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Pellesi L, Do TP, Hougaard A. Pharmacological management of migraine: current strategies and future directions. Expert Opin Pharmacother 2024; 25:673-683. [PMID: 38720629 DOI: 10.1080/14656566.2024.2349791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 04/26/2024] [Indexed: 06/12/2024]
Abstract
INTRODUCTION Migraine is a complex neurological disorder that affects a significant portion of the global population. As traditional pharmacological approaches often fall short in alleviating symptoms, the development of innovative therapies has garnered significant interest. This text aims to summarize the current pharmacological options for managing migraine and to explore the potential impact of novel therapies. AREAS COVERED We focused on conventional treatments, emerging therapies, and novel compounds in clinical development, including therapies targeting the trigeminovascular system, cannabis-based therapies, hormonal and metabolic therapies, and other options. English peer-reviewed articles were searched in PubMed, Scopus, and ClinicalTrials.gov electronic databases. EXPERT OPINION Several novel treatment options for migraine have become available in recent years. Emerging pharmacological therapies targeting the trigeminovascular system, cannabis-based therapies, hormonal and metabolic interventions, and other emerging treatment modalities, may prove to be valuable for the treatment of migraine. Further research, clinical trials, and substantiated evidence are necessary to validate the efficacy, safety, and long-term outcomes of these therapeutic options.
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Affiliation(s)
- Lanfranco Pellesi
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Thien Phu Do
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Neurology, Danish Knowledge Center on Headache Disorders, Glostrup, Denmark
- Department of Clinical Medicine, Faculty of Medical and Health Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Neurology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Anders Hougaard
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Medical and Health Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Neurology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
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ANAEIGOUDARI A, SEYEDI F, KOOSHKI R, PORAN M, ZAMYAD M, ABBASNEJAD M. Methyl Jasmonate Modulates Feeding Behaviors and Hypothalamic Expression of the Orexin 1 Receptor in Rats. Turk J Pharm Sci 2024; 20:374-379. [PMID: 38254344 PMCID: PMC10803927 DOI: 10.4274/tjps.galenos.2023.63833] [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: 10/20/2022] [Accepted: 02/01/2023] [Indexed: 02/11/2023]
Abstract
Objectives Active plant ingredients have been successfully used in modern medicine to control appetite and energy hemostasis. This study was designed to evaluate the efficacy of the phytohormone methyl jasmonate (MJ) on food-related behaviors in rats. Materials and Methods Adult male Wistar rats were randomly divided into different groups (7 rats) and infused intracerebroventricularly (i.c.v.) with MJ vehicle (DMSO) or MJ (2.5, 5 and 10 μg/rat). Then, the individual rats were placed in an automated open field-like apparatus to assess a 12-h food-related activity in light and dark times. After behavioral tests, immunofluorescence staining of the orexin 1 receptor (Orx1R) was studied in the hypothalamus of rats. Results MJ (2.5, 5, and 10 μg/rat) administration significantly decreased food intake in the light and dark phases compared with the control group. Moreover, all the MJ-treated groups exhibited a decrease in visits to food containers at the light and dark times (p < 0.001). In addition, rats infused with MJ at 5 μg and 10 μg spent less time in the ports of food containers in the light and dark phases in comparison with control rats. Time in zone-related to food and locomotor activity was significantly decreased in the MJ (5 μg) groups during the light time and in all MJ-injected groups in the dark time. Moreover, hypothalamic expression of Orx1R in rats treated with MJ (5 μg) was significantly lower as compared to the control group. Conclusion Overall, the results indicated the potential of MJ to modulate feeding-related behavior and Orx1R expression in the hypothalamus of rats.
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Affiliation(s)
- Akbar ANAEIGOUDARI
- Jiroft University of Medical Sciences School, of Medicine, Department of Physiology, Jiroft, Iran
| | - Fatemeh SEYEDI
- Jiroft University of Medical Sciences School, of Medicine, Department of Anatomy, Jiroft, Iran
| | - Razieh KOOSHKI
- Lorestan University Faculty of Sciences, Department of Biology, Khorramabad, Iran
| | - Mohadeseh PORAN
- Shahid Bahonar University of Kerman Faculty, of Sciences, Department of Biology, Kerman, Iran
| | - Mahnaz ZAMYAD
- Shahid Bahonar University of Kerman Faculty, of Sciences, Department of Biology, Kerman, Iran
| | - Mehdi ABBASNEJAD
- Shahid Bahonar University of Kerman Faculty, of Sciences, Department of Biology, Kerman, Iran
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Kim SJ, Lee HJ, Lee SH, Cho S, Kim KM, Chu MK. Most bothersome symptom in migraine and probable migraine: A population-based study. PLoS One 2023; 18:e0289729. [PMID: 38019845 PMCID: PMC10686452 DOI: 10.1371/journal.pone.0289729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/25/2023] [Indexed: 12/01/2023] Open
Abstract
Recently, the most bothersome symptom has been recommended as a co-primary endpoint in clinical trials on the acute treatment of migraine. Probable migraine is a subtype of migraine that fulfills all but one criterion for migraine diagnosis. We aimed to compare the most bothersome symptom between probable migraine and migraine. This study analyzed data from a nationwide study conducted in Korea, and the most bothersome symptom was assessed by requesting the participants to select one of the four typical accompanying symptoms of migraine. Responses to acute treatment were evaluated using the migraine Treatment Optimization Questionnaire-6. Nausea was the most bothersome symptom, followed by phonophobia and vomiting in the migraine group (nausea, 61.8%; phonophobia, 25.3%; vomiting, 10.0%; and photophobia, 2.9%) and the probable migraine group (nausea, 82.2%; phonophobia, 9.5%; vomiting, 5.6%; and photophobia, 2.7%). In participants with migraine, vomiting (adjusted odds ratio = 6.513; 95% confidence interval, 1.763-24.057) and phonophobia (adjusted odds ratio = 0.437; 95% confidence interval, 0.206-0.929) were significantly associated with severe headache intensity and nausea was significantly associated with >3 headache days per 30 days (adjusted odds ratio = 0.441; 95% confidence, 0.210-0.927). Different patterns of associations were observed in probable migraine.
