51
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Kowacs PA, Sampaio Rocha-Filho PA, Peres MFP, Edvinsson L. The history and rationale of the development of new drugs for migraine treatment. ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:1084-1097. [PMID: 38157876 PMCID: PMC10756794 DOI: 10.1055/s-0043-1777723] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 11/21/2023] [Indexed: 01/03/2024]
Abstract
Migraine is one of the most prevalent and disabling diseases in the world. Migraine attack treatments and prophylactic treatments of this disease are essential to lessen its individual, social, and economic impact. This is a narrative review of the main drugs used for treating migraine, as well as the experimental models and the theoretical frameworks that led to their development. Ergot derivatives, triptans, non-steroid anti-inflammatory drugs, tricyclic antidepressants, beta-blockers,: flunarizine,: valproic acid,: topiramate, onabotulinumtoxin A, ditans, monoclonal antibodies against CGRP and its receptor, and gepants are discussed. Possible therapeutic targets for the development of new drugs that are under development are also addressed. Many of the drugs currently in use for treating migraine were developed for the treatment of other diseases, but have proven effective for the treatment of migraine, expanding knowledge about the disease. With a better understanding of the pathophysiology of migraine, new drugs have been and continue to be developed specifically for the treatment of this disease.
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Affiliation(s)
- Pedro André Kowacs
- Instituto de Neurologia de Curitiba, Serviço de Neurologia, Curitiba PR, Brazil.
- Universidade Federal do Paraná, Complexo Hospital de Clínicas, Unidade do Sistema Nervoso, Curitiba PR, Brazil.
| | - Pedro Augusto Sampaio Rocha-Filho
- Universidade Federal de Pernambuco, Centro de Ciências Médicas, Divisão de Neuropsiquiatria, Recife PE, Brazil.
- Universidade de Pernambuco, Hospital Universitário Oswaldo Cruz, Clínica de Cefaleia, Recife PE, Brazil.
| | | | - Lars Edvinsson
- Lund University, Institute of Clinical Sciences, 22185 Lund, Sweden.
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52
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Cortel-LeBlanc MA, Orr SL, Dunn M, James D, Cortel-LeBlanc A. Managing and Preventing Migraine in the Emergency Department: A Review. Ann Emerg Med 2023; 82:732-751. [PMID: 37436346 DOI: 10.1016/j.annemergmed.2023.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/24/2023] [Accepted: 05/25/2023] [Indexed: 07/13/2023]
Abstract
Migraine is a leading cause of disability worldwide, and acute migraine attacks are a common reason for patients to seek care in the emergency department (ED). There have been recent advancements in the care of patients with migraine, specifically emerging evidence for nerve blocks and new pharmacological classes of medications like gepants and ditans. This article serves as a comprehensive review of migraine in the ED, including diagnosis and management of acute complications of migraine (eg, status migrainosus, migrainous infarct, persistent aura without infarction, and aura-triggered seizure) and use of evidence-based migraine-specific treatments in the ED. It highlights the role of migraine preventive medications and provides a framework for emergency physicians to prescribe them to eligible patients. Finally, it evaluates the evidence for nerve blocks in the treatment of migraine and introduces the possible role of gepants and ditans in the care of patients with migraine in the ED.
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Affiliation(s)
- Miguel A Cortel-LeBlanc
- Department of Emergency Medicine, Queensway Carleton Hospital, Ottawa, ON, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada; Institut du Savoir Montfort, Ottawa, ON, Canada; 360 Concussion Care, Ottawa, ON, Canada.
| | - Serena L Orr
- Departments of Pediatrics, Community Health Sciences, and Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Maeghan Dunn
- Department of Emergency Medicine, Queensway Carleton Hospital, Ottawa, ON, Canada
| | - Daniel James
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada; Department of Emergency Medicine, The Ottawa Hospital, Ottawa, ON, Canada; Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Achelle Cortel-LeBlanc
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada; Institut du Savoir Montfort, Ottawa, ON, Canada; 360 Concussion Care, Ottawa, ON, Canada; Division of Neurology, Department of Medicine, Queensway Carleton Hospital, Ottawa, ON, Canada
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53
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Cho S, Kim BK. Update of Gepants in the Treatment of Chronic Migraine. Curr Pain Headache Rep 2023; 27:561-569. [PMID: 37656319 DOI: 10.1007/s11916-023-01167-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE OF REVIEW Despite the unmet therapeutic needs of patients with chronic migraine (CM) and/or medication overuse, available treatment options are limited. Recently, four calcitonin gene-related peptide receptor antagonists, known as gepants, have been approved for the treatment of migraine. This review focuses on the preventive treatment of CM with gepants and highlights recent findings. RECENT FINDINGS Two randomized controlled trials (RCTs) have shown promising results for rimegepant and atogepant as preventive treatments for CM. In an RCT targeting patients with CM, atogepant demonstrated a significant reduction in the mean monthly migraine days, irrespective of acute medication overuse. Moreover, the patients reported no significant safety concerns and exhibited good tolerance to treatment. These findings highlight the potential of gepants as a new and effective therapeutic option for patients with CM and/or medication overuse. Gepant use will help improve the management and quality of life of individuals with this debilitating condition.
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Affiliation(s)
- Soohyun Cho
- Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu, Korea
| | - Byung-Kun Kim
- Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea.
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54
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Juhasz G, Gecse K, Baksa D. Towards precision medicine in migraine: Recent therapeutic advances and potential biomarkers to understand heterogeneity and treatment response. Pharmacol Ther 2023; 250:108523. [PMID: 37657674 DOI: 10.1016/j.pharmthera.2023.108523] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 08/11/2023] [Accepted: 08/29/2023] [Indexed: 09/03/2023]
Abstract
After 35 years since the introduction of the International Classification of Headache Disorders (ICHD), we are living in the era of the second great revolution in migraine therapies. First, discoveries of triptans provided a breakthrough in acute migraine treatment utilizing bench-to-bedside research results on the role of serotonin in migraine. Next, the discovery of the role of neuropeptides, more specifically calcitonin gene-related peptide (CGRP) in migraine attack led to the development of anti-CGRP therapies that are effective both in acute and preventive treatment, and are also able to reduce migraine-related burden. Here, we reviewed the most recent clinical studies and real-world data on available migraine-specific medications, including triptans, ditants, gepants and anti-CGRP monoclonal antibodies. Novel drug targets, such as PACAP and amylins were also discussed. To address the main challenges of migraine therapy, the high heterogeneity of people with migraine, the prevalent presence of various comorbid disorders, and the insufficient medical care of migraine patients were covered. Promising novel approaches from the fields of omics, blood and saliva biomarker, imaging and provocation studies might bring solutions for these challenges with the potential to identify further drug targets, distinguish more homogeneous patient subgroups, contribute to more optimal drug selection strategies, and detect biomarkers in association with headache features or predicting treatment efficacy. In the future, the combined analysis of data of different biomarker modalities with machine learning algorithms may serve precision medicine in migraine treatment.
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Affiliation(s)
- Gabriella Juhasz
- Department of Pharmacodynamics, Faculty of Pharmaceutical Sciences, Semmelweis University, Budapest, Hungary; NAP3.0 Neuropsychopharmacology Research Group, Hungarian Brain Research Program, Semmelweis University, Budapest, Hungary.
| | - Kinga Gecse
- Department of Pharmacodynamics, Faculty of Pharmaceutical Sciences, Semmelweis University, Budapest, Hungary; NAP3.0 Neuropsychopharmacology Research Group, Hungarian Brain Research Program, Semmelweis University, Budapest, Hungary
| | - Daniel Baksa
- Department of Pharmacodynamics, Faculty of Pharmaceutical Sciences, Semmelweis University, Budapest, Hungary; NAP3.0 Neuropsychopharmacology Research Group, Hungarian Brain Research Program, Semmelweis University, Budapest, Hungary; Department of Personality and Clinical Psychology, Institute of Psychology, Faculty of Humanities and Social Sciences, Pazmany Peter Catholic University, Budapest, Hungary
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55
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Rastogi RG, Hastriter EV, Evans RL, Bassal F, Hickman C, Karnik KT, Little R, Lewis KS. Advances in the Acute and Preventive Treatment of Pediatric Migraine. Curr Pain Headache Rep 2023; 27:521-529. [PMID: 37561313 DOI: 10.1007/s11916-023-01157-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2023] [Indexed: 08/11/2023]
Abstract
PURPOSE OF REVIEW Headaches are common in children and adolescents. Treatments for debilitating migraine are often not FDA approved or lack evidence of efficacy for children. This narrative review looks at the evidence for acute and preventative pharmacologic and non-pharmacologic treatment of pediatric migraine, as well as reviewing any recent or ongoing clinical trials. RECENT FINDINGS Studies have been published on pharmacological treatments for headache, as well as non-pharmacological treatments. Recent findings in pediatric migraine using onabotulinumtoxinA, calcitonin gene related peptide antagonists, interventional procedures, and devices are reviewed. Pharmacologic as well as non-pharmacologic approaches for the prevention and treatment of migraine show safety and efficacy data that is promising. These treatments should be incorporated in a multi-modal approach to the management of pediatric migraine. Continued studies, prospective and randomized, are needed to further assess these newer treatments for migraine in the pediatric setting.
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Affiliation(s)
- Reena Gogia Rastogi
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, USA.
| | - Eric Vance Hastriter
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, USA
| | - Rachel L Evans
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, USA
| | - Frederick Bassal
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, USA
| | - Carolyn Hickman
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, USA
| | - Kavitha T Karnik
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, USA
| | - Robert Little
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, USA
| | - Kara Stuart Lewis
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, USA
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56
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Li D, Abreu J, Tepper SJ. A Brief Review of Gepants. Curr Pain Headache Rep 2023; 27:479-488. [PMID: 37531032 DOI: 10.1007/s11916-023-01142-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2023] [Indexed: 08/03/2023]
Abstract
PURPOSE OF REVIEW Gepants are small molecules that antagonize calcitonin gene-related peptide (CGRP) receptors. Due to their favorable side effect profile and versatility in treating headaches acutely and preventively, gepants are preferred over triptans. We will cover the indications for the four FDA-approved gepants in adults: rimegepant, atogepant, ubrogepant, and zavegepant. This review will illustrate how gepants will continue to revolutionize the acute and preventive treatment of headaches. RECENT FINDINGS Gepants are now available in oral tablet, dissolving tablet, and intra-nasal spray formulations. Recent studies have shown promising utility in treating the pre-headache or prodromal phase. They have favorable tolerability, no evidence for association with medication overuse, and remain a safer alternative in those who have cerebrovascular risk factors. Additional research is needed to explore occurrence of Raynaud's phenomenon in participants treated with gepants, as it has been associated with CGRP monoclonal antibodies, but are not extensively studied in gepants. Gepants are expected to play a significant role in the next generation of migraine treatments.
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Affiliation(s)
- Diana Li
- Dartmouth Headache Center, Neurology Department, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA.
| | - Jessica Abreu
- Dartmouth Headache Center, Neurology Department, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA
| | - Stewart J Tepper
- Dartmouth Headache Center, Neurology Department, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA
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57
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Bhardwaj R, Ivans A, Stringfellow J, Morris B, Coric V, Croop R, Bertz R. Rimegepant 75 mg in Subjects With Hepatic Impairment: Results of a Phase 1, Open-Label, Single-Dose, Parallel-Group Study. Clin Pharmacol Drug Dev 2023; 12:790-800. [PMID: 37073443 DOI: 10.1002/cpdd.1244] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 02/16/2023] [Indexed: 04/20/2023]
Abstract
Rimegepant is a small-molecule calcitonin gene-related peptide receptor antagonist (gepant) with demonstrated efficacy and safety in the acute and preventive treatment of migraine. Here, we report the pharmacokinetics and safety of a single 75-mg oral dose of rimegepant in subjects with severe, moderate, or mild hepatic impairment and matched healthy subjects from an open-label, single-dose, 4-group phase 1 study. Thirty-six subjects aged 41-71 years were enrolled, including 6 each with severe, moderate, or mild hepatic impairment and 18 healthy subjects. All subjects completed the study. A <20% increase in total and unbound pharmacokinetics was observed in subjects with mild hepatic impairment and ≤65% increase with moderate hepatic impairment versus matched healthy controls. Total and unbound systemic exposure increased 2.0- and 3.9-fold in the severe hepatic impairment group. In subjects with severe hepatic impairment, geometric mean ratios (severe impairment/controls) for total concentrations were 202.2% for area under the plasma concentration-time curve from time 0 to the last quantifiable concentration, 202.2% for area under the plasma concentration-time curve from time 0 to infinity, and 189.1% for maximum observed plasma concentration. Corresponding geometric mean ratios using unbound concentrations were 388.8% and 388.7%, respectively. Three (8.3%) subjects reported 4 treatment-emergent adverse events. Rimegepant is not recommended for use in adults with severe hepatic impairment.
