorder is warranted in older patients with new-onset headache. They are roughly 12 times more likely to have serious underlying causes and, frequently, have different symptomatic presentations compared to younger adults. Various imaging and laboratory evaluations are indicated in the presence of any "red flag" signs or symptoms. Head CT is the procedure of choice for acute headache presentations, and brain MRI for those with chronic headache complaints. Management of headache in elderly populations can be challenging due to the presence of multiple medical comorbidities, polypharmacy, and differences in drug metabolism and clearance.

Aura and Head pain: relationship and gaps in the translational models

Migraine is a complex brain disorder and initiating events for acute attacks still remain unclear. It seems difficult to explain the development of migraine headache with one mechanism and/or a single anatomical location. Cortical spreading depression (CSD) is recognized as the biological substrate of migraine aura and experimental animal studies have provided mechanisms that possibly link CSD to the activation of trigeminal neurons mediating lateralized head pain. However, some CSD features do not match the clinical features of migraine headache and there are gaps in translating CSD to migraine with aura. Clinical features of migraine headache and results from research are critically evaluated; and consistent and inconsistent findings are discussed according to the known basic features of canonical CSD: typical SD limited to the cerebral cortex as it was originally defined. Alternatively, arguments related to the emergence of SD in other brain structures in addition to the cerebral cortex or CSD initiated dysfunction in the thalamocortical network are proposed. Accordingly, including thalamus, particularly reticular nucleus and higher order thalamic nuclei, which functions as a hub connecting the visual, somatosensory, language and motor cortical areas and subjects to modulation by brain stem projections into the CSD theory, would greatly improve our current understanding of migraine.

Lamotrigine in the Prevention of Migraine With Aura: A Narrative Review

BACKGROUND

Lamotrigine is not recommended in the prevention of migraine in general but some reports suggest that it might be effective for treating specifically migraine with aura (MA). This review aims to summarize the related data from the literature and to better understand this discrepancy.

METHODS

All reports from the literature related to the use of lamotrigine in migraine with or without aura published prior to February 2019 found using PUBMED and the 2 keywords "migraine" AND "lamotrigine" were reviewed. Original studies, published in full, systematic reviews, and all case reports were synthetized. We also examined the risk profile, pharmacokinetics, and mode of action of lamotrigine in view of the presumed mechanism of MA.

RESULTS

Lamotrigine was tested in different populations of migraineurs, but previous studies had small sample sizes (n < 35) and might not have been powered enough for detecting a potential benefit of lamotrigine in MA. Accumulating data suggest that the drug can reduce both the frequency and severity of aura symptoms in multiple conditions and is well tolerated.

CONCLUSION

Lamotrigine appears promising for treating attacks of MA and related clinical manifestations because of its high potential of efficacy, low-risk profile, and cost. Additional studies are needed for testing lamotrigine in patients with MA.

Diagnosis and Treatment of Primary Headache Disorders in Older Adults

OBJECTIVES

To provide a unique perspective on geriatric headache and a number of novel treatment options that are not well known outside of the headache literature.

DESIGN

Review of the most current and relevant headache literature for practitioners specializing in geriatric care.

RESULTS

Evaluation and management of headache disorders in older adults requires an understanding of the underlying pathophysiology and how it relates to age-related physiological changes. To treat headache disorders in general, the appropriate diagnosis must first be established, and treatment of headaches in elderly adults poses unique challenges, including potential polypharmacy, medical comorbidities, and physiological changes associated with aging.

CONCLUSION

The purpose of this review is to provide a guide to and perspective on the challenges inherent in treating headaches in older adults. J Am Geriatr Soc 66:2408-2416, 2018.

Understanding Spreading Depression from Headache to Sudden Unexpected Death

Spreading depression (SD) is a neurophysiological phenomenon characterized by abrupt changes in intracellular ion gradients and sustained depolarization of neurons. It leads to loss of electrical activity, changes in the synaptic architecture, and an altered vascular response. Although SD is often described as a unique phenomenon with homogeneous characteristics, it may be strongly affected by the particular triggering event and by genetic background. Furthermore, SD may contribute differently to the pathogenesis of widely heterogeneous clinical conditions. Indeed, clinical disorders related to SD vary in their presentation and severity, ranging from benign headache conditions (migraine syndromes) to severely disabling events, such as cerebral ischemia, or even death in people with epilepsy. Although the characteristics and mechanisms of SD have been dissected using a variety of approaches, ranging from cells to human models, this phenomenon remains only partially understood because of its complexity and the difficulty of obtaining direct experimental data. Currently, clinical monitoring of SD is limited to patients who require neurosurgical interventions and the placement of subdural electrode strips. Significantly, SD events recorded in humans display electrophysiological features that are essentially the same as those observed in animal models. Further research using existing and new experimental models of SD may allow a better understanding of its core mechanisms, and of their differences in different clinical conditions, fostering opportunities to identify and develop targeted therapies for SD-related disorders and their worst consequences.

