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Dodick DW, Lipton RB, Ailani J, Halker Singh RB, Shewale AR, Zhao S, Trugman JM, Yu SY, Viswanathan HN. Ubrogepant, an Acute Treatment for Migraine, Improved Patient-Reported Functional Disability and Satisfaction in 2 Single-Attack Phase 3 Randomized Trials, ACHIEVE I and II. Headache 2020; 60:686-700. [PMID: 32073660 PMCID: PMC7155006 DOI: 10.1111/head.13766] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/14/2020] [Accepted: 01/15/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To evaluate the efficacy of ubrogepant on patient-reported functional disability, satisfaction with study medication, and global impression of change. BACKGROUND Ubrogepant is a small-molecule, oral calcitonin gene-related peptide receptor antagonist indicated for the acute treatment of migraine. In 2 phase 3 trials (ACHIEVE I and II), ubrogepant demonstrated efficacy vs placebo on the 2 co-primary endpoints of headache pain freedom and absence of the most bothersome migraine-associated symptom at 2 hours post dose for the 50 and 100 mg doses. Patient-reported outcomes, such as functional disability, satisfaction, and patient global impression of change, can provide additional evidence of the efficacy of an acute treatment for migraine on clinically meaningful and patient-relevant outcomes. METHODS ACHIEVE I and ACHIEVE II were multicenter, randomized, double-blind, placebo-controlled, parallel-group, single-attack trials in adults (18-75 years) with migraine. In ACHIEVE I, participants were randomized 1:1:1 to placebo or ubrogepant 50 or 100 mg; in ACHIEVE II, participants were randomized 1:1:1 to placebo or ubrogepant 25 or 50 mg to treat a migraine attack with moderate or severe headache pain. Participants rated ability to perform daily activities on the Functional Disability Scale, before dosing and at 1, 2, 4, and 8 hours after the initial dose; satisfaction with study medication at 2 and 24 hours; and impression of overall change in migraine on the Patient Global Impression of Change scale at 2 hours. In prespecified analyses for each trial, each outcome was compared between each ubrogepant dose group and the relevant placebo group. Data were pooled from the ubrogepant 50 mg and placebo groups of the 2 trials in a post hoc analysis. RESULTS In ACHIEVE I, 559 participants were randomized to placebo, 556 to ubrogepant 50 mg, and 557 to ubrogepant 100 mg; in ACHIEVE II, 563 were randomized to placebo, 561 to ubrogepant 25 mg, and 562 to ubrogepant 50 mg. At 2 hours post dose, significantly higher proportions of ubrogepant-treated participants vs placebo-treated participants reported being able to function normally (ACHIEVE I: ubrogepant 50 mg, 40.6% [171/421], P = .0012 vs placebo; ubrogepant 100 mg, 42.9% [192/448], P < .0001 vs placebo; placebo, 29.8% [136/456]; ACHIEVE II: ubrogepant 25 mg, 42.6% [185/434], P = .0015 vs placebo; ubrogepant 50 mg, 40.5% [188/464], P = .0118 vs placebo; placebo, 34.2% [156/456]; pooled 50 mg, 40.6% [359/885], vs pooled placebo, 32.0% [292/912]; P < .0001), were satisfied/extremely satisfied with study medication (ACHIEVE I: 50 mg, 36.3% [147/405], P < .0001 vs placebo; 100 mg, 35.8% [149/416], P = .0002 vs placebo; placebo, 24.1% [104/432]; ACHIEVE II: 25 mg, 35.1% [141/402], P = .0018 vs placebo; 50 mg, 37.8% [163/431], P < .0001 vs placebo; placebo, 24.8% [106/427]; pooled ubrogepant 50 mg, 37.1% [310/836], vs pooled placebo, 24.5% [210/859]; P < .0001), and indicated that their migraine was much/very much better on the Patient Global Impression of Change scale (ACHIEVE I: 50 mg, 34.4% [103/299], P = .0006 vs placebo; 100 mg, 34.3% [102/297], P = .0009 vs placebo; placebo, 22.0% [69/313]; ACHIEVE II: 25 mg, 34.1% [124/364], P < .0001 vs placebo; 50 mg, 33.4% [131/392], P = .0002 vs placebo; placebo, 20.7% [78/376]; pooled 50 mg, 33.9% [234/691], vs pooled placebo, 21.3% [147/689]; P < .0001). CONCLUSIONS A significantly higher proportion of participants treated with ubrogepant were able to function normally, were satisfied with the study medication, and reported clinically meaningful improvement compared with those receiving placebo. The results reinforce the potential benefits of ubrogepant on patient-centered outcomes in the acute treatment of migraine.
