A randomized trial of frovatriptan for the intermittent prevention of menstrual migraine.
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Adult↗
Biomedical subjects
James U Adelman
Publications and source records attributed to James U Adelman.
The effect of early intervention with sumatriptan tablets on migraine-associated productivity loss.
OBJECTIVE: Impaired performance, which can considerably impact employee output, occurs when employees attempt to continue work with inadequate treatment while experiencing a migraine episode. This analysis examined productivity loss as a result of migraine after treatment with sumatriptan tablets and patients' usual non-triptan therapy when pain was mild (early intervention) versus when pain was moderate/severe. METHODS: The authors conducted a retrospective analysis of data on 6803 migraine days reported by 251 subjects who participated in a clinical trial. RESULTS: Although early intervention significantly reduced productivity loss compared with treatment when pain was moderate/severe for both sumatriptan and non-triptan therapy, productivity loss was consistently lower for sumatriptan than non-triptan therapy for all predose pain intensity levels. CONCLUSIONS: These findings suggest that the pharmaco-economic benefits of early intervention with sumatriptan tablets, like the clinical benefits, exceed those of delayed intervention.
Adult↗
Laboratory monitoring of OxyContin (oxycodone): clinical pitfalls.
Some patients have headaches that are refractory to standard treatments, and they require chronic administration of opioid analgesics. The use of opioids in a clinical setting must be closely monitored due to the medications' potential for addiction, abuse, and fatal interactions. Limited access to opioids and the demand for them outside the clinical setting leads to another danger. Patients can mislead their providers into prescribing opioids, intending to sell the medications instead of using them to alleviate their own pain. For protection of the patient, as well as the community, it is vital that such activity be prevented. We recently encountered a patient we suspected of abusing or misusing OxyContin (oxycodone). In order to determine whether the patient was taking the medication as prescribed, we ordered a urine-based immunoassay drug screen. The results were negative; the patient appeared to not have oxycodone in his system. Based on these results, we dismissed the patient from our practice. At the patient's request, a second test was performed, this time using gas chromatography-mass spectrometry. It indicated that the patient did indeed have sufficiently high levels of oxycodone in the urine. The minimum level threshold was too high to detect the presence of oxycodone in the immunoassay. We would like to help prevent future misunderstandings such as we experienced. To do so, we will first present the case of our patient, followed by a discussion of the actions taken. Finally, we will provide an overview of analgesic monitoring systems.
Adult↗
Rofecoxib in the prevention of perimenstrual migraine: an open-label pilot trial.
OBJECTIVE: To investigate the effectiveness of rofecoxib in the prevention of perimenstrual migraine. BACKGROUND: Nonsteroidal anti-inflammatory drugs have demonstrated benefit in reducing the frequency and intensity of menstrual migraine when administered perimenstrually. Anti-inflammatory drugs, however, may not be well tolerated and can produce gastrointestinal irritation. Rofecoxib, a selective cyclooxygenase-2 inhibitor, has anti-inflammatory and analgesic properties, and a significantly improved gastrointestinal tolerability profile. METHODS: A pilot study was conducted in which patients with a history of menstrually associated migraine and experiencing at least one migraine monthly during the perimenstrual period were enrolled. Patients who completed a baseline diary for the first month were randomized to receive either rofecoxib 25 mg or 50 mg daily for 10 days, starting 5 days before menstrual flow. Headaches experienced during this 10-day period were recorded in the patient's diary. Patients continued rofecoxib for 2 consecutive menstrual cycles. Mean migraine frequency, intensity, and duration as well as patient's level of functioning during the 2 cycles were compared with baseline. RESULTS: Fourteen patients completed baseline and rofecoxib dosing for 2 menstrual cycles. Mean migraine frequency decreased from 5.6 to 2.6 migraines per menstrual cycle (P=.005). Eight (57%) of 14 patients had a > or = 50% reduction in headache frequency. No significant improvement in headache intensity, duration, and functional impairment were observed. Both doses of rofecoxib were well tolerated with no statistical difference in patient response between the doses. CONCLUSION: Rofecoxib at a perimenstrual daily dose of 25 or 50 mg demonstrated a significant reduction in frequency of perimenstrual migraine. A double-blind, placebo-controlled trial of rofecoxib in the prevention of perimenstrual migraine is warranted.
