Treatment Update of Chronic Migraine

Animal Models of Chronic Migraine: From the Bench to Therapy

PURPOSE OF REVIEW

Chronic migraine is a disabling progressive disorder without effective management approaches. Animal models have been developed and used in chronic migraine research. However, there are several problems with existing models. Therefore, we aimed to summarize and analyze existing animal models to facilitate translation from basic to clinical.

RECENT FINDINGS

The most commonly used models are the inflammatory soup induction model and the nitric oxide donor induction model. In addition, KATP openers have also been used in model induction. Based on the above models, some molecular targets have been identified, such as glutamate receptors. However, each model has its shortcomings and characteristics, and there are still some common problems that need to be solved, such as spontaneous headache, evaluation criteria after model establishment, and identification methods. In this review, we summarized and highlighted the advantages and limitations of the currently commonly used animal models of chronic migraine with a special focus on drug discovery and current therapeutic strategies, and discussed the directions that can be worked on in the future.

Peppermint and menthol: a review on their biochemistry, pharmacological activities, clinical applications, and safety considerations

In this manuscript, we conducted a comprehensive review of the diverse effects of peppermint on human health and explored the potential underlying mechanisms. Peppermint contains three main groups of phytochemical constituents, including essential oils (mainly menthol), flavonoids (such as hesperidin, eriodictyol, naringenin, quercetin, myricetin, and kaempferol), and nonflavonoid phenolcarboxylic acids. Peppermint exhibits antimicrobial, antioxidant, anti-inflammatory, immunomodulatory, anti-cancer, anti-aging, and analgesic properties and may be effective in treating various disorders, including gastrointestinal disorders (e.g., irritable bowel syndrome, dyspepsia, constipation, functional gastrointestinal disorders, nausea/vomiting, and gallbladder stones). In addition, peppermint has therapeutic benefits for psychological and cognitive health, dental health, urinary retention, skin and wound healing, as well as anti-depressant and anti-anxiety effects, and it may improve memory. However, peppermint has paradoxical effects on sleep quality and alertness, as it has been shown to improve sleep quality in patients with fatigue and anxiety, while also increasing alertness under conditions of monotonous work and relaxation. We also discuss its protective effects against toxic agents at recommended doses, as well as its safety and potential toxicity. Overall, this review provides the latest findings and insights into the properties and clinical effects of peppermint/menthol and highlights its potential as a natural therapeutic agent for various health conditions.

Predicting the efficacy of non-steroidal anti-inflammatory drugs in migraine using deep learning and three-dimensional T1-weighted images

Deep learning (DL) models based on individual images could contribute to tailored therapies and personalized treatment strategies. We aimed to construct a DL model using individual 3D structural images for predicting the efficacy of non-steroidal anti-inflammatory drugs (NSAIDs) in migraine. A 3D convolutional neural network model was constructed, with ResNet18 as the classification backbone, to link structural images to predict the efficacy of NSAIDs. In total, 111 patients were included and allocated to the training and testing sets in a 4:1 ratio. The prediction accuracies of the ResNet34, ResNet50, ResNeXt50, DenseNet121, and 3D ResNet18 models were 0.65, 0.74, 0.65, 0.70, and 0.78, respectively. This model, based on individual 3D structural images, demonstrated better predictive performance in comparison to conventional models. Our study highlights the feasibility of the DL algorithm based on brain structural images and suggests that it can be applied to predict the efficacy of NSAIDs in migraine treatment.

