Defeating migraine pain with triptans: A race against the development of cutaneous allodynia

Abstract

For many migraine patients, triptan therapy provides complete pain relief in some attacks but not in others. Here, we tested whether the success of triptan therapy is hindered in the presence of cutaneous allodynia (pain resulting from a nonnoxious stimulus to normal skin), a phenomenon we previously described develop gradually during the course of the migraine attack in more than 70% of patients. We studied migraine patients repeatedly on three visits to the clinic: in the absence of migraine (baseline), within the first hour of one attack, or at 4 hours from onset of another attack. Presence or absence of allodynia was determined based on differences between migraine and baseline pain thresholds to mechanical and thermal stimulation of periorbital skin. In 31 patients, we studied 34 migraine attacks that were associated with allodynia at the time of triptan treatment and 27 attacks that were not. Within 2 hours of triptan treatment, patients were rendered pain-free in 5 of 34 (15%) of allodynic attacks versus 25 of 27 (93%) of nonallodynic attacks. Treating migraine attacks 1 hour (early) or 4 hours (late) after the onset of pain was equally ineffective in inducing a pain-free state in the presence of allodynia, and equally effective in the absence of allodynia. For patients susceptible to allodynia during the attack, triptan therapy was by far more likely to provide complete pain relief if administered before rather than after the establishment of cutaneous allodynia. Patients who never developed allodynia were highly likely to be rendered pain-free by triptan therapy anytime after the onset of pain. We conclude that the probability of consistent pain-free outcome increases drastically if triptan therapy is vigilantly timed to precede any signs of cutaneous allodynia.

Indomethacin, alone and combined with prochlorperazine and caffeine, but not sumatriptan, abolishes peripheral and central sensitization in in vivo models of migraine

“…This result confirms that triptans cannot abolish already established central sensitization, 5,7 but it also suggests that triptans cannot abolish already established peripheral sensitization.…”

“…12 However, it has recently been shown that the triptans are less effective in aborting a migraine attack if the central sensitization is already established. 5 The combination of indomethacin, prochlorperazine, and caffeine (IndoProCaf) is a drug of well-established use in Italy with a recognized efficacy and a good level of safety in the acute treatment of migraine. Each active ingredient of IndoProCaf has specific antimigraine properties.…”

The prevalence of allodynia, osmophobia and red ear syndrome in the juvenile headache: preliminary data

“…Considering also the different responses to triptans in migraine, with or without allodynia [4], we may suppose that allodynia and osmophobia help distinguish two migraineur subgroups with different disabilities, different therapeutic responses and perhaps different follow-ups; therefore, we think that it is useful to ask patients with migraine about these two features. Allodynia and osmophobia could be predictive factors for a negative evolution of migraine.…”

Preventing chronicity of migraine

“…Triptans can abort pain prior to the development of central sensitisation, but not after allodynia has been established [4]. Unfortunately, when central sensitisation and allodynia are established, pharmacological agents only attenuate migraine symptoms but do not stop the underlying pathophysiologic process.…”