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Pellesi L, De Icco R, Al-Karagholi MAM, Ashina M. Reducing Episodic Cluster Headaches: Focus on Galcanezumab. J Pain Res 2020; 13:1591-1599. [PMID: 32753938 PMCID: PMC7342329 DOI: 10.2147/jpr.s222604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 06/08/2020] [Indexed: 12/20/2022] Open
Abstract
The involvement of calcitonin gene-related peptide in migraine and cluster headache has led to the recent development of new therapies. Galcanezumab, a novel monoclonal antibody targeting the calcitonin gene-related peptide, is approved for the migraine prevention and has recently been tested for the prevention of cluster headache. Two clinical trials have been conducted to investigate the efficacy and safety of galcanezumab in episodic cluster headache and chronic cluster headache. While efficacy endpoints were not met in the chronic subtype, galcanezumab reduced the weekly frequency of attacks in patients with episodic cluster headaches. In both studies, the antibody was well tolerated. This review summarizes and critically reviews the available data regarding the rationale behind targeting the calcitonin gene-related peptide with galcanezumab for the prevention of cluster headache.
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Affiliation(s)
- Lanfranco Pellesi
- Danish Headache Center, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Roberto De Icco
- Headache Science Center, IRCCS Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | | | - Messoud Ashina
- Danish Headache Center, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Danish Headache Knowledge Center, Rigshospitalet Glostrup, Glostrup, Denmark
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Giani L, Proietti Cecchini A, Leone M. Galcanezumab for the prevention of cluster headache. Expert Opin Biol Ther 2020; 20:1133-1142. [PMID: 32702245 DOI: 10.1080/14712598.2020.1800635] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Cluster headache (CH) is among the worst painful conditions. The available therapies are scarce and not specific, leaving many patients unsatisfied because of poor efficacy and/or tolerability. Patients not responding to common treatments are offered semi-invasive and invasive procedures with uncertain results. Based on the current understanding of CH pathophysiology, new possible therapeutic approaches come from drugs interfering with Calcitonin Gene Related Peptide (CGRP). AREAS COVERED After summarizing the evidence for CGRP involvement in CH pathophysiology, we review the published literature (PubMed) and information (clinicaltrials.gov, EudraCT, EMA and FDA websites) regarding a novel anti-CGRP monoclonal antibody, Galcanezumab, its pharmacological properties, development, and evidence for the treatment of CH. Publications regarding other indications (migraine) are considered for completeness and safety/tolerability profile. EXPERT OPINION In one randomized clinical trial, Galcanezumab has proven to be effective and safe as a preventive treatment in episodic CH, with a favorable tolerability profile offering a potential new option in the therapeutic arsenal. Inefficacy of galcanezumab in chronic CH as well as the inefficacy of another monoclonal antibody against CGRP (fremanezumab) in both episodic and chronic CH question the scalability of the drug in CH management. Further, studies comparing galcanezumab to the current standard treatments are highly desirable.
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Affiliation(s)
- Luca Giani
- Neuroalgology Unit, Fondazione IRCCS Istituto Neurologico "Carlo Besta" , 20133, Milano (MI), Italy
| | | | - Massimo Leone
- Neuroalgology Unit, Fondazione IRCCS Istituto Neurologico "Carlo Besta" , 20133, Milano (MI), Italy
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Schoenen J, Manise M, Nonis R, Gérard P, Timmermans G. Monoclonal antibodies blocking CGRP transmission: An update on their added value in migraine prevention. Rev Neurol (Paris) 2020; 176:788-803. [PMID: 32758365 DOI: 10.1016/j.neurol.2020.04.027] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/28/2020] [Indexed: 12/29/2022]
Abstract