Targeting N-type calcium channels in young-onset of some neurological diseases

Calcium (Ca ²⁺) is an important second messenger in charge of many critical processes in the central nervous system (CNS), including membrane excitability, neurotransmission, learning, memory, cell proliferation, and apoptosis. In this way, the voltage-gated calcium channels (VGCCs) act as a key supply for Ca²⁺ entry into the cytoplasm and organelles. Importantly, the dysregulation of these channels has been reported in many neurological diseases of young-onset, with associated genetic factors, such as migraine, multiple sclerosis, and Huntington's disease. Notably, the literature has pointed to the role of N-type Ca²⁺ channels (NTCCs) in controlling a variety of processes, including pain, inflammation, and excitotoxicity. Moreover, several Ca²⁺ channel blockers that are used for therapeutic purposes have been shown to act on the N-type channels. Therefore, this review provides an overview of the NTCCs in neurological disorders focusing mainly on Huntington's disease, multiple sclerosis, and migraine. It will discuss possible strategies to generate novel therapeutic strategies.

Long‐term efficacy and safety of erenumab in patients with chronic migraine in whom prior preventive treatments had failed: A subgroup analysis

Objective

To assess the long‐term efficacy and safety of erenumab in the subgroup of patients with chronic migraine (CM) in whom prior preventive treatments had failed (TF) (≥1, ≥2, and ≥3 TF medication categories) and never failed (preventive naïve or prior preventive treatments had not failed), using the data from a 52‐week, open‐label treatment period (OLTP) of the parent study.

Background

Erenumab is a fully human monoclonal antibody that selectively binds to and inhibits the canonical calcitonin gene‐related peptide receptor. There are limited long‐term data evaluating the efficacy and safety of erenumab in patients with CM in whom prior preventive treatments had failed.

Methods

Patients who had completed the 12‐week double‐blind treatment period (DBTP) in the parent study were eligible to participate in the 52‐week OLTP, during which they received erenumab every 4 weeks. The TF subgroups (≥1, ≥2, and ≥3 TF medication categories) were not mutually exclusive; patients in whom prior preventive treatments from ≥3 medication categories had failed were also counted in the ≥2 and ≥1 medication categories. Endpoints included monthly migraine days (MMD), monthly acute migraine‐specific medication days (MSMD), achievement of ≥50%, ≥75%, and 100% reduction from baseline in MMD, and exposure‐adjusted patient incidence rates of adverse events (AEs; per 100 patient‐years).

Results

Erenumab treatment provided sustained mean reductions in MMD and MSMD relative to the parent study baseline throughout the 52 weeks of the OLTP across all TF subgroups. At Week 52, the mean MMD change was −8.6 (SD 6.6) (baseline: 18.4 [SD 4.5] days) in the ≥1 TF subgroup. A post hoc completer analysis (52 weeks [OLTP] erenumab) showed that compared with erenumab 70 mg, the 140 mg dose was associated with numerically greater reductions in the mean MMD (Week 40: −8.6 and −7.2 days; Week 52: −9.7 and −7.9 days [≥1 TF subgroup]) and a higher proportion of patients achieved ≥50%, ≥75%, and 100% response thresholds across all subgroups at Weeks 40 and 52. Overall the exposure‐adjusted patient incidence rates of AEs did not increase during the OLTP versus the DBTP (≥1 TF subgroup: 141.9/100 versus 317.9/100 patient‐years), and no new safety signals occurred.

Conclusion

The long‐term treatment with erenumab was well tolerated and showed sustained efficacy in patients with CM in whom prior preventive treatments had failed, with numerically greater treatment effects for 140 mg versus 70 mg.

Evaluating Plasma and Brain TRPV1 Channels in the Animal Model of Episodic and Chronic Migraine: The Possible Role of Somatosensory Cortex TRPV1 in Migraine Transformation

