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Biomedical subjects

Abouch Valenty Krymchantowski

Publications and source records attributed to Abouch Valenty Krymchantowski.

13 recordsLinked to original sources
PubMed2006

Polytherapy in the preventive and acute treatment of migraine: fundamentals for changing the approach.

The pathophysiology of migraine is complex and involves multiple neurophysiological pathways. Monotherapeutic approaches for migraine are the rule but many patients discontinue their medications owing to lack of efficacy. Polytherapy may provide a rational strategy for some of these individuals. Herein, we review the basis of polytherapy treatment for migraine. We suggest that refractory patients, with previous failure to single agents, may benefit from the use of a two- or three-drug regimen combining medications that target different neurotransmitter systems. In addition, those patients with high recurrence rates or not presenting pain free at 2 h and/or sustained pain free at 24 h may also respond better to combination therapy suited to their individual profile, which must include nonsteroidal anti-inflammatory agents plus a triptan or a gastrokinetic drug. The three-drug regimen may also be considered. Finally, changing the time medicine is taken (before the development of central sensitization and allodynia cutanea) and switching the choice of formulations to non-oral potentially achieves a better response and can be determined individually. Although highly speculative, these hypotheses could stimulate further controlled studies to support changing the current paradigm of monotherapeutic migraine treatment in some patients.

Analgesics↗
PubMed2005

Lysine clonixinate vs naproxen sodium for the acute treatment of migraine: a double-blind, randomized, crossover study.

BACKGROUND AND OBJECTIVES: The process of inflammation is crucial in migraine, and several nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in the treatment of migraine attacks. Despite their efficacy, the routine use of NSAIDs is limited by side effects as well as incomplete efficacy in some patients. Among the available options, lysine clonixinate (LC) and naproxen sodium (NS) have proved effective in migraine. The aim of this study was to compare the efficacy and tolerability of oral formulations of LC and NS in the treatment of moderate or severe migraine attacks, with a double-blind, crossover design. METHODS: Seventy subjects (62 women, 8 men) between ages 18 and 71 years (mean age, 41) with migraine according to the criteria of the International Headache Society were prospectively enrolled. The patients were randomized into 2 groups and each participant treated 2 migraine attacks. Group 1 treated the first attack with LC and the second attack with NS. Group 2 treated 2 attacks in a counterbalanced order. Doses were 250 mg of LC or 550 mg of NS, which were encapsulated for equal appearance. Headache intensity, nausea, photophobia, and side effects were evaluated at baseline, 1 hour, and 2 hours after drug administration. Rescue drugs were allowed after 2 hours for those who didn't respond, and this was also compared between groups. RESULTS: Sixty patients (54 women, 6 men) completed the study. At 1 hour, 13.6% patients who used LC were pain-free compared with 11.9% who used NS (P = .78). At 2 hours, 35.6% patients who took LC and 32.2% who took NS were pain-free (P = .69). At baseline, 52.5% of the patients randomized to group 1 reported nausea, compared with 33.9% in group 2, and both drugs eliminated nausea: At both 1 hour and 2 hours, nausea diminished significantly for those taking LC, but only after 2 hours for those who took NS (P < .0001). Both drugs eliminated photophobia at 1 hour and 2 hours; however, LC was superior to NS in reducing photophobia at 2 hours (P = .027). Ten patients who took LC and 8 who took NS required rescue drugs after 2 hours. Twelve patients who used LC and 16 who took NS reported side effects. COMMENTS: Although this study did not include a placebo arm, which impairs any definitive efficacy claims, we found LC and NS to be similarly effective and well tolerated in patients presenting moderate or severe attacks of migraine.

Adolescent↗
PubMed2005

Aura with non-migraine headache.

The typical aura associated with migraine is characterized by visual or sensory and speech symptoms, with a mix of positive and negative features and complete reversibility within 1 hour. However, auras are not an exclusive migraine-dependent phenomenon. There have been descriptions of aura occurring in association with cluster headache, hemicrania continua, and even with chronic paroxysmal hemicrania. In addition, the occurrence of aura without headache or followed by a headache resembling the criteria of tension-type headache is encountered in clinical practice. This paper reviews the literature about auras in non-migraine headaches and the features involving this uncommon presentation. The possibility of a specific genetic origin for the auras, not related to the primary headache type, also is raised.

