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May A, Evers S, Goadsby PJ, Leone M, Manzoni GC, Pascual J, Carvalho V, Romoli M, Aleksovska K, Pozo-Rosich P, Jensen RH. European Academy of Neurology guidelines on the treatment of cluster headache. Eur J Neurol 2023; 30:2955-2979. [PMID: 37515405 DOI: 10.1111/ene.15956] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 06/22/2023] [Accepted: 06/23/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND AND PURPOSE Cluster headache is a relatively rare, disabling primary headache disorder with a major impact on patients' quality of life. This work presents evidence-based recommendations for the treatment of cluster headache derived from a systematic review of the literature and consensus among a panel of experts. METHODS The databases PubMed (Medline), Science Citation Index, and Cochrane Library were screened for studies on the efficacy of interventions (last access July 2022). The findings in these studies were evaluated according to the recommendations of the European Academy of Neurology, and the level of evidence was established using GRADE (Grading of Recommendations Assessment, Development, and Evaluation). RECOMMENDATIONS For the acute treatment of cluster headache attacks, there is a strong recommendation for oxygen (100%) with a flow of at least 12 L/min over 15 min and 6 mg subcutaneous sumatriptan. Prophylaxis of cluster headache attacks with verapamil at a daily dose of at least 240 mg (maximum dose depends on efficacy and tolerability) is recommended. Corticosteroids are efficacious in cluster headache. To reach an effect, the use of at least 100 mg prednisone (or equivalent corticosteroid) given orally or at up to 500 mg iv per day over 5 days is recommended. Lithium, topiramate, and galcanezumab (only for episodic cluster headache) are recommended as alternative treatments. Noninvasive vagus nerve stimulation is efficacious in episodic but not chronic cluster headache. Greater occipital nerve block is recommended, but electrical stimulation of the greater occipital nerve is not recommended due to the side effect profile.
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Affiliation(s)
- Arne May
- Department of Systems Neuroscience, University Medical Center Hamburg- Eppendorf, Hamburg, Germany
| | - Stefan Evers
- Department of Neurology, Lindenbrunn Hospital, Coppenbrügge, Germany
- Faculty of Medicine, University of Münster, Münster, Germany
| | - Peter J Goadsby
- NIHR King's CRF, SLaM Biomedical Research Centre, King's College London, London, UK
| | - Massimo Leone
- Neuroalgology Department, Foundation of the Carlo Besta Neurological Institute, IRCCS, Milan, Italy
| | | | - Julio Pascual
- Service of Neurology, University Hospital Marqués de Valdecilla, Universidad de Cantabria and IDIVAL, Santander, Spain
| | - Vanessa Carvalho
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
- Centro de Estudos Egas Moniz, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Michele Romoli
- Neurology and Stroke Unit, Bufalini Hospital, Cesena, Italy
| | | | - Patricia Pozo-Rosich
- Headache Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Headache Research Group, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Rigmor H Jensen
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, University of Copenhagen, Copenhagen, Denmark
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Zhao YJ, Idu Jion YB, Ho KH, Wong PS, Lo YL, Chan YC, Ang LL, Yeo SN, Soh SB, Wu TS, Yuan Ong JJ. Approach to headache disorders and the management of migraine: consensus guidelines from the Headache Society of Singapore, first edition (2023). Singapore Med J 2023:386395. [PMID: 37870040 DOI: 10.4103/singaporemedj.smj-2022-195] [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: 10/24/2023]
Abstract
Headache disorders, particularly migraine, are one of the most common and disabling neurological disorders. There is a need for high-quality, accessible care for patients with headache disorders across all levels of the healthcare system in Singapore. The role of the Headache Society of Singapore is to increase awareness and advance the understanding of these disorders and to advocate for the needs of affected patients. In this first edition of local consensus guidelines, we focus on treatment approaches for headaches and provide consensus recommendations for the management of migraine in adults. The recommendations in these guidelines can be used as a practical tool in routine clinical practice by primary care physicians, neurologists and other healthcare professionals who have a common interest in headache disorders.
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Affiliation(s)
- Yi Jing Zhao
- Department of Neurology, National Neuroscience Institute, Singapore
| | | | - King Hee Ho
- Ho Neurology Pte Ltd, Gleneagles Medical Centre, Singapore
| | - Pei Shieen Wong
- Department of Pharmacy, Singapore General Hospital, Singapore
| | - Yew Long Lo
- Department of Neurology, National Neuroscience Institute, Singapore
| | - Yee Cheun Chan
- Division of Neurology, Department of Medicine, National University Hospital; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Lai Lai Ang
- Yong Loo Lin School of Medicine, National University of Singapore; National University Polyclinics, National University Health System, Singapore
| | - Sow Nam Yeo
- The Pain Specialist, Mount Elizabeth Hospital and Mount Elizabeth Novena Hospital, Singapore
| | - Soon Beng Soh
- Primary Care Network, National University Health System, Singapore
| | - Tuck Seng Wu
- Department of Pharmacy, National University Hospital, Singapore
| | - Jonathan Jia Yuan Ong
- Division of Neurology, Department of Medicine, National University Hospital; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Peres MFP, Scala WAR, Salazar R. Comparison between metamizole and triptans for migraine treatment: a systematic review and network meta-analysis. HEADACHE MEDICINE 2022. [DOI: 10.48208/headachemed.2021.32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Objective The aim of this systematic review was to evaluate the efficacy of metamizole and triptans for the treatment of migraine. MethodsRandomized controlled trials including people who received metamizole or triptan by multiple routes of administration and at all doses as treatment compared to subjects who received another treatment or placebo were included in the systematic review. The primary outcomes were freedom from pain at 2 hours; pain relief at 2 hours; sustained headache response at 24 hours; sustained freedom from pain at 24 hours. The statistical analysis of all interventions of interest were based on random effect models compared through a network meta-analysis. Results 209 studies meeting the inclusion and exclusion criteria were analyzed. Of these, 130 had data that could be analyzed statistically. Only 3.0% provided enough information and were judged to have a low overall risk of bias for all categories evaluated; approximately 50% of the studies presented a low risk of selection bias. More than 75% of the studies presented a low risk of performance bias, and around 75% showed a low risk of detection and attrition bias. ConclusionThere is no evidence of a difference between dipyrone and any triptan for pain freedom after 2 hours of medication. Our study suggests that metamizole may be equally effective as triptans in acute migraine treatment.