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Affiliation(s)
- Seung Jae Kim
- Department of Neurology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Jeong Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
- Department of Neurology, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Gyeonggi-do, Korea
| | - Sue Hyun Lee
- Department of Neurology, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Gangwon-do, Korea
| | - Soomi Cho
- Department of Neurology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Min Kim
- Department of Neurology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Min Kyung Chu
- Department of Neurology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Li G, Duan S, Zhu T, Ren Z, Xia H, Wang Z, Liu L, Liu Z. Efficacy and safety of intranasal agents for the acute treatment of migraine: a systematic review and network meta-analysis. J Headache Pain 2023; 24:129. [PMID: 37723470 PMCID: PMC10506288 DOI: 10.1186/s10194-023-01662-6] [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: 07/27/2023] [Accepted: 08/28/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Intranasal agents may be ideal for the treatment of migraine patients. Many new acute intranasal-specific therapies have been developed, but few of them have been directly compared. The aim of this network meta-analysis (NMA) was to compare the efficacy and safety of various intranasal agents for the treatment of acute migraine in adult patients. METHODS The Cochrane Register of Controlled Trials, Embase, and PubMed were searched from inception to 15 August 2023. Randomized controlled trials (RCTs) using intranasal agents (no restrictions on dose, formulation, dosing regimen or timing of the first dose) to treat adult patients with acute migraine were included. The primary efficacy endpoint was pain freedom at 2 h, and the primary safety endpoint was adverse events (AEs). The analysis process followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS Nineteen studies (21 RCTs, 9738 participants) were included. Compared to the placebo, 5 mg of zolmitriptan using a conventional liquid nasal spray device was the most effective for pain freedom at 2 h [odds ratio (OR): 4.67, 95% confidence interval (CI): 3.43 to 6.43] and 24 h (OR: 5.49, 95% CI: 3.58 to 8.42) among all the interventions. Butorphanol nasal spray 1 mg was the most effective (OR: 8.62, 95% CI: 1.11 to 66.92) for pain freedom at 1 h, but with low-quality evidence. DFN-02 presented the highest freedom from nausea (OR: 4.95, 95% CI: 1.29 to 19.01) and phonophobia (OR: 5.36, 95% CI: 1.67 to 17.22) at 2 h, albeit with lower odds of achieving complete pain freedom. ROX-828 showed the highest improvement in freedom from photophobia at 2 h (OR: 4.03, 95% CI: 1.66 to 9.81). Dihydroergotamine nasal spray was significantly associated with the highest risk of AEs (OR: 9.65, 95% CI: 4.39 to 21.22) and was not recommended for routine use. Zavegepant nasal spray demonstrated the lowest risk of AEs (OR: 2.04, 95% CI: 1.37 to 3.03). The results of sensitivity analyses for the primary endpoints (pain freedom at 2 h and AEs) were generally consistent with those of the base case model. CONCLUSIONS Compared with other new intranasal-specific therapies in treating migraine attacks, zolmitriptan nasal spray 5 mg was the most effective agent for pain freedom at 2 h. Zavegepant nasal spray 10 mg had the fewest adverse side effects.
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Affiliation(s)
- Guanglu Li
- Graduate School of Beijing, University of Chinese Medicine, Beijing, China
- Department of Neurology, China-Japan Friendship Hospital, Beijing, China
| | - Shaojie Duan
- Department of Geriatrics, Taizhou Central Hospital (Taizhou University Hospital), Taizhou, China
| | - Tiantian Zhu
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhiying Ren
- Graduate School of Beijing, University of Chinese Medicine, Beijing, China
- Department of Neurology, China-Japan Friendship Hospital, Beijing, China
| | - Hui Xia
- Graduate School of Beijing, University of Chinese Medicine, Beijing, China
- Department of Neurology, China-Japan Friendship Hospital, Beijing, China
| | - Ziyao Wang
- Graduate School of Beijing, University of Chinese Medicine, Beijing, China
- Department of Neurology, China-Japan Friendship Hospital, Beijing, China
| | - Lei Liu
- Department of Neurology, China-Japan Friendship Hospital, Beijing, China.
| | - Zunjing Liu
- Department of Neurology, Peking University People's Hospital, Beijing, China.
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Madden S, Carrazana E, Rabinowicz AL. Optimizing Absorption for Intranasal Delivery of Drugs Targeting the Central Nervous System Using Alkylsaccharide Permeation Enhancers. Pharmaceutics 2023; 15:2119. [PMID: 37631332 PMCID: PMC10458890 DOI: 10.3390/pharmaceutics15082119] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/19/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
Intranasal delivery of drugs offers several potential benefits related to ease of delivery, rapid onset, and patient experience, which may be of particular relevance to patients with central nervous system (CNS) conditions who experience acute events. Intranasal formulations must be adapted to address anatomical and physiological characteristics of the nasal cavity, including restricted dose volume, limited surface area, and barriers to mucosal absorption, in addition to constraints on the absorption window due to mucociliary clearance. Development of an effective formulation may utilize strategies including the addition of excipients to address the physicochemical properties of the drug within the constraints of nasal delivery. Dodecyl maltoside (DDM) and tetradecyl maltoside are alkylsaccharide permeation enhancers with well-established safety profiles, and studies have demonstrated transiently improved absorption and favorable bioavailability of several compounds in preclinical and clinical trials. Dodecyl maltoside is a component of three US Food and Drug Administration (FDA)-approved intranasal medications: diazepam for the treatment of seizure cluster in epilepsy, nalmefene for the treatment of acute opioid overdose, and sumatriptan for the treatment of migraine. Another drug product with DDM as an excipient is currently under FDA review, and numerous investigational drugs are in early-stage development. Here, we review factors related to the delivery of intranasal drugs and the role of alkylsaccharide permeation enhancers in the context of approved and future intranasal formulations of drugs for CNS conditions.
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Affiliation(s)
- Stuart Madden
- Neurelis, Inc., San Diego, CA 92121, USA; (E.C.); (A.L.R.)
| | - Enrique Carrazana
- Neurelis, Inc., San Diego, CA 92121, USA; (E.C.); (A.L.R.)
