“My migraine always comes back”

Presented by:

Julio Pascual

Neuroscience Area, Service of Neurology, University Hospital

Central de Asturias and Ineuropa, Oviedo,

Asturias, Spain

CLINICAL CASE

IDENTIFICATION

• This 34-year old otherwise healthy woman presented with a long history of headache attacks that lasted 2 days and were difficult to treat

PAST CLINICAL HISTORY AND FAMILY HISTORY

• No personal antecedents

• 18-year history of headache attacks

• Frequency: two episodes/month

• One of the episodes usually prior to menstruation

• Hemicranial (both sides) pulsating headaches

• Pain develops in 2 h and she has to go to bed during its peak

• Accompanying symptoms: nausea, phonophobia and photophobia

• No aura symptoms

• Family history: mother with migraine attacks until menopause

DIAGNOSTIC PROCEDURES

• General clinical and neurological examinations were unremarkable

• Routine laboratory determinations without abnormal findings

• MRI, performed due to her headaches 4 years earlier, was within normal limits

DIAGNOSIS

• Migraine without aura

PAST TREATMENT (I)

• The main reason for consulting us was difficulty in managing her migraine attacks:– Simple analgesics: no improvement

– Ergot drugs: increase in nausea and vomiting

– NSAIDs (e.g. naproxen, ibuporfen): moderate and inconsistent improvement

PAST TREATMENT (II)

Treatment with triptans after 4 years:

• Sumatriptan, zolmitriptan and rizatriptan relieved pain and nausea by 3 hours

• Moderate-severe pain recurred within 15-20 hours

• Pain also recurred with both sumatriptan and zolmitriptan intranasal formulations

• Recurrence usually responded well to triptans

TREATMENT

Theoretical options:

• Initiating preventative treatment– Frequency of attacks is lower

• Combining a NSAID and a triptan– Good option in terms of efficacy and decrease in recurrence

rate, but increased risk of overuse and adverse events

• Long-acting triptan:

– A long-duration triptan would be able to reduce recurrence

Oral frovatriptan, 2.5 mg, at the beginning of her

migraine attacks was recommended

FOLLOW-UP VISIT

• Assessment after 3 months:

– 7 migraine attacks treated with frovatriptan

– No subjective adverse events

– Pain-free always by 2 h

– Recurrence on just one occasion, after 28 h and with

mild pain, which responded well to a second dose of

frovatriptan

– She was told to continue taking frovatriptan for future

attacks

COMMENTS (I)

• Abortive treatment is mandatory for migraine attacks as they are invalidating

• Drugs not recommended:

– Simple analgesics: low efficacy

– Combination analgesics and opioids: rebound headache

– Ergot drugs: rebound headache and adverse events

• NSAIDs could be useful for mild-moderate attacks

• Triptans should be the standard therapy of choice for moderate-severe attacks or for those attacks which do not respond to NSAIDs

Evers S, et al. Eur J Neurol 2009;16:968-81; Tfelt-Hansen P, et al. Brain 2000;123:9-18.

Figure 1: AN ALGORITHM FOR THE TREATMENT OF MIGRAINE

Evers S, Lisotto C. World Congress of Neurology, Vienna, Austria, 2013.

COMMENTS (II)

Triptans

• In contrast to ergot drugs, they are selective for 5-HT1B/1D receptors

• All 7 available triptans share the same mechanism of action and almost identical pharmacodynamics

• However, their quite different pharmacokinetic profiles and metabolism make each of them preferable or not, depending on the characteristics of the attack/patient to be treated

COMMENTS (III)

Frovatriptan

• Frovatriptan is a potent 5-HT1B/1D agonist

• Frovatriptan response rates are comparable to those of the standard triptans and this triptan is very well tolerated 1,2

• Frovatriptan has the longest half-life among triptans 1,3 (Fig. 2), which translates in a remarkably low recurrence rate (17% in phase III trials) 2

1. Sanford M. CNS Drugs 2012; 26: 791-811, 2. Cortelli P, et al. Neurol Sci 2011; 32 (Suppl 1): S95-98;

3. Tfelt-Hansen P, et al. Drugs 2000;60(6):1259-87.

Figure 2: HALF-LIFE OF THE DIFFERENT TRIPTANS

Sumatriptan

Rizatriptan

Zolmitriptan

Alomtriptan

Eletriptan

Naratriptan

Frovatriptan

0 5 10 15 20 25 30

2

2.5

3

3.5

6

26

5

Hours

Tfelt-Hansen P, et al. Drugs 2000;60(6):1259-87.

COMMENTS (IV)

Frovatriptan and recurrence

• Pain recurrence within a migraine attack (<3 days) is interpreted by the patients as a treatment failure and requires further symptomatic treatment

• This is costly and can contribute to overuse and migraine chronification

• Therefore, frovatriptan is a triptan of choice for the acute treatment of prolonged migraine attacks at risk of relapse

Lisotto C, et al. J Headache Pain 2013;14:96.