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Abstract
Cluster headache belongs to the group of trigeminal autonomic headaches. This review summarizes drug therapy of cluster attacks and prophylactic treatment. Neurostimulation methods are not addressed. The therapy for acute cluster attacks includes inhalation of 100% oxygen, subcutaneous administration of sumatriptan, and intranasal application of sumatriptan or zolmitriptan. Bridging therapy, which is used until oral prophylactic therapy is effective, is performed either with oral prednisolone or with a pharmacological block of the major occipital nerves. Best documented drugs for preventive treatment of cluster headache are verapamil and lithium, and possibly effective drugs are gabapentin, topiramate, divalproex sodium, and melatonin. The efficacy of monoclonal antibodies to the calcitonin gene-related peptide so far has been only demonstrated for episodic cluster headache. Several drug therapies are being investigated including ketamine, onabotulinumtoxinA, lysergic acid, and sodium oxybate.
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Affiliation(s)
- Hans Christoph Diener
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology (IMIBE), Medical Faculty of the University Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany.
| | - Arne May
- Department of Systems Neuroscience, University Hospital Hamburg-Eppendorf (UKE), Hamburg, Germany
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Roy A, Geetha RV, Magesh A, Vijayaraghavan R, Ravichandran V. Autoinjector - A smart device for emergency cum personal therapy. Saudi Pharm J 2021; 29:1205-1215. [PMID: 34703373 PMCID: PMC8523323 DOI: 10.1016/j.jsps.2021.09.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 09/11/2021] [Indexed: 12/18/2022] Open
Abstract
Autoinjectors are self-injectable devices; they are important class of medical devices which can deliver drugs through subcutaneous or intramuscular route. They enclose prefilled syringes or cartridges which are driven by a spring system. The major benefits of this device are easy self-administration, improved patient compliance, reduced anxiety, and dosage accuracy. Immediate treatment during emergency conditions such as anaphylaxis, migraine, and status epilepticus or for chronic conditions like psoriasis, diabetes, multiple sclerosis, and rheumatoid arthritis, Reformulation of first-generation biologics, technical advancements, innovative designs, patient compliance, overwhelming interest for self-administration all these made entry of more and more autoinjectors into use. In this review, intensive efforts have been made for exploring the different types of currently available autoinjectors for the management of emergency and chronic diseases.
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Affiliation(s)
- Anitha Roy
- Department of Pharmacology, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Chennai, Tamil Nadu, India
| | - Royapuram Veeraragavan Geetha
- Department of Microbiology, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Chennai, Tamil Nadu, India
| | - Anitha Magesh
- Department of Research and Development, Saveetha Institute of Medical and Technical Sciences, Chennai, Tamil Nadu, India
| | - Rajagopalan Vijayaraghavan
- Department of Research and Development, Saveetha Institute of Medical and Technical Sciences, Chennai, Tamil Nadu, India
| | - Veerasamy Ravichandran
- Pharmaceutical Chemistry Unit, Faculty of Pharmacy, AIMST University, Semeling-08100, Bedong, Malaysia.,Centre of Excellence for Biomaterials Engineering, AIMST University, Semeling-08100, Bedong, Malaysia.,Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Chennai, Tamil Nadu, India
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Gaul C, Förderreuther S. [Sumatriptan 3 mg subcutaneous : Clinical relevance of acute treatment of migraine despite dose reduction]. DER NERVENARZT 2021; 93:612-617. [PMID: 34557933 DOI: 10.1007/s00115-021-01189-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/23/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Triptans are a highly effective substance class in the acute treatment of migraine attacks. They contribute to a substantial improvement in the quality of life and help to reduce the socioeconomic burden of the disease. RESULTS Sumatriptan is the only triptan that is available for subcutaneous administration. It is primarily indicated in patients with the need for rapid relief or insufficient enteral resorption due to nausea and vomiting. In the treatment of migraine attacks with 6 mg subcutaneous sumatriptan the number needed to treat (NNT) is 2.3 for freedom from pain within 2 h and the NNT is 2.1 for pain relief within 2 h; however, the fast resorption of sumatriptan after subcutaneous administration induces more side effects than the oral route, for example dizziness, paresthesia or chest pressure sensation. CONCLUSION Clinical studies showed that reducing the subcutaneous dose to 3 mg in migraine treatment has significantly better tolerability with high response rates and freedom from pain within 2 h with 66.7% (3 mg) or 50% (6 mg).
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Affiliation(s)
- Charly Gaul
- Kopfschmerzzentrum Frankfurt, Dalbergstr. 2a, 65929, Frankfurt am Main, Deutschland.
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Ailani J, Burch RC, Robbins MS. The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice. Headache 2021; 61:1021-1039. [PMID: 34160823 DOI: 10.1111/head.14153] [Citation(s) in RCA: 318] [Impact Index Per Article: 106.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/04/2021] [Accepted: 05/09/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To incorporate recent research findings, expert consensus, and patient perspectives into updated guidance on the use of new acute and preventive treatments for migraine in adults. BACKGROUND The American Headache Society previously published a Consensus Statement on the use of newly introduced treatments for adults with migraine. This update, which is based on the expanded evidence base and emerging expert consensus concerning postapproval usage, provides practical recommendations in the absence of a formal guideline. METHODS This update involved four steps: (1) review of data about the efficacy, safety, and clinical use of migraine treatments introduced since the previous Statement was published; (2) incorporation of these data into a proposed update; (3) review and commentary by the Board of Directors of the American Headache Society and patients and advocates associated with the American Migraine Foundation; (4) consideration of these collective insights and integration into an updated Consensus Statement. RESULTS Since the last Consensus Statement, no evidence has emerged to alter the established principles of either acute or preventive treatment. Newly introduced acute treatments include two small-molecule calcitonin gene-related peptide (CGRP) receptor antagonists (ubrogepant, rimegepant); a serotonin (5-HT1F ) agonist (lasmiditan); a nonsteroidal anti-inflammatory drug (celecoxib oral solution); and a neuromodulatory device (remote electrical neuromodulation). New preventive treatments include an intravenous anti-CGRP ligand monoclonal antibody (eptinezumab). Several modalities, including neuromodulation (electrical trigeminal nerve stimulation, noninvasive vagus nerve stimulation, single-pulse transcranial magnetic stimulation) and biobehavioral therapy (cognitive behavioral therapy, biofeedback, relaxation therapies, mindfulness-based therapies, acceptance and commitment therapy) may be appropriate for either acute and/or preventive treatment; a neuromodulation device may be appropriate for acute migraine treatment only (remote electrical neuromodulation). CONCLUSIONS The integration of new treatments into clinical practice should be informed by the potential for benefit relative to established therapies, as well as by the characteristics and preferences of individual patients.