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Affiliation(s)
| | | | - Jessica Ailani
- MedStar Georgetown University Hospital, Washington, DC, USA
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Wattiez AS, Sowers LP, Russo AF. Calcitonin gene-related peptide (CGRP): role in migraine pathophysiology and therapeutic targeting. Expert Opin Ther Targets 2020; 24:91-100. [PMID: 32003253 DOI: 10.1080/14728222.2020.1724285] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: The neuropeptide calcitonin gene-related peptide (CGRP) is recognized as a critical player in migraine pathophysiology. Excitement has grown regarding CGRP because of the development and clinical testing of drugs targeting CGRP or its receptor. While these drugs alleviate migraine symptoms in half of the patients, the remaining unresponsive half of this population creates an impetus to address unanswered questions that exist in this field.Areas covered: We describe the role of CGRP in migraine pathophysiology and CGRP-targeted therapeutics currently under development and in use. We also discuss how a second CGRP receptor may provide a new therapeutic target.Expert opinion: CGRP-targeting drugs have shown a remarkable safety profile. We speculate that this may reflect the redundancy of peptides within the CGRP family and a second CGRP receptor that may compensate for reduced CGRP activity. Furthermore, we propose that an inherent safety feature of peptide-blocking antibodies is attributed to the fundamental nature of peptide release, which occurs as a large bolus in short bursts of volume transmission. These facts support the development of more refined CGRP therapeutic drugs, as well as drugs that target other neuropeptides. We believe that the future of migraine research is bright with exciting advances on the horizon.
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Affiliation(s)
- Anne-Sophie Wattiez
- Department of Physiology and Biophysics, University of Iowa, Iowa City, IA, USA.,VA Center for the Prevention and Treatment of Visual Loss, VA Medical Center, Iowa City, IA, USA
| | - Levi P Sowers
- Department of Physiology and Biophysics, University of Iowa, Iowa City, IA, USA.,VA Center for the Prevention and Treatment of Visual Loss, VA Medical Center, Iowa City, IA, USA
| | - Andrew F Russo
- Department of Physiology and Biophysics, University of Iowa, Iowa City, IA, USA.,VA Center for the Prevention and Treatment of Visual Loss, VA Medical Center, Iowa City, IA, USA.,Department of Neurology, University of Iowa, Iowa City, IA, USA
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53
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Arca K, Reynolds J, Sands KA, Shiue HJ. Calcitonin Gene-Related Peptide Antagonists for the Prevention of Migraine: Highlights From Pivotal Studies and the Clinical Relevance of This New Drug Class. Ann Pharmacother 2020; 54:795-803. [DOI: 10.1177/1060028020903417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Objective: To review the new drug class of calcitonin gene-related peptide antagonists (monoclonal antibodies) and their clinical relevance in migraine prophylaxis. Data Sources: A literature search was performed in PubMed (January 2009 to November 2019) using the terms migraine, calcitonin gene-related peptide (CGRP), erenumab, fremanezumab, and galcanezumab for clinical trials and studies. Study Selection and Data Extraction: Reports from human studies in English were evaluated for clinical evidence supporting pharmacology, efficacy, and adverse events. Initial pharmacokinetic and preclinical studies were excluded. Data Synthesis: In chronic and episodic migraine, prophylaxis with injections of monoclonal antibodies antagonizing CGRP reduced monthly migraine days with minimal clinically significant adverse events. In addition, there is evidence supporting efficacy in refractory migraine despite optimal prophylaxis. Relevance to Patient Care and Clinical Practice: This is the first target-specific migraine prophylaxis treatment to show efficacy with minimal adverse effects. A higher drug cost is a barrier but is balanced by improved quality of life. Current therapies have limited efficacy and tolerability because of poor side effect profiles. CGRP antagonists represent a shift to more precise migraine treatments. Conclusions: Monoclonal antibodies inhibiting CGRP are effective in migraine prophylaxis with minimal adverse effects. Targeting CGRP is a novel clinical strategy in managing migraine.
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Affiliation(s)
- Karissa Arca
- Department of Neurology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Jenna Reynolds
- Department of Pharmacy, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Kara A. Sands
- Department of Neurology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Harn J. Shiue
- Department of Pharmacy, Mayo Clinic Hospital, Phoenix, AZ, USA
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Dux M, Rosta J, Messlinger K. TRP Channels in the Focus of Trigeminal Nociceptor Sensitization Contributing to Primary Headaches. Int J Mol Sci 2020; 21:ijms21010342. [PMID: 31948011 PMCID: PMC6981722 DOI: 10.3390/ijms21010342] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 12/31/2019] [Accepted: 01/02/2020] [Indexed: 12/12/2022] Open
Abstract
Pain in trigeminal areas is driven by nociceptive trigeminal afferents. Transduction molecules, among them the nonspecific cation channels transient receptor potential vanilloid 1 (TRPV1) and ankyrin 1 (TRPA1), which are activated by endogenous and exogenous ligands, are expressed by a significant population of trigeminal nociceptors innervating meningeal tissues. Many of these nociceptors also contain vasoactive neuropeptides such as calcitonin gene-related peptide (CGRP) and substance P. Release of neuropeptides and other functional properties are frequently examined using the cell bodies of trigeminal neurons as models of their sensory endings. Pathophysiological conditions cause phosphorylation, increased expression and trafficking of transient receptor potential (TRP) channels, neuropeptides and other mediators, which accelerate activation of nociceptive pathways. Since nociceptor activation may be a significant pathophysiological mechanism involved in both peripheral and central sensitization of the trigeminal nociceptive pathway, its contribution to the pathophysiology of primary headaches is more than likely. Metabolic disorders and medication-induced painful states are frequently associated with TRP receptor activation and may increase the risk for primary headaches.