- John A. Burns School of Medicine, University of Hawaii, Honolulu, HI 96813, USA
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Drug delivery to the brain via the nasal route of administration: exploration of key targets and major consideration factors. JOURNAL OF PHARMACEUTICAL INVESTIGATION 2023; 53:119-152. [PMID: 35910081 PMCID: PMC9308891 DOI: 10.1007/s40005-022-00589-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 06/30/2022] [Indexed: 01/06/2023]
Abstract
Background Cranial nerve-related diseases such as brain tumors, Alzheimer's disease, and epilepsy are serious diseases that continue to threaten human. Brain-related diseases are increasing worldwide, including in the United States and Korea, and these increases are closely related to the exposure to harmful substances and excessive stress caused by rapid industrialization and environmental pollution. Drug delivery to the brain is very important for the effective prevention and treatment of brain-related diseases. However, due to the presence of the blood-brain barrier and the extensive first-pass metabolism effect, the general routes of administration such as oral and intravenous routes have limitations in drug delivery to the brain. Therefore, as an alternative, the nasal-brain drug delivery route is attracting attention as a route for effective drug delivery to the brain. Areas covered This review includes physiological factors, advantages, limitations, current application status, especially in clinical applications, and the necessary factors for consideration in formulation development related to nasal-brain drug delivery. Expert opinion The nasal-brain drug delivery route has the advantage of enhancing drug delivery to the brain locally, mainly through the olfactory route rather than the systemic circulation. The nasal-brain lymphatic system has recently attracted attention, and it has been implied that the delivery of anticancer drugs to the brain nervous system is possible effectively. However, there are limitations such as low drug permeability, as well as nasal mucosa and the mucociliary system, as obstacles in nasal-brain drug delivery. Therefore, to overcome the limitations of nasal-brain drug delivery, the use of nanocarriers and mucoadhesive agents is being attempted. However, very few drugs have been officially approved for clinical application via the nasal-brain drug delivery route. This is probably because the understanding of and related studies on nasal-brain drug delivery are limited. In this review, we tried to explore the major considerations and target factors in drug delivery through the nasal-brain route based on physiological knowledge and formulation research information. This will help to provide a mechanistic understanding of drug delivery through the nasal-brain route and bring us one step closer to developing effective formulations and drugs in consideration of the key factors for nasal-brain drug delivery.
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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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A double-blind controlled clinical trial to evaluate the effects of nasal therapy with Vrihatajivakadya oil on different viscosities in patients with migraine. J Ayurveda Integr Med 2022:100662. [DOI: 10.1016/j.jaim.2022.100662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/08/2022] [Accepted: 10/07/2022] [Indexed: 11/15/2022] Open
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Berger AA, Winnick A, Carroll AH, Welschmeyer A, Li N, Colon M, Paladini A, Ramírez GF, Hasoon J, Cornett EM, Song J, Varrassi G, Kaye AM, Kaye AD, Ganti L. Rimegepant for the treatment of migraine. Health Psychol Res 2022; 10:38534. [PMID: 36262478 PMCID: PMC9560892 DOI: 10.52965/001c.38534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023] Open
Abstract
Migraine is a common form of primary headache, affecting up to 1 in every 6 Americans. The pathophysiology is an intricate interplay of genetic factors and environmental influence and is still being elucidated in ongoing studies. The trigeminovascular system is now known to have a significant role in the initiation of migraines, including the release of pain mediators such as CGRP and substance P. Traditional treatment of migraine is usually divided into acute and preventive treatment. Acute therapy includes non-specific therapy, such as NSAIDs and other analgesics, which may provide relief in mild to moderate migraines. 5-HT1 agonists may provide relief in severe migraine, but are not universally effective and carry a significant side-effect profile with frequent redosing requirement. Prophylactic therapy may reduce the occurrence of acute migraine attacks in selected patients, but does not completely eliminate it. More recently, CGRP antagonism has been studied and shown to be effective in both abortion and prevention of migraine. Novel medications, targeting CGRP, divide into CGRP antibodies and receptor antagonists (gepants). Rimegepant, a second-generation gepant, has shown efficacy in several clinical trials in treating acute migraine. Ongoing trials are also evaluating its role in migraine prophylaxis, and results are promising. It is also generally safer for use than existing options, does not appear to increase the chance of developing chronic migraines, and carries a very tolerable side effects profile. It is a part of a growing arsenal in migraine treatment, and may present the silver bullet for treatment of this disease.
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Affiliation(s)
- Amnon A Berger
- Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School
| | - Ariel Winnick
- Soroka University Medical Center and Faculty of Health Sciences, Ben Gurion University of the Negev, University of California School of Optometry
| | | | | | | | - Marc Colon
- Department of Psychiatry, and Behavioral Medicine, Louisiana State University Health Science Center Shreveport
| | | | | | - Jamal Hasoon
- Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center
| | | | | | | | - Adam M Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Shreveport
| | - Latha Ganti
- University of Central Florida College of Medicine
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Johnson B, Freitag FG. New Approaches to Shifting the Migraine Treatment Paradigm. FRONTIERS IN PAIN RESEARCH 2022; 3:873179. [PMID: 36147034 PMCID: PMC9488522 DOI: 10.3389/fpain.2022.873179] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 06/21/2022] [Indexed: 11/13/2022] Open
Abstract
The standard of care paradigm for migraine treatment has been based almost exclusively on approaches that grew out of the happenstance use of market pharmaceuticals. Only methysergide, which has long since been removed from use for safety concerns, the ergotamine family of drugs, and the triptans were explicitly developed with migraine and other vascular headaches in mind. While the forward and innovative thinking to utilize the broad array of agents to treat migraine served millions well, their therapeutic efficacy was often low, and adverse event profiles were troublesome in the least. Advances in biochemical and molecular biology and the application of advanced "designing drugs" methods have brought about a potentially significant shift in treatment. The gepants have efficacies similar to the triptans but without vascular safety or medication overuse concerns. Preventative gepants offer innovative approaches to prevention and efficacy that exceed even the CGRP monoclonal antibodies. Those monoclonal antibodies brought rapid and highly effective outcomes across the spectrum of migraine. They outpaced older oral medication efficacy and eliminated most adverse events while potentially improving compliance with monthly or quarterly dosing. Other serotonin receptors beyond the 5HT1B and1D receptors have been targeted for decades. They now lead us to better formulations of dihydroergotamine for efficacy, convenience, and tolerability, and a 5HT1F-specific acute treatment like the gepants opens new options for acute management. Neuromodulation goes back to the mid-1800's. Our improved understanding of applied biomedical engineering has brought forward several tantalizing devices, including the application of currents distant from the target and patient regulated. Whether these advances change the paradigm of migraine treatment and standards of care remains to be seen, and issues such as cost and patient acceptance will help mold it.
