Treatment of refractory chronic daily headache with the atypical antipsychotic ziprasidone--a case series

A Systematic Review of Atypical Antipsychotics in Chronic Pain Management: Olanzapine Demonstrates Potential in Central Sensitization, Fibromyalgia, and Headache/Migraine

INTRODUCTION

Many psychopharmacologic agents are used as primary or adjuncts in pain management. Atypical antipsychotics (AAs) have also been used as adjuncts in pain management regimens in a variety of manners; however, their efficacy in this capacity is unclear.

METHODS

A systematic review of all studies examining AA use for pain was conducted. Three literature databases were utilized to search for word combinations of "pain" and a variety of commonly prescribed AAs ie, (olanzapine, quetiapine, risperidone, aripiprazole, ziprasidone, clozapine, paliperidone, iloperidone, lurasidone). Articles chosen for review included retrospective analyses, randomized control trials, and case series/reports. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram illustrates the study selection process.

RESULTS

Olanzapine, quetiapine, risperidone, aripiprazole, and ziprasidone are the only AAs with published studies in pain management. Among these, olanzapine and quetiapine have the most studies (11 and 6, respectively). Olanzapine shows preliminary and consistent efficacy in fibromyalgia and headache/migraine, although only 1 study was a randomized controlled trial with level I evidence of efficacy. Other AAs eg, (quetiapine) fail to demonstrate efficacy in pain syndromes and/or lack robust study designs.

CONCLUSIONS

Few studies have been conducted to evaluate the analgesic effects of AAs. The collective findings of multiple studies evaluating olanzapine in pain syndromes suggest a high, yet preliminary level of evidence of efficacy, warranting prospective studies in various pain syndrome contexts. Pharmacological mechanisms of AA action are elaborated, and the findings of this review are discussed. Risk and benefits of using AAs in chronic pain are described, and investigational implications and future directions are explored.

Ziprasidone as a Potential Abortive Therapy for Status Migrainosus

Migraine headache is among the most prevalent neurologic disorders. Status migrainosus often leads to hospitalization, and multiple medications are sometimes required for symptomatic relief. In 2008, neurologists at our institution started using the atypical antipsychotic ziprasidone as an abortive medication for status migrainosus. The Clinical Investigation Data Exploration Repository was used to search for patients admitted to the Barnes-Jewish Hospital inpatient neurology service with diagnoses of "headache" or "migraine." Patients were identified as having status migrainosus if they met the International Headache Society criteria for a migraine lasting >72 hours. Clinical records of identified patients were then entered into a secure online database (REDCap). Between 2008 and 2015, a total of 34 patients received 10 to 40 mg of ziprasidone for the treatment of status migrainosus. Among patients who received ziprasidone, headache severity decreased 5.68 ± 3.0 points on a 10-point scale, from admission to discharge. Ziprasidone was the last abortive medication added prior to discharge in 65% of cases. The 30-day readmission rate for migraine headache in patients who received ziprasidone was 12%. Ziprasidone was well tolerated, with side effects limited to a mild dystonic reaction (n = 1), rhinorrhea (n = 1), and a prolonged QTc of 495 milliseconds (n = 1). This observational study suggests that ziprasidone may be a safe, effective abortive medication for the treatment of status migrainosus. Further studies comparing ziprasidone to standard of care are warranted.

Use of dopamine antagonists in treatment of migraine

OPINION STATEMENT

Dopamine antagonists are indicated for treatment of nausea or psychosis and have an established role in the treatment of migraine. Neuroleptics, including antipsychotics, act as antagonists at the dopamine D2 receptor type. These medications also have variable activity as antihistamines and anticholinergics, and they block alpha-adrenergic and some serotonin receptor types, but their actions on dopamine are likely the reason for their efficacy in treating nausea, psychosis, and acute migraine. Neuroleptics are first-line agents in the emergency room setting for migraine, especially for patients with nausea and vomiting. In the setting of a clear prodrome, antiemetics may prevent migraine when taken before an attack. They are also indicated in clinical situations such as patients who are pregnant or have contraindications to migraine-specific medications or NSAIDs. Recent developments suggest that dopamine is particularly important in chronic pain, and we most commonly use neuroleptic medications in the treatment of status migrainosus or medication-overuse headache. Clinicians may avoid dopamine antagonists because of unfamiliarity and a lack of large, controlled clinical trials. Their use requires special care to avoid adverse events such as sedation, akathisia or dystonic reactions, neuroleptic malignant syndrome, or movement disorders with long-term use. Some newer atypical neuroleptic agents appear promising for both acute and prophylactic migraine treatment with a lower risk of adverse events.

Relief from migraine headache with aripiprazole treatment

There have been many reports of the association between migraine headaches and psychiatric disorders as well as of the utility of dopamine antagonists in the treatment of migraine headache. There is increasing evidence to support the activation of dopaminergic systems as a primary component of migraine pathogenesis. This report documents 3 cases of female migraineurs who received the dopamine modulator aripiprazole for treatment of co-occurring psychiatric disorders and experienced a decrease in migraine frequency and severity. A hypothesis as to the mechanism of action of dopamine regulation in migraine treatment is discussed.