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Abstract
PURPOSE OF REVIEW Migraine is a disabling disease of attacks of moderate to severe pain with associated symptoms. Every person with migraine requires treatment for acute attacks. Treatments can range from behavioral management and nonspecific medications to migraine-specific medications and neuromodulation. For many with migraine, having a combination of tools allows for effective treatment of all types of attacks. RECENT FINDINGS Over the past several years, four neuromodulation devices have been cleared by the US Food and Drug Administration (FDA) for treatment of acute migraine, and three medications with novel mechanisms of action have been FDA approved. They add to the arsenal available to people with migraine and focus on migraine-specific pathways to allow for precise care with fewer side effects. SUMMARY This article discusses acute migraine therapy, focusing on best-level evidence.
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Silberstein SD, Shrewsbury SB, Hoekman J. Dihydroergotamine (DHE) - Then and Now: A Narrative Review. Headache 2019; 60:40-57. [PMID: 31737909 PMCID: PMC7003832 DOI: 10.1111/head.13700] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To provide a narrative review of clinical development programs for non-oral, non-injectable formulations of dihydroergotamine (DHE) for the treatment of migraine. BACKGROUND Dihydroergotamine was one of the first "synthetic drugs" developed in the 20th century for treating migraine. It is effective and recommended for acute migraine treatment. Since oral DHE is extensively metabolized, it must be given by a non-oral route. Intravenous DHE requires healthcare personnel to administer, subcutaneous/intramuscular injection is challenging to self-administer, and the approved nasal spray formulation exhibits low bioavailability and high variability that limits its efficacy. Currently there are several attempts underway to develop non-oral, non-injected formulations of DHE. METHOD A systematic search of MEDLINE/PubMed and ClinicalTrials.gov databases, then narrative review of identified reports, focusing on those published in the last 10 years. RESULTS Of 1881 references to DHE from a MEDLINE/PubMed search, 164 were from the last 10 years and were the focus of this review. Further cross reference was made to ClinicalTrials.gov for 19 clinical studies, of which some results have not yet been published, or are studies that are currently underway. Three nasal DHE products are in clinical development, reawakening interest in this route of delivery for migraine. Other routes of DHE administration have been, or are being, explored. CONCLUSION There is renewed appreciation for DHE and the need for non-oral, non-injected delivery is now being addressed.
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Vandenbussche N, Goadsby PJ. The discovery and development of inhaled therapeutics for migraine. Expert Opin Drug Discov 2019; 14:591-599. [PMID: 30924698 DOI: 10.1080/17460441.2019.1598373] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Migraine is a disabling primary headache disorder that requires effective treatments. Inhalation is currently being explored for the delivery of drugs for migraine. Pulmonary-route delivery of drugs shows potential advantages for its use as a treatment, particularly compared the oral route. Areas covered: The authors highlight the current state of the literature and review multiple therapies for migraine-utilizing inhalation as the route of administration. The following therapeutics are discussed: inhaled ergotamine, inhaled dihydroergotamine mesylate (MAP0004), inhaled prochlorperazine, and inhaled loxapine. Coverage is also given to normobaric oxygen, hyperbaric oxygen, and nitrous oxide therapies. Expert opinion: Inhalation of MAP0004 showed promising results in terms of efficacy for acute migraine treatment in phase 3 studies, together with a more favorable tolerability profile compared to parenteral dosing and a better pharmacokinetic profile versus oral or intranasal delivery. In phase 2 trials, inhaled prochlorperazine shows good pharmacokinetics and efficacy, in contrast to inhaled loxapine that did not provide encouraging results in terms of efficacy. The authors see the potential for the use of dihydroergotamine mesylate in clinical practice pending regulatory approval.
