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Dalby SW, Hvedstrup J, Carlsen LN, Ashina S, Bendtsen L, Schytz HW. Pericranial Muscle Stiffness, Pain Thresholds, and Tenderness during a Treatment Cycle of OnabotulinumtoxinA for Chronic Migraine Prevention. Diagnostics (Basel) 2024; 14:330. [PMID: 38337846 PMCID: PMC10855466 DOI: 10.3390/diagnostics14030330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/25/2024] [Accepted: 02/01/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Treatment with OnabotulinumtoxinA (BoNT-A) is effective as a preventive treatment for chronic migraine (CM). Preclinical studies suggest that the mechanism of action of BoNT-A in migraine is based on blocking unmyelinated C fibers. We aimed to investigate whether the muscle-relaxing effect of BoNT-A is associated with the preventive mechanism in patients with chronic migraine by measuring the stiffness, pain thresholds, and tenderness of the BoNT-A-applied muscles. METHODS A total of 22 patients with CM who were already in BoNT-A treatment participated in this longitudinal prospective study. Pericranial muscle stiffness was measured using ultrasound shear wave elastography, which measures the speed of shear waves propagating through the muscle. Pressure pain thresholds (PPT) were obtained via algometry, and muscle tenderness was measured via manual palpation. Measurements were made before BoNT-A injections and six weeks after the treatment. The measurements were performed while the muscles were maximally relaxed. The patients also completed daily diaries on headache and neck pain. RESULTS No change was observed in muscle stiffness (p = 0.737) or pericranial muscle tenderness (p = 0.400). The PPT over the trapezius muscles increased from 250 kPa before treatment to 304 kPa six weeks after treatment (p = 0.027). No change was observed on the temporalis muscles (p = 0.200) nor the non-dominant index finger (p = 0.067). BoNT-A decreased neck pain (p = 0.008) and headache (p = 0.007). CONCLUSIONS The findings suggest that BoNT-A leads to the desensitization of cutaneous and muscle nociceptors in the head and neck regions, whereas muscle relaxation might not be an important part of the anti-migraine effect.
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Affiliation(s)
- Sebastian Worsaae Dalby
- Danish Headache Center, Department of Neurology, Copenhagen University Hospital–Rigshospitalet-Glostrup, 2600 Copenhagen, Denmark; (S.W.D.); (J.H.)
| | - Jeppe Hvedstrup
- Danish Headache Center, Department of Neurology, Copenhagen University Hospital–Rigshospitalet-Glostrup, 2600 Copenhagen, Denmark; (S.W.D.); (J.H.)
| | - Louise Ninett Carlsen
- Danish Headache Center, Department of Neurology, Copenhagen University Hospital–Rigshospitalet-Glostrup, 2600 Copenhagen, Denmark; (S.W.D.); (J.H.)
| | - Sait Ashina
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 1871 Copenhagen, Denmark
- Comprehensive Headache Center, Department of Neurology, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02115, USA
| | - Lars Bendtsen
- Danish Headache Center, Department of Neurology, Copenhagen University Hospital–Rigshospitalet-Glostrup, 2600 Copenhagen, Denmark; (S.W.D.); (J.H.)
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 1871 Copenhagen, Denmark
| | - Henrik Winther Schytz
- Danish Headache Center, Department of Neurology, Copenhagen University Hospital–Rigshospitalet-Glostrup, 2600 Copenhagen, Denmark; (S.W.D.); (J.H.)