The avenue of effective migraine therapies blocking calcitonin gene-related peptide (CGRP) transmission is the successful outcome of 35 years of translational research. Developed after short-acting, the small antagonists of the CGRP receptor (the "gepants"), the monoclonal antibodies blocking CGRP or its receptor (CGRP/rec mAbs) have changed the paradigm in migraine treatment. Contrary to the classical acute medications like triptans or nonsteroidal anti-inflammatory drugs (NSAIDs) with a transient effect, they act for long durations exclusively in the peripheral portion of the trigeminovascular system and can thus be assimilated to a durable attack treatment, unlike the classical preventives that chiefly act upstream on the central facets of migraine pathophysiology. Randomized controlled trials (RCT) of eptinezumab, erenumab, fremanezumab and galcanezumab have included collectively several thousands of patients, making them the most extensively studied class of preventive migraine treatments. Their results clearly indicate that CGRP/rec mAbs are significantly superior to placebo and have been comprehensively reviewed by Dodick [Cephalalgia 2019;39(3):445-458]. In this review we will briefly summarize the placebo-subtracted outcomes and number-needed-to-treat (NNT) of these pivotal RCTs and analyze new and post-hoc studies published afterwards focusing on effect size, effect onset and sustainability, response in subgroups of patients, safety and tolerability, and cost-effectiveness. We will also summarize our limited real-world experience with one of the CGRP/rec mAbs. Although methodological differences and lack of direct comparative trials preclude any reliable comparison, the overall impression is that there are only minor differences in efficacy and tolerability profiles between the four monoclonals: the average placebo-subtracted 50% responder rates for reduction in migraine headaches are 21.4% in episodic migraine (NNTs: 4-5), 17.4% in chronic migraine (NNTs: 4-8). Patients with an improvement exceeding 50% are rare, chronic migraineurs with continuous headache are unlikely to be responders and migraine auras are not improved. The effect starts within the first week after administration and is quasi maximal at one month. It is sustained for long time periods and may last for several months after treatment termination. CGRP/rec mAbs are effective even after prior preventive treatment failures and in patients with medication overuse, but the effect size might be smaller. They significantly reduce disability and health care resource utilization. The adverse effect profile of CGRP/rec mAbs is close to that of placebo with few minor exceptions and despite concerns related to the safeguarding role of CGRP in ischemia, no treatment-related vascular adverse events have been reported to date. Putting the CGRP/rec mAbs in perspective with available preventive migraine drug treatments, their major advantage seems not to be chiefly their superior efficacy but their unprecedented efficacy over adverse event ratio. Regarding cost-effectiveness, preliminary pharmaco-economic analyses of erenumab suggest that it is cost-effective for chronic migraine compared to no treatment or to onabotulinumtoxinA, but likely not for episodic migraine unless attack frequency is high, indirect costs are considered and its price is lowered.
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Affiliation(s)
- J Schoenen
- Headache Research Unit, Department of Neurology, University of Liège, Citadelle Hospital, 4000 Liège, Belgium.
| | - M Manise
- Headache Research Unit, Department of Neurology, University of Liège, Citadelle Hospital, 4000 Liège, Belgium
| | - R Nonis
- Headache Research Unit, Department of Neurology, University of Liège, Citadelle Hospital, 4000 Liège, Belgium
| | - P Gérard
- Headache Research Unit, Department of Neurology, University of Liège, Citadelle Hospital, 4000 Liège, Belgium
| | - G Timmermans
- Headache Research Unit, Department of Neurology, University of Liège, Citadelle Hospital, 4000 Liège, Belgium
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Meßlinger K. [Pathophysiological role of calcitonin gene-related peptide (CGRP) in migraine and cluster headache]. Schmerz 2020; 34:181-187. [PMID: 32103345 DOI: 10.1007/s00482-020-00448-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Calcitonin gene-related peptide (CGRP) is released from trigeminal afferents during migraine and cluster headache attacks and can be detected in the jugular plasma. Infusion of CGRP can induce headache attacks in migraine and cluster patients. Inhibition of the CGRP signal system is therapeutic in migraine and cluster headache. CGRP is a potent dilator of intracranial arteries but does not immediately activate the trigeminal pain system. CGRP may act as a signal molecule between different cells in the trigeminal ganglion and enhances nociceptive transmission in the spinal trigeminal nucleus. Peripheral inhibition of the CGRP system reduces these actions. Outside the trigeminovascular system, CGRP is important for maintaining the perfusion of organs in critical situations, promotes growth and repair functions and is an immunomodulatory factor. These actions should be considered when the CGRP system is suppressed for a long time.
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Affiliation(s)
- Karl Meßlinger
- Institut für Physiologie und Pathophysiologie, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 17, 91054, Erlangen, Deutschland.
