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Bedrin K, Shah T, Vaidya S, Ailani J. CGRP Modulating Therapies: An Update. Curr Neurol Neurosci Rep 2024:10.1007/s11910-024-01363-w. [PMID: 39017828 DOI: 10.1007/s11910-024-01363-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2024] [Indexed: 07/18/2024]
Abstract
INTRODUCTION Calcitonin-gene related peptide (CGRP) is a vasoactive neuropeptide involved in the pathophysiology ofmigraine. CGRP has been targeted for both preventive and acute treatment of migraine. OBJECTIVE Provide a summary of the most clinically relevant literature surrounding CGRP modulating therapies. METHODS This update on CGRP modulating therapies includes articles selected as most clinically relevant by theauthors. CONCLUSION CGRP modulating therapies are an exciting new addition to migraine treatment given their safety andtolerability. Additionally, compared to traditional migraine preventive medication these treatments are migrainespecific.Further real-world and clinical data is ongoing to better understand these treatments that continue to gainfavor in the management of migraine.
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Affiliation(s)
- Kate Bedrin
- Virginia Mason Franciscan Health, Seattle, USA.
- , 33501 First Way S., Federal Way, WA, 98003, USA.
| | - Tulsi Shah
- Medstar Georgetown University Hospital, Washington, USA
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True D, Mullin K, Croop R. Safety of Rimegepant in Adults with Migraine and Cardiovascular Risk Factors: Analysis of a Multicenter, Long-Term, Open-Label Study. Pain Ther 2024:10.1007/s40122-024-00626-1. [PMID: 38985436 DOI: 10.1007/s40122-024-00626-1] [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: 04/19/2024] [Accepted: 06/05/2024] [Indexed: 07/11/2024] Open
Abstract
INTRODUCTION Cardiovascular (CV) risk factors can limit treatment options for migraine. Rimegepant is an orally administered small-molecule calcitonin gene-related peptide receptor antagonist that does not induce vasoconstriction. The aim of these post hoc subgroup analyses was to assess the safety of rimegepant according to CV risk. METHODS In a multicenter, long-term, open-label, phase II/III safety study, participants with a history of 2-14 migraine attacks per month of moderate or severe pain intensity self-administered rimegepant 75 mg, orally, to treat migraine up to once daily for up to 52 weeks. Uncontrolled, unstable, or recently diagnosed CV disease was part of the exclusion criteria. Safety was assessed across subgroups according to number of CV risk factors (0, 1, or ≥ 2) and Framingham Risk Score (< 10% or ≥ 10%). RESULTS Of 1800 treated participants, 28.8% had one CV risk factor and 12.1% had ≥ 2 CV risk factors; 7.0% had Framingham Risk Score ≥ 10%. Across the subgroups with 0, 1, and ≥ 2 CV risk factors and Framingham Risk Score < 10% and ≥ 10%, respectively, proportions of participants reporting adverse events (AEs; 59.6%, 61.4%, 62.2%, 59.9%, 67.5%) and serious AEs (2.7%, 2.5%, 2.3%, 2.6%, 2.4%) were consistent, and AEs leading to study drug discontinuation were low (1.9%, 3.1%, 5.5%, 2.5%, 4.8%). CONCLUSIONS Rimegepant showed favorable safety and tolerability in adults with migraine and CV risk factors, including those with moderate to high CV risk. TRIAL REGISTRATION ClinicalTrials.gov NCT03266588.
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Affiliation(s)
- David True
- Clinvest Research, 909 E Republic Rd Building D 200, Springfield, MO, 65807, USA.
| | - Kathleen Mullin
- New England Institute for Clinical Research, Stamford, CT, USA
| | - Robert Croop
- Biohaven Pharmaceuticals Inc, New Haven, CT, USA
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Wells BJ, Wood MJ, O’Duffy AE, Sumner JA, Chi G, Grodzinsky A, Gornik HL, Kadian-Dodov D, Taylor A, Hess CN, Sanghavi M, Henkin S, Wells G, Tam L, Orford J, Lindley K, Kumbhani DJ, Vitarello C, Alkhalfan F, Gibson CM, Leon KK, Naderi S, Kim ESH. Migraine headache in patients with spontaneous coronary artery dissection: A report of the iSCAD Registry. Vasc Med 2024; 29:286-295. [PMID: 38898631 PMCID: PMC11188565 DOI: 10.1177/1358863x241252444] [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: 06/21/2024]
Abstract
INTRODUCTION Spontaneous coronary artery dissection (SCAD) is a nonatherosclerotic cause of myocardial infarction. Migraine headache has been reported to be common among patients with SCAD, but the degree of migraine-related disability has not been quantified. METHODS Clinical data and headache variables were obtained from the baseline assessment of the prospective, multicenter iSCAD Registry. Migraine-related disability was quantified using the self-reported Migraine Disability Assessment (MIDAS). Demographic, clinical, psychosocial, and medical characteristics from data entry forms were compared between patients with and without migraine. RESULTS Of the 773 patients with available data, 46% reported previous or current migraines. Those with migraines were more likely to be women (96.9% vs 90.3%, p = 0.0003). The presence of underlying carotid fibromuscular dysplasia was associated with migraine (35% vs 27%, p = 0.0175). There was not a significant association with carotid artery dissection and migraine. Current migraine frequency was less than monthly (58%), monthly (24%), weekly (16%), and daily (3%). Triptan use was reported in 32.5% of patients, and 17.5% used daily migraine prophylactic medications. Using the MIDAS to quantify disability related to migraine, 60.2% reported little or no disability, 14.4% mild, 12.7% moderate, and 12.7% severe. The mean MIDAS score was 9.9 (mild to moderate disability). Patients with SCAD had higher rates of depression and anxiety (28.2% vs 17.7% [p = 0.0004] and 35.3% vs 26.7% [p = 0.0099], respectively). CONCLUSIONS Migraines are common, frequent, and a source of disability in patients with SCAD. The association between female sex, anxiety, and depression may provide some insight for potential treatment modalities.
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Affiliation(s)
- Bryan J Wells
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Malissa J Wood
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
- Lee Health Heart Institute, Fort Myers, FL, USA
| | - Anne E O’Duffy
- Division of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jennifer A Sumner
- Department of Psychology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Gerald Chi
- Department of Medicine, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Anna Grodzinsky
- Saint Luke’s Mid America Heart Institute, University of Missouri-Kansas City, MO, USA
| | - Heather L Gornik
- University Hospitals Harrington Heart & Vascular Institute; Case Western Reserve University, Cleveland, OH, USA
| | - Daniella Kadian-Dodov
- Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Angela Taylor
- Division of Cardiology, University of Virginia Health System, Charlottesville, VA, USA
| | - Connie N Hess
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Monika Sanghavi
- Department of Medicine, Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Stanislav Henkin
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
- Current: Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
| | - Gretchen Wells
- University of Kentucky College of Medicine, Lexington, KY, USA
- Current: University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Lori Tam
- Providence Heart Institute, Portland, OR, USA
| | - James Orford
- Intermountain Heart Institute, Intermountain Medical Center, Murray, UT, USA
| | - Kathryn Lindley
- Division of Cardiovascular Medicine, Washington University, St Louis, MO, USA
- Current: Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dharam J Kumbhani
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Clara Vitarello
- Department of Medicine, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Fahad Alkhalfan
- Department of Medicine, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - C Michael Gibson
- Department of Medicine, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Sahar Naderi
- Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Esther SH Kim
- Current: Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Current: Atrium Health, Sanger Heart and Vascular Institute, Charlotte, NC, USA
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Mascarella D, Andrini G, Baraldi C, Altamura C, Favoni V, Lo Castro F, Pierangeli G, Vernieri F, Guerzoni S, Cevoli S. Blood pressure monitoring in elderly migraineurs starting an anti-CGRP monoclonal antibody: a real-world prospective study. Neurol Sci 2024:10.1007/s10072-024-07567-9. [PMID: 38795273 DOI: 10.1007/s10072-024-07567-9] [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: 01/29/2024] [Accepted: 04/27/2024] [Indexed: 05/27/2024]
Abstract
BACKGROUND While monoclonal antibodies (mAbs) targeting the CGRP pathway have revolutionized migraine management due to their improved tolerance and adherence, concerns remain about their potential impact on blood pressure (BP), especially in older patients, due to CGRP-mediated vasodilation blockade. Given the growing use of these therapies in older populations, assessing their cardiovascular (CV) safety is of paramount importance. METHODS This multicentric observational prospective study focused on migraine sufferers aged ≥ 60 who began erenumab, galcanezumab, or fremanezumab for prevention. Baseline, three-month, and twelve-month BP measurements were collected. Changes in antihypertensive medication and "Newly or Worsened Hypertensive" patients (NWHP) were assessed. RESULTS Among 155 patients receiving anti-CGRP mAbs (40 Erenumab, 47 Galcanezumab, 68 Fremanezumab), 42.5% had hypertension history and 39% were on antihypertensive treatment. No significant systolic or diastolic BP changes occurred at any time point compared to baseline (all p > 0.05), with no differences between the three groups. After one year, 20/155 (12.9%) patients were considered NWHP; 11/20 had prior hypertension, and 5/11 adjusted antihypertensive therapy. Among 9/20 newly hypertensive patients, 5/9 had a single measurement above the normal threshold with no requirement for new pharmacological therapy. A higher baseline BP value was associated with increased BP (p = 0.002). CONCLUSIONS The study concludes that treatment with anti-CGRP mAbs over one year does not significantly affect BP in patients aged ≥ 60, nor does it increase the incidence of hypertension compared to general population trends. Nonetheless, continuous monitoring and further long-term studies are necessary to fullya scertain the cardiovascular safety of these medications in the elderly.
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Affiliation(s)
- Davide Mascarella
- Department of Biomedical and Neuromotor Science DIBINEM, Alma Mater Studiorum Bologna, Bologna, Italy
| | - Giorgia Andrini
- Department of Biomedical and Neuromotor Science DIBINEM, Alma Mater Studiorum Bologna, Bologna, Italy
| | - Carlo Baraldi
- Digital and Predictive Medicine, Pharmacology and Clinical Metabolic Toxicology-Headache Center and Drug Abuse-Laboratory of Clinical Pharmacology and Pharmacogenomics, Department of Specialist Medicines, AOU Policlinico Di Modena, Modena, Italy
| | - Claudia Altamura
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - Valentina Favoni
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna ISNB, Bologna, Italy
| | - Flavia Lo Castro
- Digital and Predictive Medicine, Pharmacology and Clinical Metabolic Toxicology-Headache Center and Drug Abuse-Laboratory of Clinical Pharmacology and Pharmacogenomics, Department of Specialist Medicines, AOU Policlinico Di Modena, Modena, Italy
| | - Giulia Pierangeli
- Department of Biomedical and Neuromotor Science DIBINEM, Alma Mater Studiorum Bologna, Bologna, Italy
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna ISNB, Bologna, Italy
| | - Fabrizio Vernieri
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - Simona Guerzoni
- Digital and Predictive Medicine, Pharmacology and Clinical Metabolic Toxicology-Headache Center and Drug Abuse-Laboratory of Clinical Pharmacology and Pharmacogenomics, Department of Specialist Medicines, AOU Policlinico Di Modena, Modena, Italy
| | - Sabina Cevoli
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna ISNB, Bologna, Italy.
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Stearns SA, Xun H, Haddad A, Rinkinen J, Bustos VP, Lee BT. Therapeutic Options for Migraines in the Microsurgical Patient: A Scoping Review. Plast Reconstr Surg 2024; 153:988e-1001e. [PMID: 37337332 DOI: 10.1097/prs.0000000000010861] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND There exists an increasing array of treatments proposed to prevent, alleviate, and abort symptoms of a migraine; however, for patients who undergo reconstructive microsurgery, caution must be taken to preserve vascular integrity. This study is the first-to-date scoping review of vascular and bleeding risk of current migraine therapies, with the purpose of identifying potential therapeutic agents for postoperative migraine management appropriate for microsurgical patients. METHODS Currently available migraine therapeutics were compiled from the UpToDate software system and the American Academy of Family Physicians. A PubMed literature review was performed for each therapeutic's effect on bleeding or vascular involvement. Data were compiled into tables of abortive, symptom-controlling and prophylactic, and nonpharmacologic treatments. Expert microsurgeons reviewed the data to provide recommendations for optimized patient care. RESULTS Triptans and other ergot derivatives demonstrated strong evidence of vasoconstriction and were greatly advised against for immediate postmicrosurgical use. Novel pharmaceutical therapies such as lasmiditan and calcitonin gene-related peptide antagonists have no literature indicating potential for vasoconstriction or hematoma and remain an investigational option for abortive medical treatment. For symptom control, acetaminophen appears the safest option, with clinical judgment and further research needed for use of nonsteroidal antiinflammatory drugs. Alternative treatment techniques may include migraine prophylaxis with botulinum toxin injection or nutraceutical treatment by means of magnesium supplementation or coenzyme Q10 administration, minimizing the need for additional medication in the postoperative setting. CONCLUSIONS Patients undergoing reconstructive microsurgery have a unique medical profile limiting the therapeutic options available to treat migraines. This review provides preliminary evidence to be considered as a guide for prescribing therapeutics for migraine in the postoperative setting.
