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Diener HC, May A. New migraine drugs: A critical appraisal of the reason why the majority of migraine patients do not receive an adequate medication. Cephalalgia 2024; 44:3331024241228605. [PMID: 38520255 DOI: 10.1177/03331024241228605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2024]
Abstract
The last three decades have produced several novel and efficient medications to treat migraine attacks and reduce attack frequency. Additionally, promising approaches for the development of acute therapy and migraine prophylaxis continue to be pursued. At the same time as we witness the development of better and more efficient medications with continuously fewer side effects, we also realise that the high cost of such therapies means that only a minority of migraine patients who could benefit from these medications can afford them. Furthermore, information on cost-effectiveness is still lacking. Here, we compare availiable data, highlight open questions and suggest trials to close knowledge gaps. With good reason, our medicine is evidence-based. However, if this evidence is not collected, our decisions will continue to be based on marketing and assumptions. At the moment, we are not doing justice to our patients.
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Affiliation(s)
- Hans Christoph Diener
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology (IMIBE), Faculty of Medicine, University Duisburg-Essen, Essen, Germany
| | - Arne May
- Department of Systems Neuroscience, University Hamburg, Hamburg, Germany
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Abstract
PURPOSE OF REVIEW Chronic migraine (CM) affects a large proportion of the population and is a significant source of disability and lost productivity. Numerous non-pharmacological approaches have been attempted during the past decades. This review discusses the most recent and evidence-based advances in acute and preventive non-pharmacological therapeutic approaches for CM, offering alternatives to drug treatment. RECENT FINDINGS A growing number of non-pharmacological treatment options, including non-invasive or invasive neuromodulation, acupuncture, psychotherapy, and physiotherapy, have shown promising efficacy in CM. There is strong evidence for the effectiveness of non-invasive neuromodulation such as transcranial magnetic stimulation, transcranial direct current stimulation, and transcutaneous electrical nerve stimulation (TENS) in CM, but less evidence for approaches such as invasive neuromodulation, physical therapy, or dietary approaches. Acupuncture for migraine remains controversial, with the main point of contention still being the placebo effect. Non-pharmacological approaches can be offered as a reliable alternative for patients with CM, and more research is being done to evaluate the efficacy of non-invasive neuromodulation with different parameters and the combination of different treatments in CM.
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Affiliation(s)
- Xun Han
- Department of Neurology, The First Medical Center of Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Shengyuan Yu
- Department of Neurology, The First Medical Center of Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China.
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3
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Moskatel LS, Zhang N. The Role of Step Therapy in the Treatment of Migraine. Curr Pain Headache Rep 2023; 27:571-577. [PMID: 37542597 DOI: 10.1007/s11916-023-01155-w] [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: 07/16/2023] [Indexed: 08/07/2023]
Abstract
PURPOSE OF REVIEW This review examines recent evidence and applies bioethical principles to evaluate the benefits and risks of using step therapy in the treatment of migraine. RECENT FINDINGS With the CGRP mAbs, gepants, and lasmiditan now on the market for up to 5 years, new research, including network meta-analyses and long-term use studies, can evaluate the comparative efficacy, tolerability, and adherence of these medications relative to older acute and preventive medications for the treatment of migraine. Deciding how medications are chosen for patients requires accounting for many factors including sustainability, efficacy, tolerability, and preference. Newer research can help give clarity on the appropriateness of gating certain treatment options behind others.
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Affiliation(s)
- Leon S Moskatel
- Division of Headache, Department of Neurology and Neurological Sciences, Stanford University, 211 Quarry Road, Suite #206, Palo Alto, CA, 94304, USA.
| | - Niushen Zhang
- Division of Headache, Department of Neurology and Neurological Sciences, Stanford University, 211 Quarry Road, Suite #206, Palo Alto, CA, 94304, USA
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Machado-Duque ME, Echeverry-Gutiérrez MF, Gaviria-Mendoza A, Valladales-Restrepo LF, Machado-Alba JE. Potentially Inappropriate Use of Opioids in the Management of Migraine in Colombia. Biomedicines 2023; 11:2385. [PMID: 37760827 PMCID: PMC10525423 DOI: 10.3390/biomedicines11092385] [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: 07/10/2023] [Revised: 08/08/2023] [Accepted: 08/22/2023] [Indexed: 09/29/2023] Open
Abstract
RESEARCH OBJECTIVE To identify the frequency of opioid use in a group of patients diagnosed with migraine in Colombia. METHODS Study of a retrospective cohort of patients with a diagnosis of migraine and a first prescription of antimigraine drugs from emergency services and a priority outpatient clinic. Sociodemographic, clinical, and pharmacological variables were identified; a 12-month follow-up was carried out to identify the use of a new opioid. RESULTS A total of 6309 patients with a diagnosis of migraine were identified, with a mean age of 35.5 ± 12.3 years, of which 81.3% were women. Nonsteroidal anti-inflammatory drugs (51.1%) were the most frequently prescribed medications, followed by ergotamine + caffeine (31.3%), acetaminophen (15.05%), and acetaminophen + codeine (14.4%). At the time of the index, 1300 (20.6%) patients received some opioid. During the follow-up, a total of 1437 (22.8%) patients received a new opioid, of which 31.8% belonged to the group that received an initial opioid and 20.4% to the group that did not receive one, which was statistically significant (OR:1.81; 95%CI:1.58-2.07; p < 0.001). CONCLUSIONS The frequent use of opioids in the management of migraines is potentially inappropriate and can lead to problems of tolerance, abuse and dependence. This combined with the low prescription of triptans, offers an opportunity for improvements in medical practice.
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Affiliation(s)
- Manuel E. Machado-Duque
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira 660003, Colombia; (M.E.M.-D.); (A.G.-M.); (L.F.V.-R.)
- Grupo de Investigación Biomedicina, Facultad de Medicina, Fundación Universitaria Autónoma de Las Américas, Pereira 660003, Colombia;
| | | | - Andrés Gaviria-Mendoza
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira 660003, Colombia; (M.E.M.-D.); (A.G.-M.); (L.F.V.-R.)
- Grupo de Investigación Biomedicina, Facultad de Medicina, Fundación Universitaria Autónoma de Las Américas, Pereira 660003, Colombia;
| | - Luis F. Valladales-Restrepo
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira 660003, Colombia; (M.E.M.-D.); (A.G.-M.); (L.F.V.-R.)
- Grupo de Investigación Biomedicina, Facultad de Medicina, Fundación Universitaria Autónoma de Las Américas, Pereira 660003, Colombia;
| | - Jorge E. Machado-Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira 660003, Colombia; (M.E.M.-D.); (A.G.-M.); (L.F.V.-R.)
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Mitsikostas DD, Waeber C, Sanchez-Del-Rio M, Raffaelli B, Ashina H, Maassen van den Brink A, Andreou A, Pozo-Rosich P, Rapoport A, Ashina M, Moskowitz MA. The 5-HT 1F receptor as the target of ditans in migraine - from bench to bedside. Nat Rev Neurol 2023:10.1038/s41582-023-00842-x. [PMID: 37438431 DOI: 10.1038/s41582-023-00842-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2023] [Indexed: 07/14/2023]
Abstract
Migraine is a leading cause of disability in more than one billion people worldwide, yet it remains universally underappreciated, even by individuals with the condition. Among other shortcomings, current treatments (often repurposed agents) have limited efficacy and potential adverse effects, leading to low treatment adherence. After the introduction of agents that target the calcitonin gene-related peptide pathway, another new drug class, the ditans - a group of selective serotonin 5-HT1F receptor agonists - has just reached the international market. Here, we review preclinical studies from the late 1990s and more recent clinical research that contributed to the development of the ditans and led to their approval for acute migraine treatment by the US Food and Drug Administration and the European Medicines Agency.
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Affiliation(s)
- Dimos D Mitsikostas
- 1st Neurology Department, Eginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.
| | - Christian Waeber
- School of Pharmacy, University College Cork, Cork, Ireland
- Department of Pharmacology and Therapeutics, University College Cork, Cork, Ireland
| | | | - Bianca Raffaelli
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Håkan Ashina
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Brain and Spinal Cord Injury, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Anaesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Antoinette Maassen van den Brink
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Anna Andreou
- Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Headache Centre, Guy's and St Thomas's NHS Foundation Trust, King's Health Partners, London, UK
| | - Patricia Pozo-Rosich
- Neurology Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Headache Unit, Neurology Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Headache and Neurological Pain Research Group, Vall d'Hebron Research Institute, Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alan Rapoport
- Department of Neurology, The David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Messoud Ashina
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Michael A Moskowitz
- Departments of Radiology and Neurology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
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Abstract
Migraine is a global neurologic disease that is highly prevalent, especially in women. Studies have observed a predisposition for the development of migraine in women, although the mechanisms involved have yet to be fully elucidated. This review aimed to summarize the recent evidence regarding the epidemiology, pathophysiology, and treatment of migraine and highlight key sex differences. We also identify gaps in care for both women and men living with migraine and discuss the presence of migraine-related stigma and how this may impact the efficacy of clinical care.
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Nascimento TD, Kim DJ, Chrabol C, Lim M, Hu XS, DaSilva AF. Management of Episodic Migraine with Neuromodulation: A Case Report. Dent Clin North Am 2023; 67:157-171. [PMID: 36404076 DOI: 10.1016/j.cden.2022.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Migraine is a highly prevalent neurovascular disorder that affects approximately 15% of the global population. Migraine attacks are a complex cascade of neurologic events that lead to debilitating symptoms and are often associated with inhibitory behavior. The constellation of severe signs and symptoms during the ictal phase (headache attack) makes migraine the third most common cause of disability globally in both sexes under the age of 50. Misuse of pharmaceuticals, such as opiates, can lead to devastating outcomes and exacerbation of pain and headache attacks. A safe and well-tolerated non-pharmacological research approach is high-definition transcranial direct current stimulation over the M1.