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Affiliation(s)
- Jessica Ailani
- Department of Neurology, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Rebecca C Burch
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Yang CP, Huang KT, Chang CM, Yang CC, Wang SJ. Acute Treatment of Migraine: What has Changed in Pharmacotherapies? Neurol India 2021; 69:S25-S42. [PMID: 34003146 DOI: 10.4103/0028-3886.315995] [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: 11/04/2022]
Abstract
Background Migraine is the most prevalent neurological disorder and the leading cause of disability in individuals under 50 years of age. Two types of migraine therapies have been defined: acute therapy (abortive or symptomatic treatment), the purpose of which is to interrupt migraine attacks, and preventive treatment (prophylactic treatment), the purpose of which is to reduce the frequency and severity of migraine attacks. Objective This paper reviews research advances in new agents for acute therapy of migraine. Material and Methods This review provides an overview of emerging new drugs for acute treatment of migraine based on clinical evidence and summarizes the milestones of different stages of clinical development. Results Two new formulations of sumatriptan, DFN-11 (3 mg doses of subcutaneous sumatriptan) and DFN-02 (a nasal spray of sumatriptan 10 mg and a permeation-enhancing excipient), have been developed, and both of them showed a fast-onset action with efficacy for acute treatment of migraine with fewer adverse events. New drug discovery programs shifted the focus to the development of ditans, a group of antimigraine drugs targeting 5-HT1F receptors. Only lasmiditan has progressed to phase III clinical trials and was finally approved by the Food and Drug Administration (FDA) for acute migraine treatment. The other target for acute therapy is CGRP receptor antagonists, namely, gepants. Ubrogepant and rimegepant demonstrated statistically significant efficacy, and both were recently approved by the FDA. These 5-HT1F receptor agonists and CGRP receptor antagonists did not cause vasoconstriction, offering advantages over the current mainstay of specific acute migraine treatment. Conclusions Overall, these new agents have expanded the available acute therapies for migraine treatment and will likely change the strategy with which we treat patients with migraine in the future.
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Affiliation(s)
- Chun-Pai Yang
- Department of Neurology, Kuang Tien General Hospital; Department of Nutrition, Huang-Kuang University, Taichung, Taiwan
| | - Kuo-Ting Huang
- Department of Anesthesiology, Mackay Memorial Hospital, Taipei, Taiwan
| | - Ching-Mao Chang
- Center for Traditional Medicine, Neurological Institute, Taipei Veterans General Hospital; Faculty of Medicine, National Yang Ming Chiao Tung University; Institute of Traditional Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-Chia Yang
- Department of Healthcare Administration, Asia University, Taichung, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital; National Yang Ming Chiao Tung University, School of Medicine; Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Sasmal PK, Ramachandran G, Zhang Y, Liu Z. First total synthesis of 3a-hydroxy-1,1-dimethyl-5-((N-methylsulfamoyl)methyl)-1,2,3,3a,8,8a-hexahydropyrrolo[2,3-b]indol-1-ium 2,2,2-trifluoroacetate by mimicking the oxidative degradation pathway of sumatriptan. RESULTS IN CHEMISTRY 2021. [DOI: 10.1016/j.rechem.2021.100173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Tepper SJ, Vasudeva R, Krege JH, Rathmann SS, Doty E, Vargas BB, Magis D, Komori M. Evaluation of 2-Hour Post-Dose Efficacy of Lasmiditan for the Acute Treatment of Difficult-to-Treat Migraine Attacks. Headache 2020; 60:1601-1615. [PMID: 32634275 PMCID: PMC7496706 DOI: 10.1111/head.13897] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/20/2020] [Accepted: 05/28/2020] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To identify factors predicting response (2-hour headache pain freedom or most bothersome symptom freedom) to lasmiditan based on individual patient characteristics, migraine disease characteristics, and migraine attack characteristics. Further, efficacy specifically in difficult-to-treat patient/migraine disease characteristics or attack characteristics (ie, historically considered less responsive to certain acute therapies) subgroups was analyzed. BACKGROUND Knowledge of factors associated with a positive or negative response to acute treatment would be useful to practitioners prescribing acute treatments for migraine. Additionally, practitioners and patients would benefit from understanding the efficacy of lasmiditan specifically in subgroups of patients with migraine disease characteristics and migraine attack characteristics historically associated with decreased pain threshold, reduced efficacy of acute treatment, or increased burden of migraine. METHODS Pooled analyses were completed from 2 Phase 3 double-blind clinical trials, SPARTAN and SAMURAI. Data from baseline to 2 hours after taking lasmiditan (50, 100, or 200 mg) or placebo were analyzed to assess efficacy based on patient characteristics, migraine disease characteristics, and migraine attack characteristics. A total of 3981 patients comprising the intent-to-treat population were treated with placebo (N = 1130), lasmiditan 50 mg (N = 598), lasmiditan 100 mg (N = 1133), or lasmiditan 200 mg (N = 1120). Data were analyzed for the following efficacy measures at 2 hours: headache pain freedom and most bothersome symptom freedom. RESULTS None of the analyzed subgroups based on individual patient characteristics, migraine disease characteristics, or migraine attack characteristics predicted headache pain freedom or most bothersome symptom freedom response at 2 hours following lasmiditan treatment (interaction P ≥ .1). For the difficult-to-treat patient/migraine disease characteristics subgroups (defined as those with ≥24 headache days in the past 3 months, duration of migraine history ≥20 years, severe disability [Migraine Disability Assessment score ≥21], obesity [≥30 kg/m2 ], and history of psychiatric disorder), single doses of lasmiditan (100 or 200 mg) were significantly more effective than placebo (P ≤ .002) in achieving both endpoints. Headache pain freedom response rates for higher doses of lasmiditan were numerically greater than for lower doses of lasmiditan. For the difficult-to-treat migraine attack subgroups, patients with severe headache, co-existent nausea at the time of treatment, or who delayed treatment for ≥2 hours from the time of headache onset, both endpoint response rates after lasmiditan 100 or 200 mg were significantly greater than after placebo. Among those who delayed treatment for ≥4 hours from the time of headache onset, headache pain freedom response rates for the 200 mg dose of lasmiditan met statistical significance vs placebo (32.4% vs 15.9%; odds ratio = 2.7 [1.17, 6.07]; P = .018). While the predictors of response interaction test showed similar efficacy of lasmiditan vs placebo across subgroups defined by baseline functional disability (mild, moderate, or needs complete bed rest) at the time of treatment, analyses of lasmiditan efficacy within the subgroup "needs complete bed rest" appeared to show less efficacy (eg, in the 200 mg vs placebo group, 25.9% vs 18.5%; odds ratio = 1.56 [0.96, 2.53]; P = .070). CONCLUSIONS Efficacy of lasmiditan 200 and 100 mg for headache pain freedom and most bothersome symptom freedom at 2 hours post-treatment was generally not influenced by the individual patient characteristics, migraine disease history, or migraine attack characteristics that were analyzed. In the analyses of difficult-to-treat subgroups, patients receiving lasmiditan achieved greater responses (2-hour headache pain freedom and most bothersome symptom freedom) vs placebo recipients.
