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Chichorro JG, Gambeta E, Baggio DF, Zamponi GW. Voltage-gated Calcium Channels as Potential Therapeutic Targets in Migraine. THE JOURNAL OF PAIN 2024; 25:104514. [PMID: 38522594 DOI: 10.1016/j.jpain.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 03/06/2024] [Accepted: 03/12/2024] [Indexed: 03/26/2024]
Abstract
Migraine is a complex and highly incapacitating neurological disorder that affects around 15% of the general population with greater incidence in women, often at the most productive age of life. Migraine physiopathology is still not fully understood, but it involves multiple mediators and events in the trigeminovascular system and the central nervous system. The identification of calcitonin gene-related peptide as a key mediator in migraine physiopathology has led to the development of effective and highly selective antimigraine therapies. However, this treatment is neither accessible nor effective for all migraine sufferers. Thus, a better understanding of migraine mechanisms and the identification of potential targets are still clearly warranted. Voltage-gated calcium channels (VGCCs) are widely distributed in the trigeminovascular system, and there is accumulating evidence of their contribution to the mechanisms associated with headache pain. Several drugs used in migraine abortive or prophylactic treatment target VGCCs, which probably contributes to their analgesic effect. This review aims to summarize the current evidence of VGGC contribution to migraine physiopathology and to discuss how current pharmacological options for migraine treatment interfere with VGGC function. PERSPECTIVE: Calcitonin gene-related peptide (CGRP) represents a major migraine mediator, but few studies have investigated the relationship between CGRP and VGCCs. CGRP release is calcium channel-dependent and VGGCs are key players in familial migraine. Further studies are needed to determine whether VGCCs are suitable molecular targets for treating migraine.
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Affiliation(s)
- Juliana G Chichorro
- Biological Sciences Sector, Department of Pharmacology, Federal University of Parana, Curitiba, Parana, Brazil.
| | - Eder Gambeta
- Cumming School of Medicine, Department of Clinical Neuroscience, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Darciane F Baggio
- Biological Sciences Sector, Department of Pharmacology, Federal University of Parana, Curitiba, Parana, Brazil
| | - Gerald W Zamponi
- Cumming School of Medicine, Department of Clinical Neuroscience, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
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Lee DA, Lee HJ, Kim J, Park KM. Association between patients with migraine and sarcopenia: A retrospective study. Medicine (Baltimore) 2024; 103:e38941. [PMID: 38996151 PMCID: PMC11245205 DOI: 10.1097/md.0000000000038941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 06/24/2024] [Indexed: 07/14/2024] Open
Abstract
Recently, interest in sarcopenia has been increasing in patients with various neurological diseases. Thus, we investigated the presence of sarcopenia in patients with episodic migraine (EM) based on temporal muscle thickness (TMT). This was a retrospectively observational study following STROBE guidelines. We enrolled patients with EM and healthy controls. Both groups underwent brain magnetic resonance imaging, including three-dimensional T1-weighted imaging. We calculated the TMT using T1-weighted imaging, which is a marker for sarcopenia. We compared TMT between patients with EM and healthy controls, and analyzed it according to presence of migraine aura. We retrospectively enrolled 82 patients with EM and 53 healthy controls. TMT was not different between patients with EM and healthy controls (10.804 ± 2.045 mm in patients with EM vs 10.721 ± 1.547 mm in healthy controls, P = .801). Furthermore, TMT was not different according to presence of migraine aura in patients with EM (10.994 ± 2.016 mm in patients with migraine aura vs 10.716 ± 2.071 mm in those without, P = .569). There were no correlations between TMT and clinical characteristics in patients with EM, including age, age of onset, duration of migraine, headache intensity, and headache frequency. This study found no statistical difference in TMT between patients with EM and healthy controls or between patients with EM with and without aura. These findings suggest that there is no evidence of sarcopenia in patients with EM.
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Affiliation(s)
- Dong Ah Lee
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Ho-Joon Lee
- Department of Radiology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Jinseung Kim
- Department of Family Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Kang Min Park
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
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Bagues A, Hu J, Alshanqiti I, Chung MK. Neurobiological mechanisms of botulinum neurotoxin-induced analgesia for neuropathic pain. Pharmacol Ther 2024; 259:108668. [PMID: 38782121 PMCID: PMC11182613 DOI: 10.1016/j.pharmthera.2024.108668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 05/15/2024] [Accepted: 05/20/2024] [Indexed: 05/25/2024]
Abstract
Botulinum neurotoxins (BoNTs) are a family of neurotoxins produced by Clostridia and other bacteria that induce botulism. BoNTs are internalized into nerve terminals at the site of injection and cleave soluble N-ethylmaleimide-sensitive factor attachment protein receptor (SNARE) proteins to inhibit the vesicular release of neurotransmitters. BoNTs have been approved for multiple therapeutic applications, including the treatment of migraines. They have also shown efficacies for treating neuropathic pain, such as diabetic neuropathy, and postherpetic and trigeminal neuralgia. However, the mechanisms underlying BoNT-induced analgesia are not well understood. Peripherally administered BoNT is taken up by the nerve terminals and reduces the release of glutamate, calcitonin gene-related peptide, and substance P, which decreases neurogenic inflammation in the periphery. BoNT is retrogradely transported to sensory ganglia and central terminals in a microtubule-dependent manner. BoNTs decrease the expression of pronociceptive genes (ion channels or cytokines) from sensory ganglia and the release of neurotransmitters and neuropeptides from primary afferent central terminals, which likely leads to decreased central sensitization in the dorsal horn of the spinal cord or trigeminal nucleus. BoNT-induced analgesia is abolished after capsaicin-induced denervation of transient receptor potential vanilloid 1 (TRPV1)-expressing afferents or the knockout of substance P or the neurokinin-1 receptor. Although peripheral administration of BoNT leads to changes in the central nervous system (e.g., decreased phosphorylation of glutamate receptors in second-order neurons, reduced activation of microglia, contralateral localization, and cortical reorganization), whether such changes are secondary to changes in primary afferents or directly mediated by trans-synaptic, transcytotic, or the hematogenous transport of BoNT is controversial. To enhance their therapeutic potential, BoNTs engineered for specific targeting of nociceptive pathways have been developed to treat chronic pain. Further mechanistic studies on BoNT-induced analgesia can enhance the application of native or engineered BoNTs for neuropathic pain treatment with improved safety and efficacy.
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Affiliation(s)
- Ana Bagues
- Área de Farmacología, Nutrición y Bromatología, Dpto. C.C. Básicas de la Salud, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Unidad Asociada I+D+i al Instituto de Química Médica (CSIC), Alcorcón, Spain; High Performance Research Group in Experimental Pharmacology (PHARMAKOM), Spain
| | - Jiaxin Hu
- Department of Neural and Pain Sciences, School of Dentistry, University of Maryland Baltimore, Baltimore, MD 21201, USA
| | - Ishraq Alshanqiti
- Department of Neural and Pain Sciences, School of Dentistry, University of Maryland Baltimore, Baltimore, MD 21201, USA; Program in Dental Biomedical Sciences, University of Maryland Baltimore, School of Dentistry, Baltimore, MD 21201, USA; Department of Basic and Clinical Sciences, School of Dentistry, Umm Al-Qura University, Makkah 24382, Kingdom of Saudi Arabia
| | - Man-Kyo Chung
- Department of Neural and Pain Sciences, School of Dentistry, University of Maryland Baltimore, Baltimore, MD 21201, USA; Program in Dental Biomedical Sciences, University of Maryland Baltimore, School of Dentistry, Baltimore, MD 21201, USA; Center to Advance Chronic Pain Research, University of Maryland Baltimore, Baltimore, MD 21201, USA.
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Conti M, Bovenzi R, Palmieri MG, Placidi F, Stefani A, Mercuri NB, Albanese M. Early effect of onabotulinumtoxinA on EEG-based functional connectivity in patients with chronic migraine: A pilot study. Headache 2024; 64:825-837. [PMID: 38837259 DOI: 10.1111/head.14750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 03/27/2024] [Accepted: 04/03/2024] [Indexed: 06/07/2024]
Abstract
OBJECTIVE In this pilot prospective cohort study, we aimed to evaluate, using high-density electroencephalography (HD-EEG), the longitudinal changes in functional connectivity (FC) in patients with chronic migraine (CM) treated with onabotulinumtoxinA (OBTA). BACKGROUND OBTA is a treatment for CM. Several studies have shown the modulatory action of OBTA on the central nervous system; however, research on migraine is limited. METHODS This study was conducted at the Neurology Unit of "Policlinico Tor Vergata," Rome, Italy, and included 12 adult patients with CM treated with OBTA and 15 healthy controls (HC). Patients underwent clinical scales at enrollment (T0) and 3 months (T1) from the start of treatment. HD-EEG was recorded using a 64-channel system in patients with CM at T0 and T1. A source reconstruction method was used to identify brain activity. FC in δ-θ-α-β-low-γ bands was analyzed using the weighted phase-lag index. FC changes between HCs and CM at T0 and T1 were assessed using cross-validation methods to estimate the results' reliability. RESULTS Compared to HCs at T0, patients with CM showed hyperconnected networks in δ (p = 0.046, area under the receiver operating characteristic curve [AUC: 0.76-0.98], Cohen's κ [0.65-0.93]) and β (p = 0.031, AUC [0.68-0.95], Cohen's κ [0.51-0.84]), mainly involving orbitofrontal, occipital, temporal pole and orbitofrontal, superior temporal, occipital, cingulate areas, and hypoconnected networks in α band (p = 0.029, AUC [0.80-0.99], Cohen's κ [0.42-0.77]), predominantly involving cingulate, temporal pole, and precuneus. Patients with CM at T1, compared to T0, showed hypoconnected networks in δ band (p = 0.032, AUC [0.73-0.99], Cohen's κ [0.53-0.90]) and hyperconnected networks in α band (p = 0.048, AUC [0.58-0.93], Cohen's κ [0.37-0.78]), involving the sensorimotor, orbitofrontal, cingulate, and temporal cortex. CONCLUSION These preliminary results showed that patients with CM presented disrupted EEG-FC compared to controls restored by a single session of OBTA treatment, suggesting a primary central modulatory action of OBTA.
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Affiliation(s)
- Matteo Conti
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Roberta Bovenzi
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | | | - Fabio Placidi
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Alessandro Stefani
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | | | - Maria Albanese
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
- Neurology Unit, Regional Referral Headache Center, University of Rome "Tor Vergata", Rome, Italy
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Raciti L, Raciti G, Ammendolia A, de Sire A, Onesta MP, Calabrò RS. Improving Spasticity by Using Botulin Toxin: An Overview Focusing on Combined Approaches. Brain Sci 2024; 14:631. [PMID: 39061372 PMCID: PMC11274891 DOI: 10.3390/brainsci14070631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 06/11/2024] [Accepted: 06/20/2024] [Indexed: 07/28/2024] Open
Abstract
Spasticity is a very common sign in the neurological field. It can be defined as "a motor disorder marked by a velocity-dependent increase in muscle tone or tonic stretch reflexes" associated with hypertonia. It leads to a high risk of limb deformities and pain that prejudices residual motor function, impairing quality of life". The treatment of spasticity depends on its severity and its location and, in general, it is based on rehabilitation, oral therapies (the gamma-aminobutyric acid b agonist baclofen) and injectable medications (i.e., botulin toxins, acting on polysynaptic reflex mechanisms). The botulin toxin type A (BoNT-A) injection has been effectively used to improve different types of spasticity. However, when BoNT-A is not sufficient, a combination of nonpharmacological approaches could be attempted. Therefore, additional intervention, such as conventional physical therapy by itself or further combined with robotic gait training, may be needed. Indeed, it has been shown that combination of BoNT-A and robotics has a positive effect on activity level and upper limb function in patients with stroke, including those in the chronic phase. The aim of this review is to evaluate the efficacy of pharmacological or nonpharmacological treatment in combination with BoNT-A injections on spasticity. The combined therapy of BoNT with conventional or adjunct activities or robot-assisted training, especially with end-effectors, is a valid tool to improve patients' performance and outcomes. The combined strategies might rise the toxin's effect, lowering its dosages of botulinum and reducing side effects and costs.
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Affiliation(s)
- Loredana Raciti
- Unità Spinale Unipolare, AO Cannizzaro, 98102 Catania, Italy; (L.R.); (M.P.O.)
| | - Gianfranco Raciti
- Department of Medical and Surgical Sciences, Magna Græcia University, 88100 Catanzaro, Italy; (G.R.); (A.A.); (A.d.S.)
| | - Antonio Ammendolia
- Department of Medical and Surgical Sciences, Magna Græcia University, 88100 Catanzaro, Italy; (G.R.); (A.A.); (A.d.S.)
| | - Alessandro de Sire
- Department of Medical and Surgical Sciences, Magna Græcia University, 88100 Catanzaro, Italy; (G.R.); (A.A.); (A.d.S.)
| | - Maria Pia Onesta
- Unità Spinale Unipolare, AO Cannizzaro, 98102 Catania, Italy; (L.R.); (M.P.O.)
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Zhao C, Li C, Yu X, Dai X, Zou W. Effectiveness and safety of pharmacological prophylaxis for chronic migraine: a systematic review and network meta-analysis. J Neurol 2024:10.1007/s00415-024-12512-z. [PMID: 38910144 DOI: 10.1007/s00415-024-12512-z] [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: 03/28/2024] [Revised: 06/05/2024] [Accepted: 06/10/2024] [Indexed: 06/25/2024]
Abstract
BACKGROUND Chronic migraine (CM) significantly impacts both the physical and mental health of patients. Current studies on the safety and effectiveness of different pharmacological prophylaxis interventions for CM are limited. To address this gap, we conducted a network meta-analysis (NMA) to compare and rank the efficacy and safety of various drugs in preventing CM. METHODS Two independent researchers systematically searched four databases from their inception to August 1, 2023, to identify eligible randomized controlled trials (RCTs). Subsequently, they performed data extraction and assessed the risk of bias. A NMA was then performed. Continuous outcomes and binary outcomes were displayed as weighted mean difference (WMD) and risk ratio (RR), respectively, and corresponding 95% confidence intervals (CI) were reported. The surface under the cumulative ranking curve (SUCRA) was used to rank each intervention separately. RESULTS 24 RCTs involving 8789 patients were included. Compared to placebo, Botulinum toxin A demonstrated the most significant effect in reducing the monthly migraine days for CM patients (MD = 3.88, 95% CI 0.48, 7.28); in terms of improving the response rate by a 50% reduction in monthly migraine days, Topiramate (RR = 50.06, 95% CI 3.18, 787.30) was the most effective; there was no statistically significant difference between all preventive drugs and placebo in improving the migraine disability assessment (MIDAS) score; in terms of the incidence of adverse events, Eptinezumab (RR = 1.09, 95% CI 0.8, 1.54) exhibited the highest safety profile. CONCLUSION Among all the drugs for the preventive drugs for CM, Botulinum toxin A has the best efficacy and safety profile, closely followed by calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAbs).