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Affiliation(s)
- Thiago D Nascimento
- Department of Biologic and Materials Sciences & Prosthodontics, University of Michigan School of Dentistry, Ann Arbor, MI, USA; Michigan Neuroscience Institute (MNI), Headache & Orofacial Pain Effort (H.O.P.E.) Laboratory, 205 Zina Pitcher Pl, Room 1027, Ann Arbor, MI 48109, USA
| | - Dajung J Kim
- Department of Biologic and Materials Sciences & Prosthodontics, University of Michigan School of Dentistry, Ann Arbor, MI, USA; Michigan Neuroscience Institute (MNI), Headache & Orofacial Pain Effort (H.O.P.E.) Laboratory, 205 Zina Pitcher Pl, Room 1027, Ann Arbor, MI 48109, USA
| | - Conrad Chrabol
- Department of Biologic and Materials Sciences & Prosthodontics, University of Michigan School of Dentistry, Ann Arbor, MI, USA; Michigan Neuroscience Institute (MNI), Headache & Orofacial Pain Effort (H.O.P.E.) Laboratory, 205 Zina Pitcher Pl, Room 1027, Ann Arbor, MI 48109, USA
| | - Manyoel Lim
- Department of Biologic and Materials Sciences & Prosthodontics, University of Michigan School of Dentistry, Ann Arbor, MI, USA; Michigan Neuroscience Institute (MNI), Headache & Orofacial Pain Effort (H.O.P.E.) Laboratory, 205 Zina Pitcher Pl, Room 1027, Ann Arbor, MI 48109, USA
| | - Xiao-Su Hu
- Department of Biologic and Materials Sciences & Prosthodontics, University of Michigan School of Dentistry, Ann Arbor, MI, USA; Michigan Neuroscience Institute (MNI), Headache & Orofacial Pain Effort (H.O.P.E.) Laboratory, 205 Zina Pitcher Pl, Room 1027, Ann Arbor, MI 48109, USA
| | - Alexandre F DaSilva
- Department of Biologic and Materials Sciences & Prosthodontics, University of Michigan School of Dentistry, Ann Arbor, MI, USA; Michigan Neuroscience Institute (MNI), Headache & Orofacial Pain Effort (H.O.P.E.) Laboratory, 205 Zina Pitcher Pl, Room 1027, Ann Arbor, MI 48109, USA.
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8
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Khokhlov AL, Leykin ZN. [Comparative clinical study of pharmacokinetics and bioequivalence of Relonova and Maxalt]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:68-74. [PMID: 37655413 DOI: 10.17116/jnevro202312308168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
OBJECTIVE Evaluation of the bioequivalence of the tested Relonova, tablets, 10 mg and Maxalt, tablets, 10 mg drugs on an empty stomach in healthy volunteers. MATERIAL AND METHODS The pharmacokinetic analysis population included 40 volunteers, the safety analysis population included 40 volunteers. The average age of randomized volunteers (men - 20, women - 20) was 29.3±8.9 years, height 1.71±0.09 m, body weight 70.86±11.66 kg, mean BMI 24.18±2.81 kg/m2. The method used high performance liquid chromatography with tandem mass spectrometric detection. Statistical analysis of the obtained data was performed based on the assumption of a log-normal distribution of the parameters AUC0-72 and Cmax. RESULTS The ratio of geometric means for the key pharmacokinetic parameters (AUC0-t, AUC0-inf and Cmax) of rizatriptan is close to 90%, CI is within the acceptable range for bioequivalent drugs (80-125%). The intrasubject variability (CVintra) for rizatriptan was 23.74% (Cmax), 10.94% (AUC0-t). The average profiles of the pharmacokinetic curves of rizatriptan when taking the test and reference drugs have similar shapes. Relonova and reference Maxalt are bioequivalent. CONCLUSION The results of the study make it possible to recommend Relonova for further clinical study and wide practical application.
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Affiliation(s)
- A L Khokhlov
- Yaroslavl State Medical University, Yaroslavl, Russia
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9
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Berger AA, Winnick A, Carroll AH, Welschmeyer A, Li N, Colon M, Paladini A, Ramírez GF, Hasoon J, Cornett EM, Song J, Varrassi G, Kaye AM, Kaye AD, Ganti L. Rimegepant for the treatment of migraine. Health Psychol Res 2022; 10:38534. [PMID: 36262478 PMCID: PMC9560892 DOI: 10.52965/001c.38534] [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] [Indexed: 10/05/2023] Open
Abstract
Migraine is a common form of primary headache, affecting up to 1 in every 6 Americans. The pathophysiology is an intricate interplay of genetic factors and environmental influence and is still being elucidated in ongoing studies. The trigeminovascular system is now known to have a significant role in the initiation of migraines, including the release of pain mediators such as CGRP and substance P. Traditional treatment of migraine is usually divided into acute and preventive treatment. Acute therapy includes non-specific therapy, such as NSAIDs and other analgesics, which may provide relief in mild to moderate migraines. 5-HT1 agonists may provide relief in severe migraine, but are not universally effective and carry a significant side-effect profile with frequent redosing requirement. Prophylactic therapy may reduce the occurrence of acute migraine attacks in selected patients, but does not completely eliminate it. More recently, CGRP antagonism has been studied and shown to be effective in both abortion and prevention of migraine. Novel medications, targeting CGRP, divide into CGRP antibodies and receptor antagonists (gepants). Rimegepant, a second-generation gepant, has shown efficacy in several clinical trials in treating acute migraine. Ongoing trials are also evaluating its role in migraine prophylaxis, and results are promising. It is also generally safer for use than existing options, does not appear to increase the chance of developing chronic migraines, and carries a very tolerable side effects profile. It is a part of a growing arsenal in migraine treatment, and may present the silver bullet for treatment of this disease.
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Affiliation(s)
- Amnon A Berger
- Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School
| | - Ariel Winnick
- Soroka University Medical Center and Faculty of Health Sciences, Ben Gurion University of the Negev, University of California School of Optometry
| | | | | | | | - Marc Colon
- Department of Psychiatry, and Behavioral Medicine, Louisiana State University Health Science Center Shreveport
| | | | | | - Jamal Hasoon
- Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center
| | | | | | | | - Adam M Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Shreveport
| | - Latha Ganti
- University of Central Florida College of Medicine
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Cowan RP, Marmura MJ, Diener HC, Starling AJ, Schim J, Hirman J, Brevig T, Cady R. Quantity changes in acute headache medication use among patients with chronic migraine treated with eptinezumab: subanalysis of the PROMISE-2 study. J Headache Pain 2022; 23:115. [PMID: 36068494 PMCID: PMC9446734 DOI: 10.1186/s10194-022-01482-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 08/09/2022] [Indexed: 11/10/2022] Open
Abstract
Background Patients with chronic migraine (CM) treated with eptinezumab in the PROMISE-2 trial achieved greater reductions in migraine and headache frequency, impact, and acute headache medication (AHM) use than did patients who received placebo. This post hoc analysis examines relationships between headache frequency reductions and changes in AHM use in patients in PROMISE-2. Methods PROMISE-2 was a double-blind, placebo-controlled trial conducted in adults with CM. Patients were randomized to eptinezumab 100 mg, 300 mg, or placebo, administered intravenously once every 12 weeks for up to two doses. Patients recorded headache/AHM information daily and for each event in an electronic diary; data from all days with daily reports were included. Shifts in headache frequency and AHM use were assessed in the three populations: total CM population, patients with CM and medication-overuse headache (MOH), and patients with CM and MOH who were ≥ 50% responders during treatment (response over weeks 1–24). Results A total of 1072 adults with CM received treatment (eptinezumab, n = 706; placebo, n = 366). Mean baseline headache frequency was 20.5 days; mean baseline AHM days was 13.4; 431 patients had MOH, of which 225 (52.2%) experienced ≥50% response over weeks 1–24. Relative to baseline, the proportion of days with both headache and AHM use decreased 25.1% (eptinezumab) versus 17.0% (placebo) in the total population (N = 1072), 29.2% versus 18.4% in the MOH subpopulation (n = 431), and 38.3% versus 31.5% in the CM with MOH population with ≥50% response subgroup (n = 225) during weeks 1–24. The proportion of days with headache and triptan use decreased 9.1% (eptinezumab) versus 5.8% (placebo), 11.8% versus 7.2%, and 14.5% versus 12.6%, respectively. Reductions in other AHM types were smaller. Conclusions In this post hoc analysis, eptinezumab use in patients with CM was associated with greater decreases in days with headache with AHM overall and with triptans in particular. The magnitude of effect was greater in the subgroup of CM patients with MOH and ≥ 50% response. Trial registration ClinicalTrials.gov Identifier: NCT02974153. Graphical abstract Eptinezumab reduces headache frequency and acute medication use in patients with chronic migraine.![]()
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Affiliation(s)
| | | | - Hans-Christoph Diener
- Medical Faculty of the University Duisburg-Essen, Institute for Medical Informatics, Biometry and Epidemiology, Essen, Germany
| | | | - Jack Schim
- The Neurology Center of Southern California, Carlsbad, CA, USA
| | - Joe Hirman
- Pacific Northwest Statistical Consulting, Inc., Woodinville, WA, USA
| | | | - Roger Cady
- Lundbeck LLC, Deerfield, IL, USA. .,RK Consults, Ozark, MO, USA. .,Missouri State University, Springfield, MO, USA.
