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Karsan N, Goadsby PJ. Intervening in the Premonitory Phase to Prevent Migraine: Prospects for Pharmacotherapy. CNS Drugs 2024; 38:533-546. [PMID: 38822165 DOI: 10.1007/s40263-024-01091-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2024] [Indexed: 06/02/2024]
Abstract
Migraine is a common brain condition characterised by disabling attacks of headache with sensory sensitivities. Despite increasing understanding of migraine neurobiology and the impacts of this on therapeutic developments, there remains a need for treatment options for patients underserved by currently available therapies. The first specific drugs developed to treat migraine acutely, the serotonin-5-hydroxytryptamine [5-HT1B/1D] receptor agonists (triptans), seem to require headache onset in order to have an effect, while early treatment during mild pain before headache escalation improves short-term and long-term outcomes. Some patients find treating in the early window once headache has started but not escalated difficult, and migraine can arise from sleep or in the early hours of the morning, making prompt treatment after pain onset challenging. Triptans may be deemed unsuitable for use in patients with vascular disease and in those of older age and may not be effective in a proportion of patients. Headache is also increasingly recognised as being just one of the many facets of the migraine attack, and for some patients it is not the most disabling symptom. In many patients, painless symptoms can start prior to headache onset and can reliably warn of impending headache. There is, therefore, a need to identify therapeutic targets and agents that may be used as early as possible in the course of the attack, to prevent headache onset before it starts, and to reduce both headache and non-headache related attack burden. Early small studies using domperidone, naratriptan and dihydroergotamine have suggested that this approach could be useful; these studies were methodologically less rigorous than modern day treatment studies, of small sample size, and have not since been replicated. The emergence of novel targeted migraine treatments more recently, specifically calcitonin gene-related peptide (CGRP) receptor antagonists (gepants), has reignited interest in this strategy, with encouraging results. This review summarises historical and emerging data in this area, supporting use of the premonitory phase as an opportunity to intervene as early as possible in migraine to prevent attack-related morbidity.
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Affiliation(s)
- Nazia Karsan
- Headache Group, Wolfson SPaRC, Institute of Psychiatry, Psychology and Neuroscience, Wellcome Foundation Building, King's College London, Denmark Hill, London, SE5 9PJ, UK
- NIHR King's Clinical Research Facility and SLaM Biomedical Research Centre, King's College Hospital, London, UK
| | - Peter J Goadsby
- Headache Group, Wolfson SPaRC, Institute of Psychiatry, Psychology and Neuroscience, Wellcome Foundation Building, King's College London, Denmark Hill, London, SE5 9PJ, UK.
- NIHR King's Clinical Research Facility and SLaM Biomedical Research Centre, King's College Hospital, London, UK.
- Department of Neurology, University of California, Los Angeles, Los Angeles, CA, USA.
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Göbel CH, Heinze A, Cirkel A, Göbel H. Rizatriptan as an Over-the-Counter Triptan in the Treatment of Migraine Attacks. Pain Ther 2024:10.1007/s40122-024-00625-2. [PMID: 38886287 DOI: 10.1007/s40122-024-00625-2] [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: 05/12/2024] [Accepted: 06/03/2024] [Indexed: 06/20/2024] Open
Abstract
Around 91% of migraine patients use over-the-counter medicines to treat attacks, often without further treatment or medical consultation. This therapeutic principle is established in most countries, regardless of how the healthcare system is otherwise structured or financed. Using Germany as an example, the basis for an expansion of attack therapy with rizatriptan as an over-the-counter triptan is described. To achieve the best possible tolerability and safety in the context of self-medication, the lowest possible dose should be selected to provide the most favourable tolerability and safety profile in the context of self-medication through low dosages. The lowest approved dose of rizatriptan is 5 mg. This was investigated in three randomized controlled trials with 752 patients. The results show that rizatriptan at a dose of 5 mg is more effective than the triptans naratriptan 2.5 mg, almotriptan 12.5 mg and sumatriptan 50 mg, which were previously available for self-medication in Germany. There was no significant difference in the frequency of adverse events with rizatriptan 5 mg compared to placebo. Rizatriptan 5 mg does not have a higher side effect potential than sumatriptan 50 mg, which is already exempt from the prescription requirement. The reasons given show that rizatriptan in a dose of 5 mg for the treatment of acute migraine attacks fulfils the requirements for a transfer from prescription to pharmacy-only status at least as well as sumatriptan 50 mg, naratriptan 2.5 mg and almotriptan 12.5 mg. From a clinical care perspective, it is desirable for affected patients to have other options available for self-medication. Non-responders to other substances also have a further treatment option with rizatriptan 5 mg, with the same or even better risk-benefit profile, to treat migraine attacks safely, effectively and in a tolerable manner as part of self-medication.
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Affiliation(s)
- Carl H Göbel
- Kiel Migraine and Headache Centre, Heikendorfer Weg 9-27, 24149, Kiel, Germany.
| | - Axel Heinze
- Kiel Migraine and Headache Centre, Heikendorfer Weg 9-27, 24149, Kiel, Germany
| | - Anna Cirkel
- Kiel Migraine and Headache Centre, Heikendorfer Weg 9-27, 24149, Kiel, Germany
- Department of Neurology, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Hartmut Göbel
- Kiel Migraine and Headache Centre, Heikendorfer Weg 9-27, 24149, Kiel, Germany
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Svane N, Pedersen ABV, Rodenberg A, Ozgür B, Saaby L, Bundgaard C, Kristensen M, Tfelt-Hansen P, Brodin B. The putative proton-coupled organic cation antiporter is involved in uptake of triptans into human brain capillary endothelial cells. Fluids Barriers CNS 2024; 21:39. [PMID: 38711118 DOI: 10.1186/s12987-024-00544-6] [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: 03/13/2024] [Accepted: 04/25/2024] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND Triptans are anti-migraine drugs with a potential central site of action. However, it is not known to what extent triptans cross the blood-brain barrier (BBB). The aim of this study was therefore to determine if triptans pass the brain capillary endothelium and investigate the possible underlying mechanisms with focus on the involvement of the putative proton-coupled organic cation (H+/OC) antiporter. Additionally, we evaluated whether triptans interacted with the efflux transporter, P-glycoprotein (P-gp). METHODS We investigated the cellular uptake characteristics of the prototypical H+/OC antiporter substrates, pyrilamine and oxycodone, and seven different triptans in the human brain microvascular endothelial cell line, hCMEC/D3. Triptan interactions with P-gp were studied using the IPEC-J2 MDR1 cell line. Lastly, in vivo neuropharmacokinetic assessment of the unbound brain-to-plasma disposition of eletriptan was conducted in wild type and mdr1a/1b knockout mice. RESULTS We demonstrated that most triptans were able to inhibit uptake of the H+/OC antiporter substrate, pyrilamine, with eletriptan emerging as the strongest inhibitor. Eletriptan, almotriptan, and sumatriptan exhibited a pH-dependent uptake into hCMEC/D3 cells. Eletriptan demonstrated saturable uptake kinetics with an apparent Km of 89 ± 38 µM and a Jmax of 2.2 ± 0.7 nmol·min-1·mg protein-1 (n = 3). Bidirectional transport experiments across IPEC-J2 MDR1 monolayers showed that eletriptan is transported by P-gp, thus indicating that eletriptan is both a substrate of the H+/OC antiporter and P-gp. This was further confirmed in vivo, where the unbound brain-to-unbound plasma concentration ratio (Kp,uu) was 0.04 in wild type mice while the ratio rose to 1.32 in mdr1a/1b knockout mice. CONCLUSIONS We have demonstrated that the triptan family of compounds possesses affinity for the H+/OC antiporter proposing that the putative H+/OC antiporter plays a role in the BBB transport of triptans, particularly eletriptan. Our in vivo studies indicate that eletriptan is subjected to simultaneous brain uptake and efflux, possibly facilitated by the putative H+/OC antiporter and P-gp, respectively. Our findings offer novel insights into the potential central site of action involved in migraine treatment with triptans and highlight the significance of potential transporter related drug-drug interactions.
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Affiliation(s)
- Nana Svane
- Department of Pharmacy, University of Copenhagen, Copenhagen, Denmark
| | | | - Anne Rodenberg
- Department of Pharmacy, University of Copenhagen, Copenhagen, Denmark
| | - Burak Ozgür
- Department of Pharmacy, University of Copenhagen, Copenhagen, Denmark
- Biotherapeutic Discovery, H. Lundbeck A/S, Valby, Denmark
| | - Lasse Saaby
- Department of Pharmacy, University of Copenhagen, Copenhagen, Denmark
- Bioneer: FARMA, Bioneer A/S, Copenhagen, Denmark
| | | | - Mie Kristensen
- Department of Pharmacy, University of Copenhagen, Copenhagen, Denmark
| | - Peer Tfelt-Hansen
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, University of Copenhagen, Glostrup, Denmark
| | - Birger Brodin
- Department of Pharmacy, University of Copenhagen, Copenhagen, Denmark.
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Frattale I, Ferilli MAN, Ursitti F, Sforza G, Monte G, Proietti Checchi M, Tarantino S, Mazzone L, Valeriani M, Papetti L. Unsatisfactory response to acute medications does not affect the medication overuse headache development in pediatric chronic migraine. J Headache Pain 2024; 25:61. [PMID: 38649822 PMCID: PMC11036745 DOI: 10.1186/s10194-024-01766-7] [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: 02/29/2024] [Accepted: 04/04/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Chronic migraine (CM) negatively impacts the quality of life of 2 to 4% of pediatric patients. In adults, CM is frequently linked to medication overuse headache (MOH), but there is a much lower prevalence of MOH in children. A suboptimal response to acute therapies may lead to their reduced use, thus preventing MOH development in children and adolescents. The frequency of patients with CM who do not respond to acute therapies was examined in the present study. We investigated whether the prevalence of MOH was different between responders and non-responders. We also examined whether patients receiving prophylactic therapy had an improved response to acute therapy. Finally, we investigated if there was a difference in the frequency of psychiatric comorbidities between responders and non-responders. METHODS We retrospectively analysed clinical data of all chronic pediatric migraineurs under the age of 18 referred to the Headache Centre at Bambino Gesù Children Hospital in June 2021 and February 2023. ICHD3 criteria were used to diagnose CM and MOH. We collected demographic data, including the age at onset of migraine and the age of the CM course. At baseline and after 3 months of preventive treatment, we evaluated the response to acute medications. Neuropsychiatric comorbidities were referred by the children's parents during the first attendance evaluation. RESULTS Seventy patients with CM were assessed during the chosen period. Paracetamol was tried by 41 patients (58.5%), NSAIDs by 56 patients (80.0%), and triptans by 1 patient (1.4%). Fifty-one participants (73%) were non-responder to the abortive treatment. The presence of MOH was detected in 27.1% of the whole populations. Regarding our primary aim, MOH was diagnosed in 29% of non-responder patients and 22% of responders (p > 0.05). All patients received preventative treatment. After 3 months of preventive pharmacological therapy, 65.4% of patients who did not respond to acute medications achieved a response, while 34.6% of patients who were non-responder remain non-responder (p < 0.05). Prophylactic therapy was also effective in 69% of patients who responded to acute medication (p < 0.05). Psychiatric comorbidities were detected in 68.6% of patients, with no difference between responders and non-responders (72.2% vs. 67.3%; p = 0.05). CONCLUSIONS Despite the high prevalence of unresponsiveness to acute therapies in pediatric CM, it does not act as a protective factor for MOH. Moreover, responsiveness to acute drugs is improved by pharmacological preventive treatment and it is not affected by concomitant psychiatric comorbidities.
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Affiliation(s)
- Ilaria Frattale
- Child Neurology and Psychiatry Unit, Department of Wellbeing of Mental and Neurological, Dental and Sensory Organ Health, Policlinico Tor Vergata Foundation Hospital, Rome, Italy
| | - Michela Ada Noris Ferilli
- Developmental Neurology, Bambino Gesù Children' s Hospital, IRCCS, Piazza di Sant'Onofrio 4, 00165, Rome, Italy
| | - Fabiana Ursitti
- Developmental Neurology, Bambino Gesù Children' s Hospital, IRCCS, Piazza di Sant'Onofrio 4, 00165, Rome, Italy
| | - Giorgia Sforza
- Developmental Neurology, Bambino Gesù Children' s Hospital, IRCCS, Piazza di Sant'Onofrio 4, 00165, Rome, Italy
| | - Gabriele Monte
- Developmental Neurology, Bambino Gesù Children' s Hospital, IRCCS, Piazza di Sant'Onofrio 4, 00165, Rome, Italy
| | - Martina Proietti Checchi
- Developmental Neurology, Bambino Gesù Children' s Hospital, IRCCS, Piazza di Sant'Onofrio 4, 00165, Rome, Italy
| | - Samuela Tarantino
- Developmental Neurology, Bambino Gesù Children' s Hospital, IRCCS, Piazza di Sant'Onofrio 4, 00165, Rome, Italy
| | - Luigi Mazzone
- Child Neurology and Psychiatry Unit, Department of Wellbeing of Mental and Neurological, Dental and Sensory Organ Health, Policlinico Tor Vergata Foundation Hospital, Rome, Italy
| | - Massimiliano Valeriani
- Developmental Neurology, Bambino Gesù Children' s Hospital, IRCCS, Piazza di Sant'Onofrio 4, 00165, Rome, Italy.
- System Medicine Department, Tor Vergata University of Rome, Rome, Italy.
- Center for Sensory-Motor Interaction, Aalborg University, Aalborg, Denmark.
| | - Laura Papetti
- Developmental Neurology, Bambino Gesù Children' s Hospital, IRCCS, Piazza di Sant'Onofrio 4, 00165, Rome, Italy
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Zhong C, Zhang X, Sun Y, Shen Z, Mao Y, Liu T, Wang R, Nie L, Shavandi A, Yunusov KE, Jiang G. Rizatriptan benzoate-loaded dissolving microneedle patch for management of acute migraine therapy. J Biomater Appl 2024; 38:989-999. [PMID: 38427917 DOI: 10.1177/08853282241237323] [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: 03/03/2024]
Abstract
In this study, dissolving microneedles (MNs) using polyvinyl alcohol (PVA) and poly (1-vinylpyrrolidone-co-vinyl acetate) (P(VP-co-VA)) as matrix materials were developed for transdermal delivery of rizatriptan benzoate (RB) for acute migraine treatment. In-vitro permeation studies were conducted to assess the feasibility of the as-fabricated dissolving MNs to release RB. Drug skin penetration were tested by Franz diffusion cells, showing an increase of the transdermal flux compared to passive diffusion due to the as-fabricated dissolving MNs having a sufficient mechanical strength to penetrate the skin and form microchannels. The pharmacological study in vivo showed that RB-loaded dissolving MNs significantly alleviated migraine-related response by up-regulating the level of 5-hydroxytryptamine (5-HT) and down-regulating the levels of calcitonin gene-related peptide (CGRP) and substance P (SP). In conclusion, the RB-loaded dissolving MNs have advantages of safety, convenience, and high efficacy over conventional administrations, laying a foundation for the transdermal drug delivery system treatment for acute migraine.
