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Fiorella D, Arthur AS, Yuan H, Bhogal P, Goyal N, Khattar NK, Albuquerque FC, Jadhav AP, Catapano JS, Silberstein S. Refractory migraine: a cerebrovascular disease? J Neurointerv Surg 2024; 16:637-639. [PMID: 37940385 DOI: 10.1136/jnis-2023-021148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2023] [Indexed: 11/10/2023]
Affiliation(s)
- David Fiorella
- Department of Neurosurgery, Stony Brook University, Stony Brook, New York, USA
- SUNY SB, Stony Brook, New York, USA
| | - Adam S Arthur
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
- Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Hsiangkuo Yuan
- Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Nitin Goyal
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
| | - Nicolas K Khattar
- Department of Neurosurgery, University of Louisville School of Medicine, Louisiville, Kentucky, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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Barbanti P, Aurilia C, Egeo G, Proietti S, D'Onofrio F, Torelli P, Aguggia M, Bertuzzo D, Finocchi C, Trimboli M, Cevoli S, Fiorentini G, Orlando B, Zucco M, Di Clemente L, Cetta I, Colombo B, di Poggio MLB, Favoni V, Grazzi L, Salerno A, Carnevale A, Robotti M, Frediani F, Altamura C, Filippi M, Vernieri F, Bonassi S. Ultra-late response (> 24 weeks) to anti-CGRP monoclonal antibodies in migraine: a multicenter, prospective, observational study. J Neurol 2024; 271:2434-2443. [PMID: 38231271 PMCID: PMC11055785 DOI: 10.1007/s00415-023-12103-4] [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: 10/03/2023] [Revised: 11/04/2023] [Accepted: 11/06/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVE Nearly 60% of migraine patients treated with monoclonal antibodies (mAbs) targeting the calcitonin gene-related peptide (CGRP) pathway experience a ≥ 50% reduction in monthly migraine days (MMD) at 12 weeks compared to baseline (responders). However, approximately half of the patients not responding to anti-CGRP mAbs ≤ 12 weeks do respond ≤ 24 weeks (late responders). We assessed frequency and characteristics of patients responding to anti-CGRP mAbs only > 24 weeks (ultra-late responders). METHODS In this multicenter (n = 16), prospective, observational, real-life study, we enrolled all consecutive adults affected by high-frequency episodic migraine (HFEM: ≥ 8 days/month) or chronic migraine (CM), with ≥ 3 prior therapeutic failures, treated with any anti-CGRP mAbs for ≥ 48 weeks. We defined responders patients with a ≥ 50% response rate ≤ 12 weeks, late responders those with a ≥ 50% response rate ≤ 24 weeks, and ultra-late responders those achieving a ≥ 50% response only > 24 weeks. RESULTS A total of 572 migraine patients completed ≥ 48 weeks of anti-CGRP mAbs treatment. Responders accounted for 60.5% (346/572), late responders for 15% (86/572), and ultra-late responders for 15.7% (90/572). Among ultra-late responders, 7.3% (42/572) maintained the ≥ 50% response rate across all subsequent time intervals (weeks 28, 32, 36, 40, 44, and 48) and were considered persistent ultra-late responders, while 8.4% (48/572) missed the ≥ 50% response rate at ≥ 1 subsequent time interval and were classified as fluctuating ultra-late responders. Fifty patients (8.7%) did not respond at any time interval ≤ 48 weeks. Ultra-late responders differed from responders for higher BMI (p = 0.033), longer duration of medication overuse (p < 0.001), lower NRS (p = 0.017) and HIT-6 scores (p = 0.002), higher frequency of dopaminergic symptoms (p = 0.002), less common unilateral pain-either alone (p = 0.010) or in combination with UAS (p = 0.023), allodynia (p = 0.043), or UAS and allodynia (p = 0.012)-a higher number of comorbidities (p = 0.012), psychiatric comorbidities (p = 0.010) and a higher proportion of patients with ≥ 1 comorbidity (p = 0.020). CONCLUSION Two-thirds of patients not responding to anti-CGRP mAbs ≤ 24 weeks do respond later, while non-responders ≤ 48 weeks are quite rare (8.7%). These findings suggest to rethink the duration of migraine prophylaxis and the definition of resistant and refractory migraine, currently based on the response after 2-3 months of treatment.