Possible Involvement of the CACNA1E Gene in Migraine: A Search for Single Nucleotide Polymorphism in Different Clinical Phenotypes

OBJECTIVE

To search for differences in prevalence of a CACNA1E variant between migraine without aura, various phenotypes of migraine with aura, and healthy controls.

BACKGROUND

Familial hemiplegic migraine type 1 (FHM1) is associated with mutations in the CACNA1A gene coding for the alpha 1A (Ca_v 2.1) pore-forming subunit of P/Q voltage-dependent Ca²⁺ channels. These mutations are not found in the common forms of migraine with or without aura. The alpha 1E subunit (Ca_v 2.3) is the counterpart of Ca_v 2.1 in R-type Ca²⁺ channels, has different functional properties, and is encoded by the CACNA1E gene.

METHODS

First, we performed a total exon sequencing of the CACNA1E gene in three probands selected because they had no abnormalities in the three FHM genes. In a patient suffering from basilar-type migraine, we identified a single nucleotide polymorphism (SNP) in exon 20 of the CACNA1E gene (Asp859Glu - rs35737760; Minor Allele Frequency 0.2241) hitherto not studied in migraine. In a second step, we determined its occurrence in four groups by direct sequencing on blood genomic DNA: migraine patients without aura (N = 24), with typical aura (N = 55), complex neurological auras (N = 19; hemiplegic aura: N = 15; brain stem aura: N = 4), and healthy controls (N = 102).

RESULTS

The Asp859Glu - rs35737760 SNP of the CACNA1E gene was present in 12.7% of control subjects and in 20.4% of the total migraine group. In the migraine group it was significantly over-represented in patients with complex neurological auras (42.1%), OR 4.98 (95% CI: 1.69-14.67, uncorrected P = .005, Bonferroni P = .030, 2-tailed Fisher's exact test). There was no significant difference between migraine with typical aura (10.9%) and controls.

CONCLUSIONS

We identified a polymorphism in exon 20 of the CACNA1E gene (Asp859Glu - rs35737760) that is more prevalent in hemiplegic and brain stem aura migraine. This missense variant causes a change from aspartate to glutamate at position 859 of the Ca_v 2.3 protein and might modulate the function of R-type Ca²⁺ channels. It could thus be relevant for migraine with complex neurological aura, although this remains to be proven.

WITHDRAWN: Anticonvulsant drugs for migraine prophylaxis

July 2015: This review has been split and updated in a series of four new reviews (Linde 2013a; Linde 2013b; Linde 2013c; Linde 2013d). Readers are referred to those reviews for updated results. This review will not be updated.

May 2016: This review has now been withdrawn as it has been replaced by the four new titles listed above.

The editorial group responsible for this previously published document have withdrawn it from publication.

Biochemistry of primary headaches: role of tyrosine and tryptophan metabolism

The pathogenesis of migraine as well as cluster headache (CH) is yet a debated question. In this review, we discuss the possible role of the of tyrosine and tryptophan metabolism in the pathogenesis of these primary headaches. These include the abnormalities in the synthesis of neurotransmitters: high level of DA, low level of NE and very elevated levels of octopamine and synephrine (neuromodulators) in plasma of episodic migraine without aura and CH patients. We hypothesize that the imbalance between the levels of neurotransmitters and elusive amines synthesis is due to a metabolic shift directing tyrosine toward an increased decarboxylase and reduced hydroxylase enzyme activities. The metabolic shift of the tyrosine is favored by a state of neuronal hyperexcitability and a reduced mitochondrial activity present in migraine. In addition we present biochemical studies performed in chronic migraine and chronic tension-type headache patients to verify if the same anomalies of the tyrosine and tryptophan metabolism are present in these primary headaches and, if so, their possible role in the chronicity process of CM and CTTH. The results show that important abnormalities of tyrosine metabolism are present only in CM patients (very high plasma levels of DA, NE and tryptamine). Tryptamine plasma levels were found significantly lower in both CM and CTTH patients. In view of this, we propose that migraine and, possibly, CH attacks derive from neurotransmitter and neuromodulator metabolic abnormalities in a hyperexcitable and hypoenergetic brain that spread from the frontal lobe, downstream, resulting in abnormally activated nuclei of the pain matrix. The low tryptamine plasma levels found in CM and CTTH patients suggest that these two primary chronic headaches are characterized by a common insufficient serotoninergic control of the pain threshold.

Current Perspectives on the Beneficial Role of Ginkgo biloba in Neurological and Cerebrovascular Disorders

Ginkgo biloba extract is an alternative medicine available as a standardized formulation, EGb 761^®, which consists of ginkgolides, bilobalide, and flavonoids. The individual constituents have varying therapeutic mechanisms that contribute to the pharmacological activity of the extract as a whole. Recent studies show anxiolytic properties of ginkgolide A, migraine with aura treatment by ginkgolide B, a reduction in ischemia-induced glutamate excitotoxicity by bilobalide, and an alternative antihypertensive property of quercetin, among others. These findings have been observed in EGb 761 as well and have led to clinical investigation into its use as a therapeutic for conditions such as cognition, dementia, cardiovascular, and cerebrovascular diseases. This review explores the therapeutic mechanisms of the individual EGb 761 constituents to explain the pharmacology as a whole and its clinical application to cardiovascular and neurological disorders, in particular ischemic stroke.