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Affiliation(s)
- Chao Zhong
- School of Materials Science and Engineering, Zhejiang Sci-Tech University, Hangzhou, China
- International Scientific and Technological Cooperation Base of Intelligent Biomaterials and Functional Fibers, Hangzhou, China
| | - Xiufeng Zhang
- Department of Anorectal Surgery, Hangzhou Third People's Hospital, Hangzhou, China
| | - Yanfang Sun
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, China
| | - Zhong Shen
- Department of Anorectal Surgery, Hangzhou Third People's Hospital, Hangzhou, China
| | - Yanan Mao
- School of Materials Science and Engineering, Zhejiang Sci-Tech University, Hangzhou, China
- International Scientific and Technological Cooperation Base of Intelligent Biomaterials and Functional Fibers, Hangzhou, China
| | - Tianqi Liu
- School of Materials Science and Engineering, Zhejiang Sci-Tech University, Hangzhou, China
- International Scientific and Technological Cooperation Base of Intelligent Biomaterials and Functional Fibers, Hangzhou, China
| | - Rui Wang
- School of Materials Science and Engineering, Zhejiang Sci-Tech University, Hangzhou, China
- International Scientific and Technological Cooperation Base of Intelligent Biomaterials and Functional Fibers, Hangzhou, China
| | - Lei Nie
- College of Life Sciences, Xinyang Normal University, Xinyang, China
| | - Amin Shavandi
- École polytechnique de Bruxelles, 3BIO-BioMatter, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Khaydar E Yunusov
- Institute of Polymer Chemistry and Physics, Uzbekistan Academy of Sciences, Tashkent, Uzbekistan
| | - Guohua Jiang
- School of Materials Science and Engineering, Zhejiang Sci-Tech University, Hangzhou, China
- International Scientific and Technological Cooperation Base of Intelligent Biomaterials and Functional Fibers, Hangzhou, China
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Burch R. Acute Treatment of Migraine. Continuum (Minneap Minn) 2024; 30:344-363. [PMID: 38568487 DOI: 10.1212/con.0000000000001402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
OBJECTIVE Most patients with migraine require acute treatment for at least some attacks. This article reviews the approach to the acute treatment of migraine, migraine-specific and nonspecific treatment options, rescue treatment and options for management in the emergency department and inpatient settings, and treatment during pregnancy and lactation. LATEST DEVELOPMENTS Triptans, ergot derivatives, and nonsteroidal anti-inflammatory drugs have historically been the main acute treatments for migraine. The development of new classes of acute treatment, including the small-molecule calcitonin gene-related peptide receptor antagonists (gepants) and a 5-HT1F receptor agonist (lasmiditan), expands available options. These new treatments have not been associated with vasospasm or increased cardiovascular risk, therefore allowing migraine-specific acute treatment for the more than 20% of adults with migraine who are at increased risk of cardiovascular events. Neuromodulation offers a nonpharmacologic option for acute treatment, with the strongest evidence for remote electrical neuromodulation. ESSENTIAL POINTS The number of available migraine treatments continues to expand, although triptans are still the mainstay of migraine-specific acute treatment. There is no one-size-fits-all acute treatment and multiple treatment trials are sometimes necessary to determine the optimal regimen for patients. Switching within and between classes, using the maximum allowed dose, using combination therapy, and counseling patients to treat early are all strategies that may improve patient response to acute treatment.
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Rossignol J, Ouimet T, Poras H, Dallel R, Luccarini P. Synergistic effect of combining dual enkephalinase inhibitor PL37 and sumatriptan in a preclinical model of migraine. Headache 2024; 64:243-252. [PMID: 38385629 DOI: 10.1111/head.14681] [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: 08/30/2023] [Revised: 01/19/2024] [Accepted: 01/25/2024] [Indexed: 02/23/2024]
Abstract
OBJECTIVE The aim of this study was to test whether a combination of sumatriptan with dual enkephalinase inhibitor PL37 would result in an additive or a synergistic effect. BACKGROUND Combination treatment is frequently used to improve the therapeutic efficacy of drugs. The co-administration of two drugs may result in efficacy at lower doses than those needed for either drug alone, thus minimizing side effects. Here, we tested the effect of the co-administration of two drugs on cutaneous mechanical hypersensitivity (MH), a symptom often affecting cephalic regions in patients with migraine: dual enkephalinase inhibitor PL37, a small molecule that protects enkephalins from rapid degradation, and sumatriptan, a serotonin 5-HT1B/1D receptor agonist. METHODS We investigated the effects of oral administrations of sumatriptan, PL37, or their combination on changes in cutaneous mechanical sensitivity induced by a single intraperitoneal administration of the nitric oxide donor, isosorbide dinitrate (ISDN) in male rats. Mechanical sensitivity was assessed using von Frey filaments applied to the face of animals to determine pain thresholds. Isobolographic analysis was performed to determine the nature of the interaction between sumatriptan and PL37. RESULTS Sumatriptan as well as PL37 each produced a dose-dependent inhibition of ISDN-induced cephalic MH. Median effective dose (ED50 ) values were 0.3 and 1.1 mg/kg for sumatriptan and PL37, respectively. An isobolographic analysis of the effect of combined doses of sumatriptan and PL37 based on their calculated ED50 values demonstrated a synergistic effect of the combination on cephalic MH, with an interaction index of 0.14 ± 0.04. CONCLUSION These results suggest that PL37 acts synergistically with sumatriptan to produce an anti-allodynic effect in a rat model of migraine. Thus, combining PL37 and sumatriptan may be a useful therapeutic strategy in the management of migraine. PLAIN LANGUAGE SUMMARY There have been many advances in migraine treatment, but we still need more options that are effective and have few side effects. Sumatriptan is one available drug for acute treatment of migraine, but it does not work for every patient and is not suitable for some people. We tested a new drug called PL37 (that blocks enkephalinases) together with sumatriptan and the combination minimized side effects and allowed lower doses of the drugs for effective migraine treatment in an animal model.
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Affiliation(s)
- Jeanne Rossignol
- Neuro-Dol, Inserm, CHU Clermont-Ferrand, Université Clermont Auvergne, Clermont-Ferrand, France
- R & D Department, Pharmaleads SA, Paris, France
| | | | - Hervé Poras
- R & D Department, Pharmaleads SA, Paris, France
| | - Radhouane Dallel
- Neuro-Dol, Inserm, CHU Clermont-Ferrand, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Philippe Luccarini
- Neuro-Dol, Inserm, CHU Clermont-Ferrand, Université Clermont Auvergne, Clermont-Ferrand, France
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Wei S, Lv H, Yang D, Zhang L, Li X, Ning Y, Tang Y, Wu X, Han J. Drug-related side effects and adverse reactions in the treatment of migraine: a bibliometric and visual analysis. Front Neurol 2024; 15:1342111. [PMID: 38379705 PMCID: PMC10878131 DOI: 10.3389/fneur.2024.1342111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 01/19/2024] [Indexed: 02/22/2024] Open
Abstract
Background Migraine imposes a substantial global burden, impacting patients and society. Pharmacotherapy, as a primary treatment, entails specific adverse reactions. Emphasizing these reactions is pivotal for improving treatment strategies and enhancing patients' well-being. Thus, we conducted a comprehensive bibliometric and visual analysis of relevant literature. Methodology We conducted a comprehensive search on the Science Citation Index Expanded within the Web of Science, restricting the literature for analysis based on criteria such as document type, publication date, and language. Subsequently, we utilized various analytical tools, including VOSviewer, Scimago Graphica, the R package 'bibliometrix', CiteSpace, and Excel programs, for a meticulous examination and systematic organization of data concerning journals, authors, countries/regions, institutions, keywords, and references. Results By August 31, 2023, the literature was distributed across 379 journals worldwide, authored by 4,235 individuals from 1726 institutions. It featured 2,363 keywords and 38,412 references. 'HEADACHE' led in publication count, with 'SILBERSTEIN S' as the most prolific author. The United States ranked highest in publication volume, with 'UNIV COPENHAGEN' leading among institutions. Conclusion Our research findings indicate that researchers in the field continue to maintain a focus on the calcitonin gene-related peptide (CGRP) system and explore diverse mechanisms for drug development through the application of novel biotechnological approaches. Furthermore, it is imperative to enhance the assessment of clinical trial outcomes, consistently monitor the efficacy and safety of prominent drugs such as Erenumab and Fremanezumab. There is a need for further evaluation of acute and preventive treatments tailored to different populations and varying types of migraine.
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Affiliation(s)
- Shijie Wei
- School of Acupuncture and Tuina, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Hao Lv
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Dianhui Yang
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Lili Zhang
- Institute of Acupuncture and Moxibustion, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Xuhao Li
- School of Acupuncture and Tuina, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Yike Ning
- School of Acupuncture and Tuina, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Yu Tang
- School of Acupuncture and Tuina, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Xinyu Wu
- School of Acupuncture and Tuina, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Jing Han
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
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Mainland RL, Skinner CR, Saary J. Aeromedical Risk of Migraine. Aerosp Med Hum Perform 2024; 95:101-112. [PMID: 38263111 DOI: 10.3357/amhp.6291.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
INTRODUCTION: Migraine is a common condition that can carry considerable risk to aeromedical duties. Because randomized controlled trials are not an appropriate method to evaluate flight safety risk for medical conditions that may cause subtle or sudden incapacitation, the determination of fitness-to-fly must be based on risk assessments informed by extrapolated evidence. Therefore, we conducted a review of current literature to provide background information to inform the aeromedical risk assessment of migraine using a risk matrix approach.METHODS: We identified studies on topics pertinent to conducting an aeromedical risk assessment of migraine. We generated an overview of the literature synthesizing the findings of articles retrieved from searches of Scopus, Ovid, PubMed, and the Cochrane Library published in English from all years, in both general and aircrew populations. International headache and neurology guidelines, as well as headache policies from the U.S. Air Force, were also reviewed.RESULTS: This review includes information on the following topics relevant to conducting an evidence-based risk assessment of migraine: diagnosis, prevalence, incidence, natural course, clinical presentation, triggers, comorbidities, neuroimaging, implications of family history, and efficacy of pharmacological and nonpharmacological therapies.DISCUSSION: This review summarizes current literature on migraine for use in a risk matrix approach to the aeromedical assessment of migraine in prospective and current aircrew. Awareness of the most current epidemiological data related to a variety of migraine parameters facilitates an evidence-based risk assessment of migraine in aircrew and requires iterative updates as new information becomes available.Mainland RL, Skinner CR, Saary J. Aeromedical risk of migraine. Aerosp Med Hum Perform. 2024; 95(2):101-112.
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Zhong C, Zhang X, Qin G, Wu J, Tian Y. Comparison of Lasmiditan 200 mg Versus 100 mg for Migraine Patients: A Meta-analysis of Randomized Controlled Studies. Clin Neuropharmacol 2024; 47:1-6. [PMID: 38154072 DOI: 10.1097/wnf.0000000000000567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Abstract
INTRODUCTION The ideal dose of lasmiditan for migraine is not clear. This meta-analysis aims to compare the efficacy of lasmiditan 200 mg versus 100 mg for migraine patients. METHODS We have searched several databases including PubMed, Embase, Web of Science, EBSCO, and Cochrane Library Databases and selected the randomized controlled trials comparing the efficacy of lasmiditan 200 mg versus 100 mg for migraine patients. This meta-analysis was conducted using the random-effect model. RESULTS Five randomized controlled trials were included in this meta-analysis. Compared with lasmiditan 100-mg group in migraine patients, lasmiditan 200-mg group was associated with substantially increased pain free at 2 hours (odds ratio [OR], 1.27; 95% confidence interval [CI], 1.12-1.44; P = 0.0002) and pain free at 24 hours (OR, 1.31; 95% CI, 1.08-1.60; P = 0.007) but demonstrated no obvious impact on pain relief at 2 hours (OR, 1.02; 95% CI, 0.91-1.16; P = 0.72) or MBS free at 2 hours (OR, 0.94; 95% CI, 0.77-1.14; P = 0.52). In addition, the incidence of adverse events was higher in lasmiditan 200-mg group than that in lasmiditan 100-mg group (OR, 1.29; 95% CI, 1.15-1.45; P < 0.0001). CONCLUSIONS Lasmiditan 200 mg is better for the treatment of migraine patients than lasmiditan 100 mg.
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Affiliation(s)
- Chuan Zhong
- Department of Neurology, The People's Hospital of DaZu District, Chongqing, China
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Bentivegna E, Galastri S, Onan D, Martelletti P. Unmet Needs in the Acute Treatment of Migraine. Adv Ther 2024; 41:1-13. [PMID: 37943442 PMCID: PMC10796525 DOI: 10.1007/s12325-023-02650-7] [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: 03/15/2023] [Accepted: 08/16/2023] [Indexed: 11/10/2023]
Abstract
Migraine represents the most common neurologic disorder, ranking second among the world's causes of disability [expressed as years lived with disability (YLDs)]. Patients often do not receive the best therapy because of safety issues, tolerance, and prescription accessibility. General practitioners are not always educated about the disease, and specialists are few and often difficult to reach. Therapies are limited and have many side effects that can impede the prescription. Prophylactic therapy is recommended in case of four or more headaches a month, eight or more headache days a month, debilitating headaches, and medication-overuse headaches. The available therapeutic options are in constant development. The classic one consists of non-specific drugs: β-blockers, tricyclics, antiepileptics, and botulinum toxin. Monoclonal antibodies targeting the calcitonin gene receptor (CGRP) peptide or its receptor are the only ones specifically designed to treat migraine. Their efficiency and convenient safety profile have been demonstrated in a number of trials versus both placebo and classic therapies. The treatment of acute migraine attack consists of medications designed to affect the painful symptoms. For over 30 years, the cornerstones of treatment in clinical practice have continued to be represented by triptans and non-steroidal anti-inflammatory drugs (NSAIDs), with the well-know related adverse effects. Opioids are used inappropriately and overprescribed. Polytherapy is strongly not recommended but is still a common practice because treatment is not optimized and thus not efficient. Great promise comes from gepants, also targeting CGRP, and ditans, 5-HT1F receptor agonists. They seem to outweigh the risk of medication overuse headache because of their efficacy and rapid onset and have no cardiovascular contraindications. Nonetheless, these points remain to be confirmed. Although therapies have been implemented in the last years, significant unmet treatment needs remain a reality in patients' lives. This commentary aims to identify the most important unmet needs in the acute treatment of migraine, analyzing the current status of available therapies and their limits. We also analyzed some of the prophylactic therapies available, especially focusing on anti-CGRP monoclonal antibodies, to better understand the importance of setting a therapeutic strategy that includes the two modes, both acute and prophylactic, to reach the best result. We hope that having an overview of the shortcomings will help to provide constructive ideas for improvement.
