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van Lohuizen R, Paungarttner J, Lampl C, MaassenVanDenBrink A, Al-Hassany L. Considerations for hormonal therapy in migraine patients: a critical review of current practice. Expert Rev Neurother 2023; 24:1-21. [PMID: 38112066 PMCID: PMC10791067 DOI: 10.1080/14737175.2023.2296610] [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: 07/18/2023] [Accepted: 12/06/2023] [Indexed: 12/20/2023]
Abstract
INTRODUCTION Migraine, a neurovascular headache disorder, is a leading cause of disability worldwide. Within the multifaceted pathophysiology of migraine, hormonal fluctuations play an evident triggering and exacerbating role, pointing toward the need for identification and proper usage of both existing and new hormonal targets in migraine treatment. AREAS COVERED With a threefold higher incidence of migraine in women than in men, the authors delve into sex hormone-related events in migraine patients. A comprehensive overview is given of existing hormonal therapies, including oral contraceptives, intrauterine devices, transdermal and subcutaneous estradiol patches, gnRH-agonists, oral testosterone, and 5α reductase inhibitors. The authors discuss their effectiveness and risks, noting their suitability for different patient profiles. Next, novel evolving hormonal treatments, such as oxytocin and prolactin, are explored. Lastly, the authors cover hormonal conditions associated with migraine, such as polycystic ovary syndrome, endometriosis, and transgender persons receiving gender affirming hormone therapy, aiming to provide more personalized and effective solutions for migraine management. EXPERT OPINION Rigorous research into both existing and new hormonal targets, as well as the underlying pathophysiology, is needed to support a tailored approach in migraine treatment, in an ongoing effort to alleviate the impact of migraine on individuals and society.
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Affiliation(s)
- Romy van Lohuizen
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | | | - Christian Lampl
- Headache Medical Center Linz, Linz, Austria
- Department of Neurology and Stroke Unit, Koventhospital Barmherzige Brüder Linz, Linz, Austria
| | - Antoinette MaassenVanDenBrink
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Linda Al-Hassany
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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MacGregor EA, Hutchinson S, Lai H, Dabruzzo B, Yu SY, Trugman JM, Ailani J. Safety and efficacy of ubrogepant for the acute treatment of perimenstrual migraine attacks: A post hoc analysis. Headache 2023; 63:1135-1144. [PMID: 37655536 DOI: 10.1111/head.14619] [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: 11/15/2022] [Revised: 07/11/2023] [Accepted: 07/14/2023] [Indexed: 09/02/2023]
Abstract
OBJECTIVE To evaluate the efficacy and safety of ubrogepant for the acute treatment of perimenstrual migraine (pmM) attacks. BACKGROUND Ubrogepant is an oral calcitonin gene-related peptide receptor antagonist approved for the acute treatment of migraine in adults. METHODS After completing one of two phase 3 trials, participants could enroll in a phase 3, 52-week, open-label, long-term safety extension trial and were re-randomized 1:1:1 to usual care, ubrogepant 50 mg, or ubrogepant 100 mg. This post hoc analysis evaluated the efficacy of ubrogepant in a subset of women who treated ≥1 pmM or non-pmM attack with ubrogepant. A pmM attack started on or between 2 days before and the first 3 days of menstrual bleeding. Mean (standard deviation [SD]) percentages of ubrogepant-treated attacks achieving 2-h pain freedom and pain relief were reported, with outcomes weighted equally by participant. RESULTS Of 734 women in the modified intent-to-treat population, 354 reported ≥1 menstrual cycle start date and a ubrogepant-treated headache day in the same month. A qualifying pmM and non-pmM attack was reported by 278 and 716 women, respectively. Pain freedom at 2 h was achieved in a mean (SD) of 28.7% (37.4) of pmM attacks and 22.1% (26.9) of non-pmM attacks treated with ubrogepant 50 mg (p = 0.054) and 29.7% (35.2) versus 25.3% (26.3) of attacks treated with ubrogepant 100 mg (p = 0.757). No difference was found in the mean percentage of ubrogepant-treated pmM and non-pmM attacks that achieved 2-h pain relief with ubrogepant 50 mg (64.8% [39.9] vs. 65.2% [32.4]; p = 0.683) and with 100 mg (67.1% [37.4] vs. 68.4% [30.2]; p = 0.273). Treatment-related treatment-emergent adverse events were reported by 8.8% (12/137) and 12.8% (18/141) in the ubrogepant 50 and 100 mg pmM subgroups, respectively. CONCLUSIONS Ubrogepant demonstrated similar efficacy for the treatment of pmM and non-pmM attacks. No new safety signals were identified.
