Severe migraine and its control: A proposal for definitions and consequences for care

BACKGROUND AND OBJECTIVE: Nonsteroidal anti-inflammatory drugs (NSAID) are effective to treat migraine attacks. Lysine clonixinate (LC) and dipyrone (metamizol) have been proven effective to treat acute migraine. The aim of this study was to evaluate the efficacy and tolerability of the intravenous formulations of LC and dipyrone in the treatment of severe migraine attacks. METHOD: Thirty patients (28 women, 2 men), aged 18 to 48 years with migraine according the International Headache Society (IHS) (2004) were studied. The patients were randomized into 2 groups when presenting to an emergency department with a severe migraine attack. The study was single-blind. Headache intensity, nausea, photophobia and side effects were evaluated at 0, 30, 60 and 90 minutes after the drug administration. Rectal indomethacin as rescue medication (RM) was available after 2 hours and its use compared between groups. RESULTS: All patients completed the study. At 30 minutes, 0% of the dipyrone group 13% of the LC group were pain free (p=0.46). At 60 and 90 minutes, 2 (13%) and 5 (33%) patients from the dipyrone group and 11 (73%) and 13 (86.7%) patients from the LC group were pain free (p<0.001). At 60 minutes, significantly more patients from the LC group were nausea-free (p<0.001). Regarding photophobia, there were no differences between groups at 60 minutes (p=0.11). The use of RM at 2 hours did not differ among groups (p=0.50). Pain in the site of the injection was reported by more patients of the LC group compared to the dipyrone group (p<0.0001). CONCLUSION: LC is significantly superior to dipyrone in treating severe migraine attacks. LC promotes significantly more burning at the site of the injection.

Download Full-text

Effect of galcanezumab on severity and symptoms of migraine in phase 3 trials in patients with episodic or chronic migraine

The Journal of Headache and Pain ◽

10.1186/s10194-021-01215-9 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Michael Ament ◽

Kathleen Day ◽

Virginia L Stauffer ◽

Vladimir Skljarevski ◽

Mallikarjuna Rettiganti ◽

...

Keyword(s):

Chronic Migraine ◽

Migraine Headache ◽

Randomized Clinical Trials ◽

Episodic Migraine ◽

Double Blind Study ◽

Double Blind ◽

Prodromal Symptoms ◽

Link Type ◽

Associated Symptoms ◽

Severe Migraine

Abstract Background Galcanezumab, a humanized monoclonal antibody that binds calcitonin gene-related peptide, has demonstrated a significant reduction in monthly migraine headache days compared with placebo. Here, we analyze data from 3 randomized clinical trials (2 episodic trials [EVOLVE-1, EVOLVE-2] and 1 chronic trial [REGAIN]), to examine if galcanezumab also alleviates the severity and symptoms of migraine. Methods The episodic migraine trials were 6-month, double-blind studies in patients with episodic migraine (4–14 monthly migraine headache days). The chronic migraine trial was a 3-month, double-blind study in patients with chronic migraine (≥ 15 headache days per month, where ≥ 8 met criteria for migraine). Patients (18–65 years) were randomized to placebo or galcanezumab 120 mg with a 240-mg loading dose or 240 mg. Patients recorded headache characteristics, duration, severity, and presence of associated symptoms with each headache. The outcomes analyzed were changes from baseline in number of monthly migraine headache days with nausea and/or vomiting, photophobia and phonophobia, aura, and prodromal symptoms other than aura. Additional outcomes analyzed included the number of moderate-to-severe monthly migraine headache days, number of severe migraine headache days, and mean severity of remaining migraine headache days. Change from baseline in the proportion of days with nausea and/or vomiting and the proportion of days with photophobia and phonophobia among the remaining monthly migraine headache days were also analyzed. Results Galcanezumab was superior to placebo in reducing the frequency of migraine headache days with associated symptoms of migraine such as nausea and/or vomiting, photophobia and phonophobia, and prodromal symptoms. Galcanezumab reduced the frequency of migraine headache days with aura in the episodic migraine studies. There was a significant reduction in the proportion of remaining migraine headache days with nausea and/or vomiting for the episodic and chronic migraine studies, and with photophobia and phonophobia for the episodic migraine studies. Galcanezumab was superior to placebo in reducing the number of monthly moderate-to-severe migraine headache days and the overall and monthly severe migraine headache days. Conclusions Galcanezumab reduces the frequency of migraine headache days and can alleviate potentially disabling non-pain symptoms on days when migraine is present in patients with episodic or chronic migraine. Trial registration NCT, NCT02614183 (EVOLVE-1), registered 25 November 2015; NCT, NCT02614196, (EVOLVE-2), registered 25 November 2015; NCT, NCT02614261 (REGAIN), registered 25 November 2015.

