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Prazosin for Post-Concussive Headaches

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ClinicalTrials.gov Identifier: NCT02965027
Recruitment Status : Recruiting
First Posted : November 16, 2016
Last Update Posted : December 11, 2017
Sponsor:
Collaborators:
VA Puget Sound Health Care System
Madigan Army Medical Center
Information provided by (Responsible Party):
Seattle Institute for Biomedical and Clinical Research

Brief Summary:

Mild traumatic brain injury (mTBI) caused by blast effects of explosive devices has been called the "signature injury" of soldiers who served in the Iraq and Afghanistan conflicts. mTBI can also occur from impact or hitting the head on an object or the ground. Although termed "mild" in comparison to major brain injuries, people with mTBI can have problems with their memory and concentration. People with mTBI can also find they are more irritable, have more anxiety, and have trouble with their mood and sleep.

The purpose of this study is to see if a medication called prazosin can help treat chronic headaches in people with mTBI. The Food and Drug Administration (FDA) has approved prazosin for treating people with high blood pressure. At this time, the FDA has not approved prazosin in the treatment of mTBI or headaches. Some people who have posttraumatic stress disorder (PTSD) and have been taking prazosin for their medical conditions or who have taken it in research studies have said they have fewer headaches.


Condition or disease Intervention/treatment Phase
Post-Traumatic Headache Drug: Prazosin Drug: Placebos Phase 4

Detailed Description:

Background and Rationale: Headaches following mild traumatic brain injury (mTBI) are common, can be refractory to standard therapies, and may persist and worsen to become a debilitating chronic pain syndrome. The purpose of this study is to evaluate the centrally acting alpha-1 adrenoreceptor (AR) antagonist drug prazosin as a prophylactic treatment for chronic posttraumatic headaches (PTHAs). The impetus for this study comes from a large open-label case series in Iraq and Afghanistan Veterans with mTBI and PTHAs and data from a placebo-controlled trial evaluating use of prazosin for posttraumatic stress disorder (PTSD) in active-duty Servicemembers (SMs). Findings from these studies showed that in addition to decreasing PTSD-related symptoms and improving sleep quality, prazosin decreased the frequency and severity of headaches, which were common in the study populations.

Study Objectives, Specific Aims, and Hypotheses: The objective of this study is to evaluate the efficacy of prazosin as a prophylactic treatment for persistent PTHAs, which will be accomplished by conducting a randomized placebo-controlled double blind trial of prazosin vs. placebo in active-duty SMs and Veterans who were in military service at any time from October 7, 2001 to the present with persistent PTHAs.

  • Specific Aim 1: To determine the effect of prazosin compared to placebo on headache frequency, headache severity and duration, use of abortive/analgesic medications, and headache-related disability.
  • Specific Aim 2: To determine the effect of prazosin on sleep disturbance, PTSD symptoms, depressive symptoms, alcohol consumption, global cognitive function, health-related quality of life, and global clinical status.

Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 228 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Primary Purpose: Treatment
Official Title: Prazosin for the Prophylaxis of Chronic Post-Traumatic Headaches in OEF/OIF/OND Service Members and Veterans With Mild TBI
Study Start Date : November 2016
Estimated Primary Completion Date : December 2020
Estimated Study Completion Date : December 2020

Resource links provided by the National Library of Medicine

MedlinePlus related topics: Headache

Arm Intervention/treatment
Experimental: Prazosin
Prazosin capsules beginning at 1 mg orally at bedtime. Titrate over 5 weeks to maximum dose of 5 mg in the morning and 20 mg at bedtime.
Drug: Prazosin
Other Name: Minipress

Placebo Comparator: Placebo
Placebo capsules
Drug: Placebos



Primary Outcome Measures :
  1. Change from baseline in headache frequency [ Time Frame: 5 weeks before baseline, baseline, 4,8, and 12 weeks after steady dose ]
    Headache log to be filled out by participant


Secondary Outcome Measures :
  1. Overall sleep quality as assessed by Pittsburgh Sleep Quality Index [ Time Frame: baseline, 4, 8, 12 weeks after steady dose ]
  2. Insomnia Severity Index [ Time Frame: baseline, 4, 8, 12 weeks after steady dose ]
  3. Clinician-Administered PTSD Scale (CAPS) [ Time Frame: baseline, 4, 8, 12 weeks after steady dose ]
    Assessment of PTSD symptoms

  4. Clinical Global Impression of Change (CGIC) [ Time Frame: baseline, 4, 8, 12 weeks after steady dose ]
    Assessment of overall change in symptoms