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Affiliation(s)
- Mária Dux
- Department of Physiology, University of Szeged, Dóm tér 10, H-6720 Szeged, Hungary;
- Correspondence: ; Tel.: +36-62-545-374; Fax: +36-62-545-842
| | - Judit Rosta
- Department of Physiology, University of Szeged, Dóm tér 10, H-6720 Szeged, Hungary;
| | - Karl Messlinger
- Institute of Physiology and Pathophysiology, Friedrich-Alexander-University Erlangen-Nürnberg, Universitätsstr. 17, D-91054 Erlangen, Germany;
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55
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Edvinsson L, Haanes KA. Views on migraine pathophysiology: Where does it start? ACTA ACUST UNITED AC 2019. [DOI: 10.1111/ncn3.12356] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Lars Edvinsson
- Department of Clinical Sciences Division of Experimental Vascular Research Lund University Lund Sweden
- Department of Clinical Experimental Research Glostrup Research Institute Rigshospitalet Glostrup Denmark
| | - Kristian Agmund Haanes
- Department of Clinical Experimental Research Glostrup Research Institute Rigshospitalet Glostrup Denmark
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Abstract
Migraine affects over a billion people worldwide in any year and is the second most common cause of years lost due to disability. Not "just a headache", morbidity washes though society and carries a substantial economic and social cost. Understanding of migraine pathophysiology has progressed significantly. Animal models and functional neuroimaging have yielded significant insight into brain structures that mediate migraine symptoms. The role of small peptides as neurotransmitters within this network has been elucidated, allowing the generation of novel therapeutic approaches that have been validated by randomised placebo-controlled trials. Migraine is underdiagnosed and undertreated. Treatment of migraine should be proactive. An acute and, when indicated, preventive strategy should be formulated with the patient. Comorbid medication overuse must be supportively managed. Migraine-specific medications are making their way from bench to bedside. They promise an improved safety profile and ease of use in comparison to older, repurposed medications. Devices promise a non-drug alternative should patients prefer. The migraine understanding and treatment landscape is changing rapidly.
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Warfvinge K, Edvinsson L. Cellular distribution of PACAP-38 and PACAP receptors in the rat brain: Relation to migraine activated regions. Cephalalgia 2019; 40:527-542. [DOI: 10.1177/0333102419893962] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Pituitary adenylate cyclase-activating polypeptide (PACAP) occurs as either a 27- or 38-amino acid neuropeptide and belongs to the vasoactive intestinal polypeptide/glucagon/secretin family of peptides. PACAP and vasoactive intestinal polypeptide have a 68% homology of their amino acid sequences and share three B-type G-protein coupled receptors: VPAC1, VPAC2 and PAC1 receptors. Methods/results The distribution of PACAP-38 and its receptors in the brain is only partly described in the literature. Here, we have performed a study to provide the more general picture of this system in rat brain in order to understand a putative role in primary headaches and partly in relation to the calcitonin gene-related peptide system. We observed a rich expression of PACAP-38 and PAC1 receptor immunoreactivity in many regions throughout the cerebrum, cerebellum and brainstem. The expression pattern points to multiple functions, not least associated with pain and reactions to pain. The expression of VPAC1 and VPAC2 receptor immunoreactivity was very sparse. In several regions such as the cerebral cortex, trigeminal nucleus caudalis, hypothalamus and pons there was a close relation to calcitonin gene-related peptide expression. Conclusion The findings suggest that the rich supply of PACAP-38 and PAC1 receptors is associated with basic functional responses in the central nervous system (CNS), and there are important close anatomical relations with calcitonin gene-related peptide in CNS regions associated with migraine pathophysiology.