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Affiliation(s)
| | - Andrea Ivans
- Biohaven Pharmaceuticals, Inc., New Haven, Connecticut, USA
| | | | - Beth Morris
- Biohaven Pharmaceuticals, Inc., New Haven, Connecticut, USA
| | - Vladimir Coric
- Biohaven Pharmaceuticals, Inc., New Haven, Connecticut, USA
| | | | - Richard Bertz
- Biohaven Pharmaceuticals, Inc., New Haven, Connecticut, USA
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58
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Valecha J, Khandait H, SK A, Gupta V, Kumawat S, Anamika FNU, Jain R, Dua D. Migraine and heart: A reality check. Glob Cardiol Sci Pract 2023; 2023:e202320. [PMID: 37575293 PMCID: PMC10422873 DOI: 10.21542/gcsp.2023.20] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 05/15/2023] [Indexed: 08/15/2023] Open
Abstract
Migraine is a common neurological disorder affecting 12% of the global population. The common risk factors are adolescent age, genetics, and female sex, and are triggered by hormonal fluctuations, emotional stress, sensory overload, weather changes, alcohol consumption, fasting, cheese, chocolate, smoked fish, yeast extract, cured meats, artificial sweeteners, food preservatives containing nitrates and nitrites, and sleep disturbances. Migraine with aura is associated with an increased risk of cardiovascular disease events, such as myocardial infarction, angina pectoris, and cardiac arrhythmias, and has recently been added to the QRISK3 cardiovascular disease prediction score. Population-based cohort studies have shown a significant association of migraine with aura and cardiac arrhythmias, most importantly atrial fibrillation. Patients suffering from migraine with aura are at an increased risk for cardiac arrhythmias; thus, it is essential to screen these patients for undiagnosed cardiovascular disorders.
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Affiliation(s)
- Jayesh Valecha
- Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
| | | | - Anagha SK
- Government Medical College, Thiruvananthapuram, India
| | - Vasu Gupta
- Dayanand Medical College and Hospital, Ludhiana, India
| | - Sunita Kumawat
- Index Medical College Hospital & Research Center, Indore, India
| | - FNU Anamika
- University College of Medical Sciences, New Delhi, India
| | - Rohit Jain
- Penn State Milton S Hershey Medical Center, Hershey, PA, USA
| | - Dharti Dua
- The Ohio State University College of Medicine, Columbus, Ohio, United States
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59
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Karsan N, Gosalia H, Goadsby PJ. Molecular Mechanisms of Migraine: Nitric Oxide Synthase and Neuropeptides. Int J Mol Sci 2023; 24:11993. [PMID: 37569369 PMCID: PMC10418996 DOI: 10.3390/ijms241511993] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 07/12/2023] [Accepted: 07/17/2023] [Indexed: 08/13/2023] Open
Abstract
Migraine is a common condition with disabling attacks that burdens people in the prime of their working lives. Despite years of research into migraine pathophysiology and therapeutics, much remains to be learned about the mechanisms at play in this complex neurovascular condition. Additionally, there remains a relative paucity of specific and targeted therapies available. Many sufferers remain underserved by currently available broad action preventive strategies, which are also complicated by poor tolerance and adverse effects. The development of preclinical migraine models in the laboratory, and the advances in human experimental migraine provocation, have led to the identification of key molecules likely involved in the molecular circuity of migraine, and have provided novel therapeutic targets. Importantly, the identification that vasoconstriction is neither necessary nor required for headache abortion has changed the landscape of migraine treatment and has broadened the therapy targets for patients with vascular risk factors or vascular disease. These targets include nitric oxide synthase (NOS) and several neuropeptides that are involved in migraine. The ability of NO donors and infusion of some of these peptides into humans to trigger typical migraine-like attacks has supported the development of targeted therapies against these molecules. Some of these, such as those targeting calcitonin gene-related peptide (CGRP), have already reached clinical practice and are displaying a positive outcome in migraineurs for the better by offering targeted efficacy without significant adverse effects. Others, such as those targeting pituitary adenylate cyclase activating polypeptide (PACAP), are showing promise and are likely to enter phase 3 clinical trials in the near future. Understanding these nitrergic and peptidergic mechanisms in migraine and their interactions is likely to lead to further therapeutic strategies for migraine in the future.
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Affiliation(s)
- Nazia Karsan
- Headache Group, NIHR King’s Clinical Research Facility and SLaM Biomedical Research Centre, The Wolfson Sensory, Pain and Regeneration Research Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 9PJ, UK; (N.K.); (H.G.)
| | - Helin Gosalia
- Headache Group, NIHR King’s Clinical Research Facility and SLaM Biomedical Research Centre, The Wolfson Sensory, Pain and Regeneration Research Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 9PJ, UK; (N.K.); (H.G.)
| | - Peter J. Goadsby
- Headache Group, NIHR King’s Clinical Research Facility and SLaM Biomedical Research Centre, The Wolfson Sensory, Pain and Regeneration Research Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 9PJ, UK; (N.K.); (H.G.)
- Department of Neurology, University of California, Los Angeles, CA 90095, USA
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60
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Mitsikostas DD, Waeber C, Sanchez-Del-Rio M, Raffaelli B, Ashina H, Maassen van den Brink A, Andreou A, Pozo-Rosich P, Rapoport A, Ashina M, Moskowitz MA. The 5-HT 1F receptor as the target of ditans in migraine - from bench to bedside. Nat Rev Neurol 2023:10.1038/s41582-023-00842-x. [PMID: 37438431 DOI: 10.1038/s41582-023-00842-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2023] [Indexed: 07/14/2023]
Abstract
Migraine is a leading cause of disability in more than one billion people worldwide, yet it remains universally underappreciated, even by individuals with the condition. Among other shortcomings, current treatments (often repurposed agents) have limited efficacy and potential adverse effects, leading to low treatment adherence. After the introduction of agents that target the calcitonin gene-related peptide pathway, another new drug class, the ditans - a group of selective serotonin 5-HT1F receptor agonists - has just reached the international market. Here, we review preclinical studies from the late 1990s and more recent clinical research that contributed to the development of the ditans and led to their approval for acute migraine treatment by the US Food and Drug Administration and the European Medicines Agency.
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Affiliation(s)
- Dimos D Mitsikostas
- 1st Neurology Department, Eginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.
| | - Christian Waeber
- School of Pharmacy, University College Cork, Cork, Ireland
- Department of Pharmacology and Therapeutics, University College Cork, Cork, Ireland
| | | | - Bianca Raffaelli
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Håkan Ashina
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Brain and Spinal Cord Injury, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Anaesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Antoinette Maassen van den Brink
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Anna Andreou
- Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Headache Centre, Guy's and St Thomas's NHS Foundation Trust, King's Health Partners, London, UK
| | - Patricia Pozo-Rosich
- Neurology Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Headache Unit, Neurology Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Headache and Neurological Pain Research Group, Vall d'Hebron Research Institute, Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alan Rapoport
- Department of Neurology, The David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Messoud Ashina
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Michael A Moskowitz
- Departments of Radiology and Neurology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
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61
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Wang Q, Wang S, Zhu Y, Lin F. Clinical efficacy and safety of rimegepant in the treatment of migraine: a meta-analysis of randomized controlled trials. Front Neurol 2023; 14:1205778. [PMID: 37409024 PMCID: PMC10318539 DOI: 10.3389/fneur.2023.1205778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 06/06/2023] [Indexed: 07/07/2023] Open
Abstract
Background This study aims to evaluate the clinical efficacy and safety of rimegepant for the treatment of migraine in adult patients using a meta-analysis. Methods The PubMed, EMBASE, and Cochrane Library were searched up to March 2022. Only randomized controlled trials (RCTs) that evaluated migraine and other comparator treatments in adult patients were included. The clinical response at the post-treatment evaluation, including acute pain free and relief effect, whereas the secondary outcomes were the risk of adverse events (AEs). Results A total of 4 RCTs involving 4,230 patients with episodic migraine were included. Outcome indicators for the number of pain free and relief patients at 2 h, 2-24 h, 2-48 h post-dose showed that rimegepant had better effects relative to the placebo [free at 2 h: OR = 1.84, 95% CI (1.55, 2.18), P < 0.00001; relief at 2 h: OR = 1.80, 95% CI (1.59, 2.04), P < 0.00001]. And there was no significant difference between the occurrence of adverse events in the experimental and control groups [OR = 1.29, 95% CI (0.99, 1.67), P = 0.06]. Conclusion Rimegepant has better therapeutic effects compared to placebo and no significant difference in adverse events.
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Affiliation(s)
- Qinghui Wang
- Department of Pharmacy, Chengdu Jinniu District People's Hospital, Chengdu, Sichuan, China
| | - Shuangmei Wang
- Department of Pharmacy, Chengdu Jinniu District People's Hospital, Chengdu, Sichuan, China
| | - Yi Zhu
- Department of Pharmacy, Chengdu Jinniu District People's Hospital, Chengdu, Sichuan, China
| | - Fei Lin
- Department of Pharmacy, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
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62
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Diener HC, Gaul C. [Drug therapy of the acute migraine attack and prophylaxis of migraine]. Dtsch Med Wochenschr 2023; 148:678-684. [PMID: 37216943 DOI: 10.1055/a-1857-3887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Migraine has a prevalence of 10 % in Germany, making it the most common neurological disorder. Migraine is a prevalent disorder not only for neurologist, it's an everyday topic for general physicians and internal medicine as well. Acute migraine attacks are treated with analgesics or triptans. In case of frequent migraine attacks, there is an indication for medicinal and non-pharmacological migraine prophylaxis. Medications include beta-blockers, flunarizine, anticonvulsants, amitriptyline or, in the case of chronic migraine, onabotulinumtoxinA. If these drugs are not effective, are not tolerated or contraindicated, monoclonal antibodies against calcitonin gene-related peptide (CGRP) or the CGRP receptor can be used.
