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Introduction: Topiramate and onabotulinumtoxin A have proven to be effective in chronic migraine with or without medication abuse according to recent criteria of the International Headache Society's Headache Classification., Aims: To show that flunarizine is as effective as topiramate in cases of chronic migraine without medication abuse., Patients and Methods: We conducted a prospective, non-randomised, comparative study of two groups of patients paired by age and sex, with chronic migraine without abuse, who had been treated preventively for the first time with topiramate or flunarizine., Results: Forty patients treated with flunarizine were assigned a patient of their same sex and age who was being treated with topiramate. The mean rate of reduction in intense migraines in the topiramate group was 59% and in the flunarizine group, 58.5% (p = 0.9444); the responder rate at four months of treatment did not show any significant differences either, the figures being 75% for topiramate and 70% for flunarizine (p = 0.6236). The mean reduction of other headaches in the topiramate group was 57% and in the flunarizine group, 64% (p = 0.4261); the responder rate at four months of treatment was similar in the two groups: 76%. The percentage of dropouts from treatment was higher with topiramate (19.5%) than with flunarizine (10%) (p = 0.3493). No serious side effects occurred in either of the groups. In all, 78.9% of the patients who took topiramate said they were satisfied with the drug versus 75% of those in the flunarizine group (p = 0.7903)., Conclusions: Flunarizine proved to be as effective as topiramate in the treatment of chronic migraine without medication abuse.

Introduction: The drop-out rate among patients receiving preventive treatment for migraine is higher than 30%. This situation is not very widely known and the risk factors that lead patients to drop out from treatment have yet to be identified., Aim: To evaluate some of the factors that can predispose patients to drop out of preventive treatment., Patients and Methods: We conducted a prospective study of patients suffering from migraine who required preventive treatment for the first time with one of what are considered the top three first-choice drugs, i.e. a beta-blocker (nadolol), a neuromodulator (topiramate) or a calcium antagonist (flunarizine). Two groups were established according to whether patients dropped out of treatment or not. Different demographic and clinical variables were analysed and compared in the two groups., Results: Of 800 patients with migraine who required preventive treatment for the first time, the drop-out rate was 19.7%. In the drop-out group, the variables 'age', 'number of seizures', 'number of seizures prior to preventive treatment' and 'side effects' showed significant differences with those from the group of patients who did not drop out of preventive treatment., Conclusions: The drug used as preventive treatment, the side effects, a younger age and a lower number of seizures before starting the preventive treatment favoured higher drop-out rates. Whether the migraine was episodic or chronic, the presence of medication abuse and the drugs used to treat the seizures were not related with dropping out of preventive treatment., (© 2011 Revista de Neurología)

Introduction: Topiramate and nadolol with levels A and C of scientific evidence, respectively, would be indicated as preventive treatments of migraine. To date only one study of satisfaction has been carried out to compare the two pharmaceuticals., Aim: To compare the effectiveness parameters in independent groups of patients treated preventively with one of the pharmaceuticals from the study., Patients and Methods: From a database of 700 patients with migraine, those with episodic migraine and who had followed a course of preventive treatment, for the first time, with topiramate or nadolol were selected for the study. The effectiveness variables (reduction in the number of crises at four months of preventive treatment and responder rates) were analysed., Results: Altogether 208 patients with were included for treatment: 140 with topiramate (77.8% females; mean age, 37.9) and 68 with nadolol (69% females; mean age, 36.9). The mean number of crises in the month prior to treatment was: topiramate group, 6.3 +/- 2.6; nadolol group 5.3 +/- 2.0 (p = 0.0066). At four months after starting treatment: topiramate group, 2.69 +/- 2.6; nadolol group 2.6 +/- 2.2 (NS). The percentage of reduction in the number of migraines was 56.6% with topiramate and 51.6% with nadolol (NS). The responder rate (reduction in the frequency of crises by at least 50%) was 71.3% with topiramate versus 69% with nadolol (NS). The excellent response rate (reduction in crises by at least 75%) was 53.3% with topiramate versus 32.2% with nadolol (p = 0.0077). Adverse side effects were reported by 54% of patients treated with topiramate versus 30.8% of those treated with nadolol (p = 0.0015). The rate of satisfaction was 61% for the topiramate group and 71% for the group with nadolol (NS)., Conclusions: Both topiramate and nadolol proved to be effective in the preventive treatment of episodic migraine. Topiramate was found to be more effective than nadolol, although it was used in patients with a higher frequency of crises, and was not tolerated so well.

