Migraine Abortive Treatment in Children and Adolescents in Israel

Migraine headaches in children may cause attacks that require abortive treatment. This study evaluated the incidence and efficacy of medications used for relieving migraine headache attacks in the pediatric population in Israel. Children 6–18 years of age who were diagnosed in our pediatric neurology clinic as having migraine headaches were enrolled into the study. Children and their parents recorded the children response to abortive treatment during three consecutive migraine attacks. Fifty children, with 116 migraine attacks, were included in the study (30 females; mean age 12; range 6–18). Forty-seven (94%) reported on abortive treatment on the first migraine attack, 43 (86%) on a second migraine attack and 26 (52%) on a third migraine attack. During the first recorded migraine attack, 41 children (87.5%) reported taking only one type of medication for each headache episode, mainly ibuprofen or acetaminophen; less than a quarter used dipyrone. The improvement rate after two hours was 65.4%±27 for ibuprofen, 59.8±35.3 for acetaminophen and 50.9±27.4 for dipyrone. In conclusion, Children with migraine in Israel mainly use a single medication for each headache episode. Ibuprofen is the most commonly used abortive treatment; however, acetaminophen was associated with a better response.

COMPLICATED MIGRAINE

Migraine is a chronic paroxysmal neurological disease characterized by attacks of moderate or severe headache accompanied by reversible neurologic and systemic symptoms. Although not life threatening, migraine can cause disability in the productive population. Migraine sufferers generally have a family history of migraine so that migraine is considered a genetic disease. Endogenous psychological factors such as stress or fatigue are the main triggers for migraine. Migraine pathophysiology involves various parts of the brain so that migraine symptoms are complex. Management of acute migraine can be done pharmacologically and non-pharmacologically. Migraine preventive management is needed if the patient has a chronic migraine or does not respond to abortive treatment.

Gepants, calcitonin gene-related peptide antagonists, for abortive treatment of migraine: current status

Migraine is a neurovascular disorder characterized by unilateral, recurrent, pulsating, throbbing, and moderate to severe headache. Triptans use is often limited by their poor efficacy, reports of poor responders, and contraindicated in patients with cardiovascular disorders. Calcitonin gene-related peptide (CGRP), a neuropeptide, regulates vascular tonicity as well as potent pain mediator, and both the mechanisms involved in development of migraine headache. Gepants are non-peptide, small molecules, highly selective, and potent CGRP antagonists. These novel drugs have been approved for abortive treatment of acute migraine with or without aura. These are being evaluated for their effectiveness and showing promising results in the prevention of migraine. Gepants do not have vasoconstrictive properties, are safe to use in patients with cardiovascular risk, and best alternative to triptan therapy. These are available in tablet, orally disintegrating tablet, and nasal forms to improve patient compliance. Ubrogepant and rimegepant are the two oral CGRP antagonists approved whereas atogepant and zavegepant are at late stage of development for approval.

Assessment of Alteration of Serum Adiponectin Levels in Migraineurs: An Interventional Case Control Study

Background and Objectives: Migraine is one of the major headache disorders. Epidemiological studies have shown its high prevalence and negative impact on personal and socioeconomic aspects. It is currently ranked 19th by the “World Health Organization” amongst all diseases, leading to disability worldwide. Inflammatory mediators, which include adipokines, have been analyzed in migraine pathophysiology. Nevertheless, their role is not well recognized. This study is aimed to assess serum high molecular weight adiponectin (HMW-ADP) levels in migraineurs: during the ictal phase, prior to, and postabortive treatment. Methods: This was a hospital-based interventional case-controlled study, checking the peripheral blood samples from migraineurs during an acute attack and after one hour of treatment with naproxen sodium (10–15 mg/kg). Age, sex, and BMI matched controls without headache were taken, and a single blood sample was drawn in them. HMW-ADP levels were evaluated by immunoassays. Results: A total of 120 patients which included 60 migraine patients along with 60 controls without headache were involved in the study. HMW-ADP was higher in migraine patients (9.89 ± 5.04 mcg/mL) than in patients without headache history (4.63 ± 2.98 mcg/mL; P = < .001); along with this, serum HMW-ADP (6.4 ± 4.09 mcg/mL; P = <.001) was found to be significantly lower in responders 60 min after acute abortive treatment. Conclusion: HMW-ADP levels were raised in migraineurs. Additionally, among responders following abortive treatment a considerable reduction in the levels was noted. These results recommend that the HMW-ADP might be a possible “novel biomarker of acute remedy response in acute migraineurs”.

