Rizatriptan for the Acute Treatment of ICHD-II Proposed Menstrual Migraine: Two Prospective, Randomized, Placebo-Controlled, Double-Blind Studies

Management of Pain and Headache After Traumatic Brain Injury

This article will identify common causes of pain following traumatic brain injury (TBI), discuss current treatment strategies for these complaints, and help tailor treatments for both acute and chronic settings. We will also briefly discuss primary and secondary headache disorders, followed by common secondary pain disorders that may be related to trauma.

Current and Emerging Pharmacotherapy for Menstrual Migraine: A Narrative Review

INTRODUCTION

In this article, we discuss menstrual migraine (MM), which can be categorized as menstrually related migraine (MRM) or pure menstrual migraine (PMM). MM attacks are often longer, more severe, and harder to treat than other migraine attacks. Appropriate treatment strategies include acute treatment, short term preventive treatment, and daily preventive treatment, depending on the patient's pattern of migraine and occurrence of migraine outside the menstrual period.

AREAS COVERED

A PubMed, Cochrane Library, Medline, and Ovid search from inception to October 2022 provided articles relating to MM pathophysiology and treatment.

EXPERT OPINION

In patients for whom standard acute therapy is inadequate, short term or daily preventive treatment should be considered. Patients with PMM may be adequately managed with short term preventive treatment started 2 days prior to the onset of migraine and continued for 5-6 days. Frovatriptan is the mainstay of short-term prevention. Patients who experience additional attacks outside the menstrual period may benefit from daily preventive treatment. Estrogen-containing contraceptive treatment may be effective in appropriately selected patients. Emerging research on the pathophysiology of MM indicates that oxytocin agonists and CGRP antagonists may prove to be effective treatment options.

Efficacy of lasmiditan for the acute treatment of perimenstrual migraine

BACKGROUND

Perimenstrual migraine attacks in women with menstrual migraine is difficult to treat. This post-hoc analysis evaluated the efficacy of lasmiditan, a high affinity and selective 5-HT_1F receptor agonist, for perimenstrual attacks.

METHODS

Patients from two randomized, double-blind, placebo-controlled clinical trials (MONONOFU and CENTURION) were instructed to treat an attack with a single dose of study medication within four hours of pain onset. After dosing, the proportion of patients who achieved freedom from migraine-related head pain, most bothersome symptom, and disability was reported at baseline up to 48 hours after dose and pooled data were evaluated.

RESULTS

A total of 303 patients (MONONOFU N = 78; CENTURION N = 225) treated perimenstrual migraine attacks with lasmiditan 50 mg (N = 24), 100 mg (N = 90), 200 mg (N = 110), and placebo (N = 79). More patients achieved migraine-related head pain freedom with lasmiditan 200 mg versus placebo at all time points assessed. At 2 hours, 33.6% of patients in the 200-mg group (p < 0.001), and 16.7% of patients in the 100-mg (p = 0.11) and 50-mg (p = 0.19) groups were pain free, compared with 7.6% in the placebo group.

CONCLUSIONS

Lasmiditan treatment of perimenstrual migraine attacks was associated with freedom from migraine-related head pain at two hours, early onset of efficacy, and sustained efficacy.Clinical Trial registration: NCT03962738 and NCT03670810.

Comparison between metamizole and triptans for migraine treatment: a systematic review and network meta-analysis

Objective The aim of this systematic review was to evaluate the efficacy of metamizole and triptans for the treatment of migraine. MethodsRandomized controlled trials including people who received metamizole or triptan by multiple routes of administration and at all doses as treatment compared to subjects who received another treatment or placebo were included in the systematic review. The primary outcomes were freedom from pain at 2 hours; pain relief at 2 hours; sustained headache response at 24 hours; sustained freedom from pain at 24 hours. The statistical analysis of all interventions of interest were based on random effect models compared through a network meta-analysis. Results 209 studies meeting the inclusion and exclusion criteria were analyzed. Of these, 130 had data that could be analyzed statistically. Only 3.0% provided enough information and were judged to have a low overall risk of bias for all categories evaluated; approximately 50% of the studies presented a low risk of selection bias. More than 75% of the studies presented a low risk of performance bias, and around 75% showed a low risk of detection and attrition bias. ConclusionThere is no evidence of a difference between dipyrone and any triptan for pain freedom after 2 hours of medication. Our study suggests that metamizole may be equally effective as triptans in acute migraine treatment.

