Oral Sumatriptan for the Acute Treatment of Probable Migraine: First Randomized, Controlled Study

Migraine without aura

Migraine without aura is the commonest form of migraine in both children and adults. The diagnosis is made by applying the International Classification of Headache Disorders Third Edition subsection for migraine without aura (ICHD-3 subsection 1.1). Attacks in patients with migraine without aura are characterized by their polyphasic presentation (prodrome, headache phase, postdromal phase). The symptomatology of attacks is diverse and heterogeneous, with most common symptoms being photophobia, phonophobia, nausea, vomiting, and aggravation of pain by movement. The clinician and researcher who wants to learn about migraine without aura needs to be able to apply the ICHD-3 criteria with its specific symptomatology to make a correct diagnosis, but also needs to be aware about the plethora of symptoms patients may experience. In this chapter, the reader will explore the clinical phenotypical features of migraine without aura.

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.

Clinical Features of Probable Cluster Headache: A Prospective, Cross-Sectional Multicenter Study

Background: Epidemiological data of probable cluster headaches (CH) are scarce in the relevant literature. Here, we sought to assess the prevalence and clinical characteristics of probable CH in comparison with definite CH.

Methods: Data used in this study were obtained from the Korean Cluster Headache Registry (KCHR), a prospective, cross-sectional, multicenter headache registry that collected data from consecutive patients diagnosed with CH.

Results: In total, 159 patients were enrolled in this study; 20 (12.6%) were diagnosed with probable CH. The most common unfulfilled criterion in patients with probable CH was the duration of attack, which was found in 40% of patients with probable CH. Among clinical characteristics, the number of autonomic symptoms tended to be lower in probable CH than in definite CH (1.7 ± 1.2 vs. 2.4 ± 1.5, p = 0.051) and conjunctival injection and lacrimation showed an increased odds ratio (OR) [OR = 3.03; 95% confidence interval (CI): 1.03–8.33] in definite CH. The groups did not differ with regard to baseline demographic characteristics, disability, impact on life, or treatment response.

Conclusions: Probable CH is relatively common among CH disorders, with a clinical impact similar to that of definite CH.

Single-item migraine screening tests, self-reported bothersome headache or stripe pattern hypersensitivity?

BACKGROUND

A simple screening tool may potentially help the migraine diagnosis in a primary care setting. The use of single-item tests, such as stripe pattern hypersensitivity test and self-reported bothersome headache (HA) question, as migraine screening tools have not been fully explored.

METHODS

Two hundred and fifty-four subjects (patients and companions) were randomly enrolled from an OB/GYN clinic (men 82, women 172; age 38 ± 14). They were instructed to rate the stripe sensitivity level (0-4) and to report any bothersome HA (yes/no). A brief structured HA interview was conducted to describe the HA characteristics and for migraine diagnosis based on the ICHD-IIIβ criteria.

RESULTS

In a multivariate model, bothersome HA question and stripe pattern hypersensitivity test were both significantly associated with EM+PM+CM (odds ratio: 24.0, P < 0.01 vs 2.6, P = 0.01) or EM (odds ratio: 16.2, P < 0.01 vs 3.0, P < 0.01). Bothersome HA question had a greater screening power than stripe pattern hypersensitivity for screening EM+PM+CM (area under the ROC curve: 0.84 [95% CI 0.78-0.89] vs 0.62 [95% CI 0.55-0.69]) or EM (area under the ROC curve: 0.80 [95% CI 0.73-0.86] vs 0.64 [95% CI 0.56-0.72]).

CONCLUSION

When performed in an OB/GYN clinic, self-reported bothersome HA question seemed more powerful than visual stripe pattern test in screening migraine thus could potentially be used as a single-item screening test.

Comparative tolerability of treatments for acute migraine: A network meta-analysis

Introduction

Migraine headache is a neurological disorder whose attacks are associated with nausea, vomiting, photophobia and phonophobia. Treatments for migraine aim to either prevent attacks before they have started or relieve attacks (abort) after onset of symptoms and range from complementary therapies to pharmacological interventions. A number of treatment-related adverse events such as somnolence, fatigue, and chest discomfort have previously been reported in association with triptans. The comparative tolerability of available agents for the abortive treatment of migraine attacks has not yet been systematically reviewed and quantified.

Methods

We performed a systematic literature review and Bayesian network meta-analysis for comparative tolerability of treatments for migraine. The literature search targeted all randomized controlled trials evaluating oral abortive treatments for acute migraine over a range of available doses in adults. The primary outcomes of interest were any adverse event, treatment-related adverse events, and serious adverse events. Secondary outcomes were fatigue, dizziness, chest discomfort, somnolence, nausea, and vomiting.

