Migraine associated with brain artery defect..


The network of arteries supplying blood flow to the brain is more likely to be incomplete in people who suffer migraine, a new study by researchers in the Perelman School of Medicine at the University of Pennsylvania reports. Variations in arterial anatomy lead to asymmetries in cerebral blood flow that might contribute to the process triggering migraines.

The arterial supply of blood to the brain is protected by a series of connections between the major arteries, termed the “circle of Willis” after the English physician who first described it in the 17th century. People with migraine, particularly migraine with aura, are more likely to be missing components of the circle of Willis.

migraine-aura-1

Migraine affects an estimated 28 million Americans, causing significant disability. Experts once believed that migraine was caused by dilation of blood vessels in the head, while more recently it has been attributed to abnormal neuronal signals. In this study, appearing in PLOS ONE, researchers suggest that blood vessels play a different role than previously suspected: structural alterations of the blood supply to the brain may increase susceptibility to changes in cerebral blood flow, contributing to the abnormal neuronal activity that starts migraine.

“People with migraine actually have differences in the structure of their blood vessels; this is something you are born with,” said the study’s lead author, Brett Cucchiara, MD, Associate Professor of Neurology. “These differences seem to be associated with changes in blood flow in the brain, and it’s possible that these changes may trigger migraine, which may explain why some people, for instance, notice that dehydration triggers their headaches.”

In a study of 170 people from three groups—a control group with no headaches, those who had migraine with aura, and those who had migraine without aura—the team found that an incomplete circle of Willis was more common in people with migraine with aura (73 percent) and migraine without aura (67 percent), compared to a headache-free control group (51 percent). The team used magnetic resonance angiography to examine blood vessel structure and a noninvasive magnetic resonance imaging method pioneered at the University of Pennsylvania, called Arterial spin labeling (ASL), to measure changes in cerebral blood flow.

“Abnormalities in both the circle of Willis and blood flow were most prominent in the back of the brain, where the visual cortex is located. This may help explain why the most common migraine auras consist of visual symptoms such as seeing distortions, spots, or wavy lines,” said the study’s senior author, John Detre, MD, Professor of Neurology and Radiology.

Both migraine and incomplete circle of Willis are common, and the observed association is likely one of many factors that contribute to migraine in any individual. The researchers suggest that at some point diagnostic tests of circle of Willis integrity and function could help pinpoint this contributing factor in an individual patient. Treatment strategies might then be personalized and tested in specific subgroups.

In addition to Dr. Cucchiara and Dr. Detre, the research team at Penn includes Scott Kasner, MD, Ritobrato Datta, PhD, Geoffrey Aguirre, MD, PhD from Neurology, and Ronald Wolf, MD, PhD, from Radiology. Radiologists Lidia Nagae, MD, from the Children’s Hospital of Philadelphia, and Quan Zhang, PhD, from Tianjin Medical University in Tianjin, China, contributed to the study.

Source: http://machineslikeus.com

Magnetic resonance angiography of intracranial and extracranial arteries in patients with spontaneous migraine without aura: a cross-sectional study.


Summary

Background

Extracranial arterial dilatation has been hypothesised to be the cause of pain in patients who have migraine without aura. To test that hypothesis, we aimed to measure extracranial and intracranial arteries during attacks of migraine without aura.

Methods

In this cross-sectional study, we recruited patients aged 18–60 years from the Danish Headache Centre and via announcements on a Danish website. We did magnetic resonance angiography during spontaneous unilateral migraine attacks. Primary endpoints were difference in circumference of extracranial and intracranial arterial segments comparing attack and attack-free days and the pain and the non-pain side. The extracranial arterial segments measured were the external carotid (ECA), the superficial temporal (STA), the middle meningeal (MMA), and the cervical part of the internal carotid (ICAcervical) arteries. The intracranial arterial segments were the cavernous (ICAcavernous) and cerebral (ICAcerebral) parts of the internal carotid, the middle cerebral (MCA), and the basilar (BA) arteries. This study is registered at Clinicaltrials.gov, numberNCT01471314.