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 1871 Copenhagen, Denmark
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Rodríguez-Montolio J, Navarro-Pérez MP, Almeida-Zurita M, Santos-Lasaosa S. Early Wearing-Off Effect of OnabotulinumtoxinA in Chronic Migraine: A Prospective Real-Life Study. J Clin Med 2023; 12:5360. [PMID: 37629402 PMCID: PMC10455650 DOI: 10.3390/jcm12165360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 08/14/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023] Open
Abstract
OBJECTIVE Chronic migraine (CM) is a significant public health problem that affects 2.2% of the global population. Onabotulinumtoxin A (OnabotA) is a safe and effective prophylactic treatment for patients with CM. The standard injection interval for OnabotA is 12 weeks. Nevertheless, some patients experience a wearing-off effect (WOE) in the weeks preceding the next scheduled cycle. The objectives of this study are to determine the prevalence of early WOE, to analyze variables that could be clinical predictors and to specify which interval is the most appropriate to define the existence of this phenomenon. METHODS This is a prospective single-center study of consecutive adult patients with CM who, after failing previous prophylactic therapies, started OnabotA treatment following the PREEMPT protocol between June and December of 2021. RESULTS A total of 59 patients (93.2% female, age 44 ± 12 years) were included. A total of 37 patients (64.9%) fulfilled medication overuse criteria. Of the total patients, 40.6% reported WOE and this was more frequent after the first cycle (35.6%). Depression and anxiety disorder was a statistically significant clinical predictor of WOE (OR 3.4; CI 95% 1.22-10.84; p = 0.028). A better cut-off point to consider WOE seems to be at 10 weeks. CONCLUSIONS Early WOE is common in patients on OnabotA treatment for CM. Individualizing the standard 12-week injection, using total doses of 195 U, and managing psychiatric comorbidities with pharmacological and non-pharmacological strategies may improve treatment outcomes and reduce OnabotA WOE.
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Affiliation(s)
- Joana Rodríguez-Montolio
- Neurology Department, Hospital Clínico Universitario Lozano Blesa, 50009 Zaragoza, Spain (S.S.-L.)
- Aragon Institute for Health Research (IIS Aragón), 50009 Zaragoza, Spain
| | - María Pilar Navarro-Pérez
- Neurology Department, Hospital Clínico Universitario Lozano Blesa, 50009 Zaragoza, Spain (S.S.-L.)
- Aragon Institute for Health Research (IIS Aragón), 50009 Zaragoza, Spain
| | | | - Sonia Santos-Lasaosa
- Neurology Department, Hospital Clínico Universitario Lozano Blesa, 50009 Zaragoza, Spain (S.S.-L.)
- Aragon Institute for Health Research (IIS Aragón), 50009 Zaragoza, Spain
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Asawavichienjinda T, Sathitratanacheewin S, Chokesuwattanaskul R. "Wearing-off" efficacy of CGRP monoclonal antibodies for migraine prevention: A meta-analysis of randomized controlled trials. Cephalalgia 2023; 43:3331024231161261. [PMID: 36924253 DOI: 10.1177/03331024231161261] [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: 03/18/2023]
Abstract
BACKGROUND A new migraine prevention, CGRP monoclonal antibodies (mAbs), is injectable on a monthly or quarterly basis. In clinical practice, some patients reported that drug effectiveness does not last until the upcoming scheduled injection, a so-called "wearing-off" effect. We aimed to evaluate the wearing-off effect of the CGRP mAbs for migraine prevention in patients with different monthly migraine days. METHODS We conducted a literature search for studies that reported migraine frequency after CGRP monoclonal antibody administration from MEDLINE, SCOPUS, Web of Science, and Cochrane Database from inception through February 2022. A meta-analysis, random-effects model was applied to assess the difference in migraine frequency between early and later weeks after medication to assess the presence of a wearing-off effect. Risk ratio was calculated to report the pooled treatment effect. RESULTS Four studies were entered for the analysis, comprising 2409 patients in randomized controlled trials. There was no association between CGRP mAbs and wearing-off effect in patients with galcanezumab with a pooled risk ratio of 1.29 (95% CI 0.73 to 2.28) compared to placebo group. However, there was an association between galcanezumab and wearing-off effect in patients with chronic migraine with a pooled risk ratio of 1.91 (95% CI 1.11 to 3.28) compared to placebo group. CONCLUSION In this meta-analysis, there was a wearing-off efficacy of galcanezumab but only in a small percentage of patients with chronic migraine in randomized controlled trials.
