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Kramer J, Hayek S, Levy R. Neuromodulation treatments for migraine: a contemporary update. Curr Opin Anaesthesiol 2024:00001503-990000000-00216. [PMID: 39011719 DOI: 10.1097/aco.0000000000001414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/17/2024]
Abstract
PURPOSE OF REVIEW Neuromodulation approaches have been a part of a revolution in migraine therapies with multiple devices approved or in development. These devices vary in the nerve(s) being targeted, implantable versus noninvasive form factors as well as their effectiveness for acute pain reduction or migraine prevention. This review will summarize these recent advancements and approaches that are being developed which build upon prior work and improved technology that may help enhance the effectiveness as well as the patient experience. RECENT FINDINGS Both noninvasive and implantable devices primarily targeting cranial nerves have shown the ability to help alleviate migraine symptoms. Multiple prospective and retrospective studies have demonstrated clinically meaningful reductions in headache intensity with noninvasive approaches, while prevention of migraine demonstrates more modest effects. Implantable neuromodulation technologies focusing on occipital and supraorbital stimulation have shown promise in migraine/headache prevention in chronic migraine patients, but there is a need for improvements in technology to address key needs for surgical approaches. SUMMARY Electrical neuromodulation approaches in the treatment of migraine is undergoing a transformation towards improved outcomes with better technologies that may suit various patient needs on a more individualized basis.
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Affiliation(s)
- Jeffery Kramer
- Volta Research, Minneapolis, Minnesota
- University of Illinois, Chicago, Illinois
| | - Salim Hayek
- Case Western Reserve University, Cleveland, Ohio
| | - Robert Levy
- Neurosurgery and Clinical Research, Anesthesia Pain Care Consultants, Inc, Tamarac, Florida, USA
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2
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Lipton RB, Ailani J, Mullin K, Pavlovic JM, Tepper SJ, Dodick DW, Blumenfeld AM. Situational prevention: Pharmacotherapy during periods of increased risk for migraine attacks. Headache 2024; 64:859-864. [PMID: 38957980 DOI: 10.1111/head.14775] [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: 03/08/2024] [Revised: 05/10/2024] [Accepted: 05/27/2024] [Indexed: 07/04/2024]
Abstract
The small molecule calcitonin gene-related peptide receptor antagonists (gepants) are the only drug class with medicines indicated for both the acute and preventive treatment of migraine. Given this dual capacity to both treat and prevent, along with their favorable tolerability profiles and lack of an association with medication-overuse headache, headache specialists have begun to use gepants in ways that transcend the traditional categories of acute and preventive treatment. One approach, called situational prevention, directs patients to treat during the interictal phase, before symptoms develop, in situations of increased risk for migraine attacks. Herein, we present three patients to illustrate scenarios of gepant use for situational prevention. In each case, a gepant was started in anticipation of a period of increased headache probability (vulnerability) and continued for a duration of 1 day to 5 consecutive days. Although this approach may expose patients to medication when headache may not have developed, the tolerability and safety profile and preventive effect of gepants may represent a feasible approach for some patients. Situational prevention is an emerging strategy for managing migraine before symptoms develop in individuals who can identify periods when the probability of headache is high. This paper is intended to increase awareness of this strategy and stimulate future randomized, placebo-controlled trials to rigorously assess this strategy.
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Affiliation(s)
- Richard B Lipton
- Department of Neurology, Albert Einstein College of Medicine, Bronx, New York, USA
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
- Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jessica Ailani
- Department of Neurology, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Kathleen Mullin
- The New England Institute for Neurology and Headache, Stamford, Connecticut, USA
| | - Jelena M Pavlovic
- Department of Neurology, Albert Einstein College of Medicine, Bronx, New York, USA
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
- Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Stewart J Tepper
- The New England Institute for Neurology and Headache, Stamford, Connecticut, USA
| | - David W Dodick
- Department of Neurology, Mayo Clinic, Scottsdale, Arizona, USA
- Atria Academy of Science and Medicine, New York, New York, USA
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3
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Suzuki K, Suzuki S, Fujita H, Sakuramoto H, Shioda M, Hirata K. Can calcitonin gene-related peptide monoclonal antibodies ameliorate writer's cramp and migraine? Neuropsychopharmacol Rep 2024; 44:482-484. [PMID: 38602109 PMCID: PMC11144594 DOI: 10.1002/npr2.12444] [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] [Received: 02/21/2024] [Revised: 04/05/2024] [Accepted: 04/07/2024] [Indexed: 04/12/2024] Open
Abstract
Recently, calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAbs) have become available as a prophylactic treatment for migraine and have shown high efficacy and safety in clinical practice. CGRP mAbs have been reported to be effective not only for migraine but also for other comorbidities, such as psychiatric complications in patients with migraine. However, there are no reports examining the effect of CGRP mAbs on dystonia. We treated a patient with comorbid migraine and focal task-specific dystonia (writer's cramp) with a CGRP mAb (erenumab) because of an increase in monthly migraine days despite the addition of migraine prophylaxis. In this patient, erenumab treatment for 3 months led to improvements in symptoms of both focal dystonia and migraine, suggesting a role for CGRP in the pathophysiology of both conditions.
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Affiliation(s)
- Keisuke Suzuki
- Department of NeurologyDokkyo Medical UniversityMibuJapan
| | - Shiho Suzuki
- Department of NeurologyDokkyo Medical UniversityMibuJapan
| | - Hiroaki Fujita
- Department of NeurologyDokkyo Medical UniversityMibuJapan
| | | | - Mukuto Shioda
- Department of NeurologyDokkyo Medical UniversityMibuJapan
| | - Koichi Hirata
- Department of NeurologyDokkyo Medical UniversityMibuJapan
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Al-Hassany L, Boucherie DM, Couturier EGM, MaassenVanDenBrink A. Case reports: Could sexual dysfunction in women with migraine be a side effect of CGRP inhibition? Cephalalgia 2024; 44:3331024241248837. [PMID: 38796855 DOI: 10.1177/03331024241248837] [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: 05/29/2024]
Abstract
BACKGROUND The development and approval of antibodies targeting calcitonin gene-related peptide or its receptor mark a revolutionary era for preventive migraine treatment. Real-world evidence sheds light on rare, stigmatized or overlooked side effects of these drugs. One of these potential side effects is sexual dysfunction. CASE REPORTS We present two cases of one 42-year-old and one 45-year-old female patient with chronic migraine who both reported sexual dysfunction as a possible side effect of treatment with galcanezumab, a monoclonal antibody targeting calcitonin gene-related peptide. DISCUSSION As calcitonin gene-related peptide is involved in vaginal lubrication as well as genital sensation and swelling, inhibiting the calcitonin gene-related peptide pathway may lead to sexual dysfunction as a potential side effect. CONCLUSION Sexual dysfunction in female migraine patients might be a rare and overlooked side effect of monoclonal antibodies targeting the calcitonin gene-related peptide pathway. Considering the discomfort and stigma surrounding both migraine and sexual dysfunction, we advocate for an open attitude and awareness among clinicians toward such side effects.
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Affiliation(s)
- Linda Al-Hassany
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Deirdre M Boucherie
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Emile G M Couturier
- Department of Neurology/Clinical Neurophysiology, Neurologie Centrum Amsterdam, Amsterdam, The Netherlands
| | - Antoinette MaassenVanDenBrink
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Singh S, Kopruszinski CM, Watanabe M, Dodick DW, Navratilova E, Porreca F. Female-selective mechanisms promoting migraine. J Headache Pain 2024; 25:63. [PMID: 38658853 PMCID: PMC11040950 DOI: 10.1186/s10194-024-01771-w] [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: 04/03/2024] [Accepted: 04/15/2024] [Indexed: 04/26/2024] Open
Abstract
Sexual dimorphism has been revealed for many neurological disorders including chronic pain. Prelicinal studies and post-mortem analyses from male and female human donors reveal sexual dimorphism of nociceptors at transcript, protein and functional levels suggesting different mechanisms that may promote pain in men and women. Migraine is a common female-prevalent neurological disorder that is characterized by painful and debilitating headache. Prolactin is a neurohormone that circulates at higher levels in females and that has been implicated clinically in migraine. Prolactin sensitizes sensory neurons from female mice, non-human primates and humans revealing a female-selective pain mechanism that is conserved evolutionarily and likely translationally relevant. Prolactin produces female-selective migraine-like pain behaviors in rodents and enhances the release of calcitonin gene-related peptide (CGRP), a neurotransmitter that is causal in promoting migraine in many patients. CGRP, like prolactin, produces female-selective migraine-like pain behaviors. Consistent with these observations, publicly available clinical data indicate that small molecule CGRP-receptor antagonists are preferentially effective in treatment of acute migraine therapy in women. Collectively, these observations support the conclusion of qualitative sex differences promoting migraine pain providing the opportunity to tailor therapies based on patient sex for improved outcomes. Additionally, patient sex should be considered in design of clinical trials for migraine as well as for pain and reassessment of past trials may be warranted.
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Affiliation(s)
- Shagun Singh
- Banner - University Medicine Sunrise Primary Care, Tucson, AZ, 85750, USA
| | - Caroline M Kopruszinski
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, AZ, 85724, USA
| | - Moe Watanabe
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, AZ, 85724, USA
| | - David W Dodick
- Department of Neurology, Mayo Clinic, Phoenix, AZ, USA
- Atria Academy of Science and Medicine, New York, NY, USA
| | - Edita Navratilova
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, AZ, 85724, USA
- Department of Neurology, Mayo Clinic, Phoenix, AZ, USA
| | - Frank Porreca
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, AZ, 85724, USA.
- Department of Neurology, Mayo Clinic, Phoenix, AZ, USA.
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Oliveira R, Gil-Gouveia R, Puledda F. CGRP-targeted medication in chronic migraine - systematic review. J Headache Pain 2024; 25:51. [PMID: 38575868 PMCID: PMC10996229 DOI: 10.1186/s10194-024-01753-y] [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] [Received: 11/12/2023] [Accepted: 03/18/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Chronic migraine is a highly debilitating condition that is often difficult to manage, particularly in the presence of medication overuse headache. Drugs targeting the calcitonin gene-related peptide (CGRP), or its receptor have shown promising results in treating this disorder. METHODS We searched Pubmed and Embase to identify randomized clinical trials and real-world studies reporting on the use of medication targeting the calcitonin gene-related peptide in patients with chronic migraine. RESULTS A total of 270 records were identified. Nineteen studies qualified for the qualitative analysis. Most studies reported on monoclonal antibodies targeting CGRP (anti-CGRP mAbs), that overall prove to be effective in decreasing monthly migraine days by half in about 27.6-61.4% of the patients. Conversion from chronic to episodic migraine was seen in 40.88% of the cases, and 29-88% of the patients stopped medication overuse. Obesity seems to be the main negative predictor of response to anti-CGRP mAbs. There is no evidence to suggest the superiority of one anti-CGRP mAb. Despite the lack of strong evidence, the combination of anti-CGRP medication with onabotulinumtoxinA in chronic migraine is likely to bring benefits for resistant cases. Atogepant is the first gepant to demonstrate a significant decrease in monthly migraine days compared to placebo in a recent trial. Further, anti-CGRP mAb and gepants have a good safety profile. CONCLUSION There is strong evidence from randomized trials and real-world data to suggest that drugs targeting CGRP are a safe and effective treatment for chronic migraine.
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Affiliation(s)
- Renato Oliveira
- Headache Group, Wolfson SPaRRC, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 9PJ, UK
- Neurology Department, Barking, Havering and Redbridge University Hospitals NHS Foundation Trust, London, UK
| | - Raquel Gil-Gouveia
- Hospital da Luz Headache Center, Neurology Department, Hospital da Luz Lisboa, Lisbon, Portugal
- Center for Interdisciplinary Research in Health, Universidade Católica Portuguesa, Lisbon, Portugal
| | - Francesca Puledda
- Headache Group, Wolfson SPaRRC, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 9PJ, UK.
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Sutherland HG, Jenkins B, Griffiths LR. Genetics of migraine: complexity, implications, and potential clinical applications. Lancet Neurol 2024; 23:429-446. [PMID: 38508838 DOI: 10.1016/s1474-4422(24)00026-7] [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: 05/09/2023] [Revised: 01/09/2024] [Accepted: 01/11/2024] [Indexed: 03/22/2024]
Abstract
Migraine is a common neurological disorder with large burden in terms of disability for individuals and costs for society. Accurate diagnosis and effective treatments remain priorities. Understanding the genetic factors that contribute to migraine risk and symptom manifestation could improve individual management. Migraine has a strong genetic basis that includes both monogenic and polygenic forms. Some distinct, rare, familial migraine subtypes are caused by pathogenic variants in genes involved in ion transport and neurotransmitter release, suggesting an underlying vulnerability of the excitatory-inhibitory balance in the brain, which might be exacerbated by disruption of homoeostasis and lead to migraine. For more prevalent migraine subtypes, genetic studies have identified many susceptibility loci, implicating genes involved in both neuronal and vascular pathways. Genetic factors can also reveal the nature of relationships between migraine and its associated biomarkers and comorbidities and could potentially be used to identify new therapeutic targets and predict treatment response.
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Affiliation(s)
- Heidi G Sutherland
- Centre for Genomics and Personalised Health, Genomics Research Centre, School of Biomedical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
| | - Bronwyn Jenkins
- Department of Neurology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Lyn R Griffiths
- Centre for Genomics and Personalised Health, Genomics Research Centre, School of Biomedical Sciences, Queensland University of Technology, Brisbane, QLD, Australia.
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Albanese M, Pescini F, Di Bonaventura C, Iannone LF, Bianchi S, Poggesi A, Bengala M, Mercuri NB, De Cesaris F. Long-Term Treatment with the Calcitonin Gene-Related Peptide Receptor Antagonist Erenumab in CADASIL: Two Case Reports. J Clin Med 2024; 13:1870. [PMID: 38610637 PMCID: PMC11012730 DOI: 10.3390/jcm13071870] [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: 02/11/2024] [Revised: 03/14/2024] [Accepted: 03/21/2024] [Indexed: 04/14/2024] Open
Abstract
Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is the most common monogenic form of cerebral small vessel disease, caused by a mutation in the NOTCH3 gene on chromosome 19. The main clinical features include migraine (often with aura), early onset, recurrent subcortical ischemic strokes, mood disturbances, and cognitive impairment, frequently leading to dementia and disability with a reduction in life expectancy. Cerebral chronic global hypoperfusion, due to impaired cerebrovascular reactivity, seems to play a primary role in CADASIL. Migraine is the most common early feature of the disease, and to date, there are no consensus guidelines for treatment. Given the vasomodulatory influence of many antimigraine drugs, there is concern about their use in this disease. In particular, the calcitonin gene-related peptide (CGRP) system serves as a vasodilatory protective mechanism during cerebral and cardiac ischemia. Blocking this system could exacerbate ischemic events. Herein, we describe two CADASIL patients who were treated with the calcitonin gene-related peptide (CGRP) receptor antagonist erenumab for chronic migraine, reporting a significant reduction in the frequency of attacks and intensity of pain, and an improvement in quality of life without adverse effects.