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Affiliation(s)
- Enrico Bentivegna
- Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Sapienza University, Via di Grottarossa 1035-1039, 00189, Rome, Italy.
| | - Silvia Galastri
- Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Sapienza University, Via di Grottarossa 1035-1039, 00189, Rome, Italy
| | - Dilara Onan
- Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Sapienza University, Via di Grottarossa 1035-1039, 00189, Rome, Italy
- Back and Neck Health Unit, Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Sapienza University, Via di Grottarossa 1035-1039, 00189, Rome, Italy
- Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy
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12
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Di Lauro M, Guerriero C, Cornali K, Albanese M, Costacurta M, Mercuri NB, Di Daniele N, Noce A. Linking Migraine to Gut Dysbiosis and Chronic Non-Communicable Diseases. Nutrients 2023; 15:4327. [PMID: 37892403 PMCID: PMC10609600 DOI: 10.3390/nu15204327] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/02/2023] [Accepted: 10/07/2023] [Indexed: 10/29/2023] Open
Abstract
In the world, migraine is one of the most common causes of disability in adults. To date, there is no a single cause for this disorder, but rather a set of physio-pathogenic triggers in combination with a genetic predisposition. Among the factors related to migraine onset, a crucial role seems to be played by gut dysbiosis. In fact, it has been demonstrated how the intestine is able to modulate the central nervous system activities, through the gut-brain axis, and how gut dysbiosis can influence neurological pathologies, including migraine attacks. In this context, in addition to conventional pharmacological treatments for migraine, attention has been paid to an adjuvant therapeutic strategy based on different nutritional approaches and lifestyle changes able to positively modulate the gut microbiota composition. In fact, the restoration of the balance between the different gut bacterial species, the reconstruction of the gut barrier integrity, and the control of the release of gut-derived inflammatory neuropeptides, obtained through specific nutritional patterns and lifestyle changes, represent a possible beneficial additive therapy for many migraine subtypes. Herein, this review explores the bi-directional correlation between migraine and the main chronic non-communicable diseases, such as diabetes mellitus, arterial hypertension, obesity, cancer, and chronic kidney diseases, whose link is represented by gut dysbiosis.
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Affiliation(s)
- Manuela Di Lauro
- Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, RM, Italy; (M.D.L.); (C.G.); (K.C.); (M.A.); (N.B.M.); (N.D.D.)
| | - Cristina Guerriero
- Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, RM, Italy; (M.D.L.); (C.G.); (K.C.); (M.A.); (N.B.M.); (N.D.D.)
| | - Kevin Cornali
- Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, RM, Italy; (M.D.L.); (C.G.); (K.C.); (M.A.); (N.B.M.); (N.D.D.)
| | - Maria Albanese
- Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, RM, Italy; (M.D.L.); (C.G.); (K.C.); (M.A.); (N.B.M.); (N.D.D.)
- Neurology Unit, Headache Center, Tor Vergata University Hospital, 00133 Rome, RM, Italy
| | - Micaela Costacurta
- Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, RM, Italy;
| | - Nicola Biagio Mercuri
- Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, RM, Italy; (M.D.L.); (C.G.); (K.C.); (M.A.); (N.B.M.); (N.D.D.)
- Neurology Unit, Headache Center, Tor Vergata University Hospital, 00133 Rome, RM, Italy
| | - Nicola Di Daniele
- Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, RM, Italy; (M.D.L.); (C.G.); (K.C.); (M.A.); (N.B.M.); (N.D.D.)
- Fondazione Leonardo per le Scienze Mediche Onlus, Policlinico Abano, 35031 Abano Terme, PD, Italy
| | - Annalisa Noce
- Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, RM, Italy; (M.D.L.); (C.G.); (K.C.); (M.A.); (N.B.M.); (N.D.D.)
- UOSD Nephrology and Dialysis, Policlinico Tor Vergata, 00133 Rome, RM, Italy
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13
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Ruscheweyh R, Gossrau G, Dresler T, Freilinger T, Förderreuther S, Gaul C, Kraya T, Neeb L, Ruschil V, Straube A, Scheidt J, Jürgens TP. Triptan non-response in specialized headache care: cross-sectional data from the DMKG Headache Registry. J Headache Pain 2023; 24:135. [PMID: 37817093 PMCID: PMC10563311 DOI: 10.1186/s10194-023-01676-0] [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: 07/31/2023] [Accepted: 09/30/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND Triptans are effective for many migraine patients, but some do not experience adequate efficacy and tolerability. The European Headache Federation (EHF) has proposed that patients with lack of efficacy and/or tolerability of ≥ 2 triptans ('triptan resistance') could be considered eligible for treatment with the novel medications from the ditan and gepant groups. There is little data on the frequency of 'triptan resistance'. METHODS We used patient self-report data from the German Migraine and Headache Society (DMKG) Headache Registry to assess triptan response and triptan efficacy and/or tolerability failure. RESULTS A total of 2284 adult migraine patients (females: 85.4%, age: 39.4 ± 12.8 years) were included. 42.5% (n = 970) had failed ≥ 1 triptan, 13.1% (n = 300) had failed ≥ 2 triptans (meeting the EHF definition of 'triptan resistance'), and 3.9% (n = 88) had failed ≥ 3 triptans. Compared to triptan responders (current use, no failure, n = 597), triptan non-responders had significantly more severe migraine (higher frequency (p < 0.001), intensity (p < 0.05), and disability (p < 0.001)), that further increased with the level of triptan failure. Responders rates were highest for nasal and oral zolmitriptan, oral eletriptan and subcutaneous sumatriptan. CONCLUSION In the present setting (specialized headache care in Germany), 13.1% of the patients had failed ≥ 2 triptans. Triptan failure was associated with increased migraine severity and disability, emphasizing the importance of establishing an effective and tolerable acute migraine medication. Acute treatment optimization might include switching to one of the triptans with the highest responder rates and/or to a different acute medication class. TRIAL REGISTRATION The DMKG Headache Registry is registered with the German Clinical Trials Register (DRKS 00021081).
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Affiliation(s)
- Ruth Ruscheweyh
- Department of Neurology, LMU University Hospital, LMU Munich, Marchioninistr. 15, Munich, 81377, Germany.
- German Migraine and Headache Society, Frankfurt, Germany.
- Department of Psychosomatic Medicine and Psychotherapy, Technical University of Munich, Munich, Germany.
| | - Gudrun Gossrau
- Interdisciplinary Pain Center, University Hospital and Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Thomas Dresler
- LEAD Graduate School & Research Network, University of Tuebingen, Tuebingen, Germany
- Department of Psychiatry and Psychotherapy, Tuebingen Center for Mental Health, University Hospital of Tuebingen, Tuebingen, Germany
- German Center for Mental Health (DZPG), Partner Site Tuebingen, Tuebingen, Germany
| | | | - Stefanie Förderreuther
- Department of Neurology, LMU University Hospital, LMU Munich, Marchioninistr. 15, Munich, 81377, Germany
| | - Charly Gaul
- Headache Center Frankfurt, Frankfurt, Germany
| | - Torsten Kraya
- Department of Neurology, Hospital Sankt Georg Leipzig gGmbH, Leipzig, Germany
- Headache Center Halle, Department of Neurology, University Hospital Halle, Halle, Germany
| | - Lars Neeb
- Helios Global Health, Friedrichstraße 136, Berlin, 10117, Germany
| | - Victoria Ruschil
- Department of Neurology and Epileptology, Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Andreas Straube
- Department of Neurology, LMU University Hospital, LMU Munich, Marchioninistr. 15, Munich, 81377, Germany
| | - Jörg Scheidt
- Institute for Information Systems, University of Applied Sciences Hof, Hof, Germany
| | - Tim Patrick Jürgens
- Department of Neurology, Headache Center North-East, University Medical Center Rostock, Rostock, Germany
- Department of Neurology, KMG Klinikum Güstrow, Güstrow, Germany
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14
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Juhasz G, Gecse K, Baksa D. Towards precision medicine in migraine: Recent therapeutic advances and potential biomarkers to understand heterogeneity and treatment response. Pharmacol Ther 2023; 250:108523. [PMID: 37657674 DOI: 10.1016/j.pharmthera.2023.108523] [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: 04/16/2023] [Revised: 08/11/2023] [Accepted: 08/29/2023] [Indexed: 09/03/2023]
Abstract
After 35 years since the introduction of the International Classification of Headache Disorders (ICHD), we are living in the era of the second great revolution in migraine therapies. First, discoveries of triptans provided a breakthrough in acute migraine treatment utilizing bench-to-bedside research results on the role of serotonin in migraine. Next, the discovery of the role of neuropeptides, more specifically calcitonin gene-related peptide (CGRP) in migraine attack led to the development of anti-CGRP therapies that are effective both in acute and preventive treatment, and are also able to reduce migraine-related burden. Here, we reviewed the most recent clinical studies and real-world data on available migraine-specific medications, including triptans, ditants, gepants and anti-CGRP monoclonal antibodies. Novel drug targets, such as PACAP and amylins were also discussed. To address the main challenges of migraine therapy, the high heterogeneity of people with migraine, the prevalent presence of various comorbid disorders, and the insufficient medical care of migraine patients were covered. Promising novel approaches from the fields of omics, blood and saliva biomarker, imaging and provocation studies might bring solutions for these challenges with the potential to identify further drug targets, distinguish more homogeneous patient subgroups, contribute to more optimal drug selection strategies, and detect biomarkers in association with headache features or predicting treatment efficacy. In the future, the combined analysis of data of different biomarker modalities with machine learning algorithms may serve precision medicine in migraine treatment.
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Affiliation(s)
- Gabriella Juhasz
- Department of Pharmacodynamics, Faculty of Pharmaceutical Sciences, Semmelweis University, Budapest, Hungary; NAP3.0 Neuropsychopharmacology Research Group, Hungarian Brain Research Program, Semmelweis University, Budapest, Hungary.
| | - Kinga Gecse
- Department of Pharmacodynamics, Faculty of Pharmaceutical Sciences, Semmelweis University, Budapest, Hungary; NAP3.0 Neuropsychopharmacology Research Group, Hungarian Brain Research Program, Semmelweis University, Budapest, Hungary
| | - Daniel Baksa
- Department of Pharmacodynamics, Faculty of Pharmaceutical Sciences, Semmelweis University, Budapest, Hungary; NAP3.0 Neuropsychopharmacology Research Group, Hungarian Brain Research Program, Semmelweis University, Budapest, Hungary; Department of Personality and Clinical Psychology, Institute of Psychology, Faculty of Humanities and Social Sciences, Pazmany Peter Catholic University, Budapest, Hungary
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15
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Onan D, Younis S, Wellsgatnik WD, Farham F, Andruškevičius S, Abashidze A, Jusupova A, Romanenko Y, Grosu O, Moldokulova MZ, Mursalova U, Saidkhodjaeva S, Martelletti P, Ashina S. Debate: differences and similarities between tension-type headache and migraine. J Headache Pain 2023; 24:92. [PMID: 37474899 PMCID: PMC10360340 DOI: 10.1186/s10194-023-01614-0] [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: 04/11/2023] [Accepted: 06/16/2023] [Indexed: 07/22/2023] Open
Abstract
Tension-type headache (TTH) and migraine are two common primary headaches distinguished by clinical characteristics according to the 3rd edition of the International Classification of Headache Disorders. Migraine is identified by specific features such as being more prevalent in females, being aggravated by physical activity, certain genetic factors, having photophobia, phonophobia, nausea, vomiting, or aura, and responding to specific drugs. Nonetheless, TTH and migraine share some common characteristics, such as onset occurring in the 20 s, and being triggered by psychological factors like stress, moderate pain severity, and mild nausea in chronic TTH. Both conditions involve the trigeminovascular system in their pathophysiology. However, distinguishing between TTH and migraine in clinical practice, research, and epidemiological studies can be challenging, as there is a lack of specific diagnostic tests and biomarkers. Moreover, both conditions may coexist, further complicating the diagnostic process. This review aims to explore the similarities and differences in the pathophysiology, epidemiology, burden and disability, comorbidities, and responses to pharmacological and non-pharmacological treatments of TTH and migraine. The review also discusses future research directions to address the diagnostic challenges and improve the understanding and management of these conditions.
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Affiliation(s)
- Dilara Onan
- Spine Health Unit, Faculty of Physical Therapy and Rehabilitation, Institute of Health Sciences, Hacettepe University, Ankara, Turkey
| | - Samaira Younis
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Copenhagen, Denmark
| | | | - Fatemeh Farham
- Department of Headache, Iranian Centre of Neurological Researchers, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Saulius Andruškevičius
- Center of Neurology and Center of Anesthesiology, Intensive Care and Pain Management, Vilnius University Hospital SantarosKlinikos, Vilnius, Lithuania
| | - Ana Abashidze
- Department of Neuroscience, Caucasus Medical Centre, Tbilisi, Georgia
| | - Asel Jusupova
- Department of Neurology and Clinical Genetics, Kyrgyz State Medical Academy, Bishkek, Kyrgyzstan
| | | | - Oxana Grosu
- Diomid Gherman Institute of Neurology and Neurosurgery, Headache Center, Chisinau, Moldova
| | | | | | - Saida Saidkhodjaeva
- Department of Neurology, Child Neurology and Medical Genetics, Tashkent Pediatric Medical Institute, Tashkent, Uzbekistan
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Sait Ashina
- Department of Neurology and Department of Anesthesia, Critical Care and Pain Medicine, BIDMC Comprehensive Headache Center, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA.
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.
