Epidemiology and Treatment of Menstrual Migraine and Migraine During Pregnancy and Lactation: A Narrative Review

The peak prevalence of migraine occurs in women of reproductive age, and women experience a higher burden of migraine symptoms and disability compared to men. This increased burden of migraine in women is related to both developmental and temporally variable activational effects of female sex hormones. Changing levels of female sex hormones affect the expression of migraine during pregnancy, and, to a lesser degree, lactation, and are the mechanism underlying menstrual migraine. This review describes the evidence for sex differences in the expression of migraine across the reproductive epoch; reviews the epidemiology of migraine during pregnancy, lactation, and menses; and summarizes the available evidence for safety and efficacy of acute treatments during pregnancy and lactation and for menstrual migraine. Areas of controversy in treatment of migraine during pregnancy, including the use of magnesium, triptans vs butalbital combination medications, and onabotulinum toxin, are also explored.     

偏头痛的临床特征与治疗

目的探讨偏头痛的临床特点、实验室检查及治疗.方法对267例偏头痛患者的临床表现、血流变、TCD、影像学改变及治疗方法进行分析.结果 (1)偏头痛发病率女性是男性的3.5倍;(2)高发年龄在26～53岁;(3)有阳性家族史的占54.6%;(4)头痈发作存在许多促发因素;(5)头TCD检查血流速度增快或减慢者占58.9%、脑电异常率19.6%、头CT发现第五脑室者23.4%;(6)不同程度的偏头痛需用不同类别的药物治疗.结论偏头痛有其遗传易感性、特定的促发因素、特征性的反复发作的临床表现,恰当的早期防治结合用药,可明显减少头痛的发作频度和程度.     

Migraine and Migraines of Specialists: Perceptions and Management

(Headache 2010;50:1115‐1125) Objectives.— To describe the perception of migraine by neurologists in France, to compare perceptions between neurologists who did and did not suffer from migraines and to describe treatments used for their own migraines. Background.— Patients with migraine are usually undertreated, as treatment guidelines are frequently not followed and, therefore, resulting treatment satisfaction is low. One reason for this may be inappropriate perceptions of physicians concerning the seriousness of the pathology and the need to treat. However, available information on physician perceptions of migraine is limited. Methods.— This was an observational, epidemiological survey conducted both in hospital‐ and community‐based neurologists in France. Participating neurologists completed an anonymous questionnaire which collected data on demographics, migraine status, and perceptions of migraine. Neurologists who considered themselves migraineurs also provided data on migraine impact, treatment and on treatment satisfaction. Distributions of responses to questions on migraine perceptions were compared between migraineur and nonmigraineur neurologists. Results.— The study included 368 neurologists, of whom 179 (48.6%) were migraineurs themselves. Some 92.3% of participants claimed to be very or quite interested in migraine. Migraine was considered a real illness by 96.5% of neurologists and to be very or quite disabling by 96.6%. Around half perceived migraine as a challenging condition to manage with respect to unrealistic patient expectations (46.2%), time‐consuming treatment (48.9%), and complications because of anxious or depressive comorbidity (59.9%) or medical nomadism (consulting multiple physicians for the same condition; 47.0%). No significant differences in any perception items were observed between migraineur and nonmigraineur neurologists. In total, 83.1% of neurologists were satisfied with acute headache treatments and 60.4% with prophylactic headache treatments. The most frequently reported treatments for neurologist's own migraines were nonsteroidal anti‐inflammatory drugs (used by 57.0%) and triptans (50.3%). Conclusions.— French neurologists are interested and concerned about migraine but find it challenging to treat. Migraine perceptions do not differ between neurologists who do and do not suffer from migraines themselves. Neurology training needs to prepare medical students adequately for the challenges of migraine treatment in terms of patient communication and psychiatric issues.     

Comparison of Contingent Negative Variation Between Migraine Interval and Migraine Attack Before and After Treatment With Sumatriptan

SYNOPSIS
We compared in a placebo controlled, double blind, cross-over within-subject design, the amplitude and area integral of contingent negative variation (CNV) using a 2 second interstimulus interval in migraine patients between attack and interval before and after treatment. The study was conducted on 14 female subjects suffering from migraine without aura. The measurements were performed in a balanced sequence at four different times on each patient, twice during the migraine interval and once in each of two migraine attacks. The CNV in the patients was measured first (baseline), then medication was administered on a double-blind basis with an auto-injector, using either 6 mg sumatriptan or a placebo solution. Thirty minutes after administration the CNV parameters were measured again and the changes between pre-and post-treatment were taken as dependent variables. CNV amplitude baseline readings did not differ significantly between the four conditions, Neither administration of placebo nor sumatriptan led to a significant change in CNV parameters independent of whether significant clinical improvement of migraine headache occurred or not. According to our findings CNV-mechanisms between attack and interval are not subject to short-term changes, even though a small, not significant tendency towards · decrease in CNV amplitude during migraine attacks appears to exist. Therefore, it can be assumed that changes in the systems which are depicted by CNV readings are not involved in initiating and terminating acute migraine attacks.     

Migraine Mimics

The symptoms of migraine are non‐specific and can be present in many other primary and secondary headache disorders, which are reviewed. Even experienced headache specialists may be challenged at times when diagnosing what appears to be first or worst, new type, migraine status, and chronic migraine.     

