Safety and efficacy of ergotamine tartrate and dihydroergotamine in the treatment of migraine and status migrainosus [RETIRED]. Working Panel of the Headache and Facial Pain Section of the American Academy of Neurology

Drug Safety in Episodic Migraine Management in Adults Part 1: Acute Treatments

PURPOSE OF REVIEW

The aim of this review is to aid in choosing safe options when assessing potential risks of acute migraine treatments based on known mechanisms of action and anticipated safety concerns.

RECENT FINDINGS

Part 1 highlights safety issues associated with commonly used medications to treat acute migraine attacks. Strategies to mitigate cardiovascular and gastrointestinal risks of nonsteroidal anti-inflammatory drugs, evaluation of cardiovascular risks of triptan and ergot alkaloids, and precautions with use of antiemetics and the novel drugs gepants and ditans are discussed to help practitioners in clinical decision-making. When available, we included recommendations from professional societies and data from pharmacovigilance systems. While guidelines on efficacy are available, one must also consider the possible risks and adverse effects of a drug when creating treatment plans.

Acute Care and Treatment of Migraine

OBJECTIVE

Migraine is a chronic neurological disease involving the brain and its vasculature, typically characterized by recurrent attacks of moderate or severe throbbing headache, accompanied by sensitivity to light and sound, and associated with nausea, vomiting, and inability to move due to worsening of pain. About 30% of migraineurs have some type of aura, most often visual. Migraine attacks, if untreated or suboptimally treated, usually result in significant disability, requiring bed rest and resulting in poor quality of life. Increased frequency of attacks and overuse of acute care medication are significant risks for chronification, resulting in the transformation of episodic migraine into chronic migraine. We aim to review most acute care treatments for migraine.

METHODS

Current treatment options for migraine attacks were reviewed from the selected literature and combined with our clinical experience.

RESULTS

Current acute treatment options for migraine attacks include over-the-counter analgesics, at times combined with caffeine, nonsteroidal anti-inflammatory medications, opioids, and migraine-specific medications such as triptans and ergots. In the near future, we will probably have 3 gepants (small-molecule calcitonin gene-related peptide [CGRP] receptor antagonists). The first one was just approved in the United States. A ditan acting as a stimulator of 5-HT1F receptors, was also just approved by the FDA. Stimulation of the trigeminal, vagal, occipital, and even upper arm peripheral nerves through electrical nerve stimulation devices and magnetic stimulation devices are available as alternative, nondrug treatment options. Several devices have already been FDA-allowed for treatment in the United States and/or approved elsewhere, and others will follow soon. Behavioral medicine techniques such as biofeedback training and mindfulness have been available for some time and are often helpful.

CONCLUSION

A wide variety of acute care options to treat migraine are available, and others will soon be and will herein be described in further detail. Some medications have been approved by regulatory authorities in countries other than the United States, and some devices have been given a CE Mark in Europe.

Inpatient Management of Migraine

Migraine is a frequently disabling neurologic condition which can be complicated by medication overuse headache and comorbid medical disorders, including obesity, anxiety and depression. Although most migraine management takes place in outpatient clinics, inpatient treatment is indicated for migraine refractory to multiple outpatient treatments, with intractable nausea or vomiting, need for detoxification from medication overuse (such as opioids and barbiturates), and significant medical and psychiatric disease. The goals of inpatient treatment include breaking the current cycle of headache pain, reducing the frequency and/or severity of future attacks, monitored detoxification of overused medications, and reducing disability and improving quality of life.

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

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

Ergotamine Use and Overuse in Taiwan: A Retrospective Cohort Study

OBJECTIVE

The aim of this study was to investigate the pattern of ergotamine prescription and overuse in Taiwan.

BACKGROUND

Ergotamine is a frequently prescribed medication for the treatment of migraine, although excessive use may lead to medication-overuse headache.

METHODS

We conducted a retrospective cohort study by using the Longitudinal Health Insurance Database 2005 in Taiwan. Patients enrolled in the study were between the ages of 18 and 80 years, received at least two prescriptions of ergotamine, and follow-up for more than 1 year at outpatient clinics during 1999 to 2013. Each ergotamine prescription was converted into a defined daily dose (DDD) and patients were sorted into two groups: occasional users, having fewer than 3 consecutive months of use, and regular users, with 3 consecutive months of use or more. Regular users were further divided into overusers (DDDs ≥ 10 per month) and non-overusers.

RESULTS

A total of 41,023 migraine patients were enrolled in the study; 5803 patients were classified as regular users, with 859 of those being overusers. Of the ergotamine overusers, around 698/859 (82%) continued to use, and 443/859 (52%) remained overusers of ergotamine in the subsequent year after the index date. The most frequently prescribed prophylactic medications were propranolol and flunarizine, which were prescribed in 30.4% and 20.0% of overuse patients, respectively.

CONCLUSIONS

Ergotamine overuse remains common in Taiwan, while prophylactic medicine is still underutilized. More education on ergotamine-overuse headache is needed to improve awareness.

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

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."

