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Kong F, Buse DC, Zhu G, Xu J. Comparative efficacy and safety of different pharmacological therapies to medication overuse headache: a network meta-analysis. J Headache Pain 2024; 25:168. [PMID: 39375607 PMCID: PMC11457448 DOI: 10.1186/s10194-024-01878-0] [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: 07/28/2024] [Accepted: 09/24/2024] [Indexed: 10/09/2024] Open
Abstract
BACKGROUND Controversy exists whether prophylactic drugs are necessary in the treatment of medication overuse headache (MOH). OBJECTIVES To determine comparative benefits and safety of available drugs for the treatment of MOH including elimination of medication overuse (MO). METHODS We systematically reviewed randomized controlled trials though an extensive literature search comparing different drug effects on MOH. A random-effect network meta-analysis was conducted to rank comparative effects of interventions. Outcome improvements from baseline include responder rate defined as ≥ 50% reduction of headache frequency, proportion of patients who revert to no acute medication overuse (nMO), and reduction in monthly headache and acute medication intake frequency. Certainty of evidence was classified using the Grading of Recommendations, Assessment, Development & Evaluation (GRADE). RESULTS Of 8,248 screened publications, 28 were eligible for analysis. Topiramate was found to be beneficial based on its responder rate (odds ratios [OR] 4.93), headache frequency (weighted mean difference [WMD] -5.53) and acute medication intake frequency (WMD - 6.95), with fewer safety issues (i.e., tolerability, or more adverse events) than placebo (OR 0.20). Fremanezumab, galcanezumab and botulinum toxin type A (BTA) were beneficial for increased responder rates (OR 3.46 to 3.07, 2.95, and 2.57, respectively). For reversion to nMO, eptinezumab, fremanezumab and BTA were superior to placebo (OR 2.75 to 2.64, 1.87 to1.57, and 1.55, respectively). Eptinezumab, fremanezumab, erenumab 140 mg, and BTA were more efficacious than erenumab 70 mg (OR 3.84 to 3.70, 2.60 to 2.49, 2.44 and 2.16, respectively) without differences in safety and tolerability. CONCLUSION Despite lower safety and greater intolerability issues, topiramate has large beneficial effects probably on increasing responder rates, reducing headache frequency, and might reduce monthly medication intake frequency. Fremanezumab, galcanezumab, and eptinezumab are promising for increasing responder rates. For reversion to nMO, eptinezumab has large beneficial effects, fremanezumab has a smaller effect. BTA might have a moderate effect on responder rates and probably has a small effect on reversion to nMO. TRIAL REGISTRATION PROSPERO, CRD42021193370.
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Affiliation(s)
- Fanyi Kong
- Department of Neurology, The Affiliated Hospital of Yunnan University, Yunnan Province, PR, China
| | - Dawn C Buse
- Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Guoliang Zhu
- Department of Neurology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Sichuan Province, PR, China
| | - Jingjing Xu
- Department of Neurology, Xiangya Changde Hospital, No. 1688, Yueliang Road, Changde, 415000, Hunan Province, P R China.
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Goadsby PJ, Friedman DI, Holle-Lee D, Demarquay G, Ashina S, Sakai F, Neel B, Gandhi P, Dabruzzo B, Smith JH, Liu Y, Trugman JM. Efficacy of Atogepant in Chronic Migraine With and Without Acute Medication Overuse in the Randomized, Double-Blind, Phase 3 PROGRESS Trial. Neurology 2024; 103:e209584. [PMID: 38924724 PMCID: PMC11254449 DOI: 10.1212/wnl.0000000000209584] [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: 09/08/2023] [Accepted: 05/15/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Atogepant is an oral, calcitonin gene-related peptide receptor antagonist approved for the preventive treatment of migraine. We evaluated the efficacy of atogepant for the preventive treatment of chronic migraine (CM) in participants with and without acute medication overuse. METHODS This subgroup analysis of the phase 3, 12-week, randomized, double-blind, placebo-controlled PROGRESS trial evaluated adults with a ≥1-year history of CM, ≥15 monthly headache days (MHDs), and ≥8 monthly migraine days (MMDs) during the 4-week baseline period. Participants were randomized (1:1:1) to placebo, atogepant 30 mg twice daily (BID), or atogepant 60 mg once daily (QD) for 12 weeks and were analyzed by acute medication overuse status (triptans/ergots for ≥10 days per month, simple analgesics for ≥15 days per month, or combinations of triptans/ergots/simple analgesics for ≥10 days per month). Outcomes included change from baseline in mean MMDs, MHDs, and monthly acute medication use days; ≥50% reduction in mean MMDs across 12 weeks; and patient-reported outcome (PRO) measures. RESULTS Of 755 participants in the modified intent-to-treat population, 500 (66.2%) met baseline acute medication overuse criteria (placebo, n = 169 [68.7%]; atogepant 30 mg BID, n = 161 [63.6%]; atogepant 60 mg QD, n = 170 [66.4%]). The least squares mean difference (LSMD) (95% CI) from placebo in MMDs was -2.7 (-4.0 to -1.4) with atogepant 30 mg BID and -1.9 (-3.2 to -0.6) with atogepant 60 mg QD. Mean MHDs (LSMD [95% CI] -2.8 [-4.0 to -1.5] and -2.1 [-3.3 to -0.8]) and mean acute medication use days (LSMD [95% CI] -2.8 [-4.1 to -1.6] and -2.6 [-3.9 to -1.3]) were reduced and a higher proportion of participants achieved ≥50% reduction in MMDs (odds ratio [95% CI] 2.5 [1.5-4.0] and 2.3 [1.4-3.7]) with atogepant 30 mg BID and atogepant 60 mg QD. There was a 52.1%-61.9% reduction in the proportion of atogepant-treated participants meeting acute medication overuse criteria over 12 weeks. Atogepant improved PRO measures. Similar results were observed in the subgroup without acute medication overuse. DISCUSSION Atogepant was effective in participants with CM, with and without acute medication overuse, as evidenced by reductions in mean MMDs, MHDs, and acute medication use days; reductions in the proportion of participants meeting acute medication overuse criteria; and improvements in PROs. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov NCT03855137. Submitted: February 25, 2019; first patient enrolled: March 11, 2019. clinicaltrials.gov/ct2/show/NCT03855137. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that atogepant reduces mean MMDs, MHDs, and monthly acute medication use days in adult patients with or without medication overuse.
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Affiliation(s)
- Peter J Goadsby
- From the NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Key-Whitman Eye Center (D.I.F.), Dallas, TX; Department of Neurology (D.H.-L.), West German Headache and Vertigo Center Essen, University of Essen, Germany; Department of Neurology (G.D.), Hospices Civils de Lyon, Lyon Neuroscience Research Center, France; BIDMC Comprehensive Headache Center (S.A.), Beth Israel Deaconess Medical Center; Department of Neurology and Department of Anesthesia, Critical Care and Pain Medicine (S.A.), Harvard Medical School, Boston, MA; International Headache Society Global Patient Advocacy Coalition Executive Committee (F.S.), Saitama International Headache Center, Saitama Neuropsychiatric Institute, Japan; AbbVie (B.N.), Irvine, CA; AbbVie (P.G., B.D., J.M.T.), Madison, NJ; and AbbVie (J.H.S., Y.L.), North Chicago, IL
| | - Deborah I Friedman
- From the NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Key-Whitman Eye Center (D.I.F.), Dallas, TX; Department of Neurology (D.H.-L.), West German Headache and Vertigo Center Essen, University of Essen, Germany; Department of Neurology (G.D.), Hospices Civils de Lyon, Lyon Neuroscience Research Center, France; BIDMC Comprehensive Headache Center (S.A.), Beth Israel Deaconess Medical Center; Department of Neurology and Department of Anesthesia, Critical Care and Pain Medicine (S.A.), Harvard Medical School, Boston, MA; International Headache Society Global Patient Advocacy Coalition Executive Committee (F.S.), Saitama International Headache Center, Saitama Neuropsychiatric Institute, Japan; AbbVie (B.N.), Irvine, CA; AbbVie (P.G., B.D., J.M.T.), Madison, NJ; and AbbVie (J.H.S., Y.L.), North Chicago, IL
| | - Dagny Holle-Lee
- From the NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Key-Whitman Eye Center (D.I.F.), Dallas, TX; Department of Neurology (D.H.-L.), West German Headache and Vertigo Center Essen, University of Essen, Germany; Department of Neurology (G.D.), Hospices Civils de Lyon, Lyon Neuroscience Research Center, France; BIDMC Comprehensive Headache Center (S.A.), Beth Israel Deaconess Medical Center; Department of Neurology and Department of Anesthesia, Critical Care and Pain Medicine (S.A.), Harvard Medical School, Boston, MA; International Headache Society Global Patient Advocacy Coalition Executive Committee (F.S.), Saitama International Headache Center, Saitama Neuropsychiatric Institute, Japan; AbbVie (B.N.), Irvine, CA; AbbVie (P.G., B.D., J.M.T.), Madison, NJ; and AbbVie (J.H.S., Y.L.), North Chicago, IL
| | - Genevieve Demarquay
- From the NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Key-Whitman Eye Center (D.I.F.), Dallas, TX; Department of Neurology (D.H.-L.), West German Headache and Vertigo Center Essen, University of Essen, Germany; Department of Neurology (G.D.), Hospices Civils de Lyon, Lyon Neuroscience Research Center, France; BIDMC Comprehensive Headache Center (S.A.), Beth Israel Deaconess Medical Center; Department of Neurology and Department of Anesthesia, Critical Care and Pain Medicine (S.A.), Harvard Medical School, Boston, MA; International Headache Society Global Patient Advocacy Coalition Executive Committee (F.S.), Saitama International Headache Center, Saitama Neuropsychiatric Institute, Japan; AbbVie (B.N.), Irvine, CA; AbbVie (P.G., B.D., J.M.T.), Madison, NJ; and AbbVie (J.H.S., Y.L.), North Chicago, IL
| | - Sait Ashina
- From the NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Key-Whitman Eye Center (D.I.F.), Dallas, TX; Department of Neurology (D.H.-L.), West German Headache and Vertigo Center Essen, University of Essen, Germany; Department of Neurology (G.D.), Hospices Civils de Lyon, Lyon Neuroscience Research Center, France; BIDMC Comprehensive Headache Center (S.A.), Beth Israel Deaconess Medical Center; Department of Neurology and Department of Anesthesia, Critical Care and Pain Medicine (S.A.), Harvard Medical School, Boston, MA; International Headache Society Global Patient Advocacy Coalition Executive Committee (F.S.), Saitama International Headache Center, Saitama Neuropsychiatric Institute, Japan; AbbVie (B.N.), Irvine, CA; AbbVie (P.G., B.D., J.M.T.), Madison, NJ; and AbbVie (J.H.S., Y.L.), North Chicago, IL
| | - Fumihiko Sakai
- From the NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Key-Whitman Eye Center (D.I.F.), Dallas, TX; Department of Neurology (D.H.-L.), West German Headache and Vertigo Center Essen, University of Essen, Germany; Department of Neurology (G.D.), Hospices Civils de Lyon, Lyon Neuroscience Research Center, France; BIDMC Comprehensive Headache Center (S.A.), Beth Israel Deaconess Medical Center; Department of Neurology and Department of Anesthesia, Critical Care and Pain Medicine (S.A.), Harvard Medical School, Boston, MA; International Headache Society Global Patient Advocacy Coalition Executive Committee (F.S.), Saitama International Headache Center, Saitama Neuropsychiatric Institute, Japan; AbbVie (B.N.), Irvine, CA; AbbVie (P.G., B.D., J.M.T.), Madison, NJ; and AbbVie (J.H.S., Y.L.), North Chicago, IL
| | - Brian Neel
- From the NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Key-Whitman Eye Center (D.I.F.), Dallas, TX; Department of Neurology (D.H.-L.), West German Headache and Vertigo Center Essen, University of Essen, Germany; Department of Neurology (G.D.), Hospices Civils de Lyon, Lyon Neuroscience Research Center, France; BIDMC Comprehensive Headache Center (S.A.), Beth Israel Deaconess Medical Center; Department of Neurology and Department of Anesthesia, Critical Care and Pain Medicine (S.A.), Harvard Medical School, Boston, MA; International Headache Society Global Patient Advocacy Coalition Executive Committee (F.S.), Saitama International Headache Center, Saitama Neuropsychiatric Institute, Japan; AbbVie (B.N.), Irvine, CA; AbbVie (P.G., B.D., J.M.T.), Madison, NJ; and AbbVie (J.H.S., Y.L.), North Chicago, IL
| | - Pranav Gandhi
- From the NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Key-Whitman Eye Center (D.I.F.), Dallas, TX; Department of Neurology (D.H.-L.), West German Headache and Vertigo Center Essen, University of Essen, Germany; Department of Neurology (G.D.), Hospices Civils de Lyon, Lyon Neuroscience Research Center, France; BIDMC Comprehensive Headache Center (S.A.), Beth Israel Deaconess Medical Center; Department of Neurology and Department of Anesthesia, Critical Care and Pain Medicine (S.A.), Harvard Medical School, Boston, MA; International Headache Society Global Patient Advocacy Coalition Executive Committee (F.S.), Saitama International Headache Center, Saitama Neuropsychiatric Institute, Japan; AbbVie (B.N.), Irvine, CA; AbbVie (P.G., B.D., J.M.T.), Madison, NJ; and AbbVie (J.H.S., Y.L.), North Chicago, IL
| | - Brett Dabruzzo
- From the NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Key-Whitman Eye Center (D.I.F.), Dallas, TX; Department of Neurology (D.H.-L.), West German Headache and Vertigo Center Essen, University of Essen, Germany; Department of Neurology (G.D.), Hospices Civils de Lyon, Lyon Neuroscience Research Center, France; BIDMC Comprehensive Headache Center (S.A.), Beth Israel Deaconess Medical Center; Department of Neurology and Department of Anesthesia, Critical Care and Pain Medicine (S.A.), Harvard Medical School, Boston, MA; International Headache Society Global Patient Advocacy Coalition Executive Committee (F.S.), Saitama International Headache Center, Saitama Neuropsychiatric Institute, Japan; AbbVie (B.N.), Irvine, CA; AbbVie (P.G., B.D., J.M.T.), Madison, NJ; and AbbVie (J.H.S., Y.L.), North Chicago, IL
| | - Jonathan H Smith
- From the NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Key-Whitman Eye Center (D.I.F.), Dallas, TX; Department of Neurology (D.H.-L.), West German Headache and Vertigo Center Essen, University of Essen, Germany; Department of Neurology (G.D.), Hospices Civils de Lyon, Lyon Neuroscience Research Center, France; BIDMC Comprehensive Headache Center (S.A.), Beth Israel Deaconess Medical Center; Department of Neurology and Department of Anesthesia, Critical Care and Pain Medicine (S.A.), Harvard Medical School, Boston, MA; International Headache Society Global Patient Advocacy Coalition Executive Committee (F.S.), Saitama International Headache Center, Saitama Neuropsychiatric Institute, Japan; AbbVie (B.N.), Irvine, CA; AbbVie (P.G., B.D., J.M.T.), Madison, NJ; and AbbVie (J.H.S., Y.L.), North Chicago, IL
| | - Yingyi Liu
- From the NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Key-Whitman Eye Center (D.I.F.), Dallas, TX; Department of Neurology (D.H.-L.), West German Headache and Vertigo Center Essen, University of Essen, Germany; Department of Neurology (G.D.), Hospices Civils de Lyon, Lyon Neuroscience Research Center, France; BIDMC Comprehensive Headache Center (S.A.), Beth Israel Deaconess Medical Center; Department of Neurology and Department of Anesthesia, Critical Care and Pain Medicine (S.A.), Harvard Medical School, Boston, MA; International Headache Society Global Patient Advocacy Coalition Executive Committee (F.S.), Saitama International Headache Center, Saitama Neuropsychiatric Institute, Japan; AbbVie (B.N.), Irvine, CA; AbbVie (P.G., B.D., J.M.T.), Madison, NJ; and AbbVie (J.H.S., Y.L.), North Chicago, IL
| | - Joel M Trugman