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63
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Yu S, Kim BK, Guo A, Kim MH, Zhang M, Wang Z, Liu J, Moon HS, Tan G, Yang Q, McGrath D, Hanna M, Stock DA, Gao Y, Croop R, Lu Z. Safety and efficacy of rimegepant orally disintegrating tablet for the acute treatment of migraine in China and South Korea: a phase 3, double-blind, randomised, placebo-controlled trial. Lancet Neurol 2023; 22:476-484. [PMID: 37210098 DOI: 10.1016/s1474-4422(23)00126-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 03/20/2023] [Accepted: 03/27/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND No acute treatments targeting calcitonin gene-related peptide (CGRP) have been approved for use in China or South Korea. We aimed to compare the efficacy and safety of rimegepant-an orally administered small molecule CGRP antagonist-with placebo in the acute treatment of migraine among adults in these countries. METHODS This double-blind, randomised, placebo-controlled, multicentre phase 3 trial was done at 86 outpatient clinics at hospitals and academic medical centres (73 in China and 13 in South Korea). Participants were adults (≥18 years) with at least a 1-year history of migraine who had two to eight moderate or severe attacks per month and fewer than 15 headache days per month within the 3 months before the screening visit. Participants were randomly assigned (1:1) to 75 mg rimegepant or placebo to treat a single migraine attack of moderate or severe pain intensity. Randomisation was stratified by the use of preventive medication and by country. The allocation sequence was generated and implemented by study personnel using an interactive web-response system accessed online from each study centre. All participants, investigators, and the sponsor were masked to treatment assignment. The coprimary endpoints of freedom from pain and freedom from the most bothersome symptom (nausea, phonophobia, or photophobia) 2 h after dosing were assessed in the modified intention-to-treat (mITT) population (randomly assigned participants who took study medication for a migraine attack of moderate or severe pain intensity, and provided at least one efficacy datapoint after treatment) using Cochran-Mantel Haenszel tests. Safety was assessed in all participants who received rimegepant or placebo. The study is registered with ClinicalTrials.gov, number NCT04574362, and is completed. FINDINGS 1431 participants were randomly assigned (716 [50%] to rimegepant and 715 [50%] to placebo). 668 (93%) participants in the rimegepant group and 674 (94%) participants in the placebo group received treatment. 1340 participants were included in the mITT analysis (666 [93%] in the rimegepant group and 674 [94%] in the placebo group). 2 h after dosing, rimegepant was superior to placebo for pain freedom (132 [20%] of 666 vs 72 [11%] of 674, risk difference 9·2, 95% CI 5·4-13·0; p<0·0001) and freedom from the most bothersome symptom (336 [50%] of 666 participants vs 241 [36%] of 674 participants, 14·8, 9·6-20·0; p<0·0001). The most common (≥1%) adverse events were protein in urine (8 [1%] of 668 participants in the rimepegant group vs 7 [1%] of 674 participants in the placebo group), nausea (7 [1%] of 668 vs 18 [3%] of 674), and urinary tract infection (5 [1%] of 668 vs 8 [1%] of 674). There were no rimegepant-related serious adverse events. INTERPRETATION Among adults living in China or South Korea, a single dose of 75 mg rimegepant was effective for the acute treatment of migraine. Safety and tolerability were similar to placebo. Our findings suggest that rimegepant might be a useful new addition to the range of medications for the acute treatment of migraine in China and South Korea, but further studies are needed to support long-term efficacy and safety and to compare rimegepant with other medications for the acute treatment of migraine in this population. FUNDING BioShin Limited. TRANSLATIONS For the Chinese and Korean translations of the abstract see Supplementary Materials section.
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Affiliation(s)
| | | | - Aihong Guo
- Yan'an University Xianyang Hospital, Xianyang, China
| | - Man-Ho Kim
- Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | | | - Zhen Wang
- Changsha Central Hospital, Changsha, China
| | | | - Heui-Soo Moon
- Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ge Tan
- The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qian Yang
- Shanxi Provincial Hospital, Xi'an, China
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64
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Mitsikostas DD. Rimegepant for migraine: acute efficacy beyond the USA. Lancet Neurol 2023; 22:456-457. [PMID: 37210086 DOI: 10.1016/s1474-4422(23)00160-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 04/19/2023] [Indexed: 05/22/2023]
Affiliation(s)
- Dimos D Mitsikostas
- National and Kapodistrian Univeristy of Athens, Aeginition Hospital, 11521 Athens, Greece.
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Bhardwaj R, Stringfellow JC, Morris B, Croop RS, Bertz RJ. Effects of rimegepant 75 mg daily on the pharmacokinetics of a combined oral contraceptive containing ethinyl estradiol and norgestimate in healthy female participants. Headache 2023; 63:652-662. [PMID: 37140071 DOI: 10.1111/head.14512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 02/24/2023] [Accepted: 02/28/2023] [Indexed: 05/05/2023]
Abstract
OBJECTIVE To assess the effect of single and multiple doses of rimegepant 75 mg dose on the pharmacokinetics of an oral contraceptive containing ethinyl estradiol (EE)/norgestimate (NGM) in healthy females of childbearing potential or non-menopausal females with tubal ligation. BACKGROUND Females of childbearing age experience the highest prevalence of migraine and frequently inquire about the concomitant use of anti-migraine medications and contraceptives. Rimegepant, a calcitonin gene-related peptide receptor antagonist, demonstrated efficacy and safety for treating an acute migraine attack and preventing migraine. METHODS This open-label, single-center, phase 1, drug-drug interaction study explored the effects of rimegepant 75 mg daily dose on the pharmacokinetics of an oral contraceptive containing EE/NGM 0.035 mg/0.25 mg in healthy females of childbearing potential or non-menopausal females with tubal ligation. During cycles 1 and 2, participants received EE/NGM once daily for 21 days followed by placebo tablets with inactive ingredients for 7 days. Rimegepant was administered during only cycle 2 for 8 days, from days 12 through 19. The primary endpoint was the effect of single and multiple doses of rimegepant on the pharmacokinetics of EE and norelgestromin (NGMN), an active metabolite of NGM, at steady state, including area under the concentration-time curve for 1 dosing interval (AUC0-τ,ss ) and maximum observed concentration (Css[max] ). RESULTS The study enrolled 25 participants, with pharmacokinetic data assessed for 20 participants. A single 75 mg dose of rimegepant co-administered with EE/NGM increased exposures of EE and NGMN by ≤16% (geometric mean ratio [GMR], 1.03; 90% confidence interval [CI], 1.01-1.06; and GMR, 1.16; 90% CI, 1.13-1.20, respectively). After 8 days of co-administering EE/NGM with rimegepant, EE pharmacokinetic parameters, AUC0-τ,ss and Css(max) , increased by 20% (GMR, 1.20; 90% CI, 1.16-1.25) and 34% (GMR, 1.34; 90% CI, 1.23-1.46), respectively, and NGMN pharmacokinetic parameters increased by 46% (GMR, 1.46; 90% CI, 1.39-1.52) and 40% (GMR, 1.40; 90% CI, 1.30-1.51), respectively. CONCLUSIONS The study identified modest elevations in overall EE and NGMN exposures after multiple doses of rimegepant, but these elevations are unlikely to be clinically relevant in healthy females with migraine.
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Affiliation(s)
| | | | - Beth Morris
- Biohaven Pharmaceuticals, New Haven, Connecticut, USA
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Puledda F, Silva EM, Suwanlaong K, Goadsby PJ. Migraine: from pathophysiology to treatment. J Neurol 2023:10.1007/s00415-023-11706-1. [PMID: 37029836 DOI: 10.1007/s00415-023-11706-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 04/03/2023] [Indexed: 04/09/2023]
Abstract
Migraine is an extremely disabling, common neurological disorder characterized by a complex neurobiology, involving a series of central and peripheral nervous system areas and networks. A growing increase in the understanding of migraine pathophysiology in recent years has facilitated translation of that knowledge into novel treatments, which are currently becoming available to patients in many parts of the world and are substantially changing the clinical approach to the disease. In the first part of this review, we will provide an up to date overview of migraine pathophysiology by analyzing the anatomy and function of the main regions involved in the disease, focusing on how these give rise to the plethora of symptoms characterizing the attacks and overall disease. The second part of the paper will discuss the novel therapeutic agents that have emerged for the treatment of migraine, including molecules targeting calcitonin gene-related peptide (gepants and monoclonal antibodies), serotonin 5-HT1F receptor agonists (ditans) and non-invasive neuromodulation, as well as providing a brief overview of new evidence for classic migraine treatments.
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Affiliation(s)
- Francesca Puledda
- Headache Group, Wolfson CARD, Institute of Psychiatry, Psychology and Neuroscience, King's College London, and National Institute for Health Research (NIHR) SLaM Clinical Research Facility at King's, Wellcome Foundation Building, King's College Hospital, London, SE5 9PJ, UK
| | | | - Kanokrat Suwanlaong
- Division of Neurology, Department of Medicine, Songkhla Medical Education Center, Songkhla, Thailand
| | - Peter J Goadsby
- Headache Group, Wolfson CARD, Institute of Psychiatry, Psychology and Neuroscience, King's College London, and National Institute for Health Research (NIHR) SLaM Clinical Research Facility at King's, Wellcome Foundation Building, King's College Hospital, London, SE5 9PJ, UK.
- Department of Neurology, University of California, Los Angeles, Los Angeles, CA, USA.
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Ceriani CEJ, Silberstein SD. Current and Emerging Pharmacotherapy for Menstrual Migraine: A Narrative Review. Expert Opin Pharmacother 2023; 24:617-627. [PMID: 36946205 DOI: 10.1080/14656566.2023.2194487] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
INTRODUCTION In this article, we discuss menstrual migraine (MM), which can be categorized as menstrually related migraine (MRM) or pure menstrual migraine (PMM). MM attacks are often longer, more severe, and harder to treat than other migraine attacks. Appropriate treatment strategies include acute treatment, short term preventive treatment, and daily preventive treatment, depending on the patient's pattern of migraine and occurrence of migraine outside the menstrual period. AREAS COVERED A PubMed, Cochrane Library, Medline, and Ovid search from inception to October 2022 provided articles relating to MM pathophysiology and treatment. EXPERT OPINION In patients for whom standard acute therapy is inadequate, short term or daily preventive treatment should be considered. Patients with PMM may be adequately managed with short term preventive treatment started 2 days prior to the onset of migraine and continued for 5-6 days. Frovatriptan is the mainstay of short-term prevention. Patients who experience additional attacks outside the menstrual period may benefit from daily preventive treatment. Estrogen-containing contraceptive treatment may be effective in appropriately selected patients. Emerging research on the pathophysiology of MM indicates that oxytocin agonists and CGRP antagonists may prove to be effective treatment options.
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Affiliation(s)
- Claire E J Ceriani
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Stephen D Silberstein
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
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Shah T, Bedrin K, Tinsley A. Calcitonin gene relating peptide inhibitors in combination for migraine treatment: A mini-review. FRONTIERS IN PAIN RESEARCH 2023; 4:1130239. [PMID: 37006413 PMCID: PMC10064089 DOI: 10.3389/fpain.2023.1130239] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 02/24/2023] [Indexed: 03/19/2023] Open
Abstract
The discovery of calcitonin gene-related peptide (CGRP) and its role in migraine pathophysiology has led to advances in the treatment of migraine. Since 2018, the Food and Drug Administration (FDA) has approved four monoclonal antibody (mab) therapies targeting either the CGRP ligand or receptor and 3 oral small molecule CGRP receptor antagonists. These targeted therapies have been shown to be safe and effective for either preventive or acute treatment of migraine in adults. Given their efficacy and tolerability profile, CGRP inhibitors have revolutionized the approach to migraine treatment. Theoretically, combining therapies within this therapeutic class could lead to more CGRP blockade and, subsequently, improved patient outcomes. There are providers currently combining CGRP therapies in clinical practice. However, limited data are available regarding the efficacy and safety of this practice. This mini-review provides a summary of available data and poses important considerations when combining CGRP therapies for migraine treatment.
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Puledda F, Younis S, Huessler EM, Haghdoost F, Lisicki M, Goadsby PJ, Tassorelli C. Efficacy, safety and indirect comparisons of lasmiditan, rimegepant, and ubrogepant for the acute treatment of migraine: A systematic review and network meta-analysis of the literature. Cephalalgia 2023; 43:3331024231151419. [PMID: 36786357 DOI: 10.1177/03331024231151419] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
BACKGROUND We performed a random-effects network meta-analysis to study the efficacy and safety of newly developed drugs for the acute treatment of migraine attacks. METHODS MEDLINE via PubMed, Embase and The Cochrane Register of Controlled Trials were searched from inception to 11 February 2022. Phase 3 randomized controlled trials examining all formulations of lasmiditan, rimegepant and ubrogepant for the acute treatment of adults with migraine, were included. Data were extracted following the PRISMA guidelines. RESULTS Seven studies (SAMURAI, SPARTAN, CENTURION, Study 302, Study 303, ACHIEVE I and II) involving n = 12,859 patients were included. All treatments were superior in efficacy to placebo. Lasmiditan 200 mg showed the highest two-hour pain freedom, while two-hour freedom from most bothersome symptom was equally achieved by the higher doses of lasmiditan (100 and 200 mg), rimegepant and the higher doses of ubrogepant (50 and 100 mg). The odds of treatment-emergent adverse events were greatest with all doses of lasmiditan. CONCLUSION Lasmiditan 200 mg was the most effective intervention in the treatment of migraine attacks, although it was associated with high degrees of dizziness, nausea and somnolence. Rimegepant showed slightly lower, but similar efficacy rates to lasmiditan. Ubrogepant had overall the best tolerability profile. These conclusions are limited by the absence of head-to-head comparisons, limitations of individual trials and of the meta-analysis methodology itself.PROSPERO trial registration: CRD42022308224.
