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Peng KP, Jürgens T, Basedau H, Ortlieb L, May A. Sumatriptan prevents central sensitisation specifically in the trigeminal dermatome in humans. Eur J Pain 2022; 26:2152-2161. [PMID: 36001070 DOI: 10.1002/ejp.2027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 07/22/2022] [Accepted: 08/20/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND The exact mechanism and site of action of triptans in aborting migraine attacks remain under debate. We hypothesized that the clinical efficacy of triptans lies in aborting central sensitization and focused on the question of why triptans are headache-specific, i.e. highly effective in migraine and cluster headache and ineffective in extracephalic pain. METHODS Forty healthy participants were enrolled in this double-blinded, randomized, placebo-controlled study. The effect of sumatriptan (n=20) vs placebo (n=20) was investigated in a cephalic (V1) vs an extracephalic dermatome (forearm) using a topical capsaicin sensitization model. Capsaicin-induced primary and secondary hyperalgesia were evaluated using quantitative sensory testing. RESULTS After capsaicin application, primary hyperalgesia developed in both sumatriptan and placebo groups in both dermatomes. However, sumatriptan exclusively prevented secondary hyperalgesia in the V1 dermatome but not on the forearm. Placebo exerted no effects on secondary hyperalgesia in both trigeminal and extracephalic dermatomes. Additionally, sumatriptan reduced the flare size exclusively in the V1 dermatome. CONCLUSIONS Our data suggest that sumatriptan reduces central sensitization (secondary hyperalgesia) without modulating peripheral sensitization (primary hyperalgesia) in a human pain model of capsaicin-induced sensitization. Moreover, despite a systemic administration of sumatriptan, the modulatory effects are trigeminal-specific, echoing the clinical effect of triptans in aborting headaches, but not extracephalic pain.
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Affiliation(s)
- Kuan-Po Peng
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tim Jürgens
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Neurology, KMG Medical Center, Güstrow, Germany
| | - Hauke Basedau
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Luise Ortlieb
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Arne May
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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2
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Descheemaeker A, Poras H, Wurm M, Luccarini P, Ouimet T, Dallel R. Dual enkephalinase inhibitor PL37 as a potential novel treatment of migraine: evidence from a rat model. Brain 2022; 145:2664-2670. [PMID: 35411377 DOI: 10.1093/brain/awac139] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 03/22/2022] [Accepted: 03/29/2022] [Indexed: 11/14/2022] Open
Abstract
The dual enkephalinase inhibitor PL37, a small molecule that protects enkephalins from their rapid degradation, has demonstrated analgesic properties in animal pain models and in early human clinical trials. This study tested the antimigraine potential of PL37 on cutaneous mechanical hypersensitivity affecting cephalic regions in migraineurs. Using behavioral testing and c-Fos immunoreactivity in male rats, we investigated the effects of single (oral or intravenous) and repeated oral administration of PL37 on changes in cutaneous mechanical sensitivity and sensitization of the trigeminocervical complex induced by repeated administration of the nitric oxide donor, isosorbide dinitrate. In naive rats, single or repeated administration of PL37 or vehicle had no effect on cephalic mechanical sensitivity. However, single oral PL37 treatment effectively inhibited isosorbide dinitrate-induced acute cephalic mechanical hypersensitivity. Single intravenous but not oral PL37 administration inhibited chronic cephalic mechanical hypersensitivity. Daily oral administration of PL37 prevented cephalic mechanical hypersensitivity and decreased touch-induced c-Fos expression in trigeminocervical complex following repeated isosorbide dinitrate administration. These data reveal the therapeutic potential of the dual enkephalinase inhibitor PL37 as an acute and prophylactic treatment for migraine. Protecting enkephalins from their degrading enzymes therefore appears as an innovative approach to treat migraine.
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Affiliation(s)
- Amélie Descheemaeker
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm, Neuro-Dol, F-63000 Clermont-Ferrand, France
| | | | | | - Philippe Luccarini
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm, Neuro-Dol, F-63000 Clermont-Ferrand, France
| | | | - Radhouane Dallel
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm, Neuro-Dol, F-63000 Clermont-Ferrand, France
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3
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Pascual J, Vila C. Almotriptan: a review of 20 years' clinical experience. Expert Rev Neurother 2019; 19:759-768. [PMID: 30845850 DOI: 10.1080/14737175.2019.1591951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Introduction: Almotriptan (ALT), a serotonin 5-HT1B/1D agonist has been used in the acute treatment of migraine with or without aura for 20 years, accumulating data on more than 15,000 patients in studies and from an estimated >150 million treated migraine attacks in daily clinical practice. The last major review of ALT was written almost 10 years ago. The current narrative review provides an overview of the experience gained with almotriptan over that time, and highlights data published in the last decade. Areas covered: Randomized clinical trials, observational studies, postmarketing studies and meta-analyses involving ALT for the treatment of acute migraine identified through a systematic literature search. Expert opinion: Triptans are a mainstay of anti-migraine treatment. Findings with ALT over the last 10 years have reinforced the positive efficacy and tolerability results that were reported during the first 10 years following its introduction. In particular, more recent clinical results have confirmed its efficacy in women with menstrual migraine, the usefulness of early intervention, long-term benefit in adults, and also its efficacy and safety in adolescents. Overall, ALT can be considered an optimal choice for managing acute migraine resistant to first-line drugs.