- From the NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Key-Whitman Eye Center (D.I.F.), Dallas, TX; Department of Neurology (D.H.-L.), West German Headache and Vertigo Center Essen, University of Essen, Germany; Department of Neurology (G.D.), Hospices Civils de Lyon, Lyon Neuroscience Research Center, France; BIDMC Comprehensive Headache Center (S.A.), Beth Israel Deaconess Medical Center; Department of Neurology and Department of Anesthesia, Critical Care and Pain Medicine (S.A.), Harvard Medical School, Boston, MA; International Headache Society Global Patient Advocacy Coalition Executive Committee (F.S.), Saitama International Headache Center, Saitama Neuropsychiatric Institute, Japan; AbbVie (B.N.), Irvine, CA; AbbVie (P.G., B.D., J.M.T.), Madison, NJ; and AbbVie (J.H.S., Y.L.), North Chicago, IL
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Rizzoli P. Medication-Overuse Headache. Continuum (Minneap Minn) 2024; 30:379-390. [PMID: 38568489 DOI: 10.1212/con.0000000000001403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
OBJECTIVE Medication-overuse headache (MOH) has been described for almost 100 years and is characterized as a daily or near-daily headache that usually presents in patients with preexisting primary headache disorders who are overusing one or more acute or symptomatic headache medications. This article reviews the diagnosis and management of patients with MOH. LATEST DEVELOPMENTS The International Classification of Headache Disorders criteria for MOH have changed over time. The worldwide prevalence appears to be between 1% and 2%. Together, headache disorders, including MOH, are currently ranked as the second leading cause of years lived with disability in the Global Burden of Disease world health survey. Significant neurophysiologic changes are seen in the brains of patients with MOH, including functional alterations in central pain processing and modulating systems and central sensitization. Research supports updates to the principles of management, including weaning off the overused medication, preventive therapy, biobehavioral therapy, and patient education. ESSENTIAL POINTS MOH is a fairly common and treatable secondary headache disorder that produces significant disability and a substantial reduction in quality of life. The costs related to lost income and disability are substantial. MOH is intimately related to chronic migraine, which continues to be underrecognized and undertreated. Treatment focuses on both the institution of effective preventive migraine therapy and the reduction or removal of the overused medications. Educational efforts directed toward both providers and patients have been shown to be effective in reducing the effect of MOH.
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Krymchantowski A, Jevoux C, Krymchantowski AG, Ramos LB, Barbosa JSS, Silva-Neto RP. Medication-overuse headache-a review of different treatment strategies. FRONTIERS IN PAIN RESEARCH 2023; 4:1103497. [PMID: 37881687 PMCID: PMC10597723 DOI: 10.3389/fpain.2023.1103497] [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: 11/20/2022] [Accepted: 03/23/2023] [Indexed: 10/27/2023] Open
Abstract
Medication-overuse headache (MOH) can develop from primary headaches. MOH is usually the result of overuse of symptomatic medications. It is a noteworthy personal and societal burden. The identification and treatment of patients at risk for MOH is an essential component of MOH management. Medication overuse can be modifiable and can advance from episodic to chronic migraine. Treatment for MOH is complex, and experts in the field have varied views on the most appropriate strategy for MOH treatment. The objective of this review is to give a comprehensive synopsis of the literature for the management of MOH. Treatment strategies, such as detoxification and prevention, are the debatable issues. Medication withdrawal is the foundation for management. The available literature suggested abrupt withdrawal with preventive approaches for early management. Bridging therapy could be useful to get relief from withdrawal symptoms. Multidisciplinary choices proved beneficial in supporting withdrawal and preventing relapse. Worldwide, the termination of overused medications has been observed as a standard treatment strategy; however, patient-specific approaches should be taken.
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Schoenen J, Van Dycke A, Versijpt J, Paemeleire K. Ten open questions in migraine prophylaxis with monoclonal antibodies blocking the calcitonin-gene related peptide pathway: a narrative review. J Headache Pain 2023; 24:99. [PMID: 37528353 PMCID: PMC10391994 DOI: 10.1186/s10194-023-01637-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 07/21/2023] [Indexed: 08/03/2023] Open
Abstract
The monoclonal antibodies (mAbs) blocking the calcitonin-gene related peptide (CGRP) pathway, collectively called here "anti-CGRP/rec mAbs", have dramatically improved preventive migraine treatment. Although their efficacy and tolerability were proven in a number of randomized controlled trials (RCTs) and, maybe even more convincingly, in real world settings, a number of open questions remain. In this narrative review, we will analyze published data allowing insight in some of the uncertainties related to the use of anti-CGRP/rec mAbs in clinical practice: their differential efficacy in migraine subtypes, outcome predictors, switching between molecules, use in children and adolescents, long-term treatment adherence and persistence, effect persistence after discontinuation, combined treatment with botulinum toxin or gepants, added-value and cost effectiveness, effectiveness in other headache types, and potential contraindications based on known physiological effects of CGRP. While recent studies have already provided hints for some of these questions, many of them will not find reliable and definitive answers before larger studies, registries or dedicated RCTs are available.
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Affiliation(s)
- Jean Schoenen
- Headache Research Unit, Department of Neurology‑Citadelle Hospital, University of Liège, Boulevard du 12 ème de Ligne 1, Liège, 4000, Belgium.
| | - Annelies Van Dycke
- Department of Neurology, General Hospital Sint-Jan Bruges, Ruddershove 10, Bruges, 8000, Belgium
| | - Jan Versijpt
- Department of Neurology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, Brussels, 1090, Belgium
| | - Koen Paemeleire
- Department of Neurology, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, 9000, Belgium
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Hird MA, Sandoe CH. Medication Overuse Headache: an Updated Review and Clinical Recommendations on Management. Curr Neurol Neurosci Rep 2023; 23:389-398. [PMID: 37271793 DOI: 10.1007/s11910-023-01278-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] [Accepted: 05/18/2023] [Indexed: 06/06/2023]
Abstract
OVERVIEW Medication overuse headache (MOH) is highly prevalent among individuals with primary headache disorders. PURPOSE OF REVIEW (1) Provide an update on epidemiology, risk factors, and treatment strategies of MOH and (2) provide recommendations on the management of MOH. RECENT FINDINGS The prevalence of MOH ranges from 0.5 to 7.2%. Risk factors for MOH include female sex, lower socioeconomic status, some psychiatric conditions, and substance use disorders, among others. Recent large clinical trials support preventative therapy as an integral component of MOH management. Emerging clinical trial evidence supports anti-CGRP mAbs as effective preventative treatments among individuals with migraine and MOH. Among the large clinical trials, candesartan, topiramate, amitriptyline, and onabotulinumtoxinA were the most used preventative therapies, providing further support for these agents. MOH management requires a multifaceted and patient-centered approach that involves patient education, behavioral interventions, withdrawal of the overused medication, and initiation of preventative medication.
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Affiliation(s)
- Megan A Hird
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Claire H Sandoe
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Canada.
- Centre for Headache, Women's College Hospital, 3rd Floor, 76 Grenville St, Toronto, Ontario, M5S 1B2, Canada.
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Alpuente A, Torres-Ferrus M, Terwindt GM. Preventive CGRP-targeted therapies for chronic migraine with and without medication-overuse headache. Cephalalgia 2023. [DOI: 10.1177/03331024221150235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
Background: Calcitonin gene-related peptide (CGRP) targeted therapies are an important breakthrough in migraine prevention. Randomized clinical trials, post-hoc analyses, and phase IV studies have demonstrated their efficacy and safety in chronic migraine patients, including those with concomitant medication-overuse and medication-overuse headache. Real world evidence studies support these findings and provide realistic endpoints for estimation of effect. Methods and results We have performed a narrative review including results from double-blind placebo-controlled randomized clinical trials and real-world evidence studies regarding efficacy of the CGRP(-receptor) monoclonal antibodies and CGRP-receptor antagonists (gepants) in patients with chronic migraine with concomitant medication overuse (headache). We have included patient profiles and main efficacy endpoints (monthly migraine days, monthly headache days, monthly acute medication days and percentage responder rates). Conclusion The results of this review show that CGRP monoclonal antibodies are effective in chronic migraine patients, also in those with medication overuse (headache). At the time of this review, atogepant clinical trials in chronic migraine have not been communicated. Direct comparative studies are needed for comparison with other treatment options.
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Affiliation(s)
- Alicia Alpuente
- Headache Clinic, Neurology Department, Vall d’Hebron University Hospital, Barcelona, Spain
- Headache and Neurological Pain Research Group, Vall d’Hebron Research Institute, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marta Torres-Ferrus
- Headache Clinic, Neurology Department, Vall d’Hebron University Hospital, Barcelona, Spain
- Headache and Neurological Pain Research Group, Vall d’Hebron Research Institute, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Gisela M. Terwindt
- Department of Neurology, Leiden Headache Center, Leiden University Medical Center, Leiden, the Netherlands
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Abstract
Medication overuse headache (MOH) is a secondary headache disorder attributed to overuse of acute headache medications by a person with an underlying headache disorder, usually migraine or tension-type headache. MOH is common among individuals with 15 or more headache days per month. Although MOH is associated with substantial disability and reductions in quality of life, this condition is often under-recognized. As MOH is both preventable and treatable, it warrants greater attention and awareness. The diagnosis of MOH is based on the history and an unremarkable neurological examination, and is made according to the diagnostic criteria of the International Classification of Headache Disorders third edition (ICHD-3). Pathophysiological mechanisms of MOH include altered descending pain modulation, central sensitization and biobehavioural factors. Treatment of MOH includes the use of headache preventive therapies, but essential to success is eliminating the cause, by reducing the frequency of use of acute headache medication, and perhaps withdrawing the overused medication altogether. Appropriate treatment is usually highly effective, leading to reduced headache burden and acute medication consumption.
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Diener HC, Rizzoli P. Chronic migraine and medication overuse. HANDBOOK OF CLINICAL NEUROLOGY 2023; 198:187-200. [PMID: 38043961 DOI: 10.1016/b978-0-12-823356-6.00008-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
Though clearly described as far back as the 17th century, chronic migraine has defied precise categorization and has continued to develop as an important diagnostic concept with significant societal impact. Worldwide prevalence is estimated to be between 1% and 3%, and these patients form a dynamic group cycling between chronic and episodic migraine. Theories of pathogenesis are developing supported by recent imaging and other findings. Of the many determinants of progression to chronic migraine, overuse of acute abortive headache medications may be one of the most important modifiable factors. Treatment strategies, in addition to educational measures, have included various preventive migraine medications such as topiramate, valproate, and onabotulinumtoxinA. CGRP monoclonal antibodies are efficacious for the management of chronic migraine both with and without medication overuse.
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Affiliation(s)
- Hans Christoph Diener
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology (IMIBE), Medical Faculty of the University Duisburg-Essen, Essen, Germany.
| | - Paul Rizzoli
- Department of Neurology, Brigham and Women's Hospital; John R Graham Headache Center, Brigham and Women's Faulkner Hospital, Harvard Medical School, Boston, MA, United States
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Kaltseis K, Hamann T, Gaul C, Broessner G. Is prednisone still a reasonable option in the treatment of withdrawal headache in patients with chronic migraine and medication overuse headache in the age of CGRP antibodies? A narrative review. Headache 2022; 62:1264-1271. [PMID: 36437611 PMCID: PMC10100419 DOI: 10.1111/head.14415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 08/29/2022] [Accepted: 08/31/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Along with the development of novel migraine therapies as the monoclonal antibodies against calcitonin gene-related peptide (CGRP) and its receptor, the question arises if the treatment of chronic migraine (CM) and medication overuse headache (MOH) must be reconsidered. Have previous therapeutic approaches, including glucocorticoids, lost their role in the management of this debilitating disorder? In this narrative review, we present an overview of the available treatment options in CM and MOH in light of CGRP antibodies as well as an evaluation of the role of glucocorticoids in withdrawal therapy. BACKGROUND Chronic migraine and medication overuse continues to be a difficult to treat condition. To date, potent treatment options are scarce and algorithms for advising patients with MOH are often still based on expert consensus rather than evidence-based medicine. For years and probably due to lack of effective alternatives, glucocorticoids have been used in MOH, especially to alleviate withdrawal symptoms caused by detoxification. Small case series report positive effects of steroids in this respective patient group; however, randomized controlled trials did not show a consistent benefit, although this may be due to methodological limitations. Because of these discrepancies, their role in MOH has been under debate ever since. METHODS We searched the electronic database PubMed for articles up to June 1, 2022 on the use of glucocorticoids in CM and MOH. CONCLUSION Despite popular use in clinical practice, there is currently still no scientific evidence for the efficacy of glucocorticoids in patients with CM and MOH. Treatment with monoclonal antibodies achieved high transition rates from medication overuse to non-overuse. However, further research is needed to evaluate the additional benefit of these new agents.
