Consensus statement: the development of a national Canadian Migraine Strategy.

BACKGROUND: Migraine is a significant cause of suffering and disability in the Canadian population, and imposes a major cost on Canadian Society. Based on current medical science, much more could be done to provide better comprehensive medical care to the millions of individuals with migraine in Canada. OBJECTIVE: To propose and design a national Canadian Migraine Strategy which could be implemented to reduce migraine related disability in Canada. METHODS: A multidisciplinary task force of the Canadian Headache Society met for a Canadian Migraine Summit Meeting in Halifax, Nova Scotia in June, 2009. Pertinent literature was reviewed and a consensus document was produced based upon the round table discussion at the meeting. RESULTS: The outline of a national Canadian Migraine Strategy was created. This strategy is based on the chronic disease management model, and would include: an outline of what constitutes appropriate migraine care for Canadians, educational programs (for health care professionals, individuals with migraine, and the general public), research programs, and the development of the necessary organizations and partnerships to develop further and implement the Canadian Migraine Strategy. CONCLUSIONS: Based upon the medical literature and expert discussion at the meeting, a national Canadian Migraine Strategy with a patient self-management focus has the potential to improve patient care and reduce headache related disability in Canada.

Clinical features and pharmacological treatment of migraine patients referred to headache specialists in Canada.

We set out to examine selected clinical characteristics of migraine patients referred to neurologists specializing in headache in Canada, and to document their pharmacological therapy both before and after consultation with the neurologist. Demographic, clinical and pharmacotherapy data were collected at the time of consultation for 606 patients referred to five headache clinics and who were given a migraine diagnosis by the neurologist. Data were analysed as part of the Canadian Headache Outpatient Registry and Database (CHORD) Project. The mean age of the migraine patients was 39.7 years; and 82.5% were female. The majority of patients suffered severe impact from their headaches. Prior to consultation, 48.7% were taking a triptan; after consultation, 97.2% were on a triptan. Before consultation, 30.9% were on a prophylactic drug; after consultation, 70.4% were. 20.8% of patients were medication overusers. Of these medication overusers, 42.4% were overusing an opiate, usually in combination with other analgesics; 21.6% were overusing a triptan. Medication changes made by the neurologists at consultation included a large increase in the use of both triptans and prophylactic medications. Medication overuse, particularly opiate overuse, remains a significant problem in patients with migraine in Canada.

Pneumocephalus as a cause for headache.

BACKGROUND: Pneumocephalus can be a cause of headache, but is easily overlooked in some clinical circumstances. CASE STUDY: A 35-year-old woman developed severe headache of abrupt onset during an epidural blood patch procedure done for a post-lumbar puncture headache. A brain CT scan showed subarachnoid air even though there was no evidence of a dural puncture having occurred during the procedure. RESULTS: The experience of our patient, and a review of the literature suggests that air injected into the epidural space during use of the "loss of resistance" technique can enter the subarachnoid space if a dural puncture site from a previous lumbar puncture is present. CONCLUSIONS: Pneumocephalus should be considered as a potential cause for a severe headache occurring in association with epidural procedures, and also in a number of other clinical settings. Use of a high inspired air oxygen concentration can hasten absorption of an intracranial air collection.

Communication with the migraine patient.

Much has been added to our knowledge of effective physician-patient communication by the research of the past two decades. Good communication skills are especially important for the clinician dealing with a migraine patient, as neither laboratory tests nor diagnostic physical findings are available to assist the physician in diagnosis and treatment. It is important for clinicians to understand that effective communication skills can be taught and learned and that, once mastered, they have the potential to improve patient outcomes.

Assessing health-related quality of life in patients with migraine.

BACKGROUND: The place of health-related quality of life (HRQoL) instruments in clinical research trials and clinical practice as compared to more traditional clinical outcome measures such as headache intensity and frequency is unclear. OBJECTIVES: To review the current status of HRQoL measurement in migraine. METHODS: A literature search was done for HRQoL and migraine. Selected articles dealing with migraine and commonly used HRQoL instruments and HRQoL measures used in recent clinical trials were reviewed. RESULTS: Several general and migraine specific HRQoL instruments can detect changes over time in response to at least major changes in migraine therapy. Both also show a correlation with clinical headache features. However, their sensitivity to detect clinically significant changes over time is not clear. CONCLUSION: The SF-36, a general HRQoL measure and several migraine-specific HRQoL instruments are useful endpoints for migraine clinical trials. Their role in clinical practice is yet to be established.

A comparison of disability and psychological factors in migraine and transformed migraine.

The classification of patients with migraine who develop chronic daily headache is controversial, with some classifying such patients as 'transformed migraine'. We compared patients with intermittent migraine attacks and patients with transformed migraine in terms of mean headache intensity on days with headache, depression, pain-related anxiety and headache-related disability. Patients classified clinically as also having tension-type headache were excluded. Aside from the number of days with headache per month, patients with intermittent migraine attacks and patients with transformed migraine were very similar in terms of all parameters studied. Our results support the concept that these two headache groups are closely related.

Zolmitriptan orally disintegrating tablet is effective in the acute treatment of migraine.