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Affiliation(s)
| | - Helen Xun
- the Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Anthony Haddad
- the Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Jacob Rinkinen
- the Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Valeria P Bustos
- the Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Bernard T Lee
- the Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School
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Shahouzehi B, Masoumi-Ardakani Y, Fallah H, Aminizadeh S. Evaluation of the effect of Exercise Trainings and CGRP receptor antagonist (BIBN 4096) on mitochondrial dynamic in the hippocampus of male Wistar rats. Neurosci Lett 2024; 828:137752. [PMID: 38552868 DOI: 10.1016/j.neulet.2024.137752] [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] [Received: 12/25/2023] [Revised: 03/19/2024] [Accepted: 03/26/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Exercise training showed beneficial effects on brain. The purpose of the present study is to evaluate the effect of six weeks of high-intensity interval training (HIIT) and Endurance training (ET) with calcitonin gene-related peptide (CGRP) receptor antagonist on the expression of genes involved in mitochondrial dynamics and apoptosis in hippocampal tissue of male Wistar rats. METHODS In this study, forty-two healthymale Wistar rats (8-week) were randomly divided into 6 groups (n = 7) as follow; 1) Control; 2) HIIT which performed 6 weeks of HIIT; 3) ET which performed 6 weeks of endurance training; 4) CGRPi received 10 mg/kg CGRP receptor antagonist every day at the last 2 weeks; 5) CGRPi-HIIT performed HIIT and received CGRP receptor antagonist; 6) CGRPi-ET performed ET and received CGRP receptor antagonist. Real-time PCR (2-ΔΔCT) and western blotting were employedto measure the expression of genes and protein, respectively. RESULTS HIIT and ET significantly increased Bcl-2, Pgc-1α, Sirt3, and Nrf-1 gene expression in the hippocampal tissue (p < 0.05, p < 0.01, p < 0.01, and p < 0.001, respectively). ET-CGRPi and HIIT-CGRPi significantly increased Sirt3, Pgc-1α, and Nrf-1 gene expression compared to the control group (p < 0.05, p < 0.01, and p < 0.05, respectively). CONCLUSION ET and HIIT-induced physiological alterations in the hippocampus. In fact, this modulation showed protective properties in the hippocampusvia up regulation of Bcl-2, Pgc-1α, Nrf-1, and Sirt3 gene expression. CGRPi did not cause gene or protein changes harmful to mitochondrial dynamic balance and apoptosis in the hippocampus of rats.
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Affiliation(s)
- Beydolah Shahouzehi
- Cardiovascular Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran; Gastroenterology and Hepatology Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran
| | - Yaser Masoumi-Ardakani
- Physiology Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran
| | - Hossein Fallah
- Applied Cellular and Molecular Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Soheil Aminizadeh
- Department of Physiology and Pharmacology, Afzalipour School of Medicine, and Physiology Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran.
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Pellesi L, Ashina M, Martelletti P. Targeting the PACAP-38 pathway is an emerging therapeutic strategy for migraine prevention. Expert Opin Emerg Drugs 2024; 29:57-64. [PMID: 38337150 DOI: 10.1080/14728214.2024.2317778] [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] [Received: 01/13/2024] [Accepted: 02/08/2024] [Indexed: 02/12/2024]
Abstract
INTRODUCTION The pituitary adenylate cyclase-activating polypeptide-38 (PACAP-38) has emerged as a key mediator of migraine pathogenesis. PACAP-38 and its receptors are predominantly distributed in arteries, sensory and parasympathetic neurons of the trigeminovascular system. Phase 2 trials have tested human monoclonal antibodies designed to bind and inhibit PACAP-38 and the pituitary adenylate cyclase-activating polypeptide type I (PAC1) receptor for migraine prevention. AREAS COVERED This review focuses on the significance of the PACAP-38 pathway as a target in migraine prevention. English peer-reviewed articles were searched in PubMed, Scopus and ClinicalTrials.gov electronic databases. EXPERT OPINION A PAC1 receptor monoclonal antibody was not effective for preventing migraine in a proof-of-concept trial, paving the way for alternative strategies to be considered. Lu AG09222 is a humanized monoclonal antibody targeting PACAP-38 that was effective in preventing physiological responses of PACAP38 and reducing monthly migraine days in individuals with migraine. Further studies are necessary to elucidate the clinical utility, long-term safety and cost-effectiveness of therapies targeting the PACAP pathway.
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Affiliation(s)
- Lanfranco Pellesi
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Messoud Ashina
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Paolo Martelletti
- School of Health Sciences, Unitelma Sapienza University of Rome, Rome, Italy
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Sorbara EE, Barbieri MA, Russo G, Cicala G, Spina E. Cardiovascular Adverse Drug Reactions of Anti-Calcitonin Gene-Related Peptide Monoclonal Antibodies for Migraine Prevention: An Analysis from the European Spontaneous Adverse Event Reporting System. BioDrugs 2024; 38:275-285. [PMID: 38402495 DOI: 10.1007/s40259-024-00651-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2024] [Indexed: 02/26/2024]
Abstract
INTRODUCTION Anti-calcitonin gene-related peptide monoclonal antibodies (anti-CGRP-mAbs) have recently been approved for the prevention of migraine, and their safety profile is not fully characterized. OBJECTIVE The aim of this study was to evaluate the adverse drug reactions (ADRs) of anti-CGRP-mAbs through the analysis of individual case safety reports (ICSRs) collected in the EudraVigilance (EV) database, with a specific focus on cardiovascular (CV) ADRs. METHODS Data on ICSRs recorded between July 2018 and December 2022 in the EV database, involving one of the anti-CGRP-mAbs for migraine prevention-erenumab (ERE), galcanezumab (GMB), fremanezumab (FMB), and eptinezumab (EPT)-were included in the analysis. All ICSRs reporting at least one CV ADR, as identified within the MedDRA® System Organ Classes (SOCs) "cardiac disorders" or "vascular disorders," were selected for the analysis. The frequency of disproportionate reporting was expressed as the reporting odds ratio (ROR) with its 95% confidence interval (CI), to evaluate the frequency of reporting of CV ADRs for each anti-CGRP-mAb compared with all other monoclonal antibodies (mAbs). A case-by-case analysis was conducted paying particular attention to serious CV ADR reports, focusing on the type of seriousness, age group, sex, and concomitant drugs. RESULTS A total of 9441 ICSRs were recorded in the EV database from 2018 to 2022, of which more than half were related to ERE (58.9%), followed by GMB (21.4%), FMB (19.0%), and EPT (0.7%). CV ICSRs accounted for 1205 cases (12.8%), with a total of 1599 CV ADRs. The CV ICSRs were mainly related to female patients (82.6%) aged 18-64 years (73.4%). Of the reported CV ADRs, 67.5% were considered serious. Among the total number of ICSRs related to each anti-CGRP-mAb, those associated with FMB had a higher percentage of CV ADRs (n = 253; 14.1%), followed by ERE (n = 707; 12.7%), EPT (n = 8; 12.7%), and GMB (n = 237; 11.7%). A higher frequency of reporting hypertension was shown for ERE (ROR = 1.45; 95% CI = 1.14-1.85). Pallor was mainly observed with FMB (5.00; 1.68-14.89), as well as deep vein thrombosis (3.86; 1.57-9.51), hot flush (2.16; 1.43-3.25), and palpitations (1.48; 1.05-2.08). Atrial fibrillation (2.36; 1.02-5.46) and myocardial infarction (2.21; 1.37-3.58) were mostly reported for GMB. CONCLUSION The analysis of anti-CGRP-related CV ADRs was consistent with the information reported in the literature. However, hypertension with ERE, atrial fibrillation and myocardial infarction with GMB, as well as pallor, deep vein thrombosis, hot flush, and palpitations with FMB were not reported in the Summary of Product Characteristics (SmPCs). Considering this, more post-marketing analyses are needed to improve knowledge on the CV safety profiles of anti-CGRP-mAbs, especially for the last approved medication, EPT.
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Affiliation(s)
- Emanuela Elisa Sorbara
- Department of Clinical and Experimental Medicine, University of Messina, 98125, Messina, Italy
| | | | - Giulia Russo
- Department of Clinical and Experimental Medicine, University of Messina, 98125, Messina, Italy
| | - Giuseppe Cicala
- Department of Clinical and Experimental Medicine, University of Messina, 98125, Messina, Italy
| | - Edoardo Spina
- Department of Clinical and Experimental Medicine, University of Messina, 98125, Messina, Italy.
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van Lohuizen R, Paungarttner J, Lampl C, MaassenVanDenBrink A, Al-Hassany L. Considerations for hormonal therapy in migraine patients: a critical review of current practice. Expert Rev Neurother 2023; 24:1-21. [PMID: 38112066 PMCID: PMC10791067 DOI: 10.1080/14737175.2023.2296610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 12/06/2023] [Indexed: 12/20/2023]
Abstract
INTRODUCTION Migraine, a neurovascular headache disorder, is a leading cause of disability worldwide. Within the multifaceted pathophysiology of migraine, hormonal fluctuations play an evident triggering and exacerbating role, pointing toward the need for identification and proper usage of both existing and new hormonal targets in migraine treatment. AREAS COVERED With a threefold higher incidence of migraine in women than in men, the authors delve into sex hormone-related events in migraine patients. A comprehensive overview is given of existing hormonal therapies, including oral contraceptives, intrauterine devices, transdermal and subcutaneous estradiol patches, gnRH-agonists, oral testosterone, and 5α reductase inhibitors. The authors discuss their effectiveness and risks, noting their suitability for different patient profiles. Next, novel evolving hormonal treatments, such as oxytocin and prolactin, are explored. Lastly, the authors cover hormonal conditions associated with migraine, such as polycystic ovary syndrome, endometriosis, and transgender persons receiving gender affirming hormone therapy, aiming to provide more personalized and effective solutions for migraine management. EXPERT OPINION Rigorous research into both existing and new hormonal targets, as well as the underlying pathophysiology, is needed to support a tailored approach in migraine treatment, in an ongoing effort to alleviate the impact of migraine on individuals and society.
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Affiliation(s)
- Romy van Lohuizen
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | | | - Christian Lampl
- Headache Medical Center Linz, Linz, Austria
- Department of Neurology and Stroke Unit, Koventhospital Barmherzige Brüder Linz, Linz, Austria
| | - Antoinette MaassenVanDenBrink
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Linda Al-Hassany
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Alsaadi T, Kayed DM, Al-Madani A, Hassan AM, Terruzzi A, Krieger D, Riachi N, Sarathchandran P, Al-Rukn S. Consensus-Based Recommendations on the Use of CGRP-Based Therapies for Migraine Prevention in the UAE. Neurol Ther 2023; 12:1845-1865. [PMID: 37792218 PMCID: PMC10630270 DOI: 10.1007/s40120-023-00550-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 09/19/2023] [Indexed: 10/05/2023] Open
Abstract
INTRODUCTION Migraine is a common debilitating neurological disorder affecting a large proportion of the general population. Calcitonin gene-related peptide (CGRP), a 37-amino acid neuropeptide, plays a key role in the pathophysiology of migraine, and the development of therapies targeting the anti-CGRP pathway has revolutionized the field of migraine treatment. METHODS An expert task force of neurologists in the United Arab Emirates (UAE) developed and critically assessed recommendations on the use of CGRP-based therapies in migraine treatment and management in the UAE, based on available published literature. A consensus was reached for each statement by means of an open-voting process, based on a predefined agreement level of at least 60%. RESULTS The consensus recommendations advocate the need for guidelines for the appropriate use of CGRP-based therapies by defining patient cohorts and appropriate monitoring of therapeutic response as well as standardizing the initiation, assessment, and cessation of treatment. The consensus recommendations were primarily formulated on the basis of international studies, because of the limited availability of regional and local data. As such, they may also act as guidelines for global healthcare providers. CONCLUSIONS These are the first consensus recommendations for the UAE that address the use of CGRP-based therapies in the treatment and management of migraine, integrating both clinical evidence and medical expertise to enhance clinical judgment and decision-making.
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Affiliation(s)
- Taoufik Alsaadi
- Department of Neurology, American Center for Psychiatry and Neurology, Abu Dhabi, UAE.
| | - Deeb M Kayed
- Neurology Department, Mediclinic City Hospital, Dubai, UAE
| | | | | | | | - Derk Krieger
- Neurology Department, Mediclinic Parkview Hospital, Dubai, UAE
| | - Naji Riachi
- Sheikh Shakhbout Medical City, Khalifa University College of Medicine and Health Sciences, Abu Dhabi, UAE
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11
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Al-Hassany L, Linstra KM, Meun C, van den Berg J, Boersma E, Danser AHJ, Fauser BCJM, Laven JSE, Wermer MJH, Terwindt GM, Maassen Van Den Brink A. Decreased role of neuropeptides in the microvascular function in migraine patients with polycystic ovary syndrome. Atherosclerosis 2023; 384:117172. [PMID: 37400308 DOI: 10.1016/j.atherosclerosis.2023.06.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 06/13/2023] [Accepted: 06/15/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND AND AIMS To understand pathophysiological mechanisms underlying migraine as a cardiovascular risk factor, we studied neuropeptide action and endothelial function as measures of peripheral microvascular function in middle-aged women with or without migraine. METHODS We included women with the endocrine disorder polycystic ovary syndrome (PCOS), a population with supposed elevated cardiovascular risk, with and without comorbid migraine. In 26 women without and 23 women with migraine in the interictal phase (mean age 50.8 ± 2.9 years) local thermal hyperemia (LTH) of the skin of the volar forearm was measured cross-sectionally under control conditions, after inhibition of neuropeptide release by 5% lidocaine/prilocaine (EMLA) cream application, and after inhibition of nitric oxide formation by iontophoresis of NG-monomethyl-l-arginine (L-NMMA). Hereafter, changes in the natural logarithm of the reactive hyperemia index (lnRHI) and augmentation index (AI) during reperfusion after occlusion-derived ischemia were measured. RESULTS While mean values under control conditions and L-NMMA conditions were similar, migraine patients had a significantly higher mean area of the curve (AUC) of the total LTH response after EMLA application than those without (86.7 ± 26.5% versus 67.9 ± 24.2%; p = 0.014). This was also reflected by a higher median AUC of the plateau phase under similar conditions in women with migraine compared to those without (83.2% (IQR[73.2-109.5]) versus 73.2% (IQR[54.3-92.0]); p = 0.039). Mean changes in lnRHI and AI scores were similar in both groups. CONCLUSIONS In PCOS patients with migraine, neuropeptide action was lower compared with those without migraine. While larger studies are warranted, these findings provide a potential mechanism supporting previous findings that migraine may be independent from traditional risk factors, including atherosclerosis.