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Affiliation(s)
- Julio Pascual
- a Neurology Service , University Hospital Marqués de Valdecilla and IDIVAL , Santander , Spain
| | - Carlos Vila
- b Global Medical Affairs , Almirall S.A , Barcelona , Spain
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4
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Akerman S, Karsan N, Bose P, Hoffmann JR, Holland PR, Romero-Reyes M, Goadsby PJ. Nitroglycerine triggers triptan-responsive cranial allodynia and trigeminal neuronal hypersensitivity. Brain 2019; 142:103-119. [PMID: 30596910 PMCID: PMC6308314 DOI: 10.1093/brain/awy313] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/26/2018] [Accepted: 10/23/2018] [Indexed: 12/29/2022] Open
Abstract
Cranial allodynia associated with spontaneous migraine is reported as either responsive to triptan treatment or to be predictive of lack of triptan efficacy. These conflicting results suggest that a single mechanism mediating the underlying neurophysiology of migraine symptoms is unlikely. The lack of a translational approach to study cranial allodynia reported in migraine patients is a limitation in dissecting potential mechanisms. Our objective was to study triptan-responsive cranial allodynia in migraine patients, and to develop an approach to studying its neural basis in the laboratory. Using nitroglycerine to trigger migraine attacks, we investigated whether cranial allodynia could be triggered experimentally, observing its response to treatment. Preclinically, we examined the cephalic response properties of central trigeminocervical neurons using extracellular recording techniques, determining changes to ongoing firing and somatosensory cranial-evoked sensitivity, in response to nitroglycerine followed by triptan treatment. Cranial allodynia was triggered alongside migraine-like headache in nearly half of subjects. Those who reported cranial allodynia accompanying their spontaneous migraine attacks were significantly more likely to have symptoms triggered than those that did not. Patients responded to treatment with aspirin or sumatriptan. Preclinically, nitroglycerine caused an increase in ongoing firing and hypersensitivity to intracranial-dural and extracranial-cutaneous (noxious and innocuous) somatosensory stimulation, reflecting signatures of central sensitization potentially mediating throbbing headache and cranial allodynia. These responses were aborted by a triptan. These data suggest that nitroglycerine can be used as an effective and reliable method to trigger cranial allodynia in subjects during evoked migraine, and the symptom is responsive to abortive triptan treatments. Preclinically, nitroglycerine activates the underlying neural mechanism of cephalic migraine symptoms, central sensitization, also predicting the clinical outcome to triptans. This supports a biological rationale that several mechanisms can mediate the underlying neurophysiology of migraine symptoms, with nitrergic-induced changes reflecting one that is relevant to spontaneous migraine in many migraineurs, whose symptoms of cranial allodynia are responsive to triptan treatment. This approach translates directly to responses in animals and is therefore a relevant platform to study migraine pathophysiology, and for use in migraine drug discovery.
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Affiliation(s)
- Simon Akerman
- Headache Group-Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
- Department of Oral and Maxillofacial Pathology, Radiology and Medicine, New York University College of Dentistry, New York, NY, USA
- Department of Neural and Pain Sciences, University of Maryland Baltimore, Baltimore, Maryland, MD, USA
| | - Nazia Karsan
- Headache Group, Department of Basic and Clinical Neuroscience, Institute of Psychology, Psychiatry and Neuroscience, King’s College London, London, UK
- NIHR-Wellcome Trust King’s Clinical Research Facility, King’s College Hospital, London, UK
| | - Pyari Bose
- Headache Group, Department of Basic and Clinical Neuroscience, Institute of Psychology, Psychiatry and Neuroscience, King’s College London, London, UK
- NIHR-Wellcome Trust King’s Clinical Research Facility, King’s College Hospital, London, UK
| | - Jan R Hoffmann
- Headache Group-Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
- Headache Group, Department of Basic and Clinical Neuroscience, Institute of Psychology, Psychiatry and Neuroscience, King’s College London, London, UK
| | - Philip R Holland
- Headache Group, Department of Basic and Clinical Neuroscience, Institute of Psychology, Psychiatry and Neuroscience, King’s College London, London, UK
| | - Marcela Romero-Reyes
- Department of Oral and Maxillofacial Pathology, Radiology and Medicine, New York University College of Dentistry, New York, NY, USA
- Department of Neural and Pain Sciences, University of Maryland Baltimore, Baltimore, Maryland, MD, USA
| | - Peter J Goadsby
- Headache Group-Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
- Headache Group, Department of Basic and Clinical Neuroscience, Institute of Psychology, Psychiatry and Neuroscience, King’s College London, London, UK
- NIHR-Wellcome Trust King’s Clinical Research Facility, King’s College Hospital, London, UK
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Abstract
Context The classification of headache disorders has improved over the years, but further work is needed to develop and improve headache diagnosis within headache subtypes. The present review is a call for action to implement laboratory tests in the classification and management of primary and some secondary headaches. Background In this narrative review we present and discuss published tests that might be useful in phenotyping and/or diagnosis of long-lasting headache disorders such as migraine, tension-type headache, trigeminal autonomic cephalalgias, trigeminal neuralgia and persisting secondary headaches. Aim The palpometer test, quantitative sensory testing, nociceptive blink reflex and autonomic tests may be valuable to phenotype and/or diagnose subforms of migraine, tension-type headache, cluster headache, trigeminal neuralgia and medication-overuse headache. Provocation tests with glyceryl trinitrate (GTN) and calcitonin gene-related peptide (CGRP) may be valuable in subclassification of migraine and cluster headache. Lumbar pressure monitoring and optical coherence tomography may valuable tools to diagnose and follow patients with chronic headache and raised intracranial pressure. Finding A number of laboratory tests in headache research are presently available, but have primarily been performed in single research studies or a few studies that differ in methods and patient groups. At present, there is no evidence-based strategy for implementing diagnostic tests, but this could be achieved if well-reputed tertiary headache centers commence developing and implementing laboratory tests in order to improve the classification and treatment of headache patients.
