Migraine ICYMI

Diplopia, commonly known as double vision, was depicted in a significantly higher percentage of drawings by children (aged 6-18 years) with pseudotumor cerebri than drawings by children with migraine, a recent study found. In all other respects, headache drawings by both groups of children were similar. In this study, children attending university hospital pediatric neurology clinics were asked to draw a picture of how their headache feels. Headache drawings of 21 children (16 females) with pseudotumor were compared with those of 518 children with migraine. Researchers found:

• Pseudotumor drawings depicted a variety of symptoms including pounding pain (n=11), pressure-like pain (n=3), photophobia (n=3), dizziness (n=1), and recumbency (n=1).
• Severe pain indicators included hammers, bombs, an anvil, and vise grip.
• Positive visual phenomena included scintillations, scotomata, or blurring (n=8).
• Negative visual phenomena included field defects (n=2).

Pseudotumor drawings were similar to migraine drawings except that 6 of 21 pseudotumor drawings (28.6%) depicted diplopia, whereas only 3 of 518 migraine drawings (0.6%) depicted diplopia.

Evidence of diplopia in children's headache drawings helps to differentiate pseudotumor cerebri from migraine. 2018;79:40-44. Pediatr Neurol.  doi:10.1016/j.pediatrneurol.2017.10.020.

Diplopia, commonly known as double vision, was depicted in a significantly higher percentage of drawings by children (aged 6-18 years) with pseudotumor cerebri than drawings by children with migraine, a recent study found. In all other respects, headache drawings by both groups of children were similar. In this study, children attending university hospital pediatric neurology clinics were asked to draw a picture of how their headache feels. Headache drawings of 21 children (16 females) with pseudotumor were compared with those of 518 children with migraine. Researchers found:

• Pseudotumor drawings depicted a variety of symptoms including pounding pain (n=11), pressure-like pain (n=3), photophobia (n=3), dizziness (n=1), and recumbency (n=1).
• Severe pain indicators included hammers, bombs, an anvil, and vise grip.
• Positive visual phenomena included scintillations, scotomata, or blurring (n=8).
• Negative visual phenomena included field defects (n=2).

Pseudotumor drawings were similar to migraine drawings except that 6 of 21 pseudotumor drawings (28.6%) depicted diplopia, whereas only 3 of 518 migraine drawings (0.6%) depicted diplopia.

Evidence of diplopia in children's headache drawings helps to differentiate pseudotumor cerebri from migraine. 2018;79:40-44. Pediatr Neurol.  doi:10.1016/j.pediatrneurol.2017.10.020.

Diplopia, commonly known as double vision, was depicted in a significantly higher percentage of drawings by children (aged 6-18 years) with pseudotumor cerebri than drawings by children with migraine, a recent study found. In all other respects, headache drawings by both groups of children were similar. In this study, children attending university hospital pediatric neurology clinics were asked to draw a picture of how their headache feels. Headache drawings of 21 children (16 females) with pseudotumor were compared with those of 518 children with migraine. Researchers found:

• Pseudotumor drawings depicted a variety of symptoms including pounding pain (n=11), pressure-like pain (n=3), photophobia (n=3), dizziness (n=1), and recumbency (n=1).
• Severe pain indicators included hammers, bombs, an anvil, and vise grip.
• Positive visual phenomena included scintillations, scotomata, or blurring (n=8).
• Negative visual phenomena included field defects (n=2).

Pseudotumor drawings were similar to migraine drawings except that 6 of 21 pseudotumor drawings (28.6%) depicted diplopia, whereas only 3 of 518 migraine drawings (0.6%) depicted diplopia.

Evidence of diplopia in children's headache drawings helps to differentiate pseudotumor cerebri from migraine. 2018;79:40-44. Pediatr Neurol.  doi:10.1016/j.pediatrneurol.2017.10.020.

Women with migraine have a higher relative risk of developing hypertension compared to women without migraine, according to a recent study. Researchers performed a prospective cohort study among 29,040 women without hypertension at baseline. Women were classified as having active migraine with aura, active migraine without aura, a past history of migraine, or no history of migraine. Incident hypertension was defined as new physician diagnosis or newly self-reported systolic or diastolic blood pressure ≥140 mmHg or ≥90 mmHg, respectively. They found:

• During a mean follow-up of 12.2 years, 15,176 incident hypertension cases occurred.
• Compared to those with no history of migraine, women who experience migraine with aura had a 9% increase in their risk of developing hypertension; women who experience migraine without aura had a 21% increase in their risk of developing hypertension; and women with a past history of migraine had a 15% increase in their risk of developing hypertension.

