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Allodynia? Take your triptans early
Allodynia has until now been thought of as an odd little side-effect that affects some migraineurs. Now it has been found that migraineurs with allodynia (increased sensitivity of the skin) often don´t get an effect from their triptans if they take their medicine a couple of hours into the attack.In a study in Boston, USA, it was found that treatment with triptans worked in 93% of 27 attacks that were not followed by allodynia, but only in 15% of 34 attacks that were followed by allodynia was the treatment with triptans satisfactory.
The doctors concluded that it is especially important to treat attacks accompanied by allodynia early.
R. Burstein, B. Collins and M. Jakubowski, 2004. Defeating migraine pain with triptans: a race against the development of cutaneous allodynia. Ann Neurol. 55, 19-26.
Allodynia: increased sensitivity of the skin when being touched. Many migraineurs experience ´painful hair´ when they have migraine.
06-04-2006
Acute treatment
Triptans
Which triptan should I choose?
Could one of the other triptans be better for me? We all speculate that way.Now there have been comparative tests that can give us an indication about whether we take the most suitable triptan. Here are some of the measurements that have been collected by the journal 'Headache'.
Time to maximum concentration in the blood (hours) determines how fast the medicine acts. Half-life in the body indicates how long it takes for the the active ingredient to disappear; larger numbers mean that the ingredient works longer). Sulphonamide is an ingredient in some pills and some patients react to this chemical
• Imigran takes 2-3 hours to maximum concentration in the body and its half life is 2 hours; contains sulphonamide
• Zomig takes 1.5-2 hours to maximum concentration in the body and its half life is 3 hours; does not contain sulphonamide
• Naragran takes 2-3 hours to maximum concentration in the body and its half life is 6 hours; contains sulphonamide
• Maxalt takes 1-1.5 hours to reach maximum concentration in the body and its half life is 2 hours; does not contain sulphonamide
• Almogran takes 1.5-2 hours to reach maximum concentration in the body and its half life is 3 hours; contains sulphonamide
• Relpax takes 1-1.5 hours to reach maximum concentration in the body and its half life is 4 hours; does not contain sulphonamide
• Frova (not yet on the Danish market in 2003) takes 2-3 hours to reach maximum concentration in te body and its half life is 26 hours; does not contain sulphonamide
If you want a fast reaction, it is better to choose pills with rapid absorption - i.e. Zomig, Maxalt, Almogran or Relpax.
If you want a long-lasting effect, it's a good idea to choose Naragran, which takes twice as long to be excreted as Imigran, Zomig, Maxalt and Almogran. Frova, which is about to be launched, has an even longer residence time in the body.
All pills give some pain reduction among about 60% of patients after 2 hours, and side effects (greater or lesser) are common among 50% of patients, although only ca. 20% of those who took Naragran and ca. 10% of those who took Almogran reported side effects.
*Sulphonamide is an antibiotic and is used e.g. against infection of the bladder. Some people react to it with nausea, vomiting, headache, lack of appetite eczema and finally fever. If you react to it in this way, it's worth remembering which triptans contain sulphonamide. There is an additional danger that bacteria can develop resistance to sulphonamide with continued use, so the antibiotic would become ineffective against bladder infections and the like.
Time to maximum concentration in the blood (hours) Half-life in the body (How long it takes for the the active ingredient to disappear; larger numbers mean that the ingredient works longer) Sulphonamide in pills (some patients react to this chemical)*
D. W. Dodick, S. Silberstein and C. G. Dahlöf, 2002. Is there a preferred Triptan? Headache 42 (1) 1 - 7.
Uploaded 16-12-2004
Triptans and aura
It is normally thought that you should not take a triptan while you are experiencing an aura and many studies have shown that the tablets eaten while the aura is raging have no significant effect (e.g. the latest study by J. Olesen and a number of scientists from other countries (1)).A comment in the journal ‘Headache’ (2) has raised the question whether this is correct, that a tablet taken during aura doesn’t work, because the active ingredient doesn’t evaporate if the tablet is eaten 20 minutes earlier than just after the aura. The commentator concludes that the existing studies probably do not contain enough data.
So we have to conclude that this case isn't closed and recommend that migraineurs with aura should take their tablets when it is most convenient. (1) J. Olesen, H. C. Diener, J. Schoen and J. Hettiarachchi. 2004. No effect of eletriptan administration during the aura phase of migraine. Eur. J. Neurolo. 11, 671-677.
(2) Comment by S. J. Tepper and D. S. Millson, Headache 45 (2005), p. 401.
Uploaded 21-10-2006
Fat solubility is important!
One important difference between sumatriptan (the active ingredient of Imigran (Imitrex)) and zolmitriptan (the active ingredient in Zomig) is that zolmitriptan is more soluble in fat than sumatriptan. The higher fat solubility means that injected zolmitriptan can be transported more easily through the membranes that divide the blood-vessels from the central nervous system. A greater proportion of the active chemical thereby reaches the places where it works.Zolmitriptan is also absorbed more easily through the digestive system.
PSL Group Information from the Internet.
Uploaded 16-12-2004
Triptans only work sometimes
28 migraineurs took triptan for a total of 168 migraine attacks. They reported how great an effect the medicine had. 85% got relief from the medicine for at least one attack, 63% had relief in two out of three attacks, and only 44% got relief in three out of three attacks. The effect of the medicine was calculated as 'pain free after 4 hours'. Some migraineurs have to live with the thought that triptans don't work every time.C. Dahlof and M. Linde, 2000. Intra-patient consistency of response in multiple consecutive attacks treated with triptans. Cephalalgia 20, 269.
Uploaded 16-12-2004
Pregnancy and triptans
Migraineur mothers who have been given a prescription for Imigran (Imitrex) during their pregnancy had a clearly increased risk of a premature delivery (before week 37). Mothers with migraine who were not given a prescription for Imigran during their term did not have this increased risk. The data were from Nordjyllands County, Denmark from 1991 to 1996, and included 34 mothers who had taken Imigran, 89 mothers who had migraine but did not take Imigran, and 15,995 mothers without migraine.C. Olesen, F. H. Steffensen, H. T. Sørensen, G. L. Nielsen and J. Olsen, 2000: Pregnancy outcome following prescription for sumatriptan. Headache 40, 20-24.
Uploaded 16-12-2004
Blood circulation in the brain and sumatriptan
Sumatriptan (Imigran, Imitrex) increases the speed of circulation of the blood through two of the large blood vessels in the brain, but only in that side of the head where the pain is! The changes are largest half an hour after an injection of Imigran (Imitrex), and after 2 hours there's no difference between the two sides. Before the injection, the blood circulation was the same on the two sides even though the patient had migraine.R. Totaro, G. De Matteis, C. Marini, M. Baldassarre and A. Carolei, 1997: Sumatriptan and Cerebral Blood Flow Velocity Changes During Migraine Attacks. Headache 37, p. 635-639.
Uploaded 16-12-2004
Nose sprays and cream caramels
A doctor has explained in the journal Headache that some of his patients don't like the taste of triptans when used as a nose spray. He recommends that they eat a cream caramel a couple of minutes after using the spray to take away the unpleasant taste.H. J. Blumenthal, 2001. Butterscotch masks the bitter taste of sumatriptan nasal spray. Headache 41,2, 210.
Many other sweets contain compounds that may trigger migraine, hence the recommendation for sweets without added flavours or sweeteners.
Uploaded 16-12-2004
When do triptans kick in – and for how long?
