Venlafaxine extended release (XR) for the prophylaxis of migraine and tension-type headache: A retrospective study in a clinical setting.

OBJECTIVE: To assess the efficacy of extended-release venlafaxine in the prophylaxis of migraine and chronic tension-type headache. BACKGROUND: Venlafaxine, a structurally novel antidepressant, is a selective serotonin-norepinephrine reuptake inhibitor. This study is the first to test the effects of extended-release venlafaxine on headaches. METHODS: Patients were evaluated on a retrospective basis. Fifty-six patients with chronic tension-type headache and 114 patients with migraine were prescribed extended-release venlafaxine. Nearly all the study subjects had been resistant to several previous preventive medications. Patients took venlafaxine for an average of 6 months with a median dose of 150 mg (range, 37.5 to 300 mg). RESULTS: The mean frequency of headaches in the group with chronic tension-type headache fell from 24.0 to 15.2 per month (P <.0001). The group with migraine showed a reduction from 16.1 to 11.1 headaches per month (P <.0001). The medicine was well tolerated. CONCLUSIONS: This trial indicates that extended-release venlafaxine has potential in headache prophylaxis based on its efficacy and safety profile. We recommend a double-blind, placebo-controlled study to further assess the role of extended-release venlafaxine in headache prevention.

Rizatriptan tablet versus wafer: patient preference.

After taking both conventional oral rizatriptan tablets and oral disintegrating rizatriptan tablets in the treatment of migraine with or without aura, patients were permitted to select their formulation preference. All adult patients who had requested continuation of rizatriptan during a 6-month period were included in the study. Of the 367 patients studied, 188 selected the oral disintegrating tablet, while 179 preferred the conventional tablet. Although individual patients had strong preferences for one preparation over the other, no group preference was found.

Migraine preventive medications: a reappraisal.

Newer acute care migraine medications demonstrate improved rapidity of action, consistent effectiveness, excellent safety profiles, and rarely cause rebound headaches. Their use could decrease the need for migraine-preventive medication. The present analysis derives a formula that can be used by practitioners to determine the cost-effectiveness of various migraine-preventive medications relative to selected acute-care medications. We propose a measure called the cost-equivalent number (CEN), the number of headaches per month at which the cost of the preventive medication equals the cost savings in acute-care treatment realized by using the preventive medication. The use of the CEN individualizes the decision of whether to use a migraine-preventive medication, weighing both the efficacy and cost of the preventive medication against the cost of the acute-care medication. A CEN lower than the migraine frequency suggests that use of a preventive medication will be cost-effective.

Oral narcotic protocol to reduce narcotic injections in refractory migraine patients.

Refractory headache patients who require narcotic injections for acute attacks frequently utilize health care facilities. The experience is often unpleasant and costly to the patient and health care system. We have developed an oral narcotic protocol for home administration. The patient starts with an antiemetic suppository, followed in 30 minutes by oral metoclopramide. After controlling nausea and vomiting, the patient administers a high dose of oral narcotic plus a hypnotic. The dosing of the narcotic analgesics incorporates seldom-used, but well-published pharmacokinetics. This protocol allows the patient to successfully treat a severe headache without using a health care facility. Eleven patients in our practice were prescribed the oral narcotic protocol. Their need for narcotic injections at our office or emergency department was monitored for up to 1 year before and after the start of the protocol. Combined office visits were reduced from 81 to 53 (34.6%) and emergency department visits from 47 to 26 (44.7%). An annual cost savings of $1960 for office visits and $3024 for emergency department visits was realized. This was offset by an oral narcotic protocol medication cost of only $392. This treatment method has been well accepted by patients and has proven to be a safe and cost-effective approach to treating refractory migraine patients.

Cost considerations in headache treatment. Part 2: Acute migraine treatment.

Today's physician has many useful medication options available for acute migraine treatment. There is a wide cost range among these drugs and today's health care environment demands that cost be factored into the decision process. Effective migraine abortive treatment decreases the costs of repeat dosing and disability. Early use of migraine abortive medication can increase its rapidity of action and effectiveness. Adjunctive medication such as metoclopramide ($0.10) is inexpensive and may improve the effectiveness of the primary abortive medication. Over-the-counter medications such as aspirin ($0.02/325 mg), Excedrin ($0.09/tablet), ibuprofen ($0.04/200 mg), or naproxen sodium ($0.09/220 mg) are inexpensive and effective. "Triple therapy" combining metoclopramide, a nonsteroidal anti-inflammatory agent, and an ergotamine preparation may improve tolerance and effectiveness of the ergot. Locally compounded dihydroergotamine nasal spray is inexpensive ($0.78/1 mg spray). The cost of using oral sumatriptan can be almost halved by prescribing half of a 50-mg tablet. Emergency department services are expensive. Huge cost savings occur through self-controlled administration of oral, rectal, or even intramuscular narcotic medications. Oral narcotic agents such as hydromorphone ($0.42/4 mg) and meperidine ($0.92/200 mg) are generally used in inadequate doses to be effective for severe migraine. Guidelines are give for more effective use of these agents. Sophisticated comparative studies are needed to evaluate, not only the direct costs of medications, but all costs of treatment of an acute migraine attack, as well as indirect costs to the patient, family, and society.

Cost considerations in headache treatment. Part 1: Prophylactic migraine treatment.

Effective migraine treatment is clearly the most cost-effective in terms of both direct and indirect costs. Patient education, behavior changes, and prudent medication selection can minimize costs. Low-dose aspirin may reduce headache frequency. Among the antidepressant medications used, amitriptyine 25 mg, 3 qhs ($4.16/month) and doxepin 25 mg, 3 qhs ($10.50/month) remain the standard. Imipramine (25 mg, 3 qhs ($3.75/month) is very inexpensive and should replace nortriptyline 25 mg, 3 qhs ($64.29/month) as a second-line agent. The specific serotonin reuptake inhibitors are expensive and have no proven effect for migraine prevention. Propranolol 80 mg bid ($7.80/month) is inexpensive and frequently a good choice among beta-blockers. Atenolol 100 mg qd ($27.50/month) is less expensive than long-acting propranolol 160 mg ($35.56/month) and nadolol 120 mg qd ($43.68/month) with equivalent effectiveness. It is thus recommended as the long-acting beta-blocker of choice. Sustained-release preparations of verapamil 240 mg qd ($31.98/month) are twice the cost and less well-absorbed than the standard preparation of 120 mg bid ($17.62/month). Better information is needed concerning effectiveness and optimal dosing of some older low-cost medications in the preventive treatment of migraine.

Culture and antibiotic monitoring service in a community hospital.

A culture-antibiotic monitoring service (CAMS) established by the pharmacy in a 254-bed community hospital is described. CAMS was offered as a clinical pharmacy consultation service to reduce the delay between availability of culture-report results in the laboratory and evaluation of these results by the physician. The pharmacist reviews culture results in conjunction with the patient's antibiotic therapy and clinical condition and contacts the physician regarding changes in therapy according to predetermined criteria. The pharmacist is also able to promote appropriate antibiotic prescribing and generate cost savings through interactions with physicians facilitated by CAMS. More than 98% of physicians agreed to participate in CAMS. During a one-year period, physicians implemented 87.1% of pharmacist-recommended changes in antibiotic therapy in 202 patients. The projected cost savings through a reduction in inappropriate prescribing of ceftazidime alone during a 10-month period enabled the pharmacy to easily justify hiring an additional clinical pharmacist. The culture-antibiotic monitoring service has enabled the pharmacy department to foster appropriate use of antibiotics and to realize substantial cost savings.