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Affiliation(s)
- Francesca Puledda
- Headache Group, Wolfson CARD, SLaM Biomedical Research Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London and NIHR-Wellcome Trust King's Clinical Research Facility, King's College Hospital, London, United Kingdom
| | - Samaira Younis
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Denmark
| | - Eva-Maria Huessler
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Germany
| | - Faraidoon Haghdoost
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Marco Lisicki
- Headache Department, Neuroscience Unit, Conci·Carpinella Institute, Córdoba, Argentina
| | - Peter J Goadsby
- Headache Group, Wolfson CARD, SLaM Biomedical Research Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London and NIHR-Wellcome Trust King's Clinical Research Facility, King's College Hospital, London, United Kingdom.,Department of Neurology, University of California, Los Angeles, CA, United States
| | - Cristina Tassorelli
- Headache Science Center, C. Mondino Foundation, Pavia, Italy.,University of Pavia, Department of Brain and Behavioral Sciences, Pavia, Italy
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Abstract
Rimegepant [Nurtec® ODT (USA); Vydura® (EU)] is a calcitonin gene-related peptide (CGRP) receptor antagonist approved for the acute treatment of migraine with or without aura in adults, and for the preventive treatment of episodic migraine in adults. Rimegepant is available as an orally disintegrating tablet (ODT), which offers convenience and a potentially faster response time than the conventional tablet formulation. In pivotal phase III trials, rimegepant was more effective than placebo at relieving pain and the most bothersome symptom when taken as needed for the acute treatment of migraine. Rimegepant was also more effective than placebo at reducing the number of monthly migraine days when taken every other day for the preventive treatment of migraine. The beneficial effects of rimegepant in reducing migraine frequency and improving quality of life were maintained over the longer term (up to 52 weeks). Rimegepant was generally well tolerated, with no evidence of hepatotoxicity or cardiovascular toxicity in clinical trials. As the first dual agent approved for both treatment and prevention of migraine, rimegepant represents a useful option for the management of migraine in adults.
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Affiliation(s)
- Hannah A Blair
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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Li Y, Wang X, Ballesteros-Perez A, Bertz R, Lu Z. Pharmacokinetics and Safety of Single and Multiple Daily Dosing of 75-mg Rimegepant Orally Disintegrating Tablets in Healthy Chinese Adults: A Randomized Placebo-Controlled Trial. Clin Pharmacol Drug Dev 2023. [PMID: 36808268 DOI: 10.1002/cpdd.1230] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 01/13/2023] [Indexed: 02/22/2023]
Abstract
Rimegepant is an oral small-molecule calcitonin gene-related peptide antagonist for acute migraine treatment with or without aura and prevention of episodic migraine in adults. This was a rimegepant single- and multiple-dose phase 1, randomized, placebo-controlled, double-blind study to evaluate the pharmacokinetics and confirm safety in healthy Chinese participants. Participants received a 75-mg rimegepant orally disintegrating tablet (ODT) (N = 12) or matching placebo (N = 4) ODT on days 1 and 3-7 after fasting for pharmacokinetic assessments. Safety assessments included 12-lead electrocardiograms, vital signs, clinical laboratory data, and adverse events (AEs). After a single dose (9 females, 7 males) median time to maximum plasma concentration was 1.5 hours; mean values were 937 ng/mL (maximum concentration), 4582 h*ng/mL (area under the concentration-time curve, 0 to infinity), 7.7 hours (terminal elimination half-life), and 19.9 L/h (apparent clearance). Similar results were seen after 5 daily doses, with minimal accumulation. Six (37.5%) participants experienced ≥1 treatment-emergent AE: 4 (33.3%) had received rimegepant and 2 (50.0%) had received placebo. All AEs were grade 1 and resolved by the end of the study with no deaths, serious/significant AEs, or AEs leading to discontinuation. Overall, single- and multiple-dose rimegepant ODT 75 mg was safe and well-tolerated in healthy Chinese adults with similar pharmacokinetics to non-Asian healthy participants. Trial registration: This trial is registered with the China Center for Drug Evaluation (CDE): CTR20210569.
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Affiliation(s)
- Yan Li
- Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing, China
| | - Xinghe Wang
- Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing, China
| | | | - Richard Bertz
- Biohaven Pharmaceuticals Inc., New Haven, Connecticut, USA
| | - Zhihong Lu
- Bioshin Limited, Pudong New District, Shanghai, China
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Abstract
Medication overuse headache (MOH) is a secondary headache disorder attributed to overuse of acute headache medications by a person with an underlying headache disorder, usually migraine or tension-type headache. MOH is common among individuals with 15 or more headache days per month. Although MOH is associated with substantial disability and reductions in quality of life, this condition is often under-recognized. As MOH is both preventable and treatable, it warrants greater attention and awareness. The diagnosis of MOH is based on the history and an unremarkable neurological examination, and is made according to the diagnostic criteria of the International Classification of Headache Disorders third edition (ICHD-3). Pathophysiological mechanisms of MOH include altered descending pain modulation, central sensitization and biobehavioural factors. Treatment of MOH includes the use of headache preventive therapies, but essential to success is eliminating the cause, by reducing the frequency of use of acute headache medication, and perhaps withdrawing the overused medication altogether. Appropriate treatment is usually highly effective, leading to reduced headache burden and acute medication consumption.
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Begasse de Dhaem O, Takizawa T, Dodick DW. Long-term open-label and real-world studies of lasmiditan, ubrogepant, and rimegepant for the acute treatment of migraine attacks. Cephalalgia 2023; 43:3331024221137092. [PMID: 36739505 DOI: 10.1177/03331024221137092] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Long-term data helps assess the consistency of efficacy, tolerability, and safety of acute treatment over repeated use for different attacks. Real-world studies help assess tolerability, safety, and efficacy in patients with possibly refractory chronic migraine, more comorbidities, other diseases such as cardiovascular diseases, and polypharmacy. METHODS This is a narrative review of the long-term open-label and real-world studies of lasmiditan, ubrogepant, and rimegepant for the acute treatment of migraine. Both manuscripts and abstracts were reviewed. RESULTS The efficacy and tolerability of lasmiditan, ubrogepant, and rimegepant are maintained over time. No significant cardiovascular adverse events were thought to be related to any of these medications. The rare instances of palpitations and/or tachycardia occurred within 48 hours of lasmiditan. One participant with a history of supraventricular tachycardia had sinus tachycardia thought to be related to ubrogepant which did not recur despite continued use. One case of thrombocytopenia and two cases of increased aspartate aminotransferase and alanine transaminase were thought to be possibly related, but the alanine transaminase and aspartate aminotransferase levels normalized despite continued use of ubrogepant. A case of first-degree atrioventricular block was considered possibly related to rimegepant. Acute use of rimegepant was associated with a decrease in monthly migraine days over time. The three medications were associated with improvement in function and/or productivity. CONCLUSION Long-term and real-world data of tolerability, safety and efficacy of lasmiditan, ubrogepant, and rimegepant is thus far consistent with prior studies, but more longitudinal data that clarifies long-term safety as well as consistency and predictors of response is needed.
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Affiliation(s)
| | - Tsubasa Takizawa
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - David W Dodick
- Department of Neurology, Mayo Clinic, Phoenix, AZ, USA.,Atria Institute, New York, NY, USA
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Lipton RB, Blumenfeld A, Jensen CM, Croop R, Thiry A, L'Italien G, Morris BA, Coric V, Goadsby PJ. Efficacy of rimegepant for the acute treatment of migraine based on triptan treatment experience: Pooled results from three phase 3 randomized clinical trials. Cephalalgia 2023; 43:3331024221141686. [PMID: 36739511 DOI: 10.1177/03331024221141686] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND This post-hoc analysis from three phase 3 treatment trials of rimegepant 75 mg - an oral small molecule calcitonin gene-related peptide receptor antagonist for acute and preventive treatment of migraine - assessed efficacy in adults with migraine based on triptan treatment experience. METHODS Participants were assigned to one of four groups based on triptan treatment experience: insufficient response (e.g. lack of efficacy and/or poor tolerability) to 1 triptan, insufficient response to ≥2 triptans, current triptan users, and triptan-naïve participants. The co-primary efficacy endpoints were pain freedom and most bothersome symptom freedom at two hours postdose. RESULTS In the three trials (N = 3507; rimegepant n = 1749, placebo n = 1758), 1235 (35.2%) participants had a history of insufficient response to 1 triptan (n = 910 [25.9%]) or ≥2 triptans (n = 325 [9.3%]), and 2272 (64.8%) had no history of insufficient response to triptans (current use = 595 [17.0%], naïve = 1677 [47.8%]). Rimegepant was effective on the co-primary endpoints in all subgroups (p ≤ 0.013), except for freedom from the most bothersome symptom in the triptan-naïve group (p = 0.06). No differences on co-primary endpoints were found in pairwise comparisons of rimegepant-treated participants. CONCLUSIONS Rimegepant was effective for the acute treatment of migraine in adults with a history of insufficient response to 1 or ≥2 triptans and in current triptan users. Efficacy on co-primary endpoints did not differ based on the number of insufficient triptan responses.Trial registration: Clinicaltrials.gov: NCT03235479, NCT03237845, NCT03461757.
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Affiliation(s)
- Richard B Lipton
- Departments of Neurology, Epidemiology and Population Health, and Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | | | | | | | | | | | | | - Peter J Goadsby
- NIHR SLaM Clinical Research Facility @ King's College Hospital/SLaM Biomedical Research Centre, King's College London, UK.,Department of Neurology, University of California, Los Angeles, Los Angeles, CA, USA
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Gawde P, Shah H, Patel H, Bharathi KS, Patel N, Sethi Y, Kaka N. Revisiting Migraine: The Evolving Pathophysiology and the Expanding Management Armamentarium. Cureus 2023; 15:e34553. [PMID: 36879707 PMCID: PMC9985459 DOI: 10.7759/cureus.34553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2023] [Indexed: 02/05/2023] Open
Abstract
Migraine affects about one billion people worldwide yearly and is one of the most common neurologic illnesses, with a high prevalence and morbidity, particularly among young adults and females. Migraine is associated with many comorbidities, including stress, sleep difficulties, and suicidal ideation. Migraine, despite its widespread occurrence, is underdiagnosed and undertreated. Because of the complicated and primarily unknown mechanisms of migraine formation, several social and biological risk factors, such as hormone imbalances, genetic and epigenetic impacts, and cardiovascular, neurological, and autoimmune illnesses, have been proposed. Through the mid-20th century diversion of the now-defunct vascular theory, the pathophysiology of migraine has developed from a historical study of the "humours" to a distinct entity as a neurological disorder. The range of therapeutic targets has broadened significantly, increasing the number of specialized clinical trials. Understanding the biology of migraine through careful research has resulted in the identification of major therapeutic classes: (i) triptans, serotonin 5-HT1B/1D receptor agonists, (ii) gepants, calcitonin gene-related peptide (CGRP) receptor antagonists, (iii) ditans, 5-HT1F receptor agonists, (iv) CGRP monoclonal antibodies, and (v) glurants, mGlu5 modulators, with further targets being explored. This review provides a comprehensive overview of the most recent literature on epidemiology and risk factors and exposes knowledge gaps.
