Does Early Migraine Treatment Shorten Time to Headache Peak and Reduce Its Severity?

Objective.— To explore whether early treatment would shorten the duration of headache from headache onset to its peak and reduce headache severity at peak.
Background.— Prior clinical studies almost exclusively focused on headache relief after dosing. No data are available on whether early intervention affects the duration from headache onset to peak and headache severity at peak.
Methods.— Adult migraineurs were enrolled in this observational study from multi-site headache clinics. Patients recorded their migraine experiences via an electronic diary over 1 month. Patients reported the time and pain severity at onset, dosing, and peak. We used a linear mixed model to evaluate the impact of the timing of treatment and to adjust for covariates and correlation of observations within subjects.
Results.— A total of 182 patients reported 970 migraine episodes, 620 of which were treated before headaches progressed to peak. Mean time from headache onset to peak varied from 1.9 hours to 8.9 hours for patients treated within 15 minutes of onset and those who waited for 4 or more hours, respectively. However, early intervention was not associated with reduced headache severity at peak. In multivariate analysis, early treatment, use of triptans, and mild migraine headache in the past 3 months were significantly associated with shorter time from onset to headache peak. A separate model indicated that the timing of medication was not associated with the duration between dosing and headache peak, but use of triptans shortened the time from dosing to headache peak.
Conclusions.— Early treatment and use of triptans may lead to shorter duration from migraine headache onset to its peak but did not alleviate headache severity at peak. This could result in decreased migraine burden by reducing total migraine headache duration.     

Acute confusional migraine: Clinical and electroencephalographic aspects

Twelve patients with episodes of acute confusional migraine (ACM) are reported. Prolonged agitation and mental confusion characterized the headache attacks, occurring mostly among adolescents. The ictal EEG showed diffuse, slow abnormalities and a peculiar pattern known as FIRDA (frontal intermittent rhythmic delta activity). Neuroradiologic examinations and laboratory tests were unremarkable. After the acute stage, EEG gradually tended to show normalization. Apart from the noticeable similarities to the "juvenile head trauma syndrome", the authors assume that ACM represents a peculiar clinical form among the different types of migraine associated with disorders of higher mental functions.     

Rizatriptan 10-mg ODT for Early Treatment of Migraine and Impact of Migraine Education on Treatment Response

Objective.— To examine the efficacy of rizatriptan 10-mg orally disintegrating tablet (ODT) for treating migraines of mild intensity soon after onset, with or without patient-specific migraine education.
Background.— Studies have shown rizatriptan tablet efficacy in early migraine treatment.
Methods.— In this randomized, placebo-controlled, double-blind, factorial design study, adults with a history of migraine were assigned to rizatriptan 10-mg ODT ± patient education (personalized summary of early migraine signs and symptoms) or placebo ± patient education in a 1 : 1 : 1 : 1 ratio. Patients were instructed to treat 1 attack at the earliest time they knew that their headache was a migraine, while pain was mild. During the next 24 hours, patients assessed pain severity, associated symptoms, functional disability, use of rescue medication, and treatment satisfaction. The primary endpoint was pain freedom at 2 hours; a key secondary endpoint was 24-hour sustained pain freedom.
Results.— Of 207 patients randomized to treatment, 188 (91%) treated a study migraine. Significantly more patients taking rizatriptan reported pain freedom at 2 hours compared with placebo (66.3% vs 28.1%, P  < .001). Similarly, significantly more patients taking rizatriptan reported 24-hour sustained pain freedom (52.2% vs 17.7%, P  < .001). A greater proportion of patients in the rizatriptan + education group reported pain freedom at 2 hours compared with those in the rizatriptan + no education group (71.7% vs 60.9%, P  = .430). Few adverse events were reported.
Conclusion.— Rizatriptan 10-mg ODT, when taken early, while headache pain is mild, was superior to placebo at providing pain freedom at 2 hours and 24-hour sustained pain freedom (NCT00516737).     