Glutamate receptor antagonists in the management of migraine

Migraine is a neurovascular disorder that is associated with severe headache and neurologic symptoms. The pathogenesis of migraine is believed to involve trigeminovascular system activation with the primary dysfunction located in brainstem. Glutamate, the major excitatory neurotransmitter in the central nervous system, and its receptors have since long been suggested in migraine pathophysiology. Different preclinical studies have confirmed their potential role in migraine. Moreover, several glutamate receptor modulators have been studied in clinical studies, some with promising results. In this review, we will give an overview of what is known about the role of glutamate in the pathogenesis of migraine, which will be followed by an overview of available efficacy, safety and tolerability data for glutamate receptor inhibitors in clinical development for the treatment of migraine.

Comparison of Levetiracetam and sodium Valproate in migraine prophylaxis: A randomized placebo-controlled study

Background:

Migraine is a chronic and disabling disorder. Treatment of migraine often comprises of symptomatic (abortive) and preventive (prophylactic) treatment. The current drugs used in migraine prophylaxis include antidepressant drugs (Serotonin Reuptake Inhibitors, Tricyclic antidepressants), and anti-epileptic drugs (valproate, gabapentin, etc).

Objective:

The objective of our study was to assess the efficacy and tolerability of levetiracetam in adult migraine prophylaxis, compared to valproate and placebo.

Materials and Methods:

We conducted a prospective, randomized, placebo-controlled study. A total of 85 patients were randomized to receive levetiracetam 500 mg/d (n = 27), valproate 500 mg/d (n = 32) or placebo (n = 26). The patients were evaluated for treatment efficacy after 6 months. Efficacy was assessed as a more than 50% decrease in headache frequency.

Results:

In levetiracetam group, 17 (63.0%) patients experienced a more than 50% decrease in headache frequency, while this efficacy number was 21 (65.6%) for valproate group and 4 (15.4%) for placebo group. The difference was not statistically significant between levetiracetam and valproate, while it was significant when comparing either levetiracetam or valproate to placebo.

Conclusion:

Compared to placebo, levetiracetam offers improvement in headache frequency in patients with migraine. The efficacy of levetiracetam in migraine prophylaxis is comparable to currently used drugs such as valproate.

The visual system in migraine: from the bench side to the office

BACKGROUND

Throughout history, migraine-associated visual symptoms have puzzled patients, doctors, and neuroscientists. The visual aspects of migraine extend far beyond the aura phenomena, and have several clinical implications.

METHODS

A narrative review was conducted, beginning with migraine mechanisms, then followed by pertinent aspects of the anatomy of visual pathways, clinical features, implications of the visual system on therapy, migraine on visually impaired populations, treatment of visual auras and ocular (retinal) migraine, effect of prophylactic migraine treatments on visual aura, visual symptoms induced by anti-migraine or anti-headache drugs, and differential diagnosis.

RESULTS

A comprehensive narrative review from both basic and clinical standpoints on the visual aspects of migraine was attained; however, the results were biased to provide any useful information for the clinician.

CONCLUSION

This paper achieved its goals of addressing and condensing information on the pathophysiology of the visual aspects of migraine and its clinical aspects, especially with regards to therapy, making it useful not only for those unfamiliar to the theme but to experienced physicians as well.

Late-life migraine accompaniments: A narrative review

BACKGROUND

Migraine is one of the most common chronic neurological disorders. In 1980, C. Miller Fisher described late-life migraine accompaniments as transient neurological episodes in older individuals that mimic transient ischemic attacks. There has not been an update on the underlying nature and etiology of late-life migraine accompanimentsd since the original description.

PURPOSE

The purpose of this article is to provide a comprehensive and extensive review of the late-life migraine accompaniments including the epidemiology, clinical characteristics, differential diagnosis, and treatment.

METHODS

Literature searches were performed in MEDLINE®, PubMed, Cochrane Library, and EMBASE databases for publications from 1941 to July 2014. The search terms "Migraine accompaniments," "Late life migraine," "Migraine with aura," "Typical aura without headache," "Migraine equivalents," "Acephalic migraine," "Elderly migraine," and "Transient neurological episodes" were used.

CONCLUSION

Late-life onset of migraine with aura is not rare in clinical practice and can occur without headache, especially in elderly individuals. Visual symptoms are the most common presentation, followed respectively by sensory, aphasic, and motor symptoms. Gradual evolution, the march of transient neurological deficits over several minutes and serial progression from one symptom to another in succession are typical clinical features for late-life migraine accompaniments. Transient neurological disturbances in migraine aura can mimic other serious conditions and can be easily misdiagnosed. Careful clinical correlation and appropriate investigations are essential to exclude secondary causes. Treatments are limited and still inconsistent.