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Affiliation(s)
- Henrik Winther Schytz
- University of Copenhagen, Danish Headache Centre, Department of Neurology at Glostrup Hospital, Denmark
| | - Jes Olesen
- University of Copenhagen, Danish Headache Centre, Department of Neurology at Glostrup Hospital, Denmark
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Meents JE, Hoffmann J, Chaplan SR, Neeb L, Schuh-Hofer S, Wickenden A, Reuter U. Two TRPV1 receptor antagonists are effective in two different experimental models of migraine. J Headache Pain 2015; 16:57. [PMID: 26109436 PMCID: PMC4491068 DOI: 10.1186/s10194-015-0539-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 06/05/2015] [Indexed: 11/18/2022] Open
Abstract
Background The capsaicin and heat responsive ion channel TRPV1 is expressed on trigeminal nociceptive neurons and has been implicated in the pathophysiology of migraine attacks. Here we investigate the efficacy of two TRPV1 channel antagonists in blocking trigeminal activation using two in vivo models of migraine. Methods Male Sprague–Dawley rats were used to study the effects of the TRPV1 antagonists JNJ-38893777 and JNJ-17203212 on trigeminal activation. Expression of the immediate early gene c-fos was measured following intracisternal application of inflammatory soup. In a second model, CGRP release into the external jugular vein was determined following injection of capsaicin into the carotid artery. Results Inflammatory up-regulation of c-fos in the trigeminal brain stem complex was dose-dependently and significantly reduced by both TRPV1 antagonists. Capsaicin-induced CGRP release was attenuated by JNJ-38893777 only in higher dosage. JNJ-17203212 was effective in all doses and fully abolished CGRP release in a time and dose-dependent manner. Conclusion Our results describe two TRPV1 antagonists that are effective in two in vivo models of migraine. These results suggest that TRPV1 may play a role in the pathophysiological mechanisms, which are relevant to migraine.
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Affiliation(s)
- Jannis E Meents
- Department of Physiology, Uniklinik RWTH Aachen, Pauwelsstr. 30, D-52074, Aachen, Germany,
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Tajti J, Majláth Z, Szok D, Csáti A, Vécsei L. Drug safety in acute migraine treatment. Expert Opin Drug Saf 2015; 14:891-909. [DOI: 10.1517/14740338.2015.1026325] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Allais G, Rolando S, De Lorenzo C, Benedetto C. The efficacy and tolerability of frovatriptan and dexketoprofen for the treatment of acute migraine attacks. Expert Rev Neurother 2014; 14:867-77. [DOI: 10.1586/14737175.2014.940901] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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9
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Silberstein SD, Stirpe JC. COX inhibitors for the treatment of migraine. Expert Opin Pharmacother 2014; 15:1863-74. [DOI: 10.1517/14656566.2014.937704] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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10
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Allais G, Tullo V, Cortelli P, Barbanti P, Valguarnera F, Sette G, D'Onofrio F, Curone M, Zava D, Pezzola D, Reggiardo G, Omboni S, Frediani F, Bussone G, Benedetto C. Efficacy of early vs. late use of frovatriptan combined with dexketoprofen vs. frovatriptan alone in the acute treatment of migraine attacks with or without aura. Neurol Sci 2014; 35 Suppl 1:107-13. [PMID: 24867846 PMCID: PMC4035546 DOI: 10.1007/s10072-014-1751-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Early triptan use after headache onset may help improve the efficacy of acute migraine treatment. This may be particularly the case when triptan therapy is combined with a nonsteroidal anti-inflammatory drug (NSAID). The objective of this is to assess whether the combination of frovatriptan 2.5 mg + dexketoprofen 25 or 37.5 mg (FroDex25 and FroDex37.5) is superior to frovatriptan 2.5 mg alone (Frova) in the acute treatment of migraine attacks in patients who took the drug within 30 min from the onset of pain (early use) or after (late use). A total of 314 subjects with a history of migraine with or without aura were randomized into a double-blind, multicenter, parallel group, pilot study to Frova, FroDex25 or FroDex37.5 and were required to treat at least one migraine attack. In the present post hoc analysis, traditional migraine endpoints were compared across study drugs for subgroups of the 279 patients of the full analysis set according to early (n = 172) or late (n = 107) drug use. The proportion of patients pain free at 2 h in the early drug use subgroup was 33 % with Frova, 50 % with FroDex25 and 51 % with FroDex37.5 mg (p = NS combinations vs. monotherapy), while in the late drug use subgroup was 22, 51 and 50 % (p < 0.05 FroDex25 and FroDex37.5 vs. Frova), respectively. Pain-free episodes at 4 h were 54 % for early and 34 % for late use of Frova, 71 and 57 % with FroDex25 and 74 and 68 % with FroDex37.5 (p < 0.05 for early and p < 0.01 for late use vs. Frova). The proportion of sustained pain free at 24 h was 26 % under Frova, 43 % under FroDex25 mg and 40 % under FroDex37.5 mg (p = NS FroDex25 or 37.5 vs. Frova) in the early drug intake subgroup, while it was 19 % under Frova, 43 % under FroDex25 mg and 45 % under FroDex37.5 mg (p < 0.05 FroDex25 and FroDex37.5 vs. Frova) in the late drug intake subgroup. Risk of relapse at 48 h was similar (p = NS) among study drug groups (Frova: 25 %, FroDex25: 21 %, and FroDex37.5: 37 %) for the early as well as for the late drug use subgroup (14, 42 and 32 %). FroDex was found to be more effective than Frova taken either early or late. The intrinsic pharmacokinetic properties of the two single drug components made FroDex combination particularly effective within the 2–48-h window from the onset of the acute migraine attack. The efficacy does not seem to be influenced by the time of drug use relative to the onset of headache.