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Affiliation(s)
- Maria Albanese
- Headache Center, Neurology Unit, Tor Vergata University Hospital, 00133 Rome, Italy; (M.A.); (N.B.M.)
- Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Francesca Pescini
- Stroke Unit, Emergency Department, AOU Careggi, 50134 Florence, Italy;
- NEUROFARBA Department, University of Florence, 50121 Florence, Italy
| | - Chiara Di Bonaventura
- Department of Experimental and Clinical Medicine, University of Florence, 50121 Florence, Italy;
| | - Luigi Francesco Iannone
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, 50121 Florence, Italy
| | - Silvia Bianchi
- Department of Medical Surgical and Neurological Sciences, University of Siena, 53100 Siena, Italy;
| | - Anna Poggesi
- Stroke Unit, Emergency Department, AOU Careggi, 50134 Florence, Italy;
- NEUROFARBA Department, University of Florence, 50121 Florence, Italy
| | - Mario Bengala
- Tor Vergata University Hospital, Medical Genetics Unit, 00133 Rome, Italy;
| | - Nicola Biagio Mercuri
- Headache Center, Neurology Unit, Tor Vergata University Hospital, 00133 Rome, Italy; (M.A.); (N.B.M.)
- Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Francesco De Cesaris
- Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, 50134 Florence, Italy;
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Porreca F, Navratilova E, Hirman J, van den Brink AM, Lipton RB, Dodick DW. Evaluation of outcomes of calcitonin gene-related peptide (CGRP)-targeting therapies for acute and preventive migraine treatment based on patient sex. Cephalalgia 2024; 44:3331024241238153. [PMID: 38477313 DOI: 10.1177/03331024241238153] [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: 03/14/2024]
Abstract
BACKGROUND Women show increased prevalence and severity of migraine compared to men. Whether small molecule calcitonin gene-related peptide receptor (CGRP-R) antagonists (i.e., gepants) and monoclonal antibodies targeting either the CGRP-R or the CGRP peptide might show sexually dimorphic outcomes for acute and preventive therapy has not been established. METHODS We conducted a subpopulation analysis of available published data from FDA reviews to evaluate potential sex differences in the response rates of ubrogepant, rimegepant and zavegepant for acute migraine therapy. Available data from FDA reviews of erenumab, fremanezumab, galcanezumab and eptinezumab, approved CGRP-R and CGRP monoclonal antibodies and of atogepant were examined for prevention outcomes based on patient sex. Preventive outcomes were analyzed separately for patients with episodic migraine and chronic migraine. RESULTS In women, the three approved gepants produced statistically significant drug effects regardless of dose tested on the FDA mandated co-primary endpoints, the proportion of patients achieving two-hour pain-freedom and the proportion of patients free of their most bothersome symptom at two hours post-dose. In women, the average placebo-subtracted two-hour pain-freedom proportion was 9.5% (CI: 7.4 to 11.6) and the average numbers needed to treat was 11. The free from most bothersome symptom at two hours outcomes were also significant in women. The gepant drugs did not reach statistically significant effects on the two-hour pain-freedom endpoint in the men, with an average drug effect of 2.8% (CI: -2.5 to 8.2) and an average number needed to treat of 36. For freedom from most bothersome symptom at two hours post-dose endpoint, differences were not significant in male patients. The treatment effect in each of the gepant studies was always numerically greater in women than in men. In evaluation of prevention outcomes with the antibodies or atogepant using the change from the specified primary endpoint (e.g., monthly migraine days), the observed treatment effect for episodic migraine patients almost always favored drug over placebo in both women and men. For chronic migraine patients the treatment effects of antibodies were similar in men and women and always favored the drug treated group.Conclusion/Interpretation: Small molecule CGRP-R antagonists are effective in acute migraine therapy in women but available data do not demonstrate effectiveness in men. CGRP-targeting therapies are effective for migraine prevention in both male and female episodic migraine patients but possible sex differences remain uncertain. In male and female chronic migraine patients, CGRP/CGRP-R antibodies were similarly effective. The data highlight possible differential effects of CGRP targeted therapies in different patient populations and the need for increased understanding of CGRP neurobiology in men and women.
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Affiliation(s)
- Frank Porreca
- Department of Pharmacology, University of Arizona, Tucson, USA
- Mayo Clinic Arizona, Phoenix, USA
| | - Edita Navratilova
- Department of Pharmacology, University of Arizona, Tucson, USA
- Mayo Clinic Arizona, Phoenix, USA
| | - Joe Hirman
- Pacific Northwest Statistical Consulting, Woodinville, USA
| | - Antoinette Maassen van den Brink
- Department of Internal Medicine, Division of Pharmacology, Vascular Medicine and Metabolic Diseases, Erasmus MC University Medical Center Rotterdam, The Netherlands
| | - Richard B Lipton
- Departments of Neurology, Psychiatry and Behavioral Science, and Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - David W Dodick
- Mayo Clinic Arizona, Phoenix, USA
- Atria Academy of Science and Medicine, New York, USA
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Hay DL. A future treatment horizon for migraine? Lancet Neurol 2024; 23:226-227. [PMID: 38365364 DOI: 10.1016/s1474-4422(24)00032-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 01/18/2024] [Indexed: 02/18/2024]
Affiliation(s)
- Debbie L Hay
- Department of Pharmacology & Toxicology, University of Otago, Dunedin 9054, New Zealand.
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Noseda R, Bedussi F, Gobbi C, Ceschi A, Zecca C. Calcitonin gene-related peptide antagonists in pregnancy: a disproportionality analysis in VigiBase ®. J Headache Pain 2024; 25:10. [PMID: 38243189 PMCID: PMC10799383 DOI: 10.1186/s10194-024-01715-4] [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] [Received: 12/21/2023] [Accepted: 01/11/2024] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND Current evidence on the safety of calcitonin gene-related peptide antagonists (CGRP-A) in pregnancy for the treatment of both episodic and chronic migraine is scarce and does not yet provide definitive information. By querying VigiBase®, the World Health Organization global pharmacovigilance database, this study aimed to detect differences in the reporting frequency between CGRP-A and triptans in relation to pregnancy. METHODS Disproportionality analyses on de-duplicated safety reports collected in VigiBase® as of 31.05.2023 reporting exposure to CGRP-A in pregnancy with or without pregnancy outcomes. A Reporting Odds Ratio (ROR) with a 95% confidence interval (CI) was used as a measure of disproportionality and the threshold for the detection of a signal of disproportionate reporting was set with a 95% CI lower limit > 1. FINDINGS Four hundred sixty-seven safety reports reported exposure to CGRP-A in pregnancy, mostly originating from the United States of America (360/467, 77%), more frequently reported by patients (225/467, 48%), who were mainly females (431/467, 92%), and more frequently reported exposure to CGRP-A during pregnancy (400/467, 86%). Compared to triptans, no signals of disproportionate reporting were detected with CGRP-A either for the overall reporting of pregnancy-related safety reports (ROR 0.91, 95% CI 0.78-1.06), for the reporting of pregnancy outcomes (maternal and/or foetal/neonatal, ROR 0.54, 95% CI 0.45-0.66), or for the reporting of foetal/neonatal outcomes (ROR 0.53, 95% CI 0.41-0.68). CONCLUSIONS This study showed that, to date, there are no signals of increased reporting with CGRP-A compared to triptans in relation to pregnancy in VigiBase®. Future pharmacovigilance studies are needed to confirm these findings.
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Affiliation(s)
- Roberta Noseda
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Francesca Bedussi
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Claudio Gobbi
- Department of Neurology, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Alessandro Ceschi
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
- Clinical Trial Unit, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland
| | - Chiara Zecca
- Department of Neurology, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland.
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland.
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van Lohuizen R, Paungarttner J, Lampl C, MaassenVanDenBrink A, Al-Hassany L. Considerations for hormonal therapy in migraine patients: a critical review of current practice. Expert Rev Neurother 2023; 24:1-21. [PMID: 38112066 PMCID: PMC10791067 DOI: 10.1080/14737175.2023.2296610] [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: 07/18/2023] [Accepted: 12/06/2023] [Indexed: 12/20/2023]
Abstract
INTRODUCTION Migraine, a neurovascular headache disorder, is a leading cause of disability worldwide. Within the multifaceted pathophysiology of migraine, hormonal fluctuations play an evident triggering and exacerbating role, pointing toward the need for identification and proper usage of both existing and new hormonal targets in migraine treatment. AREAS COVERED With a threefold higher incidence of migraine in women than in men, the authors delve into sex hormone-related events in migraine patients. A comprehensive overview is given of existing hormonal therapies, including oral contraceptives, intrauterine devices, transdermal and subcutaneous estradiol patches, gnRH-agonists, oral testosterone, and 5α reductase inhibitors. The authors discuss their effectiveness and risks, noting their suitability for different patient profiles. Next, novel evolving hormonal treatments, such as oxytocin and prolactin, are explored. Lastly, the authors cover hormonal conditions associated with migraine, such as polycystic ovary syndrome, endometriosis, and transgender persons receiving gender affirming hormone therapy, aiming to provide more personalized and effective solutions for migraine management. EXPERT OPINION Rigorous research into both existing and new hormonal targets, as well as the underlying pathophysiology, is needed to support a tailored approach in migraine treatment, in an ongoing effort to alleviate the impact of migraine on individuals and society.
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Affiliation(s)
- Romy van Lohuizen
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | | | - Christian Lampl
- Headache Medical Center Linz, Linz, Austria
- Department of Neurology and Stroke Unit, Koventhospital Barmherzige Brüder Linz, Linz, Austria
| | - Antoinette MaassenVanDenBrink
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Linda Al-Hassany
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Suzuki S, Suzuki K, Shiina T, Kobayashi S, Shioda M, Hirata K. Switching from calcitonin gene-related peptide monoclonal antibody monthly to fremanezumab quarterly based on the patient's preferred dosing schedule. J Neurol Sci 2023; 455:122786. [PMID: 37993359 DOI: 10.1016/j.jns.2023.122786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 11/09/2023] [Indexed: 11/24/2023]
Affiliation(s)
- Shiho Suzuki
- Department of Neurology, Dokkyo Medical University, Japan
| | - Keisuke Suzuki
- Department of Neurology, Dokkyo Medical University, Japan.
| | | | - Saro Kobayashi
- Department of Neurology, Dokkyo Medical University, Japan
| | - Mukuto Shioda
- Department of Neurology, Dokkyo Medical University, Japan
| | - Koichi Hirata
- Department of Neurology, Dokkyo Medical University, Japan
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14
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Fila M, Chojnacki J, Pawlowska E, Sobczuk P, Chojnacki C, Blasiak J. The Ketogenic Diet in the Prevention of Migraines in the Elderly. Nutrients 2023; 15:4998. [PMID: 38068855 PMCID: PMC10707997 DOI: 10.3390/nu15234998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 11/23/2023] [Accepted: 11/30/2023] [Indexed: 12/18/2023] Open
Abstract
Migraines display atypical age dependence, as the peak of their prevalence occurs between the ages of 20-40 years. With age, headache attacks occur less frequently and are characterized by a lower amplitude. However, both diagnosis and therapy of migraines in the elderly are challenging due to multiple comorbidities and polypharmacy. Dietary components and eating habits are migraine triggers; therefore, nutrition is a main target in migraine prevention. Several kinds of diets were proposed to prevent migraines, but none are commonly accepted due to inconsistent results obtained in different studies. The ketogenic diet is featured by very low-carbohydrate and high-fat contents. It may replace glucose with ketone bodies as the primary source of energy production. The ketogenic diet and the actions of ketone bodies are considered beneficial in several aspects of health, including migraine prevention, but studies on the ketogenic diet in migraines are not standardized and poorly evidenced. Apart from papers claiming beneficial effects of the ketogenic diet in migraines, several studies have reported that increased levels of ketone bodies may be associated with all-cause and incident heart failure mortality in older adults and are supported by research on mice showing that the ketogenic diets and diet supplementation with a human ketone body precursor may cause life span shortening. Therefore, despite reports showing a beneficial effect of the ketogenic diet in migraines, such a diet requires further studies, including clinical trials, to verify whether it should be recommended in older adults with migraines.
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Affiliation(s)
- Michal Fila
- Department of Developmental Neurology and Epileptology, Polish Mother’s Memorial Hospital—Research Institute, 93-338 Lodz, Poland;
| | - Jan Chojnacki
- Department of Clinical Nutrition and Gastroenterological Diagnostics, Medical University of Lodz, 90-647 Lodz, Poland; (J.C.), (C.C.)
| | - Elzbieta Pawlowska
- Department of Pediatric Dentistry, Medical University of Lodz, 92-217 Lodz, Poland;
| | - Piotr Sobczuk
- Emergency Medicine and Disaster Medicine Department, Medical University of Lodz, 92-209 Lodz, Poland;
- Department of Orthopaedics and Traumatology, Polish Mother’s Memorial Hospital—Research Institute, Rzgowska 281, 93-338 Lodz, Poland
| | - Cezary Chojnacki
- Department of Clinical Nutrition and Gastroenterological Diagnostics, Medical University of Lodz, 90-647 Lodz, Poland; (J.C.), (C.C.)
| | - Janusz Blasiak
- Faculty of Medicine, Collegium Medicum, The Mazovian Academy in Plock, 09-402 Plock, Poland
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15
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Alsaadi T, Kayed DM, Al-Madani A, Hassan AM, Terruzzi A, Krieger D, Riachi N, Sarathchandran P, Al-Rukn S. Consensus-Based Recommendations on the Use of CGRP-Based Therapies for Migraine Prevention in the UAE. Neurol Ther 2023; 12:1845-1865. [PMID: 37792218 PMCID: PMC10630270 DOI: 10.1007/s40120-023-00550-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 09/19/2023] [Indexed: 10/05/2023] Open
Abstract
INTRODUCTION Migraine is a common debilitating neurological disorder affecting a large proportion of the general population. Calcitonin gene-related peptide (CGRP), a 37-amino acid neuropeptide, plays a key role in the pathophysiology of migraine, and the development of therapies targeting the anti-CGRP pathway has revolutionized the field of migraine treatment. METHODS An expert task force of neurologists in the United Arab Emirates (UAE) developed and critically assessed recommendations on the use of CGRP-based therapies in migraine treatment and management in the UAE, based on available published literature. A consensus was reached for each statement by means of an open-voting process, based on a predefined agreement level of at least 60%. RESULTS The consensus recommendations advocate the need for guidelines for the appropriate use of CGRP-based therapies by defining patient cohorts and appropriate monitoring of therapeutic response as well as standardizing the initiation, assessment, and cessation of treatment. The consensus recommendations were primarily formulated on the basis of international studies, because of the limited availability of regional and local data. As such, they may also act as guidelines for global healthcare providers. CONCLUSIONS These are the first consensus recommendations for the UAE that address the use of CGRP-based therapies in the treatment and management of migraine, integrating both clinical evidence and medical expertise to enhance clinical judgment and decision-making.
