Treatment of Perimenstrual Migraine with Triptans: an Update

Pure menstrual migraine (PMM) and menstrually related migraine (MRM) are difficult challenges in migraine management. Triptans are a class of highly selective serotonin receptor agonists, which interfere with the pathogenesis of migraine and are effective in relieving the associated neurovegetative symptoms. In recent years triptans have been extensively proposed for the treatment of severe, disabling, and recurrent perimenstrual migraine attacks. This review summarizes the different levels of recommendations for the use of triptans in the treatment of perimenstrual migraine. This review is also intended to offer an updated reasonable guide to physicians treating perimenstrual migraine in daily practice.     

Short-lasting headache syndromes and treatment options

A number of primary headache syndromes are marked by their short duration of pain. Many of these syndromes have their own unique treatment, so they must be recognized by practicing physicians. In this article, a number of the shortlasting headache disorders are reviewed, including chronic paroxysmal hemicrania, SUNCT syndrome, hypnic headache, exploding head syndrome, primary stabbing headache, and cough headache.     

Chronic cluster headache: New and emerging treatment options

Cluster headache (CH) is a primary headache syndrome characterized by short-lasting unilateral head pain attacks accompanied by ipsilateral oculofacial autonomic phenomena. Approximately 20% of CH patients have the chronic form and need continuous medical care. In the chronic form, attacks continue unabated for years, often on a daily basis, resulting in severe debilitation. It is a common experience that drug treatments are able to control or prevent the attacks in approximately 80% of chronic CH patients. In the remaining 20% of chronic cases, drugs are ineffective. Until recently, the etiology of CH was poorly understood and this hampered the development of new therapies. However, we have now gained a much improved understanding of the peripheral and central mechanisms giving rise to the pain in CH and this has inspired the development of new treatment approaches, which, although still in the initial phases of validation, appear to be very promising. Among these, the novel approach based on hypothalamic deep brain stimulation is one of the most promising.     

Perimenstrual headaches: Unmet needs

The risk of migraine is increased among women during a 5-day perimenstrual window that starts 2 days before the onset of menses and continues through the first 3 days of menstruation. For some women with menstrual migraine, headaches that occur at this time are more severe, of longer duration, and more disabling. Although it is recognized that menstrual migraine requires specific management, there remain a number of unmet needs. In particular, comorbidity can result in women with menstrual migraine presenting to obstetrician/gynecologists or psychiatrists rather than primary care physicians or neurologists. Failure to diagnose menstrual migraine will lead to suboptimal management. Accurate diagnosis is insufficient unless it results in effective treatment strategies. Although effective and specific treatments for menstrual migraine have been developed, there is a need to define individual timing and duration of perimenstrual prophylaxis.     

Interventional treatment for cluster headache: A review of the options

There is no more severe pain than that sustained by a cluster headache sufferer. Surgical treatment of cluster headache should only be considered after a patient has exhausted all medical options or when a patient’s medical history precludes the use of typical cluster abortive and preventive medications. Once a cluster patient is deemed a medical failure only those who have strictly side-fixed headaches should be considered for surgery. Other criteria for cluster surgery include pain localizing to the ophthalmic division of the trigeminal nerve, a psychologically stable individual, and absence of addictive personality traits. To understand the rationale behind the surgical treatment strategies for cluster, one must have a general understanding of the anatomy of cluster pathogenesis. The most frequently used surgical techniques for cluster are directed toward the sensory trigeminal nerve and the cranial parasympathetic system.     

Comorbidity in Perimenstrual Migraine

Comorbidity may be defined as the association of two or more diseases in individuals at a frequency greater than that expected statistically by chance. Studying the co-occurrence of two disorders requires a careful statistical analysis before any clear conclusion on causality is reached. Many studies have looked for an association between migraine and many diseases, reporting several sometimes controversial comorbidities in migraine subjects. Although migraine is more common in women than in men, very few studies have analyzed the comorbidity of perimenstrual migraine, a migraine sub-type characterized by attacks of migraine without aura related to menstruation. We review the studies on migraine comorbidities, particularly migraine without aura in women.     