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16
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Mitsikostas DD, Waeber C, Sanchez-Del-Rio M, Raffaelli B, Ashina H, Maassen van den Brink A, Andreou A, Pozo-Rosich P, Rapoport A, Ashina M, Moskowitz MA. The 5-HT 1F receptor as the target of ditans in migraine - from bench to bedside. Nat Rev Neurol 2023:10.1038/s41582-023-00842-x. [PMID: 37438431 DOI: 10.1038/s41582-023-00842-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2023] [Indexed: 07/14/2023]
Abstract
Migraine is a leading cause of disability in more than one billion people worldwide, yet it remains universally underappreciated, even by individuals with the condition. Among other shortcomings, current treatments (often repurposed agents) have limited efficacy and potential adverse effects, leading to low treatment adherence. After the introduction of agents that target the calcitonin gene-related peptide pathway, another new drug class, the ditans - a group of selective serotonin 5-HT1F receptor agonists - has just reached the international market. Here, we review preclinical studies from the late 1990s and more recent clinical research that contributed to the development of the ditans and led to their approval for acute migraine treatment by the US Food and Drug Administration and the European Medicines Agency.
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Affiliation(s)
- Dimos D Mitsikostas
- 1st Neurology Department, Eginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.
| | - Christian Waeber
- School of Pharmacy, University College Cork, Cork, Ireland
- Department of Pharmacology and Therapeutics, University College Cork, Cork, Ireland
| | | | - Bianca Raffaelli
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Håkan Ashina
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Brain and Spinal Cord Injury, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Anaesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Antoinette Maassen van den Brink
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Anna Andreou
- Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Headache Centre, Guy's and St Thomas's NHS Foundation Trust, King's Health Partners, London, UK
| | - Patricia Pozo-Rosich
- Neurology Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Headache Unit, Neurology Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Headache and Neurological Pain Research Group, Vall d'Hebron Research Institute, Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alan Rapoport
- Department of Neurology, The David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Messoud Ashina
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Michael A Moskowitz
- Departments of Radiology and Neurology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
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17
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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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18
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Ramachanderan R, Schramm S, Schaefer B. Migraine drugs. CHEMTEXTS 2023. [DOI: 10.1007/s40828-023-00178-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
AbstractAccording to recent studies, migraine affects more than 1 billion people worldwide, making it one of the world’s most prevalent diseases. Although this highly debilitating illness has been known since ancient times, the first therapeutic drugs to treat migraine, ergotamine (Gynergen) and dihydroergotamine (Dihydergot), did not appear on the market until 1921 and 1946, respectively. Both drugs originated from Sandoz, the world’s leading pharmaceutical company in ergot alkaloid research at the time. Historically, ergot alkaloids had been primarily used in obstetrics, but with methysergide (1-methyl-lysergic acid 1′-hydroxy-butyl-(2S)-amide), it became apparent that they also held some potential in migraine treatment. Methysergide was the first effective prophylactic drug developed specifically to prevent migraine attacks in 1959. On the basis of significantly improved knowledge of migraine pathophysiology and the discovery of serotonin and its receptors, Glaxo was able to launch sumatriptan in 1992. It was the first member from the class of triptans, which are selective 5-HT1B/1D receptor agonists. Recent innovations in acute and preventive migraine therapy include lasmiditan, a selective 5-HT1F receptor agonist from Eli Lilly, the gepants, which are calcitonin gene-related peptide (CGRP) receptor antagonists discovered at Merck & Co and BMS, and anti-CGRP/receptor monoclonal antibodies from Amgen, Pfizer, Eli Lilly, and others.
Graphical abstract
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19
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Puledda F, Younis S, Huessler EM, Haghdoost F, Lisicki M, Goadsby PJ, Tassorelli C. Efficacy, safety and indirect comparisons of lasmiditan, rimegepant, and ubrogepant for the acute treatment of migraine: A systematic review and network meta-analysis of the literature. Cephalalgia 2023; 43:3331024231151419. [PMID: 36786357 DOI: 10.1177/03331024231151419] [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: 02/15/2023]
Abstract
BACKGROUND We performed a random-effects network meta-analysis to study the efficacy and safety of newly developed drugs for the acute treatment of migraine attacks. METHODS MEDLINE via PubMed, Embase and The Cochrane Register of Controlled Trials were searched from inception to 11 February 2022. Phase 3 randomized controlled trials examining all formulations of lasmiditan, rimegepant and ubrogepant for the acute treatment of adults with migraine, were included. Data were extracted following the PRISMA guidelines. RESULTS Seven studies (SAMURAI, SPARTAN, CENTURION, Study 302, Study 303, ACHIEVE I and II) involving n = 12,859 patients were included. All treatments were superior in efficacy to placebo. Lasmiditan 200 mg showed the highest two-hour pain freedom, while two-hour freedom from most bothersome symptom was equally achieved by the higher doses of lasmiditan (100 and 200 mg), rimegepant and the higher doses of ubrogepant (50 and 100 mg). The odds of treatment-emergent adverse events were greatest with all doses of lasmiditan. CONCLUSION Lasmiditan 200 mg was the most effective intervention in the treatment of migraine attacks, although it was associated with high degrees of dizziness, nausea and somnolence. Rimegepant showed slightly lower, but similar efficacy rates to lasmiditan. Ubrogepant had overall the best tolerability profile. These conclusions are limited by the absence of head-to-head comparisons, limitations of individual trials and of the meta-analysis methodology itself.PROSPERO trial registration: CRD42022308224.
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Affiliation(s)
- Francesca Puledda
- Headache Group, Wolfson CARD, SLaM Biomedical Research Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London and NIHR-Wellcome Trust King's Clinical Research Facility, King's College Hospital, London, United Kingdom
| | - Samaira Younis
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Denmark
| | - Eva-Maria Huessler
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Germany
| | - Faraidoon Haghdoost
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Marco Lisicki
- Headache Department, Neuroscience Unit, Conci·Carpinella Institute, Córdoba, Argentina
| | - Peter J Goadsby
- Headache Group, Wolfson CARD, SLaM Biomedical Research Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London and NIHR-Wellcome Trust King's Clinical Research Facility, King's College Hospital, London, United Kingdom.,Department of Neurology, University of California, Los Angeles, CA, United States
| | - Cristina Tassorelli
- Headache Science Center, C. Mondino Foundation, Pavia, Italy.,University of Pavia, Department of Brain and Behavioral Sciences, Pavia, Italy
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20
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de Boer I, Verhagen IE, Souza MNP, Ashina M. Place of next generation acute migraine specific treatments among triptans, non-responders and contraindications to triptans and possible combination therapies. Cephalalgia 2023; 43:3331024221143773. [PMID: 36739516 DOI: 10.1177/03331024221143773] [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: 02/06/2023]
Abstract
Background: For many years triptans have been the cornerstone of acute migraine treatment. Nevertheless, treatment with triptans may not always be initiated due to contraindications (seen in approximately one fifth of patients) or inadequate response (seen in approximately one third of patients). New acute therapies, including 5-hydroxytryptamine (5-HT)1F receptor agonists, also known as ditans (lasmiditan) and small molecule antagonists of the calcitonin gene-related peptide receptor, also known as gepants (rimegepant and ubrogepant), may be an effective alternative. Methods: We searched Pubmed for keywords, summarized the literature and provided a comprehensive review on the place of next generation acute migraine specific treatments among triptans. Results and conclusion: Post-hoc analyses reported no differences in efficacy of gepants/ditans between responders and non-responders to triptans, but research is hampered by lack of consensus on the definition of non-responder. Due to (partially) overlapping mechanisms of action, it remains unknown whether combination therapy with lasmiditan, gepants and triptans will have added value over monotherapy. Preclinical studies and post-hoc analyses cautiously indicate that these new drugs are safe for patients with cardiovascular risk factors. However, long-term studies are needed to prove cardiovascular safety. The risk of developing medication overuse headache may differ between triptans, ditans and gepants, but further studies are needed to confirm this difference. Head-to-head randomized controlled trials of acute therapies and combinations of therapies are needed to determine their place in migraine treatment among established therapies.
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Affiliation(s)
- Irene de Boer
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - Iris Elsa Verhagen
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Messoud Ashina
- Department of Neurology, Rigshospitalet Glostrup, University of Copenhagen, Glostrup, Denmark
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Metal, iodine and oxidant-free electrosynthesis of substituted indoles from 1-(2-aminophenyl)alcohols. GREEN SYNTHESIS AND CATALYSIS 2022. [DOI: 10.1016/j.gresc.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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22
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Wang K, Mao Y, Lu M, Ding Y, Li Z, Li Y, Liu X, Sun Y, Hong J, Xu D, Wu T. Association between migraine and cardiovascular disease: A cross-sectional study. Front Cardiovasc Med 2022; 9:1044465. [PMID: 36505362 PMCID: PMC9729705 DOI: 10.3389/fcvm.2022.1044465] [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: 09/14/2022] [Accepted: 11/10/2022] [Indexed: 11/26/2022] Open
Abstract
Background Cardiovascular disease (CVD) poses a tremendous threat to global health, giving rise to exceedingly high morbidity and mortality among patients. A migraine is a common neurological disorder characterized by recurrent attacks of severe headache, while its cardiovascular burden remains unclear. Therefore, this study aims to investigate whether migraine is associated with CVD. Methods The cross-sectional data of 5,692 subjects aged 20 or above was obtained from the National Health and Nutrition Examination Survey (NHANES) 1999-2004. To determine whether migraine is associated with CVD, weighted logistic regression models were used. In a subsequent subgroup analysis, several confounding factors were also explored to investigate the association between migraine and CVD. Results In total, 5,692 subjects were enrolled in this study, with the prevalence of CVD being 13.3%. Participants with CVD tended to be older, male, non-Hispanic whites, more educated, former smokers, and alcohol drinkers, and had a higher waist circumference, less physical activity, a higher level of triglyceride and creatinine as well as a lower level of high-density lipoprotein cholesterol (HDL-C) and estimated glomerular filtration rate (eGFR) (all P < 0.05). Considering all potential confounders, migraine was associated with a higher risk of CVD [odds ratios (ORs) 2.77; 95% confidence intervals (CIs): 1.56-4.90]. Subgroup analysis showed a higher risk of CVD in females, those older than 60 years, with a lower body mass index (BMI) level (≤ 30 kg/m2), a higher level of eGFR (> 90 mL/min/1.73 m2), hypertension and hyperlipidemia and without diabetes. Conclusion In summary, our study revealed a positive association between migraine with CVD in a nationally representative US adult population. Our findings highlighted that migraine should be considered an important risk factor for CVD.
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Affiliation(s)
- Kai Wang
- Department of Geriatrics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yukang Mao
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China,Department of Cardiology, Suzhou Municipal Hospital, Gusu School, The Affiliated Suzhou Hospital of Nanjing Medical University, Nanjing Medical University, Suzhou, Jiangsu, China
| | - Miao Lu
- Department of Geriatrics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yinzhang Ding
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Zhongming Li
- Department of Geriatrics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yansong Li
- Department of Geriatrics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xianling Liu
- Department of Geriatrics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yan Sun
- Department of Geriatrics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jian Hong
- Department of Geriatrics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Di Xu
- Department of Geriatrics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China,*Correspondence: Di Xu,
| | - Tingting Wu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China,Tingting Wu,
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23
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Tepper SJ, Ailani J, Ray S, Hirman J, Shrewsbury SB, Aurora SK. Variability in recurrence rates with acute treatments for migraine: why recurrence is not an appropriate outcome measure. J Headache Pain 2022; 23:148. [PMID: 36414952 PMCID: PMC9682643 DOI: 10.1186/s10194-022-01519-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 09/07/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Headache recurrence is a common feature of acute therapies, whether approved or still in development, and continues to be a significant problem for both the patient and the clinician. Further complicating this issue is lack of standardization in definitions of recurrence used in clinical trials, as well as disparity in patient characteristics, rendering a comparison of different acute medications challenging. Recurrence has serious clinical implications, which can include an increased risk for new-onset chronic migraine and/or development of medication overuse headache. The aim of this review is to illustrate variability of recurrence rates depending on prevailing definitions in the literature for widely used acute treatments for migraine and to emphasize sustained response as a clinically relevant endpoint for measuring prolonged efficacy. BODY: A literature search of PubMed for articles of approved acute therapies for migraine that reported recurrence rates was performed. Study drugs of interest included select triptans, gepants, lasmiditan, and dihydroergotamine mesylate. An unpublished post hoc analysis of an investigational dihydroergotamine mesylate product that evaluated recurrence rates using several different definitions of recurrence common in the literature is also included. Depending on the criteria established by the clinical trial and the definition of recurrence used, rates of recurrence vary considerably across different acute therapies for migraine, making it difficult to compare results of different trials to assess the sustained (i.e., over a single attack) and the prolonged (i.e., over multiple attacks) efficacy of a particular study medication. CONCLUSION A standardized definition of recurrence is necessary to help physicians evaluate recurrence rates of different abortive agents for migraine. Sustained pain relief or freedom may be more comprehensive efficacy outcome measures than recurrence. Future efficacy studies should be encouraged to use the recommended definition of sustained pain freedom set by the International Headache Society.
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Affiliation(s)
| | - Jessica Ailani
- MedStar Georgetown University Hospital, Washington, DC, USA
| | | | - Joe Hirman
- Pacific Northwest Statistical Consulting, Inc, Woodinville, WA, USA
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Berger AA, Keefe J, Stark CW, Moore M, Ramírez GF, Cucarola JR, Han AH, Kaye AD, Ganti L. Eptinezumab-jjmr, a humanized monoclonal specific to Calcitonin Gene Related Peptide, for the preventive treatment of migraine in adults. Health Psychol Res 2022; 10:38439. [DOI: 10.52965/001c.38439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose of Review Migraines are prevalent and cause significant morbidity, decline in quality of life and healthcare costs universally. Treatment options are varied, but efficacy is limited. This review centers on Eptinezumab-jjmr, a humanized monoclonal specific to CGRP for the prevention of migraines in adults. Herein presented are the science and mechanism of action, indication and clinical evidence for use. Recent Findings Migraines are severe, recurrent headaches, which are either episodic or chronic in nature. The pain is severe, often accompanied by co-morbid symptoms, such as photophobia, phonophobia, nausea and emesis, and is limiting in nature. It is a prevalent disorder that causes significant, worldwide disability, morbidity, suffering, and costs. The pathophysiology of migraines is actively studied, though recent research points to an initiating event causing migraine generation, that is then propagated by other brain regions, a significant one being the trigeminocervical complex. This is driven by biochemical transmitters, chiefly CGRP. This discovery led to the development of CGRP-targeting drugs, including gepants (small molecular antagonists) and anti-CGRP antibodies, such as Eptinezumab-jjmr. Traditional therapy includes preventative and abortive treatment; however, adherence with preventative treatment has been historically poor, and certain types of abortive therapy carry risks and side effects that preclude them from a large patient population. Moreover, traditional therapy often falls short in migraine therapy. CGRP antagonist, including Eptinezumab, aims to cover the gaps in migraine therapy. We present here evidence to support the safe and effective use of Eptinezumab for the prevention of migraines. Summary Migraines are a prevalent primary headache disorder causing significant morbidity worldwide. Traditional abortive and preventative treatments fall short for many patients. Eptinezumab is part of new generation of CGRP-targeting medications and has shown significant evidence to support its use for the prevention of migraines. Further research is required to properly compare eptinezumab with existing pharmacotherapy and update guidelines on the appropriate combinations of therapies that are not available and the correct patient selection for each.