[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.

Migraine Treatment: Current Acute Medications and Their Potential Mechanisms of Action

Migraine is a common and disabling primary headache disorder with a significant socioeconomic burden. The management of migraine is multifaceted and is generally dichotomized into acute and preventive strategies, with several treatment modalities. The aims of acute pharmacological treatment are to rapidly restore function with minimal recurrence, with the avoidance of side effects. The choice of pharmacological treatment is individualized, and is based on the consideration of the characteristics of the migraine attack, the patient's concomitant medical problems, and treatment preferences. Notwithstanding, a good understanding of the pharmacodynamic and pharmacokinetic properties of the various drug options is essential to guide therapy. The current approach and concepts relevant to the acute pharmacological treatment of migraine will be explored in this review.

Menstrual migraine: a review of current and developing pharmacotherapies for women

INTRODUCTION

Migraine is one of the most common neurological disorders in the general population. It affects 18% of women and 6% of men. In more than 50% of women migraineurs the occurrence of migraine attacks correlates strongly with the perimenstrual period. Menstrual migraine is highly debilitating, less responsive to therapy, and attacks are longer than those not correlated with menses. Menstrual migraine requires accurate evaluation and targeted therapy, that we aim to recommend in this review.

AREAS COVERED

This review of the literature provides an overview of currently available pharmacological therapies (especially with triptans, anti-inflammatory drugs, hormonal strategies) and drugs in development (in particular those acting on calcitonin gene-related peptide) for the treatment of acute migraine attacks and the prophylaxis of menstrual migraine. The studies reviewed here were retrieved from the Medline database as of June 2017.

EXPERT OPINION

The treatment of menstrual migraine is highly complex. Accurate evaluation of its characteristics is prerequisite to selecting appropriate therapy. An integrated approach involving neurologists and gynecologists is essential for patient management and for continuous updating on new therapies under development.

Network meta-analysis of migraine disorder treatment by NSAIDs and triptans

Background

Migraine is a neurological disorder resulting in large socioeconomic burden. This network meta-analysis (NMA) is designed to compare the relative efficacy and tolerability of non-steroidal anti-inflammatory agents (NSAIDs) and triptans.

Methods

We conducted systematic searches in database PubMed and Embase. Treatment effectiveness was compared by synthesizing direct and indirect evidences using NMA. The surface under curve ranking area (SUCRA) was created to rank those interventions.

Results

Eletriptan and rizatriptan are superior to sumatriptan, zolmitriptan, almotriptan, ibuprofen and aspirin with respect to pain-relief. When analyzing 2 h-nausea-absence, rizatriptan has a better efficacy than sumatriptan, while other treatments indicate no distinctive difference compared with placebo. Furthermore, sumatriptan demonstrates a higher incidence of all-adverse-event compared with diclofenac-potassium, ibuprofen and almotriptan.

Conclusion

This study suggests that eletriptan may be the most suitable therapy for migraine from a comprehensive point of view. In the meantime ibuprofen may also be a good choice for its excellent tolerability. Multi-component medication also attracts attention and may be a promising avenue for the next generation of migraine treatment.

Electronic supplementary material

The online version of this article (doi:10.1186/s10194-016-0703-0) contains supplementary material, which is available to authorized users.