Perimenstrual Headache in Adolescence

Headaches are a common complaint of childhood with the majority of the recurrent headaches seen by medical practitioners representing migraine. The incidence increases throughout adolescents as both boys and girls go through puberty. At this same time the ratio between girls and boys with migraine starts to become evident. This most likely etiology of these observations is the biological effects of hormonal progression and the expression of menstrual-related migraine. This development has begun to be delineated and this review will report on some of the advances toward this understanding.     

Classification of Perimenstrual Headache: Clinical Relevance

Although more than 50% of women with migraine report an association between migraine and menstruation, menstruation has generally considered to be no more than one of a variety of different migraine triggers. In 2004, the second edition of the International Classification of Headache Disorders introduced specific diagnostic criteria for menstrual migraine. Results from research undertaken subsequently lend support to the clinical impression that menstrual migraine should be seen as a distinct clinical entity. This paper reviews the recent research and provides specific recommendations for consideration in future editions of the classification.     

Treatment options for paraphimosis

Paraphimosis is a frequently presented complaint in the emergency department. This review outlines the treatment options available for resolving this condition: manual reduction methods, osmotic methods, puncture and aspiration methods and treatments using sharp incision. The technique of penile block local anaesthesia is described. A technique sequence for treatment is suggested.     

Treatment options for insomnia

Complaints of insomnia, including reports of difficulty initiating and remaining asleep, are often reported to primary healthcare providers. Nurse practitioners must be prepared to screen patients for this common sleep disorder as well as understand the latest treatment options for optimal patient outcomes.     

Treatment options for insomnia

The frequency of sleep disruption and the degree to which insomnia significantly affects daytime function determine the need for evaluation and treatment. Physicians may initiate treatment of insomnia at an initial visit; for patients with a clear acute stressor such as grief, no further evaluation may be indicated. However, if insomnia is severe or long-lasting, a thorough evaluation to uncover coexisting medical, neurologic, or psychiatric illness is warranted. Treatment should begin with nonpharmacologic therapy, addressing sleep hygiene issues and exercise. There is good evidence supporting the effectiveness of cognitive behavior therapy. Exercise improves sleep as effectively as benzodiazepines in some studies and, given its other health benefits, is recommended for patients with insomnia. Hypnotics generally should be prescribed for short periods only, with the frequency and duration of use customized to each patient's circumstances. Routine use of over-the-counter drugs containing antihistamines should be discouraged. Alcohol has the potential for abuse and should not be used as a sleep aid. Opiates are valuable in pain-associated insomnia. Benzodiazepines are most useful for short-term treatment; however, long-term use may lead to adverse effects and withdrawal phenomena. The better safety profile of the newer-generation nonbenzodiazepines (i.e., zolpidem, zaleplon, eszopidone, and ramelteon) makes them better first-line choices for long-term treatment of chronic insomnia.     

Treatment of chronic daily headache

Patients with chronic daily headache (CDH) are difficult to treat. A combination of general measures and specific pharmacological treatments is necessary. When possible, pharmacological management should be planned on an outpatient basis. The general protocol should include abrupt discontinuation of the offending symptomatic medications, specific treatment for detoxification, daily nonsteroidal anti-inflammatory drugs (NSAIDs) for about 1 month, triptans only for moderate-severe headache, and prophylactic treatment. Either amitriptyline plus propranolol or valproic acid have been classically recommended for transformed migraine prophylaxis. Refractory patients can respond to a combination of a beta-blocker and valproic acid, possibly due to their complementary mechanisms of action. Recently, the new antiepileptic topiramate has been shown to be especially useful in this indication. At least one-third of patients, however, do not improve. Therefore, the best treatment of this incapacitating entity continues to be its prevention. Preventive measures should include: (1) public information concerning the risk of frequent self-treatment for headaches; (2) inform headache patients of the risk of analgesic overuse/rebound headache; (3) recommend NSAIDs and triptans as symptomatic medications; and (4) active use of preventive medications when headaches begin to increase in frequency.