1. My migraine ruins my weekends CLINICAL CASE Presented by: Julio Pascual Neuroscience Area, Service of Neurology, University Hospital Central de Asturias and Ineuropa, Oviedo, Asturias, Spain

2. 31-year-old otherwise healthy man who consulted us because of a history of headache attacks appearing during weekends IDENTIFICATION

3. FAMILY HISTORY AND PAST CLINICAL HISTORY No personal antecedents; working as a bank employee 13-year history of migraine without aura attacks Past frequency: one episode every three months Three months prior to consultation he had began with migraine without aura episodes every weekend Headache began during Saturday morning Headache was present on awakening and lasted up to 36 h He tended to experience one more migraine episode per month History of migraine in his father and his grandmother

4. Systemic and neurological examination was unremarkable No complementary determinations of neuroimaging procedures were carried out DIAGNOSTIC PROCEDURES

5. “Weekend” migraine without aura attacks DIAGNOSIS

6. PAST TREATMENT (I) The main reason for consultation was the difficulty to control migraine without aura during weekends: –Simple analgesics: no improvement –Tramadol: poor response –Ibuprofen: poor response

7. PAST TREATMENT (II) Triptans Zolmitriptan 2.5 mg –Partial response –Good tolerability Zolmitriptan 5 mg –Usually response at 2 h –Headache tended to recur after 12 h –Asthenia after the second dose of zolmitriptan for recurrence

8. TREATMENT (I) Theoretical options Long-acting triptans –A long-acting triptan would be able to reduce recurrence Conventional preventive treatment –The frequency and severity of the attacks requires to start with preventatives Preemptive treatment –Weekend migraine attacks are predictable –More difficult to treat as headache is present on awakening

9. TREATMENT (II) Recommendations Preventative –Nadolol 80 mg daily Acute treatment –Frovatriptan 2.5 mg when the first symptoms appear Rescue medication –Frovatriptan 2.5 mg or dexketoprofen 25 mg

10. FOLLOW-UP VISIT Assessment after 2 months −Four migraine attacks had occurred: two in the first and third weekend after the first visit and one out of the weekend −They responded to a further dose of frovatriptan 2.5 mg or to 25 mg dexketoprofen −Tolerability to nadolol and frovatriptan was excellent −He was told to continue nadolol taking for 4 months and early frovatriptan 2.5 mg as acute treatment

11. REMARKS (I) Weekend migraine In up to 20% of patients with migraine, the attacks are concentrated during the days off “Weekend migraine” attacks seem to be related to habit changes due to social life or psychological factors Weekend migraine seems to be more frequent in males Patients usually complain of higher severity and frequency of associated symptoms during weekend attacks Torelli P, Cologno D, Manzoni GC. Headache 1999;39:11-20; Alstadhaug KB, Salvesen R; Bekkelund S. Cephalalgia 2007;27:343-346; Nattero G, De Lorenzo C, Biale L, et al. Headache 1989;29:93-99; Morrison DP. Cephalalgia 1990;10:189-193; Couturier EG, Hering R, Steinert TJ. Cephalalgia 1992;12:99-100.

12. Triptans All 7 available triptans share the same mechanism of action and almost identical pharmacodynamics However, their quite different pharmacokinetic profiles and metabolism make each of them preferable or not, depending on the characteristics of the attack/patient to be treated Recurrence is a usual limitation of triptans with short half-life (e.g. zolmitriptan) mainly in cases with prolonged and severe attacks as happens in menstrual or weekend migraine REMARKS (II)

13. REMARKS (III) Frovatriptan Frovatriptan is a potent 5-HT1B/1D agonist Frovatriptan response rates are comparable to those of the standard triptans and shows an excellent tolerability 1,2 Frovatriptan has the longest half-life among triptans 1,3, which translates in a remarkably low recurrence rate (17% in phase III trials) 2 1. Sanford M. CNS Drugs 2012; 26: 791-811, 2. Cortelli P, et al. Neurol Sci 2011; 32 (Suppl 1): S95-98; 3. Tfelt-Hansen P, et al. Drugs 2000;60(6):1259-87.

14. Weekend migraine and frovatriptan Attacks of weekend migraine are predictable It is reccommendable to initiate with conventional preventive teatment (e.g. nadolol) Frovatriptan should be kept as early, acute treatment on weekends until preventatives are acting which can take one or two months Practical managment of weekend migraine is shown in figure 1 REMARKS (IV)

15. Figure 1: PRACTICAL TREATMENT OF WEEKEND MIGRAINE Patient consulting due to migraine attacks appearing during weekends Keep routine habits (eg. sleep, coffee) as much as possible during the weekend Up to two episodes/month More than two episodes/week Early treatment Conventional Acute treatment with frovatriptan preventatives with frovatriptan