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Schmidt S. Pain Pathways: Linking Environmental Pollutants with Migraine-Associated Pain Signaling. ENVIRONMENTAL HEALTH PERSPECTIVES 2024; 132:24003. [PMID: 38416538 PMCID: PMC10901286 DOI: 10.1289/ehp14416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
Using human cells and a mouse study, researchers found that pesticides, phthalates, hormone-like compounds, and other chemicals affected the TRPA1 channel-which is also implicated in migraine.
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Microneedle arrays for cutaneous and transcutaneous drug delivery, disease diagnosis, and cosmetic aid. J Drug Deliv Sci Technol 2022. [DOI: 10.1016/j.jddst.2022.104058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
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Wang M, Castonguay WC, Duong TL, Huebner MW, Flinn HC, Greenway AM, Russo AF, Sowers LP. Stimulation of CGRP-expressing neurons in the medial cerebellar nucleus induces light and touch sensitivity in mice. NEUROBIOLOGY OF PAIN (CAMBRIDGE, MASS.) 2022; 12:100098. [PMID: 35782531 PMCID: PMC9240374 DOI: 10.1016/j.ynpai.2022.100098] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/17/2022] [Accepted: 06/20/2022] [Indexed: 04/30/2023]
Abstract
Calcitonin gene-related peptide (CGRP) is considered a major player in migraine pathophysiology. However, the location and mechanisms of CGRP actions in migraine are not clearly elucidated. One important question yet to be answered is: Does central CGRP signaling play a role in migraine? One candidate site is the cerebellum, which serves as a sensory and motor integration center and is activated in migraine patients. The cerebellum has the most CGRP binding sites in the central nervous system and a deep cerebellar nucleus, the medial nucleus (MN), expresses CGRP (MNCGRP). A previous study demonstrated that CGRP delivery into the cerebellum induced migraine-like behaviors. We hypothesized that stimulation of MNCGRP neurons might induce migraine-like behaviors. To test the hypothesis, we used an optogenetic strategy using CalcaCre/+ mice to drive Cre-dependent expression of channelrhodopsin-2 selectively in CGRP neurons in the cerebellar MN. A battery of behavioral tests was done to assess preclinical behaviors that are surrogates of migraine symptoms, including light aversion, cutaneous allodynia, and spontaneous pain when MNCGRP neurons were optically stimulated. Motor functions were also assessed. Optical stimulation of MNCGRP neurons decreased the time spent in the light, which was coupled to increased time spent resting in the dark, but not the light. These changes were only significant in female mice. Plantar tactile sensitivity was increased in the ipsilateral paws of both sexes, but contralateral paw data were less clear. There was no significant increase in anxiety-like behavior, spontaneous pain (squint), or changes in gait. These discoveries reveal that MNCGRP neurons may contribute to migraine-like sensory hypersensitivity to light and touch.
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Affiliation(s)
- Mengya Wang
- Department of Neuroscience and Pharmacology, University of Iowa, Iowa City, IA 52242, USA
| | - William C. Castonguay
- Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, IA 52242, USA
| | - Thomas L. Duong
- Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, IA 52242, USA
| | - Michael W. Huebner
- Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, IA 52242, USA
| | - Harold C. Flinn
- Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, IA 52242, USA
| | - Agatha M. Greenway
- Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, IA 52242, USA
| | - Andrew F. Russo
- Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, IA 52242, USA
- Center for the Prevention and Treatment of Visual Loss, Veterans Administration Health Center, Iowa City, IA 52246, USA
- Department of Neurology, University of Iowa, Iowa City, IA 52242, USA
| | - Levi P. Sowers
- Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, IA 52242, USA
- Center for the Prevention and Treatment of Visual Loss, Veterans Administration Health Center, Iowa City, IA 52246, USA
- Corresponding author at: Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, IA 52242, USA.