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Affiliation(s)
- Katharina Kaltseis
- Department of Neurology, Headache Outpatient Clinic, Innsbruck Medical University, Innsbruck, Austria
| | - Till Hamann
- Department of Neurology, Headache Center North-East, University Medical Center Rostock, Rostock, Germany
| | - Charly Gaul
- Headache Center Frankfurt, Frankfurt, Germany
| | - Gregor Broessner
- Department of Neurology, Headache Outpatient Clinic, Innsbruck Medical University, Innsbruck, Austria
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Wang YF, Wang SJ. CGRP Targeting Therapy for Chronic Migraine-Evidence from Clinical Trials and Real-world Studies. Curr Pain Headache Rep 2022; 26:543-554. [PMID: 35567661 DOI: 10.1007/s11916-022-01056-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2022] [Indexed: 01/19/2023]
Abstract
PURPOSE OF REVIEW Monoclonal antibodies against calcitonin gene-related peptide (CGRP) or its receptor have become part of the standard treatment for migraine in clinical practice. The current review focuses on the clinical evidence of CGRP monoclonal antibodies in patients with chronic migraine (CM), including more challenging cases. RECENT FINDINGS CGRP monoclonal antibodies were more effective than placebo in reducing the number of monthly migraine days (MMDs), and the change relative to placebo in the treatment group was between - 1.2 and - 2.7 days at 3 months. CGRP monoclonal antibodies resulted in ≥ 50% response in 27.5 to 61.4% of patients, and doubled the odds for having ≥ 50% response. The findings were generally consistent in patients with coexisting medication overuse or with treatment failures to multiple preventive medications, including onabotulinumtoxinA. The results from real-world studies (RWS) were similar to those seen in clinical trials, and the changes from baseline in the number of MMDs and the response rates largely fell within the ranges of those reported in the treatment group in pivotal trials. The therapeutic effects typically started within a few days, and remained steady after regular treatment for up to 1 year. These agents were generally well tolerated, and the discontinuation rates due to adverse events in clinical trials and in many RWS were < 4.5%. CGRP monoclonal antibodies are effective and safe in the treatment of patients with CM, including clinical challenging cases. However, the role of CGRP monoclonal antibodies in a number of conditions, such as cardiovascular or cerebrovascular diseases, pregnancy, and overuse of opioids or barbiturates, needs to be further clarified.
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Affiliation(s)
- Yen-Feng Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Bei-Tou District, Taipei, 11217, Taiwan. .,College of Medicine National Yang Ming Chiao Tung University, Taipei, Taiwan. .,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Bei-Tou District, Taipei, 11217, Taiwan.,College of Medicine National Yang Ming Chiao Tung University, Taipei, Taiwan.,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
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12
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Atraszkiewicz D, Ito R, Bahra A. The efficacy of botulinum toxin type-A for intractable chronic migraine patients with no pain-free time. Br J Pain 2022; 16:41-49. [PMID: 35111313 PMCID: PMC8801685 DOI: 10.1177/20494637211014544] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
AIM This is a retrospective report of the efficacy of botulinum toxin-A, Botox® (Allergan), in intractable chronic migraine patients non-responsive to previous pharmacological management and with largely no pain-free time, including those with new onset daily persistent headache. METHODS Thirty-three patients, all with severe Headache Impact Test (HIT)-6 scores at baseline, received 3-monthly injections of Botox® as per Phase III REsearch Evaluating Migraine Prophylaxis Therapy (PRE-EMPT) protocol over a maximum 33-month period. Response criteria were a sustained reduction of HIT-6 scores below 60. RESULTS Four patients had headache on at least 20 days a month; the remaining patients had daily headache with no pain-free time, including nine patients with new onset persistent migraine. There was a significant reduction in HIT-6 scores following Botox® therapy (x̅ = -5.45, p = 0.000920). Twenty-one percent of the cohort exhibited a sustained reduction in HIT-6 scores below 60. The number of headache days and pain-free time did not change in five of the six responders, but disability improved. There was no difference between patients with episodic migraine evolving to chronic as opposed to those with chronic migraine from onset. CONCLUSION This report suggests that Botox® treatment is efficacious in intractable chronic migraine without pain-free time. The HIT-6 is a reliable and practical parameter to assess disability in this patient group. Use of such validated parameters should be considered with greater weight in future International Classification of Headache Disorders (ICHD) guidelines for controlled clinical trials.
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Affiliation(s)
| | - Rieko Ito
- The National Hospital for Neurology and Neurosurgery, London, UK
| | - Anish Bahra
- The National Hospital for Neurology and Neurosurgery, London, UK,Barts Health NHS Trust, London, UK,Anish Bahra, The National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK.
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13
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Propranolol ebenso wirksam wie Topiramat. INFO NEUROLOGIE + PSYCHIATRIE 2022. [PMCID: PMC8765808 DOI: 10.1007/s15005-021-2219-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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Park HK, Cho SJ. Comprehensive approach for the treatment of medication-overuse headache. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2021. [DOI: 10.5124/jkma.2021.64.12.843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: Medication-overuse headache (MOH) is defined by the International Classification of Headache Disorders as a headache in patients with a pre-existing primary headache disorder that occurs on 15 or more days per month for more than 3 months. It is caused by overuse of medication for acute or symptomatic headache treatment. Regular and frequent use of acute or symptomatic medications can worsen headaches and lead to chronic headache or MOH. MOH is a burdensome medical condition that is difficult to treat, and the frequent recurrence of headaches may result in disability in individuals and impair socioeconomic outcomes.Current Concepts: Awareness of MOH and the education of patients, the general population, and healthcare providers are important for the first step of treatment. Scientific research regarding the treatment of MOH has been published in the past few years.Discussion and Conclusion: Physicians should educate and counsel patients to stop or at least reduce the intake of acute or symptomatic medications that can be discontinued abruptly or tapered slowly. During the period after the discontinuation of the overused medications, some withdrawal symptoms including headache might be manageable with bridging therapy. Evidence-based preventive therapies including anticonvulsants (topiramate and divalproex sodium), botulinum toxin A, and medications acting by antagonism of the calcitonin generelated peptide pathway might be helpful in patients with MOH for both avoiding the overused medication and preventing the relapse of overuse. A comprehensive and multidisciplinary approach may improve the outcomes of patients with MOH.
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15
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Corand V, Moisset X, Radat F, Lucas C. Medication overuse headache: Updating of the French recommendations regarding the treatments strategies. Rev Neurol (Paris) 2021; 177:760-764. [PMID: 34332779 DOI: 10.1016/j.neurol.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 07/09/2021] [Indexed: 10/20/2022]
Abstract
Regular and frequent use of analgesics and acute antimigraine drugs can increase the frequency of headache, and induce the transition from episodic to chronic migraine or medication-overuse headache (MOH). The one-year prevalence of this condition is between 1% and 2% in Europe, provoking substantial burden. MOH is more prevalent in people with comorbid depression, anxiety, and other chronic pain conditions. This paper aims at presenting an updating of French recommendations regarding treatments strategies. Prior French recommendations, published in 2014, were written in French. A literature search in the major medical databases including the terms "medication overuse headache", "symptomatic medication overuse", published between 2010 and 2020 was carried out. Three main strategies can be recommended and conducted in parallel: education and explanations about the negative consequences of overusing acute antimigraine drugs, discontinuation of the overused medication, and finally, preventive drug therapy and non-pharmacological prevention. Medication overuse headache remains a debated problem and evidence for the most effective treatment strategy is needed.
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Affiliation(s)
- V Corand
- Centre d'Etude et de Traitement de la Douleur, hôpital Pellegrin, CHU de Bordeaux, place Amélie Raba Léon, 33076 Bordeaux cedex, France
| | | | - X Moisset
- Université Clermont Auvergne, Inserm U-1107, Neuro-Dol, 63000 Clermont-Ferrand, France
| | - F Radat
- 107, rue Judaïque, 33000 Bordeaux, France
| | - C Lucas
- Centre d'Evaluation et de Traitement de la Douleur, Service de Neurochirurgie, hôpital Salengro, CHU de Lille, 2, avenue Oscar Lambret, 59037 Lille cedex, France.
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16
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Dodick DW, Doty EG, Aurora SK, Ruff DD, Stauffer VL, Jedynak J, Dong Y, Pearlman EM. Medication overuse in a subgroup analysis of phase 3 placebo-controlled studies of galcanezumab in the prevention of episodic and chronic migraine. Cephalalgia 2020; 41:340-352. [PMID: 33143451 DOI: 10.1177/0333102420966658] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Acute medication overuse is prevalent in patients with migraine. METHODS In three phase 3, double-blind, randomized, placebo-controlled studies, patients with episodic migraine (EVOLVE-1 and EVOLVE-2) or chronic migraine (REGAIN) were randomized 2:1:1 to monthly subcutaneous injections of placebo or galcanezumab 120 or 240 mg for 3 or 6 months. This subgroup analysis evaluated mean changes in the number of monthly migraine headache days in each treatment among patients with versus without baseline acute medication overuse via mixing modelling with repeated measures. RESULTS The percentages of patients with baseline medication overuse in placebo, galcanezumab 120-mg and 240-mg groups, respectively, were 19.4%, 17.3%, and 19.3% for EVOLVE-1/-2 (pooled; post hoc), and 63.4%, 64.3%, and 64.1% for REGAIN (a priori). Both galcanezumab doses demonstrated significant improvement compared with placebo for overall least squares mean change in monthly migraine headache days in patients with baseline medication overuse in both the episodic and chronic migraine studies (p ≤ 0.001). Furthermore, both galcanezumab doses reduced average monthly medication overuse rates compared to placebo (p < 0.001) in both patient populations with medication overuse at baseline. CONCLUSIONS Galcanezumab appears to be effective for the preventive treatment of episodic and chronic migraine in patients who overuse acute medications.Trial registration: ClinicalTrials.gov Identifiers: NCT02614183, NCT02614196, and NCT02614261.
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Affiliation(s)
| | - Erin G Doty
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - Sheena K Aurora
- Impel Neuropharma, 201 Elliott Avenue West, Seattle, WA, USA
| | - Dustin D Ruff
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | | | - Jakub Jedynak
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - Yan Dong
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - Eric M Pearlman
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
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17
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Silberstein SD, Cohen JM, Seminerio MJ, Yang R, Ashina S, Katsarava Z. The impact of fremanezumab on medication overuse in patients with chronic migraine: subgroup analysis of the HALO CM study. J Headache Pain 2020; 21:114. [PMID: 32958075 PMCID: PMC7507645 DOI: 10.1186/s10194-020-01173-8] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 08/13/2020] [Indexed: 12/23/2022] Open
Abstract
Background We evaluated the efficacy of fremanezumab, a fully humanized monoclonal antibody that selectively targets calcitonin gene-related peptide, in patients with chronic migraine (CM) with and without medication overuse (MO). Methods In a 12-week, phase 3 trial, patients with CM were randomized to fremanezumab quarterly (675 mg/placebo/placebo), monthly (675 mg/225 mg/225 mg), or placebo. Post hoc analyses assessed the impact of fremanezumab in patients with and without MO (monthly use of acute headache medication ≥15 days, migraine-specific acute medication ≥10 days, or combination medication ≥10 days) on efficacy outcomes, including headache days of at least moderate severity (HDs), and six-item Headache Impact Test (HIT-6) and Migraine-Specific Quality of Life (MSQoL) questionnaire scores. Results Of 1130 patients enrolled, 587 (51.9%) had baseline MO. Fremanezumab reduced placebo-adjusted least-squares mean (95% confidence interval) monthly HDs (− 2.2 [− 3.1 to − 1.2] and − 2.7 [− 3.7 to − 1.8]; P < 0.0001) in patients with MO and without MO (quarterly − 1.4 [− 2.3 to − 0.5], P = 0.0026; monthly − 1.4 [− 2.3 to − 0.6], P = 0.0017). Significantly more fremanezumab-treated patients had ≥ 50% reduction in HDs versus placebo, regardless of baseline MO (with: quarterly 70/201 [34.8%], monthly 78/198 [39.4%] vs placebo 26/188 [13.8%]; without: quarterly 71/174 [40.8%], monthly 75/177 [42.4%] vs placebo 41/183 [22.4%]). Fremanezumab improved HIT-6 and MSQoL scores. Significantly more fremanezumab-treated patients reverted to no MO (quarterly 111/201 [55.2%], monthly 120/198 [60.6%]) versus placebo (87/188 [46.3%]). Conclusions Fremanezumab is effective for prevention of migraine in patients with CM, regardless of MO, and demonstrated a benefit over placebo in reducing MO. Trial registration ClinicalTrials.gov NCT02621931 (HALO CM), registered December 12, 2012.