Role of 5-HT5A and 5-HT1B/1D receptors in the antinociception produced by ergotamine and valerenic acid in the rat formalin test

Sumatriptan, dihydroergotamine and methysergide inhibit 1% formalin-induced nociception by activation of peripheral 5-HT1B/1D receptors. This study set out to investigate the pharmacological profile of the antinociception produced by intrathecal and intraplantar administration of ergotamine (a 5-HT1B/1D and 5-HT5A/5B receptor agonist) and valerenic acid (a partial agonist at 5-HT5A receptors). Intraplantar injection of 1% formalin in the right hind paw resulted in spontaneous flinching behavior of the injected hindpaw of female Wistar rats. Intrathecal ergotamine (15nmol) or valerenic acid (1 nmol) blocked in a dose dependent manner formalin-induced nociception. The antinociception by intrathecal ergotamine (15nmol) or valerenic acid (1nmol) was partly or completely blocked by intrathecal administration of the antagonists: (i) methiothepin (non-selective 5-HT5A/5B; 0.01-0.1nmol); (ii) SB-699551 (selective 5-HT5A; up to 10nmol); (iii) anti-5-HT5A antibody; (iv) SB-224289 (selective 5-HT1B; 0.1-1nmol); or (v) BRL-15572 (selective 5-HT1D; 0.1-1nmol). Likewise, antinociception by intraplantar ergotamine (15nmol) and valerenic acid (10nmol) was: (i) partially blocked by methiothepin (1nmol), SB-699551 (10nmol) or SB-224289 (1nmol); and (ii) abolished by BRL-15572 (1nmol). The above doses of antagonists (which did not affect per se the formalin-induced nociception) were high enough to completely block their respective receptors. Our results suggest that ergotamine and valerenic acid produce antinociception via 5-HT5A and 5-HT1B/1D receptors located at both spinal and peripheral sites. This provides new evidence for understanding the modulation of nociceptive pathways in inflammatory pain.

Acute treatment of migraines

Migraine is a prevalent and disabling brain disorder that costs billions of dollars annually in direct healthcare costs, and school and work absenteeism and presenteeism. The objective of acute treatment is a cost-effective, rapid restoration of functional ability, with minimal recurrence and adverse effects. The acute treatment of migraine includes specific drugs, which currently all have vasoconstrictive effects (dihydroergotamine and triptans), and nonspecific drugs that include paracetamol (acetaminophen), combination analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), dopamine antagonists, narcotics and corticosteroids. NSAIDs have both peripheral and central effects on reversing migraine, and so may represent the best alternative for patients who cannot use triptans and ergots due to vascular contraindications. Narcotics and habituating medications should be avoided in the acute treatment of migraine, as the risk for transformation to chronic daily headache is excessively high at a relatively infrequent rate of exposure.

Overview of migraine treatment

SUMMARY Migraine is ranked as the 19th top cause of disability worldwide by WHO. Despite advancements in migraine-specific acute treatment, only a minority of patients utilize these medications. Specific pharmacologic treatments consist of the ergot alkaloids and triptans (serotonin 5-HT1B/1D receptor agonists). Both classes are regarded as relatively safe and effective; however, there is a greater concern for vasoconstrictive effects with the ergots, which limits their use. Triptans transformed migraine therapy, setting in motion revolutionary research that heightened our understanding of migraine mechanisms. However, one in three migraineurs may be triptan nonresponders and there is a group of migraine patients that remains ‘refractory’ to conventional pharmacologic migraine therapy. This article discusses the approach to migraine management, reviews currently available acute and preventive pharmacologic and nonpharmacologic treatment options for migraine headache, as well as briefly focuses on novel and upcoming medicines presently under investigation.

The analgesic and antiemetic efficacy of gabapentin or ergotamine/caffeine for the treatment of postdural puncture headache

PURPOSE

We investigated the analgesic and antiemetic efficacy of gabapentin or ergotamine/caffeine (Cafergot), in addition to conservative treatment consisting of bed rest and adequate fluid intake, for the treatment of postdural puncture headache (PDPH).

METHODS

In this randomized, prospective, controlled study, gabapentin or Cafergot was administered to 42 adult patients suffering from PDPH. Patients were asked to record the severity of their headache and the number of vomiting episodes on a visual analogue scale (VAS) on days 1, 2, 3 and 4. The pain scale consisted of a 10 cm horizontal line marked from 0 (denoting no pain) to 10 (denoting worst possible imaginable pain) Emesis was scored as 0 = no emetic symptoms, 1 = nausea or 2 = vomiting.

RESULTS

Demographic and anesthetic variables were similar between the groups. Gabapentin group had less pain, nausea and vomiting compared to the Cafergot group. No patients withdrew, gabapentin and Cafergot were well tolerated, and adverse events (somnolence, dizziness, tremor, and ataxia) did not occur.

CONCLUSIONS

Gabapentin significantly reduced pain, nausea and vomiting compared to Cafergot in patients with PDPH. Lastly, we hypothesize that the gabaergic action of gabapentin, perhaps combined with other mechanisms, such as calcium channel blockade, may be responsible for its remarkable effects on PDPH.

