Relief of acute migraine headache with intravenous oxytocin: report of two cases

We present 2 cases, one adult and one pediatric, of acute migraine headache promptly relieved by intravenous oxytocin. Both cases were typical flares of a chronic intermittent headache pattern with classic vascular symptoms. Pain relief in both cases was rapid and temporally related to oxytocin administration. Vascular headache pathophysiology and possible oxytocin mechanisms of action are discussed.     

Prediction of headache response in migraine treatment

Triptans are efficacious for the acute treatment of migraine attacks. Yet, defining a concentration-effect relation for these compounds is difficult as the dynamics of the migraine attack are not thoroughly understood. The objective of this investigation was to develop a disease model to predict measures of headache in randomized placebo-controlled clinical trials investigating oral sumatriptan as a paradigm compound. A hidden Markov model based on the states of response (no relief, relief, and pain free) and headache scores (observed variable) was used in conjunction with population pharmacokinetics. Model parameters were capable of predicting the course of headache relief, pain-free status and headache recurrence. It was shown that sumatriptan shortens mean transit times between states by up to 5 h. The potency of sumatriptan (EC(50)) was 9 ng/ml. These findings demonstrate the value of combining pharmacokinetic and efficacy information to model disease and characterize time-independent drug properties in a population of migraineurs.     

Antidepressants in the treatment of migraine headache

Antidepressants, particularly tricyclic antidepressants, have been a mainstay in the prophylactic therapy of migraine. The tricyclic antidepressants amitriptyline, nortriptyline, and doxepin have been the major agents for prophylactic treatment of migraine. These cause significant side effects in some patients. The high-affinity selective serotonin reuptake inhibitors and other newer antidepressants have been disappointing and much less effective in the treatment of migraine. In patients who are depressed with severe migraine, a tricyclic antidepressant may treat both conditions; however, the addition of a newer atypical antidepressant may be needed.     

Intranasal civamide for the acute treatment of migraine headache

The objective of this study was to investigate the safety and efficacy of intranasal civamide for the acute treatment of migraine headache with or without aura. Civamide is a vanilloid receptor agonist and neuronal calcium channel blocker that inhibits the neuronal release of excitatory neurotransmitters (e.g. calcitonin gene-related peptide (CGRP) and substance P (SP)) and depletes the neurones of the trigeminal plexus of their neurotransmitter content. Applied intranasally, the release of neurotransmitters to meningeal and dural blood vessels should be decreased, along with the resultant vasodilatation, plasma extravasation, and histamine/serotonin release. Subsequent migraine headache pain may also be diminished. Thirty-four patients were enrolled into a double-blind study of intranasal civamide, and randomized to receive a single dose of either 20 microg or 150 microg of civamide, for the treatment of a single migraine headache, with or without aura, of moderate to severe pain. At 2 h post-dose, 55.6% of patients treated with either dose had a decrease in pain severity, with 22.2% of patients being pain-free. At 4 h post-dose, 72.7% of patients treated with either dose had a decrease in pain severity, with 33.0% of patients being pain-free. Adverse events were similar for both dosages, with 91.2% of patients experiencing nasal burning and 44.1% of patients experiencing lacrimation. No systemic side-effects were observed. Based upon the results of this study, intranasal civamide may be effective in the acute treatment of migraine headache. Given civamide's proposed mechanism of action, intranasal civamide should be substantially more effective for prophylaxis than acute treatment of migraine. A study evaluating its efficacy in prophylaxis of migraine is currently planned.     

Hypnosis and biofeedback in the treatment of migraine headache

A study was made to explore the decta of subject-hypnotizability in response to 3 treatment procedures applied to 33 migraine headache sufferers. These treatment procedures included biofeedback training for hand-warming, biofeedback training for alpha enhancement, and training for self-hypnosis. The Hypnotic Induction Profile (HIP) of Spiegel & Bridger (1970) was given to each s to determine degree of hypnotizability and the MMF'I was administered to all 8s. All 3 treatment groups showed aigdicant reductions in headache rates and there were no gignificant differences between groups. Cutting acros treatment groups, high hypnotizable Ss (N = 15) showed significant reductions in headache rates when compared with low hypnotizable Ss (N = 13). There was no correlation between HIP scores and the hysteria scale of the MMPI.     

How to pick optimal acute treatment for migraine headache

Drug selection for the acute treatment of migraine is based on comorbid disorders, coexistent diseases, and the patient’s pain profile and specific needs and expectations. Patients should be instructed to tailor their treatment strategy to meet their specific needs by varying their medications according to pain intensity. This will aid in successful headache management, by increasing compliance and decreasing disability and cost.     

Pathophysiology of migraine headache

The underlying mechanism of migraine and pain has been unraveled recently with the advent of neuroimaging. In this article mechanism of migraine aura and the pain of migraine are discussed. In addition, interictal studies demonstrating hyperexcitability in migraine are reviewed.     

