Download CLINICAL CASE My migraine always comes back

CLINICAL CASE
Man with migraine headaches
occurring only at weekends
Presented by:
Carlo Lisotto
Headache Centre
Department of Neurosciences
University of Padua, Italy
IDENTIFICATION
• 40-year-old man with migraine headaches
occurring almost exclusively at weekends
• The attacks usually occur on Saturdays, less
frequently on Sundays and not uncommonly on
both days
PAST CLINICAL HISTORY AND FAMILY HISTORY
(I)
• He experienced headaches since the age of 25, when he started
working as a lawyer
• He is a non-smoker, does not consume alcohol, drinks little caffeine,
and exercises regularly
• Since their onset his headaches have occurred almost exclusively at
weekends
• The frequency of the attacks was initially low, on average one attack
every two months, but over time it has progressively increased
• During the past three years the patient has experienced headaches
on at least three weekends out of four
• The headaches are already present on awakening in the morning, or
come on by noon; they build in intensity, reaching maximum
intensity in one to two hours
• The response to acute medications is poor and unsatisfactory if he
is not able to abort an attack early
PAST CLINICAL HISTORY AND FAMILY HISTORY
(II)
• The attacks usually occur on Saturdays, less frequently on
Sundays and not uncommonly on both days
• The headaches are severe in intensity and throbbing in nature
• They are unilaterally located, usually on the right
• They often begin in the side of the nose and extend from
there to behind the eye. They sometimes begin in the back of
the neck
• They are associated with photophobia and phonophobia, and
especially with severe nausea, usually followed by vomiting
• Non-steroidal anti-inflammatory drugs, in particular ibuprofen,
are partially effective, but their intake is associated with an
unpleasant gastric burning sensation
DIAGNOSTIC PROCEDURES (I)
• His general examination was normal: BP 130/90 mm/Hg,
pulse rate 65 bpm
• Pupillary examination and fundoscopy were normal
• His neurological examination (cranial nerves, power, tone,
sensory function, reflexes, gait and coordination) was also
within normal limits
• His psychological profile was normal, and there was no
indication of depression or anxiety
• Routine laboratory data were normal, except for mild
hypercholesterolaemia
• A previous CT scan of the brain did not reveal any
abnormality
DIAGNOSTIC PROCEDURES (II)
• A headache diary, completed for a four-week period
before the first consultation, confirmed the occurrence of
migraine attacks only at weekends
• The headaches have onset on awakening in the
morning, or during sleep, 30-60 minutes prior to the
scheduled waking-up time
• The pain occasionally starts by noon, and quite rarely in
the afternoon or in the evening
• The patient gave a total score of 65 on the six-item
Headache Impact Test (HIT-6) (Fig. 1), which indicates a
severe impact
Figure 1: THE PATIENT’S HIT-6
1
When you have headaches, how often is the pain severe ?
Never
2
4
6
X
Very often
Always
Rarely
Sometimes
X
Very often
Always
X
Very often
Always
When you have a headache, how often do you wish you could lie down ?
Never
Rarely
Sometimes
In the past 4 weeks, how often have you felt too tired to do work or daily activities because of your
headaches ?
Never
5
Sometimes
How often do headaches limit your ability to do usual daily activities including household work, work,
school, or social activities ?
Never
3
Rarely
Rarely
X
Sometimes
Very often
Always
Very often
Always
In the past 4 weeks, how often have you felt fed up or irritated because of your headaches ?
Never
Rarely
Sometimes
X
In the past 4 weeks, how often did headaches limit your ability to concentrate on work or daily activities ?
Never
Rarely
Sometimes
X
Very often
Always
COLUMN 1
COLUMN 2
COLUMN 3
COLUMN 4
COLUMN 5
(6 points each)
(8 points each)
(10 points each)
(11 points each)
(13 points each)
Total Score
65
Kosinski M, et al. Qual Life Res 2003;12:963-974.
DIAGNOSIS
• Migraine without aura, with predictable
attacks (at weekends)
TREATMENT
• Given the typical characteristics of this migraine,
occurring at the weekend, frovatriptan 2.5 mg od was
considered to be the first-line medication for this patient
having the longest duration of action and the lowest
relapse rate
FOLLOW-UP VISIT
•
Assessment after 4 months:
- frovatriptan was consistently effective when taken
acutely in the morning on the appearance of the first
symptoms
- in particular, he was satisfied with its reliability of
efficacy, sustained duration of action and lack of side
effects, and with the improvement in his quality of life
- he reported a prolonged effect, with a low occurrence
of relapses and few doses needed to treat long-lasting
attacks, provided the medication was taken promptly
on appearance of the premonitory signs of a migraine
attack
COMMENTS (I)
• The term weekend migraine (WM) is used to define a type of
headache that occurs only or almost only at weekends.
