[The transformed migraine]. / La migraine transformée.

Patients consulting in headache centers complained very often of chronic daily or near daily headaches unclassifiable with the IHS criteria of the categories migraine, migraine + chronic tension headache or chronic tension headache. Many of these patients report a clear-cut history of distinct attacks of migraine with an aggravation of the headaches over the years. For these patients the term "transformed migraine" was recently proposed. The authors described and discussed the criteria of this concept. Knowledge of transformed migraine seems to be justified because their natural history and their response to treatment which is different from chronic tension-type headache.

Failure of omega-3 polyunsaturated fatty acids in prevention of migraine: a double-blind study versus placebo.

Omega-3 polyunsaturated fatty acids (OPFA) have beneficial effects on inflammatory reactions and production of cytokines. They decrease the release of 5HT by platelets and possess vasorelaxant activity. This led them to be tried in the prophylactic treatment of migraine. After 4 weeks of a single-blind placebo run-in period, patients were randomized and treated in double-blind condition by placebo or OPFA 6 g a day for 16 weeks, followed by a 4-week placebo run-out period. The intention to treat population included 196 patients. Those who received all four treatment periods included 96 patients taking OPFA and 87 taking placebo. The primary efficacy analysis was the number of migraine attacks during the last 4 weeks of treatment. During this period, the mean number of attacks was 1.20 +/- 1.40 in the OPFA group and 1.26 +/- 1.11 in the placebo group (NS). The total number of attacks during the 4-month period of the study was significantly different between groups: 7.05 in the placebo group, 5.95 in the OPFA group (P = 0.036). Mean intensity, mean duration of the attacks and rescue medication use, were not significantly different between the two groups. Except for a significant difference against OPFA for eructations, the tolerance was satisfying. Despite a run-in placebo period of 1 month, a very strong placebo effect was observed in this trial: 45% reduction of the attacks between run-in and 4-month treatment period (55% in the OPFA group, P = 0.058). Finally, this large study did not confirm two previous studies based on a small number of patients.

[Treatment of cluster headache]. / Le traitement de l'algie vasculaire de la face.

INTRODUCTION: The cluster headache (CH) is one of the most severe types of head pain. It is a typical example of a periodic disease and the International Headache Society classification recognizes two forms of this disease: episodic and chronic CH. Its prevalence is about 0.1 to 0.4% in the general population. PATHOPHYSIOLOGY: A global hypothesis is still lacking to explain the pain, the vasodilation, the autonomic features (ipsilateral lacrimation, conjunctiva injection, rhinorrhea, partial Horner syndrome, etc.) and the periodicity of the CH. Pain and vasodilation seem secondary to an activation of the trigeminal vascular system and the periodicity of the attacks is thought to be due to a dysfunction of hypothalamic biologic clock mechanisms. Treatment of acute CH attacks. The most effective agents are oxygen inhalation and subcutaneous sumatriptan, a 5HT1B and D receptor agonist which has vasoconstrictor and anti-neurogenic inflammation properties by blocking the release from the trigeminal-sensitive fibers of neuropeptides such as CGRP and substance P. With subcutaneous sumatriptan, headache relief is very rapid, within 5 to 10 min. Prophylactic treatment of CH: The number of attacks per day varies from one to three, but some patients can have four to eight per day and acute treatments fail to provide sufficient relief or give rise to side-effects. Several different regimens have been proven effective. FUTURE PROSPECTS AND PROJECTS: Contraindications and side-effects of the drugs limit the choice of the prophylactic treatment: corticosteroids in a tapering course, verapamil and methysergide are the most useful treatments of the episodic form. Lithium carbonate is more effective for the chronic stage of CH, but side-effects are often troublesome. Numerous other medications have been used for prophylaxis: valproate, capsaicin, beta-blockers. Unfortunately, double-blind studies are often lacking and are difficult to realize due to spontaneous variable remission of episodic CH. When adequate trials of drug therapies show a total resistance to the treatments, surgery may be considered. Radiofrequency trigeminal rhizotomy is the treatment of choice with 70% of beneficial effects. Risks and complications have to be discussed in balance with the benefit of the different surgical procedures.

[Treatment of migraine attacks]. / Traitement de la crise migraineuse.

The authors have presented a review of the main controlled studies on drug treatment for the management of migraine attacks: non-steroidal anti-inflammatory drugs (NSAIDs), rye ergot derivatives, and the recently commercialized triptan group of drugs. An overview is provided of their specific properties, indications and contraindications, and their respective use in the treatment of migraine headaches.

Safety and efficacy of combined lysine acetylsalicylate and metoclopramide: repeated intakes in migraine attacks.

The efficacy of the combination of lysine acetylsalicylate and metoclopramide in the treatment of migraine attacks has been established previously. The value of repeated doses of such a combination has been reported in a recent study. The purposes of this open-label study performed by general practitioners on a very large sample of migraine sufferers were to confirm that repeated doses of the combined treatment are efficient and well-tolerated, and to assess the efficacy of treatment according to the initial headache intensity. Three thousand seven hundred twenty-seven general practitioners entered 7259 migraine sufferers. Patients had to use a first dose, the efficacy of which was assessed 2 hours later. In the case of failure, they were then able to take a second dose and possibly a third dose, 2 hours after the second, in the case of persistent failure. Twelve thousand five hundred sixty-two migraine attacks were analyzed. Tolerance, as assessed by the patients, was considered as good in more than 85% of attacks, whatever the number of doses utilized. Five hundred thirty-five adverse effects were reported after the use of 22,697 sachets. Of 12,515 attacks documented for efficacy, patients considered the treatment as good or excellent in 80% of attacks treated with one dose, 55% of those treated with two doses, and 27% of those treated with three doses. Relief of headache (reduction of its severity from grade 3 or 2 to 1 or 0) was observed in 51% of episodes after the first sachet, 51% of episodes treated with a second sachet, and 56% of episodes treated with a third sachet. The first dose of treatment was found to be more effective when the initial severity of the headache was moderate (improvement in 66% of attacks) than when it was severe (improvement in 30% of attacks). Efficacy appeared to increase according to the number of doses when headache was initially severe. This trial confirms that repeated doses of this combination is well-tolerated and effective. Our results show that repeated doses are particularly useful for severe attacks.