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Affiliation(s)
- Stephen D Silberstein
- Jefferson Headache Center, Thomas Jefferson University, 900 Walnut Street, Second Floor, Philadelphia, PA, 19107, USA.
| | - Joshua M Cohen
- Teva Branded Pharmaceutical Products R&D, Inc., West Chester, PA, USA
| | | | - Ronghua Yang
- Teva Branded Pharmaceutical Products R&D, Inc., West Chester, PA, USA
| | - Sait Ashina
- BIDMC Comprehensive Headache Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Zaza Katsarava
- Evangelical Hospital Unna, Unna, Germany.,Department of Neurology, University of Duisburg-Essen, Essen, Germany.,EVEX Medical Corporation, Tbilisi, Georgia.,IM Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation
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Abstract
BACKGROUND AND AIMS Medication-overuse headache (MOH) is a common chronic headache caused by overuse of headache analgesics. It has similarities with substance dependence disorders. The treatment of choice for MOH is withdrawal of the offending analgesics. Behavioral brief intervention treatment using methods adapted from substance misuse settings is effective. Here we investigate the severity of analgesics dependence in MOH using the Severity of Dependence Scale (SDS), validate the SDS score against formal substance dependence diagnosis based on the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) and examine whether the SDS predicts successful withdrawal. METHODS Representative recruitment from the general population; 60 MOH patients, 15 chronic headache patients without medication overuse and 25 population controls. Headaches were diagnosed using the International Classification of Headache Disorders, medication use was assessed and substance dependence classified according to the DSM-IV. The SDS was scored by interviewers blinded to patient group. Descriptive statistics were used and validity of the SDS score assessed against a substance dependence diagnosis using ROC analysis. RESULTS Sixty-two percent of MOH patients overused simple analgesics, 38% centrally acting analgesics (codeine, opiates, triptans). Fifty percent of MOH patients were classified as DSM-IV substance dependent. Centrally active medication and high SDS scores were associated with higher proportions of dependence. ROC analysis showed SDS scores accurately identified dependence (area under curve 88%). Lower SDS scores were associated with successful withdrawal (P = 0.004). CONCLUSIONS MOH has characteristics of substance dependence which should be taken into account when choosing treatment strategy. TRIAL REGISTRATION Based on data collected in previously reported randomized BIMOH trial (; in the present manuscript, Clinical trials registration number: NCT01314768). The present part, however, represents observational data and is not a treatment trial.
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19
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Krymchantowski AV, Jevoux CC, Krymchantowski AG, Vivas RS, Silva-Néto R. Medication overuse headache: an overview of clinical aspects, mechanisms, and treatments. Expert Rev Neurother 2020; 20:591-600. [PMID: 32463304 DOI: 10.1080/14737175.2020.1770084] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Medication-overuse headache (MOH) is a common debilitating neurological disorder, with a prevalence of 1% to 7% in general population. It affects more than 60 million people worldwide and provokes substantial burden. Despite that, most practitioners don't know MOH. This review aims at presenting MOH clinical features, pathophysiology insights, and recent knowledge and guidance regarding treatments. AREAS COVERED A literature search in the major medical databases including the terms 'medication overuse headache,' 'chronic daily headache,' 'chronic migraine,' 'symptomatic medication overuse' and others, published between 1990 and 2020, was carried out. EXPERT COMMENTARY Primary headache sufferers such as migraineurs and tension-type headache patients may increase the headache frequency and induce the transition from episodic to chronic forms, as well as develop MOH, in the presence of medication overuse. There is evidence of structural and functional changes in some areas of the brain, which may identify those likely to respond or not to treatments. Despite the geographical differences and lack of consensus regarding approaches, to educate the patients about reducing medication intake, to withdraw overused medications and to start prophylaxis in some sufferers are crucial steps. Emerging treatments as monoclonal antibodies to migraine may result in better adherence and tolerability profiles as well as outcomes.
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Affiliation(s)
| | | | | | | | - Raimundo Silva-Néto
- Department of Neurology, Universidade Federal do Delta do Parnaíba , Piauí, Brazil
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20
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Diener HC, Antonaci F, Braschinsky M, Evers S, Jensen R, Lainez M, Kristoffersen ES, Tassorelli C, Ryliskiene K, Petersen JA. European Academy of Neurology guideline on the management of medication‐overuse headache. Eur J Neurol 2020; 27:1102-1116. [DOI: 10.1111/ene.14268] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/06/2020] [Accepted: 04/09/2020] [Indexed: 11/30/2022]
Affiliation(s)
- H. C. Diener
- Institute for Medical Informatics, Biometry and Epidemiology Faculty of Medicine University Duisburg‐Essen Essen Germany
| | - F. Antonaci
- IRCCS C. Mondino Foundation Pavia Italy
- Department of Brain and Behavioral Sciences University of Pavia Pavia Italy
| | - M. Braschinsky
- Headache Clinic Neurology Clinic Tartu University Hospital Tartu Estonia
| | - S. Evers
- Faculty of Medicine University of Münster MünsterGermany
- Krankenhaus Lindenbrunn Coppenbrügge Germany
| | - R. Jensen
- Danish Headache Center Neurological Clinic Rigshospitalet‐Glostrup University of Copenhagen Copenhagen Denmark
| | - M. Lainez
- Department of Neurology Hospital Clínico Universitario ValenciaSpain
- Department of Neurology Universidad Católica de Valencia Valencia Spain
| | - E. S. Kristoffersen
- Department of Neurology Akershus University Hospital OsloNorway
- Department of General Practice University of Oslo Oslo Norway
| | - C. Tassorelli
- IRCCS C. Mondino Foundation Pavia Italy
- Department of Brain and Behavioral Sciences University of Pavia Pavia Italy
| | - K. Ryliskiene
- Department of Neurology Institute of Clinical Medicine Faculty of Medicine Vilnius University Vilnius Lithuania
| | - J. A. Petersen
- Department Of Neurology University Hospital Zurich Zurich Switzerland
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Vandenbussche N, Paemeleire K, Katsarava Z. The Many Faces of Medication-Overuse Headache in Clinical Practice. Headache 2020; 60:1021-1036. [PMID: 32232847 DOI: 10.1111/head.13785] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 02/28/2020] [Indexed: 12/24/2022]
Abstract
The management of medication-overuse headache (MOH) is multifaceted and headache experts have different views on the optimal strategy to tackle this type of secondary headache. The purpose of this review is to provide an overview of the literature on the management of MOH, and to highlight important considerations in the clinical evaluation of the MOH patient. Managing MOH in clinical practice starts by evaluating the headache patient with medication overuse, determining the overused drug(s), assessing the impact of headaches on the patient and assessing comorbid conditions and disorders. Withdrawal of the overused medication is the cornerstone of treatment. An inpatient or outpatient setting is chosen based on the clinical profile of the patient. There is evidence for abrupt withdrawal combined with headache preventive treatment. Bridging therapy to bring relief to withdrawal headaches and/or symptoms should be offered. Education and motivational work through multidisciplinary assessment show benefits in sustaining withdrawal and preventing relapse. Although the reversal of chronic headache after cessation of overused acute medication has been noticed worldwide, different aspects of the management of MOH, such as complete or gradual withdrawal, or preventive treatment with or without withdrawal are still debated.
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Affiliation(s)
| | - Koen Paemeleire
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Zaza Katsarava
- Department of Neurology, University of Duisburg-Essen, Essen, Germany.,Department of Neurology, Evangelical Hospital Unna, Unna, Germany.,EVEX Medical Corporation, Tbilisi, GA, USA.,Sechenov University Moscow, Moscow, Russian Federation
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Abstract
Migraine affects over a billion people worldwide in any year and is the second most common cause of years lost due to disability. Not "just a headache", morbidity washes though society and carries a substantial economic and social cost. Understanding of migraine pathophysiology has progressed significantly. Animal models and functional neuroimaging have yielded significant insight into brain structures that mediate migraine symptoms. The role of small peptides as neurotransmitters within this network has been elucidated, allowing the generation of novel therapeutic approaches that have been validated by randomised placebo-controlled trials. Migraine is underdiagnosed and undertreated. Treatment of migraine should be proactive. An acute and, when indicated, preventive strategy should be formulated with the patient. Comorbid medication overuse must be supportively managed. Migraine-specific medications are making their way from bench to bedside. They promise an improved safety profile and ease of use in comparison to older, repurposed medications. Devices promise a non-drug alternative should patients prefer. The migraine understanding and treatment landscape is changing rapidly.
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Abstract
Headache is the most common neurologic symptom and affects nearly half the world's population at any given time. Although the prevalence declines with age, headache remains a common neurologic complaint among elderly populations. Headaches can be divided into primary and secondary causes. Primary headaches comprise about two-thirds of headaches among the elderly. They are defined by clinical criteria and are diagnosed based on symptom pattern and exclusion of secondary causes. Primary headaches include migraine, tension-type, trigeminal autonomic cephalalgias, and hypnic headache. Secondary headaches are defined by their suspected etiology. A higher index of suspicion for a secondary headache disorder is warranted in older patients with new-onset headache. They are roughly 12 times more likely to have serious underlying causes and, frequently, have different symptomatic presentations compared to younger adults. Various imaging and laboratory evaluations are indicated in the presence of any "red flag" signs or symptoms. Head CT is the procedure of choice for acute headache presentations, and brain MRI for those with chronic headache complaints. Management of headache in elderly populations can be challenging due to the presence of multiple medical comorbidities, polypharmacy, and differences in drug metabolism and clearance.
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Affiliation(s)
- Robert G Kaniecki
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.
| | - Andrew D Levin
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
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Kowacs F, Roesler CADP, Piovesan ÉJ, Sarmento EM, Campos HCD, Maciel JA, Calia LC, Barea LM, Ciciarelli MC, Valença MM, Costa MENDM, Peres MFP, Kowacs PA, Rocha-Filho PAS, Silva-Néto RPD, Villa TR, Jurno ME. Consensus of the Brazilian Headache Society on the treatment of chronic migraine. ARQUIVOS DE NEURO-PSIQUIATRIA 2019; 77:509-520. [PMID: 31365643 DOI: 10.1590/0004-282x20190078] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 03/29/2019] [Indexed: 12/27/2022]
Abstract
Chronic migraine poses a significant personal, social and economic burden and is characterized by headache present on 15 or more days per month for at least three months, with at least eight days of migrainous headache per month. It is frequently associated with analgesic or acute migraine medication overuse and this should not be overlooked. The present consensus was elaborated upon by a group of members of the Brazilian Headache Society in order to describe current evidence and to provide recommendations related to chronic migraine pharmacological and nonpharmacological treatment. Withdrawal strategies in medication overuse headache are also described, as well as treatment risks during pregnancy and breastfeeding. Oral topiramate and onabotulinum toxin A injections are the only treatments granted Class A recommendation, while valproate, gabapentin, and tizanidine received Class B recommendation, along with acupuncture, biofeedback, and mindfulness. The anti-CGRP or anti-CGRPr monoclonal antibodies, still unavailable in Brazil, are promising new drugs already approved elsewhere for migraine prophylactic treatment, the efficacy of which in chronic migraine is still to be definitively proven.
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Affiliation(s)
- Fernando Kowacs
- Departamento Científico de Cefaleia da Academia Brasileira de Neurologia, São Paulo SP, Brasil.,Universidade Federal de Ciências da Saúde de Porto Alegre, Irmandade Santa Casa de Misericórdia, Serviço de Neurologia, Porto Alegre RS, Brasil.,Hospital Moinhos de Vento, Serviço de Neurologia e Neurocirurgia, Porto Alegre RS, Brasil
| | - Célia Aparecida de Paula Roesler
- Departamento Científico de Cefaleia da Academia Brasileira de Neurologia, São Paulo SP, Brasil.,Clínica de Cefaleia e Neurologia Dr. Edgard Raffaelli, São Paulo SP, Brasil
| | - Élcio Juliato Piovesan
- Universidade Federal do Paraná, Hospital das Clínicas, Departamento de Clínica Médica, Serviço de Neurologia, Curitiba PR, Brasil
| | - Elder Machado Sarmento
- Centro Universitário de Volta Redonda, Volta Redonda RJ, Brasil.,Fundação Educacional Dom André Arcoverde, Centro de Ensino Superior de Valença, Valença RJ, Brasil
| | | | | | | | - Liselotte Menke Barea
- Universidade Federal de Ciências da Saúde de Porto Alegre, Irmandade Santa Casa de Misericórdia, Serviço de Neurologia, Porto Alegre RS, Brasil
| | | | | | | | - Mário Fernando Prieto Peres
- Hospital Israelita Albert Einstein, São Paulo SP, Brasil.,Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas Instituto de Psiquiatria, São Paulo SP, Brasil
| | - Pedro André Kowacs
- Universidade Federal do Paraná, Hospital das Clínicas, Departamento de Clínica Médica, Serviço de Neurologia, Curitiba PR, Brasil.,Instituto de Neurologia de Curitiba, Curitiba PR, Brasil
| | - Pedro Augusto Sampaio Rocha-Filho
- Universidade Federal de Pernambuco, Recife PE, Brasil.,Universidade de Pernambuco, Hospital Universitário Oswaldo Cruz, Ambulatório de Cefaleias, Recife PE, Brasil
| | - Raimundo Pereira da Silva-Néto
- Departamento Científico de Cefaleia da Academia Brasileira de Neurologia, São Paulo SP, Brasil.,Universidade Federal do Piauí, Teresina PI, Brasil
| | - Thais Rodrigues Villa
- Universidade Federal de São Paulo, Setor de Cefaleias, São Paulo SP, Brasil.,Headache Center Brasil, São Paulo SP, Brasil
| | - Mauro Eduardo Jurno
- Faculdade de Medicina de Barbacena, Barbacena MG, Brasil.,Fundação Hospital do Estado de Minas Gerais, Hospital Regional de Barbacena Dr. José Américo, São Paulo SP, Brasil
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Birlea M, Penning S, Callahan K, Schoenen J. Efficacy and safety of external trigeminal neurostimulation in the prevention of chronic migraine: An open-label trial. CEPHALALGIA REPORTS 2019. [DOI: 10.1177/2515816319856625] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Objective: This trial explored the therapeutic utility and safety of external trigeminal neurostimulation (eTNS) as a preventive treatment in patients suffering from chronic migraine (CM). Methods: It was a monocenter, prospective, open-label, pilot trial conducted at the University of Colorado, Anschutz Medical Campus (Aurora, CO, USA). Participants were adult patients with a history of CM meeting International Classification of Headache Disorder-3 beta (2013) diagnostic criteria with or without medication overuse. After a 1-month baseline period, the patients still fulfilling the inclusion criteria applied at least one daily 20-min session of eTNS for 3 months. Primary outcomes were mean monthly changes in frequency of headache days and in overall acute headache medication intake. Results: Eighty patients were assessed for eligibility, 73 were included in the baseline period after which 58 entered the treatment period and were included in the intention-to-treat analysis. Compared to baseline, frequency of headache days decreased by −3.12 days (−16.21%, p < 0.001) and acute medication intake decreased from 26.33 to 18.22 (−30.81%, p < 0.001) during the third month of treatment. Twenty-six patients reported 47 minor adverse events, of which only 2 were related to the use of the device (skin irritation under the electrode and headache worsening with vertigo). Conclusions: This trial suggests that eTNS is safe and effective as prophylactic treatment for CM and indicates that a randomized sham-controlled trial is worthwhile. Trial registration: ClinicalTrials.gov (identifier: NCT02342743).