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11
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Dalenogare DP, Theisen MC, Peres DS, Fialho MFP, Andrighetto N, Barros L, Landini L, Titiz M, De Logu F, Oliveira SM, Geppetti P, Nassini R, Trevisan G. Transient receptor potential ankyrin 1 mediates headache-related cephalic allodynia in a mouse model of relapsing-remitting multiple sclerosis. Pain 2022; 163:1346-1355. [PMID: 34711761 DOI: 10.1097/j.pain.0000000000002520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 10/07/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Primary headache conditions are frequently associated with multiple sclerosis (MS), but the mechanism that triggers or worsens headaches in patients with MS is poorly understood. We previously showed that the proalgesic transient receptor potential ankyrin 1 (TRPA1) mediates hind paw mechanical and cold allodynia in a relapsing-remitting experimental autoimmune encephalomyelitis (RR-EAE) model in mice. Here, we investigated the development of periorbital mechanical allodynia (PMA) in RR-EAE, a hallmark of headache, and if TRPA1 contributed to this response. RR-EAE induction by injection of the myelin oligodendrocyte peptide fragment35-55 (MOG35-55) and Quillaja A adjuvant (Quil A) in C57BL/6J female mice elicited a delayed and sustained PMA. The PMA at day 35 after induction was reduced by the calcitonin gene-related peptide receptor antagonist (olcegepant) and the serotonin 5-HT1B/D receptor agonist (sumatriptan), 2 known antimigraine agents. Genetic deletion or pharmacological blockade of TRPA1 attenuated PMA associated with RR-EAE. The levels of oxidative stress biomarkers (4-hydroxynonenal and hydrogen peroxide, known TRPA1 endogenous agonists) and superoxide dismutase and NADPH oxidase activities were increased in the trigeminal ganglion of RR-EAE mice. Besides, the treatment with antioxidants (apocynin or α-lipoic acid) attenuated PMA. Thus, the results of this study indicate that TRPA1, presumably activated by endogenous agonists, evokes PMA in a mouse model of relapsing-remitting MS.
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Affiliation(s)
- Diéssica P Dalenogare
- Department of Physiology and Pharmacology, Graduate Program in Pharmacology, Federal University of Santa Maria (UFSM), Avenida Roraima, Santa Maria, RS, Brazil
| | - Maria C Theisen
- Department of Physiology and Pharmacology, Graduate Program in Pharmacology, Federal University of Santa Maria (UFSM), Avenida Roraima, Santa Maria, RS, Brazil
| | - Diulle S Peres
- Department of Physiology and Pharmacology, Graduate Program in Pharmacology, Federal University of Santa Maria (UFSM), Avenida Roraima, Santa Maria, RS, Brazil
| | - Maria F P Fialho
- Department of Biochemistry and Molecular Biology, Graduate Program in Biological Sciences, Toxicological Biochemistry, Federal University of Santa Maria (UFSM), Santa Maria, RS, Brazil
| | - Nathaly Andrighetto
- Department of Physiology and Pharmacology, Graduate Program in Pharmacology, Federal University of Santa Maria (UFSM), Avenida Roraima, Santa Maria, RS, Brazil
| | - Laura Barros
- Department of Physiology and Pharmacology, Graduate Program in Pharmacology, Federal University of Santa Maria (UFSM), Avenida Roraima, Santa Maria, RS, Brazil
| | - Lorenzo Landini
- Department of Health Sciences, Clinical Pharmacology Unit, University of Florence, Florence, Italy
| | - Mustafa Titiz
- Department of Health Sciences, Clinical Pharmacology Unit, University of Florence, Florence, Italy
| | - Francesco De Logu
- Department of Health Sciences, Clinical Pharmacology Unit, University of Florence, Florence, Italy
| | - Sara M Oliveira
- Department of Biochemistry and Molecular Biology, Graduate Program in Biological Sciences, Toxicological Biochemistry, Federal University of Santa Maria (UFSM), Santa Maria, RS, Brazil
| | - Pierangelo Geppetti
- Department of Health Sciences, Clinical Pharmacology Unit, University of Florence, Florence, Italy
| | - Romina Nassini
- Department of Health Sciences, Clinical Pharmacology Unit, University of Florence, Florence, Italy
| | - Gabriela Trevisan
- Department of Physiology and Pharmacology, Graduate Program in Pharmacology, Federal University of Santa Maria (UFSM), Avenida Roraima, Santa Maria, RS, Brazil
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Katsuki M, Kashiwagi K, Kawamura S, Koh A. The Efficacy of Japanese Herbal Kampo Medicine as an Acute and Prophylactic Medication to Treat Chronic Daily Headache and Medication Overuse Headache:-Single Arm Retrospective Study. Cureus 2022; 14:e25419. [PMID: 35769688 PMCID: PMC9233981 DOI: 10.7759/cureus.25419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2022] [Indexed: 11/05/2022] Open
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13
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Sette L, Caponnetto V, Ornello R, Nežádal T, Čtrnáctá D, Šípková J, Matoušová Z, Sacco S. Acute Medication Use in Patients With Migraine Treated With Monoclonal Antibodies Acting on the CGRP Pathway: Results From a Multicenter Study and Proposal of a New Index. Front Neurol 2022; 13:846717. [PMID: 35295829 PMCID: PMC8918478 DOI: 10.3389/fneur.2022.846717] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 02/01/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionAssessing the impact of migraine preventive treatments on acute medication consumption is important in clinical evaluation. The number of acute medication intakes per each monthly migraine day (MMD) could provide insights on migraine burden and represent a new proxy of treatment effectiveness in clinical trials and real-life studies. We evaluated the effect of monoclonal antibodies acting on calcitonin gene-related peptide (CGRP) pathway on the consumption of migraine acute medication in real-life.MethodsIn two headache centers in Prague (CZ), we included and followed up to 6 months consecutive patients treated with MoAbs acting on CGRP (erenumab or fremanezumab). For each month of treatment, we reported monthly drug intake (MDI) in doses of any medication, migraine-specific (MS), and non-migraine-specific (non-MS) medications, and computed a ratio between MMDs and MDI, i.e., Migraine Medication Index (MMI) for MS and non-MS medications.ResultsWe included 90 patients (91.1% women) with a median age of 47 [interquartile range (IQR) 42–51] years; 81 (90.0%) treated with erenumab and 9 (10.0%) with fremanezumab. Median MMDs decreased from 11 (IQR 8–14) at baseline to 4 (IQR 2–5) at Month 3 (p < 0.001 vs. baseline) and 3 (IQR 2–6) at Month 6 (p < 0.001 vs. baseline). Median MDI decreased from 15 drug intakes (IQR 11–20) at baseline to four drug intakes (IQR 2–7) at Month 3 (p < 0.001) and four drug intakes (IQR 2–7) at Month 6 (p < 0.001).The corresponding MDIs for MS medications were 10 (IQR 6–14) at baseline, 3 (IQR 1–5, p < 0.001) at Month 3, and 2 (IQR 0–4, p < 0.001) at Month 6. Monthly drug intakes for non-MS medications were 4 (IQR 0–9) at baseline, 1 (IQR 0–3, p < 0.001) at Month 3 and at Month 6.Median MMI decreased from 1.32 (IQR 1.11–1.68) at baseline to 1.00 (IQR 1.00–1.50, p < 0.001) at Month 3 and 1.00 (IQR 1.00–1.34, p < 0.001) at Month 6.ConclusionsWe confirmed that MoAbs acting on CGRP pathway decrease acute migraine medication consumption. We proposed a new index that can be easily applied in clinical practice to quantify migraine burden and its response to acute medication. Our index could help optimizing migraine acute treatment in clinical practice.
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Affiliation(s)
- Lucia Sette
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy
| | - Valeria Caponnetto
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy
| | - Raffaele Ornello
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy
| | - Tomáš Nežádal
- Department of Neurology, 1st Faculty of Medicine, Military University Hospital Prague, Charles University, Prague, Czechia
| | - Dana Čtrnáctá
- Department of Neurology, 1st Faculty of Medicine, Military University Hospital Prague, Charles University, Prague, Czechia
| | - Jitka Šípková
- Department of Neurology, 1st Faculty of Medicine, Military University Hospital Prague, Charles University, Prague, Czechia
| | - Zuzana Matoušová
- Department of Neurology, 2nd Faculty of Medicine, Motol University Hospital Prague, Charles University, Prague, Czechia
| | - Simona Sacco
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy
- *Correspondence: Simona Sacco
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Coppola G, Magis D, Casillo F, Sebastianelli G, Abagnale C, Cioffi E, Di Lenola D, Di Lorenzo C, Serrao M. Neuromodulation for Chronic Daily Headache. Curr Pain Headache Rep 2022; 26:267-278. [PMID: 35129825 PMCID: PMC8927000 DOI: 10.1007/s11916-022-01025-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2022] [Indexed: 11/29/2022]
Abstract
Purpose of Review We reviewed the literature that explored the use of central and peripheral neuromodulation techniques for chronic daily headache (CDH) treatment. Recent Findings Although the more invasive deep brain stimulation (DBS) is effective in chronic cluster headache (CCH), it should be reserved for extremely difficult-to-treat patients. Percutaneous occipital nerve stimulation has shown similar efficacy to DBS and is less risky in both CCH and chronic migraine (CM). Non-invasive transcutaneous vagus nerve stimulation is a promising add-on treatment for CCH but not for CM. Transcutaneous external trigeminal nerve stimulation may be effective in treating CM; however, it has not yet been tested for cluster headache. Transcranial magnetic and electric stimulations have promising preventive effects against CM and CCH. Summary Although the precise mode of action of non-invasive neuromodulation techniques remains largely unknown and there is a paucity of controlled trials, they should be preferred to more invasive techniques for treating CDH.