We want fast relief when we take a triptan. And if the migraine returns after 8 – 24 hours, we wish the first dose had had lasted longer, so we wouldn’t need another dose.But we cannot have both; a comparison among the presently-available triptans shows that the migraine returns in 7 – 50% percent of the treated attacks. The triptan that stays in the body for the longest period is also the one that best prevents the migraine from coming back; patients taking the ones we excrete faster experience that the migraine comes back more often.
If we prefer to take one dose only, we should choose a triptan that stays in the body for a longer time. If we prefer our bodies to be free of medicine once the attack has subsided, we should choose a triptan that is excreted faster.
| Triptan | Amount | Trade name | Half life in he body, hours | % of patients who feel a significant improvement within 2 or 4(*) hours | % relapse within 24 hours |
| Rizatriptan | 10 mg | Maxalt | 2 | 65 | 50 |
| Sumatriptan | 100 mg | Imigran | 2-2.5 | 57 | 33 |
| Zolmitriptan | 2.5 mg | Zomig | 2.5-3 | 66 | 31 |
| Almotriptan | 12.5 mg | Almogran | 3.5 | 60 | 25 |
| Naratriptan | 2.5 mg | Naragran | 6 | 64* | 23 |
| Eletriptan | 40 mg | Relpax | 5 | 64 | 24 | Frovatriptan | 2.5 mg | Migard | 26 | 63* | 17 |
G. Géraud, C. Keywood and J. M. Senard, 2003. Migraine headache recurrence: relationship to clinical, pharmacological, and pharmacokinetic properties of triptans. Headache 43, 376-388.
Uploaded 02-03-2005
Triptans may be an unfortunate mix with other medicines
Two or more triptans should never be mixed. Triptans should also never be taken together with MAOIs (Mono-Amine Oxidase Inhibitors), which are used as anti-depressives.Cimetidin (used against ulcers) delays the excretion of Zomig, while Propranolol (used against high blood pressure, after a heart, attack and as prevention against migraine) increases the effect of Maxalt; so they should be used together only with the smallest dose of Maxalt. Finally, antidepressives of the type SSRI in combination with triptans or ergotamines may inflict ‘serotonine syndrome’, which includes depression, fatigue, sleep problems, heart palpitations, dizziness and a lot more.
A quarter of a million users of triptans with a total of 1.3 million prescriptions (at least 2 prescriptions during 12 months) could be identified from prescription registers in the USA and EU.
MAPO and triptans were only rarely given to the same patient (0.01 – 0.02% of the prescriptions), but 1.5% of patients were given triptans and ergotamines on the same prescription. 0.5% of the patients were given Cimetidin in combination with Zomig and 2.7% were given thea larger dose of Maxalt together with Propranolol.
Antidepressives were prescribed together with triptans to 21% of patients!
The survey was sponsored by Merck (producer of Maxalt) and the authors point out that the ‘serotonine syndrome’, due to the combination of antidepressives and triptans, is reported only rarely.
S. Tepper, C. Allen, D. Sanders, A. Greene and S. Boccuzzi, 2003. Coprescription of triptans with potentially interacting medications: a cohort study involving 240268 patients. Headache 42, 44-48.
Uploaded 02-03-2005
Information about triptans doesn't alter patients' use of them
2,445 users of triptans (all of whom used more than 20 doses in 3 months) were divided into 2 groups - half of them were just given the medicine and the other half got a pamphlet and a comprehensive verbal explanation about how they got most from their medicine.No difference was found in the use of the medicine by the migraineurs who had received the comprehensive explanation.
M. Andersen, A. Foged, D. Gaist, J. Søndergaard. 2003. Extended information to triptan users. A randomised, controlled study. Lecture at Danish Pharmacology 2003, 22nd January 2003.
The Danish Migraine Association suggests that most migraineurs learn quickly to administrate their triptan use themselves in a way that is satisfactory for them.
Uploaded 16-12-2004
Triptans only once for 1/3 of migraineurs
A Dutch study shows that about half of the people whose first prescription is for ergotamines and about a third of people whose first prescription is for triptans do not return to the doctor for repeat prescriptions for these medicaments. The same tendency is found for Danish patients.The Danish Migraine Association of course speculates whether this could be because the diagnosis of migraine is so specific that not all who are diagnosed with migraine in fact suffer from it. If they don't have migraine, patients clearly have no need to to renew their prescriptions.
H. Rahimtoola, A. C. B. Egberts, H. Buurma, C. C. Tijssen and H. G. Leufkens, 2001. Patterns of ergotamine and sumatriptan use in the Netherlands from 1991 to 1997. Cephalalgia 21, 596 - 603.
Uploaded 16-12-2004
Triptan cream maybe a possibility in the future?
New methods of taking triptans are being studied. A team of Spanish scientists has shown that Sumatriptan (the active ingredient in Imigran (Imitrex)) can be absorbed through the skin of pigs’ ears when it is applied to them together with the chemical R-limonene. R-limonene is a solvent that is used in e.g. some insect repellents. It is a synthetic version of d-limonene which is obtained from the skins of citrus fruits (oranges and lemons etc.). Limonene can cause allergies, so maybe we'll not be able to use the smell of oranges to identify those of us who have migraine.A. Femenýa-Fonta, C. Balaguer-Fernandeza, V. Merinob, V. Rodillaa and A. Lopez-Castellano, 2005. Effect of chemical enhancers on the in vitro percutaneous absorption of sumatriptan succinate. European Journal of Pharmaceutics and Biopharmaceutics 61, 50–55.
Uploaded 21-10-2006
Ergotamine or triptan?
In Austria many people still use ergotamine for migraine, possibly because this treatment is cheaper than triptans.The total costs in Austria for ergotamines in 1999 were €700,000, and €300,000 were spent during the same period to detoxify people who overdosed on ergotamine until they had serious side-effects.
96 patients were detoxified during which they spent 11 days in hospital. The most important side-effects of ergotamines were nausea, dizziness, fatigue, poor circulation in the feet and one case of a rectal ulcer.
The Austrian doctors think that on average it takes 1.7 years to develop an overuse of triptans and about 2.7 years for an overuse of ergotamines. The doctors think that it is difficult to compare the economic aspects, the side-effects and the quality of life aspects of the two types of medicine, but ergotamine, despite the many detoxifications, gives cheaper treatment, while triptans give fewer side-effects and correspondingly less need for prevention.
C. Lampl, A. Buzath, K. Yazdi and P. S. Sandor, 2002. Ergot and triptan overuse in Austria - an evaluation of clinical data and cost. Cephalalgia 22, 807-811.
Uploaded 16-12-2004
Take your medicine early during an attack
For many years, the done thing has been to wait until a migraine attck was fully developed before taking medicine. Without having any basis for doing so, doctors assumed that we couldn't be sure that we had migraine before we were really suffering.Now two studies have shown that triptans work more effectively if we take our medicine early during an attack. The effect shows up as an earlier reduction in pain and a corresponding improved ability to restart daily activities within an hour of taking taking the pill.
X. H. Hu, N. H. Raskin, R. Cowan, L. E. Markson and M. L. Berger, 2002. Treatment of migraine with rizatriptan: when to take the medication. Headache 42, 16 - 20.
J. Pascual and X. Cabarrocas, 2002. Within-patient early versus delayed treatment of migraine attacks with almotriptan: the sooner the better. Headache 42, 28-31.