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Affiliation(s)
- Taoufik Alsaadi
- Department of Neurology, American Center for Psychiatry and Neurology, Abu Dhabi, UAE.
| | - Deeb M Kayed
- Neurology Department, Mediclinic City Hospital, Dubai, UAE
| | | | | | | | - Derk Krieger
- Neurology Department, Mediclinic Parkview Hospital, Dubai, UAE
| | - Naji Riachi
- Sheikh Shakhbout Medical City, Khalifa University College of Medicine and Health Sciences, Abu Dhabi, UAE
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Abstract
Targeting CGRP-pathways has substantially expanded our options for treating individuals with migraine. Although the efficacy of these drugs on migraine aura is yet to be fully revealed, it seems from existing studies that CGRP antagonism reduces the number of migraine auras. The present perspective summarizes the evidence linking CGRP to the migraine aura and proposes a model by which targeting the CGRP-pathways and, thus, inhibition the interaction between C- and Aδ-trigeminal fibers might reverse a possible high cortical glutamate level leading to a reduced number of migraine auras.
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Affiliation(s)
- Mohammad Al-Mahdi Al-Karagholi
- Danish Headache Center, Department of Neurology, Rigshospitalet- Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
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17
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Fila M, Pawlowska E, Szczepanska J, Blasiak J. Different Aspects of Aging in Migraine. Aging Dis 2023; 14:2028-2050. [PMID: 37199585 PMCID: PMC10676778 DOI: 10.14336/ad.2023.0313] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 03/13/2023] [Indexed: 05/19/2023] Open
Abstract
Migraine is a common neurological disease displaying an unusual dependence on age. For most patients, the peak intensity of migraine headaches occurs in 20s and lasts until 40s, but then headache attacks become less intense, occur less frequently and the disease is more responsive to therapy. This relationship is valid in both females and males, although the prevalence of migraine in the former is 2-4 times greater than the latter. Recent concepts present migraine not only as a pathological event, but rather as a part of evolutionary adaptive response to protect organism against consequences of stress-induced brain energy deficit. However, these concepts do not fully explain that unusual dependence of migraine prevalence on age. Many aspects of aging, both molecular/cellular and social/cognitive, are interwound in migraine pathogenesis, but they neither explain why only some persons are affected by migraine, nor suggest any causal relationship. In this narrative/hypothesis review we present information on associations of migraine with chronological aging, brain aging, cellular senescence, stem cell exhaustion as well as social, cognitive, epigenetic, and metabolic aging. We also underline the role of oxidative stress in these associations. We hypothesize that migraine affects only individuals who have inborn, genetic/epigenetic, or acquired (traumas, shocks or complexes) migraine predispositions. These predispositions weakly depend on age and affected individuals are more prone to migraine triggers than others. Although the triggers can be related to many aspects of aging, social aging may play a particularly important role as the prevalence of its associated stress has a similar age-dependence as the prevalence of migraine. Moreover, social aging was shown to be associated with oxidative stress, important in many aspects of aging. In perspective, molecular mechanisms underlying social aging should be further explored and related to migraine with a closer association with migraine predisposition and difference in prevalence by sex.
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Affiliation(s)
- Michal Fila
- Department of Developmental Neurology and Epileptology, Polish Mother’s Memorial Hospital Research Institute, 93-338 Lodz, Poland.
| | - Elzbieta Pawlowska
- Department of Pediatric Dentistry, Medical University of Lodz, 92-216 Lodz, Poland.
| | - Joanna Szczepanska
- Department of Pediatric Dentistry, Medical University of Lodz, 92-216 Lodz, Poland.
| | - Janusz Blasiak
- Department of Molecular Genetics, University of Lodz, Pomorska 141/143, 90-236, Lodz, Poland.
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Caponnetto V, Russo A, Silvestro M, Tessitore A, De Icco R, Vaghi G, Sances G, Tassorelli C, Baraldi C, Castro FL, Guerzoni S, Prudenzano MP, Fallacara A, Gentile M, Ornello R, Onofri A, Burgalassi A, Chiarugi A, De Cesaris F, Granato A, Casalena A, De Tommaso M, Mampreso E, Merlo P, Coppola G, Battistini S, Rebecchi V, Rainero I, Sepe FN, Dalla Volta G, Sacco S, Geppetti P, Iannone LF. Long-Term Treatment Over 52 Weeks with Monthly Fremanezumab in Drug-Resistant Migraine: A Prospective Multicenter Cohort Study. CNS Drugs 2023; 37:1069-1080. [PMID: 37999868 PMCID: PMC10703741 DOI: 10.1007/s40263-023-01050-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/25/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND Real-world studies on fremanezumab, an anti-calcitonin gene-related peptide monoclonal antibody for migraine prevention, are few and with limited follow-up. OBJECTIVE We aimed to evaluate the long-term (up to 52 weeks) effectiveness and tolerability of fremanezumab in high-frequency episodic migraine and chronic migraine. METHODS This s an independent, prospective, multicenter cohort study enrolling outpatients in 17 Italian Headache Centers with high-frequency episodic migraine or chronic migraine and multiple preventive treatment failures. Patients were treated with fremanezumab 225 mg monthly. The primary outcomes included changes from baseline (1 month before treatment) in monthly headache days, response rates (reduction in monthly headache days from baseline), and persistence in medication overuse at months 3, 6, and 12 (all outcome timeframes refer to the stated month). Secondary outcomes included changes from baseline in acute medication intake and disability questionnaires scores at the same timepoints. A last observation carried forward analysis was also performed. RESULTS A total of 90 patients who received at least one dose of fremanezumab and with a potential 12-month follow-up were included. Among them, 15 (18.0%) patients discontinued treatment for the entire population, a reduction in monthly headache days compared with baseline was reported at month 3, with a significant median [interquartile range] reduction in monthly headache days (- 9.0 [11.5], p < 0.001). A statistically different reduction was also reported at month 6 compared with baseline (- 10.0 [12.0]; p < 0.001) and at 12 months of treatment (- 10.0 [14.0]; p < 0.001). The percentage of patients with medication overuse was significantly reduced compared with baseline from 68.7% (57/83) to 29.6% (24/81), 25.3% (19/75), and 14.7% (10/68) at 3, 6, and 12 months of treatment, respectively (p < 0.001). Acute medication use (days and total number) and disability scores were also significantly reduced (p < 0.001). A ≥ 50% response rate was achieved for 51.9, 67.9, and 76.5% of all patients at 3, 6, and 12 months, respectively. Last observation carried forward analyses confirmed these findings. Fremanezumab was well tolerated, with just one patient discontinuing treatment because of adverse events. CONCLUSIONS This study provides evidence for the real-world effectiveness of fremanezumab in treating both high-frequency episodic migraine and chronic migraine, with meaningful and sustained improvements in multiple migraine-related variables. No new safety issue was identified.
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Affiliation(s)
- Valeria Caponnetto
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Antonio Russo
- Department of Advanced Medical and Surgical Sciences, Headache Centre, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Marcello Silvestro
- Department of Advanced Medical and Surgical Sciences, Headache Centre, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Alessandro Tessitore
- Department of Advanced Medical and Surgical Sciences, Headache Centre, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Roberto De Icco
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Headache Science and Neurorehabilitation Center, IRCCS Mondino Foundation, Pavia, Italy
| | - Gloria Vaghi
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Headache Science and Neurorehabilitation Center, IRCCS Mondino Foundation, Pavia, Italy
| | - Grazia Sances
- Headache Science and Neurorehabilitation Center, IRCCS Mondino Foundation, Pavia, Italy
| | - Cristina Tassorelli
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Headache Science and Neurorehabilitation Center, IRCCS Mondino Foundation, Pavia, Italy
| | - Carlo Baraldi
- Laboratory of Clinical Pharmacology and Pharmacogenomics, Department of Specialist Medicines, Digital and Predictive Medicine, Pharmacology and Clinical Metabolic Toxicology-Headache Center and Drug Abuse, AOU Policlinico di Modena, Modena, Italy
| | - Flavia Lo Castro
- Laboratory of Clinical Pharmacology and Pharmacogenomics, Department of Specialist Medicines, Digital and Predictive Medicine, Pharmacology and Clinical Metabolic Toxicology-Headache Center and Drug Abuse, AOU Policlinico di Modena, Modena, Italy
| | - Simona Guerzoni
- Laboratory of Clinical Pharmacology and Pharmacogenomics, Department of Specialist Medicines, Digital and Predictive Medicine, Pharmacology and Clinical Metabolic Toxicology-Headache Center and Drug Abuse, AOU Policlinico di Modena, Modena, Italy
| | - Maria Pia Prudenzano
- Headache Center, Amaducci Neurological Clinic, Policlinico General Hospital, Bari, Italy
| | - Adriana Fallacara
- Headache Center, Amaducci Neurological Clinic, Policlinico General Hospital, Bari, Italy
| | - Martino Gentile
- Headache Center, Amaducci Neurological Clinic, Policlinico General Hospital, Bari, Italy
| | - Raffaele Ornello
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Agnese Onofri
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Andrea Burgalassi
- Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, Florence, Italy
| | - Alberto Chiarugi
- Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, Florence, Italy
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Francesco De Cesaris
- Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, Florence, Italy
| | - Antonio Granato
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Headache Centre, School of Neurology, University Hospital and Health Services of Trieste, ASUGI, University of Trieste, Trieste, Italy
| | | | - Marina De Tommaso
- Department of Basic Medical Science, Neuroscience and Sense Organs, University of Bari Aldo Moro, Bari, Italy
| | - Edoardo Mampreso
- Headache Centre, Neurology-Euganea, Padua Health Unit, Padua, Italy
| | - Paola Merlo
- Neurological Unit, Headache Centre, Humanitas Gavazzeni, Bergamo, Italy
| | - Gianluca Coppola
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino ICOT, Latina, Italy
| | - Stefania Battistini
- Neurology and Clinical Neurophysiology Unit, Headache Center, Siena University Hospital Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy
| | | | - Innocenzo Rainero
- Department of Neuroscience "Rita Levi Montalcini", Headache Center, University of Torino, Torino, Italy
| | - Federica Nicoletta Sepe
- Neurology Department, Azienda Ospedaliera Nazionale Santi Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Giorgio Dalla Volta
- U.O. Neurologia, Headache Center Istituto Clinico "Città di Brescia", Gruppo San Donato Brescia, Brescia, Italy
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Pierangelo Geppetti
- Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, Florence, Italy
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Luigi Francesco Iannone
- Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, Florence, Italy.
- Department of Health Sciences, University of Florence, Viale Pieraccini 6, Florence, Italy.
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Hyeraci G, Paoletti O, Iannone LF, Gini R, De Cesaris F, Geppetti P, Roberto G. Patterns of anti-CGRP mAbs use and variation of triptan consumption following treatment initiation: A descriptive drug utilization study in the Tuscany region, Italy. Headache 2023; 63:1391-1402. [PMID: 37830925 DOI: 10.1111/head.14639] [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] [Received: 03/13/2023] [Revised: 09/07/2023] [Accepted: 09/13/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVE To describe the pattern of anti-calcitonin gene-related peptide monoclonal antibodies (anti-CGRP mAbs) utilization in the Tuscany region, Italy, and the variation of triptan consumption after treatment initiation. BACKGROUND Given the recent commercialization of anti-CGRP mAbs as migraine preventive medications, real-world evidence on their patterns of utilization and their impact on migraine abortive medication use is still limited. METHODS A retrospective, descriptive, cohort study on the real-world utilization of anti-CGRP mAbs was performed using the population-based regional administrative database of Tuscany. Patients with ≥1 anti-CGRP mAb dispensing (namely erenumab, galcanezumab, fremanezumab) between April 1, 2019, and September 30, 2021, were identified. The first dispensing was the cohort entry (CE). New users (NUs) were patients with no anti-CGRP mAb dispensing before CE. Kaplan-Meier (KM) curves were plotted to describe the cumulative probability of remaining with the initial anti-CGRP mAb during a 15-month follow-up period as a measure of treatment persistence. Among NUs with ≥2 triptan dispensings during the 6 months before CE (i.e., baseline), the mean monthly number of triptan dosage units dispensed was measured in five consecutive follow-up time windows (months 1-3, 4-6, 7-9, 10-12, 13-15) and the difference from the baseline was calculated. RESULTS A total of 624 NUs (erenumab = 295, galcanezumab = 223, fremanezumab = 106) were identified, of whom 188 (78%) were women. Mean age was 49.2 years (standard deviation [SD] = 12.6). The survival to discontinuation at 6, 12, and 15 months was about 69%, 48%, and 6%, respectively. The survival to switch was about 6% at 15 months. The observed variation of triptan consumption at 3/6/9/12/15 months and the corresponding SD was -4.4 [8.2]/-5.2 [9.0]/-5.5 [9.2]/-5.4 [9.2]/-4.5 [10.0], respectively. CONCLUSION Patient demographics reflect the place of these medications in therapy. Overall, findings seem to indicate a favorable tolerability and effectiveness profile. Further studies are warranted to better establish the long-term comparative effectiveness, safety, and cost effectiveness of anti-CGRP mAbs compared to other preventive medications.
