Dispute settlement understanding on the use of Botox in chronic migraine

The impact of topiramate, botulinum toxin type A, and CGRP-antibodies on medication overuse headache in patients with chronic migraine: A protocol for systematic review and meta-analysis

Medication overuse headache (MOH) is defined as headache occurring ≥15 days/month developing as a consequence of regular overuse of acute or symptomatic headache medication for more than 3 months. MOH is present in more than 50% of patients with chronic migraine (CM). Although, studies have shown a positive impact for MOH patients of early introduction of preventive treatment and withdrawal of overused medication, uncertainties remain. The main purpose of this systematic review and meta-analysis is to assess the relative impact of topiramate, botulinum toxin type A, and human monoclonal antibodies (mAbs) targeting calcitonin gene-related peptide (CGRP) or its receptor (CGRPr) among MOH patients with CM. The PRISMA guideline for conducting systematic review will be followed. CENTRAL, MEDLINE, Embase and Web of Science databases will be searched. RCTs reporting outcomes such as change in migraine/headache frequency, change from MOH to no MOH, and ≥50% response rate will be included. The effect will be measured as mean difference (MD) for continuous data and odds ratio (OR) for dichotomous data. Heterogeneity across studies will be assessed using the Cochrane I2 statistics. The Cochrane RoB2 tool will be used to assess risk of bias, and the quality of evidence for outcomes will be rated according to five factors defined in Cochrane GRADE approach. The revision of the included articles, data extraction, risk of bias assessment, and quality rating of evidence will be independently done by two reviewers. Any discrepancies will be resolved through consensus with the third reviewer.

Economic burden of medication-overuse headache in Iran: direct and indirect costs

BACKGROUND AND OBJECTIVE

Medication-overuse headache (MOH) as a secondary chronic headache imposes a considerable burden on both individuals and societies. Nevertheless, little is known about the burden of MOH in Iran. Therefore, in the current study, we aimed to quantify the annual cost of MOH among Iranian patients.

METHODS

In this cross-sectional study, 84 patients were recruited. Demographic data, headache attack characteristics, related disability, and information about the economic burden of MOH were collected through face-to-face interview. Direct medical and nonmedical costs as well as indirect costs were included in our cost analysis. The prevalence-based approach was applied to estimate the economic burden of MOH.

RESULTS

We found that MOH patients in Iran spend averagely $1046 for medical services, $132 for nonmedical services, and $1432 due to lost productivity per year. The per-person annual cost of MOH was US$2610, and the total annual cost for Iran was $10,179,000,000, with direct and indirect cost accounting for 45% and 55%, respectively.

CONCLUSION

MOH leads to substantial healthcare costs and significant loss of productivity in Iran. Therefore, raising awareness in this area especially for policymakers can use in future health planning and lead to resource allocation in the field of disabling type of headache disorders such as MOH. Our findings also provide a different insight into the burden of MOH, which are likely closer to the actual costs in middle- and low-income countries, and also it could be a sample of such a study in western Asia.

The therapeutic armamentarium in migraine is quite elderly

Global Burden of Disease 2010 study considers migraine as one of the most important noncommunicable diseases in the world, classifying it third in terms of global prevalence (14.70%): it sums up the 54.19% of all the years of life lived with disabilities caused by the rest of all neurological disorders. This Editorial provides an historical excursus of old and new-entry molecules in migraine therapeutic area. Drugs for acute treatment such as triptans date back to the early 1990s with the appearance of sumatriptan and the following six triptans in the years immediately after (zolmitriptan, rizatriptan, naratriptan, eletriptan, almotriptan, frovatriptan). Prophylaxis drugs, dedicated to patients with medium/high frequency of crises, show as last entries topiramate and botulinum toxin type A. The use of this preventative group, with its intrinsic limits, is mandatory to reduce the risk of migraine chronification, a highly harmful clinical phenomenon that produces as its natural consequence the medication overuse headache. The development of new acute and preventative compounds, such as 5HT (serotonin) 1F receptor (5-HT1F) agonist lasmiditan, calcitonin gene related peptide (CGRP) peptide receptor antagonists, anti-CGRP monoclonal antibodies (LY2951742, ALD403, LBR101) and anti-CGRP-r monoclonal antibody (AMG334), is warranted and might be soon completed in order to offer new opportunities to migraine patients.

Chronic daily headaches

Chronic Daily Headache is a descriptive term that includes disorders with headaches on more days than not and affects 4% of the general population. The condition has a debilitating effect on individuals and society through direct cost to healthcare and indirectly to the economy in general. To successfully manage chronic daily headache syndromes it is important to exclude secondary causes with comprehensive history and relevant investigations; identify risk factors that predict its development and recognise its sub-types to appropriately manage the condition. Chronic migraine, chronic tension-type headache, new daily persistent headache and medication overuse headache accounts for the vast majority of chronic daily headaches. The scope of this article is to review the primary headache disorders. Secondary headaches are not discussed except medication overuse headache that often accompanies primary headache disorders. The article critically reviews the literature on the current understanding of daily headache disorders focusing in particular on recent developments in the treatment of frequent headaches.

Chronic migraine plus medication overuse headache: two entities or not?

Chronic migraine (CM) represents migraine natural evolution from its episodic form. It is realized through a chronicization phase that may require months or years and varies from patient to patient. The transition to more frequent attacks pattern is influenced by lifestyle, life events, comorbid conditions and personal genetic terrain, and it often leads to acute drugs overuse. Medication overuse headache (MOH) may complicate every type of headache and all the drugs employed for headache treatment can cause MOH. The first step in the management of CM complicated by medication overuse must be the withdrawal of the overused drugs and a detoxification treatment. The goal is not only to detoxify the patient and stop the chronic headache but also to improve responsiveness to acute or prophylactic drugs. Different methods have been suggested: gradual or abrupt withdrawal; home treatment, hospitalization, or a day-hospital setting; re-prophylaxes performed immediately or at the end of the wash-out period. Up to now, only topiramate and local injection of onabotulinumtoxinA have shown efficacy as therapeutic agents for re-prophylaxis after detoxification in patients with CM with and without medication overuse. Although the two treatments showed similar efficacy, onabotulinumtoxinA is associated with a better adverse events profile. Recently, the Phase III Research Evaluating Migraine Prophylaxis Therapy (PREEMPT) clinical program proved that patients with CM, even those with MOH, are the ones most likely to benefit from onabotulinumtoxinA treatment. Furthermore, it provided an injection paradigm that can be used as a guide for a correct administration of onabotulinumtoxinA.