The acute treatment of migraine in adults: the american headache society evidence assessment of migraine pharmacotherapies

The study aims to provide an updated assessment of the evidence for individual pharmacological therapies for acute migraine treatment. Pharmacological therapy is frequently required for acutely treating migraine attacks. The American Academy of Neurology Guidelines published in 2000 summarized the available evidence relating to the efficacy of acute migraine medications. This review, conducted by the members of the Guidelines Section of the American Headache Society, is an updated assessment of evidence for the migraine acute medications. A standardized literature search was performed to identify articles related to acute migraine treatment that were published between 1998 and 2013. The American Academy of Neurology Guidelines Development procedures were followed. Two authors reviewed each abstract resulting from the search and determined whether the full manuscript qualified for review. Two reviewers studied each qualifying full manuscript for its level of evidence. Level A evidence requires at least 2 Class I studies, and Level B evidence requires 1 Class I or 2 Class II studies. The specific medications - triptans (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan [oral, nasal spray, injectable, transcutaneous patch], zolmitriptan [oral and nasal spray]) and dihydroergotamine (nasal spray, inhaler) are effective (Level A). Ergotamine and other forms of dihydroergotamine are probably effective (Level B). Effective nonspecific medications include acetaminophen, nonsteroidal anti-inflammatory drugs (aspirin, diclofenac, ibuprofen, and naproxen), opioids (butorphanol nasal spray), sumatriptan/naproxen, and the combination of acetaminophen/aspirin/caffeine (Level A). Ketoprofen, intravenous and intramuscular ketorolac, flurbiprofen, intravenous magnesium (in migraine with aura), and the combination of isometheptene compounds, codeine/acetaminophen and tramadol/acetaminophen are probably effective (Level B). The antiemetics prochlorperazine, droperidol, chlorpromazine, and metoclopramide are probably effective (Level B). There is inadequate evidence for butalbital and butalbital combinations, phenazone, intravenous tramadol, methadone, butorphanol or meperidine injections, intranasal lidocaine, and corticosteroids, including dexamethasone (Level C). Octreotide is probably not effective (Level B). There is inadequate evidence to refute the efficacy of ketorolac nasal spray, intravenous acetaminophen, chlorpromazine injection, and intravenous granisetron (Level C). There are many acute migraine treatments for which evidence supports efficacy. Clinicians must consider medication efficacy, potential side effects, and potential medication-related adverse events when prescribing acute medications for migraine. Although opioids, such as butorphanol, codeine/acetaminophen, and tramadol/acetaminophen, are probably effective, they are not recommended for regular use.

Triptans in the Acute Treatment of Migraine: A Systematic Review and Network Meta-Analysis

BACKGROUND

Although triptans are widely used in the acute management of migraine, there is uncertainty around the comparative efficacy of triptans among each other and vs non-triptan migraine treatments. We conducted systematic reviews and network meta-analyses to compare the relative efficacy of triptans (alone or in combination with other drugs) for acute treatment of migraines compared with other triptan agents, non-steroidal anti-inflammatory drugs (NSAIDs), acetylsalicylic acid (ASA), acetaminophen, ergots, opioids, or anti-emetics.

METHODS

The Cochrane Library, MEDLINE, and EMBASE were searched for randomized controlled trials that compared triptans (alone or in combination with other drugs) with placebo-controlled or active migraine treatments. Study selection, data extraction, and quality assessment were completed independently by multiple reviewers. Outcome data were combined and analyzed using a Bayesian network meta-analysis. For each outcome, odds ratios, relative risks, and absolute probability of response were calculated.

RESULTS

A total of 133 randomized controlled trials met the inclusion criteria. Standard dose triptans relieved headaches within 2 hours in 42 to 76% of patients, and 2-hour sustained freedom from pain was achieved for 18 to 50% of patients. Standard dose triptans provided sustained headache relief at 24 hours in 29 to 50% of patients, and sustained freedom from pain in 18 to 33% of patients. Use of rescue medications ranged from 20 to 34%. For 2-hour headache relief, standard dose triptan achieved better outcomes (42 to 76% response) than ergots (38%); equal or better outcomes than NSAIDs, ASA, and acetaminophen (46 to 52%); and equal or slightly worse outcomes than combination therapy (62 to 80%). Among individual triptans, sumatriptan subcutaneous injection, rizatriptan ODT, zolmitriptan ODT, and eletriptan tablets were associated with the most favorable outcomes.