Acute migraine therapy: new drugs and new approaches

OPINION STATEMENT

The conceptual shift of our understanding of migraine from a vascular disorder to a brain disorder has dramatically altered the approach to the development of new medicines in the field. Current pharmacologic treatments of acute migraine consist of nonspecific and relatively specific agents. Migraine-specific drugs comprise two classes, the ergot alkaloid derivatives and the triptans, serotonin 5-HT(1B/1D) receptor agonists. The ergots, consisting of ergotamine and dihydroergotamine (DHE), are the oldest specific antimigraine drugs available and are considered relatively safe and effective. Ergotamine has been used less extensively because of its adverse effects; DHE is better tolerated. The triptan era, beginning in the 1990s, was a period of considerable change, although these medicines retained vasoconstrictor actions. New methods of delivering older drugs include orally inhaled DHE and the transdermal formulation of sumatriptan, both currently under study. Novel medicines being developed are targeted at neural sites of action. Serotonin 5-HT(1F) receptor agonists have proven effective in phase II studies and have no vascular actions. Calcitonin gene-related peptide (CGRP) receptor antagonists are another promising nonvasoconstrictor approach to treating acute migraine. Olcegepant (BIBN4096BS) and telcagepant (MK-0974) have been shown to be safe and effective in phase I, II, and (for telcagepant) phase III clinical trials. Other targets under investigation include glutamate (AMPA/kainate), TRPV1, prostanoid EP4, and nitric oxide synthase. With new neural targets and the potential for therapeutic advances, the next era of antimigraine medications is near.

Orally inhaled dihydroergotamine: reviving and improving a classic

Migraine pathophysiology continues to evolve, and additional therapeutic receptors influencing unrecognized neural networks within the cortex, brainstem and cerebral vasculature likely exist. Following the advent of the triptans, the use of dihydroergotamine (DHE) declined, because of the ease of use and improved side effect profiles of triptans. However, there remain many patients who respond poorly to triptans, yet respond significantly better to DHE. This may be due to the broader neuroreceptor targets that DHE interacts with, as opposed to the selective receptor activity of the triptans. Unfortunately, DHE is still infrequently utilized compared with other acute treatments such as triptans, primarily because of difficulty in administration and physician unfamiliarity and inexperience with its use. However, the new orally inhaled DHE appears to be as effective with a better side effect profile compared with intravenous DHE, thus eliminating the complexities typically associated with DHE administration.

Where is dihydroergotamine mesylate in the changing landscape of migraine therapy?

IMPORTANCE OF THE FIELD

Migraine affects approximately 18% of women and 6% of men, and has an immense impact on quality of life and productivity. Advancement in therapeutic options has been slow. For many patients with difficult-to-treat migraine, the appropriate use of dihydroergotamine mesylate (DHE) can result in treatment success and unprecedented patient satisfaction.

AREAS COVERED IN THIS REVIEW

Migraine treatment guidelines regarding the role of DHE are highlighted. An overview of the market for antimigraine drugs is provided in the context of DHE, since its introduction in 1943, and the novel agents that are likely to be available in the near future. An extensive literature search was undertaken using Medline and the Cochrane Systematic Review and Clinical Trial databases.

WHAT THE READER WILL GAIN

An understanding of which migraine patients are likely to benefit maximally from treatment with DHE in its various forms.

TAKE HOME MESSAGE

In the most difficult patient groups - including those with status migrainosus, migraine recurrence, medication-overuse headache, and chronic daily headache - DHE has therapeutic efficacy superior to other agents. The side-effect profile of DHE is more benign than is often perceived and should not be a deterrent for use in well-chosen cases.

Revisiting the role of ergots in the treatment of migraine and headache

The harmful side effects of the ergots described by early civilizations have been overcome with efficacious treatment for headaches including migraine, cluster, and chronic daily headache. Use of ergots contributed to initial theories of migraine pathogenesis and provided the substrate for development of the triptans. Triptans are very efficacious for many migraineurs, and since their widespread use, use of ergots has significantly declined. Unfortunately, there remain many migraineurs who benefit little from triptans, yet respond very well to ergots. Discoveries in migraine pathophysiology have given us better understanding of the complex processes involved, although there remain many unknown factors in migraine treatment. Additional, unrecognized therapeutic targets may exist throughout the neuronal connections of the brainstem, cortex, and cerebral vasculature. Ergots interact with a broader spectrum of receptors than triptans. This lack of receptor specificity explains potential ergot side effects, but may also account for efficacy. The role of ergots in headache should be revisited, especially in view of newer ergot formulations with improved tolerability and side effect profiles, such as orally inhaled dihydroergotamine. Redefining where in the headache treatment spectrum ergots belong and deciding when they may be the optimal choice of treatment is necessary.

Acute treatment of migraine

The goals of acute treatment of migraine are cost-effective rapid relief, consistent reduction of disability, and reduced use of rescue medications. Key to acute treatment is matching medication to disability as a surrogate marker for disease severity with a stratified care approach. In the absence of vascular contraindications, triptans are first-line acute treatments for disabling migraine. Acute treatment success can be assessed with use of the paper tool, Migraine-ACT. Opioids and butalbital should be avoided in acute migraine treatment. Triptan type can be selected for patients by differences in speed or effect, formulation, and formulary tier.

A possible perianesthetic serotonin syndrome related to intrathecal fentanyl

Serotonin syndrome occurs with selective serotonin reuptake inhibitors, opioids, and other serotonergic agents. We describe a possible serotonin syndrome related to intrathecal fentanyl in a patient taking multiple drugs and substances such as ergot alkaloids, marijuana, methylenedioxy-N-methylamphetamine, and ephedrine.