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Affiliation(s)
- E Anne MacGregor
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute of Cell and Molecular Science, Barts and the London School of Medicine and Dentistry, London, UK
- Centre for Reproductive Medicine, St. Bartholomew's Hospital, London, UK
| | - Susan Hutchinson
- Orange County Migraine and Headache Center, Irvine, California, USA
| | | | | | | | | | - Jessica Ailani
- Department of Neurology, MedStar Georgetown University Hospital, DC, Washington, USA
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Kardes G, Hadimli A, Ergenoglu AM. Determination of the Frequency of Migraine Attacks in Pregnant Women and the Ways They Cope with Headaches: A Cross-Sectional Study. Healthcare (Basel) 2023; 11:2070. [PMID: 37510512 PMCID: PMC10379615 DOI: 10.3390/healthcare11142070] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 07/06/2023] [Accepted: 07/17/2023] [Indexed: 07/30/2023] Open
Abstract
One out of every five women of reproductive age suffers from migraine. Although headaches subside in most women during pregnancy, attacks continue and even worsen in some women. Pregnant women try to relieve pain with medication or non-pharmacological treatment methods. This descriptive and cross-sectional study was conducted to determine the incidence of migraine attacks in pregnant women diagnosed with migraine and the ways they cope with headaches. The study included 191 pregnant women who were diagnosed with migraine in the pre-pregnancy period. McNemar analysis was performed to test the relationship between descriptive statistical methods and categorical variables when the data were analyzed. The mean gestational age of the participants was 28.31 ± 8.64 weeks, and their mean age at the onset of migraine was 20.74 ± 5.63 years. The comparison of the duration, frequency, and severity of headaches suffered before and during pregnancy demonstrated that there were statistical differences between them (p < 0.05). The frequency of using methods such as taking painkillers, resting in a dark room, and having cold application and massage to relieve headaches before pregnancy decreased statistically significantly during pregnancy (p < 0.05). As a result, the frequency and severity of migraines decrease during pregnancy. The tendency to resort to pharmacological or non-pharmacological methods used to relieve headaches decreases during pregnancy. Although migraine has many adverse effects on pregnancy, pregnant women do not demand satisfactory information from health professionals about migraine headaches during pregnancy.