INTERPRETATION/CONCLUSIONS

Triptans are effective for migraine relief. Standard dose triptans are associated with better outcomes than ergots, and most triptans are associated with equal or better outcomes compared with NSAIDs, ASA, and acetaminophen. Use of triptans in combination with ASA or acetaminophen, or using alternative modes of administration such as injectables, may be associated with slightly better outcomes than standard dose triptan tablets.

Pharmacological Acute Migraine Treatment Strategies: Choosing the Right Drug for a Specific Patient

Background:

In our targeted review (Section 2), 12 acute medications received a strong recommendation for use in acute migraine therapy while four received a weak recommendation for use. Strong recommendations were made to avoid use of two other medications, except for exceptional circumstances. Two anti-emetics received strong recommendations for use as needed.

Objective:

To organize the available acute migraine medications into acute migraine treatment strategies in order to assist the practitioner in choosing a specific medication(s) for an individual patient.

Methods:

Acute migraine treatment strategies were developed based on the targeted literature review used for the development of this guideline (Section 2), and a general literature review. Expert consensus groups were used to refine and validate these strategies.

Results:

Based on evidence for drug efficacy, drug side effects, migraine severity, and coexistent medical disorders, our analysis resulted in the formulation of eight general acute migraine treatment strategies. These could be grouped into four categories: 1) two mild-moderate attack strategies, 2) two moderate-severe attack or NSAID failure strategies, 3) three refractory migraine strategies, and 4) a vasoconstrictor unresponsive-contraindicated strategy. In addition, strategies were developed for menstrual migraine, migraine during pregnancy, and migraine during lactation. The eight general treatment strategies were coordinated with a “combined acute medication approach” to therapy which used features of both the “stratified” and the “step care across attacks” approaches to acute migraine management.

Conclusions:

The available medications for acute migraine treatment can be organized into a series of strategies based on patient clinical features. These strategies may help practitioners make appropriate acute medication choices for patients with migraine.

Menstrual versus non-menstrual attacks of migraine without aura in women with and without menstrual migraine

Objective

The objective of this article is to compare clinical characteristics of menstrual and non-menstrual attacks of migraine without aura (MO), prospectively recorded in a headache diary, by women with and without a diagnosis of menstrual migraine without aura (MM) according to the International Classification of Headache Disorders (ICHD).

Material and methods

A total of 237 women from the general population with self-reported migraine in ≥50% of their menstrual periods were interviewed and classified by a physician according to the criteria of the ICHD II. Subsequently, all participants were instructed to complete a prospective headache diary for at least three menstrual cycles. Clinical characteristics of menstrual and non-menstrual attacks of MO were compared by a regression model for repeated measurements.

Results

In total, 123 (52%) women completed the diary. In the 56 women who were prospectively diagnosed with MM by diary, the menstrual MO-attacks were longer (on average 10.65 hours, 99% CI 3.17–18.12) and more frequently accompanied by severe nausea (OR 2.14, 99% CI 1.20–3.84) than non-menstrual MO-attacks. No significant differences between menstrual and non-menstrual MO-attacks were found among women with MO, but no MM.

Conclusion

In women from the general population, menstrual MO-attacks differ from non-menstrual attacks only in women who fulfil the ICHD criteria for MM.

A cyclic pain: the pathophysiology and treatment of menstrual migraine

Catamenial migraine is a headache disorder occurring in reproductive-aged women relevant to menstrual cycles. Catamenial migraine is defined as attacks of migraine that occurs regularly in at least 2 of 3 consecutive menstrual cycles and occurs exclusively on day 1 to 2 of menstruation, but may range from 2 days before (defined as -2) to 3 days after (defined as +3 with the first day of menstruation as day +1). There are 2 subtypes: the pure menstrual migraine and menstrually related migraine. In pure menstrual migraine, there are no aura and no migraine occurring during any other time of the menstrual cycle. In contrast, menstrually related migraine also occurs in 2 of 3 consecutive menstrual cycles, mostly on days 1 and 2 of menstruation, but it may occur outside the menstrual cycle. Catamenial migraine significantly interferes with the quality of life and causes functional disability in most sufferers. The fluctuation of estrogen levels is believed to play a role in the pathogenesis of catamenial migraine. In this review, we discuss estrogen and its direct and indirect pathophysiologic roles in menstrual-related migraine headaches and the available treatment for women.