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Affiliation(s)
- Thanin Asawavichienjinda
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Seelwan Sathitratanacheewin
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Ronpichai Chokesuwattanaskul
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
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Zandieh A, Cutrer FM. OnabotulinumtoxinA in chronic migraine: is the response dose dependent? BMC Neurol 2022; 22:218. [PMID: 35698027 PMCID: PMC9190093 DOI: 10.1186/s12883-022-02742-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 04/01/2022] [Indexed: 11/18/2022] Open
Abstract
Background OnabotulinumtoxinA has been widely used for control of chronic migraine. The aim of the current study was to evaluate the efficacy of different doses of the onabotulinumtoxinA therapy in patients with chronic migraine. Methods This is a retrospective paired comparison study on patients with chronic migraine who received at least 3 rounds of 150 units of onabotulinumtoxinA followed by at least 3 rounds of 200 units of onabotulinumtoxinA. The data from the patient-reported questionnaires about headache days, severe headache days and wearing off periods were reviewed. Results A total of 175 patients were included in this study. The headache days and severe headache days decreased from 13.62 ± 10.79 and 5.88 ± 6.73 to 11.02 ± 10.61and 4.01 ± 4.89 days, after increase in the onabotulinumtoxinA dose, respectively (P < 0.001 for both comparisons). The favorable effect of the 200 units compared to the 150 units of the onabotulinumtoxinA, was independent from the headache location and the duration of the onabotulinumtoxinA 150 units therapy; and persisted as patients continued to receive the higher dose of onabotulinumtoxinA. Increase in the onabotulinumtoxinA dose was also associated with a decreased wearing off period (P < 0.05). Conclusion We found that increase in the onabotulinumtoxinA is associated with fewer headache and severe headache days. Future randomized clinical trials are needed to confirm the dose-dependent response to onabotulinumtoxinA.
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Affiliation(s)
- Ali Zandieh
- Department of Neurology, University of Wisconsin, 1685 Highland Avenue, Madison, WI, 53705, USA
| | - Fred Michael Cutrer
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Ailani J, Kuruppu DK, Rettiganti M, Oakes T, Schroeder K, Wietecha L, Port M, Blumenfeld AM. Does “wearing off” of efficacy occur in galcanezumab‐treated patients at the end of the monthly treatment cycle? Post hoc analyses of four phase III randomized trials. Headache 2022; 62:198-207. [PMID: 35076090 PMCID: PMC9306502 DOI: 10.1111/head.14257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 11/11/2021] [Accepted: 11/13/2021] [Indexed: 11/28/2022]
Abstract
Objective The purpose of this study was to propose a definition of “wearing off” at the individual patient‐level and determine the percentage of patients with migraine who experience “wearing off” of efficacy of galcanezumab at the end of a treatment cycle using this predefined threshold. Background Anecdotal reports suggest that some patients may experience “wearing off” of efficacy during the last week of their calcitonin gene‐related peptide monoclonal antibody treatment cycle. A previous post hoc analysis of galcanezumab demonstrated consistent efficacy at each week throughout all monthly dosing intervals at the population‐level, but “wearing off” has not been assessed at the individual patient‐level. Methods Post hoc analyses of clinical trial data from four galcanezumab phase III, randomized, placebo‐controlled studies in a total of 2680 patients with high‐frequency episodic migraine (EVOLVE‐1, EVOLVE‐2, and CONQUER studies) or chronic migraine (CM; REGAIN and CONQUER studies) were conducted. “Wearing off” was defined as an increase of greater than or equal to 2 weekly migraine headache days in the last week of the treatment cycle compared to the second week for at least 2 months. The analyses were conducted (1) in all patients and (2) in patients with a clinically meaningful response to treatment. Results The percentage of patients meeting the threshold of “wearing off” was not statistically significantly different among the placebo, galcanezumab 120 mg, and galcanezumab 240 mg treatment groups, both in the total population and in patients with a clinically meaningful response (all ≤9.0%). Although the frequency of “wearing off” in patients with CM and prior preventive failures was numerically greater in the galcanezumab groups (8/89 or 9.0%) compared to placebo (3/95 or 3.2%), these differences were not statistically significant. Conclusions Consistent with previous analyses at the population‐level that showed no evidence of decreased efficacy at the end of a treatment cycle, rates of individual patients meeting the threshold of “wearing off” in this analysis were low and similar among placebo, galcanezumab 120 mg, and galcanezumab 240 mg treatment groups.
