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Terruzzi A, AlMadani A, Al-Rukn S, Farghaly M, Dallal SA, Zayed M, Vainstein N, Fathy M, Uboweja A, Natarajan A, Subramanyam K, Ramachandrachar BC, Aljabban A. A Retrospective Analysis of Disease Epidemiology, Comorbidity Burden, Treatment Patterns, and Healthcare Resource Utilization of Migraine in the United Arab Emirates. Pain Ther 2024; 13:1235-1255. [PMID: 39030417 PMCID: PMC11393247 DOI: 10.1007/s40122-024-00634-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 06/26/2024] [Indexed: 07/21/2024] Open
Abstract
INTRODUCTION Migraine is a recurrent, disabling neurological disorder with a substantial global disease burden. However, limited real-world data are available on the patient characteristics, treatment patterns, comorbidities, and economic burden of migraine in the United Arab Emirates (UAE). In this study, we evaluated the disease burden, comorbidities, treatment patterns, specialties involved in migraine diagnosis, and healthcare resource utilization (HCRU) and associated costs in patients with migraine in Dubai, UAE. METHODS A retrospective, secondary database cohort study was conducted from 01 January 2014 to 31 March 2022 using the Dubai Real-World Database. Patients aged ≥ 18 years with at least one diagnosis claim for migraine with continuous enrollment during the study period were included. Patients were stratified into treatment sub-cohorts. Outcomes were evaluated in terms of clinical characteristics, comorbidities, specialists visited, treatment patterns, and HCRU. RESULTS The study included 203,222 patients (mean age: 40 years), with male predominance (55.4%). About 13.4% of patients had specific cardiovascular comorbidities. Frequently prescribed drug classes were nonsteroidal anti-inflammatory drugs (84.4%), triptans (29.8%), and beta-blockers (12.8%), while only 1.0% of patients with migraine were prescribed newer medications like calcitonin gene-related peptide antagonists. General medicine was the most frequently visited specialty on the index date (51.5%). The all-cause and migraine-specific median gross costs during the 12-month post-index period were US $1252.6 (2.4-564,740.7) and US $198.1 (0-168,903.3) respectively, with maximum contribution from inpatients. The contribution of migraine-specific median costs to all-cause median costs was highest for the diagnosis-related group (64.9%), followed by consumables (35.2%), medications (32.0%), procedures (24.5%), and services (24.5%). CONCLUSION Migraine significantly impacts healthcare costs in the UAE. The role of newer therapies in migraine management should be explored to reduce the associated socioeconomic burden and improve patients' quality of life.
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Affiliation(s)
| | | | | | - Mohamed Farghaly
- Health Economics and Insurance Policies Department, Dubai Health Authority, Dubai, UAE
| | | | - Mostafa Zayed
- Health Economics and Outcomes Research (HEOR), Pfizer, Dubai, UAE
| | - Nora Vainstein
- Cardiovascular Scientific Expert Emerging Market, Pfizer, Dubai, UAE
| | | | - Anup Uboweja
- Value and Implementation Global Medical and Scientific Affairs, MSD, Mumbai, Maharashtra, India
| | | | | | | | - Ali Aljabban
- Pfizer, Dubai Media City, P.O. Box 502749, Dubai, UAE.
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2
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Zhang C, He Y, Liu L. Identifying therapeutic target genes for migraine by systematic druggable genome-wide Mendelian randomization. J Headache Pain 2024; 25:100. [PMID: 38867170 PMCID: PMC11167905 DOI: 10.1186/s10194-024-01805-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Accepted: 06/05/2024] [Indexed: 06/14/2024] Open
Abstract
BACKGROUND Currently, the treatment and prevention of migraine remain highly challenging. Mendelian randomization (MR) has been widely used to explore novel therapeutic targets. Therefore, we performed a systematic druggable genome-wide MR to explore the potential therapeutic targets for migraine. METHODS We obtained data on druggable genes and screened for genes within brain expression quantitative trait locis (eQTLs) and blood eQTLs, which were then subjected to two-sample MR analysis and colocalization analysis with migraine genome-wide association studies data to identify genes highly associated with migraine. In addition, phenome-wide research, enrichment analysis, protein network construction, drug prediction, and molecular docking were performed to provide valuable guidance for the development of more effective and targeted therapeutic drugs. RESULTS We identified 21 druggable genes significantly associated with migraine (BRPF3, CBFB, CDK4, CHD4, DDIT4, EP300, EPHA5, FGFRL1, FXN, HMGCR, HVCN1, KCNK5, MRGPRE, NLGN2, NR1D1, PLXNB1, TGFB1, TGFB3, THRA, TLN1 and TP53), two of which were significant in both blood and brain (HMGCR and TGFB3). The results of phenome-wide research showed that HMGCR was highly correlated with low-density lipoprotein, and TGFB3 was primarily associated with insulin-like growth factor 1 levels. CONCLUSIONS This study utilized MR and colocalization analysis to identify 21 potential drug targets for migraine, two of which were significant in both blood and brain. These findings provide promising leads for more effective migraine treatments, potentially reducing drug development costs.
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Affiliation(s)
- Chengcheng Zhang
- Department of Acupuncture and Moxibustion, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing Key Laboratory of Acupuncture Neuromodulation, No. 23, Meishuguan Houjie, Beijing, 100010, China
| | - Yiwei He
- State Key Laboratory of Networking and Switching Technology, Beijing University of Posts and Telecommunications, Beijing, 100876, China
| | - Lu Liu
- Department of Acupuncture and Moxibustion, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing Key Laboratory of Acupuncture Neuromodulation, No. 23, Meishuguan Houjie, Beijing, 100010, China.
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3
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Abdelmonem H, Abdelhay HM, Abdelwadoud GT, Alhosini ANM, Ahmed AE, Mohamed SW, Al-Dardery NM, Abd-ElGawad M, Kamel MA. The efficacy and safety of metoclopramide in relieving acute migraine attacks compared with other anti-migraine drugs: a systematic review and network meta-analysis of randomized controlled trials. BMC Neurol 2023; 23:221. [PMID: 37291500 DOI: 10.1186/s12883-023-03259-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 05/25/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Many drugs are prescribed in relieving acute migraine attacks, we aim to compare metoclopramide with other antimigraine drugs. METHODS We searched online databases like PubMed, Cochrane Library, Scopus, and Web of Science till June 2022 for RCTs that compared metoclopramide alone with placebo or active drugs. The main outcomes were the mean change in headache score and complete headache relief. The secondary outcomes were the rescue medications need, side effects, nausea and recurrence rate. We qualitatively reviewed the outcomes. Then, we performed the network meta-analyses (NMAs) when it was possible. which were done by the Frequentist method using the MetaInsight online software. RESULTS Sixteen studies were included with a total of 1934 patients: 826 received metoclopramide, 302 received placebo, and 806 received other active drugs. Metoclopramide was effective in reducing headache outcomes even for 24 h. The intravenous route was the most chosen route in the included studies and showed significant positive results regarding headache outcomes; however, the best route whether intramuscular, intravenous, or suppository was not compared in the previous studies. Also, both 10 and 20 mg doses of metoclopramide were effective in improving headache outcomes; however, there was no direct comparison between both doses and the 10 mg dose was the most frequently used dosage. In NMA of headache change after 30 min or 1 h, metoclopramide effect came after granisetron, ketorolac, chlorpromazine, and Dexketoprofen trometamol. Only granisetron's effect was significantly higher than metoclopramide's effect which was only significantly higher than placebo and sumatriptan. In headache-free symptoms, only prochlorperazine was non-significantly higher than metoclopramide which was higher than other medications and showed significantly higher effects only with placebo. In rescue medication, metoclopramide's effect was only non-significantly lower than prochlorperazine and chlorpromazine while its effect was higher than other drugs and showed higher significant effects only than placebo and valproate. In the recurrence rate, studies showed no significant difference between metoclopramide and other drugs. Metoclopramide significantly decreased nausea more than the placebo. Regarding side effects, metoclopramide showed a lower incidence of mild side effects than pethidine and chlorpromazine and showed a higher incidence of mild side effects than placebo, dexamethasone, and ketorolac. The reported extrapyramidal symptoms with metoclopramide were dystonia or akathisia. CONCLUSION A dose of 10 mg IV Metoclopramide was effective in relieving migraine attacks with minimal side effects. Compared to other active drugs, it only showed a lower significant effect compared with granisetron regarding headache change while it showed significantly higher effects only with placebo in both rescue medication needs and headache-free symptoms and valproate in only rescue medication need. Also, it significantly decreased headache scores more than placebo and sumatriptan. However, more studies are needed to support our results.
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Teelucksingh S, Murali Govind R, Dobson R, Nelson-Piercy C, Ovadia C. Treating Vestibular Migraine When Pregnant and Postpartum: Progress, Challenges and Innovations. Int J Womens Health 2023; 15:321-338. [PMID: 36814528 PMCID: PMC9940493 DOI: 10.2147/ijwh.s371491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 01/18/2023] [Indexed: 02/18/2023] Open
Abstract
Vestibular migraine is a leading cause of vertigo in pregnancy and, although not a distinct migraine subtype, is an episodic syndrome associated with migraine. Vestibular migraine is associated with diverse symptoms such as vertigo, aura, allodynia, osmophobia, nausea, vomiting and tinnitus, many of which may be exacerbated by, masked or even dismissed in pregnancy. Vestibular migraine is likely an underdiagnosed and undertreated condition in pregnancy. The aetiology of vestibular migraine remains incompletely understood, although various theories have been proposed, including genetic predisposition, neurochemical dysregulation and pro-inflammatory mechanisms, all of which are derived from the pathophysiology of classical migraine. Physiologic changes to the endocrine, haematologic and vascular systems in pregnancy may affect pathophysiological processes in vestibular migraine, and can alter the course of symptoms experienced in pregnancy. These changes also predispose to secondary headache disorders, which may have similar presentations. There has been considerable progress in therapeutic advances in vestibular migraine prophylaxis and treatment outside of pregnancy. There is currently no significant evidence base for acute treatment or prophylaxis for pregnant patients, with treatment recommendations extrapolated from studies on classical migraine, and offered on a benefit versus risk basis. Challenges commonly encountered include difficulty establishing a diagnosis, in addition to recognising and treating neuropsychiatric and gestational co-morbidities. Anxiety, depression, hypertensive disorders and cardiovascular disease are closely associated with migraine, and important contributors to morbidity and mortality during pregnancy. Identifying and treating vestibular migraine during pregnancy offers a unique opportunity to impact future patient health through screening and early treatment of associated co-morbidities. There have been innovations in classical migraine therapy that may confer benefit in vestibular migraine in pregnancy, with emphasis on lifestyle modification, effective prophylaxis, abortive therapies, cognitive behaviour therapy and management of vestibular migraine-related comorbidities.
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Affiliation(s)
- Siara Teelucksingh
- Department of Obstetric Medicine, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK
| | - Renuka Murali Govind
- Department of Obstetric Medicine, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK
| | - Ruth Dobson
- Preventive Neurology Unit, Queen Mary University of London, London, UK
- Department of Neurology, Royal London Hospital, London, UK
| | - Catherine Nelson-Piercy
- Department of Obstetric Medicine, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK
- Department of Women and Children’s Health, King’s College London, London, UK
| | - Caroline Ovadia
- Department of Women and Children’s Health, King’s College London, London, UK
- Department of Obstetrics and Gynaecology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
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5
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Hauser Chatterjee J, Hartford EA, Law E, Barry D, Blume H. Sumatriptan as a First-Line Treatment for Headache in the Pediatric Emergency Department. Pediatr Neurol 2023; 142:68-75. [PMID: 36958085 DOI: 10.1016/j.pediatrneurol.2023.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 09/23/2022] [Accepted: 01/29/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Headache is a common presenting condition for patients seen in the pediatric emergency department (ED). Intranasal (IN) sumatriptan is a well-tolerated and safe abortive treatment for migraine headache, but it is infrequently administered in pediatric EDs. In this study we characterize an ED migraine pathway that uses IN sumatriptan as a first-line treatment. METHODS We performed retrospective chart analysis from a single center, reviewing a cohort of patients treated on an ED migraine pathway between October 2016 and February 2020. We reviewed patient demographics, clinical characteristics, treatment patterns, change in pain scores, sumatriptan prescriptions at discharge, length of stay (LOS), ED charges, and unexpected return visits. RESULTS A total of 558 patients (aged six to 21 years, 66% female) were included in this study. Overall, the median pretreatment pain score was 7 (interquartile range [IQR]: 5 to 8) and the median post-treatment pain score was 2 (IQR: 0 to 4). Forty-eight percent of patients received IN sumatriptan in the ED, and 36% of those who received sumatriptan were prescribed oral sumatriptan at discharge. When intravenous (IV) access was obtained for headache management, this was associated with a significantly longer LOS and higher ED charges. CONCLUSIONS IN sumatriptan shows promise as a feasible and potentially effective first-line treatment for pediatric migraine in the ED that could reduce the need for IV therapies, shorten LOS, and lower ED charges. Further research is needed to determine the efficacy of IN sumatriptan relative to other common first-line therapies used to treat pediatric migraine in the ED.
