Quetiapine for the prevention of migraine refractory to the combination of atenolol + nortriptyline + flunarizine: an open pilot study

Abstract

-Background:Migraine is a prevalent neurological disorder. Although prevention is the mainstream treatment, some patients are refractory to standard therapies. Aim: To evaluate the use of quetiapine (QTP) in the preventive treatment of refractory migraine, defined as previous unresponsiveness to the combination atenolol + nortriptyline + flunarizine. Method: Thirty-four consecutive patients (30 women and 4 men) with migraine (ICHD-II) and headache attacks on less than 15 days per month not overusing symptomatic medications were studied. The main inclusion criterion was the lack of response (<50% reduction in attack frequency) after ten weeks to the combination of atenolol (60 mg/day) + nortriptyline (25 mg/day) + flunarizine (3 mg/day). The patients started on QTP as the sole treatment in a single daily dose of 25 mg, titrated to 75 mg. After ten weeks, headache frequency, consumption of rescue medications and adverse events were analyzed. Results: Twenty nine patients completed the study. Among completers, 22 (75.9%; 64.7% of the intention-to-treat population) presented >50% headache reduction. The mean frequency of migraine days decreased from 10.2 to 6.2 and the average consumption of rescue medications decreased from 2.3 to 1.2 days/week. Adverse events were reported by 9 (31%) patients. Conclusion: Although limited by the open design, this study provides a pilot data to support the use of quetiapine in preventive treatment of refractory migraine.Key worDs: migraine, quetiapine, preventive treatment, refractory.Quetiapina para a prevenção da migrânea refratária à combinação de atenolol + nortriptilina + flunarizina: estudo piloto aberto Resumo -Introdução: A migrânea é uma doença neurológica prevalente. embora a prevenção seja o esteio principal do tratamento, alguns pacientes são refratários aos tratamentos tradicionais. Objetivo: Avaliar o uso da quetiapina (QTP) no tratamento preventivo da migrânea refratária definida como ausência de resposta ao uso prévio da combinação de atenolol com nortriptilina e flunarizina. Método: Trinta e quatro pacientes consecutivos (30 mulheres e 4 homens) com migrânea (CIC-II) e crises de cefaléia em menos de 15 dias/mês sem uso excessivo de sintomáticos foram estudados. o critério de inclusão principal foi a não obtenção na redução da frequência de cefaléia >50% após 10 semanas de uso da combinação de atenolol (60 mg/dia) + nortriptilina (25 mg/dia) + flunarizina (3 mg/dia). os pacientes iniciaram a QTP como tratamento único na dose de 25 mg à noite e aumentaram-na até 75 mg. Após 10 semanas de uso, a frequência da cefaléia, o consumo de sintomáticos e os efeitos colaterais foram avaliados. Resultados: Vinte e nove pacientes completaram o estudo. entre os que completaram, 22 (75.9%; 64.7% dos pacientes que foram incluídos) obtiveram redução da frequência >50%. A frequência média de dias com migrânea por mês decresceu de 10,2 para 6,2. o consumo médio de sintomáticos caiu de 2,3 para 1,2 dias/semana. efeitos colaterais foram relatados por 9 (31%) pacientes. Conclusã...

Latin American consensus on guidelines for chronic migraine treatment

“…The parenteral application of sodium valproate 55 , magnesium sulphate 56 , chlorpromazine 57,58 , haloperidol 59 , olanzapine 60,61 , lidocaine 57 , and propofol 62 is particularly useful in treatments within hospital environments, and the use of the first four of them and/or their analogues 63,64 can be extended to transition and/or preventive treatment. Parenteral dihydroergotamine, particularly useful in the treatment of migraine crises, exacerbations of chronic migraine, and rebound headaches 57 , is not available in Brazil, only in some Latin-American countries.…”

Headache Research and Medical Practice in Brazil: An Historical Overview

“…Ribeirão Preto School of Medicine‐USP's main contributions are on pharmacology of pain mechanisms, epidemiological studies, and clinical research on the relationship between primary headaches and temporo‐mandibular joint disorders; Universidade Federal Fluminense (Niteroi) is notable for its studies on chronic daily headache and psychiatric comorbidities and headache in the elderly. Abouch Krymchantowski obtained his MSc and PhD at this university and has published a number of papers in the area of headache . Universidade Federal do Rio de Janeiro , for its part, researches spreading depression in chicken retina and neuroimaging.…”

“…In Rio de Janeiro, São Paulo, Paraná, Santa Catarina, and Rio Grande do Sul, there are several centers dealing with headache disorders and an excellent scientific production has been made by a number of headache specialists, mentioning Abouch Krymchantowski, Carla da Cunha Jevoux, Maurice Vincent, Pedro Ferreira Moreira Filho, Jano Alves de Souza, Maria Eduarda Nobre in Rio de Janeiro; Celia P. Roesler, Deusvenir de Souza Carvalho, Eliova Zukerman, Mario Fernando Prieto Peres,…”

Posttraumatic Headache

“…44,57 Other medications that can be useful for migraine prevention include nortriptyline, gabapentin, calcium channel blockers, pregabalin, and quetiapine. 44,57,66,67 Selection of a migraine prophylactic agent is influenced by the patient's comorbid conditions. Amitriptyline and quetiapine are options in the setting of comorbid insomnia.…”