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Affiliation(s)
- Stewart J. Tepper
- Department of NeurologyGeisel School of Medicine at DartmouthHanoverNHUSA
| | | | | | | | - Erin Doty
- Eli Lilly and Company, IndianapolisINUSA
| | - Bert B. Vargas
- Eli Lilly and Company, IndianapolisINUSA
- University of Texas Southwestern Medical CenterDallasTXUSA
| | - Delphine Magis
- Department of Neurology and Headache and Pain Multimodal Management ClinicCHR East Belgium HospitalVerviersBelgium
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Huang PC, Yang FC, Chang CM, Yang CP. Targeting the 5-HT 1B/1D and 5-HT 1F receptors for acute migraine treatment. PROGRESS IN BRAIN RESEARCH 2020; 255:99-121. [PMID: 33008517 DOI: 10.1016/bs.pbr.2020.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 04/19/2020] [Accepted: 05/01/2020] [Indexed: 01/03/2023]
Abstract
Migraine is a common and highly disabling headache disorder associated with a substantial socioeconomic burden. Migraine treatments can be categorized as preventive treatment, aimed at reducing the frequency and severity of migraine attacks, and acute therapy, intended to abort attacks. Traditionally, acute treatment can be classified as specific (ergot derivatives and triptans) or nonspecific (analgesics and nonsteroidal anti-inflammatory drugs). Triptans, a class of 5-HT1B/1D receptor agonists with some affinity for the 5-HT1F receptor subtype, have been proven to be efficacious for acute treatment of moderate to severe migraine and have been deemed the gold standard. The availability of triptans in non-oral formulations, such as subcutaneous (SC) and intranasal forms, can be beneficial for patients who suffer from prominent nausea or vomiting, have a suboptimal response to oral agents, and/or seek a more rapid onset of treatment effects. However, triptans are contraindicated in patients with preexisting cardiovascular and/or cerebrovascular diseases due to their 5-HT1B-mediated vasoconstrictive action. For this reason, studies have focused on the development of ditans, a group of antimigraine drugs targeting 5-HT1D and 5-HT1F receptors. Unfortunately, 5-HT1D receptor agonists have been shown to be ineffective in the acute treatment of migraine. Several ditans targeting the 5-HT1F receptor have been developed and have shown no vasoconstrictive effect in preclinical studies, but only two of them, lasmiditan and LY334370, have been tested in clinical trials for migraine, and only lasmiditan has reached to Phase III clinical trials. These Phase III trials have demonstrated the efficacy and safety of lasmiditan, a selective 5-HT1F receptor agonist, in acute migraine treatment. Lasmiditan might offer an alternative migraine therapy without cardiovascular risks. This review will summarize the development of agents targeting the 5-HT1B/1D and 5-HT1F receptors and the clinical evidence supporting the use of these agents for acute migraine treatment.
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Affiliation(s)
- Pin-Chung Huang
- Department of Neurology, Kuang Tien General Hospital, Taichung, Taiwan
| | - Fu-Chi Yang
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ching-Mao Chang
- Center for Traditional Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chun-Pai Yang
- Department of Neurology, Kuang Tien General Hospital, Taichung, Taiwan; Department of Nutrition, Huang-Kuang University, Taichung, Taiwan.
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Lai Y, Huang Y, Huang L, Chen R, Chen C. Cervical Noninvasive Vagus Nerve Stimulation for Migraine and Cluster Headache: A Systematic Review and Meta‐Analysis. Neuromodulation 2020; 23:721-731. [DOI: 10.1111/ner.13122] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 11/25/2019] [Accepted: 01/14/2020] [Indexed: 01/02/2023]
Affiliation(s)
- Yin‐Hsuan Lai
- Department of Pediatrics Wan Fang Hospital, Taipei Medical University Taipei Taiwan
- Graduate Institute of Medical Sciences, College of Medicine Taipei Medical University Taipei Taiwan
| | - Yu‐Chen Huang
- Department of Dermatology Wan Fang Hospital, Taipei Medical University Taipei Taiwan
- Department of Dermatology School of Medicine, College of Medicine, Taipei Medical University Taipei Taiwan
- Research Center of Big Data and Meta‐Analysis Wan Fang Hospital, Taipei Medical University Taipei Taiwan
| | - Liang‐Ti Huang
- Department of Pediatrics Wan Fang Hospital, Taipei Medical University Taipei Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine Taipei Medical University Taipei Taiwan
| | - Ruei‐Ming Chen
- Graduate Institute of Medical Sciences, College of Medicine Taipei Medical University Taipei Taiwan
- Cell Physiology and Molecular Image Research Center Wan Fang Hospital, Taipei Medical University Taipei Taiwan
| | - Chiehfeng Chen
- Graduate Institute of Clinical Medicine, College of Medicine Taipei Medical University Taipei Taiwan
- Division of Plastic Surgery, Department of Surgery Wan Fang Hospital, Taipei Medical University Taipei Taiwan
- Cochrane Taiwan Taipei Medical University Taipei Taiwan
- Evidence‐Based Medicine Center Wan Fang Hospital, Taipei Medical University Taipei Taiwan
- Department of Public Health School of Medicine, College of Medicine, Taipei Medical University Taipei Taiwan