Results

Our search yielded 141 trials covering 15 distinct treatments. Of the triptans, sumatriptan, eletriptan, rizatriptan, zolmitriptan, and the combination treatment of sumatriptan and naproxen were associated with a statistically significant increase in odds of any adverse event or a treatment-related adverse event occurring compared with placebo. Of the non-triptans, only acetaminophen was associated with a statistically significant increase in odds of an adverse event occurring when compared with placebo. Overall, triptans were not associated with increased odds of serious adverse events occurring and the same was the case for non-triptans. For the secondary outcomes, with the exception of vomiting, all triptans except for almotriptan and frovatriptan were significantly associated with increased risk for all outcomes. Almotriptan was significantly associated with an increased risk of vomiting, whereas all other triptans yielded non-significant lower odds compared with placebo. Generally, the non-triptans were not associated with decreased tolerability for the secondary outcomes.

Discussion

In summary, triptans were associated with higher odds of any adverse event or a treatment-related adverse event occurring when compared to placebo and non-triptans. Non-significant results for non-triptans indicate that these treatments are comparable with one another and placebo regarding tolerability outcomes.

Prevalence of migraine headache in an in-patient stroke population

INTRODUCTION

Migraine, especially with aura, is a risk factor for ischemic stroke. In this study, we investigated descriptive data and prevalence of migraine in an in-patient stroke population.

MATERIALS AND METHODS

Patients with acute cerebrovascular disease (CVD) admitted to the stroke unit during a 6-month period were recruited. Prevalence of migraine was assessed using a structured questionnaire. Additional clinical data regarding risk factors for CVD were evaluated for all responding patients.

RESULTS

A total of 229 patients received a questionnaire and 175 answers were collected (response frequency of 76.4%). Responders matched the initial cohort regarding distribution of age, sex, and type of stroke. Thirty-six cases (20.6%) fulfilled the criteria for migraine or probable migraine according to the 2nd edition of the International Headache Classification (ICHD-2). Sixty percent of migraine patients had migraine with aura. Stroke patients with migraine were younger (P = 0.007), the presence of patent foramen ovale (PFO) was significantly increased (P = 0.008), and atrial fibrillation was less common (P = 0.048). There were no other differences between patients with and without migraine headache regarding conventional risk factors.

CONCLUSIONS

The prevalence of migraine in this hospital-based stroke cohort was comparable to the estimated prevalence of migraine usually described in population studies. In our study population, the prevalence of migraine with aura was higher than expected. The increased prevalence of PFO in patients with migraine headache corresponds well to previous population studies.

Sumatriptan/naproxen sodium for the acute treatment of probable migraine without aura: A randomized study

Objective

Probable migraine is a common, disabling migraine subtype fulfilling all but one of the diagnostic criteria for migraine. This study was conducted to evaluate the efficacy and tolerability of sumatriptan/naproxen sodium for the acute treatment of probable migraine without aura.

Methods

Patients treated a headache of probable migraine without aura when pain was moderate or severe with sumatriptan/naproxen sodium ( n = 222 intent-to-treat (ITT)) or placebo ( n = 221 ITT/complete case analysis a ) in this randomized, double-blind, parallel-group study.

Results

Sumatriptan/naproxen sodium was more effective than placebo with respect to the co-primary efficacy endpoints two-hour pain-free response (29% sumatriptan/naproxen sodium vs 11% placebo, p < 0.001) and two- to 24-hour sustained pain-free response (24% sumatriptan/naproxen sodium vs 9% placebo, p < 0.001). Sumatriptan/naproxen sodium was significantly more effective than placebo with respect to the secondary efficacy endpoints of pain-free response four hours postdose ( p < 0.001), pain-free response maintained one to two hours postdose ( p = 0.034) and two to four hours postdose ( p < 0.001), headache relief four hours postdose ( p < 0.001), headache relief maintained two to four hours postdose ( p = 0.015), sustained headache relief two through 24 hours postdose ( p = 0.002), and rescue medication use ( p < 0.001); but not productivity scores. The most common adverse events were dizziness (4% sumatriptan/naproxen sodium,<1% placebo), dry mouth (2% sumatriptan/naproxen sodium, <1% placebo), and nausea (2% sumatriptan/naproxen sodium, <1% placebo).

Conclusion

Sumatriptan/naproxen sodium is effective in the acute treatment of probable migraine as demonstrated by higher rates of freedom from pain and restoration of function.