Migraine and the risk of incident hypertension among women. [Published online ahead of print February 1, 2018]. Cephalalgia. doi:10.1177/0333102418756865.

Women with migraine have a higher relative risk of developing hypertension compared to women without migraine, according to a recent study. Researchers performed a prospective cohort study among 29,040 women without hypertension at baseline. Women were classified as having active migraine with aura, active migraine without aura, a past history of migraine, or no history of migraine. Incident hypertension was defined as new physician diagnosis or newly self-reported systolic or diastolic blood pressure ≥140 mmHg or ≥90 mmHg, respectively. They found:

• During a mean follow-up of 12.2 years, 15,176 incident hypertension cases occurred.
• Compared to those with no history of migraine, women who experience migraine with aura had a 9% increase in their risk of developing hypertension; women who experience migraine without aura had a 21% increase in their risk of developing hypertension; and women with a past history of migraine had a 15% increase in their risk of developing hypertension.

Migraine and the risk of incident hypertension among women. [Published online ahead of print February 1, 2018]. Cephalalgia. doi:10.1177/0333102418756865.

Women with migraine have a higher relative risk of developing hypertension compared to women without migraine, according to a recent study. Researchers performed a prospective cohort study among 29,040 women without hypertension at baseline. Women were classified as having active migraine with aura, active migraine without aura, a past history of migraine, or no history of migraine. Incident hypertension was defined as new physician diagnosis or newly self-reported systolic or diastolic blood pressure ≥140 mmHg or ≥90 mmHg, respectively. They found:

• During a mean follow-up of 12.2 years, 15,176 incident hypertension cases occurred.
• Compared to those with no history of migraine, women who experience migraine with aura had a 9% increase in their risk of developing hypertension; women who experience migraine without aura had a 21% increase in their risk of developing hypertension; and women with a past history of migraine had a 15% increase in their risk of developing hypertension.

Migraine and the risk of incident hypertension among women. [Published online ahead of print February 1, 2018]. Cephalalgia. doi:10.1177/0333102418756865.

Group education on headache evaluation and lifestyle management has potential as an effective, low-cost intervention for treatment of chronic headaches among adolescents, according to a recent study. This retrospective chart review study evaluated a group education program for 155 adolescents, aged 12-17 years, enrolled in the US military medical system with at least 3 months of chronic headaches and who were referred to a headache evaluation clinic. The primary outcome of the study was self-reported number of days with a headache in the previous 30 days based on patient recall. Researchers found:

• Most participants in the program were female (114/155 [73.5%]) and suffered from migraine headaches (108/155 [69.8%]).
• Severe headache-related disability was reported by 40.6% of subjects (63/155).
• Subjects reported an average of 19 days with headache during the previous 30 days.
• Participation in the group education was associated with an 11.5-day decrease in the frequency of headaches during the previous 30 days at follow-up at least 6 months after the class, with largest decline seen in patients with the highest level of migraine-related disability at baseline.

Group education and multidisciplinary management for chronic headaches among adolescents in a military treatment facility: A retrospective chart review. [Published online ahead of print February 7, 2018]. Headache. doi:10.1111/head.13274.

Group education on headache evaluation and lifestyle management has potential as an effective, low-cost intervention for treatment of chronic headaches among adolescents, according to a recent study. This retrospective chart review study evaluated a group education program for 155 adolescents, aged 12-17 years, enrolled in the US military medical system with at least 3 months of chronic headaches and who were referred to a headache evaluation clinic. The primary outcome of the study was self-reported number of days with a headache in the previous 30 days based on patient recall. Researchers found:

• Most participants in the program were female (114/155 [73.5%]) and suffered from migraine headaches (108/155 [69.8%]).
• Severe headache-related disability was reported by 40.6% of subjects (63/155).
• Subjects reported an average of 19 days with headache during the previous 30 days.
• Participation in the group education was associated with an 11.5-day decrease in the frequency of headaches during the previous 30 days at follow-up at least 6 months after the class, with largest decline seen in patients with the highest level of migraine-related disability at baseline.

Group education and multidisciplinary management for chronic headaches among adolescents in a military treatment facility: A retrospective chart review. [Published online ahead of print February 7, 2018]. Headache. doi:10.1111/head.13274.