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Affiliation(s)
- Gianluca Coppola
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino, Latina, Italy.
| | - Delphine Magis
- Headache and Pain Multimodal Treatment Centre (CMTCD), Department of Neurology, Neuromodulation Centre, CHR East Belgium, Verviers, Belgium
| | - Francesco Casillo
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino, Latina, Italy
| | - Gabriele Sebastianelli
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino, Latina, Italy
| | - Chiara Abagnale
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino, Latina, Italy
| | - Ettore Cioffi
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino, Latina, Italy
| | - Davide Di Lenola
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino, Latina, Italy
| | - Cherubino Di Lorenzo
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino, Latina, Italy
| | - Mariano Serrao
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino, Latina, Italy
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Gottschalk C, Basu A, Blumenfeld A, Torphy B, Marmura MJ, Pavlovic JM, Dumas PK, Lalvani N, Buse DC. The importance of an early onset of migraine preventive disease control: A roundtable discussion. CEPHALALGIA REPORTS 2022. [DOI: 10.1177/25158163221134593] [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: Newly approved migraine preventive therapies have allowed for rapid control of migraine activity, offering potential to minimize the burden of migraine. This report summarizes a roundtable discussion convened to analyze evidence for early onset of prevention, ascertain its clinical relevance, and provide guidance for healthcare professionals in crafting goals and treatment expectations for patients with migraine initiating preventive therapy. Methods: A virtual roundtable meeting of migraine clinicians, researchers, and patient advocates convened in October 2020. Participants reviewed and discussed data summarizing patient and healthcare professional perceptions of migraine prevention and evidence from the peer-reviewed and gray literature to develop corresponding recommendations. Summary: Evidence from clinical studies of anti-calcitonin gene-related peptide monoclonal antibodies (erenumab, fremanezumab, galcanezumab, and eptinezumab) and the chemodenervation agent onabotulinumtoxinA indicate that patients may experience reduction of migraine activity within 7 days of drug administration and early attainment of disease control is associated with improvements in clinically important outcomes. The roundtable of experts proposes that early onset be defined as demonstration of preventive benefits within 1 week of treatment initiation. We recommend focusing discussion with patients around “disease control” and potential benefits of early onset of prevention, so patients can set realistic preventive therapy goals and expectations.
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Affiliation(s)
| | - Anirban Basu
- The CHOICE Institute, School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Andrew Blumenfeld
- Headache Center of Southern California, The Neurology Center, Carlsbad, CA, USA
| | - Bradley Torphy
- Chicago Headache Center and Research Institute, Chicago, IL, USA
| | - Michael J Marmura
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jelena M Pavlovic
- Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Nim Lalvani
- American Migraine Foundation, Mount Royal, NJ, USA
| | - Dawn C Buse
- Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
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Yuan H, Curran JG, Keith SW, Hopkins MM, Silberstein SD. Intravenous ibuprofen for acute treatment of migraine: A double-blind, randomized, placebo-controlled pilot study. Headache 2021; 61:1432-1440. [PMID: 34601736 DOI: 10.1111/head.14214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 07/22/2021] [Accepted: 08/18/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of intravenous (IV) Ibuprofen for acute treatment of migraine. BACKGROUND IV nonsteroidal anti-inflammatory drugs (NSAIDs) are an alternative to oral NSAIDs, especially in patients with severe migraine who have emesis or gastroparesis. To date, only three IV NSAIDs (ketorolac, ibuprofen, and meloxicam) are available in the United States for use in moderate and severe pain, but no placebo-controlled trial is available for migraine. We performed a single-center, double-blind, randomized, placebo-controlled pilot study to evaluate the efficacy and safety of IV ibuprofen as an acute treatment of migraine (NCT01230411). METHODS Individuals with episodic migraine were screened at the Jefferson Headache Center. Qualified subjects were treated for migraine attacks within 2-72 h following the headache onset with either 800 mg of IV ibuprofen or placebo in 250 ml saline bolus. Migraine pain intensity (4-point Likert scale) and associated symptoms were assessed at predetermined time points (0.25, 0.5, 1, 1.5, 2, 4, 8, 24 h). The primary endpoint was pain relief at 2 h after infusion. Important secondary endpoints included pain freedom at 2 h, sustained relief over 24 h, use of rescue therapy, and absence of associated symptoms. Adverse events (AEs) were also collected. RESULTS Seventy-four participants were enrolled between 2011 and 2017. Forty-four subjects (female 33/44; 75.0%) with mean (SD) age 41.0 (11.2) 11.2 years came for the treatment. All treated subjects (n = 44) were included in the analysis. Among them, 23 were randomized to receive IV ibuprofen. Both groups were demographically similar except for longer migraine duration (i.e., years lived with disease) in the active treatment than in the placebo group. At 2 h posttreatment, pain relief was found in 74% (17/23) and 48% (10/21) after IV ibuprofen and placebo, respectively (odds ratio [OR] 3.12, 95% CI: 0.88-11.0; p = 0.078). Other secondary endpoints at 2 and 24 h were not significant. The longitudinal repeated-measures analysis within 2 h on ibuprofen treatment showed significant pain relief (OR 2.47, 95% CI 1.08-5.7; p = 0.033) and absence of associated symptoms: photophobia (OR 4.0, 95% CI 1.57-10.3; p = 0.004), phonophobia (OR 3.12, 95% CI 1.16-8.4; p = 0.025), and osmophobia (OR 3.45, 95% CI 1.01-11.8; p = 0.048). AEs were observed in seven subjects in both groups, with arm pain being the most common. No serious AE was reported. CONCLUSION This study did not meet the primary endpoint but showed pain relief and elimination of several associated symptoms within 2 h on repeated-measures analysis. Although limited by small sample size and high placebo response, our results indicate that IV ibuprofen may be a safe and effective option for acute treatment of migraine, but more extensive studies are necessary.
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Affiliation(s)
- Hsiangkuo Yuan
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - John G Curran
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Scott W Keith
- Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mary M Hopkins
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Stephen D Silberstein
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Dalenogare DP, Ritter C, Bellinaso FRA, Kudsi SQ, Pereira GC, Fialho MFP, Lückemeyer DD, Antoniazzi CTDD, Landini L, Ferreira J, Bochi GV, Oliveira SM, De Logu F, Nassini R, Geppetti P, Trevisan G. Periorbital Nociception in a Progressive Multiple Sclerosis Mouse Model Is Dependent on TRPA1 Channel Activation. Pharmaceuticals (Basel) 2021; 14:831. [PMID: 34451927 PMCID: PMC8400939 DOI: 10.3390/ph14080831] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 12/16/2022] Open
Abstract
Headaches are frequently described in progressive multiple sclerosis (PMS) patients, but their mechanism remains unknown. Transient receptor potential ankyrin 1 (TRPA1) was involved in neuropathic nociception in a model of PMS induced by experimental autoimmune encephalomyelitis (PMS-EAE), and TRPA1 activation causes periorbital and facial nociception. Thus, our purpose was to observe the development of periorbital mechanical allodynia (PMA) in a PMS-EAE model and evaluate the role of TRPA1 in periorbital nociception. Female PMS-EAE mice elicited PMA from day 7 to 14 days after induction. The antimigraine agents olcegepant and sumatriptan were able to reduce PMA. The PMA was diminished by the TRPA1 antagonists HC-030031, A-967079, metamizole and propyphenazone and was absent in TRPA1-deficient mice. Enhanced levels of TRPA1 endogenous agonists and NADPH oxidase activity were detected in the trigeminal ganglion of PMS-EAE mice. The administration of the anti-oxidants apocynin (an NADPH oxidase inhibitor) or alpha-lipoic acid (a sequestrant of reactive oxygen species), resulted in PMA reduction. These results suggest that generation of TRPA1 endogenous agonists in the PMS-EAE mouse model may sensitise TRPA1 in trigeminal nociceptors to elicit PMA. Thus, this ion channel could be a potential therapeutic target for the treatment of headache in PMS patients.
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Affiliation(s)
- Diéssica Padilha Dalenogare
- Graduated Program in Pharmacology, Federal University of Santa Maria (UFSM), Santa Maria 97105-900, RS, Brazil; (D.P.D.); (C.R.); (F.R.A.B.); (S.Q.K.); (G.C.P.); (C.T.d.D.A.); (G.V.B.)
| | - Camila Ritter
- Graduated Program in Pharmacology, Federal University of Santa Maria (UFSM), Santa Maria 97105-900, RS, Brazil; (D.P.D.); (C.R.); (F.R.A.B.); (S.Q.K.); (G.C.P.); (C.T.d.D.A.); (G.V.B.)
| | - Fernando Roberto Antunes Bellinaso
- Graduated Program in Pharmacology, Federal University of Santa Maria (UFSM), Santa Maria 97105-900, RS, Brazil; (D.P.D.); (C.R.); (F.R.A.B.); (S.Q.K.); (G.C.P.); (C.T.d.D.A.); (G.V.B.)
| | - Sabrina Qader Kudsi
- Graduated Program in Pharmacology, Federal University of Santa Maria (UFSM), Santa Maria 97105-900, RS, Brazil; (D.P.D.); (C.R.); (F.R.A.B.); (S.Q.K.); (G.C.P.); (C.T.d.D.A.); (G.V.B.)
| | - Gabriele Cheiran Pereira
- Graduated Program in Pharmacology, Federal University of Santa Maria (UFSM), Santa Maria 97105-900, RS, Brazil; (D.P.D.); (C.R.); (F.R.A.B.); (S.Q.K.); (G.C.P.); (C.T.d.D.A.); (G.V.B.)
| | - Maria Fernanda Pessano Fialho
- Graduated Program in Biological Sciences: Toxicological Biochemistry, Federal University of Santa Maria (UFSM), Santa Maria 97105-900, RS, Brazil; (M.F.P.F.); (S.M.O.)
| | - Débora Denardin Lückemeyer
- Graduated Program in Pharmacology, Federal University of Santa Catarina (UFSC), Florianópolis 88040-900, SC, Brazil; (D.D.L.); (J.F.)
| | - Caren Tatiane de David Antoniazzi
- Graduated Program in Pharmacology, Federal University of Santa Maria (UFSM), Santa Maria 97105-900, RS, Brazil; (D.P.D.); (C.R.); (F.R.A.B.); (S.Q.K.); (G.C.P.); (C.T.d.D.A.); (G.V.B.)
| | - Lorenzo Landini
- Department of Health Science, Clinical Pharmacology and Oncology, University of Florence, 50139 Florence, FI, Italy; (L.L.); (F.D.L.); (P.G.)
| | - Juliano Ferreira
- Graduated Program in Pharmacology, Federal University of Santa Catarina (UFSC), Florianópolis 88040-900, SC, Brazil; (D.D.L.); (J.F.)
| | - Guilherme Vargas Bochi
- Graduated Program in Pharmacology, Federal University of Santa Maria (UFSM), Santa Maria 97105-900, RS, Brazil; (D.P.D.); (C.R.); (F.R.A.B.); (S.Q.K.); (G.C.P.); (C.T.d.D.A.); (G.V.B.)
| | - Sara Marchesan Oliveira
- Graduated Program in Biological Sciences: Toxicological Biochemistry, Federal University of Santa Maria (UFSM), Santa Maria 97105-900, RS, Brazil; (M.F.P.F.); (S.M.O.)
| | - Francesco De Logu
- Department of Health Science, Clinical Pharmacology and Oncology, University of Florence, 50139 Florence, FI, Italy; (L.L.); (F.D.L.); (P.G.)
| | - Romina Nassini
- Department of Health Science, Clinical Pharmacology and Oncology, University of Florence, 50139 Florence, FI, Italy; (L.L.); (F.D.L.); (P.G.)
| | - Pierangelo Geppetti
- Department of Health Science, Clinical Pharmacology and Oncology, University of Florence, 50139 Florence, FI, Italy; (L.L.); (F.D.L.); (P.G.)
| | - Gabriela Trevisan
- Graduated Program in Pharmacology, Federal University of Santa Maria (UFSM), Santa Maria 97105-900, RS, Brazil; (D.P.D.); (C.R.); (F.R.A.B.); (S.Q.K.); (G.C.P.); (C.T.d.D.A.); (G.V.B.)