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Affiliation(s)
- Linda Al-Hassany
- Erasmus MC University Medical Center, Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Rotterdam, the Netherlands
| | - Katie M Linstra
- Erasmus MC University Medical Center, Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Rotterdam, the Netherlands; Leiden University Medical Center, Department of Neurology, Leiden, the Netherlands
| | - Cindy Meun
- Erasmus MC University Medical Center, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Rotterdam, the Netherlands
| | - Jeffrey van den Berg
- Erasmus MC University Medical Center, Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Rotterdam, the Netherlands
| | - Eric Boersma
- Erasmus MC University Medical Center Rotterdam, Department of Cardiology, the Netherlands
| | - A H Jan Danser
- Erasmus MC University Medical Center, Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Rotterdam, the Netherlands
| | - Bart C J M Fauser
- University Medical Center Utrecht, Department of Reproductive Medicine & Gynaecology, Utrecht, the Netherlands
| | - Joop S E Laven
- Erasmus MC University Medical Center, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Rotterdam, the Netherlands
| | - Marieke J H Wermer
- Leiden University Medical Center, Department of Neurology, Leiden, the Netherlands
| | - Gisela M Terwindt
- Leiden University Medical Center, Department of Neurology, Leiden, the Netherlands
| | - Antoinette Maassen Van Den Brink
- Erasmus MC University Medical Center, Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Rotterdam, the Netherlands.
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12
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Hugger SS, Do TP, Ashina H, Goicochea MT, Jenkins B, Sacco S, Lee MJ, Brennan KC, Amin FM, Steiner TJ, Ashina M. Migraine in older adults. Lancet Neurol 2023; 22:934-945. [PMID: 37717587 DOI: 10.1016/s1474-4422(23)00206-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 03/20/2023] [Accepted: 05/23/2023] [Indexed: 09/19/2023]
Abstract
Migraine is an evolving, and sometimes lifelong disorder. The prevalence of episodic migraine peaks among individuals aged in their late 30s, implying a tendency for the disorder to remit with increasing age thereafter, whereas chronic migraine is more likely to persist into later life. Diagnosis and treatment of migraine in older adults, defined as individuals aged 60 years or older, is rendered more complex by increasing probabilities of atypical clinical features and comorbidities, with patients' comorbidities sometimes limiting their therapeutic options. However, the changing clinical presentation of migraine over an individual's lifespan is not well characterised. The neurobiological basis of remission in older adults remains unclear, although vascular, neuronal, and hormonal changes are likely to be involved. Long-term longitudinal studies of individuals with migraine would be particularly informative, with the potential not only to suggest new research directions, but also to lead to the identification of novel therapeutic agents. Although several novel migraine medications are becoming available, their effectiveness, tolerability, and safety often remain uncertain in older adults, who have commonly been excluded from the evaluation of these agents in randomised controlled trials, or who constitute only a small proportion of study populations. There is a need to recognise these limitations in the available evidence, and the specific, and often unmet, clinical needs of older adults with migraine, not least because older adults constitute an increasing proportion of populations worldwide.
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Affiliation(s)
- Sarah Sonja Hugger
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Thien Phu Do
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark; Danish Knowledge Center on Headache Disorders, Glostrup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Håkan Ashina
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Brain and Spinal Cord Injury, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark; Harvard Medical School, Boston, MA, USA; Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | | | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Mi Ji Lee
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - K C Brennan
- Headache Physiology Laboratory, Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Faisal Mohammad Amin
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Brain and Spinal Cord Injury, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Timothy J Steiner
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway; Division of Brain Sciences, Imperial College London, London, UK
| | - Messoud Ashina
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark; Danish Knowledge Center on Headache Disorders, Glostrup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Neurology, Azerbaijan Medical University, Baku, Azerbaijan.
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13
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Martinez CI, Liktor-Busa E, Largent-Milnes TM. Molecular mechanisms of hormones implicated in migraine and the translational implication for transgender patients. FRONTIERS IN PAIN RESEARCH 2023; 4:1117842. [PMID: 37795389 PMCID: PMC10546064 DOI: 10.3389/fpain.2023.1117842] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 09/05/2023] [Indexed: 10/06/2023] Open
Abstract
Migraine is a primary headache disorder recognized by the World Health Organization as one of the most poorly understood and debilitating neurological conditions impacting global disability. Chronic pain disorders are more frequently diagnosed among cisgender women than men, suggesting that female sex hormones could be responsible for mediating chronic pain, including migraine and/or that androgens can be protective. This review discusses the major gonadal hormones, estrogens, progesterone, and testosterone in the context of molecular mechanisms by which they play a role in migraine pathophysiology. In addition, the literature to date describing roles of minor sex hormones including prolactin, luteinizing hormone, follicular stimulating hormone, and gonadotropin releasing hormone in migraine are presented. Because transgender and gender non-conforming (trans*) individuals are an underserved patient population in which gender-affirming sex hormone replacement therapy (HRT) is often medically necessary to align biological sex with gender identity, results from cisgender patient populations are discussed in the context of these major and minor sex hormones on migraine incidence and management in trans* patients.
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Affiliation(s)
| | | | - Tally M. Largent-Milnes
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, AZ, United States
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14
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Bonura A, Brunelli N, Marcosano M, Iaccarino G, Fofi L, Vernieri F, Altamura C. Calcitonin Gene-Related Peptide Systemic Effects: Embracing the Complexity of Its Biological Roles-A Narrative Review. Int J Mol Sci 2023; 24:13979. [PMID: 37762283 PMCID: PMC10530509 DOI: 10.3390/ijms241813979] [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: 07/28/2023] [Revised: 08/30/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
The calcitonin gene-related peptide (CGRP) is a neuropeptide widely distributed throughout the human body. While primarily recognized as a nociceptive mediator, CGRP antagonists are currently utilized for migraine treatment. However, its role extends far beyond this, acting as a regulator of numerous biological processes. Indeed, CGRP plays a crucial role in vasodilation, inflammation, intestinal motility, and apoptosis. In this review, we explore the non-nociceptive effects of CGRP in various body systems, revealing actions that can be contradictory at times. In the cardiovascular system, it functions as a potent vasodilator, yet its antagonists do not induce arterial hypertension, suggesting concurrent modulation by other molecules. As an immunomodulator, CGRP exhibits intriguing complexity, displaying both anti-inflammatory and pro-inflammatory effects. Furthermore, CGRP appears to be involved in obesity development while paradoxically reducing appetite. A thorough investigation of CGRP's biological effects is crucial for anticipating potential side effects associated with its antagonists' use and for developing novel therapies in other medical fields. In summary, CGRP represents a neuropeptide with a complex systemic impact, extending well beyond nociception, thus offering new perspectives in medical research and therapeutics.
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Affiliation(s)
- Adriano Bonura
- Instituite of Neurology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy; (A.B.); (N.B.); (M.M.); (L.F.); (F.V.)
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, 00128 Roma, Italy
| | - Nicoletta Brunelli
- Instituite of Neurology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy; (A.B.); (N.B.); (M.M.); (L.F.); (F.V.)
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, 00128 Roma, Italy
| | - Marilena Marcosano
- Instituite of Neurology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy; (A.B.); (N.B.); (M.M.); (L.F.); (F.V.)
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, 00128 Roma, Italy
| | - Gianmarco Iaccarino
- Instituite of Neurology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy; (A.B.); (N.B.); (M.M.); (L.F.); (F.V.)
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, 00128 Roma, Italy
| | - Luisa Fofi
- Instituite of Neurology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy; (A.B.); (N.B.); (M.M.); (L.F.); (F.V.)
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, 00128 Roma, Italy
| | - Fabrizio Vernieri
- Instituite of Neurology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy; (A.B.); (N.B.); (M.M.); (L.F.); (F.V.)
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, 00128 Roma, Italy
| | - Claudia Altamura
- Instituite of Neurology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy; (A.B.); (N.B.); (M.M.); (L.F.); (F.V.)
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, 00128 Roma, Italy
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15
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Kesav P, Manesh Raj D, John S. Cerebrovascular Fibromuscular Dysplasia - A Practical Review. Vasc Health Risk Manag 2023; 19:543-556. [PMID: 37664168 PMCID: PMC10473246 DOI: 10.2147/vhrm.s388257] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 08/11/2023] [Indexed: 09/05/2023] Open
Abstract
Fibromuscular dysplasia (FMD) is a rare idiopathic, segmental, noninflammatory and nonatherosclerotic arteriopathy of medium-sized arteries. It is classically considered to be a disease of young and middle adulthood, with females more commonly affected than males. FMD is a systemic disease. Although historically considered to be rare, cerebrovascular FMD (C-FMD) has now been recognized to be as common as the renovascular counterpart. Extracranial carotid and vertebral arteries are the most commonly involved vascular territories in C-FMD with the clinical presentation determined by vessels affected. Common symptoms include headaches and pulsatile tinnitus, with transient ischemic attacks, ischemic stroke and subarachnoid or intracerebral hemorrhage constituting the more severe clinical manifestations. Cervical artery dissection involving carotids more often than vertebral arteries and intracranial aneurysms account for the cerebrovascular pathologies detected in C-FMD. Our understanding regarding C-FMD has been augmented in the recent past on account of dedicated C-FMD data from North American, European and other international FMD cohorts. In this review article, we provide an updated and comprehensive overview on epidemiology, clinical presentation, etiology, diagnosis and management of C-FMD.
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Affiliation(s)
- Praveen Kesav
- Department of Neurology, Neurological Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Divya Manesh Raj
- Research Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Seby John
- Department of Neurology and Neuro Interventional Surgery, Neurological Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
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16
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Al-Karagholi MAM, Kalatharan V, Fagerberg PS, Amin FM. The vascular role of CGRP: a systematic review of human studies. Front Neurol 2023; 14:1204734. [PMID: 37483452 PMCID: PMC10359159 DOI: 10.3389/fneur.2023.1204734] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 06/19/2023] [Indexed: 07/25/2023] Open
Abstract
Intravenous infusion of human alpha calcitonin gene-related peptide (h-α-CGRP) has been applied to explore migraine pathogenesis and cerebral hemodynamics during the past three decades. Cumulative data implicate h-α-CGRP in regulating the vascular tone. In this systematic review, we searched PubMed and EMBASE for clinical studies investigating the vascular changes upon intravenous infusion of h-α-CGRP in humans. A total of 386 studies were screened by title and abstract. Of these, 11 studies with 61 healthy participants and 177 participants diagnosed with migraine were included. Several studies reported hemodynamic effects including flushing, palpitation, warm sensation, heart rate (HR), mean arterial blood pressure (MABP), mean blood flow velocity of middle cerebral artery (mean VMCA), and diameter of superficial temporal artery (STA). Upon the start of h-α-CGRP infusion, 163 of 165 (99%) participants had flushing, 98 of 155 (63%) participants reported palpitation, and 160 of 165 (97%) participants reported warm sensation. HR increased with 14%-58% and MABP decreased with 7%-12%. The mean VMCA was decreased with 9.5%-21%, and the diameter of the STA was dilated with 41%-43%. The vascular changes lasted from 20 to >120 min. Intravenous infusion of h-α-CGRP caused a universal vasodilation without any serious adverse events. The involvement of CGRP in the systemic hemodynamic raises concerns regarding long-term blockade of CGRP in migraine patients with and without cardiovascular complications.
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17
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Battini V, Carnovale C, Clementi E, Sessa M. Ubrogepant and rimegepant: signal detection using spontaneous reports of adverse events from the Food and Drug Administration Adverse Event Reporting System. Expert Opin Drug Saf 2023; 22:1105-1112. [PMID: 37293948 DOI: 10.1080/14740338.2023.2223958] [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] [Received: 03/29/2023] [Accepted: 05/12/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND In this study, we fill this gap in knowledge by updating the safety profile of ubrogepant and rimegepant via disproportionality analysis in the Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS), a US-based database registering spontaneous reports. RESEARCH DESIGN AND METHODS ASCII files of quarterly extraction of FAERS data were downloaded from the FDA website up to the 3rd quarter (Q3) of 2021 (last accessed 03/02/2022). Disproportionality analysis was done using the Reporting Odds Ratio (ROR) as a disproportionality measure. RORs of all AEs related to ubrogepant and rimegepant in FAERS were calculated in comparison with those related to erenumab. Drug-event pairs with a frequency ≤ 2, were removed according to European Medicine Agency (EMA)'s procedures. RESULTS In total, 2010 and 3691 individual case safety reports (ICSRs) recorded in FAERS reported ubrogepant and rimegepant, respectively, as suspect drugs. Ten disproportionality signals for ubrogepant and 25 disproportionality signals for rimegepant were identified; these were mostly related to psychiatric, neurological, gastrointestinal, skin, vascular, and infectious type of adverse events. CONCLUSIONS New safety aspects related to the treatment of ubrogepant and rimegepant using disproportionality analysis from spontaneous reporting databases were identified. Further studies are needed to confirm these findings.
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Affiliation(s)
- Vera Battini
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
- Pharmacovigilance & Clinical Research, International Centre for Pesticides and Health Risk Prevention, Department of Biomedical and Clinical Sciences (DIBIC), ASST Fatebenefratelli-Sacco University Hospital, Università Degli Studi di Milano, Milan, Italy
| | - Carla Carnovale
- Pharmacovigilance & Clinical Research, International Centre for Pesticides and Health Risk Prevention, Department of Biomedical and Clinical Sciences (DIBIC), ASST Fatebenefratelli-Sacco University Hospital, Università Degli Studi di Milano, Milan, Italy
| | - Emilio Clementi
- Pharmacovigilance & Clinical Research, International Centre for Pesticides and Health Risk Prevention, Department of Biomedical and Clinical Sciences (DIBIC), ASST Fatebenefratelli-Sacco University Hospital, Università Degli Studi di Milano, Milan, Italy
- Scientific Institute, IRCCS E. Medea, Bosisio Parini, LC, Italy
| | - Maurizio Sessa
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
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18
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Al-Hassany L, Karsan N, Lampl C, Goadsby PJ, MaassenVanDenBrink A. Revisiting dose-finding of monoclonal antibodies in migraine. J Headache Pain 2023; 24:69. [PMID: 37296378 DOI: 10.1186/s10194-023-01602-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023] Open
Abstract
Migraine is a debilitating disorder, and while the introduction of monoclonal antibodies (mAbs) has led to efficacious and tolerable responses, a substantial number of patients are so-called "non-responders". We introduce reasons for this insufficient response, including insufficient blockade of Calcitonin Gene-Related Peptide (CGRP) or its receptor. We present a clinical case, i.e. a female migraine patient who mistakenly administered supratherapeutic (three-fold higher) doses of erenumab leading to more efficacious clinical responses without any side-effects. This example illustrates that the initial dosages might have been too low, resulting in a remaining undesired increased effect of CGRP. While a capsaicin forearm model has repeatedly been used to evaluate the pharmacokinetic-pharmacodynamic relationship of mAbs, we provide directions to revisit or reconsider dose-finding and dose-ranging of these drugs. These directions include (i) refinement and application of a capsaicin forehead model (instead of a forearm model) to study trigeminovascular activity and improve dosing, and (ii) reconsideration of trial populations. Indeed, the dose-finding studies were mainly performed in relatively young and normal-weight males, while most phase III/IV trials are marked by a high female-to-male ratio, mainly consisting of overweight to obese females. Considering these aspects in future trials could optimize healthcare for a larger proportion of migraine patients.