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Affiliation(s)
- Giulia Hyeraci
- Agenzia regionale di sanità della Toscana (ARS), Florence, Italy
| | - Olga Paoletti
- Agenzia regionale di sanità della Toscana (ARS), Florence, Italy
| | - Luigi Francesco Iannone
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Florence, Italy
- Headache Centre, Department of Health Sciences, Careggi University Hospital, University of Florence, Florence, Italy
| | - Rosa Gini
- Agenzia regionale di sanità della Toscana (ARS), Florence, Italy
| | - Francesco De Cesaris
- Headache Centre, Department of Health Sciences, Careggi University Hospital, University of Florence, Florence, Italy
| | - Pierangelo Geppetti
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Florence, Italy
- Headache Centre, Department of Health Sciences, Careggi University Hospital, University of Florence, Florence, Italy
| | - Giuseppe Roberto
- Agenzia regionale di sanità della Toscana (ARS), Florence, Italy
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Tokumoto M, Nakasa T, Nekomoto A, Ishikawa M, Ikuta Y, Miyaki S, Adachi N. Expression of calcitonin gene-related peptide induces ligament degeneration through endochondral ossification in osteoarthritis. Int J Rheum Dis 2023; 26:1932-1941. [PMID: 37452551 DOI: 10.1111/1756-185x.14840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 12/11/2022] [Accepted: 07/04/2023] [Indexed: 07/18/2023]
Abstract
AIM Osteoarthritis (OA) is a disease in which degeneration occurs in various tissues such as cartilage and subchondral bone. Degeneration of ligaments also plays an important role in OA progression, resulting in an increase in chondrocytes and ossification, but the factor that causes this is still unclear. It is reported that the expression of calcitonin gene-related peptide (CGRP) increases OA progression, and CGRP might play a role in ligament degeneration because CGRP has a function in endochondral ossification. The purpose of this study is to analyze the mechanism of ligament degeneration and the function of CGRP. METHODS To examine the relationship between ligament degeneration and CGRP expression, human posterior cruciate ligaments (PCL) from OA patients, and senescence-accelerated mouse prone 8 (SAMP8) mice were histologically analyzed. The effect of CGRP on human ligament cells on chondrogenesis, osteogenesis, and adipogenesis was also examined. RESULTS In human PCL and SAMP8 mice, CGRP expression increased as degeneration progressed, and decreased in severe degeneration. CGRP was expressed in the chondrocyte-like cells with SOX9. CGRP-positive cells expressing type II collagen increased with OA progression. CGRP upregulated the gene expression of VEGF, SOX9, RUNX2, COL10a1, and MMP13 in the human ligament cells. CGRP also promoted chondrogenesis and osteogenesis from the human ligament cells. CONCLUSION During OA progression, CGRP plays a role in the transdifferentiation from ligament cells to chondrocytes and promotes endochondral ossification in the ligament. CGRP would be the therapeutic target to prevent ligament degeneration.
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Affiliation(s)
- Maya Tokumoto
- Department of Orthopedic Surgery, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Tomoyuki Nakasa
- Department of Orthopedic Surgery, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
- Medical Center for Translation and Clinical Research, Hiroshima University Hospital, Hiroshima, Japan
| | - Akinori Nekomoto
- Department of Orthopedic Surgery, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Masakazu Ishikawa
- Department of Artificial Joints and Biomaterials, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yasunari Ikuta
- Department of Orthopedic Surgery, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Shigeru Miyaki
- Medical Center for Translation and Clinical Research, Hiroshima University Hospital, Hiroshima, Japan
| | - Nobuo Adachi
- Department of Orthopedic Surgery, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
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21
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Hugger SS, Do TP, Ashina H, Goicochea MT, Jenkins B, Sacco S, Lee MJ, Brennan KC, Amin FM, Steiner TJ, Ashina M. Migraine in older adults. Lancet Neurol 2023; 22:934-945. [PMID: 37717587 DOI: 10.1016/s1474-4422(23)00206-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 03/20/2023] [Accepted: 05/23/2023] [Indexed: 09/19/2023]
Abstract
Migraine is an evolving, and sometimes lifelong disorder. The prevalence of episodic migraine peaks among individuals aged in their late 30s, implying a tendency for the disorder to remit with increasing age thereafter, whereas chronic migraine is more likely to persist into later life. Diagnosis and treatment of migraine in older adults, defined as individuals aged 60 years or older, is rendered more complex by increasing probabilities of atypical clinical features and comorbidities, with patients' comorbidities sometimes limiting their therapeutic options. However, the changing clinical presentation of migraine over an individual's lifespan is not well characterised. The neurobiological basis of remission in older adults remains unclear, although vascular, neuronal, and hormonal changes are likely to be involved. Long-term longitudinal studies of individuals with migraine would be particularly informative, with the potential not only to suggest new research directions, but also to lead to the identification of novel therapeutic agents. Although several novel migraine medications are becoming available, their effectiveness, tolerability, and safety often remain uncertain in older adults, who have commonly been excluded from the evaluation of these agents in randomised controlled trials, or who constitute only a small proportion of study populations. There is a need to recognise these limitations in the available evidence, and the specific, and often unmet, clinical needs of older adults with migraine, not least because older adults constitute an increasing proportion of populations worldwide.
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Affiliation(s)
- Sarah Sonja Hugger
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Thien Phu Do
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark; Danish Knowledge Center on Headache Disorders, Glostrup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Håkan Ashina
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Brain and Spinal Cord Injury, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark; Harvard Medical School, Boston, MA, USA; Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | | | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Mi Ji Lee
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - K C Brennan
- Headache Physiology Laboratory, Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Faisal Mohammad Amin
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Brain and Spinal Cord Injury, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Timothy J Steiner
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway; Division of Brain Sciences, Imperial College London, London, UK
| | - Messoud Ashina
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark; Danish Knowledge Center on Headache Disorders, Glostrup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Neurology, Azerbaijan Medical University, Baku, Azerbaijan.
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22
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Suzuki K, Suzuki S, Shiina T, Haruyama Y, Fujita H, Funakoshi K, Hirata K. Could efficacy at 1 week after galcanezumab administration for patients with migraine predict responders at 3 months? A real world study. J Neurol 2023; 270:4377-4384. [PMID: 37219606 DOI: 10.1007/s00415-023-11788-x] [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] [Received: 04/25/2023] [Revised: 05/16/2023] [Accepted: 05/17/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND In real-world studies, it is unclear whether galcanezumab has a significant effect in the first week after administration. METHODS We retrospectively assessed 55 high-frequency episodic migraine (HFEM) and chronic migraine patients who received three galcanezumab doses. Mean changes in the numbers of weekly migraine days (WMDs) during month 1 and migraine days per month (MMDs) after 1-3 months of treatment were obtained. Clinical factors related to a ≥ 50% response rate (RR) at month 3 were analyzed. The prediction of ≥ 50% responders at month 3 using different weekly RRs at week 1 (W1) was evaluated. The RR at W1 was calculated with the following formula: RR (%) = 100 - [(WMDs at W1/baseline WMD) × 100]. RESULTS The number of MMDs significantly improved from baseline to 1, 2 and 3 months. The ≥ 50% RR was 50.9% at 3 months. The number of WMDs decreased significantly from baseline to week 1 (- 1.6 ± 1.7 days), week 2 (- 1.2 ± 1.6 days), week 3 (- 1.0 ± 1.3 days), and week 4 (- 1.1 ± 1.6 days) during month 1. The RR at W1 was largest (44.6 ± 42.2%). The ≥ 30%, ≥ 50% and ≥ 75% RRs at W1 were significantly predictive of a ≥ 50% RR at 3 months. Logistic regression analysis predicting a ≥ 50% RR at month 3 showed that the RR at W1 was the sole contributing factor. CONCLUSION In our study, galcanezumab showed a significant effect in the first week after administration, and the RR at W1 could predict the RR at 3 months.
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Affiliation(s)
- Keisuke Suzuki
- Department of Neurology, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Shimotsuga, Tochigi, 321-0293, Japan.
| | - Shiho Suzuki
- Department of Neurology, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Shimotsuga, Tochigi, 321-0293, Japan
| | - Tomohiko Shiina
- Department of Neurology, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Shimotsuga, Tochigi, 321-0293, Japan
| | - Yasuo Haruyama
- Integrated Research Faculty for Advanced Medical Sciences, Dokkyo Medical University, Mibu, Japan
| | - Hiroaki Fujita
- Department of Neurology, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Shimotsuga, Tochigi, 321-0293, Japan
| | - Kei Funakoshi
- Department of Neurology, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Shimotsuga, Tochigi, 321-0293, Japan
| | - Koichi Hirata
- Department of Neurology, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Shimotsuga, Tochigi, 321-0293, Japan
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23
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Al-Karagholi MAM, Kalatharan V, Fagerberg PS, Amin FM. The vascular role of CGRP: a systematic review of human studies. Front Neurol 2023; 14:1204734. [PMID: 37483452 PMCID: PMC10359159 DOI: 10.3389/fneur.2023.1204734] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 06/19/2023] [Indexed: 07/25/2023] Open
Abstract
Intravenous infusion of human alpha calcitonin gene-related peptide (h-α-CGRP) has been applied to explore migraine pathogenesis and cerebral hemodynamics during the past three decades. Cumulative data implicate h-α-CGRP in regulating the vascular tone. In this systematic review, we searched PubMed and EMBASE for clinical studies investigating the vascular changes upon intravenous infusion of h-α-CGRP in humans. A total of 386 studies were screened by title and abstract. Of these, 11 studies with 61 healthy participants and 177 participants diagnosed with migraine were included. Several studies reported hemodynamic effects including flushing, palpitation, warm sensation, heart rate (HR), mean arterial blood pressure (MABP), mean blood flow velocity of middle cerebral artery (mean VMCA), and diameter of superficial temporal artery (STA). Upon the start of h-α-CGRP infusion, 163 of 165 (99%) participants had flushing, 98 of 155 (63%) participants reported palpitation, and 160 of 165 (97%) participants reported warm sensation. HR increased with 14%-58% and MABP decreased with 7%-12%. The mean VMCA was decreased with 9.5%-21%, and the diameter of the STA was dilated with 41%-43%. The vascular changes lasted from 20 to >120 min. Intravenous infusion of h-α-CGRP caused a universal vasodilation without any serious adverse events. The involvement of CGRP in the systemic hemodynamic raises concerns regarding long-term blockade of CGRP in migraine patients with and without cardiovascular complications.
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24
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Al-Hassany L, Boucherie DM, Creeney H, van Drie RWA, Farham F, Favaretto S, Gollion C, Grangeon L, Lyons H, Marschollek K, Onan D, Pensato U, Stanyer E, Waliszewska-Prosół M, Wiels W, Chen HZ, Amin FM. Future targets for migraine treatment beyond CGRP. J Headache Pain 2023; 24:76. [PMID: 37370051 DOI: 10.1186/s10194-023-01567-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 03/14/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Migraine is a disabling and chronic neurovascular headache disorder. Trigeminal vascular activation and release of calcitonin gene-related peptide (CGRP) play a pivotal role in the pathogenesis of migraine. This knowledge has led to the development of CGRP(-receptor) therapies. Yet, a substantial proportion of patients do not respond to these treatments. Therefore, alternative targets for future therapies are warranted. The current narrative review provides a comprehensive overview of the pathophysiological role of these possible non-CGRP targets in migraine. FINDINGS We covered targets of the metabotropic receptors (pituitary adenylate cyclase-activating polypeptide (PACAP), vasoactive intestinal peptide (VIP), amylin, and adrenomedullin), intracellular targets (nitric oxide (NO), phosphodiesterase-3 (PDE3) and -5 (PDE5)), and ion channels (potassium, calcium, transient receptor potential (TRP), and acid-sensing ion channels (ASIC)). The majority of non-CGRP targets were able to induce migraine-like attacks, except for (i) calcium channels, as it is not yet possible to directly target channels to elucidate their precise involvement in migraine; (ii) TRP channels, activation of which can induce non-migraine headache; and (iii) ASICs, as their potential in inducing migraine attacks has not been investigated thus far. Drugs that target its receptors exist for PACAP, NO, and the potassium, TRP, and ASIC channels. No selective drugs exist for the other targets, however, some existing (migraine) treatments appear to indirectly antagonize responses to amylin, adrenomedullin, and calcium channels. Drugs against PACAP, NO, potassium channels, TRP channels, and only a PAC1 antibody have been tested for migraine treatment, albeit with ambiguous results. CONCLUSION While current research on these non-CGRP drug targets has not yet led to the development of efficacious therapies, human provocation studies using these targets have provided valuable insight into underlying mechanisms of migraine headaches and auras. Further studies are needed on these alternative therapies in non-responders of CGRP(-receptor) targeted therapies with the ultimate aim to pave the way towards a headache-free future for all migraine patients.
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Affiliation(s)
- Linda Al-Hassany
- Department of Internal Medicine, Division of Vascular Medicine and Pharmacology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Deirdre M Boucherie
- Department of Internal Medicine, Division of Vascular Medicine and Pharmacology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Hannah Creeney
- Wolfson Centre for Age-Related Diseases, King's College London, London, UK
| | - Ruben W A van Drie
- Department of Internal Medicine, Division of Vascular Medicine and Pharmacology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Cardiology, Division of Experimental Cardiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Fatemeh Farham
- Department of Headache, Iranian Centre of Neurological Researchers, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Silvia Favaretto
- Headache Center, Neurology Clinic, University Hospital of Padua, Padua, Italy
| | - Cédric Gollion
- Department of Neurology, University Hospital of Toulouse, Toulouse, France
| | - Lou Grangeon
- Neurology Department, Rouen University Hospital, Rouen, France
| | - Hannah Lyons
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Karol Marschollek
- Department of Neurology, Wroclaw Medical University, Wrocław, Poland
| | - Dilara Onan
- Spine Health Unit, Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Umberto Pensato
- Neurology and Stroke Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Humanitas University, Pieve Emanuele, Milan, Italy
| | - Emily Stanyer
- Wolfson Centre for Age-Related Diseases, King's College London, London, UK
| | | | - Wietse Wiels
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Hui Zhou Chen
- Wolfson Centre for Age-Related Diseases, King's College London, London, UK
| | - Faisal Mohammad Amin
- Danish Headache Center, Department of Neurology, Faculty of Health and Medical Sciences, Rigshospitalet Glostrup, University of Copenhagen, Copenhagen, Denmark.
