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A 71-year-old female patient with a history of chronic
migraine for two decades was presented. She had not experienced insomnia
problems before the first onset of a migraine. Episodes of migraine occurred
3-4 times in a week and persisted around 4-8 hours. The pain was localised at
right half of the head. Stress, sudden cold weather and an increase in physical
activities were considered as precipitating factors. On the other hand, a
comfortable environment, warm temperature and slower pacing of life were
considered as relieving factors. The head tense feeling was experienced between
migraine episodes but it did not lead to headache severity. There were no
differences in functional outcomes except avoiding exercise during and between
the migraine episodes.
What do you think, is the most efficient management drug
for the case presented above?
Selective melatonin receptor agonist effect of ramelteon is
useful for insomnia. In this study, a case of a refractory chronic migraine,
with insomnia problem has been presented.
The patient with refractory chronic
migraine with insomnia described improvement after 6 months of ramelteon
treatment.
No family history of
headache was mentioned.
Migraine condition was diagnosed by the International
Headache Society criteria. CT scan revealed no findings indicating other causes
for headache, such as a haemorrhage or tumour.
The patient received many medications including aspirin,
nonsteroidal anti-inflammatory drugs, ergots, triptans, glucocorticoids and
anticonvulsants. However, the severity of migraine-associated symptoms such as
moderate headache, nausea, dizziness and sound sensitivity was moderate. The
incidence of migraine also worsened insomnia problems, with fragmented sleep
and inadequate sleep duration. She didn't report any comorbid mental disorder.
She chose to take ramelteon due to the fear of abusive potential associated
with hypnotics. The concurrent analgesic medicine used was ibuprofen 400 mg/day
for migraine. Two weeks of treatment with ramelteon 8 mg/day, prolonged her
sleep duration from 2 to 4-5 hours with less fragmentation. Her migraine
severity also declined. The patient reported less severe migraine with stable
sleeping quality after six months of ramelteon 8 mg/day treatment.
Ramelteon would relieve pain sensitisation by modulating
melatonin system. After administration of ramelteon, the patient showed
significant improvements in migraine severity and insomnia. The patient did not
complain of insomnia, therefore it could be hypothesized that ramelteon was
effective in migraine and mild prolongation of sleep duration. Melatonin may
relieve headache by possible mechanisms such as free radical scavenging,
anti-inflammatory effect, dopamine release inhibition, GABA and opioid
analgesia potentiation, neurovascular regulation, glutamate neurotoxicity
protection, antiallodynic action and cytoprotection. Pineal gland could play a
significant role in analgesic effect as it is the primary source of melatonin
and serotonin. However, no significant improvement in migraine severity was
observed in clinical trials of melatonin administration, which suggested that
the modulation of melatonin receptor could be beneficial in inducing analgesic
effects.
This case highlighted the effectiveness of ramelteon in the
treatment of refractory chronic migraine, therefore the use of ramelteon should
be considered for refractory chronic migraine with insomnia.
Clin Psychopharmacol Neurosci. 2016 Nov; 14(4): 405–406.
The Relief Effects of Ramelteon on Refractory Chronic Migraine: A Case Report
Yi-Cheng Hou, Chien-Han Lai
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