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Affiliation(s)
- Prathamesh Gawde
- Medicine and Surgery, Lokmanya Tilak Municipal Medical College, Mumbai, IND
| | - Harsh Shah
- Medicine and Surgery, Pandit Deendayal Upadhyay Medical College, Rajkot, IND
| | - Harsh Patel
- Internal Medicine, GMERS (Gujarat Medical Education and Research Society) Medical College, Sola, Ahmedabad, IND
| | | | - Neil Patel
- Medicine and Surgery, GMERS (Gujarat Medical Education and Research Society) Medical College, Himmatnagar, IND
| | - Yashendra Sethi
- Medicine and Surgery, Government Doon Medical College, Dehradun, IND
| | - Nirja Kaka
- Medicine and Surgery, GMERS (Gujarat Medical Education and Research Society) Medical College, Himmatnagar, IND
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de Boer I, Verhagen IE, Souza MNP, Ashina M. Place of next generation acute migraine specific treatments among triptans, non-responders and contraindications to triptans and possible combination therapies. Cephalalgia 2023; 43:3331024221143773. [PMID: 36739516 DOI: 10.1177/03331024221143773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background: For many years triptans have been the cornerstone of acute migraine treatment. Nevertheless, treatment with triptans may not always be initiated due to contraindications (seen in approximately one fifth of patients) or inadequate response (seen in approximately one third of patients). New acute therapies, including 5-hydroxytryptamine (5-HT)1F receptor agonists, also known as ditans (lasmiditan) and small molecule antagonists of the calcitonin gene-related peptide receptor, also known as gepants (rimegepant and ubrogepant), may be an effective alternative. Methods: We searched Pubmed for keywords, summarized the literature and provided a comprehensive review on the place of next generation acute migraine specific treatments among triptans. Results and conclusion: Post-hoc analyses reported no differences in efficacy of gepants/ditans between responders and non-responders to triptans, but research is hampered by lack of consensus on the definition of non-responder. Due to (partially) overlapping mechanisms of action, it remains unknown whether combination therapy with lasmiditan, gepants and triptans will have added value over monotherapy. Preclinical studies and post-hoc analyses cautiously indicate that these new drugs are safe for patients with cardiovascular risk factors. However, long-term studies are needed to prove cardiovascular safety. The risk of developing medication overuse headache may differ between triptans, ditans and gepants, but further studies are needed to confirm this difference. Head-to-head randomized controlled trials of acute therapies and combinations of therapies are needed to determine their place in migraine treatment among established therapies.
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Affiliation(s)
- Irene de Boer
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - Iris Elsa Verhagen
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Messoud Ashina
- Department of Neurology, Rigshospitalet Glostrup, University of Copenhagen, Glostrup, Denmark
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77
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Powell LC, L'Italien G, Popoff E, Johnston K, O'Sullivan F, Harris L, Croop R, Coric V, Lipton RB. Health State Utility Mapping of Rimegepant for the Preventive Treatment of Migraine: Double-Blind Treatment Phase and Open Label Extension (BHV3000-305). Adv Ther 2023; 40:585-600. [PMID: 36417057 PMCID: PMC9898331 DOI: 10.1007/s12325-022-02369-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 10/24/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The objectives of this study were to (1) report long-term health-related quality of life (HRQoL) outcomes among patients using rimegepant preventatively in BHV3000-305 (NCT03732638) open-label extension (OLE) and (2) map Migraine-Specific Quality of Life questionnaire version 2.1 (MSQv2) to EQ-5D-3L utility values over the double-blind treatment (DBT; 0-12 weeks) and the OLE (13-64 weeks) to assess the influence of treatment on these values. METHODS This was a post hoc analysis using data from a rimegepant study for the prevention of migraine (BHV3000-305). Adult patients with migraine took either rimegepant 75 mg or placebo every other day (EOD) during the DBT phase. All patients received rimegepant during the OLE. MSQv2 was measured at baseline, weeks 12, 24, and 64. A validated algorithm was used to map MSQv2 scores to EQ-5D utilities. RESULTS Baseline data were available for 347 patients treated with placebo and 348 treated with rimegepant in the DBT period, who continued to the OLE. Baseline EQ-5D utilities were similar between trial arms: 0.598 for placebo and 0.614 for rimegepant. EQ-5D improved from baseline to week 12 and utilities increased by + 0.09 for placebo and + 0.10 for rimegepant (p value = 0.011). By 24 weeks, at which point patients who were originally randomized to placebo had received rimegepant 75 mg EOD for 12 weeks, HRQoL measures (MSQv2 and EQ-5D) were similar across groups, demonstrating rapid onset of treatment effect. This HRQoL improvement was durable out to 64 weeks. CONCLUSION Compared to placebo, treatment with rimegepant 75 mg was associated with greater improvement in EQ-5D utilities during the 12-week DBT phase. Patients originally randomized to placebo experienced a similar improvement in EQ-5D utilities after switching to rimegepant during the OLE, demonstrating that benefits are realized within 12 weeks of active treatment. This preventive effect was durable out to 64 weeks and was associated with an additional increase in HRQoL over time. TRIAL REGISTRATION NCT03732638.
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Affiliation(s)
- Lauren C Powell
- Broadstreet Health Economics and Outcomes Research, 201-343 Railway Street, Vancouver, BC, V6A 1A4, Canada.
| | | | - Evan Popoff
- Broadstreet Health Economics and Outcomes Research, 201-343 Railway Street, Vancouver, BC, V6A 1A4, Canada
| | - Karissa Johnston
- Broadstreet Health Economics and Outcomes Research, 201-343 Railway Street, Vancouver, BC, V6A 1A4, Canada
| | - Fiona O'Sullivan
- Broadstreet Health Economics and Outcomes Research, 201-343 Railway Street, Vancouver, BC, V6A 1A4, Canada
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78
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Dong G, Kjærgaard NA, Shakibfar S, Sessa M. Ubrogepant and rimegepant: systematic review, meta-analysis, and meta-regression of clinical studies. Expert Opin Drug Saf 2023; 22:59-70. [PMID: 36737057 DOI: 10.1080/14740338.2023.2177270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES This study aimed at providing pooled estimates of the incidence of adverse drug reactions (ADRs) of ubrogepant and rimegepant and to use meta-regression to identify correlations between the occurrence of selected ADRs, socio-demographic, and clinical characteristics from data published in clinical studies. METHODS Ovid MEDLINE (up to 03/02/2022) was searched along with the references listed in the reviews identified with the research query. Random intercept and slope logistic regression models were used to estimate the logit transformation of the pooled incidence. To examine how selected clinical and socio-demographic characteristics correlated with the pooled incidence rates, we performed random-effects meta-regression. RESULTS Significant heterogeneity of incidence estimates was observed in clinical studies along with correlations between ADRs and the sociodemographic and clinical characteristics of patients exposed to ubrogepant. In particular, we observed a correlation between ubrogepant dosage and muscle strain and between Body Mass Index (BMI) and liver function values. For rimegepant, significant correlations were observed between age and infections and having aura symptoms at baseline and nausea/dizziness/diarrhea/muscle strain. CONCLUSION This study provided pooled incidence estimates of ubrogepant and rimegepant's ADRs and highlighted new safety aspects of the pharmacological treatment with ubrogepants and rimigepants from correlations obtained from the meta-regression.
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Affiliation(s)
- Guojun Dong
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Naoko Adachi Kjærgaard
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Saeed Shakibfar
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Maurizio Sessa
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
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79
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Rissardo JP, Caprara ALF. Gepants for Acute and Preventive Migraine Treatment: A Narrative Review. Brain Sci 2022; 12:1612. [PMID: 36552072 PMCID: PMC9775271 DOI: 10.3390/brainsci12121612] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 11/11/2022] [Accepted: 11/22/2022] [Indexed: 11/27/2022] Open
Abstract
Calcitonin gene-related peptide (CGRP) antagonists are a class of medications that act as antagonists of the CGRP receptor or ligand. They can be divided into monoclonal antibodies and non-peptide small molecules, also known as gepants. CGRP antagonists were the first oral agents specifically designed to prevent migraines. The second generation of gepants includes rimegepant (BHV-3000, BMS-927711), ubrogepant (MK-1602), and atogepant (AGN-241689, MK-8031). Zavegepant (BHV-3500, BMS-742413) belongs to the third generation of gepants characterized by different administration routes. The chemical and pharmacological properties of this new generation of gepants were calculated. The clinical trials showed that the new generation of CGRP antagonists is effective for the acute and/or preventive treatment of migraines. No increased mortality risks were observed to be associated with the second- and third-generation gepants. Moreover, the majority of the serious adverse events reported probably occurred unrelated to the medications. Interesting facts about gepants were highlighted, such as potency, hepatotoxicity, concomitant use with monoclonal antibodies targeting the CGRP, comparative analysis with triptans, and the "acute and preventive" treatment of migraine. Further studies should include an elderly population and compare the medications inside this class and with triptans. There are still concerns regarding the long-term side effects of these medications, such as chronic vascular hemodynamic impairment. Meanwhile, careful pharmacovigilance and safety monitoring should be performed in the clinical practice use of gepants.
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Affiliation(s)
- Jamir Pitton Rissardo
- Medicine Department, Federal University of Santa Maria, Santa Maria 97105-900, Brazil
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80
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Tepper SJ, Ailani J, Ray S, Hirman J, Shrewsbury SB, Aurora SK. Variability in recurrence rates with acute treatments for migraine: why recurrence is not an appropriate outcome measure. J Headache Pain 2022; 23:148. [PMID: 36414952 PMCID: PMC9682643 DOI: 10.1186/s10194-022-01519-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 09/07/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Headache recurrence is a common feature of acute therapies, whether approved or still in development, and continues to be a significant problem for both the patient and the clinician. Further complicating this issue is lack of standardization in definitions of recurrence used in clinical trials, as well as disparity in patient characteristics, rendering a comparison of different acute medications challenging. Recurrence has serious clinical implications, which can include an increased risk for new-onset chronic migraine and/or development of medication overuse headache. The aim of this review is to illustrate variability of recurrence rates depending on prevailing definitions in the literature for widely used acute treatments for migraine and to emphasize sustained response as a clinically relevant endpoint for measuring prolonged efficacy. BODY: A literature search of PubMed for articles of approved acute therapies for migraine that reported recurrence rates was performed. Study drugs of interest included select triptans, gepants, lasmiditan, and dihydroergotamine mesylate. An unpublished post hoc analysis of an investigational dihydroergotamine mesylate product that evaluated recurrence rates using several different definitions of recurrence common in the literature is also included. Depending on the criteria established by the clinical trial and the definition of recurrence used, rates of recurrence vary considerably across different acute therapies for migraine, making it difficult to compare results of different trials to assess the sustained (i.e., over a single attack) and the prolonged (i.e., over multiple attacks) efficacy of a particular study medication. CONCLUSION A standardized definition of recurrence is necessary to help physicians evaluate recurrence rates of different abortive agents for migraine. Sustained pain relief or freedom may be more comprehensive efficacy outcome measures than recurrence. Future efficacy studies should be encouraged to use the recommended definition of sustained pain freedom set by the International Headache Society.
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Affiliation(s)
| | - Jessica Ailani
- MedStar Georgetown University Hospital, Washington, DC, USA
| | | | - Joe Hirman
- Pacific Northwest Statistical Consulting, Inc, Woodinville, WA, USA
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81
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Johnston KM, Powell L, Popoff E, Harris L, Croop R, Coric V, L’Italien G. Rimegepant, Ubrogepant, and Lasmiditan in the Acute Treatment of Migraine Examining the Benefit-Risk Profile Using Number Needed to Treat/Harm. Clin J Pain 2022; 38:680-685. [PMID: 36125279 PMCID: PMC9555761 DOI: 10.1097/ajp.0000000000001072] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 08/23/2022] [Accepted: 09/01/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To develop and compare benefit-risk profiles for rimegepant, ubrogepant, and lasmiditan based on a network meta-analysis (NMA) of published clinical trials. METHODS A fixed-effects Bayesian NMA of randomized controlled trials of lasmiditan, rimegepant, and ubrogepant for the acute treatment of adults with migraine were used to determine risk differences for efficacy and safety outcomes of the 3 treatments compared with pooled placebo. Risk differences were used to calculate number needed to treat (NNT) for pain relief and pain freedom at 2 and 2 to 24 hours and freedom from most bothersome symptoms at 2 hours; and number needed to harm (NNH) for dizziness and nausea, relative to placebo. RESULTS Results were based on 5 randomized controlled trials (NCT03461757, NCT02828020, NCT02867709, NCT02439320, and NCT02605174). NNT to achieve sustained pain relief at 2 to 24 hours was lowest for rimegepant 75 mg (5; 95% credible interval [Crl]: 4, 7) and ubrogepant 100 mg (5; 95% Crl: 4, 8) and highest for ubrogepant 25 mg (8; 95% Crl: 5, 16). Rimegepant had the lowest NNT to achieve sustained pain freedom at 2 to 24 hours and lasmiditan 50 mg had the highest (7; 95% Crl: 5, 12 vs. 26; 95% Crl: 13, 95). NNH for dizziness and nausea was highest for ubrogepant 25 mg (28; 95% Crl: 15, 62 and 99; 95% Crl: -2580, 2378, respectively). Lasmiditan 200 mg had the lowest NNH for dizziness and rimegepant 75 mg had the lowest NNH for nausea. CONCLUSIONS The benefit-risk profiles of lasmiditan, rimegepant, and ubrogepant may improve clinical decision-making.