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Affiliation(s)
- Linda Al-Hassany
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Nazia Karsan
- NIHR SLaM Clinical Research Facility, King's College London, London, UK
- Department of Neurology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Christian Lampl
- Department of Neurology and Stroke Unit, Koventhospital Barmherzige Brüder Linz, Linz, Austria
- Headache Medical Center Linz, Linz, Austria
| | - Peter J Goadsby
- NIHR SLaM Clinical Research Facility, King's College London, London, UK
- Department of Neurology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Antoinette MaassenVanDenBrink
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.
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19
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Starling AJ, Kymes S, Asher D, Soni-Brahmbhatt S, Karnik-Henry M. Early clinical experience with eptinezumab: results of a retrospective observational study of patient response in the United States. BMC Neurol 2023; 23:158. [PMID: 37081405 PMCID: PMC10116681 DOI: 10.1186/s12883-023-03204-8] [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: 08/12/2022] [Accepted: 04/11/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND The efficacy and safety of eptinezumab for preventive migraine treatment in adults have been demonstrated in multiple, large-scale clinical trials. This non-interventional, retrospective, observational chart review was conducted to examine patient response to eptinezumab 100 mg or 300 mg every 12 weeks for 6 months in the clinical setting. METHODS Eight headache specialists who reported early clinical experience with eptinezumab enrolled the first adults (1-6 adults per clinician; age ≥ 18 years) who met predefined selection criteria (including ≥ 12-month history of migraine, ≥ 4 migraine days/month prior to eptinezumab initiation, receipt of ≥ 2 consecutive eptinezumab doses, and ≥ 12-week follow-up period), and provided detailed patient, disease, treatment, and outcome information via SurveyMonkey and standardized case-report forms. RESULTS Charts from 31 adults (median age, 49 years) with migraine (93.6% chronic) who received eptinezumab for the preventive treatment of migraine were reviewed. Most patients (26/31 [83.9%]) were initiated at 100 mg. Eptinezumab reduced mean headache frequency (24.3 monthly headache days [MHDs] at baseline; 17.1 MHDs at Month 6); mean migraine frequency (17.3 monthly migraine days [MMDs] at baseline; 9.1 MMDs at Month 6); attack severity (17/31 [54.8%] patients); acute headache medication use (12.5 acute medication days at baseline; 7.4 at Month 6); and patient-reported disability (11/22 [50.0%] severe at baseline; 7/19 [36.8%] at Month 6). More than three-quarters of patients (24/31 [77.4%]) perceived improved disability/function and most (30/31 [96.8%]) perceived eptinezumab to be well tolerated after 6 months. Most of the headache specialists reported that eptinezumab was well tolerated by patients (30/31 [96.8%]) and that the intravenous infusion experience was not challenging. CONCLUSIONS Patients with migraine who received 6 months of preventive treatment with eptinezumab experienced reductions in migraine and headache frequency, disability, and acute medication use during the course of treatment.
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Affiliation(s)
- Amaal J Starling
- Mayo Clinic Arizona, 13400 East Shea Boulevard, Scottsdale, AZ, 85259, USA.
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Ceriani CEJ, Silberstein SD. Current and Emerging Pharmacotherapy for Menstrual Migraine: A Narrative Review. Expert Opin Pharmacother 2023; 24:617-627. [PMID: 36946205 DOI: 10.1080/14656566.2023.2194487] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
INTRODUCTION In this article, we discuss menstrual migraine (MM), which can be categorized as menstrually related migraine (MRM) or pure menstrual migraine (PMM). MM attacks are often longer, more severe, and harder to treat than other migraine attacks. Appropriate treatment strategies include acute treatment, short term preventive treatment, and daily preventive treatment, depending on the patient's pattern of migraine and occurrence of migraine outside the menstrual period. AREAS COVERED A PubMed, Cochrane Library, Medline, and Ovid search from inception to October 2022 provided articles relating to MM pathophysiology and treatment. EXPERT OPINION In patients for whom standard acute therapy is inadequate, short term or daily preventive treatment should be considered. Patients with PMM may be adequately managed with short term preventive treatment started 2 days prior to the onset of migraine and continued for 5-6 days. Frovatriptan is the mainstay of short-term prevention. Patients who experience additional attacks outside the menstrual period may benefit from daily preventive treatment. Estrogen-containing contraceptive treatment may be effective in appropriately selected patients. Emerging research on the pathophysiology of MM indicates that oxytocin agonists and CGRP antagonists may prove to be effective treatment options.
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Affiliation(s)
- Claire E J Ceriani
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Stephen D Silberstein
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
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Blumenfeld AM, Boinpally R, De Abreu Ferreira R, Trugman JM, Dabruzzo B, Ailani J, Lipton RB. Phase Ib, open-label, fixed-sequence, drug-drug interaction, safety, and tolerability study between atogepant and ubrogepant in participants with a history of migraine. Headache 2023; 63:322-332. [PMID: 36602199 DOI: 10.1111/head.14433] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/07/2022] [Accepted: 10/11/2022] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To evaluate potential drug-drug interactions of ubrogepant and atogepant. BACKGROUND Ubrogepant and atogepant, calcitonin gene-related peptide (CGRP) receptor antagonists, are recently approved drugs for acute and preventive treatment of migraine, respectively. For patients with migraine who are prescribed atogepant for the preventive treatment of migraine, health care providers could prescribe ubrogepant for the acute treatment of breakthrough migraine attacks. METHODS A phase Ib, multi-center, open-label, fixed-sequence study was conducted in participants diagnosed with migraine for at least 1 year. To assess the primary objective of pharmacokinetic interactions in this phase I trial, the highest United States Food and Drug Administration-approved individual dose strengths of atogepant (60 mg once daily) and ubrogepant (100 mg) were utilized, with ubrogepant being administered on a fixed-dose schedule every 3 days, regardless of whether a participant was experiencing a migraine attack. Secondary endpoints included safety and tolerability. Clinical safety measurements were monitored throughout the study. RESULTS Of the 31 participants enrolled, 26 completed the study. A single dose of ubrogepant had no statistically significant effect on atogepant pharmacokinetics. Co-administration of ubrogepant with atogepant resulted in a 19% increase (geometric mean ratio 118.80, 90% confidence interval [CI] 108.69-129.84) in the ubrogepant area under the plasma concentration-time curve and a 26% increase (geometric mean ratio 125.63, 90% CI 105.58-149.48) in the ubrogepant maximum plasma concentration. These statistically significant changes in ubrogepant exposure were not clinically meaningful, and no new safety concerns were identified for the combination. CONCLUSION The combination use of atogepant and ubrogepant was safe and well tolerated in adult participants with a history of migraine enrolled in the study. Pharmacokinetic changes during co-administration were not clinically meaningful.
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Affiliation(s)
| | | | | | - Joel M Trugman
- Clinical Pharmacology, AbbVie Inc., Madison, New Jersey, USA
| | - Brett Dabruzzo
- Clinical Pharmacology, AbbVie Inc., Madison, New Jersey, USA
| | - Jessica Ailani
- MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Richard B Lipton
- The Saul R. Korey Department of Neurology, Albert Einstein College of Medicine, Bronx, New York, USA
- Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Bronx, New York, USA
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
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22
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Al-Hassany L, Lyons HS, Boucherie DM, Farham F, Lange KS, Marschollek K, Onan D, Pensato U, Storch E, Torrente A, Waliszewska-Prosół M, Reuter U. The sense of stopping migraine prophylaxis. J Headache Pain 2023; 24:9. [PMID: 36792981 PMCID: PMC9933401 DOI: 10.1186/s10194-023-01539-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 01/18/2023] [Indexed: 02/17/2023] Open
Abstract
INTRODUCTION Migraine prophylactic therapy has changed over recent years with the development and approval of monoclonal antibodies (mAbs) targeting the calcitonin gene-related peptide (CGRP) pathway. As new therapies emerged, leading headache societies have been providing guidelines on the initiation and escalation of such therapies. However, there is a lack of robust evidence looking at the duration of successful prophylaxis and the effects of therapy discontinuation. In this narrative review we explore both the biological and clinical rationale for prophylactic therapy discontinuation to provide a basis for clinical decision-making. METHODS Three different literature search strategies were conducted for this narrative review. These include i) stopping rules in comorbidities of migraine in which overlapping preventives are prescribed, notably depression and epilepsy; ii) stopping rules of oral treatment and botox; iii) stopping rules of antibodies targeting the CGRP (receptor). Keywords were utilized in the following databases: Embase, Medline ALL, Web of Science Core collection, Cochran Central Register of Controlled Trials, and Google Scholar. DISCUSSION Reasons to guide decision-making in stopping prophylactic migraine therapies include adverse events, efficacy failure, drug holiday following long-term administration, and patient-specific reasons. Certain guidelines contain both positive and negative stopping rules. Following withdrawal of migraine prophylaxis, migraine burden may return to pre-treatment level, remain unchanged, or lie somewhere in-between. The current suggestion to discontinue CGRP(-receptor) targeted mAbs after 6 to 12 months is based on expert opinion, as opposed to robust scientific evidence. Current guidelines advise the clinician to assess the success of CGRP(-receptor) targeted mAbs after three months. Based on excellent tolerability data and the absence of scientific data, we propose if no other reasons apply, to stop the use of mAbs when the number of migraine days decreases to four or fewer migraine days per month. There is a higher likelihood of developing side effects with oral migraine preventatives, and so we suggest stopping these drugs according to the national guidelines if they are well tolerated. CONCLUSION Translational and basic studies are warranted to investigate the long-term effects of a preventive drug after its discontinuation, starting from what is known about the biology of migraine. In addition, observational studies and, eventually, clinical trials focusing on the effect of discontinuation of migraine prophylactic therapies, are essential to substantiate evidence-based recommendations on stopping rules for both oral preventives and CGRP(-receptor) targeted therapies in migraine.
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Affiliation(s)
- Linda Al-Hassany
- grid.5645.2000000040459992XDepartment of Internal Medicine, Division of Vascular Medicine and Pharmacology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Hannah S. Lyons
- grid.6572.60000 0004 1936 7486Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Deirdre M. Boucherie
- grid.5645.2000000040459992XDepartment of Internal Medicine, Division of Vascular Medicine and Pharmacology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Fatemeh Farham
- grid.411705.60000 0001 0166 0922Department of Headache, Iranian Centre of Neurological Researchers, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Kristin S. Lange
- grid.6363.00000 0001 2218 4662Department of Neurology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Karol Marschollek
- grid.4495.c0000 0001 1090 049XDepartment of Neurology, Wroclaw Medical University, Wrocław, Poland
| | - Dilara Onan
- grid.14442.370000 0001 2342 7339Spine Health Unit, Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey ,grid.7841.aDepartment of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Umberto Pensato
- grid.417728.f0000 0004 1756 8807Neurology and Stroke Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy ,grid.452490.eHumanitas University, Pieve Emanuale, Milan, Italy
| | - Elisabeth Storch
- grid.6363.00000 0001 2218 4662Department of Neurology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Angelo Torrente
- grid.10776.370000 0004 1762 5517Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Marta Waliszewska-Prosół
- grid.4495.c0000 0001 1090 049XDepartment of Neurology, Wroclaw Medical University, Wrocław, Poland
| | - Uwe Reuter
- Department of Neurology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany. .,Universitätsmedizin Greifswald, Greifswald, Germany.
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23
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Altamura C, Ornello R, Ahmed F, Negro A, Miscio AM, Santoro A, Alpuente A, Russo A, Silvestro M, Cevoli S, Brunelli N, Grazzi L, Baraldi C, Guerzoni S, Andreou AP, Lambru G, Frattale I, Kamm K, Ruscheweyh R, Russo M, Torelli P, Filatova E, Latysheva N, Gryglas-Dworak A, Straburzynski M, Butera C, Colombo B, Filippi M, Pozo-Rosich P, Martelletti P, Sacco S, Vernieri F. OnabotulinumtoxinA in elderly patients with chronic migraine: insights from a real-life European multicenter study. J Neurol 2023; 270:986-994. [PMID: 36326890 DOI: 10.1007/s00415-022-11457-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 10/17/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Although migraine prevalence decreases with aging, some older patients still suffer from chronic migraine (CM). This study aimed to investigate the outcome of OnabotulinumtoxinA (OBT-A) as preventative therapy in elderly CM patients. METHODS This is a post hoc analysis of real-life prospectively collected data at 16 European headache centers on CM patients treated with OBT-A over the first three treatment cycles (i.e., Cy1-3). We defined: OLD patients aged ≥ 65 years and nonOLD those < 65-year-old. The primary endpoint was the changes in monthly headache days (MHDs) from baseline to Cy 1-3 in OLD compared with nonOLD participants. The secondary endpoints were the responder rate (RR) ≥ 50%, conversion to episodic migraine (EM) and the changes in days with acute medication use (DAMs). RESULTS In a cohort of 2831 CM patients, 235 were OLD (8.3%, 73.2% females, 69.6 years SD 4.7). MHDs decreased from baseline (24.8 SD 6.2) to Cy-1 (17.5 SD 9.1, p < 0.000001), from Cy-1 to Cy-2 (14.8 SD 9.2, p < 0.0001), and from Cy-2 to Cy-3 (11.9 SD 7.9, p = 0.001). DAMs progressively reduced from baseline (19.2 SD 9.8) to Cy-1 (11.9 SD 8.8, p < 0.00001), to Cy-2 (10.9 SD 8.6, p = 0.012), to Cy-3 (9.6 SD 7.4, p = 0.049). The 50%RR increased from 30.7% (Cy-1) to 34.5% (Cy-2), to 38.7% (Cy-3). The above outcome measures did not differ in OLD compared with nonOLD patients. CONCLUSION In a population of elderly CM patients with a long history of migraine OBT-A provided a significant benefit, over the first three treatment cycles, as good as in non-old patients.