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Wang M, Duong TL, Rea BJ, Waite JS, Huebner MW, Flinn HC, Russo AF, Sowers LP. CGRP Administration Into the Cerebellum Evokes Light Aversion, Tactile Hypersensitivity, and Nociceptive Squint in Mice. FRONTIERS IN PAIN RESEARCH 2022; 3:861598. [PMID: 35547239 PMCID: PMC9082264 DOI: 10.3389/fpain.2022.861598] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/17/2022] [Indexed: 12/16/2022] Open
Abstract
The neuropeptide calcitonin gene-related peptide (CGRP) is a major player in migraine pathophysiology. Previous preclinical studies demonstrated that intracerebroventricular administration of CGRP caused migraine-like behaviors in mice, but the sites of action in the brain remain unidentified. The cerebellum has the most CGRP binding sites in the central nervous system and is increasingly recognized as both a sensory and motor integration center. The objective of this study was to test whether the cerebellum, particularly the medial cerebellar nuclei (MN), might be a site of CGRP action. In this study, CGRP was directly injected into the right MN of C57BL/6J mice via a cannula. A battery of tests was done to assess preclinical behaviors that are surrogates of migraine-like symptoms. CGRP caused light aversion measured as decreased time in the light zone even with dim light. The mice also spent more time resting in the dark zone, but not the light, along with decreased rearing and transitions between zones. These behaviors were similar for both sexes. Moreover, significant responses to CGRP were seen in the open field assay, von Frey test, and automated squint assay, indicating anxiety, tactile hypersensitivity, and spontaneous pain, respectively. Interestingly, CGRP injection caused significant anxiety and spontaneous pain responses only in female mice, and a more robust tactile hypersensitivity in female mice. No detectable effect of CGRP on gait was observed in either sex. These results suggest that CGRP injection in the MN causes light aversion accompanied by increased anxiety, tactile hypersensitivity, and spontaneous pain. A caveat is that we cannot exclude contributions from other cerebellar regions in addition to the MN due to diffusion of the injected peptide. These results reveal the cerebellum as a new site of CGRP actions that may contribute to migraine-like hypersensitivity.
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Affiliation(s)
- Mengya Wang
- Department of Neuroscience and Pharmacology, University of Iowa, Iowa City, IA, United States
| | - Thomas L. Duong
- Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, IA, United States
| | - Brandon J. Rea
- Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, IA, United States
- Center for the Prevention and Treatment of Visual Loss, Veterans Administration Health Center, Iowa City, IA, United States
| | - Jayme S. Waite
- Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, IA, United States
| | - Michael W. Huebner
- Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, IA, United States
| | - Harold C. Flinn
- Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, IA, United States
| | - Andrew F. Russo
- Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, IA, United States
- Center for the Prevention and Treatment of Visual Loss, Veterans Administration Health Center, Iowa City, IA, United States
- Department of Neurology, University of Iowa, Iowa City, IA, United States
| | - Levi P. Sowers
- Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, IA, United States
- Center for the Prevention and Treatment of Visual Loss, Veterans Administration Health Center, Iowa City, IA, United States
- *Correspondence: Levi P. Sowers
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González-Hernández A, Marichal-Cancino BA, Villalón CM. The impact of CGRPergic monoclonal antibodies on prophylactic antimigraine therapy and potential adverse events. Expert Opin Drug Metab Toxicol 2021; 17:1223-1235. [PMID: 34535065 DOI: 10.1080/17425255.2021.1982892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Migraine is a prevalent medical condition and the second most disabling neurological disorder. Regarding its pathophysiology, calcitonin gene-related peptide (CGRP) plays a key role, and, consequently, specific antimigraine pharmacotherapy has been designed to target this system. Hence, apart from the gepants, the recently developed monoclonal antibodies (mAbs) are a novel approach to treat this disorder. In this review we consider the current knowledge on the mechanisms of action, specificity, safety, and efficacy of the above mAbs as prophylactic antimigraine agents, and examine the possible adverse events that these agents may trigger. Antimigraine mAbs act as direct scavengers of CGRP (galcanezumab, fremanezumab, and eptinezumab) or against the CGRP receptor (erenumab). Due to their long half-lives, these molecules have revolutionized the prophylactic treatment of this neurovascular disorder. Moreover, because of their physicochemical properties, these agents are hepato-friendly and do not cross the blood-brain barrier (highlighting the relevance of peripheral mechanisms in migraine). Nevertheless, apart from potential cardiovascular side effects, the interaction with AMY1 receptors and immunogenicity induced by autoantibodies against mAbs could be a concern for the safety of long-term treatment with these molecules.