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Affiliation(s)
- Piero Barbanti
- Headache and Pain Unit, IRCCS San Raffaele Roma, Via Della Pisana 235, 00163, Rome, Italy.
- San Raffaele University, Rome, Italy.
| | - Cinzia Aurilia
- Headache and Pain Unit, IRCCS San Raffaele Roma, Via Della Pisana 235, 00163, Rome, Italy.
| | - Gabriella Egeo
- Headache and Pain Unit, IRCCS San Raffaele Roma, Via Della Pisana 235, 00163, Rome, Italy
| | - Stefania Proietti
- Clinical and Molecular Epidemiology, IRCCS San Raffaele Roma, Rome, Italy
| | - Florindo D'Onofrio
- Headache Center Neurology Unit, San Giuseppe Moscati Hospital, Avellino, Italy
| | - Paola Torelli
- Unit of Neurology, Department of Medicine and Surgery, Headache Center, University of Parma, Parma, Italy
| | | | | | - Cinzia Finocchi
- Divisione di Neurologia, Ospedale San Paolo, ASL 2 Savonese, Savona, Italy
| | | | - Sabina Cevoli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Giulia Fiorentini
- Headache and Pain Unit, IRCCS San Raffaele Roma, Via Della Pisana 235, 00163, Rome, Italy
| | - Bianca Orlando
- Headache and Pain Unit, IRCCS San Raffaele Roma, Via Della Pisana 235, 00163, Rome, Italy
| | - Maurizio Zucco
- Headache Center, San Camillo-Forlanini Hospital, Rome, Italy
| | | | - Ilaria Cetta
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Bruno Colombo
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | | | - Valentina Favoni
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Licia Grazzi
- Neuroalgology Unit, Headache Center Fondazione, IRCCS Istituto Neurologico"Carlo Besta", Milan, Italy
| | - Antonio Salerno
- Headache Center San Giovanni Addolorata Hospital, Rome, Italy
| | | | | | | | - Claudia Altamura
- Headache and Neurosonology Unit, Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Massimo Filippi
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Fabrizio Vernieri
- Headache and Neurosonology Unit, Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Stefano Bonassi
- San Raffaele University, Rome, Italy
- Headache Center Neurology Unit, San Giuseppe Moscati Hospital, Avellino, Italy
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Argoff C, Herzog SP, Smith RM, Kotak SV, Sopina L, Saltarska Y, Soni-Brahmbhatt S, Khan FA. Real-world effectiveness and satisfaction with intravenous eptinezumab treatment in patients with chronic migraine: REVIEW, an observational, multi-site, US-based study. J Headache Pain 2024; 25:65. [PMID: 38664605 PMCID: PMC11044317 DOI: 10.1186/s10194-024-01764-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 04/03/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Despite recent advancements in migraine treatment, some patients continue to endure significant disease burden. Due to the controlled nature of randomized trials in migraine prevention, many real-world patients with comorbidities or prior exposure to certain therapies are excluded. Capturing evidence of the effectiveness of treatment in real-world clinical settings can further shape treatment paradigms. The objective of this study was to develop a comprehensive understanding of both patients' and physicians' real-world experiences with eptinezumab for chronic migraine (CM). METHODS REVIEW (Real-world EVidence and Insights into Experiences With eptinezumab) is an observational, multi-site (n = 4), US-based study designed to evaluate real-world experiences of patients treated with eptinezumab and their treating physicians. Patients were ≥ 18 years of age, with a diagnosis of CM, who had completed ≥ 2 consecutive eptinezumab infusion cycles (≥ 6 months of exposure). The study included a retrospective chart review, a patient survey, and a semi-structured physician interview that assessed patient and/or physician satisfaction with elements of daily living / well-being, migraine symptomology, and perspectives of the eptinezumab infusion experience. RESULTS Of the 94 patients enrolled, 83% (78/94) were female, the mean age was 49.2 years, and the mean time since migraine diagnosis was 15.4 years. Before eptinezumab treatment, patients experienced a mean of 8 self-reported "good" days/month, which increased to 18 after treatment. Most patients took, on average, ≥ 10 days/month of prescription and/or over-the-counter medication (81% [75/93] and 66% [61/93], respectively) to treat migraine attacks before eptinezumab treatment, which dropped to 26% (24/93) and 23% (21/93) following eptinezumab treatment. Prior to receiving eptinezumab, 62% (58/93) of patients indicated being at least slightly concerned about infusions; after eptinezumab infusion, this dropped to 14% (13/93). These patient survey findings were consistent with physician responses. CONCLUSION This real-world evidence study demonstrated high overall satisfaction with the effectiveness of eptinezumab treatment for CM among most patients and their physicians.