Findings

Between Oct 12, 2010, and Feb 8, 2012, we recruited 78 patients, of whom 19 women had a scan during migraine and were included in the final analysis. On migraine compared with non-migraine days, we detected no statistically significant dilatation of the extracranial arteries on the pain side (ECA, mean difference 1·2% [95% CI −5·7 to 8·2] p=0·985, STA 3·6% [–3·7 to 11·0] p=0·532, MMA 1·7% [–1·7 to 5·2] p=0·341, and ICAcervical 2·3% [–0·3 to 4·9] p=0·093); the intracranial arteries were more dilated during attacks (MCA, 13·0% [6·4 to 19·6] p=0·001, ICAcerebral 11·5% [5·6 to 17·3] p=0·0004, and ICAcavernous 11·4% [5·3 to 17·5] p=0·001), except for the BA (1·6% [–2·7 to 5·9] p=0·621). Compared with the non-pain side, during attacks we detected dilatation on the pain side of the intracranial arteries (MCA, mean difference 10·5% [0·7–20·3] p=0·044, ICAcerebral (14·4% [4·6–24·1] p=0·013), and ICAcavernous (9·1% [3·9–14·4] p=0·003) but not of the extracranial arteries (ECA, 2·1% [–3·8 to 9·2] p=0·238, STA, 3·6% [–3·7 to 10·8] p=0·525, MMA, 2·7% [–1·3 to 5·6] p=0·531, and ICAcervical, 5·0% [–0·5 to 10·4] p=0·119).

Interpretation

Migraine pain was not accompanied by extracranial arterial dilatation, and by only slight intracranial dilatation. Future migraine research should focus on the peripheral and central pain pathways rather than simple arterial dilatation.

Source: http://www.sciencedirect.com

Paracetamol (acetaminophen) with or without an antiemetic for acute migraine headaches in adults..


This is an updated version of the original Cochrane review published in Issue 11, 2010 (Derry 2010). Migraine is a common, disabling condition and a burden for the individual, health services and society. Many sufferers choose not to, or are unable to, seek professional help and rely on over-the-counter analgesics. Co-therapy with an antiemetic should help to reduce nausea and vomiting, which are commonly associated with migraine.

OBJECTIVES: To determine the efficacy and tolerability of paracetamol (acetaminophen), alone or in combination with an antiemetic, compared with placebo and other active interventions in the treatment of acute migraine in adults. SEARCH
METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and the Oxford Pain Relief Database for studies through 4 October 2010 for the original review, and to 13 February 2013 for the update. Two clinical trials registers (ClinicalTrials.gov and gsk-clinicalstudyregister.com) were also searched on both occasions.
SELECTION CRITERIA: We included randomised, double-blind, placebo- or active-controlled studies using self-administered paracetamol to treat a migraine headache episode, with at least 10 participants per treatment arm.
DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted data. Numbers of participants achieving each outcome were used to calculate relative risk and numbers needed to treat (NNT) or harm (NNH) compared with placebo or other active treatment.
MAIN RESULTS: Searches for the update identified one additional study for inclusion. Eleven studies (2942 participants, 5109 attacks) compared paracetamol 1000 mg, alone or in combination with an antiemetic, with placebo or other active comparators, mainly sumatriptan 100 mg. For all efficacy outcomes paracetamol was superior to placebo, with NNTs of 12 (19% response with paracetamol, 10% with placebo), 5.0 (56% response with paracetamol, 36% with placebo) and 5.2 (39% response with paracetamol, 20% with placebo) for 2-hour pain-free and 2- and 1-hour headache relief, respectively, when medication was taken for moderate to severe pain.Paracetamol 1000 mg plus metoclopramide 10 mg was not significantly different from oral sumatriptan 100 mg for 2-hour headache relief; there were no 2-hour pain-free data.Adverse event rates were similar between paracetamol and placebo, and between paracetamol plus metoclopramide and sumatriptan. No serious adverse events occurred with paracetamol alone, but more serious and/or severe adverse events occurred with sumatriptan than with the combination therapy (NNH 32).
AUTHORS’ CONCLUSIONS: Paracetamol 1000 mg alone is statistically superior to placebo in the treatment of acute migraine, but the NNT of 12 for pain-free response at two hours is inferior to at of other commonly used analgesics. Given the low cost and wide availability of paracetamol, it may be a useful first choice drug for acute migraine in those with contraindications to, or who cannot tolerate, non-steroidal anti-inflammatory drugs (NSAIDs) or aspirin. The addition of 10 mg metoclopramide gives short-term efficacy equivalent to oral sumatriptan 100 mg. Adverse events with paracetamol did not differ from placebo; serious and/or severe adverse events were slightly more common with sumatriptan than with paracetamol plus metoclopramide.