• About 30% of migraineurs claim to experience attacks mainly
at weekends 1,2
• The question of whether days off represent a trigger for
headache has been debated in recent years, with some
studies showing a clear relationship 2,3 and other surveys
failing to confirm this association 4-6
• Moreover, the sleep-wake cycle is reportedly altered at
weekends (people generally get up later and sleep longer
than on working days) and this may be a trigger for WM 7
1. Torelli P, et al. Headache 1999;39:11-20; 2. Cugini P, et al.Chronobiol Int 1990;7:467-469; 3. Torelli P, et al .
Headache 1999;39:398-408; 4. Wöber C, et al. Cephalalgia 2007;27:304-314; 5. Morrison DP. Cephalalgia
1990;10:189-193; 6. Alstadhaug KB, et al. Cephalalgia 2007;27:343-346; 7. Nattero G, et al. Headache 1989;29:93-99.
COMMENTS (II)
• In an observational study of 3,301 patients it was found that
more than 5% of all migraineurs have their attacks mostly at
weekends 1
• WM seems to affect men more than women; in one survey 2,
males accounted for the majority of the 200 patients with WM
(102 cases, 51.0%)
• The attacks were found to be severe in intensity and disabling
in most cases, responding only to triptans in over 55% of the
subjects
• Because of the severely reduced functioning at weekends,
resulting from these attacks, the patient misses many leisure
and social activities, and feels deeply frustrated
1.Evers S, et al. Eur Neurol Rev 2013;8:149-152; 2. Kelman L. Pain Headache 2006;46:942-953.
COMMENTS (III)
• Although WM has been a poorly investigated condition and
specific evidence of drug efficacy for treatment of this
condition is lacking, there is no reason to doubt that current
medications for migraine treatment can also be effective in
this type of headache
• Limited evidence is available on the efficacy of anti-migraine
drugs in patients whose attacks occur mostly at weekends
• Selective serotonin 5-HT1B/1D receptor agonists (the triptans)
have been shown to be effective acute migraine drugs, and
are currently recommended, by the EFNS Guidelines 1, as
first-line treatments for moderate-to-severe migraine, and for
mild-to-moderate migraine attacks which have not responded
to adequate doses of simple analgesics
1. Evers S, et al. Eur J Neurol 2009;16:968-981.
COMMENTS (IV)
• Since WM attacks usually last a long time, up to two days, the
triptans with a long half-life are the most suitable medications
• The ideal drug for the present patient is a compound with
some prerequisite pharmacokinetic properties, in particular a
long-lasting effect.
• Frovatriptan, having the longest duration of action (26 hours)
(Table 2) and the lowest risk of relapses, could be considered
a first-line medication for patients affected by WM since it is
likely to provide a more sustained effect
• Due to the consistent predictability of his attacks, the present
patient was instructed to take frovatriptan as soon as
possible, during the migraine premonitory phase
1. Evers S, et al. Eur J Neurol 2009;16:968-981.
Table 2: HALF-LIVES OF THE DIFFERENT TRIPTANS
Triptan
Route and dose (mg)
Half-life (hours)
Sumatriptan
SC 6
2
Sumatrriptan
PO 50
2
Sumatriptan
100
2
Sumatriptan
NS 20
2
Zolmitriptan
2.5
3
Zolmitriptan
5
2.71
Zolmitriptan
ODT 2.5
2.5-3
Zolmitriptan
NS 5
2.82
Rizatriptan
10
2
Rizatriptan
ODT 10
2
Naratriptan
2.5
5-6.3
Almotriptan
12.5
3.2-3.7
Eletriptan
40
3.6
Eletriptan
40
5.5
Frovatriptan
2.5
26
NS=nasal spray; ODT=orally disintegrating tablet; PO=oral tablet; SC=subcutaneous injection
Johnston MM, et al. Drugs 2010; 70:1505-1518.
COMMENTS (V)
• A retrospective analysis of three randomised, double-blind,
crossover studies comparing frovatriptan vs other secondgeneration triptans was carried out 1
• Of the 346 intention-to-treat population patients, 188 (54%)
had WM and were included in the analysis. A total of 569
attacks occurred during weekends and 1,281 on workdays
• The proportion of pain-free episodes at two hours did not
significantly differ between weekend and workday attacks for
frovatriptan (26% vs 27%) or for comparators (34% vs 32%)
• Conversely (Fig. 2) the relapse rate within 48 hours for
weekend attacks compared to workday attacks was
significantly lower with frovatriptan (17% vs 30%, p<0.05), but
not with comparators (weekends 34% vs workdays 40%,
p=NS)
1. Lisotto C, et al. Brain Disord Ther 2014;3:3. http://dx.doi.org/10.4172/2168-975X.1000128.
Figure 2: RELAPSE RATES WITHIN 48 HOURS
Modified from: Lisotto C, et al. Brain Disord Ther 2014;3:3. http://dx.doi.org/10.4172/2168-975X.1000128.
COMMENTS (VI)
• In conclusion, frovatriptan seems to be unique in the
triptan class, having the longest duration of action and
the lowest recurrence rate
• Compared to the other triptans, frovatriptan seems to
offer the advantage of a lower risk of relapse and
therefore a more sustained effect