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Affiliation(s)
- Jessica Ailani
- Department of Neurology MedStar Georgetown University Hospital Washington DC USA
| | | | | | - Tina Oakes
- Eli Lilly and Company Indianapolis Indiana USA
| | | | | | - Martha Port
- Eli Lilly and Company Indianapolis Indiana USA
| | - Andrew M. Blumenfeld
- The Headache Center of Southern California The Neurology Center Carlsbad California USA
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Algahtani H, Shirah B, Sukkar G, Bukhari H, Meftah I, Alhazmi A, Alshareef A, Algethami A, Alshanqiti A, Andeejani M. Botulinum toxin injection in the management of chronic migraine: the Saudi experience with a proposal for a new protocol. Acta Neurol Belg 2021; 121:1783-1787. [PMID: 33058053 DOI: 10.1007/s13760-020-01521-0] [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: 08/23/2020] [Accepted: 10/05/2020] [Indexed: 11/25/2022]
Abstract
There are no data from Saudi Arabia about the use of botulinum toxin for migraine prevention. In this article, we aim to study the clinical profile, safety, and response to treatment with botulinum toxin injection for migraine patients. In addition, we aim to share our experience with the use of botulinum toxin modified injection protocol (5/20/100 protocol) in the management of migraine in Saudi patients. A retrospective single-center observational study was conducted at King Abdulaziz Medical City in Jeddah, Saudi Arabia. The protocol for botulinum toxin injection for migraine in our hospital consisted of injecting five muscles with a total of 20 injection sites consuming 100 units of Onabotulinumtoxin A (BOTOX®, Allergan, Inc., Irvine, CA). A total of 30 patients were included in our study. The mean frequency of migraine days showed a significant reduction from baseline at 15.61 ± 10.92 days per month to 6.14 ± 6.16 days (9.47 days reduction) after botulinum toxin injection (39.3% reduction; paired t test = 5.177; p = 0.0001). The frequency of using abortive medications was reduced in 19 patients (63.3%). Only four patients (13.3%) achieved a headache-free status. Only three patients (10%) had adverse events from botulinum toxin injection. In conclusion, botulinum toxin is an effective, safe, and well-tolerated treatment option for the prevention of chronic migraine. Our protocol (5/20/100 protocol) may improve the safety and cost and reduce the incidence of adverse events. Patients who do not respond to our protocol may switch to the standard protocol after the failure of the first treatment session.
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Affiliation(s)
- Hussein Algahtani
- King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Sciences, P.O. Box 12723, Jeddah, 21483, Saudi Arabia.
| | - Bader Shirah
- King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Ghassan Sukkar
- King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Sciences, P.O. Box 12723, Jeddah, 21483, Saudi Arabia
| | - Hatim Bukhari
- King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Ibraheem Meftah
- King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Asim Alhazmi
- King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Abid Alshareef
- King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | | | - Ammar Alshanqiti
- King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Mahmoud Andeejani
- King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
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Pak AT, Üstün İ, Sengul Y. Botulinum toxin type A wear-off phenomenon in chronic migraine patients: how long does the maximum efficiency last? ARQUIVOS DE NEURO-PSIQUIATRIA 2021; 79:886-890. [PMID: 34550173 DOI: 10.1590/0004-282x-anp-2020-0542] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 02/19/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Botulinum toxin Type A (BoNTA) is a successful treatment for chronic migraine prophylaxis. OBJECTIVE We aimed to evaluate the monthly change of effectiveness of BoNTA treatment. METHODS A total of 80 patients (70 females and 10 males) with chronic migraine were included. In our study protocol, we applied to 155 U across 31 fixed-sites and if the patient had pain, 40 U dose injections were applied across 8 specific head/neck muscle areas. Headache days and analgesic intake were noted before the BoNTA injection and during the interviews at the first, second, and third months after the BoNTA injection. RESULTS The mean age was 37.59 ± 7.60 and 87.5% of the patients were female. The mean number of headache days/month before BoNTA was 18.95±2.69, decreasing to 10.55±3.15 days/month in the first month (p<0.001), 9.31±2.43 days/month in the second month (p<0.001), and increased to 11.97±3.27 days/month in the third month (p<0.001). The mean analgesic intake before BoNTA was 11.48±4.68 tablets/month, while it decreased to 6.53±2.72 tablets/month in the first month (p<0.001) and 5.40±2.46 tablets/month in the second month (p<0.001). In the third month, it was 5.85±2.59 tablets/month (p<0.001). There was a significant increase in pain medication use from the second to the third month (p<0.001). CONCLUSION In our study, there was a significant reduction in analgesic intake and headache days in the first and second months after BoNTA injection, and an increase was observed in the third month.