Uploaded 16-12-2004
Choice of medicine
A study of migraineurs' medicines of choice showed that about half of patients who came to a clinic in Illinois, USA, took triptans and no other medicine for their migraine. About 21% used over-the-counter pain-killers exclusively and about 18% took both triptans and over-the-counter medicine. The patients had reasons for their choice of treatment. The exclusive users of triptans chose them because they were effective, while the reasons given by users of over-the-counter medicines were especially because of fewer side-effects.L. Robbins, 2002. Triptans versus analgesics. Headache 42, 903-907.
Uploaded 16-12-2004
What do we want from medicine?
A group of German scientists asked many (418) migraine patients and a smaller group (22) of neurologists what they thought was most important in choosing a medicine against migraine.Being completely free of pain was most important for 61% of the patients. The doctors generally did not think that being pain-free was most important (only 31% of them put that criterion on top). 78% of patients thought that a medicine that gave fewer side effects but worked more slowly was better than one that worked rapidly but had more side effects. 90% of the doctors prefered to write a prescription for the slow-working medicine with few side effects. 68% of the doctors would rather prescribe the cheapest medicine if there were a choice between two types with the same side effects, but only 25% of the patients thought that the price was important. 80% of the patients thought that there were reasons for taking preventive medicine if they had 4 or more attacks per month.
Earlier studies (from the USA, UK and Italy) had concluded that patients wanted a rapid effect more than anything else. 56% of patients thought that they might not be able to function completely on days when they had migraine even though they took medicine against their attack.
E. Leinisch-Dahlke, E. Akova-Öztürk, U. Bertheau, I. Isberner, S. Evers and A. May, 2004. Patient preference in clinical trials for headache medication: the patient's view. Cephalalgia 24, 6347-355.
Uploaded 30-10-2005
How quickly does medicine start to work?
An injection works quickly – peak concentration is reached after only 20 minutes, but excretion is also relatively fast.Pills take longer to reach peak concentration in the blood – about two hours. The greater the dosage, the larger peak concentration in the blood. Suppositories are absorbed faster than pills, and excreted faster as well.
A nasal spray gives the smallest concentration in the blood for the same dose.
After A. W. Fox, 2004. Onset of effect of 5-HT 1B/1D agonists: a model with pharmacokinetic validation. Headache 44, 142-147.
Uploaded 02-03-2005
Pills are preferred by migraineurs
To take triptans, we can choose between pills, disolvable tablets, suppositories, nose-sprays and injections. A study from the USA has shown that, even though use of a nose-spray or injection means that the active ingredient is absorbed faster than tablets, most patients nonetheless prefer pills. Doctors now speculate that that may be because a nose-spray leaves an unpleasant taste.Only migraineurs who experience strong nausea are prepared to choose nose-sprays instead of tablets.
A. M. Rapoport, M. E. Bigal, S. J. Tepper and F. D. Sheftell, 2004. Intranasal medications for the treatment of migraine and cluster headache. CNS-Drugs 18, 671-85.
Uploaded 30-10-2005
When should an attack be treated?
A study sponsored by AstraZeneca (producer of Zomig) compared the effect felt by 136 patients who took their pills within 15 minutes of first experiencing an attack with those felt by 53 patients who took their pills 30 minutes after the start of an attack.Both groups experienced a significant effect compared with a placebo group, but no comparison was made between the effects of taking the pills less than 15 minutes after the start of an attack and taking the pills between 15 and 30 minutes. The scientists concluded that it is important to find a medicine that can be taken while the attack is still mild (1).
Employees of GlaxoSmithKline (producers of Imigran) studied the same problem. In this study, 83 patients took their medicine immediately after recognising an attack and 70 patients took theirs later (when the pain was moderate to strong). This study found that the patients who took their medicine immediatly got the greatest effect. There were more side-effects from the medicine in the group that took their medicine immediately, but the article gives no information about whether the differences were significant between the group that took their medicine immediately and the group that waited (i.e. whether the reported difference can be trusted) (2).
The papers got a reaction from the editor of the journal Cephalalgia and he commented that there still are no results that give any clear reasons for recommending early treatment as long as you know that the pills work effectively (3).
(1) J. Klapper, C. Lucas, Ø. Røsjø and B. Charlesworth, 2004. Benefits of treating highly disabled migraine patients with zolmitriptan while pain is mild. Cephalalgia 24, 918-924.
(2) J. Scholpp, R. Schellenberg, B. Moeckesch and N. Banik, 2004. Early treatment of a migraine attack while pain is still mild increases the efficacy of sumatriptan. Cephalagia 24, 925-933.
(3) M. D. Ferrari, 2004. Should we advise patients to treat migraine attacks early? Cephalagia 24, 915-917.
Uploaded 06-04-2006
Triptans should be taken after an aura
Migrainerus who experience aura know very well that they get a migraine attack immediately afterwards. It is therefore tempting to take a triptan while the aura is still happening. 123 patients were given a triptan (eletriptan) or a placebo while the aura was happening and their reaction was measured 6 hours after taking the pill.There was no significan difference between the effect of the triptan or the placebo if taken during aura. So the scientists advise that a triptan should first be taken after an aura has ceased.
J. Olesen, H. C. Diener, J. Schoenen and J. Hettiarachchi, 2004. No effect of eletriptan administration during the aura phase of migraine. Eurpean Journal of Neurololy 11, 671-7.
Uploaded 06-04-2006
Are you a triptan user? – if so, remember that...
Side-effects of triptans can include:
Less common side-effects can be a burning sensation in the skin or dryness in the mouth.
It is normally thought that taking a second triptan if the first does not work will have no effect. Many patients have, none-the-less, the experience that one dose is insufficient and that tablet number 2 can tame an attack.
The effect of a triptan is greatest if it is taken early in an attack. Remember that, if you experience aura, you should not take the triptan until the aura has disappeared.
From J. F. Rothrock, 2007. Patient information regarding subcutaneous self-administration of Sumatriptan (Imitrex). Headache 47, 639.
Uploaded 28-08-2008
Triptans don't work for everyone
About 3 in 10 migraineurs experience no effect within two hours of taking any specific triptan. This is, of course, unsatisfactory and other triptans should be tried to see if they work better.A number of studies have compared Imigran (Imitrex) with one of the other triptans (Almogran, Maxalt, Naragran, Relpax og Zomig) and each of these studies showed that some patients (but not all) who got no improvement from Imigran could get a reaction from one of the other medicines. They also discovered that one in three migraineurs did, in fact, get an effect during the study within 2 hours of Imigran being given even though the patients themselves thought that Imigran had no effect on them. The doctors thought that this may have happened either because the patients hadn't taken a big enough dose or because they had taken the medicine too late during an attack.
The doctors also thought that the lack of effect from Imigran could be caused by the patients having medicine-induced migraine (caused by too great a use of over-the-counter medicine), or that they had not absorbed the active ingredient of the triptan. One out of three migraineurs had experienced no effect from at least one treatment by a triptan, regardless of which triptan they used. The doctors measured this by looking at what effect was caused by three treatments, one after the other.
The doctors recommended that patients should be offered several different triptans if the first one doesn't work satisfactorally.
D. W. Dodick, 2004. Triptan Nonresponder Studies: Implications for Clinical Practice. Headache 45, 156 - 162.
Uploaded 06-04-2006
The differences between how the various triptans affect the basilar artery
A study using pieces of human basilar artery showed that Sumatriptan/Imigran affected these blood vessels more than Zolmitriptan (Zomig) and Naratriptan (Naragran/Naramig).The diameter of the basilar artery in most migraineurs does not change during a migraine attack. The scientists therefore conclude that Zomig and Naramig/Naragran are more specific in their effect than is Sumatriptan.