History of the Use of Ergotamine and Dihydroergotamine in Migraine From 1906 and Onward

Dale showed in 1906 in a seminal work that ergot inhibits the pressor effect of adrenaline. Stoll at Sandoz isolated ergotamine from ergot in 1918. Based on the belief that migraine was due to increased sympathetic activity, ergotamine was first used in the acute treatment of migraine by Maier in Switzerland in 1925. In 1938 Graham and Wolff demonstrated the parallel decrease of temporal pulsations and headache after ergotamine i.v. This inspired the vascular theory of Wolff: an initial cerebral vasoconstriction followed by an extracranial vasodilation. Dihydroergotamine (DHE) was introduced as an adrenolytic agent in 1943. It is still in use parenterally and by the nasal route. Before the triptan era ergotamine and DHE had widespread use as the only specific antimigraine drugs. From 1950 the world literature on ergotamine was dominated by two adverse events: ergotamine overuse headache and the relatively rare overt ergotism. Recently, oral ergotamine, which has an oral bioavailability of < 1%, has been inferior to oral triptans in randomized clinical trials. A European Consensus in 2000 concluded that ergotamine is not a drug of first choice. In an American review of 2003 it was suggested that ergotamine may be considered in the treatment of selected patients with moderate to severe migraine.

Recommendations for the management of migraine in paediatric patients

Migraine is a common and disabling condition in children and adolescents. The complexity of migraine on a pathogenetic and clinical level results from the interaction between biological, psychological and environmental factors. Appropriate management requires an individually tailored strategy giving due consideration to both pharmacological and non-pharmacological measures. Ibuprofen (7.5-10.0 mg/kg) and acetaminophen (15 mg/kg) are safe and effective, and should be considered for symptomatic treatment. Sumatriptan nasal spray (5 and 20 mg) is also likely to be effective, but at the moment, should be considered for the treatment of adolescents only. With reference to prophylactic drug treatment, the available data suggest that flunarizine (5 mg/day) is likely to be effective and pizotifen and clonidine are likely to be ineffective. The efficacy data regarding propranolol, nimodipine and trazodone are conflicting. Insufficient evidence is available on cyproheptadine, amitriptyline, divalproex sodium, topiramate, levetiracetam, gabapentin or zonisamide. The management of migraine in children needs an individualised therapeutic approach, directed to the whole person of the child, taking into account the developmental perspective and the high rate of psychiatric comorbidities. It is the authors' opinion that for the prophylaxis of migraine, interventions such as identification and avoidance of trigger factors, regulation of lifestyle, relaxation, biofeedback, cognitive behavioural treatment and psychological or psychotherapeutic interventions (e.g., psychodynamics) could be much more effective than pharmacotherapy.

Pharmacology of dihydroergotamine and evidence for efficacy and safety in migraine

Dihydroergotamine mesylate (DHE), an ergot alkaloid, has been extensively utilized and studied in the treatment of episodic and chronic migraine. This article reviews the pharmacokinetics, pharmacodynamics, and clinical efficacy and safety of DHE, particularly in comparison to ergotamine tartrate (ET), a similar ergot alkaloid with a long history of use in the treatment of migraine. Structural differences between these 2 compounds account for clinically important distinctions in their pharmacokinetic, pharmacodynamic, and adverse event profiles. DHE is a significantly less potent arterioconstrictor than is ET, which makes it a potentially much safer drug. In addition, DHE is associated with a markedly lower incidence of medication-withdrawal headache, nausea, and vomiting than is ET. The safety and efficacy data presented here are derived from clinical trials and case series involving DHE administered by intravenous infusion, intramuscular or subcutaneous injection, or intranasal spray.

Céphalées par abus médicamenteux

Medication overuse headache (MOH) is a secondary chronic daily headache resulting from overuse of symptomatic drugs in a headache-prone patient. MOH is a serious public health problem and the French national health care accreditation and evaluation agency (Agence Nationale d'Accréditation et d'Evaluation en Santé) recently proposed MOH management guidelines. Beyond these guidelines and according to the latest data in the literature, a relevant approach to MOH requires answering questions concerning: (i) diagnostic criteria of MOH, (ii) prevalence of MOH, (iii) implication of various drugs capable of inducing and sustaining MOH, (iv) pathophysiological mechanisms underlying MOH, (v) severity of MOH and (vi) the best management strategy for MOH.

Traitement médicamenteux de l’accès migraineux chez l’enfant

Migraine, according to the criteria of the International Headache Society, occurs in about 5 to 10% of children. Management of acute headache is only one of the parts of the treatment, along with identification of migraine precipitants, adjustments in lifestyle, and when necessary the use of preventive therapy, which can include non pharmacologic (relaxation or biofeedback) or pharmacologic treatment. In the acute migraine attack, a single dose of either ibuprofen 10 mg/kg or paracetamol 15 mg/kg has been shown to be effective, with only a few adverse effects. In severe migraine attacks, dihydroergotamine mesylate administered orally (20 to 40 microg/kg) or intravenously (maximum 1 mg/day) may be helpful, but there have been no large placebo-controlled trials of this treatment. Among the different triptans, it is the sumatriptan nasal spray whose efficacy has been best demonstrated. The most frequent adverse event is transitory unpleasant taste.