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Affiliation(s)
| | | | | | - Matthew Moore
- Louisiana State University Shreveport School of Medicine
| | | | | | | | | | - Latha Ganti
- University of Central Florida School of Medicine
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25
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Sacco S, Lampl C, Amin FM, Braschinsky M, Deligianni C, Uludüz D, Versijpt J, Ducros A, Gil-Gouveia R, Katsarava Z, Martelletti P, Ornello R, Raffaelli B, Boucherie DM, Pozo-Rosich P, Sanchez-Del-Rio M, Sinclair A, Maassen van den Brink A, Reuter U. European Headache Federation (EHF) consensus on the definition of effective treatment of a migraine attack and of triptan failure. J Headache Pain 2022; 23:133. [PMID: 36224519 PMCID: PMC9555163 DOI: 10.1186/s10194-022-01502-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 09/21/2022] [Indexed: 12/01/2022] Open
Abstract
Background Triptans are migraine-specific acute treatments. A well-accepted definition of triptan failure is needed in clinical practice and for research. The primary aim of the present Consensus was to provide a definition of triptan failure. To develop this definition, we deemed necessary to develop as first a consensus definition of effective treatment of an acute migraine attack and of triptan-responder. Main body The Consensus process included a preliminary literature review, a Delphi round and a subsequent open discussion. According to the Consensus Panel, effective treatment of a migraine attack is to be defined on patient well-being featured by a) improvement of headache, b) relief of non-pain symptoms and c) absence of adverse events. An attack is considered effectively treated if patient’s well-being, as defined above, is restored within 2 hours and for at least 24 hours. An individual with migraine is considered as triptan-responder when the given triptan leads to effective acute attack treatment in at least three out of four migraine attacks. On the other hand, an individual with migraine is considered triptan non-responder in the presence of failure of a single triptan (not matching the definition of triptan-responder). The Consensus Panel defined an individual with migraine as triptan-resistant in the presence of failure of at least 2 triptans; triptan refractory, in the presence of failure to at least 3 triptans, including subcutaneous formulation; triptan ineligibile in the presence of an acknowledged contraindication to triptan use, as specified in the summary of product characteristics. Conclusions The novel definitions can be useful in clinical practice for the assessment of acute attack treatments patients with migraine. They may be helpful in identifying people not responding to triptans and in need for novel acute migraine treatments. The definitions will also be of help in standardizing research on migraine acute care. Supplementary Information The online version contains supplementary material available at 10.1186/s10194-022-01502-z.
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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.
| | - Christian Lampl
- Department of Neurology, Headache Medical Center at the Konventhospital BHB Linz, Linz, Austria
| | - 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
| | - Mark Braschinsky
- Department of Neurology, Institute of Clinical Medicine, University of Tartu; Headache Clinic, Department of Neurology, Tartu University Hospital, Tartu, Estonia
| | - Christina Deligianni
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, University of Copenhagen, Copenhagen, Denmark
| | - Derya Uludüz
- Department of Neurology Istanbul Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Jan Versijpt
- Department of Neurology, Vrije Universiteit Brussel (VUB), Universitair, Ziekenhuis Brussel, Brussels, Belgium
| | - Anne Ducros
- Neurology Department, CHU de Montpellier Charles Coulomb Laboratory, Montpellier University, Montpellier, France
| | - Raquel Gil-Gouveia
- Neurology Department, Hospital da Luz Headache Center, Hospital da Luz, Lisbon, Portugal.,Center for Interdisciplinary Research in Health, Universidade Católica Portuguesa, Lisbon, Portugal
| | - Zaza Katsarava
- Christian Hospital, Unna, Germany.,University of Duisburg-Essen, Essen, Germany
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Raffaele Ornello
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Via Vetoio 1, L'Aquila, Italy
| | - Bianca Raffaelli
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Deirdre M Boucherie
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Patricia Pozo-Rosich
- Headache Unit, Neurology Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Department of Medicine, Headache and Neurological Pain Research Group, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Alexandra Sinclair
- Institute of Metabolism and Sytems Research, University of Birmingham, Birmingham, UK.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | | | - Uwe Reuter
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany.,Universitätsmedizin Greifswald, Greifswald, Germany
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26
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Matsumori Y, Komori M, Tanji Y, Ozeki A, Sakai F. Rapid Onset and Sustained Efficacy of Lasmiditan Among Japanese Patients with Migraine: Prespecified Analyses of a Randomized Controlled Trial. Neurol Ther 2022; 11:1721-1734. [PMID: 36136232 DOI: 10.1007/s40120-022-00403-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 08/25/2022] [Indexed: 10/14/2022] Open
Abstract
INTRODUCTION Rapid onset and sustained efficacy are important for acute migraine treatment. Global phase 3 trials have demonstrated the early onset and sustained efficacy of the 5-HT1F receptor agonist lasmiditan. In this prespecified analysis of the MONONOFU study, we assessed the onset and sustained efficacy of lasmiditan in Japanese patients with migraine. METHODS MONONOFU was a multicenter, randomized, placebo-controlled, phase 2 study conducted in Japan (May 2019-June 2020). Eligible adults with migraine (N = 846; modified intent-to-treat population, N = 682) were randomized 7:3:7:6 to placebo, lasmiditan 50 mg, 100 mg, or 200 mg, taken orally within 4 h of moderate-to-severe migraine onset. Patients recorded headache severity and symptoms predose and 0.5-48 h postdose. Sustained and modified sustained pain freedom were defined as patients who were headache pain-free 2 h postdose and had no pain (sustained pain freedom) or had mild or no pain (modified sustained pain freedom) at 24 or 48 h without rescue/recurrence medications. Efficacy outcomes were analyzed by logistic regression. Patients also recorded the actual time of pain-free and of meaningful pain relief (Kaplan-Meier analysis). RESULTS Compared with placebo, significantly more lasmiditan-treated (100 or 200 mg) patients were headache pain-free, had pain relief, were free of their most bothersome symptom, or had total migraine freedom (no headache or migraine-associated symptoms) within 30-60 min. Median time to pain-free was 9.26, 6.88, 2.75, and 2.30 h in placebo, 50-mg, 100-mg, and 200-mg lasmiditan groups, respectively. Significantly greater proportions of patients treated with 100 (19.7-29.5%) or 200 mg (21.1-35.7%) lasmiditan had sustained or modified sustained pain freedom at 24 or 48 h compared with placebo (10.4-15.8%). CONCLUSION This prespecified analysis of data from MONONOFU has confirmed that the efficacy of lasmiditan is rapid in onset and sustained in patients with moderate-to-severe migraine in Japan. TRIAL REGISTRATION ClinicalTrials.gov (NCT03962738).
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Affiliation(s)
| | - Mika Komori
- Japan Drug Development and Medical Affairs, Eli Lilly Japan K.K., 5-1-28, Isogamidori, Chuo-ku, Kobe, 651-0086, Japan.
| | - Yuka Tanji
- Japan Drug Development and Medical Affairs, Eli Lilly Japan K.K., 5-1-28, Isogamidori, Chuo-ku, Kobe, 651-0086, Japan
| | - Akichika Ozeki
- Japan Drug Development and Medical Affairs, Eli Lilly Japan K.K., 5-1-28, Isogamidori, Chuo-ku, Kobe, 651-0086, Japan
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27
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Eller M, Cheng S. Migraine management: an update for the 2020s. Intern Med J 2022; 52:1123-1128. [PMID: 35879242 PMCID: PMC9545433 DOI: 10.1111/imj.15843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 02/19/2022] [Indexed: 12/11/2022]
Abstract
Migraine is a common malady cutting across socioeconomic and ethnic divides in Australia. It is typically diagnosed late with significant impact on quality of life. Management options have emerged over the past several years that promise simpler treatment regimens with less potential for side‐effects. The development of rationally designed migraine preventives is the most significant advance in treatment since the development of the triptans and delivers significant hope to many headache sufferers.
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Affiliation(s)
- Michael Eller
- Monash Medical Centre and Monash University, Melbourne, Victoria, Australia
| | - Shuli Cheng
- Alfred Health, Melbourne, Victoria, Australia
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Yu T, He L, Yang X, Zhou J, Luo G, Wang H, Zhao H, Hu Q, Ji F, Yu S. Efficacy and Safety of Lasmiditan as a Novel Acute Treatment in Chinese Patients with Migraine: A Subpopulation Analysis of the Randomized Controlled Phase 3 CENTURION Trial. Neurol Ther 2022; 11:1269-1283. [PMID: 35713760 PMCID: PMC9338201 DOI: 10.1007/s40120-022-00369-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 05/18/2022] [Indexed: 02/05/2023] Open
Abstract
Introduction Over the last two decades, there has been no novel acute treatment for migraine to address the large unmet medical need in Chinese patients. Lasmiditan, a novel selective serotonin 1F receptor agonist (ditan), is anticipated to bring clinical benefit in Chinese patients with migraine. The CENTURION study is a multi-country, placebo-controlled phase 3 study designed to assess the first attack efficacy and the consistency of response of lasmiditan in acute treatment of migraine. This subpopulation analysis pooled Chinese patients’ data from the primary cohort and additional extended enrollment cohort which was not published previously. This is the first analysis focusing on lasmiditan’s efficacy and safety in Chinese patients with migraine and aims to provide relevant evidence for Chinese physicians. Methods Patients were randomized 1:1:1 to one of the three treatment groups for four attacks: (a) lasmiditan 100 mg; (b) lasmiditan 200 mg; or (c) control group. Primary endpoints were pain freedom at 2 h (first attack) and pain freedom at 2 h in at least two out of three attacks. Secondary endpoints included pain relief, sustained pain freedom, and disability freedom. Results In total, 281 Chinese patients (lasmiditan 100 mg, 95; lasmiditan 200 mg, 92; control, 94) were treated for at least one migraine attack. Both doses of lasmiditan showed improvement versus placebo for pain freedom at 2 h after first attack, with lasmiditan 200 mg showing nominal significance. An early onset of effect was observed with lasmiditan versus placebo. Both doses of lasmiditan showed better results for all key secondary endpoints versus placebo. The most commonly reported treatment-emergent adverse event across all groups was dizziness. Conclusion In the Chinese population, lasmiditan was better than placebo for both primary endpoints and key secondary endpoints with an acceptable safety profile. No new safety signals were detected in the Chinese population. These findings are generally consistent with those observed in the CENTURION study published data and the established product profile. Trial Registration Number NCT03670810. Supplementary Information The online version contains supplementary material available at 10.1007/s40120-022-00369-1.
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Affiliation(s)
- Tingmin Yu
- Department of Neurology, Second Hospital, Jilin University, Changchun, China
| | - Li He
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
| | - Xiaosu Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Jiying Zhou
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Guogang Luo
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Hebo Wang
- Department of Neurology, Hebei General Hospital, Shijiazhuang, Hebei, China
| | - Hongru Zhao
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Quan Hu
- LCDDMAC, Eli Lilly and Company, Shanghai, China
| | - Fei Ji
- LCDDMAC, Eli Lilly and Company, Shanghai, China
| | - Shengyuan Yu
- Department of Neurology, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China.
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Low adherence to the guideline for the acute treatment of migraine. Sci Rep 2022; 12:8487. [PMID: 35589944 PMCID: PMC9120453 DOI: 10.1038/s41598-022-12545-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 05/10/2022] [Indexed: 12/26/2022] Open
Abstract
The real-world use of triptans in the treatment of migraine is disappointing. Only 12% of the Danish migraine population purchased a triptan between 2014 and 2019, and only 43% repurchased a triptan after first prescription. The aim of the present study was to assess whether physicians and patients adhere to the therapeutic guideline on acute migraine treatment. We interviewed 299 triptan experienced participants with migraine and 101 triptan naïve participants with migraine from the Danish Migraine Population Cohort, using a semi-structured questionnaire. Descriptive statistical analyses were used to study the association with triptan use and the assessed factors. Among triptan naïve participants with migraine, 64% had consulted their general practitioner about their migraine, of whom only 23% received information about the possibility of triptan treatment. Among triptan experienced participants, 77% had only tried one type of triptan. Only 12% could recall they had been informed by their general practitioner to try each triptan three times before giving up. Twenty percent were informed to try three different triptans in total, if the first did not work. In disagreement with the guideline, participants who reported a low pain reduction by a triptan had only tried one type of triptan. Our study shows a low adherence to therapeutic guideline for the attack treatment of migraine. There is a need for better education of general practitioners regarding treatment of migraine. Future campaigns should aim to inform both the public and the general practitioner about antimigraine treatments.
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Inhibiting Endocannabinoid Hydrolysis as Emerging Analgesic Strategy Targeting a Spectrum of Ion Channels Implicated in Migraine Pain. Int J Mol Sci 2022; 23:ijms23084407. [PMID: 35457225 PMCID: PMC9027089 DOI: 10.3390/ijms23084407] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 04/08/2022] [Accepted: 04/13/2022] [Indexed: 12/23/2022] Open
Abstract
Migraine is a disabling neurovascular disorder characterized by severe pain with still limited efficient treatments. Endocannabinoids, the endogenous painkillers, emerged, alternative to plant cannabis, as promising analgesics against migraine pain. In this thematic review, we discuss how inhibition of the main endocannabinoid-degrading enzymes, monoacylglycerol lipase (MAGL) and fatty acid amide hydrolase (FAAH), could raise the level of endocannabinoids (endoCBs) such as 2-AG and anandamide in order to alleviate migraine pain. We describe here: (i) migraine pain signaling pathways, which could serve as specific targets for antinociception; (ii) a divergent distribution of MAGL and FAAH activities in the key regions of the PNS and CNS implicated in migraine pain signaling; (iii) a complexity of anti-nociceptive effects of endoCBs mediated by cannabinoid receptors and through a direct modulation of ion channels in nociceptive neurons; and (iv) the spectrum of emerging potent MAGL and FAAH inhibitors which efficiently increase endoCBs levels. The specific distribution and homeostasis of endoCBs in the main regions of the nociceptive system and their generation ‘on demand’, along with recent availability of MAGL and FAAH inhibitors suggest new perspectives for endoCBs-mediated analgesia in migraine pain.