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Affiliation(s)
- Gianni Allais
- Women's Headache Center, Department of Surgical Sciences, University of Turin, Via Ventimiglia 3, 10126, Turin, Italy,
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Lovati C, D’Amico D, Bertora P. Allodynia in migraine: frequent random association or unavoidable consequence? Expert Rev Neurother 2014; 9:395-408. [DOI: 10.1586/14737175.9.3.395] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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12
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Abstract
Refractory migraine has long been a challenge to all headache specialists. This subgroup of migraine patients experience disability and impaired quality of life, despite optimal treatment. This article reviews the proposed definitions and epidemiology of refractory migraine, as well as the pathophysiology that may contribute to the genesis of this disorder. Aspects of treatment, including pharmacological, complementary/adjunct, and invasive approaches, are reviewed. Comorbid factors, medication overuse, potential pitfalls to treatment, and areas for future investigation are highlighted.
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Affiliation(s)
- Elliott Schulman
- Lankenau Medical Center and Lankenau Institute for Medical Research, Wynnewood, PA, USA
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Abstract
Migraine constitutes a relatively common reason for pediatric emergency room visits. Given the paucity of randomized trials involving pediatric migraineurs in the emergency department setting compared with adults, recommendations for managing these children are largely extrapolated from adult migraine emergency room studies and trials involving outpatient home pediatric migraine therapy. We review current knowledge about pediatric migraineurs presenting at the emergency room and their management, and summarize the best evidence available to guide clinical decision-making.
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Affiliation(s)
- Amy A Gelfand
- Division of Child Neurology, Department of Neurology, University of California, San Francisco, San Francisco, California, USA.
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Hoffmann J, Wecker S, Neeb L, Dirnagl U, Reuter U. Primary trigeminal afferents are the main source for stimulus-induced CGRP release into jugular vein blood and CSF. Cephalalgia 2012; 32:659-67. [DOI: 10.1177/0333102412447701] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Jan Hoffmann
- Department of Neurology, Charité - Universitätsmedizin Berlin, Germany
- Department of Neurology, University of California San Francisco, USA
| | - Sascha Wecker
- Department of Neurology, Charité - Universitätsmedizin Berlin, Germany
| | - Lars Neeb
- Department of Neurology, Charité - Universitätsmedizin Berlin, Germany
| | - Ulrich Dirnagl
- Department of Neurology, Charité - Universitätsmedizin Berlin, Germany
| | - Uwe Reuter
- Department of Neurology, Charité - Universitätsmedizin Berlin, Germany
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Tepper SJ, Kori SH, Borland SW, Wang MH, Hu B, Mathew NT, Silberstein SD. Efficacy and Safety of MAP0004, Orally Inhaled DHE in Treating Migraines With and Without Allodynia. Headache 2011; 52:37-47. [DOI: 10.1111/j.1526-4610.2011.02041.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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16
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Tepper SJ, Kori SH, Goadsby PJ, Winner PK, Wang MH, Silberstein SD, Cutrer FM. MAP0004, orally inhaled dihydroergotamine for acute treatment of migraine: efficacy of early and late treatments. Mayo Clin Proc 2011; 86:948-55. [PMID: 21964172 PMCID: PMC3184024 DOI: 10.4065/mcp.2011.0093] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate the efficacy of MAP0004, an orally inhaled dihydroergotamine, for acute treatment of migraine when administered at various time points from within 1 hour to more than 8 hours after migraine onset. PATIENTS AND METHODS This post hoc subanalysis was conducted using data from 902 patients enrolled in a randomized, double-blind, placebo-controlled, 2-arm, phase 3, multicenter study conducted from July 14, 2008, through March 23, 2009. End points were 2-hour pain relief and pain-free rates in patients who treated a migraine in ≤1 hour, from >1 hour to ≤4 hours, from >4 to ≤8 hours, or in >8 hours after onset of migraine, given that patients may be unwilling or unable to initiate treatment at headache inception. RESULTS Treatment with MAP0004 was significantly more effective than placebo in relieving pain at all treatment points (≤1 hour after start of migraine: 66% [74/112] for MAP0004 vs 41% [48/118] for placebo, P<.001; >1 to ≤4 hours: 60% [91/153] vs 35% [58/168], P<.001; >4 to ≤8 hours: 53% [36/68] vs 30% [16/54], P=.008; and >8 hours: 48% [25/52] vs 24% [11/46], P=.007). Pain-free rates were also significantly higher with MAP0004 than placebo for treatment within 8 hours after migraine onset (≤1 hour: 38% [43/112] for MAP0004 vs 13% [15/118] for placebo, P<.001; >1 to ≤4 hours: 28% [43/153] vs 10% [17/168], P<.001; >4 to ≤8 hours: 22% [15/68] vs 7% [4/54], P<.025) but not at >8 hours (19% [10/52] vs 9% [4/46], P=.106). CONCLUSION This post hoc subanalysis shows that MAP0004 was effective in treating migraine irrespective of the time of treatment, even more than 8 hours after onset of migraine pain.