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Affiliation(s)
- Karin Warfvinge
- Department of Clinical Experimental Research, Glostrup Research Institute, Rigshospitalet, Glostrup, Denmark
| | - Lars Edvinsson
- Department of Clinical Experimental Research, Glostrup Research Institute, Rigshospitalet, Glostrup, Denmark
- Division of Experimental Vascular Research, Department of Clinical Sciences, Lund University Hospital, Lund, Sweden
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Goadsby PJ, Tepper SJ, Watkins PB, Ayele G, Miceli R, Butler M, Severt L, Finnegan M, Szegedi A, Trugman JM, Jakate A. Safety and tolerability of ubrogepant following intermittent, high-frequency dosing: Randomized, placebo-controlled trial in healthy adults. Cephalalgia 2019; 39:1753-1761. [PMID: 31537107 PMCID: PMC6900570 DOI: 10.1177/0333102419869918] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/15/2019] [Accepted: 07/17/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Ubrogepant is a novel, oral calcitonin gene-related peptide (CGRP) receptor antagonist in development for the acute treatment of migraine. This trial evaluated the safety and tolerability of ubrogepant, focusing on hepatic safety, when administered intermittently with high-frequency dosing to healthy participants. METHODS In this phase 1, multicenter, double-blind, parallel-group trial, healthy adults (age 18-50 years) were randomized 1:1 to placebo or ubrogepant. Ubrogepant was dosed at 100 mg (2 × 50 mg tablets) on 2 consecutive days followed by 2 consecutive days of placebo, alternating for 8 weeks. Primary outcome measures were safety and tolerability. RESULTS Of participants randomized (n = 518), 516 were included in the safety population (n = 260 placebo; n = 256 ubrogepant). Treatment-emergent adverse events were reported in 45% of placebo and 44% of ubrogepant participants. The most common was headache (10% placebo; 11% ubrogepant). Overall, seven cases of alanine aminotransferase and/or aspartate aminotransferase levels ≥ 3 × the upper limit of normal (five placebo, two ubrogepant) were reported and adjudicated by a panel of independent liver experts blinded to treatment. Four cases were judged unlikely related to treatment. Two cases (one placebo, one ubrogepant) were judged possibly related, and one (ubrogepant) probably related. Alanine aminotransferase increases to ≥ 3 × the upper limit of normal in the two ubrogepant cases (possibly or probably related) were transient and resolved with continued dosing; both cases were asymptomatic, with no concurrent bilirubin elevation. CONCLUSION Ubrogepant was well tolerated following intermittent, high-frequency dosing in healthy participants, with no clinically relevant signal of hepatotoxicity. TRIAL REGISTRATION NA.
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Affiliation(s)
- Peter J Goadsby
- NIHR-Wellcome Trust King's Clinical
Research Facility, SLaM Biomedical Research Centre, King's College London, London,
UK
| | | | - Paul B Watkins
- Institute for Drug Safety Sciences,
University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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59
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Edvinsson L. The CGRP Pathway in Migraine as a Viable Target for Therapies. Headache 2019; 58 Suppl 1:33-47. [PMID: 29697153 DOI: 10.1111/head.13305] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 03/21/2018] [Accepted: 03/22/2018] [Indexed: 12/22/2022]
Abstract
The neuropeptide calcitonin gene-related peptide is well established as a key player in the pathogenesis of migraine. Clinical studies show calcitonin gene-related peptide levels correlate with migraine attacks, and decreases in this neuropeptide can indicate antimigraine therapy effectiveness. Research has revealed a wide distribution of expression sites for calcitonin gene-related peptide in the central and peripheral nervous system. Of these, the calcitonin gene-related peptide receptor, which binds calcitonin gene-related peptide with high affinity, has attracted growing interest as a viable target for antimigraine therapies. An incentive to pursue such research is the continuing unmet medical need of patients. Triptans have offered some clinical benefit, but many patients do not respond and these drugs have important safety considerations. Initial calcitonin gene-related peptide-focused research led to development of the "gepant" small-molecule calcitonin gene-related peptide receptor blockers. Positive efficacy reports concerning the gepants have been tempered by safety findings which led to the discontinuation of some of these agents. Currently, there is considerable excitement regarding monoclonal antibodies against calcitonin gene-related peptide (eptinezumab, galcanezumab, fremanezumab) and the calcitonin gene-related peptide receptor (erenumab). To date, these monoclonal antibodies have shown promising efficacy in clinical trials, with no major safety concerns. If ongoing long-term studies show that their efficacy can be maintained, this may herald a new era for effective antimigraine therapies.
