Michael J. Marmura

The Acute Treatment of Migraine in Adults: The American Headache Society Evidence Assessment of Migraine Pharmacotherapies

The study aims to provide an updated assessment of the evidence for individual pharmacological therapies for acute migraine treatment. Pharmacological therapy is frequently required for acutely treating migraine attacks. The American Academy of Neurology Guidelines published in 2000 summarized the available evidence relating to the efficacy of acute migraine medications. This review, conducted by the members of the Guidelines Section of the American Headache Society, is an updated assessment of evidence for the migraine acute medications. A standardized literature search was performed to identify articles related to acute migraine treatment that were published between 1998 and 2013. The American Academy of Neurology Guidelines Development procedures were followed. Two authors reviewed each abstract resulting from the search and determined whether the full manuscript qualified for review. Two reviewers studied each qualifying full manuscript for its level of evidence. Level A evidence requires at least 2 Class I studies, and Level B evidence requires 1 Class I or 2 Class II studies. The specific medications – triptans (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan [oral, nasal spray, injectable, transcutaneous patch], zolmitriptan [oral and nasal spray]) and dihydroergotamine (nasal spray, inhaler) are effective (Level A). Ergotamine and other forms of dihydroergotamine are probably effective (Level B). Effective nonspecific medications include acetaminophen, nonsteroidal anti‐inflammatory drugs (aspirin, diclofenac, ibuprofen, and naproxen), opioids (butorphanol nasal spray), sumatriptan/naproxen, and the combination of acetaminophen/aspirin/caffeine (Level A). Ketoprofen, intravenous and intramuscular ketorolac, flurbiprofen, intravenous magnesium (in migraine with aura), and the combination of isometheptene compounds, codeine/acetaminophen and tramadol/acetaminophen are probably effective (Level B). The antiemetics prochlorperazine, droperidol, chlorpromazine, and metoclopramide are probably effective (Level B). There is inadequate evidence for butalbital and butalbital combinations, phenazone, intravenous tramadol, methadone, butorphanol or meperidine injections, intranasal lidocaine, and corticosteroids, including dexamethasone (Level C). Octreotide is probably not effective (Level B). There is inadequate evidence to refute the efficacy of ketorolac nasal spray, intravenous acetaminophen, chlorpromazine injection, and intravenous granisetron (Level C). There are many acute migraine treatments for which evidence supports efficacy. Clinicians must consider medication efficacy, potential side effects, and potential medication‐related adverse events when prescribing acute medications for migraine. Although opioids, such as butorphanol, codeine/acetaminophen, and tramadol/acetaminophen, are probably effective, they are not recommended for regular use.

Use of Dopamine Antagonists in Treatment of Migraine

Opinion statementDopamine antagonists are indicated for treatment of nausea or psychosis and have an established role in the treatment of migraine. Neuroleptics, including antipsychotics, act as antagonists at the dopamine D2 receptor type. These medications also have variable activity as antihistamines and anticholinergics, and they block alpha-adrenergic and some serotonin receptor types, but their actions on dopamine are likely the reason for their efficacy in treating nausea, psychosis, and acute migraine. Neuroleptics are first-line agents in the emergency room setting for migraine, especially for patients with nausea and vomiting. In the setting of a clear prodrome, antiemetics may prevent migraine when taken before an attack. They are also indicated in clinical situations such as patients who are pregnant or have contraindications to migraine-specific medications or NSAIDs. Recent developments suggest that dopamine is particularly important in chronic pain, and we most commonly use neuroleptic medications in the treatment of status migrainosus or medication-overuse headache. Clinicians may avoid dopamine antagonists because of unfamiliarity and a lack of large, controlled clinical trials. Their use requires special care to avoid adverse events such as sedation, akathisia or dystonic reactions, neuroleptic malignant syndrome, or movement disorders with long-term use. Some newer atypical neuroleptic agents appear promising for both acute and prophylactic migraine treatment with a lower risk of adverse events.

Intravenous Lidocaine in the Treatment of Refractory Headache: A Retrospective Case Series

Background.— New treatments are needed to treat chronic daily headache (CDH) and chronic cluster headache (CCH). New treatments are needed to treat this population and intravenous (IV) lidocaine is a novel treatment for CDH.

Expert opinion: greater occipital nerve and other anesthetic injections for primary headache disorders.