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Affiliation(s)
- Aygul Tantik Pak
- Gaziosmanpasa Training and Research Hospital, Department of Neurology, Istanbul, Turkey
| | - İsmet Üstün
- Bezmialem Foundation University Hospital, Department of Neurology, Istanbul, Turkey
| | - Yildizhan Sengul
- Gaziosmanpasa Training and Research Hospital, Department of Neurology, Istanbul, Turkey
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Caponnetto V, Deodato M, Robotti M, Koutsokera M, Pozzilli V, Galati C, Nocera G, De Matteis E, De Vanna G, Fellini E, Halili G, Martinelli D, Nalli G, Serratore S, Tramacere I, Martelletti P, Raggi A. Comorbidities of primary headache disorders: a literature review with meta-analysis. J Headache Pain 2021; 22:71. [PMID: 34261435 PMCID: PMC8278743 DOI: 10.1186/s10194-021-01281-z] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 06/22/2021] [Indexed: 12/27/2022] Open
Abstract
Background Primary headache disorders are common and burdensome conditions. They are associated to several comorbidities, such as cardiovascular or psychiatric ones, which, in turn, contribute to the global burden of headache. The aim of this study is to provide a comprehensive description of the pooled prevalence of comorbidities of primary headache disorders using a meta-analytical approach based on studies published between 2000 and 2020. Methods Scopus was searched for primary research (clinical and population studies) in which medical comorbidities were described in adults with primary headache disorders. Comorbidities were extracted using a taxonomy derived from the Global Burden of Disease (GBD) study. We compared prevalence of comorbidities among headache sufferers against general population using GBD-2019 estimates, and compared comorbidities’ proportions in clinical vs. population studies, and by age and gender. Results A total of 139 studies reporting information on 4.19 million subjects with primary headaches were included: in total 2.75 million comorbidities were reported (median per subject 0.64, interquartile range 0.32–1.07). The most frequently addressed comorbidities were: depressive disorders, addressed in 51 studies (pooled proportion 23 %, 95 % CI 20–26 %); hypertension, addressed in 48 studies (pooled proportion 24 %, 95 % CI 22–26 %); anxiety disorders addressed in 40 studies (pooled proportion 25 %, 95 % CI 22–28 %). For conditions such as anxiety, depression and back pain, prevalence among headache sufferers was higher than in GBD-2109 estimates. Associations with average age and female prevalence within studies showed that hypertension was more frequent in studies with higher age and less females, whereas fibromyalgia, restless leg syndrome, and depressive disorders were more frequent in studies with younger age and more female. Conclusions Some of the most relevant comorbidities of primary headache disorders – back pain, anxiety and depression, diabetes, ischemic heart disease and stroke – are among the most burdensome conditions, together with headache themselves, according to the GBD study. A joint treatment of headaches and of these comorbidities may positively impact on headache sufferers’ health status and contribute to reduce the impact of a group of highly burdensome diseases. Supplementary Information The online version contains supplementary material available at 10.1186/s10194-021-01281-z.