Rizatriptan: a new 5-HT1B/1D receptor agonist for the treatment of migraine

Rizatriptan (MAXALT MK-0462) is a new 5-HT(1B/1D) receptor agonist for the acute treatment of migraine. The marketed 10 mg and 5 mg oral doses are rapidly and consistently effective in relieving headache pain with associated migraine symptoms, and in enabling patients to return to their normal activities of daily living. Rizatriptan 10 mg is more effective than rizatriptan 5 mg. Compared to oral sumatriptan, the established agent in this class, rizatriptan has a shorter Tmax and greater bioavailability. In comparative clinical trials, the probability of having pain relief sooner was higher for rizatriptan 10 mg than for sumatriptan 100 mg or 50 mg. Over the 2 h after dosing, rizatriptan 10 mg was also superior to sumatriptan 100 mg and 50 mg on a range of other outcome measures. Both doses of rizatriptan are well-tolerated. The most common side-effects are dizziness, drowsiness, and asthenia/fatigue, which are short-lasting and of mild or moderate severity. In summary, rizatriptan is an effective and well-tolerated acute treatment for migraine, which may offer some advantages over oral sumatriptan.

Drug-induced headache

Medication overuse headache is a common complex disorder with physical and psychologic elements. Treatment may be difficult but often is accomplished in an outpatient setting. Some patients require inpatient treatments. An option for some is day treatment with i.v medication in an infusion center over several consecutive days. The two most common classes of drugs that acutely induce headache are NO donors, typified by NTG, and PDE inhibitors, typified by sildenafil. NO donors cause a biphasic headache in migraineurs and PDE inhibitors a monophasic one.

Chronic daily headache and the revised international headache society classification

Chronic daily headache (CDH) is surprisingly common. It is best defined as a primary headache disorder with head pain on most days. There are a number of possible secondary causes of persistent headache, including traumatic, vascular, neoplastic, and infectious processes, all of which must be ruled out when the patient with frequent headache is evaluated. However, most patients with CDH seem to have a primary neurophysiologic disorder. This category of primary CDH does not seem to be a homogeneous disorder, but rather one with important subtypes. Several authors have proposed subdivisions of primary CDH such as chronic migraine, evolved migraine, transformed migraine, chronic tension-type headache, new daily persistent headache, and hemicrania continua. The International Headache Society (IHS) Classification published in 1988 did not address CDH other than to define a category "chronic tension-type headache." The revised IHS Classification (ICHD II) attempts to characterize CDH more thoroughly with the addition of chronic migraine and new daily persistent headache diagnoses, but this complex issue continues to defy easy categorization. This article provides a review of thinking about the nature of primary CDH and how ICHD II attempts to organize this category for much needed research purposes.

Treatment of Primary Headache Disorders With Intravenous Valproate: Initial Outpatient Experience

OBJECTIVES

To evaluate the effectiveness of intravenous valproate in managing moderate to severe headaches.

BACKGROUND

Despite major strides in the understanding of primary headache disorders, there have been few additions to acute headache management other than introduction of the triptans. An intravenous antiepileptic preparation, sodium valproate, has been reported to be effective in the management of status epilepticus and acute headache.

METHODS

Between March 13, 2000 and October 11, 2000, we prospectively treated, in a nonrandomized and open-label study, every patient with a moderate to severe headache (4 or greater on a visual analog scale of head pain from 1 to 10) who wanted treatment with intravenous valproate. Using a verbal visual analog scale for pain (0 = no headache and 10 = most severe headache), we measured head pain before treatment and at time of discharge. The treating nurse monitored vital signs and side effects. A positive response was defined as a 50% or greater reduction at discharge in baseline pain. Information was collected regarding patient demographics, type of headache (according to criteria of the International Headache Society and that recently proposed for chronic headache), observation time in the treatment suite, cumulative dose of valproate, and use of concurrent medications. Univariable and multivariable correlates of response to treatment were identified using logistic regression analysis.

RESULTS

One hundred thirty treatments were given to 89 women and 17 men, aged 17 to 76 years; 92 patients received only one treatment. Valproate doses ranged between 300 and 1200 mg. Thirty-three patients (31%) presented with episodic migraine, with or without aura; 45 patients (42%) presented with chronic daily headache with a history of episodic migraine, with or without aura (transformed migraine); 22 (21%) with unclassifiable chronic headache; 2 (2%) with episodic cluster headache; and 4 (4%) with chronic tension-type headache. For first treatments only, 61 patients (57.5%) responded to treatment, whereas for all treatments, 82 patients (63.1%) responded. Age and gender did not affect likelihood of response, whereas increasing duration of treatment (P=.003) and the additional use of analgesics (P=.021) were each negatively associated with response. Among headache types, unclassifiable chronic headache segregated from all other classified headaches in terms of poor response. Aside from rare dizziness (n = 2) and one spell interpreted as a pseudoseizure, no side effects were noted.

CONCLUSIONS

Intravenous valproate is a safe, rapidly effective, abortive headache agent. It appears to be an effective analgesic for identifiable primary headaches, especially episodic headache, and less effective for unclassifiable chronic headache. Randomized, double-blind, controlled studies are warranted.

