MigraineNews.co.uk

Here’s a checklist related to pregnancy and migraine:

1. Up to 80% report improvement of migraine in later pregnancy (after 13 weeks)
2. Worsening of migraine can occur in early pregnancy, and may be associated with vomiting of pregnancy
3. A first migraine often occurs in the weeks after delivery, but a new onset severe headache just after delivery should be assessed by your midwife or doctor
4. About 50% of women will have a migraine return in the month after delivery
5. YOU CANNOT USE TRIPTAN DRUGS IF YOU ARE PREGNANT
6. The preventative drugs sodium valproate and topiramate should not be used if planning a baby or in early pregnancy as they are associated with an increased risk of birth defects

Some medicines can be used in pregnancy, but only after consulting your doctor. There are others but I do not want to post as they should be discussed with your doctor and this site is not a substitute for medical care, it is an information service only.

7. Aspirin (painkiller)
8. Paracetamol (painkiller)
9. Cyclizine (anti-sickness)
10. Propranolol in some circumstances, but may reduce blood flow to the womb or reduce baby’s blood sugar if used close to delivery

The main thing is that you have a good routine and look after yourself - old fashioned advice - remember that the following will help prevent migraine:

1. A good sleep pattern
2. Keep hydrated - a cup of water every hour while awake
3. Regular exercise, like walking 2-3 miles three times per week
4. Avoiding obesity, and keeping weight down (difficult when you are pregnant I accept )
5. Stress avoidance and biofeedback

Good luck with your pregnancy.

There is now a large and increasing range of medicines for treating a migraine attack.

Consider this list for which there is pretty sound scientific evidence for using these as migraine treatments:

1. Aspirin
2. Ibuprofen or tolfenamic acid

These drugs are from a group that get called NSAIDS (Non-Steroidal Anti-Inflammatory Drugs). They are powerful anti-inflammatory drugs - as most pain is caused by the chemical process of inflammation they are usually used as painkillers.

3. Anti-emetics
• Metoclopramide
• Prochlorperazine
• Buclizine
4. Triptans
• Almotriptan
• Eelitriptan
• Frovatriptan
• Naratriptan
• Rizatriptan
• Sumatriptan
• Zolmitriptan

There is probably not a whole lot to choose between these anti-migraine drugs. Some can be given as injection, nasal spray, a wafer that melts on the tongue or a tablet to swallow.

That’s a long list, so how do you choose which medicine to treat migraine? If your migraine is not that severe, you could easily get away without a triptan (and GPs often worry that these drugs are too expensive to use regularly - which is a fair comment if there are cheaper alternatives). However, there is some evidence that for more severe migraine episodes (one’s that really make you lose out on a days activity as you have had to take to bed), that triptans should be considered.

The final choice of migraine treatment will mostly be determined by any pre-existing medical conditions. For example, heart disease or pregnancy means that triptans are not suitable. Asthma may restrict use of certain NSAIDS.

My own choice (I am originally Scottish so a cheap drug is always preferable), for my own migraine - chew 3 x 300mg aspirin tablets and allow them to be absorbed from the mouth (your cheek and floor mouth can absorb aspirin rapidly). Then wash down the bitter taste with some water. The trials of aspirin suggest that a 50-60% chance of pain relief can be expected. The main reason not to take aspirin is that you have stomach or duodenal ulceration, and if heart burn develops you should stop using aspirin to treat your migraine headache.

About 5% of people will experience headaches when they travel by plane. This headache has been called “Flight-Associated-Headache”.

A recent paper from Dr Potasman on headache associated with air travel has studied these people. It will come as no surprise that people with a previous history of headache, that’s usually those people with migraine, were twice as likely to experience flight-associated headache, than those without a previous history of headache.

When the headaches that happened during flight were studied in more detail, about 20% were diagnosed as migraine headaches.

The other headaches were not migraine, and the researchers said that low oxygen levels in the cabin, poor quality of recirculated air or changes in air pressure in the sinuses may have contributed to other headaches.

The researchers do not give any specific preventative advice, but if you have migraine and are going to be flying, it may be worth carrying rescue treatment with you - you have a fair chance of experiencing a headache when you fly.

For the airline industry - they may wish to take note - 20% of airline passengers is an awful lot of people who are experiencing migraine or other pain after spending a lot of money on a plane ticket. The first airline to offer a reduction in headache risk will become very popular!

The preferred rescue treatments for migraine are (as you may know):

1. Aspirin or Ibuprofen or Naproxen or Tolfenamic Acid
2. Anti-emetics such as prochlorperazine or buclizine
3. Triptans - such as Imigran (Imitrex), Zomig

Remember that prevention is better than cure - I can’t repeat the seven simple steps to control migraine enough - the better you look after yourself, the less migraine you will experience.

Does regular exercise help reduce migraine headaches?

The answer is a probable yes.