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Affiliation(s)
- Jessica Hauser Chatterjee
- Division of Child Neurology, Department of Neurology, University of Washington School of Medicine and the Seattle Children's Research Institute, Center for Integrative Brain Research, Seattle, Washington.
| | - Emily A Hartford
- Department of Pediatric Emergency Medicine, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Emily Law
- Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine, Seattle, Washington; Center for Child Health, Behavior & Development, Seattle Children's Research Institute, Seattle, Washington
| | - Dwight Barry
- Clinical Analytics, Seattle Children's Hospital, Seattle, Washington
| | - Heidi Blume
- Division of Child Neurology, Department of Neurology, University of Washington School of Medicine and the Seattle Children's Research Institute, Center for Integrative Brain Research, Seattle, Washington
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Elser H, Rowland ST, Marek MS, Kiang MV, Shea B, Do V, Benmarhnia T, Schneider ALC, Casey JA. Wildfire smoke exposure and emergency department visits for headache: A case-crossover analysis in California, 2006-2020. Headache 2023; 63:94-103. [PMID: 36651537 PMCID: PMC10066880 DOI: 10.1111/head.14442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 10/26/2022] [Accepted: 11/02/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To evaluate the association of short-term exposure to overall fine particulate matter of <2.5 μm (PM2.5 ) and wildfire-specific PM2.5 with emergency department (ED) visits for headache. BACKGROUND Studies have reported associations between PM2.5 exposure and headache risk. As climate change drives longer and more intense wildfire seasons, wildfire PM2.5 may contribute to more frequent headaches. METHODS Our study included adult Californian members (aged ≥18 years) of a large de-identified commercial and Medicare Advantage claims database from 2006 to 2020. We identified ED visits for primary headache disorders (subtypes: tension-type headache, migraine headache, cluster headache, and "other" primary headache). Claims included member age, sex, and residential zip code. We linked daily overall and wildfire-specific PM2.5 to residential zip code and conducted a time-stratified case-crossover analysis considering 7-day average PM2.5 concentrations, first for primary headache disorders combined, and then by headache subtype. RESULTS Among 9898 unique individuals we identified 13,623 ED encounters for primary headache disorders. Migraine was the most frequently diagnosed headache (N = 5534/13,623 [47.6%]) followed by "other" primary headache (N = 6489/13,623 [40.6%]). For all primary headache ED diagnoses, we observed an association of 7-day average wildfire PM2.5 (odds ratio [OR] 1.17, 95% confidence interval [CI] 0.95-1.44 per 10 μg/m3 increase) and by subtype we observed increased odds of ED visits associated with 7-day average wildfire PM2.5 for tension-type headache (OR 1.42, 95% CI 0.91-2.22), "other" primary headache (OR 1.40, 95% CI 0.96-2.05), and cluster headache (OR 1.29, 95% CI 0.71-2.35), although these findings were not statistically significant under traditional null hypothesis testing. Overall PM2.5 was associated with tension-type headache (OR 1.29, 95% CI 1.03-1.62), but not migraine, cluster, or "other" primary headaches. CONCLUSIONS Although imprecise, these results suggest short-term wildfire PM2.5 exposure may be associated with ED visits for headache. Patients, healthcare providers, and systems may need to respond to increased headache-related healthcare needs in the wake of wildfires and on poor air quality days.
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Affiliation(s)
- Holly Elser
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Population Health Sciences, Stanford University, Stanford, California, USA
| | - Sebastian T Rowland
- Environmental Health Sciences, Columbia Mailman School of Public Health, New York, New York, USA.,PSE Healthy Energy, Oakland, New York, USA
| | - Maksym S Marek
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mathew V Kiang
- Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | - Brittany Shea
- Environmental Health Sciences, Columbia Mailman School of Public Health, New York, New York, USA
| | - Vivian Do
- Environmental Health Sciences, Columbia Mailman School of Public Health, New York, New York, USA
| | - Tarik Benmarhnia
- Scripps Institution of Oceanography, University of California, San Diego, La Jolla, California, USA
| | - Andrea L C Schneider
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Joan A Casey
- Environmental Health Sciences, Columbia Mailman School of Public Health, New York, New York, USA
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Lipton RB, Singh RBH, Revicki DA, Zhao S, Shewale AR, Lateiner JE, Dodick DW. Functionality, satisfaction, and global impression of change with ubrogepant for the acute treatment of migraine in triptan insufficient responders: a post hoc analysis of the ACHIEVE I and ACHIEVE II randomized trials. J Headache Pain 2022; 23:50. [PMID: 35468729 PMCID: PMC9036751 DOI: 10.1186/s10194-022-01419-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 04/04/2022] [Indexed: 12/14/2022] Open
Abstract
Background Triptans are the first-line option for the acute treatment of migraine attacks; however, triptans are contraindicated in people with certain underlying cardiovascular risk factors and are associated with inadequate efficacy or poor tolerability in some individuals. Ubrogepant is an oral calcitonin gene–related peptide receptor antagonist approved for the acute treatment of migraine. Methods This post hoc analysis of the phase 3 ACHIEVE trials examined the impact of ubrogepant on the Functional Disability Scale (FDS), satisfaction with medication, and Patient Global Impression of Change (PGIC) in participants who were self-reported triptan insufficient responders (TIRs), defined as those who are unable to take triptans due to contraindications, tolerability issues, or insufficient efficacy. Responder definitions for the FDS, satisfaction measures, and PGIC were based on qualitative interpretation of the respective response options for the pooled ubrogepant 50 mg and placebo groups. Results In the pooled analysis population (n = 1799), 451 (25%) participants were TIRs, with most (80%) reporting insufficient efficacy with triptan use. A significantly higher proportion of TIRs treated with ubrogepant vs placebo reported being able to function normally from 2 to 8 h post dose (P < 0.05). Notably, significance was demonstrated at the time of the primary outcome assessments (2 h post dose), where rates of normal function were 38% for ubrogepant vs 29% for placebo (P = 0.048). A greater proportion of TIRs in the ubrogepant arm vs the placebo arm were satisfied with treatment at 2 (33% vs 21%, P = 0.006) and 24 h (58% vs 28%, P < 0.001) and indicated that their migraine improved at 2 h vs placebo (30% vs 18%, P = 0.006). Results were generally similar in the insufficient efficacy subpopulation of TIRs as in the overall TIRs group. Ubrogepant was safe and well tolerated in TIRs, with no new safety signals identified. Conclusions In people with migraine who are TIRs, individuals treated with ubrogepant had favorable 2-h outcomes, as measured by the FDS, satisfaction with medication, and PGIC, compared with placebo. Trial registration ClinicalTrials.gov: NCT02828020 (ACHIEVE I), registered July 11, 2016; NCT02867709 (ACHIEVE II), registered August 16, 2016.
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Vong CT, Chen Y, Chen Z, Gao C, Yang F, Wang S, Wang Y. Classical prescription Dachuanxiong Formula delays nitroglycerin-induced pain response in migraine mice through reducing endothelin-1 level and regulating fatty acid biosynthesis. JOURNAL OF ETHNOPHARMACOLOGY 2022; 288:114992. [PMID: 35032586 DOI: 10.1016/j.jep.2022.114992] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 12/15/2021] [Accepted: 01/09/2022] [Indexed: 06/14/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Dachuanxiong Formula (DCXF) is a classical Chinese medicine prescription and is composed of dried rhizomes from Ligusticum striatum DC. (Chuanxiong Rhizoma) and Gastrodia elata Bl. (Gastrodiae Rhizoma) at the ratio of 4:1 (w/w). It has been used as Chinese medicine prescription for thousands of years. DCXF is used traditionally to treat many diseases, including migraine, atherosclerosis and ischemic stroke. AIM OF THE STUDY This study aimed to investigate the effects of DCXF on pain response in migraine mice, and the underlying mechanisms using proteomics and bioinformatics analyses. MATERIALS AND METHODS DCXF extract was prepared by mixing Chuanxiong Rhizoma and Gastrodiae Rhizoma at a mass ratio of 4:1 (w/w). After extraction, the extract was filtered prior to high performance liquid chromatography (HPLC) analysis. Nitroglycerin (NTG) was used to establish a mouse migraine model, and a behaviour study was conducted by hot plate test. In addition, proteomics and bioinformatics studies were conducted to investigate the mechanisms of DCXF-mediating anti-migraine treatment. RESULTS Our results showed that there were significant differences in the latencies between NTG-treated and DCXF low dose- and high doses-treated groups at 30 min after NTG injection, this suggested that DCXF could ameliorate pain response in migraine mice. Besides, the plasma levels of endothelin-1 were also measured. NTG group significantly enhanced the endothelin-1 level compared to the control group. In contrast, DCXF low dose and high dose groups significantly reduced this level compared to NTG group. In addition, the underlying mechanisms were also investigated. Our results demonstrated that the anti-migraine treatment of DCXF was highly associated with fatty acid synthesis, suggesting that DCXF ameliorated pain response through reducing endothelin-1 level and regulating fatty acid synthesis. CONCLUSIONS The present study revealed the anti-migraine effect of DCXF in migraine mice and provided insights into the mechanisms of DCXF-mediating anti-migraine treatment.
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Affiliation(s)
- Chi Teng Vong
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macau, China.
| | - Yulong Chen
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macau, China.
| | - Zhejie Chen
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macau, China.
| | - Caifang Gao
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macau, China.
| | - Fengqing Yang
- School of Chemistry and Chemical Engineering, Chongqing University, Chongqing, China.
| | - Shengpeng Wang
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macau, China.
| | - Yitao Wang
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macau, China.
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9
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Patel D, Taljaard M, Yadav K, James D, Perry JJ. Current practice for primary headache disorders and perspectives on peripheral nerve blocks among emergency physicians in Canada: A national survey. Headache 2022; 62:512-521. [PMID: 35403242 DOI: 10.1111/head.14293] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 02/24/2022] [Accepted: 02/28/2022] [Indexed: 01/23/2023]
Abstract
OBJECTIVE This national postal survey aimed to examine Canadian emergency physicians' practice patterns with respect to drug treatment and perspectives on peripheral nerve blocks. BACKGROUND The treatment of primary headache disorders in the emergency department is variable. METHODS We surveyed 500 emergency physicians listed in the Canadian Medical Directory according to a modified Dillman's method: an initial invitation was followed by up to four reminders to nonresponders. Physicians were asked questions regarding their frequency of medication administration and perspectives toward peripheral nerve blocks. RESULTS Of 500 mailed surveys, 468 were delivered and 179 physicians responded (response rate = 38.2%). The majority of physicians were men (92/144, 63.9%); 80.6% (116/144) had been in practice for greater than or equal to 10 years with 50.7% (75/148) in a community or district general teaching hospital. Commonly used pharmacotherapies for primary headaches were intravenous dopamine receptor antagonists (69%), co-administration of ketorolac and a dopamine receptor antagonist (54.2%), intravenous fluid boluses (54%), nonsteroidal anti-inflammatory drugs (NSAIDs) alone (53.5%), and acetaminophen (51.4%). Only 80 of 144 physicians (55.6%) reported previous experience with peripheral nerve blocks (95% confidence interval [CI] = 48%-65%). The majority (68/80, 85.0%) agreed peripheral nerve blocks are safe and 55.1% (43/78) agreed they are effective. The vast majority (118/140, 84.3%) would consider peripheral nerve blocks as a first-line treatment option given sufficient evidence from a future trial (95% CI = 78%-90%). CONCLUSION NSAIDs alone, as well as dopamine receptor antagonists with or without ketorolac are commonly used for primary headache in Canadian emergency departments. A large proportion of physicians have never used a peripheral nerve block in their practice; among those who have experience with peripheral nerve blocks, the majority find them safe and effective. The majority of respondents would consider peripheral nerve blocks as a first-line treatment option given sufficient evidence from a future trial.