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Affiliation(s)
- Nicolas Vandenbussche
- a Headache Group, Department of Basic and Clinical Neuroscience , King's College London , London , UK.,b Department of Neurology , Ghent University Hospital , Ghent , Belgium
| | - Peter J Goadsby
- a Headache Group, Department of Basic and Clinical Neuroscience , King's College London , London , UK.,c NIHR Wellcome Trust King's Clinical Research Facility, SLaM Biomedical research Centre , King's College London , UK
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Chua AL, Silberstein S. Inhaled drug therapy development for the treatment of migraine. Expert Opin Pharmacother 2016; 17:1733-43. [DOI: 10.1080/14656566.2016.1203901] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Abigail L. Chua
- Jefferson Headache Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Stephen Silberstein
- Jefferson Headache Center, Thomas Jefferson University, Philadelphia, PA, USA
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Lovati C, D’Amico D, Bertora P. Allodynia in migraine: frequent random association or unavoidable consequence? Expert Rev Neurother 2014; 9:395-408. [DOI: 10.1586/14737175.9.3.395] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Tepper SJ, Kori SH, Borland SW, Wang MH, Hu B, Mathew NT, Silberstein SD. Efficacy and Safety of MAP0004, Orally Inhaled DHE in Treating Migraines With and Without Allodynia. Headache 2011; 52:37-47. [DOI: 10.1111/j.1526-4610.2011.02041.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Tepper SJ, Kori SH, Goadsby PJ, Winner PK, Wang MH, Silberstein SD, Cutrer FM. MAP0004, orally inhaled dihydroergotamine for acute treatment of migraine: efficacy of early and late treatments. Mayo Clin Proc 2011; 86:948-55. [PMID: 21964172 PMCID: PMC3184024 DOI: 10.4065/mcp.2011.0093] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate the efficacy of MAP0004, an orally inhaled dihydroergotamine, for acute treatment of migraine when administered at various time points from within 1 hour to more than 8 hours after migraine onset. PATIENTS AND METHODS This post hoc subanalysis was conducted using data from 902 patients enrolled in a randomized, double-blind, placebo-controlled, 2-arm, phase 3, multicenter study conducted from July 14, 2008, through March 23, 2009. End points were 2-hour pain relief and pain-free rates in patients who treated a migraine in ≤1 hour, from >1 hour to ≤4 hours, from >4 to ≤8 hours, or in >8 hours after onset of migraine, given that patients may be unwilling or unable to initiate treatment at headache inception. RESULTS Treatment with MAP0004 was significantly more effective than placebo in relieving pain at all treatment points (≤1 hour after start of migraine: 66% [74/112] for MAP0004 vs 41% [48/118] for placebo, P<.001; >1 to ≤4 hours: 60% [91/153] vs 35% [58/168], P<.001; >4 to ≤8 hours: 53% [36/68] vs 30% [16/54], P=.008; and >8 hours: 48% [25/52] vs 24% [11/46], P=.007). Pain-free rates were also significantly higher with MAP0004 than placebo for treatment within 8 hours after migraine onset (≤1 hour: 38% [43/112] for MAP0004 vs 13% [15/118] for placebo, P<.001; >1 to ≤4 hours: 28% [43/153] vs 10% [17/168], P<.001; >4 to ≤8 hours: 22% [15/68] vs 7% [4/54], P<.025) but not at >8 hours (19% [10/52] vs 9% [4/46], P=.106). CONCLUSION This post hoc subanalysis shows that MAP0004 was effective in treating migraine irrespective of the time of treatment, even more than 8 hours after onset of migraine pain.
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Affiliation(s)
- Stewart J Tepper
- Center for Headache and Pain, Neurological Institute, Cleveland Clinic, Cleveland, OH 44195-0002, USA.
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Baron EP, Tepper SJ. Orally inhaled dihydroergotamine: reviving and improving a classic. FUTURE NEUROLOGY 2011. [DOI: 10.2217/fnl.11.24] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Migraine pathophysiology continues to evolve, and additional therapeutic receptors influencing unrecognized neural networks within the cortex, brainstem and cerebral vasculature likely exist. Following the advent of the triptans, the use of dihydroergotamine (DHE) declined, because of the ease of use and improved side effect profiles of triptans. However, there remain many patients who respond poorly to triptans, yet respond significantly better to DHE. This may be due to the broader neuroreceptor targets that DHE interacts with, as opposed to the selective receptor activity of the triptans. Unfortunately, DHE is still infrequently utilized compared with other acute treatments such as triptans, primarily because of difficulty in administration and physician unfamiliarity and inexperience with its use. However, the new orally inhaled DHE appears to be as effective with a better side effect profile compared with intravenous DHE, thus eliminating the complexities typically associated with DHE administration.
