Research Spotlight: Migraines With and Without Aura

Researchers recently sought to determine whether acute migraine treatment outcome is different in migraine with aura compared with migraine without aura. The result, in a word: yes.

“The main point of our study (Neurology, May 2015) for neurologists is that attacks of migraine with aura versus without aura may have different responses to different acute therapies,” said lead author Jakob M. Hansen, MD, PhD of Danish Headache Center at the University of Copenhagen, and the Headache Research and Treatment Program at UCLA, in an interview with Practical Neurology™.

To reach their conclusion, the researchers examined pooled outcome data for sumatriptan treatment of migraine with and without aura from the sumatriptan/naratriptan aggregate patient database. They also looked at similar outcome data for inhaled dihydroergotamine (DHE) from a single, large randomized controlled study.

The pooled pain-free rates two hours post-dose for sumatriptan 100mg were significantly higher in patients treating attacks without aura compared with the group who treated attacks with aura. The number needed to treat for two hours of pain freedom was 4.4 for attacks without aura and 6.2 for attacks with aura.

For the clinical trial of DHE, the two-hour pain-free rates did not differ between patients treating attacks without aura compared with those who treated attacks with aura. The relative risk for pain freedom two hours post-dose for attacks without aura versus with aura was 1.08. The number needed to treat for two hours pain free was 5.8 for attacks without aura and 5.0 for attacks with aura.

The post hoc analysis of pooled data from multiple randomized trials, “indicates that sumatriptan is less effective as acute therapy for migraine attacks with aura compared with attacks without aura,” the authors conclude. In the single study of inhaled DHE, the treatment had similar efficacy for migraine attacks with and without aura. “Different responses of migraine with versus without aura to acute therapies may provide insight into underlying migraine mechanisms and influence the choice of acute therapies for different types of migraine attacks.”

Dr. Hansen said some of the results were surprising. “In the headache literature some studies find reduced efficacy of triptans administered during the aura. We are able to show that this may in fact be more broadly true for attacks with aura, and also, although to a lesser degree, patients with aura compared to patients without aura.

“Our study thus raises the possibility that a general reduced responsiveness to triptans in attacks with aura, rather than simply the timing of their administration during the attack, contributed to the previously reported lower efficacy of triptans when administered during the aura phase,” he said. “Again, future studies should address this point.”

Discussing the limitations of the analysis, Dr. Hansen noted the study was a post-hoc comparison, and data for future analysis should ideally be prospectively collected in RCTs.

“For our analysis we could only get data from two acute medications. Before we can give firm recommendations on which drugs are the best for each type of attack, more types of medications should be examined,” he said. “We think it would be helpful to conduct a comprehensive systematic review and meta-analysis of treatment effects across medications.”

His team suggests that future clinical trials should classify the attack under treatment according to the International Classification of Headache Disorders, as suggested by the International Headache Society clinical trials subcommittee.¹

“More trials collecting reporting for these data will be of great value and help us tailor the correct treatment for each patient,” Dr. Hansen said. n

1. Guidelines for controlled trials of drugs in migraine: Third edition. A guide for investigators, Cephalalgia; 32 (1): 6-38.