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Affiliation(s)
- Dilan Patel
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Monica Taljaard
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Krishan Yadav
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Emergency Medicine, University of Ottawa, Ontario, Canada
| | - Daniel James
- Department of Anesthesia and Pain Medicine, University of Ottawa, Ontario, Canada.,Department of Emergency Medicine, University of Ottawa, Ontario, Canada
| | - Jeffrey J Perry
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Emergency Medicine, University of Ottawa, Ontario, Canada
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10
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Patel D, Yadav K, Taljaard M, Shorr R, Perry JJ. Effectiveness of Peripheral Nerve Blocks for the Treatment of Primary Headache Disorders: A Systematic Review and Meta-Analysis. Ann Emerg Med 2021; 79:251-261. [PMID: 34756448 DOI: 10.1016/j.annemergmed.2021.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/06/2021] [Accepted: 08/10/2021] [Indexed: 12/18/2022]
Abstract
STUDY OBJECTIVE Primary headache disorders are prevalent and account for 2% of all emergency department visits. Current treatment options are effective; however, time to pain relief is suboptimal. Alternatives such as peripheral nerve blocks have shown promising results. The objective of this systematic review is to examine the effectiveness of peripheral nerve blocks for timely pain relief. METHODS We searched Ovid MEDLINE, EMBASE, Web of Science Core Collection, and the Cochrane Central Register of Controlled Trials and included randomized controlled trials comparing peripheral nerve blocks to placebo or active therapy. The primary outcome was pain within 120 minutes. Secondary outcomes were pain after 120 minutes, adverse events, need for rescue medications, and relapse of headache. Two reviewers screened and extracted data independently; mean differences (MDs) were calculated, and results were pooled using a random-effects model. RESULTS Eleven studies met our eligibility criteria (n=860), of which 9 were included in the meta-analysis. Pain scores were significantly lower in patients treated with peripheral nerve blocks than with placebo at 15 minutes (MD: -1.17; 95% confidence interval: -1.82 to -0.51) and 30 minutes (MD: -0.99; 95% confidence interval: -1.66 to -0.32), and no serious adverse events were reported. Pain scores for peripheral nerve blocks versus active therapy and secondary outcomes were not pooled due to clinical heterogeneity. CONCLUSION Our review shows peripheral nerve blocks are effective as a rapid treatment option when compared to placebo; however, we were unable to assess effectiveness against standard treatment. Emergency physicians should consider peripheral nerve blocks as an adjunct therapy for patients with primary headache disorders.
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Affiliation(s)
- Dilan Patel
- School of Epidemiology and Public Health, University of Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Monica Taljaard
- School of Epidemiology and Public Health, University of Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Risa Shorr
- Learning Services, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Jeffrey J Perry
- School of Epidemiology and Public Health, University of Ottawa, Ontario, Canada; Department of Emergency Medicine, University of Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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11
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Yuan H, Curran JG, Keith SW, Hopkins MM, Silberstein SD. Intravenous ibuprofen for acute treatment of migraine: A double-blind, randomized, placebo-controlled pilot study. Headache 2021; 61:1432-1440. [PMID: 34601736 DOI: 10.1111/head.14214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 07/22/2021] [Accepted: 08/18/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of intravenous (IV) Ibuprofen for acute treatment of migraine. BACKGROUND IV nonsteroidal anti-inflammatory drugs (NSAIDs) are an alternative to oral NSAIDs, especially in patients with severe migraine who have emesis or gastroparesis. To date, only three IV NSAIDs (ketorolac, ibuprofen, and meloxicam) are available in the United States for use in moderate and severe pain, but no placebo-controlled trial is available for migraine. We performed a single-center, double-blind, randomized, placebo-controlled pilot study to evaluate the efficacy and safety of IV ibuprofen as an acute treatment of migraine (NCT01230411). METHODS Individuals with episodic migraine were screened at the Jefferson Headache Center. Qualified subjects were treated for migraine attacks within 2-72 h following the headache onset with either 800 mg of IV ibuprofen or placebo in 250 ml saline bolus. Migraine pain intensity (4-point Likert scale) and associated symptoms were assessed at predetermined time points (0.25, 0.5, 1, 1.5, 2, 4, 8, 24 h). The primary endpoint was pain relief at 2 h after infusion. Important secondary endpoints included pain freedom at 2 h, sustained relief over 24 h, use of rescue therapy, and absence of associated symptoms. Adverse events (AEs) were also collected. RESULTS Seventy-four participants were enrolled between 2011 and 2017. Forty-four subjects (female 33/44; 75.0%) with mean (SD) age 41.0 (11.2) 11.2 years came for the treatment. All treated subjects (n = 44) were included in the analysis. Among them, 23 were randomized to receive IV ibuprofen. Both groups were demographically similar except for longer migraine duration (i.e., years lived with disease) in the active treatment than in the placebo group. At 2 h posttreatment, pain relief was found in 74% (17/23) and 48% (10/21) after IV ibuprofen and placebo, respectively (odds ratio [OR] 3.12, 95% CI: 0.88-11.0; p = 0.078). Other secondary endpoints at 2 and 24 h were not significant. The longitudinal repeated-measures analysis within 2 h on ibuprofen treatment showed significant pain relief (OR 2.47, 95% CI 1.08-5.7; p = 0.033) and absence of associated symptoms: photophobia (OR 4.0, 95% CI 1.57-10.3; p = 0.004), phonophobia (OR 3.12, 95% CI 1.16-8.4; p = 0.025), and osmophobia (OR 3.45, 95% CI 1.01-11.8; p = 0.048). AEs were observed in seven subjects in both groups, with arm pain being the most common. No serious AE was reported. CONCLUSION This study did not meet the primary endpoint but showed pain relief and elimination of several associated symptoms within 2 h on repeated-measures analysis. Although limited by small sample size and high placebo response, our results indicate that IV ibuprofen may be a safe and effective option for acute treatment of migraine, but more extensive studies are necessary.
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Affiliation(s)
- Hsiangkuo Yuan
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - John G Curran
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Scott W Keith
- Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mary M Hopkins
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Stephen D Silberstein
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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12
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Gebhardt M, Kropp P, Hoffmann F, Zettl UK. Headache in multiple sclerosis - pharmacological aspects. Curr Pharm Des 2021; 28:445-453. [PMID: 34551691 DOI: 10.2174/1381612827666210922114100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 07/19/2021] [Indexed: 12/11/2022]
Abstract
For decades, headache was not considered a typical symptom of multiple sclerosis (MS) and was construed as a "red flag" for important differential diagnoses such as cerebral vasculitis. Meanwhile, several studies have demonstrated an increased prevalence of headache in MS compared to the general population. This is due to the heterogeneity of headache genesis with frequent occurrence of both primary and secondary headaches in MS. On the one hand, MS and migraine are often comorbid. On the other hand, secondary headaches occur frequently, especially in the course of MS relapses. These are often migraine-like headaches caused by inflammation, which can improve as a result of MS-specific therapy. Headaches are particularly common in the early stages of chronic inflammatory CNS disease, where inflammatory activity is greatest. In addition, headache can also occur as a side effect of disease-modifying drugs (DMDs). Headache can occur with most DMDs and is most frequently described with interferon-beta therapy. The aim of this work is to present the prevalence of headache and describe the heterogeneity of possible causes of headache in MS. In addition, important therapeutic aspects in the treatment of MS patients in general will be presented as well as different approaches to the treatment of headache in MS depending on the etiological classification.
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Affiliation(s)
- Marcel Gebhardt
- Krankenhaus Martha-Maria Halle-Dölau, Klinik für Neurologie, Röntgenstraße 1, 06120 Halle. Germany
| | - Peter Kropp
- Institute of Medical Psychology and Medical Sociology, Medical Faculty, University of Rostock, Gehlsheimer Straße 20, 18147, Rostock. Germany
| | | | - Uwe K Zettl
- Department of Neurology, Neuroimmunological Section, University of Rostock, Rostock. Germany
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13
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Zhao YJ, Lim JYX, Wong PS. Diagnosis and Management of Headaches in the Emergency Department (ED) in Adults and Children. Neurol India 2021; 69:S173-S182. [PMID: 34003163 DOI: 10.4103/0028-3886.315977] [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: 11/04/2022]
Abstract
Background Headache accounts for a significant number of cases presenting to the Emergency Department (ED) and has a high societal cost, contributed by recurrent ED and clinic visits, and unnecessary diagnostic tests. Objective This review article covers the important clinical tools needed to evaluate headaches in both adults and children in the ED. Methods Medline/PubMed was searched using the keywords "Emergency department", "headache", "adult", "pediatric", "clinical assessment", "diagnosis" and "treatment", in the title or abstract. The search covers the period from 1 January 1990 to 31 December 2019. Results The articles selected were based on their relevancy to the objective of this review article. Additional relevant publications were identified from article references lists. Conclusion The emergency physician plays a key role in differentiating between primary and secondary headaches. Within the limited ED resources, appropriate diagnostic testing should be used to identify the life-threatening headaches. This will ensure patients are given the appropriate evidence-based pharmacological therapy and holistic management.
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Affiliation(s)
- Yi J Zhao
- Department of Neurology, National Neuroscience Institute -SGH Campus, Singapore
| | - Jocelyn Y X Lim
- KK Women and Children's Hospital, Neurology Service, Singapore
| | - Pei S Wong
- SGH Department of Pharmacy, NUS Dept of Pharmacy, Singapore
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14
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Alqahtani M, Barmherzig R, Lagman-Bartolome AM. Approach to Pediatric Intractable Migraine. Curr Neurol Neurosci Rep 2021; 21:38. [PMID: 34089140 DOI: 10.1007/s11910-021-01128-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW Intractable migraine in children and adolescents is a significant cause of disability and decreased quality of life (QoL) in this population. Challenges include lack of unifying definition for intractable migraine, and limited data on best-practice management in this age group, with most current treatment pathways extrapolated from adult studies or expert consensus. RECENT FINDINGS A comprehensive approach in the evaluation and management of intractable migraine in this age group encompasses excluding secondary causes of headache; making an accurate diagnosis; identifying and appropriately managing modifiable risk factors; and initiating appropriate pharmacologic therapy to reduce disability, improve health-related quality of life, reduce risk of progression, and develop adaptive pain coping strategies. Several strategies for management of pediatric intractable migraine including use of acute medications, bridge therapy in outpatient setting, emerging therapies for preventive therapy, and a stepwise combination therapy for management of pediatric intractable migraine in emergency and inpatient setting are presented based on available clinical data, safety/tolerability, availability, cost-effectiveness, and expert consensus. This descriptive review of the available literature focuses on approach to therapy for acute intractable migraine in a pediatric population including outpatient, emergency department (ED), and inpatient management.
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Affiliation(s)
- Mohammed Alqahtani
- Division of Neurology, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
| | - Rebecca Barmherzig
- Pediatric Headache Program, Division of Neurology, Children's Hospital of Philadelphia (CHOP), 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Ana Marissa Lagman-Bartolome
- Division of Neurology, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada. .,Centre for Headache, Women's College Hospital, University of Toronto, 76 Grenville Street, Toronto, Ontario, M5B1S2, Canada.
