Migraine research methods
CMAJ 1997;157:1015
Re: "Guidelines for the diagnosis and management of migraine in clinical practice," CMAJ 1997;156:1273-87 [full text / résumé], by Dr. William E.M. Pryse-Phillips and associates
In response to: H. Fisher
It is well understood that guidelines must be ever-changing; revision is certainly planned, for publication in approximately 2 years' time.
We realize that emergency physicians often see patients with severe and ultra-severe attacks; for this reason the consensus panel included a prominent emergency physician, who was extremely forceful, as was appropriate in the circumstances. However, since the article represented the position of the Canadian Headache Society, authorship was restricted to members of the society.
The methodology of migraine research has changed over the years. Before the studies of sumatriptan, the design of trials was very variable and often poor, making it difficult to interpret and to compare the literature. The studies conducted after the sumatriptan trials have all followed the same basic system, although this is not to say that the trials are ideal. Indeed, at the International Headache Congress held in Amsterdam in June 1997, guidelines for future studies were discussed and the consensus was that even the methods of recently published studies were somewhat simplistic and needed revision. The definition of "responder" was a particular problem. With further refinement, we hope that future studies will be more realistic and comparable. The assessment of quality of life in current studies is extremely important, as interest is shifting away from the 1-time efficacy of medications to their impact on the patient's life.
In regard to butorphanol, the study by Elenbaas and associates1 was of different intramuscular doses and involved patients with migraine (with and without aura) and with cluster headache. The study by Holfert and associates2 involving butorphanol nasal spray found that migraine pain was reduced from moderate, severe or incapacitating to slight or absent within 30 minutes in 15 patients (33%), within 1 hour in 50 patients (47%) and within 6 hours in 76 patients (71%), compared with, respectively, 2 patients (4%), 8 patients (16%) and 15 patients (30%) taking a placebo. The placebo-response rates in this study are unusually low, but it is otherwise difficult to argue with these figures.
We agree that orthostatic hypotension is a significant side effect of chlorpromazine, although it can be obviated by giving 500 mL of normal saline solution intravenously before administration of the drug.
Marek J. Gawel, MD
President
Canadian Headache Society
Assistant Professor of Medicine
University of Toronto
Toronto, Ont.
William E.M. Pryse-Phillips, MD
Professor of Medicine (Neurology)
Memorial University of Newfoundland
Health Science Centre
St. John's, Nfld.
References
- Elenbaas RM, Iacono CU, Koelner KJ, et al. Dose effectiveness and safety of butorphanol in acute migraine headache. Pharmacotherapy 1991;11(1):56-63.
- Holfert MJ, Couch JR, Diamond S, et al. Transnasal butorphanol in the treatment of acute migraine. Headache 1995;35:65-9.
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