Migraine,Migraine Features,and Cardiovascular Disease

(Headache 2010;50:1031‐1040) Background.— Many studies support an association between migraine and cardiovascular disease (CVD). This association appears particularly in migraine with aura and is also modified by additional factors. Objective.— We sought to investigate whether the association between migraine and CVD in addition to aura status is affected by certain migraine features. Methods.— Cohort study among 27,840 women, participating in the Women's Health Study. We had detailed self‐reported information on migraine and migraine features among women with active migraine (migraine during the year prior to baseline). Incident CVD events were confirmed after medical record review. We used Cox proportional hazards models to evaluate the association between migraine and incident CVD. The results have been presented in part before. We ran additional analyses according to migraine features. Results.— At baseline, 5125 (18.4%) women reported history of migraine; 39.7% of the 3610 women with active migraine indicated aura. During a mean of 11.9 years of follow‐up, 708 CVD events occurred. Migraine with aura doubled the risk for CVD, ischemic stroke, and myocardial infarction. With regard to ischemic stroke, this association seemed stronger in the absence than in the presence of migraine features. This was most pronounced in the absence (hazard ratio = 3.27; 95% CI = 1.93‐5.51; P < .0001) than in the presence of nausea/vomiting (hazard ratio = 0.91; 95% CI = 0.43‐1.93; P = .80). In contrast, the association with myocardial infarction did not reveal a certain pattern. Conclusions.— These data suggest that the association between migraine with aura and ischemic stroke may differ by absence or presence of migraine features.     

Memantine in the Preventive Treatment of Refractory Migraine

Objectives.— To assess the efficacy and tolerability of memantine (MEM) in the preventive treatment of refractory migraine. Background.— Glutamate is of importance in migraine pathophysiology and may be related to progression from episodic to chronic mirgraine. Furthermore, individuals with chronic pain often report cognitive problems. MEM has the potential to address both issues, justifying this pilot study. Methods.— We included subjects with refractory migraine (episodic migraine with 8‐14 days of headache per month or transformed migraine, who had previously failed at least 2 trials of adequate preventive therapy). Other preventive drugs were allowed if the patient had been on a stable dose for more than 30 days. MEM dose ranged from 10 mg to 20 mg per day. The treatment phase lasted 3 months. The primary endpoint was number of days with headache at month 3. Cognitive performance was assessed with the trail making tests A and B (TMT‐A and B). Statistical analyses were performed on the intent‐to‐treat (ITT) population, using data subjected to the last observation carried forward algorithm. We also conducted per protocol analyses. Results.— In the ITT population (n = 28), monthly headache frequency was reduced from 21.8 days at baseline to 16.1 (P < .01) at 3 months. The mean number of days with severe pain was reduced from 7.8 to 3.2 at 3 months (P < .01). The mean disability scores were significantly reduced at 3 months, compared with baseline (36.6 vs 54.9, P < .01). There was a significant reduction in the time to complete TMT‐A at termination vs baseline (28.4 vs 23.2, P = .02) and also TMT‐B (70.1 vs 50.4, P = .04). Side effects were present in 37.5% of the patients; 5.5% dropped out the study because of poor tolerability. Most adverse events were mild. Conclusion.— This study offers preliminary evidence for the use of MEM in the prevention of refractory migraine. Double‐blind studies are now required.     

Neuromodulation for the Acute and Preventive Therapy of Migraine and Cluster Headache

Headache disorders are among the most common and disabling medical conditions worldwide. Pharmacologic acute and preventive treatments are often insufficient and poorly tolerated, and the majority of patients are unable to adhere to their migraine treatments due to these issues. With improvements in our understanding of migraine and cluster headache pathophysiology, neuromodulation devices have been developed as safe and effective acute and preventive treatment options. In this review, we focus on neuromodulation devices that have been studied for migraine and cluster headache, with special attention to those that have gained food and drug administration (FDA) clearance. We will also explore how these devices can be used in patients who might have limited pharmacologic options, including the elderly, children, and pregnant women.     

Sumatriptan - Nonresponders: A Survey in 366 Migraine Patients

Sumatriptan, notably after subcutaneous administration, is highly effective in the acute treatment of migraine in the majority of patients. The response is consistent within patients and over time. To determine risk factors for nonresponse to sumatriptan, we compared clinical characteristics. In responders and nonresponders and, within patients, between attacks with and without response. We found no differences at the strict level of significance (P<0.001 because of multiple comparisons), but only tendencies for differences (0.001相似文献   

Practice and Economics Cost Considerations in Headache Treatment Part 1: Prophylactic Migraine Treatment

Effective migraine treatment is clearly the most cost-effective in terms of both direct and indirect costs. Patient education, behavior changes, and prudent medication selection can minimize costs. Low-dose aspirin may reduce headache frequency. Among the antidepressant medications used, amitriptyine 25 mg, 3 qhs ($4.16/month) and doxepin 25 mg, 3 qhs ($10.50/month) remain the standard. Imipramine (25 mg, 3 qhs ($3.75/month) is very inexpensive and should replace nortriptyline 25 mg, 3 qhs ($64.29/month) as a second-line agent. The specific serotonin reuptake inhibitors are expensive and have no proven effect for migraine prevention.
Propranolol 80 mg bid ($7.80/month) is inexpensive and frequently a good choice among beta-blockers. Atenolol 100 mg qd ($27.50/month) is less expensive than long-acting propranolol 160 mg ($35.56/month) and nadolol 120 mg qd ($43.68/month) with equivalent effectiveness. It is thus recommended as the ong-acting beta-blocker of choice. Sustained-release preparations of verapamil 240 mg qd ($31.98/ month) are twice the cost and less well-absorbed than the standard preparation of 120 mg bid ($17.62/month).
Better information is needed concerning effectiveness and optimal dosing of some older low-cost medications in the preventive treatment of migraine.     

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).