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Affiliation(s)
- Claudia Altamura
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy.
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy.
| | - R Ornello
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, Via Vetoio 1 Coppito, 67100, L'Aquila, Italy
| | - F Ahmed
- Department of Neurosciences, Hull University Teaching Hospitals, Hull, UK
| | - A Negro
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sant'Andrea Hospital, Sapienza University, 00189, Rome, RM, Italy
| | - A M Miscio
- Unit of Neurology, Headache Center, Fondazione IRCCS "Casa Sollievo Della Sofferenza", San Giovanni Rotondo, FG, Italy
| | - A Santoro
- Unit of Neurology, Headache Center, Fondazione IRCCS "Casa Sollievo Della Sofferenza", San Giovanni Rotondo, FG, Italy
| | - A Alpuente
- Headache Unit, Department of Neurology, Vall d'Hebron University, Barcelona, Spain
- Headache and Neurological Pain Research Group, Department of Medicine, Vall d'Hebron Institute of Research (VHIR), Universitat Autonoma de Barcelona, Barcelona, Spain
| | - A Russo
- Department of Medical, Surgical, Neurological, Metabolic, and Aging Sciences, Headache Center, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - M Silvestro
- Department of Medical, Surgical, Neurological, Metabolic, and Aging Sciences, Headache Center, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - S Cevoli
- IRCCS Istituto delle scienze Neurologiche di Bologna, Bologna, Italy
| | - N Brunelli
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - L Grazzi
- Neurology Department, Headache Center, IRCCS Foundation "Carlo Besta" Neurological Institute, Via Celoria,11, 20133, Milan, Italy
| | - C Baraldi
- Digital and Predictive Medicine, Pharmacology and Clinical Metabolic Toxicology-Headache Center and Drug Abuse, Laboratory of Clinical Pharmacology and Pharmacogenomics, Department of Specialist Medicines, AOU Policlinico Di Modena, Modena, Italy
| | - S Guerzoni
- Digital and Predictive Medicine, Pharmacology and Clinical Metabolic Toxicology-Headache Center and Drug Abuse, Laboratory of Clinical Pharmacology and Pharmacogenomics, Department of Specialist Medicines, AOU Policlinico Di Modena, Modena, Italy
| | - A P Andreou
- Headache Service, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - G Lambru
- Headache Service, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - I Frattale
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, Via Vetoio 1 Coppito, 67100, L'Aquila, Italy
| | - K Kamm
- Department of Neurology, Ludwig Maximilians University München, Munich, Germany
| | - R Ruscheweyh
- Department of Neurology, Ludwig Maximilians University München, Munich, Germany
- Department of Psychosomatic Medicine and Psychotherapy, Technical University of Munich, Munich, Germany
| | - M Russo
- Neurology Unit, Neuromotor and Rehabilitation Department, Headache Center, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - P Torelli
- Headache Center, University of Parma, Parma, Italy
| | - E Filatova
- Department of Neurology, Institute for Postgraduate Education, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | | | | | - M Straburzynski
- Headache Clinic, Terapia Neurologiczna Samodzielni, Maurycego Mochnackiego 10, 02-042, Warsaw, Poland
| | - C Butera
- Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - B Colombo
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - M Filippi
- Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - P Pozo-Rosich
- Headache Unit, Department of Neurology, Vall d'Hebron University, Barcelona, Spain
- Headache and Neurological Pain Research Group, Department of Medicine, Vall d'Hebron Institute of Research (VHIR), Universitat Autonoma de Barcelona, Barcelona, Spain
| | - P Martelletti
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sant'Andrea Hospital, Sapienza University, 00189, Rome, RM, Italy
| | - S Sacco
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, Via Vetoio 1 Coppito, 67100, L'Aquila, Italy
| | - F Vernieri
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
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24
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Raffaelli B, De Icco R, Corrado M, Terhart M, Ailani J. Open-label trials for CGRP-targeted drugs in migraine prevention: A narrative review. Cephalalgia 2023; 43:3331024221137091. [PMID: 36718044 DOI: 10.1177/03331024221137091] [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: 02/01/2023]
Abstract
BACKGROUND Calcitonin gene-related peptide-targeted drugs have proven safe and effective for migraine prevention in large randomized-controlled, double-blind trials with an average duration of six months. Open-label studies may provide additional information on the long-term safety and efficacy of these substances. METHODS We searched PubMed for open-label trials with calcitonin gene-related peptide(-receptor) monoclonal antibodies and calcitonin gene-related peptide-receptor antagonists. We summarized and critically analyzed the literature in a narrative way. RESULTS Overall, 13 open-label trials were included in this review (n = 4 for erenumab, n = 4 for galcanezumab, n = 3 for fremanezumab, n = 1 for eptinezumab, n = 1 for atogepant). Open-label trial duration ranged between 12 and 264 weeks. No safety concerns emerged, and the adverse events profile was similar to the double-blind study phase. Discontinuation rates were generally low with >75% of patients remaining in the trials after one year. Efficacy data showed a sustained reduction of migraine frequency throughout the trials, along with a lasting improvement in quality of life. CONCLUSIONS The open-label study program for calcitonin gene-related peptide-targeted migraine preventives confirms the favorable safety and efficacy profile of these drugs over time. Treatment adherence appears higher than with previous unspecific migraine preventives. Real-world data and post-marketing surveillance studies may corroborate and complement open-label results.
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Affiliation(s)
- Bianca Raffaelli
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany.,Clinician Scientist Program, Berlin Institute of Health, Berlin, Germany
| | - Roberto De Icco
- Headache Science & Neurorehabilitation Center, IRCCS Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Michele Corrado
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Maria Terhart
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jessica Ailani
- MedStar Georgetown University Hospital, Washington, DC, USA
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25
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Raffaelli B, Terhart M, Fitzek MP, Lange KS, Mecklenburg J, Overeem LH, Siebert A, Storch E, Reuter U. Change of CGRP Plasma Concentrations in Migraine after Discontinuation of CGRP-(Receptor) Monoclonal Antibodies. Pharmaceutics 2023; 15:pharmaceutics15010293. [PMID: 36678920 PMCID: PMC9861447 DOI: 10.3390/pharmaceutics15010293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/08/2023] [Accepted: 01/13/2023] [Indexed: 01/17/2023] Open
Abstract
Discontinuation of treatment with monoclonal antibodies (mAb) targeting the Calcitonin Gene-Related Peptide (CGRP) pathway leads to an increase in migraine frequency. We aimed to assess changes in free and total CGRP plasma concentrations after the discontinuation of CGRP(-receptor) mAbs. This prospective analysis included 59 patients with migraine (n = 25 erenumab, n = 25 galcanezumab, n = 9 fremanezumab) who discontinued mAbs after ≥8 months of treatment. Patients were visited at the time of the last mAb injection (V1) and 16 weeks later (V2). For control, 30 migraine patients without preventive drug therapy were included. We measured free CGRP plasma concentrations in the erenumab and fremanezumab group and total CGRP concentrations in the galcanezumab group. Free CGRP plasma concentrations did not change after treatment discontinuation [erenumab: V1 31.2 pg/mL (IQR 25.8−45.6), V2 30.3 pg/mL (IQR 22.9−47.6), p = 0.65; fremanezumab V1 29.4 pg/mL (IQR 16.4−61.9), V2 34.4 (19.2−62.0), p = 0.86]. Controls had similar CGRP values of 32.6 pg/mL (IQR 21.3−44.6). Total CGRP concentrations in the galcanezumab group were 5439.3 pg/mL (2412.7−6338.1) at V1, and decreased to 1853.2 pg/mL (1136.5−3297.0) at V2 (p < 0.001). Cessation of treatment with CGRP(-R) mAbs did not have an impact on the free-circulating CGRP concentrations. Total CGRP decreased significantly after three months of treatment discontinuation.
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Affiliation(s)
- Bianca Raffaelli
- Department of Neurology, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
- Clinician Scientist Program, Berlin Institute of Health at Charité (BIH), 10117 Berlin, Germany
- Correspondence: ; Tel.: +49-(0)30-450-660888; Fax: +49-(0)30-450-560932
| | - Maria Terhart
- Department of Neurology, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Mira Pauline Fitzek
- Department of Neurology, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Kristin Sophie Lange
- Department of Neurology, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Jasper Mecklenburg
- Department of Neurology, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | | | - Anke Siebert
- Department of Neurology, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Elisabeth Storch
- Department of Neurology, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Uwe Reuter
- Department of Neurology, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
- Universitätsmedizin Greifswald, 17475 Greifswald, Germany
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26
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Adverse Events Reported with Therapies Targeting the CGRP Pathway During the First 6 Months Post-launch: A Retrospective Analysis Using the FDA Adverse Events Reporting System. Adv Ther 2023; 40:445-459. [PMID: 36350532 PMCID: PMC9898337 DOI: 10.1007/s12325-022-02346-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 09/30/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Through 2018, three calcitonin gene-related peptide pathway-targeted monoclonal antibodies (CGRP mAbs) had received US Food and Drug Administration (FDA) approval for migraine prevention: erenumab, fremanezumab, and galcanezumab. METHODS This retrospective analysis evaluated adverse events (AEs) spontaneously reported to the FDA Adverse Event Reporting System (FAERS) safety surveillance database during the first 6 months post-approval of erenumab (May 2018 to November 2018), fremanezumab (September 2018 to March 2019), and galcanezumab (September 2018 to March 2019). Reporting rates (RR) per 1000 exposed patients were calculated from number of reported events (when product classified as "primary suspect") in each AE category and estimated number of treated patients based on de-identified prescription data (IQVIA database) and were ranked on the basis of frequency for each product. RESULTS RR per 1000 exposed patients for "migraine" (erenumab, 4.89; fremanezumab, 1.01; galcanezumab, 2.99), "headache" (3.32, 1.27, 3.07), and "drug ineffective" (3.68, 1.14, 1.69) were commonly reported for all three products, as were migraine-associated symptoms ("nausea": 2.94, 0.91, 1.09) and "injection-site" reactions ("pain": 2.94, 0.8, 4.9; "swelling": 0.56, 0.53, 1.25; "pruritus": 0.26, 0.63, 1.14; "erythema": 0.58, 0.71, 1.58). "Constipation" ranked second for erenumab (4.90) but did not make the top ten events for fremanezumab (0.46) or galcanezumab (0.76); cardiovascular events did not rank in the top ten AEs for any product. The frequency of serious outcomes was low, with ≤ 2% of AEs categorized as serious across the CGRP mAbs. CONCLUSION These results aid in supporting the safety profile of CGRP mAbs in the real-world setting and may provide clinicians and patients with additional insight when considering migraine preventive treatments.
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27
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Klein BC, Miceli R, Severt L, McAllister P, Mechtler L, McVige J, Diamond M, Marmura MJ, Guo H, Finnegan M, Trugman JM. Safety and tolerability results of atogepant for the preventive treatment of episodic migraine from a 40-week, open-label multicenter extension of the phase 3 ADVANCE trial. Cephalalgia 2023; 43:3331024221128250. [PMID: 36620892 DOI: 10.1177/03331024221128250] [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: 01/10/2023]
Abstract
BACKGROUND Atogepant is a United States Food and Drug Administration-approved oral calcitonin gene-related peptide receptor antagonist for the preventive treatment of episodic migraine. The study objective was to evaluate the long-term safety and tolerability of atogepant in participants who completed the phase 3 ADVANCE trial (NCT03777059). METHODS This 40-week, open-label extension trial (NCT03939312) monitored safety in participants receiving oral atogepant 60 mg once daily, followed by a four-week safety follow-up period. RESULTS Of the 685 participants taking at least one dose of atogepant, the treatment period was completed by 74.6% of participants with a mean (standard deviation) treatment duration of 233.6 (89.3) days. Treatment-emergent adverse events occurred in 62.5% of participants, with upper respiratory tract infection (5.5%), urinary tract infection (5.3%), nasopharyngitis (4.8%), sinusitis (3.6%), constipation (3.4%), and nausea (3.4%) occurring at ≥3%. Serious adverse events were observed in 3.4% of participants (none were treatment-related), and there were no deaths. Adverse events leading to discontinuation occurring at >0.1% were nausea (0.4%) and abdominal pain, vomiting, weight decrease, dizziness, and migraine (0.3% each). CONCLUSION These results are consistent with atogepant's known safety profile and support long-term use of atogepant 60 mg once daily dosing as safe and well tolerated.ClinicalTrials.gov Registration Number: NCT03939312.
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Affiliation(s)
- Brad C Klein
- Abington Neurological Associates, Ltd., Abington, PA, USA
| | | | | | - Peter McAllister
- New England Institute for Neurology & Headache, Stamford, CT, USA
| | | | | | | | - Michael J Marmura
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Hua Guo
- AbbVie Inc., Madison, NJ, USA
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28
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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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Albanese M. Clinical Management of Migraine. J Clin Med 2022; 11:jcm11175225. [PMID: 36079154 PMCID: PMC9457445 DOI: 10.3390/jcm11175225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/01/2022] [Indexed: 11/18/2022] Open
Affiliation(s)
- Maria Albanese
- Regional Referral Headache Center, Neurology Unit, University Hospital Tor Vergata, 00133 Rome, Italy;
- Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
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Reducing the Burden of Migraine: Safety and Efficacy of CGRP Pathway-Targeted Preventive Treatments. J Clin Med 2022; 11:jcm11154359. [PMID: 35955976 PMCID: PMC9369309 DOI: 10.3390/jcm11154359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 06/24/2022] [Accepted: 06/29/2022] [Indexed: 11/16/2022] Open
Abstract
Migraine is a highly disabling and often chronic neurological disease that affects more than one billion people globally. Preventive migraine treatment is recommended for individuals who have frequent and/or disabling attacks; however, many of the medications used for migraine prevention (e.g., antiepileptics, antidepressants, antihypertensives) were not specifically developed for migraine, and often have limited efficacy or poor tolerability. Four monoclonal antibodies targeting the calcitonin gene-related peptide (CGRP) pathway, which is believed to play a crucial role in the pathophysiology of migraine, have been approved by the US Food and Drug Administration for the preventive treatment of migraine in adults. All four migraine-specific treatments have demonstrated efficacy based on reductions in monthly days with migraine for patients with both episodic and chronic migraine, including those with comorbidities. They have also demonstrated favorable safety and tolerability profiles. Based on these accounts, CGRP pathway-targeted monoclonal antibodies have the potential to revolutionize preventive treatment for patients with migraine.
