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Shimoda M, Hoshikawa K, Oda S, Imai M, Osada T, Aoki R, Sunaga A, Shinohara C. Cortical Hyperperfusion on MRI Arterial Spin-Labeling during the Interictal Period of Patients with Migraine Headache. AJNR Am J Neuroradiol 2024; 45:686-692. [PMID: 38663988 DOI: 10.3174/ajnr.a8208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 01/25/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND AND PURPOSE Concentrations of calcitonin gene-related peptide, a neuropeptide and potent endogenous vasodilator, are reportedly higher in patients with migraine than in healthy subjects, both during and between migraine attacks, reflecting ongoing activation of the trigeminal nervous system. In this prospective study, we measured CBF during the interictal period of patients with migraine after considering insomnia and depression and examined the effects of ongoing activation of the trigeminal nervous system, including during the interictal period, on CBF. MATERIALS AND METHODS In a total of 242 patient with migraine (age range, 18-75 years), CBF was measured by MR imaging arterial spin-labeling during the interictal period and was compared with results from 26 healthy volunteers younger than 45 years of age as control subjects (age range, 22-45 years). Cortical hyperperfusion was defined as identification of ≥2 cerebral cortical regions with regional CBF values at least 2 SDs above the mean regional CBF in control subjects. RESULTS The overall frequency of cortical hyperperfusion was significantly higher in patients with migraine (115 of 242, 48%) than in control subjects (1 of 26, 4%). Multivariable analysis revealed the 18- to 40-year age group and patients with migraine without insomnia as significant positive clinical factors associated with cortical hyperperfusion. Among patients with migraine without insomnia, the frequency of cortical hyperperfusion was >92% (89 of 97). One-way ANOVA showed that in all ROIs of the cortex, regional CBF was significantly higher in patients with migraine without insomnia than in patients with migraine with insomnia or control subjects. In patients with migraine without insomnia, cortical hyperperfusion findings showed a sensitivity of 0.918 and a specificity of 0.962 for migraine in the interictal period, representing excellent accuracy. In contrast, among patients with migraine with insomnia, sensitivity was only 0.179 but specificity was 0.962. CONCLUSIONS Patients with migraine without insomnia may have cortical hyperperfusion during the interictal period; however, the findings of the present study need to be prospectively validated on a larger scale before clinical applicability can be considered.
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Affiliation(s)
- Masami Shimoda
- From the Department of Neurosurgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Kaori Hoshikawa
- From the Department of Neurosurgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Shinri Oda
- From the Department of Neurosurgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Masaaki Imai
- From the Department of Neurosurgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Takahiro Osada
- From the Department of Neurosurgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Rie Aoki
- From the Department of Neurosurgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Azusa Sunaga
- From the Department of Neurosurgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Chiaki Shinohara
- From the Department of Neurosurgery, Tokai University Hachioji Hospital, Tokyo, Japan
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Barbanti P, Aurilia C, Egeo G, Proietti S, Torelli P, d'Onofrio F, Carnevale A, Tavani S, Orlando B, Fiorentini G, Colombo B, Filippi M, Bonassi S, Cevoli S. Impact of multiple treatment cycles with anti-CGRP monoclonal antibodies on migraine course: focus on discontinuation periods. Insights from the multicenter, prospective, I-GRAINE study. J Neurol 2024; 271:2605-2614. [PMID: 38342785 PMCID: PMC11055727 DOI: 10.1007/s00415-024-12192-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/06/2024] [Accepted: 01/13/2024] [Indexed: 02/13/2024]
Abstract
OBJECTIVES While a single 12-month treatment cycle (TrC) with anti-CGRP mAbs is not disease-modifying for most patients, there is limited understanding of the effects of multiple TrCs on migraine course. We evaluated whether a second TrC might modify the migraine course by comparing the occurrence of migraine relapse after discontinuation of the second TrC to that following the cessation of the first TrC. METHODS In a real-life, multicenter, prospective study we considered all consecutive patients diagnosed with high-frequency episodic migraine (HFEM) or chronic migraine (CM) with > 3 treatment failures and treated with any anti-CGRP mAbs for ≥ 2 consecutive 12-month TrCs who were responders at week 12. The primary endpoint was the change in monthly migraine days (MMD) for HFEM or monthly headache days (MHD) for CM at the first month of treatment discontinuation after the second TrC (D2) compared to the first TrC (D1). Secondary endpoints included variations in monthly analgesic medications (MAM), Numeric Rating Scale (NRS), and Headache Impact Test (HIT-6) scores, ≥ 50%, ≥ 75%, and 100% response rates, and relapse from episodic migraine to CM and from no-medication overuse (MO) to MO at D2 vs. D1. RESULTS One-hundred-seventy-eight patients completed two 12-month TrCs with anti-CGRP mAbs. At D2, patients