The Course of Frequent Episodic Migraine in a Large Headache Clinic Population: A 12-Year Retrospective Follow-Up Study

Background.— Despite its high prevalence, little is known about the clinical course of migraine. Presented here are the findings of a 12-year follow-up study involving patients diagnosed at baseline with frequent episodic migraine.
Objective.— The main objectives were to determine the long-term outcome of patients with frequent episodic migraine and to identify factors predictive of a favorable vs less favorable prognosis.
Methods.— A total of 374 subjects (200 women, 174 men) were selected randomly from a total population of 2812 patients initially diagnosed before December 31, 1996, with episodic migraine and at baseline experiencing 1 to 6 attacks per month. Their subsequent migraine course was evaluated via telephone interviews conducted between 2005 and 2006.
Results.— Migraine attacks had ceased in 110 (29%) of the 374 patients (57 women and 53 men). The remaining 264 subjects continued to experience migraine attacks at follow-up, and a change in attack frequency was reported by 80% (of whom 80% reported fewer attacks). Sixty-six percent reported a change in pain intensity over time, and of these 83% reported milder pain. Only 6 subjects (6/374 = 1.6%) had developed chronic migraine.
Conclusion.— These data from a headache clinic population suggest that migraine has a favorable prognosis in most patients. Whether the findings reflect the natural history of the disorder or interval improvements in headache management remains conjectural.     

Seasonal Variation of Migraine in an Arctic Population

Objectives.— To investigate seasonal variation of migraine headache in a population residing in an extreme Arctic locale.
Background.— Exposure to light may trigger migraine attacks and patients may also be hypersensitive to light between the attacks. In previous studies of migraine in Northern latitudes we have demonstrated that patients with migraine experience more attacks in the summer. In order to confirm this finding and gain more insight into a possible north-south effect of seasonal migraine variation, we performed a population-based study in Svalbard, which is one of the northernmost populated areas of the world.
Method.— A postal questionnaire was mailed to all inhabitants aged 12 years or older living in Svalbard and the migraine diagnosis made by a structured telephone interview.
Results.— Of a total of 1569, 1029 (66%) returned the questionnaire. Of them, 184 (18%) experienced headache within the recent year prior to the study that could not be explained by alcohol, trauma, or viral infections. Eighty-eight individuals had migraine according to the revised criteria set by the International Headache Society. Nineteen (22%) reported seasonal variation of migraine. Ten (12%) experienced more migraine in the light season, while 9 (10%) got worse in the dark season. No differences in proportions of migraine with aura (MA) and migraine without aura (MO) could be detected. Also, the frequency of MA patients who used sunglasses to avoid migraine headache was nonstatistically increased compared with MO.
Conclusion.— There was no indication of more seasonal variation of headache in a population of otherwise healthy people with migraine living in an extreme Arctic area with long periods of midnight sun and polar nights with complete darkness. The strength of conclusion, however, is significantly limited by a low response rate and small sample size.     

Inpatient Treatment of Status Migraine With Dihydroergotamine in Children and Adolescents

Objective.— To assess the effectiveness of aggressive therapy of status migraine in children and adolescents.
Background.— Inpatient management of pediatric status migraine and intractable headache is limited because of a lack of studies and guidelines. Adult treatment is often based on anecdotal experience, although a few controlled studies have been reported. Added to that is the discomfort of general pediatricians and neurologists in using available effective treatments in pediatric patients (such as dihydroergotamine: DHE).
Methods.— Charts of all patients admitted to the neurology service, at Cincinnati Children's Hospital Medical Center—Department of Neurology, for inpatient treatment for intractable headache/status migraine over a 6-week period were reviewed. Demographics, evaluation, diagnosis, and treatment used were tabulated. Data on the effectiveness of the treatments provided were evaluated. Thirty-two total consecutive charts were retrospectively reviewed during that period.
Results.— Upon discharge, 74.4% of the patients were headache-free. The mean severity of the pain upon discharge was 1.02 ± 2.22 (using the 0-10 pain scale).
Conclusion.— From our review, DHE is very effective in treating and aborting an episode of status migraine and should be offered to children and adolescent patients who have failed their usual abortive therapy to prevent further severe disability that mainly affects their schooling and social activities.     

Disability associated with headaches occurring inside and outside the menstrual period in those with migraine: a general practice study

Objectives.—This study investigated the disability of females who have migraine and other headache attacks occurring during and outside the menstrual period.
Methods.—One thousand four hundred and thirty-four of 3470 female patients (41.3%) aged 14 to 50 years registered at a UK general practice completed two questionnaires. The first questionnaire assessed the prevalence of headache, depression, and bodily pain in the total population. The second questionnaire assessed the disability of all headaches over a 2-month period (to capture a complete menstrual cycle) for patients reporting migraine who were still menstruating. Disability was assessed as the time lost and time spent at less than 50% productivity in normal activities due to headache, and analyzed as rank sums using the Mann-Whitney U -test.
Results.—The first part of the study showed that the prevalence of headache (66.1%), depression (55.4%), and bodily pain (40.6%) were high in this population of women. Thirty migraine patients who were still menstruating reported 89 migraine and 114 nonmigraine headache episodes in the second part of the study. For migraine, the rank order of time at less than 50% productivity was greater for attacks taking place inside the menstrual period than for those occurring outside the menstrual period. The comparison was significant for time at less than 50% productivity ( P = .01). For nonmigraine headaches, the rank order of time lost was greater for attacks taking place outside the menstrual period than for those occurring inside the menstrual period. The comparison was not significant for time lost ( P = .06).
Conclusions.—For those with migraine, migraine attacks that took place during the menstrual period tended to be slightly more disabling than those taking place outside the menstrual period, but the opposite was true for nonmigraine headache.     