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Peng KP, May A. Targeting migraine treatment with neuroimaging-Pharmacological neuroimaging in headaches. PROGRESS IN BRAIN RESEARCH 2020; 255:327-342. [PMID: 33008512 DOI: 10.1016/bs.pbr.2020.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 04/23/2020] [Accepted: 05/01/2020] [Indexed: 01/20/2023]
Abstract
PURPOSE The current review provides a recapitulation of recent advances in pharmacological neuroimaging in headache, a promising tool to understanding of how a drug works in the brain and how it may lead to new insights of disease mechanisms of headache. RESULTS Pharmacological positron emission tomography with radioligand-labeled medication may provide evidence whether and where a medication binds in the brain but is still mostly restricted to animal work. Pharmacological functional MRI using task-specific approaches identified central modulation patterns as a consequence of attack and preventative headache medication, which may be distinct to a specific drug mechanism. Pharmacological neuroimaging and specifically in combination with functional imaging is a promising tool to better understand not only certain medications but also certain disease mechanisms. SUMMARY Pharmacological imaging techniques have advanced over the last few years and showed great potential of providing new insights into drug pharmacodynamics and disease mechanism. There are still limitations and challenges to be overcome.
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Affiliation(s)
- Kuan-Po Peng
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Brain Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Arne May
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Clemow DB, Johnson KW, Hochstetler HM, Ossipov MH, Hake AM, Blumenfeld AM. Lasmiditan mechanism of action - review of a selective 5-HT 1F agonist. J Headache Pain 2020; 21:71. [PMID: 32522164 PMCID: PMC7288483 DOI: 10.1186/s10194-020-01132-3] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 05/25/2020] [Indexed: 01/13/2023] Open
Abstract
Migraine is a leading cause of disability worldwide, but it is still underdiagnosed and undertreated. Research on the pathophysiology of this neurological disease led to the discovery that calcitonin gene-related peptide (CGRP) is a key neuropeptide involved in pain signaling during a migraine attack. CGRP-mediated neuronal sensitization and glutamate-based second- and third-order neuronal signaling may be an important component involved in migraine pain. The activation of several serotonergic receptor subtypes can block the release of CGRP, other neuropeptides, and neurotransmitters, and can relieve the symptoms of migraine. Triptans were the first therapeutics developed for the treatment of migraine, working through serotonin 5-HT1B/1D receptors. The discovery that the serotonin 1F (5-HT1F) receptor was expressed in the human trigeminal ganglion suggested that this receptor subtype may have a role in the treatment of migraine. The 5-HT1F receptor is found on terminals and cell bodies of trigeminal ganglion neurons and can modulate the release of CGRP from these nerves. Unlike 5-HT1B receptors, the activation of 5-HT1F receptors does not cause vasoconstriction.The potency of different serotonergic agonists towards 5-HT1F was correlated in an animal model of migraine (dural plasma protein extravasation model) leading to the development of lasmiditan. Lasmiditan is a newly approved acute treatment for migraine in the United States and is a lipophilic, highly selective 5-HT1F agonist that can cross the blood-brain barrier and act at peripheral nervous system (PNS) and central nervous system (CNS) sites.Lasmiditan activation of CNS-located 5-HT1F receptors (e.g., in the trigeminal nucleus caudalis) could potentially block the release of CGRP and the neurotransmitter glutamate, thus preventing and possibly reversing the development of central sensitization. Activation of 5-HT1F receptors in the thalamus can block secondary central sensitization of this region, which is associated with progression of migraine and extracephalic cutaneous allodynia. The 5-HT1F receptors are also elements of descending pain modulation, presenting another site where lasmiditan may alleviate migraine. There is emerging evidence that mitochondrial dysfunction might be implicated in the pathophysiology of migraine, and that 5-HT1F receptors can promote mitochondrial biogenesis. While the exact mechanism is unknown, evidence suggests that lasmiditan can alleviate migraine through 5-HT1F agonist activity that leads to inhibition of neuropeptide and neurotransmitter release and inhibition of PNS trigeminovascular and CNS pain signaling pathways.