Source: Cochrane Database

Management of infantile colic.


Abstract

Although infantile colic is considered to be a self-limiting and benign condition, it is often a frustrating problem for parents and caregivers. It is a frequent source of consultation with healthcare professionals and is associated with high levels of parental stress and anxiety.1,2Several published reviews of the literature have explored dietary, pharmacological, complementary and behavioural therapies as options for the management of infantile colic.1,3 Here, we assess whether these management options are supported by the literature and if there are any novel treatment options.

About infantile colic

Infantile colic has been defined as paroxysmal uncontrollable crying in an otherwise healthy infant less than 3 months of age, with more than 3 hours of crying per day, in more than 3 days a week and for more than 3 weeks.4,5 It is known to have a significant impact on infants and their families, with up to one in six families with children with symptoms of colic consulting healthcare professionals.6

Background

Despite the prevalence of the condition, the pathogenesis remains incompletely understood. One hypothesis has suggested that infantile colic is caused by the impact of abnormal gastrointestinal motility and pain signals from sensitised pathways in the gut viscera.2 Another hypothesis is that inadequate amounts of lactobacilli and increased amounts of coliform bacteria in the intestinal microbiota influences gut motor function and gas production, which subsequently contributes to the condition.2

More controversially, behavioural issues such as family tension, parental anxiety or inadequate parent-infant interaction have also been explored as causative factors for infantile colic.1 In addition, little is known about concomitant risk factors; however, maternal smoking, increased maternal age and firstborn status are thought to be associated with the development of infantile colic. No association with feeding method has been noted.1

As a consequence of the lack of understanding of the cause of the condition, a wide spectrum of treatment modalities have been suggested, with each one targeted to address a postulated cause.

Diagnosis

Although infantile colic is by definition a benign condition, healthcare professionals should address parental concerns carefully, as the diagnosis is made by exclusion of more sinister causes.

Management options

There are numerous issues with the methodological rigour of many intervention studies with several systematic reviews on infantile colic describing shortcomings in trial methodology. Whilst some form of randomisation was performed with many of these studies, lack of a clear definition for infantile colic, absence of clinically meaningful  end-points (aside from crying duration), and limited detail on sample size calculations, allocation concealment and randomisation methods are likely to have affected the validity of the results. It is therefore appropriate to take a cautious approach in translating the outcomes of research to practical recommendations for managing infantile colic.