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Affiliation(s)
- Guzin Kardes
- Faculty of Health Science, Ege University, Izmir 35575, Turkey
| | - Aytul Hadimli
- Faculty of Health Science, Ege University, Izmir 35575, Turkey
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Bhardwaj R, Stringfellow JC, Morris B, Croop RS, Bertz RJ. Effects of rimegepant 75 mg daily on the pharmacokinetics of a combined oral contraceptive containing ethinyl estradiol and norgestimate in healthy female participants. Headache 2023; 63:652-662. [PMID: 37140071 DOI: 10.1111/head.14512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 02/24/2023] [Accepted: 02/28/2023] [Indexed: 05/05/2023]
Abstract
OBJECTIVE To assess the effect of single and multiple doses of rimegepant 75 mg dose on the pharmacokinetics of an oral contraceptive containing ethinyl estradiol (EE)/norgestimate (NGM) in healthy females of childbearing potential or non-menopausal females with tubal ligation. BACKGROUND Females of childbearing age experience the highest prevalence of migraine and frequently inquire about the concomitant use of anti-migraine medications and contraceptives. Rimegepant, a calcitonin gene-related peptide receptor antagonist, demonstrated efficacy and safety for treating an acute migraine attack and preventing migraine. METHODS This open-label, single-center, phase 1, drug-drug interaction study explored the effects of rimegepant 75 mg daily dose on the pharmacokinetics of an oral contraceptive containing EE/NGM 0.035 mg/0.25 mg in healthy females of childbearing potential or non-menopausal females with tubal ligation. During cycles 1 and 2, participants received EE/NGM once daily for 21 days followed by placebo tablets with inactive ingredients for 7 days. Rimegepant was administered during only cycle 2 for 8 days, from days 12 through 19. The primary endpoint was the effect of single and multiple doses of rimegepant on the pharmacokinetics of EE and norelgestromin (NGMN), an active metabolite of NGM, at steady state, including area under the concentration-time curve for 1 dosing interval (AUC0-τ,ss ) and maximum observed concentration (Css[max] ). RESULTS The study enrolled 25 participants, with pharmacokinetic data assessed for 20 participants. A single 75 mg dose of rimegepant co-administered with EE/NGM increased exposures of EE and NGMN by ≤16% (geometric mean ratio [GMR], 1.03; 90% confidence interval [CI], 1.01-1.06; and GMR, 1.16; 90% CI, 1.13-1.20, respectively). After 8 days of co-administering EE/NGM with rimegepant, EE pharmacokinetic parameters, AUC0-τ,ss and Css(max) , increased by 20% (GMR, 1.20; 90% CI, 1.16-1.25) and 34% (GMR, 1.34; 90% CI, 1.23-1.46), respectively, and NGMN pharmacokinetic parameters increased by 46% (GMR, 1.46; 90% CI, 1.39-1.52) and 40% (GMR, 1.40; 90% CI, 1.30-1.51), respectively. CONCLUSIONS The study identified modest elevations in overall EE and NGMN exposures after multiple doses of rimegepant, but these elevations are unlikely to be clinically relevant in healthy females with migraine.
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Affiliation(s)
| | | | - Beth Morris
- Biohaven Pharmaceuticals, New Haven, Connecticut, USA
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Bentivegna E, Luciani M, Scarso F, Bruscia C, Chiappino D, Amore E, Nalli G, Martelletti P. Hormonal therapies in migraine management: current perspectives on patient selection and risk management. Expert Rev Neurother 2021; 21:1347-1355. [PMID: 34739361 DOI: 10.1080/14737175.2021.2003706] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
INTRODUCTION The link between sex hormones and migraines has long been investigated but the mechanisms underlying this altered interaction are not yet fully understood. Herein, we retrace the knowledge on this association in relationship with risk of stroke. AREAS COVERED Estrogens fluctuations could trigger migraine attacks and exogenous estrogens intake could be a risk factor for venous thromboembolism (VTE) and stroke. At the same time, ischemic heart diseases and stroke share a common substrate with migraine and other mood disorders, depression, and anxiety. EXPERT OPINION The use of hormonal therapies in the context of contraception or replacement therapy must be closely evaluated in a careful risk assessment. We highlight the complex interaction of hormone/neuroinflammation pathways underlying the pathophysiology of migraine glimpsing in mood disorders a possible common denominator of link between hormonal and neuronal systems.