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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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Abstract
Introduction: Migraine is one of the most common neurological disorders. Nowadays, the 5-HT1B/1D receptor agonists, namely triptans, are considered as the standard of care for migraine acute treatment. However, triptans have limitations in some patients, such as incomplete pain relief, headache recurrence, and cardiovascular contraindications. New 5-HT1F receptor agonists, namely ditans, and calcitonin gene-related peptide receptor antagonists, namely gepants, have been developed as migraine-specific treatments.Areas covered: This paper reviews the available data from RCTs to assess the clinical efficacy, safety, and tolerability profile of lasmiditan, rimegepant, and ubrogepant for the acute treatment of migraine and atogepant for the prevention of migraine.Expert opinion: Available data suggest that lasmiditan, rimegepant, and ubrogepant might not have a clinical efficacy similar to triptans. Lasmiditan did not cause the typical triptan side effects but was associated with central nervous system side effects, causing temporary driving impairment. On the contrary, the new generation of gepants showed a placebo-like tolerability profile and the absence of a specific pattern of side effects. Future studies on lasmiditan and gepants with respect to established effective comparators are mandatory to support phase III results and to help clinicians to balance the benefit/risk profiles of the various acute and preventive medications.
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Affiliation(s)
- Andrea Negro
- Department of Clinical and Molecular Medicine, Sant'Andrea University Hospital, Via di Grottarossa, Rome, Italy.,Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sant'Andrea University Hospital, Via di Grottarossa, Rome, Italy.,Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy
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Tepper SJ, Lin T, Montal T, Ironi A, Dougherty C. Real-world Experience with Remote Electrical Neuromodulation in the Acute Treatment of Migraine. PAIN MEDICINE 2020; 21:3522-3529. [PMID: 32935848 DOI: 10.1093/pm/pnaa299] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Remote electrical neuromodulation (REN) is a nonpharmacological acute migraine treatment that stimulates upper-arm peripheral nerves. The aim of this investigation was to evaluate the effectiveness and safety of REN for acute treatment of migraine in a real-world setting. METHODS Real-world data were collected from patients who were using REN (Nerivio®, Theranica Bio-Electronics Ltd., Israel) between October 1, 2019, and March 31, 2020. Patients recorded their symptoms at baseline, two hours, and 24 hours post-treatment. Patients were stratified based on the type of visit and provider; in-person visits with headache specialists (HS group) or virtual visits with nonheadache specialists (NHS group). Efficacy outcome focused on intra-individual consistency of response across multiple attacks. RESULTS We found that 58.9% (662/1,123) of the patients in the HS group and 74.2% (23/31) of the patients in the NHS group experienced pain relief at two hours in at least 50% of their treated attacks and 20.0% (268/1,339) of the patients in the HS group and 35.6% (16/45) of the patients in the NHS group experienced pain freedom at two hours in at least 50% of their treated attacks. The effects of REN on associated symptoms and improvement in function were also consistent in both groups. The incidence of device-related adverse events was very low (0.5%). CONCLUSIONS Real-world data confirm that REN results in meaningful clinical benefits with minimal side effects. REN may provide an effective drug-free treatment option for achieving consistent relief from migraine symptoms and may reduce the use of acute medications.
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Affiliation(s)
- Stewart J Tepper
- The Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Tamar Lin
- Theranica Bio-Electronics Ltd., Netanya, Israel
| | - Tal Montal
- Theranica Bio-Electronics Ltd., Netanya, Israel
| | - Alon Ironi
- Theranica Bio-Electronics Ltd., Netanya, Israel
| | - Carrie Dougherty
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA
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21
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Remote Electrical Neuromodulation for the Acute Treatment of Migraine in Patients with Chronic Migraine: An Open-Label Pilot Study. Pain Ther 2020; 9:531-543. [PMID: 32648205 PMCID: PMC7648773 DOI: 10.1007/s40122-020-00185-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION Remote electrical neuromodulation (REN) is a novel acute treatment of migraine. Upper arm peripheral nerves are stimulated to induce conditioned pain modulation (CPM)-an endogenous analgesic mechanism in which conditioning stimulation inhibits pain in remote body regions. The REN device (Nerivio®, Theranica Bio-Electronics LTD., Israel) is FDA-authorized for acute treatment of migraine in adults who do not have chronic migraine. The current study assessed the consistency of response over multiple migraine attacks in people with chronic migraine who are typically characterized with severe pain intensity, high disability, and less robust response to triptans. METHODS This was an open-label, single-arm, dual-center study conducted on adults with chronic migraine. Participants underwent a 4-week treatment phase in which they treated their migraine headaches with the device for 45 min within 1 h of attack onset. Pain levels were recorded at baseline, 2 h, and 24 h post-treatment. Efficacy outcomes (pain relief and pain-free responses at 2 h, sustained pain relief and sustained pain-free responses at 24 h) focused on intra-individual consistency of response across multiple attacks, which was defined as response in at least 50% of the treatments. RESULTS Forty-two participants were enrolled, and 38 participants were evaluable for analyses; 73.7% (28/38) achieved pain relief at 2 h, 26.3% (10/38) were pain-free at 2 h, 84.4% (27/32) had sustained pain relief response at 24 h and 45.0% (9/20) had sustained pain relief response at 24 h in at least 50% of their treated attacks. The effects of REN on associated symptoms and improvement in function were also consistent. The incidence of device-related adverse events was low (1.8%). CONCLUSIONS REN used for a series of migraine attacks was effective and well tolerated across attacks. REN may offer a safe and effective non-pharmacological alternative for acute treatment in patients with chronic migraine. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT04161807. Retrospectively registered on November 13, 2019.
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Yang Y, Chen M, Sun Y, Gao B, Chen Z, Wang Z. Safety and Efficacy of Ubrogepant for the Acute Treatment of Episodic Migraine: A Meta-Analysis of Randomized Clinical Trials. CNS Drugs 2020; 34:463-471. [PMID: 32193827 DOI: 10.1007/s40263-020-00715-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Ubrogepant is a small molecular calcitonin gene-related peptide receptor antagonist that is used for the acute treatment of migraine. OBJECTIVE The aim was to conduct a meta-analysis to systematically evaluate the efficacy and safety of ubrogepant for the treatment of episodic migraine compared with placebo in the adult population. METHODS We systematically searched PubMed, EMBASE, and the Cochrane Library Central Register of Controlled Trials for relevant randomized clinical trials, from the earliest available date to November 10, 2019, to evaluate the efficacy and safety of short-term ubrogepant use. Inclusion criteria were (1) randomized clinical trial; (2) enrolled adult participants diagnosed with episodic migraine; (3) compared ubrogepant with placebo at doses that were evaluated in phase III clinical trials; (4) enrolled more than 100 patients in each group; and (5) provided any information on primary or secondary outcomes. Trials were excluded if their participants were diagnosed with chronic migraine. RESULTS A total of three multicenter, randomized clinical trials with 3326 patients were included. Ubrogepant use was associated with a significantly higher percentage of patients with pain freedom (ubrogepant 20.8%; placebo 12.6%; relative risk [RR] 1.65, 95% confidence interval [CI] 1.38-1.98) and absence of the most bothersome migraine-associated symptoms (ubrogepant 37.3%; placebo 27.6%; RR 1.35, 95% CI 1.20-1.53) at 2 h post-dose compared with placebo. Ubrogepant increased the rate of absence of migraine-associated symptoms at 2 h post-dose compared with placebo (photophobia: RR 1.30 [95% CI 1.18-1.44], I2 = 49%; phonophobia: RR 1.20 [95% CI 1.11-1.29]; nausea: RR 1.07 [95% CI 1.02-1.13]), and patients were more likely to function normally at 2 h post-dose compared with placebo (RR 1.30 [95% CI 1.16-1.45]). No significant difference was found for treatment-related adverse events within 48 h or 30 days for ubrogepant compared with placebo (48 h: RR 1.07 [95% CI 0.85-1.35]; 30 days: RR 1.03 [95% CI 0.79-1.34]). Subgroup analysis demonstrated that compared to placebo, ubrogepant led to greater rates of freedom from pain at 2 h with 25-mg, 50-mg, and 100-mg doses and absence of the most bothersome symptoms with 50-mg and 100-mg doses. CONCLUSIONS The use of ubrogepant as an acute treatment of episodic migraine in adults led to a greater percentage of freedom from pain and absence of the most bothersome symptoms at 2 h post-dose. Short-term use of ubrogepant was not related to an increased risk for adverse events. Further studies are needed to evaluate efficacy and safety for long-term use and in specific subgroups of patients.