Diet modification

Based on the theory that infantile colic results from excessive gas production from poor gut digestion of cow’s milk proteins, several nutritional interventions have been reviewed.2

In practice, any positive impact of diet modification may result from improving symptoms of colic secondary to a previously undiagnosed cow’s milk protein allergy in the infant. Therefore, it is important that cow’s milk protein allergy is considered during the assessment of an infant with inconsolable crying. There are currently no reported unwanted effects for any of the diet modification studies described below.9

Hypoallergenic formula preparations for bottle-fed infants

In hydrolysed formulae, whole milk proteins are broken down to prepare them for digestion. These can range from partially hydrolysed to completely hydrolysed formula preparations with the former often used for lactose intolerance and the latter used in the management of cow’s milk protein allergy.9

Several systematic reviews have identified studies that demonstrated that completely hydrolysed formulae significantly improved clinical symptoms of infantile colic, such as crying time.1,9,10 These studies used standard cow’s milk formula as the comparator and improvements were noted from 7 days onwards. When carbohydrate and fat content compositions were varied in one study, both proved similarly effective in reducing colic symptoms, suggesting that changes to carbohydrate and fat content had no effect.9

In one systematic review, two randomised controlled trials (RCTs) noted that partially hydrolysed formulae reduced colic symptoms after 14 days of feeding. However, the trials did not involve a direct comparison with a regular cow’s milk formula, but compared partially hydrolysed formulae and soy-based formulae.9

Where a suspicion of cow’s milk protein allergy exists there is some evidence that the use of an empirical time limited trial of a completely hydrolysed formula is a reasonable option.1,9,10Correspondingly, whilst there is some literature advocating the use of partially hydrolysed formula,9 its use for the dietary management of colic would not be recommended because partially hydrolysed formulae are not hypoallergenic and therefore will not address colic symptoms secondary to a protein allergy.10

High-fibre formula

High fibre or fibre-enriched formulas are those that are fortified with typically a soy polysaccharide to increase the dietary fibre concentration. An RCT identified by two systematic reviews found no significant difference in symptoms when comparing a high-fibre formula with a standard formula.1,9

Soy-based formula

Two systematic reviews noted several low quality studies that demonstrated a reduction in crying duration when comparing soy-based formula with standard cow’s milk formula after 7 days of feeding.9,10 However, due to concerns about the levels of phytoestrogens in soy-based formula and that soy protein may be an allergen in infancy, its use in infantile colic is not recommended.10,11

Hypoallergenic maternal diet for breast-fed infants

A hypoallergenic diet for breast feeding mothers excludes cow’s milk products and other possible trigger foods. In comparison to the use of a hypoallergenic infant formula, there is limited evidence supporting the use of hypoallergenic maternal diet, with several studies noting equivocal results.1,9,10 This has been attributed to the use of an incompletely hydrolysed diet without a thorough exclusion of trigger foods that could have reduced the effect of the intervention.9

One systematic review, identified a good quality RCT in which mothers eliminated dairy foods, eggs, peanuts, tree nuts, wheat, soy and fish from their diet.9 The primary endpoint of the study was a reduction in cry/fuss duration of >25% from baseline with more responders in the low-allergen diet group compared with the control group, 74% vs. 37%, an absolute risk reduction of 37% (95%CI 18% to 56%).10 Two earlier studies reported similar findings but neither separated the results for breastfed infants from hypoallergenic formula fed infants.9

On balance there is limited evidence to suggest that hypoallergenic diets in mothers may be helpful. If a time limited trial is undertaken, mothers should be advised to exclude trigger foods including cow’s milk products from their diet and to ensure that they and their infant receive appropriate nutritional support, including calcium and vitamin D intake. They should also be advised not to discontinue breastfeeding while switching to the hypoallergenic maternal diet.1,9,10

Lactase therapy

In lactase therapy, galactosidase (lactase) drops are mixed with breast or bottle milk feeds up to 24 hours prior to feeding the infant. A systematic review identified two RCTs where an improvement in symptoms was noted with the use of lactase therapy. In one RCT, a relative decrease in crying time of 22.4% (95% CI 13% to 44%) was noted.1 This conflicted with several other RCTs noting no improvement with the use of lactase in either breast or formula milk. In one example, only a 40-minute reduction in crying time was observed compared with placebo.1

Pharmacological management

It is hypothesised that the gut’s peristaltic cholinergic activity is linked to gastrointestinal discomfort in infantile colic. Consequently, anticholinergics, such as dicyclomine hydrochloride and cimetopium bromide, which reduce smooth muscle activity, have been studied. Neither of these drugs are licensed in the UK for use in infants.