Introduction: Patients with headache and medication abuse (HMA) are difficult to treat, have a greater tendency towards chronification and a poorer quality of life than those with other types of headache. AIM. To evaluate the indicators showing that these patients are responding to ambulatory treatment., Patients and Methods: From a series of patients with migraine, we selected those who satisfied HMA criteria according to the appendix of the 2006 International Classification of the Headache Disease (ICHD-2) and who had never previously undergone treatment. As outpatients, they were advised to stop taking the drug that they were abusing. The treatment of their seizures was adjusted with the most efficient drugs and preventive treatment was started from the outset with topiramate or flunarizine. Patients were grouped according to whether they continued with HMA or not. Comparisons were made between the number of days with headache during the previous month and after four months of treatment and the persistence of abuse., Results: HMA criteria were met by 178 patients (mean age 40.9; 88.7% females). Results showed that 68.5% (122 patients) responded and no longer met HMA criteria after treatment. The treatment used for their seizures (triptans, nonsteroidal antiinflammatory drugs, analgesics) and preventive treatment (topiramate or flunarizine) were similar in both groups. The average number of days with headache prior to treatment was 18.52 in the group that responded and 20.87 (p = 0.0263) in the group that did not respond to treatment. In the group of responders 7.3% dropped out of preventive treatment compared with 35% (p = 0.0001) in the group of non-responders., Conclusions: A higher number of days with headache during the previous month and withdrawing from preventive treatment were indicators of a bad progression.

Introduction: Chronic daily headache (CDH) includes primary headaches that last more than four hours with a frequency equal or superior to 15 days a month over the last three months. It has a prevalence of 4-5% in the general population and is a frequent reason for visiting the physician in headache units., Aim: To evaluate the effectiveness of topiramate, as the primary drug, in CDH due to probable chronic migraine with or without medication abuse., Patients and Methods: From the 447 patients with migraine in our database, we selected those: a) satisfying Silberstein criteria for CDH; b) that had not followed prior prophylactic treatment; and c) who were treated with topiramate as the primary drug. The mean number of days with headache and bouts of severe migraine in the fourth month of treatment using topiramate as compared to the month preceding treatment, as well as the percentage of responses and the rate of respondents in the fourth month were all analysed., Results: Eighty-three patients (88% females) with a mean age of 38.0 +/- 14.13 years were selected. Medication abuse was reported in 44% of cases. At the fourth month of treatment, the mean number of days with headache dropped significantly from 20.8 to 7.9 (p < 0.0001) and the mean number of bouts of severe migraine diminished from 4.4 to 1.7 (p < 0.0001). The rate of respondents was 72%. Medication abuse continued in 14% of cases. Side effects were produced in 58% of patients and the dropout rate was 24%., Conclusions: Topiramate proved to be effective in the treatment of CDH due to probable chronic migraine and with probable medication abuse in de novo migraine patients.

Introduction: Both flunarizine and, more recently, topiramate have proved to be effective in the prophylaxis of migraine., Aim: To compare two independent groups of patients with similar clinical and demographic characteristics who were treated with flunarizine or topiramate as the preferred drug in the prevention of their migraines and to evaluate effectiveness and safety according to the medication they received., Patients and Methods: All the patients reported more than four episodes a month and/or transformed migraine according to Silberstein's criteria, and had never received prophylactic treatment. Data determined: the number and average number of migraines in the previous month and at the fourth month of treatment, and the rate of respondents., Results: A total of 125 patients were included in each group. No significant differences were found between the groups as regards mean age or the average number of migraines in the previous month. With both drugs there was a significant decrease (0.0001) in the mean number of episodes in the fourth month of treatment, but with no significant difference between them: topiramate (5.88 +/- 3.7 to 2.1 +/- 2.5) and flunarizine (5.24 +/- 3.2 to 2.3 +/- 2.7). The mean reduction in the number of migraines at the fourth month was 58.2 +/- 38.2% with topiramate, and 55.4 +/- 37.5% with flunarizine. The respondent rate was 71% with topiramate and 67% with flunarizine. The percentage of dropouts with topiramate (28%) was higher than with flunarizine (11%) (0.0013). With topiramate 69 patients reported side effects and 53 patients reported them with flunarizine (0.0427)., Conclusions: Both drugs showed a high degree of effectiveness when used as the preferred drug in the preventive treatment of migraine. Topiramate offered better results as far as effectiveness is concerned, but also more side effects, none of which were serious.

Introduction: Migraine accounts for 10% of patients first visits due to neurological reasons in Spain and over half the new visits in headache units (HU) and hence the importance of this pathology., Aims: The aim of this study is to determine whether there are any differences between migraine patients referred to a general neurology service (GNS) or to a HU., Patients and Methods: Two groups of patients with migraine were compared: those sent for the first time to a GNS and the others, who were sent directly to a HU., Results: In a GNS, 10.7% (374 patients) of the overall number of new visits concerned migraines; these were compared with 107 migraines (64%) from the total number of headaches treated for the first time in the HU during the year 2000. The average age and distribution of sexes were similar in both groups. In the group of migraines from the HU there were more requests for CAT/MRI (20%), 77.5% had previous treatment, 71% were given preventive therapy, 51% received triptans and 44.8% needed an examination. In the group of migraines from visits to general service, there were fewer requests for CAT/MRI (14%), only 20% had previous therapy, preventive therapy was started in 45%, 6% received triptans and 25% required an examination., Conclusions: The group of patients with migraine who were sent to the HU presented a more serious pathology, required more preventive therapies, more triptans and more monitoring than the group of patients with migraine referred to the GNS.