Migraine in multiple sclerosis patients: potential links and treatment approach

The anti-CGRP mAb Fremanezumab reverts the anti-inflammatory effects of CGRP in vitro but does not alter disease evolution in a mouse model of progressive multiple sclerosis

Migraine has been reported to be twice as prevalent in patients with multiple sclerosis (MS) compared to the non-MS population, highlighting the importance of the treatment for migraine in the MS population. Because of their efficacy, safety profile, and target specificity, the anti-CGRP monoclonal antibodies (mAbs) represent a promising option in MS patients concomitantly exposed to disease-modifying drugs. However, growing evidence reports the role of CGRP in regulating the immune system, raising a question about the safety use of anti-CGRP mAbs in autoimmune disorders such as MS. In the present study, by adopting NOD mice immunized with MOG35-55 as a model of progressive experimental autoimmune encephalomyelitis (PEAE), we evaluated the effects of the anti-CGRP mAb fremanezumab on disease evolution. We report that CGRP inhibited both LPS-induced microglia activation and lymphocyte proliferation in a concentration-dependent manner and that a concomitant fremanezumab exposure counteracted these effects in vitro. However, we found that fremanezumab administered every 2 weeks from the day of immunization, did not worsen disease evolution or survival in PEAE mice. Accordingly, no difference in innate and adaptive immune responses as well as spinal cord degeneration was observed in immunized mice treated with fremanezumab. Notably, we also demonstrated the ability of fremanezumab to reach the site of neurodegeneration, showing its presence in the spinal cord. Data indicate that CGRP has an irrelevant immunosuppressant effect in the complex pathophysiological scenario of MS, and suggest that the use of anti-CGRP antibodies for migraine treatment in MS patients is safe.

Effectiveness, safety, and impact on multiple sclerosis course of anti-CGRP monoclonal antibodies

BACKGROUND

Migraine affects up to 40% of people with multiple sclerosis (PwMS). This study aimed to evaluate the effectiveness and safety of the combination of antibodies (mAbs) against CGRP (anti-CGRP mAbs) with disease-modifying treatments (DMTs) for MS (mAb and non-mAbs) and their impact on MS disease course.

METHODS

This retrospective, multicentric study included PwMS from 14 MS Centers, treated with an anti-CGRP mAb and a stable treatment with DMTs. MS outcome measures included clinical relapses, EDSS score, and MRI activity from the year before starting anti-CGRP mAbs at the time of initiation (baseline) and last follow-up. Migraine outcomes included reductions in Monthly Headache Days (MHDs) and analgesic use. Adverse events (AEs) were recorded.

RESULTS

Twenty-five patients were included (mean age of 39.4 ± 9.7 years). Nine PwMS (36.0%) were treated with non-mAb DMTs and 16 (64.0%) with mAb DMTs. During the concurrent treatment, six patients (24.0%) stopped anti-CGRP mAbs after 12.7 ± 11.6 months due to ineffectiveness (n = 3) migraine sustained improvement (n = 2) and AEs (n = 1). MHDs significantly decreased from baseline (22.0 ± 8.2) to the last follow-up (11.5 ± 13.7) (p = 0.002). EDSS score did not significantly change from the year before initiating anti-CGRP mAb (1.9 ± 1.4) to baseline (1.9 ± 1.4) and last follow-up (1.9 ± 1.5)(p = 0.497). Two patients (8.0%) had a clinical relapse, and one (4.0%) had MRI activity during treatment with anti-CGRP mAbs. Overall, DMTs were discontinued in two patients (8%). Mild AEs were reported in 2 PwMS (8.0%), none leading to discontinuation.

CONCLUSIONS

Long-term treatment with anti-CGRP mAbs and DMTs for MS showed safety and effectiveness with no significant effect on MS disease course.

Headache disorders in multiple sclerosis: Is there an association? A systematic review and meta-analysis

OBJECTIVE

To look for any potential association of headache disorders with multiple sclerosis (MS).

BACKGROUND

The prevalence of headache disorders has been found to be increased in people with MS (pwMS), however, an association has not been established. Existing studies have provided conflicting results mostly because of methodological differences.

METHODS

PubMed, Embase and Scopus were searched to identify eligible studies. Studies were included if they were cross-sectional, case-control or cohort. Newcastle-Ottawa Scale (NOS) was used to assess the risk of bias of the included studies. Case-control, cross sectional or cohort studies that used the International Classification of Headache Disorders (ICHD)-2 or-3 criteria for headache diagnosis and Mc Donald or Poser criteria for MS diagnosis were included. Data were extracted using standardized data collection form. Meta-analysis was conducted by calculating the overall prevalence of headache disorders in pwMS as well as the association of headache disorders with MS. The Newcastle-Ottawa Scale (NOS), a tool for assessing the quality of non-randomized studies, was used to assess the quality of the included studies.

RESULTS

Twenty-three studies were included yielding a total of 5,440 MS patients and 28,0958 controls. The majority of them scored a NOS score between 5 and 6 (max 9), which indicates that they did not rank high in terms of quality, because most studies were cross-sectional and uncontrolled, and only one was prospective, controlled, and longitudinal, but with small population size. Pooled prevalence for all headache disorders, migraine and tension-type headache (TTH) in pwMS was 58 % (95 % CI 0.54-0.61), 30 % (95 % CI 0.25-0.34) and 19 % (95 % CI 0.15-0.23) respectively. A significant association between migraine and MS was found (OR = 2.02, 95 % CI = 1.14-3.57).

CONCLUSION

PwMS are twice as likely to experience migraine as controls, but the results need to be translated with caution since most of the studies included in the meta-analysis were of low or moderate quality. Larger prospective cohort, controlled, longitudinal studies are needed to confirm whether there is indeed an association between MS and migraine.

Headache in Multiple Sclerosis: A Narrative Review

Background: Multiple sclerosis (MS) is a chronic inflammatory demyelinating disorder of the central nervous system characterized by autoimmune-mediated damage to oligodendrocytes and subsequent myelin destruction. Clinical implications: Clinically, the disease presents with many symptoms, often evolving over time. The insidious onset of MS often manifests with non-specific symptoms (prodromal phase), which may precede a clinical diagnosis by several years. Among them, headache is a prominent early indicator, affecting a significant number of MS patients (50-60%). Results: Headache manifests as migraine or tension-type headache with a clear female predilection (female-male ratio 2-3:1). Additionally, some disease-modifying therapies in MS can also induce headache. For instance, teriflunomide, interferons, ponesimod, alemtuzumab and cladribine are associated with an increased incidence of headache. Conclusions: The present review analyzed the literature data on the relationship between headache and MS to provide clinicians with valuable insights for optimized patient management and the therapeutic decision-making process.