- Department of Neurorehabilitation/Traumatic Brain Injury, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
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25
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Al-Hassany L, Karsan N, Lampl C, Goadsby PJ, MaassenVanDenBrink A. Revisiting dose-finding of monoclonal antibodies in migraine. J Headache Pain 2023; 24:69. [PMID: 37296378 DOI: 10.1186/s10194-023-01602-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023] Open
Abstract
Migraine is a debilitating disorder, and while the introduction of monoclonal antibodies (mAbs) has led to efficacious and tolerable responses, a substantial number of patients are so-called "non-responders". We introduce reasons for this insufficient response, including insufficient blockade of Calcitonin Gene-Related Peptide (CGRP) or its receptor. We present a clinical case, i.e. a female migraine patient who mistakenly administered supratherapeutic (three-fold higher) doses of erenumab leading to more efficacious clinical responses without any side-effects. This example illustrates that the initial dosages might have been too low, resulting in a remaining undesired increased effect of CGRP. While a capsaicin forearm model has repeatedly been used to evaluate the pharmacokinetic-pharmacodynamic relationship of mAbs, we provide directions to revisit or reconsider dose-finding and dose-ranging of these drugs. These directions include (i) refinement and application of a capsaicin forehead model (instead of a forearm model) to study trigeminovascular activity and improve dosing, and (ii) reconsideration of trial populations. Indeed, the dose-finding studies were mainly performed in relatively young and normal-weight males, while most phase III/IV trials are marked by a high female-to-male ratio, mainly consisting of overweight to obese females. Considering these aspects in future trials could optimize healthcare for a larger proportion of migraine patients.
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Affiliation(s)
- Linda Al-Hassany
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Nazia Karsan
- NIHR SLaM Clinical Research Facility, King's College London, London, UK
- Department of Neurology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Christian Lampl
- Department of Neurology and Stroke Unit, Koventhospital Barmherzige Brüder Linz, Linz, Austria
- Headache Medical Center Linz, Linz, Austria
| | - Peter J Goadsby
- NIHR SLaM Clinical Research Facility, King's College London, London, UK
- Department of Neurology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Antoinette MaassenVanDenBrink
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.
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26
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Abstract
Zavegepant is a third generation, small-molecule, calcitonin gene-related peptide (CGRP) receptor antagonist being developed by Pfizer, under a license from Bristol-Myers Squibb, for the prevention and treatment of chronic and episodic migraine. In March 2023, zavegepant nasal spray (ZAVZPRET™) received its first approval in the USA for the acute treatment of migraine with or without aura in adults. Clinical development of an oral formulation of zavegepant is currently underway. This article summarizes the milestones in the development of zavegepant leading to this first approval for the acute treatment of migraine with or without aura in adults.
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Affiliation(s)
- Sohita Dhillon
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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27
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Puledda F, Silva EM, Suwanlaong K, Goadsby PJ. Migraine: from pathophysiology to treatment. J Neurol 2023:10.1007/s00415-023-11706-1. [PMID: 37029836 DOI: 10.1007/s00415-023-11706-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 04/03/2023] [Indexed: 04/09/2023]
Abstract
Migraine is an extremely disabling, common neurological disorder characterized by a complex neurobiology, involving a series of central and peripheral nervous system areas and networks. A growing increase in the understanding of migraine pathophysiology in recent years has facilitated translation of that knowledge into novel treatments, which are currently becoming available to patients in many parts of the world and are substantially changing the clinical approach to the disease. In the first part of this review, we will provide an up to date overview of migraine pathophysiology by analyzing the anatomy and function of the main regions involved in the disease, focusing on how these give rise to the plethora of symptoms characterizing the attacks and overall disease. The second part of the paper will discuss the novel therapeutic agents that have emerged for the treatment of migraine, including molecules targeting calcitonin gene-related peptide (gepants and monoclonal antibodies), serotonin 5-HT1F receptor agonists (ditans) and non-invasive neuromodulation, as well as providing a brief overview of new evidence for classic migraine treatments.
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Affiliation(s)
- Francesca Puledda
- Headache Group, Wolfson CARD, Institute of Psychiatry, Psychology and Neuroscience, King's College London, and National Institute for Health Research (NIHR) SLaM Clinical Research Facility at King's, Wellcome Foundation Building, King's College Hospital, London, SE5 9PJ, UK
| | | | - Kanokrat Suwanlaong
- Division of Neurology, Department of Medicine, Songkhla Medical Education Center, Songkhla, Thailand
| | - Peter J Goadsby
- Headache Group, Wolfson CARD, Institute of Psychiatry, Psychology and Neuroscience, King's College London, and National Institute for Health Research (NIHR) SLaM Clinical Research Facility at King's, Wellcome Foundation Building, King's College Hospital, London, SE5 9PJ, UK.
- Department of Neurology, University of California, Los Angeles, Los Angeles, CA, USA.
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28
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Iannone LF, Burgalassi A, Vigani G, Tabasso G, De Cesaris F, Chiarugi A, Geppetti P. Switching anti-CGRP(R) monoclonal antibodies in multi-assessed non-responder patients and implications for ineffectiveness criteria: A retrospective cohort study. Cephalalgia 2023; 43:3331024231160519. [PMID: 36918752 DOI: 10.1177/03331024231160519] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND A pharmacological class effect was initially proposed for monoclonal antibodies against the calcitonin gene related peptide pathway. However, preliminary evidence shows that switching patients who were non-responding to one monoclonal antibody to another could provide some benefit. Herein, we assess treatment response to an anti-calcitonin gene related peptide/receptor monoclonal antibody in patients who have failed to respond to anti-calcitonin gene related peptide/ligand monoclonal antibodies calcitonin gene related peptide/ligand monoclonal antibodies and vice versa. In addition, we select non-responders to the first anti- monoclonal antibody by three or five more stringent variables. METHODS Retrospective cohort study including outpatients treated consecutively with two anti-calcitonin gene related peptide monoclonal antibodies. Ineffectiveness to the first monoclonal antibody was assessed using three (MIDAS score, monthly headache days, and analgesic monthly days) variables or five (monthly headache days, MIDAS score, analgesic monthly days, analgesic monthly number and HIT-6 score) variables in the same cohort of patients. The primary endpoints were the absolute change from baseline in monthly headache days, response rate, and persistence in medication overuse at three months of treatment with the second anti-CGRP mAb. RESULTS In patients selected by three variables, a sustained reduction in monthly headache days, analgesic monthly days, MIDAS and HIT-6 scores was observed at month-3 of treatment with the second monoclonal antibody. Ten (45.4%) patients achieved at least a ≥30% response rate. No difference was reported switching anti-CGRP mAb against ligand or receptor. In the patient subgroup selected by five variables, only HIT-6 was reduced from baseline at month-3. However, a trend toward a reduction in monthly headache days, analgesic monthly days, and MIDAS score was observed at month-3. CONCLUSIONS Switching anti-calcitonin gene related peptide monoclonal antibodies in selected patients might be an option to achieve or improve clinical benefit. More studies are required to establish the effectiveness of switching these treatments.
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Affiliation(s)
- Luigi Francesco Iannone
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Florence, Italy.,Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, Florence, Italy
| | - Andrea Burgalassi
- Department of Neurosciences, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, Florence, Italy
| | - Giulia Vigani
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Giorgio Tabasso
- Department of Neurosciences, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, Florence, Italy
| | - Francesco De Cesaris
- Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, Florence, Italy
| | - Alberto Chiarugi
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Florence, Italy.,Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, Florence, Italy
| | - Pierangelo Geppetti
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Florence, Italy.,Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, Florence, Italy
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29
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Russo AF, Hay DL. CGRP physiology, pharmacology, and therapeutic targets: migraine and beyond. Physiol Rev 2023; 103:1565-1644. [PMID: 36454715 PMCID: PMC9988538 DOI: 10.1152/physrev.00059.2021] [Citation(s) in RCA: 54] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 11/23/2022] [Accepted: 11/27/2022] [Indexed: 12/03/2022] Open
Abstract
Calcitonin gene-related peptide (CGRP) is a neuropeptide with diverse physiological functions. Its two isoforms (α and β) are widely expressed throughout the body in sensory neurons as well as in other cell types, such as motor neurons and neuroendocrine cells. CGRP acts via at least two G protein-coupled receptors that form unusual complexes with receptor activity-modifying proteins. These are the CGRP receptor and the AMY1 receptor; in rodents, additional receptors come into play. Although CGRP is known to produce many effects, the precise molecular identity of the receptor(s) that mediates CGRP effects is seldom clear. Despite the many enigmas still in CGRP biology, therapeutics that target the CGRP axis to treat or prevent migraine are a bench-to-bedside success story. This review provides a contextual background on the regulation and sites of CGRP expression and CGRP receptor pharmacology. The physiological actions of CGRP in the nervous system are discussed, along with updates on CGRP actions in the cardiovascular, pulmonary, gastrointestinal, immune, hematopoietic, and reproductive systems and metabolic effects of CGRP in muscle and adipose tissues. We cover how CGRP in these systems is associated with disease states, most notably migraine. In this context, we discuss how CGRP actions in both the peripheral and central nervous systems provide a basis for therapeutic targeting of CGRP in migraine. Finally, we highlight potentially fertile ground for the development of additional therapeutics and combinatorial strategies that could be designed to modulate CGRP signaling for migraine and other diseases.
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Affiliation(s)
- Andrew F Russo
- Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, Iowa
- Department of Neurology, University of Iowa, Iowa City, Iowa
- Center for the Prevention and Treatment of Visual Loss, Department of Veterans Affairs Health Center, Iowa City, Iowa
| | - Debbie L Hay
- Department of Pharmacology and Toxicology, University of Otago, Dunedin, New Zealand
- Maurice Wilkins Centre for Molecular Biodiscovery, School of Biological Sciences, The University of Auckland, Auckland, New Zealand
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30
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Szewczyk AK, Ulutas S, Aktürk T, Al-Hassany L, Börner C, Cernigliaro F, Kodounis M, Lo Cascio S, Mikolajek D, Onan D, Ragaglini C, Ratti S, Rivera-Mancilla E, Tsanoula S, Villino R, Messlinger K, Maassen Van Den Brink A, de Vries T. Prolactin and oxytocin: potential targets for migraine treatment. J Headache Pain 2023; 24:31. [PMID: 36967387 PMCID: PMC10041814 DOI: 10.1186/s10194-023-01557-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 02/28/2023] [Indexed: 03/28/2023] Open
Abstract
Migraine is a severe neurovascular disorder of which the pathophysiology is not yet fully understood. Besides the role of inflammatory mediators that interact with the trigeminovascular system, cyclic fluctuations in sex steroid hormones are involved in the sex dimorphism of migraine attacks. In addition, the pituitary-derived hormone prolactin and the hypothalamic neuropeptide oxytocin have been reported to play a modulating role in migraine and contribute to its sex-dependent differences. The current narrative review explores the relationship between these two hormones and the pathophysiology of migraine. We describe the physiological role of prolactin and oxytocin, its relationship to migraine and pain, and potential therapies targeting these hormones or their receptors.In summary, oxytocin and prolactin are involved in nociception in opposite ways. Both operate at peripheral and central levels, however, prolactin has a pronociceptive effect, while oxytocin appears to have an antinociceptive effect. Therefore, migraine treatment targeting prolactin should aim to block its effects using prolactin receptor antagonists or monoclonal antibodies specifically acting at migraine-pain related structures. This action should be local in order to avoid a decrease in prolactin levels throughout the body and associated adverse effects. In contrast, treatment targeting oxytocin should enhance its signalling and antinociceptive effects, for example using intranasal administration of oxytocin, or possibly other oxytocin receptor agonists. Interestingly, the prolactin receptor and oxytocin receptor are co-localized with estrogen receptors as well as calcitonin gene-related peptide and its receptor, providing a positive perspective on the possibilities for an adequate pharmacological treatment of these nociceptive pathways. Nevertheless, many questions remain to be answered. More particularly, there is insufficient data on the role of sex hormones in men and the correct dosing according to sex differences, hormonal changes and comorbidities. The above remains a major challenge for future development.
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Affiliation(s)
- Anna K Szewczyk
- Doctoral School, Medical University of Lublin, Lublin, Poland
- Department of Neurology, Medical University of Lublin, Lublin, Poland
| | - Samiye Ulutas
- Department of Neurology, Kartal Dr. Lutfi Kirdar Research and Training Hospital, Istanbul, Turkey
| | - Tülin Aktürk
- Department of Neurology, Kartal Dr. Lutfi Kirdar Research and Training Hospital, Istanbul, Turkey
| | - Linda Al-Hassany
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Corinna Börner
- Department of Pediatrics - Dr. von Hauner Children's Hospital, LMU Hospital, Division of Pediatric Neurology and Developmental Medicine, Ludwig-Maximilians Universität München, Lindwurmstr. 4, 80337, Munich, Germany
- LMU Center for Children with Medical Complexity - iSPZ Hauner, Ludwig-Maximilians-Universität München, Lindwurmstr. 4, 80337, Munich, Germany
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Federica Cernigliaro
- Child Neuropsychiatry Unit Department, Pro.M.I.S.E. "G D'Alessandro, University of Palermo, 90133, Palermo, Italy
| | - Michalis Kodounis
- First Department of Neurology, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Salvatore Lo Cascio
- Child Neuropsychiatry Unit Department, Pro.M.I.S.E. "G D'Alessandro, University of Palermo, 90133, Palermo, Italy
| | - David Mikolajek
- Department of Neurology, City Hospital Ostrava, Ostrava, Czech Republic
| | - Dilara Onan
- Spine Health Unit, Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Chiara Ragaglini
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, 67100, L'Aquila, Italy
| | - Susanna Ratti
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, 67100, L'Aquila, Italy
| | - Eduardo Rivera-Mancilla
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sofia Tsanoula
- Department of Neurology, 401 Military Hospital of Athens, Athens, Greece
| | - Rafael Villino
- Department of Neurology, Clínica Universidad de Navarra, Pamplona, Spain
| | - Karl Messlinger
- Institute of Physiology and Pathophysiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Antoinette Maassen Van Den Brink
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Tessa de Vries
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands.
