Reports

This report is based on medical evidence presented at sanctioned medical congress, from peer reviewed literature or opinion provided by a qualified healthcare practitioner. The consumption of the information contained within this report is intended for qualified Canadian healthcare practitioners only.

48th Annual Scientific Meeting of the American Headache Society

Los Angeles, California / June 22-25, 2006

Women’s issues regarding migraines were at the forefront during the scientific sessions here this week. Dr. Stephen Silberstein, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, and President of the American Headache Society (AHS), welcomed delegates to the “community of clinicians and scientists devoted to improving the lives of headache sufferers.”

There were a wide range of formats and topics of discussion, ranging from lectures and debates to presentations about behavioural and non-pharmacologic interventions to new imaging strategies and pharmacologic therapies. As Dr. Kenneth Holroyd, Ohio University, Athens, reminded delegates, “A stated goal of the AHS is to reduce the burden of migraine headaches.” According to the AHS, over 28 million people in North America, with nearly one in five women, suffer from migraines.

Menstruation is known to be a common trigger for migraine attacks for many women, but the symptoms may be more severe, painful and longer lasting. Study findings presented by Dr. Vincent Martin, University of Cincinnati, Ohio, and colleagues consisted of two parallel, placebo-controlled, randomized, double-blind, single-attack cohorts that were approved by an institutional review board. Patients participating in the study were asked to treat a migraine early. The hypothesis is that migraine treatment is more effective while the migraine is still mild in severity, present for under an hour, and of a type that does not spontaneously resolve. Past studies have indicated that triptans can help improve treatment outcomes if used in this manner (Cady et al. Headache 2006;46(6):914-24).

The inclusion criteria for this study were women at least 18 years of age with a history of migraine with or without aura as defined by the 2004 International Headache Society criteria, and history of attacks typically mild at outset with an increasing severity of pain.

Patients were randomized to either rizatriptan, a selective 5-hydoxytryptamine type 1B/1D agonist or a placebo regimen in a 2:1 ratio. The results of this study showed that out of 94 patients, those patients taking the triptan were significantly more likely to be pain-free at two hours’ post-dose when compared to those taking placebo (63.5% (40/63) vs. 29.0% (9/31), P=0.002). These findings were consistent with previous reports of rizatriptan patients with non-menstrual migraine when compared to placebo (57.5% vs. 31.3%). Researchers also found that the incidence of photophobia and phonophobia were reduced with active therapy when compared to placebo (22% vs. 39% [P=0.066] and 17% vs. 29% [P=0.196], respectively) with a significant reduction in nausea (10% vs. 39%, P=0.001). These findings led Dr. Martin and his team to conclude, “Rizatriptan 10 mg was effective for the treatment of menstrual migraine in an early intervention model.” Their conclusions were reaffirmed by other presentations demonstrating the efficacy of the triptan class in general with regards to menstrual migraines.

Patient Preference

In choosing migraine therapy, patients often prefer quick-acting therapies that most effectively result in freedom from migraine-related pain. A study presented at the AHS annual meeting compared the effectiveness of rizatriptan with a range of usual-care migraine medications using an open-label crossover study. For the purposes of this study, usual-care medications were defined as non-triptan medication or any triptan other than rizatriptan such as sumatriptan, zolmitriptan, eletriptan or almotriptan.

Migraine sufferers treated two sequential attacks with rizatriptan 10 mg and another prescription medication, choosing which medication to take first. Patients were recruited into the study if they were at least 18 years of age, had physician-diagnosed migraines with at least one migraine per month, were rizatriptan-naïve and had been prescribed oral medication for migraine treatment. Study participants provided written consent and completed a baseline questionnaire at the outset of the study. The primary end point for this study was the time to headache freedom.

Patients were asked to use a stopwatch and keep a treatment diary to record their outcomes. Of the 1489 patients who treated two sequential migraine episodes, it was found that 81% used oral triptans for both episodes. When compared to usual-care medications, the use of rizatriptan in this study resulted in reduced times to pain freedom (mean 222 vs. 298 minutes; P<0.001) and onset of pain relief (84 vs. 107 minutes; P<0.01). In addition, when compared to other medications, significantly more patient described themselves as “very satisfied” or “satisfied” with rizatriptan (65.4% vs. 57.7%, P<0.001) and indicating a preference for it (58% vs. 42%, P<0.001).

Given these findings, the researchers observed that the use of rizatriptan, when compared with usual-care medications, offered faster time to pain freedom and onset of pain relief, which they took to be indicative of greater treatment satisfaction and medication preference.

Although triptan therapy has been shown to be effective in the treatment of migraines, they are often not used as first-line treatment for acute episodes. Dr. Daisy Ng-Mak, West Point, Pennsylvania, and colleagues examined the reasons for this phenomenon. For this study, researchers compared rizatriptan with non-triptan medications in respect to three parameters: time to pain freedom and time to onset of headache relief; patient satisfaction; and patient preference. The study was designed to be a prospective, multicentre, open-label crossover study, in which patients were provided with a stopwatch and treatment diary to record outcomes.

Patients were recruited into the study if they were at least 18 years of age, had physician-diagnosed migraines with at least one migraine per month, were triptan-naïve and had been prescribed a non-triptan oral medication for migraine treatment prior to study entry. The primary end point for this study was the time to headache freedom. Patients were to self-report treatment outcomes of two sequential migraine attacks treated in a crossover manner. One of the two episodes was to be treated with a triptan and the other with the non-triptan, at the patient’s choosing.