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Affiliation(s)
| | - Manuela Deodato
- Department of Life Sciences, University of Trieste, Trieste, Italy. .,Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy.
| | - Micaela Robotti
- Centro di Diagnosi e Cura delle Cefalee, Palazzo della Salute, Gruppo San Donato, Milano, Italy.,PainClinicMilano, Centro Medico Visconti di Modrone, Milano, Italy
| | | | - Valeria Pozzilli
- Internal Medicine Unit, Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Cristina Galati
- UO Neuropsichiatria Infantile, Policlinico Universitario Paolo Giaccone, Università degli Studi di Palermo, Palermo, Italy
| | - Giovanna Nocera
- UO Neuropsichiatria Infantile, Policlinico Universitario Paolo Giaccone, Università degli Studi di Palermo, Palermo, Italy
| | - Eleonora De Matteis
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy
| | - Gioacchino De Vanna
- Clinica Neurologica, Dipartimento di Medicina, Università degli Studi di Perugia, Perugia, Italy
| | - Emanuela Fellini
- Internal Medicine Unit, Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Gleni Halili
- Department of Neurology, University Hospital Center 'Mother Teresa', Tirana, Albania
| | - Daniele Martinelli
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.,Headache Science and Neurorehabilitation Center, IRCCS Mondino Foundation, Pavia, Italy
| | - Gabriele Nalli
- Internal Medicine Unit, Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Serena Serratore
- Internal Medicine Unit, Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Irene Tramacere
- Dipartimento di Ricerca e Sviluppo Clinico, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University, Roma, Italy.,Regional Referral Headache Center, Sant'Andrea University Hospital, Roma, Italy
| | - Alberto Raggi
- UOC Neurologia, Salute Pubblica, Disabilità, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
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OnabotulinumtoxinA in Migraine: A Review of the Literature and Factors Associated with Efficacy. J Clin Med 2021; 10:jcm10132898. [PMID: 34209849 PMCID: PMC8269087 DOI: 10.3390/jcm10132898] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/12/2021] [Accepted: 06/16/2021] [Indexed: 11/17/2022] Open
Abstract
The efficacy of onabotulinumtoxinA (OnaB-A) as a preventative treatment for chronic migraine, emerging fortuitously from clinical observation is now supported by class one evidence and over two decades of real-world clinical data. There is still limited ability to predict a clinically meaningful response to OnaB-A for individual patients, however. This review summarises briefly the proposed mechanism of OnaB-A in chronic migraine, the literature of predictors of clinical response, and recent developments in the field.
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10
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Blumenfeld AM, Stevanovic DM, Ortega M, Cohen JM, Seminerio MJ, Yang R, Jiang B, Tepper SJ. No "Wearing-Off Effect" Seen in Quarterly or Monthly Dosing of Fremanezumab: Subanalysis of a Randomized Long-Term Study. Headache 2020; 60:2431-2443. [PMID: 33009665 PMCID: PMC7756709 DOI: 10.1111/head.13994] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/02/2020] [Accepted: 09/25/2020] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To evaluate whether quarterly or monthly administration of fremanezumab for migraine prevention exhibits a pattern of decreased efficacy toward the end of the dosing interval (wearing-off effect). BACKGROUND The main goals of migraine preventive treatment are to reduce the frequency, severity, and duration of migraine attacks, and migraine-associated disability. Wearing-off refers to the phenomenon whereby clinical symptoms return or worsen before the next dose of a drug is due and has been reported previously with migraine preventive medications. DESIGN AND METHODS This was a long-term, 12-month, multicenter, randomized, double-blind, parallel-group phase 3 study (NCT02638103) that included chronic (CM) and episodic migraine (EM) patients who rolled over from the 12-week phase 3 HALO CM (NCT02621931) and EM trials (NCT02629861), as well as an additional subset of 312 new patients. Patients with CM or EM received fremanezumab either monthly or quarterly. In this post hoc analysis, for selected months, the difference in the average number of migraine days between weeks 1-2 and weeks 3-4, between weeks 1-3 and week 4, and between weeks 1-2 and weeks 11-12 were calculated. RESULTS A total of 1890 patients (CM, 1110; EM, 780) were enrolled. At months 3, 6, 9, and 15, there were no substantial differences in mean weekly migraine days between weeks 1-2 and weeks 3-4 or between weeks 1-3 and week 4 with quarterly or monthly fremanezumab in the CM or EM subgroups. There were no substantial increases in mean weekly migraine days between weeks 1-2 and weeks 11-12 during the first quarter of treatment (months 1-3) or the second quarter of treatment (months 4-6) with quarterly or monthly fremanezumab in the CM or EM subgroups. Across both dosing subgroups in CM and EM patients, the mean weekly number of migraine days decreased substantially (30%-42%) during the first 2 weeks; decreases in weekly migraine days remained steady during the last 2 weeks of the first quarter, with a similar maintenance of response during the second quarter. CONCLUSIONS This analysis of data from a long-term, phase 3 study showed that patients receiving quarterly fremanezumab or monthly fremanezumab did not experience a wearing-off effect toward the end of the dosing interval.