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Dodick DW, Lipton RB, Ailani J, Halker Singh RB, Shewale AR, Zhao S, Trugman JM, Yu SY, Viswanathan HN. Ubrogepant, an Acute Treatment for Migraine, Improved Patient-Reported Functional Disability and Satisfaction in 2 Single-Attack Phase 3 Randomized Trials, ACHIEVE I and II. Headache 2020; 60:686-700. [PMID: 32073660 PMCID: PMC7155006 DOI: 10.1111/head.13766] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/14/2020] [Accepted: 01/15/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To evaluate the efficacy of ubrogepant on patient-reported functional disability, satisfaction with study medication, and global impression of change. BACKGROUND Ubrogepant is a small-molecule, oral calcitonin gene-related peptide receptor antagonist indicated for the acute treatment of migraine. In 2 phase 3 trials (ACHIEVE I and II), ubrogepant demonstrated efficacy vs placebo on the 2 co-primary endpoints of headache pain freedom and absence of the most bothersome migraine-associated symptom at 2 hours post dose for the 50 and 100 mg doses. Patient-reported outcomes, such as functional disability, satisfaction, and patient global impression of change, can provide additional evidence of the efficacy of an acute treatment for migraine on clinically meaningful and patient-relevant outcomes. METHODS ACHIEVE I and ACHIEVE II were multicenter, randomized, double-blind, placebo-controlled, parallel-group, single-attack trials in adults (18-75 years) with migraine. In ACHIEVE I, participants were randomized 1:1:1 to placebo or ubrogepant 50 or 100 mg; in ACHIEVE II, participants were randomized 1:1:1 to placebo or ubrogepant 25 or 50 mg to treat a migraine attack with moderate or severe headache pain. Participants rated ability to perform daily activities on the Functional Disability Scale, before dosing and at 1, 2, 4, and 8 hours after the initial dose; satisfaction with study medication at 2 and 24 hours; and impression of overall change in migraine on the Patient Global Impression of Change scale at 2 hours. In prespecified analyses for each trial, each outcome was compared between each ubrogepant dose group and the relevant placebo group. Data were pooled from the ubrogepant 50 mg and placebo groups of the 2 trials in a post hoc analysis. RESULTS In ACHIEVE I, 559 participants were randomized to placebo, 556 to ubrogepant 50 mg, and 557 to ubrogepant 100 mg; in ACHIEVE II, 563 were randomized to placebo, 561 to ubrogepant 25 mg, and 562 to ubrogepant 50 mg. At 2 hours post dose, significantly higher proportions of ubrogepant-treated participants vs placebo-treated participants reported being able to function normally (ACHIEVE I: ubrogepant 50 mg, 40.6% [171/421], P = .0012 vs placebo; ubrogepant 100 mg, 42.9% [192/448], P < .0001 vs placebo; placebo, 29.8% [136/456]; ACHIEVE II: ubrogepant 25 mg, 42.6% [185/434], P = .0015 vs placebo; ubrogepant 50 mg, 40.5% [188/464], P = .0118 vs placebo; placebo, 34.2% [156/456]; pooled 50 mg, 40.6% [359/885], vs pooled placebo, 32.0% [292/912]; P < .0001), were satisfied/extremely satisfied with study medication (ACHIEVE I: 50 mg, 36.3% [147/405], P < .0001 vs placebo; 100 mg, 35.8% [149/416], P = .0002 vs placebo; placebo, 24.1% [104/432]; ACHIEVE II: 25 mg, 35.1% [141/402], P = .0018 vs placebo; 50 mg, 37.8% [163/431], P < .0001 vs placebo; placebo, 24.8% [106/427]; pooled ubrogepant 50 mg, 37.1% [310/836], vs pooled placebo, 24.5% [210/859]; P < .0001), and indicated that their migraine was much/very much better on the Patient Global Impression of Change scale (ACHIEVE I: 50 mg, 34.4% [103/299], P = .0006 vs placebo; 100 mg, 34.3% [102/297], P = .0009 vs placebo; placebo, 22.0% [69/313]; ACHIEVE II: 25 mg, 34.1% [124/364], P < .0001 vs placebo; 50 mg, 33.4% [131/392], P = .0002 vs placebo; placebo, 20.7% [78/376]; pooled 50 mg, 33.9% [234/691], vs pooled placebo, 21.3% [147/689]; P < .0001). CONCLUSIONS A significantly higher proportion of participants treated with ubrogepant were able to function normally, were satisfied with the study medication, and reported clinically meaningful improvement compared with those receiving placebo. The results reinforce the potential benefits of ubrogepant on patient-centered outcomes in the acute treatment of migraine.
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Affiliation(s)
| | | | - Jessica Ailani
- MedStar Georgetown University Hospital, Washington, DC, USA
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Alpuente A, Tassorelli C, Diener HC, Silberstein SD, Pozo-Rosich P. Have the IHS Guidelines for controlled trials of acute treatment of migraine attacks been followed? Laying the ground for the 4th edition. Cephalalgia 2020; 40:778-787. [DOI: 10.1177/0333102420906843] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background The International Headache Society (IHS) has published four editions of Guidelines for acute clinical trials in migraine in the past 28 years. This continuous update process has been driven by the increasing amount of scientific data in the field of migraine and by the need to continuously improve the quality of trials. Objectives To illustrate: i) the results of the analysis on the adherence of published trials to the 3rd edition published in 2012, in order to identify the critical areas that needed to be addressed in the 4th edition and ii) the changes introduced in this latter edition for improving adherence and methodology robustness. Methods We searched and reviewed all controlled trials on acute treatment of migraine published in the period 2012–2018 and we assessed their adherence to the 3rd edition of the IHS Guidelines using a score system based on the most important recommendations. Afterwards, we compared the two editions of the Guidelines and assessed the changes between them. Results We included data from 24 controlled clinical trials. Most trials had a randomized double-blind controlled (RDB) design, while a minority (16.7%) were non-randomized double-blind trials. Less than half (44.6%) of the RDB trials used the recommended “pain-free at 2 hours” endpoint as the primary efficacy measure. Trial design and evaluation of results were the areas that diverged the most from the recommendations. Conclusion Adherence to IHS guidelines for clinical trials has been suboptimal so far. The new edition has been adapted and optimized to facilitate uptake and strengthen the quality of evidence.