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Affiliation(s)
- Lars Edvinsson
- Institute of Clinical Sciences, Lund University, Lund, Sweden
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60
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Ceriani CEJ, Wilhour DA, Silberstein SD. Novel Medications for the Treatment of Migraine. Headache 2019; 59:1597-1608. [PMID: 31559638 DOI: 10.1111/head.13661] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2019] [Indexed: 12/17/2023]
Abstract
OBJECTIVE To describe the new classes of medication for headache management and their roles in clinical practice. BACKGROUND Calcitonin gene-related peptide (CGRP) is a key component in the underlying pathophysiology of migraine. Research focused on targeting CGRP for headache treatment has led to the development of entirely new classes of medications - the gepants and the CGRP monoclonal antibodies (mAbs) - for both acute and preventive treatment. A third class, the ditans, is being developed to target the 5-HT1F receptor to provide acute treatment without vasoconstrictive effects. METHODS This article reviews the pathophysiology of migraine that has led to these new pharmacologic developments. Available information from randomized controlled trials, abstracts, press releases, and relevant preclinical studies is summarized for each class of medications. RESULTS At the time of this writing, one ditan has been submitted to the U.S. Food and Drug Administration (FDA) for approval. One gepant is anticipated to be submitted within the first quarter of 2019, and others are in clinical trials. Three CGRP mAbs have been FDA approved and are now available in clinical practice, and a fourth was submitted in the first quarter of 2019. CONCLUSIONS The development of new migraine-specific classes of medications provides more treatment options for both acute and preventive treatment of migraine.
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Affiliation(s)
- Claire E J Ceriani
- Jefferson Headache Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Danielle A Wilhour
- Jefferson Headache Center, Thomas Jefferson University, Philadelphia, PA, USA
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61
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Borkum JM. CGRP and Brain Functioning: Cautions for Migraine Treatment. Headache 2019; 59:1339-1357. [DOI: 10.1111/head.13591] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Jonathan M. Borkum
- Department of Psychology University of Maine Orono ME USA
- Health Psych Maine Waterville ME USA
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62
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Tiseo C, Ornello R, Pistoia F, Sacco S. How to integrate monoclonal antibodies targeting the calcitonin gene-related peptide or its receptor in daily clinical practice. J Headache Pain 2019; 20:49. [PMID: 31060490 PMCID: PMC6734464 DOI: 10.1186/s10194-019-1000-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 04/18/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Migraine is a major public health issue associated with significant morbidity, considerable negative impact on quality of life, and significant socioeconomic burden. Preventive treatments are required to reduce the occurrence and the severity of acute attacks and to minimize the use of abortive medications and the associate risk of drug-related adverse events, as well as the onset of medication-overuse headache and chronification of migraine. We performed a review of all available evidence on the safety and efficacy of monoclonal antibodies targeting the calcitonin gene-related peptide or its receptor for the preventive treatment of migraine to provide evidence-based guidance on their use in clinical practice. Monoclonal antibodies targeting the calcitonin gene-related peptide or its receptor are mechanism-specific drugs for the preventive treatment of migraine. Double-blind randomized clinical trials have shown that monoclonal antibodies targeting the calcitonin gene-related peptide or its receptor are effective across all the spectrum of migraine patients who require prevention and have a good safety and tolerability profile. Nevertheless, high costs limit the affordability of those drugs at the moment. CONCLUSIONS Specificity, long half-life, efficacy, tolerability, and ease of use make monoclonal antibodies targeting the calcitonin gene-related peptide or its receptor an appealing treatment option for migraine prevention. Optimal strategies to manage treatment over time still need to be clarified with real-life data.
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Affiliation(s)
- Cindy Tiseo
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, 67100 L’Aquila, Italy
| | - Raffaele Ornello
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, 67100 L’Aquila, Italy
| | - Francesca Pistoia
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, 67100 L’Aquila, Italy
| | - Simona Sacco
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, 67100 L’Aquila, Italy
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Abstract
OBJECTIVE The goal of this narrative review is to provide an overview of migraine pathophysiology, with an emphasis on the role of calcitonin gene-related peptide (CGRP) within the context of the trigeminovascular system. BACKGROUND Migraine is a prevalent and disabling neurological disease that is characterized in part by intense, throbbing, and unilateral headaches. Despite recent advances in understanding its pathophysiology, migraine still represents an unmet medical need, as it is often underrecognized and undertreated. Although CGRP has been known to play a pivotal role in migraine for the last 2 decades, this has now received more interest spurred by the early clinical successes of drugs that block CGRP signaling in the trigeminovascular system. DESIGN This narrative review presents an update on the role of CGRP within the trigeminovascular system. PubMed searches were used to find recent (ie, 2016 to November 2018) published articles presenting new study results. Review articles are also included not as primary references but to bring these to the attention of the reader. Original research is referenced in describing the core of the narrative, and review articles are used to support ancillary points. RESULTS The trigeminal ganglion neurons provide the connection between the periphery, stemming from the interface between the primary afferent fibers of the trigeminal ganglion and the meningeal vasculature and the central terminals in the trigeminal nucleus caudalis. The neuropeptide CGRP is abundant in trigeminal ganglion neurons, and is released from the peripheral nerve and central nerve terminals as well as being secreted within the trigeminal ganglion. Release of CGRP from the peripheral terminals initiates a cascade of events that include increased synthesis of nitric oxide and sensitization of the trigeminal nerves. Secreted CGRP in the trigeminal ganglion interacts with adjacent neurons and satellite glial cells to perpetuate peripheral sensitization, and can drive central sensitization of the second-order neurons. A shift in central sensitization from activity-dependent to activity-independent central sensitization may indicate a mechanism driving the progression of episodic migraine to chronic migraine. The pathophysiology of cluster headache is much more obscure than that of migraine, but emerging evidence suggests that it may also involve hypersensitivity of the trigeminovascular system. Ongoing clinical studies with therapies targeted at CGRP will provide additional, valuable insights into the pathophysiology of this disorder. CONCLUSIONS CGRP plays an essential role in the pathophysiology of migraine. Treatments that interfere with the functioning of CGRP in the peripheral trigeminal system are effective against migraine. Blocking sensitization of the trigeminal nerve by attenuating CGRP activity in the periphery may be sufficient to block a migraine attack. Additionally, the potential exists that this therapeutic strategy may also alleviate cluster headache as well.