In one systematic review, two studies investigating dicyclomine hydrochloride noted improvement in colic symptoms. However, severe adverse effects including respiratory distress and seizures led to its licence withdrawal in infants less than 6 months of age.7 One study has reported significant improvements with the use of cimetropium bromide with only drowsiness noted as a side effect.1,37

Simethicone (Infacol®), which reduces intraluminal gas and is readily available over the counter, has been studied in two RCTs. No difference in reducing colic episodes was shown compared with placebo.1,7

Complementary therapies and other interventions

In the absence of safe and effective pharmacological interventions, complementary therapies have taken a more prominent role in the management of infantile colic. These can range from conventional therapies, such as dietary supplements, sugar solutions, herbal extracts or massage, to controversial options such as chiropractic treatment.

Herbal supplements

A systematic review identified several studies of herbal supplements, such as fennel extract and mixed herbal tea that showed a reduction in symptoms of infantile colic.12 However, several adverse effects such as vomiting, sleepiness, constipation and loss of appetite were also noted.12 Minimal information on extraction and preparation of herbs and lack of standardisation of dosage and formulations have also limited their use.2

Sucrose solutions

Two studies compared glucose solutions with placebo and found positive effects in relieving symptoms.2 However, there are concerns about potential nutritional effects, in particular the content of sugar and alcohol, the lack of formulation standardisation and the poor quality of the evidence.2,12,13

Probiotics

Based on the hypothesis that aberrant intestinal microflora affecting gut function and gas production may contribute to the condition, the use of probiotics in infantile colic has become more common. Numerous studies have been identified in a systematic review.12,14,15 One randomised double blind placebo controlled trial involving 46 infants used a suspension of freeze-dried Lactobacillus reuteri. There were significantly more responders (50% reduction in crying time from baseline) in the L reuteri group on days 7 (20 vs. 8; p = 0.006), 14 (24 vs. 13; p = 0.007), and 21 (24 vs. 15; p = 0.036). A further RCT identified good weight gain and gastrointestinal tolerance.2

Massage

One study noted a positive effect in massage utilising aromatherapy oils. However, the results were not separated between massage and aromatherapy.16 Whilst several other studies identified in a systematic review12,13 showed some improvement on symptoms of colic, overall the quality of these studies is poor.

Swaddling

Swaddling has traditionally been used by some parents to reduce crying in infancy. A systematic review noted that swaddling reduced crying symptoms compared with massage in excessively crying infants with cerebral damage.17 However, there is a known associated risk of developing hip dysplasia, overheating or sudden infant death syndrome if placed in the prone position. The current evidence base, therefore, does not support the use of swaddling in the management of infantile colic.

Chiropractic treatment

As a more controversial complementary therapy, chiropractic care is sometimes advocated as a treatment option for infantile colic. Chiropractic care can include, but is not limited to, cranial osteopathy and spinal manipulation therapy. The evaluation of treatment options in this field is challenging due to the absence of good quality RCTs. Additionally, adverse effects such as vertebral artery dissection have been reported anecdotally.18,19

It is hypothesised that chiropractic care can have a positive effect on symptoms; however, the literature has noted that this may be a consequence of improving parents’ coping ability with the condition rather than true effectiveness of chiropractic care.20

In several systematic reviews, one single blinded RCT was identified noting no differences in outcomes between chiropractic care and placebo, which was infant holding by a nurse.21Several other studies were identified noting positive treatment effects; however, these were noted to be of low quality.12,18,19,21,22

Acupuncture

Several RCTs evaluating acupuncture were identified, of which two RCTs noted a shorter duration and intensity of infantile colic symptoms.23,24 Another good quality double blinded RCT comparing acupuncture with a sham needle insertion noted no major effect on symptoms including feeding, bowel movement frequency and sleep.25