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Affiliation(s)
| | - Frederick G. Freitag
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, United States
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Resting-state occipital alpha power is associated with treatment outcome in patients with chronic migraine. Pain 2022; 163:1324-1334. [PMID: 35708466 DOI: 10.1097/j.pain.0000000000002516] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 10/05/2021] [Indexed: 01/03/2023]
Abstract
ABSTRACT Preventive treatment is crucial for patients with chronic migraine (CM). This study explored the association between resting-state cortical oscillations and 3-month treatment outcome in patients with CM. Treatment-naïve patients with CM were recruited with their demographic data, psychosocial data, and headache profiles as well as the healthy controls (HCs). Resting-state cortical activities were recorded using an electroencephalogram and analysed using source-based and electrode-based spectral power method. The regions of interest were the bilateral primary somatosensory (S1) and visual (V1) cortices. After 3-month treatment with flunarizine, patients with CM were categorized into responders and nonresponders. Demographic, clinical, and electroencephalogram data from 72 patients with CM and 50 HCs were analysed. Elevated anxiety, depression, and stress were observed in patients with CM. Theta power in bilateral S1 and alpha and gamma powers in the right S1 increased in patients with CM. Nonresponders (n = 34) exhibited larger alpha powers in bilateral V1 than those in responders (n = 38). Alpha powers also exhibited significant correlations with changes of monthly headache days. Notably, in responders and nonresponders, occipital alpha powers did not differ at baseline and in the third month. In conclusion, patients with CM who were not responsive to preventive treatment were associated with augmented resting-state occipital alpha activity. Moreover, changes in migraine attack frequency were associated with baseline occipital alpha power. However, the prognostic feature of visual alpha oscillation seems to be inherent because it is not altered by flunarizine treatment. These findings may be useful for developing personalised migraine treatment plans.
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Tu Y, Wang Y, Yuan H, Chen S, Tzeng Y, Chen W, Lai K, Ling Y, Wang S. Most bothersome symptoms in patients with migraine: A hospital‐based study in Taiwan. Headache 2022; 62:596-603. [DOI: 10.1111/head.14308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 03/21/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Yi‐Hsien Tu
- Department of Neurology National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University Tainan Taiwan
- Department of Neurology E‐Da Hospital I‐Shou University Kaohsiung Taiwan
| | - Yen‐Feng Wang
- School of Medicine National Yang Ming Chiao Tung University Taipei Taiwan
- Department of Neurology Neurological Institute Taipei Veterans General Hospital Taipei Taiwan
- Brain Research Center and College of Medicine National Yang Ming Chiao Tung University Taipei Taiwan
| | - Hsiangkuo Yuan
- Jefferson Headache Center, Department of Neurology Thomas Jefferson University Philadelphia Pennsylvania USA
| | - Shih‐Pin Chen
- School of Medicine National Yang Ming Chiao Tung University Taipei Taiwan
- Department of Neurology Neurological Institute Taipei Veterans General Hospital Taipei Taiwan
- Brain Research Center and College of Medicine National Yang Ming Chiao Tung University Taipei Taiwan
- Institute of Clinical Medicine National Yang Ming Chiao Tung University Taipei Taiwan
- Division of Translational Research Department of Medical Research Taipei Veterans General Hospital Taipei Taiwan
| | - Yi‐Shiang Tzeng
- Department of Neurology Neurological Institute Taipei Veterans General Hospital Taipei Taiwan
| | - Wei‐Ta Chen
- School of Medicine National Yang Ming Chiao Tung University Taipei Taiwan
- Department of Neurology Neurological Institute Taipei Veterans General Hospital Taipei Taiwan
- Brain Research Center and College of Medicine National Yang Ming Chiao Tung University Taipei Taiwan
| | - Kuan‐Lin Lai
- School of Medicine National Yang Ming Chiao Tung University Taipei Taiwan
- Department of Neurology Neurological Institute Taipei Veterans General Hospital Taipei Taiwan
| | - Yu‐Hsiang Ling
- School of Medicine National Yang Ming Chiao Tung University Taipei Taiwan
- Department of Neurology Neurological Institute Taipei Veterans General Hospital Taipei Taiwan
| | - Shuu‐Jiun Wang
- School of Medicine National Yang Ming Chiao Tung University Taipei Taiwan
- Department of Neurology Neurological Institute Taipei Veterans General Hospital Taipei Taiwan
- Brain Research Center and College of Medicine National Yang Ming Chiao Tung University Taipei Taiwan
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Rabinowicz AL, Carrazana E, Maggio ET. Improvement of Intranasal Drug Delivery with Intravail ® Alkylsaccharide Excipient as a Mucosal Absorption Enhancer Aiding in the Treatment of Conditions of the Central Nervous System. Drugs R D 2021; 21:361-369. [PMID: 34435339 PMCID: PMC8602465 DOI: 10.1007/s40268-021-00360-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2021] [Indexed: 10/26/2022] Open
Abstract
Intranasal drug administration is a commonly used route for therapeutic formulations, but there may be challenges associated with a lack of absorption and bioavailability, as well as damage to mucosal tissue. To address these issues, potential absorption enhancers that are generally nonirritating to nasal mucosal tissue have been investigated as excipients in intranasal formulations. Among those studied are alkylsaccharides, which are composed of sugars covalently coupled to at least one alkyl chain. Alkylsaccharides have been shown to be nontoxic and have been used in food products as emulsifiers. In clinical trials, alkylsaccharide excipients have demonstrated substantially increased absorption of therapeutic agents across mucosal membranes and have been shown to be applicable to a wide range of types of molecules and molecular weights. Because they are water and oil soluble, alkylsaccharide excipients can be used in formulations with both hydrophilic and hydrophobic drugs. They are also effective in safely stabilizing protein therapeutics. An example of an alkylsaccharide excipient is dodecyl maltoside (Intravail®; 511 Da, stable long term when stored cold), which provides absorption enhancement by paracellular and transcellular routes. Dodecyl maltoside has been shown to be generally nonirritating to the nose and to promote systemic bioavailability. Dodecyl maltoside is used in US Food and Drug Administration-approved intranasal formulations of sumatriptan for migraine headaches and diazepam nasal spray for patients with epilepsy with acute seizure clusters.