Background: Despite extensive research, the exact molecular mechanisms underlying migraine development and especially its progression and transformation from episodic into chronic is still unknown. Objectives: This study aimed to assess the role of somatosensory cortex and hippocampal transient receptor potential vanilloid 1 (TRPV1) in migraine in a rat model. Methods: This study was an intervention study. Adult male Wistar rats were divided into three groups, including sham, episodic migraine (EM), and chronic migraine (CM). The sham group received normal intraperitoneal (IP) saline injections every two days for 11 days, and the EM group received a single dose of trinitroglycerin (TNG) injection (IP; 10 mg/kg). For the CM group, TNG was administrated every two days (on days 3, 5, 7, 9, and 11; IP; 10 mg/kg). TRPV1 levels in plasma, somatosensory cortex, and hippocampus were detected with an enzyme-linked immunosorbent assay (ELISA) kit. Results: The findings showed that in both CM and EM groups the TRPV1 levels in plasma (P < 0.001 in both groups), somatosensory cortex (P < 0.05 and P < 0.001, respectively), and hippocampus (P < 0.01 in both groups) increased after migraine induction. Interestingly, in the somatosensory cortex, this TRPV1 elevation in the CM group was much greater than the EM group, and a significant difference was observed between the two groups (P < 0.05). Conclusions: Our results suggested that headache severity and frequency may enhance concomitant with the upregulation of somatosensory cortex TRPV1. This new achievement can help to develop new drug approaches to prevent CM.

Disability and Economic Loss Caused by Headache among Information Technology Workers in Korea

Background and Purpose

Headache disorders are a leading cause of disability globally. However, there is inadequate information available about these disorders and the related economic loss in the workplace in Asian countries. Information technology (IT) jobs are intellectually and cognitively challenging, and hence IT workers are a suitable population for assessing headache disorders and related economic loss.

Methods

We sent invitation emails to all employees of selected IT companies. A comprehensive Web-based questionnaire regarding headache characteristics, disability, quality of life, and economic loss was completed by 522 participants from 8 companies.

Results

The participants included 450 (86.2%) who had experienced headache more than once during the previous year. The frequencies of migraine, probable migraine (PM), and tension-type headache (TTH) were 18.2%, 21.1%, and 37.0%, respectively. The Migraine Disability Assessment score was higher for participants with migraine [median and interquartile range, 3.0 (0.0–6.0)] than for those with PM [0.0 (0.0–2.0), p<0.001] and TTH [0.0 (0.0–1.0), p<0.001]. The estimated annual economic losses caused by migraine per person associated with absenteeism and presenteeism were USD 197.5±686.1 and USD 837.7±22.04 (mean±standard deviation), respectively. The total annual economic loss per person caused by migraine (USD 1,023.3±1,972.7) was higher than those caused by PM (USD 424.8±1,209.1, p<0.001) and TTH (USD 197.6±636.4, p<0.001).

Conclusions

Migraine, PM, and TTH were found to be prevalent among IT workers in Korea. Disability and economic loss were significantly greater in participants with migraine than in those with PM or TTH.

Chronic Migraine Pathophysiology and Treatment: A Review of Current Perspectives

Chronic migraine is a disabling neurological disorder that imposes a considerable burden on individual and socioeconomic outcomes. Chronic migraine is defined as headaches occurring on at least 15 days per month with at least eight of these fulfilling the criteria for migraine. Chronic migraine typically evolves from episodic migraine as a result of increasing attack frequency and/or several other risk factors that have been implicated with migraine chronification. Despite this evolution, chronic migraine likely develops into its own distinct clinical entity, with unique features and pathophysiology separating it from episodic migraine. Furthermore, chronic migraine is characterized with higher disability and incidence of comorbidities in comparison to episodic migraine. While existing migraine studies primarily focus on episodic migraine, less is known about chronic migraine pathophysiology. Mounting evidence on aberrant alterations suggest that pronounced functional and structural brain changes, central sensitization and neuroinflammation may underlie chronic migraine mechanisms. Current treatment options for chronic migraine include risk factor modification, acute and prophylactic therapies, evidence-based treatments such as onabotulinumtoxinA, topiramate and newly approved calcitonin gene-related peptide or receptor targeted monoclonal antibodies. Unfortunately, treatments are still predominantly ineffective in aborting migraine attacks and decreasing intensity and frequency, and poor adherence and compliance with preventative medications remains a significant challenge. Novel emerging chronic migraine treatments such as neuromodulation offer promising therapeutic approaches that warrant further investigation. The aim of this narrative review is to provide an update of current knowledge and perspectives regarding chronic migraine background, pathophysiology, current and emerging treatment options with the intention of facilitating future research into this debilitating and largely indeterminant disorder.