In his 1948 headache book, Harold Wolff described 3 types of occipital neuralgia.“The first and most common is characterized by a long-lasting (day, weeks, or months), more or less sustained aching of low or moderate intensity. It is commonly bilateral but may be unilateral. It is associated with stiffness of the muscles of the neck, tender points, often with muscle nodules, and with head tilting. . . . and results from the sustained contraction of skeletal muscle. It may be reduced in intensity or eliminated by procaine injection into the tender regions.” “A second type of occipital headache is characterized by recurrent attacks of high intensity pain with complete freedom from pain between attacks. The headache is of 2 to 36 hours’ duration, is usually unilateral in onset, but may spread to the opposite side. It is throbbing. . . . The headache is commonly associated with anorexia, nausea, and vomiting, and is occasionally preceded by visual scotomas and paresthesias of the extremities. It is promptly and dramatically modified by ergotamine tartrate. . . . Procaine injection into the region of the occipital artery may eliminate the headache. The interval between attacks and the intensity of attacks is modified by adjustments of life situations and changes in attitude.” “A third type of occipital headache is due to inflammation, injury, or pressure on the occipital nerves, upper cervical spinal roots or dorsal horn or root ganglions. . . .” Sixty years later, Wolff’s descriptions are still insightful. He even reported a novel treatment, occipital nerve block, for acute migraine (although misdiagnosed as occipital neuralgia).

Use of Common Migraine Treatments in Breast-Feeding Women: A Summary of Recommendations

Breast‐feeding has important health and emotional benefits for both mother and infant, and should be encouraged. While there are some data to suggest migraine may improve during breast‐feeding, more than half of women experience migraine recurrence with 1 month of delivery. Thus, a thorough knowledge base of the safety and recommended use of common acute and preventive migraine drugs during breast‐feeding is vital to clinicians treating migraine sufferers. Choice of treatment should take into account the balance of benefit and risk of medication. For some of the medications commonly used during breast‐feeding, there is not good evidence about benefits.

Interictal pain in cluster headache

Introduction: Cluster headache is characterized by severe attacks of unilateral pain, but many patients experience symptoms more commonly associated with migraine such as persistent pain. Patients and methods: We evaluated cluster headache patients using a questionnaire and chart review to determine clinical characteristics. Results: Twenty-four of 50 subjects reported interictal pain outside of their acute attacks. Sixteen reported persistent pain more than half the time while in cycle. Unlike acute attacks, this pain was generally mild. Conclusions: Subjects with persistent interictal pain were more likely to have chronic cluster, allodynia, and suboptimal response to sumatriptan, suggesting that interictal pain in cluster headache may predict a more severe disease process.

Mexiletine for Refractory Chronic Daily Headache: A Report of Nine Cases

Objective.— To describe the use of mexiletine in the treatment of chronic daily headache in a refractory headache population.

New therapeutic developments in chronic migraine.

Purpose of reviewChronic migraine is a common cause of chronic daily headache, which is often refractory to standard treatment. New research has increased our understanding of this disorder and its treatment. This review focuses on recent clinical trials and advances in our understanding of migraine pathophysiology. Recent findingsMigraine research has traditionally focused on the more common episodic form of the disorder, but recent clinical trials have started to focus on chronic migraine or chronic daily headache. Topiramate, onabotulinum toxin type A, gabapentin, petasites and tizanidine are among the agents that appear to be effective in the treatment of chronic migraine. New acute medications including an inhaled form of dihydroergotamine will soon be available and neuromodulatory procedures such as occipital nerve stimulation may be effective for the most disabled patients. In the past few years, other studies have shed light on potential risk factors for chronic migraine such as medication-overuse headache, temporomandibular disorders, obstructive sleep apnea and obesity. SummaryThis review explains advances in the treatment of chronic migraine, a common disorder seen in neurological practice. These new advances in preventive treatment and a better understanding of its risk factors will allow clinicians to better identify individuals at greatest risk and prevent the development of chronic migraine.

Metabolic syndrome and migraine

Migraine and metabolic syndrome are highly prevalent and costly conditions. The two conditions coexist, but it is unclear what relationship may exist between the two processes. Metabolic syndrome involves a number of findings, including insulin resistance, systemic hypertension, obesity, a proinflammatory state, and a prothrombotic state. Only one study addresses migraine in metabolic syndrome, finding significant differences in the presentation of metabolic syndrome in migraineurs. However, controversy exists regarding the contribution of each individual risk factor to migraine pathogenesis and prevalence. It is unclear what treatment implications, if any, exist as a result of the concomitant diagnosis of migraine and metabolic syndrome. The cornerstone of migraine and metabolic syndrome treatments is prevention, relying heavily on diet modification, sleep hygiene, medication use, and exercise.

Headaches Caused by Nasal and Paranasal Sinus Disease

Headache and rhinosinusitis are 2 of the most common conditions seen in clinical practice. In general, chronic and disabling headaches, especially if migraine features are present, are not due to sinus abnormalities. In suspected cases of bacterial sinusitis, computed tomography and magnetic resonance imaging are both effective in demonstrating the infection. Although most cases of sinusitis are fairly easy to diagnose, sphenoid sinusitis may be overlooked, and can present with progressive or thunderclap headache in adults. Contact-point headache should be considered in patients with focal headaches and a contact point on the lateral nasal wall.