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31
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Johnston K, Harris L, Powell L, Popoff E, Coric V, L'Italien G, Schreiber CP. Monthly migraine days, tablet utilization, and quality of life associated with Rimegepant - post hoc results from an open label safety study (BHV3000-201). J Headache Pain 2022; 23:10. [PMID: 35038983 PMCID: PMC8903552 DOI: 10.1186/s10194-021-01378-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 12/21/2021] [Indexed: 11/24/2022] Open
Abstract
Background The objective of this study was to describe patterns in monthly migraine days (MMD) and tablet utilization, and to estimate health-related quality of life (HRQoL) measures in patients treated as needed (PRN) with rimegepant 75 mg over 52-weeks. Methods Eligible subjects were adults with ≥1 year history of migraine and ≥ 6 MMD at baseline, who used rimegepant 75 mg up to once daily PRN (at their discretion) for up to 52-weeks in an open-label safety study (BHV3000–201; NCT03266588). Mean MMD were calculated at each 4-week period, along with mean monthly tablets taken. Migraine-specific quality of life (MSQv2) data were mapped to EQ-5D utilities and used to characterize HRQoL over time. A published network meta-analysis was used to characterize pain hours as well as time periods spent migraine free. Results One thousand forty four subjects were included in this post-hoc analysis. Overall mean MMD were 10.9 at baseline and decreased to 8.9 by week 52. Tablet use remained stable over the follow-up period. A total of 0.08 incremental QALYs were associated with rimegepant use. Conclusion For subjects with 6 or more MMD, acute treatment of migraine attacks with rimegepant 75 mg on a PRN basis over one-year of follow-up was found to be associated with reduced MMD frequency without an increase in monthly tablet utilization, and improved HRQoL. There was no evidence of medication-related increases in MMDs when rimegepant 75 mg was used as needed for the acute treatment of migraine over 52-weeks. Trial registration ClinicalTrials.gov identifier NCT03266588. Supplementary Information The online version contains supplementary material available at 10.1186/s10194-021-01378-5.
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Affiliation(s)
- Karissa Johnston
- Broadstreet Health Economics & Outcomes Research, Vancouver, BC, Canada.
| | | | - Lauren Powell
- Broadstreet Health Economics & Outcomes Research, Vancouver, BC, Canada
| | - Evan Popoff
- Broadstreet Health Economics & Outcomes Research, Vancouver, BC, Canada
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Abstract
Migraine is a common, chronic, disorder that is typically characterized by recurrent disabling attacks of headache and accompanying symptoms, including aura. The aetiology is multifactorial with rare monogenic variants. Depression, epilepsy, stroke and myocardial infarction are comorbid diseases. Spreading depolarization probably causes aura and possibly also triggers trigeminal sensory activation, the underlying mechanism for the headache. Despite earlier beliefs, vasodilation is only a secondary phenomenon and vasoconstriction is not essential for antimigraine efficacy. Management includes analgesics or NSAIDs for mild attacks, and, for moderate or severe attacks, triptans or 5HT1B/1D receptor agonists. Because of cardiovascular safety concerns, unreliable efficacy and tolerability issues, use of ergots to abort attacks has nearly vanished in most countries. CGRP receptor antagonists (gepants) and lasmiditan, a selective 5HT1F receptor agonist, have emerged as effective acute treatments. Intramuscular onabotulinumtoxinA may be helpful in chronic migraine (migraine on ≥15 days per month) and monoclonal antibodies targeting CGRP or its receptor, as well as two gepants, have proven effective and well tolerated for the preventive treatment of migraine. Several neuromodulation modalities have been approved for acute and/or preventive migraine treatment. The emergence of new treatment targets and therapies illustrates the bright future for migraine management.
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Azimova Y, Amelin A, Alferova V, Artemenko A, Akhmadeeva L, Golovacheva V, Danilov A, Ekusheva E, Isagulian E, Koreshkina M, Kurushina O, Latysheva N, Lebedeva E, Naprienko M, Osipova V, Pavlov N, Parfenov V, Rachin A, Sergeev A, Skorobogatykh K, Tabeeva G, Filatova E. Clinical guidelines "Migraine". Zh Nevrol Psikhiatr Im S S Korsakova 2022. [DOI: 10.17116/jnevro20221220134] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Jin C, Yi C, Zhong W, Xue Y, Chen K, Deng K, Wang Z, Wang T. Design, synthesis and biological evaluation of pyridinylmethylenepiperidine derivatives as potent 5-HT 1F receptor agonists for migraine therapy. Eur J Med Chem 2021; 225:113782. [PMID: 34419891 DOI: 10.1016/j.ejmech.2021.113782] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/08/2021] [Accepted: 08/13/2021] [Indexed: 11/16/2022]
Abstract
Migraine is a common neurovascular disease which has been classified as the sixth most disabling disorder. Current migraine therapy was triptans, however, riptans can cause contraction of blood vessels. Therefore, novel drugs without cardiovascular effects emerged, such as CGRP and selective 5-HT1F receptor agonists. In this work, a series of pyridinylmethylenepiperidine derivatives were designed, synthesized and evaluated for their 5-HT1F receptor agonist activity. The results in vitro showed that compound C1-C6 displayed potent agonist activities compared with positive drug lasmiditan. Pharmacokinetic properties in rat indicated that 2,4,6-trifluoro-N-(6-(fluoro(1-methylpiperidin-4-ylidene)methyl)pyridin-2-yl)benzamide (C5) possessed high AUC and good bioavailability. In two rodent models of migraine, C5 significantly inhibited dural plasma protein extravasation and c-fos expression in the trigeminal nucleus caudalis. Moreover, C5 showed no effect on vasoconstriction. Through these studies, we identified C5 as a potent 5-HT1F receptor agonist for migraine therapy.
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Affiliation(s)
- Chuanfei Jin
- Sunshine Lake Pharma Co. Ltd., Shenzhen 518000; HEC Pharm Group, HEC Research and Development Center, Dongguan 523871, PR China.
| | - Chao Yi
- Sunshine Lake Pharma Co. Ltd., Shenzhen 518000; HEC Pharm Group, HEC Research and Development Center, Dongguan 523871, PR China
| | - Wenhe Zhong
- Sunshine Lake Pharma Co. Ltd., Shenzhen 518000; HEC Pharm Group, HEC Research and Development Center, Dongguan 523871, PR China
| | - Yaping Xue
- Sunshine Lake Pharma Co. Ltd., Shenzhen 518000; HEC Pharm Group, HEC Research and Development Center, Dongguan 523871, PR China
| | - Kangzhi Chen
- Sunshine Lake Pharma Co. Ltd., Shenzhen 518000; HEC Pharm Group, HEC Research and Development Center, Dongguan 523871, PR China
| | - Kang Deng
- Sunshine Lake Pharma Co. Ltd., Shenzhen 518000; HEC Pharm Group, HEC Research and Development Center, Dongguan 523871, PR China
| | - Zusheng Wang
- Sunshine Lake Pharma Co. Ltd., Shenzhen 518000; HEC Pharm Group, HEC Research and Development Center, Dongguan 523871, PR China
| | - Tao Wang
- Sunshine Lake Pharma Co. Ltd., Shenzhen 518000; HEC Pharm Group, HEC Research and Development Center, Dongguan 523871, PR China
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Silvestro M, Orologio I, Bonavita S, Scotto di Clemente F, Fasano C, Tessitore A, Tedeschi G, Russo A. Effectiveness and Safety of CGRP-mAbs in Menstrual-Related Migraine: A Real-World Experience. Pain Ther 2021; 10:1203-1214. [PMID: 34106431 PMCID: PMC8586402 DOI: 10.1007/s40122-021-00273-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/13/2021] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Migraine shows a significantly higher prevalence in women, especially during reproductive age when menstrual-related hormonal fluctuations represent the most common migraine trigger. Indeed, over 50% of patients report a higher occurrence of migraine attacks during the perimenstrual window. Menstrual migraine attacks are consistently referred to as more disabling, less responsive to symptomatic treatments, longer in duration, and more prone to relapse than non-menstrual migraine attacks. Evidence strongly suggests that estrogen fluctuations are involved in migraine attacks worsening during the perimenstrual window through several mechanisms directly or indirectly involving the CGRP pathway. We aimed to evaluate whether mAbs blocking CGRP-ligand or receptor (CGRP-mAbs) could represent an effective and safe preventive treatment for menstrual migraine attacks in patients with menstrual-related migraine (MRM) with previous treatment failures. METHODS Forty patients with MRM with at least three previous treatment failures received monthly CGRP-mAbs. At the baseline and after six CGRP-mAbs administrations, patients underwent to extensive interviews to assess frequency, duration, intensity, and responsiveness to painkiller intake of migraine attacks occurring during the perimenstrual window. RESULTS After six administrations of CGRP-mAbs we observed a reduction of median menstrual migraine frequency (from 5 to 2 days per month), pain intensity (from 8/10 to 6/10), and attacks duration (from 24 to 8 h) (p < 0.001). Nevertheless, a significant increase in the percentage of responding to migraine painkillers was observed from 42.5% at baseline to 95% at T1 (p < 0.001). CONCLUSIONS CGRP-mAbs could represent a safe and effective preventive therapeutic strategy able to reduce the disabling burden of menstrual migraine attack frequency, duration, intensity, and significantly improve the response to painkillers. These findings could be related to and further indirectly prove the greater influence of CGRP-mediated mechanisms in the pathophysiology of menstrual migraine attacks.
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Affiliation(s)
- Marcello Silvestro
- Department of Advanced Medical and Surgical Sciences (DAMS), Headache Center, University of Campania "Luigi Vanvitelli", Piazza Miraglia 2, 80138, Naples, Italy
| | - Ilaria Orologio
- Department of Advanced Medical and Surgical Sciences (DAMS), Headache Center, University of Campania "Luigi Vanvitelli", Piazza Miraglia 2, 80138, Naples, Italy
| | - Simona Bonavita
- Department of Advanced Medical and Surgical Sciences (DAMS), Headache Center, University of Campania "Luigi Vanvitelli", Piazza Miraglia 2, 80138, Naples, Italy
| | - Fabrizio Scotto di Clemente
- Department of Advanced Medical and Surgical Sciences (DAMS), Headache Center, University of Campania "Luigi Vanvitelli", Piazza Miraglia 2, 80138, Naples, Italy
| | - Carla Fasano
- Department of Advanced Medical and Surgical Sciences (DAMS), Headache Center, University of Campania "Luigi Vanvitelli", Piazza Miraglia 2, 80138, Naples, Italy
| | - Alessandro Tessitore
- Department of Advanced Medical and Surgical Sciences (DAMS), Headache Center, University of Campania "Luigi Vanvitelli", Piazza Miraglia 2, 80138, Naples, Italy
| | - Gioacchino Tedeschi
- Department of Advanced Medical and Surgical Sciences (DAMS), Headache Center, University of Campania "Luigi Vanvitelli", Piazza Miraglia 2, 80138, Naples, Italy
| | - Antonio Russo
- Department of Advanced Medical and Surgical Sciences (DAMS), Headache Center, University of Campania "Luigi Vanvitelli", Piazza Miraglia 2, 80138, Naples, Italy.
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Beauchene JK, Levien TL. Lasmiditan: Acute Migraine Treatment Without Vasoconstriction. A Review. J Pharm Technol 2021; 37:244-253. [PMID: 34752575 DOI: 10.1177/87551225211024630] [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: 11/15/2022] Open
Abstract
Objective: To review the efficacy and safety of the newly Food and Drug Administration approved drug lasmiditan, and its place in therapy in the treatment of acute migraine attacks. Data Sources: A literature search of Web of Science, PubMed, and Google Scholar was preformed (September 1999 to May 2021) using the following search terms: acute migraine treatment, triptans, lasmiditan, Reyvow, Rimegepant, Nurtec, Ubrogepant, Ubrelvy, migraine, vasoconstriction, and cardiovascular risk. Product labeling, https://www.clinicaltriasl.gov, and product monographs were also reviewed. Study Selection and Data Extraction: Relevant English-language studies were considered. Data Synthesis: Lasmiditan is the first in its class approved for acute migraine treatment. Lasmiditan exerts its therapeutic effect through agonism at the 5-HT1F receptor, which has been shown to produce no vasoconstriction in preclinical models. Relevance to Patient Care and Clinical Practice: It is both scientifically and clinically relevant to review lasmiditan and determine the value of an acute migraine drug that does not induce vasoconstriction. Patients with preexisting cardiovascular conditions for which current migraine therapy is contraindicated may benefit from therapeutic use of lasmiditan. However, the potential cardiovascular benefit needs to be weighed against the increased central nervous system risks observed with lasmiditan. Conclusions: Lasmiditan is an oral tablet drug that is used for acute migraine abortive treatment and data suggest that it does not induce vasoconstriction, a common side effect often observed with the current first-line abortive migraine treatment drug class, triptans. This is especially important in acute migraine patients with cardiovascular risk factors in which triptan use is contraindicated.
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Reuter U, Krege JH, Lombard L, Gomez Valderas E, Krikke-Workel J, Dell-Agnello G, Dowsett SA, Buse DC. Lasmiditan efficacy in the acute treatment of migraine was independent of prior response to triptans: Findings from the CENTURION study. Cephalalgia 2021; 42:20-30. [PMID: 34644189 DOI: 10.1177/03331024211048507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND A significant proportion of triptan users exhibit an insufficient response or inadequate tolerability to a triptan, and some may develop a contraindication. Lasmiditan, a selective 5-HT1F receptor agonist, may be an option for these individuals. We assessed lasmiditan efficacy in a subgroup of patients in CENTURION (Phase 3 migraine consistency study) who exhibited an insufficient response to triptans, including a subgroup with insufficient response due to efficacy only. METHODS Patients were randomized to lasmiditan 200 mg for four attacks, lasmiditan 100 mg for four attacks, or placebo for three and lasmiditan 50 mg for one attack. Triptan insufficient responders were pre-defined as patients with insufficient efficacy or tolerability, or who developed a contraindication. RESULTS In triptan insufficient responders, lasmiditan was superior to placebo (p < 0.05) for pain freedom beginning at 1 h (both doses); pain relief beginning at 0.5 (200 mg) or 1 h (100 mg); migraine-related disability freedom, much/very much better on the Patient Global Impression of Change, and most bothersome symptom freedom at 2 h; sustained pain freedom; and need for rescue medication. Lasmiditan showed benefit for consistency of effect across attacks for 2-h pain freedom and pain relief. Findings were similar in triptan responders and triptan naïve patients and when the triptan insufficient response definition was based on efficacy only. CONCLUSIONS Lasmiditan was efficacious across multiple clinically relevant endpoints in the acute treatment of migraine independent of prior response to triptans.Trial Registration: CENTURION (NCT03670810); SAMURAI (NCT02439320); SPARTAN (NCT02605174).