experienced a significant reduction in MMD (- 0.6, p = 0.028), MHD (- 2.6, p < 0.001), monthly analgesic medications (- 2.0, p < 0.001), and HIT-6 score (- 2.2, p < 0.001) compared to D1, indicating improved effectiveness. The ≥ 50% response rate at weeks 45-48 during the first TrC was 95.5%, while at weeks 45-48 of the second TrC was 99.4%. Corresponding rates at D1 was 20.2% whereas at D2 was 51.6% (p < 0.0001). No statistical difference emerged in ≥ 75% and 100% responders. The relapse rate from episodic migraine to CM at D2 was lower than at D1 (12.3% vs 30.4%; p = 0.0002) Fewer patients experienced relapse from no-MO to MO at D2 compared to D1 (29.5% vs 68.7%; p = 0.00001). DISCUSSION A second TrC with anti-CGRP mAbs demonstrated clinical improvements compared to the first one, as indicated by a milder migraine relapse at D2 compared to D1. Multiple TrCs with anti-CGRP mAbs could progressively modify migraine evolution by reducing CGRP-dependent neuroinflammatory nociceptive inputs to the brain.
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Affiliation(s)
- Piero Barbanti
- Headache and Pain Unit, IRCCS San Raffaele, Via Della Pisana 235, 00163, Rome, Italy.
- San Raffaele University, Rome, Italy.
| | - Cinzia Aurilia
- Headache and Pain Unit, IRCCS San Raffaele, Via Della Pisana 235, 00163, Rome, Italy
| | - Gabriella Egeo
- Headache and Pain Unit, IRCCS San Raffaele, Via Della Pisana 235, 00163, Rome, Italy
| | - Stefania Proietti
- Clinical and Molecular Epidemiology, IRCCS San Raffaele, Rome, Italy
| | - Paola Torelli
- Unit of Neurology, Department of Medicine and Surgery, Headache Center, University of Parma, Parma, Italy
| | - Florindo d'Onofrio
- Headache Center Neurology Unit, San Giuseppe Moscati Hospital, Avellino, Italy
| | | | - Sofia Tavani
- Catholic University of Sacred Heart Rome, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Bianca Orlando
- Headache and Pain Unit, IRCCS San Raffaele, Via Della Pisana 235, 00163, Rome, Italy
| | - Giulia Fiorentini
- Headache and Pain Unit, IRCCS San Raffaele, Via Della Pisana 235, 00163, Rome, Italy
- San Raffaele University, Rome, Italy
| | - Bruno Colombo
- Headache Unit, Department of Neurology, Scientific Institute San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Massimo Filippi
- Headache Unit, Department of Neurology, Scientific Institute San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Stefano Bonassi
- San Raffaele University, Rome, Italy
- Clinical and Molecular Epidemiology, IRCCS San Raffaele, Rome, Italy
| | - Sabina Cevoli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
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Rattanawong W, Rapoport A, Srikiatkhachorn A. Medication "underuse" headache. Cephalalgia 2024; 44:3331024241245658. [PMID: 38613233 DOI: 10.1177/03331024241245658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
BACKGROUND Many risk factors have been associated with migraine progression, including insufficient and ineffective utilization of migraine medications; however, they have been inadequately explored. This has resulted in suboptimal usage of medications without effective altering of prescribing recommendations for patients, posing a risk for migraine chronification. METHODS Our aim is to conduct a comprehensive review of the available evidence regarding the underuse of migraine medications, both acute and preventive. The term "underuse" includes, but is not limited to: (1) ineffective use of appropriate and inappropriate medication; (2) underutilization; (3) inappropriate timing of usage; and (4) patient dissatisfaction with medication. RESULTS The underuse of both acute and preventive medications has been shown to contribute to the progression of migraine. In terms of acute medication, chronification occurs as a result of insufficient drug use, including failure of the prescriber to select the appropriate type based on pain intensity and disability, patients taking medication too late (more than 60 minutes after the onset or after central sensitization has occurred as evidenced by allodynia), and discontinuation because of lack of effect or intolerable side effects. The underlying cause of inadequate effectiveness of acute medication lies in its inability to halt the propagation of peripheral activation to central sensitization in a timely manner. For oral and injectable preventive migraine medications, insufficient efficacy and intolerable side effects have led to poor adherence and discontinuation with subsequent progression of migraine. The underlying pathophysiology here is rooted in the repetitive stimulation of afferent sensory pain fibers, followed by ascending brainstem pain pathways plus dysfunction of the endogenous descending brainstem pain inhibitory pathway. Although anti-calcitonin gene-related peptide (CGRP) medications partially address pain caused by the above factors, including decreased efficacy and tolerability from conventional therapy, some patients do not respond well to this treatment. Research suggests that initiating preventive anti-CGRP treatment at an early stage (during low frequency episodic migraine attacks) is more beneficial than commencing it during high frequency episodic attacks or when chronic migraine has begun. CONCLUSIONS The term "medication underuse" is underrecognized, but it holds significant importance. Optimal usage of acute care and preventive migraine medications could potentially prevent migraine chronification and improve the treatment of migraine attacks.