Comprehensive management of adults with chronic migraine: Clinical practice guidelines in Mexico

Introduction:

Migraine is a polygenic multifactorial disorder with a neuronal initiation of a cascade of neurochemical processes leading to incapacitating headaches. Headaches are generally unilateral, throbbing, 4–72 h in duration, and associated with nausea, vomiting, photophobia, and sonophobia. Chronic migraine (CM) is the presence of a headache at least 15 days per month for ≥3 months and has a high global impact on health and economy, and therapeutic guidelines are lacking.

Methods:

Using the Grading of Recommendations, Assessment, Development, and Evaluations system, we conducted a search in MEDLINE and Cochrane to investigate the current evidence and generate recommendations of clinical practice on the identification of risk factors and treatment of CM in adults.

Results:

We recommend avoiding overmedication of non-steroidal anti-inflammatory drugs (NSAIDs); ergotamine; caffeine; opioids; barbiturates; and initiating individualized prophylactic treatment with topiramate eptinezumab, galcanezumab, erenumab, fremanezumab, or botulinum toxin. We highlight the necessity of managing comorbidities initially. In the acute management, we recommend NSAIDs, triptans, lasmiditan, and gepants alone or with metoclopramide if nausea or vomiting. Non-pharmacological measures include neurostimulation.

Conclusions:

We have identified the risk factors and treatments available for the management of CM based on a grading system, which facilitates selection for individualized management.

Eptinezumab for the treatment of migraine

INTRODUCTION

Migraine is one of the most common illnesses in the world, with severe economical and subjective implications. Nowadays specific and nonspecific drugs are used for migraine chronic therapy, but a portion of patients have no benefit from these administrations. CGRP receptor antagonists are a good preventive treatment for episodic and chronic migraine.

AREAS COVERED

This article reviews both preclinical and clinical studies on eptinezumab as a potential preventive therapy for migraine, as well as pharmacokinetic and pharmacodynamic features. Thus, it summarizes safety and tolerability data based on human studies.

EXPERT OPINION

Eptinezumab had good results in several trials, making this molecule a promising migraine preventive drug. Although preclinical and clinical studies showed a significant efficacy, there are no data on the use of Eptinezumab during pregnancy or breastfeeding. There are still some knowledge limits about its pharmacokinetics and metabolism. This is a matter of concern that should be addressed in future studies.

Ubrogepant to Treat Acute Migraine in Adults

Migraine is a neurobiological headache disorder that affects around 16% of adults in the United States. Medical treatment of mild to moderate migraines include non-prescription non-steroidal anti-inflammatory drugs, acetaminophen, or aspirin and caffeine-containing combination analgesics. Additionally, moderate to severe migraines and those that are mild to moderate that have not responded to analgesics can be treated with triptans, which are drugs specific for migraine treatment. Non-pharmacological treatments include cognitive behavioral therapy and relaxation training. Medications for the prevention of migraines have also been developed since they are more affective in offsetting the symptoms. Ubrogepant's high specificity and selectivity for calcitonin gene-related peptide (CGRP) sets it apart from certain other drugs, which previously limited the treatment of migraines with or without aura due to their decreased selectivity. The most frequently reported side effects are oropharyngeal pain, nasopharyngitis, and headache. Most studies found that participants receiving Ubrogepant were free from pain within 2 h when compared to placebo. Patients taking Ubrogepant should avoid taking it when pregnant or with end stage renal disease. In summary, Ubrogepant has good tolerability and an overall favorable safety profile. It appears to hold promise for the acute treatment of migraines with or without aura in adults.