Group education on headache evaluation and lifestyle management has potential as an effective, low-cost intervention for treatment of chronic headaches among adolescents, according to a recent study. This retrospective chart review study evaluated a group education program for 155 adolescents, aged 12-17 years, enrolled in the US military medical system with at least 3 months of chronic headaches and who were referred to a headache evaluation clinic. The primary outcome of the study was self-reported number of days with a headache in the previous 30 days based on patient recall. Researchers found:

• Most participants in the program were female (114/155 [73.5%]) and suffered from migraine headaches (108/155 [69.8%]).
• Severe headache-related disability was reported by 40.6% of subjects (63/155).
• Subjects reported an average of 19 days with headache during the previous 30 days.
• Participation in the group education was associated with an 11.5-day decrease in the frequency of headaches during the previous 30 days at follow-up at least 6 months after the class, with largest decline seen in patients with the highest level of migraine-related disability at baseline.

Group education and multidisciplinary management for chronic headaches among adolescents in a military treatment facility: A retrospective chart review. [Published online ahead of print February 7, 2018]. Headache. doi:10.1111/head.13274.

Serotonin syndrome (SS) is diagnosed by the clinical triad of dysautonomia (fever, mydriasis, diaphoresis, tachycardia), neuromuscular signs (ataxia, hyperreflexia, tremor, myoclonus), and altered mental status (seizures, delirium). Two validated criteria groups are accepted, the Hunter criteria and the Sternbach criteria. These criteria require a menu-like approach of clinical manifestations of the above signs with known addition or increase of a serotonergic medication and the absence of other possible causes, such as neuroleptics.

In 2006, the FDA issued a clinical warning titled “Potentially Life-Threatening Serotonin Syndrome With Combined Use of SSRIs or SNRIs and Triptan Medications.” Subsequently, Randolph W. Evans, MD, and others conducted a close evaluation of the cases used by the FDA as the basis for their warning. They noted that none of the initial cases met Hunter criteria, only 10 of 29 met Sternbach criteria, and a second set of 11 patients also were questionable in terms of the diagnosis of serotonin toxicity. Serotonin (5-HT) toxicity is mediated by excessive activity of 5-HT_2A receptors, and triptans have no action at those receptors, only having activity at 5-HT_1B, _1D, and _1F receptors.

In 2010, the American Headache Society (AHS) published a position paper on this drug-drug interaction. In it, they stated, “with only Class IV evidence available in the literature and available through the FDA registration of adverse events, …the currently available evidence does not support limiting the use of triptans with SSRIs or SNRIs, or the use of triptan monotherapy, due to concerns for serotonin syndrome (Level U).”

Confirming the lack of evidence for an interaction, Dr. Yulia Orlova from the Graham Headache Center in Boston reported from the Partners Healthcare System Research Patient Data Registry on about 48,000 patients prescribed triptans, of whom about 19,000 were also co-prescribed SSRI or SNRI antidepressants. None of the cases met Hunter and Sternbach criteria and one patient who manifested serotonin toxicity had signs that preceded triptan use.  A previous trial of a cohort of 240,268 patients receiving pharmacy benefits reported that the frequency of co-prescription of triptans with SSRIs was about 20%. With the size of these reports, the absence of documented cases fulfilling both sets of criteria, and the lack of receptor plausibility as a cause for serotonin toxicity from triptans, the likelihood of the syndrome from triptan use is low, and the warning inappropriate. The co-occurrence of depression, anxiety, and migraine often makes co-prescription of triptans and antidepressants necessary, and the concern for co-prescription excessive.

—Stewart J. Tepper, MD
Professor of Neurology
Geisel School of Medicine at Dartmouth

Serotonin syndrome (SS) is diagnosed by the clinical triad of dysautonomia (fever, mydriasis, diaphoresis, tachycardia), neuromuscular signs (ataxia, hyperreflexia, tremor, myoclonus), and altered mental status (seizures, delirium). Two validated criteria groups are accepted, the Hunter criteria and the Sternbach criteria. These criteria require a menu-like approach of clinical manifestations of the above signs with known addition or increase of a serotonergic medication and the absence of other possible causes, such as neuroleptics.

