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Article | Advancements
in the Treatment of Headache . . . .
Patients and physicians are continuing
to search for newer and more effective methods for the treatment
of headache. The past decade has seen significant advances
in the available therapies and with this medications with
better safety, reliability and consistency.
Important in this process has been the
increased understanding of the nature of headaches. Cluster
headache has been linked to alterations in the hypothalamic
area of the brain. This may help to localize our therapies
for increased efficacy. Migraine and tension-type headache
increasingly appear to represent part of a continuum of headache.
This may lend treatments to broader uses. Even how a patient’s
headaches develop during an attack has been researched to
improve treatment. It has been demonstrated with headache
pain arising from the neck and from the facial regions and
a linkage to migraine.
How a headache is treated can affect the
outcome for patients. Evidence supports the idea that migraine
headache should be treated as early as possible into the attack,
when the pain is still mild, rather than waiting for it to
develop into a disabling headache. This early intervention
strategy studied with sumatriptan has been shown to increase
the likelihood of rapid and complete resolution of the attack.
Similar results have been shown with other triptans. Rapid
relief of migraine translates into less medication, less medication
side effects and increased chances that the headache won’t
return.
On the acute treatment front for migraine
are several newer triptan medications. The first is almotriptan
which became available in the last year. It is a relatively
rapid-acting triptan similar in its onset of action to others
on the market such as sumatriptan and zolmitriptan. It has
a low headache recurrence rate in clinical trials, similar
to naratriptan, and appears from these trials to have exceptionally
good tolerability with a low incidence of side effects. For
those who must pay for their own medications it is about 2/3
of the cost of other triptans on the market.
Being introduced in 2002 will be frovatriptan
and probably eletriptan. Frovatriptan may be somewhat slower
to start relieving the migraine than other triptans. It appears
to have a very low rate of headache recurrence, in clinical
trials. Its long acting power in the body makes it useful
for those who tend to have migraines lasting several days
as well as for "mini-preventive" treatments. Examples
of this use are menstrual migraines and cluster headache.
Eletriptan may be one of the most potent triptans to come
to market as suggested by the clinical trials especially if
the highest dose is approved for use. Concerns regarding drug
interactions may limit its widespread use. The results of
ongoing studies are still pending to further examine safety
concerns.
Acute treatment extends beyond the triptans.
Investigational therapies with dihydroergotamine and several
different anti-inflammatories alone or combined with other
agents have provided other treatment opportunities to patients
who have been unsuccessful in the past. The use of one of
these agents, in the COX2 inhibitor class of anti-inflammatories,
has been used not only for acute migraine but also as a preventive
treatment for migraine and was quite successful when used
with a drug for asthma that works on other inflammatory changes
in the body.
Preventive treatment of headache has been
studied. Those with significant migraine and migraine-related
headaches who experience loss of time from work, home and
leisure activities or who can’t be as effective as they
wish, may benefit from such treatment. Two major areas of
study that are resulting in improved quality of life for patients
with headache are the anti-epileptic drugs and botulinum toxin.
The interest in anti-epileptic drugs for
headache evolved from the approval by the FDA of divalproex
sodium for the prevention of migraine. It is considered to
be a first tier preventive medication along with propranolol,
timolol and amitriptyline by the US Headache Guidelines Consortium.
A recently available extended-release formulation, which can
improve compliance, was shown to have side effects rates comparable
to placebo in its trial. An intravenous form of this drug
can be extremely effective as a treatment for severe or prolonged
migraine attacks that have to respond to other medications.
New anti-epileptic drugs that are available
include gabapentin, topiramate, oxcarbazepine, levrictracam,
and zonisamide. Gabapentin has been shown to be effective
for preventive treatment in several trials. Doses of 900 mg
to 2400 mg per day may be needed to produce benefit. While
it is well tolerated at lower doses, it can have sedation
issues at the higher dose range. Topiramate appears to have
exceptional promise as a preventive agent in migraine, chronic
daily headache, and even in cluster headache. While trials
of this agent are still in process at the Clinic, it is also
available for prescription use. Fairly modest doses compared
to those for epilepsy appear useful for prevention of headache.
At these doses, especially with slow titration, side effects
are not often a problem. Nuisance side effects such as altered
taste of carbonated beverages and tingling sensation do occur
but rarely are severe enough to cause the medication to be
stopped. Weight loss is a side effect from topiramate. Cognitive
slowing can occur in some patients and may lead to drug discontinuation.
Oxcarbazepine is still being investigated at the Clinic in
preventive trials but is also available for prescription use.
Our experience with it to date is limited but it appears to
be a potentially safe and effective treatment. Similarly,
zonisamide is being studied in those with frequent migraine
headaches in a research trial at the Clinic. It is an extended
long-acting medication which allows it to be taken once a
day. In general, the medication seems to be well-tolerated
and effective from open clinical use. Concerns exist related
to skin rashes, which can be serious. Levrictracam has been
studied at the clinic and is available by prescription. Our
experience suggests it to be useful in the prevention of migraine
and cluster headache. It appears to have a low likelihood
of side effects.
Botulinum toxins started as a migraine
treatment due to reports from plastic surgeons on the disappearance
of migraine headache following injection of the toxin for
treating wrinkles. A number of studies have been conducted
with it including several studies that are still ongoing at
the Clinic with botulinum toxin. To date, these studies have
suggested that it may be an effective preventive treatment
for some patients with migraine, tension- type headache and
chronic daily headache. Our clinical experience verifies these
results. There is only minimal risk of side effects or complications
with treatment. Occasionally, insurance companies are hesitant
to pay for this costly treatment.
Other natural therapies for migraine and other headaches have
been used and studied at the Clinic as well. Capsaicin, derived
from hot peppers, has been demonstrated to have analgesic
effects. Its use has been applied to headaches such as cluster.
Unfortunately, the side effects with it have been too great
to warrant continued use. Recently, a compound related to
capsaicin has been studied in clinical trials. It appears
promising and has less side effects than capsaicin.
Since its inception, the Clinic has been
one of the leading centers for research into new therapies
for headache. The pivotal studies that lead to approval of
many currently available treatments were conducted here. The
Clinic, through its research department, continues to lead
the way in the development of newer therapies and approaches
to the management of headache. Current studies are investigating
several of the triptans in special patient treatment situations.
Preventive treatment studies are focused on the development
course of the newer anti-epileptic drugs and botulinum toxin.
Patients who are interested in these newer treatments should
contact the research department for further information on
qualifying for these newest studies. Patients participating
in clinical trials receive compensation based on the number
of visits and time commitment needed for treatment and evaluation.
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