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Affiliation(s)
- Marius Birlea
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sophie Penning
- Department of Research and Development, CEFALY Technology, Seraing, Belgium
| | - Kyle Callahan
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jean Schoenen
- Headache Research Unit, Citadelle Hospital, University of Liege, Liege, Belgium
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26
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Pathophysiology, prevention, and treatment of medication overuse headache. Lancet Neurol 2019; 18:891-902. [PMID: 31174999 DOI: 10.1016/s1474-4422(19)30146-2] [Citation(s) in RCA: 136] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Revised: 03/08/2019] [Accepted: 03/13/2019] [Indexed: 12/25/2022]
Abstract
Regular or frequent use of analgesics and acute antimigraine drugs can increase the frequency of headache, and induce the transition from episodic to chronic headache or medication overuse headache. The 1-year prevalence of this condition in the general population is between 1% and 2%. Medication overuse headache is more common in women and in people with comorbid depression, anxiety, and other chronic pain conditions. Treatment of medication overuse headache has three components. First, patients need education and counselling to reduce the intake of medication for acute headache attacks. Second, some patients benefit from drug withdrawal (discontinuation of the overused medication). Finally, preventive drug therapy and non-medical prevention might be necessary in patients at onset of treatment or in patients who do not respond to the first two steps. The optimal therapeutic approach requires validation in controlled trials.
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Munksgaard SB, Madsen SK, Wienecke T. Treatment of medication overuse headache-A review. Acta Neurol Scand 2019; 139:405-414. [PMID: 30710346 DOI: 10.1111/ane.13074] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 01/10/2019] [Accepted: 01/29/2019] [Indexed: 12/19/2022]
Abstract
Medication overuse headache (MOH) is the most prevalent chronic headache disorder with a prevalence between 1% and 2% worldwide. The disease has been acknowledged for almost 30 years, yet experts still disagree on how best to treat MOH. By performing a search in PubMed on the terms "medication overuse headache," "analgesics abuse headache," "rebound headache," "drug induced headache," and "headache AND drug misuse" limited to human studies published in English between January 1, 2004, and November 1, 2017, we aimed to evaluate current literature concerning predictors of treatment outcome, inpatient and outpatient treatment programs, initial versus latent administration of prophylactic medications, and to review the effect of prophylactic medications. Selection criteria were prospective, comparative, or controlled trials on treatment of MOH in persons of at least 18 years of age. Several studies evaluated risk factors to predict the outcome of MOH treatment, but many studies were underpowered. Psychiatric comorbidity, high dependence score, and overuse of barbiturates, benzodiazepines, and opioids predicted a poorer outcome of withdrawal therapy. Patients with these risk factors benefit from inpatient treatment, whereas patients without risk factors benefit equally from inpatient and outpatient treatment. Some medications for migraine prophylactics have shown better effect on MOH compared with placebo, but not when combined with withdrawal. We conclude that detoxification programs are of great importance in MOH treatment. Latent administration of prophylactic medications reduces the number of patients needing prophylactic medication. Individualizing treatment according to the predictors of outcome may improve treatment outcome and thus reduce work-related and treatment-related costs.
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Affiliation(s)
- Signe B. Munksgaard
- Danish Headache Center, Department of Neurology Rigshospitalet‐Glostrup Glostrup Denmark
- Neurovascular Center, Department of Neurology Zealand University Hospital Roskilde Denmark
| | - Samuel K. Madsen
- Danish Headache Center, Department of Neurology Rigshospitalet‐Glostrup Glostrup Denmark
- Neurovascular Center, Department of Neurology Zealand University Hospital Roskilde Denmark
| | - Troels Wienecke
- Danish Headache Center, Department of Neurology Rigshospitalet‐Glostrup Glostrup Denmark
- Neurovascular Center, Department of Neurology Zealand University Hospital Roskilde Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
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28
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Tepper SJ, Diener HC, Ashina M, Brandes JL, Friedman DI, Reuter U, Cheng S, Nilsen J, Leonardi DK, Lenz RA, Mikol DD. Erenumab in chronic migraine with medication overuse: Subgroup analysis of a randomized trial. Neurology 2019; 92:e2309-e2320. [PMID: 30996056 PMCID: PMC6598821 DOI: 10.1212/wnl.0000000000007497] [Citation(s) in RCA: 139] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 01/16/2019] [Indexed: 01/03/2023] Open
Abstract
Objective To determine the effect of erenumab, a human anti-calcitonin gene-related peptide receptor monoclonal antibody, in patients with chronic migraine and medication overuse. Methods In this double-blind, placebo-controlled study, 667 adults with chronic migraine were randomized (3:2:2) to placebo or erenumab (70 or 140 mg), stratified by region and medication overuse status. Data from patients with baseline medication overuse at baseline were used to assess changes in monthly migraine days, acute migraine-specific medication treatment days, and proportion of patients achieving ≥50% reduction from baseline in monthly migraine days. Results Of 667 patients randomized, 41% (n = 274) met medication overuse criteria. In the medication overuse subgroup, erenumab 70 or 140 mg groups had greater reductions than the placebo group at month 3 in monthly migraine days (mean [95% confidence interval] −6.6 [−8.0 to −5.3] and −6.6 [−8.0 to −5.3] vs −3.5 [−4.6 to −2.4]) and acute migraine-specific medication treatment days (−5.4 [−6.5 to −4.4] and −4.9 [−6.0 to −3.8] vs −2.1 [−3.0 to −1.2]). In the placebo and 70 and 140 mg groups, ≥50% reductions in monthly migraine days were achieved by 18%, 36% (odds ratio [95% confidence interval] 2.67 [1.36–5.22]) and 35% (odds ratio 2.51 [1.28–4.94]). These clinical responses paralleled improvements in patient-reported outcomes with a consistent benefit of erenumab across multiple measures of impact, disability, and health-related quality of life. The observed treatment effects were similar in the non–medication overuse subgroup. Conclusions Erenumab reduced migraine frequency and acute migraine-specific medication treatment days in patients with chronic migraine and medication overuse, improving disability and quality of life. Clinicaltrials.gov identifier NCT02066415. Classification of evidence This study provides Class II evidence that erenumab reduces monthly migraine days at 3 months in patients with chronic migraine and medication overuse.
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Affiliation(s)
- Stewart J Tepper
- From the Geisel School of Medicine at Dartmouth (S.J.T.), Hanover, NH; Department of Neurology (H.-C.D.), University of Duisburg-Essen, Germany; Department of Neurology (M.A.), Danish Headache Center, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Neurology (J.L.B.), Vanderbilt University School of Medicine; Nashville Neuroscience Group (J.L.B.), TN; Neurology and Neurotherapeutics and Ophthalmology (D.I.F.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (U.R.), Charité Universitätsmedizin Berlin, Germany; and Amgen Inc (S.C., J.N., D.K.L., R.A.L., D.D.M.), Thousand Oaks, CA.
| | - Hans-Christoph Diener
- From the Geisel School of Medicine at Dartmouth (S.J.T.), Hanover, NH; Department of Neurology (H.-C.D.), University of Duisburg-Essen, Germany; Department of Neurology (M.A.), Danish Headache Center, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Neurology (J.L.B.), Vanderbilt University School of Medicine; Nashville Neuroscience Group (J.L.B.), TN; Neurology and Neurotherapeutics and Ophthalmology (D.I.F.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (U.R.), Charité Universitätsmedizin Berlin, Germany; and Amgen Inc (S.C., J.N., D.K.L., R.A.L., D.D.M.), Thousand Oaks, CA
| | - Messoud Ashina
- From the Geisel School of Medicine at Dartmouth (S.J.T.), Hanover, NH; Department of Neurology (H.-C.D.), University of Duisburg-Essen, Germany; Department of Neurology (M.A.), Danish Headache Center, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Neurology (J.L.B.), Vanderbilt University School of Medicine; Nashville Neuroscience Group (J.L.B.), TN; Neurology and Neurotherapeutics and Ophthalmology (D.I.F.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (U.R.), Charité Universitätsmedizin Berlin, Germany; and Amgen Inc (S.C., J.N., D.K.L., R.A.L., D.D.M.), Thousand Oaks, CA
| | - Jan Lewis Brandes
- From the Geisel School of Medicine at Dartmouth (S.J.T.), Hanover, NH; Department of Neurology (H.-C.D.), University of Duisburg-Essen, Germany; Department of Neurology (M.A.), Danish Headache Center, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Neurology (J.L.B.), Vanderbilt University School of Medicine; Nashville Neuroscience Group (J.L.B.), TN; Neurology and Neurotherapeutics and Ophthalmology (D.I.F.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (U.R.), Charité Universitätsmedizin Berlin, Germany; and Amgen Inc (S.C., J.N., D.K.L., R.A.L., D.D.M.), Thousand Oaks, CA
| | - Deborah I Friedman
- From the Geisel School of Medicine at Dartmouth (S.J.T.), Hanover, NH; Department of Neurology (H.-C.D.), University of Duisburg-Essen, Germany; Department of Neurology (M.A.), Danish Headache Center, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Neurology (J.L.B.), Vanderbilt University School of Medicine; Nashville Neuroscience Group (J.L.B.), TN; Neurology and Neurotherapeutics and Ophthalmology (D.I.F.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (U.R.), Charité Universitätsmedizin Berlin, Germany; and Amgen Inc (S.C., J.N., D.K.L., R.A.L., D.D.M.), Thousand Oaks, CA
| | - Uwe Reuter
- From the Geisel School of Medicine at Dartmouth (S.J.T.), Hanover, NH; Department of Neurology (H.-C.D.), University of Duisburg-Essen, Germany; Department of Neurology (M.A.), Danish Headache Center, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Neurology (J.L.B.), Vanderbilt University School of Medicine; Nashville Neuroscience Group (J.L.B.), TN; Neurology and Neurotherapeutics and Ophthalmology (D.I.F.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (U.R.), Charité Universitätsmedizin Berlin, Germany; and Amgen Inc (S.C., J.N., D.K.L., R.A.L., D.D.M.), Thousand Oaks, CA
| | - Sunfa Cheng
- From the Geisel School of Medicine at Dartmouth (S.J.T.), Hanover, NH; Department of Neurology (H.-C.D.), University of Duisburg-Essen, Germany; Department of Neurology (M.A.), Danish Headache Center, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Neurology (J.L.B.), Vanderbilt University School of Medicine; Nashville Neuroscience Group (J.L.B.), TN; Neurology and Neurotherapeutics and Ophthalmology (D.I.F.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (U.R.), Charité Universitätsmedizin Berlin, Germany; and Amgen Inc (S.C., J.N., D.K.L., R.A.L., D.D.M.), Thousand Oaks, CA
| | - Jon Nilsen
- From the Geisel School of Medicine at Dartmouth (S.J.T.), Hanover, NH; Department of Neurology (H.-C.D.), University of Duisburg-Essen, Germany; Department of Neurology (M.A.), Danish Headache Center, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Neurology (J.L.B.), Vanderbilt University School of Medicine; Nashville Neuroscience Group (J.L.B.), TN; Neurology and Neurotherapeutics and Ophthalmology (D.I.F.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (U.R.), Charité Universitätsmedizin Berlin, Germany; and Amgen Inc (S.C., J.N., D.K.L., R.A.L., D.D.M.), Thousand Oaks, CA
| | - Dean K Leonardi
- From the Geisel School of Medicine at Dartmouth (S.J.T.), Hanover, NH; Department of Neurology (H.-C.D.), University of Duisburg-Essen, Germany; Department of Neurology (M.A.), Danish Headache Center, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Neurology (J.L.B.), Vanderbilt University School of Medicine; Nashville Neuroscience Group (J.L.B.), TN; Neurology and Neurotherapeutics and Ophthalmology (D.I.F.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (U.R.), Charité Universitätsmedizin Berlin, Germany; and Amgen Inc (S.C., J.N., D.K.L., R.A.L., D.D.M.), Thousand Oaks, CA
| | - Robert A Lenz
- From the Geisel School of Medicine at Dartmouth (S.J.T.), Hanover, NH; Department of Neurology (H.-C.D.), University of Duisburg-Essen, Germany; Department of Neurology (M.A.), Danish Headache Center, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Neurology (J.L.B.), Vanderbilt University School of Medicine; Nashville Neuroscience Group (J.L.B.), TN; Neurology and Neurotherapeutics and Ophthalmology (D.I.F.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (U.R.), Charité Universitätsmedizin Berlin, Germany; and Amgen Inc (S.C., J.N., D.K.L., R.A.L., D.D.M.), Thousand Oaks, CA
| | - Daniel D Mikol
- From the Geisel School of Medicine at Dartmouth (S.J.T.), Hanover, NH; Department of Neurology (H.-C.D.), University of Duisburg-Essen, Germany; Department of Neurology (M.A.), Danish Headache Center, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Neurology (J.L.B.), Vanderbilt University School of Medicine; Nashville Neuroscience Group (J.L.B.), TN; Neurology and Neurotherapeutics and Ophthalmology (D.I.F.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (U.R.), Charité Universitätsmedizin Berlin, Germany; and Amgen Inc (S.C., J.N., D.K.L., R.A.L., D.D.M.), Thousand Oaks, CA
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Frederiksen SD, Haanes KA, Warfvinge K, Edvinsson L. Perivascular neurotransmitters: Regulation of cerebral blood flow and role in primary headaches. J Cereb Blood Flow Metab 2019; 39:610-632. [PMID: 29251523 PMCID: PMC6446417 DOI: 10.1177/0271678x17747188] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 11/04/2017] [Accepted: 11/06/2017] [Indexed: 12/17/2022]
Abstract
In order to understand the nature of the relationship between cerebral blood flow (CBF) and primary headaches, we have conducted a literature review with particular emphasis on the role of perivascular neurotransmitters. Primary headaches are in general considered complex polygenic disorders (genetic and environmental influence) with pathophysiological neurovascular alterations. Identified candidate headache genes are associated with neuro- and gliogenesis, vascular development and diseases, and regulation of vascular tone. These findings support a role for the vasculature in primary headache disorders. Moreover, neuronal hyperexcitability and other abnormalities have been observed in primary headaches and related to changes in hemodynamic factors. In particular, this relates to migraine aura and spreading depression. During headache attacks, ganglia such as trigeminal and sphenopalatine (located outside the blood-brain barrier) are variably activated and sensitized which gives rise to vasoactive neurotransmitter release. Sympathetic, parasympathetic and sensory nerves to the cerebral vasculature are activated. During migraine attacks, altered CBF has been observed in brain regions such as the somatosensory cortex, brainstem and thalamus. In regulation of CBF, the individual roles of neurotransmitters are partly known, but much needs to be unraveled with respect to headache disorders.