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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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Nasal Delivery of Acute Medications for Migraine: The Upper Versus Lower Nasal Space. J Clin Med 2021; 10:jcm10112468. [PMID: 34199479 PMCID: PMC8199675 DOI: 10.3390/jcm10112468] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 05/26/2021] [Accepted: 05/27/2021] [Indexed: 11/17/2022] Open
Abstract
The acute treatment of migraine requires effective drugs that are well tolerated and provide rapid and consistent pain relief. Oral tablets are the most commonly used acute treatment for migraine; however, their effectiveness is limited by the rate of gastrointestinal (GI) tract absorption and first-pass hepatic metabolism, and they may not be ideal for patients experiencing GI motility issues. Nasal delivery is an attractive alternative route as it may circumvent GI tract absorption, avoid first-pass metabolism in the liver, and potentially reduce the frequency of GI adverse events. The large surface area and high vascularity within the nose may permit rapid absorption of therapeutics into the systemic circulation, allowing for rapid onset of action. However, the site of drug deposition (upper versus lower nasal cavity) may influence drug pharmacokinetics. Most approved nasal migraine therapies target the lower nasal space where the epithelium is less permeable, and they may be quickly cleared away due to increased ciliary function or dripping from the nose or swallowing, resulting in variable absorption and limited bioavailability. Together with its abundant vascularization, relative mucosal thickness stability, and low clearance rates, the upper nasal space harnesses the benefits of nasal delivery to potentially maximize drug efficacy.
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Abstract
PURPOSE OF REVIEW Migraine is a disabling disease of attacks of moderate to severe pain with associated symptoms. Every person with migraine requires treatment for acute attacks. Treatments can range from behavioral management and nonspecific medications to migraine-specific medications and neuromodulation. For many with migraine, having a combination of tools allows for effective treatment of all types of attacks. RECENT FINDINGS Over the past several years, four neuromodulation devices have been cleared by the US Food and Drug Administration (FDA) for treatment of acute migraine, and three medications with novel mechanisms of action have been FDA approved. They add to the arsenal available to people with migraine and focus on migraine-specific pathways to allow for precise care with fewer side effects. SUMMARY This article discusses acute migraine therapy, focusing on best-level evidence.
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17
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In vitro - in vivo correlation of intranasal drug deposition. Adv Drug Deliv Rev 2021; 170:340-352. [PMID: 32918968 DOI: 10.1016/j.addr.2020.09.002] [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: 12/18/2019] [Revised: 09/03/2020] [Accepted: 09/07/2020] [Indexed: 12/31/2022]
Abstract
In vitro - in vivo correlation (IVIVC) allows prediction of in vivo drug deposition from a nasally inhaled drug based on in vitro drug measurements. In vitro measurements include physical particle characterization and, more recently, deposition studies using anatomical models. Currently, there is a lack of IVIVC for deposition measurements in anatomical models, especially for deposition patterns in various nasal cavity regions. Therefore, improvement of in vitro and in vivo measurement methods and knowledge about nasal deposition mechanisms should help IVIVC in the future.
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18
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Turner DP. Experimental Study Designs. Headache 2020; 60:1501-1507. [PMID: 33448352 DOI: 10.1111/head.13928] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 07/15/2020] [Indexed: 01/08/2023]
Affiliation(s)
- Dana P Turner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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19
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Huang PC, Yang FC, Chang CM, Yang CP. Targeting the 5-HT 1B/1D and 5-HT 1F receptors for acute migraine treatment. PROGRESS IN BRAIN RESEARCH 2020; 255:99-121. [PMID: 33008517 DOI: 10.1016/bs.pbr.2020.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 04/19/2020] [Accepted: 05/01/2020] [Indexed: 01/03/2023]
Abstract
Migraine is a common and highly disabling headache disorder associated with a substantial socioeconomic burden. Migraine treatments can be categorized as preventive treatment, aimed at reducing the frequency and severity of migraine attacks, and acute therapy, intended to abort attacks. Traditionally, acute treatment can be classified as specific (ergot derivatives and triptans) or nonspecific (analgesics and nonsteroidal anti-inflammatory drugs). Triptans, a class of 5-HT1B/1D receptor agonists with some affinity for the 5-HT1F receptor subtype, have been proven to be efficacious for acute treatment of moderate to severe migraine and have been deemed the gold standard. The availability of triptans in non-oral formulations, such as subcutaneous (SC) and intranasal forms, can be beneficial for patients who suffer from prominent nausea or vomiting, have a suboptimal response to oral agents, and/or seek a more rapid onset of treatment effects. However, triptans are contraindicated in patients with preexisting cardiovascular and/or cerebrovascular diseases due to their 5-HT1B-mediated vasoconstrictive action. For this reason, studies have focused on the development of ditans, a group of antimigraine drugs targeting 5-HT1D and 5-HT1F receptors. Unfortunately, 5-HT1D receptor agonists have been shown to be ineffective in the acute treatment of migraine. Several ditans targeting the 5-HT1F receptor have been developed and have shown no vasoconstrictive effect in preclinical studies, but only two of them, lasmiditan and LY334370, have been tested in clinical trials for migraine, and only lasmiditan has reached to Phase III clinical trials. These Phase III trials have demonstrated the efficacy and safety of lasmiditan, a selective 5-HT1F receptor agonist, in acute migraine treatment. Lasmiditan might offer an alternative migraine therapy without cardiovascular risks. This review will summarize the development of agents targeting the 5-HT1B/1D and 5-HT1F receptors and the clinical evidence supporting the use of these agents for acute migraine treatment.