Acetylsalicylic Acid in migraine with aura prevention - a retrospective study

In a retrospective study we evaluated the efficacy and tolerability of Acetylsalicylic Acid (ASA), an antiplatelet drug, in the prophylactic treatment of migraine with aura (MA). We reviewed the charts of 203 patients suffering from MA according to the ICHD II criteria, attending to Turin University Headache Centre. 95 subjects (46.8%) were treated with ASA at low dose, 108 (53.2%) with other prophylactic therapies normally used for migraine for a period that ranged from at least 4 months to 194 months. Eighty-four patients (88.4%) treated with ASA referred positive results, while only 64 patients (59.3%) who underwent other prophylactic treatments did (p < 0.001). The attacks' frequency of patients treated with ASA decreased significantly from 3.83±1.57 pre-treatment to 1.38±0.87 after treatment (p<0.001). Aura duration was markedly reduced from 36.21±19.80 pre-treatment to 22.0±15.5 after treatment (p<0.001). ASA was well-tolerated. ASA is a safe drug with minor possible side effects that can be routinely used when prophylactic treatment of MA is required.

Cortical spreading depression as a target for anti-migraine agents

Spreading depression (SD) is a slowly propagating wave of neuronal and glial depolarization lasting a few minutes, that can develop within the cerebral cortex or other brain areas after electrical, mechanical or chemical depolarizing stimulations. Cortical SD (CSD) is considered the neurophysiological correlate of migraine aura. It is characterized by massive increases in both extracellular K⁺ and glutamate, as well as rises in intracellular Na⁺ and Ca²⁺. These ionic shifts produce slow direct current (DC) potential shifts that can be recorded extracellularly. Moreover, CSD is associated with changes in cortical parenchymal blood flow. CSD has been shown to be a common therapeutic target for currently prescribed migraine prophylactic drugs. Yet, no effects have been observed for the antiepileptic drugs carbamazepine and oxcarbazepine, consistent with their lack of efficacy on migraine. Some molecules of interest for migraine have been tested for their effect on CSD. Specifically, blocking CSD may play an enabling role for novel benzopyran derivative tonabersat in preventing migraine with aura. Additionally, calcitonin gene-related peptide (CGRP) antagonists have been recently reported to inhibit CSD, suggesting the contribution of CGRP receptor activation to the initiation and maintenance of CSD not only at the classic vascular sites, but also at a central neuronal level. Understanding what may be lying behind this contribution, would add further insights into the mechanisms of actions for "gepants", which may be pivotal for the effectiveness of these drugs as anti-migraine agents. CSD models are useful tools for testing current and novel prophylactic drugs, providing knowledge on mechanisms of action relevant for migraine.

Antiepileptics other than gabapentin, pregabalin, topiramate, and valproate for the prophylaxis of episodic migraine in adults

BACKGROUND

Some antiepileptic drugs but not others are useful in clinical practice for the prophylaxis of migraine. This might be explained by the variety of actions of these drugs in the central nervous system. The present review is part of an update of a Cochrane review first published in 2004, and previously updated (conclusions not changed) in 2007.

OBJECTIVES

To describe and assess the evidence from controlled trials on the efficacy and tolerability of antiepileptic drugs other than gabapentin, pregabalin, topiramate, and valproate (which are the subjects of separate Cochrane reviews) for preventing migraine attacks in adult patients with episodic migraine.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library 2012, Issue 12), PubMed/MEDLINE (1966 to 15 January 2013), MEDLINE In-Process (current week, 15 January 2013), and EMBASE (1974 to 15 January 2013) and handsearched Headache and Cephalalgia through January 2013.

SELECTION CRITERIA

Studies were required to be prospective, controlled trials of antiepileptic drugs other than gabapentin, pregabalin, topiramate, and valproate taken regularly to prevent the occurrence of migraine attacks, to improve migraine-related quality of life, or both.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies and extracted data. For headache frequency data, we calculated mean differences (MDs) between antiepileptic drugs and comparators (placebo, active control, or same drug in a different dose) for individual studies and pooled these across studies. For dichotomous data on responders (patients with ≥ 50% reduction in headache frequency), we calculated odds ratios (ORs) and numbers needed to treat (NNTs). We also summarised data on adverse events from placebo-controlled trials and calculated risk differences (RDs) and numbers needed to harm (NNHs).