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Affiliation(s)
| | | | | | | | - Ann M Hake
- Eli Lilly and Company, Indianapolis, IN, USA
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA
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Zhang J, Czerpaniak K, Huang L, Liu X, Cloud ME, Unsinger J, Hotchkiss RS, Li D, Cao YQ. Low-dose interleukin-2 reverses behavioral sensitization in multiple mouse models of headache disorders. Pain 2020; 161:1381-1398. [PMID: 32028334 PMCID: PMC7230033 DOI: 10.1097/j.pain.0000000000001818] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Headache disorders are highly prevalent and debilitating, with limited treatment options. Previous studies indicate that many proinflammatory immune cells contribute to headache pathophysiology. Given the well-recognized role of regulatory T (Treg) cells in maintaining immune homeostasis, we hypothesized that enhancing Treg function may be effective to treat multiple headache disorders. In a mouse model of chronic migraine, we observed that repeated nitroglycerin (NTG, a reliable trigger of migraine in patients) administration doubled the number of CD3 T cells in the trigeminal ganglia without altering the number of Treg cells, suggesting a deficiency in Treg-mediated immune homeostasis. We treated mice with low-dose interleukin-2 (ld-IL2) to preferentially expand and activate endogenous Treg cells. This not only prevented the development of NTG-induced persistent sensitization but also completely reversed the established facial skin hypersensitivity resulting from repeated NTG administration. The effect of ld-IL2 was independent of mouse sex and/or strain. Importantly, ld-IL2 treatment did not alter basal nociceptive responses, and repeated usage did not induce tolerance. The therapeutic effect of ld-IL2 was abolished by Treg depletion and was recapitulated by Treg adoptive transfer. Furthermore, treating mice with ld-IL2 1 to 7 days after mild traumatic brain injury effectively prevented as well as reversed the development of behaviors related to acute and chronic post-traumatic headache. In a model of medication overuse headache, Ld-IL2 completely reversed the cutaneous hypersensitivity induced by repeated administration of sumatriptan. Collectively, this study identifies ld-IL2 as a promising prophylactic for multiple headache disorders with a mechanism distinct from the existing treatment options.
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Affiliation(s)
- Jintao Zhang
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110
- Washington University Pain Center, Washington University School of Medicine, St. Louis, MO 63110
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China 510510
| | - Katherine Czerpaniak
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110
- Washington University Pain Center, Washington University School of Medicine, St. Louis, MO 63110
| | - Liang Huang
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110
- Washington University Pain Center, Washington University School of Medicine, St. Louis, MO 63110
- Present address: Department of Anesthesiology, New York University Langone Health, New York University Grossman School of Medicine, New York, NY 10016
| | - Xuemei Liu
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110
- Washington University Pain Center, Washington University School of Medicine, St. Louis, MO 63110
| | - Megan E Cloud
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110
- Washington University Pain Center, Washington University School of Medicine, St. Louis, MO 63110
| | - Jacqueline Unsinger
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110
| | - Richard S Hotchkiss
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110
- Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110
- Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110
| | - Daizong Li
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110
- Washington University Pain Center, Washington University School of Medicine, St. Louis, MO 63110
| | - Yu-Qing Cao
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110
- Washington University Pain Center, Washington University School of Medicine, St. Louis, MO 63110
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Christensen SL, Ernstsen C, Olesen J, Kristensen DM. No central action of CGRP antagonising drugs in the GTN mouse model of migraine. Cephalalgia 2020; 40:924-934. [DOI: 10.1177/0333102420914913] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
IntroductionClinically, calcitonin gene-related peptide antagonising drugs are recognized as effective in migraine treatment, but their site of action is debated. Only a small fraction of these compounds pass the blood-brain barrier and accesses the central nervous system. Regardless, it has been argued that the central nervous system is the site of action. Here, we test this hypothesis by bypassing the blood-brain barrier through intracerebroventricular injection of calcitonin gene-related peptide antagonising drugs.MethodsWe used the glyceryl trinitrate (GTN) mouse model, which is well validated by its response to specific migraine drugs. The calcitonin gene-related peptide receptor antagonist olcegepant and the calcitonin gene-related peptide monoclonal antibody ALD405 were administered either intraperitoneally or intracerebroventricularly. The outcome measure was cutaneous mechanical allodynia.ResultsMice given olcegepant intraperitoneally + GTN on day 1 had a mean 50% withdrawal threshold of 1.2 g in contrast to mice receiving placebo + GTN, which had a threshold of 0.3 g ( p < 0.001). Similarly, in the ALD405 + GTN group, mice had thresholds of 1.2 g versus 0.2 g in the placebo + GTN group ( p < 0.001). However, both drugs were ineffective when delivered intracerebroventricularly, as control and active groups had identical mechanical sensitivity thresholds, 0.2 g versus 0.1 g and 0.1 g versus 0.1 g for olcegepant and ALD405, respectively ( p > 0.99 in both cases).DiscussionThe site of action of olcegepant and of the monoclonal antibody ALD405 is outside the blood-brain barrier in this mouse model of migraine. It is likely that these results can be generalised to all gepants and all antibodies and that the results are relevant for human migraine.