TARGET AUDIENCE

Obstetricians and gynecologists, family physicians.

LEARNING OBJECTIVES

After completing this CME activity, physicians should be better able to discuss the pathophysiology of catamenial migraine, identify the risk factors for catamenial migraine among women, and list the prophylactic and abortive treatments for migraines.

Treatment strategies for menstrually related migraine

Approximately 50% of migrainous women suffer from menstrually related migraine (MRM), a type of migraine in which the attacks occur at the same time as or near the menstrual flow. Attacks of MRM tend to be longer, more intense and disabling and sometimes less responsive to treatment than non-menstrual migraines. Similar to the management of non-menstrual migraine, the use of triptans and NSAIDs is the gold standard for MRM treatment. In this paper, the most important studies in the literature that report the effectiveness of triptans, of certain associated drugs and other analgesic agents are summarized. Preventive strategies that can be used if a prophylactic treatment is needed is also analyzed, with particular attention paid to the use of perimenstrual prophylaxis with triptans and/or NSAIDs. Moreover, considering the peculiar interaction between menstrual migraine and female sex hormones, brief mention is made to possible hormonal manipulations.

Pharmacokinetic evaluation of frovatriptan

INTRODUCTION

Migraine is the most common painful neurological disorder, affecting 13% of the general population. Triptans represent a powerful pharmacological tool in acute migraine treatment, however, a significant portion of treated patients cannot have access to this class due to possible adverse affects. Today, a total of seven triptan molecules are available, representing a commonly prescribed migraine treatment. Although there is a need of extensive use of triptans, only 25% of migraine patients are using triptans.

AREAS COVERED

This review includes triptans and evidence for the use of frovatriptan. A systematic approach is used to discuss the pharmacodynamic and pharmacokinetic aspects of frovatriptan, considering the emerging data on the clinical efficacy of frovatriptan in the treatment of migraine and cluster headaches. The data were obtained by searching the following key words in MEDLINE: pharmacokinetic, pharmacodynamic, triptans, frovatriptan, migraine, menstrual migraine, relatively to the period 1988 - 2011.

EXPERT OPINION

Frovatriptan has been developed in order to improve safety and efficacy of triptans. It shows a favorable tolerability and efficacy profile, limited to 24/48-h headache recurrence, when compared with other triptans. Preclinical data suggest that the pharmacokinetic profile of frovatriptan may differ from other available triptans. In fact, among triptans, frovatriptan showed the highest potency at the 5-HT1B receptor (8.2) and the longer half-life (26 h). These parameters determine the clinical properties of frovatriptan; in particular the lowest rate of headache recurrence in comparison with other triptans.

Management of menstrual migraine: a review of current abortive and prophylactic therapies

After menarche, women have an increased prevalence of migraine compared to men. There is significant variability in the frequency and severity of migraine throughout the menstrual cycle. Women report migraines occur more frequently during menses, and that those are more severe than other migraines. This creates a unique challenge of effectively treating menstrually related and pure menstrual migraines. As with treatment of other migraines, both abortive and prophylactic treatment regimens are used. Triptans demonstrate efficacy in the abortive management of menstrually related and pure menstrual migraines. For migraines that occur primarily during menses or that are particularly resistant to other therapies, intermittent prophylactic therapies can be used. Naproxen and estrogens have been studied for this use. More recently, triptans have been examined and have shown efficacy for intermittent prophylaxis of menstrual migraine.

Almotriptan for menstrually related migraine

INTRODUCTION

Approximately 50% of migrainous women associate their headache temporally to menses. Menstrually related migraine (MRM) is a disabling form of migraine characterized by attacks that are generally longer, more severe and less drug-responsive than nonmenstrual ones. Since MRM may be difficult to treat, it is important to find an appropriate treatment option for women suffering from this condition.

AREAS COVERED

This paper provides an overview of the clinical features of MRM, with special attention on the use of almotriptan for its treatment. Four studies on almotriptan in the treatment of MRM are present in the medical literature. Two report post hoc analyses of data derived from larger studies on the use of almotriptan for migraine treatment. One reports the results from a study specifically dedicated to MRM and one illustrates a subanalysis on the accompanying symptomatology.