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Affiliation(s)
| | - Lauren Powell
- Broadstreet Health Economics & Outcomes Research, Vancouver, BC, Canada
| | - Evan Popoff
- Broadstreet Health Economics & Outcomes Research, Vancouver, BC, Canada
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82
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Sacco S, Lampl C, Amin FM, Braschinsky M, Deligianni C, Uludüz D, Versijpt J, Ducros A, Gil-Gouveia R, Katsarava Z, Martelletti P, Ornello R, Raffaelli B, Boucherie DM, Pozo-Rosich P, Sanchez-Del-Rio M, Sinclair A, Maassen van den Brink A, Reuter U. European Headache Federation (EHF) consensus on the definition of effective treatment of a migraine attack and of triptan failure. J Headache Pain 2022; 23:133. [PMID: 36224519 PMCID: PMC9555163 DOI: 10.1186/s10194-022-01502-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 09/21/2022] [Indexed: 12/01/2022] Open
Abstract
Background Triptans are migraine-specific acute treatments. A well-accepted definition of triptan failure is needed in clinical practice and for research. The primary aim of the present Consensus was to provide a definition of triptan failure. To develop this definition, we deemed necessary to develop as first a consensus definition of effective treatment of an acute migraine attack and of triptan-responder. Main body The Consensus process included a preliminary literature review, a Delphi round and a subsequent open discussion. According to the Consensus Panel, effective treatment of a migraine attack is to be defined on patient well-being featured by a) improvement of headache, b) relief of non-pain symptoms and c) absence of adverse events. An attack is considered effectively treated if patient’s well-being, as defined above, is restored within 2 hours and for at least 24 hours. An individual with migraine is considered as triptan-responder when the given triptan leads to effective acute attack treatment in at least three out of four migraine attacks. On the other hand, an individual with migraine is considered triptan non-responder in the presence of failure of a single triptan (not matching the definition of triptan-responder). The Consensus Panel defined an individual with migraine as triptan-resistant in the presence of failure of at least 2 triptans; triptan refractory, in the presence of failure to at least 3 triptans, including subcutaneous formulation; triptan ineligibile in the presence of an acknowledged contraindication to triptan use, as specified in the summary of product characteristics. Conclusions The novel definitions can be useful in clinical practice for the assessment of acute attack treatments patients with migraine. They may be helpful in identifying people not responding to triptans and in need for novel acute migraine treatments. The definitions will also be of help in standardizing research on migraine acute care. Supplementary Information The online version contains supplementary material available at 10.1186/s10194-022-01502-z.
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Affiliation(s)
- Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Via Vetoio 1, L'Aquila, Italy.
| | - Christian Lampl
- Department of Neurology, Headache Medical Center at the Konventhospital BHB Linz, Linz, Austria
| | - Faisal Mohammad Amin
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, University of Copenhagen, Copenhagen, Denmark.,Department of Neurorehabilitation/Traumatic Brain Injury, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Mark Braschinsky
- Department of Neurology, Institute of Clinical Medicine, University of Tartu; Headache Clinic, Department of Neurology, Tartu University Hospital, Tartu, Estonia
| | - Christina Deligianni
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, University of Copenhagen, Copenhagen, Denmark
| | - Derya Uludüz
- Department of Neurology Istanbul Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Jan Versijpt
- Department of Neurology, Vrije Universiteit Brussel (VUB), Universitair, Ziekenhuis Brussel, Brussels, Belgium
| | - Anne Ducros
- Neurology Department, CHU de Montpellier Charles Coulomb Laboratory, Montpellier University, Montpellier, France
| | - Raquel Gil-Gouveia
- Neurology Department, Hospital da Luz Headache Center, Hospital da Luz, Lisbon, Portugal.,Center for Interdisciplinary Research in Health, Universidade Católica Portuguesa, Lisbon, Portugal
| | - Zaza Katsarava
- Christian Hospital, Unna, Germany.,University of Duisburg-Essen, Essen, Germany
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Raffaele Ornello
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Via Vetoio 1, L'Aquila, Italy
| | - Bianca Raffaelli
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Deirdre M Boucherie
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Patricia Pozo-Rosich
- Headache Unit, Neurology Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Department of Medicine, Headache and Neurological Pain Research Group, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Alexandra Sinclair
- Institute of Metabolism and Sytems Research, University of Birmingham, Birmingham, UK.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | | | - Uwe Reuter
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany.,Universitätsmedizin Greifswald, Greifswald, Germany
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83
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Berger AA, Winnick A, Carroll AH, Welschmeyer A, Li N, Colon M, Paladini A, Ramírez GF, Hasoon J, Cornett EM, Song J, Varrassi G, Kaye AM, Kaye AD, Ganti L. Rimegepant for the treatment of migraine. Health Psychol Res 2022; 10:38534. [PMID: 36262478 PMCID: PMC9560892 DOI: 10.52965/001c.38534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023] Open
Abstract
Migraine is a common form of primary headache, affecting up to 1 in every 6 Americans. The pathophysiology is an intricate interplay of genetic factors and environmental influence and is still being elucidated in ongoing studies. The trigeminovascular system is now known to have a significant role in the initiation of migraines, including the release of pain mediators such as CGRP and substance P. Traditional treatment of migraine is usually divided into acute and preventive treatment. Acute therapy includes non-specific therapy, such as NSAIDs and other analgesics, which may provide relief in mild to moderate migraines. 5-HT1 agonists may provide relief in severe migraine, but are not universally effective and carry a significant side-effect profile with frequent redosing requirement. Prophylactic therapy may reduce the occurrence of acute migraine attacks in selected patients, but does not completely eliminate it. More recently, CGRP antagonism has been studied and shown to be effective in both abortion and prevention of migraine. Novel medications, targeting CGRP, divide into CGRP antibodies and receptor antagonists (gepants). Rimegepant, a second-generation gepant, has shown efficacy in several clinical trials in treating acute migraine. Ongoing trials are also evaluating its role in migraine prophylaxis, and results are promising. It is also generally safer for use than existing options, does not appear to increase the chance of developing chronic migraines, and carries a very tolerable side effects profile. It is a part of a growing arsenal in migraine treatment, and may present the silver bullet for treatment of this disease.
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Affiliation(s)
- Amnon A Berger
- Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School
| | - Ariel Winnick
- Soroka University Medical Center and Faculty of Health Sciences, Ben Gurion University of the Negev, University of California School of Optometry
| | | | | | | | - Marc Colon
- Department of Psychiatry, and Behavioral Medicine, Louisiana State University Health Science Center Shreveport
| | | | | | - Jamal Hasoon
- Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center
| | | | | | | | - Adam M Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Shreveport
| | - Latha Ganti
- University of Central Florida College of Medicine
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84
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Switzer MP, Robinson JE, Joyner KR, Morgan KW. Atogepant for the prevention of episodic migraine in adults. SAGE Open Med 2022; 10:20503121221128688. [PMID: 36226229 PMCID: PMC9549103 DOI: 10.1177/20503121221128688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 09/08/2022] [Indexed: 11/06/2022] Open
Abstract
Objective Atogepant is a newly approved medication for the prevention of migraine. This review aims to discuss the efficacy, safety, cost, and place in therapy of atogepant. Methods The authors performed a systematic search for sources, including articles, abstracts, and poster presentations. Queried databases were the National Institute of Health, US National Library of Medicine Clinical Trials, PubMed, European PMC, and the Cochrane Library. Search terms included atogepant, QULIPTA™, AGN-241689, MK-803, and N02CD07. Full-text, English language, randomized-controlled trials from 1 February 2012 to 1 February 2022 were included in the review. Additional relevant prescribing information, abstracts, and articles identified through the search were considered for inclusion in this review. A total of 193 database entries were evaluated for inclusion in this narrative review. Three articles representing two randomized controlled trials were reviewed. Results and conclusions Atogepant, a small-molecule calcitonin gene-related peptide (CGRP) receptor antagonist, is a daily oral treatment for migraine prevention. In placebo-controlled clinical trials, atogepant decreased mean monthly migraine days (MMD) over 12 weeks in patients with episodic migraine. Major treatment-related adverse effects include nausea and constipation. Long-term placebo-controlled efficacy and safety studies, chronic migraine studies, and studies in patients that failed more than two classes of preventive therapies are still pending. Atogepant represents one of many novel therapies for the prevention of migraine. To date, no head-to-head comparisons of atogepant versus other agents indicated for migraine prevention have been published. Atogepant offers patients an alternative therapy to injectable or infusion monoclonal antibody treatments and offers an alternative to non-specific migraine medications that are associated with poor tolerability. Due to its high cost and narrower therapeutic indications, atogepant may be reserved for a small subset of migraineurs who prefer oral therapy.
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Affiliation(s)
| | | | - Kayla Rena Joyner
- Department of Pharmacy Practice, Bernard J. Dunn School of Pharmacy, Shenandoah University, Winchester, VA, USA
- Valley Health Winchester Medical Center, Winchester, VA, USA
| | - Kelsey Woods Morgan
- Department of Pharmacy Practice, Bernard J. Dunn School of Pharmacy, Shenandoah University, Winchester, VA, USA
- Valley Health Winchester Medical Center, Winchester, VA, USA
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85
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Scuteri D, Tarsitano A, Tonin P, Bagetta G, Corasaniti MT. Focus on zavegepant: the first intranasal third-generation gepant. Pain Manag 2022; 12:879-885. [PMID: 36189708 DOI: 10.2217/pmt-2022-0054] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Migraine is the leading cause of years lived with disability in people under 50 and its burden is increased by calcitonin gene-related peptide (CGRP)-driven chronicity. Newly approved small molecules that antagonize the CGRP receptor, gepants, have advanced from the hepatotoxic first-generation telcagepant to third-generation intranasal zavegepant; during this process of drug development, rimegepant, ubrogepant and atogepant, which are orally administered, have been launched and approved for clinical use with no warning for hepatotoxicity. Real-world, long-term postmarketing data about the efficacy and safety of gepants are awaited. The aim of the present drug evaluation study was to provide an overview of the novel, third-generation intranasal Zavegepant, encompassing its development and future perspectives.
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Affiliation(s)
- Damiana Scuteri
- Department of Pharmacy, Pharmacotechnology Documentation & Transfer Unit, Preclinical & Translational Pharmacology, Health & Nutritional Sciences, University of Calabria, Rende, 87036, Italy.,Regional Center for Serious Brain Injuries, S. Anna Institute, Crotone, 88900, Italy
| | - Assunta Tarsitano
- Pain Therapy Center, Provincial Health Authority (ASP), Cosenza, 87100, Italy
| | - Paolo Tonin
- Regional Center for Serious Brain Injuries, S. Anna Institute, Crotone, 88900, Italy
| | - Giacinto Bagetta
- Department of Pharmacy, Pharmacotechnology Documentation & Transfer Unit, Preclinical & Translational Pharmacology, Health & Nutritional Sciences, University of Calabria, Rende, 87036, Italy
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Davis L, Torphy B. Managing migraine on the frontline: Identifying disease, understanding burden, and incorporating CGRP pathway-targeting therapies in primary care. Br J Pain 2022; 16:560-573. [PMID: 36389011 PMCID: PMC9644104 DOI: 10.1177/20494637221104292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023] Open
Abstract
Migraine is a common neurologic disorder with clinical phenotypes encompassing a variety of symptoms which all contribute to the burden felt by patients. In addition to negative impacts on a patient's quality of life, migraine has both direct medical costs and indirect costs related to missed work and decreased productivity that affect individuals as well as society at large. Unfortunately, migraine diagnoses are often missed, and many patients do not receive appropriate treatment. Primary care providers are in a key position to provide timely diagnosis and effectively manage migraine for many patients. This review aims to be a guide for improving migraine management in the primary care setting by providing strategies to overcome common challenges in migraine diagnosis; summarizing current knowledge on the mechanism of action, efficacy, and safety of calcitonin gene-related peptide (CGRP) pathway-targeting therapies; and reviewing approaches to incorporate traditional and emerging treatment options into a patient-centric migraine management strategy.