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Affiliation(s)
- Sarah L Christensen
- Danish Headache Center, Glostrup Research Institute, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Charlotte Ernstsen
- Danish Headache Center, Glostrup Research Institute, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Jes Olesen
- Danish Headache Center, Glostrup Research Institute, Rigshospitalet Glostrup, Glostrup, Denmark
| | - David M Kristensen
- Danish Headache Center, Glostrup Research Institute, Rigshospitalet Glostrup, Glostrup, Denmark
- University of Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail) – UMR_S 1085, Rennes, France
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59
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Peng KP, Chen SP, Gudmundsson LS. Headache highlights 2019: Junior editors’ choice. CEPHALALGIA REPORTS 2020. [DOI: 10.1177/2515816320903292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Kuan-Po Peng
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Brain Research Center and School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Shih-Pin Chen
- Brain Research Center and School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Translational Research, Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Neurology, Taipei Veterans, Taiwan General Hospital, Taipei, Taiwan
| | - Larus S Gudmundsson
- Faculty of Pharmaceutical Sciences, School of Health Sciences, University of Iceland, Reykjavik, Iceland
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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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Noseda R, Schain AJ, Melo-Carrillo A, Tien J, Stratton J, Mai F, Strassman AM, Burstein R. Fluorescently-labeled fremanezumab is distributed to sensory and autonomic ganglia and the dura but not to the brain of rats with uncompromised blood brain barrier. Cephalalgia 2019; 40:229-240. [PMID: 31856583 PMCID: PMC7233263 DOI: 10.1177/0333102419896760] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Background The presence of calcitonin gene-related peptide and its receptors in multiple brain areas and peripheral tissues previously implicated in migraine initiation and its many associated symptoms raises the possibility that humanized monoclonal anti-calcitonin gene-related peptide antibodies (CGRP-mAbs) can prevent migraine by modulating neuronal behavior inside and outside the brain. Critical to our ability to conduct a fair discussion over the mechanisms of action of CGRP-mAbs in migraine prevention is data generation that determines which of the many possible peripheral and central sites are accessible to these antibodies – a question raised frequently due to their large size. Material and methods Rats with uncompromised and compromised blood-brain barrier (BBB) were injected with Alexa Fluor 594-conjugated fremanezumab (Frema594), sacrificed 4 h or 7 d later, and relevant tissues were examined for the presence of Frema594. Results In rats with uncompromised BBB, Frema594 was similarly observed at 4 h and 7 d in the dura, dural blood vessels, trigeminal ganglion, C2 dorsal root ganglion, the parasympathetic sphenopalatine ganglion and the sympathetic superior cervical ganglion but not in the spinal trigeminal nucleus, thalamus, hypothalamus or cortex. In rats with compromised BBB, Frema594 was detected in the cortex (100 µm surrounding the compromised BBB site) 4 h but not 7 d after injections. Discussion Our inability to detect fluorescent (CGRP-mAbs) in the brain supports the conclusion that CGRP-mAbs prevent the headache phase of migraine by acting mostly, if not exclusively, outside the brain as the amount of CGRP-mAbs that enters the brain (if any) is too small to be physiologically meaningful.
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Affiliation(s)
- Rodrigo Noseda
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Aaron J Schain
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Agustin Melo-Carrillo
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | | | - Fanny Mai
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston MA, USA
| | - Andrew M Strassman
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Rami Burstein
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston MA, USA.,Harvard Medical School, Boston, MA, USA
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62
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Chiarugi A. A Popperian View on Anti‐CGRP Biologics in Migraine. Headache 2019; 59:1855-1860. [DOI: 10.1111/head.13695] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2019] [Indexed: 12/23/2022]
Affiliation(s)
- Alberto Chiarugi
- Headache Center Careggi University Hospital University of Florence Florence Italy
- Department of Health Sciences Section of Clinical Pharmacology and Oncology University of Florence Florence Italy
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63
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Abstract
Migraine is among the most common and most disabling disorders worldwide, yet its underlying pathophysiology is among the most poorly understood. New information continues to emerge on mechanisms within the central and peripheral nervous systems that may contribute to migraine attacks. Additionally, new therapeutics have recently become available and along with much needed relief for many patients, these drugs provide insight into the disorder based on their mechanism of action. This review will cover new findings within the last several years that add to the understanding of migraine pathophysiology, including those related to the vasculature, calcitonin gene-related peptide (CGRP), and mechanisms within the cortex and meninges that may contribute to attacks. Discussion will also cover recent findings on novel therapeutic targets, several of which continue to show promise in new preclinical studies, including acid-sensing ion channels (ASICs) and the delta-opioid receptor (DOR).
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Affiliation(s)
- Greg Dussor
- School of Behavioral and Brain Sciences, Center for Advanced Pain Studies, The University of Texas at Dallas, Richardson, TX 75080
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