Repetitive transcranial magnetic stimulation as a prophylactic treatment in migraine

Background Clinical applications of transcranial magnetic stimulation (TMS) have shown promising results in the treatment of headache disorders, with migraine being one of the most encountered. Objective To assess the role of low-frequency repetitive transcranial magnetic stimulation as a preventive treatment of migraine (with and without aura) and correlate the results with the serum level of the inflammatory biomarker (neurokinin A). Methods Forty patients, with age ranging from 15 to 55 years, diagnosed with migraine (30 migraine without aura and 10 with aura) and 20 apparently healthy individuals, who were age and sex matched with the patient group, were included in this study. A low-frequency (1 Hz) rTMS protocol was applied for all patients for five consecutive days interictally. Assessment of pain intensity using visual analogue scale and frequency and duration of attacks as well as number of pills taken by patients as an abortive treatment according to the Basic Diagnostic Headache Diary for 4 weeks before and 4 weeks after TMS sessions was done. In addition, the Migraine Disability Assessment scale (MIDAS) was applied to assess the severity and degree of disability caused by migraine. Measurement of neurokinin A serum level was done by using ELISA for all patients before and after TMS and for control group once. Results There was a significant reduction in pain intensity, frequency and duration of migraine attacks, migraine disability scores, and number of pills taken as abortive treatment for attacks after rTMS (P < 0.001). Also, serum level of neurokinin A in the patients was significantly reduced after rTMS (P < 0.001). Conclusion Low-frequency rTMS is an effective prophylactic treatment for migraine with and without aura.

Migraine Prophylaxis Using Novel Monoclonal Antibody Injections in a Commercial Pilot

BACKGROUND: Frequent migraine headaches are disabling and aeromedically disqualifying. Four new monoclonal antibody medications, targeting calcitonin gene-related peptide (CGRP), have been approved by the U.S. Food and Drug Administration (FDA) since 2018, with more expected in the coming years. These medications present new alternatives for the treatment of migraine unresponsive to other therapeutic and prophylactic agents.CASE REPORT: We present a case of a 45-yr-old commercial pilot who presented with migraine headaches increasing in frequency to 1315 per month in spite of the use of propranolol for prophylaxis and sumatriptan for abortive treatment of the headaches. Upon presentation, he was not flying due to his frequent headaches and he was started on monthly subcutaneous injections of fremanezumab. Following his second injection, his headaches stopped entirely, and he has continued on the medication and not experienced another migraine headache. He underwent an aeromedical neurology evaluation and consideration for Authorization of Special Issuance of Medical Certificate, which was granted by the Federal Aviation Administration (FAA).DISCUSSION: This is the first case to our knowledge of the successful use of an anti-CGRP monoclonal antibody medication in an active pilot. The pilot appears to be a super responder to the medication, having achieved complete remission of a nearly life-long condition. Though only a small portion of treated individuals will see this sort of response, these medications represent an effective additional option for migraine prophylaxis in the pilot population.Garber MA, Sirven JI, Roth RS, Hemphill JM. Migraine prophylaxis using novel monoclonal antibody injections in a commercial pilot. Aerosp Med Hum Perform. 2020; 91(10):824825.

Cluster headache beyond the pain phase

ObjectiveTo describe the nature, prevalence, and duration of symptoms in the preictal, ictal, and postictal phases of cluster headache (CH) attacks.MethodsFifty-seven patients with episodic or chronic CH participated in this prospective, observational study. In a questionnaire concerning 33 CH and migraine-related symptoms, patients reported the clinical features of up to 10 CH attacks/patient. The questionnaire was divided into 3 sections: a preictal phase, ictal phase, and postictal phase. For each phase, patients documented whether the given symptom was present, and if possible estimated the duration of the symptom.ResultsIn total, 500 CH attack descriptions were obtained. In the preictal phase, general symptoms (most frequently concentration difficulties, restlessness, and mood changes) occurred 20 minutes prior to 46.0% of attacks. Local painful and autonomic symptoms were observed 10 minutes prior to 54.6% and 35% of attacks, respectively. Postictally, pain and autonomic symptoms resolved over 20 minutes, leaving patients with fatigue (36.2%), decreased energy (39.0%), and concentration difficulties (27.6%), lasting a median of 60 minutes.ConclusionsPreictal and postictal symptoms are very frequent in CH, demonstrating that CH attacks are not composed of a pain phase alone. Since the origin of CH attacks is unresolved, studies of preictal and postictal symptoms could contribute to the understanding of CH pathophysiology and, potentially, early, abortive treatment strategies.