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Affiliation(s)
- Wanakorn Rattanawong
- Faculty of Medicine, King Mongkut's Institute of Technology Ladkrabang, Bangkok, Thailand
| | - Alan Rapoport
- Department of Neurology, The David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Anan Srikiatkhachorn
- Faculty of Medicine, King Mongkut's Institute of Technology Ladkrabang, Bangkok, Thailand
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Dermitzakis EV, Vikelis M, Xiromerisiou G, Rallis D, Soldatos P, Litsardopoulos P, Rikos D, Argyriou AA. Nine-Month Continuous Fremanezumab Prophylaxis on the Response to Triptans and Also on the Incidence of Triggers, Hypersensitivity and Prodromal Symptoms of Patients with High-Frequency Episodic Migraine. J Clin Med 2024; 13:386. [PMID: 38256516 PMCID: PMC10816996 DOI: 10.3390/jcm13020386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/06/2024] [Accepted: 01/08/2024] [Indexed: 01/24/2024] Open
Abstract
Objective: To investigate whether the incidence of triggers, prodromal symptoms, hypersensitivity symptoms accompanying headache and responses to triptans were modified during a continuous 9-month fremanezumab therapy for migraine prophylaxis. Patients and methods: We studied 63 patients with high-frequency episodic migraine (HFEM). Enrolled patients received fremanezumab for nine consecutive months before defining the response rates and being stratified into treatment responders (≥50-74% reduction in monthly headache days (MHDs)), super responders (≥75%), partial non-responders (<50%) and super non-responders (<30%). Through headache diaries, patients provided data in order to document the impact of fremanezumab on the incidence of triggers, associated symptoms followed by headache and response to triptans (the use of the migraine treatment optimization questionnaire-4 (mTOQ-4)) during the 9-month treatment period. Results: Fremanezumab had early (after 3 monthly cycles) beneficial effects on the response to triptans in the majority of responders with relevant increases in mTOQ-4 scoring, but also in half of partial non-responders. A significant reduction in median days with migraine-associated symptoms was seen in responders after 6 months of therapy with fremanezumab, mostly for osmophobia, photophobia, phonophobia and nausea/vomiting, but partial non-responders also benefited. Likewise, the incidence of self-reported prodromal symptoms was significantly reduced in responders and was modestly diminished in partial non-responders. Triggers remained unaffected in both responders and non-responders. Conclusions: Fremanezumab given for at least 6-9 months may exert neuromodulatory effects in the migraine brain. These effects could result both in the inhibition of migraine chronification, but also in the diminishing of the magnitude of migraine-associated symptoms, mostly in responders and in partial non-responders.
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Affiliation(s)
| | - Michail Vikelis
- Headache Clinic, Mediterraneo Hospital, 16675 Athens, Greece;
| | - Georgia Xiromerisiou
- Department of Neurology, University Hospital of Larissa, University of Thessaly, 41110 Larissa, Greece;
| | - Dimitrios Rallis
- Department of Neurology, Tzaneio General Hospital of Piraeus, 18536 Athens, Greece;
| | | | - Pantelis Litsardopoulos
- Headache Outpatient Clinic, Department of Neurology, Agios Andreas State General Hospital of Patras, 26335 Patras, Greece; (P.L.); (A.A.A.)
| | | | - Andreas A. Argyriou
- Headache Outpatient Clinic, Department of Neurology, Agios Andreas State General Hospital of Patras, 26335 Patras, Greece; (P.L.); (A.A.A.)
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