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15
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Lim JH, Karimi L, Wijeratne T. An Evaluation of Medication Prescribing Patterns for Acute Migraine in the Emergency Department: A Scoping Review. J Clin Med 2021; 10:jcm10061191. [PMID: 33809194 PMCID: PMC7998873 DOI: 10.3390/jcm10061191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 03/04/2021] [Accepted: 03/05/2021] [Indexed: 11/18/2022] Open
Abstract
Migraine is one of the leading causes of disability worldwide and patients with acute migraine frequently present to emergency departments (ED). The current literature suggests that ED treatment of migraine headache varies across institutions. Considering this, we conducted a scoping review to summarize trends in medication prescribing patterns for acute migraine treatment in the ED setting. Trends were evaluated for factors influencing treatment choices, with particular attention placed on opioids and migraine specific therapy. This scoping review was based on the Arksey and O’Malley methodological framework and included studies published between 1 January 2000 and 31 May 2020. 14 publications met the inclusion criteria. The most common classes of medication prescribed were anti-emetics or Non-steroidal anti-inflammatory drugs (NSAID), but rates varied between studies. There was a concerning trend towards an underutilization of triptans and overutilization of opiates. The use of specific clinical treatment goals (e.g., two-hour pain free freedom response) was also not evident. Additionally, 88% (n = 8) of the nine studies commenting on adherence to hospital or evidence-based guidelines stated that practices were non-adherent. Overall, the reviewed literature reveals treatment practices for acute migraine in the ED are heterogeneous and deviate from established international recommendations.
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Affiliation(s)
- Jun Hua Lim
- Department of Neurology, AIMSS, Sunshine Hospital, Western Health, Melbourne, St Albans, VIC 3021, Australia;
| | - Leila Karimi
- School of Psychology and Public Health, La Trobe University, Bundoora, VIC 3083, Australia;
| | - Tissa Wijeratne
- Department of Neurology, AIMSS, Sunshine Hospital, Western Health, Melbourne, St Albans, VIC 3021, Australia;
- School of Psychology and Public Health, La Trobe University, Bundoora, VIC 3083, Australia;
- Department of Medicine, Faculty of Medicine, Rajarata University, Saliyapura, Anuradhapuraya 50000, Sri Lanka
- Correspondence:
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16
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Tauchen J. Natural Products and their (Semi-)Synthetic Forms in the Treatment of Migraine: History and Current Status. Curr Med Chem 2020; 27:3784-3808. [PMID: 30686246 DOI: 10.2174/0929867326666190125155947] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 01/04/2019] [Accepted: 01/16/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Migraine may be described as a headache with moderate to extreme pain that is often accompanied by incapacitating neurological symptoms. It is estimated that 12% of the world population suffers from migraine. Although a number of drugs have been used for treatment of migraine, most of these are not effective for every patient and may have undesirable side-effects. Thus, there is an enormous unmet need in current migraine therapy for discovering safer and more effective agents. METHODS The information summarized in this review was obtained through extensive literature review and search of relevant books and articles with the use of Web of Knowledge and SciVerse Scopus databases. RESULTS Greater understanding of the molecular mechanisms underlying the etiopathogenesis of migraine is helpful in identifying novel targets for antimigraine drugs such as cannabinoid, histamine, and melatonin receptors. In the past, natural product-derived constituents have served as an invaluable source of numerous medicinally useful antimigraine agents and it may be expected that further promising drug candidates from natural products will be discovered for antimigraine pharmacotherapy with better efficacy and fewer adverse-effects. CONCLUSION The discovery of novel targets in migraine therapy has opened new horizons for compounds that have not been clinically tested or that previously failed in clinical trials as potential antimigraine drugs. Ginkgolide B, melatonin, histamine, oxytocin, various ribosomal peptide toxins, kavalactones, devil's claw-derived compounds, salvinorin A and petasin are among those agents that show considerable promise as novel drugs in migraine prevention and treatment. It is necessary to conduct more research to better understand their antimigraine action, to confirm their effectiveness and safety, and to introduce them into clinical practice.
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Affiliation(s)
- Jan Tauchen
- Department of Food Science, Faculty of Agrobiology, Food and Natural Resources, Czech University of Life Sciences Prague, Kamycka 129, 165 00 Prague - Suchdol, Czech Republic
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17
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Takizawa T, Qin T, Lopes de Morais A, Sugimoto K, Chung JY, Morsett L, Mulder I, Fischer P, Suzuki T, Anzabi M, Böhm M, Qu WS, Yanagisawa T, Hickman S, Khoury JE, Whalen MJ, Harriott AM, Chung DY, Ayata C. Non-invasively triggered spreading depolarizations induce a rapid pro-inflammatory response in cerebral cortex. J Cereb Blood Flow Metab 2020; 40:1117-1131. [PMID: 31242047 PMCID: PMC7181092 DOI: 10.1177/0271678x19859381] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Cortical spreading depolarization (CSD) induces pro-inflammatory gene expression in brain tissue. However, previous studies assessing the relationship between CSD and inflammation have used invasive methods that directly trigger inflammation. To eliminate the injury confounder, we induced CSDs non-invasively through intact skull using optogenetics in Thy1-channelrhodopsin-2 transgenic mice. We corroborated our findings by minimally invasive KCl-induced CSDs through thinned skull. Six CSDs induced over 1 h dramatically increased cortical interleukin-1β (IL-1β), chemokine (C-C motif) ligand 2 (CCL2), and tumor necrosis factor-α (TNF-α) mRNA expression peaking around 1, 2 and 4 h, respectively. Interleukin-6 (IL-6) and intercellular adhesion molecule-1 (ICAM-1) were only modestly elevated. A single CSD also increased IL-1β, CCL2, and TNF-α, and revealed an ultra-early IL-1β response within 10 min. The response was blunted in IL-1 receptor-1 knockout mice, implicating IL-1β as an upstream mediator, and suppressed by dexamethasone, but not ibuprofen. CSD did not alter systemic inflammatory indices. In summary, this is the first report of pro-inflammatory gene expression after non-invasively induced CSDs. Altogether, our data provide novel insights into the role of CSD-induced neuroinflammation in migraine headache pathogenesis and have implications for the inflammatory processes in acute brain injury where numerous CSDs occur for days.
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Affiliation(s)
- Tsubasa Takizawa
- Neurovascular Research Laboratory,
Department of Radiology, Massachusetts General Hospital, Harvard Medical School,
Charlestown, MA, USA
| | - Tao Qin
- Neurovascular Research Laboratory,
Department of Radiology, Massachusetts General Hospital, Harvard Medical School,
Charlestown, MA, USA
| | - Andreia Lopes de Morais
- Neurovascular Research Laboratory,
Department of Radiology, Massachusetts General Hospital, Harvard Medical School,
Charlestown, MA, USA
| | - Kazutaka Sugimoto
- Neurovascular Research Laboratory,
Department of Radiology, Massachusetts General Hospital, Harvard Medical School,
Charlestown, MA, USA
| | - Joon Yong Chung
- Neuroscience Center, Massachusetts
General Hospital, Harvard Medical School, Charlestown, MA, USA
- Department of Pediatrics, Massachusetts
General Hospital, Harvard Medical School, Boston, MA, USA
| | - Liza Morsett
- Center for Immunology & Inflammatory
Diseases, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA,
USA
| | - Inge Mulder
- Neurovascular Research Laboratory,
Department of Radiology, Massachusetts General Hospital, Harvard Medical School,
Charlestown, MA, USA
| | - Paul Fischer
- Neurovascular Research Laboratory,
Department of Radiology, Massachusetts General Hospital, Harvard Medical School,
Charlestown, MA, USA
- Department of Neurology, Charité –
Universitätsmedizin Berlin, Berlin, Germany
| | - Tomoaki Suzuki
- Neurovascular Research Laboratory,
Department of Radiology, Massachusetts General Hospital, Harvard Medical School,
Charlestown, MA, USA
| | - Maryam Anzabi
- Neurovascular Research Laboratory,
Department of Radiology, Massachusetts General Hospital, Harvard Medical School,
Charlestown, MA, USA
| | - Maximilian Böhm
- Neurovascular Research Laboratory,
Department of Radiology, Massachusetts General Hospital, Harvard Medical School,
Charlestown, MA, USA
- Department of Neurology, Charité –
Universitätsmedizin Berlin, Berlin, Germany
| | - Wen-sheng Qu
- Neurovascular Research Laboratory,
Department of Radiology, Massachusetts General Hospital, Harvard Medical School,
Charlestown, MA, USA
| | - Takeshi Yanagisawa
- Neurovascular Research Laboratory,
Department of Radiology, Massachusetts General Hospital, Harvard Medical School,
Charlestown, MA, USA
| | - Suzanne Hickman
- Center for Immunology & Inflammatory
Diseases, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA,
USA
| | - Joseph El Khoury
- Center for Immunology & Inflammatory
Diseases, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA,
USA
| | - Michael J Whalen
- Neuroscience Center, Massachusetts
General Hospital, Harvard Medical School, Charlestown, MA, USA
- Department of Pediatrics, Massachusetts
General Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrea M Harriott
- Neurovascular Research Laboratory,
Department of Radiology, Massachusetts General Hospital, Harvard Medical School,
Charlestown, MA, USA
- Department of Neurology, Massachusetts
General Hospital, Harvard Medical School, Boston, MA, USA
| | - David Y Chung
- Neurovascular Research Laboratory,
Department of Radiology, Massachusetts General Hospital, Harvard Medical School,
Charlestown, MA, USA
- Department of Neurology, Massachusetts
General Hospital, Harvard Medical School, Boston, MA, USA
| | - Cenk Ayata
- Neurovascular Research Laboratory,
Department of Radiology, Massachusetts General Hospital, Harvard Medical School,
Charlestown, MA, USA
- Department of Neurology, Massachusetts
General Hospital, Harvard Medical School, Boston, MA, USA
- Cenk Ayata, Massachusetts General Hospital,
149 13th Street, 6403, Charlestown, MA 02129, USA.
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18
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Acute Migraine Prescription Patterns Vary by Baseline Cardiovascular Risk and Clinical Characteristics: A Real-World Evidence Study. Pain Ther 2020; 9:499-509. [PMID: 32328974 PMCID: PMC7648791 DOI: 10.1007/s40122-020-00167-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Indexed: 01/11/2023] Open
Abstract
Introduction Migraine is a debilitating neurological disease and one of the most common disorders in the world. Although the triptans, potent 5-HT1B/1D receptor agonists, are an effective and widely used acute treatment of migraine, few studies have assessed how their cardiovascular risk warnings could impact prescription patterns. This study characterized cardiovascular risk factors and other aspects of people with migraine in real-world settings and confirmed patterns of acute migraine care. Methods This retrospective study included five cohorts: people with migraine prescribed acute treatments [triptans, opiates, prescription nonsteroidal anti-inflammatory drugs (NSAIDs)], untreated people with migraine, and individuals without migraine diagnosis. Baseline demographic and clinical characteristics were used to develop and validate a 1-year myocardial infarction (MI) risk prediction model among untreated people with migraine. This validated prediction model generated disease risk scores (DRSs) for MI among untreated cohorts. Results Patients in the study included 436,642 prescribed a triptan, 55,234 prescribed opiates, and 334,152 prescribed NSAIDs; as well as 1,168,212 untreated persons with migraine and 11,735,009 nonmigraine participants. Those prescribed triptans were younger, had fewer cardiovascular risk factors and hospitalizations, and lower concomitant medication use than those in the NSAID and opiate cohorts. The distribution of the DRS showed that compared to patients prescribed NSAIDs (4.2%) or opiates (3.5%), a smaller proportion of patients prescribed triptans (1.3%) were at high risk for MI at 1 year (> 10%). Conclusion People with migraine who had more cardiovascular risk factors and greater 1-year MI risk score were disproportionately prescribed opiates and NSAIDs compared to triptans. Future research should explore unmet needs for patients with disorders for which triptan therapy is contraindicated.