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Affiliation(s)
- Charles Argoff
- Albany Medical Center, 47 New Scotland Ave, 12208, Albany, NY, USA.
| | | | | | | | | | | | | | - Fawad A Khan
- The McCasland Family Comprehensive Headache Center, Ochsner Neurosciences Institute, New Orleans, LA, USA
- University of Queensland-Ochsner Clinical School, New Orleans, LA, USA
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Ornello R, Andreou AP, De Matteis E, Jürgens TP, Minen MT, Sacco S. Resistant and refractory migraine: clinical presentation, pathophysiology, and management. EBioMedicine 2024; 99:104943. [PMID: 38142636 PMCID: PMC10788408 DOI: 10.1016/j.ebiom.2023.104943] [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: 11/05/2023] [Revised: 12/09/2023] [Accepted: 12/13/2023] [Indexed: 12/26/2023] Open
Abstract
Migraine is a leading cause of disability worldwide. A minority of individuals with migraine develop resistant or refractory conditions characterised by ≥ 8 monthly days of debilitating headaches and inadequate response, intolerance, or contraindication to ≥3 or all preventive drug classes, respectively. Resistant and refractory migraine are emerging clinical definitions stemming from better knowledge of the pathophysiology of migraine and from the advent of migraine-specific preventive treatments. Resistant migraine mostly results from drug failures, while refractory migraine has complex and still unknown mechanisms that impair the efficacy of preventive treatments. Individuals with resistant migraine can be treated with migraine-specific preventive drugs. The management of refractory migraine is challenging and often unsuccessful, being based on combinations of different drugs and non-pharmacological treatment. Future research should aim to identify individuals at risk of developing treatment failures, prevent the condition, investigate the mechanisms of refractoriness to treatments, and find effective treatment strategies.
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Affiliation(s)
- Raffaele Ornello
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Anna P Andreou
- Headache Research-Wolfson CARD, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; Headache Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Eleonora De Matteis
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Tim P Jürgens
- Headache Center North-East, Department of Neurology, University Medical Center Rostock, Rostock, Germany; Department of Neurology, KMG Hospital Güstrow, Güstrow, Germany
| | - Mia T Minen
- Departments of Neurology and Population Health, NYU Langone Health, New York, USA
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy.
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Robblee J. Breaking the cycle: unraveling the diagnostic, pathophysiological and treatment challenges of refractory migraine. Front Neurol 2023; 14:1263535. [PMID: 37830088 PMCID: PMC10565861 DOI: 10.3389/fneur.2023.1263535] [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: 07/19/2023] [Accepted: 09/11/2023] [Indexed: 10/14/2023] Open
Abstract
Background Refractory migraine is a poorly described complication of migraine in which migraine has chronified and become resistant to standard treatments. The true prevalence is unknown, but medication resistance is common in headache clinic patient populations. Given the lack of response to treatment, this patient population is extremely difficult to treat with limited guidance in the literature. Objective To review the diagnostic, pathophysiological, and management challenges in the refractory migraine population. Discussion There are no accepted, or even ICHD-3 appendix, diagnostic criteria for refractory migraine though several proposed criteria exist. Current proposed criteria often have low bars for refractoriness while also not meeting the needs of pediatrics, lower socioeconomic status, and developing nations. Pathophysiology is unknown but can be hypothesized as a persistent "on" state as a progression from chronic migraine with increasing central sensitization, but there may be heterogeneity in the underlying pathophysiology. No guidelines exist for treatment of refractory migraine; once all guideline-based treatments are tried, treatment consists of n-of-1 treatment trials paired with non-pharmacologic management. Conclusion Refractory migraine is poorly described diagnostically, its pathophysiology can only be guessed at by extension of chronic migraine, and treatment is more the art than science of medicine. Navigating care of this refractory population will require multidisciplinary care models and an emphasis on future research to answer these unknowns.