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Affiliation(s)
- Chengqi Zhao
- First School of Clinical Medicine, Heilongjiang University of Chinese Medicine, Harbin, 150040, Heilongjiang, China
| | - Changxin Li
- The Second Department of Rehabilitation, Heilongjiang Provincial Hospital of Traditional Chinese Medicine, Harbin, 150030, Heilongjiang, China
| | - Xueping Yu
- The Third Department of Acupuncture and Moxibustion, The First Affiliated Hospital of Heilongjiang University of Chinese Medicine, 26 Heping Road, Xiangfang District, Harbin, 150040, Heilongjiang, China
| | - Xiaohong Dai
- The Third Department of Acupuncture and Moxibustion, The First Affiliated Hospital of Heilongjiang University of Chinese Medicine, 26 Heping Road, Xiangfang District, Harbin, 150040, Heilongjiang, China
| | - Wei Zou
- The Third Department of Acupuncture and Moxibustion, The First Affiliated Hospital of Heilongjiang University of Chinese Medicine, 26 Heping Road, Xiangfang District, Harbin, 150040, Heilongjiang, China.
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Ilgaz Aydinlar E, Erdogan Soyukibar T, Yalinay Dikmen P. The effectiveness and predictors influencing the outcome of onabotulinumtoxinA treatment in chronic migraine: understanding from diverse patient profiles in a single session. Front Neurol 2024; 15:1417303. [PMID: 38962481 PMCID: PMC11219632 DOI: 10.3389/fneur.2024.1417303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Accepted: 05/31/2024] [Indexed: 07/05/2024] Open
Abstract
Objective This real-world study aimed to investigate how onabotulinumtoxinA affects the outcome of migraine, along with accompanying anxiety, depression, and bruxism among a group of patients with chronic migraine (CM) and define predictors of good response. Methods Patients diagnosed with CM who received onabotulinumtoxinA were included in this single-center, real-world retrospective cohort study. Monthly headache days (MHDs), monthly migraine days (MMDs), headache intensity (numeric rating scale-NRS) and headache characteristics were evaluated at baseline and 12 weeks post-treatment. Patient-reported outcome measures (PROMs) included Migraine Disability Assessment Scale (MIDAS), Headache Impact Test-6 (HIT-6) scores, 12-item Allodynia Symptom Checklist (ASC-12), Beck Anxiety Inventory (BAI) and Beck Depression Inventory (BDI). Response to onabotulinumtoxinA (% reduction in MHDs) and treatment-related adverse events (TRAEs) were also evaluated. OnabotulinumA was applied to the masseter muscles in patients complaining of bruxism. Results A total of 72 patients (mean ± SD age: 36.3 ± 8.5 years; 91.7% were female) diagnosed with CM were included. OnabotulinumtoxinA revealed significant decrease in median (IQR) MHDs [from 20(15-25) at baseline to 6(4-10), p < 0.001], MMDs [from 9(6-12) to 3(1-6), p < 0.001] and NRS [from 9(8-10) to 7(6-8), p < 0.001], and the MIDAS [from 54(30-81) to 16(7-24), p < 0.001], HIT-6 [from 67(65-69) to 58(54-64), p < 0.001], ASC-12 [from 6(1.5-9) to 2(0-9), p = 0.002], BAI [from 12(6.5-19) to 9(3-17), p < 0.001] and BDI [from 11(6.5-17) to 3(2-7) p < 0.001] scores at 12 weeks post-treatment. Patients complaining of bruxism received onabotulinumtoxinA injections in the first n = 27 (37.5%) and 12. week post-treatment n = 19 (70.4%) periods. Overall, 70.8% of patients responded (≥50% reduction in MHDs), while 29.2% did not (<50% reduction). Both groups showed similar characteristics in demographics, migraine history, baseline PROMs scores, comorbidities, and prior treatments. Conclusion OnabotulinumtoxinA is an effective treatment option that rapidly improves migraine outcomes, disability, and impact while also alleviating comorbid depression and/or anxiety. This study's noteworthy finding is that onabotulinumtoxinA is effective in a majority of CM patients, irrespective of their prior treatment history, migraine characteristics, or concurrent comorbidities. Furthermore, we identified no specific predictors for a favorable response to onabotulinumtoxinA. Applying onabotulinumtoxinA to the masseter muscles can relieve discomfort associated with concurrent bruxism; however, it does not impact migraine outcomes.
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Affiliation(s)
- Elif Ilgaz Aydinlar
- Department of Neurology, Acıbadem University School of Medicine, Istanbul, Türkiye
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Brin MF, Nelson M, Ashourian N, Brideau-Andersen A, Maltman J. Update on Non-Interchangeability of Botulinum Neurotoxin Products. Toxins (Basel) 2024; 16:266. [PMID: 38922160 PMCID: PMC11209304 DOI: 10.3390/toxins16060266] [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: 05/02/2024] [Revised: 06/01/2024] [Accepted: 06/05/2024] [Indexed: 06/27/2024] Open
Abstract
The growing use of botulinum neurotoxins (BoNTs) for medical and aesthetic purposes has led to the development and marketing of an increasing number of BoNT products. Given that BoNTs are biological medications, their characteristics are heavily influenced by their manufacturing methods, leading to unique products with distinct clinical characteristics. The manufacturing and formulation processes for each BoNT are proprietary, including the potency determination of reference standards and other features of the assays used to measure unit potency. As a result of these differences, units of BoNT products are not interchangeable or convertible using dose ratios. The intrinsic, product-level differences among BoNTs are compounded by differences in the injected tissues, which are innervated by different nerve fiber types (e.g., motor, sensory, and/or autonomic nerves) and require unique dosing and injection sites that are particularly evident when treating complex therapeutic and aesthetic conditions. It is also difficult to compare across studies due to inherent differences in patient populations and trial methods, necessitating attention to study details underlying each outcome reported. Ultimately, each BoNT possesses a unique clinical profile for which unit doses and injection paradigms must be determined individually for each indication. This practice will help minimize unexpected adverse events and maximize efficacy, duration, and patient satisfaction. With this approach, BoNT is poised to continue as a unique tool for achieving individual goals for an increasing number of medical and aesthetic indications.
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Affiliation(s)
- Mitchell F. Brin
- AbbVie/Allergan Aesthetics, Irvine, CA 92612, USA; (A.B.-A.); (J.M.)
- Department of Neurology, University of California, Irvine, CA 92697, USA
| | | | | | | | - John Maltman
- AbbVie/Allergan Aesthetics, Irvine, CA 92612, USA; (A.B.-A.); (J.M.)
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Leon J, Rozen TD, Bhatt AA. Onabotulinumtoxina (craniotomy scar combined with cranial suture line injections) for persistent post craniotomy headache: Case series with long-term follow-up. Cephalalgia 2024; 44:3331024241259452. [PMID: 38870368 DOI: 10.1177/03331024241259452] [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: 06/15/2024]
Abstract
BACKGROUND There is no defined preventive treatment protocol for persistent post-craniotomy headache. In several small case series and individual case reports onabotulinumtoxinA injected into the craniotomy scar has shown possible efficacy. What is lacking is long term follow-up and if focusing on the cranial suture lines along with the craniotomy scar can enhance improvement and provide more sustained benefit. METHODS Retrospective chart review with case series. RESULTS Four patients (three women, one man) with ICHD-3 defined persistent post craniotomy headache were treated using a novel onabotulinumtoxinA injection protocol. All the patients presented with continuous head pain of moderate to severe intensity. All had severe allodynia on the side of their craniotomy. All had significant reduction in quality of life. Our application of onabotulinumtoxinA involved injection into both the surgical scar and the transected/irritated cranial suture lines noted on neuroimaging and physical examination. With treatment all patients demonstrated significant benefit including a reduction in daily pain intensity (75%-100%), developing periods of pain freedom (2-7 days per week) and having a dramatic improvement in quality of life (close to 100% in all). The benefit was sustained for at least five years of follow-up. CONCLUSION From our case series it appears that injection not only along the painful craniotomy scar but into the involved cranial suture lines provides positive efficacy and sustained improvement in patients with persistent post craniotomy headache.
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Affiliation(s)
- Janet Leon
- Department of Adolescent and Pediatric Neurology, Mayo Clinic, Jacksonville, FL, USA
| | - Todd D Rozen
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | - Alok A Bhatt
- Department of Neuroradiology, Mayo Clinic, Jacksonville, FL, USA
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Suzuki K, Suzuki S, Fujita H, Sakuramoto H, Shioda M, Hirata K. Can calcitonin gene-related peptide monoclonal antibodies ameliorate writer's cramp and migraine? Neuropsychopharmacol Rep 2024; 44:482-484. [PMID: 38602109 PMCID: PMC11144594 DOI: 10.1002/npr2.12444] [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: 02/21/2024] [Revised: 04/05/2024] [Accepted: 04/07/2024] [Indexed: 04/12/2024] Open
Abstract
Recently, calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAbs) have become available as a prophylactic treatment for migraine and have shown high efficacy and safety in clinical practice. CGRP mAbs have been reported to be effective not only for migraine but also for other comorbidities, such as psychiatric complications in patients with migraine. However, there are no reports examining the effect of CGRP mAbs on dystonia. We treated a patient with comorbid migraine and focal task-specific dystonia (writer's cramp) with a CGRP mAb (erenumab) because of an increase in monthly migraine days despite the addition of migraine prophylaxis. In this patient, erenumab treatment for 3 months led to improvements in symptoms of both focal dystonia and migraine, suggesting a role for CGRP in the pathophysiology of both conditions.
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Affiliation(s)
- Keisuke Suzuki
- Department of NeurologyDokkyo Medical UniversityMibuJapan
| | - Shiho Suzuki
- Department of NeurologyDokkyo Medical UniversityMibuJapan
| | - Hiroaki Fujita
- Department of NeurologyDokkyo Medical UniversityMibuJapan
| | | | - Mukuto Shioda
- Department of NeurologyDokkyo Medical UniversityMibuJapan
| | - Koichi Hirata
- Department of NeurologyDokkyo Medical UniversityMibuJapan
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Salim A, Hennessy E, Sonneborn C, Hogue O, Biswas S, Mays M, Suneja A, Ahmed Z, Mata IF. Synergism of Anti-CGRP Monoclonal Antibodies and OnabotulinumtoxinA in the Treatment of Chronic Migraine: A Real-World Retrospective Chart Review. CNS Drugs 2024; 38:481-491. [PMID: 38583127 PMCID: PMC11098928 DOI: 10.1007/s40263-024-01086-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Many patients with chronic migraine do not achieve clinically meaningful improvement in their headache frequency with monotherapy. The burden associated with chronic migraine calls for a multifaceted treatment approach targeting multiple aspects of migraine pathophysiology. OBJECTIVE The aim of this study was to evaluate the effect of concurrent anti-calcitonin gene-related peptide (CGRP) monoclonal antibody (mAb) and onabotulinumtoxinA (onabot) treatment on median monthly migraine days (MMD) in patients with chronic migraine, through a retrospective study. METHODS The electronic medical records of Cleveland Clinic patients either concurrently (dual therapy) or consecutively (monotherapy) treated with anti-CGRP mAbs and onabot between June 2018 and November 2021 were extracted. Only adult patients (≥ 18 years of age) were included in this study. MMDs for 194 concurrently treated (86.6% female and a median [interquartile range] age of 51 [41-61] years) and 229 consecutively treated (88.2% female and median age of 47 [IQR 39-57] years) patients were examined at baseline, after first therapy of either anti-CGRP mAb or onabot, and following dual therapy for 3 consecutive months. The reduction of MMDs for each treatment group were compared. The same approach was utilized to compare consecutive monotherapy at separate times (n = 229) and dual-therapy groups. RESULTS The initial treatment of the dual-therapy group reduced the median (IQR) MMDs from 30 (30-30) to 15 (12-30) [p < 0.0001]. After initiation of dual therapy, the median MMDs was further decreased from 15 (12-30) to 8 (3-22) [p < 0.0001]. A majority [132/194 (68.0%)] of the dual-therapy patients reported a ≥ 50% reduction in MMD and 90/194 (46.4%) reported a ≥ 75% reduction. For the consecutive monotherapy group, median MMDs changed from a baseline of 30 (25-30) to 15 (8-25) from onabot monotherapy and decreased from 25 (15-30) to 12 (4-25) after anti-CGRP mAb monotherapy. Almost half (113/229 [49.3%] from onabot, and 104/229 [45.4%] from anti-CGRP mAb) of these patients achieved a ≥ 50% reduction in MMDs and a minority (38/229 [16.6%] from onabot, and 45/229 [19.7%] from anti-CGRP mAb) achieved a reduction of ≥ 75%. Additionally, dual therapy showed significant improvement in MMDs compared with monotherapy of either treatment (p < 0.0001). CONCLUSION Dual therapy of anti-CGRP mAbs and onabot may be more efficacious than monotherapy, possibly due to their synergistic mechanisms of action.
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Affiliation(s)
- Amira Salim
- Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
- Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Elise Hennessy
- Neuroscience Institute, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Claire Sonneborn
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Olivia Hogue
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sudipa Biswas
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - MaryAnn Mays
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Aarushi Suneja
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Zubair Ahmed
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ignacio F Mata
- Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA.
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Zeccardi S, Seligman R. Migraine in adults: Overview of pharmacologic treatments. Nurse Pract 2024; 49:14-18. [PMID: 38941074 DOI: 10.1097/01.npr.0000000000000190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
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13
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Ashina S, Robertson CE, Srikiatkhachorn A, Di Stefano G, Donnet A, Hodaie M, Obermann M, Romero-Reyes M, Park YS, Cruccu G, Bendtsen L. Trigeminal neuralgia. Nat Rev Dis Primers 2024; 10:39. [PMID: 38816415 DOI: 10.1038/s41572-024-00523-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2024] [Indexed: 06/01/2024]
Abstract
Trigeminal neuralgia (TN) is a facial pain disorder characterized by intense and paroxysmal pain that profoundly affects quality of life and presents complex challenges in diagnosis and treatment. TN can be categorized as classical, secondary and idiopathic. Epidemiological studies show variable incidence rates and an increased prevalence in women and in the elderly, with familial cases suggesting genetic factors. The pathophysiology of TN is multifactorial and involves genetic predisposition, anatomical changes, and neurophysiological factors, leading to hyperexcitable neuronal states, central sensitization and widespread neural plasticity changes. Neurovascular compression of the trigeminal root, which undergoes major morphological changes, and focal demyelination of primary trigeminal afferents are key aetiological factors in TN. Structural and functional brain imaging studies in patients with TN demonstrated abnormalities in brain regions responsible for pain modulation and emotional processing of pain. Treatment of TN involves a multifaceted approach that considers patient-specific factors, including the type of TN, with initial pharmacotherapy followed by surgical options if necessary. First-line pharmacological treatments include carbamazepine and oxcarbazepine. Surgical interventions, including microvascular decompression and percutaneous neuroablative procedures, can be considered at an early stage if pharmacotherapy is not sufficient for pain control or has intolerable adverse effects or contraindications.