Effect of ergotamine on plasma metabolite and insulin-like growth factor-1 concentrations in cows

Bovine plasma was assayed to determine if ergotamine affected plasma metabolite and insulin-like growth factor-1 (IGF-1) concentrations. In Experiment 1, four cows received a single bolus intravenous injection of ergotamine tartrate (19 microg/kg body wt.) or saline vehicle in a crossover design 2 days after prostaglandin-induced luteolysis. Treatmentxtime affected plasma glucose, triglyceride, total cholesterol and IGF-1 concentrations. Glucose and cholesterol were increased after ergotamine. Triglycerides were elevated within 1 h after ergotamine, but were decreased 3 h after ergotamine treatment. Plasma IGF-1 decreased in response to ergotamine. Blood constituents were unchanged after treatment with saline. In Experiment 2, six cows received a single bolus intravenous injection of ergotamine (20 microg/kg body wt.) or saline vehicle in a crossover design 10 days after receiving norgestomet (6 mg) via subcutaneous ear implant. Treatmentxtime affected glucose, triglycerides, total cholesterol and IGF-1 concentrations. Glucose and cholesterol were increased after ergotamine. Triglycerides were elevated 1 h after ergotamine and decreased 3-7 h after ergotamine. Plasma IGF-1 decreased after ergotamine treatment. Blood constituents were unresponsive to the saline vehicle. Results indicated ergotamine altered plasma metabolite and IGF-1 concentrations in cows.

Ergotamine and dihydroergotamine: history, pharmacology, and efficacy

Ergotamine and dihydroergotamine share structural similarities with the adrenergic, dopaminergic, and serotonergic neurotransmitters. As a result, they have wide-ranging effects on the physiologic processes that they mediate. Ergotamine and dihydroergotamine are highly potent at the 5-HT1B and 5-HT1D antimigraine receptors and, as a consequence, the plasma concentrations that are necessary to produce the appropriate therapeutic and physiologic effects are very low. The broad spectrum of activity at other monoamine receptors is responsible for their side effect profile (dysphoria, nausea, emesis, unnecessary vascular effects). Both ergotamine and dihydroergotamine have sustained vasoconstrictor actions. In acute migraine treatment, their mechanisms of action involve constricting the pain-producing intracranial extracerebral blood vessels at the 5-HT1B receptors and inhibiting the trigeminal neurotransmission at the peripheral and central 5-HT1D receptors. The scientific evidence for efficacy is stronger for dihydroergotamine than for ergotamine. Their wide use is based on long-term experience.

Ergotamine and dihydroergotamine: a review

The ergot alkaloids were the first specific antimigraine therapy available. However, with the advent of the triptans, their use in the treatment of migraine has declined and their role has become less clear. This review discusses the pharmacology, efficacy, and safety of the ergots. In randomized clinical trials, oral ergotamine was found to be superior to placebo, but inferior to 100 mg of oral sumatriptan. In contrast, rectal ergotamine was found to have higher efficacy (73% headache relief) than rectal sumatriptan (63% headache relief). Intranasal dihydroergotamine was found to be superior to placebo, but less effective than subcutaneous and intranasal sumatriptan. Ergotamine is still widely used in some countries for the treatment of severe migraine attacks. It is generally regarded as a safe and useful drug if prescribed for infrequent use, in the correct dose, and in the absence of contraindications; however, safer and more effective options do exist in the triptans. In patients with status migrainous and patients with frequent headache recurrence, ergotamine is still probably useful.

Drug overuse and rebound headache

The overuse of acute medications in patients who are headache-prone poses a great challenge to headache management. Medication overuse-induced headache represents one of the most common iatrogenic disorders. It is the reason that most patients visit headache subspecialty clinics worldwide and often is the cause of an intractable or worsening headache in primary headache sufferers. The recent development of acute headache medications, especially the triptans, has provided increased migraine relief; however, the incidence of triptan-overuse headache has also increased. Awareness of medication overuse-induced headache and familiarity with the diagnosis and the treatment of this disorder are important to physicians who treat patients with headache.

Dihydroergotamine: discrepancy between arterial, arteriolar and pharmacokinetic data

AIMS

To investigate the peripheral vascular effects and pharmacokinetics of dihydroergotamine (DHE) 0.5 mg after a single subcutaneous administration in humans.

METHODS

A double-blind, placebo-controlled cross-over study was performed in 10 healthy male subjects. A wash-out period of 2 weeks separated the two study periods. During each period, just before and at regular intervals after drug administration, vascular measurements were performed and venous blood samples were drawn. Vessel wall properties were assessed at the brachial artery, by ultrasound and applanation tonometry. Blood pressure and heart rate were recorded with an oscillometric device. Forearm blood flow was measured with venous occlusion plethysmography. For all parameter-time curves the area under the curve (AUC) was calculated. Differences in AUC after placebo and DHE (DeltaAUC) were analysed and the time-course of the difference assessed. DHE pharmacokinetics were analysed according to a two-compartment open model with an absorption phase.

RESULTS

AUC for blood pressure, heart rate and forearm vascular resistance did not change after DHE. Brachial artery diameter and compliance decreased (P < 0.01); DeltaAUC (95% confidence interval) equalled -8.81 mm h (-12.97/-4.65) and -0.98 mm2 kPa(-1) h (-1.61/-0.34), respectively. Diameter decreased (P < 0.05) from 1 until 24 h after DHE (peak decrease 9.7% at 10 h); compliance from 2 until 32 h (24.8% at 2 h). Time to reach maximum plasma concentration of DHE averaged 0.33 +/- 0.08 h (+/- s.e.mean); terminal half-life was 5.63 +/- 1.15 h.

CONCLUSIONS

DHE decreased diameter and compliance of the brachial artery whereas forearm vascular resistance remained unchanged. Thus, DHE acts on conduit arteries without affecting resistance arteries. Furthermore, a discrepancy was demonstrated between the plasma concentrations of DHE which rapidly reach peak levels and quickly decline, and its long lasting vasoconstrictor activity.