Behaviour modification

Several behavioural interventions were identified, that aimed to provide reassurance to parents and offer alternative methods to treat colic.3

One systematic review identified two controlled trials where the use of modified parent and infant interaction led to significant reduction in colic symptoms and additional benefits of early gains in development.1,26 This has been attributed to increased maternal responsiveness and time spent with infants resulting in increased infant alertness. In another study, entire family involvement utilising an integrated care model led to the relief of infantile colic symptoms more readily than standard care.27 The use of ‘contingent music’ was noted to decrease symptoms in another study.1

It has been noted that the identification of effective coping strategies and counselling methods to assist parents in managing this stressful condition is imperative.28 A systematic review identified two studies addressing this; one study utilised a home based nursing intervention and another utilised counselling on specific management techniques and car ride simulation in infants over 6 weeks of age, leading to significant reductions in parental stress and anxiety.1,3

Guidelines

The National Institute for Health and Clinical Excellence guideline on postnatal care advises that holding the baby through the crying episode, and accessing peer support may be helpful, and that the use of hypoallergenic formula in bottle-fed babies should be considered for treating colic, but only under medical guidance.29

A position statement by the Canadian Paediatric Society on dietary interventions commented that a minority of infants have symptoms of infantile colic secondary to cow’s milk protein allergy, and in such cases a maternal hypoallergenic diet for breastfed infants and an extensively hydrolysed formula for bottle fed infants may help.10 In addition, it concluded that there is no proven role for the use of soy-based formulas or lactase therapy and insufficient data to make a recommendation on the effect of probiotics.

The Clinical Knowledge Summary (CKS) noted that “although there are many studies of interventions for infantile colic, most are of poor methodological quality”.30 The guidance suggests that clinicians should “only consider trying medical treatments if parents feel unable to cope despite advice and reassurance”. Options listed include a 1-week trial of simeticone drops (breastfed or bottle-fed infants); a 1-week trial of diet modification to exclude cow’s milk protein (dairy-free diet for the mother [breast-fed infants], hypoallergenic formula [bottle-fed infants]); a 1-week trial of lactase drops (breastfed or bottle-fed infants). However, it should be noted that the CKS guidance was last revised in 2007. A Map of Medicine healthguide on infantile colic also cites the CKS guidance.31

Other issues

There is evidence of inconsistent advice relating to early infant crying and colic in various media outlets such as parenting magazines.32 Advice was noted to be “diffuse, varied, and generally unrelated to the current evidence-based conceptualization of early infant crying”.

Advice for community pharmacists has summarised many of the options available over the counter (including those for which there is little evidence of efficacy e.g. gripe water) and highlighted resources and support groups.33

Conclusion

Parents with infants with colic commonly consult a healthcare professional. Each case should be thoroughly assessed because of the wide range of other conditions that can present in a similar way. For the majority of cases simple reassurance is all that is required. If the clinician feels intervention is required, there are a wide range of options available with a poor evidence base to support any of them.

Currently, there are no effective and safe pharmacological management options available over the counter or by prescription. Simeticone, lactase drops and probiotics are unlikely to be harmful, but there is little evidence to support their use. Whilst complementary treatment options exist there is currently insufficient evidence to recommend their use. The absence of strong evidence is similarly noted for behavioural modification interventions. Despite this, the absence of side effects makes the argument for a trial of such an intervention more compelling.

Where there is a suspicion of cow’s milk protein allergy, a short trial of hypoallergenic feeding, through a hypoallergenic formula in bottle-fed infants may be considered. The improvement in infants with this approach may in part be as a result of treatment of undiagnosed cow’s milk allergy rather than symptomatic improvement of colic. In breastfeeding mothers there is limited evidence that a fully hypoallergenic exclusion diet may be helpful if undertaken carefully.

Infantile colic, whilst self-limiting and benign, can cause considerable distress to parents and it is therefore important that parental support is provided. Advice and guidance on where to obtain support outside conventional healthcare sources should be discussed with parents.

