Effects of DFN-15 on Migraine With Allodynia
Phase: PHASE2
Conditions: Migraine With Aura, Migraine Without Aura, Allodynia
Sponsor: Hartford Hospital

 
DFN-15 effects on migraine with allodynia 
February 27th, 2018 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
DFN-15 effects on migraine with allodynia 
 
 
 
Objectives:  
 
1. To determine whether oral administration of DFN-15 (solution of a COX2 
inhibitor celecoxib) terminates migraine attacks when given to allodynic patients 
3 hours after attack onset. 
2. To determine whether mechanical and heat allodynia that develop during acute 
migraine attacks could be reversed by late (> 3hrs after attack onset) treatment 
with DFN-15.  
 
Background: 
 
The majority of migraineurs seeking secondary or tertiary medical care develop 
cutaneous allodynia during the course of migraine (Burstein et al., 2000), a sensory 
abnormality mediated by sensitization of central trigeminovascular neurons in the spinal 
trigeminal nucleus (Burstein et al., 1998).  Triptan therapy can render allodynic 
migraineurs pain-free within a narrow window of time (20-120 min) that opens with the 
onset of pain and closes with the establishment of central sensitization (Burstein et al., 
2004).  This calls for the development of drugs that can tackle ongoing central 
sensitization and render allodynic migraineurs pain-free after the window for triptan 
therapy has expired.    
 
Rational for testing a DFN-15: 
 
Several years ago, we (the Burstein group) published a series of papers showing that 
parenteral administration of ketorolac and indomethacin reverse central sensitization in 
animals and cutaneous allodynia in episodic migraine patients, and proposed that these 
actions of the drugs are critical in terminating migraine attacks that are unrelieved by 
triptan therapy (Jakubowski et al., 2005).  The premise behind these studies was that 
there is an association between headache and inflammation.  This association is based on 
(1) demonstrated efficacy of NSAIDs in treating migraine (Snow et al., 2002), (2) RCT 
trials showing that the efficacy of oral NSAIDs and oral triptans is equal in treating 
migraine (Tfelt-Hansen, 2008), (3) epidemiological studies demonstrating the protective 
role of NSAIDs therapy in preventing patients’ transition from episodic to chronic 
migraine (Bigal et al., 2008; Scher et al., 2010), and (4) the American Academy of 
Family Physicians, American College of Physicians, and American Society of Internal 
Medicine guideline recommendation to use NSAIDs as a first-line treatment choice for 
all migraine attacks (Schroeder, 2003). 
 
Rational for testing DFN-15? In the concluding remarks of our papers on parenteral 
COX1/COX2 inhibitors we wrote: “Parenteral administration of COX-1/COX-2 
inhibitors is impractical in routine migraine therapy as it required that patient travel to 

hospitals.” We then concluded the following: “To allow patients to treat themselves at 
home, it will be useful to develop oral formulations of COX-1/COX-2 inhibitors with 
comparable bioavailability to the spinal cord.”  DFN-15 is a COX-2 selective NSAID.  It 
is extensively expressed in cells involved in inflammation and is upregulated by bacterial 
lipopolysaccharides, cytokines, growth factors, and tumor promoters.  As such, it is used 
to treat a variety of conditions associated with pain and inflammation.  
 
 
Study design: 
 
Overall strategy: This study will be a proof-of-concept study to determine the mechanism 
of action of DFN-15 on cutaneous allodynia and central sensitization. To achieve our 
objectives, we will determine the cutaneous pain thresholds (mechanical, heat) and 
headache severity of episodic migraine patients under 3 different conditions: (a) while 
pain-free, (b) during migraine predosing, (c) 2 hours after treatment with either DFN-15 
or a matching placebo. 
 
Participant selection:  
COX-2 inhibitors have been shown to have a lower GI toxicity than other more 
commonly-used NSAIDS. Although, COX-2 inhibitors can have severe cardiovascular 
and renal adverse events including, but not limited to: myocardial infarction, stroke, heart 
failure, and hypertension (Mathew et al., 2011). Therefore, the inclusion/exclusion 
criteria for this study will be designed to minimize adverse events. 
 
Individuals with episodic migraine will be considered for participation in this study. 
Primary inclusion criteria will be (1) age 18-64 years old, (2) history of migraine with or 
without aura, based on the International Classification of Headache Disorders (3rd 
edition) for at least 3 years, (3) two or more migraine attacks per month on average 
during the previous year, and (4) ability to communicate in English (in order to 
understand and follow instructions of testing). Exclusion criteria will include: (1) fifteen 
or more headache days per month; (2) aspirin or NSAID-induced asthma or allergy; (3) 
pregnancy and/or lactating; (4) history of coronary artery bypass surgery, heart attack, 
angina, stroke, serious gastrointestinal bleeding, peptic ulcer disease; or chronic kidney 
disease; (5) having medical conditions requiring use of diuretics or daily anticoagulants; 
(6) having severe uncontrolled medical problems or medications that may influence 
measurements or impair ability to participate in the testing (e.g. daily or frequent use of 
opiates or barbiturates (>8 days per month), or NSAIDs or other analgesics (>14 days per 
month); known creatinine > 2.5 md/dl or GFR < 30, severe peripheral neuropathy, 
dementia, etc.); and (7) having been advised by a health professional not to use COX-2 
inhibitors. 
 