Patterns of ergotamine and sumatriptan use in the Netherlands from 1991 to 1997

The objective of this study was to assess usage patterns of ergotamine and sumatriptan over a period of 6 years, primarily to evaluate the impact that sumatriptan has had on the prescription of ergotamine. This study used ergotamine and sumatriptan prescription data representing inhabitants of eight cities in the Netherlands and covering the period of 1991-1997. The yearly incidence of new users between 1991 and 1997 was estimated for both drugs as well as for the drug of first choice to be prescribed to patients initiating specific abortive migraine treatment with either ergotamine or sumatriptan. Intra-individual ergotamine and sumatriptan usage patterns, characterized by single (incidental), continuous (rate of retention) or switch use, were examined for five patient cohorts, each for a follow-up period of 1 year. During the year of sumatriptan introduction (1991-1992), the overall incidence of new use for both drugs was highest (5.4 per 1000 inhabitants). Hereafter, a substantial reduction of more than 50% was observed. From 1992 to 1996, the yearly incidence of ergotamine first-time use was significantly higher than that of sumatriptan and up to 1996 ergotamine was more than twice as likely than sumatriptan to be prescribed to patients initiating specific abortive treatment. Hereafter, sumatriptan was as likely as ergotamine to be prescribed as the drug of first choice, which coincided with the full reimbursement of sumatriptan tablets. Overall, neurologists were more likely than general practitioners (GPs), to prescribe sumatriptan as the drug of first choice. Approximately half of the total study population were identified as single-time users. This phenomonen occurred more frequently in the ergotamine cohorts. The sumatriptan cohorts displayed a slight yet significant stronger retention rate compared with the ergotamine cohorts. The overall impact of sumatriptan on ergotamine use in The Netherlands was marginal, predominantly due to GP's adherence to migraine treatment guidelines and reimbursement policies concerning sumatriptan tablets. Overall, incidental use was relatively high and may reflect the reported difficulties in diagnosing migraine, lack of patient-doctor consultation, or that anticipated benefits of the drug were not achieved. Further study is required to clarify these issues.

Diagnosis and management of headache

Migraine and tension headaches are among the most common diagnoses in women's health. Secondary causes of headache such as brain tumor, subarachnoid hemorrhage, and meningitis are uncommon but must not be missed. A careful history and physical examination, use of diagnostic criteria, and certain facts about the serious causes of headache are the keys to diagnosis and treatment. Neuroimaging should be limited to patients displaying signs or symptoms of a secondary headache cause. Menstrual migraine can be managed similarly to nonmenstrual migraine.

Intravenous metamizol (Dipyrone) in acute migraine treatment and in episodic tension-type headache--a placebo-controlled study

Acute headache is a very frequent symptom, responsible for significant demand at primary care units and emergency rooms. In such sets in Brazil, metamizol is easily found but, on the other hand, neither ergotics nor triptans are available. The aim of this study is to compare intravenous metamizol with placebo in the acute treatment of migraine with aura, migraine without aura and episodic tension-type headache. Fifty-four migraine with aura patients, 95 migraine without aura patients and 30 tension-type headache patients were treated with metamizol. Ninety patients (30 migraine with aura, 30 migraine without aura and 30 tension-type headache patients) received placebo. Pain intensity, nausea, aura, photo- and phonophobia were investigated at 30 min and 60 min after the administration of the drug. Significant improvement of pain after 30 min and 60 min post-dosage was achieved from metamizol groups compared with placebo groups. Significant improvement of all other symptoms was achieved after 60 min post-dosage. Side-effects were mild and with small incidence. Metamizol is an effective, safe and low price drug. It may be regarded as a good alternative drug for the treatment of common acute primary headaches.

Medication Overuse Headache

Medication overuse headache is common and affects 2% of the United States population. Simple analgesics, caffeine-containing analgesics, butalbital-containing analgesics, opioids, ergotamine, and triptans may cause medication overuse headache. The recidivism rate is higher after detoxification from butalbital and opioids than after detoxification from other substances. Treatment venues have included the patient's home, an infusion center, or a hospital setting. No consensus exists to determine the setting that is most appropriate. Patients with analgesic overuse headache have a different psychologic substrate than psychiatric substance abusers. Most should not be treated in psychiatric detoxification facilities, although, psychiatric assessment and support may be beneficial.

Ergotamine, dihydroergotamine: current uses and problems

In randomized clinical trials oral ergotamine was found superior to placebo but inferior to oral sumatriptan 100mg. In contrast rectal ergotamine was found to have higher efficacy (73% headache relief) than rectal sumatriptan (63% headache relief). Intranasal dihydroergotamine (DHE) was found superior to placebo but less effective than subcutaneous and intranasal sumatriptan. In general, the use of the more specific drugs, the triptans, causing less adverse events and being more effective, is preferable to the use of the ergotamine in the acute treatment of migraine. If ergotamine is to be used the rectal route is preferable. The rectal dose of ergotamine should be tailored to the individual patient. The intranasal dose of DHE , between 1 and 2 mg, should also be tailored to the individual patient. In order to avoid drug-induced headache ergotamine and DHE should not be used daily.

