Frederick R. Taylor

Validity and reliability of the Migraine-Specific Quality of Life Questionnaire (MSQ version 2.1)

Objective.–To assess the scaling properties, reliability, and validity of the revised Migraine‐Specific Quality of Life Questionnaire (MSQ) (Version 2.1)

Nutraceuticals and headache: the biological basis.

Nutrition must affect the structure and functioning of the brain. Since the brain has very high metabolic activity, what we consume throughout the day is likely to dramatically influence both its structure and moment to moment function. It follows that nutritional approaches to all neurological disorders are being researched and entering medical practice, while nutraceutical use is a mainstay of public habits. This review discusses the biological basis for non‐conventional or non‐mainstream approaches to the treatment of migraine. This requires at least limited discussion of current migraine pathophysiologic theory. How nutrients and other chemicals and approaches are mechanistically involved within migraine pathways is the focus of this article. The nutraceuticals reviewed in detail are: magnesium, riboflavin, coenzyme Q10, petasites, and feverfew with additional comments on marijuana and oxygen/hyperbaric oxygen. This article reviews the science when known related to the potential genetic susceptibility and sensitivity to these treatments. As we know, the basic science in this field is very preliminary, so whether to combine approaches and presumably mechanisms or use them alone or with or without conventional therapies is far from clear. Nonetheless, as more patients and providers participate in patient‐centered approaches to care, knowledge of the science underpinning nutritional, nutraceutical, and complementary approaches to treatment for migraine will certainly benefit this interaction.

“Natural” or Alternative Medications for Migraine Prevention

CLINICAL HISTORY A medical school statistician/epidemiologist has frequent migraines. She is interested in the possibility of a preventative medication. From her research, she concludes that the usual preventative medications reduce headache frequency by about 50% in about 50% of patients, but she is concerned about the potential for side-effects and wonders about the efficacy of alternative treatments. She is also curious about the scientific validity of the studies. Question: What is the efficacy of alternative treatments such as feverfew, petasites, magnesium, ri-

Allergy and Immunotherapy: Are They Related to Migraine Headache?

(Headache 2011;51:8‐20)

Weight change associated with the use of migraine-preventive medications.

BACKGROUND Medications administered long term, such as those used for migraine prophylaxis, are often associated with weight change as a side effect. Such effects may compromise general health status, exacerbate coexisting medical conditions, and affect medication adherence. Weight gain should be of particular concern in patients with migraine, as there is evidence that overweight and obese patients with migraine are at risk for an increased frequency and severity of migraine attacks. OBJECTIVE This article reviews weight-change data from recent clinical studies of migraine-preventive medications in children, adolescents, and adults with migraine. METHODS A PubMed search was conducted for English-language articles published between January 1970 and November 2007. Among the search terms were migraine prevention, migraine prophylaxis, migraine treatment, antidepressant drug, beta-adrenergic-receptor blockers, antiepileptic drug, anticonvulsant drug, weight gain, and weight loss. Studies that reported weight-change data (gain, loss, or neutral) were included. When available, double-blind, placebo-controlled studies were selected for review. Open-label, retrospective or prospective trials may also have been included. RESULTS Most of the migraine-preventive medications classified by the United States Headache Consortium as group 1 based on the high level of evidence for their efficacy--for instance, amitriptyline, propranolol, and divalproex sodium-have been associated with varying degrees of weight gain. The exceptions are timolol, which is weight neutral, and topiramate, which is associated with weight loss. Among the drugs that have been associated with weight gain, a higher incidence of weight gain was observed with amitriptyline and divalproex sodium than with propranolol. CONCLUSION Weight-change effects require careful consideration when selecting migraine-preventive medications, and weight should be monitored carefully over the course of any migraine treatment plan.

The effect of early intervention with sumatriptan tablets on migraine-associated productivity loss.

Objective:Impaired performance, which can considerably impact employee output, occurs when employees attempt to continue work with inadequate treatment while experiencing a migraine episode. This analysis examined productivity loss as a result of migraine after treatment with sumatriptan tablets and patients’ usual nontriptan therapy when pain was mild (early intervention) versus when pain was moderate/severe. Methods:The authors conducted a retrospective analysis of data on 6803 migraine days reported by 251 subjects who participated in a clinical trial. Results:Although early intervention significantly reduced productivity loss compared with treatment when pain was moderate/severe for both sumatriptan and nontriptan therapy, productivity loss was consistently lower for sumatriptan than nontriptan therapy for all predose pain intensity levels. Conclusions:These findings suggest that the pharmacoeconomic benefits of early intervention with sumatriptan tablets, like the clinical benefits, exceed those of delayed intervention.

