Eyeworld

EW NEWS & OPINION 22 February 2015 by Maxine Lipner EyeWorld Senior Contributing Writer Beta blocker drops soothe acute migraines added that migraineurs noted the relief usually came within about 15 minutes. "Most people told me they would get some relief with one drop in each eye, blinking vigorous- ly after each application," he said. "There were other patients who told me they had to use 2 instillations." His recommendation over the years was after 5 or 10 minutes if migraineurs did not experience relief, repeat the drops. However, because he knew that blood levels were obtained fairly rapidly, after 2 instillations he cautioned patients against using additional drops— which at that point would not likely help. He found that the strategy was a success. "The people I knew who used the drops had a favorable response," he said. "I didn't have anyone say that the drops didn't help some- what." However, he acknowledged that this was based on his recollec- tion of who received the drops over a 15-year period. Dr. Hagan examined the liter- ature. He found there were 5 other papers reporting on beta blocker eye drops for migraines, including one paper published as far back as 1980. New research Dr. Migliazzo said their paper is the largest case series on this in the world literature currently. Topical approach spells relief for migraineurs I magine a patient with a migraine reaching for a bottle of beta blocker eye drops. A new case series published in the July/August 2014 issue of Missouri Medicine found this to be a viable strategy for halting acute migraines in their tracks, according to Carl V. Migliazzo, MD, Overland Park, Kan. While Dr. Migliazzo knew that oral beta blockers are effective for prophylactically keeping migraines at bay in some people, it took serendipitous results from patients to consider drops for acute cases. "When I started using topical beta blockers, patients sometimes would spontaneously report that their headaches got better," Dr. Migliazzo said. "That's when I started thinking about using them in an acute situation." When patients tried it a few times, they had positive results, he said. Topical success What Dr. Migliazzo did not realize at first is that oral beta blockers are actually not effective for acute migraines. The drops, however, were helping his patients with acute cases. Such success with beta block- ers, he theorized, is related to the mode of administration. "We think that the rapid blood absorption or plasma absorption of medication through the nasal mucosa, which is where the drops usually wind up, is responsible for that," Dr. Migliazzo said. "There have been documented studies showing that you can get therapeutic blood levels of beta blockers within minutes after applying the drops topically." He likens it to an IV infusion. "Time seems to be an important el- ement in treating acute migraines— the sooner you get the treatment on board, the faster the relief," he said. John C. Hagan III, MD, Kansas City, agrees. While oral beta blockers had become the standard for preventing migraines from starting, these could not halt an acute attack once it begun, Dr. Hagan said. The drops, however, seem different because they get in the blood stream quickly. "It's like a forest fire—if you're right there when the fire starts, a glass of water may put it out, but 30 minutes later it may be a conflagration that the local fire department can't put out," he said. While Dr. Migliazzo had been using beta blocker drops such as timolol 0.5% ophthalmic solution for some time, it was not until Dr. Hagan heard what his friend was doing that the idea for the study was born. Dr. Hagan, who has been the editor of Missouri Medicine for 15 years and who has 2 daughters with migraines, was excited to hear about the results that Dr. Migliazzo found. "I think the quote that I put in my editorial (for Missouri Medicine) was, 'Carl, this is new knowledge; we have to write this up,'" Dr. Hagan said. Spurred by this, Dr. Migliazzo developed a survey to give to migraineurs (those experiencing a migraine) who were taking the drops. "I knew of several patients who were continuing to use beta blocker eye drops for (acute) migraines," he said. "So I handed surveys out to people who I knew were still using the drops." The reports he collected were universally positive. "I asked them to rate the relief on a scale of 1 to 10 and virtually every one of them had 80–100% relief," Dr. Migliazzo said. He "The take-home message is there is solid anecdotal evidence that beta blocker eye drops may be effective in treating acute migraine," he said. "We need a good randomized controlled trial of these medications to see where they fit in the spectrum of treatment for acute migraine." Moving forward, Dr. Hagan would like to see neurologists pick up the mantle. "Both Dr. Migliazzo and I hope this isn't the 6th paper that reports successful use of beta blocker eye drops for migraine [attacks] that's left to die on its own," Dr. Hagan said, adding that he would like to see neurologists and headache specialists start doing prospective studies on this. "Even if the research were to show that with bigger numbers and masking it's not effective, that would be a worthwhile addition to the literature," Dr. Hagan said. "However, we'd still be left to wonder why this subset of 7 patients that used it for so long did find it effective." EW Editors' note: Drs. Hagan and Migliazzo have no financial interests related to their comments. Contact information Hagan: jhagan@bizkc.rr.com Migliazzo: carl@migliazzo.com

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