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Affiliation(s)
- Smriti Iyengar
- Eli Lilly and CompanyIndianapolisINUSA
- Present address:
Indiana University School of MedicineIndianapolisINUSA
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64
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Farhangi M, Diel RJ, Buse DC, Huang AM, Levitt RC, Sarantopoulos CD, Felix ER, Galor A. Individuals with migraine have a different dry eye symptom profile than individuals without migraine. Br J Ophthalmol 2019; 104:260-264. [PMID: 31040130 DOI: 10.1136/bjophthalmol-2018-313471] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 03/28/2019] [Accepted: 04/03/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND Many individuals with migraine report symptoms of dry eye (DE). However, it is not known whether DE profiles are similar between individuals with and without migraine. To bridge this gap, we evaluated symptoms and signs of DE, including symptoms suggestive of nerve dysfunction, in a large group of individuals with DE symptoms, and compared profiles between individuals with migraine and those without migraine or headache. METHODS Prospective cross-sectional study of individuals with DE symptoms seen at the Miami VA. RESULTS Of 250 individuals, 31 met International Classification of Headache Disorders criteria for migraine based on a validated screen. Individuals with migraine were significantly younger (57 vs 62 years) and more likely to be female (26% vs 6%) than controls. Individuals with migraine had more severe DE symptoms and ocular pain compared with controls (mean Ocular Surface Disease Index 53.93 ± 21.76 vs 36.30 ± 22.90, p=0.0001; mean Neuropathic Pain Symptom Inventory modified for the Eye 39.39 ± 23.33 vs 21.86 ± 20.17, p=0.0001). The difference in symptom profile occurred despite similar ocular surface parameters between the groups. CONCLUSIONS Individuals with migraine had a different DE symptom yet a similar DE sign profile when compared with controls without migraine. This suggests that DE symptoms in individuals with migraine may be driven by nerve dysfunction as opposed to ocular surface abnormalities.
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Affiliation(s)
- Monika Farhangi
- Bascom Palmer Eye Institute, University of Miami, Miami, Florida, USA
| | - Ryan J Diel
- Department of Ophthalmology and Visual Sciences, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA
| | - Dawn C Buse
- Department of Neurology, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Roy C Levitt
- Department of Anesthesiology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | | | - Elizabeth R Felix
- Physical Medicine & Rehabilitation, University of Miami, Miami, Florida, USA.,Miami Veterans Administration Medical Center, Miami, Florida, USA
| | - Anat Galor
- Bascom Palmer Eye Institute, University of Miami, Miami, Florida, USA .,Miami Veterans Administration Medical Center, Miami, Florida, USA
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65
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Johnson KW, Morin SM, Wroblewski VJ, Johnson MP. Peripheral and central nervous system distribution of the CGRP neutralizing antibody [125I] galcanezumab in male rats. Cephalalgia 2019; 39:1241-1248. [DOI: 10.1177/0333102419844711] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Objective The objective of this investigation was to examine the distribution of galcanezumab and a control immunoglobulin 4 antibody containing the same constant regions as galcanezumab, into peripheral and central tissues. Methods Galcanezumab and a control immunoglobulin 4 antibody were radioiodinated with Iodine-125 to specific activities of 0.11 mCi/mg and 0.16 mCi/mg, respectively. At 24, 72, and 168 hours following subcutaneous injection of either antibody (4 mg/kg), cerebrospinal fluid and plasma were obtained followed by saline perfusion to remove residual blood and collection of selected tissues for determination of Iodine-125 content by gamma counting. Results The peak plasma levels of Iodine-125 galcanezumab and Iodine-125 control immunoglobulin 4 were observed at 72 hours and remained high at 168 hours post-dose. The rank order of tissue levels was dura mater = spleen > trigeminal ganglia ≫hypothalamus = spinal cord = prefrontal cortex = cerebellum. Iodine-125 galcanezumab levels in peripheral tissue (dura mater, spleen, and trigeminal ganglia) averaged 5% to 11% of plasma, whereas all of the central nervous system (CNS) tissue levels and the cerebrospinal fluid levels were < 0.4% of plasma. Distribution of the antibodies into the dura mater and the trigeminal ganglia was similar to that observed in the spleen and significantly greater than exposure in the brain or spinal cord. Conclusions The central levels of galcanezumab were relatively low, which would favor the dura mater and trigeminal ganglia as sites of action for its observed clinical efficacy. However, a central site of action cannot be excluded.