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Affiliation(s)
- Sait Ashina
- BIDMC Comprehensive Headache Center, Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA.
- BIDMC Comprehensive Headache Center, Department of Anaesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA.
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | | | - Anan Srikiatkhachorn
- Faculty of Medicine, King Mongkut's Institute of Technology Ladkrabang, Bangkok, Thailand
| | - Giulia Di Stefano
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Anne Donnet
- Department of Evaluation and Treatment of Pain, FHU INOVPAIN, Centre Hospitalier Universitaire de Marseille, Hopital de la Timone, Assistance Publique-Hopitaux de Marseille, Marseille, France
| | - Mojgan Hodaie
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Ontairo, Canada
| | - Mark Obermann
- Department of Neurology, Hospital Weser-Egge, Hoexter, Germany
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Marcela Romero-Reyes
- Department of Pain and Neural Sciences, Brotman Facial Pain Clinic, University of Maryland, School of Dentistry, Baltimore, MD, USA
| | - Young Seok Park
- Department of Medical Neuroscience, College of Medicine, Chungbuk National University, Cheongju, Republic of Korea
- Department of Neurosurgery, Gamma Knife Icon Center, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Giorgio Cruccu
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Lars Bendtsen
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Department of Neurology, University of Copenhagen, Danish Headache Center, Copenhagen University Hospital - Rigshospitalet, Glostrup, Copenhagen, Denmark
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Karaoğlan M. Addressing limitations of single GON blockade treatment and repetitive intervention with GON block or onabotulinum toxin A in chronic migraine- part 2 of three men in a boat study. Clin Neurol Neurosurg 2024; 240:108242. [PMID: 38518628 DOI: 10.1016/j.clineuro.2024.108242] [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: 02/17/2024] [Revised: 03/09/2024] [Accepted: 03/10/2024] [Indexed: 03/24/2024]
Abstract
This study investigated the effectiveness of three treatment interventions for managing migraine symptoms over a three-month assessment period: single greater occipital nerve block (GON), repetitive GON block, and single GON block combined with onabotulinium toxin A (BoNT-A) treatment. Significant improvements were observed across all treatment groups in various migraine-related parameters, including medication usage, frequency and severity of attacks, and subjective measures such as Headache Impact Test-6 scores and Pittsburgh Sleep Quality Index scores. Notably, all groups showed reductions in NSAID and triptan usage, total number of attacks with VAS>4, and number of headache days. However, slight differences in the magnitude of improvements were observed between the groups, with GON block combined with BoNT-A treatment demonstrating slightly greater reductions compared to single GON block treatment. Additionally, the integration of BoNT-A therapy alongside GON blockade appeared to confer supplementary benefits in migraine prophylaxis. These findings highlight the importance of implementing comprehensive treatment approaches to address various aspects of migraine management and improve patient outcomes.
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Alonge P, Brighina F, Maccora S, Pilati L, Di Marco S, Ventimiglia D, Maggio B, Cutrò I, Camarda C, Torrente A. Beyond Pain: The Effects of OnabotulinumtoxinA Therapy on Sensitization and Interictal Symptoms in Chronic Migraine. Toxins (Basel) 2024; 16:203. [PMID: 38787055 PMCID: PMC11125997 DOI: 10.3390/toxins16050203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/20/2024] [Accepted: 04/22/2024] [Indexed: 05/25/2024] Open
Abstract
Chronic migraine is a disease with a high burden on patients from both a working and quality of life point of view. The pathophysiology of this subtype of migraine is due to several factors, such as medication overuse. Nevertheless, the detrimental recurring of headache attacks with central and peripheral sensitization plays a central role and explains some additional symptoms complained about by these patients even in the interictal phase. OnabotulinumtoxinA is a therapy indicated for chronic migraine since it has proven to reduce peripheral sensitization, showing even efficacy on central symptoms. The aim of this narrative review is to present the current evidence regarding the effect of OnabotulinumtoxinA on sensitization and interictal symptoms.
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Affiliation(s)
- Paolo Alonge
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University of Palermo, 90127 Palermo, Italy; (P.A.); (S.M.); (L.P.); (S.D.M.); (D.V.); (B.M.); (I.C.); (C.C.); (A.T.)
| | - Filippo Brighina
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University of Palermo, 90127 Palermo, Italy; (P.A.); (S.M.); (L.P.); (S.D.M.); (D.V.); (B.M.); (I.C.); (C.C.); (A.T.)
| | - Simona Maccora
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University of Palermo, 90127 Palermo, Italy; (P.A.); (S.M.); (L.P.); (S.D.M.); (D.V.); (B.M.); (I.C.); (C.C.); (A.T.)
- Neurology Unit, ARNAS Civico di Cristina and Benfratelli Hospitals, 90127 Palermo, Italy
| | - Laura Pilati
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University of Palermo, 90127 Palermo, Italy; (P.A.); (S.M.); (L.P.); (S.D.M.); (D.V.); (B.M.); (I.C.); (C.C.); (A.T.)
- Neurology and Stroke Unit, P.O. “S. Antonio Abate”, 91016 Erice, Italy
| | - Salvatore Di Marco
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University of Palermo, 90127 Palermo, Italy; (P.A.); (S.M.); (L.P.); (S.D.M.); (D.V.); (B.M.); (I.C.); (C.C.); (A.T.)
- Neurology and Stroke Unit, P.O. “S. Antonio Abate”, 91016 Erice, Italy
| | - Davide Ventimiglia
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University of Palermo, 90127 Palermo, Italy; (P.A.); (S.M.); (L.P.); (S.D.M.); (D.V.); (B.M.); (I.C.); (C.C.); (A.T.)
| | - Bruna Maggio
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University of Palermo, 90127 Palermo, Italy; (P.A.); (S.M.); (L.P.); (S.D.M.); (D.V.); (B.M.); (I.C.); (C.C.); (A.T.)
| | - Ivana Cutrò
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University of Palermo, 90127 Palermo, Italy; (P.A.); (S.M.); (L.P.); (S.D.M.); (D.V.); (B.M.); (I.C.); (C.C.); (A.T.)
| | - Cecilia Camarda
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University of Palermo, 90127 Palermo, Italy; (P.A.); (S.M.); (L.P.); (S.D.M.); (D.V.); (B.M.); (I.C.); (C.C.); (A.T.)
| | - Angelo Torrente
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University of Palermo, 90127 Palermo, Italy; (P.A.); (S.M.); (L.P.); (S.D.M.); (D.V.); (B.M.); (I.C.); (C.C.); (A.T.)
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Belvís R, Irimia P, González N, García-Ull J, Pozo-Rosich P, López-Bravo A, Morollón N, Quintas S, Plana A, Baz PG, Tentor A, Gallego Artiles N, León FJ, Pérez Martín M, Rivera I, Ramírez R, Colomina I, Lainez JM, Pascual J. Migraine treatment consensus document of the Spanish Society of Neurology (SEN), Spanish Society of Family and Community Medicine (SEMFYC), Society of Primary Care Medicine (SEMERGEN) and Spanish Association of Migraine and Headache (AEMICE) on migraine treatment. Med Clin (Barc) 2024:S0025-7753(24)00137-4. [PMID: 38643025 DOI: 10.1016/j.medcli.2024.02.006] [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: 09/28/2023] [Revised: 01/30/2024] [Accepted: 02/01/2024] [Indexed: 04/22/2024]
Abstract
Migraine is a disease with a high prevalence and incidence, in addition to being highly disabling, causing a great impact on the patient's quality of life at a personal, family and work level, but also social, given its high expense due to its direct (care) and indirect (presenteeism and work absenteeism) costs. The multiple and recent developments in its pathophysiological knowledge and in its therapy require updating and, therefore, in this article the Spanish scientific societies most involved in its study and treatment (SEN, SEMFYC and SEMERGEN), together with the Association Spanish Association for Patients with Migraine and other Headaches (AEMICE), we have developed these updated care recommendations. We reviewed the treatment of migraine attacks, which consisted mainly of the use of NSAIDs and triptans, to which ditans and gepants have been added. We also discuss preventive treatment consisting of oral preventive drugs, botulinum toxin, and treatments that block the action of calcitonin-related peptide (CGRP). Finally, we emphasize that pharmacological treatments must be complementary to carrying out general measures consisting of identifying and managing/deletion the precipitating factors of the attacks and the chronicizing factors, controlling the comorbidities of migraine and eliminating analgesic overuse.
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Affiliation(s)
- Robert Belvís
- Unidad de Cefaleas y Neuralgias, Servicio de Neurología, Hospital de la Santa Creu i Sant Pau. Grupo de Estudio de Cefaleas de la SEN, Barcelona, España.
| | - Pablo Irimia
- Servicio de Neurología, Clínica Universidad de Navarra. Grupo de Estudio de Cefaleas de la SEN, Pamplona, España
| | - Nuria González
- Servicio de Neurología, Hospital Universitario San Carlos. Grupo de Estudio de Cefaleas de la SEN, Madrid, España
| | - Jésica García-Ull
- Servicio de Neurología, Hospital Clínico. Grupo de Estudio de Cefaleas de la SEN, Valencia, España
| | - Patricia Pozo-Rosich
- Unidad de Cefalea y Grupo de Investigación en Cefalea, Servicio de Neurología, Hospital Vall d'Hebron y Vall d'Hebron Institut de Recerca (VHIR), Universitat Autònoma de Barcelona. Grupo de Estudio de Cefaleas de la SEN, Barcelona, España
| | - Alba López-Bravo
- Unidad de Cefaleas, Sección de Neurología, Hospital Reina Sofía. Instituto de Investigación Sanitaria de Aragón (IIS-A). Grupo de Estudio de Cefaleas de la SEN, Tudela, Navarra, España
| | - Noemí Morollón
- Unidad de Cefaleas y Neuralgias, Servicio de Neurología, Hospital de la Santa Creu i Sant Pau. Grupo de Estudio de Cefaleas de la SEN, Barcelona, España
| | - Sonia Quintas
- Servicio de Neurología, Hospital de La Princesa. Grupo de Estudio de Cefaleas de la SEN, Madrid, España
| | - Antoni Plana
- ABS Balàfia-Pardinyes-Secà de Sant Pere de Lleida, Àmbit Lleida. Institut Català de la Salut (ICS). Grupo de Trabajo de Neurología SEMFYC, Lleida, España
| | | | | | | | - Francisco Javier León
- Centro de Salut Dúrcal, Distrito Sanitario Granada Metropolitano. Grupo de Trabajo de Neurología SEMFYC, Granada, España
| | | | - Inés Rivera
- C.S. Barranco Grande, Santa Cruz de Tenerife, España
| | - Raquel Ramírez
- Servicio de Medicina de Familia, Clínica Universitaria de Navarra, Madrid, España
| | | | - José Miguel Lainez
- Servicio de Neurología, Hospital Clínico. Grupo de Estudio de Cefaleas de la SEN, Valencia, España
| | - Julio Pascual
- Servicio de Neurología, Hospital Marqués de Valdecilla, Universidad de Cantabria e IDIVAL. Grupo de Estudio de Cefaleas de la SEN, Santander, España
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Oliveira R, Gil-Gouveia R, Puledda F. CGRP-targeted medication in chronic migraine - systematic review. J Headache Pain 2024; 25:51. [PMID: 38575868 PMCID: PMC10996229 DOI: 10.1186/s10194-024-01753-y] [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: 11/12/2023] [Accepted: 03/18/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Chronic migraine is a highly debilitating condition that is often difficult to manage, particularly in the presence of medication overuse headache. Drugs targeting the calcitonin gene-related peptide (CGRP), or its receptor have shown promising results in treating this disorder. METHODS We searched Pubmed and Embase to identify randomized clinical trials and real-world studies reporting on the use of medication targeting the calcitonin gene-related peptide in patients with chronic migraine. RESULTS A total of 270 records were identified. Nineteen studies qualified for the qualitative analysis. Most studies reported on monoclonal antibodies targeting CGRP (anti-CGRP mAbs), that overall prove to be effective in decreasing monthly migraine days by half in about 27.6-61.4% of the patients. Conversion from chronic to episodic migraine was seen in 40.88% of the cases, and 29-88% of the patients stopped medication overuse. Obesity seems to be the main negative predictor of response to anti-CGRP mAbs. There is no evidence to suggest the superiority of one anti-CGRP mAb. Despite the lack of strong evidence, the combination of anti-CGRP medication with onabotulinumtoxinA in chronic migraine is likely to bring benefits for resistant cases. Atogepant is the first gepant to demonstrate a significant decrease in monthly migraine days compared to placebo in a recent trial. Further, anti-CGRP mAb and gepants have a good safety profile. CONCLUSION There is strong evidence from randomized trials and real-world data to suggest that drugs targeting CGRP are a safe and effective treatment for chronic migraine.
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Affiliation(s)
- Renato Oliveira
- Headache Group, Wolfson SPaRRC, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 9PJ, UK
- Neurology Department, Barking, Havering and Redbridge University Hospitals NHS Foundation Trust, London, UK
| | - Raquel Gil-Gouveia
- Hospital da Luz Headache Center, Neurology Department, Hospital da Luz Lisboa, Lisbon, Portugal
- Center for Interdisciplinary Research in Health, Universidade Católica Portuguesa, Lisbon, Portugal
| | - Francesca Puledda
- Headache Group, Wolfson SPaRRC, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 9PJ, UK.
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Pellesi L, Ashina M, Martelletti P. Targeting the PACAP-38 pathway is an emerging therapeutic strategy for migraine prevention. Expert Opin Emerg Drugs 2024; 29:57-64. [PMID: 38337150 DOI: 10.1080/14728214.2024.2317778] [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: 01/13/2024] [Accepted: 02/08/2024] [Indexed: 02/12/2024]
Abstract
INTRODUCTION The pituitary adenylate cyclase-activating polypeptide-38 (PACAP-38) has emerged as a key mediator of migraine pathogenesis. PACAP-38 and its receptors are predominantly distributed in arteries, sensory and parasympathetic neurons of the trigeminovascular system. Phase 2 trials have tested human monoclonal antibodies designed to bind and inhibit PACAP-38 and the pituitary adenylate cyclase-activating polypeptide type I (PAC1) receptor for migraine prevention. AREAS COVERED This review focuses on the significance of the PACAP-38 pathway as a target in migraine prevention. English peer-reviewed articles were searched in PubMed, Scopus and ClinicalTrials.gov electronic databases. EXPERT OPINION A PAC1 receptor monoclonal antibody was not effective for preventing migraine in a proof-of-concept trial, paving the way for alternative strategies to be considered. Lu AG09222 is a humanized monoclonal antibody targeting PACAP-38 that was effective in preventing physiological responses of PACAP38 and reducing monthly migraine days in individuals with migraine. Further studies are necessary to elucidate the clinical utility, long-term safety and cost-effectiveness of therapies targeting the PACAP pathway.