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Affiliation(s)
- Jennifer Robblee
- Department of Neurology, Dignity Health, St Joseph’s Hospital and Medical Center, Lewis Headache Clinic, Barrow Neurological Institute, Phoenix, AZ, United States
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Barbanti P, Aurilia C, Egeo G, Torelli P, Proietti S, Cevoli S, Bonassi S. Late Response to Anti-CGRP Monoclonal Antibodies in Migraine: A Multicenter Prospective Observational Study. Neurology 2023; 101:482-488. [PMID: 37072224 PMCID: PMC10513886 DOI: 10.1212/wnl.0000000000207292] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 02/28/2023] [Indexed: 04/20/2023] Open
Abstract
OBJECTIVES To assess the frequency and characteristics of late responders (>12 weeks) to monoclonal antibodies (mAbs) targeting the calcitonin gene-related peptide (CGRP). METHODS This is a multicenter (n = 16) prospective real-life study considering all consecutive adults with high-frequency or chronic migraine treated with anti-CGRP mAbs for ≥24 weeks. We defined responder patients with a ≥50% reduction from baseline in monthly migraine/headache days at weeks 9-12 and late responders as those achieving a ≥50% reduction only afterward. RESULTS A total of 771 people with migraine completed ≥24 weeks of anti-CGRP mAb treatment. Responders at 12 weeks were 65.6% (506/771) of the patients, while nonresponders were 34.4% (265/771). A total of 146 of the 265 nonresponders (55.1%) at 12 weeks responded afterward (late responders): they differed from responders for a higher BMI (+0.78, 95% CI [0.10; 1.45]; p = 0.024), more frequent treatment failures (+0.52, 95% CI [0.09; 0.95]; p = 0.017) and psychiatric comorbidities (+10.1%, 95% CI [0.1; 0.20]; p = 0.041), and less common unilateral pain, alone (-10,9%, 95% CI [-20.5; -1.2]; p = 0.025) or in combination with unilateral cranial autonomic symptoms (-12.3%, 95% CI [-20.2;-3.9]; p = 0.006) or allodynia (-10.7, 95% CI [-18.2; -3.2]; p = 0.01). DISCUSSION Half of nonresponders to anti-CGRP mAbs at 12 weeks are indeed late responders. Efficacy of anti-CGRP mAbs should be assessed at 24 weeks while treatment duration should be extended beyond 12 months.
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Affiliation(s)
- Piero Barbanti
- From the Headache and Pain Unit (P.B., C.A., G.E.), IRCCS San Raffaele Roma; San Raffaele University (P.B., S.B.), Rome; Unit of Neurology, Department of Medicine and Surgery (P.T.), Headache Center, University of Parma, Parma; Clinical and Molecular Epidemiology (S.P.), IRCCS San Raffaele Roma; IRCCS Istituto delle Scienze Neurologiche di Bologna (S.C.), Bologna, Italy.
| | - Cinzia Aurilia
- From the Headache and Pain Unit (P.B., C.A., G.E.), IRCCS San Raffaele Roma; San Raffaele University (P.B., S.B.), Rome; Unit of Neurology, Department of Medicine and Surgery (P.T.), Headache Center, University of Parma, Parma; Clinical and Molecular Epidemiology (S.P.), IRCCS San Raffaele Roma; IRCCS Istituto delle Scienze Neurologiche di Bologna (S.C.), Bologna, Italy
| | - Gabriella Egeo
- From the Headache and Pain Unit (P.B., C.A., G.E.), IRCCS San Raffaele Roma; San Raffaele University (P.B., S.B.), Rome; Unit of Neurology, Department of Medicine and Surgery (P.T.), Headache Center, University of Parma, Parma; Clinical and Molecular Epidemiology (S.P.), IRCCS San Raffaele Roma; IRCCS Istituto delle Scienze Neurologiche di Bologna (S.C.), Bologna, Italy
| | - Paola Torelli
- From the Headache and Pain Unit (P.B., C.A., G.E.), IRCCS San Raffaele Roma; San Raffaele University (P.B., S.B.), Rome; Unit of Neurology, Department of Medicine and Surgery (P.T.), Headache Center, University of Parma, Parma; Clinical and Molecular Epidemiology (S.P.), IRCCS San Raffaele Roma; IRCCS Istituto delle Scienze Neurologiche di Bologna (S.C.), Bologna, Italy
| | - Stefania Proietti
- From the Headache and Pain Unit (P.B., C.A., G.E.), IRCCS San Raffaele Roma; San Raffaele University (P.B., S.B.), Rome; Unit of Neurology, Department of Medicine and Surgery (P.T.), Headache Center, University of Parma, Parma; Clinical and Molecular Epidemiology (S.P.), IRCCS San Raffaele Roma; IRCCS Istituto delle Scienze Neurologiche di Bologna (S.C.), Bologna, Italy