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19
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Gunasekera L, Akhlaghi H, Sun-Edelstein C, Heywood J, Sanders L. Overuse of opioids for acute migraine in an Australian emergency department. Emerg Med Australas 2020; 32:763-768. [PMID: 32270597 DOI: 10.1111/1742-6723.13504] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 03/01/2020] [Accepted: 03/08/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Acute migraine is associated with significant personal, economic and work-related disability. Management guidelines advise the use of simple analgesia, triptans, chlorpromazine and anti-emetics based on severity, with avoidance of opioids. We aimed to determine consistency of prescribing patterns in our ED with national guidelines. METHODS We performed a retrospective cohort analysis of migraine presentations (ICD-10-AM G439) between 2012 and 2016. Exclusion criteria included migraine without headache, other primary headaches and secondary headaches. Demographic and prescribing data were extracted from medical records. Results have been reported as proportions. RESULTS Of 4769 headache presentations, the application of exclusion criteria led to a total of 744 patients who received a migraine diagnosis (G439). Most were female (558/744, 75%), young (mean age 36.4 years) and had a self-reported migraine history (558/744, 75%). There were 54 different medications prescribed. Paracetamol was more frequently prescribed (385/744, 52%) than aspirin (134/744, 18%). Opioid prescription occurred in nearly half of all presentations (345/744, 46%). Similar opioid prescriptions were also observed in those with a documented history of migraines (253/558, 45%). A minority of patients received triptans (51/744, 7%). Overall, a quarter of patients (189/744, 25%) received no guideline-recommended medications. CONCLUSION We observed considerable polypharmacy in ED migraine management with inconsistent prescribing patterns. Recommended medications were infrequently used and opioid use was common. Factors influencing prescribing patterns require further investigation in order to improve rates of guideline recommended treatment.
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Affiliation(s)
- Lakshini Gunasekera
- Department of Neurology, St Vincent's Health, Melbourne, Victoria, Australia
| | - Hamed Akhlaghi
- Emergency Department, St Vincent's Health, Melbourne, Victoria, Australia
| | | | - John Heywood
- Department of Neurology, St Vincent's Health, Melbourne, Victoria, Australia
| | - Lauren Sanders
- Department of Neurology, St Vincent's Health, Melbourne, Victoria, Australia
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20
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Giamberardino MA, Affaitati G, Costantini R, Guglielmetti M, Martelletti P. Acute headache management in emergency department. A narrative review. Intern Emerg Med 2020; 15:109-117. [PMID: 31893348 DOI: 10.1007/s11739-019-02266-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 12/17/2019] [Indexed: 12/12/2022]
Abstract
Headache is a significant reason for access to Emergency Departments (ED) worldwide. Though primary forms represent the vast majority, the life-threatening potential of secondary forms, such as subarachnoid hemorrage or meningitis, makes it imperative for the ED physician to rule out secondary headaches as first step, based on clinical history, careful physical (especially neurological) examination and, if appropriate, hematochemical analyses, neuroimaging or lumbar puncture. Once secondary forms are excluded, distinction among primary forms should be performed, based on the international headache classification criteria. Most frequent primary forms motivating ED observation are acute migraine attacks, particularly status migrainous, and cluster headache. Though universally accepted guidelines do not exist for headache management in an emergency setting, pharmacological parenteral treatment remains the principal approach worldwide, with NSAIDs, neuroleptic antinauseants, triptans and corticosteroids, tailored to the specific headache type. Opioids should be avoided, for their scarce effectiveness in the acute phase, while IV hydration should be limited in cases of ascertained dehydration. Referral of the patient to a Headache Center should subsequently be an integral part of the ED approach to the headache patients, being ascertained that lack of this referral involves a high rate of relapse and new accesses to the ED. More controlled studies are needed to establish specific protocols of management for the headache patient in the ED.
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Affiliation(s)
- Maria Adele Giamberardino
- Headache Center, Geriatrics Clinic, Department of Medicine and Science of Aging and Ce.S.I.-Met, G. D'Annunzio University of Chieti, 66100, Chieti, Italy
| | - Giannapia Affaitati
- Headache Center, Geriatrics Clinic, Department of Medicine and Science of Aging and Ce.S.I.-Met, G. D'Annunzio University of Chieti, 66100, Chieti, Italy
| | - Raffaele Costantini
- Institute of Surgical Pathology, G. D'Annunzio University of Chieti, Chieti, Italy
| | - Martina Guglielmetti
- Department of Clinical Pathology, University of Sassari, Sassari, Italy
- Department of Clinical and Molecular Medicine, Sapienza University, Via di Grottarossa, 1035, 00189, Rome, Italy
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University, Via di Grottarossa, 1035, 00189, Rome, Italy.
- UOC Medicina Interna, AOU Sant'Andrea, Rome, Italy.
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Kopruszinski CM, Navratilova E, Vagnerova B, Swiokla J, Patwardhan A, Dodick D, Porreca F. Cannabinoids induce latent sensitization in a preclinical model of medication overuse headache. Cephalalgia 2019; 40:68-78. [PMID: 31311288 DOI: 10.1177/0333102419865252] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
AIM Evaluation of cannabinoid receptor agonists in a preclinical model of medication overuse headache. METHODS Female Sprague Dawley rats received graded intraperitoneal doses of WIN55,212-2 or Δ-9-tetrahydrocannabinol (Δ-9-THC). Antinociception (tail-flick test), catalepsy and hypomotility (open field test) and impairment of motor function (rotarod test) were assessed to establish effective dosing. Rats were then treated twice daily with equianalgesic doses of WIN55,212-2 or Δ-9-THC, or vehicle, for 7 days and cutaneous tactile sensory thresholds were evaluated during and three weeks following drug discontinuation. Rats then received a one-hour period of bright light stress (BLS) on two consecutive days and tactile sensory thresholds were re-assessed. RESULTS WIN55,212-2 and Δ-9-THC produced antinociception as well as hypomotility, catalepsy and motor impairment. Repeated administration of WIN55,212-2 and Δ-9-THC induced generalized periorbital and hindpaw allodynia that resolved within 3 weeks after discontinuation of drug. Two episodes of BLS produced delayed and long-lasting periorbital and hindpaw allodynia selectively in rats previously treated with WIN55,212-2, and Δ-9-THC. INTERPRETATION Cannabinoid receptor agonists including Δ-9-THC produce a state of latent sensitization characterized by increased sensitivity to stress, a presumed migraine trigger. Overuse of cannabinoids including cannabis may increase the risk of medication overuse headache in vulnerable individuals.
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Affiliation(s)
| | - Edita Navratilova
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Barbora Vagnerova
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Juliana Swiokla
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Amol Patwardhan
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - David Dodick
- Department of Neurology, Mayo Clinic, Phoenix, AZ, USA
| | - Frank Porreca
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, AZ, USA.,Department of Neurology, Mayo Clinic, Phoenix, AZ, USA
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van Hoogstraten WS, MaassenVanDenBrink A. The need for new acutely acting antimigraine drugs: moving safely outside acute medication overuse. J Headache Pain 2019; 20:54. [PMID: 31096904 PMCID: PMC6734450 DOI: 10.1186/s10194-019-1007-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 04/26/2019] [Indexed: 12/14/2022] Open
Abstract
Background The treatment of migraine is impeded by several difficulties, among which insufficient headache relief, side effects, and risk for developing medication overuse headache (MOH). Thus, new acutely acting antimigraine drugs are currently being developed, among which the small molecule CGRP receptor antagonists, gepants, and the 5-HT1F receptor agonist lasmiditan. Whether treatment with these drugs carries the same risk for developing MOH is currently unknown. Main body Pathophysiological studies on MOH in animal models have suggested that decreased 5-hydroxytryptamine (5-HT, serotonin) levels, increased calcitonin-gene related peptide (CGRP) expression and changes in 5-HT receptor expression (lower 5-HT1B/D and higher 5-HT2A expression) may be involved in MOH. The decreased 5-HT may increase cortical spreading depression frequency and induce central sensitization in the cerebral cortex and caudal nucleus of the trigeminal tract. Additionally, low concentrations of 5-HT, a feature often observed in MOH patients, could increase CGRP expression. This provides a possible link between the pathways of 5-HT and CGRP, targets of lasmiditan and gepants, respectively. Since lasmiditan is a 5-HT1F receptor agonist and gepants are CGRP receptor antagonists, they could have different risks for developing MOH because of the different (over) compensation mechanisms following prolonged agonist versus antagonist treatment. Conclusion The acute treatment of migraine will certainly improve with the advent of two novel classes of drugs, i.e., the 5-HT1F receptor agonists (lasmiditan) and the small molecule CGRP receptor antagonists (gepants). Data on the effects of 5-HT1F receptor agonism in relation to MOH, as well as the effects of chronic CGRP receptor blockade, are awaited with interest.
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Affiliation(s)
| | - Antoinette MaassenVanDenBrink
- Div. of Pharmacology, Dept. of Internal Medicine, Erasmus University Medical Centre, PO Box 2040, 3000, CA, Rotterdam, The Netherlands.
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23
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Rashed A, Mazer-Amirshahi M, Pourmand A. Current Approach to Undifferentiated Headache Management in the Emergency Department. Curr Pain Headache Rep 2019; 23:26. [PMID: 30868276 DOI: 10.1007/s11916-019-0765-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW To discuss pharmacological interventions in the emergency department (ED) setting for the management of acute primary headache. RECENT FINDINGS Acute headache treatment in the ED has seen an expansion in terms of possible pharmacological interventions in recent years. After a thorough evaluation ruling out dangerous causes of headache, providers should take the patient's history, comorbidities, and prior therapy into consideration. Antidopaminergics have an established role in the management of acute, severe, headache with manageable side-effect profiles. However, recent studies suggest anesthetic and anti-epileptic drugs may play roles in headache treatment in the ED. Current literature also suggest steroids as a promising tool for emergency department clinicians combating the readmission of patients with recurrent headaches. Emergency medicine providers must be cognizant of these traditional and emerging therapies in order to optimize the care of headache patients.
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Affiliation(s)
- Amir Rashed
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, 2120 L St., Washington, DC, 20037, USA
| | - Maryann Mazer-Amirshahi
- Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC, USA.,School of Medicine, Georgetown University, Washington, DC, USA
| | - Ali Pourmand
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, 2120 L St., Washington, DC, 20037, USA.
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Khazaei M, Hosseini Nejad Mir N, Yadranji Aghdam F, Taheri M, Ghafouri-Fard S. Effectiveness of intravenous dexamethasone, metoclopramide, ketorolac, and chlorpromazine for pain relief and prevention of recurrence in the migraine headache: a prospective double-blind randomized clinical trial. Neurol Sci 2019; 40:1029-1033. [PMID: 30783794 DOI: 10.1007/s10072-019-03766-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 02/14/2019] [Indexed: 12/27/2022]
Abstract
Dexamethasone, metoclopramide, ketorolac, and chlorpromazine have been used for the treatment of migraine headache. However, the effectiveness of these drugs in pain relief and prevention of recurrence and their side effects have not been compared yet. This was a randomized, double-blind clinical trial. Subjects were randomized to four groups; each received one of the following drugs intravenously: dexamethasone 8 mg, ketorolac 30 mg, metoclopramide 10 mg, and chlorpromazine 25 mg. The severity of headache in the two groups was assessed at starting point, 1 h and 24 h after the administration of drug using the visual analogue scale (VAS) on a scale of 0 to 10. No significant difference was found in the severity of symptoms between the four study groups before treatment, 1 h, and 24 h after treatment. The effect of all mentioned drugs on acute migraine headache was statistically significant at 1 and 24 h post-treatment compared to baseline. No significant difference was detected in the number of unresponsive cases between the four groups. There was a trend toward higher effectiveness of dexamethasone in prevention of recurrence (P = 0.05). Side effects were more common in chlorpromazine and less common in the dexamethasone-treated patients (P < 0.001). The present clinical trial shows the effectiveness of dexamethasone in prevention of recurrence and low frequency of treatment side effects.