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31
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Zhou M, Pang F, Liao D, He X, Yang Y, Tang C. Electroacupuncture at Fengchi(GB20) and Yanglingquan(GB34) Ameliorates Paralgesia through Microglia-Mediated Neuroinflammation in a Rat Model of Migraine. Brain Sci 2023; 13:brainsci13040541. [PMID: 37190506 DOI: 10.3390/brainsci13040541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/17/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023] Open
Abstract
Background: Multiple studies have suggested that paralgesia (hyperalgesia and cutaneous allodynia) in migraine reflects the activation and sensitisation of the trigeminovascular system (TGVS). In particular, it reflects the second-order and higher nerve centre sensitisation, which is caused and maintained by neuroinflammation. Microglia activation leads to the release of proinflammatory cytokines involved in inflammatory responses. Accumulating evidence indicates that electroacupuncture (EA) is effective in ameliorating paralgesia, but the underlying mechanisms of EA in migraine attacks caused by microglia and microglia-mediated inflammatory responses are still unclear. The purpose of this study was to explore whether EA could ameliorate the dysregulation of pain sensation by suppressing microglial activation and the resulting neuroinflammatory response, and to evaluate whether this response was regulated by Toll-like receptor 4 (TLR4)/nuclear factor-kappa B(NF-κB) in the trigeminal nucleus caudalis (TNC) in a rat model of migraine. Methods: Repeated Inflammatory Soup (IS) was infused into the dura for seven sessions to establish a recurrent migraine-like rat model, and EA treatment was administered at Fengchi (GB20) and Yanglingquan (GB34) after daily IS infusion. Facial mechanical withdrawal thresholds were measured to evaluate the change in pain perception, and plasma samples and the TNC tissues of rats were collected to examine the changes in calcitonin gene-related peptide (CGRP), the Ibal-1-labelled microglial activation, and the resulting inflammatory response, including interleukin-1β (IL-1β), tumour necrosis factor-α (TNF-α), interleukin-6 (IL-6), and their regulatory molecules TLR4/NF-κB, via enzyme-linked immunosorbent assay (ELISA), real-time polymerase chain reaction (RT-PCR), immunohistochemistry (IHC) and Western blot analysis. Results: Repeated IS injections into the dura induced facial mechanical paralgesia, which is the manifestation of migraine attacks, and increased the expression of CGRP, Ibal-1, microglial mediated inflammatory cytokines (IL-1β, TNF-α, IL-6), and regulatory molecules TLR4/NF-κB. EA at GB20/34 significantly attenuated repetitive IS-induced pain hypersensitivity. This effect was consistent with decreased levels of CGRP and inflammatory cytokines in the plasma and the TNC via the inhibition of microglia activation, and this response may be regulated by TLR4/NF-κB. Conclusions: EA ameliorated paralgesia in repetitive IS-induced migraine-like rats, which was mainly mediated by a reduction in microglial activation and microglial-mediated inflammatory responses that could be regulated by TLR4/NF-κB.
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Spiteri JA, Camilleri G, Piccinni C, Sultana J. Safety of drugs used for the treatment of migraine during pregnancy: a narrative review. Expert Rev Clin Pharmacol 2023; 16:207-217. [PMID: 36803196 DOI: 10.1080/17512433.2023.2181157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
INTRODUCTION Migraine is common in females of childbearing age and negatively impacts quality of life. The majority of those with migraine who become pregnant see an improvement in their condition but not all do. Providing evidence-based recommendations for the pharmacological management of migraine in pregnancy is challenging. AREAS COVERED This narrative review provides an update on the safety of drugs used for migraine in pregnancy. National and international guidelines on the management of episodic migraine in adults were used to select the drugs of relevance to pregnant women. The final list of drugs was chosen by a pain specialist who categorized them according to drug class and use in acute management or prevention. PubMed was searched from inception to 31st July 2022 for evidence on drug safety. EXPERT OPINION Obtaining high-quality drug safety data in pregnant migraineurs is difficult not least because exposing a fetus to research-related risks is often considered unethical. There is reliance on observational studies which often group drugs together and lack specificities pertinent to drug prescribing like timing, dosing and duration. Improved statistical tools, study designs and the creation of international collaborative frameworks are ways to advance knowledge on drug safety in pregnancy.
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Affiliation(s)
- Jessica A Spiteri
- Department of Anaesthesia, Intensive Care and Pain Medicine, Mater Dei Hospital, Triq Dun Karm, Malta
| | - Gabrielle Camilleri
- Department of Clinical Pharmacology and Therapeutics, University of Malta, Msida MSD, Malta
| | - Carlo Piccinni
- Fondazione Ricerca e Salute (ReS)-Research and Health Foundation, Casalecchio di Reno, Italy
| | - Janet Sultana
- Exeter College of Medicine and Health, University of Exeter, Exeter, UK
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Al-Hassany L, Lyons HS, Boucherie DM, Farham F, Lange KS, Marschollek K, Onan D, Pensato U, Storch E, Torrente A, Waliszewska-Prosół M, Reuter U. The sense of stopping migraine prophylaxis. J Headache Pain 2023; 24:9. [PMID: 36792981 PMCID: PMC9933401 DOI: 10.1186/s10194-023-01539-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 01/18/2023] [Indexed: 02/17/2023] Open
Abstract
INTRODUCTION Migraine prophylactic therapy has changed over recent years with the development and approval of monoclonal antibodies (mAbs) targeting the calcitonin gene-related peptide (CGRP) pathway. As new therapies emerged, leading headache societies have been providing guidelines on the initiation and escalation of such therapies. However, there is a lack of robust evidence looking at the duration of successful prophylaxis and the effects of therapy discontinuation. In this narrative review we explore both the biological and clinical rationale for prophylactic therapy discontinuation to provide a basis for clinical decision-making. METHODS Three different literature search strategies were conducted for this narrative review. These include i) stopping rules in comorbidities of migraine in which overlapping preventives are prescribed, notably depression and epilepsy; ii) stopping rules of oral treatment and botox; iii) stopping rules of antibodies targeting the CGRP (receptor). Keywords were utilized in the following databases: Embase, Medline ALL, Web of Science Core collection, Cochran Central Register of Controlled Trials, and Google Scholar. DISCUSSION Reasons to guide decision-making in stopping prophylactic migraine therapies include adverse events, efficacy failure, drug holiday following long-term administration, and patient-specific reasons. Certain guidelines contain both positive and negative stopping rules. Following withdrawal of migraine prophylaxis, migraine burden may return to pre-treatment level, remain unchanged, or lie somewhere in-between. The current suggestion to discontinue CGRP(-receptor) targeted mAbs after 6 to 12 months is based on expert opinion, as opposed to robust scientific evidence. Current guidelines advise the clinician to assess the success of CGRP(-receptor) targeted mAbs after three months. Based on excellent tolerability data and the absence of scientific data, we propose if no other reasons apply, to stop the use of mAbs when the number of migraine days decreases to four or fewer migraine days per month. There is a higher likelihood of developing side effects with oral migraine preventatives, and so we suggest stopping these drugs according to the national guidelines if they are well tolerated. CONCLUSION Translational and basic studies are warranted to investigate the long-term effects of a preventive drug after its discontinuation, starting from what is known about the biology of migraine. In addition, observational studies and, eventually, clinical trials focusing on the effect of discontinuation of migraine prophylactic therapies, are essential to substantiate evidence-based recommendations on stopping rules for both oral preventives and CGRP(-receptor) targeted therapies in migraine.
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Affiliation(s)
- Linda Al-Hassany
- grid.5645.2000000040459992XDepartment of Internal Medicine, Division of Vascular Medicine and Pharmacology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Hannah S. Lyons
- grid.6572.60000 0004 1936 7486Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Deirdre M. Boucherie
- grid.5645.2000000040459992XDepartment of Internal Medicine, Division of Vascular Medicine and Pharmacology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Fatemeh Farham
- grid.411705.60000 0001 0166 0922Department of Headache, Iranian Centre of Neurological Researchers, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Kristin S. Lange
- grid.6363.00000 0001 2218 4662Department of Neurology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Karol Marschollek
- grid.4495.c0000 0001 1090 049XDepartment of Neurology, Wroclaw Medical University, Wrocław, Poland
| | - Dilara Onan
- grid.14442.370000 0001 2342 7339Spine Health Unit, Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey ,grid.7841.aDepartment of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Umberto Pensato
- grid.417728.f0000 0004 1756 8807Neurology and Stroke Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy ,grid.452490.eHumanitas University, Pieve Emanuale, Milan, Italy
| | - Elisabeth Storch
- grid.6363.00000 0001 2218 4662Department of Neurology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Angelo Torrente
- grid.10776.370000 0004 1762 5517Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Marta Waliszewska-Prosół
- grid.4495.c0000 0001 1090 049XDepartment of Neurology, Wroclaw Medical University, Wrocław, Poland
| | - Uwe Reuter
- Department of Neurology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany. .,Universitätsmedizin Greifswald, Greifswald, Germany.
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Lee MJ, Al-Karagholi MAM, Reuter U. New migraine prophylactic drugs: Current evidence and practical suggestions for non-responders to prior therapy. Cephalalgia 2023; 43:3331024221146315. [PMID: 36759320 DOI: 10.1177/03331024221146315] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
BACKGROUND Monoclonal antibodies against calcitonin gene-related peptide (CGRP) or its receptor (anti-CGRP(-R) mAbs) and small-molecule CGRP receptor antagonists (gepants) are new mechanism-based prophylactic drugs developed to address the unmet needs of pre-existing migraine prophylactic medications. However, several uncertainties remain in their real-world applications. METHODS This is a narrative review of the literature on the use of CGRP-targeting novel therapeutics in specific situations, including non-responders to prior therapy, combination therapy, switching, and treatment termination. In the case of lack of available literature, we made suggestions based on clinical reasoning. RESULTS High-quality evidence supports the use of all available anti-CGRP(-R) mAbs (erenumab, galcanezumab, fremanezumab, and eptinezumab) in non-responders to prior therapy. There is insufficient evidence to support or reject the efficacy of combining CGRP(-R) mAbs or gepants with oral migraine prophylactic agents or botulinum toxin A. Switching from one CGRP(-R) mAb to another might benefit a fraction of patients. Currently, treatment termination depends on reimbursement policies, and the optimal mode of termination is discussed. CONCLUSIONS New prophylactic drugs that target the CGRP pathway are promising treatment options for patients with difficult-to-treat migraine. Individualized approaches using a combination of new substances with oral prophylactic drugs or botulinum toxin A, switching between new drugs, and adjusting treatment duration could enhance excellence in practice.
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Affiliation(s)
- Mi Ji Lee
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Mohammad Al-Mahdi Al-Karagholi
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Uwe Reuter
- Department of Neurology, Charité Universitätsmedizin Berlin, Greifswald, Germany.,Board of Directors, Universitätsmedizin Greifswald, Greifswald, Germany
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Yang DG, Gao YY, Yin ZQ, Wang XR, Meng XS, Zou TF, Duan YJ, Chen YL, Liao CZ, Xie ZL, Fan XD, Sun L, Han JH, Yang XX. Roxadustat alleviates nitroglycerin-induced migraine in mice by regulating HIF-1α/NF-κB/inflammation pathway. Acta Pharmacol Sin 2023; 44:308-320. [PMID: 35948752 PMCID: PMC9889379 DOI: 10.1038/s41401-022-00941-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 06/08/2022] [Indexed: 02/04/2023] Open
Abstract
Sensitization of central pain and inflammatory pathways play essential roles in migraine, a primary neurobiological headache disorder. Since hypoxia-inducible factor-1α (HIF-1α) is implicated in neuroprotection and inflammation inhibition, herein we investigated the role of HIF-1α in migraine. A chronic migraine model was established in mice by repeated injection of nitroglycerin (10 mg/kg, i.p.) every other day for 5 total injections. In the prevention and acute experiments, roxadustat, a HIF-1α stabilizer, was orally administered starting before or after nitroglycerin injection, respectively. Pressure application measurement, and tail flick and light-aversive behaviour tests were performed to determine the pressure pain threshold, thermal nociceptive sensitivity and migraine-related light sensitivity. At the end of experiments, mouse serum samples and brain tissues were collected for analyses. We showed that roxadustat administration significantly attenuated nitroglycerin-induced basal hypersensitivity and acute hyperalgesia by improving central sensitization. Roxadustat administration also decreased inflammatory cytokine levels in serum and trigeminal nucleus caudalis (TNC) through NF-κB pathway. Consistent with the in vivo results showing that roxadustat inhibited microglia activation, roxadustat (2, 10, and 20 μM) dose-dependently reduced ROS generation and inflammation in LPS-stimulated BV-2 cells, a mouse microglia cell line, by inhibiting HIF-1α/NF-κB pathway. Taken together, this study demonstrates that roxadustat administration ameliorates migraine-like behaviours and inhibits central pain sensitization in nitroglycerin-injected mice, which is mainly mediated by HIF-1α/NF-κB/inflammation pathway, suggesting the potential of HIF-1α activators as therapeutics for migraine.
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Affiliation(s)
- Dai-Gang Yang
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, College of Food and Biological Engineering, Hefei University of Technology, Hefei, 230009, China
| | - Yong-Yao Gao
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, College of Food and Biological Engineering, Hefei University of Technology, Hefei, 230009, China
| | - Ze-Qun Yin
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, College of Food and Biological Engineering, Hefei University of Technology, Hefei, 230009, China
| | - Xue-Rui Wang
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, College of Food and Biological Engineering, Hefei University of Technology, Hefei, 230009, China
| | - Xian-She Meng
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, College of Food and Biological Engineering, Hefei University of Technology, Hefei, 230009, China
| | - Ting-Feng Zou
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, College of Food and Biological Engineering, Hefei University of Technology, Hefei, 230009, China
| | - Ya-Jun Duan
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, College of Food and Biological Engineering, Hefei University of Technology, Hefei, 230009, China
| | - Yuan-Li Chen
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, College of Food and Biological Engineering, Hefei University of Technology, Hefei, 230009, China
| | - Chen-Zhong Liao
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, College of Food and Biological Engineering, Hefei University of Technology, Hefei, 230009, China
| | - Zhou-Ling Xie
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, College of Food and Biological Engineering, Hefei University of Technology, Hefei, 230009, China
| | - Xiao-Dong Fan
- Department of General Gynecology, Tianjin Central Hospital of Gynecology and Obstetrics/Tianjin Key Laboratory of Human Development and Reproductive Regulation, Tianjin, 300100, China
| | - Lu Sun
- Department of General Gynecology, Tianjin Central Hospital of Gynecology and Obstetrics/Tianjin Key Laboratory of Human Development and Reproductive Regulation, Tianjin, 300100, China
| | - Ji-Hong Han
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, College of Food and Biological Engineering, Hefei University of Technology, Hefei, 230009, China.