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Affiliation(s)
- Simona D Frederiksen
- Department of Clinical Experimental Research, Glostrup Research Institute, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Kristian A Haanes
- Department of Clinical Experimental Research, Glostrup Research Institute, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Karin Warfvinge
- Department of Clinical Experimental Research, Glostrup Research Institute, Rigshospitalet Glostrup, Glostrup, Denmark
- Division of Experimental Vascular Research, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Lars Edvinsson
- Department of Clinical Experimental Research, Glostrup Research Institute, Rigshospitalet Glostrup, Glostrup, Denmark
- Division of Experimental Vascular Research, Department of Clinical Sciences, Lund University, Lund, Sweden
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Parikh SK, Silberstein SD. Current Status of Antiepileptic Drugs as Preventive Migraine Therapy. Curr Treat Options Neurol 2019; 21:16. [PMID: 30880369 DOI: 10.1007/s11940-019-0558-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Antiepileptic drugs (AEDs) are an important class of agents used in the treatment of migraine, a neurological disorder that imparts significant socioeconomic burden. It is important for neurologists to understand the rationale for AEDs in migraine-preventive treatment, as well as each agent's efficacy and tolerability profile, in order to best determine clinical care. PURPOSE OF THIS REVIEW This article specifically provides the following: (1) a review of the mechanism of action, efficacy, and tolerability of topiramate and divalproex sodium/sodium valproate, the most widely used AEDs for migraine prevention, (2) a discussion on emerging evidence regarding the efficacy of zonisamide and levetiracetam, and (3) comments on gabapentin, pregabalin, carbamazepine, oxcarbazepine, and lamotrigine, AEDs which have insufficient evidence for use in migraine prevention. RECENT FINDINGS The potential role for new extended-release formulations of topiramate in migraine prevention is discussed. There is substantial evidence supporting the use of AEDs in migraine prevention. Specific agents should be chosen based on their efficacy and tolerability profiles. Further studies are needed to determine the efficacy of the newer AEDs, zonisamide and levetiracetam, in migraine prevention and to clarify the role of gabapentinoids in headache management.
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Affiliation(s)
- Simy K Parikh
- Jefferson Headache Center, Thomas Jefferson University, Suite 200, Philadelphia, PA, 19107, USA
| | - Stephen D Silberstein
- Jefferson Headache Center, Thomas Jefferson University, Suite 200, Philadelphia, PA, 19107, USA.
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31
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Seng EK, Gelfand AA, Nicholson RA. Assessing evidence-based medicine and opioid/barbiturate as first-line acute treatment of pediatric migraine and primary headache: A retrospective observational study of health systems data. Cephalalgia 2019; 39:1000-1009. [PMID: 30786733 DOI: 10.1177/0333102419833080] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVES To evaluate providers' use and predictors of evidence-based medicine or opioid/barbiturate as first-line acute treatment for children's initial presentation of acute migraine or primary headache. METHODS This retrospective, observational study utilized patient (children ages 6-17) and provider/encounter characteristics extracted from the patient's Electronic Health Record from 2008-2014 during an initial encounter for migraine or primary headache. The primary outcome was provider evidence-based medicine utilization; overall prescriptions and opioid/barbiturate prescriptions were also evaluated. Hierarchical linear modeling examined whether Level 1 (patient: Demographic, insurance type) and Level 2 (provider/encounter: Treatment setting/location, encounter diagnoses) characteristics influenced outcomes. RESULTS In all, 38,926 patients (56.7% female, mean age = 12.1) and 1617 providers were evaluated. Only 17.7% of patients were diagnosed with migraine; 16.1% received evidence-based medicine. Older children (OR = 1.07, p < 0.001), females (OR = 1.14, p < 0.001), and those diagnosed with migraine (OR = 4.71, p < 0.001) were more likely to receive evidence-based medicine. Among prescriptions, 15.8% were for opioids/barbiturates. Older children (OR = 1.14, p < 0.001) and those cared for in the emergency department/urgent care (OR = 2.02, p < 0.001) were at increased risk. CONCLUSIONS Demographics and migraine diagnosis are associated with evidence-based medicine and opioid/barbiturates. Primary care provides an opportunity to target provider interventions to enhance effective pediatric headache treatment.
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Affiliation(s)
- Elizabeth K Seng
- 1 Ferkauf Graduate School of Psychology, Yeshiva University, New York, NY, USA.,2 Saul R Korey, Department of Neurology, Albert Einstein College of Medicine, Yeshiva University, Bronx, NY, USA.,3 Montefiore Medical Center, Bronx, NY, USA
| | - Amy A Gelfand
- 4 UCSF Pediatric Headache, Departments of Neurology and Pediatrics, San Francisco, CA, USA
| | - Robert A Nicholson
- 5 Mercy Research, Chesterfield, MO, USA.,6 Mercy Clinic Headache Center, Chesterfield, MO, USA
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Marmura MJ, Kumpinsky AS. Refining the Benefit/Risk Profile of Anti-Epileptic Drugs in Headache Disorders. CNS Drugs 2018; 32:735-746. [PMID: 30073584 DOI: 10.1007/s40263-018-0555-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Anti-epileptic drugs are among the most effective drugs for migraine prophylaxis, and will likely continue to have a role even as new therapies emerge. Topiramate and valproate are effective for the preventive treatment of migraine, and other medications such as gabapentin or lamotrigine may have a role in the treatment of those with allodynia or frequent aura, respectively. Oxcarbazepine, carbamazepine, phenytoin, gabapentin, and others may alleviate pain in trigeminal neuralgia. While many anti-epileptic drugs can be effective in those with migraine or other headaches, most of these agents can potentially cause serious side effects. In particular, valproate, topiramate, carbamazepine, and phenytoin may lead to adverse outcomes for infants of exposed mothers. Valproate should not be given to women of childbearing potential for migraine prevention.
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Affiliation(s)
- Michael J Marmura
- Department of Neurology, Jefferson Headache Center, Thomas Jefferson University, 900 Walnut ST #200, Philadelphia, PA, 19107, USA.
| | - Aliza S Kumpinsky
- Department of Neurology, Jefferson Headache Center, Thomas Jefferson University, 900 Walnut ST #200, Philadelphia, PA, 19107, USA
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Bottiroli S, Allena M, Sances G, De Icco R, Avenali M, Fadic R, Katsarava Z, Lainez MJA, Goicochea MT, Bendtsen L, Jensen RH, Nappi G, Tassorelli C. Psychological, clinical, and therapeutic predictors of the outcome of detoxification in a large clinical population of medication-overuse headache: A six-month follow-up of the COMOESTAS Project. Cephalalgia 2018; 39:135-147. [DOI: 10.1177/0333102418783317] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Aim To identify factors that may be predictors of the outcome of a detoxification treatment in medication-overuse headache. Methods Consecutive patients entering a detoxification program in six centres in Europe and Latin America were evaluated and followed up for 6 months. We evaluated anxious and depressive symptomatology (though patients with severe psychiatric comorbidity were excluded), quality of life, headache-related disability, headache characteristics, and prophylaxis upon discharge. Results Of the 492 patients who completed the six-month follow up, 407 ceased overuse following the detoxification (non overusers), another 23 ceased overuse following detoxification but relapsed during the follow-up. In the 407 non-overusers, headache acquired an episodic pattern in 287 subjects (responders). At the multivariate analyses, lower depression scores (odds ratio = 0.891; p = 0.001) predicted ceasing overuse. The primary headache diagnosis – migraine with respect to tension-type headache (odds ratio = 0.224; p = 0.001) or migraine plus tension-type headache (odds ratio = 0.467; p = 0.002) – and the preventive treatment with flunarizine (compared to no such treatment) (odds ratio = 0.891; p = 0.001) predicted being a responder. A longer duration of chronic headache (odds ratio = 1.053; p = 0.032) predicted relapse into overuse. Quality of life and disability were not associated with any of the outcomes. Conclusions Though exploratory in nature, these findings point to specific factors that are associated with a positive outcome of medication-overuse headache management, while identifying others that may be associated with a negative outcome. Evaluation of the presence/absence of these factors may help to optimize the management of this challenging groups of chronic headache sufferers.
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Affiliation(s)
- Sara Bottiroli
- Headache Science Centre, IRCCS Mondino Foundation, Pavia, Italy
| | - Marta Allena
- Headache Science Centre, IRCCS Mondino Foundation, Pavia, Italy
| | - Grazia Sances
- Headache Science Centre, IRCCS Mondino Foundation, Pavia, Italy
| | - Roberto De Icco
- Headache Science Centre, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, Italy
| | - Micol Avenali
- Headache Science Centre, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, Italy
| | - Ricardo Fadic
- Department of Neurology, Pontificia Catolica University of Chile, Santiago, Chile
| | | | - Miguel JA Lainez
- Foundation of the Valencian Community, University Clinical Hospital, Spain
| | - Maria Teresa Goicochea
- Integral Pain Centre, Fundación para la Lucha contra las Enfermedades Neurológicas Infantiles (FLENI), Buenos Aires, Argentina
| | - Lars Bendtsen
- Danish Headache Centre, Department of Neurology, Glostrup Hospital, Glostrup, Denmark
| | - Rigmor Højland Jensen
- Danish Headache Centre, Department of Neurology, Glostrup Hospital, Glostrup, Denmark
| | - Giuseppe Nappi
- Headache Science Centre, IRCCS Mondino Foundation, Pavia, Italy
| | - Cristina Tassorelli
- Headache Science Centre, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, Italy
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Diener HC, Holle D, Dresler T, Gaul C. Chronic Headache Due to Overuse of Analgesics and Anti-Migraine Agents. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 115:365-370. [PMID: 29932046 PMCID: PMC6039717 DOI: 10.3238/arztebl.2018.0365] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 10/30/2017] [Accepted: 03/15/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND The frequent or regular use of analgesics and anti-migraine drugs can make headache more frequent and induce the transformation of episodic to chronic headache. Chronic headache due to medication overuse is defined as headache that is present on ≥ 15 days per month for at least three months in a patient who previously suffered from primary headaches, and who takes analgesics on ≥ 15 days per month or anti-migraine drugs (triptans or ergot alkaloids), opioid drugs, or combined analgesics on ≥ 10 days per month. METHODS This review is based on pertinent articles published up to December 2017 that were retrieved by a selective search in PubMed employing the terms "medication overuse AND headache" and "medication overuse headache." RESULTS The prevalence of medication overuse headache in the general population in Germany is 0.7% -1%. This disorder is more common in women and in persons suffering from comorbid mental disorders or other painful conditions. The treatment of medication overuse headache consists of three steps. Patient education and counseling are given with the goal of reducing the intake of medication for acute headache treatment. The ensuing headache prophylaxis is with topiramate, amitriptyline, or onabotulinum toxin A. If these treatment strategies fail, a drug holiday is recommended. This can be in the outpatient, day clinic, or inpatient setting, depending on the severity of the condition and its comorbidities. CONCLUSION Patients who frequently take acute medication to treat headache episodes must be identified early in order to avoid headache chronification and medication overuse headache. The suggested treatment algorithm is still in need of validation by randomized trials.
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Affiliation(s)
| | - Dagny Holle
- Department of Neurology and West German Headache Center, Essen
| | - Thomas Dresler
- Department of Psychiatry and Psychotherapy, University Hospital and Faculty of Medicine, Tübingen LEAD Graduate School & Research Network, University of Tübingen
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Liu L, Zhao LP, Zhang CS, Zeng L, Wang K, Zhao J, Wang L, Jing X, Li B. Acupuncture as prophylaxis for chronic migraine: a protocol for a single-blinded, double-dummy randomised controlled trial. BMJ Open 2018; 8:e020653. [PMID: 29858418 PMCID: PMC5988062 DOI: 10.1136/bmjopen-2017-020653] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Approximately 1.4%-2.2% of the global population suffers from chronic migraine. Acupuncture may serve as an alternative management for chronic migraine, where pharmacological prophylaxis is not suitable. However, the effects of acupuncture as migraine prophylaxis have not been confirmed. This study is designed as a single-blinded, double-dummy randomised controlled trial to evaluate the efficacy and safety of acupuncture compared with topiramate in patients with chronic migraine. METHODS AND ANALYSIS A total of 60 participants will be randomly assigned to two different groups. Participants will receive verum acupuncture and placebo medicine in the treatment group, while participants in the control group will be treated with sham acupuncture and real medicine (topiramate). All participants will receive a 12-week treatment and then be followed up for another 12 weeks. The primary outcome is the reduction of monthly headache days, and the secondary outcomes include the reduction of the number of days with acute headache medications, and changes of Migraine Disability Assessment, Migraine-Specific Quality of Life Questionnaire, Headache Impact Test, State-Trait Anxiety Inventory-trait, and Beck Depression Inventory-II scores from baseline to endpoints. ETHICS AND DISSEMINATION Ethical approval of this study was granted by the Research Ethical Committee of Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University (2017BL-045-01). Written informed consent will be obtained from all participants. Outcomes of the trial will be disseminated through peer-reviewed publications. TRIAL REGISTRATION NUMBER ISRCTN13563102; Pre-results.