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Affiliation(s)
- Mojtaba Khazaei
- Department of Neurology, Hamadan University of Medical Sciences, Hamadan, Iran
| | | | | | - Mohammad Taheri
- Urogenital Stem Cell Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Soudeh Ghafouri-Fard
- Department of Medical Genetics, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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25
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Masic D, Liang E, Long C, Sterk EJ, Barbas B, Rech MA. Intravenous Lidocaine for Acute Pain: A Systematic Review. Pharmacotherapy 2018; 38:1250-1259. [DOI: 10.1002/phar.2189] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Dalila Masic
- Loyola University Medical Center Maywood Illinois
| | - Edith Liang
- Loyola University Medical Center Maywood Illinois
| | | | | | - Brian Barbas
- Loyola University Medical Center Maywood Illinois
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Hamilton KT, Robbins MS. Migraine Treatment in Pregnant Women Presenting to Acute Care: A Retrospective Observational Study. Headache 2018; 59:173-179. [PMID: 30403400 DOI: 10.1111/head.13434] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2018] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To assess the acute treatment of pregnant women presenting to a hospital with migraine. BACKGROUND Migraine is a common problem in pregnancy; however, migraine treatment is challenging in pregnant women for fears of medication teratogenicity and lack of data in this population. To date, no study has directly explored physician practices for treatment of acute migraine in pregnant women. METHODS We conducted a retrospective chart review of medication administration for pregnant women who presented to an acute care setting with a migraine attack and received neurology consultation between 2009 and 2014. RESULTS We identified 72 pregnant women with migraine who were treated with pain medications. Fifty-one percent (37/72) were in the third trimester of pregnancy, 39% (28/72) in the second trimester, and 10% (7/72) in the first trimester. Thirty-two percent (23/72) had not tried any acute medications at home before coming to the hospital, and 47% (34/72) presented in status migrainosus. Patients received treatment in the hospital for a median of 23 hours (interquartile range = 5-45 hours). The most common medications prescribed were metoclopramide in 74% (53/72) of patients (95% confidence interval [CI] 62-82%) and acetaminophen in 69% (50/72) of patients (95% CI 58-79%). Metoclopramide was administered along with diphenhydramine in 81% (44/53) of patients (95% CI 71-91%). Acetaminophen was the most frequent medicine administered first (53%, 38/72). Patients were often treated with butalbital (35%, 25/72) or opioids (30%, 22/72), which were used as second- or third-line treatments in 29% of patients (20/72). Thirty-eight percent (27/72) received an intravenous (IV) fluid bolus, 24% received IV magnesium (17/72), and 6% (4/72) had peripheral nerve blocks performed. CONCLUSIONS While the majority of pregnant women with acute migraine received medications considered relatively safe in pregnancy, there was variation in treatment choice and sequence. Some acute medications considered potentially hazardous for fetal health and less effective for migraine (opioids and butalbital) were used frequently, whereas other treatments that may have low teratogenic risk (nerve blocks, IV fluid boluses, and triptans) were used less or not at all. These results indicate a need for developing guidelines and protocols to standardize acute treatment of migraine in pregnancy.
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Affiliation(s)
- Katherine T Hamilton
- Department of Neurology, Montefiore Headache Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Matthew S Robbins
- Department of Neurology, Montefiore Headache Center, Albert Einstein College of Medicine, Bronx, NY, USA
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Deepika D, Dewangan HK, Maurya L, Singh S. Intranasal Drug Delivery of Frovatriptan Succinate-Loaded Polymeric Nanoparticles for Brain Targeting. J Pharm Sci 2018; 108:851-859. [PMID: 30053555 DOI: 10.1016/j.xphs.2018.07.013] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 07/10/2018] [Accepted: 07/17/2018] [Indexed: 01/07/2023]
Abstract
The objective of the present study was to develop polymeric nanoparticles (PNPs) of frovatriptan succinate for brain targeting by nasal route. Double emulsion method was used to increase the entrapment efficiency of hydrophilic drug, and formulation was optimized by central composite design to achieve critical quality attributes namely particle size, zeta potential, and entrapment efficiency. Optimized batch was evaluated for surface morphology, in vitro release, permeation across nasal mucosa, stability, histopathology, and brain tissue uptake study. Prepared PNPs were found to be smooth with particle size of 264.4 ± 0.04 nm, zeta potential -35.17 ± 0.07 mV, and 65.2 ± 0.06% entrapment efficiency. PNPs showed biphasic release pattern, initial burst release followed by sustained release up to 72 h. Ex vivo diffusion study using goat nasal mucosa at pH 6.8 revealed that PNPs permeation across nasal mucosa was about 3 times more than the pure drug solution, and quick delivery of PNPs in brain region was confirmed by fluorescence microscopic evaluation in male Wistar rats after intranasal administration. Histopathology studies further revealed integrity of nasal mucosa after treatment with PNPs. The investigation indicated that hydrophilic drug, frovatriptan succinate can be successfully entrapped in PNPs to target brain via nasal delivery, and thus it could be an effective approach for nose to brain delivery.
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Affiliation(s)
- Deepika Deepika
- Department of Pharmaceutical Engineering and Technology, Indian Institute of Technology (Banaras Hindu University), Varanasi, 221005, India
| | - Hitesh Kumar Dewangan
- Department of Pharmaceutical Engineering and Technology, Indian Institute of Technology (Banaras Hindu University), Varanasi, 221005, India
| | - Lakshmi Maurya
- Department of Pharmaceutical Engineering and Technology, Indian Institute of Technology (Banaras Hindu University), Varanasi, 221005, India
| | - Sanjay Singh
- Department of Pharmaceutical Engineering and Technology, Indian Institute of Technology (Banaras Hindu University), Varanasi, 221005, India.
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28
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Benign Headache Management in the Emergency Department. J Emerg Med 2018; 54:458-468. [DOI: 10.1016/j.jemermed.2017.12.023] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 12/01/2017] [Indexed: 01/08/2023]
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Gürger M, Atescelik M, Yilmaz M, Yildiz M, Kalayci H, Kobat MA, Demir CF. Can we define migraine patients with blood high-sensitivity C-reactive protein and galectin-3 levels in the emergency department? Arch Med Sci 2018; 14:307-312. [PMID: 29593803 PMCID: PMC5868668 DOI: 10.5114/aoms.2016.60984] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 10/13/2015] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Migraine, the most widespread cause of headache in young adults, is a frequent reason for presentation to emergency departments. The aim of this study was to determine the diagnostic value of serum galectin-3 and high-sensitivity C-reactive protein (hsCRP) levels in migraine patients. MATERIAL AND METHODS Serum galectin-3 and hsCRP levels were measured using enzyme-linked immunosorbent assay in 70 migraine patients and 70 healthy control subjects. RESULTS The mean values of hsCRP and galectin-3 levels were significantly higher in the migraine group than those in the control group (1.67 ±0.49, 1.12 ±0.38 mg/l, p < 0.001; and 3.76 ±1.45, 2.05 ±0.29 ng/ml, p < 0.001, respectively). When the diagnostic values of the biomarkers were assessed in the migraine attack and control groups, the sensitivity and specificity of the test for hsCRP at the cut-off point of 1.32 mg/l were 70% and 73% (AUC = 0.805, 95% CI: 0.74-0.88, p < 0.001), and for galectin-3 at the cut-off point of 2.4 ng/ml, 89% and 90% (AUC = 0.97, 95% CI: 0.95-0.99, p < 0.001), respectively. CONCLUSIONS This study showed the presence of a relation between high serum levels of hsCRP and galectin-3 in migraine patients. However, well-controlled, carefully executed longitudinal studies are required to confirm these findings.
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Affiliation(s)
- Mehtap Gürger
- Department of Emergency Medicine, School of Medicine, Firat University, Elazığ, Turkey
| | - Metin Atescelik
- Department of Emergency Medicine, School of Medicine, Firat University, Elazığ, Turkey
| | - Mustafa Yilmaz
- Department of Emergency Medicine, School of Medicine, Firat University, Elazığ, Turkey
| | - Mustafa Yildiz
- Department of Emergency Medicine, School of Medicine, Firat University, Elazığ, Turkey
| | - Hatice Kalayci
- Department of Biochemistry, Elazığ Education and Research Hospital, Elazığ, Turkey
| | - Mehmet Ali Kobat
- Department of Cardiology, School of Medicine, Firat University, Elazığ, Turkey
| | - Caner Fevzi Demir
- Department of Neurology, School of Medicine, Firat University, Elazığ, Turkey
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Yellepeddi VK. Stability of extemporaneously prepared preservative-free prochlorperazine nasal spray. Am J Health Syst Pharm 2018; 75:e28-e35. [PMID: 29273610 DOI: 10.2146/ajhp160531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE The stability of an extemporaneously prepared preservative-free prochlorperazine 5-mg/mL nasal spray was evaluated. METHODS The preservative-free prochlorperazine nasal spray was prepared by adding 250 mg of prochlorperazine edisylate to 50 mL of citrate buffer in a low-density polyethylene nasal spray bottle. A stability-indicating high-performance liquid chromatography (HPLC) method was developed and validated using the major degradant prochlorperazine sulfoxide and by performing forced-degradation studies. For chemical stability studies, 3 100-μL samples of the preservative-free prochlorperazine from 5 nasal spray bottles stored at room temperature were collected at days 0, 20, 30, 45, and 60 and were assayed in triplicate using the stability-indicating HPLC method. Microbiological testing involved antimicrobial effectiveness testing based on United States Pharmacopeia (USP) chapter 51 and quantitative microbiological enumeration of aerobic bacteria, yeasts, and mold based on USP chapter 61. Samples for microbiological testing were collected at days 0, 30, and 60. RESULTS The stability-indicating HPLC method clearly identified the degradation product prochlorperazine sulfoxide without interference from prochlorperazine. All tested solutions retained over 90% of the initial prochlorperazine concentration for the 60-day study period. There were no detectable changes in color, pH, and viscosity in any sample. There was no growth of bacteria, yeast, and mold for 60 days in all samples tested. CONCLUSION An extemporaneously prepared preservative-free nasal spray solution of prochlorperazine edisylate 5 mg/mL was physically, chemically, and microbiologically stable for 60 days when stored at room temperature in low-density polyethylene bottles.
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Affiliation(s)
- Venkata K Yellepeddi
- College of Pharmacy, Roseman University of Health Sciences, South Jordan, UT .,Department of Pharmaceutics and Pharmaceutical Chemistry, University of Utah, Salt Lake City, UT
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31
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Multicenter prevalence of opioid medication use as abortive therapy in the ED treatment of migraine headaches. Am J Emerg Med 2017. [DOI: 10.1016/j.ajem.2017.06.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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A Comparison of Headache Treatment in the Emergency Department: Prochlorperazine Versus Ketamine. Ann Emerg Med 2017; 71:369-377.e1. [PMID: 29033296 DOI: 10.1016/j.annemergmed.2017.08.063] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 07/08/2017] [Accepted: 08/24/2017] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE Intravenous subdissociative-dose ketamine has been shown to be effective for pain management, but has not been specifically studied for headaches in the emergency department (ED). For this reason, we designed a study to compare standard treatment (prochlorperazine) with ketamine in patients with benign headaches in the ED. METHODS This study was a multicenter, double-blind, randomized, controlled trial with a convenience sample of patients presenting to the ED with benign headaches. Patients were randomized to receive either prochlorperazine and diphenhydramine or ketamine and ondansetron. Patients' headache severity was measured on a 100-mm visual analog scale (VAS) at 0, 15, 30, 45, and 60 minutes. Nausea, vomiting, anxiety, and the need for rescue medications were also tracked. Patients were contacted at 24 to 48 hours posttreatment to rate their satisfaction and to determine whether they were still experiencing a headache. RESULTS There were a total of 54 subjects enrolled. Two patients in the ketamine group and one in the prochlorperazine group withdrew because of adverse effects of the medications. In regard to the primary outcome, at 60 minutes, the prochlorperazine group had a mean improvement in VAS pain scores of 63.5 mm compared with 43.5 mm in the ketamine group, corresponding to a between-groups difference of 20.0 mm (95% confidence interval [CI] 2.8 to 37.2 mm) and a P value of .026. At 45 minutes, the prochlorperazine group had a mean improvement in pain scores of 56.1 mm compared with 38.0 mm in the ketamine group, a difference of 18.1 mm (95% CI 1.0 to 35.2 mm). At 24- to 48-hour follow-up, the mean satisfaction score was 8.3 of 10 for prochlorperazine and 4.9 of 10 for ketamine, a difference of 3.4 (95% CI 1.2 to 5.6). There was not a statistically significant difference in the percentage of patients who had a headache at follow-up or in other secondary outcomes. CONCLUSION Prochlorperazine appears to be superior to ketamine for the treatment of benign headaches in the ED.