Investigators found that time to pain freedom was 90 minutes in the instance of the triptan compared to 150 minutes in the non-triptan episode (P=0.006) and that the time to onset of pain relief was 40 minutes for the triptan compared to 60 minutes for the non-triptan event (P=0.006). Of the triptan episodes, 60.3% patients reported being either “satisfied” or “very satisfied” with the therapy compared to 47.9% of non-triptan events. With respect to a proportional hazard model evaluating time to pain freedom, the triptan was found to be 42% more effective in achieving pain freedom when compared to non-triptans, researchers reported. They also found that the use of the triptan was 35% more effective in helping to reduce the time to onset of pain relief when compared to non-triptan therapy. In addition, of those patients reporting a preference, 63% (66/105) preferred the triptan, compared with 37% (39/105) for non-triptans; 26% of all patients in the study (36/141) did not report a medication preference.

According to Dr. Ng-Mak, “About two-thirds of patients preferred rizatriptan over other non-triptan medication for acute migraine.” Other findings included faster time to pain freedom and onset of pain relief, as well as increased satisfaction with rizatriptan when compared to non-triptans.

Future Directions

As these studies show, the future of migraine therapy may lie in educational efforts to help patients identify and treat migraines early, before severe onset. In addition, specialized episodes of migraines, such as those associated with menstruation, may also be ameliorated with early intervention.

Dr. Richard Hargreaves, West Point, Pennsylvania, discussed the future of migraine therapy research. He described the current state of migraine treatment, some aspects of migraine pathophysiology and new research that is underway to create new methods of treating migraine. Referring to new research on imaging technologies for migraines, Dr. Hargreaves said, “We need to use the imaging to understand the underlying pathophysiology.”

It was a theme echoed by Dr. Peter Goadsby, Institute of Neurology, London, UK, who described migraine as a “disorder of repeated attacks.” He added, “We are actually talking about a disease process.”

With respect to treating migraines, Dr. Hargreaves told delegates, “We really have to do better.” However, he said that the future of research looked promising. “In preventive medicine, we are not short of ideas.”

Burden of Migraine in Women

Noteworthy, in the week preceding the AHS meeting during the 41st Annual Meeting of the Canadian Congress of Neurological Sciences (CCNS) in Montreal, Dr. Allan Purdy, neurologist, Queen Elizabeth Health Sciences Centre, Halifax, Nova Scotia, reported, “Diagnosis is everything in headache, and diagnosis is exceedingly difficult in headache and in migraine.”

Migraine prevalence was confirmed to be 26% of Canadian women, or about three million women, according to the Canadian Women and Migraine Survey undertaken by Headache Network Canada. The findings were presented by Dr. Lara J. Cooke, Senior Neurology Resident, Department of Clinical Neurosciences, Foothills Medical Centre, Calgary, Alberta and Dr. Werner Becker, Professor, Department of Clinical Neurosciences, University of Calgary during the scientific sessions of the CCNS.

The population-based telephone survey identified over 1000 migraine sufferers. Of these, only 51.5% had consulted a physician and only 15% had seen a neurologist. Yet the impact on their lives was substantial. On average, each woman felt totally or partially incapacitated for 21 days a year. Almost all (92%) missed days at work or family activities.

Strikingly, the study also revealed that 61% of the women “coped” with their migraine attack by staying in bed until it was over. Most women (90%) were taking some medication for migraine, but triptan use was rare (8%). Ibuprofen was the most commonly used medication (35%), followed by acetaminophen/codeine (18%) and acetaminophen (8%).

After taking their migraine medication, only 25% of the migraine sufferers could function normally within two hours. Most women (46%) were only somewhat satisfied with treatment. Similarly, Lipton et al. had reported in 1999 that 48% of migraineurs were only somewhat satisfied with treatment (Headache 1999; 39:S20-S26).

Effective Treatments Available

“The underutilization of triptans is not entirely surprising,” Dr. Becker commented after the presentation. “It probably reflects that many patients with migraine are not aware of what the best medications for migraine are, and that there may be better things available for them than over-the-counter analgesics. It may also reflect that many physicians are not really aware how much disability migraine can cause, and therefore do not take enough time to find the best medication for each individual patient.”

There is a need to educate the public about the impact of migraine headache on society, and the availability of effective anti-migraine medications, which are currently underutilized, Dr. Cooke concurred.

“Such a common condition with significant disability in many deserves more attention from our health care system and society in general,” Dr. Becker stated. “We need to make a greater effort to educate the public about migraine, and to help physicians understand that this condition causes significant disability, but good treatments are available.”

That migraine care in Canada could be improved was also the conclusion of a recently published article based on data from the Canadian Headache Outpatient Registry and Database (CHORD) Project (Jelinski et al. Cephalalgia 2006;26(5):578-88). Dr. Becker and colleagues reported that prior to referral to a specialist, migraine treatment often fails to meet current guidelines and there is underutilization of triptans and prophylactic medications.

“The CHORD data deal with quite a different patient population; namely, the severe end of the headache spectrum that gets referred to headache specialists,” Dr. Becker explained. “Although [compared to the population-based survey of Canadian women] many more participants in the CHORD study were taking triptans at the time they saw the headache specialist—about 49%—this was still likely a much smaller percentage than it should have been.”

In fact, after consulting a specialist, 97.2% of these patients were put on a triptan. “Clearly, much remains to be done to improve the treatment of the patient with difficult migraine,” the group concluded.