Practice Update Neurology

HEADACHE/MIGRAINE

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MY APPROACH Success inmigraine preventive treatment Migraine attacks significantly interfere with quality of life despite appropriate use of acute medications. Dr Stephen Silberstein shares his principles which have led to success in preventive treatments. W hen do I use migraine preventive treatment? I consider prevention if my patients’ migraine attacks sig-

Dr Stephen D. Silberstein’s principles for successful preventive migraine treatment

• Start the drug at a low dose and in- crease it slowly until therapeutic effects develop, the ceiling dose is reached, or adverse events become intolerable. • Give the treatment an adequate trial. A full therapeutic trial may take 2 to 6 months before the maximal response to a treatment is evident. • Set realistic goals. Success is a 50% reduction in attack frequency or head- ache days, a significant decrease in at- tack duration, or an improved response to acute medication. • Reevaluate therapy . Migraine may improve or remit independent of treatment. • Involve patients in their care tomaximise compliance . I discuss the rationale for a particular treatment, when and how to use it, and what adverse events are likely. I address patient expectations and set realistic goals. I set realistic expectations regarding adverse events. Most are self-limited and dose-depend- ent, and patients should be encouraged to tolerate the early adverse events that may develop when a new medication is started.

and topiramate. An underweight patient would be a candidate for one of the medications that commonly produce weight gain, such as a tri- cyclic antidepressant; in contrast, I would try to avoid these drugs and consider topiramate when the patient is overweight. Tertiary tricy- clic antidepressants that have a sedating effect would be useful at bedtime for patients with insomnia. Older patients with cardiac disease or patients with significant hypotension may not be able to use tricyclic antidepressants, calcium channel blockers, or beta blockers, but could use divalproex sodium or topiramate. Monotherapy is a treatment goal, and taking advantage of comorbid or coexistent illness may facilitate treatment of both disorders with a single drug. However, therapeutic independ- ence may be needed should monotherapy fail. For example, tricyclic antidepressants are often recommended for patients with migraine and depression. However, appropriate manage- ment of depression often requires higher doses of tricyclic antidepressants, which may be as- sociated with more adverse effects. A better

approach might be to treat the depression with a selective serotonin reuptake inhibitor or a selective norepinephrine reuptake inhibitor. When would I stop a preventive medication? • Preventive migraine therapy should be stopped when the patient develops intoler- able adverse events or a severe drug reac- tion; the drug does not demonstrate even partial efficacy after 2 months of therapy; and disorders such as acute medication overuse have not been eliminated. • I would also stop the drug if the patient has shown significant benefit. If the headaches are well-controlled for at least 6 months, I slowly taper and, if possible, discontinue the drug.

nificantly interfere with their quality of life despite appropriate use of acute medications; if they have four or more attacks per month or eight or more headache days per month; if acute medications fail or are overused; or if they have hemiplegic migraine, basilar mi- graine, frequent, prolonged or uncomfortable aura symptoms, or migrainous infarction. I consider a preventive migraine drug successful if it reduces migraine attack frequency or days by at least 50% within 3 months. Many classes of medications are used for migraine prevention: antiepileptic drugs, an- tidepressants, beta blockers, calcium channel antagonists, serotonin antagonists, botulinum neurotoxins, NSAIDs, and vitamins. I start with a drug based on its efficacy, adverse events, patient preference, and the presence of any coexistent or comorbid conditions. The preventive drugs with the best-proven efficacy are certain beta blockers, divalproex sodium,

Stephen D. Silberstein MD is professor, Department of Neurology; director, Jefferson Headache Center, Thomas Jefferson University, Philadelphia, Pennsylvania.

NEWS Narrow band of green light may ease

JOURNAL SCAN Deep brain stimulation of the ventral tegmental area for refractory chronic cluster headache Neurology Take-home message • A small proportion of patients with chronic cluster headache (CCH) are refractory to medical therapy. In these patients, the pain is debilitating, and the periods of remission are short. In these cases, peripheral nerve stimulation and central neuromodulation have been proposed. This is an uncontrolled, open-label prospective study of deep brain stimulation (DBS) targeting the ventral tegmental area (VTA) in patients with intractable CCH. A total of 21 consecutive patients underwent the therapy under a humanitarian device intervention, using an MRI-guided approach. A high- frequency (185Hz) stimulation regimen was used. Follow-up ranged from 4 months to 5 years, with a median of 18 months. At the last follow-up point, there was an overall 60% improvement in median headache frequency (from 5 to 2 attacks per day) and an improvement in median headache severity of 30% (from 10 to 7 points on the verbal rating scale). There was a concomitant reduction in triptan intake and an improvement in quality-of-life measures. The most notable side-effect was diplopia, a known reversible stimulation-related adverse effect for this stimulation target. • The data need to be interpreted with caution, as the placebo effect can be very large with these interventions in this patient population, but the results suggest potential efficacy of VTA DBS for intractable CCH, which should be studied further, ideally with a sham stimulation control. Dr Codrin Lungu