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Affiliation(s)
- Alicia Alpuente
- Headache Unit, Neurology Department, Vall d’Hebron University Hospital, Barcelona, Spain
- Headache and Neurological Pain Research Group, VHIR, Universitat Autonoma of Barcelona, Barcelona, Spain
| | - Cristina Tassorelli
- Headache Science Center, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | | | - Stephen D Silberstein
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Patricia Pozo-Rosich
- Headache Unit, Neurology Department, Vall d’Hebron University Hospital, Barcelona, Spain
- Headache and Neurological Pain Research Group, VHIR, Universitat Autonoma of Barcelona, Barcelona, Spain
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Abstract
Background: Migraine therapy with sumatriptan may cause adverse side effects like pain at the injection site, muscle pain, and transient aggravation of headaches. In animal experiments, sumatriptan excited or sensitized slowly conducting meningeal afferents. We hypothesized that sumatriptan may activate transduction channels of the “irritant receptor,” the transient receptor potential ankyrin type (TRPA1) expressed in nociceptive neurons. Methods: Calcium microfluorometry was performed in HEK293t cells transfected with human TRPA1 (hTRPA1) or a mutated channel (TRPA1-3C) and in dissociated trigeminal ganglion neurons. Membrane currents were recorded in the whole-cell patch clamp configuration. Results: Sumatriptan (10 and 400 µM) evoked calcium transients in hTRPA1-expressing HEK293t cells also activated by the TRPA1 agonist carvacrol (100 µM). In TRPA1-3C-expressing HEK293t cells, sumatriptan had hardly any effect. In rat trigeminal ganglion neurons, sumatriptan, carvacrol, and the transient receptor potential vanillod type 1 agonist capsaicin (1 µM) generated robust calcium signals. All sumatriptan-sensitive neurons (8% of the sample) were also activated by carvacrol (14%) and capsaicin (48%). In HEK293-hTRPA1 cells, sumatriptan (100 µM) evoked outwardly rectifying currents, which were almost completely inhibited by the TRPA1 antagonist HC-030031 (10 µM). Conclusion: Sumatriptan activates TRPA1 channels inducing calcium inflow and membrane currents. TRPA1-dependent activation of primary afferents may explain the painful side effects of sumatriptan.
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Affiliation(s)
- Alexandru Babes
- Department of Anatomy, Physiology and Biophysics, University of Bucharest, Bucharest, Romania
| | - Cristian Neacsu
- Department of Anatomy, Physiology and Biophysics, University of Bucharest, Bucharest, Romania
| | - Michael JM Fischer
- Center for Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Karl Messlinger
- Institute of Physiology and Pathophysiology, University of Erlangen-Nürnberg, Erlangen, Germany
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Lupi C, Benemei S, Guerzoni S, Pellesi L, Negro A. Pharmacokinetics and pharmacodynamics of new acute treatments for migraine. Expert Opin Drug Metab Toxicol 2019; 15:189-198. [PMID: 30714429 DOI: 10.1080/17425255.2019.1578749] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Recommended medications for the acute treatment of migraine encompass triptans, nonsteroidal anti-inflammatory drugs (NSAIDs), and analgesics. While it is true that triptans have been the first successful mechanism-driven treatment in the field, recently, new targets involved in migraine pathogenesis have emerged and new drug classes have been studied for migraine attack therapy. Areas covered: Pharmacodynamics and pharmacokinetics of the new acute treatments of migraine (i.e. ditans, gepants, and glutamate receptor antagonists), considering also marketed drugs in new formulations and administration routes. Expert opinion: Research on the administration routes of marketed drugs was performed in order to improve, in accordance with basic pharmacokinetics parameters, the speed of action of these medications. Similar to the triptans, the new acute treatments are migraine-specific medications, acting on the trigeminovascular system, albeit with different mechanisms. Although available data do not conclusively indicate the superiority of a class over the others, the pharmacodynamics explains the peculiar tolerability and safety profile of different drug classes emerging from clinical trials. Further studies are needed to investigate the possibility of combining different drug classes to optimize the clinical response and the potential role of the novel drugs in medication-overuse headache.
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Affiliation(s)
- Chiara Lupi
- a Headache Centre, Careggi University Hospital, Health Sciences Department , University of Florence , Florence , Italy
| | - Silvia Benemei
- b Headache Centre, Careggi University Hospital , University of Florence , Florence , Italy
| | - Simona Guerzoni
- c Medical Toxicology, Headache and Drug Abuse Center , University of Modena and Reggio Emilia , Modena , Italy
| | - Lanfranco Pellesi
- c Medical Toxicology, Headache and Drug Abuse Center , University of Modena and Reggio Emilia , Modena , Italy
| | - Andrea Negro
- d Regional Referral Headache Centre, Sant'Andrea Hospital, Department of Clinical and Molecular Medicine , Sapienza University of Rome , Rome , Italy
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The American Headache Society Position Statement On Integrating New Migraine Treatments Into Clinical Practice. Headache 2018; 59:1-18. [PMID: 30536394 DOI: 10.1111/head.13456] [Citation(s) in RCA: 210] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To provide healthcare professionals with updated guidance in the use of novel preventive and acute treatments for migraine in adults. BACKGROUND The principles of preventive and acute pharmacotherapy for patients with migraine have been outlined previously, but the emergence of new technologies and treatments, as well as new formulations of previously established treatments, has created a need for an updated guidance on the preventive and acute treatment of migraine. METHODS This statement is based on a review of existing guidelines and principles for preventive and acute treatment of migraine, as well as the results of recent clinical trials of drugs and devices for these indications. Input was sought from health insurance providers, employers, pharmacy benefit service companies, device manufacturers, pharmaceutical and biotechnology companies, patients, and patient advocates. Expert clinicians and researchers in the field of headache medicine from across North America and the European Union provided input and feedback. RESULTS The principles of pharmacologic preventive treatment of migraine with oral treatments have been as follows: use evidence-based treatments when possible and appropriate; start with a low dose and titrate slowly; reach a therapeutic dose if possible; allow for an adequate treatment trial duration; establish expectations of therapeutic response and adverse events; and maximize adherence. Newer injectable treatments may work faster and may not need titration. The principles of acute treatment include: use evidence-based treatments when possible and appropriate; treat early after the onset of a migraine attack; choose a nonoral route of administration for selected patients; account for tolerability and safety issues; consider self-administered rescue treatments; and avoid overuse of acute medications. Neuromodulation and biobehavioral therapy may be appropriate for preventive and acute treatment, depending on the needs of individual patients. Neuromodulation may be useful for patients who prefer nondrug therapies or who respond poorly, cannot tolerate, or have contraindications to pharmacotherapy. CONCLUSIONS This statement updates prior recommendations and outlines the indications for initiating, continuing, combining, and switching preventive and acute treatments of migraine.
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Abstract
Primary headache disorders, such as migraine and cluster headache, are common and often debilitating. When preventive therapy is needed, several oral medications are used. Patients tend to have poor adherence and persistence on their preventive therapy. The introduction of treatments blocking calcitonin gene-related peptide (CGRP) is anticipated to begin a new era in migraine preventive treatment. In addition, non-triptan serotonin receptor agonists, newer delivery systems for older therapies, and innovative devices represent other exciting advances in acute and preventive migraine and cluster treatment and shall also be discussed in this review.