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Affiliation(s)
- Kirk W Johnson
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - S Michelle Morin
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - Victor J Wroblewski
- Indiana Biosciences Research Institute – Pharmaceutical Biotechnology Center, Indianapolis, IN, USA
| | - Michael P Johnson
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
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Favoni V, Giani L, Al-Hassany L, Asioli GM, Butera C, de Boer I, Guglielmetti M, Koniari C, Mavridis T, Vaikjärv M, Verhagen I, Verzina A, Zick B, Martelletti P, Sacco S. CGRP and migraine from a cardiovascular point of view: what do we expect from blocking CGRP? J Headache Pain 2019; 20:27. [PMID: 30866804 PMCID: PMC6734543 DOI: 10.1186/s10194-019-0979-y] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 02/26/2019] [Indexed: 12/14/2022] Open
Abstract
Calcitonin gene-related peptide (CGRP) is a neuropeptide with a pivotal role in the pathophysiology of migraine. Blockade of CGRP is a new therapeutic target for patients with migraine. CGRP and its receptors are distributed not only in the central and peripheral nervous system but also in the cardiovascular system, both in blood vessels and in the heart. We reviewed the current evidence on the role of CGRP in the cardiovascular system in order to understand the possible short- and long-term effect of CGRP blockade with monoclonal antibodies in migraineurs.In physiological conditions, CGRP has important vasodilating effects and is thought to protect organs from ischemia. Despite the aforementioned cardiovascular implication, preventive treatment with CGRP antibodies has shown no relevant cardiovascular side effects. Results from long-term trials and from real life are now needed.
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Affiliation(s)
- Valentina Favoni
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Via Altura, 3 Pad. G, 40139 Bologna, Italy
| | - Luca Giani
- Ricovero Ferdinando Uboldi, Paderno Dugnano, Italy
| | - Linda Al-Hassany
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Gian Maria Asioli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Via Altura, 3 Pad. G, 40139 Bologna, Italy
| | - Calogera Butera
- Dipartimento Neurologico e INSPE, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Irene de Boer
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Martina Guglielmetti
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
- Regional Referral Headache Center, Sant’Andrea Hospital, Rome, Italy
- Department of Clinical Pathology, University of Sassari, Sassari, Italy
| | - Chrysoula Koniari
- 1st Neurology Department, Aeginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodoros Mavridis
- 1st Neurology Department, Aeginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Marge Vaikjärv
- Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Iris Verhagen
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Angela Verzina
- Neurology Clinic, University of Perugia, Perugia, Italy
- S. Maria della Misericordia Hospital, Perugia, Italy
| | - Bart Zick
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
- Regional Referral Headache Center, Sant’Andrea Hospital, Rome, Italy
| | - Simona Sacco
- UOC Neurologia e Stroke Unit, Ospedale SS Filippo e Nicola, Avezzano, Italy
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, L’Aquila, Italy
| | - European Headache Federation School of Advanced Studies (EHF-SAS)
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Via Altura, 3 Pad. G, 40139 Bologna, Italy
- Ricovero Ferdinando Uboldi, Paderno Dugnano, Italy
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
- Dipartimento Neurologico e INSPE, IRCCS Ospedale San Raffaele, Milan, Italy
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
- Regional Referral Headache Center, Sant’Andrea Hospital, Rome, Italy
- Department of Clinical Pathology, University of Sassari, Sassari, Italy
- 1st Neurology Department, Aeginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Faculty of Medicine, University of Tartu, Tartu, Estonia
- Neurology Clinic, University of Perugia, Perugia, Italy
- S. Maria della Misericordia Hospital, Perugia, Italy
- UOC Neurologia e Stroke Unit, Ospedale SS Filippo e Nicola, Avezzano, Italy
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, L’Aquila, Italy
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Szperka CL, VanderPluym J, Orr SL, Oakley CB, Qubty W, Patniyot I, Lagman-Bartolome AM, Morris C, Gautreaux J, Victorio MC, Hagler S, Narula S, Candee MS, Cleves-Bayon C, Rao R, Fryer RH, Bicknese AR, Yonker M, Hershey AD, Powers SW, Goadsby PJ, Gelfand AA. Recommendations on the Use of Anti-CGRP Monoclonal Antibodies in Children and Adolescents. Headache 2018; 58:1658-1669. [PMID: 30324723 DOI: 10.1111/head.13414] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Christina L Szperka
- Division of Neurology, Children's Hospital of Philadelphia & Departments of Neurology & Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Serena L Orr
- Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | | | | | | | - Cynthia Morris
- Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Jessica Gautreaux