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Affiliation(s)
- Lanfranco Pellesi
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Messoud Ashina
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Paolo Martelletti
- School of Health Sciences, Unitelma Sapienza University of Rome, Rome, Italy
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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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Lucchese S, Daripa B, Pulimamidi S. A Retrospective Comparison of Onabotulinum Toxin A and Incobotulinum Toxin A in Terms of Efficacy, Tolerability, Duration of Effect, and Pain on Injection Administration Site for the Treatment of Chronic Migraine. Cureus 2024; 16:e53969. [PMID: 38468997 PMCID: PMC10927020 DOI: 10.7759/cureus.53969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2024] [Indexed: 03/13/2024] Open
Abstract
Background Onabotulinum toxin A (OnA) is a well-tolerated and effective treatment for chronic migraine (CM). However, based on research indications that incobotulinum toxin A (InA) would be equally effective, a Veterans Health Administration medical center mandated a two-year trial of InA as a more cost-effective alternative to OnA. Although InA is used for many similar indications as OnA, it is not Food and Drug Administration-approved for treating CM, and complications occurred in several patients with CM following this treatment change. We conducted this retrospective analysis to evaluate differences in the efficacy of OnA and InA and identify the reasons for the adverse effects of InA in some of these patients. Methods We performed a retrospective review of 42 patients who had been effectively treated with OnA and were then switched to InA. The differences between treatment responses to OnA and InA were assessed through the evaluation of pain on injection, number of headache days, and duration of action. Patients received injections at 10- to 13-week intervals. Those who reported severe pain on injection of InA were switched back to OnA. Results Severe burning pain on InA injection was reported by 38% of patients (nine males and seven females, i.e., a total of 16 patients out of 42 patients). One male patient reported the same degree of pain from both InA and OnA injections. A total of 66.7% of women with obesity and 83.3% of men with obesity or diabetes experienced severe pain on injection. Neither migraine suppression nor the duration of effect was significantly different between OnA and InA. Conclusions OnA is better tolerated than InA in the treatment of CM. InA appears to effectively suppress migraines, but some patients complain of a severe localized burning sensation during the injections. Some of these patients, all of whom were previously treated with OnA, requested to switch back to OnA. This suggested that InA is not equivalent to OnA in terms of tolerability and effectiveness. The present study found 2.38% of patients experienced an insufficient duration of effect with InA, and none with OnA. However, these lower rates may, in part, be due to variability in injection intervals in this sample, which could be because of scheduling considerations at the Harry S. Truman Veterans Health Administration Medical Center. In cases where OnA fails because of the development of antibodies, it might be reasonable to switch to InA treatment. Reformulation of InA with a pH-buffered solution may eliminate the difference in pain on injection. InA would then be a good alternative to OnA for treating CM.
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Affiliation(s)
- Scott Lucchese
- Neurology/Headache Medicine, University of Arkansas for Medical Sciences, Little Rock, USA
- Neurology, University of Missouri School of Medicine, Columbia, USA
| | - Bob Daripa
- Internal Medicine/Neurology, Singapore General Hospital, Singapore, SGP
- Neurology, University Hospital, Columbia, USA
- Internal Medicine/Neurology, Grant Medical College and Sir J.J. Group of Hospitals, Mumbai, IND
| | - Shruthi Pulimamidi
- Internal Medicine, University of Missouri School of Medicine, Columbia, USA
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Gandara CK, Palacios JL, Luis Quintanar J, Zhang Y, Li X, Munoz A. Improvement of neurogenic urinary dysfunctions in female rats treated with an injection of botulinum toxin A at the epicenter of the spinal cord injured site. Neurourol Urodyn 2024; 43:246-257. [PMID: 37901953 DOI: 10.1002/nau.25311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 09/25/2023] [Accepted: 10/11/2023] [Indexed: 10/31/2023]
Abstract
OBJECTIVE To assess the effect of an injection of botulinum toxin A (BoNT/A) at the epicenter of the spinal cord injury (SCI) site on the recovery of lower urinary tract function in female rats with thoracic SCI. MATERIALS AND METHODS Twenty-four female Wistar rats with Sham (laminectomy at T8/T9 level) or SCI (at T8/T9; 30 g compression for 5 s) were assigned into Sham-SS (injected with 5 µL of saline solution), Sham-BoNT/A (injected with 15 pg/rat, equivalent to 7.5 Units/kg of BoNT/A in 5 µL volume), SCI-SS (injured and injected with saline), SCI-BoNT/A (injured and injected with BoNT/A), N = 6 per group. Weekly evaluation of stereotyped micturition behavior, hind-limb nociception, and locomotor activity was performed 1 week before and during 6 weeks after surgery. Subsequently, all groups underwent simultaneous electromyography of the external urethral sphincter (EUS-EMG) and cystometric (CMG) studies. RESULTS A compression SCI at the T8/T9 thoracic level significantly impairs sensory and locomotive functions, as well as stereotyped micturition behavior. However, these impairments were improved by BoNT/A injection after SCI. Neither injections of saline solution nor BoNT/A had an appreciable effect on the same parameters evaluated in the Sham groups. The combined EUS-EMG and CMG evaluations revealed important improvements of lower urinary tract physiology, particularly a reduction in the frequency of non-voiding contractions and the properties of EUS bursting activity indicated as the amplitude of the EUS-EMG signal and duration of burst electrical activity during effective voiding. CONCLUSION The severe impairments on sensory and locomotive functions as well stereotyped micturition caused by an SCI could be potentially attenuated by an injection of a small amount of BoNT/A directly into the epicenter of the SCI region. A reduction in the release of neurotoxic neurotransmitters requiring the SNARE complex may be the mechanism triggered by BoNT/A to reduce neurotoxicity and hyperexcitability created in the SCI area to improve the survival of spinal cord cells involved in micturition.
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Affiliation(s)
- Cynthia K Gandara
- Centro Universitario del Norte, Universidad de Guadalajara, Colotlán, Jalisco, México
| | - Jose L Palacios
- Facultad de Ciencias para el Desarrollo Humano, Universidad Autónoma de Tlaxcala, Tlaxcala, Tlaxcala, Mexico
| | - J Luis Quintanar
- Centro de Ciencias Básicas, Universidad Autónoma de Aguascalientes, Aguascalientes, Aguascalientes, México
| | - Yingchun Zhang
- Department of Biomedical Engineering, University of Houston, Houston, Texas, USA
| | - Xuhong Li
- Department of Rehabilitation Medicine, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Alvaro Munoz
- Centro Universitario del Norte, Universidad de Guadalajara, Colotlán, Jalisco, México
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22
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Yu WR, Kuo HC. Multimodal therapies and strategies for the treatment of interstitial cystitis/bladder pain syndrome in Taiwan. Low Urin Tract Symptoms 2024; 16:e12508. [PMID: 37987028 DOI: 10.1111/luts.12508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/03/2023] [Accepted: 11/09/2023] [Indexed: 11/22/2023]
Abstract
Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic disease characterized by bladder pain, frequency, and nocturia. The most common pathologies include chronic inflammation and bladder urothelium dysfunction. According to the bladder condition with or without Hunner's lesions, IC/BPS can be divided into "IC" in patients with Hunner's lesion (HIC) and "BPS" in those without Hunner's lesion (NHIC). Previous studies have reported greater central sensitization and interorgan cross-talk in patients with NHIC. Multimodal treatments have been recommended in clinical guidelines under the biopsychosocial model. The bladder-gut-brain axis has also been speculated, and multimodal therapies are necessary. Unfortunately, currently, no treatment has been reported durable for IC/BPS. Patients with IC/BPS usually experience anxiety, depression, holistic physical responses, and even threats to social support systems. The lack of durable treatment outcomes might result from inadequate diagnostic accuracy and differentiation of clinical phenotypes based on the underlying pathophysiology. Precision assessment and treatment are essential for optimal therapy under definite IC/BPS phenotype. This article reviewed currently available literature and proposed a diagnosis and treatment algorithm. Based on bladder therapy combined with suitable physical and psychological therapies, a well-grounded multimodal therapy and treatment algorithm for IC/BPS following a diagnostic protocol are indispensable.
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Affiliation(s)
- Wan-Ru Yu
- Department of Nursing, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
- Department of Urology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Hann-Chorng Kuo
- Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
- Department of Urology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
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23
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Corasaniti MT, Lawrence GW, Bagetta G, Iannacchero R, Tarsitano A, Monteleone A, Pagliaro M, Tonin P, Sandrini G, Nicotera P, Scuteri D. Combination of anti-CGRP/CGRP-R mAbs with onabotulinumtoxin A as a novel therapeutic approach for refractory chronic migraine: a retrospective study of real-world clinical evidence and a protocol for a double-blind, randomized clinical trial to establish the efficacy and safety. Front Pharmacol 2023; 14:1296577. [PMID: 38152694 PMCID: PMC10751376 DOI: 10.3389/fphar.2023.1296577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 11/22/2023] [Indexed: 12/29/2023] Open
Abstract
Chronic migraine is a disabling neurovascular disorder that ranks amongst the top causes of years lived with disability worldwide. The duration and the frequency of migraine affect cognitive and affective domains, inducing worsening of memory, executive functions, orientation and causing anxiety. Population-based studies report a worrying level of resistance to treatments. Therefore, this study aims: 1) to assess efficacy of monoclonal antibodies (mAbs) directed towards the calcitonin gene-related peptide (CGRP) or its receptor (CGRP-R) for chronic migraine resistant to current preventatives; 2) to design a clinical trial protocol to evaluate the efficacy and safety of combination therapy utilizing anti-CGRP/CGRP-R together with onabotulinumtoxin A in patients suffering from resistant chronic migraine; 3) to provide a molecular rationale for combination therapy. A controlled trial is warranted as pooled analysis of real-world data from our group highlighted that combined treatment provides ≥50% reduction vs. baseline (onabotulinumtoxin A) of monthly headache days (MHDs) in up to 58.8% of patients, but there has been only sparse application of this combined therapy to date. The mAbs chosen are: erenumab, because its combination effect with onabotulinumtoxin A improved symptoms in 65% of patients; eptinezumab, due to its faster action. The results highlight that early diagnosis of migraine improves therapeutic outcomes with mAbs alone, confirming their effectiveness and the need for an adequately powered clinical trial evaluating the safety and potential superior effectiveness of eptinezumab/erenumab and onabotulinumtoxin A together.
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Affiliation(s)
- M. T. Corasaniti
- Department of Health Sciences, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - G. W. Lawrence
- Department of Biotechnology, Dublin City University, Dublin, Ireland
| | - G. Bagetta
- Pharmacotechnology Documentation and Transfer Unit, Preclinical and Translational Pharmacology, Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy
| | - R. Iannacchero
- Department of Neurology, Headache Center, Regional Hospital “Pugliese-Ciaccio”, Catanzaro, Italy
| | - A. Tarsitano
- Pain Therapy Center, Provincial Health Authority (ASP), Cosenza, Italy
| | - A. Monteleone
- Pharmacotechnology Documentation and Transfer Unit, Preclinical and Translational Pharmacology, Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy
| | - M. Pagliaro
- Pharmacotechnology Documentation and Transfer Unit, Preclinical and Translational Pharmacology, Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy
| | - P. Tonin
- Regional Center for Serious Brain Injuries, S. Anna Institute, Crotone, Italy
| | - G. Sandrini
- Department of Brain and Behavioral Sciences, IRCCS C. Mondino Foundation Neurologic Institute, University of Pavia, Pavia, Italy
| | - P. Nicotera
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - D. Scuteri
- Pharmacotechnology Documentation and Transfer Unit, Preclinical and Translational Pharmacology, Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy
- Regional Center for Serious Brain Injuries, S. Anna Institute, Crotone, Italy
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24
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Morse BL, Karian V. Supporting the Young Adulthood Transitions in Women With Migraine. Nurs Womens Health 2023; 27:457-466. [PMID: 37804861 DOI: 10.1016/j.nwh.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/01/2023] [Accepted: 09/13/2023] [Indexed: 10/09/2023]
Abstract
Migraine is a painful neurological disorder that disproportionately affects women and has a significant impact on quality of life. This article summarizes the critical role of women's health nurses in supporting young adult women with migraine during major life transitions. Nurses can advocate for workplace or school disability accommodations for women with migraine. Nurses can also support young adult women with migraine by providing education about available treatment that becomes available after an individual's 18th birthday. Women's health nurses can also provide counseling on healthy lifestyle habits to sustain through life transitions, such as guidance on safe alcohol consumption and wellness approaches to migraine management. Through these interventions, women's health nurses can help women with migraine to succeed personally, professionally, and academically while effectively managing migraine symptoms.
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25
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Karian V, Morton H, Schefter ZJ, Smith A, Rogan H, Morse B, LeBel A. OnabotulinumtoxinA for Pediatric Migraine. Pain Manag Nurs 2023; 24:610-616. [PMID: 37183070 DOI: 10.1016/j.pmn.2023.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 04/08/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND Migraine is a painful, prevalent, and problematic condition among children. Children need access to safe and effective treatment options to alleviate the impact of this chronic condition on their wellbeing. CLINICAL IMPLICATIONS Nurses have a crucial role in supporting patient access to BTX-A. Given the results of this and other studies demonstrating the safety and efficacy of BTX-A in children, nurses can support policy change for health plans to fund this intervention for pediatric migraineurs. Allowing children to receive the safe and effective BTX-A injections will lessen the already significant impact of chronic migraine on their physical, emotional and mental health. Nurses can also play a key role in providing education to patients regarding safe administration of BTX-A for migraine. AIM The objective of this study was to define the experiences, effects, and clinical response of children to onabotulinumtoxinA (BTX-A) for migraine prevention. METHODS Clinical documentation for patients aged 13-17 years presenting for BTX-A treatment for chronic migraine between 2016-2022 in a community-based specialty clinic within a large, urban, pediatric academic medical center were included. A series of one-way repeated measures (analysis of variance [ANOVA]) were conducted to compare headache frequency, severity, and duration at baseline, and following first and second injections of BTX-A. RESULTS Of 32 eligible participants, administration of BTX-A demonstrated a decrease in headache frequency and severity. Participants reported nearly seven fewer headache days per month. Participants reported neck stiffness, fever or flu-like symptoms, fatigue, and worsening pain following BTX-A administration. CONCLUSIONS Pediatric migraineurs need therapies that are safe, effective, and accessible. BTX-A was a safe and effective treatment for migraine among the children included in this study.
