New Approaches to Shifting the Migraine Treatment Paradigm.

The standard of care paradigm for migraine treatment has been based almost exclusively on approaches that grew out of the happenstance use of market pharmaceuticals. Only methysergide, which has long since been removed from use for safety concerns, the ergotamine family of drugs, and the triptans were explicitly developed with migraine and other vascular headaches in mind. While the forward and innovative thinking to utilize the broad array of agents to treat migraine served millions well, their therapeutic efficacy was often low, and adverse event profiles were troublesome in the least.

Medical management of adult headache.

We review the therapies for primary headache disorders: migraine, chronic migraine, tension-type headache, and cluster headache. Recommendations follow the evidence-based treatments so far as is possible with expert opinion to give clinical guidance. Headache has 2 levels of care: acute treatments designed to stop a headache from progressing and alleviate all symptoms associated with the headache and preventive therapies for patients whose headache frequency is such that by itself produces significant disability and impact on quality of life, or where the frequency of use of acute medications, regardless of efficacy, poses risks in terms of overuse or adverse events.

Migraine disability, healthcare utilization, and expenditures following treatment in a tertiary headache center.

Headache is among the most common disabling pain complaints. While many patients are managed in primary care or referral neurology practices, some patients have refractive situations that necessitate referral to a tertiary headache center. Increasing frequency of headache is strongly associated with increasing disability and workplace absenteeism as well as increased healthcare utilization.

A review of needle-free sumatriptan injection for rapid control of migraine.

The treatment of migraine was transformed in 1992 with the introduction of the first triptan-based therapy, subcutaneous (SC) sumatriptan. SC sumatriptan has high efficacy and a rapid onset of action compared with other available triptans and formulations presumably because of its short Tmax, high Cmax, and avoidance of enteral absorption. Because of these characteristics, SC sumatriptan is still considered the most reliably and rapidly effective self-administered medication available for acute migraine.

Sumatriptan needle-free subcutaneous (Sumavel(®) DosePro™) approved for the acute treatment of migraine, with or without aura, and cluster headaches.

Sumatriptan subcutaneous administration is the fastest and most effective of the triptans for relief of acute migraine headache. This occurs even when the patient has already developed symptoms related to central sensitization, a key parameter in determining the effectiveness of these agents. In patients whose migraine attacks have historically failed to respond to oral triptans, this route of administration has also proven to be more consistent and effective.

Allodynia-associated symptoms, pain intensity and time to treatment: predicting treatment response in acute migraine intervention.

Objective: To evaluate the relationship between treatment outcomes and allodynia-associated symptoms (AAS) at the time of treatment with almotriptan.

Methods: Analyses were performed with data collected prospectively from patients in 2 recently completed early intervention trials, AXERT Early miGraine Intervention Study (AEGIS) and AXERT 12.5 mg time vs Intensity Migraine Study (AIMS): 2-hour pain free, 2-hour pain relief (AEGIS only), sustained pain free (SPF), use of rescue medication, and median headache duration (AIMS only), in the presence and absence of pretreatment AAS, which was determined by responses to a questionnaire.

Pharmacoeconomic benefits of almotriptan in the acute treatment of migraine.

Almotriptan is one of seven oral triptans available in the USA and much of the rest of the world. Reviews of its efficacy and tolerability demonstrate it to be among the most effective and well tolerated of this class. Studies of almotriptan in a variety of early intervention paradigms demonstrate significant improvements in efficacy and further improved tolerability compared with standard treatment of headaches of at least moderate severity.

Botulinum Toxin Type A in the treatment of chronic migraine without medication overuse.

Introduction: Chronic migraine is a recent diagnostic term that has undergone evolution from its original description. Clinically it has been believed that medication overuse contributed to its development and would block attempts at prevention. Previous studies with Botulinum Toxin Type A have demonstrated that it is effective even in patients with medication overuse.

The cycle of migraine: patients' quality of life during and between migraine attacks.

Background: Despite advances in therapy, the prevalence of migraine has remained constant over the past 17 years. The current diagnostic procedure for migraine does not take into account the entire cycle of migraine, which includes both the pain of the acute attack and the worry between attacks.

Objectives: This review discusses the effects of migraine on health-related quality of life.

Effect of pain intensity and time to administration on responsiveness to almotriptan: results from AXERT 12.5 mg Time Versus Intensity Migraine Study (AIMS).

Objective: To determine whether time-based early treatment, independent of pain intensity, is superior to a pain intensity-based treatment, where patients are asked to treat at least moderate intensity headaches, resulting in a reduction of overall migraine headache duration.

Background: Retrospective and prospective trials have reported improved outcomes when triptans were used early or to treat mild migraine headache pain. However, tolerability as well as efficacy may be 2 of several key issues that have prevented this new treatment paradigm from becoming universally accepted.

Efficacy and safety of topiramate for the treatment of chronic migraine: a randomized, double-blind, placebo-controlled trial.

Objective: To evaluate the efficacy and safety of topiramate (100 mg/day) compared with placebo for the treatment of chronic migraine.

Methods: This was a randomized, placebo-controlled, parallel-group, multicenter study consisting of 16 weeks of double-blind treatment. Subjects aged 18 to 65 years with 15 or more headache days per month, at least half of which were migraine/migrainous headaches, were randomized 1:1 to either topiramate 100 mg/day or placebo.

Oral sumatriptan for the acute treatment of probable migraine: first randomized, controlled study.

Objective: To evaluate the efficacy and tolerability of sumatriptan tablets in adults who meet International Headache Society (IHS) criteria for probable migraine but who do not meet IHS criteria for migraine with or without aura.

Background: Headaches with some but not all of the features of migraine meet criteria for probable migraine, a form of migraine recognized by the IHS. Probable migraine attacks are also prevalent and frequently underdiagnosed.

Tramadol/acetaminophen for the treatment of acute migraine pain: findings of a randomized, placebo-controlled trial.

Objective: To compare tramadol/acetaminophen (APAP) and placebo for the management of acute migraine pain.

Background: Tramadol/APAP tablets reduced moderate-to-moderately severe acute pain in controlled studies of other painful conditions.

Methods: This randomized, double-blind, placebo-controlled, parallel group study enrolled adults with migraine pain as per International Headache Society criteria.

Pain-free rates with zolmitriptan 2.5 mg ODT in the acute treatment of migraine: results of a large double-blind placebo- controlled trial.

Context: Zolmitriptan 2.5 mg orally disintegrating tablets (ODT) allow patients to take the medication without fluids, which is convenient and avoids the risk of fluid-induced exacerbation of nausea/vomiting.

Objective: To evaluate the efficacy and tolerability of zolmitriptan 2.

Cluster headache.

Cluster headache is a relatively rare episodic headache disorder.Although traditionally it is believed to be a male-related disorder,the sex ratios are changing toward a more even balance. The disorder is characterized by bouts of daily headaches with pain-free remissions for extended times.

Inpatient treatment of headache: an evidence-based assessment.

Objective: To evaluate inpatient treatment of headache in the United States.

Participants: Participants were selected by the meeting chairpersons, Drs. Diamond and Silberstein as well as Dr.

Divalproex in the treatment of migraine.

Valproic acid has been used in the treatment of migraine headache for nearly 20 years. During this period of use several additional delivery modes have been developed to either improve tolerability or patient compliance with the divalproex sodium formulation and the extended-release formulation of divalproex sodium. Additionally, an intravenous formulation has become available which permits rapid achievement of therapeutic levels of the drug.