Potential participants will be recruited from the Hartford Healthcare Headache Program.   
 
Randomized controlled trial: After screening, which will be performed on a non-migraine 
day, participants will be randomized in a double-blinded fashion to receive either the 
active drug (DFN-15) or placebo in a ratio of 4:1.  They will be instructed to return to the 

clinic during a migraine.  At the ‘during-migraine’ visit, which will begin 3 hours after 
onset of headache, we will document headache intensity, associated symptoms, and 
mechanical and heat pain threshold (first) before treatment (at 180 min after onset of 
headache) and (second) at a 120 min after treatment (5 hours after headache onset).  
Based on our prior experience studying migraine patients, we plan to screen 100 patients 
to achieve 50 participants completing the 2 study visits as planned.  80/100 patients will 
be randomized to receive the active drug and 20/100 patients will receive the placebo.  
The study will be terminated as soon as the first 40 patients who received the DFN-15 
and first 10 patients who received placebo completed visit 2.  
 
Screening visit  - In the first appointment we will identify patients who are good 
candidate to participate in the study and measure their pain thresholds following an initial 
evaluation.  This appointment will allow us to train patients in how the quantitative 
sensory testing is performed.  
 
‘During-migraine” visit – In the second appointment patients’ headache intensity, 
associated symptoms, and mechanical and heat pain thresholds will be tested 180 min 
after the onset of a migraine headache.  Pain threshold will be determined within the 
referred pain area in the head.  These tests will provide the pre-treatment data to be 
compared later with post-treatment data.   Once pain thresholds are established, patients 
will be treated and their headache intensity, associated symptoms and pain thresholds will 
be re-examined 120 minutes later.   
 
Quantitative Sensory testing (QST): Testing will be done in a quiet room away from 
noise and distraction.  Patients will be able to choose their most comfortable position 
(sitting on a chair or lying in bed) during the sensory testing.  In each testing session, pain 
thresholds to hot and mechanical stimulation will be determined in the skin over the site 
to where the pain is referred to.  This site includes most commonly the periorbital and 
temporal regions. Heat skin stimuli will be delivered through a 30x30 mm2 thermode (Q-
Sense 2016, Medoc) attached to the skin at a constant pressure and their pain thresholds 
will be determined by using the Method of Limit.   To determine pain thresholds, the skin 
will be allowed to adapt to a temperature of 32C (89.5 oF) for 5 minutes and then 
warmed up at a slow rate (1 C/sec) until pain sensation is perceived, at which moment 
the subject stops the stimulus by pressing a button on a patient response unit.  Heat 
stimuli will be repeated three times each (with 10 seconds between each test) and the 
mean of recorded temperatures will be considered threshold.  Pain threshold to 
mechanical stimuli will be determined by using a set of 20 calibrated von Frey hairs 
(VFH, Stoelting).  Each VFH monofilament is assigned a scalar number in an ascending 
order (1 = 0.0045g, 2 = 0.023g, 3 = 0.027g, 4 = 0.07g, 5 = 0.16g, 6 = 0.4g, 7 = 0.7g, 8 = 
1.2g, 9 = 1.5g, 10 = 2.0g, 11 = 3.6g, 12 = 5.4g, 13 = 8.5g, 14 = 11.7g, 15 = 15.1g, 16 = 
28.8g, 17 = 75g, 18 = 125g, 19 = 281g).  Because a linear relationship exists between the 
log force and the ranked number, mechanical pain thresholds are expressed as VFH 
numbers (#) rather then their forces (g).  Each monofilament will be applied to the skin 3 
times (for 2 sec and 2 sec in between each application) and the smallest VFH number 
capable of inducing pain at two out of three trials will be considered threshold.  Skin 
sensitivity will also be determined by recording patient’s perception of soft skin brushing, 

which is a dynamic mechanical stimulus, as distinguished from the VFH, which is a static 
mechanical stimulus.  The equipment used for quantitative sensory testing has an FDA 
approval.  It is routinely used by neurologists, nurses, and pain specialists throughout the 
country.  It imposes no risk or discomfort, and since it is controlled by the patient, stimuli 
can be stopped at any time. Each QST will last about 10 minutes. 
 
Patient Safety: 
 
Throughout the treatment and testing the patients will be monitored (vitals, etc.) 
to ensure their safety. If a member of the control group is in excruciating pain and their 
migraine is intolerable they will be prescribed a rescue medication. In this case the 
participant will drop out of the study. The participants will have the option to drop out at 
any point in the study. At the end of the testing (5 hours after migraine onset), if a 
participant (from either group) is still symptomatic and in pain, they will have the 
opportunity to have a rescue medication prescribed by one of the specialists at the 
Headache Center. In the case that a patient does not respond well to the study treatment 
they will be monitored for at least 1 hour before leaving the clinic.  
 