Download Full-text

Migraine in Children: Association With Primary and Familial Dyslipoproteinemias

PEDIATRICS ◽

10.1542/peds.77.3.316 ◽

1986 ◽

Vol 77 (3) ◽

pp. 316-321

Author(s):

Charles J. Glueck ◽

Stephen R. Bates

Keyword(s):

Low Density Lipoprotein ◽

Density Lipoprotein ◽

Lipoprotein Cholesterol ◽

Degree Relative ◽

Presumptive Diagnosis ◽

History Of ◽

Premature Myocardial Infarction ◽

Disproportionate Number ◽

Severe Migraine ◽

Cerebral Vascular

We studied lipids and lipoprotein cholesterols in 39 children (26 boys, 13 girls) with severe migraine, to examine the hypothesis that primary and familial lipoprotein abnormalities might be associated with or predispose children to the migraine syndrome. Each of the children, 4 to 20 years of age, had severe migraine, leading to pediatric neurologic referral and therapy. Twenty-five of the 39 probands (64%) had a first degree relative with severe migraine, and 18% had a second degree relative with severe migraine. In 11 of the 39 kindreds (28%), there was a family history of premature myocardial infarction and/or cerebral vascular accident (<age 55 years), involving one grandparent from each of ten kindreds and one parent in the 11th kindred. In nine of the 26 boys, low-density lipoprotein cholesterol (LDL-C) levels were greater than or equal to the age-, sex-, race-specific 90th percentile, and in three of these nine children, there was at least one additional first degree relative also having a primary top decile LDL-C level, consistent with the presumptive diagnosis of familial hypercholesterolemia. The finding of more than three times as many boys with migraine headache having top decile LDL-C than expected (9 v 2.6) was significant (x2 = 17.5, P <.01). Also, there were six boys having bottom decile levels of high-density lipoprotein cholesterol (HDL-C); all six came from kindreds with at least one first degree relative also having bottom decile HDL-C. The finding of more than two times as many boys with migraine having bottom decile HDL-C than expected (6 v 2.6) was significant (x2 = 4.94, P < .05). Of the 13 female pediatric probands, two had top decile LDL-C and two had bottom decile HDL-C and came from families with at least one additional first degree family relative also having a primary and similar dyslipoproteinemia. Our observations suggest that the clinical diagnosis of severe migraine in childhood should lead to measurement of lipids and lipoprotein cholesterols, particularly in boys, because they represent a cohort with a disproportionate number of hyper-β- and hypo-α-lipoproteinemic subjects. We speculate that primary and familial lipoprotein abnormalities, particularly those involving high levels of LDL-C and/or low levels of HDL-C, may be etiologically related to migraine, perhaps related to platelet hyperaggregability, and/or increased likelihood of cerebral vascular instability.

Download Full-text

Occipital nerve block for the short-term preventive treatment of migraine: A randomized, double-blinded, placebo-controlled study

Cephalalgia ◽

10.1177/0333102414561872 ◽

2014 ◽

Vol 35 (11) ◽

pp. 959-968 ◽

Cited By ~ 60

Author(s):

Esma Dilli ◽

Rashmi Halker ◽

Bert Vargas ◽

Joseph Hentz ◽

Teresa Radam ◽

...

Keyword(s):

Chronic Migraine ◽

Nerve Block ◽

Preventive Treatment ◽

Placebo Treatment ◽

Baseline Period ◽

Controlled Study ◽

Double Blind ◽

Occipital Nerve ◽

Occipital Nerve Block ◽

Severe Migraine

Background Occipital nerve (ON) injections with corticosteroids and/or local anesthetics have been employed for the acute and preventive treatment of migraine for decades. However, to date there is no randomized, placebo-controlled evidence to support the use of occipital nerve block (ONB) for the prevention of migraine. Objective The objective of this article is to determine the efficacy of ONB with local anesthetic and corticosteroid for the preventive treatment of migraine. Participants and methods Patients between 18 and 75 years old with ICHD-II-defined episodic (> 1 attack per week) or chronic migraine (modified ICHD-II as patients with > 10 days with consumption of acute medications were permitted into the study) were randomized to receive either 2.5 ml 0.5% bupivacaine plus 0.5 ml (20 mg) methylprednisolone over the ipsilateral (unilateral headache) or bilateral (bilateral headache) ON or 2.75 ml normal saline plus 0.25 ml 1% lidocaine without epinephrine (placebo). Patients completed a one-month headache diary prior to and after the double-blind injection. The primary outcome measure was defined as a 50% or greater reduction in the frequency of days with moderate or severe migraine headache in the four-week post-injection compared to the four-week pre-injection baseline period. Results Thirty-four patients received active and 35 patients received placebo treatment. Because of missing data, the full analysis of 33 patients in the active and 30 patients in the placebo group was analyzed for efficacy. In the active and placebo groups respectively, the mean frequency of at least moderate (mean 9.8 versus 9.5) and severe (3.6 versus 4.3) migraine days and acute medication days (7.9 versus 10.0) were not substantially different at baseline. The percentage of patients with at least a 50% reduction in the frequency of moderate or severe headache days was 30% for both groups (10/30 vs nine of 30, Δ 0.00, 95% CI –0.22 to 0.23). Conclusions Greater ONB does not reduce the frequency of moderate to severe migraine days in patients with episodic or chronic migraine compared to placebo. The study was registered with ClinicalTrial.gov (NCT00915473).