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Affiliation(s)
- Stewart J Tepper
- Center for Headache and Pain, Neurological Institute, Cleveland Clinic, Cleveland, OH 44195-0002, USA.
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Landy S, Hoagland R, Hoagland NA. Sumatriptan-Naproxen Migraine Efficacy in Allodynic Patients: Early Intervention. Headache 2011; 52:133-9. [DOI: 10.1111/j.1526-4610.2011.01992.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Díaz-Insa S, Goadsby PJ, Zanchin G, Fortea J, Falqués M, Vila C. The impact of allodynia on the efficacy of almotriptan when given early in migraine: data from the "Act when mild" study. Int J Neurosci 2011; 121:655-61. [PMID: 21777163 DOI: 10.3109/00207454.2011.605191] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The objective of this study was to evaluate the impact of allodynia on treatment outcomes in the patients with acute migraine treated in the "Act when Mild" (AwM) study. AwM, a randomized placebo-controlled trial, studied almotriptan 12.5 mg in the early treatment (within 1 hr) of acute migraine when the pain was still mild, and investigated clinical outcomes in the presence or absence of allodynia, which was prospectively recorded using patient questionnaires. Of the total population, 39% (n = 404) reported allodynia that did not alter the efficacy of almotriptan administered for early/mild pain in terms of 2-hr pain-free rates (53.9% for allodynic patients vs. 52.5% for nonallodynic patients). Similarly, sustained pain-free rates were 47.2% versus 45.5%, and migraine duration 1.40 versus 1.54 hr, respectively. However, allodynia impaired the effectiveness of almotriptan in the patients with moderate/severe pain in terms of longer migraine duration, fewer patients achieving pain-free status, and more requiring rescue medication. In conclusion, the lack of effect of allodynia on the efficacy of almotriptan given for early/mild migraine pain might help explain the improved outcomes associated with the early-treatment strategy in AwM. Moreover, the data suggest that pain intensity is the main driver of triptan response, and not the presence or absence of allodynia.
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Affiliation(s)
- S Díaz-Insa
- Headache-Neurology Unit, Hospital Francesc de Borja de Gandia, Spain.
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Göbel H, Heinze A. The Migraine Intervention Score - a tool to improve efficacy of triptans in acute migraine therapy: the ALADIN study. Int J Clin Pract 2011; 65:879-86. [PMID: 21762313 DOI: 10.1111/j.1742-1241.2011.02720.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The 'Migraine Intervention Score' (MIS) is a new self-administered scale that can be used to quantify the severity of specific migraine symptoms. The objective of this study was to determine if MIS could be used to improve the efficacy of frovatriptan 2.5 mg in the early treatment of migraine attacks for clinical practice. METHODS In this prospective observational study, patients suffering from migraines with or without aura were enrolled and permitted to choose the time of self-medication with frovatriptan 2.5 mg. At the time of intake of medication, patients evaluated the severity of individual migraine symptoms using MIS. The scores for each symptom were then totalled to provide an overall level of symptom severity. A total of 1620 patients completed the treatment of three migraine attacks with frovatriptan. A total of 1518 patients could be analysed with respect to the documented efficacy parameters of the third attack. Patients initiating treatment at low symptom severity levels were compared with those initiating treatment at high symptom severity levels. RESULTS Time to the achievement of the primary endpoint (headache response) was significantly lower in patients who initiated treatment at low vs. high symptom severity levels (42.06 ± 32.33 vs. 49.25 ± 34.92 min; p = 0.0023). Likewise, patients who initiated treatment at low symptom severity levels achieved complete headache relief more rapidly (79.37 ± 65.33 vs. 96.05 ± 100.85 min; p = 0.0109) and required escape medication less frequently (3.88% vs. 13.73%; p < 0.0001). CONCLUSIONS The initiation of attack treatment with frovatriptan at low severity of migraine symptoms is more effective than starting therapy at higher symptom levels. Together with the low recurrence headache rate, the decreased necessity for escape medication and the low number of tablets needed, these data demonstrate that operationalised intervention with frovatriptan 2.5 mg is a valuable method for improving the treatment of migraine attacks.
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Affiliation(s)
- H Göbel
- Kiel Headache and Pain Centre, Schmerzklinik Kiel, Kiel, Germany.
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Mathew NT. Pathophysiology of Chronic Migraine and Mode of Action of Preventive Medications. Headache 2011; 51 Suppl 2:84-92. [DOI: 10.1111/j.1526-4610.2011.01955.x] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Straube A, Aicher B, Fiebich BL, Haag G. Combined analgesics in (headache) pain therapy: shotgun approach or precise multi-target therapeutics? BMC Neurol 2011; 11:43. [PMID: 21453539 PMCID: PMC3080296 DOI: 10.1186/1471-2377-11-43] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2010] [Accepted: 03/31/2011] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Pain in general and headache in particular are characterized by a change in activity in brain areas involved in pain processing. The therapeutic challenge is to identify drugs with molecular targets that restore the healthy state, resulting in meaningful pain relief or even freedom from pain. Different aspects of pain perception, i.e. sensory and affective components, also explain why there is not just one single target structure for therapeutic approaches to pain. A network of brain areas ("pain matrix") are involved in pain perception and pain control. This diversification of the pain system explains why a wide range of molecularly different substances can be used in the treatment of different pain states and why in recent years more and more studies have described a superior efficacy of a precise multi-target combination therapy compared to therapy with monotherapeutics. DISCUSSION In this article, we discuss the available literature on the effects of several fixed-dose combinations in the treatment of headaches and discuss the evidence in support of the role of combination therapy in the pharmacotherapy of pain, particularly of headaches. The scientific rationale behind multi-target combinations is the therapeutic benefit that could not be achieved by the individual constituents and that the single substances of the combinations act together additively or even multiplicatively and cooperate to achieve a completeness of the desired therapeutic effect.As an example the fixed-dose combination of acetylsalicylic acid (ASA), paracetamol (acetaminophen) and caffeine is reviewed in detail. The major advantage of using such a fixed combination is that the active ingredients act on different but distinct molecular targets and thus are able to act on more signalling cascades involved in pain than most single analgesics without adding more side effects to the therapy. SUMMARY Multitarget therapeutics like combined analgesics broaden the array of therapeutic options, enable the completeness of the therapeutic effect, and allow doctors (and, in self-medication with OTC medications, the patients themselves) to customize treatment to the patient's specific needs. There is substantial clinical evidence that such a multi-component therapy is more effective than mono-component therapies.