Data analysis:  
 
Primary endpoint:  There are 2 primary endpoints in this study.  The first is reduction in 
headache intensity after DFN-15 treatment, and the second is reduction in skin sensitivity 
at 2 hours after DFN-15 treatment.   
For reduction in headache intensity, level of pain will be documented at 1 and 2 hours 
after treatment using a visual analogue scale of 0 (no pain) to 10 (worst pain).  
Comparisons of these ordinal (repeated) measures will be performed using Friedman 
two-way analysis of variance followed by Wilcoxon matched-pairs signed-ranks test. 
 
For reduction in skin sensitivity (allodynia), pain thresholds will be determined 2 
hours after DFN-15 or placebo treatment.  Since the detection of pain thresholds depends 
on subjective data input, several algorithms have been developed in order to minimize 
subjective variation, and make the results as objective as possible.  These algorithms are 
incorporated into the software program that controls the thermal and mechanical sensory 
analyzer (Q-Sense 2016).  Changes in skin sensitivity will be determined by comparing 
corresponding pain thresholds obtained in the pain-free session (baseline) to pain 
thresholds obtained during migraine, first before (untreated migraine) and then after 
(treated migraine) treatment with DFN-15 or placebo.  In healthy subjects, pain 
thresholds for heat and mechanical skin stimuli range between 42-47 oC (107.3-116 oF) 
(Lindblom, 1994), and 75-281 g (Strigo et al., 2000), respectively. Using a more stringent 
criteria, we will consider a patient to be allodynic if her/his pain threshold is below 41 oC 
(105.8 oF) for heat, and below 30 g for skin indentation with the calibrated von Frey hairs.  
Meeting the criterion for any one of modality will be sufficient to determine that the 
patient is allodynic at the ‘during untreated migraine’ testing.  For this endpoint, the 
database will consisted of pain threshold measurements in 50 patients, taken while they 
are pain-free (baseline), during untreated migraine attack (before DFN-15 or placebo 
treatment), after treatment with DFN-15 or placebo.  Only those patients who completed 
all 3 testing sessions will be included in the data analysis. The resulting distributions will 
be tested for normality, and their descriptive statistics computed.  The differences 

between before and after DFN-15 treatment will be computed on a pair-wise basis.  To 
increase the sensitivity of detecting changes, patients in this study will be compared to 
themselves (baseline vs. during untreated migraine vs. during treated migraine) rather 
than to control subjects because the large normative range of pain thresholds reduces the 
sensitivity of detecting allodynia in reference to the normal range.  Differences between 
pain-free vs. during untreated migraine vs. during treated migraine will be computed on a 
multiple sample pair-wise basis.  Differences in mean pain threshold will be judged 
(significant or not significant) by using appropriate pair-wise multiple sample comparison 
(Newman-Keuls, Kruskal-Wallis) tests. Alternatively, repeated measurements of pain 
thresholds (allodynia) will be analyzed using Friedman two-way analysis of variance. 
Finally, secondary analyses using the collected data may be done as a part of this study 
including, but not limited to, the duration and intensity of the headache prior to arrival at 
the clinic. 
 
The primary outcome measure in the current study is the proportion of patients 
demonstrating a headache intensity decrease that is greater than 50% (post-treatment 
compared to pre-treatment). Secondary outcome measures are proportions of patients 
demonstrating allodynia before and after treatment; allodynia to thermal stimuli is 
defined as a pain threshold < 41 0C, and to mechanical stimuli as pressure pain threshold 
of < 30 g.  
The primary and secondary outcome measures will be examined using the Z test 
for comparison of independent proportions and Chi-square (x2) test to assess the 
categorical association between the group (treatment / placebo) and (i) reduction rate of 
headache intensity (below / above 50%; primary outcome measure); (ii) proportion of 
thermally allodynic participants (pain threshold below / above 41 0C; secondary outcome 
measure); and (iii) proportion of mechanically allodynic participants (pressure pain 
threshold below / above 30 g; secondary outcome measure). 
Power analysis was based on the Z test for comparison of independent 
proportions. Incorporated were α of 5% (significance level), 1-β error probability of 90% 
(power), and allocation ratio of 4:1 (treatment:placebo, respectively). Based on 
previously published data (Burstein et al., Annals of Neurology 2004), the primary 
outcome measure is expected to be lower in the treatment group; accordingly, power 
analysis was one-tailed. The primary hypothesis was that post-intervention proportions of 
patients demonstrating a headache intensity decrease that is greater than 50% in the 
treatment and placebo groups would be 80% and 30%, respectively. This computation 
yielded a required number of 9 subjects in the placebo group and 36 patients in the 
treatment group (critical Z = -1.645). An additional 20% were accounted for potential 
dropout. Thus, a total of 54 participants (11 placebo, 43 treatment) are to be enrolled in 
the entire study.  
 
 
 
 
 
 
 

 
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