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Affiliation(s)
- Uwe Reuter
- Charité-Universitätsmedizin Berlin, Berlin, Germany.,Universitätsmedizin Greifswald, Greifswald, Germany
| | | | | | | | | | | | | | - Dawn C Buse
- Albert Einstein College of Medicine, Bronx, NY, USA
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Yang CP, Liang CS, Chang CM, Yang CC, Shih PH, Yau YC, Tang KT, Wang SJ. Comparison of New Pharmacologic Agents With Triptans for Treatment of Migraine: A Systematic Review and Meta-analysis. JAMA Netw Open 2021; 4:e2128544. [PMID: 34633423 PMCID: PMC8506232 DOI: 10.1001/jamanetworkopen.2021.28544] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IMPORTANCE New therapeutic classes of migraine-specific treatment have been developed, including 5-hydroxytryptamine1F receptor agonists (lasmiditan) and calcitonin gene-related peptide antagonists (rimegepant and ubrogepant). OBJECTIVE To compare outcomes associated with the use of lasmiditan, rimegepant, and ubrogepant vs triptans for acute management of migraine headaches. DATA SOURCES The Cochrane Register of Controlled Trials, Embase, and PubMed were searched from inception to March 5, 2020. STUDY SELECTION Double-blind randomized clinical trials examining current available migraine-specific acute treatments were included. DATA EXTRACTION AND SYNTHESIS The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was applied to extract the data according to a predetermined list of variables of interest, and all network meta-analyses were conducted using a random-effects model. MAIN OUTCOMES AND MEASURES The primary outcome was the odds ratio (OR) for freedom from pain (hereafter referred to as pain freedom) at 2 hours after the dose, and the secondary outcomes were ORs for pain relief at 2 hours after the dose and any adverse events. RESULTS A total of 64 randomized clinical trials were included (46 442 participants; 74%-87% women; age range, 36-43 years). Most of the included treatments were associated with reduced pain at 2 hours compared with placebo. Most triptans were associated with higher ORs for pain freedom at 2 hours compared with lasmiditan (range: OR, 1.72 [95% CI, 1.06-2.80] to OR, 3.40 [95% CI, 2.12-5.44]), rimegepant (range: OR, 1.58 [95% CI, 1.07-2.33] to OR, 3.13 [95% CI, 2.16-4.52]), and ubrogepant (range: OR, 1.54 [95% CI, 1.00-2.37] to OR, 3.05 [95% CI, 2.02-4.60]). Most triptans were associated with higher ORs for pain relief at 2 hours compared with lasmiditan (range: OR, 1.46 [95% CI, 1.09-1.96] to OR, 3.31 [95% CI, 2.41-4.55]), rimegepant (range: OR, 1.33 [95% CI, 1.01-1.76] to OR, 3.01 [95% CI, 2.33-3.88]), and ubrogepant (range: OR, 1.38 [95% CI, 1.02-1.88] to OR, 3.13 [95% CI, 2.35-4.15]). The comparisons between lasmiditan, rimegepant, and ubrogepant were not statistically significant for both pain freedom and pain relief at 2 hours. Lasmiditan was associated with the highest risk of any adverse events, and certain triptans (rizatriptan, sumatriptan, and zolmitriptan) were also associated with a higher risk of any adverse events than the calcitonin gene-related peptide antagonists. CONCLUSIONS AND RELEVANCE For pain freedom or pain relief at 2 hours after the dose, lasmiditan, rimegepant, and ubrogepant were associated with higher ORs compared with placebo but lower ORs compared with most triptans. However, the lack of cardiovascular risks for these new classes of migraine-specific treatments may offer an alternative to triptans.
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Affiliation(s)
- Chun-Pai Yang
- Department of Neurology, Kuang Tien General Hospital, Taichung, Taiwan
- Department of Nutrition, Hungkuang University, Taichung, Taiwan
| | - Chih-Sung Liang
- Beitou Branch, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ching-Mao Chang
- Center for Traditional Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Traditional Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-Chia Yang
- Department of Healthcare Administration, Asia University, Taichung, Taiwan
| | - Po-Hsuan Shih
- Institute of Traditional Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Chinese Medicine, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Yun-Chain Yau
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung, Taipei, Taiwan
| | - Kuo-Tung Tang
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung, Taiwan
- PhD Program in Translational Medicine and Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Shuu-Jiun Wang
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Abstract
OBJECTIVE Migraine is a chronic neurological disease involving the brain and its vasculature, typically characterized by recurrent attacks of moderate or severe throbbing headache, accompanied by sensitivity to light and sound, and associated with nausea, vomiting, and inability to move due to worsening of pain. About 30% of migraineurs have some type of aura, most often visual. Migraine attacks, if untreated or suboptimally treated, usually result in significant disability, requiring bed rest and resulting in poor quality of life. Increased frequency of attacks and overuse of acute care medication are significant risks for chronification, resulting in the transformation of episodic migraine into chronic migraine. We aim to review most acute care treatments for migraine. METHODS Current treatment options for migraine attacks were reviewed from the selected literature and combined with our clinical experience. RESULTS Current acute treatment options for migraine attacks include over-the-counter analgesics, at times combined with caffeine, nonsteroidal anti-inflammatory medications, opioids, and migraine-specific medications such as triptans and ergots. In the near future, we will probably have 3 gepants (small-molecule calcitonin gene-related peptide [CGRP] receptor antagonists). The first one was just approved in the United States. A ditan acting as a stimulator of 5-HT1F receptors, was also just approved by the FDA. Stimulation of the trigeminal, vagal, occipital, and even upper arm peripheral nerves through electrical nerve stimulation devices and magnetic stimulation devices are available as alternative, nondrug treatment options. Several devices have already been FDA-allowed for treatment in the United States and/or approved elsewhere, and others will follow soon. Behavioral medicine techniques such as biofeedback training and mindfulness have been available for some time and are often helpful. CONCLUSION A wide variety of acute care options to treat migraine are available, and others will soon be and will herein be described in further detail. Some medications have been approved by regulatory authorities in countries other than the United States, and some devices have been given a CE Mark in Europe.
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Affiliation(s)
- Spingos Konstantinos
- Corfu Headache Clinic (SK), Corfu, Greece; Headache Clinic (VM), Mediterraneo Hospital, Glyfada, Greece and Glyfada Headache Clinic, Glyfada, Greece; and the David Geffen School of Medicine at UCLA in Los Angeles (RA), Los Angeles, California; Past President of the International Headache Society (IHS), Founder and Director-Emeritus of the New England Center for Headache, Stamford, Connecticut
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Marichal-Cancino BA, González-Hernández A, Guerrero-Alba R, Medina-Santillán R, Villalón CM. A critical review of the neurovascular nature of migraine and the main mechanisms of action of prophylactic antimigraine medications. Expert Rev Neurother 2021; 21:1035-1050. [PMID: 34388955 DOI: 10.1080/14737175.2021.1968835] [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: 10/20/2022]
Abstract
INTRODUCTION Migraine involves neurovascular, functional, and anatomical alterations. Migraineurs experience an intense unilateral and pulsatile headache frequently accompanied with vomiting, nausea, photophobia, etc. Although there is no ideal preventive medication, frequency in migraine days may be partially decreased by some prophylactics, including antihypertensives, antidepressants, antiepileptics, and CGRPergic inhibitors. However, the mechanisms of action involved in antimigraine prophylaxis remain elusive. AREAS COVERED This review recaps some of the main neurovascular phenomena related to migraine and currently available preventive medications. Moreover, it discusses the major mechanisms of action of the recommended prophylactic medications. EXPERT OPINION In the last three years, migraine prophylaxis has evolved from nonspecific to specific antimigraine treatments. Overall, nonspecific treatments mainly involve neural actions, whereas specific pharmacotherapy (represented by CGRP receptor antagonists and CGRPergic monoclonal antibodies) is predominantly mediated by neurovascular mechanisms that may include, among others: (i) reduction in the cortical spreading depression (CSD)-associated events; (ii) inhibition of pain sensitization; (iii) blockade of neurogenic inflammation; and/or (iv) increase in cranial vascular tone. Accordingly, the novel antimigraine prophylaxis promises to be more effective, devoid of significant adverse effects (unlike nonspecific treatments), and more beneficial for the quality of life of migraineurs.
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Affiliation(s)
- Bruno A Marichal-Cancino
- Departamento de Fisiología y Farmacología, Centro de Ciencias Básicas, Universidad Autónoma de Aguascalientes, Aguascalientes, Ags, México
| | | | - Raquel Guerrero-Alba
- Departamento de Fisiología y Farmacología, Centro de Ciencias Básicas, Universidad Autónoma de Aguascalientes, Aguascalientes, Ags, México
| | - Roberto Medina-Santillán
- Sección de Estudios de Posgrado e Investigación, Escuela Superior de Medicina IPN, Ciudad de México C.P, México
| | - Carlos M Villalón
- Departamento de Farmacobiología, Cinvestav-Coapa, Ciudad de México, México
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González-Hernández A, Marichal-Cancino BA, García-Boll E, Villalón CM. The locus of Action of CGRPergic Monoclonal Antibodies Against Migraine: Peripheral Over Central Mechanisms. CNS & NEUROLOGICAL DISORDERS-DRUG TARGETS 2021; 19:344-359. [PMID: 32552657 DOI: 10.2174/1871527319666200618144637] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 04/18/2020] [Accepted: 05/05/2020] [Indexed: 12/13/2022]
Abstract
Migraine is a complex neurovascular disorder characterized by attacks of moderate to severe unilateral headache, accompanied by photophobia among other neurological signs. Although an arsenal of antimigraine agents is currently available in the market, not all patients respond to them. As Calcitonin Gene-Related Peptide (CGRP) plays a key role in the pathophysiology of migraine, CGRP receptor antagonists (gepants) have been developed. Unfortunately, further pharmaceutical development (for olcegepant and telcagepant) was interrupted due to pharmacokinetic issues observed during the Randomized Clinical Trials (RCT). On this basis, the use of monoclonal antibodies (mAbs; immunoglobulins) against CGRP or its receptor has recently emerged as a novel pharmacotherapy to treat migraines. RCT showed that these mAbs are effective against migraines producing fewer adverse events. Presently, the U.S. Food and Drug Administration approved four mAbs, namely: (i) erenumab; (ii) fremanezumab; (iii) galcanezumab; and (iv) eptinezumab. In general, specific antimigraine compounds exert their action in the trigeminovascular system, but the locus of action (peripheral vs. central) of the mAbs remains elusive. Since these mAbs have a molecular weight of ∼150 kDa, some studies rule out the relevance of their central actions as they seem unlikely to cross the Blood-Brain Barrier (BBB). Considering the therapeutic relevance of this new class of antimigraine compounds, the present review has attempted to summarize and discuss the current evidence on the probable sites of action of these mAbs.
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Affiliation(s)
- Abimael González-Hernández
- Instituto de Neurobiologia, Universidad Nacional Autonoma de Mexico, Blvd. Juriquilla 3001, 76230 Queretaro, Mexico
| | - Bruno A Marichal-Cancino
- Departamento de Fisiologia y Farmacologia, Universidad Autonoma de Aguascalientes, Ciudad Universitaria, 20131 Aguascalientes, Mexico
| | - Enrique García-Boll
- Instituto de Neurobiologia, Universidad Nacional Autonoma de Mexico, Blvd. Juriquilla 3001, 76230 Queretaro, Mexico
| | - Carlos M Villalón
- Departamento de Farmacobiologia, Cinvestav-Coapa, Czda. de los Tenorios 235, Col. Granjas-Coapa, Deleg, Tlalpan, 14330 Ciudad de Mexico, Mexico
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Zobdeh F, Ben Kraiem A, Attwood MM, Chubarev VN, Tarasov VV, Schiöth HB, Mwinyi J. Pharmacological treatment of migraine: Drug classes, mechanisms of action, clinical trials and new treatments. Br J Pharmacol 2021; 178:4588-4607. [PMID: 34379793 DOI: 10.1111/bph.15657] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 07/28/2021] [Accepted: 08/02/2021] [Indexed: 11/26/2022] Open
Abstract
Migraine is the sixth most prevalent disease globally, a major cause of disability, and it imposes an enormous personal and socioeconomic burden. Migraine treatment is often limited by insufficient therapy response, leading to the need for individually adjusted treatment approaches. In this review, we analyse historical and current pharmaceutical development approaches in acute and chronic migraine based on a comprehensive and systematic analysis of Food and Drug Administration (FDA)-approved drugs and those under investigation. The development of migraine therapeutics has significantly intensified during the last 3 years, as shown by our analysis of the trends of drug development between 1970 and 2020. The spectrum of drug targets has expanded considerably, which has been accompanied by an increase in the number of specialised clinical trials. This review highlights the mechanistic implications of FDA-approved and currently investigated drugs and discusses current and future therapeutic options based on identified drug classes of interest.
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Affiliation(s)
- Farzin Zobdeh
- Department of Pharmacology, Institute of Pharmacy, I. M. Sechenov First Moscow State Medical University, Moscow, Russia.,Department of Neuroscience, Functional Pharmacology, University of Uppsala, Uppsala, Sweden
| | - Aziza Ben Kraiem
- Department of Pharmacology, Institute of Pharmacy, I. M. Sechenov First Moscow State Medical University, Moscow, Russia.,Department of Neuroscience, Functional Pharmacology, University of Uppsala, Uppsala, Sweden
| | - Misty M Attwood
- Department of Neuroscience, Functional Pharmacology, University of Uppsala, Uppsala, Sweden
| | - Vladimir N Chubarev
- Department of Pharmacology, Institute of Pharmacy, I. M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Vadim V Tarasov
- Department of Pharmacology, Institute of Pharmacy, I. M. Sechenov First Moscow State Medical University, Moscow, Russia.,Institute of Translational Medicine and Biotechnology, I. M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Helgi B Schiöth
- Department of Neuroscience, Functional Pharmacology, University of Uppsala, Uppsala, Sweden.,Institute of Translational Medicine and Biotechnology, I. M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Jessica Mwinyi
- Department of Neuroscience, Functional Pharmacology, University of Uppsala, Uppsala, Sweden
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Ducros A, de Gaalon S, Roos C, Donnet A, Giraud P, Guégan-Massardier E, Lantéri-Minet M, Lucas C, Mawet J, Moisset X, Valade D, Demarquay G. Revised guidelines of the French headache society for the diagnosis and management of migraine in adults. Part 2: Pharmacological treatment. Rev Neurol (Paris) 2021; 177:734-752. [PMID: 34340810 DOI: 10.1016/j.neurol.2021.07.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 12/21/2022]
Abstract
The French Headache Society proposes updated French guidelines for the management of migraine. This article presents the second part of the guidelines, which is focused on the pharmacological treatment of migraine, including both the acute treatment of attacks and the prophylaxis of episodic migraine as well as chronic migraine with and without medication overuse. The specific situations that can be encountered in women with migraine are also discussed, including pregnancy, menstrual migraine, contraception and hormonal replacement therapy.
