The Impact of Allodynia on the Efficacy of Almotriptan When Given Early in Migraine: Data From the “Act When Mild” Study

Abstract

The objective of this study was to evaluate the impact of allodynia on treatment outcomes in the patients with acute migraine treated in the "Act when Mild" (AwM) study. AwM, a randomized placebo-controlled trial, studied almotriptan 12.5 mg in the early treatment (within 1 hr) of acute migraine when the pain was still mild, and investigated clinical outcomes in the presence or absence of allodynia, which was prospectively recorded using patient questionnaires. Of the total population, 39% (n = 404) reported allodynia that did not alter the efficacy of almotriptan administered for early/mild pain in terms of 2-hr pain-free rates (53.9% for allodynic patients vs. 52.5% for nonallodynic patients). Similarly, sustained pain-free rates were 47.2% versus 45.5%, and migraine duration 1.40 versus 1.54 hr, respectively. However, allodynia impaired the effectiveness of almotriptan in the patients with moderate/severe pain in terms of longer migraine duration, fewer patients achieving pain-free status, and more requiring rescue medication. In conclusion, the lack of effect of allodynia on the efficacy of almotriptan given for early/mild migraine pain might help explain the improved outcomes associated with the early-treatment strategy in AwM. Moreover, the data suggest that pain intensity is the main driver of triptan response, and not the presence or absence of allodynia.

Allodynia Is Associated With Initial and Sustained Response to Acute Migraine Treatment: Results from the American Migraine Prevalence and Prevention Study

“…In addition, the presence of allodynia significantly increased the likelihood of an inadequate response to treatment for the 2hPF and the 24hPR outcome measures, but not – as in our prior analysis where medications groups were combined – for the 24hSPR outcome. These results are consistent with some human treatment studies as well as laboratory research . In addition to allodynia, significant predictors of inadequate response to acute treatment included higher pain intensity (triptans, NSAIDs, opioids) and greater monthly headache‐day frequency (triptans, NSAIDs, opioids, and ergot alkaloids).…”

“…These results are consistent with some human treatment studies as well as laboratory research. 9,15,26 In addition to allodynia, significant predictors of inadequate response to acute treatment included higher pain intensity (triptans, NSAIDs, opioids) and greater monthly headacheday frequency (triptans, NSAIDs, opioids, and ergot alkaloids).…”

Pathophysiology of migraine

“…Interestingly, the presence or absence of allodynia does not predict outcome from acute therapy in randomized controlled trials. [40]…”

Treatment of Pediatric Migraine in the Emergency Room

“…Triptans are most efficacious when taken while the head pain is still mild, which tends to be early on in the attack(55, 56). Given that the average duration of pediatric migraine exceeds twenty-four hours by the time they are presenting to the emergency room, and the fact that they have come to the emergency room makes it less likely that their pain is only mild, the response rate of triptans when used in the emergency room is likely to be decreased in the emergency room setting.…”