Cluster Headache↗
PubMed2005

Rofecoxib in migraine.

Migraine is a highly prevalent primary headache. The disability of migraine attacks results in considerable economic and social losses. The acute treatment of migraine aims to rapidly and consistently alleviate the head pain and associated symptoms, therefore reducing the headache-related disability, ideally without side effects and recurrence of the attack within 24 h. Although several drug options and different formulations are available, the choice of a specific medication should depend on an individual patients characteristics. Among the available drugs, nonsteroidal anti-inflammatory drugs still represent effective options and a new class of nonsteroidal anti-inflammatory drugs known as selective cyclooxygenase-2 inhibitors may represent an even better-tolerated therapy with regard to gastrointestinal side effects. This article aims to discuss the role of rofecoxib in the acute treatment of migraine. Although this drug was recently withdrawn from the market, it provides a good model to understand the role of the cyclooxygenase-2 inhibitors in migraine therapy overall. The pharmacologic profile and therapeutic use in the acute treatment of migraine of rofecoxib is reviewed. In addition, the limitations of a monotherapeutic orally administered approach and possible ways of raising the efficacy of rofecoxib and other acute migraine treatments are reviewed.

Cyclooxygenase 2 Inhibitors↗
PubMed2005

Rizatriptan in migraine.

The prevalence of migraine is high, affecting a significant proportion of the adult population during their most productive years of life and promoting impairment of their normal daily activities. Although guidelines for the acute treatment of migraine are available, outcome parameters are sometimes still below the expectations of both patients and physicians. Triptans represented an advance in clinical practice and have become the most well-studied class of medication for migraine. These agents present class I evidence for efficacy. However, they differ with regard to several of their clinical parameters, including onset of relief and consistency of response. Rizatriptan is a selective agonist of the 5-hydroxytryptophan(1B/1D )receptors, with proven superiority over placebo, ergotamine and selected oral triptans, demonstrating a good profile of safety and tolerability.

Dose-Response Relationship, Drug↗
PubMed2004

Rizatriptan versus rizatriptan plus rofecoxib versus rizatriptan plus tolfenamic acid in the acute treatment of migraine.

BACKGROUND: Rizatriptan is an effective and fast acting drug for the acute treatment of migraine. Some nonsteroidal anti-inflammatory drugs (NSAID) have also demonstrated efficacy in treating migraine attacks. There is evidence that the combination of a triptan and a NSAID decreases migraine recurrence in clinical practice. The primary aim of this randomized open label study was to assess the recurrence rates in migraine sufferers acutely treated with rizatriptan (RI) alone vs. rizatriptan plus a COX-2 enzyme inhibitor (rofecoxib, RO) vs. rizatriptan plus a traditional NSAID (tolfenamic acid, TO). We were also interested in comparing the efficacy rates within these three groups. METHODS: We assessed 45 patients from a headache clinic in Rio de Janeiro (35 women and 10 men, ages 18 to 65 years, mean 37 years). Patients with IHS migraine were randomized to one out of 3 groups, where they had to treat 6 consecutive moderate or severe attacks in counterbalanced order. In group 1, patients treated the first two attacks with 10 mg RI, the third and fourth attacks with RI + 50 mg RO and the last attacks with RI + 200 mg of TA. In group 2, we began with RI + TA, followed by RI, and RI + RO. Group 3 treated in the following order: RI + RO, RI + TA, RI alone. The presence of headache, nausea and photophobia at 1, 2 and 4 hours, as well as recurrence and side effects were compared. RESULTS: A total of 33 patients finished the study, treating 184 attacks. The pain-free rates at 1 hour were: RI: 15.5%; RI + RO: 22.6%; RI + TA: 20.3%(NS). Pain-free rates at 2 h were: RI: 37.9%; RI + RO: 62.9%, and RI + TA: 40.6% (p = 0.008 for RI vs. RI + RO; p = 0.007 for RI + RO vs. RI + TA, NS for RI vs RI + TA). At 4 h, pain-free rates were: RI: 69%; RI + RO: 82.3%; RI + TA: 78.1% (NS for all comparisons). The combination of RI + RO was superior to RI and to RI + TA in regard of the absence of nausea and photophobia at 4 hours. Recurrence (after being pain-free at 2 h) was observed in 50% of patients treated with RI, in 15,4% of those treated with RI + RO, and in 7,7% of those treated with RI + TA. CONCLUSIONS: Despite the methodological limitations of this study, the combination of RI and RO revealed a higher response rate at 2 hours. Recurrence was also clearly decreased with both combinations in relation to the use of RI alone. Controlled studies are necessary to provide additional evidence.