S. A. Silva, F. B. Marquesa and C. A. Fontes Ribeiro, 2007. Characterization of the human basilar artery contractile response to 5-HT and triptans Fundamental & Clinical Pharmacology 21, 265.
Uploaded 28-08-2008
Other acute medication
HIV and migraine - be careful with ergotamine!
There now are several reports about unpleasant combinations of HIV medicine protease inhibitors and ergotamine. At least 8 patients have had serious side-effects in the form of gangrene or have actually died because of the combination.The latest report describes an HIV patient who got continuous migraine-like headache and who then died after taking three Cafergot pills (Ergokoffin) over a period of 48 hours.
The problem happens because ergotamine breaks down a chemical that is strongly inhibited by ritonavir, the active ingredient in HIV medicine.
M. A. Tribble, C. R. Gregg, D. M. Margolis, R. Amirkhan og J. W. Smith, 2002. Fatal ergotism induced by HIV protease inhibitor. Headache 42, 694-695.
Uploaded 16-12-2004
CGRP and BIBN
CGRP and BIBN are acronyms we should remember. CGRP is a chemical that is released into the blood vessels in the brain during a migraine attack. It works as a neurotransmitter that causes the blood vessels to enlarge.BIBN in fact is called BIBN4096BS, but its more popular name is BIBN (pronounced 'bibben'). It is a chemical that breaks CGRP down, hereby causing the blood vessels in the brain to contract again. It is hoped that BIBN can be developed into a new type of migraine medicine that will have fewer side-effects than triptans, because BIBN works in precisely the same places as CGRP.
BIBN has been tried on healthy people and only a few minor side-effects were found. Tiredness and reduced muscle strength were the most common. BIBN breaks down rapidly in the body so the amount in the blood is halved every 2 1/2 hours.
(1) I. Edvinsson, 2004. Blockade of CGRP receptors in the intracranial vasculature: a new target in the treatment of headache. Cephalalgia 24, 611-622. (2) M. Iovino, U. Feifel, C.-L. Yong, J.-M. Wolters and G. Wallenstein, 2004. Safety, tolerability and pharmacokinetics of BIBN 4096 BS, the first selective small molecule calcitonin gene-related peptide receptor antagonist, following single intravenous administration in healthy volunteers. Cephalalgia 24, 645-656.
Uploaded 30-10-2005
Preventive medication
The effect of preventive medicine is more important that its side-effects
Most of us would like medicine completely without side-effects. Of course.125 migraineurs in USA and 125 migraineurs in Brazil were asked about their attitudes to side-effects from a number of preventive medicines. They had to prioritise what they found most important among the following: reduction in the number of days with migraine, how rapidly the medicine took effect, price, side-effects, how the medicine had to be taken, and how often it had to be taken.
The reduction in the number of days with migraine was highest priority. Next most important was that the medicine acted rapidly. In general, the migraineurs of course wanted fewer side-effects, but when they were asked about which side-effects they most wanted to avoid, most people wanted not to be tired. Increase in weight and difficulty in concentrating were somewhat less of a problem.
In general, the migraineurs chose the most effective medicine regardless of its side-effects such as weight gain, difficulty in concentrating and tiredness.
The data here comes from the answers the migraineurs gave. We do not know what they actually do in daily life.
M. F. P. Peres, S. Silberstein, F. Moreira, F. Corchs, D. S. Vieira, N. Abraham and C. Gebeline-Myers, 2007. Patients’ preference for migraine preventive therapy. Headache 47, 540-545.
Uploaded 28-8-2008
Preventive medicine made rats less able to learn
Studies have now shown that rats that have been given epilepsy medicine are less able to learn as well as having shortened short-term memories and difficulties in concentrating (1).These effects have been shown in a number of studies paid for by the producers of the medicines. Each study shows that the medicine produced by the founder of the study gives lesser effects than other epilepsy medicines (see e.g. (2)).
Luckily a single study shows that the loss of learning ability and short-term memory is recovered after the medicine is no longer used (3).
(1) H. E. Shannon and P. L. Love, 2007. Effects of antiepileptic drugs on learning as assessed by a repeated acquisition of response sequences task in rats. Epilepsy Behav. 10,16-25.
(2) D. Blum, K. Meador, V. Biton, T. Fakhoury, B. Shneker, S. Chung, K. Mills, A. Hammer and J. Isojarvi, 2006. Cognitive effects of lamotrigine compared with topiramate in patients with epilepsy. Neurology 67, 400-6.
(3) M. E. Smith, A. Gevins, L. K. McEvoy, K. J. Meador, P. G. Ray, and F. Gilliam, 2006. Distinct cognitive neurophysiologic profiles for lamotrigine and topiramate. Epilepsia 47, 695-703.
Doctors are very reluctant to give epilepsy medicine to children with a lot of migraine.
Uploaded 28-8-2008
Tingling of the fingers while taking Topamax means that it more effective against migraine
That's the conclusion of a study carried out in South Korea. 118 migraine patients took Topamax (100 mg/day) and were asked how they felt after 3 and 6 months. There was, of course, also a control group. It was found that those migraineurs who experienced tingling in their fingers and possibly also in other parts of the body while they took Topamax also had the greatest reduction in number of days with migraine. S.-T. Lee, K. Chu, J.-E. Park, H.-J. Park, J.-H. Park, S.-H. Lee and M. Kim, 2007. Paresthesia as a favorable predictor of migraine prophylaxis using topiramate European Journal of Neurology 14, 654–658.Uploaded 28-8-2008
The effect of a placebo is large compared with the effect of Topamax
384 migraineurs took Topamax and 372 took a placebo after 2 weeks without taking any medicine against their attacks. They took either the placebo or Topamax (25 mg per day increasing to 100 mg per day) for 26 weeks. The migraineurs had experienced between 3 and more than 15 migraine days per month before the start of the study and had to have used triptans on 8 days per month at most. The group therefore consisted of a mixture of many migraineurs who were not heavily affected and a smaller group of heavily affected migraineurs.The average fall in migraine days per month was from about 7 to about 4 in those who took Topamax. Those who took the placebo also experienced a fall in migraine days per month, from about 7 to about 5 at the conclusion of the study.
People who had few migraine days per month had, as expected, less effect than those who had many. Generally the effect of Topamax was less than double that of the placebo. Migraineurs with more than 15 migraine days per month before the study had their number of attacks reduced. Those who took the placebo by 6 days per month while the users of Topamax experienced a fall of 10 migraine days per month.
The amount of attack medicine used fell as expected among the hardest hit. Among the group who experienced more than 15 migraine days per month before the study, it fell by 5 treatment days per month for those who took the placebo and 6.5 days per month for those who took Topamax.
About 1 in 3 participants in the study got more migraine during the study period. There was no difference between the placebo group and the Topamax group.
The scientists concluded that Topamax does have some effect, especially in reducing the amount of chronic migraine.
V. Limroth, D. Biondi, J. Pfeil and S. Schwalen, 2007. Topiramate in patients with episodic migraine: reducing the risk for chronic forms of headache. Headache 47, 13-21.
It is true enough that Topamax had an effect, but the placebo also had a substantial effect. This should have been subtracted from the effect of Topamax to find its true effect. If this is done, then the real effect of Topamax is a reduction of 1 migraine day per month on average and a greater effect of about 4 days per month among the hardest hit.
