Headache

The study aims to provide an updated assessment of the evidence for individual pharmacological therapies for acute migraine treatment. Pharmacological therapy is frequently required for acutely treating migraine attacks. The American Academy of Neurology Guidelines published in 2000 summarized the available evidence relating to the efficacy of acute migraine medications. This review, conducted by the members of the Guidelines Section of the American Headache Society, is an updated assessment of evidence for the migraine acute medications. A standardized literature search was performed to identify articles related to acute migraine treatment that were published between 1998 and 2013. The American Academy of Neurology Guidelines Development procedures were followed. Two authors reviewed each abstract resulting from the search and determined whether the full manuscript qualified for review. Two reviewers studied each qualifying full manuscript for its level of evidence. Level A evidence requires at least 2 Class I studies, and Level B evidence requires 1 Class I or 2 Class II studies. The specific medications – triptans (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan [oral, nasal spray, injectable, transcutaneous patch], zolmitriptan [oral and nasal spray]) and dihydroergotamine (nasal spray, inhaler) are effective (Level A). Ergotamine and other forms of dihydroergotamine are probably effective (Level B). Effective nonspecific medications include acetaminophen, nonsteroidal anti‐inflammatory drugs (aspirin, diclofenac, ibuprofen, and naproxen), opioids (butorphanol nasal spray), sumatriptan/naproxen, and the combination of acetaminophen/aspirin/caffeine (Level A). Ketoprofen, intravenous and intramuscular ketorolac, flurbiprofen, intravenous magnesium (in migraine with aura), and the combination of isometheptene compounds, codeine/acetaminophen and tramadol/acetaminophen are probably effective (Level B). The antiemetics prochlorperazine, droperidol, chlorpromazine, and metoclopramide are probably effective (Level B). There is inadequate evidence for butalbital and butalbital combinations, phenazone, intravenous tramadol, methadone, butorphanol or meperidine injections, intranasal lidocaine, and corticosteroids, including dexamethasone (Level C). Octreotide is probably not effective (Level B). There is inadequate evidence to refute the efficacy of ketorolac nasal spray, intravenous acetaminophen, chlorpromazine injection, and intravenous granisetron (Level C). There are many acute migraine treatments for which evidence supports efficacy. Clinicians must consider medication efficacy, potential side effects, and potential medication‐related adverse events when prescribing acute medications for migraine. Although opioids, such as butorphanol, codeine/acetaminophen, and tramadol/acetaminophen, are probably effective, they are not recommended for regular use.

Background.—Health care providers frequently cite concerns about cardiovascular safety of the triptans as a barrier to their use. In 2002, the American Headache Society convened the Triptan Cardiovascular Safety Expert Panel to evaluate the evidence on triptan‐associated cardiovascular risk and to formulate consensus recommendations for making informed decisions for their use in patients with migraine.

Objective.—To summarize the evidence reviewed by the Triptan Cardiovascular Safety Expert Panel and their recommendations for the use of triptans in clinical practice.

Participants.—The Triptan Cardiovascular Safety Expert Panel was composed of a multidisciplinary group of experts in neurology, primary care, cardiology, pharmacology, women's health, and epidemiology.

Evidence and Consensus Process.—An exhaustive search of the relevant published literature was reviewed by each panel member in preparation for an open roundtable meeting. Pertinent issues (eg, cardiovascular pharmacology of triptans, epidemiology of cardiovascular disease, cardiovascular risk assessment, migraine) were presented as a prelude to group discussion and formulation of consensus conclusions and recommendations. Follow‐up meetings were held by telephone.

Conclusions.—(1) Most of the data on triptans are derived from patients without known coronary artery disease. (2) Chest symptoms occurring during use of triptans are generally nonserious and are not explained by ischemia. (3) The incidence of serious cardiovascular events with triptans in both clinical trials and clinical practice appears to be extremely low. (4) The cardiovascular risk‐benefit profile of triptans favors their use in the absence of contraindications.

(Headache 2010;50:1144‐1152)

Post‐dural puncture headache (PDPH) is a frequent complication of dural puncture whether performed for diagnostic purposes or accidentally, as a complication of anesthesia. Because both procedures are common, clinicians interested in headache should be familiar with this entity. The differential diagnosis of PDPH is broad and includes other complications of dural puncture as well as headaches attributable to the condition which lead to the procedure. The patterns of development of PDPH depend on a number of procedure‐ and nonprocedure‐related risk factors. Knowledge of procedure‐related factors supports interventions designed to reduce the incidence of PDPH. Finally, despite best preventive efforts, PDPH may still occur and be associated with significant morbidity. Therefore, it is important to know the management and prognosis of this disorder. In this review, we will highlight diagnosis and clinical characteristics of PDPH, differential diagnosis, frequency, and risk factors as well as pathophysiology of PDPH.