MAIN RESULTS

Eleven papers describing 10 unique trials met the inclusion criteria. The 10 trials reported results for nine antiepileptic drugs other than gabapentin, pregabalin, topiramate, and valproate. Six of the eight drugs investigated in placebo-controlled trials were not better than placebo in reducing headache frequency per 28-day period during treatment (clonazepam, lamotrigine, oxcarbazepine, and vigabatrin) and/or in the proportion of responders (acetazolamide, carisbamate, lamotrigine, oxcarbazepine). One prospective, randomised, double-blind, single cross-over trial of 48 patients demonstrated a significant superiority of carbamazepine over placebo in the proportion of responders (OR 11.77; 95% confidence interval (CI) 3.92 to 35.32). The NNT was 2 (95% CI 2 to 3). In a small prospective, randomised, double-blind, parallel-group trial, levetiracetam 1000 mg was significantly superior to placebo in reducing headache frequency per 28-day period during treatment (MD -2.40; 95% CI -4.52 to -0.28; 26 patients), as well as in the proportion of responders (OR 26.07; 95% CI 1.30 to 521.91; 26 patients). The NNT was 2 (95% CI 1 to 4). The same trial examined levetiracetam 1000 mg versus topiramate 100 mg and found a small but significant difference favouring topiramate in headache frequency per 28-day period during treatment (MD 1.40; 95% CI 0.14 to 2.66; 28 patients). There was no significant difference between levetiracetam and topiramate in the proportion of responders (OR 0.71; 95% CI 0.16 to 3.23; 28 patients). Finally, one trial with 75 participants examined zonisamide versus topiramate (200 and 100 mg, respectively) and found no significant difference between them in reduction of headache frequency from baseline during the third month of treatment. Adverse events for active treatment versus placebo were available for all investigated drugs except levetiracetam, vigabatrin, and zonisamide. A high prevalence of adverse events was noted for carbamazepine, with a NNH of only 2 (95% CI 2 to 4).

AUTHORS' CONCLUSIONS

Available evidence does not allow robust conclusions regarding the efficacy of antiepileptic drugs other than gabapentin, pregabalin, topiramate, and valproate in the prophylaxis of episodic migraine among adults. Acetazolamide, carisbamate, clonazepam, lamotrigine, oxcarbazepine, and vigabatrin were not more effective than placebo in reducing headache frequency. In one trial each, carbamazepine and levetiracetam were significantly superior to placebo in reducing headache frequency, and there was no significant difference in proportion of responders between zonisamide and active comparator. These three positive studies suffer from considerable methodological limitations.

Familial and sporadic hemiplegic migraine: diagnosis and treatment

OPINION STATEMENT

Hemiplegic migraine (HM) is a rare subtype of migraine with aura, characterized by transient hemiparesis during attacks. Diagnosis is based on the International Classification of Headache Disorders criteria (ICHD-II). Two types of HM are recognized: familial (FHM) and sporadic hemiplegic migraine (SHM). HM is genetically heterogeneous. Three genes have been identified (CACNA1A, ATP1A2, and SCN1A) but more, so far unknown genes, are involved. Clinically, attacks of the 3 subtypes cannot be distinguished. The diagnosis can be confirmed but not ruled out by genetic testing, because in some HM patients other, not yet identified, genes are involved. The presence of additional symptoms (such as chronic ataxia or epilepsy) may increase the likelihood of identifying a mutation. Additional diagnostics like imaging, CSF analysis, or an EEG are mainly performed to exclude other causes of focal neurological symptoms associated with headache. Conventional cerebral angiography is contraindicated in HM because this may provoke an attack. Because HM is a rare condition, no clinical treatment trials are available in this specific subgroup of migraine patients. Thus, the treatment of HM is based on empirical data, personal experience of the treating neurologist, and involves a trial-and-error strategy. Acetaminophen and NSAIDs often are the first choice in acute treatment. Although controversial in HM, triptans can be prescribed when headaches are not relieved sufficiently with common analgesics. An effective treatment for the severe and often prolonged aura symptoms is more warranted, but currently no such acute treatment is available. Prophylactic treatment can be considered when attack frequency exceeds 2 attacks per month, or when severe attacks pose a great burden that requires reduction of severity and frequency. In no strictly preferred order, flunarizine, sodium valproate, lamotrigine, verapamil, and acetazolamide can be tried. While less evidence is available for prophylactic treatment with topiramate, candesartan, and pizotifen, these drugs can also be considered. The use of propranolol in HM is more controversial, but evidence of adverse effects is insufficient to contraindicate beta-blockers.

Hypnic headache: Response to lamotrigine in two cases

Background: Hypnic headache (HH) is a rare primary headache that occurs exclusively during sleep. Drug therapy of HH is often associated with side effects. In a few cases, antiepileptic drugs have been useful in preventing HH attacks.

Cases: We describe two patients, a man aged 57 and a woman aged 63, both with a history of duodenal ulcer and both suffering from several months of frequent and moderate headaches (at least 15 days/month), which occurred only at night and resisted treatment. Physical examination and imaging were unremarkable. Sleep polysomnography was normal in the man. In both patients, the diagnosis of HH was made on the basis of the International Classification of Headache Disorders, 2nd edition criteria. Given the prior history of duodenal ulcer and the unavailability of some drugs in Morocco, we opted for the administration of moderate doses of lamotrigine. The outcome was favourable at one year follow-up and beyond.

Conclusion: To our knowledge, the response to lamotrigine in HH cases has never been reported. Because of its safety profile and availability, lamotrigine can be an effective alternative treatment in HH.

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.