Uploaded 28-8-2008
Preventative treatment often lasts for only a limited period
A study from the Netherlands showed that migraineurs who take prophylactic medicine commonly give up using the medicine after only a short period. About half of those who began prophylactic treatment had stopped within 3 months.Migraineurs who took valporat continued for longer than those who took beta-blockers, clonidin or flunarizin. Only about 20% of patients were continuing with the last-named drugs after a year.
The authors of the study note that they do not know why patients stop using their medicine. It could be because they thought that they no longer needed the treatment, or because side effects were so serious that they would rather avoid the medicine.
H. Rahimtoola, H. Buurma, C. C. Tijssen, H. G. Leufkens and A. C. G. Egberts, 2003. Migraine prophylactic medication usage patterns in the Netherlands. Cephalalgia 23, 293-301.
Uploaded 16-12-2004
Preventive treatment can give weight increases
We gain about 2–4 kilos (5–10 pounds) in weight if we take preventive medicine against migraine. In general, flunarizin gives the biggest weight increases (4.5 kg, 10 pounds) and propanolol the least (2.5 kg, 5 pounds). About half of those treated return to the weight they had at the start of the treatment if they stop taking the medicines.A. Granato, F. maggioni, F. Mainardi, F. Dainese, C. Lisotto and G. Zanchin, 2000. Bodyweight changes during prophylactic treatment of headache. Cephalagia 20, 307.
Uploaded 16-12-2004
Preventive treatment of migraine
Preventive treatment of migraine is used primarily to avoid attacks, but also to reduce their number and intensity. Several different types of medicine can be used: beta-blockers, calcium channel blockers, alpha agonists, NSAID and ergotamines.Beta blockers are also called beta-adrenergic blockers, as they stop the activity stimulated by adrenalin (when angry or excited) in the receptors that determine the tension in the smooth muscles in the blood vessels.
That means that beta-blockers counteract arteries dilating in the head. They also counter cramps in the vessel walls, and make the heart beat more slowly. This reduces the systolic pressure (the high number from a blood pressure measurement).
The muscles in the blood vessels are smooth muscles. Smooth muscles are found in the intestines and the blood vessels. Smooth muscles only relax when specific signals make them do so - otherwise they are active and keep a suitable tension. When the smooth muscles in the artery walls do not receive any signals, they pull together and the artery diameter gets smaller, and less blood can pass.
The normal situation is a steady stream of signals to the smooth muscles which produces a reasonable tension in the artery walls. Beta-blockers stop some of this and the vessels contract.
Clearly this may counteract the precipitation of a migraine attack, as this comes when the arteries in the head contract and later dilate more than usually. Beta-blockers ensure that the 'wrong' messages do not reach the signal receptors' smooth muscles in the arteries - they are blocked. Ca-agonists also influence the smooth muscles in the arteries, but ensure that the vessels in the periphery of the body are dilated. Ca-agonists operate directly on the smooth muscles, which relax because they run short of Ca.
In short beta-blockers and Ca-agonists cause opposite reactions, but both make sure that the artery walls get the message to keep up a suitable muscle tone, and thus work as migraine prevention.
Beta-blockers as well as Ca-agonists influence the heart rhythm, so it becomes slower. Also users have a tendency to increase weight from both.
Uploaded 16-12-2004
Dextoxification improved things for two out of three
Far too many people develop medicine-induced migraine. Consequently American scientists studied what and how much medicine was used by patients with 'chronic migraine' (patients with migraine that lasted more than 4 hours on more than 15 days a month). The results were impressive!Some folk ate up to 30 pills per day (of various types of medicine). The average was, however, only 5.2 pills per day but 11% of the chronic migraineurs took more than 10 tablets every day. About 70% of those with chronic migraine took 3 – 8 pills every day. Two out of three chronic migraineurs took more than one medicine. About ⅓ took preventive medicine together with a large amount of migraine medicine before they were detoxified.
All the patients went through a detoxification and were contacted again after a year. If, after a year, they were no longer chronically ill, but took medicine only now and again for migraine attacks, their treatment was classified as 'successful'. All patients (both successes and those who continued to have chronic migraine) were offered preventitive treatment after their detoxification.
Seventy per cent of the chronic migraineurs were 'successes'. The others still had chronic migraine a year after being detoxified. There was no difference between the two groups ('successes' and the others) in psychology, education, race or sex.
M. E. Bigal, A. M. Rappoport, F. D. Sheftell, S. J. Tepper og R. B. Lipton, 2004. Transformed migraine and medication overuse in a tertiary headache center - clinical characteristics and treatment outcomes. Cephalalgia 24, 483 - 490.
Uploaded 26-05-2005
Detoxification gives a better life to migraineurs with a large number of attacks - but only for a short time
About 25,000 Danes suffer from migraine nearly every day. Most of them could probably feel much better if they got their use of medicine under control. A detoxification - i.e. a period without medicine against attacks - halves the number of migraine days, reduces the use of medicine to a quater and gives migraineurs a much better life, both 6 and 12 months after detoxification, writes a team of scientists from Italy and the USA (1).Unfortunately there is a tendency for people to increase their use of medicine again after detoxification. Earlier studies have shown that only about one in three had less use of medicine 2 years after their detoxification (2).
German scientists writing in The Lancet say that at 1% of the population of Europe, North America and parts of Asia have migraine because of their overuse of painkillers or other medicine taken for migraine attacks. There is only one method of treatment - detoxification (3).
(1) L. Grazzi, F. Andrasik, D. D'Amico, S. Usai, S. Kass and G. Bussone, 2004. Disability in chronic migraine patients with medication overuse: Treatment effects at 1-year follow-up. Headache 44, 678-683.
(2) G.G. Tribl, P. Schnider, C. Woeber, S. Aull, A. Auterith, K. Zeiler and P. Wessely, 2001: Are there predictive factors for long-term outcome after withdrawal in drug-induced chronic daily headache? Cephalalgia 21, 691-696.
(3) H. C. Diener and V. Limmroth, 2004. Medication-overuse headache: a worldwide problem. The Lancet Neurol. 3, 475-483.
Uploaded 30-10-2005
Preventive medicine - how long time should it be taken?
That's a question without a unique answer. It is easiest to say that it all depends ..., but now there are a couple of studies that give something to build on. Most migraineurs resume attacks at the same intensity as before if they stop taking their preventive treatment after 8 weeks. If they continue with the treatment for 6 months, there is probably an effect that continues after the period of treatment, if the patient has had migraine for only a few years and does not suffer from depression or fibromyalgia. If someone has had migraine for many years, suffers from depression and/or fibromyalgia in addition to migraine, the advice is to continue with preventive treatment for 12 months. It may be best to decrease the treatment very slowly rather than stop suddenly (1).The above is based on the experience of a number of migraine doctors in the USA and the preventive treatment is topiramat (that is marketed under the name Topimax in Denmark), which is a treatment for epilepsy. The drug has a number of side-effects, such as difficulty in concentrating, muscle weakness, speech problems and loss of weight. Only 40% of a group of 487 migraineurs studied stopped taking the medicine before completion of the study period (2).
(1) E. Loder and D. M. Biondi, 2004. When can successful migraine prevention be discontinued? Headache 44, 1040-1042.
(2) Ugeskrift for Læger 14. juni 2004, nr. 25.
Uploaded 06-04-2006
Topiramat works as a preventative only for some people
An American study of 170 patients with migraine nearly every day has shown that treatment with Topiramat as a preventative was only marginally more effective than treatment with a placebo. The patients were given 25 mg every evening for a week followed by 25 mg morning and evening for a week and finally 50 mg morning and evening.32% did not complete the course because of side effects, so 116 patients were evaluated for the effects of Topiramate. 39% of the 116 patients who completed the treatment experienced substantial improvement from the treatment (defined as halving or more of the number of attacks in a month). Those who experienced no improvement from the treatment were especially those patients who had had migraine nearly every day for more than 6 months or who had tried (but experienced no improvement from) 3 or more preventative treatments.