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Affiliation(s)
- Abimael González-Hernández
- Departamento de Neurobiología del Desarrollo y Neurofisiología, Instituto de Neurobiología, Universidad Nacional Autónoma de México, Querétaro, México
| | - Bruno A Marichal-Cancino
- Departamento de Fisiología y Farmacología, Universidad Autónoma de Aguascalientes, Ciudad Universitaria, Aguascalientes, México
| | - Carlos M Villalón
- Departamento de Farmacobiología, Cinvestav‑Coapa, Ciudad de México, México
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Wang M, Mason BN, Sowers LP, Kuburas A, Rea BJ, Russo AF. Investigating Migraine-Like Behavior using Light Aversion in Mice. J Vis Exp 2021. [PMID: 34459825 DOI: 10.3791/62839] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Migraine is a complex neurological disorder characterized by headache and sensory abnormalities, such as hypersensitivity to light, observed as photophobia. Whilst it is impossible to confirm that a mouse is experiencing migraine, light aversion can be used as a behavioral surrogate for the migraine symptom of photophobia. To test for light aversion, we utilize the light/dark assay to measure the time mice freely choose to spend in either a light or dark environment. The assay has been refined by introducing two critical modifications: pre-exposures to the chamber prior to running the test procedure and adjustable chamber lighting, permitting the use of a range of light intensities from 55 lux to 27,000 lux. Because the choice to spend more time in the dark is also indicative of anxiety, we also utilize a light-independent anxiety test, the open field assay, to distinguish anxiety from light-aversive behavior. Here, we describe a modified test paradigm for the light/dark and open field assays. The application of these assays is described for intraperitoneal injection of calcitonin gene-related peptide (CGRP) in two mouse strains and for optogenetic brain stimulation studies.
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Affiliation(s)
- Mengya Wang
- Department of Neuroscience and Pharmacology, University of Iowa
| | - Bianca N Mason
- School of Behavioral and Brain Sciences, University of Texas at Dallas
| | - Levi P Sowers
- Center for the Prevention and Treatment of Visual Loss, Veterans Administration Health Center, Iowa City, IA; Department of Molecular Physiology and Biophysics, University of Iowa
| | - Adisa Kuburas
- Department of Molecular Physiology and Biophysics, University of Iowa
| | - Brandon J Rea
- Center for the Prevention and Treatment of Visual Loss, Veterans Administration Health Center, Iowa City, IA; Department of Molecular Physiology and Biophysics, University of Iowa
| | - Andrew F Russo
- Center for the Prevention and Treatment of Visual Loss, Veterans Administration Health Center, Iowa City, IA; Department of Molecular Physiology and Biophysics, University of Iowa; Department of Neurology, University of Iowa;
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Freitag FG. Headache Medicine Grand Challenge: Headache: A New Frontier, A New Challenge. FRONTIERS IN PAIN RESEARCH 2021; 2:690683. [PMID: 35295521 PMCID: PMC8915632 DOI: 10.3389/fpain.2021.690683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 06/04/2021] [Indexed: 11/26/2022] Open
Affiliation(s)
- Frederick G. Freitag
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, United States
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Börner C, Urban G, Beaulieu LD, Sollmann N, Krieg SM, Straube A, Renner T, Schandelmaier P, Lang M, Lechner M, Vill K, Gerstl L, Heinen F, Landgraf MN, Bonfert MV. The bottom-up approach: Non-invasive peripheral neurostimulation methods to treat migraine: A scoping review from the child neurologist's perspective. Eur J Paediatr Neurol 2021; 32:16-28. [PMID: 33743386 DOI: 10.1016/j.ejpn.2021.02.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 01/07/2021] [Accepted: 02/23/2021] [Indexed: 12/14/2022]
Abstract
Migraine is a common and invalidating disorder worldwide. Patients of all ages experience the disorder as very impairing regarding their personal and occupational lives. The current approach in migraine therapy is multimodal including lifestyle management, psychoeducation and, if available, psychotherapeutic interventions, and pharmacotherapy. The lack of non-pharmacological and non-invasive treatment options call for new and innovative therapeutic approaches. Peripheral neurostimulation is a relatively new method in migraine management offering a painless and non-pharmacological way of targeting specific mechanisms involved in migraine. This review summarizes 15 recent randomized clinical trials to provide an overview of non-invasive peripheral neurostimulation methods currently available for the treatment of migraine. Efficacy, tolerability, and safety of the different interventions and their feasibility in the pediatric setting are evaluated. Vagal nerve stimulation (VNS), remote electrical neuromodulation (REN) and supraorbital nerve stimulation (SNS) are considered effective in treating acute migraine attacks, the latter being more pronounced in migraine without aura. Regarding migraine prevention, occipital nerve stimulation (ONS) and supraorbital nerve stimulation (SNS) demonstrated efficacy, whereas repetitive neuromuscular magnetic stimulation (rNMS) may represent a further effective option in episodic migraine. REN and rNMS were found to be well-accepted with fewer patients discontinuing treatment than those receiving direct cranial nerve stimulation. In summary, peripheral neurostimulation represents a promising option to complement the multimodal therapy concept for pediatric migraine. In particular, rNMS opens a new field for research and treatment fitting the requirements of "non-invasiveness" for children. Given the reported efficacy, safety, and feasibility, the therapy decision should be made on an individual level.