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Affiliation(s)
- Lu Liu
- Acupuncture and Moxibustion Department, Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
| | - Luo-Peng Zhao
- Acupuncture and Moxibustion Department, Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China
- Beijing Key Laboratory of Clinic and Basic Research with Traditional Chinese Medicine on Psoriasis, Beijing Institute of Traditional Chinese Medicine, Beijing, China
| | - Claire Shuiqing Zhang
- School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia
| | - Lin Zeng
- Peking University Third Hospital, Research Centre of Clinical Epidemiology, Beijing, China
| | - Kelun Wang
- Department of Health Science and Technology, Centre for Sensory-Motor Interaction (SMI), Aalborg University, Aalborg, Denmark
| | - Jingxia Zhao
- Acupuncture and Moxibustion Department, Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China
- Beijing Key Laboratory of Clinic and Basic Research with Traditional Chinese Medicine on Psoriasis, Beijing Institute of Traditional Chinese Medicine, Beijing, China
| | - Linpeng Wang
- Acupuncture and Moxibustion Department, Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China
| | - Xianghong Jing
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
| | - Bin Li
- Acupuncture and Moxibustion Department, Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China
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Abstract
Migraine is a chronic paroxysmal neurological disorder characterised by multiphase attacks of head pain and a myriad of neurological symptoms. The underlying genetic and biological underpinnings and neural networks involved are coming sharply into focus. This progress in the fundamental understanding of migraine has led to novel, mechanism-based and disease-specific therapeutics. In this Seminar, the clinical features and neurobiology of migraine are reviewed, evidence to support available treatment options is provided, and emerging drug, device, and biological therapies are discussed.
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Cevoli S, Giannini G, Favoni V, Terlizzi R, Sancisi E, Nicodemo M, Zanigni S, Bacchi Reggiani ML, Pierangeli G, Cortelli P. Treatment of withdrawal headache in patients with medication overuse headache: a pilot study. J Headache Pain 2017; 18:56. [PMID: 28500492 PMCID: PMC5429287 DOI: 10.1186/s10194-017-0763-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 04/29/2017] [Indexed: 12/05/2023] Open
Abstract
BACKGROUND Drug withdrawal still remains the key element in the treatment of Medication Overuse Headache (MOH), but there is no consensus about the withdrawal procedure. Still debated is the role of the steroid therapy. The aim of this study was to evaluate the effectiveness of methylprednisolone or paracetamol in the treatment of withdrawal headache in MOH. METHODS We performed a pilot, randomized, single-blinded, placebo controlled trial. MOH patients, unresponsive to a 3 months prophylaxis, underwent withdrawal therapy on an inpatient basis. Overused medications were abruptly stopped and methylprednisolone 500 mg i.v (A) or paracetamol 4 g i.v. (B) or placebo i.v. (C) were given daily for 5 days. Patients were monitored at 1 and 3 months. RESULTS Eighty three consecutive MOH patients were enrolled. Fifty seven patients completed the study protocol. Nineteen patients were randomized to each group. Withdrawal headache on the 5th day was absent in 21.0% of group A, in 31.6% of group B and in 12.5% of group C without significant differences. Withdrawal headache intensity decreased significantly after withdrawal without differences among the groups. Rregardless of withdrawal treatment, 52% MOH patients reverted to an episodic migraine and 62% had no more medication overuse after 3 months. CONCLUSIONS This study suggests that in a population of severe MOH patients, withdrawal headache decreased significantly in the first 5 days of withdrawal regardless of the treatment used. Methylprednisolone and paracetamol are not superior to placebo at the end of the detoxification program.
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Affiliation(s)
- Sabina Cevoli
- 0000 0004 1784 5501grid.414405.0IRCCS Institute of Neurological Sciences of Bologna, UOC Clinica Neurologica, Bellaria Hospital, Via Altura 3, 40139 Bologna, Italy
| | - Giulia Giannini
- 0000 0004 1784 5501grid.414405.0IRCCS Institute of Neurological Sciences of Bologna, UOC Clinica Neurologica, Bellaria Hospital, Via Altura 3, 40139 Bologna, Italy ,0000 0004 1757 1758grid.6292.fDepartment of Biomedical and NeuroMotor Sciences (DiBiNeM), Alma Mater Studiorum - University of Bologna Italy, Bologna, Italy
| | - Valentina Favoni
- 0000 0004 1784 5501grid.414405.0IRCCS Institute of Neurological Sciences of Bologna, UOC Clinica Neurologica, Bellaria Hospital, Via Altura 3, 40139 Bologna, Italy ,0000 0004 1757 1758grid.6292.fDepartment of Biomedical and NeuroMotor Sciences (DiBiNeM), Alma Mater Studiorum - University of Bologna Italy, Bologna, Italy
| | - Rossana Terlizzi
- 0000 0004 1784 5501grid.414405.0IRCCS Institute of Neurological Sciences of Bologna, UOC Clinica Neurologica, Bellaria Hospital, Via Altura 3, 40139 Bologna, Italy ,0000 0004 1757 1758grid.6292.fDepartment of Biomedical and NeuroMotor Sciences (DiBiNeM), Alma Mater Studiorum - University of Bologna Italy, Bologna, Italy
| | - Elisa Sancisi
- Neurology, AUSL (Local Health Service) of Ferrara, Ferrara, Italy
| | - Marianna Nicodemo
- 0000 0004 1759 7093grid.416290.8Division of Neurology, Maggiore Hospital, IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy
| | - Stefano Zanigni
- 0000 0004 1757 1758grid.6292.fDepartment of Biomedical and NeuroMotor Sciences (DiBiNeM), Alma Mater Studiorum - University of Bologna Italy, Bologna, Italy ,grid.412311.4Functional MR Unit, Policlinico S.Orsola-Malpighi, Bologna, Italy
| | - Maria Letizia Bacchi Reggiani
- 0000 0004 1757 1758grid.6292.fDepartment of Experimental, Diagnostic and Specialty Medicine (DIMES), Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Giulia Pierangeli
- 0000 0004 1784 5501grid.414405.0IRCCS Institute of Neurological Sciences of Bologna, UOC Clinica Neurologica, Bellaria Hospital, Via Altura 3, 40139 Bologna, Italy ,0000 0004 1757 1758grid.6292.fDepartment of Biomedical and NeuroMotor Sciences (DiBiNeM), Alma Mater Studiorum - University of Bologna Italy, Bologna, Italy
| | - Pietro Cortelli
- 0000 0004 1784 5501grid.414405.0IRCCS Institute of Neurological Sciences of Bologna, UOC Clinica Neurologica, Bellaria Hospital, Via Altura 3, 40139 Bologna, Italy ,0000 0004 1757 1758grid.6292.fDepartment of Biomedical and NeuroMotor Sciences (DiBiNeM), Alma Mater Studiorum - University of Bologna Italy, Bologna, Italy
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Grazzi L, Sansone E, Raggi A, D'Amico D, De Giorgio A, Leonardi M, De Torres L, Salgado-García F, Andrasik F. Mindfulness and pharmacological prophylaxis after withdrawal from medication overuse in patients with Chronic Migraine: an effectiveness trial with a one-year follow-up. J Headache Pain 2017; 18:15. [PMID: 28161874 PMCID: PMC5292107 DOI: 10.1186/s10194-017-0728-z] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 01/27/2017] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Chronic Migraine (CM) is a disabling condition, worsened when associated with Medication Overuse (MO). Mindfulness is an emerging technique, effective in different pain conditions, but it has yet to be explored for CM-MO. We report the results of a study assessing a one-year course of patients' status, with the hypothesis that the effectiveness of a mindfulness-based approach would be similar to that of conventional prophylactic treatments. METHODS Patients with CM-MO (code 1.3 and 8.2 of the International Classification of Headache Disorders-3Beta) completed a withdrawal program in a day hospital setting. After withdrawal, patients were either treated with Prophylactic Medications (Med-Group), or participated in a Mindfulness-based Training (MT-Group). MT consisted of 6 weekly sessions of guided mindfulness, with patients invited to practice 7-10 min per day. Headache diaries, the headache impact test (HIT-6), the migraine disability assessment (MIDAS), state and trait anxiety (STAI Y1-Y2), and the Beck Depression Inventory (BDI) were administered before withdrawal and at each follow-up (3, 6, 12 after withdrawal) to patients from both groups. Outcome variables were analyzed in separate two-way mixed ANOVAs (Group: Mindfulness vs. Pharmacology x Time: Baseline, 3-, 6-, vs. 12-month follow-up). RESULTS A total of 44 patients participated in the study, with the average age being 44.5, average headache frequency/month was 20.5, and average monthly medication intake was 18.4 pills. Data revealed a similar improvement over time in both groups for Headache Frequency (approximately 6-8 days reduction), use of Medication (approximately 7 intakes reduction), MIDAS, HIT-6 (but only for the MED-Group), and BDI; no changes on state and trait anxiety were found. Both groups revealed significant and equivalent improvement with respect to what has become a classical endpoint in this area of research, i.e. 50% or more reduction of headaches compared to baseline, and the majority of patients in each condition no longer satisfied current criteria for CM. CONCLUSIONS Taken as a whole, our results suggest that the longitudinal course of patients in the MT-Group, that were not prescribed medical prophylaxis, was substantially similar to that of patients who were administered medical prophylaxis.
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Affiliation(s)
- Licia Grazzi
- Neurological Institute "C. Besta" IRCCS Foundation, Headache and Neuroalgology Unit, Via Celoria 11, 20133, Milan, Italy.
| | - Emanuela Sansone
- Neurological Institute "C. Besta" IRCCS Foundation, Neurology, Public Health and Disability Unit, Milan, Italy
| | - Alberto Raggi
- Neurological Institute "C. Besta" IRCCS Foundation, Neurology, Public Health and Disability Unit, Milan, Italy
| | - Domenico D'Amico
- Neurological Institute "C. Besta" IRCCS Foundation, Headache and Neuroalgology Unit, Via Celoria 11, 20133, Milan, Italy
| | | | - Matilde Leonardi
- Neurological Institute "C. Besta" IRCCS Foundation, Neurology, Public Health and Disability Unit, Milan, Italy
| | - Laura De Torres
- Neurological Institute "C. Besta" IRCCS Foundation, Neurology, Public Health and Disability Unit, Milan, Italy
| | | | - Frank Andrasik
- Department of Psychology, Univeristy of Memphis, Memphis, TN, USA
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Silberstein SD. Topiramate in Migraine Prevention: A 2016 Perspective. Headache 2016; 57:165-178. [PMID: 27902848 DOI: 10.1111/head.12997] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 10/14/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND In evidence-based guidelines published in 2000, topiramate was a third-tier migraine preventive with no scientific evidence of efficacy; recommendation for its use reflected consensus opinion and clinical experience. Its neurostabilizing activity, coupled with its favorable weight profile, made topiramate an attractive alternative to other migraine preventives that caused weight gain. When guidelines for migraine prevention in episodic migraine were published in 2012, topiramate was included as a first-line option based on double-blind, randomized controlled trials involving nearly 3000 patients. The scientific and clinical interest in topiramate has generated a large body of data from randomized controlled trials, meta-analyses, patient registries, cohort studies, and claims data analyses that have more fully characterized its role as a migraine preventive. AIM This article will review the profile of topiramate that has emerged out of the past decade of research and clinical use in migraine prophylaxis. It will also address the rationale for extended-release (XR) formulations in optimizing topiramate therapy in migraine. SUMMARY Topiramate has activity at multiple molecular targets, which may account for why it is effective in migraine and most other, more specific, anticonvulsants are not. Based on randomized controlled trials, topiramate reduces migraine frequency and acute medication use, improves quality of life, and reduces disability in patients with episodic migraine and in those with chronic migraine with or without medication overuse headache. Its efficacy in chronic migraine is not improved by the addition of propranolol. Topiramate's ability to prevent progression from high-frequency episodic migraine to chronic migraine remains unclear. Consistent with clinicians' perceptions, migraineurs are more sensitive to topiramate-associated side effects than patients with epilepsy. Paresthesia is a common occurrence early in treatment but is rarely cause for terminating topiramate treatment. Cognitive problems occur much less frequently than paresthesia but are more troublesome in terms of treatment discontinuation. Cognitive complaints can often be managed by slowly increasing the topiramate dose in small increments to allow habituation. As with other carbonic anhydrase inhibitors, topiramate has metabolic effects that favor the development of metabolic acidosis and possibly renal stones. Because migraineurs have an increased risk of renal stones independent of topiramate exposure, clinicians should counsel all migraine patients to maintain hydration. Abrupt onset of blurring, other visual disturbances, and/or ocular pain following topiramate's initiation should be evaluated promptly since this may indicate rare but potentially sight-threatening idiosyncratic events. Postmarketing evidence has shown that first-trimester exposure to topiramate monotherapy is associated with increased occurrence of cleft lip with or without cleft palate (Pregnancy Category D). Even though topiramate's long half-life would seemingly support q.d. dosing, randomized controlled migraine trials used b.i.d. administration of immediate-release (IR) topiramate, which has more favorable plasma concentration-time profile (ie, lower peak concentrations and higher trough concentrations) than q.d. IR dosing. Given the sensitivity of migraineurs to topiramate-related adverse events, particularly cognitive effects, pharmacokinetic profiles should be considered when optimizing migraine outcomes. The extended-release (XR) formulations Qudexy® XR (Upsher-Smith Laboratories) and Trokendi XR® (Supernus Pharmaceuticals) were specifically designed to achieve the adherence benefits of q.d. dosing but with more favorable (ie, more constant) steady-state plasma concentrations over the 24-hour dosing interval vs IR topiramate b.i.d. Intriguing results from a study in healthy volunteers showed consistently less impairment in neuropsychometric tests of verbal fluency and mental processing speed with an XR topiramate formulation (Trokendi XR) vs IR topiramate b.i.d. These findings suggest a pharmacodynamic effect associated with significantly reducing plasma concentration fluctuation when topiramate absorption is slowed. Results of retrospective studies in migraineurs treated with XR topiramate appear to support a clinically meaningful benefit of XR topiramate vs IR topiramate in terms of significantly fewer cognitive effects, improved adherence, and overall better outcomes of migraine prophylaxis with topiramate.