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Affiliation(s)
- Pin-Chung Huang
- Department of Neurology, Kuang Tien General Hospital, Taichung, Taiwan
| | - Fu-Chi Yang
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ching-Mao Chang
- Center for Traditional Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chun-Pai Yang
- Department of Neurology, Kuang Tien General Hospital, Taichung, Taiwan; Department of Nutrition, Huang-Kuang University, Taichung, Taiwan.
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Abstract
All patients with migraine merit acute treatment, which should optimally achieve a sustained pain-free response. Maximum acute treatment is associated with reduced risk of transformation of episodic to chronic migraine. The American Headache Society published the most recent complete evidence assessment of acute migraine treatments in 2015. Noninvasive neuromodulation represents a new, Food and Drug Administration-approved nonsignificant risk alternative for acute migraine therapy. The future of acute migraine treatment includes new devices and formulations of existing medications, new classes of acute medications, and new noninvasive nonsignificant risk neuromodulation devices, with many anticipated in the next few years.
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21
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Hogan RE, Gidal BE, Koplowitz B, Koplowitz LP, Lowenthal RE, Carrazana E. Bioavailability and safety of diazepam intranasal solution compared to oral and rectal diazepam in healthy volunteers. Epilepsia 2020; 61:455-464. [PMID: 32065672 PMCID: PMC7154760 DOI: 10.1111/epi.16449] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 01/25/2020] [Accepted: 01/27/2020] [Indexed: 11/28/2022]
Abstract
Objective The study assesses the bioavailability of diazepam after intranasal administration (diazepam nasal spray) in healthy volunteers. Comparative agents were diazepam rectal gel, which served as the regulatory reference product; and oral diazepam, a product with decades of clinical use. Tolerability of diazepam nasal spray was also assessed. Methods This was a phase 1, open‐label, randomized, single‐dose, three‐treatment, three‐period, six‐sequence crossover study in 48 healthy adult subjects that consisted of a screening period, a baseline period, and an open‐label treatment period. Interperiod intervals were at least 28 days. Results Forty‐eight healthy volunteer subjects were enrolled, two of whom discontinued before receiving study medication. For all routes of administration, the onset of diazepam absorption was rapid, with measurable concentrations of drug present by the first sample time point. The tmax (time to reach maximum plasma concentration) was similar for diazepam nasal spray and diazepam rectal gel, both of which were slower than oral diazepam in fasted individuals. Variability (as defined by % coefficient of variation of geometric mean) in peak plasma concentration and area under the curve0‐∞ was lowest with oral diazepam, followed by diazepam nasal spray, with diazepam rectal gel showing the greatest variability. Overall, 131 treatment‐emergent adverse events (TEAEs) were considered mild (42 subjects, 91.3%), four TEAEs were considered moderate (four subjects, 8.3%), and no TEAEs were considered severe. The most commonly reported TEAE was somnolence at 56.5% (26/46) during diazepam nasal spray treatment, 89.1% (41/46) with the rectal diazepam gel treatment, and 82.6% (38/46) with oral diazepam treatment. No nasal irritation was observed for the majority of the subjects at any time point after administration, with no score higher than 2 (“minor bleeding that stops within 1 minute”). Significance Diazepam nasal spray shows predicable pharmacokinetics and represents a potential novel therapeutic approach to control bouts of increased seizure activity (cluster seizures, acute repetitive seizures).
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Affiliation(s)
- R Edward Hogan
- Department of Neurology, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Barry E Gidal
- School of Pharmacy, University of Wisconsin, Madison, Wisconsin
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Alpuente A, Tassorelli C, Diener HC, Silberstein SD, Pozo-Rosich P. Have the IHS Guidelines for controlled trials of acute treatment of migraine attacks been followed? Laying the ground for the 4th edition. Cephalalgia 2020; 40:778-787. [DOI: 10.1177/0333102420906843] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background The International Headache Society (IHS) has published four editions of Guidelines for acute clinical trials in migraine in the past 28 years. This continuous update process has been driven by the increasing amount of scientific data in the field of migraine and by the need to continuously improve the quality of trials. Objectives To illustrate: i) the results of the analysis on the adherence of published trials to the 3rd edition published in 2012, in order to identify the critical areas that needed to be addressed in the 4th edition and ii) the changes introduced in this latter edition for improving adherence and methodology robustness. Methods We searched and reviewed all controlled trials on acute treatment of migraine published in the period 2012–2018 and we assessed their adherence to the 3rd edition of the IHS Guidelines using a score system based on the most important recommendations. Afterwards, we compared the two editions of the Guidelines and assessed the changes between them. Results We included data from 24 controlled clinical trials. Most trials had a randomized double-blind controlled (RDB) design, while a minority (16.7%) were non-randomized double-blind trials. Less than half (44.6%) of the RDB trials used the recommended “pain-free at 2 hours” endpoint as the primary efficacy measure. Trial design and evaluation of results were the areas that diverged the most from the recommendations. Conclusion Adherence to IHS guidelines for clinical trials has been suboptimal so far. The new edition has been adapted and optimized to facilitate uptake and strengthen the quality of evidence.
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Affiliation(s)
- Alicia Alpuente
- Headache Unit, Neurology Department, Vall d’Hebron University Hospital, Barcelona, Spain
- Headache and Neurological Pain Research Group, VHIR, Universitat Autonoma of Barcelona, Barcelona, Spain
| | - Cristina Tassorelli
- Headache Science Center, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | | | - Stephen D Silberstein
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Patricia Pozo-Rosich
- Headache Unit, Neurology Department, Vall d’Hebron University Hospital, Barcelona, Spain
- Headache and Neurological Pain Research Group, VHIR, Universitat Autonoma of Barcelona, Barcelona, Spain
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Rapoport AM, McAllister P. The Headache Pipeline: Excitement and Uncertainty. Headache 2020; 60:190-199. [PMID: 31889312 DOI: 10.1111/head.13728] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2019] [Indexed: 12/14/2022]
Abstract
There are many new treatment options available for migraine and more are coming. Three calcitonin gene-related peptide (CGRP) antagonist monoclonal antibodies have been approved and a 4th is due in early 2020. Small molecule CGRP receptor-blocking oral compounds, both for acute care and prevention, are also coming. Four neurostimulators are available, with others on the way. New acute treatments coming soon include the 5HT1F agonist lasmiditan, a zolmitriptan intradermal micro-needle patch, and a nasal mist sumatriptan with a permeability enhancer. Farther out, three novel dihydroergotamine delivery systems, and a liquid-filled capsule of celecoxib show early promise. A new, safer form of methysergide is in the works, as is a longer-duration onabotulinumtoxinA. As always with new products, questions regarding safety, tolerability, cost, and insurance coverage will need to be addressed. Despite these concerns and uncertainties, a robust headache treatment pipeline is good for patients who are not satisfied with the results of their treatment and/or cannot tolerate existing treatments.