J. F. Rothrock, V. A. Parada, R. Drinkard, R. M. Zweifler og K. F. Key, 2005. Predictors of a negative response to Topiramate therapy in patients with chronic migraine. Headache 45, 932-935.
Uploaded 21-10-2006
Side effects
Imigran (Imitrex) may increase pain (apart from migraine)
Some users of Imigran injections in New Zealand and the Netherlands have experienced that pains from inflammations (rheumatism, appendicitis etc.) or physical damage such as sunburns, small surgery and muscle pain could be worsened by Imigran. A few users if Imigran tablets have reported the same side-effect.The sensation of pain after a dose of Imigran was experienced as serious by the patients and lasted longer than usual. The pain began 5 minutes after the injection.
D. M. Coulter, J. L. M. Passier, D. W. J. Clark and E. P. van Puijenbroek, 2003. Activation of pain by sumatriptan. Headache 43, 994-998.
Uploaded 02-03-2005
Doctors do not tell about side-effects
A group of Danish scientists have studied whether doctors talk honestly to their patients about side-effects from the medicine they prescribe. They sent a questionnaire to 450 general practitioners. There was considerable difference in what and how much information each individual doctor gave his patients. In situations where the doctor himelf decided that there was a significant and serious side-effect, only 33% of the doctors would always inform the patient, 44% would often give information, while 23% would either never or only occasionally inform their patients.That means that two-thirds of doctors would not be in conformity with the advice given by the Danish Department of Health that says that patients must always be informed about frequent serious side-effects.
Patients should normally be informed about serious side-effects. They should also be informed about less serious but frequent side-effects.
A. Krag, H. Svarre Nielsen, M. Norup, S. M. Madsen and P. Rossel, 2004. Research report: do general practitioners tell their patients about side effects to common treatments? Social Science & Medicine 59, 1677-1683. Reported in the Danish health magazine 'HelseNyt'.
Uploaded 06-04-2006
Side effects worry migraineurs
A questionnaire study of 1160 American migraineurs showed that 3 out of 4 thought it especially important that their medicine took their pain away and that it worked quickly. 2 out of 3 had, on one or more occasions, avoided taking their medicine because they were worried about side-effects. The fear of side-effects caused every third attack to be treated later than optimally and nearly every second attack wasn't treated with medicine at all. 8 out of 10 migraineurs were very interested in trying new types of medicine with fewer side effects.R. Michael Gallagher and Robert Kunkel, 2003. Migraine Medication Attributes Important for Patient Compliance: Concerns About Side Effects May Delay Treatment. Headache 43, 36.
Uploaded 16-12-2004
Aspartame in dissolvable tablets causes extra migraine
A boy of 14 who drank excessive amounts of artificially-sweetened fizzy drinks had migraine nearly every day. When he gave up his intake of aspartam his migraines became reduced to a couple of attacks a month. Those attacks could be treated using triptans. He preferred dissolvable tablets, but they made his migraine worse. Maxalt worked well as ordinary pills.A woman of 36 had had migraine for 30 years. She avoided monosodium glutamate, nitrite and aspartam and found that this reduced the number of attacks. She could treat her attacks with triptans, including Maxalt pills, but when she tried dissolvable tablets her migraine became worse.
There is 3.75 mg aspartam in the dissolvable tablets. 8% of 171 migraine patients had migraine attacks more often when the consumed products containing aspartam than the equivalent with ordinary sugar. Saccharine is not thought to have this effect. Chewing gum containing aspartam can also trigger migraine.
L. C. Newmann and R. B. Lipton, 2001. Migraine MLT-down: An unusual presentation of migraine in patients with aspartame-triggered headaches. Headache 41, 899-901.
Uploaded 16-12-2004
Zomig and Imigran make us impulsive and a little dozy!
At long last a study has been made about the effects triptans have on how we ordinarily feel. 16 healthy women were given dozes of Imigran and Zomig on different days and were given a placebo on other days. They were subjected to a series of tests to find out how they reacted with and without the medicine in their bodies. Among other things, they were tested as to how they reacted to various words and pictures. This test showed that the triptans caused a faster reaction time, but increased the error rate. The researchers conclude that the triptans increase impulsivity to some extent.At the same time, the subjects became a little dozy because of the medicine. They reacted more slowly to sound than when they were without the medicine.
J. van der Post, M.T. Schram, R.C. Schoemaker, M. S. M. Pieters, E. Fusseau, A. Pereira, S. Baggen, A. F. Cohen and J. M. A. van Gerven, 2002 CNS effects of sumatriptan and rizatriptan in healthy female volunteers. Cephalalgia 22, 271-281.
Uploaded 16-12-2004
Triptans and the heart
Imigran (Imitrex) (and presumably also the other triptans) reduces the diameter of the coronary artery by 10 – 12%. This is a significant reduction in the coronary artery’s capacity, says a comment in the journal Headache.Cephalalgia 1999, 19, 651-654.
Uploaded 16-12-2004
Liver function and triptans
Triptan is excreted primarily through the liver. Studies have nonetheless shown that patients with much reduced liver functions have a blood-content of the break-down products from triptan. The medicine had no apparent side-effects, but patients with severe liver damage should use it repeatedly only with great care.J. Clin. Pharmacology 38, 694-701, 1998.
Uploaded 16-12-2004
Adaptation to triptans faster than to other medicines!
13 doses of triptan a month for one year can lead to 'transformed migraine' i. e. headache that is caused by (overdose of) a medicine. Similar effects happen for ergotamine, from ca. 40 doses per month after ca. 2½ years and after 4 years intake of about 85 doses a month of pain-relieving medicines.Z. Katsarava, G. Fritsche, H. C. Diener and V. Limmroth, 2000. Drug-induced headache (DIH): following the use of different triptans. Cephalalgia 20, 293.
Uploaded 16-12-2004
Coronary artery narrowing and high cholesterol, problems with triptans
The new medicines against migraine cause various vessels in the brain to contract, but the coronary artery coming from the heart also contracts. You should therefore not take triptans (or ergotamines) if you have narrowing of the coronary artery or high blood cholesterol, which can lead to deposits in the coronary artery.Doctor's Guide to Medical & Other News 6. July 1998.
Uploaded 16-12-2004
Imigran (Imitrex) gives less energy in the muscles
A study of both healthy people and migraineurs showed that migraineurs, especially those who had noticed side-effects from Imigran (Imitrex), had less energy in their leg muscles, when they undertook gymnastic exercises on a special fitness apparatus. Migraineurs with aura were especially affected. The authors suggest that the cause is contraction of the blood-vessels in the leg muscles.M.D. Boska, K.M.A. Welch, L. Schultz and J. Nelson, 2000: Effects of the anti-migraine drug sumatriptan on muscle energy metabolism: relationship to side-effects. Cephalalgia 20, 39-44.
Uploaded 16-12-2004
Imigran injections increase the liberation of growth hormone into the blood
Most migraineurs and others get an increased content of growth hormone in their blood when they are injected with Imigran (Imitrex). The increased liberation lasts for an hour. A group of Italian scientists therefore advise against taking large amounts of Imigran (Imitrex), because the long-term effects of the increased growth hormone amounts is as yet unknown.About 20% of both migraineurs and others do not react by increasing the amount of growth hormone in their blood. As yet it is not known whether they are the same people who get no effect from Imigran (Imitrex).