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Affiliation(s)
- Andreas Straube
- Department of Neurology, Klinikum Großhadern, Ludwig-Maximilians-University, D-81377 Munich, Germany
| | - Bernhard Aicher
- Boehringer Ingelheim Pharma GmbH&Co. KG, Binger-Str. 173, D-55216 Ingelheim am Rhein, Germany
| | - Bernd L Fiebich
- Dept. of Psychiatry and Psychotherapy, Universitätsklinikum Freiburg, Hauptstr. 5, D-79104 Freiburg, Germany
| | - Gunther Haag
- Michael-Balint Klinik, Hermann-Voland Str. 10, D-78126 Königsfeld im Schwarzwald, Germany
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Pascual J, Vila C, McGown CC. Almotriptan: a review of 10 years' clinical experience. Expert Rev Neurother 2011; 10:1505-17. [PMID: 20945537 DOI: 10.1586/ern.10.131] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Almotriptan, a serotonin 5-HT 1B/1D agonist, was developed for the acute treatment of migraine with or without aura and has been available for 10 years. This article evaluates the wealth of experience that has been obtained with almotriptan, including large randomized clinical trials (RCTs) and post-marketing studies that more closely reflect everyday clinical practice. Initial RCTs required patients to take almotriptan when migraine pain was of moderate or severe intensity, and found that 12.5 mg provided optimal outcomes for both pain relief and tolerability. Almotriptan effectively improved 2-h pain-relief, reduced migraine-associated symptoms and demonstrated low recurrence rates. These findings were also shown in patient subgroups, such as adolescents and menstrual migraineurs. A secondary finding in these trials was that patients who took almotriptan early, when the pain was still mild, achieved better outcomes. This prompted the initiation of studies designed to assess the effect of almotriptan in early intervention. Open-label trials reported improvements in pain-free end points (2 h, 24 h), and subsequent RCTs confirmed these findings. Pharmacovigilance data from more than 100 million tablets dispensed worldwide have confirmed that almotriptan is associated with a low occurrence of adverse effects, which, in clinical trials, has been shown to be similar to that observed with placebo. The clinical evidence obtained and comparisons made over a decade of use have demonstrated that almotriptan is one of the more effective and fast-acting triptans available, with a placebo-like tolerability profile. This suggests that almotriptan is an excellent choice for patients requiring specific acute migraine treatment.
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Affiliation(s)
- Julio Pascual
- Hospital Universitario Central de Asturias, Oviedo, Spain.
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Are the current IHS guidelines for migraine drug trials being followed? J Headache Pain 2010; 11:457-68. [PMID: 20931348 PMCID: PMC3476229 DOI: 10.1007/s10194-010-0257-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2010] [Accepted: 09/12/2010] [Indexed: 11/18/2022] Open
Abstract
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.
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Schoenen J, Vandenheede M. Almotriptan efficacy in migraine with allodynia: A rebuttal to Burstein and Jakubowski’s critique of Schoenen et al. Cephalalgia 2010; 30:1147-8. [DOI: 10.1177/0333102409360678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Pardutz A, Schoenen J. NSAIDs in the Acute Treatment of Migraine: A Review of Clinical and Experimental Data. Pharmaceuticals (Basel) 2010; 3:1966-1987. [PMID: 27713337 PMCID: PMC4033962 DOI: 10.3390/ph3061966] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Revised: 05/18/2010] [Accepted: 06/11/2010] [Indexed: 11/25/2022] Open
Abstract
Migraine is a common disabling neurological disorder with a serious socio-economical burden. By blocking cyclooxygenase nonsteroidal anti-inflammatory drugs (NSAIDs) decrease the synthesis of prostaglandins, which are involved in the pathophysiology of migraine headaches. Despite the introduction more than a decade ago of a new class of migraine-specific drugs with superior efficacy, the triptans, NSAIDs remain the most commonly used therapies for the migraine attack. This is in part due to their wide availability as over-the-counter drugs and their pharmaco-economic advantages, but also to a favorable efficacy/side effect profile at least in attacks of mild and moderate intensity. We summarize here both the experimental data showing that NSAIDs are able to influence several pathophysiological facets of the migraine headache and the clinical studies providing evidence for the therapeutic efficacy of various subclasses of NSAIDs in migraine therapy. Taken together these data indicate that there are several targets for NSAIDs in migraine pathophysiology and that on the spectrum of clinical potency acetaminophen is at the lower end while ibuprofen is among the most effective drugs. Acetaminophen and aspirin excluded, comparative trials between the other NSAIDs are missing. Since evidence-based criteria are scarce, the selection of an NSAID should take into account proof and degree of efficacy, rapid GI absorption, gastric ulcer risk and previous experience of each individual patient. If selected and prescribed wisely, NSAIDs are precious, safe and cost-efficient drugs for the treatment of migraine attacks.
