Individuals with migraine who are categorized as “pro-nociceptive” using psychophysical testing may exhibit a greater response to prophylactic treatments with serotonin norepinephrine reuptake inhibitors, according to study results published in The Clinical Journal of Pain.
Evidence supports the notion that pain modulation may be impaired in individuals with migraine.
In this randomized placebo-controlled double-blind noncrossover study, 55 patients aged 18 to 50 years with ≥4 migraine attack/days per month were enrolled. Participants were randomly assigned to receive duloxetine (n=27; 30 mg/day for the first week; 60 mg/day for the remaining 7 weeks), or placebo (n=28) for 8 weeks. Psychophysical parameters were comparable in both treatment groups.
Participants treated with duloxetine vs placebo reported greater improvement in migraine (52.3±30.4% vs 26.0±27.3%, respectively; P =.001). The improvement associated with duloxetine treatment was predicted by the level of pro-nociceptivity at baseline, with higher pain ratings in response to experimentally induced supra-threshold noxious heat stimuli predicting a greater response to duloxetine (P =.012). In addition, higher pain sensitivity prior to treatment was found to be associated with greater improvements in migraine in participants treated with duloxetine (r=0.47, P =.013), but not with placebo (r= −0.36, P =.060).
Study limitations include the lack of data from migraine diaries in the month preceding treatment, and the assessment of responses to treatment based on recall reports.
“Our results point to an advantage in [duloxetine] as compared with [placebo], reflected in the participants’ satisfaction with treatment and open the door for individualization of preventive treatment for migraine, suggesting that patients expressing a more pronociceptive pain modulation profile will benefit more from certain specific types of preventive treatment,” concluded the study authors.
Kisler LB, Weissman-Fogel I, Coghill RC, et al. Individualization of migraine prevention: a randomized controlled trial of psychophysical based prediction of duloxetine efficacy [published online Jun 24, 2019]. Clin J Pain. doi:10.1097/AJP.0000000000000739