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Affiliation(s)
- Andrew M Blumenfeld
- The Headache Center of Southern California, The Neurology Center, Carlsbad, CA, USA
| | | | - Mario Ortega
- Teva Branded Pharmaceutical Products R&D, Inc., West Chester, PA, USA
| | - Joshua M Cohen
- Teva Branded Pharmaceutical Products R&D, Inc., West Chester, PA, USA
| | | | - Ronghua Yang
- Teva Branded Pharmaceutical Products R&D, Inc., West Chester, PA, USA
| | - Bo Jiang
- Teva Branded Pharmaceutical Products R&D, Inc., West Chester, PA, USA
| | - Stewart J Tepper
- Department of Neurology, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
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Ruscheweyh R, Athwal B, Gryglas-Dworak A, Frattale I, Latysheva N, Ornello R, Pozo-Rosich P, Sacco S, Torres Ferrus M, Stark CD. Wear-Off of OnabotulinumtoxinA Effect Over the Treatment Interval in Chronic Migraine: A Retrospective Chart Review With Analysis of Headache Diaries. Headache 2020; 60:1673-1682. [PMID: 32797631 DOI: 10.1111/head.13925] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 06/26/2020] [Accepted: 07/13/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To quantify wear-off of the response to OnabotulinumtoxinA (OnabotA) treatment over the treatment cycle in chronic migraine at group and individual level. BACKGROUND OnabotA administered quarterly is an effective treatment for chronic migraine. However, some patients report that headache recurs before the scheduled follow-up injection. METHODS In this retrospective chart review performed in 6 university outpatient centers or private practices specialized in headache treatment, 112 patients with a ≥30% response to OnabotA who completed headache diaries over 13 weeks after OnabotA treatment were included (age [mean ± SD] 45 ± 12 years, 82% female, headache days/month at baseline 24 ± 6). RESULTS Compared to weeks 5 to 8 after injection, headache days/week increased significantly in weeks 12 (+0.52 ± 1.96, 95% CI [0.15, 0.88], P < .009) and 13 (+1.15 ± 1.95, CI[0.79, 1.52], P < .001), demonstrating significant wear-off of the OnabotA effect. Similarly, acute medication days/week significantly increased in weeks 12 (0.38±1.67, CI [0.06, 0.69], P ≤ .027) and 13 (+0.83 ± 1.76, CI [0.49, 1.16], P < .001). At an individual level, 57 patients (51%) showed ≥30% wear-off by weeks 12 and 13, and 28 patients (25%) showed ≥30% wear-off already by weeks 10 and 11. Age, gender, OnabotA dose or cycle number, or headache center did not predict individual wear-off. CONCLUSIONS These data show that in clinical practice, on average the response of chronic migraine patients to OnabotA injection shows a clinically significant wear-off from week 12 after treatment. About 25% of the patients experience wear-off even by weeks 10 and 11. It must be noted that wear-off detected in a real-world study on OnabotA responders can be due to wear-off of a pharmacological OnabotA effect or a placebo effect, or to regression to the mean effects. This wear-off phenomenon may negatively affect quality of life of chronic migraine patients under OnabotA treatment. The best way to counteract wear-off remains to be determined.