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Affiliation(s)
- Linda Davis
- Kolvita Family Medical
Group, Mission Viejo, CA, USA
| | - Brad Torphy
- Chicago Headache Center and Research
Institute, Chicago, IL, USA
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87
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Patniyot I, Qubty W. Headache in Adolescents. Neurol Clin 2022; 41:177-192. [DOI: 10.1016/j.ncl.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Kung D, Rodriguez G, Evans R. Chronic Migraine. Neurol Clin 2022; 41:141-159. [DOI: 10.1016/j.ncl.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Calcitonin Gene-Related Peptide (CGRP) and Pituitary Adenylate Cyclase-Activating Polypeptide (PACAP) in Migraine Pathogenesis. Pharmaceuticals (Basel) 2022; 15:ph15101189. [PMID: 36297301 PMCID: PMC9612382 DOI: 10.3390/ph15101189] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 09/12/2022] [Accepted: 09/15/2022] [Indexed: 11/17/2022] Open
Abstract
Migraine is a prevalent and debilitating neurologic disorder. Advancements in understanding the underlying pathophysiological mechanisms are spearheading the effort to introduce disease-specific treatment options. In recent years this effort has largely focused on alteration of endogenous neuropeptide signaling, namely the peptides calcitonin gene-related peptide (CGRP) and pituitary adenylate cyclase-activating polypeptide (PACAP). Human studies into the pathophysiological underpinnings of CGRP and PACAP in migraine are manifold and here we review the works investigating these neuropeptides in patients suffering from migraine in order to elucidate the background for developing new treatment options for this vastly disabling disorder.
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90
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Johnson B, Freitag FG. New Approaches to Shifting the Migraine Treatment Paradigm. FRONTIERS IN PAIN RESEARCH 2022; 3:873179. [PMID: 36147034 PMCID: PMC9488522 DOI: 10.3389/fpain.2022.873179] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 06/21/2022] [Indexed: 11/13/2022] Open
Abstract
The standard of care paradigm for migraine treatment has been based almost exclusively on approaches that grew out of the happenstance use of market pharmaceuticals. Only methysergide, which has long since been removed from use for safety concerns, the ergotamine family of drugs, and the triptans were explicitly developed with migraine and other vascular headaches in mind. While the forward and innovative thinking to utilize the broad array of agents to treat migraine served millions well, their therapeutic efficacy was often low, and adverse event profiles were troublesome in the least. Advances in biochemical and molecular biology and the application of advanced "designing drugs" methods have brought about a potentially significant shift in treatment. The gepants have efficacies similar to the triptans but without vascular safety or medication overuse concerns. Preventative gepants offer innovative approaches to prevention and efficacy that exceed even the CGRP monoclonal antibodies. Those monoclonal antibodies brought rapid and highly effective outcomes across the spectrum of migraine. They outpaced older oral medication efficacy and eliminated most adverse events while potentially improving compliance with monthly or quarterly dosing. Other serotonin receptors beyond the 5HT1B and1D receptors have been targeted for decades. They now lead us to better formulations of dihydroergotamine for efficacy, convenience, and tolerability, and a 5HT1F-specific acute treatment like the gepants opens new options for acute management. Neuromodulation goes back to the mid-1800's. Our improved understanding of applied biomedical engineering has brought forward several tantalizing devices, including the application of currents distant from the target and patient regulated. Whether these advances change the paradigm of migraine treatment and standards of care remains to be seen, and issues such as cost and patient acceptance will help mold it.
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Affiliation(s)
| | - Frederick G. Freitag
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, United States
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91
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Murray AM, Stern JI, Robertson CE, Chiang CC. Real-World Patient Experience of CGRP-Targeting Therapy for Migraine: a Narrative Review. Curr Pain Headache Rep 2022; 26:783-794. [PMID: 36063264 DOI: 10.1007/s11916-022-01077-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW To summarize available calcitonin gene-related peptide (CGRP)-targeting therapies for migraine and discuss their use in real-world populations. BACKGROUND CGRP has long been a topic of interest in migraine pathophysiology, with new therapies targeting CGRP since 2018 for both the preventive and acute treatment of migraine. METHODS We searched PubMed using keywords including "migraine," "CGRP," "real-world," "erenumab," "galcanezumab," "fremanezumab," "eptinezumab," "ubrogepant," "rimegepant," and "atogepant." We reviewed all pertinent studies and summarized main findings. We also compiled detailed patient characteristics (e.g., migraine diagnoses, medication overuse, prior treatment failures) and treatment outcome measures, such as 50% responder rates, reduction in migraine days, and adverse event rates in several tables. Overall, studies reporting real-world patient experiences of CGRP-targeting therapies suggested meaningful effectiveness for migraine treatment with response rates comparable to the numbers reported in clinical trials. Furthermore, studies suggested benefit in patients with multiple prior unsuccessful treatment trials, medication overuse, and complex medical comorbidities. In some studies, adverse event rates have been notably higher than reported in clinical trials. Additional long-term data is needed to further evaluate sustained efficacy, predictors of treatment response, and adverse events.
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Affiliation(s)
- Ann M Murray
- Department of Neurology, Mayo Clinic, Rochester, MN, 55905, USA
| | | | | | - Chia-Chun Chiang
- Department of Neurology, Mayo Clinic, Rochester, MN, 55905, USA.
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McIlvried LA, Atherton MA, Horan NL, Goch TN, Scheff NN. Sensory Neurotransmitter Calcitonin Gene-Related Peptide Modulates Tumor Growth and Lymphocyte Infiltration in Oral Squamous Cell Carcinoma. Adv Biol (Weinh) 2022; 6:e2200019. [PMID: 35388989 PMCID: PMC9474661 DOI: 10.1002/adbi.202200019] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/15/2022] [Indexed: 01/28/2023]
Abstract
Head and neck squamous cell carcinoma are highly innervated by peripheral sensory neurons. Local neurotransmitter release (e.g., calcitonin gene-related peptide (CGRP)) from sensory neurons innervating cancer is linked to tumorigenesis. CGRP-immunoreactive nerve presence comprised 9.53±1.9% of total nerve area across 11 HNSCC patients. A syngeneic tongue tumor transplant mouse model of oral cancer and a global Calca knockout mouse (CGRPKO ) are used to investigate the impact of CGRP signaling on tumor growth and the associated immune response in vivo. In tumor-bearing CGRPKO mice, there is a significant reduction in tumor size over time compared to wildtype mice using two different mouse oral cancer cell lines. Furthermore, tumor tissue from CGRPKO mice had a significant increase in tumor-infiltrating CD4+ T cells, cytotoxic CD8+ T cells, and NK1.1+ NK cells compared to wildtype. Fluorescent-activated cell sorting and real-time qPCR are used to confirm that CD4+ T cells are isolated from tumor-bearing wildtype mice containing a high expression of Ramp1 compared to sham mice. These data suggest that sensory neurotransmitter CGRP may modulate oral cancer progression via tumor immunosurveillance. Understanding the relationship between sensory neurons and cancer will aid in repurposing clinically available nervous system drugs for the treatment of cancer.
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Affiliation(s)
- Lisa A McIlvried
- Department of Neurobiology, University of Pittsburgh, 4200 Fifth Ave, Pittsburgh, PA, 15260, USA
- Hillman Cancer Center, University of Pittsburgh Medical Center, 5117 Centre Ave, Pittsburgh, PA, 15213, USA
| | - Megan A Atherton
- Department of Neurobiology, University of Pittsburgh, 4200 Fifth Ave, Pittsburgh, PA, 15260, USA
- Hillman Cancer Center, University of Pittsburgh Medical Center, 5117 Centre Ave, Pittsburgh, PA, 15213, USA
| | - Nicole L Horan
- Department of Neurobiology, University of Pittsburgh, 4200 Fifth Ave, Pittsburgh, PA, 15260, USA
| | - Tori N Goch
- Hillman Cancer Center, University of Pittsburgh Medical Center, 5117 Centre Ave, Pittsburgh, PA, 15213, USA
| | - Nicole N Scheff
- Department of Neurobiology, University of Pittsburgh, 4200 Fifth Ave, Pittsburgh, PA, 15260, USA
- Hillman Cancer Center, University of Pittsburgh Medical Center, 5117 Centre Ave, Pittsburgh, PA, 15213, USA
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Daniel O, Tepper SJ, Deutsch L, Sharon R. External Concurrent Occipital and Trigeminal Neurostimulation Relieves Migraine Headache: A Prospective, Randomized, Double-Blind, Sham-Controlled Trial. Pain Ther 2022; 11:907-922. [PMID: 35661128 PMCID: PMC9314547 DOI: 10.1007/s40122-022-00394-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 05/05/2022] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Current external peripheral nerve stimulation devices stimulate only one nerve. This prospective, randomized, double-blind, sham-controlled trial assessed efficacy, safety, and tolerability of a novel external combined occipital and trigeminal neurostimulation (eCOT-NS) device as a self-administered home treatment for migraine (Relivion®MG, Neurolief Ltd; Netanya, Israel). METHODS Episodic and chronic migraine subjects (N = 55) were randomized to receive active (n = 27) or sham (n = 28) treatment. Subjects received eCOT-NS devices and performed 60 ± 20-min home treatments within 45 min of migraine episode onset. The primary endpoint was relative (percent) change in mean baseline VAS pain scores 1 h after treatment initiation. Treatment outcomes assessed at 1-, 2-, and 24-h post-treatment initiation were pain reduction and proportion of pain-free subjects and treatment responders, defined as ≥ 50% pain reduction. Categorical pain ratings (none, mild, moderate, and severe pain) were also analyzed. RESULTS Active stimulation was significantly more effective than sham stimulation for decreasing pain intensity at 1 h (53% vs. 10%), 2 h (52% vs. 17%), and 24 h (71% vs. 34%). Pain-free ratings were greater for the active treatment arm at 1 h (29.2% vs. 16%), 2 h (41.7% vs. 20%), and 24 h (65.2% vs. 40%). The number of subjects with baseline moderate or severe migraine pain who were pain-free at 2 h was significantly greater among active treatment subjects (43% vs. 10.5%). The responder rate was significantly higher among the active treatment group at 1 h (67% vs. 20%), 2 h (66.7% vs. 32%,), and 24 h (78.3% vs. 48%). Overall headache relief was significantly higher in the active treatment group at 1 h (67% vs. 26%) and 2 h (76% vs. 31.6%). Mild adverse events, reported by a minority of subjects, resolved spontaneously. CONCLUSIONS eCOT-NS provides superior clinically meaningful relief and freedom from migraine pain, offering an effective and safe therapy for acute treatment of migraine. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT03398668.
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Affiliation(s)
- Oved Daniel
- Headache and Facial Pain Clinic, Ramat-Aviv Medical Center, Tel-Aviv, Israel
| | - Stewart J. Tepper
- Geisel School of Medicine at Dartmouth, Hanover, NH USA ,Dartmouth Headache Center, Department of Neurology, Dartmouth-Hitchcock Medical Center, Lebanon, NH USA
| | - Lisa Deutsch
- BioStats Statistical Consulting, Ltd, Modiin, Israel
| | - Roni Sharon
- Tel-Aviv University Sackler School of Medicine, Tel-Aviv, Israel ,Department of Neurology, Chaim Sheba (Tel HaShomer) Medical Center, Ramat Gan, Israel
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94
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Altamura C, Brunelli N, Marcosano M, Fofi L, Vernieri F. Gepants - a long way to cure: a narrative review. Neurol Sci 2022; 43:5697-5708. [PMID: 35650458 PMCID: PMC9159895 DOI: 10.1007/s10072-022-06184-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 05/28/2022] [Indexed: 01/01/2023]
Abstract
Calcitonin gene-related peptide (CGRP) is probably the most potent vasodilator in cerebral circulation. Forty years after its discovery, the new CGRP-targeted therapy monoclonal antibodies, and the small molecule gepants, are now available for clinical practice. While randomized controlled trials and real-world experience consistently demonstrated the high efficacy and tolerability of monoclonal antibodies, limited evidence is available to characterize gepants fully. Depending on pharmacokinetics, these CGRP receptor antagonists can be used for acute (ubrogepant, rimegepant, and the not yet approved zavegepant) or preventive (atogepant and rimegepant) migraine treatment. Randomized placebo-controlled trials demonstrated gepants efficacy in treating acute attacks to obtain 2 h pain freedom in about 20% of patients and pain relief in about 60%, while up to 60% of treated patients with episodic migraine may experience a 50% reduction in monthly migraine days. The most common treatment-related emergent adverse events were gastrointestinal (nausea, constipation) for the acute or preventive use. No vascular or hepatic concerns have emerged so far. More studies are ongoing to investigate gepant tolerability and safety also if associated with monoclonal antibodies targeting CGRP and other therapeutic classes. Gepants are also under investigation to treat other painful and non-painful conditions. Real-life studies are necessary to confirm the trials’ findings and investigate more practical clinical aspects.