Pharmacological targeting of spreading depression in migraine

Migraine, particularly with aura, is a genetically heterogeneous disorder of ion channels, pumps or transporters associated with increased cortical excitability. Spreading depression, as one reflection of hyperexcitability, is the electrophysiological event underlying aura symptoms and a trigger for headache. Endogenous (e.g., genes and hormones) and exogenous factors (e.g., drugs) modulating migraine susceptibility have also been shown to modulate spreading depression susceptibility concordantly, suggesting that spreading depression can be a relevant therapeutic target in migraine. In support of this, several migraine prophylactic drugs used in clinical practice have been shown to suppress spreading depression susceptibility as a probable mechanism of action, despite belonging to widely different pharmacological classes. Hence, susceptibility to spreading depression can be a useful preclinical model with good positive and negative predictive value for drug screening.

Migraine with aura: conventional and non-conventional treatments

Migraine with aura (MwA) is a primary headache that affects up 30% of migraine patients. Although the frequency of MwA attacks is usually low and the majority of migraine sufferers do not need prophylactic treatment(s), same particular patients do. This occurs when the neurological symptoms, that characterize the auras, determine anxiety to the migraine sufferers and when the frequency of MwA attacks is or becomes high. In this study, we review the few therapeutic conventional options specifically devoted to cure MwA attacks present in the literature together with those, recent, non-conventional.

Management of vestibular migraine

Vestibular migraine is considered to be the second most common cause of vertigo and the most common cause of spontaneous episodic vertigo. The duration of attacks varies from seconds to days, usually lasting minutes to hours, and they mostly occur independently of headaches. Long-lasting individual attacks are treated with generic antivertiginous and antiemetic drugs. Specific antimigraine drugs are unlikely to be very effective for rescue. The mainstay of the management of vestibular migraine is prophylactic medication. To date, there are no controlled trials available; the body of knowledge builds on case series and retrospective or observational studies. Most drugs are also used for the prevention of migraine headaches. The choice of medication should be guided by its side effect profile and the comorbidities of patients. Betablockers such as propanolol or metoprolol are preferred in patients with hypertension but in the absence of asthma. Anticonvulsants include topiramate when patients are obese, valproic acid and lamotrigine. Lamotrigine is preferred if vertigo is more frequent than headaches. Calcium antagonists include verapamil and flunarizine. If patients have anxiety, tricyclic antidepressants such as amitryptiline or nortryptiline or SSRIs and benzodiazepines such as clonazepam are recommended. Acetazolamide is effective in rare genetic disorders related to migraine-like episodic ataxia; however, its place in vestibular migraine is still to be established. Nonpharmacological measures such as diet, sleep, hygiene and avoidance of triggers are recommended as they are for migraine. Vestibular rehabilitation might be useful when there are complications such as loss of confidence in balance or visual dependence.

Migraine preventive drugs differentially affect cortical spreading depression in rat

Cortical spreading depression (CSD) is the most likely cause of the migraine aura. Drugs with distinct pharmacological properties are effective in the preventive treatment of migraine. To test the hypothesis that their common denominator might be suppression of CSD we studied in rats the effect of three drugs used in migraine prevention: lamotrigine which is selectively effective on the aura but not on the headache, valproate and riboflavin which have a non-selective effect. Rats received for 4 weeks daily intraperitoneal injections of one of the three drugs. For valproate and riboflavin we used saline as control, for lamotrigine its vehicle dimethyl sulfoxide. After treatment, cortical spreading depressions were elicited for 2h by occipital KCl application. We measured CSD frequency, its propagation between a posterior (parieto-occipital) and an anterior (frontal) electrode, and number of Fos-immunoreactive nuclei in frontal cortex. Lamotrigine suppressed CSDs by 37% and 60% at posterior and anterior electrodes. Valproate had no effect on posterior CSDs, but reduced anterior ones by 32% and slowed propagation velocity. Riboflavin had no significant effect at neither recording site. Frontal Fos expression was decreased after lamotrigine and valproate, but not after riboflavin. Serum levels of administered drugs were within the range of those usually effective in patients. Our study shows that preventive anti-migraine drugs have differential effects on CSD. Lamotrigine has a marked suppressive effect which correlates with its rather selective action on the migraine aura. Valproate and riboflavin have no effect on the triggering of CSD, although they are effective in migraine without aura. Taken together, these results are compatible with a causal role of CSD in migraine with aura, but not in migraine without aura.