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Affiliation(s)
- Arpad Pardutz
- Department of Neurology, University of Szeged, Semmelweis u. 6. Szeged, Hungary H-6720, Hungary.
| | - Jean Schoenen
- Headache Research Unit, Department of Neurology & GIGA Neurosciences, Liège University, CHU-Sart Tilman, T4(+1), B36, B-4000 Liège, Belgium.
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Antonaci F, De Cillis I, Cuzzoni MG, Allena M. Almotriptan for the treatment of acute migraine: a review of early intervention trials. Expert Rev Neurother 2010; 10:351-64. [PMID: 20187858 DOI: 10.1586/ern.09.160] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Almotriptan is a serotonin (5-hydroxytryptamine)(1B/1D) receptor agonist (triptan) that has shown consistent efficacy in the acute treatment of migraine with excellent tolerability. It is an effective, well-tolerated and cost-effective triptan, as demonstrated by improvement in rigorous, patient-orientated end points, such as 'sustained pain-free without adverse events'. Results from post hoc analyses, observational studies and well-controlled, prospective clinical trials have shown that significant improvements can be achieved if almotriptan 12.5 mg is administered within an hour of migraine onset, particularly when pain is mild, rather than waiting until pain is moderate-to-severe. Benefits were also achieved with early treatment of moderate-to-severe pain. Time-to-treatment was the best predictor of headache duration, whereas initial headache intensity best predicted most other efficacy outcomes. Early administration of almotriptan 12.5 mg not only produced rapid symptomatic relief, it also improved the patient's quality of life and ability to resume normal daily functioning. Furthermore, the efficacy of almotriptan is not significantly affected by allodynia (purported to reduce the efficacy of triptans). Thus, the excellent efficacy and tolerability profile of almotriptan administered early in a migraine attack indicate that it may be a first-line treatment option in this common, underdiagnosed and undertreated disorder.
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Affiliation(s)
- Fabio Antonaci
- University Centre for Adaptive Disorders and Headache (UCADH), Section of Pavia, Headache Medicine Centre, Polyclinic of Monza, Via Mondino 2, 27100 Pavia, Italy.
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Meents JE, Neeb L, Reuter U. TRPV1 in migraine pathophysiology. Trends Mol Med 2010; 16:153-9. [DOI: 10.1016/j.molmed.2010.02.004] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2009] [Revised: 02/19/2010] [Accepted: 02/19/2010] [Indexed: 11/15/2022]
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Chou CH, Fuh JL, Wu JC, Wang SJ. Comparison of self-reported cutaneous allodynia and brushing allodynia during migraine attacks. Cephalalgia 2010; 30:682-5. [DOI: 10.1177/0333102409352910] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study compares the results of brushing allodynia (BA) during migraine attacks to those of self-reported cutaneous allodynia. We recruited 100 patients (20 with chronic migraine, 80 with episodic migraine) and performed a gauze-brushing test to detect BA. A previous experience of cutaneous allodynia was queried. Seventeen patients reported having allodynia before, whereas 22 patients exhibited BA. The frequency of self-reported allodynia (12.5% vs. 35.0%, p = .040) but not BA (21.3% vs. 25.0%, p = .765) differed between patients with episodic migraine and those chronic migraine. Patients with aura ( N = 8) had a higher frequency of both self-reported allodynia (62.5% vs. 12.2%, p = .003) and BA (87.5% vs. 17.6%, p < .001) than those without aura ( N = 92). Some allodynia symptoms, including avoidance of washing hair, touching the head, combing hair and lying on the site of head pain, were associated with BA (all p < .05). Our study showed that BA during migraine attacks correlated well with prior allodynia symptoms. The frequencies of BA and self-reported allodynia depend on the composition of different migraine subtypes and the timing of the gauze-brushing test.
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Affiliation(s)
- Chi-Hsiang Chou
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Neurology, Yuan-Shan Veterans Hospital, Yi-Lan, Taiwan
| | - Jong-Ling Fuh
- Neurological Institute, Taipei Veterans General Hospital, Taiwan
- Department of Neurology, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Jaw-Ching Wu
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Medical Research and Education, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shuu-Jiun Wang
- Neurological Institute, Taipei Veterans General Hospital, Taiwan
- Department of Neurology, National Yang-Ming University School of Medicine, Taipei, Taiwan
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Goadsby PJ, Sprenger T. Current practice and future directions in the prevention and acute management of migraine. Lancet Neurol 2010; 9:285-98. [DOI: 10.1016/s1474-4422(10)70005-3] [Citation(s) in RCA: 135] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Guy N, Marques AR, Orliaguet T, Lanteri-Minet M, Dallel R, Clavelou P. Are there differences between cephalic and extracephalic cutaneous allodynia in migraine patients? Cephalalgia 2009; 30:881-6. [DOI: 10.1111/j.1468-2982.2009.02008.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Cutaneous allodynia (CA), pain in response to innocuous cutaneous stimuli, is recognized as a sign of central sensitization during migraine episodes. It is either restricted within the pain area on the ipsilateral head, or extends within and outside the head. Moreover, CA can be elicited in response to thermal (heat or cold) and/or mechanical stimuli. This raises the question as to whether cephalic and extracephalic CAs share the same properties. We assessed cephalic and extracephalic CAs in migraine episodic patients using a questionnaire completed at home during migraine attacks. A total of 67 episodic migraine patients (58 women, nine men; 40 ± 13 years old) addressed all questions in the questionnaire. Forty-nine patients (73%) cited one or more allodynic symptoms during or immediately after the migraine attack. Almost all 49 patients reported cephalic CA, whereas 24 (49%) also reported extracephalic CA. Occurrence and extension of CA correlated ( P = 0.005) with headache intensity. Modalities of cephalic and extracephalic CA were different (χ2 = 12.03; P = 0.002), extracephalic CA being mostly thermal (75%) whereas cephalic CA was mostly mechanical (92%). This suggests that cephalic and extracephalic CAs involve different mechanisms.