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Affiliation(s)
| | - Stewart J Tepper
- Cleveland Clinic Neurological Institute, Department of Neurology, Center for Headache & Pain, Center for Regional Neurology, 9500 Euclid Avenue/T33, Cleveland, OH 44195, USA
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Casucci G, Villani V, Frediani F. Remarks on an educational training course on headache. Neurol Sci 2010; 31 Suppl 1:S121-2. [PMID: 20464600 PMCID: PMC3043242 DOI: 10.1007/s10072-010-0301-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In the last years several studies have been performed on migraine; however, only few topics have changed the clinical practice. Among these, there are physiopathological insights (e.g., allodynia and gastric stasis) or therapeutical evidences (e.g., topiramate) that become very important in the management of migraine and could clarify the different response to the therapies. The aim of a training school on headache should be to link research to practice without transferring contradictory data. To teach is not only to support notions with simple data: we think that knowledge has to be used according to the condition of the patient and the situation in which the migraineurs live.
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Affiliation(s)
- G Casucci
- Casa di Cura S. Francesco, Telese Terme (BN), Italy.
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Schürks M. Dihydroergotamine: role in the treatment of migraine. Expert Opin Drug Metab Toxicol 2009; 5:1141-8. [DOI: 10.1517/17425250903164211] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Migraine is a complex neurological disorder that in recent years has received more and more attention. Knowledge regarding this primary headache has increased substantially, both with respect to its pathogenesis and how to effectively treat its symptoms. Over the years, the proposed location of the onset of migraine has moved from the periphery of the nervous system toward deeper parts of the brain. Migraine can be viewed as an inherited failure of trigeminal sensory processing with abnormal neuronal excitability in the trigeminal nucleus caudalis, which, in turn, causes central sensitization and amplification of the pain. Increased activation of the trigeminal nerve during a migraine attack causes release of the calcitonin gene-related peptide (CGRP) inside and outside the BBB. Within the CNS, CGRP promotes trigeminal sensory input and facilitates central sensitization. The future introduction of CGRP antagonists in clinical practice could represent significant progress for acute migraine therapy.
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Affiliation(s)
- Carl Dahlöf
- Professor of Neurology, Institute of Neuroscience & Physiology, Sahlgrenska University Hospital, Medical Director & Founder of Gothenburg Migraine Clinic, Gothenburg Migraine Clinic, c/o Läkarhuset, Södra vägen 27, S-411 35 Gothenburg, Sweden
| | - Hans-Christoph Diener
- Professor of Neurology, Department of Neurology, University Duisburg-Essen, Essen, Germany
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Abstract
Allodynia--perception of pain from non-noxious stimuli--is a common clinical feature in various pain syndromes. The significance for migraine has increasingly been recognized and the pathophysiology has been investigated in detail. Allodynia is a marker for sensitization of central trigeminal neurons. Intensity and persistence of allodynic symptoms are a function of duration of migraine attacks, frequency of attacks, and migraine history. It has been hypothesized that treatment success with triptans may be severely impaired in the presence of allodynia. However, randomized controlled trials did not confirm that. Treatment with cyclooxygenase inhibitors and dihydroergotamine does not seem to be limited by allodynia; these medications may be able to reverse allodynia. Data on the new class of calcitonin-gene related-peptide antagonists are not yet available. Additional and more refined randomized controlled trials, focusing on methodological issues pertaining to the determination of allodynia, are warranted to resolve the true relationship between allodynia and treatment response. Regardless--based on available randomized controlled trials--the recommendation prevails to initiate abortive treatment as soon as possible after attack onset when pain is still mild.
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Affiliation(s)
- M Schürks
- Division of Preventive Medicine, Department of Medicine, Brigham and Womens Hospital, Harvard Medical School, Boston, MA 02215-1204, USA.
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Kabbouche MA, Powers SW, Segers A, LeCates S, Manning P, Biederman S, Vaughan P, Burdine D, Hershey AD. Inpatient Treatment of Status Migraine With Dihydroergotamine in Children and Adolescents. Headache 2009; 49:106-9. [DOI: 10.1111/j.1526-4610.2008.01293.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Friedman B, Bijur P, Greenwald P, Lipton R, Gallagher EJ. Clinical Significance of Brush Allodynia in Emergency Patients With Migraine. Headache 2009; 49:31-5. [DOI: 10.1111/j.1526-4610.2008.01266.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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