- College of Life Sciences, Key Laboratory of Medicinal Chemical Biology, Key Laboratory of Bioactive Materials of Ministry of Education, Nankai University, Tianjin, 300071, China.
| | - Xiao-Xiao Yang
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, College of Food and Biological Engineering, Hefei University of Technology, Hefei, 230009, China.
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Nutrition and Calcitonin Gene Related Peptide (CGRP) in Migraine. Nutrients 2023; 15:nu15020289. [PMID: 36678160 PMCID: PMC9864721 DOI: 10.3390/nu15020289] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 12/28/2022] [Accepted: 01/03/2023] [Indexed: 01/08/2023] Open
Abstract
Targeting calcitonin gene-related peptide (CGRP) and its receptor by antibodies and antagonists was a breakthrough in migraine prevention and treatment. However, not all migraine patients respond to CGRP-based therapy and a fraction of those who respond complain of aliments mainly in the gastrointestinal tract. In addition, CGRP and migraine are associated with obesity and metabolic diseases, including diabetes. Therefore, CGRP may play an important role in the functioning of the gut-brain-microflora axis. CGRP secretion may be modulated by dietary compounds associated with the disruption of calcium signaling and upregulation of mitogen-activated kinase phosphatases 1 and 3. CGRP may display anorexigenic properties through induction of anorexigenic neuropeptides, such as cholecystokinin and/or inhibit orexigenic neuropeptides, such as neuropeptide Y and melanin-concentrating hormone CH, resulting in the suppression of food intake, functionally coupled to the activation of the hypothalamic 3',5'-cyclic adenosine monophosphate. The anorexigenic action of CGRP observed in animal studies may reflect its general potential to control appetite/satiety or general food intake. Therefore, dietary nutrients may modulate CGRP, and CGRP may modulate their intake. Therefore, anti-CGRP therapy should consider this mutual dependence to increase the efficacy of the therapy and reduce its unwanted side effects. This narrative review presents information on molecular aspects of the interaction between dietary nutrients and CGRP and their reported and prospective use to improve anti-CGRP therapy in migraine.
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Giniatullin R, Nistri A. Role of ATP in migraine mechanisms: focus on P2X3 receptors. J Headache Pain 2023; 24:1. [PMID: 36597043 PMCID: PMC9809127 DOI: 10.1186/s10194-022-01535-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 12/16/2022] [Indexed: 01/04/2023] Open
Abstract
Migraine is a major health burden worldwide with complex pathophysiology and multifarious underlying mechanisms. One poorly understood issue concerns the early steps in the generation of migraine pain. To elucidate the basic process of migraine pain further, it seems useful to consider key molecular players that may operate synergistically to evoke headache. While the neuropeptide CGRP is an important contributor, we propose that extracellular ATP (that generally plays a powerful nociceptive role) is also a major component of migraine headache, acting in concert with CGRP to stimulate trigeminal nociceptive neurons. The aim of the present focused review is to highlight the role of ATP activating its P2X3 membrane receptors selectively expressed by sensory neurons including their nerve fiber terminals in the meninges. Specifically, we present data on the homeostasis of ATP and related purines in the trigeminovascular system and in the CNS; the basic properties of ATP signalling at peripheral and central nerve terminals; the characteristics of P2X3 and related receptors in trigeminal neurons; the critical speed and persistence of P2X3 receptor activity; their cohabitation at the so-called meningeal neuro-immune synapse; the identity of certain endogenous agents cooperating with ATP to induce neuronal sensitization in the trigeminal sensory system; the role of P2X3 receptors in familial type migraine; the current state of P2X3 receptor antagonists and their pharmacological perspectives in migraine. It is proposed that the unique kinetic properties of P2X3 receptors activated by ATP offer an interesting translational value to stimulate future studies for innovative treatments of migraine pain.
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Affiliation(s)
- R. Giniatullin
- grid.9668.10000 0001 0726 2490A.I Virtanen Institute, University of Eastern Finland, 70211 Kuopio, Finland
| | - A. Nistri
- grid.5970.b0000 0004 1762 9868Department of Neuroscience, International School for Advanced Studies (SISSA), 34136 Trieste, Italy
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Abstract
Migraine affects about 1 billion people worldwide, and up to 15% of adults in the United States have migraine attacks in any given year. Migraine is associated with substantial adverse socioeconomic and personal effects. It is the second leading cause of years lived with disability worldwide for all ages and the leading cause in women aged 15 to 49 years. Diagnostic uncertainty increases the likelihood of unnecessary investigations and suboptimal management. This article advises clinicians about diagnosing migraine, ruling out secondary headache disorders, developing acute and preventive treatment plans, and deciding when to refer the patient to a specialist.
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Saigoh K, Takeshima T, Nakai M, Shibasaki Y, Ishida M, Ning X, Barash S, Isogai Y, Koga N. Fremanezumab for Chronic Migraine Prevention in Japanese Patients: Subgroup Analysis from Two International Trials. J Pain Res 2023; 16:1311-1319. [PMID: 37101521 PMCID: PMC10124568 DOI: 10.2147/jpr.s393854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 04/04/2023] [Indexed: 04/28/2023] Open
Abstract
Purpose Fremanezumab monoclonal antibody therapy has demonstrated efficacy for chronic migraine (CM) with rapid onset and good tolerability. This subgroup analysis of two clinical trials (Japanese and Korean CM Phase 2b/3 [NCT03303079] and HALO CM Phase 3 [NCT02621931]) aimed to evaluate the efficacy and safety of fremanezumab in Japanese patients. Patients and Methods Both trials randomly assigned eligible patients at baseline (1:1:1 ratio) to subcutaneous monthly fremanezumab, quarterly fremanezumab, or placebo at 4-week intervals. The primary endpoint was the mean change from baseline in the monthly (28-day) average number of headache days of at least moderate severity during the 12-week period after the first dose of study medication (analyzed by ANCOVA over 12 weeks and MMRM over initial 4 weeks). Secondary endpoints examined other aspects of efficacy, including medication use and disability. Results A total of 479 and 109 patients were Japanese in the Japanese and Korean CM Phase 2b/3 and HALO CM trials, respectively. Baseline and treatment characteristics were generally similar between treatment groups for both trials. Results of subgroup analyses for the primary endpoint according to ANCOVA demonstrated the superiority of fremanezumab over placebo in Japanese patients (quarterly fremanezumab, p=0.0005; monthly fremanezumab, p=0.0002 in both trials). Results using the MMRM analysis confirmed the rapid onset of action in this population. Results of the secondary endpoints further supported the efficacy of fremanezumab in Japanese patients. Fremanezumab was well tolerated with nasopharyngitis and injection-site reactions representing the most common adverse events in all treatment groups. Conclusion Despite the limitations of subgroup analyses, these consistent results confirm the efficacy and tolerability of fremanezumab in Japanese patients with CM.
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Affiliation(s)
- Kazumasa Saigoh
- Department of Neurology, Kindai University School of Medicine, Osaka, Japan
| | - Takao Takeshima
- Headache Center, Department of Neurology, Tominaga Hospital, Osaka, Japan
| | - Masami Nakai
- Medical Affairs, Otsuka Pharmaceutical Co., Ltd., Osaka, Japan
- Correspondence: Masami Nakai, Medical Affairs, Otsuka Pharmaceutical Co., Ltd., 3-2-27 Otedori, Chuo-ku, Osaka, 540-0021, Japan, Tel +81-80-9026-3806, Email
| | | | - Miki Ishida
- Headquarters of Clinical Development, Otsuka Pharmaceutical Co., Ltd., Osaka, Japan
| | - Xiaoping Ning
- Teva Branded Pharmaceutical Products R&D, Inc., West Chester, PA, USA
| | - Steve Barash
- Teva Branded Pharmaceutical Products R&D, Inc., West Chester, PA, USA
| | - Yuki Isogai
- Medical Affairs, Otsuka Pharmaceutical Co., Ltd., Tokyo, Japan
| | - Nobuyuki Koga
- Medical Affairs, Otsuka Pharmaceutical Co., Ltd., Tokushima, Japan
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Economics of Artificial Intelligence in Healthcare: Diagnosis vs. Treatment. Healthcare (Basel) 2022; 10:healthcare10122493. [PMID: 36554017 PMCID: PMC9777836 DOI: 10.3390/healthcare10122493] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/03/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022] Open
Abstract
Motivation: The price of medical treatment continues to rise due to (i) an increasing population; (ii) an aging human growth; (iii) disease prevalence; (iv) a rise in the frequency of patients that utilize health care services; and (v) increase in the price. Objective: Artificial Intelligence (AI) is already well-known for its superiority in various healthcare applications, including the segmentation of lesions in images, speech recognition, smartphone personal assistants, navigation, ride-sharing apps, and many more. Our study is based on two hypotheses: (i) AI offers more economic solutions compared to conventional methods; (ii) AI treatment offers stronger economics compared to AI diagnosis. This novel study aims to evaluate AI technology in the context of healthcare costs, namely in the areas of diagnosis and treatment, and then compare it to the traditional or non-AI-based approaches. Methodology: PRISMA was used to select the best 200 studies for AI in healthcare with a primary focus on cost reduction, especially towards diagnosis and treatment. We defined the diagnosis and treatment architectures, investigated their characteristics, and categorized the roles that AI plays in the diagnostic and therapeutic paradigms. We experimented with various combinations of different assumptions by integrating AI and then comparing it against conventional costs. Lastly, we dwell on three powerful future concepts of AI, namely, pruning, bias, explainability, and regulatory approvals of AI systems. Conclusions: The model shows tremendous cost savings using AI tools in diagnosis and treatment. The economics of AI can be improved by incorporating pruning, reduction in AI bias, explainability, and regulatory approvals.
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Chang CL, Cai Z, Hsu SYT. Gel-forming antagonist provides a lasting effect on CGRP-induced vasodilation. Front Pharmacol 2022; 13:1040951. [PMID: 36569288 PMCID: PMC9772450 DOI: 10.3389/fphar.2022.1040951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 11/14/2022] [Indexed: 12/14/2022] Open
Abstract
Migraine affects ∼15% of the adult population, and the standard treatment includes the use of triptans, ergotamines, and analgesics. Recently, CGRP and its receptor, the CLR/RAMP1 receptor complex, have been targeted for migraine treatment due to their critical roles in mediating migraine headaches. The effort has led to the approval of several anti-CGRP antibodies for chronic migraine treatment. However, many patients still suffer continuous struggles with migraine, perhaps due to the limited ability of anti-CGRP therapeutics to fully reduce CGRP levels or reach target cells. An alternative anti-CGRP strategy may help address the medical need of patients who do not respond to existing therapeutics. By serendipity, we have recently found that several chimeric adrenomedullin/adrenomedullin 2 peptides are potent CLR/RAMP receptor antagonists and self-assemble to form liquid gels. Among these analogs, the ADE651 analog, which potently inhibits CLR/RAMP1 receptor signaling, forms gels at a 6-20% level. Screening of ADE651 variants indicated that residues at the junctional region of this chimeric peptide are important for gaining the gel-forming capability. Gel-formation significantly slowed the passage of ADE651 molecules through Centricon filters. Consistently, subcutaneous injection of ADE651 gel in rats led to the sustained presence of ADE651 in circulation for >1 week. In addition, analysis of vascular blood flow in rat hindlimbs showed ADE651 significantly reduces CGRP-induced vasodilation. Because gel-forming antagonists could have direct and sustained access to target cells, ADE651 and related antagonists for CLR/RAMP receptors may represent promising candidates for targeting CGRP- and/or adrenomedullin-mediated headaches in migraine patients.