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Bentivegna E, Luciani M, Ferrari V, Galastri S, Baldari F, Scarso F, Lamberti PA, Martelletti P. Recently approved and emerging drug options for migraine prophylaxis. Expert Opin Pharmacother 2022; 23:1325-1335. [PMID: 35850597 DOI: 10.1080/14656566.2022.2102420] [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
INTRODUCTION : Migraine occupies the first position regarding to the disability caused in female working population (15-49 years). Research in the field of prophylaxis of this pathology has made enormous strides in recent years. AREAS COVERED In this narrative review we retrace the most important scientific evidence regarding recently approved and emerging drug for prophylactic treatment of migraine. The purpose of this article is in fact to evaluate currently approved or emerging pharmacological agents for migraine prophylaxis. This review is based on literature published in peer review journal obtained through PubMed, Cochrane library, Clinicaltrials.gov and US FDA. EXPERT OPINION : Monoclonal antibodies (mAbs) that target the calcitonin gene-related peptide signalling pathway (CGRP) have marked an innovation in prophylactic migraine therapy. The combination of Onabotulinumtoxin-A (OBTA) and mAbs appears to be an effective, but costly, therapeutic option for resistant cases. New classes of molecules like gepants and ditans seem to give exceptional results. In addition, new prophylactic drugs are emerging with several targets: the pituitary adenylate cyclase-activating polypeptide (PACAP), ion channels, several receptors coupled to G proteins, orexin, and glutamate. All these therapies will implement and improve migraine management, as well as personalized medicine for each patient.
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Affiliation(s)
- Enrico Bentivegna
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | | | - Valeria Ferrari
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Silvia Galastri
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Francesco Baldari
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Francesco Scarso
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Piera A Lamberti
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy.,Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy
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Robblee J, Harvey LK. Cardiovascular Disease and Migraine: Are the New Treatments Safe? Curr Pain Headache Rep 2022; 26:647-655. [PMID: 35751798 DOI: 10.1007/s11916-022-01064-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW The authors present data on cardiovascular safety for the new acute and preventive migraine treatments including ditans, gepants, and calcitonin gene-related peptide monoclonal antibodies (CGRP mAbs) alongside older medications like triptans and ergotamines. RECENT FINDINGS The authors conclude that there are no cardiovascular safety concerns for lasmiditan, and that it could be used in those with cardiovascular disease. In fact, the literature even suggests that triptans are safer in cardiovascular disease than their contraindications may suggest. At this time, there is insufficient evidence that gepants and CGRP mAbs should be contraindicated in those with cardiovascular disease including stroke or myocardial infarction, though erenumab has now been associated with hypertension. Vasodilation may be an important CGRP-mediated mechanism mid-ischemia especially in patients with small vessel disease; hence, CGRP antagonists should be use with caution in this context. Long-term data is still needed, and prescribers should ensure patients are aware of the limitations of our knowledge at this time, while still offering these effective and well-tolerated treatment options.
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Affiliation(s)
- Jennifer Robblee
- Lewis Headache Center, Department of Neurology, Barrow Neurological Institute
- St Joseph Health Center, 350 W. Thomas Rd, AZ, 85013, Phoenix, USA.
| | - Lauren K Harvey
- Lewis Headache Center, Department of Neurology, Barrow Neurological Institute
- St Joseph Health Center, 350 W. Thomas Rd, AZ, 85013, Phoenix, USA
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Sacco S, Amin FM, Ashina M, Bendtsen L, Deligianni CI, Gil-Gouveia R, Katsarava Z, MaassenVanDenBrink A, Martelletti P, Mitsikostas DD, Ornello R, Reuter U, Sanchez-Del-Rio M, Sinclair AJ, Terwindt G, Uluduz D, Versijpt J, Lampl C. European Headache Federation guideline on the use of monoclonal antibodies targeting the calcitonin gene related peptide pathway for migraine prevention - 2022 update. J Headache Pain 2022; 23:67. [PMID: 35690723 PMCID: PMC9188162 DOI: 10.1186/s10194-022-01431-x] [Citation(s) in RCA: 146] [Impact Index Per Article: 73.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/29/2022] [Indexed: 01/05/2023] Open
Abstract
Background A previous European Headache Federation (EHF) guideline addressed the use of monoclonal antibodies targeting the calcitonin gene-related peptide (CGRP) pathway to prevent migraine. Since then, randomized controlled trials (RCTs) and real-world evidence have expanded the evidence and knowledge for those treatments. Therefore, the EHF panel decided to provide an updated guideline on the use of those treatments. Methods The guideline was developed following the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach. The working group identified relevant questions, performed a systematic review and an analysis of the literature, assessed the quality of the available evidence, and wrote recommendations. Where the GRADE approach was not applicable, expert opinion was provided. Results We found moderate to high quality of evidence to recommend eptinezumab, erenumab, fremanezumab, and galcanezumab in individuals with episodic and chronic migraine. For several important clinical questions, we found not enough evidence to provide evidence-based recommendations and guidance relied on experts’ opinion. Nevertheless, we provided updated suggestions regarding the long-term management of those treatments and their place with respect to the other migraine preventatives. Conclusion Monoclonal antibodies targeting the CGRP pathway are recommended for migraine prevention as they are effective and safe also in the long-term. Supplementary Information The online version contains supplementary material available at 10.1186/s10194-022-01431-x.
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Affiliation(s)
- Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences - University of L'Aquila, Via Vetoio 1, L'Aquila, Italy.
| | - Faisal Mohammad Amin
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, University of Copenhagen, Copenhagen, Denmark.,Department of Neurorehabilitation/Traumatic Brain Injury, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Messoud Ashina
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, University of Copenhagen, Copenhagen, Denmark
| | - Lars Bendtsen
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, University of Copenhagen, Copenhagen, Denmark
| | - Christina I Deligianni
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, University of Copenhagen, Copenhagen, Denmark
| | - Raquel Gil-Gouveia
- Hospital da Luz Headache Center, Neurology Department, Hospital da Luz Lisboa, Lisbon, Portugal.,Center for Interdisciplinary Research in Health, Universidade Católica Portuguesa, Lisbon, Portugal
| | - Zaza Katsarava
- Christian Hospital Unna, Unna, Germany.,University of Duisburg-Essen, Duisburg, Germany
| | | | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Dimos-Dimitrios Mitsikostas
- 1st Department of Neurology, Aeginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Raffaele Ornello
- Department of Biotechnological and Applied Clinical Sciences - University of L'Aquila, Via Vetoio 1, L'Aquila, Italy
| | - Uwe Reuter
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany.,Universitätsmedizin Greifswald, Greifswald, Germany
| | | | - Alexandra J Sinclair
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2WB, UK
| | - Gisela Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Derya Uluduz
- Department of Neurology Istanbul Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Jan Versijpt
- Department of Neurology, Vrije Universiteit Brussel (VUB), Universitair, Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Christian Lampl
- Department of Neurology, Headache Medical Center at the Konventhospital BHB Linz, Linz, Austria
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Martin V, Tassorelli C, Ettrup A, Hirman J, Cady R. Eptinezumab for migraine prevention in patients 50 years or older. Acta Neurol Scand 2022; 145:698-705. [PMID: 35218203 PMCID: PMC9305510 DOI: 10.1111/ane.13603] [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: 11/11/2021] [Revised: 01/13/2022] [Accepted: 02/13/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of eptinezumab versus placebo in patients ≥50 years old with episodic (EM) or chronic migraine (CM). MATERIALS AND METHODS This post hoc analysis included data from two phase 3, parallel-group, randomized, double-blind, placebo-controlled studies in adults with EM (PROMISE-1) or CM (PROMISE-2). Patients ≥50 years at baseline treated with eptinezumab 100 mg, 300 mg, or placebo were pooled from both studies to evaluate efficacy and safety. RESULTS A total of 385/1960 (19.6%) EM and CM patients who were ≥50 years old at baseline (range, 50-71 and 50-65 years, respectively) received eptinezumab 100 mg (n = 132), 300 mg (n = 127), or placebo (n = 126) over Weeks 1-12. Reductions in mean monthly migraine days (MMDs) in ≥50-year-old EM patients were -3.8 (100 mg) and -4.4 (300 mg) with eptinezumab versus -2.6 with placebo. In ≥50-year-old CM patients, mean changes in MMDs were -7.7 (100 mg) and -8.6 (300 mg) with eptinezumab versus -6.0 with placebo. Changes in MMDs were comparable to total study results. A ≥50% MMD reduction over Weeks 1-12 was achieved by 57.9% of eptinezumab-treated versus 35.7% of patients who received placebo, and a ≥75% reduction by 30.5% versus 13.5%, respectively. The incidence of treatment-emergent adverse events (TEAEs) in EM and CM patients ≥50 years old was similar across treatment groups, with ≥96% of TEAEs mild or moderate in severity. CONCLUSIONS Treatment with eptinezumab was efficacious, tolerable, and safe in patients ≥50 years with EM or CM, congruent with results from the overall study population.
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Affiliation(s)
- Vincent Martin
- University of Cincinnati Headache and Facial Pain Center Cincinnati Ohio USA
| | - Cristina Tassorelli
- Headache Science and Neurorehabilitation Centre IRCCS Mondino Foundation Pavia Italy
- Department of Brain and Behavioral Sciences University of Pavia Pavia Italy
| | | | - Joe Hirman
- Pacific Northwest Statistical Consulting, Inc Woodinville Washington USA
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Zhu S, Zidan A, Pang K, Musayeva A, Kang Q, Yin J. Promotion of corneal angiogenesis by sensory neuron-derived calcitonin gene-related peptide. Exp Eye Res 2022; 220:109125. [PMID: 35618042 DOI: 10.1016/j.exer.2022.109125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 05/08/2022] [Accepted: 05/18/2022] [Indexed: 11/30/2022]
Abstract
The normal cornea has no blood vessels but has abundant innervation. There is emerging evidence that sensory nerves, originated from the trigeminal ganglion (TG) neurons, play a key role in corneal angiogenesis. In the current study, we examined the role of TG sensory neuron-derived calcitonin gene-related peptide (CGRP) in promoting corneal neovascularization (CNV). We found that CGRP was expressed in the TG and cultured TG neurons. In the cornea, minimal CGRP mRNA was detected and CGRP immunohistochemical staining was exclusively co-localized with corneal nerves, suggesting corneal nerves are likely the source of CGRP in the cornea. In response to intrastromal suture placement and neovascularization in the cornea, CGRP expression was increased in the TG. In addition, we showed that CGRP was potently pro-angiogenic, leading to vascular endothelial cell (VEC) proliferation, migration, and tube formation in vitro and corneal hemangiogenesis and lymphangiogenesis in vivo. In a co-culture system of TG neurons and VEC, blocking CGRP signaling in the conditioned media of TG neurons led to decreased VEC migration and tube formation. More importantly, subconjunctival injection of a CGRP antagonist CGRP8-37 reduced suture-induced corneal hemangiogenesis and lymphangiogenesis in vivo. Taken together, our data suggest that TG sensory neuron and corneal nerve-derived CGRP promotes corneal angiogenesis.
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Affiliation(s)
- Shuyan Zhu
- Department of Ophthalmology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi, China; Schepens Eye Research Institute of Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Asmaa Zidan
- Schepens Eye Research Institute of Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Kunpeng Pang
- Schepens Eye Research Institute of Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Aytan Musayeva
- Schepens Eye Research Institute of Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Qianyan Kang
- Department of Ophthalmology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi, China
| | - Jia Yin
- Schepens Eye Research Institute of Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA.
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Krasenbaum LJ, Pedarla VL, Thompson SF, Tangirala K, Cohen JM, Driessen MT. A real-world study of acute and preventive medication use, adherence, and persistence in patients prescribed fremanezumab in the United States. J Headache Pain 2022; 23:54. [PMID: 35508970 PMCID: PMC9066733 DOI: 10.1186/s10194-022-01413-z] [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: 01/04/2022] [Accepted: 03/11/2022] [Indexed: 11/25/2022] Open
Abstract
Background Following approval of fremanezumab for the prevention of migraine in adults, health care decision makers are interested in understanding real-world clinical characteristics and treatment patterns among patients initiating fremanezumab therapy. Methods Data were obtained for this retrospective (pre-post) study from the Veradigm Health Insights database. The study period was January 1, 2014, to June 30, 2019. Patients were included if they were aged ≥ 18 years; had ≥ 1 migraine diagnosis during the study period; and had a medication record for fremanezumab on or after diagnosis during the identification period (September 1, 2018–December 31, 2018). Treatment patterns, including adherence, persistence, and utilization of acute and preventive migraine medication prescriptions, were evaluated. Results Of 987 patients initiating fremanezumab during the study period, 738 (74.8%) were adherent to fremanezumab by proportion of days covered (PDC; ≥ 80%) and 780 (79.0%) were adherent by medication possession ratio (MPR; ≥ 80%). A total of 746 (75.6%) patients were persistent for ≥ 6 months. Quarterly fremanezumab (n = 186) was associated with higher rates of adherence versus monthly fremanezumab (n = 801) by PDC (quarterly, 91.3%; monthly, 84.9%; P < 0.001) and MPR (quarterly, 92.2%; monthly, 87.9%; P = 0.006) and higher persistence at ≥ 6 months (quarterly, 82.8%; monthly, 73.9%; P = 0.011). After fremanezumab initiation, patients who were persistent for ≥ 6 months experienced significant reductions from baseline in the mean monthly number of acute and preventive migraine medication prescriptions (P < 0.001). Subgroup analyses in patients with comorbid depression and anxiety showed meaningful real-world benefits based on significant reductions in the number of patients who were prescribed antidepressants (baseline, 68.6%; follow-up, 56.4%; P = 0.0025) and anxiolytic medications (baseline, 55.0%; follow-up, 47.2%; P = 0.037), respectively. In a subgroup of patients with comorbid hypertension at baseline, fremanezumab treatment resulted in nonsignificant reductions in blood pressure. Conclusions Overall, adherence and persistence to fremanezumab in this real-world study was high in patients with migraine, with higher rates observed for quarterly fremanezumab. Patients who were persistent for ≥ 6 months experienced significant reductions in acute and preventive migraine medication use, while a subgroup of migraine patients with comorbid depression and anxiety at baseline showed significant reductions in antidepressant and anxiolytic medication use. Supplementary Information The online version contains supplementary material available at 10.1186/s10194-022-01413-z.