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Affiliation(s)
- Victoria Karian
- Pediatric Headache Program, Division of Pain Medicine, Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Hannah Morton
- Pediatric Headache Program, Division of Pain Medicine, Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Zoë J Schefter
- Pediatric Headache Program, Division of Pain Medicine, Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Allison Smith
- Pediatric Headache Program, Division of Pain Medicine, Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Hannah Rogan
- Pediatric Headache Program, Division of Pain Medicine, Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Brenna Morse
- Pediatric Headache Program, Division of Pain Medicine, Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts; School of Nursing, MGH Institute of Health Professions, Boston, Massachusetts.
| | - Alyssa LeBel
- Pediatric Headache Program, Division of Pain Medicine, Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts; Department of Anesthesia, Harvard Medical School, Boston, Massachusetts
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26
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Ceccardi G, Schiano di Cola F, Caratozzolo S, Di Pasquale M, Bolchini M, Padovani A, Rao R. Onabotulinumtoxin-A: Previous Prophylactic Treatment Might Improve Subsequent Anti-CGRP Monoclonal Antibodies Response in Patients with Chronic Migraine. Toxins (Basel) 2023; 15:677. [PMID: 38133181 PMCID: PMC10747467 DOI: 10.3390/toxins15120677] [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: 10/08/2023] [Revised: 11/27/2023] [Accepted: 11/28/2023] [Indexed: 12/23/2023] Open
Abstract
The aim of the present study was to evaluate whether previous preventive treatment with onabotulinumtoxin-A might influence subsequent clinical response following a switch to anti-CGRP monoclonal antibodies (mAbs). The present retrospective study was conducted at the Headache Centre-Neurology Clinic at the Spedali Civili Hospital of Brescia between November 2018 and May 2023. The primary objective was to assess clinical outcome (monthly headache days (MHDs), monthly migraine days (MMDs), mean analgesics consumption, and clinical disability according to Migraine Disability Assessment (MIDAS)) following three months (T3) of preventive treatment with anti-CGRP mAbs comparing patients who did and those who did not previously receive treatment with Onabotulinumtoxin-A. Moreover, we aimed to evaluate whether the clinical response to anti-CGRP mAbs was affected by the number of previous Onabotulinumtoxin-A administrations. At T3, compared to Onabotulinumtoxin-A naïve patients, patients who previously received Onabotulinumtoxin-A documented fewer MMDs (3.3 ± 3.7 versus 5.2 ± 5.0; p = 0.017) and a lower MIDAS score (23.2 ± 20.9 versus 37.4 ± 39.6; p = 0.013). Patients who received at least 3 onabotulinumtoxin-A administrations documented, at T3, lower MMDs compared to those who received fewer cycles (respectively, 2.1 ± 2.7 vs. 6.5 ± 4.4; p = 0.024). In conclusion, according to our data, previous treatment with onabotulinumtoxin-A might improve subsequent response to anti-CGRP mAbs preventive treatment.
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Affiliation(s)
| | - Francesca Schiano di Cola
- Department of Care Continuity and Frialty, Neurology Unit, University of Brescia, 25128 Brescia, Italy; (G.C.); (A.P.); (R.R.)
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27
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Pellesi L. Combining onabotulinumtoxin A with a CGRP antagonist for chronic migraine prophylaxis: where do we stand? FRONTIERS IN PAIN RESEARCH 2023; 4:1292994. [PMID: 37965209 PMCID: PMC10641512 DOI: 10.3389/fpain.2023.1292994] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 10/17/2023] [Indexed: 11/16/2023] Open
Affiliation(s)
- Lanfranco Pellesi
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
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28
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Raman S, Yamamoto Y, Suzuki Y, Matsuka Y. Mechanism and clinical use of botulinum neurotoxin in head and facial region. J Prosthodont Res 2023; 67:493-505. [PMID: 36740263 DOI: 10.2186/jpr.jpr_d_22_00238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE Botulinum neurotoxin (BoNT) is a biological toxin produced by Clostridium botulinum. BoNT is a potent toxin extensively used in therapeutic interventions. This review provides an updated overview of the mechanisms of action and clinical applications of BoNT in head and facial region. STUDY SELECTION MEDLINE/PubMed searches were conducted using the terms "botulinum neurotoxin" and "dentistry" along with a combination of other related terms. In addition, studies were manually selected from reference lists of the selected articles. RESULTS The Food and Drug Administration in the United States initially approved BoNT to treat strabismus, blepharospasm, and hemifacial spasms. The use of BoNT in dermatology and cosmetics has been widely established and has created a revolution in these fields. Over the years, its applications in various medical specialties have expanded widely. Owing to its safety, efficacy, and long duration of action, it is well-accepted by patients. BoNT/A and BoNT/B are widely used in clinical practice. Several off-label uses of BoNT in the dental fraternity have yielded promising results. We have elaborated on the speculated mechanism of action, dosage, effective sites of injection, and adverse effects of each therapeutic application. The various clinical indications for BoNT include bruxism, myofascial pain, temporomandibular joint dislocation, hemifacial pain, orofacial dystonia, facial paralysis, chronic migraine, and trigeminal neuralgia. CONCLUSIONS BoNT is a safe treatment that can be used effectively, provided that the clinician has adequate knowledge regarding the mechanism, injection techniques, and local and systemic side effects and that it is administered cautiously and purposefully.
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Affiliation(s)
- Swarnalakshmi Raman
- Department of Stomatognathic Function and Occlusal Reconstruction, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Yumiko Yamamoto
- Department of Bacteriology, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Yoshitaka Suzuki
- Department of Stomatognathic Function and Occlusal Reconstruction, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Yoshizo Matsuka
- Department of Stomatognathic Function and Occlusal Reconstruction, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
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Blumenfeld AM, Lipton RB, Silberstein S, Tepper SJ, Charleston L, Landy S, Kuruvilla DE, Manack Adams A. Multimodal Migraine Management and the Pursuit of Migraine Freedom: A Narrative Review. Neurol Ther 2023; 12:1533-1551. [PMID: 37542624 PMCID: PMC10444724 DOI: 10.1007/s40120-023-00529-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 07/21/2023] [Indexed: 08/07/2023] Open
Abstract
Migraine is a neurologic disease with a complex pathophysiology that can be controlled with current treatment options but not cured. Therefore, treatment expectations are highly variable. The concept of migraine freedom was recently introduced and can mean different things, with some, for example, expecting complete freedom from headache and associated symptoms and others accepting the occasional migraine attack if it does not impact functioning. Therefore, migraine management should be optimized so that patients can have the best opportunity to achieve their optimal treatment goals. With migraine freedom as a goal and, given the complex pathophysiology of migraine and the high incidence of comorbidities among individuals with migraine, treatment with a single modality may be insufficient, as it may not achieve migraine freedom in those with more frequent or disabling attacks. In this clinical perspective article, we have identified four key, partially overlapping principles of multimodal migraine treatment: (1) manage common comorbidities; (2) control modifiable risk factors for progression by addressing medication and caffeine overuse; (3) diagnose and treat secondary causes of headache, if present; and (4) individualize acute and preventive treatments to minimize pain, functional disability, and allodynia. There are many barriers to pursuing migraine freedom, and strategies to overcome them should be optimized. Migraine freedom should be an aspirational goal both at the individual attack level and for the disease overall. We believe that a comprehensive and multimodal approach that addresses all barriers people with migraine face could move patients closer to migraine freedom.
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Affiliation(s)
| | | | | | - Stewart J Tepper
- New England Institute for Neurology and Headache, Stamford, CT, USA
| | - Larry Charleston
- Department of Neurology and Ophthalmology, Michigan State University College of Human Medicine, East Lansing, MI, USA
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30
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Juhasz G, Gecse K, Baksa D. Towards precision medicine in migraine: Recent therapeutic advances and potential biomarkers to understand heterogeneity and treatment response. Pharmacol Ther 2023; 250:108523. [PMID: 37657674 DOI: 10.1016/j.pharmthera.2023.108523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 08/11/2023] [Accepted: 08/29/2023] [Indexed: 09/03/2023]
Abstract
After 35 years since the introduction of the International Classification of Headache Disorders (ICHD), we are living in the era of the second great revolution in migraine therapies. First, discoveries of triptans provided a breakthrough in acute migraine treatment utilizing bench-to-bedside research results on the role of serotonin in migraine. Next, the discovery of the role of neuropeptides, more specifically calcitonin gene-related peptide (CGRP) in migraine attack led to the development of anti-CGRP therapies that are effective both in acute and preventive treatment, and are also able to reduce migraine-related burden. Here, we reviewed the most recent clinical studies and real-world data on available migraine-specific medications, including triptans, ditants, gepants and anti-CGRP monoclonal antibodies. Novel drug targets, such as PACAP and amylins were also discussed. To address the main challenges of migraine therapy, the high heterogeneity of people with migraine, the prevalent presence of various comorbid disorders, and the insufficient medical care of migraine patients were covered. Promising novel approaches from the fields of omics, blood and saliva biomarker, imaging and provocation studies might bring solutions for these challenges with the potential to identify further drug targets, distinguish more homogeneous patient subgroups, contribute to more optimal drug selection strategies, and detect biomarkers in association with headache features or predicting treatment efficacy. In the future, the combined analysis of data of different biomarker modalities with machine learning algorithms may serve precision medicine in migraine treatment.
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Affiliation(s)
- Gabriella Juhasz
- Department of Pharmacodynamics, Faculty of Pharmaceutical Sciences, Semmelweis University, Budapest, Hungary; NAP3.0 Neuropsychopharmacology Research Group, Hungarian Brain Research Program, Semmelweis University, Budapest, Hungary.
| | - Kinga Gecse
- Department of Pharmacodynamics, Faculty of Pharmaceutical Sciences, Semmelweis University, Budapest, Hungary; NAP3.0 Neuropsychopharmacology Research Group, Hungarian Brain Research Program, Semmelweis University, Budapest, Hungary
| | - Daniel Baksa
- Department of Pharmacodynamics, Faculty of Pharmaceutical Sciences, Semmelweis University, Budapest, Hungary; NAP3.0 Neuropsychopharmacology Research Group, Hungarian Brain Research Program, Semmelweis University, Budapest, Hungary; Department of Personality and Clinical Psychology, Institute of Psychology, Faculty of Humanities and Social Sciences, Pazmany Peter Catholic University, Budapest, Hungary
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31
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Kaji R. A look at the future-new BoNTs and delivery systems in development: What it could mean in the clinic. Toxicon 2023; 234:107264. [PMID: 37657515 DOI: 10.1016/j.toxicon.2023.107264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 08/07/2023] [Accepted: 08/22/2023] [Indexed: 09/03/2023]
Abstract
Despite the expanding clinical utility of botulinum neurotoxins, there remain problems to be solved for attaining the best outcome. The efficacy and safety need to be reconsidered for commercially available preparations all derived from subtype A1 or B1. Emerging new toxins include A2 or A6 subtypes or engineered toxins with less spread, more potency, longer durations of action, less antigenicity and better safety profile than currently used preparations. Non-toxic BoNTs with a few amino acid replacements of the light chain (LC) may have a role as a drug-delivery system if the toxicity is abolished entirely. At present, efficacy of these BoNTs in animal botulism was demonstrated.
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Affiliation(s)
- Ryuji Kaji
- Tokushima University, Department of Clinical Neuroscience, 2-50-1 Kuramoto-cho, Tokushima, 770-8503, Japan.
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Torrente A, Alonge P, Pilati L, Gagliardo A, Vassallo L, Di Stefano V, Lupica A, Quartana I, Viticchi G, Silvestrini M, Bartolini M, Camarda C, Brighina F. Effects of a Single Session of OnabotulinumtoxinA Therapy on Sleep Quality and Psychological Measures: Preliminary Findings in a Population of Chronic Migraineurs. Toxins (Basel) 2023; 15:527. [PMID: 37755953 PMCID: PMC10537449 DOI: 10.3390/toxins15090527] [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: 07/10/2023] [Revised: 08/09/2023] [Accepted: 08/24/2023] [Indexed: 09/28/2023] Open
Abstract
Chronic migraine is a burdensome condition, and onabotulinumtoxinA is revealed to be an effective therapy. Migraine shows a bidirectional relationship with sleep, but the effects of preventive therapies on sleep quality are poorly studied. This study aims to evaluate the effects of a single session of onabotulinumtoxinA on patients' sleep quality and correlates the results with measures of comorbid anxiety/depression. Patients completed self-administrable questionnaires about sleep quality (Pittsburgh Sleep Quality Index-PSQI) and psychological symptoms (Beck Depression Inventory, 2nd edition-BDI-II-and Hospital Anxiety and Depression Scale-HADS-subscales "a" and "d" for anxiety and depression, respectively), and reported migraine frequency at baseline and after 12 weeks. The 42 included patients showed a significant reduction in migraine days (from 20.6 ± 6.0 to 13.6 ± 6.2, p < 0.001), while no changes were observed in sleep quality (PSQI score from 11.0 ± 5.0 to 9.8 ± 4.6, p = 0.277) or psychological measures (BDI-II from 16.7 ± 10.2 to 15.7 ± 10.3, p = 0.678; HADS-a from 10.3 ± 4.8 to 9.3 ± 5.5, p = 0.492; and HADS-d from 7.2 ± 3.9 to 7.1 ± 5.0, p = 0.901). On the other hand, a strong correlation among PSQI, BDI-II, HADS-a, and HADS-d scores (p < 0.001, rho > 0.7) was found. Despite its efficacy in migraine prevention, a single session of onabotulinumtoxinA was not able to affect patients' sleep quality or their psychological symptoms.
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Affiliation(s)
- Angelo Torrente
- Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, 90127 Palermo, Italy; (A.T.); (P.A.); (L.P.); (A.G.); (L.V.); (V.D.S.); (A.L.); (I.Q.); (C.C.)
| | - Paolo Alonge
- Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, 90127 Palermo, Italy; (A.T.); (P.A.); (L.P.); (A.G.); (L.V.); (V.D.S.); (A.L.); (I.Q.); (C.C.)
| | - Laura Pilati
- Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, 90127 Palermo, Italy; (A.T.); (P.A.); (L.P.); (A.G.); (L.V.); (V.D.S.); (A.L.); (I.Q.); (C.C.)
| | - Andrea Gagliardo
- Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, 90127 Palermo, Italy; (A.T.); (P.A.); (L.P.); (A.G.); (L.V.); (V.D.S.); (A.L.); (I.Q.); (C.C.)