Aspirin is first-line treatment for migraine and episodic tension-type headache regardless of headache intensity

Objectives.— (1) To establish whether pre‐treatment headache intensity in migraine or episodic tension‐type headache (ETTH) predicts success or failure of treatment with aspirin; and (2) to reflect, accordingly, on the place of aspirin in the management of these disorders. Background.— Stepped care in migraine management uses symptomatic treatments as first‐line, reserving triptans for those in whom this proves ineffective. Stratified care chooses between symptomatic therapy and triptans as first‐line on an individual basis according to perceived illness severity. We questioned the 2 assumptions underpinning stratified care in migraine that greater illness severity: (1) reflects greater need; and (2) is a risk factor for failure of symptomatic treatment but not of triptans. Methods.— With regard to the first assumption, we developed a rhetorical argument that need for treatment is underpinned by expectation of benefit, not by illness severity. To address the second, we reviewed individual patient data from 6 clinical trials of aspirin 1000 mg in migraine (N = 2079; 1165 moderate headache, 914 severe) and one of aspirin 500 and 1000 mg in ETTH (N = 325; 180 moderate, 145 severe), relating outcome to pre‐treatment headache intensity. Results.— In migraine, for headache relief at 2 hours, a small (4.7%) and non‐significant risk difference (RD) in therapeutic gain favored moderate pain; for pain freedom at 2 hours, therapeutic gains were almost identical (RD: ?0.2%). In ETTH, for headache relief at 2 hours, RDs for both aspirin 500 mg (?4.2%) and aspirin 1000 mg (?9.7%) favored severe pain, although neither significantly; for pain freedom at 2 hours, RDs (?14.2 and ?3.6) again favored severe pain. Conclusion.— In neither migraine nor ETTH does pre‐treatment headache intensity predict success or failure of aspirin. This is not an arguable basis for stratified care in migraine. In both disorders, aspirin is first‐line treatment regardless of headache intensity.     

Pacing as a treatment modality in migraine and tension-type headache

Purpose: To review the pacing literature; describe the use of pacing in a specialty headache clinic; and provide client feedback regarding the effectiveness of pacing in headache self-management. Method: The evidence for this report was derived from a structured literature review, an established pacing intervention program for patients with headache, and patient self-report questionnaire. Results: There are frequent references to pacing in the chronic pain and rheumatic disease literature, but no universal definition and, until recently, few outcome studies. References to pacing in the headache literature are limited. For a small sub-group of clients at a specialty headache clinic (n?=?20), pacing principles taught by occupational therapists were reported to prevent increases in headache intensity (70%); decrease headache intensity (65%), and shorten the duration of a headache (40%). Additionally, 70% of respondents used pacing to prevent headache onset. Pacing was seen to contribute to increased quality of life, headache self-efficacy, function, and independence. There were a variety of opinions regarding the most helpful pacing components. The most frequently endorsed were identify and prioritize responsibilities; balance activity and rest; schedule regular rest breaks; and delegate or eliminate tasks. Conclusions: Pacing appears to play an important role in headache self-management. More pacing research is required in both headache and chronic pain populations.

Implications for Rehabilitation

• Migraine and tension-type headaches are associated with significant pain and disability.

• Overexertion and stress are commonly reported headache triggers.

• Activity pacing allows individuals with migraine and tension-type headache to self-regulate tasks and activities so they may manage physical exertion and mental stress levels.

• Pacing may help decrease headache intensity and duration, as well as increase quality of life, function, and self-efficacy.

     

Nitrous oxide for the treatment of acute migraine headache.

The objective of this study was to determine the efficacy of nitrous oxide in the therapy of acute migraine symptoms in emergency department (ED) patients. This was a prospective, randomized, double blind study of patients presenting to an ED. All eligible patients had a prior diagnosis and symptoms consistent with migraine headache and a normal neurological examination. Patients were randomized to receive either 50% nitrous oxide and 50% oxygen or 100% oxygen over 20 minutes. All patients completed a visual analog pain scale before and immediately after intervention. Initial pain scores and change in pain scores between the two groups were compared. There were 22 patients enrolled, 10 in the nitrous oxide group and 12 in the oxygen group. The groups were similar in age, gender, duration of headache, and initial pain scores. Pain scores decreased significantly in the nitrous oxide group (median change, 69 to 21 mm, P = .02). The oxygen group did not show significant change in pain scores (median change, 78.5 to 72, P = .09). Eighty percent of patients receiving nitrous oxide required no rescue medication at the completion of the intervention, compared with 17% of those receiving 100% oxygen (P = .008). Twenty minutes after termination of intervention, 60% of patients who had received nitrous oxide still required no rescue medication, compared with 8% of those who had received 100% oxygen (P = .02). Nitrous oxide shows efficacy in ED short-term treatment of acute migraine headache.