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Affiliation(s)
- Enrico Bentivegna
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy.,Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy
| | - Michelangelo Luciani
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy.,Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy
| | - Francesco Scarso
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy.,Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy
| | - Clara Bruscia
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy.,Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy
| | - Dario Chiappino
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy.,Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy
| | - Emanuele Amore
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy.,Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy
| | - Gabriele Nalli
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy.,Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy.,Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy
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Bérard A, Strom S, Zhao JP, Kori S, Albrecht D. Dihydroergotamine and triptan use to treat migraine during pregnancy and the risk of adverse pregnancy outcomes. Sci Rep 2021; 11:19302. [PMID: 34588467 PMCID: PMC8481540 DOI: 10.1038/s41598-021-97092-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 08/06/2021] [Indexed: 11/20/2022] Open
Abstract
Migraine is prevalent during pregnancy. Antimigraine medications such as dihydroergotamine (DHE) and triptans have been associated with adverse pregnancy outcomes in individual studies but lack of consensus remains. We compared the risk of prematurity, low birth weight (LBW), major congenital malformations (MCM), and spontaneous abortions (SA) associated with gestational use of DHE or triptans. Three cohort and one nested-case–control analyses were conducted within the Quebec Pregnancy Cohort to assess the risk of prematurity, LBW, MCM, and SA. Exposure was defined dichotomously as use of DHE or triptan during pregnancy. Generalized estimation equations were built to quantify the associations, adjusting for potential confounders. 233,900 eligible pregnancies were included in the analyses on prematurity, LBW, and MCM; 29,104 cases of SA were identified. Seventy-eight subjects (0.03%) were exposed to DHE and 526 (0.22%) to triptans. Adjusting for potential confounders, DHE and triptans were associated with increased risks of prematurity, LBW, MCM, and SA but not all estimates were statistically significant. DHE was associated with the risk of prematurity (aRR: 4.12, 95% CI 1.21–13.99); triptans were associated with the risk of SA (aOR: 1.63, 95% CI 1.34–1.98). After considering maternal migraine, all antimigraine specific medications increased the risk of some adverse pregnancy outcomes, but estimates were unstable.
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Affiliation(s)
- Anick Bérard
- Faculty of Pharmacy, University of Montreal, Montreal, QC, H3T 1J4, Canada. .,Research Center, CHU Sainte-Justine, Montreal, QC, H3T 1C5, Canada. .,Faculty of Medicine, Université Claude Bernard, Lyon 1, 69622, Lyon, France.
| | - Shannon Strom
- Satsuma Pharmaceuticals, Inc, San Francisco, CA, 94080, USA
| | - Jin-Ping Zhao
- Research Center, CHU Sainte-Justine, Montreal, QC, H3T 1C5, Canada
| | - Shashi Kori
- Satsuma Pharmaceuticals, Inc, San Francisco, CA, 94080, USA
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Abstract
PURPOSE OF REVIEW Gender differences exist in headache disorders. A greater understanding of the role of hormones in headache can help the clinician better approach and manage common primary headache disorders. RECENT FINDINGS Recent studies highlight differences in how migraine and cluster headache present in women and men. Updates to the ongoing debate of how to manage the use of hormones in women with migraine, especially with aura, have been well reviewed in the last 18 months. A new meta-analysis evaluates gender differences in response to triptans. SUMMARY This review will focus on recent updates on the role of gender and hormones on migraine and cluster headache and how this may influence treatment.
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Abstract
IMPORTANCE AND OBJECTIVES This narrative review addresses common clinical questions and concerns of both physicians and patients about migraine during and after the perimenopausal transition, specifically (1) How does the perimenopausal transition affect migraine prevalence and does this vary by migraine type? (2) Does the magnitude of stroke risk associated with migraine increase with hormone therapy (HT)?, and (3) What are best practices as regards migraine treatment in perimenopausal women? METHODS We searched PubMed from 2010 through the present. Search terms included migraine, menopause, and HT. Articles were included if they were in English and had full text availability. In addition, key references identified in the search articles were included. DISCUSSION AND CONCLUSION Many women are informed that their migraines will disappear postmenopause; there are some data to support this, but a specific time frame has not been evidenced. Stroke risk in women with migraine with aura is small in absolute terms, but important at the population level, because migraine is so prevalent. The risk becomes clinically important in the context of additional stroke risk factors, which increase with aging such as hypertension. Estrogen in combined hormonal contraception increases the risk of an ischemic stroke, however, the lower amount of estrogen in HT may not contribute to a meaningful increase in stroke risk. HT is a preventative sex-specific treatment for female migraineurs for the menopausal transition. Sex differences for other conventional treatments outside their use in menstrual and menstrually related migraine have not been studied specifically in the menopausal transition.
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