Rizatriptan in the treatment of migraine

Rizatriptan is a selective 5-hydroxytriptamine1B/1D receptor agonist that was launched in 1998 for the acute treatment of migraine in adults. Based on data from 6 large clinical trials in patients > or =18 years of age in whom migraine was diagnosed according to International Headache Society criteria, the marketed 10-mg and 5-mg oral doses of rizatriptan are effective in relieving headache pain and associated migraine symptoms. The 10-mg dose is more effective than the 5-mg dose. At 2 hours after dosing, up to 77% of patients taking rizatriptan 10 mg had pain relief compared with 37% of those taking placebo, up to 44% were completely pain free compared with 7% of those taking placebo, and up to 77% were free of nausea compared with 58% of those taking placebo (P < 0.05 for all 3 comparisons). Both doses of rizatriptan are generally well tolerated. In placebo-controlled studies involving treatment of a single migraine attack, the most common side effects (incidence > or =2%) occurred in <10% of patients, typically were transitory (2 to 3 hours), and were mild or moderate. Rizatriptan is an effective and well-tolerated acute treatment for migraine.

Acute treatment of migraine attacks: efficacy and safety of a nonsteroidal anti-inflammatory drug, diclofenac-potassium, in comparison to oral sumatriptan and placebo. The Diclofenac-K/Sumatriptan Migraine Study Group

BACKGROUND

Migraine attacks are often treated with simple analgesics or with ergotamine-containing preparations alone or in combination with anti-emetics. Although also sometimes used to treat migraine, nonsteroidal anti-inflammatory drugs (NSAIDs) have not been systematically evaluated in controlled clinical trials, particularly in comparison with the newer drug sumatriptan. Sumatriptan is a specific migraine treatment which has recently become among the most widely prescribed acute migraine therapies. However, while effective, it has low oral bioavailability and some problematic adverse effects. Diclofenac-potassium is a potent NSAID available as a fast-acting oral tablet, which has been shown to be safe and effective in several other acute pain indications. In the clinical trial reported here, the efficacy and safety of diclofenac-potassium in the acute treatment of migraine attacks has been tested in comparison with oral sumatriptan and placebo.

METHODS

Single oral doses of 50 mg and 100 mg diclofenac-potassium were compared to a single oral dose of 100 mg sumatriptan and placebo in a double-blind randomized crossover trial in 156 adult patients suffering from migraine attacks, with or without aura, selected according to the International Headache Society diagnostic criteria. The primary efficacy criterion was migraine headache pain recorded on a visual analog scale at 2 h after dosing. Secondary endpoints included pain at other time points up to 8 h and the presence of accompanying symptoms (nausea, vomiting, photophobia, phonophobia).

FINDINGS

Diclofenac-potassium was more effective than placebo in reducing migraine headache pain at 2 h after dosing, which was the primary endpoint. Secondary analyses showed that diclofenac-potassium provided significant pain relief from 60 min after dosing and for all remaining endpoints in the 8-h observation period. Both 50 and 100 mg doses of diclofenac-potassium were similarly effective. A similar effect was shown with sumatriptan; however, significant superiority to placebo was seen only from the 90-min time point. Diclofenac-potassium was generally superior to placebo or sumatriptan in reducing accompanying symptoms, particularly nausea. Diclofenac-potassium seemed to be as well tolerated as placebo, with fewer adverse events reported than after sumatriptan treatment and with more patients assessing the overall tolerability of diclofenac-potassium better than that of sumatriptan.

INTERPRETATION

Compared with placebo and the reference therapy sumatriptan, diclofenac-potassium is an effective, fast-acting, and well-tolerated acute oral therapy for migraine attacks, with advantages over oral sumatriptan in terms of onset of analgesic effect, reduction of accompanying symptoms, and tolerability profile. It may therefore be useful as an alternative oral therapy for migraine attacks.

Medication-induced headache: overview and systematic review of therapeutic approaches

OBJECTIVE

To review medication-induced headache (MIH) through a systematic evaluation of the literature regarding the pharmacologic management of this condition.

METHODOLOGY

To identify and evaluate all pharmacologic interventions for MIH, we conducted a qualitative systematic review of the English-language literature from 1966 to June 1998 using MEDLINE. The following search terms were used: chronic daily headache, transformed migraine, analgesic withdrawal headache, analgesic rebound headache, drug-associated headache, medication-induced headache, detoxification, and dihydroergotamine. In addition, a review of the references from relevant literature was also conducted to collect reports not identified in the MEDLINE search.

RESULTS

Numerous therapies for acute management of MIH have been evaluated, although no rigorously conducted clinical trials were identified. Therapies evaluated include abrupt withdrawal of analgesics, initiation of dihydroergotamine, nonsteroidal antiinflammatory agents, methylergonovine, dihydroergotamine, sumatriptan, amitriptyline, dexamethasone, piracetam, prothipendyl, and valproate. Epidemiology, diagnosis, clinical features, pathophysiology, and long-term prognosis of therapy are discussed and therapeutic guidelines are offered.

CONCLUSIONS

MIH is an underrecognized and difficult condition affecting headache-prone patients. The published literature concerning treatment of patients with MIH is scant and of poor quality, making it difficult for clinicians to decide on appropriate therapy. Recognition and treatment of MIH may lead to a long-term improvement in headache relief for many patients. It appears that complete withdrawal of the medications being overused is required for favorable long-term results.