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A case report determining the relief effects of ramelteon on refractory chronic migraine

A case report determining the relief effects of ramelteon on refractory chronic migraine A case report determining the relief effects of ramelteon on refractory chronic migraine
A case report determining the relief effects of ramelteon on refractory chronic migraine A case report determining the relief effects of ramelteon on refractory chronic migraine

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?

  • Ramelteon (Melatonin agonist)
  • Trazodone (Serotonin antagonist)

 

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.

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Key take away

The patient with refractory chronic migraine with insomnia described improvement after 6 months of ramelteon treatment. 

Medical history

No family history of headache was mentioned.

Examination & lab investigations

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.

Management

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.

Discussion

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.

Learning

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.

References

    1. Reynoldson JN, Elliott E Sr, Nelson LA. Ramelteon: a novel approach in the treatment of insomnia. Ann Pharmacother 2008;42:1262-1271.
    2. Peres MF, Masruha MR, Zukerman E, Moreira-Filho CA, Cavalheiro EA. Potential therapeutic use of melatonin in migraine and other headache disorders. Expert Opin Investig Drugs 2006;15:367-375.
    3. Srinivasan V, Pandi-Perumal SR, Spence DW, Moscovitch A, Trakht I, Brown GM, et al. Potential use of melatonergic drugs in analgesia: mechanisms of action. Brain Res Bull 2010;81:362-371.
    4. Toglia JU. Melatonin: a significant contributor to the pathogenesis of migraine. Med Hypotheses 2001;57:432-434.
    5. Alstadhaug KB, Odeh F, Salvesen R, Bekkelund SI. Prophylaxis of migraine with melatonin: a randomized controlled trial. Neurology 2010;75:1527-1532.
    6. Lionetto L, Negro A, Palmisani S, Gentile G, Del Fiore MR, Mercieri M, et al. Emerging treatment for chronic migraine and refractory chronic migraine. Expert Opin Emerg Drugs 2012;17:393-406.

Source:

Clin Psychopharmacol Neurosci. 2016 Nov; 14(4): 405–406.

Article:

The Relief Effects of Ramelteon on Refractory Chronic Migraine: A Case Report

Authors:

Yi-Cheng Hou, Chien-Han Lai

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