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Affiliation(s)
- Michail Vikelis
- Glyfada Headache Clinic, No. 8 Lazaraki Str., 16675, Glyfada, Greece.
- Mediterraneo Hospital Headache Clinic, Glyfada, Greece.
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Landy S, Munjal S, Brand-Schieber E, Rapoport AM. Efficacy and safety of DFN-11 (sumatriptan injection, 3 mg) in adults with episodic migraine: an 8-week open-label extension study. J Headache Pain 2018; 19:70. [PMID: 30112725 PMCID: PMC6093831 DOI: 10.1186/s10194-018-0882-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 07/02/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND DFN-11, a 3 mg sumatriptan subcutaneous (SC) autoinjector for acute treatment of migraine, has not been assessed previously in multiple attacks. The objective of this study was to evaluate the efficacy, tolerability, and safety of DFN-11 in the acute treatment of multiple migraine attacks. METHODS This was an 8-week open-label extension of multicenter, randomized, double-blind, placebo-controlled US study. Subjects averaging 2 to 6 episodic migraine attacks per month were randomized to DFN-11 or placebo to treat a single attack of moderate-to-severe intensity and then entered the extension study to assess the efficacy, tolerability, and safety of DFN-11 in multiple attacks of any pain intensity. RESULTS Overall, 234 subjects enrolled in the open-label period, and 29 (12.4%) discontinued early. A total of 848 migraine episodes were treated with 1042 doses of open-label DFN-11 and subjects treated a mean (SD) of 3.9 (2.3) attacks. At 2 h postdose in attacks 1 (N = 216), 2 (N = 186), 3 (N = 142) and 4 (N = 110), respectively, pain freedom rates were 57.6%, 64.6%, 61.6%, and 66.3%; pain relief rates were 83.4%, 88.4%, 84.1%, and 81.7%; most bothersome symptom (MBS)-free rates were 69.0%, 76.5%, 77.7%, and 74.7%; nausea-free rates were 78.1%, 84.6%, 86.5%, and 85.7%; photophobia-free rates were 75.3%, 76.4%, 72.3%, and 77.5%; and phonophobia-free rates were 75.2%, 77.5%, 73.6%, and 76.0%. Overall, 40.6% (89/219) of subjects reported treatment-emergent adverse events (TEAE), the most common of which were associated with the injection site: swelling (12.8%), pain (11.4%), irritation (6.4%), and bruising (6.4%). Most subjects (65.2%, 58/89) had mild TEAEs; severe TEAEs were reported by 1 subject (treatment-related jaw tightness). Five subjects (2.1%) discontinued due to adverse events, which included mild throat tightness (n = 2), moderate hernia pain (n = 1), moderate hypersensitivity (n = 1), and 1 subject with mild nausea and moderate injection site swelling. There were no serious TEAEs and no new or unexpected safety findings. CONCLUSION DFN-11 was effective, tolerable, and safe in the acute treatment of 4 migraine attacks over 8 weeks, with consistent responses on pain and associated symptoms. Most TEAEs were mild, with a very low incidence of triptan-related TEAEs. DFN-11 is potentially an effective and safe alternative for the acute treatment of migraine. TRIAL REGISTRATION ClinicalTrials.gov, NCT02569853 . Registered 07 October 2015.
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Affiliation(s)
- Stephen Landy
- Baptist Medical Group Headache Clinic, University of Tennessee Medical School, 6029 Walnut Grove, Suite 210, Memphis, TN 38120 USA
| | - Sagar Munjal
- Promius Pharma, LLC, a subsidiary of Dr. Reddy’s Laboratories, 107 College Road East, Princeton, NJ 08540 USA
| | - Elimor Brand-Schieber
- Promius Pharma, LLC, a subsidiary of Dr. Reddy’s Laboratories, 107 College Road East, Princeton, NJ 08540 USA
| | - Alan M. Rapoport
- The David Geffen School of Medicine at UCLA, 4255 Jefferson Avenue, Suite 27, Woodside, CA 94062 USA
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Landy S, Munjal S, Brand-Schieber E, Rapoport AM. Efficacy and safety of DFN-11 (sumatriptan injection, 3 mg) in adults with episodic migraine: a multicenter, randomized, double-blind, placebo-controlled study. J Headache Pain 2018; 19:69. [PMID: 30112726 PMCID: PMC6093827 DOI: 10.1186/s10194-018-0881-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 07/02/2018] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND In a previous randomized, double-blind, proof-of-concept study in rapidly escalating migraine, a 3 mg dose of subcutaneous sumatriptan (DFN-11) was associated with fewer and shorter triptan sensations than a 6 mg dose. The primary objective of the study was to assess the efficacy and safety of acute treatment with DFN-11 compared with placebo in episodic migraine. METHODS This was a multicenter, randomized, double-blind, placebo-controlled efficacy and safety study of DFN-11 in the acute treatment of adults with episodic migraine (study RESTOR). The primary endpoint was the proportion of subjects taking DFN-11 who were pain free at 2 h postdose in the double-blind period compared with placebo. Secondary endpoints included earlier postdose timepoints, assessments of pain relief and subjects' freedom from their most bothersome symptom (MBS) (among nausea, photophobia, and phonophobia). Safety and tolerability were assessed. RESULTS A total of 392 subjects was screened, 268 (68.4%) were randomized, and 234 (87.3% of those randomized) completed the double-blind treatment period. The proportion of subjects who were pain free at 2 h postdose was significantly greater in the DFN-11 group than in the placebo group (51.0% vs 30.8%, P = 0.0023). Compared with placebo, significantly higher proportions of subjects treated with DFN-11 were also pain free at 30, 60, and 90 min postdose (P ≤ 0.0195). DFN-11 was significantly superior to placebo for pain relief at 60 min, 90 min, and 2 h postdose (P ≤ 0.0179). At 2 h postdose, DFN-11 was also significantly superior to placebo for freedom from photophobia (P = 0.0056) and phonophobia (P = 0.0167). Overall, 33.3% (37/111) who received DFN-11 and 13.4% (16/119) who received placebo experienced at least 1 treatment-emergent adverse event (TEAE), the most common of which were injection site swelling (7.2% vs 0.8%) and pain (7.2% vs 5.9%). Chest discomfort was about half as common in the DFN-11 treatment group as it was in the placebo group (0.9% vs 1.7%). CONCLUSIONS This study met its primary endpoint, pain freedom at 2 h postdose, with DFN-11 significantly better than placebo, and the incidence of TEAEs and triptan sensations with DFN-11 was low. The 3 mg dose of sumatriptan in DFN-11 appears to be an effective alternative to a 6 mg SC dose of sumatriptan, with good safety and tolerability. ( clinicaltrials.gov : NCT02569853; registered 07 October 2015).