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Affiliation(s)
- Claudia Altamura
- Headache and Neurosonology Unit, Neurology, Fondazione Policlinico Universitario Campus Bio-Medico Di Roma, 00128, Rome, Italy.
| | - Nicoletta Brunelli
- Headache and Neurosonology Unit, Neurology, Fondazione Policlinico Universitario Campus Bio-Medico Di Roma, 00128, Rome, Italy
| | - Marilena Marcosano
- Headache and Neurosonology Unit, Neurology, Fondazione Policlinico Universitario Campus Bio-Medico Di Roma, 00128, Rome, Italy
| | - Luisa Fofi
- Headache and Neurosonology Unit, Neurology, Fondazione Policlinico Universitario Campus Bio-Medico Di Roma, 00128, Rome, Italy
| | - Fabrizio Vernieri
- Headache and Neurosonology Unit, Neurology, Fondazione Policlinico Universitario Campus Bio-Medico Di Roma, 00128, Rome, Italy
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Ogunlaja OI, Goadsby PJ. Headache: Treatment update. eNeurologicalSci 2022; 29:100420. [PMID: 36636337 PMCID: PMC9830470 DOI: 10.1016/j.ensci.2022.100420] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 08/10/2022] [Indexed: 01/16/2023] Open
Abstract
Primary headache disorders in particular migraine are one of the most common causes of disability worldwide. Given the high burden of migraine in terms of disability, there has been an effort to develop migraine specific therapies that has led to the availability of new drugs including 5HT1F receptor agonists-ditans (lasmiditan), small molecule calcitonin gene-related peptide (CGRP) receptor antagonists-gepants: (ubrogepant, rimegepant, atogepant) and anti-CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab and eptinezumab). However, some of these treatments incur a high cost and may not be a feasible option for most patients in resource limited settings. Lasmiditan and the gepants are a good option for patients with moderate-severe migraine attacks who cannot use triptans due variously to poor tolerability, or cardio- or cerebrovascular disease. For practical purposes, the new anti-CGRP monoclonal antibodies are best reserved for patients who have failed to have efficacy or had intolerable side effects from multiple traditional oral preventives.
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Affiliation(s)
- Oyindamola I. Ogunlaja
- NIHR King's Clinical Research Facility and SLaM Biomedical Research Centre, King's College London, UK
| | - Peter J. Goadsby
- NIHR King's Clinical Research Facility and SLaM Biomedical Research Centre, King's College London, UK,Department of Neurology, University of California, Los Angeles, CA, USA,Corresponding author at: Wellcome Foundation Building, King's College Hospital, London SE5 9PJ, UK.
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96
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Chiang CC, Halker Singh RB. Acute Treatment of Headache (Focus on Migraine). Semin Neurol 2022; 42:494-502. [DOI: 10.1055/s-0042-1757926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractAcute treatments for migraine and cluster headache are necessary to abort attacks, relieve pain and associated symptoms, and restore an individual's ability to function. Acute headache treatments consist of a variety of medication and nonmedication options. In this article, we discuss the approach to acute treatment of migraine and cluster headache. We summarize the level of evidence to support each acute medication class according to recent systematic reviews and meta-analyses, as well as guideline recommendations from the American Headache Society, American Academy of Neurology, and European Federation of Neurological Society.
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97
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Chen ST, Wu JW. CGRP-Targeted Therapy for Episodic and Chronic Cluster Headache. Curr Pain Headache Rep 2022; 26:667-675. [PMID: 35881279 DOI: 10.1007/s11916-022-01070-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Chronic cluster headache (CH) substantially affects patients' quality of life, and treatment remains challenging. The current article reviewed controlled studies for new treatment options targeting calcitonin gene-related peptide (CGRP) or its receptors in CH and discussed the current gaps and future directions for the treatment of chronic CH. RECENT FINDINGS Two anti-CGRP monoclonal antibodies (i.e., galcanezumab and fremanezumab) completed randomized-control trials for efficacy for the preventive treatment of episodic and chronic CH. Galcanezumab was effective for preventing episodic CH but not chronic CH. Fremanezumab was ineffective in preventing episodic and chronic CH. Studies for other anti-CGRP monoclonal antibodies and CGRP antagonists are still pending for results. There are no randomized controlled trials for CGRP-targeted therapies that showed efficacy for chronic CH prevention. The different responses to galcanezumab between episodic and chronic CH may be due to the study design, i.e., the allowance of concomitant preventive therapies in the chronic CH study but not in the episodic CH study. Another reason for the discrepancies is the different roles and sensitivity of CGRP in chronic CH.
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Affiliation(s)
- Shu-Ting Chen
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jr-Wei Wu
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Rd, Taipei, Taiwan, 11217. .,College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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98
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Basedau H, Oppermann T, Gundelwein Silva E, Peng KP, May A. Galcanezumab modulates Capsaicin-induced C-fiber reactivity. Cephalalgia 2022; 42:1331-1338. [PMID: 35796521 PMCID: PMC9638712 DOI: 10.1177/03331024221112906] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background The vasodilatory calcitonin-gene related peptide (CGRP) is understood as
pivotal mediator in migraine pathophysiology. Blocking CGRP with small
molecules or monoclonal antibodies (CGRP-mAb) reduces migraine frequency.
However, prescription of CGRP-mAbs is still regulated and possible
predictive measures of therapeutic success would be useful. Methods Using standardized capsaicin-induced dermal blood flow model, 29 migraine
patients underwent a laser speckle imaging measurement before and after
administration of galcanezumab. At both sessions dermal blood flow before
and after capsaicin stimulation as well as flare size were analyzed over all
three trigeminal branches and the volar forearm for extracranial control.
Long-term measures were repeated in 14 patients after continuous treatment
ranging from 6 to 12 months. Results Resting dermal blood flow remained unchanged after administration of
galcanezumab. Capsaicin-induced dermal blood flow decreased significantly
after CGRP-mAb in all tested areas compared to baseline and this was
consistent even after 12 months of treatment. However, following
galcanezumab administration, the flare size decreased only in the three
trigeminal dermatomes, not the arm and was therefore specific for the
trigemino-vascular system. None of these two markers distinguished between
responders and non-responders. Conclusion CGRP-mAb changed blood flow response to capsaicin stimulation profoundly and
this effect did not change over a 12-month application. Neither
capsaicin-induced flare nor dermal blood flow can be used as a predictor for
treatment efficacy. These data suggest that the mechanism of headache
development in migraine is not entirely CGRP-mediated.
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Affiliation(s)
- Hauke Basedau
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thalea Oppermann
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Elisa Gundelwein Silva
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kuan-Po Peng
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Arne May
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Polavieja P, Belger M, Venkata SK, Wilhelm S, Johansson E. Relative efficacy of lasmiditan versus rimegepant and ubrogepant as acute treatments for migraine: network meta-analysis findings. J Headache Pain 2022; 23:76. [PMID: 35790906 PMCID: PMC9258126 DOI: 10.1186/s10194-022-01440-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 06/04/2022] [Indexed: 11/18/2022] Open
Abstract
Background In the absence of head-to-head trials, comprehensive evidence comparing onset of efficacy of novel agents for acute treatment of migraine is lacking. This study aimed to explore the relative efficacy of lasmiditan (serotonin [5-hydroxytryptamine] 1F receptor agonist) versus rimegepant and ubrogepant (calcitonin gene-related peptide antagonists) for the acute oral treatment of migraine through network meta-analysis (NMA). Methods Data included in the NMA were identified through a systematic literature search (conducted April 2018, updated May/December 2020) of phase II–IV, randomised controlled trials (RCTs) in adults with chronic/episodic migraine with/without aura. Treatments included: lasmiditan 50, 100, 200 mg; rimegepant 75 mg; ubrogepant 25, 50, 100 mg. Pairwise treatment comparisons from Bayesian fixed-effect/random-effects NMA, adjusted by baseline risk where appropriate, were conducted. Comparisons were reported as odds ratios with 95% credible intervals. Early-onset efficacy endpoints included: pain freedom at 2 hours and pain relief at 1 and 2 hours. Adverse drug reaction (ADR) profiles were summarised. Heterogeneity and inconsistency in the network were explored; sensitivity analyses investigated robustness of findings. Results Across 12 RCTs included in the base case, females represented >80% of included patients (mean age 37.9–45.7 years). Odds of achieving both pain freedom and pain relief at 2 hours were higher with lasmiditan 100 and 200 mg versus rimegepant 75 mg and ubrogepant 25 and 50 mg. Results for pain relief at 1 hour were consistent with those at 2 hours, but fewer comparisons were available. There were no statistically significant differences between lasmiditan 50 mg and ubrogepant or rimegepant for any outcome. Sensitivity analyses were in the same direction as base case analyses. Most commonly reported ADRs (incidence ≥2%) were: dizziness, fatigue, paraesthesia, sedation, nausea/vomiting and muscle weakness with lasmiditan; nausea with rimegepant; and nausea, somnolence and dry mouth with ubrogepant. Conclusions The efficacy findings of this indirect comparison indicate that lasmiditan 100 mg or 200 mg might be an appropriate acute treatment option for patients with migraine seeking a fast onset of action. Differently from rimegepant and ubrogepant, lasmiditan use is associated with mainly neurological events, which are mostly mild or moderate in severity and self-limiting. 350/350 words Supplementary Information The online version contains supplementary material available at 10.1186/s10194-022-01440-w.
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Affiliation(s)
- Pepa Polavieja
- Eli Lilly and Company, Indianapolis, Indiana, USA. .,, Avenida de la Industria 30, 28108, Alcobendas, Madrid, Spain.
| | - Mark Belger
- Eli Lilly and Company, Indianapolis, Indiana, USA
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100
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Robblee J, Harvey LK. Cardiovascular Disease and Migraine: Are the New Treatments Safe? Curr Pain Headache Rep 2022; 26:647-655. [PMID: 35751798 DOI: 10.1007/s11916-022-01064-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW The authors present data on cardiovascular safety for the new acute and preventive migraine treatments including ditans, gepants, and calcitonin gene-related peptide monoclonal antibodies (CGRP mAbs) alongside older medications like triptans and ergotamines. RECENT FINDINGS The authors conclude that there are no cardiovascular safety concerns for lasmiditan, and that it could be used in those with cardiovascular disease. In fact, the literature even suggests that triptans are safer in cardiovascular disease than their contraindications may suggest. At this time, there is insufficient evidence that gepants and CGRP mAbs should be contraindicated in those with cardiovascular disease including stroke or myocardial infarction, though erenumab has now been associated with hypertension. Vasodilation may be an important CGRP-mediated mechanism mid-ischemia especially in patients with small vessel disease; hence, CGRP antagonists should be use with caution in this context. Long-term data is still needed, and prescribers should ensure patients are aware of the limitations of our knowledge at this time, while still offering these effective and well-tolerated treatment options.
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Affiliation(s)
- Jennifer Robblee
- Lewis Headache Center, Department of Neurology, Barrow Neurological Institute
- St Joseph Health Center, 350 W. Thomas Rd, AZ, 85013, Phoenix, USA.
| | - Lauren K Harvey
- Lewis Headache Center, Department of Neurology, Barrow Neurological Institute
- St Joseph Health Center, 350 W. Thomas Rd, AZ, 85013, Phoenix, USA
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