EXPERT OPINION

Evidence demonstrates that almotriptan is a molecule with a high efficacy in the treatment of MRM and with an excellent tolerability profile when compared with other triptans. Moreover, it shows a proven ability to control migraine-associated symptoms. All these qualities play a decidedly positive role in making almotriptan a product of choice for the treatment of MRM.

Progress in the Pharmacotherapy of Menstrual Migraine

Menstrual migraine is a common neurological condition reported to affect up to 60% of women with migraine. Most women manage migraine adequately with symptomatic treatment alone. However, in women with menstrual migraine, menstrual attacks are recognised to be more severe, last longer, and are less responsive to treatment compared with attacks at other times of the menstrual cycle. In these situations, prophylactic treatment may be necessary. Short-term perimenstrual and continuous prophylactic treatments have shown efficacy in clinical trials but none are licensed for menstrual migraine. This article reviews the evidence for acute and prophylactic drugs in the management of this condition and considers future therapeutic options.

Prevention and treatment of menstrual migraine

Migraine is a prevalent headache disorder affecting three times more women than men during the reproductive years. Menstruation is a significant risk factor for migraine, with attacks most likely to occur on or between 2 days before the onset of menstruation and the first 3 days of bleeding. Although menstrual migraine has been recognized for many years, diagnostic criteria have only recently been published. These have enabled better comparison of the efficacy of drugs for this condition. Acute treatment, if effective, may be all that is necessary for control. Evidence of efficacy, with acceptable safety and tolerability, exists for sumatriptan 50 and 100 mg, mefenamic acid 500 mg, rizatriptan 10 mg and combination sumatriptan/naproxen 85 mg/500 mg. However, there is evidence that menstrual attacks are more severe, longer, less responsive to treatment, more likely to relapse and associated with greater disability than attacks at other times of the cycle. Prophylactic strategies can reduce the frequency and severity of attacks and acute treatment is more effective. Predictable menstrual attacks offer the opportunity for perimenstrual prophylaxis taken only during the time of increased migraine incidence. There is grade B evidence of efficacy for short-term prophylaxis with transcutaneous estradiol 1.5 mg, frovatriptan 2.5 mg twice daily and naratriptan 1 mg twice daily. Contraceptive strategies offer the opportunity for treating menstrual migraine in women who also require effective contraception.

Are the current IHS guidelines for migraine drug trials being followed?

In 2000, the Clinical Trials Subcommittee of the International Headache Society (IHS) published the second edition of its guidelines for controlled trials of drugs in migraine. The purpose of this publication was to improve the quality of such trials by increasing the awareness amongst investigators of the methodological issues specific to this particular illness. Until now the adherence to these guidelines has not been systematically assessed. We reviewed all published controlled trials of drugs in migraine from 2002 to 2008. Eligible trials were scored for compliance with the IHS guidelines by using grading scales based on the most essential recommendations of the guidelines. The primary efficacy measure of each trial was also recorded. A total of 145 trials of acute treatment and 52 trials of prophylactic treatment were eligible for review. Of the randomized, double-blind trials, acute trials scored an average of 4.7 out of 7 while prophylactic trials scored an average of 5.6 out of 9 for compliance. Thirty-one percent of acute trials and 72% of prophylactic trials used the recommended primary efficacy measure. Fourteen percent of the reviewed trials were either not randomized or not double-blinded. Adherence to international guidelines like these of IHS is important to ensure that only high-quality trials are performed, and to provide the consensus that is required for meta analyses. The primary efficacy measure for trials of acute treatment should be “pain free” and not “headache relief”. Open-label or non-randomized trials generally have no place in the study of migraine drugs.

Menstrual and nonmenstrual migraines differ in women with menstrually-related migraine

Introduction: We compared migraine features and acute therapy response in menstrually-related migraines (MRMs) and non-menstrually-related migraines (NMRMs).