Low Intensity, Transcranial, Alternating Current Stimulation Reduces Migraine Attack Burden in a Home Application Set-Up: A Double-Blinded, Randomized Feasibility Study

Background: Low intensity, high-frequency transcranial alternating current stimulation (tACS) applied over the motor cortex decreases the amplitude of motor evoked potentials. This double-blind, placebo-controlled parallel group study aimed to test the efficacy of this method for acute management of migraines. Methods: The patients received either active (0.4 mA, 140 Hz) or sham stimulation for 15 min over the visual cortex with the number of terminated attacks two hours post-stimulation as the primary endpoint, as a home therapy option. They were advised to treat a maximum of five migraine attacks over the course of six weeks. Results: From forty patients, twenty-five completed the study, sixteen in the active and nine in the sham group with a total of 102 treated migraine attacks. The percentage of terminated migraine attacks not requiring acute rescue medication was significantly higher in the active (21.5%) than in the sham group (0%), and the perceived pain after active stimulation was significantly less for 2–4 h post-stimulation than after sham stimulation. Conclusion: tACS over the visual cortex has the potential to terminate migraine attacks. Nevertheless, the high drop-out rate due to compliance problems suggests that this method is impeded by its complexity and time-consuming setup.

Patterns of pharmacological treatment of patients with migraine, tension-type headache, and cluster headache in a large group of patients in Colombia, 2019

The objective was to determine the pharmacological treatment patterns of headache disorders in a Colombian population. Cross-sectional study. The dispensations of drugs for the management of tension-type headache, migraine, and cluster headache in the first trimester of 2019 were reviewed from a national medication dispensing database. Sociodemographic, diagnostic, and treatment variables (acute or prophylactic; concomitant drugs) were analyzed. During the study period, 7450 patients were identified: 68.5% with migraine, 25.1% with tension-type headache, and 6.4% with cluster headache. A total of 79.7% (n = 5937) were women, and the mean age was 38.6 ± 14.7 years. The 87.8% (n = 6539) were prescribed drugs for acute pain management, mainly nonsteroidal anti-inflammatory drugs (n = 3559; 47.8%), acetaminophen (n = 3390; 45.5%), ergotamine (n = 2158; 29.0%), and opioids (n = 1750; 23.5%). The 50.3% (n = 3750) received at least one drug used for prophylaxis, mainly antidepressants (n = 1769, 23.7%), flunarizine (n = 927; 12.4%), and β-blockers (n = 764; 10.3%). The main comedication was proton pump inhibitors (n = 921; 12.4%). Patients with tension-type headache, migraine, and cluster headache receive mainly medications for acute management, some with low therapeutic value or not recommended, such as opioids or ergotamine. Prophylactic management is mainly directed to migraines, although patients with other kinds of headache also used it, even though it was not indicated.

Efficacy and safety of the classic Chinese herbal prescription Sanpian decoction on migraine: A meta-analysis

OBJECTIVES

To evaluate the efficacy and safety of the classic Chinese herbal prescription Sanpian decoction for curing migraine.

METHODS

Scopus, PubMed, EMBASE, SPRINGER LINK, China National Knowledge Infrastructure (CNKI), Weipu Database and WanFang Database were searched from inception through January 2019 to identify randomized controlled trials (RCTs) that evaluated the efficacy and safety of Sanpian decoction.

RESULTS

Fifteen RCTs with a total of 1377 participants were identified. Compared with the control drugs, Sanpian decoction and Sanpian decoction combined with Sibelium significantly improved the clinical efficacy separately (relative risk [RR] 4.19, 95% confidence intervals [CI] 2.91 to 6.04, P < 0.00001; RR 1.29, 95% CI 1.09 to 1.54, P = 0.003 separately); the Sanpian decoction significantly improved the visual analogue scale score (VAS) (mean differences [MD] -1.83, 95% CI -2.69 to -0.97, P < 0.0001), headache score (MD -3.77, 95% CI -7.20 to -0.34, P = 0.03) and reduced the frequency of headache attacks (MD -1.61, 95% CI -2.07 to -1.14, P < 0.00001) and the concentration of endothelin (ET) (MD -11.90, 95% CI -23.22 to -0.58, P = 0.04) when compared with control drugs. There were minor side effects related to Sanpian decoction which were well tolerated.