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Affiliation(s)
- Stephen Landy
- Baptist Medical Group Headache Clinic, University of Tennessee Medical School, 6029 Walnut Grove, Suite 210, Memphis, TN 38120 USA
| | - Sagar Munjal
- Promius Pharma, a subsidiary of Dr Reddy’s Laboratories, 107 College Road East, Princeton, NJ 08540 USA
| | - Elimor Brand-Schieber
- Promius Pharma, a subsidiary of Dr Reddy’s Laboratories, 107 College Road East, Princeton, NJ 08540 USA
| | - Alan M. Rapoport
- The David Geffen School of Medicine at UCLA, 4255 Jefferson Avenue, Suite 27, Woodside, CA 94062 USA
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Tepper SJ, Johnstone MR. Breath-powered sumatriptan dry nasal powder: an intranasal medication delivery system for acute treatment of migraine. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2018; 11:147-156. [PMID: 29760572 PMCID: PMC5937501 DOI: 10.2147/mder.s130900] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
There is a need for fast-acting, non-oral medication options for migraine because some attacks develop rapidly and some are accompanied by nausea, vomiting, and gastroparesis, which can hinder oral medication uptake and absorption. The most commonly prescribed migraine medications are oral triptans, with sumatriptan as the most common. However, oral triptans are associated with adverse events (AEs) of atypical sensations that may be problematic for patients. Subcutaneous (SC) injectable sumatriptan and conventional liquid triptan nasal spray formulations are also available, but the frequency of atypical sensations is the highest with SC sumatriptan, and the intense bitter taste of conventional liquid triptan nasal spray discourages use. AVP-825 (ONZETRA® Xsail®) is an intranasal medication delivery system containing 22 mg sumatriptan nasal powder that is now available in the USA for the acute treatment of migraine with or without aura in adults. The objective of this review is to summarize the development of AVP-825, which utilizes unique features of nasal anatomy to achieve efficient absorption and reduced systemic exposure. Literature searches for “sumatriptan nasal powder”, “AVP-825”, and “sumatriptan intranasal” were conducted. Review articles and pharmacokinetic, Phase II and Phase III studies were evaluated. AVP-825 demonstrates an earlier onset of efficacy and lower rate of atypical sensations than the oral standard of care, which can be attributed to its fast absorption and low systemic exposure. AEs of abnormal taste are predominantly mild. These results confirm the initial design concept for AVP-825, which aligned pharmacokinetics, anatomy, and drug presentation in a novel device to achieve optimal outcomes for the acute treatment of migraine.
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Affiliation(s)
- Stewart J Tepper
- Department of Neurology, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
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Kamali M, Seifadini R, Kamali H, Mehrabani M, Jahani Y, Tajadini H. Efficacy of combination of Viola odorata, Rosa damascena and Coriandrum sativum in prevention of migraine attacks: a randomized, double blind, placebo-controlled clinical trial. Electron Physician 2018; 10:6430-6438. [PMID: 29765566 PMCID: PMC5942562 DOI: 10.19082/6430] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 09/21/2017] [Indexed: 01/03/2023] Open
Abstract
Background Migraine is the second most common type of headache after tension headaches. In Iranian traditional medicine several herbal drugs are used for the treatment of headache. Including, a product of Iranian traditional medicine, a combination of Viola odorata L. flowers, Rosa damascena L. flowers and Coriandrum sativum L. fruits. Objective To determine the effectiveness of a combination of Viola odorata flowers, Rosa damascene flowers and Coriandrum sativum fruits on severity, duration and frequency of migraine headaches. Methods This randomized, double blind, placebo-controlled clinical trial was performed on 88 patients who had migraine and visited Besat Neurology Clinic No. 4 at Kerman University of Medical Sciences, Kerman, Iran, from September 2016 to march 2017. Patients were randomly divided into the intervention (n=44) or placebo group (n=44). The intervention group received a product of Iranian traditional medicine, a combination of Viola odorata L. flowers, Rosa damascena L. flowers and Coriandrum sativum L. fruits in 500 mg capsules three times a day and propranolol 20mg tablet twice a day, and the control group received placebo capsules (500mg) three times a day and propranolol 20mg tablet twice a day for four weeks. Patients were asked to report the frequency, duration and severity of their headaches in designed forms at home. Then at the end of the 2nd and 4th weeks of treatment, patients were followed for clinical efficacy. Results In terms of duration, frequency and severity of headaches between the two groups of herbal medicine and placebo, the behavior of the two protocols was changed over time (p<0.001). During the 4 weeks, the time and drug interactions, were significant (p <0.001). In other words, the pattern of changes to the two protocols over time, was different. Also, at the end of the 4th week, there was a significant difference between the two groups (p<0.001). Conclusion The study findings suggest that the Iranian traditional product combination of Viola odorata flowers, Rosa damascena flowers and Coriandrum sativum fruits may be effective in improving headaches in patients with migraine. Clinical trial registration The trial was registered at the Iranian registry of clinical trials (IRCT: www.irct.ir) with registered NO. IRCT 2016110830776N1. Funding The authors received no financial support for the research, authorship, and/or publication of this article.
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Affiliation(s)
- Mohadese Kamali
- MD, Persian Medicine Student, Neurology Research Center, Kerman University of Medical Sciences, Kerman, Iran.,Department of Persian Medicine, School of Persian Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Rostam Seifadini
- MD, Neurologist, Assistant Professor, Neurology Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Hoda Kamali
- MD, Neurologist, Assistant Professor, Neurology Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Mitra Mehrabani
- Pharmacognosist, Professor, Department of Pharmacognosy, Herbal and Traditional Medicines Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Yunes Jahani
- PhD of Biostatistics, Assistant Professor, Modeling in Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran.,Department of Biostatistics and Epidemiology, School of Public Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Haleh Tajadini
- Department of Persian Medicine, School of Persian Medicine, Kerman University of Medical Sciences, Kerman, Iran.,MD, PhD of Persian Medicine, Assistant Professor, Neurology Research Center, Kerman University of Medical Sciences, Kerman, Iran
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