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Affiliation(s)
- Alan M Rapoport
- Neurology, New England Institute for Neurology and Headache, Stamford, CT, USA
| | - Peter McAllister
- Neurology, New England Institute for Neurology and Headache, Stamford, CT, USA
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Munjal S, Singh P, Reed ML, Fanning K, Schwedt TJ, Dodick DW, Buse DC, Lipton RB. Most Bothersome Symptom in Persons With Migraine: Results From the Migraine in America Symptoms and Treatment (MAST) Study. Headache 2019; 60:416-429. [PMID: 31837007 PMCID: PMC7027490 DOI: 10.1111/head.13708] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2019] [Indexed: 01/03/2023]
Abstract
Objectives The objectives of this study were to determine the rates of nausea, phonophobia, and photophobia reported overall and as the most bothersome symptom (MBS) in individuals with migraine and to identify individual characteristics associated with each of the 3 candidate MBSs. Background The MBS has emerged as an important coprimary efficacy endpoint in clinical trials of acute treatments for migraine, as recommended by the Food and Drug Administration. The current understanding of how persons with migraine designate an associated symptom as the most bothersome has been assessed primarily in the context of randomized trials. Methods Respondents (n = 95,821) in the cross‐sectional, observational Migraine in America Symptoms and Treatment (MAST) study were adults (aged ≥18 years) recruited from a US nationwide online research panel. A validated diagnostic screener identified 15,133 individuals who met modified International Classification of Headache Disorders (ICHD)‐3 beta criteria for migraine and reported at least 1 monthly headache day (MHD) over the previous 3 months. The survey ascertained sociodemographic variables, headache‐related disability, MHDs, cutaneous allodynia, medication overuse, a migraine symptom severity score, pain interference, noncephalic pain, anxiety and depression symptoms, visual aura over the previous year, and acute treatment optimization. The current analysis is based on respondents who also completed a 6‐month follow‐up assessment that included questions about their most bothersome headache symptom. Results A total of 7518 respondents completed the 6‐month follow‐up, and 6045 met inclusion criteria and were included in the analysis. The mean age of respondents was 47 (SD 13.4) years, 76.0% (4596/6045) were women, and 84.8% (5103/6017) were white. Among all respondents, 64.9% reported all 3 migraine symptoms. The MBS was photophobia in 49.1% (2967/6045), nausea in 28.1% (1697/6045), and phonophobia in 22.8% (1381/6045). Respondents reporting photophobia as the MBS were more likely to be men, to be obese, and to report visual aura. Those reporting nausea as the MBS were more likely to be women, to have lower incomes, and to report lower levels of treatment optimization. Respondents reporting phonophobia as the MBS were more likely to have cutaneous allodynia and less likely to have visual aura. Conclusion Most people with migraine in the MAST observational study reported all 3 cardinal symptoms of nausea, photophobia, and phonophobia. As in clinical trials, the most common MBS was photophobia. Patient profiles differed among the groups defined by their MBS.
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Affiliation(s)
| | | | | | | | | | | | - Dawn C Buse
- Albert Einstein College of Medicine, Bronx, NY, USA
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Goadsby PJ. Primary headache disorders: Five new things. Neurol Clin Pract 2019; 9:233-240. [PMID: 31341711 PMCID: PMC6615655 DOI: 10.1212/cpj.0000000000000654] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 04/17/2019] [Indexed: 12/12/2022]
Abstract
Purpose of review To review 5 new areas in primary headache disorders, especially migraine and cluster headache. Recent findings Calcitonin gene-related peptide (CGRP) receptor antagonists (gepants-rimegepant and ubrogepant) and serotonin 5-HT1F receptor agonists (ditans-lasmiditan) have completed phase 3 clinical trials and will soon offer novel, effective, well-tolerated nonvasoconstrictor options to treat acute migraine. CGRP preventive treatment is being revolutionized after the licensing of 3 monoclonal antibodies (MABs), erenumab, fremanezumab, and galcanezumab, with eptinezumab to follow, especially designed for migraine; they are effective and well tolerated. For patients seeking a nondrug therapy, neuromodulation approaches, single-pulse transcranial magnetic stimulation, noninvasive vagus nerve stimulation (nVNS), and external trigeminal nerve stimulation, represent licensed, well-tolerated approaches to migraine treatment. For the acute treatment of episodic cluster headache, nVNS is effective, well tolerated, and licensed; nVNS is effective and well tolerated in preventive treatment of cluster headache. The CGRP MAB galcanezumab was effective and well tolerated in a placebo-controlled trial in the preventive treatment of episodic cluster headache. Sphenopalatine ganglion stimulation has been shown to be effective and well tolerated in 2 randomized sham-controlled studies on chronic cluster headache. Understanding the premonitory (prodromal) phase of migraine during which patients experience symptoms such as yawning, tiredness, cognitive dysfunction, and food cravings may help explain apparent migraine triggers in some patients, thus offering better self-management. Summary Headache medicine has made remarkable strides, particularly in understanding migraine and cluster headache in the past 5 years. For the most common reason to visit a neurologist, therapeutic advances offer patients reduced disability and neurologists a rewarding, key role in improving the lives of those with migraine and cluster headache.