CONCLUSIONS

Sanpian decoction is of significant benefits and relative safety in treating migraine. However, more rigorous studies with larger sample sizes are needed due to methodological flaws and low quality of the included trials in this meta-analysis.

From research to clinical practice: a systematic review of the implementation of psychological interventions for chronic headache in adults

BACKGROUND

Psychological interventions have been proved to be effective in chronic headache (CH) in adults. Nevertheless, no data exist about their actual implementation into standard clinical settings. We aimed at critically depicting the current application of psychological interventions for CH into standard care exploring barriers and facilitators to their implementation. Secondarily, main outcomes of the most recent psychological interventions for CH in adults have been summarized.

METHODS

We conducted a systematic review through PubMed and PsycINFO in the time range 2008-2018. A quality analysis according to the QATSDD tool and a narrative synthesis were performed. We integrated results by: contacting the corresponding author of each paper; exploring the website of the clinical centers cited in the papers.

RESULTS

Of the 938 identified studies, 28 papers were selected, whose quality largely varied with an average %QATSDD quality score of 64.88%. Interventions included CBT (42.85%), multi-disciplinary treatments (22.43%), relaxation training (17.86%), biofeedback (7.14%), or other interventions (10.72%). Treatments duration (1 day-9 months) and intensity varied, with a prevalence of individual-basis implementation. The majority of the studies focused on all primary headaches; 4 studies focused on medication-overuse headache. Most of the studies suggest interventions as effective, with the reduction in frequency of attacks as the most reported outcome (46.43%). Studies were distributed in different countries, with a prevalent and balanced distribution in USA and Europe. Ten researches (35.71%) were performed in academic contexts, 11 (39.28%) in clinical settings, 7 (25%) in pain/headache centres. Interventions providers were professionals with certified experience. Most of the studies were funded with private or public funding. Two contacted authors answered to our e-mail survey, with only one intervention implemented in the routine clinical practice. Only in three out of the 16 available websites a reference to the implementation into the clinical setting was reported.

CONCLUSION

Analysis of contextual barriers/facilitators and cost-effectiveness should be included in future studies, and contents regarding dissemination/implementation of interventions should be incorporated in the professional training of clinical scientists. This can help in filling the gap between the existing published research and treatments actually offered to people with CH.

Pulsed Radiofrequency of C2 Dorsal Root Ganglion Under Ultrasound-Guidance and CT Confirmed for Chronic Headache: Follow-Up of 20 Cases and Literature Review

Background

Chronic headache is common but difficult to treat. Most patients respond poorly to drugs. Nerve block is an effective treatment but has no continuous effect. The pulsed radiofrequency (PRF) technique has been shown to be effective in relieving head pain and extending the effect of nerve block.

Objective

The purpose of this study is to evaluate the long-term efficacy of C2 dorsal root ganglion after pulsed radiofrequency (PRF) guided by ultrasound for chronic headache.

Setting

The Department of Pain Management, West China Hospital.

Methods

Twenty patients who did not respond to medications and peripheral nerve blocks underwent ultrasound-guided PRF of the C2 dorsal root ganglion. The patients were followed up for 6 months. Visual analog scale (VAS) score was evaluated at 1 week, 1 month, 3 months, and 6 months. The quality of life (QOL) was assessed by Brief Pain Inventory (BPI) scores which were rated at pre-procedure and 1 month, 3 months, and 6 months after the procedure. The occurrence of complications was evaluated and reported.