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Gérard AO, Merino D, Van Obberghen EK, Rocher F, Destere A, Lantéri-Minet M, Drici MD. Calcitonin gene-related peptide-targeting drugs and Raynaud's phenomenon: a real-world potential safety signal from the WHO pharmacovigilance database. J Headache Pain 2022; 23:53. [PMID: 35505285 PMCID: PMC9066820 DOI: 10.1186/s10194-022-01424-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 04/27/2022] [Indexed: 11/28/2022] Open
Abstract
Background Migraine is responsible for significant disability and societal burden. Recently, drugs targeting the calcitonin gene-related peptide (CGRP) pathway raised new hopes. CGRP, a potent vasodilator, plays a key role in the pathogenesis of migraine attacks. The deficiency of CGRP is involved in Raynaud’s phenomenon, which consists of abnormal vasoconstriction of the digits. We aimed to assess the potential association of Raynaud’s phenomenon with CGRP-targeting drugs, analyzing real-world data from the World Health Organization (VigiBase®). Methods We queried all reports of Raynaud’s phenomenon involving a CGRP-targeting drug. We sought disproportionate reporting of Raynaud’s phenomenon with these drugs. For this purpose, we relied on the calculation of the Information Component (IC). A positive lower end of the 95% confidence interval (CI) of the IC defines a statistically significant association. As migraine patients are prone to Raynaud’s phenomenon, we also calculated the IC of Raynaud’s phenomenon with CGRP-targeting drugs compared to 5HT1B/D agonists (triptans), and beta-blockers used in the treatment of migraine. Results Overall, 99 reports of Raynaud’s phenomenon involving CGRP-targeting drugs have been yielded in VigiBase®. The most reported CGRP-targeting drug was erenumab, with 56 reports (56.6%). The median time to onset was 84 days. No fatality was notified, but one patient suffered from gangrene and extremity necrosis. As a whole, CGRP-targeting drugs were significantly associated with Raynaud’s phenomenon, with an IC of 3.3 (95%CI: 3.0–3.5). There was a disproportionate reporting of Raynaud’s phenomenon with CGRP-targeting drugs compared to triptans (IC 0.4; 95%CI: 0.1–0.6) and to beta-blockers (IC 0.5; 95%CI: 0.2–0.7) as well. Conclusions There is a significant disproportionality signal of Raynaud’s phenomenon with CGRP-targeting. This signal stands out when CGRP-targeting drugs are compared to other drugs used in patients with migraine. This study is limited by missing data in pharmacovigilance reports. CGRP-targeting drugs may be subject to Weber effect and reporting bias. Nonetheless, CGRP blockade might be the last straw that disrupts the physiological balance of vascular response in patients at-risk of Raynaud’s phenomenon. Pending further data regarding vascular safety of CGRP-targeting drugs, caution is warranted in these patients.
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Affiliation(s)
- Alexandre O Gérard
- Department of Pharmacology and Pharmacovigilance Center of Nice, University Hospital Center of Nice, Nice, France.,Department of Nephrology-Dialysis-Transplantation, University Hospital Center of Nice, Nice, France.,Laboratory of Molecular Physio Medicine (LP2M), UMR 7370, CNRS, University Côte d'Azur, Nice, France
| | - Diane Merino
- Department of Pharmacology and Pharmacovigilance Center of Nice, University Hospital Center of Nice, Nice, France
| | - Elise K Van Obberghen
- Pain Department and FHU InovPain, University Hospital Center of Nice and Côte d'Azur University, Nice, France
| | - Fanny Rocher
- Department of Pharmacology and Pharmacovigilance Center of Nice, University Hospital Center of Nice, Nice, France
| | - Alexandre Destere
- Department of Pharmacology and Pharmacovigilance Center of Nice, University Hospital Center of Nice, Nice, France
| | - Michel Lantéri-Minet
- Pain Department and FHU InovPain, University Hospital Center of Nice and Côte d'Azur University, Nice, France.,Migraine and Trigeminal Pain, UMR 1107, INSERM, Auvergne University, Clermont-Ferrand, France
| | - Milou-Daniel Drici
- Department of Pharmacology and Pharmacovigilance Center of Nice, University Hospital Center of Nice, Nice, France.
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Glucose-Related Traits and Risk of Migraine—A Potential Mechanism and Treatment Consideration. Genes (Basel) 2022; 13:genes13050730. [PMID: 35627115 PMCID: PMC9141901 DOI: 10.3390/genes13050730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/19/2022] [Accepted: 04/19/2022] [Indexed: 12/16/2022] Open
Abstract
Migraine and glucose-related (glycaemic) traits (fasting glucose, fasting insulin, and type 2 diabetes) are common and complex comorbid disorders that cause major economic and social burdens on patients and their families. Studies on the relationship between migraine and glucose-related traits have yielded inconsistent results. The purpose of this review is to synthesise and discuss the information from the available literature on the relationship between fasting glucose, fasting insulin, and type 2 diabetes (T2D) with migraine. Publications on migraine and fasting glucose, migraine and fasting insulin, and migraine and T2D were identified from a PubMed and Google Scholar database search and reviewed for this article. Multiple publications have suggested that the comorbidity of migraine and glucose-related traits may have a similar complex pathogenic mechanism, including impaired glucose homeostasis, insulin resistance, reduced cerebrovascular reactivity, abnormal brain metabolism, shared genetic factors, neurotransmitters, and sex hormones. Furthermore, several studies have found a bi-directional link between migraine with insulin resistance and T2D. There is strong evidence for a biological association between migraine headache and glucose-related traits, and burgeoning evidence for shared genetic influences. Therefore, genetic research into these comorbid traits has the potential to identify new biomarkers and therapeutic targets and provide biological insight into their relationships. We encourage healthcare professionals to consider the co-occurrence of migraine with glucose-related traits in the evaluation and treatment of their patients.
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Cohen F, Yuan H, DePoy EMG, Silberstein SD. The Arrival of Anti-CGRP Monoclonal Antibodies in Migraine. Neurotherapeutics 2022; 19:922-930. [PMID: 35426060 PMCID: PMC9294119 DOI: 10.1007/s13311-022-01230-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2022] [Indexed: 01/08/2023] Open
Abstract
Remarkable advancements have been made in the field of migraine pathophysiology and pharmacotherapy over the past decade. Understanding the molecular mechanism of calcitonin gene-related peptide (CGRP) has led to the discovery of a novel class of drugs, CGRP functional blocking monoclonal antibodies (mAbs), for migraine prevention. CGRP is a neuropeptide inherently involved in migraine physiology where its receptors are found dispersed throughout the central and peripheral nervous systems. CGRP-targeted mAbs are effective in the preventive treatment of both chronic and episodic migraine. The advantages of mAbs over oral migraine preventives are numerous. Favorable attributes of the mAbs include high affinity and selectivity for CGRP molecular targets, long-circulating plasma half-lives, and limited risk for nonspecific hepatic and renal toxicity. This pharmacological profile leads to fewer off-target (side) effects and drug-drug interactions rendering mAbs an attractive alternative to traditional small molecule therapies, especially for the preventive treatment of migraine. MAbs display minimal drug interaction thus are excellent for patients prescribed with multiple medications. However, the long-term safety of CGRP blockade is incompletely known, and CGRP mAbs use should be avoided during pregnancy. CGRP mAbs represent a radical shift in preventing chronic and episodic migraine.
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Affiliation(s)
- Fred Cohen
- Department of Neurology, Jefferson Headache Center, Thomas Jefferson University, 900 Walnut Street, Suite 200, Philadelphia, PA, 19107, USA
| | - Hsiangkuo Yuan
- Department of Neurology, Jefferson Headache Center, Thomas Jefferson University, 900 Walnut Street, Suite 200, Philadelphia, PA, 19107, USA
| | - E M G DePoy
- Department of Neurology, Jefferson Headache Center, Thomas Jefferson University, 900 Walnut Street, Suite 200, Philadelphia, PA, 19107, USA
| | - Stephen D Silberstein
- Department of Neurology, Jefferson Headache Center, Thomas Jefferson University, 900 Walnut Street, Suite 200, Philadelphia, PA, 19107, USA.
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40
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Cohen F, Yuan H. Role of Atogepant in the Treatment of Episodic Migraines: Clinical Perspectives and Considerations. Ther Clin Risk Manag 2022; 18:447-456. [PMID: 35493707 PMCID: PMC9043257 DOI: 10.2147/tcrm.s348724] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 04/19/2022] [Indexed: 12/29/2022] Open
Abstract
Advances in molecular biology and neuroscience have led to the discovery of calcitonin gene-related peptide (CGRP), a 37 amino-acid neuropeptide that plays a critical role in the pathogenesis of migraine. CGRP receptor antagonist, also known as gepant, is an oral medication that inhibits the CGRP-related nociceptive signaling pathway. To date, three gepants are approved by the FDA for migraine treatment. Atogepant is a 2nd-generation gepant that non-competitively antagonizes CGRP receptors inhibiting neurogenic inflammation and pain sensitization. With its long half-life and minimal cardiovascular or liver toxicity, it is the first in its class approved primarily for migraine prevention. This article will discuss the evidence, safety, and rationale of atogepant for use in clinical practice.
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Affiliation(s)
- Fred Cohen
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - Hsiangkuo Yuan
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, 19107, USA
- Correspondence: Hsiangkuo Yuan, Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, 900 Walnut St. Suite 200, Philadelphia, PA, 19107, USA, Tel +1 215-955-2243, Fax +1 215-955-2060, Email
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Rustichelli C, Avallone R, Ferrari A. Atogepant: an emerging treatment for migraine. Expert Opin Pharmacother 2022; 23:653-662. [PMID: 35319319 DOI: 10.1080/14656566.2022.2057221] [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: 01/01/2023]
Abstract
INTRODUCTION Until recently, only nonspecific and not always well-tolerated medications were available for migraine prophylaxis. Currently, specific drugs such as calcitonin gene-related peptide (CGRP) monoclonal antibodies and second-generation gepants are marketed for migraine treatment. Atogepant, an orally active small molecule, is a potent, selective antagonist of the CGRP receptor and is the only gepant authorized exclusively for episodic migraine prophylaxis in adults. AREAS COVERED Using literature obtained from PubMed, Scopus, Web of Science, Cochrane, and ClinicalTrials.gov (up to February 13rd, 2022), the authors summarize and evaluate the available data on atogepant for the prophylaxis of episodic migraine. EXPERT OPINION From pivotal trials, the efficacy and tolerability of atogepant in episodic migraine prophylaxis seem comparable to those of CGRP monoclonal antibodies, even if comparative studies have not been conducted. To date, limited information is available on atogepant, including the optimal dose and duration of therapy; hence, it is difficult to establish whether it could be a first-line drug for migraine prophylaxis. Furthermore, it is important to evaluate if atogepant use is associated with the risk of cardiovascular and cerebrovascular events, which could result from potent and persistent blockade of vasodilation by CGRP.
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Affiliation(s)
- Cecilia Rustichelli
- Department of Life Sciences, University of Modena and Reggio Emilia, via Campi, Modena, Italy
| | - Rossella Avallone
- Department of Life Sciences, University of Modena and Reggio Emilia, via Campi, Modena, Italy
| | - Anna Ferrari
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, via del Pozzo, Modena, Italy
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Diener HC, McAllister P, Jürgens TP, Kessler Y, Ning X, Cohen JM, Campos VR, Barash S, Silberstein SD. Safety and tolerability of fremanezumab in patients with episodic and chronic migraine: a pooled analysis of phase 3 studies. Cephalalgia 2022; 42:769-780. [PMID: 35331009 PMCID: PMC9218411 DOI: 10.1177/03331024221076485] [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] [Indexed: 12/02/2022]
Abstract
Background Fremanezumab, a fully humanized monoclonal antibody that selectively targets calcitonin gene-related peptide, has demonstrated efficacy for preventive treatment of episodic and chronic migraine. Since calcitonin gene-related peptide is expressed within the cardio- and cerebrovascular system and may have cardioprotective effects, it is critical to understand the cardio- and cerebrovascular safety of fremanezumab. Methods This was a pooled analysis of three randomized, double-blind, placebo-controlled, phase 3, 12-week trials in which patients with episodic migraine or chronic migraine received quarterly fremanezumab, monthly fremanezumab, or placebo. Incidences of overall and serious adverse events were analyzed. Cardio- and cerebrovascular adverse events (CVAEs) were analyzed in subgroups stratified by cardio- and cerebrovascular medical history, cardiovascular risk factors (CVRFs), and use of cardio- and cerebrovascular medications or triptans. Results Two thousand, eight hundred and forty-two patients were included in the study. Overall (58–65%) and serious adverse events (<1–2%) occurred in similar proportions across fremanezumab and placebo groups. CVAEs were infrequent, regardless of cardio- and cerebrovascular medical history (2–6%). CVAEs occurred in low, similar proportions of patients with CVRFs and those using cardio- and cerebrovascular medications or triptans. No cardio- and cerebrovascular signals were identified. Conclusion Fremanezumab demonstrated a favorable overall and cardio- and cerebrovascular safety profile in more than 2800 patients with episodic migraine or chronic migraine, regardless of cardio- and cerebrovascular medical history, CVRFs, or medication use. Trial Registrations: NCT02629861 (HALO EM, https://clinicaltrials.gov/ct2/show/NCT02629861), NCT02621931 (HALO CM, https://clinicaltrials.gov/ct2/show/NCT02621931), NCT03308968 (FOCUS, https://clinicaltrials.gov/ct2/ show/NCT03308968)
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Affiliation(s)
- Hans Christoph Diener
- Institute for Medical Informatics, Biometry, and Epidemiology, Medical Faculty of the University Duisburg-Essen, Essen, Germany
| | - Peter McAllister
- New England Institute for Neurology and Headache, Stamford, CT, USA
| | - Tim P Jürgens
- Headache Center North-East, Department of Neurology, University Medical Center Rostock, Rostock, Germany
| | - Yoel Kessler
- Teva Branded Pharmaceutical Products R&D, Inc., West Chester, PA, USA
| | - Xiaoping Ning
- Teva Branded Pharmaceutical Products R&D, Inc., West Chester, PA, USA
| | - Joshua M Cohen
- Teva Branded Pharmaceutical Products R&D, Inc., West Chester, PA, USA
| | | | - Steve Barash
- Teva Branded Pharmaceutical Products R&D, Inc., West Chester, PA, USA
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Hamann T, Rimmele F, Jürgens TP. [CGRP antibodies in migraine prophylaxis : The new standard in migraine treatment?]. Schmerz 2022; 36:59-72. [PMID: 35041064 DOI: 10.1007/s00482-021-00613-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2021] [Indexed: 11/25/2022]
Abstract
Migraine is associated with a high individual level of suffering. Therefore, an effective preventive treatment is highly important. The spectrum of classical prophylactic drugs has now been expanded to include monoclonal antibodies against calcitonin gene-related peptide (CGRP) and its receptor. These antibodies have shown reliable efficacy compared to placebo and a rapid onset of action with a low rate of side effects and negligible interactions in pivotal studies. Recently, the efficacy of the antibody was shown in many studies even on drug-refractory migraine and migraine associated with medication overuse. Comprehensive head to head comparisons with previously established drugs and among the antibodies are not yet available; however, initial studies suggest better tolerability and efficacy compared to conventional drugs and other antibodies. The role of antibodies in established treatment cascades still needs to be clarified.