Anti-Inflammatory Agents, Non-Steroidal↗
Cost considerations of acute migraine treatment.
OBJECTIVE: To provide medication price data and cost-reducing strategies for the acute treatment of migraine. METHODS: Retail prices for common acute care medications were found at http://www.drugstore.com. Cost-reduction tactics were obtained from literature searches and clinical experience. RESULTS: Several strategies can reduce cost without sacrificing treatment outcome. In mild to moderate migraine, low-priced nonsteroidal anti-inflammatory drugs can be used as first-line medications due to their proven efficacy and favorable tolerability. For patients with more severe migraine, implementing a stratified care approach-using migraine-specific medications early in acute treatment-is cost-effective for most patients. Stratified care not only improves outcome and decreases disability, but also reduces cost. Pill splitting and early administration of triptans within an attack enhance their value. Supplying rescue medications, such as opioids, sedatives, and phenothiazines, can prevent emergency department visits. Minimizing multiple dosing of triptans and reducing utilization of expensive health care resources are key factors in reducing the cost of effective migraine treatment. An important affordability factor for patients with co-payments is the number of triptan pills per package. Sumatriptan, naratriptan, and frovatriptan each contain 9 tablets per package, while most other triptan packages contain 6. Current triptan retail prices (per unit) include: Amerge 1 and 2.5 mg, 17.78 dollars; Axert 6.25 and 12.5 mg, 16.31 dollars; Frova 2.5 mg, 13.89 dollars; Imitrex 50 mg, 14.96 dollars; Imitrex 100 mg, 14.41 dollars; Imitrex Nasal Spray 20 mg, 21.61 dollars; Imitrex SQ 6 mg, 50.26 dollars; Maxalt 5 and 10 mg, 15 dollars; Maxalt-MLT 5 and 10 mg, 15 dollars; Relpax 40 mg, 13.58 dollars; Zomig 2.5 mg, 13.67 dollars; Zomig 5 mg, 15.89 dollars; Zomig-ZMT 2.5 mg, 13.67 dollars; and Zomig-ZMT 5 mg, 15.89 dollars. CONCLUSIONS: Practitioners can optimize the use of health care dollars without compromising quality of care through awareness of cost-saving treatment strategies, as well as price variations among medications.
Acute Disease↗
Efficacy of topiramate in migraine prophylaxis: a retrospective chart analysis.
OBJECTIVE: Topiramate, a broad-spectrum anticonvulsant with multiple mechanisms of action, may be effective in preventing migraine headaches. We report the results of a retrospective chart review of patients treated with topiramate for prophylaxis of migraine. METHODS: Patients with a diagnosis of migraine who had at least one follow-up visit after > or =4 weeks on topiramate were eligible; 69 patients (56 women and 13 men) aged 18 to 68 years met these criteria. Charts were reviewed for frequency of mild or moderate/severe headaches at the start of topiramate (baseline) and at all subsequent visits up to 24 weeks. RESULTS: The 28-day frequency of moderate/severe migraines declined significantly from baseline to end of treatment (10.6 +/- 8.4 to 7.4 +/- 7.7, respectively; P = 0.0004), whereas that of mild headaches did not demonstrate a significant change (from 11.8 +/- 8.9 to 11.0 +/- 10.0). Among the 38 patients who had not responded previously to >or =9 preventive medications, the monthly frequency of moderate/severe (but not mild) headaches decreased significantly from baseline to end of treatment. Patients who previously had not responded to <9 prior medications experienced significant declines in both mild and moderate/severe headaches. The most common adverse events were paresthesias, drowsiness, diarrhea, decreased appetite, and weight loss. Twenty-seven patients discontinued topiramate therapy, 20 as a result of adverse events and 7 due to lack of response. CONCLUSION: Topiramate may be effective in reducing the frequency of both mild and moderate/severe migraine headaches. In particular, topiramate may offer relief to patients with moderate/severe migraines who do not respond to other treatments.
Adolescent↗
Almotriptan versus sumatriptan in migraine treatment: direct medical costs of managing adverse chest symptoms.