Information from the National Library of Medicine

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Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • Male and female Active-duty SMs or Veterans aged 18 or older who are in good general health.
  • History of blast and/or impact head trauma mTBI meeting Defense and Veterans Brain Injury Center (DVBIC) mTBI criteria, which define mTBI as an injury to the head causing at least one of the following: alteration in consciousness (for up to 24 hours after the injury), loss of consciousness 0-30 minutes, and/or post-traumatic amnesia up to 1 day post-injury. If available, the Glasgow Coma Scale score must be 13-15, and head imaging findings (if imaging was performed) must be negative.
  • Frequent HAs that started within 3months after a head injury. The HAs either 1) must last 4 or more hours a day and reach a moderate to severe intensity at any point during the headache, or 2) may be of any severity or duration if the participant takes a triptan or ergotamine. HAs meeting these criteria must have been present on average at least 8 days per 4-week period, starting within 30 days after head injury and occurring by self-report for at least 3 months prior to the Initial Screening Visit. The 4-week HA frequency/severity criteria must be confirmed during the Preliminary Screening Period.
  • Women of childbearing potential must agree to abstain from sexual relations that could result in pregnancy or use an effective method of birth control acceptable to both participant and the clinician prescriber during the study. Men are not required to use contraception during the study.
  • Participants must have English fluency sufficient to complete study measures.

Exclusion Criteria:

  • Participation in other interventional research.
  • History of penetrating head injury
  • History of TBI more severe than mild by DVBIC criteria
  • Diagnosis of a primary or secondary HA disorder other than PTHA
  • Lifetime history of 5 or more migraine or probable migraine headaches pre-dating mTBI
  • HAs of any kind of moderate or severe intensity on an average of more than 2 days per month preceding the concussive trauma
  • Continuous HAs of any kind (i.e., persistent daily HAs with no HA-free period less than 8 hours between attacks)
  • Acute or serious medical illness or unstable chronic medical illness (e.g., unstable angina, myocardial infarction within 6 months, congestive heart failure, clinically significant or concerning cardiac arrhythmias; preexisting hypotension [systolic blood pressure<110] or orthostatic hypotension [systolic drop >20 mm Hg after 2 min standing accompanied by lightheadedness], chronic renal or hepatic failure, acute pancreatitis, Meniere's disease, or diagnosed but untreated sleep apnea). The eligibility of potential participants having acute serious and/or chronic medical illnesses other than those listed will be evaluated on a case-by-case basis by a study physician, PA-C, or ARNP.
  • Use of prazosin or other alpha-1 antagonist (including but not limited to alfuzosin, doxazosin, silodosin, tamsulosin, terazosin) for any purpose in the 2 weeks prior to initial screen (P1) visit and prohibited throughout the study
  • Allergy or previous adverse reaction to prazosin or other alpha-1 antagonist
  • Active psychosis or psychotic disorder, severe depression (as determined per clinician prescriber judgment), severe psychiatric instability or severe situational life crisis (including evidence of being actively suicidal or homicidal).
  • Meets Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) criteria for any Substance Use Disorder except caffeine-related disorders, or tobacco-related disorders.
  • History of delirium within the prior 3 months, epilepsy, stroke, dementia, psychotic disorder, or bipolar disorder
  • Structural brain abnormalities on any prior imaging with associated clinically evident manifestations
  • Current participation in transcranial magnetic stimulation studies
  • Women of childbearing potential must not be pregnant, planning to become pregnant during the study period, or nursing.
  • Participation in a HA support group or other activity such as meditation or yoga intended to mitigate HA or other chronic pain must be stable at least 4 weeks prior to beginning the initial screen (P1) visit and may not be started during the study
  • Failure to record HA data for at least 80% of days during the Screening Period
  • Not suitable for study per clinician judgement.

Medication-Related Considerations:

  • The use of HA rescue or symptom-relieving medications will be allowed during the study. This includes triptans, ergotamines, opioids, simple analgesics (e.g. acetaminophen, aspirin, or non-steroidal anti-inflammatories [NSAIDS], and combination analgesics. Their use will be recorded on the concurrent medication CRF during the Preliminary Screening Period (P1) and throughout the remainder of the study. Randomization of participants will be stratified based on whether their use of HA medications meets ICHD-3 beta criteria for overuse of these medications, as described in section 5.5 below.
  • Opioid Medications: Use of opioids for treatment of HA or non-HA-related pain or for any other purpose is allowed during the study. Any opioid use would ideally be excluded due to potential confounding effects on interpretation of response to treatment. However, in this population, particularly in Veterans with chronic pain or undergoing minor orthopedic or dental procedures, opioid use is common. Use of opioids, including frequency and dose, will be recorded on the concurrent medication CRF.
  • Cannabis: The use of cannabis in any form is not excluded unless its use meets criteria for Cannabis Use Disorder. All use of cannabis will be documented.