- Clinical Neurophysiology Unit, Sleep Lab, “Clinical Course”, 90143 Palermo, Italy
| | - Lavinia Vassallo
- Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, 90127 Palermo, Italy; (A.T.); (P.A.); (L.P.); (A.G.); (L.V.); (V.D.S.); (A.L.); (I.Q.); (C.C.)
| | - Vincenzo Di Stefano
- Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, 90127 Palermo, Italy; (A.T.); (P.A.); (L.P.); (A.G.); (L.V.); (V.D.S.); (A.L.); (I.Q.); (C.C.)
| | - Antonino Lupica
- Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, 90127 Palermo, Italy; (A.T.); (P.A.); (L.P.); (A.G.); (L.V.); (V.D.S.); (A.L.); (I.Q.); (C.C.)
| | - Irene Quartana
- Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, 90127 Palermo, Italy; (A.T.); (P.A.); (L.P.); (A.G.); (L.V.); (V.D.S.); (A.L.); (I.Q.); (C.C.)
| | - Giovanna Viticchi
- Neurological Clinic, Marche Polytechnic University, 60020 Ancona, Italy; (G.V.); (M.S.); (M.B.)
| | - Mauro Silvestrini
- Neurological Clinic, Marche Polytechnic University, 60020 Ancona, Italy; (G.V.); (M.S.); (M.B.)
| | - Marco Bartolini
- Neurological Clinic, Marche Polytechnic University, 60020 Ancona, Italy; (G.V.); (M.S.); (M.B.)
| | - Cecilia Camarda
- Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, 90127 Palermo, Italy; (A.T.); (P.A.); (L.P.); (A.G.); (L.V.); (V.D.S.); (A.L.); (I.Q.); (C.C.)
| | - Filippo Brighina
- Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, 90127 Palermo, Italy; (A.T.); (P.A.); (L.P.); (A.G.); (L.V.); (V.D.S.); (A.L.); (I.Q.); (C.C.)
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Manack Adams A, Hutchinson S, Engstrom E, Ayasse ND, Serrano D, Davis L, Sommer K, Contreras-De Lama J, Lipton RB. Real-world effectiveness, satisfaction, and optimization of ubrogepant for the acute treatment of migraine in combination with onabotulinumtoxinA: results from the COURAGE Study. J Headache Pain 2023; 24:102. [PMID: 37537578 PMCID: PMC10399003 DOI: 10.1186/s10194-023-01622-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/26/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Individuals using onabotulinumtoxinA as a preventive migraine treatment often use acute treatments for breakthrough attacks. Data on real-world effectiveness of the small-molecule calcitonin gene-related peptide (CGRP) receptor antagonist ubrogepant in combination with onabotulinumtoxinA are limited. METHODS COURAGE, a prospective, multiple attack, observational study, evaluated the real-world effectiveness of ubrogepant (50 or 100 mg) for acute treatment of migraine in people receiving onabotulinumtoxinA, an anti-CGRP monoclonal antibody (mAb), or both. This analysis focused only on onabotulinumtoxinA users. The Migraine Buddy app was used to identify eligible participants and track response to treated attacks. For each ubrogepant-treated attack, meaningful pain relief (MPR) and return to normal function (RNF) at 2 and 4 h post-dose over 30 days was assessed. MPR was defined as a level of relief that is meaningful to the participant, usually occurring before the pain is all gone. After 30 days, satisfaction was reported on a 7-point scale and overall acute treatment optimization was evaluated using the migraine Treatment Optimization Questionnaire-4 (mTOQ-4). RESULTS This analysis included 122 participants who received ubrogepant and onabotulinumtoxinA and reported on 599 ubrogepant-treated attacks. Following the first ubrogepant-treated attack, MPR was achieved in 53.3% of participants 2 h post-dose and in 76.2% of participants 4 h post-dose. RNF was achieved in 25.4% of participants 2 h post-dose and in 45.9% of participants 4 h post-dose. MPR and RNF results were similar across up to 10 ubrogepant-treated attacks. After 30 days, satisfaction with ubrogepant in combination with onabotulinumtoxinA was reported by 69.8% of participants and acute treatment optimization (defined as mTOQ-4 score ≥ 4) was achieved in 77.6%. CONCLUSIONS In this prospective real-world effectiveness study, ubrogepant treatment in onabotulinumtoxinA users with self-identified migraine was associated with high rates of MPR and RNF at 2 and 4 h as well as satisfaction and acute treatment optimization. Although the lack of a contemporaneous control group limits causal inference, these findings demonstrate the feasibility of using a novel, app-based design to evaluate the real-world effectiveness and satisfaction of treatments.
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Affiliation(s)
| | | | | | | | | | - Linda Davis
- Kolvita Family Medical Group, Mission Viejo, CA, USA
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Liang Z, Thomas L, Jull G, Treleaven J. Subgrouping individuals with migraine associated neck pain for targeted management. Musculoskelet Sci Pract 2023; 66:102801. [PMID: 37331924 DOI: 10.1016/j.msksp.2023.102801] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/05/2023] [Accepted: 06/10/2023] [Indexed: 06/20/2023]
Abstract
INTRODUCTION Neck pain is one of the most common and burdensome symptoms associated with migraine. Many individuals with migraine and neck pain seek neck treatment, but evidence for such treatment is limited. Most studies have treated this population as a homogenous group, providing uniform cervical interventions that have yet to show clinically important effects. However, different neurophysiological and musculoskeletal mechanisms can underlie neck pain in migraine. Targeting treatment to specific underlying mechanisms may therefore be the key to improving treatment outcomes. Our research characterised neck pain mechanisms and identified subgroups based on cervical musculoskeletal function and cervical hypersensitivity. This suggests that specific management aimed towards addressing mechanisms relevant to each subgroup might be beneficial. PURPOSE This paper explains our research approach and findings to date. Potential management strategies for the identified subgroups and future research directions are discussed. IMPLICATIONS Clinicians should perform skilled physical examination with the aim of identifying if patterns of cervical musculoskeletal dysfunction and or hypersensitivity are present in the individual patient. There is currently no research into treatments differentiated for subgroups to address specific underlying mechanisms. It is possible that neck treatments addressing musculoskeletal impairments may be most beneficial for those subgroups where neck pain is primarily due to musculoskeletal dysfunction. Future research should define treatment aims and select specific subgroups for targeted management to determine which treatments are most effective for each subgroup. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Zhiqi Liang
- School of Health and Rehabilitation Sciences, Therapies Annexe, 84A, The University of Queensland, St Lucia, QLD, 4072, Australia.
| | - Lucy Thomas
- School of Health and Rehabilitation Sciences, Therapies Annexe, 84A, The University of Queensland, St Lucia, QLD, 4072, Australia.
| | - Gwendolen Jull
- School of Health and Rehabilitation Sciences, Therapies Annexe, 84A, The University of Queensland, St Lucia, QLD, 4072, Australia.
| | - Julia Treleaven
- School of Health and Rehabilitation Sciences, Therapies Annexe, 84A, The University of Queensland, St Lucia, QLD, 4072, Australia.
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Sollmann N, Schandelmaier P, Weidlich D, Stelter J, Joseph GB, Börner C, Schramm S, Beer M, Zimmer C, Landgraf MN, Heinen F, Karampinos DC, Baum T, Bonfert MV. Headache frequency and neck pain are associated with trapezius muscle T2 in tension-type headache among young adults. J Headache Pain 2023; 24:84. [PMID: 37438700 DOI: 10.1186/s10194-023-01626-w] [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: 06/19/2023] [Accepted: 07/05/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Tension-type headache (TTH) is the most prevalent primary headache disorder. Neck pain is commonly associated with primary headaches and the trigemino-cervical complex (TCC) refers to the convergence of trigeminal and cervical afferents onto neurons of the brainstem, thus conceptualizes the emergence of headache in relation to neck pain. However, no objective biomarkers exist for the myofascial involvement in primary headaches. This study aimed to investigate the involvement of the trapezius muscles in primary headache disorders by quantitative magnetic resonance imaging (MRI), and to explore associations between muscle T2 values and headache frequency and neck pain. METHODS This cohort study prospectively enrolled fifty participants (41 females, age range 20-31 years): 16 subjects with TTH only (TTH-), 12 with mixed-type TTH plus migraine (TTH+), and 22 healthy controls (HC). The participants completed fat-suppressed T2-prepared three-dimensional turbo spin-echo MRI, a headache diary (over 30 days prior to MRI), manual palpation (two weeks before MRI), and evaluation of neck pain (on the day of MRI). The bilateral trapezius muscles were manually segmented, followed by muscle T2 extraction. Associations between muscle T2 and the presence of neck pain as well as the number of days with headache (considering the 30 days prior to imaging using the headache calendar) were analyzed using regression models (adjusting for age, sex, and body mass index). RESULTS The TTH+ group demonstrated the highest muscle T2 values (right side: 31.4 ± 1.2 ms, left side: 31.4 ± 0.8 ms) as compared to the TTH- group or HC group (p < 0.001). Muscle T2 was significantly associated with the number of headache days (β-coefficient: 2.04, p = 0.04) and the presence of neck pain (odds ratio: 2.26, p = 0.04). With muscle T2 as the predictor, the area under the curve for differentiating between HC and the TTH+ group was 0.82. CONCLUSIONS Increased T2 of trapezius muscles may represent an objective imaging biomarker for myofascial involvement in primary headache disorders, which could help to improve patient phenotyping and therapy evaluation. Pathophysiologically, the increased muscle T2 values could be interpreted as a surrogate of neurogenic inflammation and peripheral sensitization within myofascial tissues.
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Affiliation(s)
- 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.
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA.
| | - Paul Schandelmaier
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Pediatrics - Dr. von Hauner Children's Hospital, Division of Pediatric Neurology and Developmental Medicine, LMU Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
- LMU Center for Children with Medical Complexity - iSPZ Hauner, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Dominik Weidlich
- Department of Diagnostic and Interventional Radiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Jonathan Stelter
- Department of Diagnostic and Interventional Radiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Gabby B Joseph
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Corinna Börner
- Department of Pediatrics - Dr. von Hauner Children's Hospital, Division of Pediatric Neurology and Developmental Medicine, LMU Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
- LMU Center for Children with Medical Complexity - iSPZ Hauner, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Severin Schramm
- 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
| | - Meinrad Beer
- Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Ulm, Germany
| | - Claus Zimmer
- 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
| | - Mirjam N Landgraf
- Department of Pediatrics - Dr. von Hauner Children's Hospital, Division of Pediatric Neurology and Developmental Medicine, LMU Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
- LMU Center for Children with Medical Complexity - iSPZ Hauner, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Florian Heinen
- Department of Pediatrics - Dr. von Hauner Children's Hospital, Division of Pediatric Neurology and Developmental Medicine, LMU Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
- LMU Center for Children with Medical Complexity - iSPZ Hauner, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Dimitrios C Karampinos
- Department of Diagnostic and Interventional Radiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Thomas Baum
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Michaela V Bonfert
- Department of Pediatrics - Dr. von Hauner Children's Hospital, Division of Pediatric Neurology and Developmental Medicine, LMU Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
- LMU Center for Children with Medical Complexity - iSPZ Hauner, Ludwig-Maximilians-Universität München, Munich, Germany
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Abstract
Studies in the 1920s found that botulinum neurotoxin type A (BoNT/A) inhibited the activity of motor and parasympathetic nerve endings, confirmed several decades later to be due to decreased acetylcholine release. The 1970s were marked by studies of cellular mechanisms aided by use of neutralizing antibodies as pharmacologic tools: BoNT/A disappeared from accessibility to neutralizing antibodies within minutes, although it took several hours for onset of muscle weakness. The multi-step mechanism was experimentally confirmed and is now recognized to consist broadly of binding to nerve terminals, internalization, and lysis or cleavage of a protein (SNAP-25: synaptosomal associated protein-25 kDa) that is part of the SNARE (Soluble NSF Attachment protein REceptor) complex needed for synaptic vesicle docking and fusion. Clinical use of the BoNT/A product onabotulinumtoxinA was based on its ability to reduce muscle contractions via inhibition of acetylcholine from motor terminals. Sensory mechanisms of onabotulinumtoxinA have now been identified, supporting its successful treatment of chronic migraine and urgency in overactive bladder. Exploration into migraine mechanisms led to anatomical studies documenting pain fibers that send axons through sutures of the skull to outside the head-a potential route by which extracranial injections could affect intracranial processes. Several clinical studies have also identified benefits of onabotulinumtoxinA in major depression, which have been attributed to central responses induced by feedback from facial muscle and skin movement. Overall, the history of BoNT/A is distinguished by basic science studies that stimulated clinical use and, conversely, clinical observations that spurred basic research into novel mechanisms of action.
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Affiliation(s)
- Mitchell F Brin
- Allergan/AbbVie, Irvine, CA, USA
- University of California, Irvine, CA, USA
| | - Rami Burstein
- Departments of Anesthesia and Neuroscience, Harvard Medical School, Boston, MA, USA
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Turkel CC, Aurora S, Diener HC, Dodick DW, Lipton RB, Silberstein SD, Brin MF. Treatment of chronic migraine with Botox (onabotulinumtoxinA): Development, insights, and impact. Medicine (Baltimore) 2023; 102:e32600. [PMID: 37499085 PMCID: PMC10374186 DOI: 10.1097/md.0000000000032600] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/29/2023] Open
Abstract
Chronic migraine (CM) is a neurological disease characterized by frequent migraine attacks that prevent affected individuals from performing daily activities of living, significantly diminish quality of life, and increase familial burden. Before onabotulinumtoxinA was approved for CM, there were few treatment options for these seriously disabled patients and none had regulatory approval. The terminology and recognition of CM evolved in parallel with the onabotulinumtoxinA clinical development program. Because there were no globally accepted classification criteria for CM when onabotulinumtoxinA was in development, the patient populations for the trials conducted by Allergan were determined by the Allergan migraine team in collaboration with headache scientists and clinicians. These trials and collaborations ultimately led to improvements in CM classifications. In 2010, onabotulinumtoxinA became the first medication and first biologic approved specifically to prevent headaches in patients with CM. Approval was based on 2 similarly designed phase 3, double-blind, randomized, placebo-controlled, multicenter clinical studies. Both studies showed significantly greater improvements in mean change from baseline in headache-day frequency in patients with CM receiving onabotulinumtoxinA compared with those receiving placebo. The safety and effectiveness of onabotulinumtoxinA have been established globally in >5000 patients with CM with or without medication overuse treated in clinical and observational studies. Benefits also include improvements in quality of life, fewer psychiatric comorbidities, and reduced healthcare resource utilization. Across studies, onabotulinumtoxinA was well tolerated; adverse events tended to be mild or moderate in severity and to decline over subsequent treatment cycles.
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Affiliation(s)
| | | | - Hans-Christoph Diener
- Faculty of Medicine, Institute for Medical Informatics, Biometry and Epidemiology, University of Duisburg-Essen, Essen, Germany
| | | | - Richard B Lipton
- Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Mitchell F Brin
- Allergan/AbbVie, Irvine, CA, USA
- University of California, Irvine, CA, USA
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Abstract
Botulinum neurotoxins (BoNTs) are multi-domain proteins whose potent and selective actions on nerve endings have led to innovations in both basic and clinical science. The various BoNT domains are responsible for binding to gangliosides and proteins associated with nerve cell membranes, internalization into the cell, and cleavage of one or more SNARE (soluble N-ethylmaleimide sensitive factor attachment protein receptor) proteins necessary for vesicle docking and fusion. Novel modifications to BoNT molecules, such as the creation of chimeras, helped identify the protein domains responsible for various aspects of BoNT action, such as localized effects. Other molecular modifications have been introduced in attempts to increase the specificity of BoNTs for autonomic or sensory neurons, with the ultimate goal of optimizing therapeutic selectivity. This research, in turn, has led to the development of BoNT-based proteins that can target non-SNARE substrates such as phosphatase and tensin homolog (PTEN). Still others are developing different BoNT serotypes, subtypes, or variants that are longer- or shorter-acting or have faster onset for various clinical purposes. New formulations of BoNTs that provide convenience for both patients and physicians are under investigation. Novel clinical uses are being evaluated for onabotulinumtoxinA, including in the prevention of post-operative atrial fibrillation. All these innovations capitalize on the unique properties of BoNTs, which continue to intrigue scientists and clinicians across numerous fields of study.