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Affiliation(s)
- Peter J Goadsby
- NIHR-Wellcome Trust King's Clinical Research Facility and SLaM Biomedical Research Centre, King's College London, UK; and Department of Neurology, University of California, San Francisco
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Lipton RB, Munjal S, Brand-Schieber E, Rapoport AM. DFN-02, Sumatriptan 10 mg Nasal Spray with Permeation Enhancer, for the Acute Treatment of Migraine: A Randomized, Double-Blind, Placebo-Controlled Study Assessing Functional Disability and Subject Satisfaction with Treatment. CNS Drugs 2019; 33:375-382. [PMID: 30877622 PMCID: PMC6441104 DOI: 10.1007/s40263-019-00614-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND The commercial formulation of sumatriptan nasal spray is an effective option for migraine patients requiring or preferring a non-oral route of drug administration, but its utility is limited by poor absorption and tolerability issues. DFN-02, a new formulation of sumatriptan 10 mg nasal spray, is co-formulated with a permeation enhancer that gives it pharmacokinetics comparable to subcutaneous sumatriptan. As reported previously, DFN-02 was significantly better than placebo on multiple efficacy endpoints at 2 h postdose, including pain freedom, absence of the most bothersome symptom, and pain relief, and its safety and tolerability profiles were excellent. OBJECTIVE The objective of this study was to assess the efficacy of acute treatment of migraine with DFN-02, including its effect on migraine-related functional disability and patient satisfaction with treatment. METHODS This was a multicenter, randomized, double-blind, placebo-controlled efficacy and safety study of DFN-02 in adults with episodic migraine. Functional disability and subject satisfaction with treatment were prespecified endpoints, assessed in real-time by subjects, using an electronic diary. RESULTS In total, 107 subjects were randomized. DFN-02 was significantly superior to placebo for the reduction in functional disability score from predose level at 2 h after treatment (- 1.2 vs. - 0.6, p < 0.001). Subjects treated with DFN-02 were also more likely to be satisfied or very satisfied than subjects treated with placebo at 2 h postdose (70.0% vs. 44.2%, p = 0.027). Using the Patient Perception of Migraine Questionnaire-Revised at 24 h postdose, DFN-02 mean scores were significantly superior to placebo for the subscales of efficacy (65.2 vs. 42.5, p = 0.016) and function (68.9 vs. 42.1, p = 0.001), and for total score (71.0 vs. 56.6, p = 0.016); global medication effectiveness (p = 0.027); and overall satisfaction (p = 0.019). Placebo was significantly better than DFN-02 on the tolerability subscale (94.8 vs. 88.5, p = 0.026). At 24 h postdose, subjects reported significantly higher satisfaction with DFN-02 compared with satisfaction reported pre-randomization regarding their usual migraine medication (p = 0.012). CONCLUSION DFN-02 was superior to placebo for the relief of migraine-related functional disability, and provided greater satisfaction than placebo or subjects' usual acute treatment. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02856802.
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Affiliation(s)
| | - Sagar Munjal
- Promius Pharma, A Subsidiary of Dr. Reddy’s Laboratories, Princeton, NJ USA
| | | | - Alan M. Rapoport
- The David Geffen School of Medicine at UCLA, Los Angeles, CA USA
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Landy S, Munjal S, Brand-Schieber E, Rapoport AM. Efficacy and safety of DFN-11 (sumatriptan injection, 3 mg) in adults with episodic migraine: a multicenter, randomized, double-blind, placebo-controlled study. J Headache Pain 2018; 19:69. [PMID: 30112726 PMCID: PMC6093827 DOI: 10.1186/s10194-018-0881-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 07/02/2018] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND In a previous randomized, double-blind, proof-of-concept study in rapidly escalating migraine, a 3 mg dose of subcutaneous sumatriptan (DFN-11) was associated with fewer and shorter triptan sensations than a 6 mg dose. The primary objective of the study was to assess the efficacy and safety of acute treatment with DFN-11 compared with placebo in episodic migraine. METHODS This was a multicenter, randomized, double-blind, placebo-controlled efficacy and safety study of DFN-11 in the acute treatment of adults with episodic migraine (study RESTOR). The primary endpoint was the proportion of subjects taking DFN-11 who were pain free at 2 h postdose in the double-blind period compared with placebo. Secondary endpoints included earlier postdose timepoints, assessments of pain relief and subjects' freedom from their most bothersome symptom (MBS) (among nausea, photophobia, and phonophobia). Safety and tolerability were assessed. RESULTS A total of 392 subjects was screened, 268 (68.4%) were randomized, and 234 (87.3% of those randomized) completed the double-blind treatment period. The proportion of subjects who were pain free at 2 h postdose was significantly greater in the DFN-11 group than in the placebo group (51.0% vs 30.8%, P = 0.0023). Compared with placebo, significantly higher proportions of subjects treated with DFN-11 were also pain free at 30, 60, and 90 min postdose (P ≤ 0.0195). DFN-11 was significantly superior to placebo for pain relief at 60 min, 90 min, and 2 h postdose (P ≤ 0.0179). At 2 h postdose, DFN-11 was also significantly superior to placebo for freedom from photophobia (P = 0.0056) and phonophobia (P = 0.0167). Overall, 33.3% (37/111) who received DFN-11 and 13.4% (16/119) who received placebo experienced at least 1 treatment-emergent adverse event (TEAE), the most common of which were injection site swelling (7.2% vs 0.8%) and pain (7.2% vs 5.9%). Chest discomfort was about half as common in the DFN-11 treatment group as it was in the placebo group (0.9% vs 1.7%). CONCLUSIONS This study met its primary endpoint, pain freedom at 2 h postdose, with DFN-11 significantly better than placebo, and the incidence of TEAEs and triptan sensations with DFN-11 was low. The 3 mg dose of sumatriptan in DFN-11 appears to be an effective alternative to a 6 mg SC dose of sumatriptan, with good safety and tolerability. ( clinicaltrials.gov : NCT02569853; registered 07 October 2015).
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Affiliation(s)
- Stephen Landy
- Baptist Medical Group Headache Clinic, University of Tennessee Medical School, 6029 Walnut Grove, Suite 210, Memphis, TN 38120 USA
| | - Sagar Munjal
- Promius Pharma, a subsidiary of Dr Reddy’s Laboratories, 107 College Road East, Princeton, NJ 08540 USA
| | - Elimor Brand-Schieber
- Promius Pharma, a subsidiary of Dr Reddy’s Laboratories, 107 College Road East, Princeton, NJ 08540 USA
| | - Alan M. Rapoport
- The David Geffen School of Medicine at UCLA, 4255 Jefferson Avenue, Suite 27, Woodside, CA 94062 USA
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