    • Other Medications: Participants who are taking other medications on a routine basis must be on a stable dose for at least 4 weeks prior to the Preliminary Screening Period (P1), and must intend to continue the medication at the same regimen for the duration of the trial unless lack of efficacy, safety, or tolerability dictates otherwise. The following medications are not excluded:
    • Psychoactive drugs (for example, anticonvulsants, benzodiazepines, antidepressants, sedative/hypnotics),
    • Antihypertensive medications (including beta-blockers, calcium channel blockers, angiotensin converting enzyme [ACE] inhibitors, and angiotensin receptor blockers),
    • The use of magnesium in any dose that is prescribed for the purpose of HA prevention or treatment must be stable for at least 4 weeks. The incidental use of magnesium in multi-vitamins, laxatives, etc. is permissible but must be documented.
    • Hormones (for example, testosterone, estrogen, or progesterone) in any form.
    • The "as-needed" (prn) use of psychoactive and other drugs such as antibiotics is not excluded; however, such use must be discussed with a clinician prescriber and documented.
  • The use of butalbital in any form within 4 weeks of beginning the Preliminary Screening Period (P1) through the end of the participant's study involvement is exclusionary.
  • Participants who have been taking trazodone will undergo a 2-week washout period before the Preliminary Screening Period (P1 visit). Combining prazosin and trazodone may increase the risk of priapism. We have decided to begin the washout period before the Preliminary Screening Period in order to remove any confounding variables while on the headache log and actigraphy.
  • Sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra), and avanafil (Stendra) will not be permitted during the study drug dose Titration Period, because of increased risk of hypotension in combination with alpha-1 blockers, but will be allowed at half the usual starting dose following the study drug dose Titration Period, per VA prescribing guidelines.
  • Use of supplements containing nitrates and supplements containing stimulants (such as ephedra) are exclusionary in the two weeks prior to initial screen (P1) visit and prohibited throughout the study. Participants who take these supplements will be asked to discontinue them for a minimum of two weeks before the Preliminary Screening Period (P1 visit)..
  • Use of prescribed stimulants (such as amphetamine or dextroamphetamine containing medications) is exclusionary in the 2 weeks prior to the initial screen (P1) visit and prohibited throughout the study. Participants who take these medications will be asked to discontinue them for a minimum of 2 weeks before the Preliminary Screening Period.

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT02965027


Contacts
Contact: Tomas Segovia 206-277-3491
Contact: Laura Crews, RN, BSN 253-968-3161

Locations
United States, Washington
VA Puget Sound Health Care System Recruiting
Seattle, Washington, United States, 98108
Contact: Tomas Segovia    206-277-3491      
Principal Investigator: Murray A Raskind, MD         
Sub-Investigator: Cynthia Mayer, DO         
Sub-Investigator: Elaine R Peskind, MD         
Madigan Army Medical Center Not yet recruiting
Tacoma, Washington, United States, 98433
Contact: Laura Crews, RN, BSN    253-968-3161      
Principal Investigator: COL Beverly Scott, MD         
Sponsors and Collaborators
Seattle Institute for Biomedical and Clinical Research
VA Puget Sound Health Care System
Madigan Army Medical Center
Investigators
Principal Investigator: Murray A Raskind, MD VA Puget Sound Health Care System

Responsible Party: Seattle Institute for Biomedical and Clinical Research
ClinicalTrials.gov Identifier: NCT02965027     History of Changes
Other Study ID Numbers: W81XWH-15-2-0060
First Posted: November 16, 2016    Key Record Dates
Last Update Posted: December 11, 2017
Last Verified: December 2017
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: No

Keywords provided by Seattle Institute for Biomedical and Clinical Research:
Chronic Headache
Post-Traumatic Stress Disorder
Iraq/Afghanistan Veteran

Additional relevant MeSH terms:
Headache
Post-Traumatic Headache
Pain
Neurologic Manifestations
Nervous System Diseases
Signs and Symptoms
Headache Disorders, Secondary
Headache Disorders
Brain Diseases
Central Nervous System Diseases
Prazosin
Antihypertensive Agents
Adrenergic alpha-1 Receptor Antagonists
Adrenergic alpha-Antagonists
Adrenergic Antagonists
Adrenergic Agents
Neurotransmitter Agents
Molecular Mechanisms of Pharmacological Action
Physiological Effects of Drugs