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Affiliation(s)
- Stephen D Silberstein
- Jefferson Headache Center, Thomas Jefferson University, Philadelphia, PA, 19107, USA
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Bigal ME, Dodick DW, Krymchantowski AV, VanderPluym JH, Tepper SJ, Aycardi E, Loupe PS, Ma Y, Goadsby PJ. TEV-48125 for the preventive treatment of chronic migraine: Efficacy at early time points. Neurology 2016; 87:41-8. [PMID: 27281531 PMCID: PMC4932236 DOI: 10.1212/wnl.0000000000002801] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 03/09/2016] [Indexed: 01/03/2023] Open
Abstract
Objective: To evaluate the onset of efficacy of TEV-48125, a monoclonal antibody against calcitonin gene-related peptide, recently shown to be effective for the preventive treatment of chronic migraine (CM) and high-frequency episodic migraine. Methods: A randomized placebo-controlled study tested once-monthly injections of TEV-48125 675/225 mg or 900 mg vs placebo. Headache information was captured daily using an electronic headache diary. The primary endpoint was change from baseline in the number of headache hours in month 3. Herein, we assess the efficacy of each dose at earlier time points. Results: The sample consisted of 261 patients. For headache hours, the 675/225-mg dose separated from placebo on day 7 and the 900-mg dose separated from placebo after 3 days of therapy (p = 0.048 and p = 0.033, respectively). For both the 675/225-mg and 900-mg doses, the improvement was sustained through the second (p = 0.004 and p < 0.001) and third (p = 0.025 and p < 0.001) weeks of therapy and throughout the study (month 3, p = 0.0386 and p = 0.0057). For change in weekly headache days of at least moderate intensity, both doses were superior to placebo at week 2 (p = 0.031 and p = 0.005). Conclusions: TEV-48125 demonstrated a significant improvement within 1 week of therapy initiation in patients with CM. Classification of evidence: This study provides Class II evidence that for patients with CM, TEV-48125 significantly decreases the number of headache hours within 3 to 7 days of injection.
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Affiliation(s)
- Marcelo E Bigal
- From Teva Pharmaceuticals (M.E.B., E.A., P.S.L., Y.M.); Mayo Clinic (D.W.D., J.H.V.P.), Phoenix, AZ; The Headache Center of Rio (A.V.K.); American Headache Society (A.V.K.); Dartmouth Medical School (S.J.T.), Hanover, NH; and NIHR-Wellcome Trust King's Clinical Research Facility (P.J.G.), King's College London, UK.
| | - David W Dodick
- From Teva Pharmaceuticals (M.E.B., E.A., P.S.L., Y.M.); Mayo Clinic (D.W.D., J.H.V.P.), Phoenix, AZ; The Headache Center of Rio (A.V.K.); American Headache Society (A.V.K.); Dartmouth Medical School (S.J.T.), Hanover, NH; and NIHR-Wellcome Trust King's Clinical Research Facility (P.J.G.), King's College London, UK
| | - Abouch V Krymchantowski
- From Teva Pharmaceuticals (M.E.B., E.A., P.S.L., Y.M.); Mayo Clinic (D.W.D., J.H.V.P.), Phoenix, AZ; The Headache Center of Rio (A.V.K.); American Headache Society (A.V.K.); Dartmouth Medical School (S.J.T.), Hanover, NH; and NIHR-Wellcome Trust King's Clinical Research Facility (P.J.G.), King's College London, UK
| | - Juliana H VanderPluym
- From Teva Pharmaceuticals (M.E.B., E.A., P.S.L., Y.M.); Mayo Clinic (D.W.D., J.H.V.P.), Phoenix, AZ; The Headache Center of Rio (A.V.K.); American Headache Society (A.V.K.); Dartmouth Medical School (S.J.T.), Hanover, NH; and NIHR-Wellcome Trust King's Clinical Research Facility (P.J.G.), King's College London, UK
| | - Stewart J Tepper
- From Teva Pharmaceuticals (M.E.B., E.A., P.S.L., Y.M.); Mayo Clinic (D.W.D., J.H.V.P.), Phoenix, AZ; The Headache Center of Rio (A.V.K.); American Headache Society (A.V.K.); Dartmouth Medical School (S.J.T.), Hanover, NH; and NIHR-Wellcome Trust King's Clinical Research Facility (P.J.G.), King's College London, UK
| | - Ernesto Aycardi
- From Teva Pharmaceuticals (M.E.B., E.A., P.S.L., Y.M.); Mayo Clinic (D.W.D., J.H.V.P.), Phoenix, AZ; The Headache Center of Rio (A.V.K.); American Headache Society (A.V.K.); Dartmouth Medical School (S.J.T.), Hanover, NH; and NIHR-Wellcome Trust King's Clinical Research Facility (P.J.G.), King's College London, UK
| | - Pippa S Loupe
- From Teva Pharmaceuticals (M.E.B., E.A., P.S.L., Y.M.); Mayo Clinic (D.W.D., J.H.V.P.), Phoenix, AZ; The Headache Center of Rio (A.V.K.); American Headache Society (A.V.K.); Dartmouth Medical School (S.J.T.), Hanover, NH; and NIHR-Wellcome Trust King's Clinical Research Facility (P.J.G.), King's College London, UK
| | - Yuju Ma
- From Teva Pharmaceuticals (M.E.B., E.A., P.S.L., Y.M.); Mayo Clinic (D.W.D., J.H.V.P.), Phoenix, AZ; The Headache Center of Rio (A.V.K.); American Headache Society (A.V.K.); Dartmouth Medical School (S.J.T.), Hanover, NH; and NIHR-Wellcome Trust King's Clinical Research Facility (P.J.G.), King's College London, UK
| | - Peter J Goadsby
- From Teva Pharmaceuticals (M.E.B., E.A., P.S.L., Y.M.); Mayo Clinic (D.W.D., J.H.V.P.), Phoenix, AZ; The Headache Center of Rio (A.V.K.); American Headache Society (A.V.K.); Dartmouth Medical School (S.J.T.), Hanover, NH; and NIHR-Wellcome Trust King's Clinical Research Facility (P.J.G.), King's College London, UK
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Abstract
Besides a similar clinical presentation, idiopathic intracranial hypertension (IIH) and chronic migraine (CM) also share relevant risk factors, show a higher prevalence of allodynic symptoms and both respond to topiramate. Moreover, sinus stenosis, a radiological marker of IIH, in CM patients is much more prevalent than expected. As a consequence of these striking similarities, IIH without papilledema (IIHWOP) may be easily misdiagnosed as CM. Actually, IIHWOP has been found in up to 14 % of CM clinical series. Considering that, on one hand, an asymptomatic sinus stenosis-associated raised intracranial pressure (ICP) may be highly prevalent in the general population, and on the other, that IIH clinical presentation with chronic headache may require a migraine predisposition, we have proposed that an overlooked IIHWOP could represent a risk factor for migraine progression. This hypothesis prompted us to investigate the prevalence of IIHWOP and its possible role in the process of migraine chronification in a consecutive series of CM patients selected for unresponsiveness to medical treatment and evidence of significant sinus stenosis. The main finding of our study is that the large majority of such patients actually suffer from a chronic headache secondary to IIHWOP. This implies that an IIHWOP mimicking CM is much more prevalent than believed, is commonly misdiagnosed as CM on the basis of ICHD criteria and is strictly predicted by refractoriness to preventive treatments. However, our data fully comply with the alternative hypothesis that an overlooked IIHWOP, although highly prevalent amongst healthy individuals, in migraine-prone subjects is a powerful (and modifiable) risk factor for the progression and the refractoriness of pain. The normalization of ICP by even a single LP with CSF withdrawal may be effective in a significant proportion of patients with a long history of refractory chronic headache, who represent about one-fifth of the patients screened in our study. We suggest that IIHWOP should be considered in all patients with almost daily migraine pain, with evidence of sinus stenosis and unresponsive to medical treatment, referred to specialized headache clinics.
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Abstract
Medication overuse headache (MOH) is a common and disabling headache disorder. It has a prevalence of about 1-2 % in the general population. The International Classification of Headache Disorders 3rd edition (beta version) has defined MOH as a chronic headache disorder in which the headache occurs on 15 or more days per month due to regular overuse of medication. These headaches must have been present for more than 3 months. The pathophysiology is complex and not completely known. It involves genetic and behavioural factors. There is evidence that cortical spreading depression, trigeminovascular system and neurotransmitters contribute to the pain pathway of MOH. The treatment of MOH includes patient education, stopping the offending drug(s), rescue therapy for withdrawal symptoms and preventative therapy. Relapse rates for MOH are high at 41 %. MOH can severely impact quality of life, so it is important to identify patients who are at risk of analgesic overuse.
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Giamberardino MA, Mitsikostas DD, Martelletti P. Update on Medication-Overuse Headache and Its Treatment. Curr Treat Options Neurol 2015; 17:368. [PMID: 26139553 DOI: 10.1007/s11940-015-0368-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OPINION STATEMENT Medication-overuse headache-i.e., a too-frequent consumption of acute headache medications leading to increased headache frequency and reduced effectiveness of acute and preventive treatments-is a serious medical condition whose pathophysiology still remains incompletely known, which is reflected into a lack of mechanism-based treatments. The first mandatory step in the therapeutic strategy remains withdrawal of the abused drug, preferably abrupt, in concomitance with a detoxification pharmacological regimen to lessen withdrawal symptoms. Intravenous hydration, antiemetics, corticosteroids (prednisone), tranquilizers (benzodiazepine), neuroleptics, and rescue medication (another analgesic than the overused) should be delivered in various combinations, on an inpatient (hospitalization and day hospital) basis or outpatient basis, depending on the characteristics of the specific patient and type of overuse. Inpatient withdrawal should be preferred in barbiturate and opioid overuse, in concomitant depression, or, in general, in patients who have difficulty in stopping the overused medication as outpatients. In contrast, in overuse limited to simple analgesics in highly motivated patients, without high levels of depression and/or anxiety, home detoxification should be chosen. Re-prophylaxis should immediately follow detoxification, ideally with local injections of onabotulinumtoxinA every 3 months or topiramate orally for at least 3 months. Adequate information to patients about the risks of a too-frequent consumption of symptomatic headache medications is essential and should constantly parallel treatment to help preventing relapse after detoxification and re-prophylaxis.
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Affiliation(s)
- Maria Adele Giamberardino
- Headache Center and Geriatrics Clinic, Department of Medicine and Science of Aging, "G. D'Annunzio" University, via Carlo de Tocco n. 3, 66100, Chieti, Italy,
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A Multicenter, Double-Blind, Randomized, Placebo-Controlled Trial to Evaluate the Efficacy and Safety of Duliang Soft Capsule in Patients with Chronic Daily Headache. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2015; 2015:694061. [PMID: 26101536 PMCID: PMC4460254 DOI: 10.1155/2015/694061] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 05/03/2015] [Accepted: 05/03/2015] [Indexed: 02/05/2023]
Abstract
Objective. To investigate the efficacy and safety of traditional Chinese medicine Duliang soft capsule (DSC) in prophylactic treatment for patients with chronic daily headache (CDH). Methods. A multicenter, double-blind, randomized, placebo-controlled clinical study was conducted at 18 Chinese clinical centers. The participants received either DSC or placebo for 4 weeks. The primary efficacy measure was headache-free rate (HFR) in a 4-week period between the pretreatment and posttreatment stages. The secondary efficacy measures were the decrease of headache days, the duration of headache attacks, the frequency of analgesic usage, quality of life, disability, and the headache severity (VAS scores). The accompanying symptoms and adverse events were also assessed. Results. Of 584 CDH patients assessed, 468 eligible patients were randomized. 338 patients received DSC, while 111 patients were assigned in the placebo group. Following treatment, there was a 16.56% difference in HFR favoring DSC over placebo (P < 0.01). Significant differences were also observed between DSC and placebo groups in the secondary measures. However, no statistical difference was found between the two groups in the associated symptoms. No severe adverse effects were observed in the study. Conclusions. DSC might be an effective and well-tolerated option for the prophylactic treatment of patients with CDH.
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Diagnosis, pathophysiology and management of chronic migraine: a proposal of the Belgian Headache Society. Acta Neurol Belg 2015; 115:1-17. [PMID: 24968722 DOI: 10.1007/s13760-014-0313-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 05/13/2014] [Indexed: 12/24/2022]
Abstract
Chronic migraine (CM) is a disabling neurological condition affecting 0.5-2 % of the population. In the current third edition of the International Classification of Headache Disorders, medication overuse is no longer an exclusion criterion and CM is diagnosed in patients suffering from at least 15 headache days per month of which at least eight are related to migraine. CM is difficult to treat, and preventive treatment options are limited. We provide a pathogenetic model for CM, integrating the latest findings from neurophysiological and neuroimaging studies. On behalf of the Belgian Headache Society, we present a management algorithm for CM based on the international literature and adapted to the Belgian situation. Pharmacological treatment options are discussed, and recent data on transcranial and invasive neuromodulation studies in CM are reviewed. An integrated multimodal treatment programme may be beneficial to refractory patients, but at present, this approach is only supported by a limited number of observational studies and quite variable between centres.
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Abstract
Medication overuse is not uncommon among children and adolescents with primary headache disorders. Medication overuse in adults is associated with increased headache frequency and reduced effectiveness of acute and preventive medications. These issues probably exist in children. While withdrawal of overused medications is generally recommended, it may not result in improved headache frequency in all patients. This review summarizes what is known about predicting the response to medication withdrawal. Strategies for managing children and adolescents with medication overuse are also offered.
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Affiliation(s)
- Amy A Gelfand
- UCSF Headache Center, 1701 Divisadero St. Suite 480, San Francisco, CA, 94115, USA,
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