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Affiliation(s)
- Yanbo Yang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, Jiangsu Province, 215006, China.,First Clinical Medical School of Soochow University, Suzhou, Jiangsu Province, 215006, China
| | - Mingjia Chen
- First Clinical Medical School of Soochow University, Suzhou, Jiangsu Province, 215006, China
| | - Yue Sun
- School of Biology and Basic Medical Science of Soochow University, Suzhou, Jiangsu Province, 215006, China
| | - Bixi Gao
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, Jiangsu Province, 215006, China
| | - Zhouqing Chen
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, Jiangsu Province, 215006, China
| | - Zhong Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, Jiangsu Province, 215006, China.
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Kouremenos E, Arvaniti C, Constantinidis TS, Giannouli E, Fakas N, Kalamatas T, Kararizou E, Naoumis D, Mitsikostas DD. Consensus of the Hellenic Headache Society on the diagnosis and treatment of migraine. J Headache Pain 2019; 20:113. [PMID: 31835997 PMCID: PMC6911284 DOI: 10.1186/s10194-019-1060-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 11/18/2019] [Indexed: 01/03/2023] Open
Abstract
More than 0.6 million people suffer from disabling migraines in Greece causing a dramatic work loss, but only a small proportion of migraineurs attend headache centres, most of them being treated by non-experts. On behalf of the Hellenic Headache Society, we report here a consensus on the diagnosis and treatment of adult migraine that is based on the recent guidelines of the European Headache Federation, on the principles of Good Clinical Practice and on the Greek regulatory affairs. The purposes are three-fold: (1) to increase awareness for migraine in Greece; (2) to support Greek practitioners who are treating migraineurs; and (3) to help Greek migraineurs to get the most appropriate treatment. For mild migraine, symptomatic treatment with high dose simple analgesics is suggested, while for moderate to severe migraines triptans or non-steroidal anti-inflammatory drugs, or both, should be administered following an individually tailored therapeutic strategy. A rescue acute treatment option should always be advised. For episodic migraine prevention, metoprolol (50–200 mg/d), propranolol (40–240 mg/d), flunarizine (5–10 mg/d), valproate (500–1800 mg/d), topiramate (25–100 mg/d) and candesartan (16–32 mg/d) are the drugs of first choice. For chronic migraine prevention topiramate (100-200 mg/d), valproate (500–1800 mg/d), flunarizine (5–10 mg/d) and venlafaxine (150 mg/d) may be used, but the evidence is very limited. Botulinum toxin type A and monoclonal antibodies targeting the CGRP pathway (anti-CGRP mAbs) are recommended for patients suffering from chronic migraine (with or without medication overuse) who failed or did not tolerate two previous treatments. Anti-CGRP mAbs are also suggested for patients suffering from high frequency episodic migraine (≥8 migraine days per month and less than 14) who failed or did not tolerate two previous treatments.
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Affiliation(s)
| | - Chrysa Arvaniti
- Second Neurology Department, School of Medicine, National & Kapodistrian University of Athens, Attikon Hospital, Athens, Greece
| | | | | | - Nikolaos Fakas
- Neurology Department, 401 Military General Hospital, Athens, Greece
| | | | - Evangelia Kararizou
- First Neurology Department, School of Medicine, National & Kapodistrian University of Athens, Aeginition Hospital, 72-74 Vl Sofia's Avenue, 11528, Athens, Greece
| | - Dimitrios Naoumis
- Neurology Department, 251 Air Force General Hospital, Athens, Greece
| | - Dimos D Mitsikostas
- First Neurology Department, School of Medicine, National & Kapodistrian University of Athens, Aeginition Hospital, 72-74 Vl Sofia's Avenue, 11528, Athens, Greece.
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Kyeremateng K, Troullos E, Paredes-Diaz A. Safety of naproxen compared with placebo, ibuprofen and acetaminophen: a pooled analysis of eight multiple-dose, short-term, randomized controlled studies. Curr Med Res Opin 2019; 35:1671-1676. [PMID: 31033364 DOI: 10.1080/03007995.2019.1612338] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: To quantify the rate of adverse events reported with naproxen compared with placebo, ibuprofen and acetaminophen at non-prescription doses in multiple-dose, multi-day (7-10 days) duration clinical trials and further contribute towards current knowledge regarding the safety profile of naproxen. Methods: Safety data were retrospectively collected from eight randomized, controlled trials that included subjects exposed to a fixed dosing regimen of 220-750 mg naproxen per day over 7-10 days. All data on adverse events and their duration, severity and possible relationship to the study drug were taken from the clinical study reports. The data were used in a post-hoc pooled analysis of participants exposed to naproxen 220-750 mg/day (N = 1494) and grouped according to age (<65 and ≥65 years), daily dose, race and gender. Results: The safety profile of naproxen closely resembled that of placebo, with similar rates of adverse events across treatment groups as the active comparators. There was no dose effect of naproxen, and there were no differences in older versus younger participants. Most events were mild to moderate. The most frequently reported adverse events in all groups were related to the gastrointestinal system (most commonly dyspepsia with naproxen), with no differences between groups. Conclusions: Our pooled analysis did not find an increased risk of adverse events with short-term use of non-prescription doses of naproxen compared with placebo, or compared to other common analgesics.
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Affiliation(s)
- Kizito Kyeremateng
- Bayer HealthCare LLC , Whippany , NJ , USA
- Ernest Mario School of Pharmacy, Rutgers - The State University of New Jersey , Piscataway , NJ , USA
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Hou M, Liu H, Li Y, Xu L, He Y, Lv Y, Zheng Q, Li L. Efficacy of triptans for the treatment of acute migraines: a quantitative comparison based on the dose-effect and time-course characteristics. Eur J Clin Pharmacol 2019; 75:1369-1378. [PMID: 31446449 DOI: 10.1007/s00228-019-02748-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 08/10/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This study aimed to establish a pharmacodynamic model to quantitatively compare the efficacy characteristics of seven kinds of triptans and their different dosage forms in the treatment of acute migraines. METHODS Clinical studies of triptans in the treatment of acute migraines were comprehensively searched in the public databases. Pharmacodynamic models were established to describe the dose-effect and time-course of each kind of triptan for the proportion of patients who became pain free or had pain relief. RESULTS A total of 92 articles involving 47,376 subjects were included in the analysis. After eliminating the placebo effect, oral eletriptan (40 mg) had the highest efficacy among all oral drugs at the maximum approved dose, and the proportion of patients who became pain free and had pain relief were 30.9% and 37.9% at 2 h, respectively. However, oral naratriptan (2.5 mg) had the lowest efficacy, and the proportion of patients who became pain free and had pain relief was 10.3% and 21.6% at 2 h, respectively. The efficacy of subcutaneous administration was significantly higher than that of oral administration, and the efficacy of nasal spray administration was comparable to that of oral administration. Regarding the dose-effect, the efficacy of the sumatriptan nasal spray significantly increased within the FDA (Food and Drug Administration)-approved dose range. When the dose was increased from 5 to 20 mg of sumatriptan nasal spray, the proportion of patients who became pain free and had pain relief increased by 16.8% and 18.3% at 2 h, respectively. Regarding the time-course, the time of onset of subcutaneous sumatriptan (6 mg) was the fastest, and the fraction of patients who were pain free at 2 h accounted for 90.6% of that at 4 h. CONCLUSIONS This study evaluated the efficacy characteristics of seven kinds of triptans and their different dosage forms. The present findings provide necessary quantitative information for migraine medication guidelines.
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Affiliation(s)
- Mengyuan Hou
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, No. 1200 Cailun Road, Shanghai, 201203, China
| | - Hongxia Liu
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, No. 1200 Cailun Road, Shanghai, 201203, China
| | - Yunfei Li
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, No. 1200 Cailun Road, Shanghai, 201203, China
| | - Ling Xu
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, No. 1200 Cailun Road, Shanghai, 201203, China
| | - Yingchun He
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, No. 1200 Cailun Road, Shanghai, 201203, China
| | - Yinghua Lv
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, No. 1200 Cailun Road, Shanghai, 201203, China
| | - Qingshan Zheng
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, No. 1200 Cailun Road, Shanghai, 201203, China.
| | - Lujin Li
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, No. 1200 Cailun Road, Shanghai, 201203, China.
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Abstract
INTRODUCTION Migraine is the most common of all neurological disorders. A breakthrough in migraine treatment emerged in the early nineties with the introduction of 5-HT1B/D receptor agonists called triptans. Triptans are used as the standard of care for acute migraine; however, they have significant limitations such as incomplete and inconsistent pain relief, high rates of headache recurrence, class- specific side effects and cardiovascular contraindications. First- and second-generation calcitonin gene-related peptide (CGRP) receptor antagonists, namely gepants, is a class of drugs primarily developed for the acute treatment of migraine. CGRP is the most evaluated target for migraine treatments that are in development. AREAS COVERED This article reviews the available data for first- and second-generation CGRP receptor antagonists, the role of CGRPs in human physiology and migraine pathophysiology and the possible mechanism of action and safety of CGRP-targeted drugs. EXPERT OPINION Available data suggest that second generation of gepants has clinical efficacy similar to triptans and lasmiditan (5-HT1F receptor agonist) and has improved tolerability. Future studies will assess their safety, especially in specific populations such as patients with cardiovascular disease and pregnant women.
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Affiliation(s)
- Andrea Negro
- a Department of Clinical and Molecular Medicine , Sapienza University , Rome , Italy.,b Regional Referral Headache Centre , Rome , Italy
| | - Paolo Martelletti
- a Department of Clinical and Molecular Medicine , Sapienza University , Rome , Italy.,b Regional Referral Headache Centre , Rome , Italy
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Pascual J, Vila C. Almotriptan: a review of 20 years' clinical experience. Expert Rev Neurother 2019; 19:759-768. [PMID: 30845850 DOI: 10.1080/14737175.2019.1591951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Introduction: Almotriptan (ALT), a serotonin 5-HT1B/1D agonist has been used in the acute treatment of migraine with or without aura for 20 years, accumulating data on more than 15,000 patients in studies and from an estimated >150 million treated migraine attacks in daily clinical practice. The last major review of ALT was written almost 10 years ago. The current narrative review provides an overview of the experience gained with almotriptan over that time, and highlights data published in the last decade. Areas covered: Randomized clinical trials, observational studies, postmarketing studies and meta-analyses involving ALT for the treatment of acute migraine identified through a systematic literature search. Expert opinion: Triptans are a mainstay of anti-migraine treatment. Findings with ALT over the last 10 years have reinforced the positive efficacy and tolerability results that were reported during the first 10 years following its introduction. In particular, more recent clinical results have confirmed its efficacy in women with menstrual migraine, the usefulness of early intervention, long-term benefit in adults, and also its efficacy and safety in adolescents. Overall, ALT can be considered an optimal choice for managing acute migraine resistant to first-line drugs.