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Affiliation(s)
- Ruth Ruscheweyh
- Department of Neurology, Ludwig Maximilians University Munich, München, Germany
| | - Bal Athwal
- Department of Neurology, Royal Free Hospital, London, UK
| | - Anna Gryglas-Dworak
- Department of Pediatrics and Rare Diseases, Headache Center Wroclaw, Wroclaw Medical University, Wroclaw, Poland
| | - Ilaria Frattale
- Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy
| | - Nina Latysheva
- Department of Neurology, Institute for Postgraduate Education, First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Raffaele Ornello
- Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy
| | - Patricia Pozo-Rosich
- Headache Unit, Neurology Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Headache and Neurological Pain Research Group, Vall d'Hebron Research Institute, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Simona Sacco
- Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy
| | - Marta Torres Ferrus
- Headache Unit, Neurology Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Headache and Neurological Pain Research Group, Vall d'Hebron Research Institute, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
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Wang YF. OnabotulinumtoxinA injection in the treatment of chronic migraine. PROGRESS IN BRAIN RESEARCH 2020; 255:171-206. [PMID: 33008506 DOI: 10.1016/bs.pbr.2020.05.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 04/29/2020] [Accepted: 05/01/2020] [Indexed: 12/19/2022]
Abstract
The earliest descriptions of botulism were in the early 19th century, and was reported by the German physician Justinus Kerner. The term "botulism" was derived from the Latin word botulus, indicating its original association with sausages. It took another 150 years or so to come into clinical use. The first clinical application was strabismus, and was developed by the American ophthalmologist Alan B. Scott, whose effort led to the pharmaceutical product known as onabotulinumtoxinA today. The therapeutic benefit in migraine was an incidental finding in a report by the American plastic surgeon William J. Binder, which inspired a series of clinical studies in headache disorders. The doses and injection techniques in the earlier reports were variable, so were the results. It was until the Phase III REsearch Evaluating Migraine Prophylaxis Therapy (PREEMPT) 1 and 2 studies when its efficacy and safety, as well as the indication, i.e., chronic migraine (CM), were ascertained. Even though there were criticisms regarding the heterogeneities in the results between the PREEMPT 1 and 2 studies, the data on efficacy endpoints and safety were generally consistent, which were subsequently confirmed by the open-label extension of the PREEMPT 1 and 2 studies, and three open-label studies, namely the Chronic Migraine OnabotulinuMtoxinA Prolonged Efficacy open Label (COMPEL), the REal-life use of botulinum toxin for the symptomatic treatment of adults with chronic migraine, measuring healthcare resource utilization, and Patient-reported OutcomeS observed in practice (REPOSE) studies, and the CM Post-Authorization Safety Study (CM PASS) studies. On the other hand, the results were challenged by the Chronification and Reversibility of Migraine (CHARM) study, which involved CM patients with medication overuse. It was concluded that the clinical improvement was attributed to early withdrawal of the overused acute medications, rather than onabotulinumtoxinA injections. However, fundamental differences in the patient profile and methodology between the CHARM and PREEMPT studies existed, and cautious should be exercised when interpreting and comparing the results. According to the practical guidelines and reimbursement regulations in many countries, its use is limited to CM patients, and is reserved for those who fail at least 2-3 preventive medications, due to either lack of efficacy or intolerability. Cessation of treatment is recommended in patients who do not respond to 2-3 injection cycles, or in patients whose headache frequency has dropped to <10-15 days a month. Even in the era of calcitonin-gene-related peptide monoclonal antibodies, onabotulinumtoxinA injection remains a treatment option of reasonable cost-effectiveness in carefully selected patients.
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Affiliation(s)
- Yen-Feng Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.
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Abstract
OnabotulinumtoxinA (Botox®; a formulation of botulinum toxin type A (BoNT/A)] is indicated for the prevention of headaches in adults with chronic migraine (CM) in numerous countries, including those of Europe. In clinical trials, intramuscular administration of BoNT/A (155-195 units at 12-week intervals) to patients with CM was generally well tolerated and associated with sustained and clinically meaningful improvements in multiple assessments of headache symptoms, headache-related impact and/or disability and migraine-specific health-related quality of life over a period of 1 year (in the pivotal PREEMPT 1 and 2 studies) and 2 years (in the phase IV COMPEL study). The efficacy and safety of BoNT/A therapy have been confirmed in a number of large, prospective, real-world studies conducted in Europe, including the 2-year REPOSE study. Intramuscular BoNT/A has also demonstrated greater clinical utility than the oral prophylactic medication topiramate in a clinical practice setting (FORWARD study).
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Affiliation(s)
- James E Frampton
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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