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Affiliation(s)
- Till Hamann
- Klinik und Poliklinik für Neurologie, Kopfschmerzzentrum Nord-Ost, Universitätsmedizin Rostock, Gehlsheimer Straße 20, 18147, Rostock, Deutschland.
| | - Florian Rimmele
- Klinik und Poliklinik für Neurologie, Kopfschmerzzentrum Nord-Ost, Universitätsmedizin Rostock, Gehlsheimer Straße 20, 18147, Rostock, Deutschland
| | - Tim Patrick Jürgens
- Klinik und Poliklinik für Neurologie, Kopfschmerzzentrum Nord-Ost, Universitätsmedizin Rostock, Gehlsheimer Straße 20, 18147, Rostock, Deutschland.,Neurologisches Zentrum, Klinik für Neurologie, KMG Klinikum Güstrow, Güstrow, Deutschland
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Myocardial infarction, stroke and cardiovascular mortality among migraine patients: a systematic review and meta-analysis. J Neurol 2022; 269:2346-2358. [PMID: 34997286 DOI: 10.1007/s00415-021-10930-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 12/02/2021] [Accepted: 12/03/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND An increasing number of studies have shown an association between migraine and cardiovascular disease, in particular cardio- and cerebro-vascular events. METHODS Three electronic databases (PubMed, Embase and Scopus) were searched from inception to May 22, 2021 for prospective cohort studies evaluating the risk of myocardial infarction, stroke and cardiovascular mortality in migraine patients. A random effects meta-analysis model was used to summarize the included studies. RESULTS A total of 18 prospective cohort studies were included consisting of 370,050 migraine patients and 1,387,539 controls. Migraine was associated with myocardial infarction (hazard ratio, 1.36; 95% CI, 1.23-1.51; p = < 0.001), unspecified stroke (hazard ratio, 1.30; 95% CI, 1.07-1.60; p = 0.01), ischemic stroke (hazard ratio, 1.35; 95% CI, 1.03-1.78; p = 0.03) and hemorrhagic stroke (hazard ratio, 1.43; 95% CI, 1.07-1.92; p = 0.02). Subgroup analysis of migraine with aura found a further increase in risk of myocardial infarction and both ischemic and hemorrhagic stroke, as well as improved substantial statistical heterogeneity. Migraine with aura was also associated with an increased risk of cardiovascular mortality (hazard ratio, 1.27; 95% CI, 1.14-1.42; p = < 0.001). CONCLUSION Migraine, especially migraine with aura, is associated with myocardial infarction and stroke. Migraine with aura increases the risk of overall cardiovascular mortality.
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Al-Hassany L, Goadsby PJ, Danser AHJ, MaassenVanDenBrink A. Calcitonin gene-related peptide-targeting drugs for migraine: how pharmacology might inform treatment decisions. Lancet Neurol 2022; 21:284-294. [DOI: 10.1016/s1474-4422(21)00409-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 09/26/2021] [Accepted: 11/04/2021] [Indexed: 12/15/2022]
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Chiang CC, Shahid AH, Harriott AM, Tietjen GE, Savastano LE, Klaas JP, Lanzino G. Evaluation and treatment of headache associated with moyamoya disease - a narrative review. Cephalalgia 2021; 42:542-552. [PMID: 34786968 DOI: 10.1177/03331024211056250] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Headache in patients with moyamoya disease is an under-addressed topic in the medical literature. Delay in the diagnosis of moyamoya disease or inappropriate treatment of headache could lead to devastating cerebrovascular outcome. With the evolving understanding of moyamoya disease, migraine pathophysiology, and various migraine-specific medications that have become available, it is crucial to provide an updated overview on this topic. METHODS We searched PubMed for keywords including moyamoya disease, moyamoya syndrome, headache in moyamoya, surgical revascularization, surgical bypass, migraine and moyamoya, and calcitonin gene-related peptide (CGRP). We summarized the literature and provide a comprehensive review of the headache presentation, possible mechanisms, the impact of various surgical revascularizations on headache in patients with moyamoya disease, and the medical management of headache incorporating novel migraine-specific treatments.Results and conclusion: The most common headache phenotype is migraine; tension-type headache, hemiplegic migraine, and cluster headache have also been reported. Most patients experience improvement of headache after surgical revascularization, though some patients report worsening, or new-onset headache after surgery. Given the complexity of moyamoya disease, careful consideration of different types of medical therapy for headache is necessary to improve the quality of life while not increasing the risk of adverse cerebrovascular events. More prospective studies are warranted to better understand and manage headache in patients with moyamoya disease.
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Affiliation(s)
- Chia-Chun Chiang
- Department of Neurology, 6915Mayo Clinic, Mayo Clinic, Rochester, MN
| | | | | | | | | | - James P Klaas
- Department of Neurology, 6915Mayo Clinic, Mayo Clinic, Rochester, MN
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Bentivegna E, Luciani M, Scarso F, Bruscia C, Chiappino D, Amore E, Nalli G, Martelletti P. Hormonal therapies in migraine management: current perspectives on patient selection and risk management. Expert Rev Neurother 2021; 21:1347-1355. [PMID: 34739361 DOI: 10.1080/14737175.2021.2003706] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
INTRODUCTION The link between sex hormones and migraines has long been investigated but the mechanisms underlying this altered interaction are not yet fully understood. Herein, we retrace the knowledge on this association in relationship with risk of stroke. AREAS COVERED Estrogens fluctuations could trigger migraine attacks and exogenous estrogens intake could be a risk factor for venous thromboembolism (VTE) and stroke. At the same time, ischemic heart diseases and stroke share a common substrate with migraine and other mood disorders, depression, and anxiety. EXPERT OPINION The use of hormonal therapies in the context of contraception or replacement therapy must be closely evaluated in a careful risk assessment. We highlight the complex interaction of hormone/neuroinflammation pathways underlying the pathophysiology of migraine glimpsing in mood disorders a possible common denominator of link between hormonal and neuronal systems.
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Affiliation(s)
- Enrico Bentivegna
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy.,Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy
| | - Michelangelo Luciani
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy.,Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy
| | - Francesco Scarso
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy.,Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy
| | - Clara Bruscia
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy.,Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy
| | - Dario Chiappino
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy.,Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy
| | - Emanuele Amore
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy.,Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy
| | - Gabriele Nalli
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy.,Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy.,Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy
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Marichal-Cancino BA, González-Hernández A, Guerrero-Alba R, Medina-Santillán R, Villalón CM. A critical review of the neurovascular nature of migraine and the main mechanisms of action of prophylactic antimigraine medications. Expert Rev Neurother 2021; 21:1035-1050. [PMID: 34388955 DOI: 10.1080/14737175.2021.1968835] [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: 10/20/2022]
Abstract
INTRODUCTION Migraine involves neurovascular, functional, and anatomical alterations. Migraineurs experience an intense unilateral and pulsatile headache frequently accompanied with vomiting, nausea, photophobia, etc. Although there is no ideal preventive medication, frequency in migraine days may be partially decreased by some prophylactics, including antihypertensives, antidepressants, antiepileptics, and CGRPergic inhibitors. However, the mechanisms of action involved in antimigraine prophylaxis remain elusive. AREAS COVERED This review recaps some of the main neurovascular phenomena related to migraine and currently available preventive medications. Moreover, it discusses the major mechanisms of action of the recommended prophylactic medications. EXPERT OPINION In the last three years, migraine prophylaxis has evolved from nonspecific to specific antimigraine treatments. Overall, nonspecific treatments mainly involve neural actions, whereas specific pharmacotherapy (represented by CGRP receptor antagonists and CGRPergic monoclonal antibodies) is predominantly mediated by neurovascular mechanisms that may include, among others: (i) reduction in the cortical spreading depression (CSD)-associated events; (ii) inhibition of pain sensitization; (iii) blockade of neurogenic inflammation; and/or (iv) increase in cranial vascular tone. Accordingly, the novel antimigraine prophylaxis promises to be more effective, devoid of significant adverse effects (unlike nonspecific treatments), and more beneficial for the quality of life of migraineurs.
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Affiliation(s)
- Bruno A Marichal-Cancino
- Departamento de Fisiología y Farmacología, Centro de Ciencias Básicas, Universidad Autónoma de Aguascalientes, Aguascalientes, Ags, México
| | | | - Raquel Guerrero-Alba
- Departamento de Fisiología y Farmacología, Centro de Ciencias Básicas, Universidad Autónoma de Aguascalientes, Aguascalientes, Ags, México
| | - Roberto Medina-Santillán
- Sección de Estudios de Posgrado e Investigación, Escuela Superior de Medicina IPN, Ciudad de México C.P, México
| | - Carlos M Villalón
- Departamento de Farmacobiología, Cinvestav-Coapa, Ciudad de México, México
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Al-Hassany L, Vries TD, Carpay JA, MaassenVanDenBrink A. Could erectile dysfunction be a side effect of CGRP inhibition? A case report. Cephalalgia 2021; 42:257-261. [PMID: 34404250 PMCID: PMC8988460 DOI: 10.1177/03331024211037304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background Recently, antimigraine drugs targeting the calcitonin gene-related peptide pathway have been approved for clinical use as preventive migraine medication. Case report We present a case of a 54-year-old male migraine patient, who reported erectile dysfunction as a possible side effect of treatment with galcanezumab, a monoclonal antibody targeting calcitonin gene-related peptide. His potency recovered after treatment discontinuation. Discussion As calcitonin gene-related peptide is involved in mammalian penile erection, erectile dysfunction is a conceivable side effect associated with calcitonin gene-related peptide inhibition. Postmarketing surveillance will elucidate the actual incidence of erectile dysfunction in patients using these new antimigraine drugs, and determine whether a causal relationship between calcitonin gene-related peptide inhibition and erectile dysfunction exists. This would be relevant not only because of the direct sexual consequences of erectile dysfunction, but also considering the potential cardiovascular consequences of calcitonin gene-related peptide (receptor) blockade and the association of both migraine and erectile dysfunction with cardiovascular disease. Conclusion Erectile dysfunction might be an overlooked, but reversible side effect in male migraine patients using monoclonal antibodies that inhibit the calcitonin gene-related peptide pathway, including galcanezumab. This paper may raise clinical awareness and suggest that this potential side effect needs to be studied further.
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Affiliation(s)
- Linda Al-Hassany
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Tessa de Vries
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Johannes A Carpay
- Department of Neurology, Tergooi Hospital, Hilversum, The Netherlands
| | - Antoinette MaassenVanDenBrink
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Ducros A, de Gaalon S, Roos C, Donnet A, Giraud P, Guégan-Massardier E, Lantéri-Minet M, Lucas C, Mawet J, Moisset X, Valade D, Demarquay G. Revised guidelines of the French headache society for the diagnosis and management of migraine in adults. Part 2: Pharmacological treatment. Rev Neurol (Paris) 2021; 177:734-752. [PMID: 34340810 DOI: 10.1016/j.neurol.2021.07.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 12/21/2022]
Abstract
The French Headache Society proposes updated French guidelines for the management of migraine. This article presents the second part of the guidelines, which is focused on the pharmacological treatment of migraine, including both the acute treatment of attacks and the prophylaxis of episodic migraine as well as chronic migraine with and without medication overuse. The specific situations that can be encountered in women with migraine are also discussed, including pregnancy, menstrual migraine, contraception and hormonal replacement therapy.
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Affiliation(s)
- A Ducros
- Department of neurology, Gui-de-Chauliac hospital, CHU Montpellier, university of Montpellier, 34000 Montpellier, France
| | - S de Gaalon
- Department of neurology, Laënnec hospital, CHU de Nantes, Nantes, France
| | - C Roos
- Emergency headache center (centre d'urgences céphalées), department of neurology, Lariboisière hospital, Assistance publique-Hôpitaux de Paris, Paris, France
| | - A Donnet
- Centre d'évaluation et de traitement de la douleur, FHU INOVPAIN, hôpital de La Timone, Marseille, France
| | - P Giraud
- Department of neurology, Annecy Genevois hospital, Annecy, France
| | | | - M Lantéri-Minet
- Pain department, FHU InovPain, CHU Nice Côte Azur université, Nice, France
| | - C Lucas
- Centre d'évaluation et de traitement de la douleur, service de neurochirurgie, hôpital Salengro, CHRU de Lille, Lille, France
| | - J Mawet
- Emergency headache center (centre d'urgences céphalées), department of neurology, Lariboisière hospital, Assistance publique-Hôpitaux de Paris, Paris, France
| | - X Moisset
- Neuro-Dol, université Clermont Auvergne, CHU de Clermont-Ferrand, INSERM, Clermont-Ferrand, France
| | - D Valade
- Department of neurosurgery, hôpital Pitié-Sapêtrière, Paris, France
| | - G Demarquay
- Neurological hospital, Lyon, neuroscience research center (CRNL), INSERM U1028, CNRS UMR5292, Lyon, France.
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