In 2006, the FDA issued a clinical warning titled “Potentially Life-Threatening Serotonin Syndrome With Combined Use of SSRIs or SNRIs and Triptan Medications.” Subsequently, Randolph W. Evans, MD, and others conducted a close evaluation of the cases used by the FDA as the basis for their warning. They noted that none of the initial cases met Hunter criteria, only 10 of 29 met Sternbach criteria, and a second set of 11 patients also were questionable in terms of the diagnosis of serotonin toxicity. Serotonin (5-HT) toxicity is mediated by excessive activity of 5-HT_2A receptors, and triptans have no action at those receptors, only having activity at 5-HT_1B, _1D, and _1F receptors.

In 2010, the American Headache Society (AHS) published a position paper on this drug-drug interaction. In it, they stated, “with only Class IV evidence available in the literature and available through the FDA registration of adverse events, …the currently available evidence does not support limiting the use of triptans with SSRIs or SNRIs, or the use of triptan monotherapy, due to concerns for serotonin syndrome (Level U).”

Confirming the lack of evidence for an interaction, Dr. Yulia Orlova from the Graham Headache Center in Boston reported from the Partners Healthcare System Research Patient Data Registry on about 48,000 patients prescribed triptans, of whom about 19,000 were also co-prescribed SSRI or SNRI antidepressants. None of the cases met Hunter and Sternbach criteria and one patient who manifested serotonin toxicity had signs that preceded triptan use.  A previous trial of a cohort of 240,268 patients receiving pharmacy benefits reported that the frequency of co-prescription of triptans with SSRIs was about 20%. With the size of these reports, the absence of documented cases fulfilling both sets of criteria, and the lack of receptor plausibility as a cause for serotonin toxicity from triptans, the likelihood of the syndrome from triptan use is low, and the warning inappropriate. The co-occurrence of depression, anxiety, and migraine often makes co-prescription of triptans and antidepressants necessary, and the concern for co-prescription excessive.

—Stewart J. Tepper, MD
Professor of Neurology
Geisel School of Medicine at Dartmouth

Serotonin syndrome (SS) is diagnosed by the clinical triad of dysautonomia (fever, mydriasis, diaphoresis, tachycardia), neuromuscular signs (ataxia, hyperreflexia, tremor, myoclonus), and altered mental status (seizures, delirium). Two validated criteria groups are accepted, the Hunter criteria and the Sternbach criteria. These criteria require a menu-like approach of clinical manifestations of the above signs with known addition or increase of a serotonergic medication and the absence of other possible causes, such as neuroleptics.

In 2006, the FDA issued a clinical warning titled “Potentially Life-Threatening Serotonin Syndrome With Combined Use of SSRIs or SNRIs and Triptan Medications.” Subsequently, Randolph W. Evans, MD, and others conducted a close evaluation of the cases used by the FDA as the basis for their warning. They noted that none of the initial cases met Hunter criteria, only 10 of 29 met Sternbach criteria, and a second set of 11 patients also were questionable in terms of the diagnosis of serotonin toxicity. Serotonin (5-HT) toxicity is mediated by excessive activity of 5-HT_2A receptors, and triptans have no action at those receptors, only having activity at 5-HT_1B, _1D, and _1F receptors.

In 2010, the American Headache Society (AHS) published a position paper on this drug-drug interaction. In it, they stated, “with only Class IV evidence available in the literature and available through the FDA registration of adverse events, …the currently available evidence does not support limiting the use of triptans with SSRIs or SNRIs, or the use of triptan monotherapy, due to concerns for serotonin syndrome (Level U).”

Confirming the lack of evidence for an interaction, Dr. Yulia Orlova from the Graham Headache Center in Boston reported from the Partners Healthcare System Research Patient Data Registry on about 48,000 patients prescribed triptans, of whom about 19,000 were also co-prescribed SSRI or SNRI antidepressants. None of the cases met Hunter and Sternbach criteria and one patient who manifested serotonin toxicity had signs that preceded triptan use.  A previous trial of a cohort of 240,268 patients receiving pharmacy benefits reported that the frequency of co-prescription of triptans with SSRIs was about 20%. With the size of these reports, the absence of documented cases fulfilling both sets of criteria, and the lack of receptor plausibility as a cause for serotonin toxicity from triptans, the likelihood of the syndrome from triptan use is low, and the warning inappropriate. The co-occurrence of depression, anxiety, and migraine often makes co-prescription of triptans and antidepressants necessary, and the concern for co-prescription excessive.

—Stewart J. Tepper, MD
Professor of Neurology
Geisel School of Medicine at Dartmouth