A new formulation of zolmitriptan has been developed that dissolves on the tongue without the need for additional fluid intake. In this double-blind, parallel study, 471 patients were randomized to receive the zolmitriptan orally disintegrating tablet 2.5 mg (n=231) or matching placebo (n=240) to treat a single moderate or severe migraine. Headache relief following zolmitriptan 2.5 mg (63%) was significantly greater than with placebo (22%) at 2 h post-dose (primary endpoint; P < 0.0001). The zolmitriptan orally disintegrating tablet was also significantly more effective than placebo for 1-, 2- and 4-h pain-free response (8% vs. 3%, P=0.0207, 27% vs. 7%, P < 0.0001, and 37% vs. 11%, P < 0.0001, respectively). Of those patients stating a preference, 70% of patients preferred the orally disintegrating tablet to a conventional tablet. Zolmitriptan orally disintegrating tablets are an effective and convenient alternative to a conventional tablet, allowing migraine attacks to be treated anytime a migraine strikes, which can facilitate earlier treatment.

Influence of barometric pressure on interleukin-1 beta secretion.

Monocytes and macrophages are activated by various environmental challenges, including microorganisms, radiation, and pollutants. These cells release cytokines, such as interleukin (IL)-1 beta, that mediate physiological adaptations to stress. This study sought to define further the role of IL-1 beta in general adaptation to environmental stress by testing the hypothesis that high altitude (20,000 ft, 6,096 m) would stimulate IL-1 beta secretion from isolated human blood mononuclear cells. Cells from six young men (aged 22--26 yr) were divided into separate cultures incubated in either standard ambient conditions or in one of three test conditions, hypobaric hypoxia (simulating 20,000 ft), hypobaric normoxia (20,000 ft, O(2) supplemented), and normobaric hypoxia (10% O(2)). This design allowed differentiation between pressure-related vs. oxygen-related effects. Each subject made multiple blood donations in order that cells from all subjects were tested in all conditions. Contrary to the hypothesis, IL-1 beta secretion was not induced at simulated altitude in basal cell cultures. In lipopolysaccharide-stimulated cell cultures, exposure to altitude inhibited IL-1 beta secretion by approximately 40%, and the inhibition was due to the change in pressure (P = 0.039) rather than the change in oxygen. Secretion of other factors (IL-1 receptor antagonist and soluble IL-1 receptor type II) was not inhibited. Although these results are in opposition to the original hypothesis, they provide insight regarding adaptations necessary for hematopoiesis in response to high altitude and also provide a cellular rationale for the mountain sanatoriums of the 19th and early 20th centuries.

Opiate use to control bowel motility may induce chronic daily headache in patients with migraine.

OBJECTIVES: To investigate whether opiate overuse might cause chronic daily headache in those with migraine, we studied patients who were taking codeine (or other opiates) for control of bowel motility after colectomy for ulcerative colitis. BACKGROUND: Analgesic overuse is considered by many to be one factor which can result in the transformation of migraine into a chronic daily headache pattern. Most of the evidence for this comes from patients with migraine who are taking increasing amounts of analgesia for headache. Many of these patients revert to an intermittent migraine pattern once the analgesics are stopped. METHODS: Women who were 1 year postcolectomy for ulcerative colitis were identified in several colorectal surgery practices in Calgary. They were sent a questionnaire designed to determine if they had a history of migraine prior to surgery, if they currently had chronic daily headache, what medications they were taking to control bowel motility, and what medications they were taking for headache. RESULTS: Twenty-eight patients who met our inclusion criteria returned completed questionnaires. Eight of these exceeded the recommended limits for opiate use in patients with headache. Eight patients met diagnostic criteria for migraine. Two patients had chronic daily headache starting after surgery. Both used daily opiates beginning after their surgery, and both had a history of migraine. The other six patients who used opiates daily did not have a history of migraine and did not have chronic daily headache. All patients with migraine who used daily opiates to control bowel motility following surgery developed chronic daily headache after surgery. CONCLUSIONS: Patients with migraine who use daily opiates for any reason are at high risk of developing transformed migraine with chronic daily headache. This risk appears much lower in patients without a history of migraine who use opiates for nonpain indications.

Sumatriptan responsiveness and clinical, psychiatric and psychologic features in migraine patients.

OBJECTIVE: To compare sumatriptan responders and nonresponders in a migraine population with regard to a number of clinical, psychiatric and psychologic features. METHODS: Patients were drawn from a referral headache clinic population, and classified as responders or nonresponders. Clinical features were assessed by a written questionnaire. The lifetime prevalence of several psychiatric disorders was determined by the National Institute of Mental Health diagnostic interview schedule and personality factors were measured by the 16 Personality Factors (16PF) Questionnaire. RESULTS: Nonresponders indicated less influence on their migraine by menstrual factors, had a higher lifetime prevalence of generalized anxiety, and showed 16PF scores indicating greater shyness, self-sufficiency and perfectionism. Nonresponders were also more imaginative and less socially outgoing. CONCLUSION: Although they must be interpreted with caution due to small sample size and the multiple comparisons made, our results indicate that there may be differences between sumatriptan responders and nonresponders with regard to a number of clinical, psychiatric and psychologic factors. These results suggest that biological differences exist between the two patient groups which likely account for both the differences in their responses to sumatriptan and in the clinical features noted above.

Are the triptans for migraine therapy worth the cost?

The triptans represent a major advance in migraine therapy but their cost per dose greatly exceeds that of many older treatments. There is evidence that for a significant proportion of migraine patients these new drugs can show a positive cost benefit and also improve quality of life. Cost benefit would be expected to be greatest in patients with more severe migraine attacks.