- Lousiana State University Health Science Center and Children's Hospital New Orleans, New Orleans, LA, USA
| | | | | | - Sona Narula
- Division of Neurology, Children's Hospital of Philadelphia & Departments of Neurology & Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Meghan S Candee
- University of Utah, Primary Children's Hospital, Salt Lake City, UT, USA
| | | | - Rashmi Rao
- Lousiana State University Health Science Center and Children's Hospital New Orleans, New Orleans, LA, USA
| | | | - Alma R Bicknese
- Feinberg School of Medicine at Northwestern University & Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | | | - Andrew D Hershey
- Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Scott W Powers
- Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Lee MJ, Lee SY, Cho S, Kang ES, Chung CS. Feasibility of serum CGRP measurement as a biomarker of chronic migraine: a critical reappraisal. J Headache Pain 2018; 19:53. [PMID: 30006780 PMCID: PMC6045522 DOI: 10.1186/s10194-018-0883-x] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 07/02/2018] [Indexed: 11/11/2022] Open
Abstract
Background Calcitonin gene-related peptide (CGRP) has been reported as elevated in chronic migraine. We aimed to validate the role of interictal serum CGRP concentration in peripheral blood samples as a biomarker of chronic migraine. Methods We prospectively recruited patients with episodic and chronic migraine and normal controls (NCs) in the Samsung Medical Center between August 2015 and May 2016. Blood samples were collected interictally from antecubital veins per prespecified protocol. Serum CGRP measurement was performed in the central laboratory by a single experienced technician blinded to clinical information. Migraine subtype, headache days in the previous month, and the presence and characteristics of headache at ±2 days of measurement were evaluated at every visit. Results A total of 156 migraineurs (106 episodic and 50 chronic) and 27 NCs were recruited in this study. Compared to NCs (75.7 ± 20.07 pg/mL) and patients with episodic migraine (67.0 ± 20.70 pg/mL), patients with chronic migraine did not show an interictal elevation of serum CGRP levels (64.9 ± 15.32 pg/mL). Serum CGRP concentration was not associated with headache status (ictal vs. interictal), migraine subtype (migraine with vs. without aura), use of preventive or acute medications, and comorbid medication overuse. Higher serum CGRP concentration did not predict treatment response in patients with chronic migraine. Conclusions Serum CGRP concentration may not be a feasible biomarker for chronic migraine. Further validation is necessary before CGRP can be used in the clinical practice. Electronic supplementary material The online version of this article (10.1186/s10194-018-0883-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mi Ji Lee
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, South Korea
| | - Sook-Yeon Lee
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Soohyun Cho
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, South Korea
| | - Eun-Suk Kang
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Chin-Sang Chung
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, South Korea. .,Neuroscience Center, Samsung Medical Center, Seoul, South Korea.
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69
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De Logu F, Nassini R, Landini L, Geppetti P. Pathways of CGRP Release from Primary Sensory Neurons. Handb Exp Pharmacol 2018; 255:65-84. [PMID: 29980913 DOI: 10.1007/164_2018_145] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The benefit reported in a variety of clinical trials by a series of small molecule antagonists for the calcitonin gene-related peptide (CGRP) receptor, or four monoclonal antibodies against the neuropeptide or its receptor, has underscored the release of CGRP from terminals of primary sensory neurons, including trigeminal neurons, as one of the major mechanisms of migraine headaches. A large variety of excitatory ion channels and receptors have been reported to elicit CGRP release, thus proposing these agonists as migraine-provoking agents. On the other side, activators of inhibitory channels and receptors may be regarded as potential antimigraine agents. The knowledge of the intracellular pathways underlying the exocytotic process that results in CGRP secretion or its inhibition is, therefore, of importance for understanding how migraine pain originates and how to treat the disease.
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Affiliation(s)
- Francesco De Logu
- Department of Health Sciences, Section of Clinical Pharmacology and Oncology, Headache Center, University of Florence, Florence, Italy
| | - Romina Nassini
- Department of Health Sciences, Section of Clinical Pharmacology and Oncology, Headache Center, University of Florence, Florence, Italy
| | - Lorenzo Landini
- Department of Health Sciences, Section of Clinical Pharmacology and Oncology, Headache Center, University of Florence, Florence, Italy
| | - Pierangelo Geppetti
- Department of Health Sciences, Section of Clinical Pharmacology and Oncology, Headache Center, University of Florence, Florence, Italy.
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