L. Pinessi, I. Rainero, L. Savi, W. Valfrè, P. Limone, P. Caævelli, P. Del Rizzo, L. Gianotti, M. Taliano, E. Ghigo and E. Arvat, 2000. Effects of subcutaneous sumatriptan on plasma growth hormone concentrations in migraine patients. Cephalagia 20, 223-227.
Uploaded 16-12-2004
We mix medicines
1160 American migraineurs were asked about their use of medicine. Three out of four preferred a quick and efficient pain relief, while two out of five thought that it was important to avoid having side-effects. Two out of three postponed taking their medicine now and again because of concerns about side-effects. Eight out of ten were willing to try new products with fewer side-effects.92% of the patients used over-the-counter medicine (OTC), 30% used triptans, 29% used alternative treatments and 16% used products they had found themselves (the sum is larger than 100% because many used more than one type of treatment). Among those that took prescription medicine, more than half also used OTC and 12% used alternative remedies. 27% took only OTC.
Prescription medication was used early in just over half of the attacks recorded during 6 months, but 29% of attacks were treated late, because the patients did not have access to their medicine, did not have pills enough (22% of attacks) or because of worries about side-effects (15%). 23% preferred OTC and 18% preferred alternative treatment because of worries about side-effects of prescription medicines.
One out of five prescriptions for Imigran/Imitrex were not used, either because of economic problems or because of worries about side-effects. 16% of migraineurs had experienced side-effects from the prescription medicine they used currently and 37% had experienced side-effects from prescription migraines they had used previously.
R. M. Gallagher and D. O. R. Kunkel, 2003. Migraine medication attributes important for patient compliance: concerns about side effects may delay treatment. Headache 43, 36-43.
Uploaded 02-03-2005
Side effects from triptans
Around 15% of triptan users report side-effects. Now some numbers have been put on how many get side-effects from each of the various brands, effects such as strange dreams, speaking difficulties, muscle weakness, problems with walking in a straight line, ordinary confusion, dizziness, tiredness, sleep disturbance, difficulty in thinking and trembling. These side-effects are caused by the effects of triptans on the central bnervous system (the brain and spinal cord).There are - of course - fewer side-effects if you take a smaller dose of triptans. But there is a big difference between the various triptans in how many people get side-effects from them (see the figure).
The most commonly reported side-effects are tiredness/sleepiness, problems in thinking clearly, heart palpitations and dizziness. Two out of three migraineurs have, at some time or other, given up using triptans from fear of side-effects.
D. W. Dodick og V. Martin, 2004. Triptans and CNS side-effects: pharmacokinetic and metabolic mechanisms. Cephalalgia 24, 417-424.
Uploaded 26-05-2005
One percent of all patients take an overdose of medicine
Of 49,064 Norwegian adults, 1.2% of women and 0.6% of men had chronic headache or migraine at the same time and they were taking an overdose of medicine (painkillers nearly every day for 12 months or more). Very few (0.1%) took a lot of painkillers and did not have migraine or headache (1). In Spain, 1.4% of of the population have chronic headache or migraine because of painkiller overdose, but there it is thought that only about 1 in 3 people taking an overdose develop heaache or migraine (2).(1) J.-A. Zwart, G. Dyb, K. Hagen, S. Svebak, L. J. Stovner og J. Holmen, 2004. Analgesic overuse among subjects with headache, neck, and low-back pain. Neurology 62(9) 1540-1544.
(2) R. Colás, P. Muñoz, R. Temprano, C. Gómez og J. Pascual, 2004. Chronic daily headache with analgesic overuse: Epidemiology and impact on quality of life. Neurology 62(8) 1338-1342.
Uploaded 26-05-2005
Elasticity of the coronary artery is less after large doses of triptan
Scientists gave rats sumatriptan (Imigran) or zolmitriptan (Zomig) every day for 14 - 18 days in doses about 10 times those that patients get. Afterwards the rats were studied to find out if any changes had happened to the elasticity of the coronary artery and of the basillary artery in their heads.After 4 weeks, the coronary artery of the treated animals could no longer compress as much as those of the control animals. The ability of the basillary artery (from the brain) to contract did not change in the same way.
We do not know if the results can be applied directly to people.
U. Reuter, S. Salomone, G. W. Ickenstein and C. Waeber, 2004. Effects of chronic sumatriptan and zolmitriptan treatment on 5-ht1 receport expression and function in rats. Cephalalgia 24, 398-407.
Uploaded 30-10-2005
Over-dosing on medicine gives migraine nearly every day
As little as one year after the first triptans came onto the market, a few migraineurs were diagnosed as having medicine-induced migraine. So it takes only a very short time to develop this unpleasant form of migraine. As a rule of thumb (and of course this number is only an indication) 18 triptan doses per month for a year is enough to develop medicine-induced migraine. Medicine-induced migraine can also develop by taking about 37 doses of ergotamin or a little over 100 doses of pain-killers per month.Women are most affected
Women have a slightly greater tendency than men to develop medicine-induced migraine, even when allowance is made for there being more female migraineurs than male. The precise mechanism behind the development of medicine-induced migraine is not known, but there appears to be a genetic component. Some people can take masses of painkillers without developing medicine-induced migraine.
Taking large amounts of triptans also appears to reduce the reaction of the walls of the blood vessels and the production of serotonin is affected. Serotonin is the generic name for a long list of chemicals that have the common property that they act as messengers from one nerve cell to another, particularly in the brain. It is thought that an overdose of painkillers halts the body's ability to control the feelings of pain, so the feeling of pain becomes continuous.
Don't take triptans 'as a preventive'!
Many migraineurs have a tendency to take triptans 'preventatively' - they are worried about being able to get through their day, so they 'just take a pill'. That often leads to overdosing and medicine-induced migraine.
A large intake of painkillers containing codeine can lead to dependency. Some of the codeine is altered in the body to morphine that gives a feeling of pleasure.
1% of the total population has medicine-induced migraine. Even young people develop the problem. Children as young as 6 years old have been diagnosed with this problem. It is the third most common form of headache dealt with by GPs.
Patients with medicine-induced migraine have generally attended several doctors and have a whole collection of prescriptions for different medicines. Detoxification at home.
Doctors recommend detoxification from medicine-induced migraine as a 'cold turkey' - total abstinence from all forms of migraine medicines. If the overdosing has been 'only' on triptans, it takes about 3 days before the medicine induced migraine disappears. If the overuse has been of a mixture of medicines, triptans together with painkillers, it takes longer. During the 'cold turkey', the patient can experience dizziness and nausea, heart palpitations, sleep disturbances, feelings of being restless, worry and nervousness. No experiments have been reported on gradual detoxification. It is a demanding job to go through a detoxification at home. Patients who take tranquilizers should not attempt a detoxification without consulting a doctor. It requires a lot of stamina to give up the medicine, so only highly motivated patients seem to have a fair chance of success on thir own. The doctors recommend that preventive medication is begun 4 weeks before the detoxification.
3 out of 4 patients feel significantly better after detoxification and take less migraine medicine. But one in five migraineurs falls back to overdosing again after a few years.
H.-C. Diener and V. Limmroth, 2004. Medication-overuse headache: a worldwide problem The Lancet Neurology 3, 475-483.
Uploaded 30-10-2005
Change your triptan- why?