Methods: Women with frequent, disabling migraines were prospectively diagnosed with MRM according to the International Classification of Headache Disorders (ICHD-II; N = 107) criteria using a daily electronic headache dairy. Participants received individualized acute therapy while free of prophylactic migraine medications.

Results: Repeated measures logistic regression revealed MRMs were longer (23.4 vs. 16.1 hours, odds ratio [OR] = 1.01, confidence interval [CI] 1.01, 1.02) and more likely associated with disability (85.6% vs. 75.6%, OR = 1.82, CI 1.27, 2.58) than NMRMs. MRMs were also less responsive to acute therapy (two-hour pain-free response = 6.7% vs. 13.4%, OR = .45, CI .26, .80) and reoccurred more frequently within 24 hours after a four-hour pain-free response (36.0% vs. 19.6%, OR = 2.12, CI 1.27, 3.53) than NMRMs.

Discussion: These results support the proposed ICHD-II classification of MRMs and suggest that MRMs may require a treatment approach different from that for NMRMs.

Clinical aspects of perimenstrual headaches

Menstrual migraine (MM) is either pure, if attacks are limited solely during the perimenstrual window (PMW), or menstrually related (MRM), if two of three PMWs are associated with attacks with additional migraine events outside the PMW. Acute migraine specific therapy is equally effective in MM and non-MM. Although the International Classification of Headache Disorders-II classifies MM without aura, data suggest this needs revision. The studies on extended-cycle oral contraceptives suggest benefits for headache-prone individuals. Triptan mini-prophylaxis outcomes are positive, but a conclusion of "minimal net benefit compared to placebo" is not entirely unwarranted. In a 2008 evidence-based review, grade B recommendations exist for sumatriptan (50 and 100 mg), mefenamic acid (500 mg), and riza-triptan (10 mg) for the acute treatment of MRM. For the preventive mini-prophylactic treatment of MRM, grade B recommendations are provided for transcutaneous estrogen (1.5 mg), frovatriptan (2.5 mg twice daily), and naratriptan (1 mg twice daily).

Ten years of rizatriptan: from development to clinical science and future directions

The year 2008 marked the 10th anniversary since rizatriptan was first launched for the acute treatment of migraine. In this article we discuss the concepts that motivated the preclinical and clinical development of rizatriptan, the clinical evidence that has driven its use over the past decade, rizatriptan's overall contribution to the field, and future directions for research.

Menstrual migraine

PURPOSE OF REVIEW

Menstrual migraine is prevalent but it is only recently that research has specifically addressed the pathophysiology and management of this disabling condition.

RECENT FINDINGS

For many years, menstrual migraine was a loose term used to describe an undefined association between migraine and menstruation. The introduction of recognized criteria has improved the diagnosis and enabled the study of a more homogenous population of women with this condition. As a consequence, studies have addressed putative mechanisms, particularly the association between oestrogen 'withdrawal' and migraine. It is recognised that other mechanisms have yet to be identified. Studies have confirmed the efficacy of perimenstrual prophylaxis with triptans and physiological doses of oestrogen. Despite robust data from randomized placebo-controlled studies, no treatments are licensed specifically for this indication at the time of writing.

SUMMARY

Recognition of menstrual migraine as a specific entity has resulted in improved diagnosis and increased research into the condition. However, our understanding of the pathophysiology and the consequent development of effective management strategies remain limited.

Rizatriptan efficacy in ICHD-II pure menstrual migraine and menstrually related migraine

OBJECTIVE

To examine the efficacy of rizatriptan for the treatment of pure menstrual migraine (PMM).

BACKGROUND

In 2004, the International Headache Society proposed new research criteria for menstrual migraine (International Classification of Headache Disorders [ICHD-II]). Two subtypes were defined: PMM, in which attacks occur exclusively with menstruation, and menstrually related migraine (MRM), in which attacks may also occur at other times of the cycle.

METHODS

The 2 protocols (MM1 and MM2) were identical randomized, double-blind studies. Adult patients with ICHD-II menstrual migraine were assigned to either rizatriptan 10-mg tablet or placebo (2:1). Patients were to treat a single menstrual migraine attack of moderate or severe pain intensity. This prospectively planned substudy pooled data from patients with a diagnosis of PMM from both studies. The primary substudy endpoint was 2-hour pain relief. Efficacy data were summarized for patients with a diagnosis of MRM.