Results

Mean VAS scores were significantly decreased at 1 week, 1 month, 3 months and 6 months compared to the pre-procedure mean VAS score. Mean BPI scores decreased significantly at each postoperative time point compared to the preoperative baseline and low scores remained throughout the follow-up period: 45.05±3.44 at pre-procedure, 10.60 ± 2.37 at 1 weeks, 12.50 ± 2.46 at 1 month, 12.90 ± 2.62 at 3 months, and 11.63 ± 2.98 at 6 months. Mild complications occurred, including 1 case (4.7%) of transient cervicalgia (lasting for 24 hrs) and 3 cases (14.2%) of transient dizziness (lasting for 30 mins).

Limitations

Firstly, it included a small sample of patients. Another is the short duration of the follow-up.

Conclusion

C2 PRF may be considered as an alternative treatment for chronic headache.

Decreased electrodermal activity in patients with epilepsy

OBJECTIVE

Biofeedback therapy using electrodermal activity (EDA) is a new noninvasive therapy for intractable epilepsy. However, the characteristics of EDA in patients with epilepsy are little known; therefore, we assessed the EDA characteristics in patients with epilepsy.

METHODS

A cross-sectional observational study was conducted in 22 patients with epilepsy and 24 healthy individuals. We collected information on demographic characteristics, EDA, and state anxiety from both groups, and epilepsy diagnosis, seizure number per month, disease duration, and number of antiepileptic drugs (AED) from the epilepsy group. A wristband device was used to measure resting EDA from both wrists for 10 min under controlled temperature and humidity. We compared the EDA levels between the epilepsy group and the control group and examined correlations between EDA and epilepsy-associated factors in the epilepsy group.

RESULTS

A decreasing trend in EDA was observed during the first 1 min from the start of the measurement in 22 patients with epilepsy (with or without seizures) compared with healthy controls (P = 0.12). However, a significant decrease in EDA was found in 18 patients with epilepsy with seizures compared with healthy controls (-0.48 versus -0.26; P = 0.036). Furthermore, seizure frequency showed a significant inverse correlation with EDA in the epilepsy group (ρ = -0.50, P = 0.016). However, neither disease duration nor the number of drugs prescribed correlated with EDA in the epilepsy group .

SIGNIFICANCE

Marginally decreased EDA was observed in patients with epilepsy, and significantly decreased EDA was found in patients with a higher seizure frequency. The present findings shed light on the appropriateness of EDA-biofeedback therapy in epilepsy.

Current and emerging evidence-based treatment options in chronic migraine: a narrative review

Background

Chronic migraine is a disabling condition that is currently underdiagnosed and undertreated. In this narrative review, we discuss the future of chronic migraine management in relation to recent progress in evidence-based pharmacological treatment.

Findings

Patients with chronic migraine require prophylactic therapy to reduce the frequency of migraine attacks, but the only currently available evidence-based prophylactic treatment options for chronic migraine are topiramate and onabotulinumtoxinA. Improved prophylactic therapy is needed to reduce the high burden of chronic migraine in Italy. Monoclonal antibodies that target the calcitonin gene-related peptide (CGRP) pathway of migraine pathogenesis have been specifically developed for the prophylactic treatment of chronic migraine. These anti-CGRP/R monoclonal antibodies have demonstrated good efficacy and excellent tolerability in phase II and III clinical trials, and offer new hope to patients who are currently not taking any prophylactic therapy or not benefitting from their current treatment.

Conclusions

Treatment of chronic migraine is a dynamic and rapidly advancing area of research. New developments in this field have the potential to improve the diagnosis and provide more individualised treatments for this condition. Establishing a culture of prevention is essential for reducing the personal, social and economic burden of chronic migraine.