Acute Disease↗
PubMed2004

[Topiramate in the preventive treatment of migraine: experience in a tertiary center].

Frequent migraine attacks require prophylactic treatment. Anticonvulsants have been suggested due to the progressive knowledge that cortical hyperexcitability is involved in migraine pathophysiology. Topiramate is one of these drugs and its efficacy has been demonstrated in several studies. The aim of this study is to evaluate the adherence and response to topiramate in migraineurs under treatment in a tertiary center. During a 2-year period, all of the patients receiving topiramate for migraine were evaluated after 3 months. The parameters evaluated were adherence to treatment, frequency reduction of attacks >50% and adverse events. Among 175 patients included, 134 (76.6%) returned. Among the 134 patients evaluated, 82 (61.2%) revealed frequency reduction >50% and 105 (78.4%) patients presented weight loss (average 3.4Kg). The most frequent side effects were paresthesias (39.6%); emotional disturbances (including depression, irritability and anxiety) in 17,9%; thinking impairment (12.7%); memory disturbances (12.7%) and altered taste (11.9%). Despite methodological limitations we concluded that adherence to its use and efficacy occurred in most of the patients. In addition, the side effect profile was acceptable. Further controlled studies are necessary to confirm these observations.

Adolescent↗
PubMed2004

Acute treatment of migraine. Breaking the paradigm of monotherapy.

BACKGROUND: Migraine is a highly prevalent disorder. The disability provoked by its attacks results in suffering as well as considerable economic and social losses. The objective of migraine acute treatment is to restore the patient to normal function as quickly and consistently as possible. There are numerous drugs available for this purpose and despite recent advances in the understanding of the mechanisms and different biological systems involved in migraine attacks, with the development of specific 5-HT agonists known as triptans, current options for acute migraine still stand below the ideal. DISCUSSION: Monotherapeutic approaches are the rule but up to one third of all patients discontinue their medications due to lack of efficacy, headache recurrence, cost and/or side effects. In addition, a rationale has been suggested for the development of polytherapeutic approaches, simultaneously aiming at some of the biological systems involved. This paper reviews the fundamentals for this changing approach as well as the evidence of its better efficacy. CONCLUSION: As a conclusion, most of the patients with a past history of not responding (no pain-free at 2 hours and/or no sustained pain-free at 24 hours) in at least 5 previous attacks should undergo a combination therapy suiting to their individual profile, which must include analgesics or non-steroidal anti-inflammatory agents plus a triptan or a gastro kinetic drug. The three-drug regimen may also be considered. In addition, changing the right moment to take it and the choice for formulations other than oral has also to be determined individually and clearly posted to the patient.

Acute Disease↗
PubMed2003

Primary headache diagnosis among chronic daily headache patients.

Chronic daily headache (CDH) refers to a group of non-paroxysmal daily or near-daily headaches with peculiar characteristics that are highly prevalent in populations of neurological clinics and not uncommon among non-patient populations. Most of the patients with CDH had, as primary diagnosis, episodic migraine, which, with the time, presented a progressive frequency, pattern modification and loss of specific migraine characteristics. Other CDH patients had chronic tension-type headache, new daily persistent headache and hemicrania continua, which evolved thru the time to the daily or near-daily presentation. The objective of this study was to determine the primary headache diagnosis among a population of chronic daily headache patients attending a tertiary center for headache treatment. During a 5-year period 651 consecutive chronic daily headache patients attending a private subspecialty center were studied prospectively. The criteria adopted were those proposed by Silberstein et al (1994, revised 1996). Five hundred seventy four patients (88.1%) had episodic migraine as primary headache before turning into daily presentation, 52 (8%) had chronic tension-type headache, 14 (2.2%) had hemicrania continua and 11 patients (1.7%) had new daily persistent headache. CDH is quite frequent in patients from clinic-based studies suggesting a high degree of disability. Emphasis on education of patients suffering from frequent primary headaches with regard to measures that are able to decrease suffering and disability as well as better medical education directed to more efficient ways to handle these patients are necessary to improve outcome of such a prevalent condition.