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Affiliation(s)
- A Ducros
- Department of neurology, Gui-de-Chauliac hospital, CHU Montpellier, university of Montpellier, 34000 Montpellier, France
| | - S de Gaalon
- Department of neurology, Laënnec hospital, CHU de Nantes, Nantes, France
| | - C Roos
- Emergency headache center (centre d'urgences céphalées), department of neurology, Lariboisière hospital, Assistance publique-Hôpitaux de Paris, Paris, France
| | - A Donnet
- Centre d'évaluation et de traitement de la douleur, FHU INOVPAIN, hôpital de La Timone, Marseille, France
| | - P Giraud
- Department of neurology, Annecy Genevois hospital, Annecy, France
| | | | - M Lantéri-Minet
- Pain department, FHU InovPain, CHU Nice Côte Azur université, Nice, France
| | - C Lucas
- Centre d'évaluation et de traitement de la douleur, service de neurochirurgie, hôpital Salengro, CHRU de Lille, Lille, France
| | - J Mawet
- Emergency headache center (centre d'urgences céphalées), department of neurology, Lariboisière hospital, Assistance publique-Hôpitaux de Paris, Paris, France
| | - X Moisset
- Neuro-Dol, université Clermont Auvergne, CHU de Clermont-Ferrand, INSERM, Clermont-Ferrand, France
| | - D Valade
- Department of neurosurgery, hôpital Pitié-Sapêtrière, Paris, France
| | - G Demarquay
- Neurological hospital, Lyon, neuroscience research center (CRNL), INSERM U1028, CNRS UMR5292, Lyon, France.
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Steiner TJ, Linde M, Schnell-Inderst P. A universal outcome measure for headache treatments, care-delivery systems and economic analysis. J Headache Pain 2021; 22:63. [PMID: 34210258 PMCID: PMC8247243 DOI: 10.1186/s10194-021-01269-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 05/26/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The first manuscript in this series delineated a model of structured headache services, potentially cost-effective but requiring formal cost-effectiveness analysis (CEA). We envisaged a need for a new outcome measure for this purpose, applicable to all forms of treatment, care and care-delivery systems as opposed to comparisons of single-modality treatments. CONCEPTION AND DELINEATION A literature review confirmed the lack of any suitable established measure. We prioritised construct validity, simplicity, comprehensiveness and expression in intuitive units. We noted that pain was the key burdensome symptom of migraine and episodic tension-type headache (TTH), that pain above a certain level was disabling, that it was difficult to put economic value to pain but relatively easy to do this for time, a casualty of headache leading to lost productivity. Alleviation of pain to a non-disabling level would be expected to bring restoration of function. We therefore based the measure on time spent in the ictal state (TIS) of migraine or TTH, either as total TIS or proportion of all time. We expressed impact on health, in units of time, as TIS*DW, where DW was the disability weight for the ictal state supplied by the Global Burden of Disease (GBD) studies. If the time unit was hours, TIS*DW yielded hours lived with (or lost to) disability (HLDs), in analogy with GBD's years lived with disability (YLDs). UTILITY ASSESSMENT Acute treatments would reduce TIS by shortening attack duration, preventative treatments by reducing attack frequency; health-care systems such as structured headache services would have these effects by delivering these treatments. These benefits were all measurable as HLDs-averted. Population-level estimates would be derived by factoring in prevalence, but also taking treatment coverage and adherence into account. For health-care systems, additional gains from provider-training (promoting adherence to guidelines and, therefore, enhancing coverage) and consumer-education (improving adherence to care plans), increasing numbers within populations gaining the benefits of treatments, would be measurable by the same metric. CONCLUSIONS The new outcome measure expressed in intuitive units of time is applicable to treatments of all modalities and to system-level interventions for multiple headache types, with utility for CEA and for informing health policy.
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Affiliation(s)
- Timothy J Steiner
- Department of Neuromedicine and Movement Science, NTNU Norwegian University of Science and Technology, Edvard Griegs gate, Trondheim, Norway.
- Division of Brain Sciences, Imperial College London, London, UK.
| | - Mattias Linde
- Department of Neuromedicine and Movement Science, NTNU Norwegian University of Science and Technology, Edvard Griegs gate, Trondheim, Norway
- Norwegian Advisory Unit on Headache, Department of Neurology and Clinical Neurophysiology, St Olavs University Hospital, Trondheim, Norway
- Tjörn Headache Clinic, Rönnäng, Sweden
| | - Petra Schnell-Inderst
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, Medical Informatics and Technology, UMIT - University for Health Sciences, Hall in Tirol, Austria
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45
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Yang CP, Huang KT, Chang CM, Yang CC, Wang SJ. Acute Treatment of Migraine: What has Changed in Pharmacotherapies? Neurol India 2021; 69:S25-S42. [PMID: 34003146 DOI: 10.4103/0028-3886.315995] [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: 11/04/2022]
Abstract
Background Migraine is the most prevalent neurological disorder and the leading cause of disability in individuals under 50 years of age. Two types of migraine therapies have been defined: acute therapy (abortive or symptomatic treatment), the purpose of which is to interrupt migraine attacks, and preventive treatment (prophylactic treatment), the purpose of which is to reduce the frequency and severity of migraine attacks. Objective This paper reviews research advances in new agents for acute therapy of migraine. Material and Methods This review provides an overview of emerging new drugs for acute treatment of migraine based on clinical evidence and summarizes the milestones of different stages of clinical development. Results Two new formulations of sumatriptan, DFN-11 (3 mg doses of subcutaneous sumatriptan) and DFN-02 (a nasal spray of sumatriptan 10 mg and a permeation-enhancing excipient), have been developed, and both of them showed a fast-onset action with efficacy for acute treatment of migraine with fewer adverse events. New drug discovery programs shifted the focus to the development of ditans, a group of antimigraine drugs targeting 5-HT1F receptors. Only lasmiditan has progressed to phase III clinical trials and was finally approved by the Food and Drug Administration (FDA) for acute migraine treatment. The other target for acute therapy is CGRP receptor antagonists, namely, gepants. Ubrogepant and rimegepant demonstrated statistically significant efficacy, and both were recently approved by the FDA. These 5-HT1F receptor agonists and CGRP receptor antagonists did not cause vasoconstriction, offering advantages over the current mainstay of specific acute migraine treatment. Conclusions Overall, these new agents have expanded the available acute therapies for migraine treatment and will likely change the strategy with which we treat patients with migraine in the future.
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Affiliation(s)
- Chun-Pai Yang
- Department of Neurology, Kuang Tien General Hospital; Department of Nutrition, Huang-Kuang University, Taichung, Taiwan
| | - Kuo-Ting Huang
- Department of Anesthesiology, Mackay Memorial Hospital, Taipei, Taiwan
| | - Ching-Mao Chang
- Center for Traditional Medicine, Neurological Institute, Taipei Veterans General Hospital; Faculty of Medicine, National Yang Ming Chiao Tung University; Institute of Traditional Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-Chia Yang
- Department of Healthcare Administration, Asia University, Taichung, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital; National Yang Ming Chiao Tung University, School of Medicine; Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Development of Mucoadhesive Buccal Film for Rizatriptan: In Vitro and In Vivo Evaluation. Pharmaceutics 2021; 13:pharmaceutics13050728. [PMID: 34063402 PMCID: PMC8157038 DOI: 10.3390/pharmaceutics13050728] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/08/2021] [Accepted: 05/13/2021] [Indexed: 02/07/2023] Open
Abstract
The reduced therapeutic efficacy of rizatriptan in migraine treatment is primarily due to low oral bioavailability and extensive first pass metabolism. The purpose of this investigation was to optimize the thin mucoadhesive buccal film of rizatriptan and assess the practicability of its development as a potential substitute for conventional migraine treatment. Buccal films (FR1-FR10) were fabricated by a conventional solvent casting method utilizing a combination of polymers (Proloc, hydroxypropyl methylcellulose and Eudragit RS 100). Drug-loaded buccal films (F1-F4) were examined for mechanical, mucoadhesive, swelling and release characteristics. In vivo pharmacokinetics parameters of selected buccal film (F1) in rabbits were compared to oral administration. Films F1-F4 displayed optimal physicomechanical properties including mucoadhesive strength, which can prolong the buccal residence time. A biphasic, complete and higher drug release was seen in films F1 and F4, which followed Weibull model kinetics. The optimized film, F1, exhibited significantly higher (p < 0.005) rizatriptan buccal flux (71.94 ± 8.26 µg/cm2/h) with a short lag time. Film features suggested the drug particles were in an amorphous form, compatible with the polymers used and had an appropriate surface morphology suitable for buccal application. Pharmacokinetic data indicated a significantly higher rizatriptan plasma level (p < 0.005) and Cmax (p < 0.0001) upon buccal film application as compared to oral solution. The observed AUC0-12h (994.86 ± 95.79 ng.h/mL) in buccal treatment was two-fold higher (p < 0.0001) than the control, and the relative bioavailability judged was 245%. This investigation demonstrates the prospective of buccal films as a viable and alternative approach for effective rizatriptan delivery.
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Ashina M, Reuter U, Smith T, Krikke-Workel J, Klise SR, Bragg S, Doty EG, Dowsett SA, Lin Q, Krege JH. Randomized, controlled trial of lasmiditan over four migraine attacks: Findings from the CENTURION study. Cephalalgia 2021; 41:294-304. [PMID: 33541117 PMCID: PMC7961651 DOI: 10.1177/0333102421989232] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background We present findings from the multicenter, double-blind Phase 3 study, CENTURION. This study was designed to assess the efficacy of and consistency of response to lasmiditan in the acute treatment of migraine across four attacks. Methods Patients were randomized 1:1:1 to one of three treatment groups – lasmiditan 200 mg; lasmiditan 100 mg; or a control group that received placebo for three attacks and lasmiditan 50 mg for either the third or fourth attack. The primary endpoints were pain freedom at 2 h (first attack) and pain freedom at 2 h in ≥2/3 attacks. Secondary endpoints included pain relief, sustained pain freedom and disability freedom. Statistical testing used a logistic regression model and graphical methodology to control for multiplicity. Results Overall, 1471 patients treated ≥1 migraine attack with the study drug. Both primary endpoints were met for lasmiditan 100 mg and 200 mg (p < 0.001). All gated secondary endpoints were met. The incidence of treatment-emergent adverse events (TEAEs) was highest during the first attack. The most common TEAEs with lasmiditan were dizziness, paresthesia, fatigue, and nausea; these were generally mild or moderate in severity. Conclusions These results confirm the early and sustained efficacy of lasmiditan 100 mg and 200 mg and demonstrate consistency of response across multiple attacks. Trial Registration Number: NCT03670810
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Affiliation(s)
- Messoud Ashina
- Danish Headache Center and Department of Neurology, Rigshospitalet Glostrup, Faculty of Medical and Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Uwe Reuter
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | | | | | - Sonja Bragg
- Eli Lilly and Company, Indianapolis, IN, USA
| | - Erin G Doty
- Eli Lilly and Company, Indianapolis, IN, USA
| | | | - Qun Lin
- Eli Lilly and Company, Indianapolis, IN, USA
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Moreno-Ajona D, Pérez-Rodríguez A, Goadsby PJ. Gepants, calcitonin-gene-related peptide receptor antagonists: what could be their role in migraine treatment? Curr Opin Neurol 2021; 33:309-315. [PMID: 32251023 DOI: 10.1097/wco.0000000000000806] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Migraine is the second leading cause of years lived with disability after back pain. Poor tolerability, contraindications, drug-drug interactions and efficacy limited to a subpopulation make new approaches necessary for the acute and preventive treatment of migraine. The study of the calcitonin-gene-related peptide (CGRP) pathway over the last decades is a good example of translational medicine leading to directed therapies for patients. RECENT FINDINGS After some of the first-generation CGRP receptor antagonists, gepants, were not fully developed because of hepatotoxicity, the second generation of gepants have shown efficacy, safety and tolerability in recent clinical trials. SUMMARY Both rimegepant and ubrogepant have published positive randomized placebo-controlled clinical trials data. Vazegepant is the first intranasal gepant for the acute treatment of migraine and has announced a positive phase II/III study. Daily rimegepant use has preliminary data to suggest efficacy. Atogepant has shown efficacy in migraine prevention in a phase II/III study. Most importantly, hepatotoxicity has not been reported in specifically designed phase I studies or long-term extension studies, with rimegepant or ubrogepant, or in a preventive study with atogepant. Given the preventive effect, it seems likely that gepants will not lead to medication overuse headache. They will likely have no cardiovascular warnings. Because of the particular benefit gepants may represent for these groups of patients, specific studies in patients with medication overuse headache, as well as those with comorbid cardiovascular diseases, would be of considerable interest.
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Affiliation(s)
- David Moreno-Ajona
- Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London.,NIHR-Wellcome Trust King's Clinical Research Facility/SLaM Biomedical Research Centre, King's College Hospital, London, UK
| | - Abigail Pérez-Rodríguez
- Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London.,NIHR-Wellcome Trust King's Clinical Research Facility/SLaM Biomedical Research Centre, King's College Hospital, London, UK.,Department of Neurology, Hospital Nuestra Señora Del Rosario, Calle del Príncipe de Vergara, Madrid, Spain
| | - Peter J Goadsby
- Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London.,NIHR-Wellcome Trust King's Clinical Research Facility/SLaM Biomedical Research Centre, King's College Hospital, London, UK
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González-Hernández A, Condés-Lara M, García-Boll E, Villalón CM. An outlook on the trigeminovascular mechanisms of action and side effects concerns of some potential neuropeptidergic antimigraine therapies. Expert Opin Drug Metab Toxicol 2021; 17:179-199. [DOI: 10.1080/17425255.2021.1856366] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
| | - Miguel Condés-Lara
- Instituto de Neurobiología, Universidad Nacional Autónoma de México, Querétaro, México
| | - Enrique García-Boll
- Instituto de Neurobiología, Universidad Nacional Autónoma de México, Querétaro, México
| | - Carlos M. Villalón
- Departamento de Farmacobiología, Cinvestav-Coapa, Ciudad de México, México
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50
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Nahas SJ. Zolmitriptan for Early Onset of Action in Acute Migraine Attacks. Neurology 2021. [DOI: 10.17925/usn.2021.17.2.74] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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