Probably many of us speculate if another triptan might be better. Maybe it would work faster. Maybe it wopuld last longer.A team of scientists in the USA asked 386 patients why they had changed from one triptan to another. The answers were all about what they expected the new triptan to do for them compared with the old one. Most triptan users did not get the effect they wanted. 70% of the users of 25 mg Imigran wanted more effect. But 20% of the users of Zomig and Naragran found that they didn't get what they wanted. Only users of injections were generally satisfied with their effect (even though 12% still didn't get the effect they wanted).
Many people talked about side effects and they were the reason given by about 30% of the users of Imigran (100 mg in pills, nose spray or injection) for changing. About 10-15% cited side effects as the reason for changing from one of the other tablets (Zomig, Maxalt or Naragran).
F. D. Sheftell, M. Feleppa, S. J. Tepper, M. Volcy, A. M. Rapoport and M. E. Bigal, 2004. Patterns of use of triptans and reasons for switching them in a tertiary care migraine population. Headache 44, 661-668.
Uploaded 30-10-2005
Triptan users find it difficult to report secondary effects
Whether triptan users can report secondary effects from their use of triptans depends entirely on how they are asked.415 migraineurs (87% women) in USA and Italy were asked which secondary effects they experienced when they took triptans. When they themselves had to tell about what they experienced, only 25% (in USA) and 35% (in Italy) could remember any secondary effects. When the triptan users were given a list of known secondary effects, they remembered much better and 63% af Americans and 54% af Italians reported that they had experienced a secondary effect. Heart palpitations and sleep disturbances were the most commonly reported secondary effects.
F. Sheftell, M. Feleppa, S. J. Trepper, A. M. Rapoport, L. Cianella and M. E. Bigal, 2004. Assessment of adverse events associated with triptans - methods of assessment influence the results. Headache 44, 978-982.
Uploaded 06-04-2006
Sumatriptan injections make the skin of migraineurs more sensitive
It has been known since 1873 that the skin of migraineurs can be more sensitive during and after a migraine attack. Now it also seems that migraineurs generally have more sensitive skin after an injection of Imigran. The reaction occured within 20 minutes and lasted at least an hour. No excess reaction was found when either cold or warmth was applied to the skin. The study involved 10 migraineurs and 8 controls.M. Linde, M. Elam, L. Lundblad, H. Olausson and C. G. H. Dahlöf, 2004. Sumatriptan (%-HT1B/1D-agonist) causes transient allodynia. Cephalalgia 24, 1057-1066.
Uploaded 06-04-2006
Four women and nearly one man in every thousand take migraine medicine on any given day
We know very well that more women than men have migraine. 15% of women and 6% of men have had an attack during the previous 12 months. Now the Danish Medicines Agency has worked out how much prescription medicine is used by each 1000 members of the population, and it gives a very clear picture. Each day, 4 women in a thousand take acute prescription migraine medicine, but hardly one in a thousand men take migraine medicine on any given day.The correlation between the percentages who have had migraine in the last year (15% of women and 6% of men) shows that about double as many women as men are treated for their migraine. Had they been treated equally, about 2.5 times as many women as men 15% is about 2.5 times 6%) would have taken migraine medicine.
The Danish Medicines Agencies annual statistics http://www.dkma.dk/1024/visUKLSArtikel.asp?artikelID=1673
Uploaded 21-10-2006
Most treated migraines are those of middle-aged people
It is possible to figure out how many in each age group get treatment for their migraine. The results for ergotamines, triptans and clonidin are combined. The highest frequency of treatment is among the group between 50 – 64 years old, in which 12 out of every thousand women receive treatment for migraine on any given day. Only two in a thousand men around the age of 50 take medicine against migraine on any given day.Some time ago, American scientists published a comparable study of how many migraineurs there are in each age class. When the two datasets are compared it is clear that the top of the curve for use of migraine medicine in both sexes lies around the age of 50, while the age during which migraine attacks peak is between 30 – 45.
We do not know whether the 50-year-olds have many more attacks than those a little younger, but it is tempting to believe that some migraineurs experience many long years without treatment while they are between 25 and about 40.
Another explanation could be that women around 50 have particularly many migraine attacks, but this has not been documented.
R. B. Lipton et al. 2001. Prevalence and burden of migraine in the United States: Data from the American Migraine Study II. Headache 41, 646-657. The Danish Medicines Agencies annual statistics http://www.dkma.dk/1024/visUKLSArtikel.asp?artikelID=1673
Uploaded 21-10-2006
Overuse of medicine and psychiatric problems
A French study involving 41 migraineurs who overdosed on medicine and 41 other migraineurs has shown that migraineurs who overdose suffer from psychiatric problems more than other migraineurs. They had their psychological problems before they started to overdose, so the problems weren't caused by the overuse of medicine (but possibly by the many migraine attacks).Of course, not everyone who overuses medicine has these problems. But it could be a good idea to talk to your doctor about it if you are offered a detoxification.
F. Radat, C. Creac'h, J. D. Swendsen, M. Latittau, S. Irachabal, V. Dousset and P. Henry, 2005. Psychiatric comorbidity in the evolution from migraine to medication overuse headache. Cephalalgia 25, 519-522.
Uploaded 21-10-2006
Paracetamol – be very careful!
275 patients with liver failure because of paracetamol who attended a number of American clinics were asked how much paracetamol they had taken every day before their liver failed.The answers showed that as little as 7.5 gm of paracetamol (equivalent to 15 tablets) per day for 7 days was enough to cause acute failure of the liver in those most disposed. Older people and those with a steady intake of alcohol were especially at risk of liver failure from taking quite small amounts of paracetamol.
Liver failure because of paracetamol comprises 42% of all cases of liver failure in the USA.
A. M. Larson , J. Polson, R. J. Fontana , T. J. Davern , E. Lalani , L. S. Hynan , J. S. Reisch , F. V. Schiødt , G. Ostapowicz , A. O. Shakil and W. M. Lee, 2005. Acetaminophen-induced acute liver failure: Results of a United States multicenter, prospective study. Hepatology 42, 1364-1372.
Uploaded 21-10-2006
Some young people use a lot of over-the-counter medicine
More than 2500 young Norwegians took part in mass study in North Trøndelag. Among other things, they were asked about their use of over-the-counter medicine for headache and migraine. 5% of the boys and 12% of the girls reported that they had migraine and used over-the-counter medicine nearly every day.There are no reasons to believe that the situation is significantly different in Denmark.
G. Dyb, T. Lingaas Holmen and J.-A. Zwart, 2006. Analgesic overuse among adolescents with headache. The Head-HUNT-Youth Study. Neurology 66, 198-201.
Uploaded 28-8-2008
Large intakes of Sumatriptan can colour the blood green
A migraineur who took 200 mg Sumatriptan every day had to undergo an operation for a different complaint. The doctors were astonished when they discovered that the man's blood was dark green in stead of the normal red colour.It was discovered that the man's hemoglobin (the chemical in the blood that binds oxygen in red blood cells and gives blood its red colour) had been altered so that, instead of the normal atom of iron in some of the hemoglobin, there was a sulpha-group and that this proportion of the hemoglobin had been converted to sulph-hemoglobin, which is green. Sulph-hemoglobin cannot transport oxygen around the body.
The operation was successful and the man gave up using Sumatriptans immediately after the operation. After 5 weeks, his blood had regained its normal red colour.
A. M. Flexman et al. 2007. Dark green blood in the operating theatre. Lancet 369, 1972.
This article in The Lancet suggests that people who take a lot of triptans might consider changing to a triptan that does not contain a sulpha-group (Zomig or Maxalt).
Uploaded 28-8-2008