Adolescent↗
PubMed2003

Overuse of symptomatic medications among chronic (transformed) migraine patients: profile of drug consumption.

Chronic daily headache and chronic (transformed) migraine (TM) patients represent more than one third of the subjects seen in specialized headache centers. Most of these patients may overuse symptomatic medications (SM) taken on a daily basis to relieve headache and associated symptoms. The conversion to the daily or near-daily pattern of headache presentation is thought to be related to the medication overuse. The aim of this study was to evaluate the profile of SM consumption among transformed migraine patients attending a tertiary center. One hundred thirty three consecutive patients (22 men and 111 women, ages 17 to 80) with TM and overuse of SM according to the proposed criteria of Silberstein et al (1994, 1996) were prospectively studied. None of the patients were under treatment for other conditions. Among them, 73 (54.9%) were using one category of SM, while 55 (41.3%) and 5 (3.8%) patients were taking simultaneously two and three categories of SM respectively. The categories of overused symptomatic medications varied from simple analgesics to narcotics, triptans and combinations of ergot derivatives and caffeine and of analgesics and caffeine. The average intake per patient per day was of 3 to 4 tablets and mostly of the patients overused simple analgesics (isolated or in combination with other substances) (75.2%), caffeine containing drugs (71.4%), drugs containing ergotamine derivatives (26.1%), triptans (alone or combined) (15.5%), drugs with narcotics or ansiolitics (13%) and anti-inflammatory drugs (3.7%). The mechanisms by which the overuse of symptomatic medications may play a role in this transformation are uncertain but despite of the necessity of controlled trials to demonstrate the real role of such compounds in the development of transformed migraine, this study emphasizes the necessity for more rigorous prescribing guidelines for patients with frequent headaches.

Adolescent↗
PubMed2002

Amitriptyline versus amitriptyline combined with fluoxetine in the preventative treatment of transformed migraine: a double-blind study.

BACKGROUND AND OBJECTIVES: Antidepressants are often used to treat chronic daily headache disorders such as transformed migraine, in part because of the high prevalence of associated mood disorder. We conducted this study to evaluate the efficacy and tolerability of combined treatment with amitriptyline and fluoxetine compared with amitriptyline alone for chronic daily headache due to transformed migraine. PATIENTS AND METHODS: Thirty-nine patients, 26 women and 13 men, aged 20 to 69 years (mean, 36.4; SD, 2.5) who fulfilled criteria for transformed migraine proposed by Silberstein et al were studied prospectively. Amitriptyline was dosed as follows: 8 mg/day for 6 days, 8 mg twice a day for 6 days, 20 mg/day for 6 days, and 20 mg twice a day for 45 days. In the group receiving combination therapy, fluoxetine was dosed and administered identically. The initial and end of the study (9 weeks) headache indices (frequency x intensity) were compared between groups. RESULTS: Twenty-seven patients completed the study, 13 in the amitriptyline-alone group (group 1) and 14 in the combination-therapy group (group 2). The most frequent adverse event in both groups was dry mouth, and there was no significant difference in the occurrence of this or other adverse events between the two groups. Initial headache indices were similar for groups 1 and 2. The mean difference between the initial and final headache index for group 1 was 513.5 (P<.0005) and 893 (P<.0017) for group 2. The difference between the final headache index for the two groups was not significant (P>.207). CONCLUSIONS: We were unable to demonstrate any significant benefit from amitriptyline plus fluoxetine over amitriptyline alone in the treatment of chronic daily headache/transformed migraine. Because of the small number of subjects involved and the short duration of our study, a type II error cannot be excluded.

Adult↗