Source: BJM

Ibuprofen with or without an antiemetic for acute migraine headaches in adults.


This is an updated version of the original review published in Issue 10, 2010 (Rabbie 2010). Migraine is a common, disabling condition and a burden for the individual, health services and society. Many sufferers do not seek professional help, relying instead on over-the-counter analgesics. Co-therapy with an antiemetic should help to reduce symptoms commonly associated with migraine headaches.

OBJECTIVES: To determine efficacy and tolerability of ibuprofen, alone or in combination with an antiemetic, compared to placebo and other active interventions in the treatment of acute migraine headaches in adults. SEARCH
METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the Oxford Pain Relief Database, ClinicalTrials.gov, and reference lists for studies through 22 April 2010 for the original review and to 14 February 2013 for the update.
SELECTION CRITERIA: We included randomised, double-blind, placebo- or active-controlled studies using self-administered ibuprofen to treat a migraine headache episode, with at least 10 participants per treatment arm.
DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted data. Numbers of participants achieving each outcome were used to calculate relative risk and number needed to treat (NNT) or harm (NNH) compared to placebo or other active treatment.
MAIN RESULTS: No new studies were found for this update. Nine included studies (4373 participants, 5223 attacks) compared ibuprofen with placebo or other active comparators; none combined ibuprofen with a self-administered antiemetic. All studies treated attacks with single doses of medication. For ibuprofen 400 mg versus placebo, NNTs for 2-hour pain-free (26% versus 12% with placebo), 2-hour headache relief (57% versus 25%) and 24-hour sustained headache relief (45% versus 19%) were 7.2, 3.2 and 4.0, respectively. For ibuprofen 200 mg versus placebo, NNTs for 2-hour pain-free (20% versus 10%) and 2-hour headache relief (52% versus 37%) were 9.7 and 6.3, respectively. The higher dose was significantly better than the lower dose for 2-hour headache relief. Soluble formulations of ibuprofen 400 mg were better than standard tablets for 1-hour, but not 2-hour headache relief.Similar numbers of participants experienced adverse events, which were mostly mild and transient, with ibuprofen and placebo.Ibuprofen 400 mg did not differ from rofecoxib 25 mg for 2-hour headache relief or 24-hour headache relief.
AUTHORS’ CONCLUSIONS: We found no new studies since the last version of this review. Ibuprofen is an effective treatment for acute migraine headaches, providing pain relief in about half of sufferers, but complete relief from pain and associated symptoms for only a minority. NNTs for all efficacy outcomes were better with 400 mg than 200 mg in comparisons with placebo, and soluble formulations provided more rapid relief. Adverse events were mostly mild and transient, occurring at the same rate as with placebo.

Source: Cochrane

 

 

Valproate Anti-Seizure Products: Drug Safety Communication – Contraindicated for Pregnant Women for Prevention of Migraine Headaches


Including valproate sodium (Depacon), divalproex sodium (Depakote, Depakote CP, and Depakote ER), valproic acid (Depakene and Stavzor), and their generics

 

 

ISSUE: FDA is advising health care professionals and women that the anti-seizure medication valproate sodium and related products, valproic acid and divalproex sodium, are contraindicated and should not be taken by pregnant women for the prevention of migraine headaches. Based on information from a recent study, there is evidence that these medications can cause decreased IQ scores in children whose mothers took them while pregnant. Stronger warnings about use during pregnancy will be added to the drug labels, and valproate’s pregnancy category for migraine use will be changed from “D” (the potential benefit of the drug in pregnant women may be acceptable despite its potential risks) to “X” (the risk of use in pregnant women clearly outweighs any possible benefit of the drug).

Valproate products will remain in pregnancy category D for treating epilepsy and manic episodes associated with bipolar disorder.