OBJECTIVE: Triptans, a popular class of drugs for treatment of migraine headaches, can cause adverse events including chest symptoms. This study estimated the direct medical costs of managing chest symptoms in patients treated for acute migraine with almotriptan or sumatriptan using an economic model. METHODS: The economic model of this study combined data from a randomized clinical trial that compared almotriptan with sumatriptan and data from a practice pattern survey of physicians. The pertinent clinical evaluation period was the time immediately after administration of the first medication dose. The model was developed from the perspective of a managed care payer. RESULTS: The average direct medical cost of managing chest symptoms that appeared after the first dose of an oral triptan was $0.22 for patients treated with almotriptan and $1.64 for patients treated with sumatriptan, a difference of $1.42 per patient. CONCLUSION: Relative to sumatriptan, treatment with almotriptan is likely to reduce patient care costs associated with chest symptom adverse events.
Chest Pain↗
Cost-effectiveness of antiepileptic drugs in migraine prophylaxis.
OBJECTIVE: To analyze the cost-effectiveness of antiepileptics in migraine prophylaxis. METHODS: A cost-effectiveness analysis was performed using efficacy data from three recent, double-blind, placebo-controlled, clinical trials of antiepileptic drugs studied for migraine prevention and cost data. Two measures of cost-effectiveness were used: cost per headache prevented and the cost-equivalent number. RESULTS: In the double-blind, placebo-controlled, clinical trials evaluated, three antiepileptic drugs were shown to be effective in migraine prevention. All three antiepileptic drugs had high costs per migraine reduced. Gabapentin was the most costly at dollars 138.00 per migraine prevented, whereas the cost per migraine prevented with topiramate was US dollars 114.80 and with divalproex sodium was US dollars 48.00. For migraine prevention divalproex sodium became cost-effective with 10 migraines per month, whereas gabapentin and topiramate required considerably more migraines per month to be cost-effective. CONCLUSIONS: Antiepileptic drugs have proven effectiveness in migraine prophylaxis. However, in patients responsive to their acute care medications, the antiepileptic drugs are only cost-effective for those patients with a high frequency of migraines and those with comorbid diseases. Future studies should be done with antiepileptic drugs in patients exhibiting a migraine frequency of 10 or more headaches per month.
Acetates↗
Does migraine preventive medication actually reduce resource utilization?
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Health Resources↗
Meta-analysis methodology: the battle continues.
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Humans↗
Pharmacoeconomics: the cost of prophylactic migraine treatments.
Migraine preventive medications considered effective reduce headache frequency by 50 percent in approximately 50 percent of treated patients. In spite of similar effectiveness, these medications vary tremendonsly in their prices. Knowledge of medication prices and employing cost-effective strategies may greatly reduce treatment costs.
Fees, Pharmaceutical↗
Meta-analysis of oral triptan therapy for migraine: number needed to treat and relative cost to achieve relief within 2 hours.
OBJECTIVE: To determine the cost-effectiveness of the 5-HT1B/1D agonists, or triptans, in the acute treatment of migraine. METHODS: To determine the cost-effectiveness of the triptans, a meta-analysis was conducted of the efficacy data from 27 oral triptan trials, using the endpoint of "pain-free" status within 2 hours after initial dosing as the indicator of efficacy. Efficacy data were used to determine the number needed to treat (NNT) to achieve pain-free status in 1 patient within 2 hours postdose and then applied the per-dose costs for each triptan to the NNT values. RESULTS: Rizatriptan 10 mg and almotriptan 12.5 mg were the most cost-effective of the triptans, costing $48.34 and $48.57 US dollars, respectively, to achieve pain-free status in 1 patient within 2 hours postdose. Frovatriptan 2.5 mg was the most costly, with a cost-effective ratio of $162.49 US dollars. All other triptans fell between these extremes: zolmitriptan 5 mg ($65.18 US dollars), sumatriptan 100 mg ($70.83 US dollars), sumatriptan 50 mg ($75.67 US dollars), zolmitriptan 2.5 mg ($78.74 US dollars), and naratriptan 2.5 mg ($141.43 US dollars), in decreasing order of cost-effectiveness. CONCLUSION: Using an NNT analysis, the least-costly drugs to achieve migraine cure within 2 hours are rizatriptan 10 mg and almotriptan 12.5 mg. From a population health perspective, the lower acquisition cost of almotriptan 12.5 mg allows for effective treatment of more patients than rizatriptan 10 mg for no additional medication cost.
Administration, Oral↗