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Affiliation(s)
- Corinna Börner
- LMU Hospital, Dr. von Hauner Children's Hospital, Division of Pediatric Neurology and Developmental Medicine and LMU Center for Children with Medical Complexity, Munich, Germany
| | - Giada Urban
- LMU Hospital, Dr. von Hauner Children's Hospital, Division of Pediatric Neurology and Developmental Medicine and LMU Center for Children with Medical Complexity, Munich, Germany
| | - Louis-David Beaulieu
- Biomechanical and Neurophysiological Research Lab in neuro-musculo-skelettal Rehabilitation (BioNR Lab), Université du Québec à Chicoutimi, Chicoutimi, Canada
| | - Nico Sollmann
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Ulm, Germany
| | - Sandro M Krieg
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | | | - Tabea Renner
- LMU Hospital, Dr. von Hauner Children's Hospital, Division of Pediatric Neurology and Developmental Medicine and LMU Center for Children with Medical Complexity, Munich, Germany
| | - Paul Schandelmaier
- LMU Hospital, Dr. von Hauner Children's Hospital, Division of Pediatric Neurology and Developmental Medicine and LMU Center for Children with Medical Complexity, Munich, Germany
| | - Magdalena Lang
- LMU Hospital, Dr. von Hauner Children's Hospital, Division of Pediatric Neurology and Developmental Medicine and LMU Center for Children with Medical Complexity, Munich, Germany
| | - Matthias Lechner
- LMU Hospital, Dr. von Hauner Children's Hospital, Division of Pediatric Neurology and Developmental Medicine and LMU Center for Children with Medical Complexity, Munich, Germany
| | - Katharina Vill
- LMU Hospital, Dr. von Hauner Children's Hospital, Division of Pediatric Neurology and Developmental Medicine and LMU Center for Children with Medical Complexity, Munich, Germany
| | - Lucia Gerstl
- LMU Hospital, Dr. von Hauner Children's Hospital, Division of Pediatric Neurology and Developmental Medicine and LMU Center for Children with Medical Complexity, Munich, Germany
| | - Florian Heinen
- LMU Hospital, Dr. von Hauner Children's Hospital, Division of Pediatric Neurology and Developmental Medicine and LMU Center for Children with Medical Complexity, Munich, Germany
| | - Mirjam N Landgraf
- LMU Hospital, Dr. von Hauner Children's Hospital, Division of Pediatric Neurology and Developmental Medicine and LMU Center for Children with Medical Complexity, Munich, Germany
| | - Michaela V Bonfert
- LMU Hospital, Dr. von Hauner Children's Hospital, Division of Pediatric Neurology and Developmental Medicine and LMU Center for Children with Medical Complexity, Munich, Germany.
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Argyriou AA, Vikelis M, Mantovani E, Litsardopoulos P, Tamburin S. Recently available and emerging therapeutic strategies for the acute and prophylactic management of cluster headache: a systematic review and expert opinion. Expert Rev Neurother 2020; 21:235-248. [PMID: 33243037 DOI: 10.1080/14737175.2021.1857240] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Introduction: Although it causes a huge burden to sufferers, cluster headache (CH), remains an undertreated condition, partly due to the absence of established acute and prophylactic treatment options. New therapeutic approaches providing fast and safe relief from CH are needed. Areas covered: A systematic review was conducted, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendation on recently published (last 5 years) papers on CH treatment. The authors also collected preliminary results from ongoing trials on emerging therapeutic/preventive pharmacological and interventional approaches for CH. Studies and results are reviewed and discussed. Expert opinion: The complexity of CH pathophysiology prevents the definition of reliable acute and preventive treatments. In the real-world clinical setting, several treatments are combined to provide relief to patients and increase their quality of life. Drugs targeting neuropeptides or their receptors within the trigeminovascular network are of particular interest to prevent CH attacks. Calcitonin gene-related peptide (CGRP) blockade seems attractive and promising, but studies on anti-CGRP monoclonal antibodies indicated rather modest or even absence of a prophylactic effect. A deeper insight into CH pathophysiology, and combined approaches may lead the path to new, more effective, and personalized CH therapies.