Prevalence, clinical characteristics and disability of migraine and probable migraine: a nationwide population-based survey in Korea

BACKGROUND

Epidemiological data on probable migraine (PM) in Asia have rarely been reported. This study aimed to assess the prevalence, clinical characteristics, and disability of PM in comparison with strict migraine (SM) in Korea.

METHODS

The Korean Headache Survey (KHS) is a nationwide interview survey that investigates the status of headache disorders among adults aged 19-69. We used data from the KHS.

RESULTS

In a representative sample of 1507 individuals, the one-year prevalence of SM was 6.0%, and that of PM was 11.5%. Most PM sufferers missed the criterion of typical headache duration (82.0%). Multivariable regression analyses revealed that PM sufferers had an increased odds ratio (OR) for mild headache intensity (OR = 2.08; 95% confidence interval (CI): 1.11-3.90) and decreased ORs for living in a small city (OR = 0.50; 95% CI: 0.26-0.94), living in a rural area (OR = 0.36; 95% CI: 0.14-0.92) and headache frequency five to nine days per month (OR = 0.29; 95% CI: 0.11-0.78) compared to SM sufferers. Some SM and PM sufferers experienced decreased activity (26.4% in SM vs. 18.0% in PM) and missed activity (12.1% in SM vs. 14.4% in PM) due to headache.

CONCLUSIONS

PM is a prevalent headache disorder in Korea. Some sociodemographic and clinical characteristics of PM are different from those of SM.

Sumatriptan (oral route of administration) for acute migraine attacks in adults

BACKGROUND

Migraine is a highly disabling condition for the individual and also has wide-reaching implications for society, healthcare services, and the economy. Sumatriptan is an abortive medication for migraine attacks, belonging to the triptan family.

OBJECTIVES

To determine the efficacy and tolerability of oral sumatriptan compared to placebo and other active interventions in the treatment of acute migraine attacks in adults.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, online databases, and reference lists for studies through 13 October 2011.

SELECTION CRITERIA

We included randomised, double-blind, placebo- and/or active-controlled studies using oral sumatriptan to treat a migraine headache episode, with at least 10 participants per treatment arm.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. We used numbers of participants achieving each outcome to calculate relative risk (or 'risk ratio') and numbers needed to treat to benefit (NNT) or harm (NNH) compared to placebo or a different active treatment.

MAIN RESULTS

Sixty-one studies (37,250 participants) compared oral sumatriptan with placebo or an active comparator. Most of the data were for the 50 mg and 100 mg doses. Sumatriptan surpassed placebo for all efficacy outcomes. For sumatriptan 50 mg versus placebo the NNTs were 6.1, 7.5, and 4.0 for pain-free at two hours and headache relief at one and two hours, respectively. NNTs for sustained pain-free and sustained headache relief during the 24 hours postdose were 9.5 and 6.0, respectively. For sumatriptan 100 mg versus placebo the NNTs were 4.7, 6.8, 3.5, 6.5, and 5.2, respectively, for the same outcomes. Results for the 25 mg dose were similar to the 50 mg dose, while sumatriptan 100 mg was significantly better than 50 mg for pain-free and headache relief at two hours, and for sustained pain-free during 24 hours. Treating early, during the mild pain phase, gave significantly better NNTs for pain-free at two hours and sustained pain-free during 24 hours than did treating established attacks with moderate or severe pain intensity.Relief of associated symptoms, including nausea, photophobia, and phonophobia, was greater with sumatriptan than with placebo, and use of rescue medication was lower with sumatriptan than with placebo. For the most part, adverse events were transient and mild and were more common with the sumatriptan than with placebo, with a clear dose response relationship (25 mg to 100 mg).Sumatriptan was compared directly with a number of active treatments, including other triptans, paracetamol (acetaminophen), acetylsalicylic acid, non-steroidal anti-inflammatory drugs (NSAIDs), and ergotamine combinations.

AUTHORS' CONCLUSIONS

Oral sumatriptan is effective as an abortive treatment for migraine attacks, relieving pain, nausea, photophobia, phonophobia, and functional disability, but is associated with increased adverse events.

Ischemic Stroke Followed by Acute Thrombocytopenia

A 23-year-old woman developed ischemic stroke (IS) 8 to 12 hours after ingestion of sumatriptan (ST) and then developed mucosal bleeding secondary to acute thrombocytopenia likely due to dipyridamole (DP) on the 10th day poststroke. Sumatriptan-associated IS and DP-induced thrombocytopenia are rare events in themselves and their sequential occurrence in the same patient is quite exceptional. We compare our case to other similar cases in the literature.

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.