Therapeutic strategies in migraine patients with mood and anxiety disorders: clinical evidence

Mood and anxiety disorders are comorbid with migraine. The coexistence of a psychiatric disorder alters the quality of life, the total disability, the course of migraine and the final prognosis; it increases the probability of central sensitization, other chronic pain conditions and the evolution to chronic migraine. All patients presenting with frequent episodic and chronic migraine should be screened for depression and anxiety. When these conditions are present, drugs for migraine prevention that may worsen the psychiatric comorbid disorder have to be avoided. When it is possible, both conditions should be treated with a single agent. Amitriptiline can be used both in mood disorders and migraine prevention. Flunarizine and beta-blockers may help if anxiety is present. Pregabalin has demonstrated efficacy in anxiety disorders and fibromyalgia. Divalproex sodium, topiramate and lamotrigine that have demonstrated efficacy in mood stabilization are also indicated in migraine without aura (divalproex sodium and topiramate) and with aura (lamotrigine). When a specific treatment for the comorbid psychiatric disorder is needed, the selective serotonin reuptake inhibitors or the serotonin norepinephrine reuptake inhibitors are the drugs of choice both in depression and anxiety, and the cognitive behavioural therapy has good evidence of efficacy in anxiety disorders. Vagal nerve stimulation may be an option in patients with refractory chronic migraine and depression.

Pathogenesis of migraine: from neurotransmitters to neuromodulators and beyond

Here, in this review, we present our hypothesis of the migraine pathogenesis. We believe that migraine attacks derive from a top-down dysfunctional process that initiates in a hyperexcitable and hypoenergetic brain in the frontal lobe and downstream in abnormally activated nuclei of the pain matrix. This hypothesis derived from the results of the biochemical studies, mainly generated from our laboratory, on the possible metabolic shifts of tyrosine toward an activation of decarboxylase enzyme activity with an increased synthesis of traces amines, i.e. tyr, oct and syn, and an unphysiological synthesis of noradrenalin and dopamine. This metabolic shift is possibly favored by the reduced mitochondrial energy and high levels of glutamate in CNS of migraine patients. The unbalanced levels of neurotransmitters (DA and NE) and neuromodulators (tyr, oct and syn) in the synaptic dopaminergic and noradrenergic clefts of the pain matrix may activate, downstream, the trigeminal system that releases calcitonin gene-related G peptide. This induces the formation of an inflammatory soup, the sensitization of first trigeminal neuron and the migraine attack.

Migraine-associated vertigo: diagnosis and treatment

Migraine-associated vertigo has become a well-recognized disease entity diagnosed based on a clinical history of recurrent vertigo attacks unexplained by other central or peripheral otologic abnormalities, which occurs in the patient with a history of migraine headaches. There is no international agreement on what spectrum of symptoms should be covered under this diagnosis, or what terminology should be used. The headaches and vestibular symptoms of migraine-associated vertigo may not be temporally associated, which often obscures the association. Diagnostic tests usually show nonspecific abnormalities that are also seen in patients with migraine who do not experience vestibular symptoms. Management generally follows the recommended treatment of migraine headaches, and includes dietary and lifestyle modifications and medical treatment with beta blockers, calcium channel blockers, and tricyclic amines. Small case series show that acetazolamide and lamotrigine appear to be more effective for the vertigo attacks than headaches. Vestibular rehabilitation has also been shown to be helpful in several studies. In this review, the epidemiologic and clinical features of the disorder, as well as the current state of knowledge on pathophysiology, diagnostic testing, and treatment are described.

Migraines with and without aura and their response to preventive therapy with topiramate

Data from the Prolonged Migraine Prevention (PROMPT) with Topiramate trial were evaluated post hoc to determine whether topiramate could prevent migraine auras, and whether its efficacy in preventing migraine headaches was similar in patients with (MA; n = 269) and without (MoA; n = 542) aura. Migraines and auras were recorded during prospective baseline, 6-month open-label (OL) topiramate and 6-month double-blind (DB), placebo-controlled phases. In the last 28 OL days, migraines without aura and migraine auras decreased by 43.1% and 54.1%, respectively, in MA patients. MoA patients experienced a 44.3% reduction in migraines. In the DB phase, increases in migraines with placebo vs. topiramate were similar to the full study, but were generally not statistically significant, probably due to lack of power in the subgroup analysis. Similarly, there were no statistically significant changes in number of auras between groups. Thus, topiramate appears to reduce migraine auras in parallel with headache reductions, which are similar in patients with and without aura.

Role of antiepileptic drugs as preventive agents for migraine

Migraine is a common neurological disease affecting about 12% of the population in Western Europe and North America, and causing a considerable burden both to migraineurs and to society. Severe, frequent and disabling migraine attacks, as well as those poorly responsive to acute care medication, require preventive treatment, which is often under-utilized. Antiepileptic drugs are used in the prevention of migraine. We performed a literature search of PubMed through June 2008 for controlled trials of antiepileptic drugs in the prevention of migraine. The search identified 70 papers for a full-text review. The majority of these papers referred to valproate and topiramate, and showed that these drugs are effective and well tolerated in migraine prevention and are suitable for first-line clinical use. On the other hand, acetazolamide, lamotrigine, oxcarbazepine and vigabatrin have been shown to be not effective and gabapentin requires further evaluation. For the rest of the antiepileptic drugs, no data from controlled trials are available.