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Affiliation(s)
- Julio Pascual
- a Neurology Service , University Hospital Marqués de Valdecilla and IDIVAL , Santander , Spain
| | - Carlos Vila
- b Global Medical Affairs , Almirall S.A , Barcelona , Spain
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28
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Parkinson B, Gumbie M, Cutler H, Gauld N, Mumford V, Haywood P. Cost-Effectiveness of Reclassifying Triptans in Australia: Application of an Economic Evaluation Approach to Regulatory Decisions. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:293-302. [PMID: 30832967 DOI: 10.1016/j.jval.2018.09.2840] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 09/05/2018] [Accepted: 09/14/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND Migraine is a common, chronic, disabling headache disorder. Triptans, used as an acute treatment for migraine, are available via prescription in Australia. An Australian Therapeutic Goods Administration (TGA) committee rejected reclassifying sumatriptan and zolmitriptan from prescription medicine to pharmacist-only between 2005 and 2009, largely on the basis of concerns about patient risk. Nevertheless, pharmacist-only triptans may reduce migraine duration and free up healthcare resources. OBJECTIVES To estimate the cost-effectiveness of reclassifying triptans from prescription-only to pharmacist-only in Australia. METHODS The study design included decision-analytic modeling combining data from various sources. Behavior before and after reclassification was estimated using medical practitioner and patient surveys and also administrative data. Health outcomes included migraine frequency and duration as well as adverse events (AEs) discussed by the TGA committee. Efficacy and AEs were estimated using randomized controlled trials and observational studies. RESULTS Reclassifying triptans will reduce migraine duration but increase AEs. This will result in 337 quality-adjusted life-years gained at an increased cost of A$5.9 million over 10 years for all Australian adults older than 15 years (19.6 million). The incremental cost-effectiveness ratio was estimated to be A$17 412/quality-adjusted life-year gained. CONCLUSIONS The incremental cost-effectiveness ratio is likely to be considered cost-effective by Australian decision makers. Serotonin syndrome, a key concern of the TGA committee, had little impact on the results. Further research is needed regarding pharmacist-only triptan use by migraineurs currently using over-the-counter medicines and by nonmigraineurs, the efficacy of triptans, and the risk of cardiovascular and cerebrovascular AEs and chronic headaches with triptans.
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Affiliation(s)
- Bonny Parkinson
- Centre for the Health Economy, Macquarie University, Sydney, NSW, Australia.
| | - Mutsa Gumbie
- Centre for the Health Economy, Macquarie University, Sydney, NSW, Australia
| | - Henry Cutler
- Centre for the Health Economy, Macquarie University, Sydney, NSW, Australia
| | - Natalie Gauld
- School of Pharmacy, University of Auckland, Auckland, New Zealand
| | - Virginia Mumford
- Australian Institute for Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - Philip Haywood
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, NSW, Australia
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Estimating relative efficacy in acute postoperative pain: network meta-analysis is consistent with indirect comparison to placebo alone. Pain 2019; 159:2234-2244. [PMID: 29965830 PMCID: PMC6203421 DOI: 10.1097/j.pain.0000000000001322] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Network meta-analysis uses direct comparisons of interventions within randomized controlled trials and indirect comparisons across them. Network meta-analysis uses more data than a series of direct comparisons with placebo, and theoretically should produce more reliable results. We used a Cochrane overview review of acute postoperative pain trials and other systematic reviews to provide data to test this hypothesis. Some 261 trials published between 1966 and 2016 included 39,753 patients examining 52 active drug and dose combinations (27,726 given active drug and 12,027 placebo), in any type of surgery (72% dental). Most trials were small; 42% of patients were in trials with arms <50 patients, and 27% in trials with arms ≥100 patients. Response to placebo in third molar extraction fell by half in studies over 30 to 40 years (171 trials, 7882 patients given placebo). Network meta-analysis and Cochrane analyses provided very similar results (average difference 0.04 number needed to treat units), with no significant difference for almost all comparisons apart from some with small patient numbers or small effect size, or both. Network meta-analysis did not detect significant differences between effective analgesics. The similarity between network meta-analysis and Cochrane indirect analyses probably arose from stringent quality criteria in trials accepted in Cochrane reviews (with consequent low risk of bias) and consistency in methods and outcomes. Network meta-analysis is a useful analytical tool that increases our confidence in estimates of efficacy of analgesics in acute postoperative pain, in this case by providing similar results.
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30
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Diener HC, Holle-Lee D, Nägel S, Dresler T, Gaul C, Göbel H, Heinze-Kuhn K, Jürgens T, Kropp P, Meyer B, May A, Schulte L, Solbach K, Straube A, Kamm K, Förderreuther S, Gantenbein A, Petersen J, Sandor P, Lampl C. Treatment of migraine attacks and prevention of migraine: Guidelines by the German Migraine and Headache Society and the German Society of Neurology. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2019. [DOI: 10.1177/2514183x18823377] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In collaboration with some of the leading headache centres in Germany, Switzerland and Austria, we have established new guidelines for the treatment of migraine attacks and the prevention of migraine. A thorough literature research of the last 10 years has been the basis of the current recommendations. At the beginning, we present therapeutic novelties, followed by a summary of all recommendations. After an introduction, we cover topics like drug therapy and practical experience, non-effective medication, migraine prevention, interventional methods, non-medicational and psychological methods for prevention and therapies without proof of efficacy.
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Affiliation(s)
- Hans-Christoph Diener
- Klinik für Neurologie und Westdeutsches Kopfschmerzzentrum, Universitätsklinikum Essen, Essen, Germany
| | - Dagny Holle-Lee
- Klinik für Neurologie und Westdeutsches Kopfschmerzzentrum, Universitätsklinikum Essen, Essen, Germany
| | - Steffen Nägel
- Klinik für Neurologie und Westdeutsches Kopfschmerzzentrum, Universitätsklinikum Essen, Essen, Germany
| | - Thomas Dresler
- Klinik für Psychiatrie und Psychotherapie, Universität Tübingen, Tübingen, Germany
- Graduiertenschule & Forschungsnetzwerk LEAD, Universität Tübingen, Tübingen, Germany
| | - Charly Gaul
- Migräne- und Kopfschmerzklinik Königstein, Königstein im Taunus, Germany
| | | | | | - Tim Jürgens
- Universitätsmedizin Rostock, Zentrum für Nervenheilkunde, Klinik und Poliklinik für Neurologie, Rostock, Germany
| | - Peter Kropp
- Institut für Medizinische Psychologie und Medizinische Soziologie, Universitätsmedizin Rostock, Zentrum für Nervenheilkunde, Rostock, Germany
| | - Bianca Meyer
- Institut für Medizinische Psychologie und Medizinische Soziologie, Universitätsmedizin Rostock, Zentrum für Nervenheilkunde, Rostock, Germany
| | - Arne May
- Institut für Systemische Neurowissenschaften, Universitätsklinikum Hamburg Eppendorf (UKE), Hamburg, Germany
| | - Laura Schulte
- Institut für Systemische Neurowissenschaften, Universitätsklinikum Hamburg Eppendorf (UKE), Hamburg, Germany
| | - Kasja Solbach
- Klinik für Neurologie, Universitätsklinikum Essen, Essen, Germany
| | - Andreas Straube
- Neurologische Klinik, Ludwig-Maximilians-Universität München, Klinikum Großhadern, München, Germany
| | - Katharina Kamm
- Neurologische Klinik, Ludwig-Maximilians-Universität München, Klinikum Großhadern, München, Germany
| | - Stephanie Förderreuther
- Neurologische Klinik, Ludwig-Maximilians-Universität München, Klinikum Großhadern, München, Germany
| | | | - Jens Petersen
- Klinik für Neurologie, Universitätsspital Zürich, Zürich, Swizterland
| | - Peter Sandor
- RehaClinic Bad Zurzach, Bad Zurzach, Swizterland
| | - Christian Lampl
- Ordensklinikum Linz, Krankenhaus der Barmherzigen Schwestern Linz Betriebsgesellschaft m.b.H., Linz, Austria
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Grazzi L, Tassorelli C, de Tommaso M, Pierangeli G, Martelletti P, Rainero I, Geppetti P, Ambrosini A, Sarchielli P, Liebler E, Barbanti P. Practical and clinical utility of non-invasive vagus nerve stimulation (nVNS) for the acute treatment of migraine: a post hoc analysis of the randomized, sham-controlled, double-blind PRESTO trial. J Headache Pain 2018; 19:98. [PMID: 30340460 PMCID: PMC6742918 DOI: 10.1186/s10194-018-0928-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 10/03/2018] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND The PRESTO study of non-invasive vagus nerve stimulation (nVNS; gammaCore®) featured key primary and secondary end points recommended by the International Headache Society to provide Class I evidence that for patients with an episodic migraine, nVNS significantly increases the probability of having mild pain or being pain-free 2 h post stimulation. Here, we examined additional data from PRESTO to provide further insights into the practical utility of nVNS by evaluating its ability to consistently deliver clinically meaningful improvements in pain intensity while reducing the need for rescue medication. METHODS Patients recorded pain intensity for treated migraine attacks on a 4-point scale. Data were examined to compare nVNS and sham with regard to the percentage of patients who benefited by at least 1 point in pain intensity. We also assessed the percentage of attacks that required rescue medication and pain-free rates stratified by pain intensity at treatment initiation. RESULTS A significantly higher percentage of patients who used acute nVNS treatment (n = 120) vs sham (n = 123) reported a ≥ 1-point decrease in pain intensity at 30 min (nVNS, 32.2%; sham, 18.5%; P = 0.020), 60 min (nVNS, 38.8%; sham, 24.0%; P = 0.017), and 120 min (nVNS, 46.8%; sham, 26.2%; P = 0.002) after the first attack. Similar significant results were seen when assessing the benefit in all attacks. The proportion of patients who did not require rescue medication was significantly higher with nVNS than with sham for the first attack (nVNS, 59.3%; sham, 41.9%; P = 0.013) and all attacks (nVNS, 52.3%; sham, 37.3%; P = 0.008). When initial pain intensity was mild, the percentage of patients with no pain after treatment was significantly higher with nVNS than with sham at 60 min (all attacks: nVNS, 37.0%; sham, 21.2%; P = 0.025) and 120 min (first attack: nVNS, 50.0%; sham, 25.0%; P = 0.018; all attacks: nVNS, 46.7%; sham, 30.1%; P = 0.037). CONCLUSIONS This post hoc analysis demonstrated that acute nVNS treatment quickly and consistently reduced pain intensity while decreasing rescue medication use. These clinical benefits provide guidance in the optimal use of nVNS in everyday practice, which can potentially reduce use of acute pharmacologic medications and their associated adverse events. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02686034 .