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Goadsby PJ, Holland PR, Martins-Oliveira M, Hoffmann J, Schankin C, Akerman S. Pathophysiology of Migraine: A Disorder of Sensory Processing. Physiol Rev 2017; 97:553-622. [PMID: 28179394 PMCID: PMC5539409 DOI: 10.1152/physrev.00034.2015] [Citation(s) in RCA: 1084] [Impact Index Per Article: 154.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Plaguing humans for more than two millennia, manifest on every continent studied, and with more than one billion patients having an attack in any year, migraine stands as the sixth most common cause of disability on the planet. The pathophysiology of migraine has emerged from a historical consideration of the "humors" through mid-20th century distraction of the now defunct Vascular Theory to a clear place as a neurological disorder. It could be said there are three questions: why, how, and when? Why: migraine is largely accepted to be an inherited tendency for the brain to lose control of its inputs. How: the now classical trigeminal durovascular afferent pathway has been explored in laboratory and clinic; interrogated with immunohistochemistry to functional brain imaging to offer a roadmap of the attack. When: migraine attacks emerge due to a disorder of brain sensory processing that itself likely cycles, influenced by genetics and the environment. In the first, premonitory, phase that precedes headache, brain stem and diencephalic systems modulating afferent signals, light-photophobia or sound-phonophobia, begin to dysfunction and eventually to evolve to the pain phase and with time the resolution or postdromal phase. Understanding the biology of migraine through careful bench-based research has led to major classes of therapeutics being identified: triptans, serotonin 5-HT1B/1D receptor agonists; gepants, calcitonin gene-related peptide (CGRP) receptor antagonists; ditans, 5-HT1F receptor agonists, CGRP mechanisms monoclonal antibodies; and glurants, mGlu5 modulators; with the promise of more to come. Investment in understanding migraine has been very successful and leaves us at a new dawn, able to transform its impact on a global scale, as well as understand fundamental aspects of human biology.
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Affiliation(s)
- Peter J Goadsby
- Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; Department of Neurology, University of California, San Francisco, San Francisco, California; Department of Neurology, University of Hamburg-Eppendorf, Hamburg, Germany; and Department of Neurology, University Hospital Bern-Inselspital, University of Bern, Bern, Switzerland
| | - Philip R Holland
- Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; Department of Neurology, University of California, San Francisco, San Francisco, California; Department of Neurology, University of Hamburg-Eppendorf, Hamburg, Germany; and Department of Neurology, University Hospital Bern-Inselspital, University of Bern, Bern, Switzerland
| | - Margarida Martins-Oliveira
- Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; Department of Neurology, University of California, San Francisco, San Francisco, California; Department of Neurology, University of Hamburg-Eppendorf, Hamburg, Germany; and Department of Neurology, University Hospital Bern-Inselspital, University of Bern, Bern, Switzerland
| | - Jan Hoffmann
- Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; Department of Neurology, University of California, San Francisco, San Francisco, California; Department of Neurology, University of Hamburg-Eppendorf, Hamburg, Germany; and Department of Neurology, University Hospital Bern-Inselspital, University of Bern, Bern, Switzerland
| | - Christoph Schankin
- Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; Department of Neurology, University of California, San Francisco, San Francisco, California; Department of Neurology, University of Hamburg-Eppendorf, Hamburg, Germany; and Department of Neurology, University Hospital Bern-Inselspital, University of Bern, Bern, Switzerland
| | - Simon Akerman
- Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; Department of Neurology, University of California, San Francisco, San Francisco, California; Department of Neurology, University of Hamburg-Eppendorf, Hamburg, Germany; and Department of Neurology, University Hospital Bern-Inselspital, University of Bern, Bern, Switzerland
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In vivo imaging reveals that pregabalin inhibits cortical spreading depression and propagation to subcortical brain structures. Proc Natl Acad Sci U S A 2017; 114:2401-2406. [PMID: 28223480 DOI: 10.1073/pnas.1614447114] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Migraine is characterized by severe headaches that can be preceded by an aura likely caused by cortical spreading depression (SD). The antiepileptic pregabalin (Lyrica) shows clinical promise for migraine therapy, although its efficacy and mechanism of action are unclear. As detected by diffusion-weighted MRI (DW-MRI) in wild-type (WT) mice, the acute systemic administration of pregabalin increased the threshold for SD initiation in vivo. In familial hemiplegic migraine type 1 mutant mice expressing human mutations (R192Q and S218L) in the CaV2.1 (P/Q-type) calcium channel subunit, pregabalin slowed the speed of SD propagation in vivo. Acute systemic administration of pregabalin in vivo also selectively prevented the migration of SD into subcortical striatal and hippocampal regions in the R192Q strain that exhibits a milder phenotype and gain of CaV2.1 channel function. At the cellular level, pregabalin inhibited glutamatergic synaptic transmission differentially in WT, R192Q, and S218L mice. The study describes a DW-MRI analysis method for tracking the progression of SD and provides support and a mechanism of action for pregabalin as a possible effective therapy in the treatment of migraine.
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Delavar Kasmaei H, Amiri M, Negida A, Hajimollarabi S, Mahdavi N. Ketorolac versus Magnesium Sulfate in Migraine Headache Pain Management; a Preliminary Study. EMERGENCY (TEHRAN, IRAN) 2017; 5:e2. [PMID: 28286809 PMCID: PMC5325888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Migraine is a common cause of emergency department (ED) visits. To date, there is no recommended drug of choice for pain management of these patients. In the present study, we aimed to evaluate the effectiveness of ketorolac and magnesium sulfate in this regard. METHODS This is a cross-sectional study performed on all 18 - 60 year-old patients, visiting two different EDs with complaint of moderate to severe migraine headache. Patients were treated with 30 mg ketorolac in one hospital and 1 gram magnesium sulfate in the other. Pain scores were assessed on arrival, 1 and 2 hours after drugs administration and quality of pain management was compared between two groups using SPSS 22. RESULTS 70 patients with the mean age of 36.4 ± 11.4 years were enrolled (51.4% male). The two groups were similar regarding baseline characteristics (p > 0.05). The improvement in pain score in magnesium sulfate group was greater than Ketorolac group after both one hour (6 vs 3; p < 0.001) and two hours (7 vs 5; p < 0.001). CONCLUSION It seems that both ketorolac and magnesium sulfate are significantly effective in pain control of patients with migraine headache presenting to the emergency department. Magnesium sulfate was superior to ketorolac both one and two hours after drug administration.
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Affiliation(s)
- Hossein Delavar Kasmaei
- Department of Neurology, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Marzieh Amiri
- Department of Emergency Medicine, Shahid Beheshti Hospital, Guilan University of Medical Sciences, Anzali, Iran.,Corresponding Author: Marzieh Amiri; Department of Emergency Medicine, Shahid Beheshti Hospital, Guilan University of Medical Sciences, Anzali, Iran. Tel: +989121955792;
| | - Ahmed Negida
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | | | - Nastaransadat Mahdavi
- Department of Anesthesiology, Torfeh Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Bekan G, Tfelt-Hansen P. Is the Generally Held View That Intravenous Dihydroergotamine Is Effective in Migraine Based on Wrong "General Consensus" of One Trial? A Critical Review of the Trial and Subsequent Quotations. Headache 2016; 56:1482-1491. [PMID: 27595607 DOI: 10.1111/head.12904] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 06/22/2016] [Accepted: 07/13/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND The claim that parenteral dihydroergotamine (DHE) is effective in migraine is based on one randomized, placebo-controlled, crossover trial from 1986. The aim of this review was to critically evaluate the original article. It was also found to be of interest to review quotes concerning the results in the more than 100 articles subsequently referring to the article. METHODS The correctness of the stated effect of intravenous DHE in the randomized clinical trial (RCT) was first critically evaluated. Then, Google Scholar was searched for references to the article and these references were classified as to whether they judged the reported RCT as positive or negative. RESULTS The design of the RCT, with a crossover within one migraine attack, only allows evaluation of the results for the first period and the effect of DHE and placebo were quite comparable. About 151 references were found for the article in Google scholar. Among the 95 articles with a judgment on the efficacy of intravenous DHE in the RCT, 90 stated that DHE was effective or likely effective whereas only 5 articles stated that DHE was ineffective. CONCLUSIONS Despite a "negative" RCT, authors of subsequent articles on the efficacy of parenteral DHE overwhelmingly reported this RCT as "positive." This is probably due to the fact that the authors concluded in the abstract that DHE is effective, and to a kind of "wrong general consensus."
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Affiliation(s)
- Goran Bekan
- Department of Neurology, North Zealand Hospital in Hillerød, Hillerød, Denmark
| | - Peer Tfelt-Hansen
- Department of Neurology, Zealand University Hospital, Roskilde, Denmark.
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Abstract
INTRODUCTION Refractory/intractable migraine headaches are associated with chronic pain that does not respond to standard care of treatment. Propofol(2,6-diisopropylphenol) in sub-anesthetic doses has been reported to be beneficial in such patients. The present article describes the complete drug profile of propofol in the management of these super-refractory migraine headaches. AREAS COVERED The article covers different preclinical and clinical studies available in the literature. Expert commentary: Propofol is useful as an off-label drug molecule in an emergency situation of refractory migraines where it has been found to reduce the pain intensity. The molecule with a narrow therapeutic index and high abuse potential is prescribed only when conventional drugs fail to deliver any relief. There are not adequate double-blind crossover studies that substantiate the effectiveness of propofol in the treatment of migraine headaches. Furthermore, long-term outcomes for the use of propofol in migraine headaches requires an extensive investigation.
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Affiliation(s)
- Ashish Dhir
- a Department of Neurology, School of Medicine , University of California Davis , Sacramento , CA , USA
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Kabbouche M. Pediatric Inpatient Headache Therapy: What is Available. Headache 2015; 55:1426-9. [PMID: 26517974 DOI: 10.1111/head.12701] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2015] [Indexed: 11/27/2022]
Abstract
Status migrainosus is defined by the international classification of headache disorders (ICHD) criteria as a debilitating migraine lasting more then 72 hours. The epidemiology of status migrainosus is still unknown in adult and children, and frequently underdiagnosed. Children and adolescents often end up in the emergency room with an intractable headache that failed outpatient therapy. Six to seven percent of these children do not respond to acute infusion therapy and require hospitalization. It is imperative that more aggressive therapy is considered when patients are affected by a severe intractable headache to prevent further disability and returning the child to baseline activity. Multiple therapies are available for adults and children. Studies for acute therapy in the emergency room are available in adults and pediatric groups. Small studies are available for inpatient therapy in children and, along with available therapies for children and adolescents, are described in this review. A review of the literature shows growing evidence regarding the use of dihydroergotamine intravenously once patients are hospitalized. Effectiveness and safety have been proven in the last decades in adults and small studies in the pediatric populations.