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Affiliation(s)
| | - J Oliver Dolly
- International Centre for Neurotherapeutics, Dublin City University, Dublin, Ireland
| | - Mitchell F Brin
- Allergan/AbbVie, Irvine, CA, USA
- University of California, Irvine, CA, USA
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van der Miesen MM, Vossen CJ, Joosten EA. Habituation to Pain in Patients with Chronic Pain: Clinical Implications and Future Directions. J Clin Med 2023; 12:4305. [PMID: 37445339 DOI: 10.3390/jcm12134305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/18/2023] [Accepted: 06/20/2023] [Indexed: 07/15/2023] Open
Abstract
In this review, the latest insights into habituation to pain in chronic pain are summarized. Using a systematic search, results of studies on the evidence of habituation to (experimental) pain in migraine, chronic low back pain, fibromyalgia, and a variety of chronic pain indications are presented. In migraine, reduced habituation based on self-report and the EEG-based N1 and N2-P2 amplitude is reported, but the presence of contradictory results demands further replication in larger, well-designed studies. Habituation to pain in chronic low back pain seems not to differ from controls, with the exception of EEG measures. In fibromyalgia patients, there is some evidence for reduced habituation of the N2-P2 amplitude. Our analysis shows that the variability between outcomes of studies on habituation to pain is high. As the mechanisms underlying habituation to pain are still not fully understood and likely involve several pathways, it is now too early to conclude that habituation to pain is related to clinical outcomes and can be used as a diagnostic marker. The review ends with a discussion on future directions for research including the use of standard outcome measures to improve comparisons of habituation to pain in patients and controls, as well as a focus on individual differences.
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Affiliation(s)
- Maite M van der Miesen
- Department of Anesthesiology and Pain Management, School for Mental Health and Neuroscience (MHeNS), Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Catherine J Vossen
- Department of Anesthesiology and Pain Management, School for Mental Health and Neuroscience (MHeNS), Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, 6229 ER Maastricht, The Netherlands
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands
| | - Elbert A Joosten
- Department of Anesthesiology and Pain Management, School for Mental Health and Neuroscience (MHeNS), Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, 6229 ER Maastricht, The Netherlands
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands
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Messina R, Christensen RH, Cetta I, Ashina M, Filippi M. Imaging the brain and vascular reactions to headache treatments: a systematic review. J Headache Pain 2023; 24:58. [PMID: 37221469 DOI: 10.1186/s10194-023-01590-5] [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: 03/14/2023] [Accepted: 04/28/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Neuroimaging studies have made an important contribution to our understanding of headache pathophysiology. This systematic review aims to provide a comprehensive overview and critical appraisal of mechanisms of actions of headache treatments and potential biomarkers of treatment response disclosed by imaging studies. MAIN BODY We performed a systematic literature search on PubMed and Embase databases for imaging studies investigating central and vascular effects of pharmacological and non-pharmacological treatments used to abort and prevent headache attacks. Sixty-three studies were included in the final qualitative analysis. Of these, 54 investigated migraine patients, 4 cluster headache patients and 5 patients with medication overuse headache. Most studies used functional magnetic resonance imaging (MRI) (n = 33) or molecular imaging (n = 14). Eleven studies employed structural MRI and a few used arterial spin labeling (n = 3), magnetic resonance spectroscopy (n = 3) or magnetic resonance angiography (n = 2). Different imaging modalities were combined in eight studies. Despite of the variety of imaging approaches and results, some findings were consistent. This systematic review suggests that triptans may cross the blood-brain barrier to some extent, though perhaps not sufficiently to alter the intracranial cerebral blood flow. Acupuncture in migraine, neuromodulation in migraine and cluster headache patients, and medication withdrawal in patients with medication overuse headache could promote headache improvement by reverting headache-affected pain processing brain areas. Yet, there is currently no clear evidence for where each treatment acts, and no firm imaging predictors of efficacy. This is mainly due to a scarcity of studies and heterogeneous treatment schemes, study designs, subjects, and imaging techniques. In addition, most studies used small sample sizes and inadequate statistical approaches, which precludes generalizable conclusions. CONCLUSION Several aspects of headache treatments remain to be elucidated using imaging approaches, such as how pharmacological preventive therapies work, whether treatment-related brain changes may influence therapy effectiveness, and imaging biomarkers of clinical response. In the future, well-designed studies with homogeneous study populations, adequate sample sizes and statistical approaches are needed.
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Affiliation(s)
- R Messina
- Neuroimaging Research Unit, Division of Neuroscience and Neurology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy.
| | - R H Christensen
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Glostrup, Denmark
| | - I Cetta
- Neuroimaging Research Unit, Division of Neuroscience and Neurology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
| | - M Ashina
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Glostrup, Denmark
| | - M Filippi
- Neuroimaging Research Unit, Division of Neuroscience and Neurology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
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Jankovic J, Carruthers J, Naumann M, Ogilvie P, Boodhoo T, Attar M, Gupta S, Singh R, Soliman J, Yushmanova I, Brin MF, Shen J. Neutralizing Antibody Formation with OnabotulinumtoxinA (BOTOX ®) Treatment from Global Registration Studies across Multiple Indications: A Meta-Analysis. Toxins (Basel) 2023; 15:toxins15050342. [PMID: 37235376 DOI: 10.3390/toxins15050342] [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: 02/23/2023] [Revised: 05/10/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
Though the formation of neutralizing antibodies (NAbs) during treatment with botulinum neurotoxin is rare, their presence may nonetheless affect the biological activity of botulinum toxin and negatively impact clinical response. The goal of this updated meta-analysis was to evaluate and characterize the rate of NAb formation using an expanded dataset composed of 33 prospective placebo-controlled and open-label clinical trials with nearly 30,000 longitudinal subject records prior to and following onabotulinumtoxinA treatment in 10 therapeutic and aesthetic indications. Total onabotulinumtoxinA doses per treatment ranged from 10 U to 600 U administered in ≤15 treatment cycles. The NAb formation at baseline and post-treatment was tested and examined for impact on clinical safety and efficacy. Overall, 27 of the 5876 evaluable subjects (0.5%) developed NAbs after onabotulinumtoxinA treatment. At study exit, 16 of the 5876 subjects (0.3%) remained NAb positive. Due to the low incidence of NAb formation, no clear relationship was discernable between positive NAb results and gender, indication, dose level, dosing interval, treatment cycles, or the site of injection. Only five subjects who developed NAbs post-treatment were considered secondary nonresponders. Subjects who developed NAbs revealed no other evidence of immunological reactions or clinical disorders. This comprehensive meta-analysis confirms the low NAb formation rate following onabotulinumtoxinA treatment across multiple indications, and its limited clinical impact on treatment safety and efficacy.
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Affiliation(s)
| | - Jean Carruthers
- Department of Ophthalmology, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
- Jean Carruthers Cosmetic Surgery Inc., Vancouver, BC V5Z 4E1, Canada
| | - Markus Naumann
- Department of Neurology and Clinical Neurophysiology, University Hospital, 86156 Augsburg, Germany
| | | | | | | | | | | | | | | | - Mitchell F Brin
- AbbVie, Irvine, CA 92612, USA
- Department of Neurology, University of California, Irvine, CA 92697, USA
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42
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Bono F, Mazza MR, Magro G, Spano G, Idone G, Laterza V, Tedeschi D, Pucci F, Gambardella A, Sarica A. Regional Targeted Subcutaneous Injection of Botulinum Neurotoxin Type A in Refractory Chronic Migraine: A Randomized, Double-Blind, Placebo-Controlled Study. Toxins (Basel) 2023; 15:toxins15050324. [PMID: 37235358 DOI: 10.3390/toxins15050324] [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: 01/31/2023] [Revised: 02/13/2023] [Accepted: 05/06/2023] [Indexed: 05/28/2023] Open
Abstract
In this randomized, double-blind, placebo-controlled study, we evaluated the efficacy of an individualized technique of subcutaneous injection of botulinum toxin type A (BoNT-A) targeted (SjBoT) to the occipital or trigeminal skin area in non-responder patients with chronic migraine (CM). Patients who had not previously responded to at least two treatments of intramuscular injections of BoNT-A were randomly assigned (2:1) to receive two subcutaneous administrations of BoNT-A (up to 200 units) with the SjBoT injection paradigm or placebo. Following the skin area where the maximum pain began, treatment was given in the trigeminal or occipital region bilaterally. The primary endpoint changed in monthly headache days from baseline to the last 4 weeks. Among 139 randomized patients, 90 received BoNT-A and 49 received placebo, and 128 completed the double-blind phase. BoNT-A significantly reduced monthly headache days versus placebo (-13.2 versus -1.2; p < 0.0001) in the majority of patients who had cutaneous allodynia. Other secondary endpoints, including measures for disability (Migraine Disability Assessment questionnaire from baseline 21.96 to 7.59 after treatment, p = 0.028), also differed. Thus, in non-responder patients with CM, BoNT-A significantly reduced migraine days when administered according to the "follow the origin of maximum pain" approach using SjBoT injection paradigm.
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Affiliation(s)
- Francesco Bono
- Headache Center, and Center for Botulinum Toxin Therapy, Neurology Unit, Azienda Ospedaliero-Universitaria "Mater Domini", 88100 Catanzaro, Italy
| | - Maria Rosaria Mazza
- Headache Center, and Center for Botulinum Toxin Therapy, Neurology Unit, Azienda Ospedaliero-Universitaria "Mater Domini", 88100 Catanzaro, Italy
| | - Giuseppe Magro
- Headache Center, and Center for Botulinum Toxin Therapy, Neurology Unit, Azienda Ospedaliero-Universitaria "Mater Domini", 88100 Catanzaro, Italy
| | - Giorgio Spano
- Headache Center, and Center for Botulinum Toxin Therapy, Neurology Unit, Azienda Ospedaliero-Universitaria "Mater Domini", 88100 Catanzaro, Italy
| | - Giovanni Idone
- Headache Center, and Center for Botulinum Toxin Therapy, Neurology Unit, Azienda Ospedaliero-Universitaria "Mater Domini", 88100 Catanzaro, Italy
| | - Vincenzo Laterza
- Headache Center, and Center for Botulinum Toxin Therapy, Neurology Unit, Azienda Ospedaliero-Universitaria "Mater Domini", 88100 Catanzaro, Italy
| | - Denise Tedeschi
- Headache Center, and Center for Botulinum Toxin Therapy, Neurology Unit, Azienda Ospedaliero-Universitaria "Mater Domini", 88100 Catanzaro, Italy
| | - Francesco Pucci
- Neurology Unit, Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, 88100 Catanzaro, Italy
| | - Antonio Gambardella
- Neurology Unit, Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, 88100 Catanzaro, Italy
| | - Alessia Sarica
- Neuroscience Research Center, Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, 88100 Catanzaro, Italy
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43
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Cohen CF, Roh J, Lee SH, Park CK, Berta T. Targeting Nociceptive Neurons and Transient Receptor Potential Channels for the Treatment of Migraine. Int J Mol Sci 2023; 24:ijms24097897. [PMID: 37175602 PMCID: PMC10177956 DOI: 10.3390/ijms24097897] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 04/22/2023] [Accepted: 04/24/2023] [Indexed: 05/15/2023] Open
Abstract
Migraine is a neurovascular disorder that affects approximately 12% of the global population. While its exact causes are still being studied, researchers believe that nociceptive neurons in the trigeminal ganglia play a key role in the pain signals of migraine. These nociceptive neurons innervate the intracranial meninges and convey pain signals from the meninges to the thalamus. Targeting nociceptive neurons is considered promising due to their accessibility and distinct molecular profile, which includes the expression of several transient receptor potential (TRP) channels. These channels have been linked to various pain conditions, including migraine. This review discusses the role and mechanisms of nociceptive neurons in migraine, the challenges of current anti-migraine drugs, and the evidence for well-studied and emerging TRP channels, particularly TRPC4, as novel targets for migraine prevention and treatment.
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Affiliation(s)
- Cinder Faith Cohen
- Pain Research Center, Department of Anesthesiology, Medical Center, University of Cincinnati, Cincinnati, OH 45219, USA
- Neuroscience Graduate Program, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Jueun Roh
- Pain Research Center, Department of Anesthesiology, Medical Center, University of Cincinnati, Cincinnati, OH 45219, USA
- Department of Physiology, Gachon Pain Center, College of Medicine, Gachon University, Incheon 21936, Republic of Korea
| | - Sang Hoon Lee
- Pain Research Center, Department of Anesthesiology, Medical Center, University of Cincinnati, Cincinnati, OH 45219, USA
- Neuroscience Graduate Program, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Chul-Kyu Park
- Department of Physiology, Gachon Pain Center, College of Medicine, Gachon University, Incheon 21936, Republic of Korea
| | - Temugin Berta
- Pain Research Center, Department of Anesthesiology, Medical Center, University of Cincinnati, Cincinnati, OH 45219, USA
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Jin MY, Everett ES, Abd-Elsayed A. Microbiological and Physiological Effects of Pain. Curr Pain Headache Rep 2023; 27:165-173. [PMID: 37086365 PMCID: PMC10122082 DOI: 10.1007/s11916-023-01114-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2023] [Indexed: 04/23/2023]
Abstract
Pain is an important innate defense mechanism that can dramatically alter a person's quality of life. Understanding the microbiological and physiological effects of pain may be important in the pursuit of novel pain interventions. The three descriptors of pain recognized by the International Association for the Study of Pain are nociceptive, neuropathic, and nociplastic pain. Our review examined the current understanding of all three pain types, focusing on the key molecules involved in the manifestation of each type as well as physiological effects. Additionally, we compared the differences in painful and painless neuropathies and discussed the neuroimmune interaction involved in the manifestation of pain.
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Affiliation(s)
- Max Y Jin
- Department of Anesthesiology, University of Wisconsin-Madison, Madison, WI, 53706, USA
| | - Erin S Everett
- Tulane University School of Medicine, New Orleans, LA, 70112, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin-Madison, Madison, WI, 53706, USA.