BACKGROUND: Valproate products are approved for the treatment of certain types of epilepsy, the treatment of manic episodes associated with bipolar disorder, and the prevention of migraine headaches. They are also used off-label (for uses not approved by FDA) for other conditions, particularly other psychiatric conditions.

This alert is based on the final results of the Neurodevelopmental Effects of Antiepileptic Drugs (NEAD) study showing that children exposed to valproate products while their mothers were pregnant had decreased IQs at age 6 compared to children exposed to other anti-epileptic drugs. For additional details, see the Drug Safety Communication Data Summary section.

RECOMMENDATION: Valproate products should not be used in pregnant women for prevention of migraine headaches and should be used in pregnant women with epilepsy or bipolar disorder only if other treatments have failed to provide adequate symptom control or are otherwise unacceptable.

Women who are pregnant and taking a valproate medication should not stop their medication but should talk to their health care professionals immediately. Stopping valproate treatment suddenly can cause serious and life-threatening medical problems to the woman or her baby.

Healthcare professionals and patients are encouraged to report adverse events or side effects related to the use of these products to the FDA’s MedWatch Safety Information and Adverse Event Reporting Program.

Source: FDA

Magnetic resonance angiography of intracranial and extracranial arteries in patients with spontaneous migraine without aura: a cross-sectional study.


Background

Extracranial arterial dilatation has been hypothesised to be the cause of pain in patients who have migraine without aura. To test that hypothesis, we aimed to measure extracranial and intracranial arteries during attacks of migraine without aura.

Methods

In this cross-sectional study, we recruited patients aged 18—60 years from the Danish Headache Centre and via announcements on a Danish website. We did magnetic resonance angiography during spontaneous unilateral migraine attacks. Primary endpoints were difference in circumference of extracranial and intracranial arterial segments comparing attack and attack-free days and the pain and the non-pain side. The extracranial arterial segments measured were the external carotid (ECA), the superficial temporal (STA), the middle meningeal (MMA), and the cervical part of the internal carotid (ICAcervical) arteries. The intracranial arterial segments were the cavernous (ICAcavernous) and cerebral (ICAcerebral) parts of the internal carotid, the middle cerebral (MCA), and the basilar (BA) arteries. This study is registered atClinicaltrials.gov, number NCT01471314.

Findings

Between Oct 12, 2010, and Feb 8, 2012, we recruited 78 patients, of whom 19 women had a scan during migraine and were included in the final analysis. On migraine compared with non-migraine days, we detected no statistically significant dilatation of the extracranial arteries on the pain side (ECA, mean difference 1·2% [95% CI −5·7 to 8·2] p=0·985, STA 3·6% [—3·7 to 11·0] p=0·532, MMA 1·7% [—1·7 to 5·2] p=0·341, and ICAcervical 2·3% [—0·3 to 4·9] p=0·093); the intracranial arteries were more dilated during attacks (MCA, 13·0% [6·4 to 19·6] p=0·001, ICAcerebral 11·5% [5·6 to 17·3] p=0·0004, and ICAcavernous 11·4% [5·3 to 17·5] p=0·001), except for the BA (1·6% [—2·7 to 5·9] p=0·621). Compared with the non-pain side, during attacks we detected dilatation on the pain side of the intracranial arteries (MCA, mean difference 10·5% [0·7—20·3] p=0·044, ICAcerebral (14·4% [4·6—24·1] p=0·013), and ICAcavernous (9·1% [3·9—14·4] p=0·003) but not of the extracranial arteries (ECA, 2·1% [—3·8 to 9·2] p=0·238, STA, 3·6% [—3·7 to 10·8] p=0·525, MMA, 2·7% [—1·3 to 5·6] p=0·531, and ICAcervical, 5·0% [—0·5 to 10·4] p=0·119).

Interpretation

Migraine pain was not accompanied by extracranial arterial dilatation, and by only slight intracranial dilatation. Future migraine research should focus on the peripheral and central pain pathways rather than simple arterial dilatation.

Source: Lancet