RESULTS

Of 707 (MM1: 357, MM2: 350) patients treated in the study, 146 patients (MM1: 81, MM2: 65) had a diagnosis of PMM. The percentage of patients reporting 2-hour pain relief was significantly greater for rizatriptan than for placebo for both PMM (73% vs 50%, P = .006) and MRM subgroups (71% vs 52%, P < .001). Most other efficacy endpoints favored rizatriptan compared with placebo in patients with either PMM or MRM.

CONCLUSION

Rizatriptan 10 mg was superior to placebo for the treatment of PMM, as measured by 2-hour pain relief. Rizatriptan was also effective for the treatment of MRM and for relief of migraine-associated symptoms for both headache subtypes.

[Migraine and hormones: what can we be certain of?]

Women suffer from migraine far more frequently than men. This sex difference during the reproductive years is considered to result from additional trigger factors, such as the fluctuating hormones of the menstrual cycle and with the reproductive milestones of women. The role of the female hormones on migraine is illustrated by the phenomenon of menstrual migraine, and the changes in the clinical course of migraine with menarche, pregnancy, menopause and the external application of hormones. In summary, epidemiological, clinical and experimental studies document a substantial influence of female sex hormones on the pathophysiology of migraine headache.

Review of frovatriptan in the treatment of migraine

Triptans are recommended for the acute treatment of moderate to severe migraine or failure to respond to other acute migraine treatments. Seven triptans are available providing a wide range of choices. These triptans are more similar than dissimilar but patients do note differences in effectiveness and in tolerance. Also migraine situations may differ from attack to attack, providing the opportunity to exploit the uniqueness of a particular triptan. Frovatriptan has a uniquely long-half life, five times that of other triptans. This provides the opportunity to use frovatriptan in mini-prophylaxis such as in menstrual-related migraine and other situations, as well as use in long-lasting or recurrent migraine.

Elimination of migraine-associated nausea in patients treated with rizatriptan orally disintegrating tablet (ODT): a randomized, double-blind, placebo-controlled study

OBJECTIVE

To confirm the efficacy of rizatriptan 10 mg orally disintegrating tablet (ODT) for the elimination of migraine-associated nausea.

BACKGROUND

Pooled studies of rizatriptan analyzing elimination of nausea as a secondary endpoint showed that 65% of rizatriptan patients reported elimination of nausea at 2 hours compared with 41% of patients taking placebo.

METHODS

This was a multicenter, randomized, double-blind, placebo-controlled single-attack trial enrolling adult patients with at least a 6-month history of migraine who typically experience migraine-associated nausea. Patients treated a moderate or severe migraine headache at the earliest sign of nausea with either rizatriptan 10 mg ODT or placebo (2 : 1). The primary endpoint was elimination of nausea at 2 hours postdose, and the secondary endpoint was pain relief at 2 hours postdose.

RESULTS

Although not statistically significant, a greater percentage of patients had elimination of nausea at 2 hours with rizatriptan compared with placebo (70.3% vs 62.0%, P = .165, odds ratio [95% CI] = 1.45 [0.86, 2.46]). When patients were grouped by baseline headache severity, rizatriptan showed a greater advantage than placebo for patients with moderate pain (rizatriptan 72.8% vs placebo 57.4%), but no difference for patients with severe pain (rizatriptan 67.7% vs placebo 66.7%). There were significantly more patients who achieved 2-hour pain relief with rizatriptan (69.7% vs 54.3%, P = .012, odds ratio [95% CI] = 1.94 [1.16, 3.25]).

CONCLUSION

Although the efficacy of rizatriptan 10 mg ODT for the elimination of migraine-associated nausea was comparable to that seen in previous rizatriptan trials, the higher-than-usual placebo response prevented a finding of a statistically significant difference. There was a sizable difference in placebo response between patients who treated moderate vs severe migraine. Rizatriptan was effective for 2-hour pain relief.