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Altamura C, Brunelli N, Viticchi G, Salvemini S, Cecchi G, Marcosano M, Fofi L, Silvestrini M, Vernieri F. Quantitative and Qualitative Pain Evaluation in Response to OnabotulinumtoxinA for Chronic Migraine: An Observational Real-Life Study. Toxins (Basel) 2023; 15:toxins15040284. [PMID: 37104222 PMCID: PMC10145239 DOI: 10.3390/toxins15040284] [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: 03/14/2023] [Revised: 04/08/2023] [Accepted: 04/11/2023] [Indexed: 04/28/2023] Open
Abstract
(1) Background: Randomized controlled trials and real-life studies demonstrated the efficacy of OnabotulinumtoxinA (OBT-A) for CM prevention. However, no studies specifically addressed its effect on pain's quantitative intensity and qualitative characteristics. (2) Methods: This is an ambispective study: a post-hoc retrospective analysis of real-life prospectively collected data from two Italian headache centers on CM patients treated with OBT-A over one year (i.e., Cy1-4). The primary endpoint was the changes in pain intensity (Numeric Rating Scale, NRS; the Present Pain Intensity (PPI) scale, the 6-point Behavioral Rating Scale (BRS-6)) and quality scale (the short-form McGill Pain Questionnaire (SF-MPQ)) scores. We also assessed the relationship between changes in intensity and quality of pain and disability scale (MIDAS; HIT-6) scores, monthly headache days (MHDs), and monthly acute medication intake (MAMI) (3) Results: We retrieved 152 cases (51.5 years SD 11.3, 80.3% females). From baseline to Cy-4, MHDs, MAMI, NRS, PPI, and BRS-6 scores decreased (consistently p < 0.001). Only the throbbing (p = 0.004), splitting (p = 0.018), and sickening (p = 0.017) qualities of pain collected in the SF-MPQ were reduced. Score variations in MIDAS related to those in PPI scales (p = 0.035), in the BRS-6 (p = 0.001), and in the NRS (p = 0.003). Similarly, HIT-6 score changes related to PPI score modifications (p = 0.027), in BRS-6 (p = 0.001) and NRS (p = 0.006). Conversely, MAMI variation was not associated with qualitative or quantitative pain score modifications except BRS-6 (p = 0.018). (4) Conclusions: Our study shows that OBT-A alleviates migraine by reducing its impact on multiple aspects, such as frequency, disability, and pain intensity. The beneficial effect on pain intensity seems specific to pain characteristics related to C-fiber transmission and is associated with a reduction in migraine-related disability.
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Affiliation(s)
- Claudia Altamura
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Nicoletta Brunelli
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Giovanna Viticchi
- Neurological Clinic, Marche Polytechnic University, Via Conca 1, 60020 Ancona, Italy
| | - Sergio Salvemini
- Neurological Clinic, Marche Polytechnic University, Via Conca 1, 60020 Ancona, Italy
| | - Gianluca Cecchi
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Marilena Marcosano
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Luisa Fofi
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Mauro Silvestrini
- Neurological Clinic, Marche Polytechnic University, Via Conca 1, 60020 Ancona, Italy
| | - Fabrizio Vernieri
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
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Mastrorilli V, De Angelis F, Vacca V, Pavone F, Luvisetto S, Marinelli S. Xeomin®, a Commercial Formulation of Botulinum Neurotoxin Type A, Promotes Regeneration in a Preclinical Model of Spinal Cord Injury. Toxins (Basel) 2023; 15:toxins15040248. [PMID: 37104185 PMCID: PMC10142820 DOI: 10.3390/toxins15040248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 03/17/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023] Open
Abstract
Xeomin® is a commercial formulation of botulinum neurotoxin type A (BoNT/A) clinically authorized for treating neurological disorders, such as blepharospasm, cervical dystonia, limb spasticity, and sialorrhea. We have previously demonstrated that spinal injection of laboratory purified 150 kDa BoNT/A in paraplegic mice, after undergoing traumatic spinal cord injury (SCI), was able to reduce excitotoxic phenomena, glial scar, inflammation, and the development of neuropathic pain and facilitate regeneration and motor recovery. In the present study, as proof of concept in view of a possible clinical application, we studied the efficacy of Xeomin® in the same preclinical SCI model in which we highlighted the positive effects of lab-purified BoNT/A. Data comparison shows that Xeomin® induces similar pharmacological and therapeutic effects, albeit with less efficacy, to lab-purified BoNT/A. This difference, which can be improved by adjusting the dose, can be attributable to the different formulation and pharmacodynamics. Although the mechanism by which Xeomin® and laboratory purified BoNT/A induce functional improvement in paraplegic mice is still far from being understood, these results open a possible new scenario in treatment of SCI and are a stimulus for further research.
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47
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Lucchese S, Daripa B, Pulimamidi S. Onabotulinum toxin A vs. incobotulinum toxin A for the treatment of chronic migraine: a retrospective review. RESEARCH SQUARE 2023:rs.3.rs-2624326. [PMID: 36993755 PMCID: PMC10055501 DOI: 10.21203/rs.3.rs-2624326/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Background Onabotulinum toxin A (OnA) is a well-tolerated and effective treatment for chronic migraine (CM). However, based on research indications that incobotulinum toxin A (InA) would be equally effective, a Veterans' Health Administration Medical Center mandated a 2-year trial of InA as more cost-effective alternative to OnA. Although InA is used for many similar indications as OnA, it is not Food and Drug Administration approved for treating CM, and complications occurred in several patients with CM following this treatment change. We conducted this retrospective analysis to evaluate differences in the efficacy of OnA and InA and identify the reasons for the adverse effects of InA in some of these patients. Methods We performed a retrospective review of 42 patients who had been effectively treated with OnA and were then switched to InA. The differences between treatment responses to OnA and InA were assessed through the evaluation of pain on injection, number of headache days, and duration of action. Patients received injections at 10- to 13-week intervals. Those who reported excessive pain on injection of InA were switched back to OnA. Findings Severe burning pain on injection was reported by 16 (38%) patients for InA only and by 1 (2%) patient for both InA and OnA. Neither migraine suppression nor the duration of effect was significantly different between OnA and InA. Conclusions Reformulation of InA with a pH-buffered solution may eliminate the difference in pain on injection. InA would then be a good alternative to OnA for treating CM.
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Affiliation(s)
| | - Bob Daripa
- Grant Medical College & Sir J.J. Group of Government Hospitals
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48
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Papetti L, Frattale I, Ursitti F, Sforza G, Monte G, Ferilli MAN, Tarantino S, Proietti Checchi M, Valeriani M. Real Life Data on OnabotulinumtoxinA for Treatment of Chronic Migraine in Pediatric Age. J Clin Med 2023; 12:jcm12051802. [PMID: 36902596 PMCID: PMC10003637 DOI: 10.3390/jcm12051802] [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: 01/19/2023] [Revised: 02/20/2023] [Accepted: 02/21/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND The use of OnabotulinumtoxinA (OBT-A) for the treatment of chronic migraine (CM) in adults represents a therapy with the greatest efficacy and safety data. However, we have little evidence on the use of OBT-A in children or adolescents. The present study aims to describe the experience with OBT-A in the treatment of CM in adolescents in an Italian third-level headache center. METHODS The analysis included all patients under the age of 18 treated with OBT-A for CM at the Bambino Gesù Children's Hospital. All patients received OBT-A following the PREEMPT protocol. Subjects were classified as good responders if a greater than 50% reduction in the monthly frequency of attacks was observed, partial responders if the reduction was between 30 and 50%, and non-responders if it was <30%. RESULTS The treated population consisted of 37 females and 9 males with a mean age of 14.7 years. Before starting OBT-A, 58.7% of the subjects had attempted prophylactic therapy with other drugs. From OBT-A initiation to the last clinical observation, the mean duration of follow-up was 17.6 ± 13.7 SD (range: 1-48) months. The number of OBT-A injections were 3.4 ± 3 SD. Sixty eight percent of the subjects responded to treatment within the first three administrations of OBT-A. Proceeding with the number of administrations, a progressive improvement in frequency was further observed. CONCLUSIONS The use of OBT-A in pediatric age can have benefits in terms of reduction in the frequency and intensity of headache episodes. Furthermore, treatment with OBT-A has an excellent safety profile. These data support the use of OBT-A in the treatment of childhood migraine.
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Affiliation(s)
- Laura Papetti
- Developmental Neurology, Bambino Gesù Children Hospital, IRCCS, 00165 Rome, Italy
- Correspondence: ; Tel.: +39-06-6859-2865
| | - Ilaria Frattale
- Child Neurology and Psychiatry Unit, Tor Vergata University of Rome, 00165 Rome, Italy
| | - Fabiana Ursitti
- Developmental Neurology, Bambino Gesù Children Hospital, IRCCS, 00165 Rome, Italy
| | - Giorgia Sforza
- Developmental Neurology, Bambino Gesù Children Hospital, IRCCS, 00165 Rome, Italy
| | - Gabriele Monte
- Developmental Neurology, Bambino Gesù Children Hospital, IRCCS, 00165 Rome, Italy
| | | | - Samuela Tarantino
- Developmental Neurology, Bambino Gesù Children Hospital, IRCCS, 00165 Rome, Italy
| | | | - Massimiliano Valeriani
- Developmental Neurology, Bambino Gesù Children Hospital, IRCCS, 00165 Rome, Italy
- Center for Sensory-Motor Interaction, Aalborg University, Fredrik Bajers Vej 7 D3, DK-9220 Aalborg, Denmark
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49
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Moore AA, Nelson M, Wickware C, Choi S, Moon G, Xiong E, Orta L, Brideau-Andersen A, Brin MF, Broide RS, Liedtke W, Moore C. OnabotulinumtoxinA effects on trigeminal nociceptors. Cephalalgia 2023; 43:3331024221141683. [PMID: 36751871 PMCID: PMC10652784 DOI: 10.1177/03331024221141683] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND OnabotulinumtoxinA (onabotA) is approved globally for prevention of chronic migraine; however, the classical mechanism of action of onabotA in motor and autonomic neurons cannot fully explain the effectiveness of onabotulinumtoxinA in this sensory neurological disease. We sought to explore the direct effects of onabotulinumtoxinA on mouse trigeminal ganglion sensory neurons using an inflammatory soup-based model of sensitization. METHODS Primary cultured trigeminal ganglion neurons were pre-treated with inflammatory soup, then treated with onabotulinumtoxinA (2.75 pM). Treated neurons were used to examine transient receptor potential vanilloid subtype 1 and transient receptor potential ankyrin 1 cell-surface expression, calcium influx, and neuropeptide release. RESULTS We found that onabotulinumtoxinA cleaved synaptosomal-associated protein-25 kDa in cultured trigeminal ganglion neurons; synaptosomal-associated protein-25 kDa cleavage was enhanced by inflammatory soup pre-treatment, suggesting greater uptake of toxin under sensitized conditions. OnabotulinumtoxinA also prevented inflammatory soup-mediated increases in TRPV1 and TRPA1 cell-surface expression, without significantly altering TRPV1 or TRPA1 protein expression in unsensitized conditions. We observed similar inhibitory effects of onabotulinumtoxinA on TRP-mediated calcium influx and TRPV1- and TRPA1-mediated release of calcitonin gene-related peptide and prostaglandin 2 under sensitized, but not unsensitized control, conditions. CONCLUSIONS Our data deepen the understanding of the sensory mechanism of action of onabotulinumtoxinA and support the notion that, once endocytosed, the cytosolic light chain of onabotulinumtoxinA cleaves synaptosomal-associated protein-25 kDa to prevent soluble N-ethylmaleimide-sensitive factor attachment protein receptor-mediated processes more generally in motor, autonomic, and sensory neurons.
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Affiliation(s)
- Ashley A Moore
- Department of Neurology, Duke University, Durham, NC, USA
| | | | | | - Shinbe Choi
- Department of Neurology, Duke University, Durham, NC, USA
| | - Gene Moon
- Department of Neurology, Duke University, Durham, NC, USA
| | - Emma Xiong
- Department of Neurology, Duke University, Durham, NC, USA
| | - Lily Orta
- Department of Neurology, Duke University, Durham, NC, USA
| | | | - Mitchell F Brin
- Allergan, an AbbVie company, Irvine, CA, USA
- Department of Neurology, University of California, Irvine, Irvine, CA, USA
| | | | - Wolfgang Liedtke
- Department of Neurology, Duke University, Durham, NC, USA
- Department of Molecular Pathobiology – Dental Pain Research, New York University College of Dentistry, New York, NY, USA
| | - Carlene Moore
- Department of Neurology, Duke University, Durham, NC, USA
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50
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Sebastianelli G, Casillo F, Di Renzo A, Abagnale C, Cioffi E, Parisi V, Di Lorenzo C, Serrao M, Pierelli F, Schoenen J, Coppola G. Effects of Botulinum Toxin Type A on the Nociceptive and Lemniscal Somatosensory Systems in Chronic Migraine: An Electrophysiological Study. Toxins (Basel) 2023; 15:76. [PMID: 36668895 PMCID: PMC9863777 DOI: 10.3390/toxins15010076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 01/08/2023] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
(1) Background: OnabotulinumtoxinA (BoNT-A) is a commonly used prophylactic treatment for chronic migraine (CM). Although randomized placebo studies have shown its clinical efficacy, the mechanisms by which it exerts its therapeutic effect are still incompletely understood and debated. (2) Methods: We studied in 15 CM patients the cephalic and extracephalic nociceptive and lemniscal sensory systems using electrophysiological techniques before and 1 and 3 months after one session of pericranial BoNT-A injections according to the PREEMPT protocol. We recorded the nociceptive blink reflex (nBR), the trigemino-cervical reflex (nTCR), the pain-related cortical evoked potential (PREP), and the upper limb somatosensory evoked potential (SSEP). (3) Results: Three months after a single session of prophylactic therapy with BoNT-A in CM patients, we found (a) an increase in the homolateral and contralateral nBR AUC, (b) an enhancement of the contralateral nBR AUC habituation slope and the nTCR habituation slope, (c) a decrease in PREP N-P 1st and 2nd amplitude block, and (d) no effect on SSEPs. (4) Conclusions: Our study provides electrophysiological evidence for the ability of a single session of BoNT-A injections to exert a neuromodulatory effect at the level of trigeminal system through a reduction in input from meningeal and other trigeminovascular nociceptors. Moreover, by reducing activity in cortical pain processing areas, BoNT-A restores normal functioning of the descending pain modulation systems.
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Affiliation(s)
- Gabriele Sebastianelli
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino-ICOT, 04100 Latina, Italy
| | - Francesco Casillo
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino-ICOT, 04100 Latina, Italy
| | | | - Chiara Abagnale
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino-ICOT, 04100 Latina, Italy
| | - Ettore Cioffi
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino-ICOT, 04100 Latina, Italy
| | | | - Cherubino Di Lorenzo
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino-ICOT, 04100 Latina, Italy
| | - Mariano Serrao
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino-ICOT, 04100 Latina, Italy
| | - Francesco Pierelli
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino-ICOT, 04100 Latina, Italy
| | - Jean Schoenen
- Headache Research Unit, CHU de Liège, Neurology, Citadelle Hospital, B-4000 Liège, Belgium
| | - Gianluca Coppola
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino-ICOT, 04100 Latina, Italy
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