Objectives.—To determine prevalence and characteristics of migraine in Japan, and to investigate use of medical care and whether food preference is associated with risk of migraine.

Methods.—Structured questionnaires were given to all adult residents (N = 5758; 2681 men and 3077 women) in Daisen, a rural community in western Japan. Second questionnaires, specific to headache, were given to 1628 residents with headache. A telephone survey was also carried out. Statistical Packages for the Social Sciences analyzed the data.

Results.—The 1‐year prevalence of migraine was 2.3% (migraine with aura, 0.4% and without aura, 1.9%) in men and 9.1% (migraine with aura, 1.0% and migraine without aura, 8.1%) in women. Overall prevalence of migraine in Daisen was 6.0% (95% confidence interval [CI], 5.4% to 6.6%). Women observed a 5.9‐fold higher risk of migraine than men (odds ratio, 5.9; 95% CI, 4.5 to 8.0; P < .0001, after age adjustment, by logistic analysis). Fatigue and loss of vigor were predominant premonitory symptoms of migraine. Fatigue, mental stress, and lack of sleep were the main headache triggers. Over a 3‐month period, 20.3% of migraineurs experienced time or days off work due to headache. Only 7.3% of those with migraine with aura and 5.3% of those with migraine without aura had consulted a physician, and of those with migraine, 61.0% with aura and 71.8% without aura had never visited a medical doctor for their headache.

Consumption of alcohol and cigarette smoking did not influence the risk for migraine or tension‐type headache, after age and gender adjustment (logistic analysis).

Migraineurs consume significantly more fatty/oily foods, coffee, and tea than nonheadache subjects of the same community. Migraineurs consume significantly fewer fish than nonheadache residents.

Conclusions.—Only a few Japanese migraineurs receive benefits of medical services and recent advances of headache medicine. Public education concerning headaches is one of the most urgent issues in Japan.

SYNOPSIS

Muscle contraction headache and migraine patients were compared for symptoms of muscular and vascular activity, and responsiveness to frontalis electromyogram (EMG) biofeedback therapy. Locations of head pain were non‐specific to the diagnostic groups. Migraine patients had higher frontalis EMG activity than muscle contraction headache patients and headache‐free controls. Both headache groups had higher neck EMG activity than controls. Pulse velocities in the superficial temporal arteries were similar in the two headache patient groups but different from controls. It is suggested that muscle contraction headache and migraine patients have similar physiologic predisposition for headaches. Further support for similar predisposition in the two groups was provided by the frontalis EMG biofeedback results which showed this treatment to be equally effective for both groups.

A disturbance in the region of the head can provoke pain in the distribution of the trigeminal and upper cervical nerves due to a convergence of the afferent fibers of the three superior cervical roots on the neurones of the spiral nucleus of the trigeminal nerve. The therapeutic value of greater occipital and supraorbital nerve blockade in 27 patients with migraine, unresponsive to several combinations of pharmacological treatments, was investigated. Patients were given repeated anesthetic blocks, on alternate days, up to a maximum of 10 blocks. Perineural injections of 0.5 to 1.0 mL of 0.5% bupivacaine were given at the epicranial emergence points of the above nerves in relation to the distribution of the cephalic pain only if such nerves were conspicuously pain sensitive to pressure. Clinical evaluation was determined by a monthly Total Pain Index and recording of the number of migraine attacks and analgesic consumption each month. A patient was considered responsive when the Total Pain Index decreased by 50% or more in the first month after treatment. Twenty‐three patients (85%) responded beneficially and maintained a favorable response for the 6‐month period of observation. The treatment was considered to be of long‐lasting effectiveness and without any side effects. Four patients (15%) were unresponsive to treatment.

We hypothesize that the anesthetic blocks extinguished presumed foci of nociceptor discharges maintained by perivascular neurogenic inflammation, thereby reestablishing normal central neurone sensitivity.

In conclusion, blockade of the supraorbital and greater occipital nerves appears to be effective in the treatment of migraine; however, controlled studies are needed to confirm these preliminary findings.