migraine symptoms Experimental light therapy finds it can ease photophobia, pain for some patients A treatment involving a narrow spectrum of low- intensity green light may help ease migraine pain, according to a study published online May 17 in Brain . Rami Burstein, PhD, of the Beth Israel Deaconess Medical Center in Boston, and colleagues exposed 69 migraine patients to different colours of light. The researchers found that while blue light exacer- bated headache pain, a narrow spectrum of low-intensity green light significantly reduced photophobia. In some cases, this green light also reduced migraine pain by about 20 percent. “Although photophobia is not usually as incapacitating as headache pain itself, the inability to endure light can be disabling,” Burstein said in a medical centre news release. “More than 80 percent of migraine attacks are associated

with and exacerbated by light sensitivity, leading many mi- graine sufferers to seek the comfort of darkness and isolate themselves from work, family, and everyday activities.”

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headache load (a composite score en- compassing frequency, severity, and duration of attacks) improved by 68% (P = 0.002). Total monthly triptan intake of the group dropped by 57% post- treatment. Significant improvement was observed in a number of QoL, dis- ability, and mood scales. Side effects included diplopia, which resolved in 2 patients following stimulation adjust- ment, and persisted in 1 patient with a history of ipsilateral trochlear nerve palsy. There were no other serious adverse events. CONCLUSIONS This study supports that VTA-DBS may be a safe and effective therapy for refractory CCH patients who failed conventional treatments. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that VTA-DBS decreases headache fre- quency, severity, and headache load in patients with medically intractable chronic cluster headaches. Ventral tegmental area deep brain stimulation for refractory chronic cluster headache Neurology 2016;86(18)1676-1682, H Akram, S Miller, S Lagrata, et al.

OBJECTIVES To present outcomes in a cohort of medically intractable chronic cluster headache (CCH) patients treat- ed with ventral tegmental area (VTA) deep brain stimulation (DBS). METHODS In an uncontrolled open- label prospective study, 21 patients (17 male; mean age 52 years) with medically refractory CCH were se- lected for ipsilateral VTA-DBS by a specialist multidisciplinary team in- cluding a headache neurologist and functional neurosurgeon. Patients had also failed or were denied access to occipital nerve stimulation within the UK National Health Service. The pri- mary endpoint was improvement in the headache frequency. Secondary outcomes included other headache scores (severity, duration, headache load), medication use, disability and affective scores, quality of life (QoL) measures, and adverse events. RESULTS Median follow-up was 18 months (range 4–60 months). At the final follow-up point, there was 60% improvement in headache frequency (P = 0.007) and 30% improvement in headache severity (P = 0.001). The

Prevalence of migraine up in patients with cardiac syndrome X Increased prevalence of migraine in CSX compared with coronary artery disease or healthy controls T he prevalence of migraine headache is elevated in pa- tients with cardiac syndrome prevalence of migraine headache in three groups: 50 patients with CSX, 50 patients with coronary artery dis- ease, and 50 healthy controls.

“Our study concluded that CSX may presumably be a manifestation of migraine as another migraine equivalent,” the authors write. “After the ongoing evidence on the multi- faceted pathophysiology of CSX, it became even more clear that there is a need for a pragmatic approach to education and training of medical practitioners in the management of patients, especially in refractory pa- tients using the current treatment.”

X (CSX) compared to patients with coronary artery disease or healthy controls, according to a research let- ter published in the May 3 issue of the Journal of the American College of Cardiology . In a prospective study, Reza Nemati, MD, from the Bushehr University of Medical Sciences in Iran, and colleagues examined the

The researchers found that the prevalence of migraine was 60, 16, and 22 percent in CSX patients, the coronary artery disease group, and the healthy control group, re- spectively (P < 0.0001). In women and men with CSX the frequency of migraine headache was 70.4 and 52.2 percent, respectively.

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