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Affiliation(s)
- N Guy
- Inserm, U929, Clermont-Ferrand, F-63000 France
- Université Clermont1, Clermont-Ferrand, F-63000 France
- CHU Clermont-Ferrand, Clermont-Ferrand, F-63000, France
| | - AR Marques
- Inserm, U929, Clermont-Ferrand, F-63000 France
- Université Clermont1, Clermont-Ferrand, F-63000 France
- CHU Clermont-Ferrand, Clermont-Ferrand, F-63000, France
| | - T Orliaguet
- Inserm, U929, Clermont-Ferrand, F-63000 France
- Université Clermont1, Clermont-Ferrand, F-63000 France
- CHU Clermont-Ferrand, Clermont-Ferrand, F-63000, France
| | - M Lanteri-Minet
- Inserm, U929, Clermont-Ferrand, F-63000 France
- CHU Nice, Nice, F-06002, France
| | - R Dallel
- Inserm, U929, Clermont-Ferrand, F-63000 France
- Université Clermont1, Clermont-Ferrand, F-63000 France
- CHU Clermont-Ferrand, Clermont-Ferrand, F-63000, France
| | - P Clavelou
- Inserm, U929, Clermont-Ferrand, F-63000 France
- Université Clermont1, Clermont-Ferrand, F-63000 France
- CHU Clermont-Ferrand, Clermont-Ferrand, F-63000, France
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Abstract
Allodynia--perception of pain from non-noxious stimuli--is a common clinical feature in various pain syndromes. The significance for migraine has increasingly been recognized and the pathophysiology has been investigated in detail. Allodynia is a marker for sensitization of central trigeminal neurons. Intensity and persistence of allodynic symptoms are a function of duration of migraine attacks, frequency of attacks, and migraine history. It has been hypothesized that treatment success with triptans may be severely impaired in the presence of allodynia. However, randomized controlled trials did not confirm that. Treatment with cyclooxygenase inhibitors and dihydroergotamine does not seem to be limited by allodynia; these medications may be able to reverse allodynia. Data on the new class of calcitonin-gene related-peptide antagonists are not yet available. Additional and more refined randomized controlled trials, focusing on methodological issues pertaining to the determination of allodynia, are warranted to resolve the true relationship between allodynia and treatment response. Regardless--based on available randomized controlled trials--the recommendation prevails to initiate abortive treatment as soon as possible after attack onset when pain is still mild.
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Affiliation(s)
- M Schürks
- Division of Preventive Medicine, Department of Medicine, Brigham and Womens Hospital, Harvard Medical School, Boston, MA 02215-1204, USA.
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Cady RK, Freitag FG, Mathew NT, Elkind AH, Mao L, Fisher AC, Biondi DM, Finlayson G, Greenberg SJ, Hulihan JF. Allodynia-associated symptoms, pain intensity and time to treatment: predicting treatment response in acute migraine intervention. Headache 2009; 49:350-63. [PMID: 19220503 DOI: 10.1111/j.1526-4610.2009.01340.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the relationship between treatment outcomes and allodynia-associated symptoms (AAS) at the time of treatment with almotriptan. METHODS Analyses were performed with data collected prospectively from patients in 2 recently completed early intervention trials, AXERT Early miGraine Intervention Study (AEGIS) and AXERT 12.5 mg time vs Intensity Migraine Study (AIMS): 2-hour pain free, 2-hour pain relief (AEGIS only), sustained pain free (SPF), use of rescue medication, and median headache duration (AIMS only), in the presence and absence of pretreatment AAS, which was determined by responses to a questionnaire. Analyses were conducted to evaluate possible prognostic variables. RESULTS The presence of pretreatment AAS did not have a significant effect on 2-hour pain-free, 2-hour pain-relief or SPF rates, use of rescue medication, or headache duration. Significant factors for most favorable outcomes (greater 2-hour pain-free, 2-hour pain-relief and SPF rates, less use of rescue medication, and shorter headache duration) included treatment with almotriptan 12.5 mg, treatment of mild or moderate headache pain, and treatment within 1 hour of headache onset. CONCLUSION Almotriptan 12.5 mg was efficacious in providing 2-hour pain free, 2-hour pain relief, SPF, and reducing rescue medication use irrespective of the presence of AAS at the time of treatment. The most optimal efficacy outcomes occurred when patients treated migraine attacks early and before the onset of severe pain. The presence of AAS, which may indicate an early phase of allodynia, did not influence the efficacy of almotriptan therapy.
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Affiliation(s)
- Roger K Cady
- Headache Care Center, Springfield, MO 65807, USA
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Abstract
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.
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Affiliation(s)
- Arnaud Fumal
- Departments of Neurology and Functional Neuroanatomy, Headache Research Unit, University of Liège, CHR Citadelle, B-4000 Liege, Belgium.
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