Spreading depression: from serendipity to targeted therapy in migraine prophylaxis

Despite the relatively well-characterized headache mechanisms in migraine, upstream events triggering individual attacks are poorly understood. This lack of mechanistic insight has hampered a rational approach to prophylactic drug discovery. Unlike targeted abortive and analgesic interventions, mainstream migraine prophylaxis has been largely based on serendipitous observations (e.g. propranolol) and presumed class effects (e.g. anticonvulsants). Recent studies suggest that spreading depression is the final common pathophysiological target for several established or investigational migraine prophylactic drugs. Building on these observations, spreading depression can now be explored for its predictive utility as a preclinical drug screening paradigm in migraine prophylaxis.

Current migraine management - patient acceptability and future approaches

Despite its high prevalence and individual as well as societal burden, migraine remains underdiagnosed and undertreated. In recent years, the options for the management of migraine patients have greatly expanded. A number of drugs belonging to various pharmacological classes and deliverable by several routes are now available both for the acute and the preventive treatments of migraine. Nevertheless, disability and satisfaction remain low in many subjects because treatments are not accessible, not optimized, not effective, or simply not tolerated. There is thus still considerable room for better education, for more efficient therapies and for greater support from national health systems. In spite of useful internationally accepted guidelines, anti-migraine treatment has to be individually tailored to each patient taking into account the migraine subtype, the ensuing disability, the patient's previous history and present expectations, and the co-morbid disorders. In this article we will summarize the phenotypic presentations of migraine and review recommendations for acute and preventive treatment, highlighting recent advances which are relevant for clinical practice in terms of both diagnosis and management.

Antiepileptic Drugs on Calcium Currents Recorded from Cortical and PAG Neurons: Therapeutic Implications for Migraine

Cortex and periaqueductal grey (PAG) play a major role in the pathophysiology of migraine. Some antiepileptic drugs (AEDs) influence the activity of these structures by modulating high-voltage-activated (HVA) Ca2+ channels and are effective in migraine prevention. The aim of the present study was to investigate the expression of total HVA Ca2+ channels in cortical and PAG neurons and to study the differential action of AEDs on these channels. Isolated neurons were visually identified based on morphological criteria. HVA currents were recorded by whole-cell patch-clamp technique. The distribution ratio of L-, N-, P-, Q- and R-type HVA Ca2+ channels was different between cortical and PAG neurons. In particular, we found that P- and Q-type HVA Ca2+ channels were more expressed in PAG neurons than in cortical cells, whereas L- and R-type HVA Ca2+ channels showed an opposite distribution. Interestingly, N-type HVA Ca2+ channels were equally distributed in these two neuronal populations. A differential sensitivity to AEDs of HVA Ca2+ channels located on cortical and PAG neurons was observed for topiramate (TPM), but not for lamotrigine (LTG) or levetiracetam (LEV). In fact, whereas both LTG and LEV were equally effective and potent in inhibiting HVA Ca2+ currents in the two neuronal populations, TPM showed a much higher potency and efficacy in blocking these currents in PAG neurons than in cortical pyramidal cells. TPM, in fact, inhibited N-, P- and L-type channels in PAG neurons, whereas in cortical neurons this AED modulated only P- and L-type channels. Unlike the other AEDs investigated, valproic acid did not affect HVA Ca2+ currents in cortical and PAG neurons. The negative modulation of specific subtypes of HVA Ca2+ channels by various AEDs can restore normal electrical activity in target brain areas such as cortex and PAG, providing interesting therapeutic approaches in migraine prevention.

Migraine prophylaxis

There is a wide array of options for migraine prophylaxis; many of the available drugs are clearly proven to be effective and yet are underused in Australia. "New" drugs which are gaining favour for migraine prophylaxis include topiramate, candesartan, gabapentin and botulinum toxin. The evidence for efficacy is excellent for topiramate and reasonably good but limited for candesartan and gabapentin. The use of botulinum toxin is controversial and has gained substantial popularity through anecdotal experience rather than convincing published evidence. Transformed or chronic migraine with medication overuse is a particularly difficult problem. New strategies to aid in medication withdrawal are reviewed. The approach to menstrual migraine and migraine with prominent aura may differ from that for typical migraine. Novel approaches are being explored for these problems.

Optimizing prophylactic treatment of migraine: Subtypes and patient matching

Advances in our understanding of the pathophysiology of migraine have resulted in important breakthroughs in treatment. For example, understanding of the role of serotonin in the cerebrovascular circulation has led to the development of triptans for the acute relief of migraine headaches, and the identification of cortical spreading depression as an early central event associated wih migraine has brought renewed interest in antiepileptic drugs for migraine prophylaxis. However, migraine still remains inadequately treated. Indeed, it is apparent that migraine is not a single disease but rather a syndrome that can manifest itself in a variety of pathological conditions. The consequences of this may be that treatment needs to be matched to particular patients. Clinical research needs to be devoted to identifying which sort of patients benefit best from which treatments, particularly in the field of prophylaxis. We propose four patterns of precipitating factors (adrenergic, serotoninergic, menstrual, and muscular) which may be used to structure migraine prophylaxis. Finally, little is known about long-term outcome in treated migraine. It is possible that appropriate early prophylaxis may modify the long-term course of the disease and avoid late complications.