Here is the evidence from the medical literature:

• One study I know of was published in 2003, and looked at about 40 people with migraine. 20 undertook a jog or walk or stepping or rowing programme in a gym three times a week for about 60 minutes. The other 20 carried on as usual - i.e. no dedicated exercise programme. Before the programme of exercise these people were having about 7-8 migraine days per month.
  After the exercise programme the exercise group reduced the number of headache days by 50% i.e to 3-4 days. Each headache episode also seemed to be shorter by about 50%. The researchers (I will get the reference on request) suggest that an exercise programme of this sort may be beneficial.
• Another study of 36 people, also published in 2003, reported a reduction in headache with exercise associated with an increase in a natural painkilling hormone called beta-endorphin. If beta-endorphin levels are increased by exercise it makes sense that pain levels may reduce.
• However, another study of an indoor cycling programme, published last year (2007) did not show any major reduction in the overall amount of migraine following a 12 week exercise programme. In the last 4 weeks of the 12 there was some reduction in the amount of headache. This seems a bit dissapointing, but could be explained by the fact that the subjects had less frequent migraine (only 4 per month). If you study people with infrequent headaches it causes a statistical querk where it becomes hardrer to establish a definite effect of a treatment - I suspect that if the study had been continued to 26 weeks or longer they may have identified a statistically definite difference.

What do I think?
Exercise has lots of health benefits besides headache relief (heart, mind, bones etc). As mild-moderate exercise is unlikely to do hram, I have no problem recommending it to my patients. There is no need to take out an expensive gym membership or buy and exercise bike or rowing machine - just go for a brisk one hour walk (that’s between 2-4 miles for most able-bodied people) 3 times per week. The studies suggest that a reduction in headache frequency of about 50% may be the result!

So a reminder of the seven simple steps to treat migraine:

1. Sleep
2. Hydration
3. Exercise >/li>
4. Diet/Weight management
5. Stress avoidance and biofeedback
6. An acute treatment that works
7. A preventative treatment that works

There have been quite a few new treatments presented over the last few days here in Boston.

I’ve already made comment upon MK0974 - telcagepant, Transcranial magnetic stimulation and tezampanel.  There were more at today’s poster session:

1. Needle-free subcutaneous sumatriptan

This is a new delivery method for sumatriptan (Imigran in UK, Imitrex in USA).  The device used a pressurised nitrogen gas to make a tiny puncture into the skin and delivers the sumatriptan without needing to use a needle. This doesn’t mean that you do not feel anything, but if you are needle-phobic you could, potentially, deliver the sumatriptan rapidly.  In patient tests, there is a strong preference for the nitrogen-pressurised system - called DosePro(TM) - the company are called Zogenix from Emeryville, California.

2. Migralex

This is a new combination tablet containing two highly effective anti-migraine treatments - aspirin 1000mg and magnesium oxide.  Both are well known and proven in migraine.  Magnesium is often forgotten but is a highly effective medicine.  Dr Mauskop from the New York Headache Centre has developed the medicine and it should available within a year.

3. Other Sumatriptan preparations

There were papers on other formulations of sumatriptan: a transdermal patch, a low dose subcutaneous injection - links to follow.

4. Inhaled dihydroergotamine

Another widely used drug in the USA, but not used much in UK.  However, this is another mode of delivery to get high doses in rapidly to try and relieve a migraine attack.  The drug has already been proven, so this will be another way to administer it.

5. Tezampanel 40mg

I covered this in an earlier post, but the subcutaneous preparation is at least as effective as sumatriptan.  There is still more testing to go. Will be a couple of years beefore this one is available on prescription.  The excitment is its new mode of action - it prevents kainate-type receptorsd from allowing the potent neurotransmitter glutamate having an effect in the development of migraine pain.  It is well known that glutamate is active in migraine pain development.

That’s the last from this years’ AHS meeting.  I’ll keep on posting - there was a lot more, but I’m taking a break the next week or so. Use the rss feed to keep updated automatically.

R

ANother interesting study from this years 50th American Headache Society Meeting.

Dr Richard Lipton presented data on the use of a magnetic stimulator to try and abort a migraine attack. The patients studied all had migraine with aura. About 100 were to try active stimulation. The other 100 used the device, but unknown to them it had been inactivated. This was an excellent randomised, blinded study - a good method.

The results of this study are notable - first the device carries virtually no detectable side effect. Second, 39% of those with active stimulation were pain free after 2 hours, compared to 22% in the “sham” stimulation group. The absolute difference was therefore 17%, which can be translated into the following statement

..for every 7 people who use a transcranial magnetic stimulator to treat a migraine attack, 1 person will pain free at 2 hours..

These results are not nearly as good as standard anti-migraine drugs, such as aspirin, anti-emetics, triptans or today’s latest addition telcagepant. However, this is a painless, almost foolproof without the concerns associated with drug treatment. It deserves further attention, especially in an increasingly medicine-averse world.