Download Full-text

Allergy Associated with Severe Migraine-Like Headaches

Southern Medical Journal ◽

10.1097/00007611-196512000-00013 ◽

1965 ◽

Vol 58 (12) ◽

pp. 1542-1545

Author(s):

BERNARD M. ZUSSMAN

Keyword(s):

Severe Migraine

Download Full-text

A retrospective review of clopidogrel as primary therapy for migraineurs with right to left shunt lesions

Cephalalgia ◽

10.1177/0333102414523845 ◽

2014 ◽

Vol 34 (11) ◽

pp. 933-937 ◽

Cited By ~ 10

Author(s):

Barbara T Spencer ◽

Yasir Qureshi ◽

Robert J Sommer

Keyword(s):

Migraine Headache ◽

Primary Therapy ◽

Foramen Ovale ◽

Trial Period ◽

Complete Elimination ◽

Open Label ◽

Platelet Inhibitor ◽

Open Label Trial ◽

Severe Migraine ◽

Pfo Closure

Background: The association of patient foramen ovale (PFO) and migraine headache (migraine) with aura (MA) is well established. Current research suggests a mechanistic link between platelet activation, paradoxical embolization and migraine in some patients. Methods: Clopidogrel, a platelet inhibitor, was added to existing migraine therapy, as a 4-week open-label trial in 15 women, aged 16–56 years, with severe migraine and documented right to left shunt (RLS). Results: 13/15 had >50% reduction or complete elimination of migraine symptoms. After completing the trial period, five responders remain on clopidogrel with ongoing benefit at 11.9 ± 4.5 months (6.5–20), one stopped clopidogrel because of side effects. Nine other responders underwent PFO closure and clopidogrel discontinuation. Eight of nine have had ongoing benefit. Conclusions: Clopidogrel may have a primary prophylactic role in migraine/RLS patients, but may also help select candidates who would benefit from PFO closure. A randomized clinical trial is being established.

Download Full-text

Are the Triptans for Migraine Therapy Worth the Cost?

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/s0317167100052197 ◽

2000 ◽

Vol 27 (2) ◽

pp. 111-115 ◽

Cited By ~ 4

Author(s):

W.J. Becker

Keyword(s):

Quality Of Life ◽

Significant Proportion ◽

Cost Benefit ◽

New Drugs ◽

Major Advance ◽

Improve Quality ◽

Migraine Therapy ◽

The Cost ◽

Severe Migraine

ABSTRACT:The triptans represent a major advance in migraine therapy but their cost per dose greatly exceeds that of many older treatments. There is evidence that for a significant proportion of migraine patients these new drugs can show a positive cost benefit and also improve quality of life. Cost benefit would be expected to be greatest in patients with more severe migraine attacks.

Download Full-text

Oral lysine clonixinate in the acute treatment of migraine: a double-blind placebo-controlled study

Arquivos de Neuro-Psiquiatria ◽

10.1590/s0004-282x2001000100010 ◽

2001 ◽

Vol 59 (1) ◽

pp. 46-49 ◽

Cited By ~ 8

Author(s):

Abouch V. Krymchantowski ◽

Jackeline S. Barbosa ◽

Celia Cheim ◽

Luiz A. Alves

Keyword(s):

Placebo Group ◽

Acute Treatment ◽

Controlled Study ◽

Double Blind ◽

Double Blind Placebo ◽

Pain Syndromes ◽

Severe Intensity ◽

Ihs Criteria ◽

Lysine Clonixinate ◽

Severe Migraine

Several oral nonsteroidal anti-inflammatory drugs (NSAIDs) are effective to treat migraine attacks. Lysine clonixinate (LC) is a NSAID derived from nicotinic acid that has proven to be effective in various pain syndromes such as renal colic and muscular pain. The aim of this double-blind, placebo-controlled study was to evaluate the efficacy of oral LC compared to placebo in the acute treatment of migraine. Sixty four patients with the diagnosis of migraine, according to the IHS criteria, were studied prospectively. Patients received LC or placebo once the headache reached moderate or severe intensity for 6 consecutive attacks. With regard to the moderate attacks, LC was superior than placebo after 1, 2 and 4 hours. The consumption of other rescue medications after 4 hours was significantly higher in the placebo group. With regard to the severe attacks, there was no difference between the active drug group and the placebo group concerning headache intensity and consumption of other rescue medications. We conclude that the NSAID lysine clonixinate is effective in treating moderately severe migraine attacks. It is not superior than placebo in treating severe migraine attacks.

Download Full-text