Ultrasonic assessment of carotid intima-media thickness in migraine: a meta-analysis

Objective

Migraine is believed to be a risk factor for cerebrovascular diseases, and previous studies have indicated an association between migraine and cerebral atherosclerosis. Carotid artery intima-media thickness (IMT) is considered to be a biomarker of atherosclerosis pathology. This study aimed to investigate the relationship between carotid IMT and migraine by conducting a meta-analysis.

Methods

We searched Web of Science, PubMed, and the Cochrane Library for eligible studies assessing carotid IMT in patients with migraine and controls. Data were extracted independently by two reviewers and analyzed using Review Manager 5.3 software.

Results

The meta-analysis included seven articles with 555 subjects (279 migraine patients, 276 controls). Carotid IMT was significantly greater in patients with migraine compared with controls. However, there were no significant differences in IMT between patients with migraine with aura (MA) and controls, migraine without aura (MO) and controls, and patients with MA and MO.

Conclusion

Patients with migraine have greater carotid IMT than individuals without migraine, suggesting an association between atherosclerosis and migraine. However, further studies with more samples are needed to confirm this finding.

Once-monthly galcanezumab for the prevention of migraine in adults: an evidence-based descriptive review and potential place in therapy

In the last 15 years relevant efforts have been made to demonstrate that calcitonin gene-related peptide (CGRP) antagonism is a valuable and druggable mechanism for treatment or prevention of migraine. Galcanezumab is one of the antibodies developed and studied to prevent migraine by targeting CGRP. The scope of this review is to report data currently available on galcanezumab. According to available data, galcanezumab is safe and efficacious in preventing migraine in episodic migraine patients, also reducing disability and functional impairment due to the disorder. In September 2018, galcanezumab was approved in the USA for the prevention of migraine in adults. The placement of galcanezumab into the current therapeutic scenario will be a revolution for migraine patients, and probably in a less near future also for patients affected by other primary headaches.

Pulsed radiofrequency of C2 dorsal root ganglion under ultrasound guidance for chronic migraine: a case report

Chronic migraine is common but difficult to treat. Most patients respond poorly to drugs. Occipital nerve block such as stellate ganglion block is an effective treatment without continuous effect for migraine. Pulsed radiofrequency (PRF) technique has been shown to be effective in relieving headache and prolonging the effect of nerve block. This case report is about a patient who suffered from chronic migraine with occipital pain and was successfully treated with PRF of C2 (axis) dorsal root ganglion (DRG) under ultrasound guidance confirmed by computed tomograpy scan. The patient did not feel headache after 1-year follow-up. This suggests that C2 DRG PRF might be considered as an alternative treatment for chronic migraine with occipital pain.

Botulinum Toxin Type A-A Modulator of Spinal Neuron-Glia Interactions under Neuropathic Pain Conditions

Neuropathic pain represents a significant clinical problem because it is a chronic condition often refractory to available therapy. Therefore, there is still a strong need for new analgesics. Botulinum neurotoxin A (BoNT/A) is used to treat a variety of clinical diseases associated with pain. Glia are in continuous bi-directional communication with neurons to direct the formation and refinement of synaptic connectivity. This review addresses the effects of BoNT/A on the relationship between glia and neurons under neuropathic pain. The inhibitory action of BoNT/A on synaptic vesicle fusion that blocks the release of miscellaneous pain-related neurotransmitters is known. However, increasing evidence suggests that the analgesic effect of BoNT/A is mediated through neurons and glial cells, especially microglia. In vitro studies provide evidence that BoNT/A exerts its anti-inflammatory effect by diminishing NF-κB, p38 and ERK1/2 phosphorylation in microglia and directly interacts with Toll-like receptor 2 (TLR2). Furthermore, BoNT/A appears to have no more than a slight effect on astroglia. The full activation of TLR2 in astroglia appears to require the presence of functional TLR4 in microglia, emphasizing the significant interaction between those cell types. In this review, we discuss whether and how BoNT/A affects the spinal neuron–glia interaction and reduces the development of neuropathy.