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Affiliation(s)
- Andreas A Argyriou
- Headache Outpatient Clinic, Department of Neurology, Saint Andrew's State General Hospital of Patras , Patras, Greece
| | - Michail Vikelis
- Headache Clinic, Mediterraneo Hospital , Glyfada, Greece.,Glyfada Headache Clinic , Glyfada, Greece
| | - Elisa Mantovani
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona , Verona, Italy
| | - Pantelis Litsardopoulos
- Headache Outpatient Clinic, Department of Neurology, Saint Andrew's State General Hospital of Patras , Patras, Greece
| | - Stefano Tamburin
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona , Verona, Italy
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[Migraine in childhood and adolescence-neurostimulation as a future innovative approach in terms of a multimodal treatment regimen]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2020; 63:872-880. [PMID: 32504242 DOI: 10.1007/s00103-020-03169-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Although migraine is a relevant health issue in children and adolescents, clinical care and research are still underrepresented and underfunded in this field. Quality of life can be significantly reduced when living with frequent episodes of pain. Due to the high level of vulnerability of the developing brain during adolescence, the risk of chronification and persistence into adulthood is high. In this narrative review, we describe the corner stones of a patient-centered, multimodular treatment regimen. Further, an update on the pathophysiology of migraine is given considering the concept of a periodically oscillating functional state of the brain in migraine patients ("migraine is a brain state"). Besides central mechanisms, muscular structures with the symptoms of muscular pain, tenderness, or myofascial trigger points play an important role. Against this background, the currently available nonpharmacological and innovative neuromodulating approaches are presented focusing on the method of repetitive peripheral magnetic stimulation.
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Pellesi L, Do TP, Ashina H, Ashina M, Burstein R. Dual Therapy With Anti-CGRP Monoclonal Antibodies and Botulinum Toxin for Migraine Prevention: Is There a Rationale? Headache 2020; 60:1056-1065. [PMID: 32437038 DOI: 10.1111/head.13843] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 04/29/2020] [Accepted: 04/29/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To narratively review the pathophysiological rationale of dual therapy with anti-calcitonin gene-related peptide monoclonal antibodies and botulinum toxin type A in treatment-resistant chronic migraine prevention. BACKGROUND For the prevention of chronic migraine, several pharmacological therapies are available, including oral medications, botulinum toxin type A, and the newly approved monoclonal antibodies targeting calcitonin gene-related peptide or its receptor. However, monotherapy does not yield benefits in some affected individuals, which raises the question of whether dual therapy with monoclonal antibodies and botulinum toxin type A hold promise in patients with treatment-resistant chronic migraine. METHOD We searched MEDLINE for articles published from database inception to December 31st, 2019. Publications were largely selected from the past 10 years but commonly referenced and highly regarded older publications were not excluded. RESULTS Preclinical data suggest that anti-calcitonin gene-related peptide monoclonal antibodies and botulinum toxin type A have synergistic effects within the trigeminovascular system. Of note, findings indicate that fremanezumab - an antibody targeting the calcitonin gene-related peptide - mainly prevents the activation of Aδ-fibers, whereas botulinum toxin type A prevents the activation of C-fibers. CONCLUSION There is currently only indirect preclinical evidence to support a rationale for dual therapy with anti-calcitonin gene-related peptide monoclonal antibodies and botulinum toxin type A for chronic migraine prevention. Rigorous studies evaluating clinical efficacy, safety, and cost-effectiveness are needed.
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Affiliation(s)
- Lanfranco Pellesi
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Thien P Do
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Håkan Ashina
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Messoud Ashina
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Rami Burstein
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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