Abstract
In the field of headache, there have been two major breakthroughs in the last 15 years: the introduction and revision of the International Headache Society (IHS) classification system for headache disorders; and the introduction of the triptans (selective serotonin 5-HT1B/1D receptor agonists). Triptans are now the treatment of choice for moderate to severe acute migraine attacks, based upon their superior efficacy relative to other classes of antimigraine agents (non-steroidal anti-inflammatory drugs, ergot derivatives).
However, the role of the triptans goes beyond that of effective acute treatment for migraine; they have also helped to extend our understanding of migraine pathophysiology. It is now established that neurogenic inflammation, peripheral sensitization of the trigeminal neurones and central sensitization of neurones in the trigeminal nucleus caudalis play a role in the generation and modulation of migraine aura, pain and cutaneous allodynia. In addition, the development of central sensitization late in a migraine attack can be linked to the pain-relieving effectiveness of the triptans. Understanding the pathophysiological mechanisms of migraine will undoubtedly lead to advances in drug therapy and management strategies. For example, early intervention with a triptan (to halt progression of an attack before central sensitization occurs) is gaining support as an optimal strategy to maximize treatment efficacy and patient outcomes. Disease modification to limit disease progression in high-risk individuals is another area of research that would benefit from advances in understanding of migraine pathophysiology.
Since the introduction of sumatriptan in 1991, seven triptans have been made commercially available. Clinical studies and meta-analyses of the oral triptans have found differences between the agents in terms of efficacy and tolerability, which are reflective of their differing pharmacokinetic profiles.
The growth in the migraine research field also triggered numerous studies into the prevalence, severity and economic burden of migraine. Such studies have shown that migraine is a common chronic condition, which is often associated with frequent attacks and severe pain. In the majority of sufferers, attacks cause substantial debilitation, limiting the functionality of the patient at both work and home for the duration of the attack. However, migraine remains underdiagnosed and undertreated.
Major surveys have been performed to identify patients’ expectations of and preferences for acute migraine therapy. The conclusion of these surveys is that patients value rapid, complete and sustained pain relief. Furthermore, patients desire a medication with good tolerability; indeed, the tolerability profile of a medication has been shown to affect patient confidence in treatment and thereby influence medication behaviour, which in turn can adversely affect patient outcomes. When choosing the ideal triptan, there still exists a practical need to obtain relevant information for each patient, in order to individualize treatment.
This supplement summarizes presentations given at a satellite symposium at the XI Congress of the IHS in Rome, September 2003, which reviewed data from both clinical trials and clinical practice showing how almotriptan meets the needs for rapid, complete and sustained efficacy with an excellent tolerability profile for the acute management of migraine.