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Affiliation(s)
- Licia Grazzi
- Neuroalgology Unit, Carlo Besta Neurological Institute and Foundation, Milan, Italy
- Department of Fondazione IRCCS Istituto Neurologico C. Besta, U.O. Neurologia III – Cefalee e Neuroalgologia, Via Celoria 11, 20133 Milan, Italy
| | - Cristina Tassorelli
- Headache Science Centre, IRCCS C. Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Marina de Tommaso
- Neurophysiology and Pain Unit, University of Bari Aldo Moro, Bari, Italy
| | - Giulia Pierangeli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | | | | | | | - Paola Sarchielli
- Neurologic Clinic, Santa Maria della Misericordia Hospital, Perugia, Italy
| | | | - Piero Barbanti
- Headache and Pain Unit, IRCCS San Raffaele Pisana, Rome, Italy
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Tfelt-Hansen P, Lindqvist JK, Do TP. Evaluating the reporting of adverse events in controlled clinical trials conducted in 2010–2015 on migraine drug treatments. Cephalalgia 2018; 38:1885-1895. [DOI: 10.1177/0333102418759785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background In 2008, the International Headache Society published guidelines on the “evaluation and registration of adverse events in clinical drug trials on migraine”. They listed seven recommendations for reporting adverse events in randomized controlled trials on migraine. The present study aimed to evaluate adherence to these recommendations, and based on the results, to recommend improvements. Methods We searched the PubMed/MEDLINE database to identify controlled trials on migraine drugs published from 2010 to 2015. For each trial, we noted whether five of the recommended parameters were presented. In addition, we noted whether adverse events were reported in abstracts. Results We identified 73 trials; 51 studied acutely administered drugs and 22 studied prophylactic drugs for migraine. The number of patients with any adverse events were reported in 74% of acute-administration and 86% of prophylactic drug trials. Only 30 (41%) of the 73 studies reported adverse events with data in the abstracts, and 27 (37%) abstracts did not mention adverse events. Conclusion Adverse events, both frequency and symptoms, should be reported to allow a fair judgement of benefit/tolerability ratio when randomized controlled trials in migraine treatment are published. Clinically significant adverse events should be included in the abstract of every randomized controlled trial in migraine treatment.
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Affiliation(s)
- Peer Tfelt-Hansen
- Danish Headache Center and Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health Sciences, University of Copenhagen, Glostrup, Denmark
| | | | - Thien Phu Do
- Danish Headache Center and Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health Sciences, University of Copenhagen, Glostrup, Denmark
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Effects of NSAIDs on the Release of Calcitonin Gene-Related Peptide and Prostaglandin E 2 from Rat Trigeminal Ganglia. Mediators Inflamm 2017; 2017:9547056. [PMID: 29209105 PMCID: PMC5676472 DOI: 10.1155/2017/9547056] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 09/26/2017] [Indexed: 11/17/2022] Open
Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently used to treat migraine, but the mechanisms of their effects in this pathology are not fully elucidated. The trigeminal ganglia and calcitonin gene-related peptide (CGRP) have been implicated in the pathophysiology of migraine. The release of CGRP and prostaglandin E2 (PGE2) from freshly isolated rat trigeminal ganglia was evaluated after oral administration of nimesulide, etoricoxib, and ketoprofen, NSAIDs with different pharmacological features. Thirty minutes after oral administration, nimesulide, 10 mg/Kg, decreased the GCRP release induced by an inflammatory soup, while the other NSAIDs were ineffective at this point in time. Two hours after oral nimesulide (5 and 10 mg/Kg) and ketoprofen (10 mg/Kg), but not of etoricoxib, a significant decrease in the CGRP release was observed. All drugs reduced PGE2, although with some differences in timing and doses, and the action on CGRP does not seem to be related to PGE2 inhibition. The reduction of CGRP release from rat trigeminal ganglia after nimesulide and ketoprofen may help to explain the mechanism of action of NSAIDs in migraine. Since at 30 minutes only nimesulide was effective in reducing CGRP release, these results suggest that this NSAID may exert a particularly rapid effect in patients with migraine.
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Osler M, Wium-Andersen IK, Jørgensen MB, Jørgensen TSH, Wium-Andersen MK. Migraine and risk of stroke and acute coronary syndrome in two case-control studies in the Danish population. Clin Epidemiol 2017; 9:439-449. [PMID: 28919819 PMCID: PMC5587091 DOI: 10.2147/clep.s144441] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Migraine has consistently been associated with increased risk of ischemic stroke, while the evidence for a relation with other types of stroke or coronary outcomes is limited. We examined the association between migraine and stroke and acute coronary syndrome (ACS) subtypes and the influence of potential confounding factors. METHODS All first-time hospital contacts for stroke (n=155,216) or ACS (n=97,799) were identified in Danish National Patient Registers and matched with 2 control groups of the background population. A hospital diagnosis of migraine and use of migraine medication were the main exposures and associations (odds ratios [OR]) were estimated using multiple logistic regression. Confounding was also addressed by including use of general headache medication as a negative control exposure. RESULTS The diagnosis of migraine was associated with increased odds of both stroke (ORcrude, age <50 years: 4.80 [95% CI: 3.75-6.21]; ORcrude, age ≥50 years:1.91 [95% CI: 1.67-2.19]) and ACS (ORcrude:1.88 [95% CI: 1.53-2.32]), while the ORs for the associations between migraine medication and stroke and ACS were lower. Patients with a diagnosis of migraine or redeemed migraine medication had increased ORs of all stroke subtypes (ischemic, hemorrhagic stroke and transient ischemic attacks). The diagnosis of migraine was also associated with both angina and myocardial infarction (ST-elevation Myocardial Infarction [STEMI], non-STEMI and unspecified) with the highest OR for angina. These associations were not fully explained by adjustment for confounding co-variables or when compared with the negative control exposure that were assumed to be influenced by similar confounding factors, but no shared pathogenesis. CONCLUSION Hospital-diagnosed migraine was associated with all stroke and ACS subtypes, with ischemic stroke and angina having the highest odds. Confounding did not explain the associations.
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Affiliation(s)
- Merete Osler
- Research Center for Prevention and Health, Rigshospitalet – Glostrup, Copenhagen University, Glostrup, Denmark
- Department of Public Health, Section of Social Medicine, University of Copenhagen
| | - Ida Kim Wium-Andersen
- Research Center for Prevention and Health, Rigshospitalet – Glostrup, Copenhagen University, Glostrup, Denmark
- Department of Psychiatry O, Rigshospitalet, Copenhagen, Denmark
| | | | - Terese Sara Høj Jørgensen
- Research Center for Prevention and Health, Rigshospitalet – Glostrup, Copenhagen University, Glostrup, Denmark
- Department of Public Health, Section of Social Medicine, University of Copenhagen
| | - Marie Kim Wium-Andersen
- Research Center for Prevention and Health, Rigshospitalet – Glostrup, Copenhagen University, Glostrup, Denmark
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Munro G, Jansen-Olesen I, Olesen J. Animal models of pain and migraine in drug discovery. Drug Discov Today 2017; 22:1103-1111. [PMID: 28476535 DOI: 10.1016/j.drudis.2017.04.016] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 03/16/2017] [Accepted: 04/26/2017] [Indexed: 12/18/2022]
Abstract
Preclinical research activities in relation to pain typically involve the 'holy trinity' of nociceptive, inflammatory and neuropathic pain for purposes of target validation and defining target product profiles of novel analgesic compounds. For some reason it seems that headache or migraine are rarely considered as additional entities to explore. Frontline medications used in the treatment of, for example, inflammatory pain, neuropathic pain and migraine (NSAIDs versus pregabalin/duloxetine versus triptans) reveal distinct differences in pathophysiology that partially explain this approach. Nevertheless, for many patients enduring chronic pain, regardless of aetiology, high unmet needs remain. By focusing more on commonalities shared between neuropathic pain and headache disorders such as migraine, drug discovery efforts could be spread more efficiently across a larger indication area. Here, some of the most commonly used models and methods employed within 'pain and migraine' drug development will be presented. Recent advances within these disciplines suggest that, with the addition of a few extra carefully chosen ancillary models and/or endpoints, the relative value in terms of resources used, reciprocal flow of information and net worth of a 'typical' package could be increased substantially for the pain and migraine fields.
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Affiliation(s)
- Gordon Munro
- Department of Neurology, Danish Headache Center, Glostrup Research Institute, Nordre Ringvej 69, 2600 Glostrup, Denmark.
| | - Inger Jansen-Olesen
- Department of Neurology, Danish Headache Center, Glostrup Research Institute, Nordre Ringvej 69, 2600 Glostrup, Denmark
| | - Jes Olesen
- Department of Neurology, Danish Headache Center, Glostrup Research Institute, Nordre Ringvej 69, 2600 Glostrup, Denmark
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