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Affiliation(s)
- Chia Lin Chang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital Linkou Medical Center, Chang Gung University, Taoyuan, Taiwan
| | - Zheqing Cai
- CL Laboratory LLC, Gaithersburg, MD, United States
| | - Sheau Yu Teddy Hsu
- Adepthera LLC, San Jose, CA, United States,*Correspondence: Sheau Yu Teddy Hsu,
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Calcitonin Gene-Related Peptide Is Potential Therapeutic Target OF Osteoporosis. Heliyon 2022; 8:e12288. [DOI: 10.1016/j.heliyon.2022.e12288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 08/31/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022] Open
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43
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Trigeminal neuralgia and the merit of small clinical trials. Lancet Neurol 2022; 21:951-953. [DOI: 10.1016/s1474-4422(22)00389-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 09/06/2022] [Accepted: 09/06/2022] [Indexed: 11/20/2022]
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Alpuente A, Gallardo VJ, Asskour L, Caronna E, Torres‐Ferrus M, Pozo‐Rosich P. Salivary
CGRP
and Erenumab Treatment Response: Towards Precision Medicine in Migraine. Ann Neurol 2022; 92:846-859. [DOI: 10.1002/ana.26472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 08/03/2022] [Accepted: 08/05/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Alicia Alpuente
- Headache Clinic, Neurology Department Vall d'Hebron University Hospital Barcelona Spain
- Headache and Neurological Pain Research Group, Vall d'Hebron Research Institute, Departament de Medicina Universitat Autònoma de Barcelona Barcelona Spain
| | - Victor J Gallardo
- Headache and Neurological Pain Research Group, Vall d'Hebron Research Institute, Departament de Medicina Universitat Autònoma de Barcelona Barcelona Spain
| | - Laila Asskour
- Headache and Neurological Pain Research Group, Vall d'Hebron Research Institute, Departament de Medicina Universitat Autònoma de Barcelona Barcelona Spain
| | - Edoardo Caronna
- Headache Clinic, Neurology Department Vall d'Hebron University Hospital Barcelona Spain
- Headache and Neurological Pain Research Group, Vall d'Hebron Research Institute, Departament de Medicina Universitat Autònoma de Barcelona Barcelona Spain
| | - Marta Torres‐Ferrus
- Headache Clinic, Neurology Department Vall d'Hebron University Hospital Barcelona Spain
- Headache and Neurological Pain Research Group, Vall d'Hebron Research Institute, Departament de Medicina Universitat Autònoma de Barcelona Barcelona Spain
| | - Patricia Pozo‐Rosich
- Headache Clinic, Neurology Department Vall d'Hebron University Hospital Barcelona Spain
- Headache and Neurological Pain Research Group, Vall d'Hebron Research Institute, Departament de Medicina Universitat Autònoma de Barcelona Barcelona Spain
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Citak A, Kilinc E, Torun IE, Ankarali S, Dagistan Y, Yoldas H. The effects of certain TRP channels and voltage-gated KCNQ/Kv7 channel opener retigabine on calcitonin gene-related peptide release in the trigeminovascular system. Cephalalgia 2022; 42:1375-1386. [PMID: 35861239 DOI: 10.1177/03331024221114773] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Calcitonin gene-related peptide release in trigeminovascular system is a pivotal component of neurogenic inflammation underlying migraine pathophysiology. Transient receptor potential channels and voltage-gated KCNQ/Kv7 potassium channels expressed throughout trigeminovascular system are important targets for modulation of calcitonin gene-related peptide release. We investigated the effects of certain transient receptor potential (TRP) channels the vanilloid 1 and 4 (TRPV1 and TRPV4), the ankyrin 1 (TRPA1), and metastatin type 8 (TRPM8), and voltage-gated potassium channel (Kv7) opener retigabine on calcitonin gene-related peptide release from peripheral (dura mater and trigeminal ganglion) and central (trigeminal nucleus caudalis) trigeminal components of rats. METHODS The experiments were carried out using well-established in-vitro preparations (hemiskull, trigeminal ganglion and trigeminal nucleus caudalis) from male Wistar rats. Agonists and antagonists of TRPV1, TRPV4, TRPA1 and TRPM8 channels, and also retigabine were tested on the in-vitro release of calcitonin gene-related peptide. Calcitonin gene-related peptide concentrations were measured using enzyme-linked immunosorbent assay. RESULTS Agonists of these transient receptor potential channels induced calcitonin gene-related peptide release from hemiskull, trigeminal ganglion and trigeminal nucleus caudalis, respectively. The transient receptor potential channels-induced calcitonin gene-related peptide releases were blocked by their specific antagonists and reduced by retigabine. Retigabine also decreased basal calcitonin gene-related peptide releases in all preparations. CONCLUSION Our findings suggest that favorable antagonists of these transient receptor potential channels, or Kv7 channel opener retigabine may be effective in migraine therapy by inhibiting neurogenic inflammation that requires calcitonin gene-related peptide release.
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Affiliation(s)
- Arzu Citak
- Department of Physiology, Faculty of Medicine, Bolu Abant Izzet Baysal University, Bolu, Turkey
| | - Erkan Kilinc
- Department of Physiology, Faculty of Medicine, Bolu Abant Izzet Baysal University, Bolu, Turkey
| | - Ibrahim Ethem Torun
- Department of Physiology, Faculty of Medicine, Bolu Abant Izzet Baysal University, Bolu, Turkey
| | - Seyit Ankarali
- Department of Physiology, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Yasar Dagistan
- Department of Neurosurgery, Faculty of Medicine, Bolu Abant Izzet Baysal University, Bolu, Turkey
| | - Hamit Yoldas
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Bolu Abant Izzet Baysal University, Bolu, Turkey
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Sacco S, Amin FM, Ashina M, Bendtsen L, Deligianni CI, Gil-Gouveia R, Katsarava Z, MaassenVanDenBrink A, Martelletti P, Mitsikostas DD, Ornello R, Reuter U, Sanchez-Del-Rio M, Sinclair AJ, Terwindt G, Uluduz D, Versijpt J, Lampl C. European Headache Federation guideline on the use of monoclonal antibodies targeting the calcitonin gene related peptide pathway for migraine prevention - 2022 update. J Headache Pain 2022; 23:67. [PMID: 35690723 PMCID: PMC9188162 DOI: 10.1186/s10194-022-01431-x] [Citation(s) in RCA: 146] [Impact Index Per Article: 73.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/29/2022] [Indexed: 01/05/2023] Open
Abstract
Background A previous European Headache Federation (EHF) guideline addressed the use of monoclonal antibodies targeting the calcitonin gene-related peptide (CGRP) pathway to prevent migraine. Since then, randomized controlled trials (RCTs) and real-world evidence have expanded the evidence and knowledge for those treatments. Therefore, the EHF panel decided to provide an updated guideline on the use of those treatments. Methods The guideline was developed following the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach. The working group identified relevant questions, performed a systematic review and an analysis of the literature, assessed the quality of the available evidence, and wrote recommendations. Where the GRADE approach was not applicable, expert opinion was provided. Results We found moderate to high quality of evidence to recommend eptinezumab, erenumab, fremanezumab, and galcanezumab in individuals with episodic and chronic migraine. For several important clinical questions, we found not enough evidence to provide evidence-based recommendations and guidance relied on experts’ opinion. Nevertheless, we provided updated suggestions regarding the long-term management of those treatments and their place with respect to the other migraine preventatives. Conclusion Monoclonal antibodies targeting the CGRP pathway are recommended for migraine prevention as they are effective and safe also in the long-term. Supplementary Information The online version contains supplementary material available at 10.1186/s10194-022-01431-x.
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Affiliation(s)
- Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences - University of L'Aquila, Via Vetoio 1, L'Aquila, Italy.
| | - Faisal Mohammad Amin
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, University of Copenhagen, Copenhagen, Denmark.,Department of Neurorehabilitation/Traumatic Brain Injury, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Messoud Ashina
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, University of Copenhagen, Copenhagen, Denmark
| | - Lars Bendtsen
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, University of Copenhagen, Copenhagen, Denmark
| | - Christina I Deligianni
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, University of Copenhagen, Copenhagen, Denmark
| | - Raquel Gil-Gouveia
- Hospital da Luz Headache Center, Neurology Department, Hospital da Luz Lisboa, Lisbon, Portugal.,Center for Interdisciplinary Research in Health, Universidade Católica Portuguesa, Lisbon, Portugal
| | - Zaza Katsarava
- Christian Hospital Unna, Unna, Germany.,University of Duisburg-Essen, Duisburg, Germany
| | | | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Dimos-Dimitrios Mitsikostas
- 1st Department of Neurology, Aeginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Raffaele Ornello
- Department of Biotechnological and Applied Clinical Sciences - University of L'Aquila, Via Vetoio 1, L'Aquila, Italy
| | - Uwe Reuter
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany.,Universitätsmedizin Greifswald, Greifswald, Germany
| | | | - Alexandra J Sinclair
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2WB, UK
| | - Gisela Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Derya Uluduz
- Department of Neurology Istanbul Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Jan Versijpt
- Department of Neurology, Vrije Universiteit Brussel (VUB), Universitair, Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Christian Lampl
- Department of Neurology, Headache Medical Center at the Konventhospital BHB Linz, Linz, Austria
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Therapies targeting CGRP signaling for medication overuse headache. Curr Opin Neurol 2022; 35:353-359. [PMID: 35674079 DOI: 10.1097/wco.0000000000001061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Medication overuse headache (MOH) affects more than 60 million individuals worldwide causing enormous personal and social burden. Only repurposed drugs are available for MOH that share limited evidence for efficacy. The preclinical data suggesting that activation of the calcitonin gene-related peptide (CGRP) pathway is involved in headache chronification along with clinical evidence that monoclonal antibodies targeting CGRP (anti-CGRP mAbs) have good efficacy in preventing chronic migraine, triggered this review that aims to summarize the current data on the effectiveness and safety of mAbs against CGRP in MOH. RECENT FINDINGS Post hoc analyses of phase-3 trials of erenumab, fremanezumab, galcanezumab, and eptinezumab for the prevention of chronic migraine revealed that patients with MOH benefit from the treatment over placebo. Several real-world studies confirm the efficacy of erenumab and galcanezumab in patients with MO. However, all published trials evaluated treatments in patients with chronic migraine with MO collectively, not in patients with MOH exclusively. SUMMARY The available data indicate that anti-CGRP mAbs represent a good mechanism-based and disease-specific therapeutical option with for MOH as long as detoxification and additional nonpharmaceutical interventions are operated. Future research should focus on long-term-controlled trials in MOH populations exclusively.
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Gérard AO, Merino D, Van Obberghen EK, Rocher F, Destere A, Lantéri-Minet M, Drici MD. Calcitonin gene-related peptide-targeting drugs and Raynaud's phenomenon: a real-world potential safety signal from the WHO pharmacovigilance database. J Headache Pain 2022; 23:53. [PMID: 35505285 PMCID: PMC9066820 DOI: 10.1186/s10194-022-01424-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 04/27/2022] [Indexed: 11/28/2022] Open
Abstract
Background Migraine is responsible for significant disability and societal burden. Recently, drugs targeting the calcitonin gene-related peptide (CGRP) pathway raised new hopes. CGRP, a potent vasodilator, plays a key role in the pathogenesis of migraine attacks. The deficiency of CGRP is involved in Raynaud’s phenomenon, which consists of abnormal vasoconstriction of the digits. We aimed to assess the potential association of Raynaud’s phenomenon with CGRP-targeting drugs, analyzing real-world data from the World Health Organization (VigiBase®). Methods We queried all reports of Raynaud’s phenomenon involving a CGRP-targeting drug. We sought disproportionate reporting of Raynaud’s phenomenon with these drugs. For this purpose, we relied on the calculation of the Information Component (IC). A positive lower end of the 95% confidence interval (CI) of the IC defines a statistically significant association. As migraine patients are prone to Raynaud’s phenomenon, we also calculated the IC of Raynaud’s phenomenon with CGRP-targeting drugs compared to 5HT1B/D agonists (triptans), and beta-blockers used in the treatment of migraine. Results Overall, 99 reports of Raynaud’s phenomenon involving CGRP-targeting drugs have been yielded in VigiBase®. The most reported CGRP-targeting drug was erenumab, with 56 reports (56.6%). The median time to onset was 84 days. No fatality was notified, but one patient suffered from gangrene and extremity necrosis. As a whole, CGRP-targeting drugs were significantly associated with Raynaud’s phenomenon, with an IC of 3.3 (95%CI: 3.0–3.5). There was a disproportionate reporting of Raynaud’s phenomenon with CGRP-targeting drugs compared to triptans (IC 0.4; 95%CI: 0.1–0.6) and to beta-blockers (IC 0.5; 95%CI: 0.2–0.7) as well. Conclusions There is a significant disproportionality signal of Raynaud’s phenomenon with CGRP-targeting. This signal stands out when CGRP-targeting drugs are compared to other drugs used in patients with migraine. This study is limited by missing data in pharmacovigilance reports. CGRP-targeting drugs may be subject to Weber effect and reporting bias. Nonetheless, CGRP blockade might be the last straw that disrupts the physiological balance of vascular response in patients at-risk of Raynaud’s phenomenon. Pending further data regarding vascular safety of CGRP-targeting drugs, caution is warranted in these patients.
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Affiliation(s)
- Alexandre O Gérard
- Department of Pharmacology and Pharmacovigilance Center of Nice, University Hospital Center of Nice, Nice, France.,Department of Nephrology-Dialysis-Transplantation, University Hospital Center of Nice, Nice, France.,Laboratory of Molecular Physio Medicine (LP2M), UMR 7370, CNRS, University Côte d'Azur, Nice, France
| | - Diane Merino
- Department of Pharmacology and Pharmacovigilance Center of Nice, University Hospital Center of Nice, Nice, France
| | - Elise K Van Obberghen
- Pain Department and FHU InovPain, University Hospital Center of Nice and Côte d'Azur University, Nice, France
| | - Fanny Rocher
- Department of Pharmacology and Pharmacovigilance Center of Nice, University Hospital Center of Nice, Nice, France
| | - Alexandre Destere
- Department of Pharmacology and Pharmacovigilance Center of Nice, University Hospital Center of Nice, Nice, France
| | - Michel Lantéri-Minet
- Pain Department and FHU InovPain, University Hospital Center of Nice and Côte d'Azur University, Nice, France.,Migraine and Trigeminal Pain, UMR 1107, INSERM, Auvergne University, Clermont-Ferrand, France
| | - Milou-Daniel Drici
- Department of Pharmacology and Pharmacovigilance Center of Nice, University Hospital Center of Nice, Nice, France.
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Iannone LF, De Cesaris F, Geppetti P. Emerging Pharmacological Treatments for Migraine in the Pediatric Population. Life (Basel) 2022; 12:536. [PMID: 35455026 PMCID: PMC9031827 DOI: 10.3390/life12040536,] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 03/31/2022] [Accepted: 04/04/2022] [Indexed: 12/07/2023] Open
Abstract
Headaches in children and adolescents have high incidence and prevalence rates, with consequent elevated disability costs to individuals and the community. Pediatric migraine is a disorder with substantial clinical differences compared to the adult form. Few clinical trials have been performed specifically on primary headache in pediatric populations using acute and preventative treatments, often with conflicting findings. The limited high-quality data on the effectiveness of treatments are also due to the high placebo effect, in terms of reductions in both the frequency and intensity of migraine attacks in the pediatric population. The recent introduction of calcitonin gene-related peptide (CGRP) pathway inhibitors and ditans is changing the treatment of migraine, but the majority of the data are still limited to adulthood. Thus, few drugs have indications for migraine treatment in the pediatric age group, and limited evidence gives guidance as to the choice of pharmacotherapy. Herein, we review the current evidence of pharmacological treatments and ongoing clinical trials on acute and preventative treatments in the pediatric population with migraine.
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Affiliation(s)
- Luigi Francesco Iannone
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, 50121 Florence, Italy;
- Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, 50134 Florence, Italy;
| | - Francesco De Cesaris
- Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, 50134 Florence, Italy;
| | - Pierangelo Geppetti
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, 50121 Florence, Italy;
- Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, 50134 Florence, Italy;
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50
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Calandre EP, Slim M, Rico-Villademoros F. How does a physician decide which pharmacotherapeutic option to select for acute migraine attacks? Expert Opin Pharmacother 2022; 23:1129-1133. [PMID: 35382662 DOI: 10.1080/14656566.2022.2060740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Elena P Calandre
- Instituto de Neurociencias, Universidad de Granada, Armilla, Spain
| | - Mahmoud Slim
- Instituto de Neurociencias, Universidad de Granada, Armilla, Spain
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