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Affiliation(s)
- Marielle Kabbouche
- Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine
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McCarthy LH, Cowan RP. Comparison of parenteral treatments of acute primary headache in a large academic emergency department cohort. Cephalalgia 2015; 35:807-15. [PMID: 25366551 PMCID: PMC4417651 DOI: 10.1177/0333102414557703] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 09/08/2014] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The objective of this article is to compare acute primary headache patient outcomes in those initially treated with parenteral opiates or non-opiate recommended headache medications in a large academic medical emergency department (ED). BACKGROUND Many acute primary headache patients are not diagnosed with a specific headache type and are treated with opiates and nonspecific pain medications in the ED setting. This is inconsistent with multiple expert recommendations. METHODS Electronic charts were reviewed from 574 consecutive patients who visited the ED for acute primary headache (identified by chief complaint and ICD9 codes) and were treated with parenteral medications. RESULTS Non-opiate recommended headache medications were given first line to 52.6% and opiates to 22.8% of all participants. Patients given opiates first had significantly longer length of stays (median 5.0 vs. 3.9 hours, p < 0.001) and higher rates of return ED visits within seven days (7.6% vs. 3.0%, p = 0.033) compared with those given non-opiate recommended medications in univariate analysis. Only the association with longer length of stay remained significant in multivariable regression including possible confounding variables. CONCLUSIONS Initial opiate use is associated with longer length of stay compared with non-opiate first-line recommended medications for acute primary headache in the ED. This association remained strong and significant even after multivariable adjustment for headache diagnosis and other possible confounders.
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Affiliation(s)
- Lucas H McCarthy
- Stanford University, Department of Neurology, USA Puget Sound VA Healthcare System, USA
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Schaefer SM, Gottschalk CH, Jabbari B. Treatment of Chronic Migraine with Focus on Botulinum Neurotoxins. Toxins (Basel) 2015; 7:2615-28. [PMID: 26184313 PMCID: PMC4516932 DOI: 10.3390/toxins7072615] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 07/02/2015] [Accepted: 07/08/2015] [Indexed: 12/27/2022] Open
Abstract
Migraine is the most common neurological disorder, and contributes to disability and large healthcare costs in the United States and the world. The treatment of migraine until recently has focused on medications, both abortive and prophylactic, but treatment of chronic migraine has been revolutionized with the introduction of botulinum toxin injection therapy. In this review, we explore the current understanding of migraine pathophysiology, and the evolution of the use of botulinum toxin therapy including proposed pathophysiological mechanisms through animal data. We also discuss the similarities and differences between three injection techniques.
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Affiliation(s)
- Sara M Schaefer
- Department of Neurology, Yale University, 20 York St., New Haven, CT 06510, USA.
| | | | - Bahman Jabbari
- Department of Neurology, Yale University, 20 York St., New Haven, CT 06510, USA.
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Sokolov AY, Lyubashina OA, Berkovich RR, Panteleev SS. Intravenous dextromethorphan/quinidine inhibits activity of dura-sensitive spinal trigeminal neurons in rats. Eur J Pain 2014; 19:1086-94. [PMID: 25410439 DOI: 10.1002/ejp.631] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND Migraine is a chronic neurological disorder characterized by episodes of throbbing headaches. Practically all medications currently used in migraine prophylaxis have a number of substantial disadvantages and use limitations. Therefore, the further search for principally new prophylactic antimigraine agents remains an important task. The objective of our study was to evaluate the effects of a fixed combination of dextromethorphan hydrobromide and quinidine sulphate (DM/Q) on activity of the spinal trigeminal neurons in an electrophysiological model of trigemino-durovascular nociception. METHODS The study was performed in 15 male Wistar rats, which were anaesthetized with urethane/α-chloralose and paralysed using pipecuronium bromide. The effects of cumulative intravenous infusions of DM/Q (three steps performed 30 min apart, 15/7.5 mg/kg of DM/Q in 0.5 mL of isotonic saline per step) on ongoing and dural electrical stimulation-induced neuronal activities were tested in a group of eight rats over 90 min. Other seven animals received cumulative infusion of equal volumes of saline and served as control. RESULTS Cumulative administration of DM/Q produced steady suppression of both the ongoing activity of the spinal trigeminal neurons and their responses to electrical stimulation of the dura mater. CONCLUSIONS It is evident that the observed DM/Q-induced suppression of trigeminal neuron excitability can lead to a reduction in nociceptive transmission from meninges to higher centres of the brain. Since the same mechanism is believed to underlie the pharmacodynamics of many well-known antimigraine drugs, results of the present study enable us to anticipate the potential efficacy of DM/Q in migraine.
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Affiliation(s)
- A Y Sokolov
- Department of Neuropharmacology, Valdman Institute of Pharmacology, First St. Petersburg Pavlov State Medical University, Russia.,Laboratory of Cortico-Visceral Physiology, Pavlov Institute of Physiology, Russian Academy of Sciences, St. Petersburg, Russia
| | - O A Lyubashina
- Department of Neuropharmacology, Valdman Institute of Pharmacology, First St. Petersburg Pavlov State Medical University, Russia.,Laboratory of Cortico-Visceral Physiology, Pavlov Institute of Physiology, Russian Academy of Sciences, St. Petersburg, Russia
| | - R R Berkovich
- Keck School of Medicine, Department of Neurology, University of Southern California, Los Angeles, USA
| | - S S Panteleev
- Department of Neuropharmacology, Valdman Institute of Pharmacology, First St. Petersburg Pavlov State Medical University, Russia.,Laboratory of Cortico-Visceral Physiology, Pavlov Institute of Physiology, Russian Academy of Sciences, St. Petersburg, Russia
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Dufka FL, Dworkin RH, Rowbotham MC. How transparent are migraine clinical trials? Repository of Registered Migraine Trials (RReMiT). Neurology 2014; 83:1372-81. [PMID: 25194013 PMCID: PMC4189098 DOI: 10.1212/wnl.0000000000000866] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 07/10/2014] [Indexed: 12/03/2022] Open
Abstract
Transparency in research requires public access to unbiased information prior to trial initiation and openly available results upon study completion. The Repository of Registered Migraine Trials is a global snapshot of registered migraine clinical trials and scorecard of results availability via the peer-reviewed literature, registry databases, and gray literature. The 295 unique clinical trials identified employed 447 investigational agents, with 30% of 154 acute migraine trials and 11% of 141 migraine prophylaxis trials testing combinations of agents. The most frequently studied categories in acute migraine trials were triptans, nonsteroidal anti-inflammatory drugs, antiemetics, calcitonin gene-related peptide antagonists, and acetaminophen. Migraine prophylaxis trials frequently studied anticonvulsants, β-blockers, complementary/alternative therapies, antidepressants, and botulinum toxin. Overall, 237 trials were eligible for a results search. Of 163 trials completed at least 12 months earlier, 57% had peer-reviewed literature results, and registries/gray literature added another 13%. Using logistic regression analysis, studies with a sample size below the median of 141 subjects were significantly less likely to have results, but the dominant factor associated with availability of results was time since study completion. In unadjusted models, trials registered on ClinicalTrials.gov and trials with industry primary sponsorship were significantly more likely to have results. Recently completed trials rarely have publicly available results; 2 years after completion, the peer-reviewed literature contains results for fewer than 60% of completed migraine trials. To avoid bias, evidence-based therapy algorithms should consider factors affecting results availability. As negative trials are less likely to be published, special caution should be exercised before recommending a therapy with a high proportion of missing trial results.
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Affiliation(s)
- Faustine L Dufka
- From the California Pacific Medical Center Research Institute (F.L.D., M.C.R.), San Francisco; and the University of Rochester School of Medicine and Dentistry (R.H.D.), NY
| | - Robert H Dworkin
- From the California Pacific Medical Center Research Institute (F.L.D., M.C.R.), San Francisco; and the University of Rochester School of Medicine and Dentistry (R.H.D.), NY
| | - Michael C Rowbotham
- From the California Pacific Medical Center Research Institute (F.L.D., M.C.R.), San Francisco; and the University of Rochester School of Medicine and Dentistry (R.H.D.), NY.
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Mazer-Amirshahi M, Dewey K, Mullins PM, van den Anker J, Pines JM, Perrone J, Nelson L. Trends in opioid analgesic use for headaches in US emergency departments. Am J Emerg Med 2014; 32:1068-73. [PMID: 25091873 DOI: 10.1016/j.ajem.2014.07.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 06/27/2014] [Accepted: 07/02/2014] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Although not recommended as first line therapy by consensus guidelines, opioid analgesics are commonly used to treat headaches. This study evaluates trends in opioid use for headaches in US emergency departments (EDs). METHODS We performed a retrospective review of the National Hospital Ambulatory Medical Care Survey, 2001 through 2010. Adult headache-related visits were identified. Medications (opioid and nonopioid) used for the treatment of headache were categorized based on medication class. Trends in ED use of the most common opioids (codeine, hydrocodone, hydromorphone, morphine, and oxycodone) were explored. The proportion of visits for which each medication was used was tabulated, and trends were analyzed using survey-weighted logistic regression. RESULTS Headache visits during which any opioid was used increased between 2001 (20.6%; 95% confidence interval [CI], 18.1-23.4) and 2010 (35.0%; 95% CI, 31.8-38.4; P < .001). Prescribing of hydromorphone, morphine, and oxycodone increased, with the largest relative increase (461.1%) in hydromorphone (2001, 1.8% [95% CI, 1.2-2.6]; 2010, 10.1% [95% CI, 8.2-12.4]). Codeine use declined, and hydrocodone use remained stable. Use of opioid alternatives, including acetaminophen, butalbital, and triptans did not change over the study period, whereas use of nonsteroidal anti-inflammatory drugs increased from 26.2% (95% CI, 23.0-29.7) to 31.4% (95% CI, 28.6-34.3). Prescribing of antiemetic agents decreased from 24.1% (95% CI, 19.6-29.2) to 23.5% (95% CI, 21.1-26.0). Intravenous fluid use increased from 20.0% (95% CI, 17.0-23.4) to 34.5% (95% CI, 31.0-38.2) of visits. CONCLUSIONS Despite limited endorsement by consensus guidelines, there was increased use of opioid analgesics to treat headaches in US EDs over the past decade.
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Affiliation(s)
- Maryann Mazer-Amirshahi
- Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC; Department of Clinical Pharmacology, Children's National Medical Center, Washington, DC.
| | - Kayla Dewey
- Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC
| | - Peter M Mullins
- The George Washington University, School of Medicine and Health Sciences, Washington, DC
| | - John van den Anker
- Department of Clinical Pharmacology, Children's National Medical Center, Washington, DC; Department of Pediatrics, The George Washington University, Washington, DC; Intensive Care, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands; Department of Pediatric Pharmacology, University Children's Hospital Basel, Switzerland
| | - Jesse M Pines
- The George Washington University, School of Medicine and Health Sciences, Washington, DC; Department of Emergency Medicine, the George Washington University, Washington, DC
| | - Jeanmarie Perrone
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lewis Nelson
- Department of Emergency Medicine, New York University, New York, NY
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Effect of Qilongtoutong granule on calcitonin gene-related peptide, beta-endorphin, serotonin, dopamine, and noradrenalin in migraine model rats and mice. J TRADIT CHIN MED 2014; 34:188-93. [DOI: 10.1016/s0254-6272(14)60077-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Goadsby PJ. Therapeutic prospects for migraine: Can paradise be regained? Ann Neurol 2013; 74:423-34. [DOI: 10.1002/ana.23996] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2013] [Revised: 08/04/2013] [Accepted: 08/04/2013] [Indexed: 11/06/2022]
Affiliation(s)
- Peter J. Goadsby
- Headache Group, Department of Neurology; University of California, San Francisco; San Francisco CA
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Gelfand AA, Gelfand JM, Goadsby PJ. Migraine and multiple sclerosis: Epidemiology and approach to treatment. Mult Scler Relat Disord 2013; 2:73-9. [DOI: 10.1016/j.msard.2012.10.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2012] [Revised: 10/12/2012] [Accepted: 10/18/2012] [Indexed: 11/25/2022]
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PAN XUEQIANG, WANG MANYUAN, WU YANCHUAN, LU XURAN, SHANG YAWEN, XU YONGSONG, ZHAI YONGSONG, LI JING, LI ZHAOXIA, GONG MUXIN. Identification of active ingredients in Wuzhuyu decoction improving migraine in mice by spectral efficiency association. Mol Med Rep 2012; 12:1524-34. [DOI: 10.3892/mmr.2015.3506] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Accepted: 02/05/2015] [Indexed: 11/06/2022] Open
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