Methodological Issues in Systematic Reviews of Headache Trials: Adapting Historical Diagnostic Classifications and Outcome Measures to Present-Day Standards

Recent efforts to make headache diagnostic classification and clinical trial methodology more consistent provide valuable advice to trialists generating new evidence on effectiveness of treatments for headache; however, interpreting older trials that do not conform to new standards remains problematic. Systematic reviewers seeking to utilize historical data can adapt currently recommended diagnostic classification and clinical trial methodological approaches to interpret all available data relative to current standards. In evaluating study populations, systematic reviewers can:

Tobacco, Nicotine, and Headache

Migraineurs variably attribute the cause of their headache to tobacco exposure, whereas tobacco is often stated to cause headache‐related disability worldwide. Given tobaccos physiological and emotional addictiveness and migraines substantial economic impact, improved functionality can be difficult for those with migraine exposed to tobacco products. Environmental tobacco exposure in indoor spaces and workplaces is associated with exacerbation of headache. Avoidance of headache triggers is included in most comprehensive migraine treatment programs, yet tobacco awareness, avoidance, or coping is rarely emphasized as part of that regimen.

Efficacy and tolerability of rizatriptan for the treatment of acute migraine in sumatriptan non-responders

Objective: The study was carried out to assess the efficacy and tolerability of rizatriptan orally disintegrating tablet (ODT) for treating acute migraine in patients who are non-responders to sumatriptan. Background: Many migraineurs report dissatisfaction with sumatriptan efficacy. It is unclear whether sumatriptan 100 mg non-responders will respond to other triptans. Methods: This was a randomized, placebo-controlled, double-blind study in adults with >1-year history of ICHD-II (International Classification of Headache Disorders, second edition) migraine who reported that they generally do not respond to sumatriptan (≥50% unsatisfactory response). In the baseline phase, participants treated a single moderate/severe migraine attack with open-label generic sumatriptan 100 mg. Those who continued to experience moderate/severe pain at two hours post-dose were eligible to enter the double-blind treatment phase, during which participants treated three migraine attacks in crossover fashion (two with rizatriptan 10-mg ODT, one with placebo) after being randomly assigned to one of three treatment sequences (1 : 1 : 1 ratio). The primary endpoint was two-hour pain relief. Results: A total of 102 (94%) participants treated at least one study migraine. Pain relief at two hours was significantly greater with rizatriptan compared with placebo (51% vs. 20%, p < .001). Response rates also favored rizatriptan on two-hour pain freedom (22% vs. 12%, p = .013) as well as 24-hour sustained pain relief (38% vs. 14%, p < .001) and sustained pain freedom (20% vs. 11%, p = .036). Treatment was generally well tolerated. Conclusion: Rizatriptan 10-mg ODT was superior to placebo at providing two-hour pain relief and two-hour pain freedom in the treatment of acute migraine in those who do not respond to sumatriptan 100 mg. Rizatriptan was generally well tolerated in this population.

Episodic Migraines in Children Limited Evidence on Preventive Pharmacological Treatments

The authors conducted a systematic literature review of preventive pharmacological treatments for episodic childhood migraines searching several databases through May 20, 2012. Episodic migraine prevention was examined in 24 publications of randomized controlled trials that enrolled 1578 children in 16 nonrandomized studies. Single randomized controlled trials provided low-strength evidence that propranolol would result in complete cessation of migraine attacks in 713 per 1000 children treated (95% confidence interval, 452-974); trazodone and nimodipine decreased migraine days, while topiramate, divalproex, and clonidine were no more effective than placebo in preventing migraines. Migraine prevention with multidisciplinary drug management was not sustained at 6 months. Divalproex resulted in treatment discontinuation due to adverse effects, and topiramate increased the risk of paresthesia, upper respiratory tract infection, and weight loss. Long-term preventive benefits and improvement in disability and quality of life are unknown. No studies examined quality of life or provided evidence for individualized treatment decisions.