Expanding Access to Triptans: Assessment of Clinical Outcome

Objective.— To evaluate whether access to more liberal quantities of rizatriptan improves clinical outcome in patients with episodic migraine.
Background.— Currently many pharmacy benefit programs limit the number of triptan tablets/injections per month based on perceived cost savings and the belief that too-frequent use of triptans may lead to medication overuse headache and headache chronification.
Methods.— This observer-blind, randomized, parallel-group study enrolled 197 subjects with migraine with or without aura. Subjects completed a 3-month baseline period to establish migraine frequency and then were randomly assigned to receive 9 (formulary limit [FL]) or 27 (clinical limit [CL]) tablets of 10 mg rizatriptan orally disintegrating tablet (ODT) per month for 3 months. The primary endpoint was change in the mean number of migraine days from the baseline to treatment period.
Results.— There was no statistically significant difference between the FL and CL groups in mean number of migraine days (FL-CL LS mean: −0.08 [−0.39, 0.23]; P  = .613). Subjects in the CL group treated attacks at lower headache severity. No CL subjects were reported to have developed chronic migraine despite utilization of greater than 10 rizatriptan ODT tablets per month. Rizatriptan was generally well tolerated by both groups.
Conclusion.— Providing a greater quantity of rizatriptan ODT 10 mg did not reduce the number of migraine days compared with providing 9 tablets per month for this population with episodic migraine with a frequency of 3-8 migraines per month. Regardless of quantity provided, rizatriptan was generally well tolerated.     

How Well Do Headache Patients Remember? A Comparison of Self-Report Measures of Headache Frequency and Severity in Patients with Migraine

Objective.— To compare patient recall of migraine headache frequency and severity over 4 weeks prior to a return visit as reported in an interval questionnaire vs a daily diary.
Background.— Many therapeutic decisions in the management of migraine patients are based on patient recall of response to treatment. As consistent completion of a daily headache diary is problematic, we have assessed the reliability of patient recall in a 1-time questionnaire.
Methods.— Headache frequency and average severity (0 to 3-point scale) were reported in an interval questionnaire by 209 patients who had also maintained a daily diary over the same 4-week period.
Results.— Headache frequency over the previous 4 weeks as reported in interval questionnaires (14.7) was not different from that documented in diaries (15.1), P  = .056. However, reported average headache severity on a 0 to 3 scale as reported in the questionnaire (1.84) was worse than that documented in the diaries (1.63), P  < .001.
Conclusions.— In the management of individual patients, the daily diary is still preferable when available. Aggregate assessment of headache frequency in groups of patients based on recall of the prior 4 weeks is equally as reliable as a diary. Headache severity reported in questionnaires tends to be greater than that documented in daily diaries and may be less reliable.     

Exercise in Migraine Therapy—Is There Any Evidence for Efficacy? A Critical Review

Background.— Some migraine patients find that regular exercise helps in reducing the frequency of headache attacks. In addition, exercise in migraine is recommended from many headache experts. However, most of these recommendations refer to some anecdotal reports or observational studies in literature stating that regular exercise can reduce the frequency and severity of migraine.
Objective.— The purpose of this review is to investigate whether recommendations for exercise in migraine are based on sufficient data to cope with requirements of an evidence-based modern migraine therapy. The review summarizes and discusses all available trials on this topic.
Results.— Eight studies und 4 case reports investigated the therapeutic role of aerobic exercise on migraine headache. Some results are controversial regarding the efficacy of sports intervention in migraine. The majority of studies did not find a significant reduction of headache attacks or headache duration and only indicate a reduction of pain intensities in migraine patients due to regular exercise. The grade of recommendation of exercise in migraine based on evidence based medicine (EBM)-criteria is presently B-C. But due to methodological limitations, the available data are insufficient for a final statement on this topic.
Conclusions.— To further recommend exercise in migraine based on EBM-criteria, more studies are imperative. Future studies should adhere to the rules for randomized clinical trials in pharmacological migraines prophylaxis. Implications for further studies are given.