American Headache Society Meeting, Boston June 27th 2008
Dr Stephen Silberstein, Thomas Jeffereson University, Philadelphia, presented the latest review of migraine prevention. He is part of a team, working in conjunction with the American Association of Neurology, to produce practice guidelines for neurologists and other physicians who treat migraine.

There are some new additions since the last guidance in 2000. Most notable is the inclusion of topiramate as a group 1, recommended, prevention. The full list of recommended prevention is:

1. Topiramate
2. Divalproate sodium
3. Sodium valproate
4. Amitryptiline
5. Metoprolol
6. Propranolol
7. Timolol
8. Petasites

If you are experiencing more than one migraine per week and have reached the point of requiring a preventative treatment, these should be tried first. The actual choice will depend on who you are and your medical history. Women planning a pregnancy are adised to avoid valproate or topiramate, people with asthma should avoid propranolol, timolol and metoprolol etc.

It is not clear when the updated guidelines will be published, but they usually appear at AAN homepage

Latest from American Headache Society Meeting in Boston

Today there were several papers on neurostimulation. Here’s my summary, hopefully, in a nutshell. The bottom line???….. it has enormous potential as a treatment for migraine, but the studies today were a bit disappointing in terms of their quality and conclusions can only be tentative.

Here’s more detail

What is neurostimulation?
A neurostimulator is a medical device that applies a weak electrical impulse over a nerve. The electircal impulse is created by a generator. The generator, which looks a bit like an oversized watch battery, sends the electrical impulse along a wire to the nerve - in the case of headache, this is the greater occipital nerve (which sits at the back of your head). A neurostimulator has to be implanted using a surgical procedure.

How does neurostimulation work?
It is now known that nerves at the back of the head have strong connections to nerves which send pain signals to your brain during a migraine attack. By stimulating the greater occipital nerve, your brain is tricked into thinking that the pain is no longer present, and pain relief occurs. This network of nerves is called the trigeminocervical complex.

What proof is there that neurostimulation can treat migraine?
There are now 4 studies of neurostimulation in chronic migraine, including a total of 94 people. The largest of these the ONSTIM study was presented today in Boston.
Overall, there are some very encouraging results, but many more questions remain unanswered.

Before today, 2 of the 4 studies had said that a significant reduction in migraine related disability was experienced by up to 50% of those stimulated. In the long term 80% of those stimulated had a 75% reduction in migraine related disability. At face value this is impressive, given that these patients were previously resistant to other treatments and would have had medication detox as well!

Today’s ONSTIM trial is a bit less impressive, but its methods were slightly more rigorous, with an attempt (not to good I must say) at blinding the researchers from whether the patient was stimulated or not. In ONSTIM, 39% of those treated with neurostimulation for chronic migraine reduced the amount of migraine by 50%. Those that did not receive stimulation had no benefit whatsoever.

Is neurostimulation to treat migraine safe?
Neurostimulation is safe, but there is a high chance that the wire connecting the generator to the end of the nerve may move (your neck is a very mobile structure). If you take an average acroos all the studies, 25/94 participants had their wires moved - that means more surgery to re-implant the wire. This is a significant inconvenience, and potential risk. Smaller devices e.g. the BION (TM) microstimulator device are about 30mm by 3mm in size. The BION (TM) contains its own generator and will a major advance if approved by regulatory authorities.

Can I recommend neurostimulation to treat migraine headaches?
At the present time, I would consider it for a very small select group of patients, but I have reservations about the risk of wire movement. To receive a neurostimulator you would ned to have tried all available lifestyle interventions, used prophylactic medication appropriately, and have kept medication to an absolute minimum. At that stage I would still go for occipital nerve injection first, and if that failed a neurostimulator could be attempted (but remember its cost - thousands of pounds/dollars).

What is Telcagepant?

This is the novel CGRP inhibitor developed by Merck to treat acute migraine episodes. It used to be known as MK0974.

The latest on Telcagepant (MK0974) from American Headache Society Meeting in Boston

Dr Ho has presented his data, and reported on 1380 people with migraine.
These people were divided into four groups:

1. Placebo
2. Zolmitriptan 5mg
3. Telcagepant 150mg
4. Telcagepant 300mg

What happened to each group?
The main outcome was the percentage of people with pain relief at 2 hours, the data were as follows:

1. Placebo 27% pain relief at 2 hours
2. Zolmitriptan 5mg 56% pain relief at 2 hours
3. Telcagepant 150mg 49% pain relief at 2 hours
4. Telcagepant 300mg 55% pain relief at 2 hours

Side effects did not appear to be serious, but he made no mention of cardiac symptoms, which a re potential problem with the triptan drugs (like zolmitriptan).

In general Telcagepant was well tolerated, but dizziness, fatigue and vomiting were reported in a minority of patients (<6%).

What is the likely role for Telcagepant to treat migraine?
Most likely it will compete with the triptans for people whose migraine does not respond to anti-inflammatories or anti-emetics. There is s poster presentation later on the cardiac symptoms associated with telcagepant, and I will update once I’ve cast my critical eye on it.