| | - Sabina Cevoli
- From the Headache and Pain Unit (P.B., C.A., G.E.), IRCCS San Raffaele Roma; San Raffaele University (P.B., S.B.), Rome; Unit of Neurology, Department of Medicine and Surgery (P.T.), Headache Center, University of Parma, Parma; Clinical and Molecular Epidemiology (S.P.), IRCCS San Raffaele Roma; IRCCS Istituto delle Scienze Neurologiche di Bologna (S.C.), Bologna, Italy
| | - Stefano Bonassi
- From the Headache and Pain Unit (P.B., C.A., G.E.), IRCCS San Raffaele Roma; San Raffaele University (P.B., S.B.), Rome; Unit of Neurology, Department of Medicine and Surgery (P.T.), Headache Center, University of Parma, Parma; Clinical and Molecular Epidemiology (S.P.), IRCCS San Raffaele Roma; IRCCS Istituto delle Scienze Neurologiche di Bologna (S.C.), Bologna, Italy
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Ravan JR, Pattnaik JI, Samantray S. Algorithm-based approach to headache. J Family Med Prim Care 2023; 12:1775-1783. [PMID: 38024919 PMCID: PMC10657066 DOI: 10.4103/jfmpc.jfmpc_1553_22] [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: 08/03/2022] [Revised: 09/22/2022] [Accepted: 10/04/2022] [Indexed: 12/01/2023] Open
Abstract
One of the most commonly encountered scenarios in any healthcare setting is a patient presenting with a headache. Yet, the assessment, diagnosis and treatment of headache disorders can be challenging and burdensome for even specialist doctors in medicine, psychiatry, oto-rhinology, neurology and so on. Apart from saving patient's and doctor's time as well as money, this article will buy leading time for better outcome and management of certain difficult headache disorders. The aim of this review is to simplify the approach to headache diagnosis for an early and proper referral. Literature search was done on PubMed and Google Scholar using key words. Only studies which were in English were considered. Sixty-one articles published from 1975 to 2022 were reviewed after screening for inclusion and exclusion criteria. It is very essential that a primary care physician is aware of the classification of headache. Red flag signs of high-risk headaches are essential for proper referral. It is also essential that we rule out secondary headaches as they are more life threatening. Vulnerable populations such as geriatric and paediatric populations require expert attention in case of headache disorders.
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Affiliation(s)
- Jayaprakash R. Ravan
- Department of Psychiatry, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Jigyansa I. Pattnaik
- Department of Psychiatry, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Swayanka Samantray
- Department of Psychiatry, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India
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Troy E, Shrukalla AA, Buture A, Conaty K, Macken E, Lonergan R, Melling J, Long N, Shaikh E, Birrane K, Tomkins EM, Goadsby PJ, Ruttledge MH. Medium-term real-world data for erenumab in 177 treatment resistant or difficult to treat chronic migraine patients: persistence and patient reported outcome measures after 17-30 months. J Headache Pain 2023; 24:5. [PMID: 36647006 PMCID: PMC9841480 DOI: 10.1186/s10194-022-01536-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 12/17/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Many migraine patients do not respond adequately to conventional preventive treatments and are therefore described as treatment/medically resistant or difficult to treat cases. Calcitonin gene-related peptide monoclonal antibodies are a relatively novel molecular treatment for episodic and chronic migraine that have been shown to be effective in short duration clinical trials in approximately 40-50% of all chronic migraine patients. Patient Related Outcome Measures (PROM) or Quality of Life (QoL) questionnaires are used to help measure response to treatment in migraine. Although some open label extension studies have become available for erenumab, there is a lack of real-world data pertaining to quality of life in the medium to long-term for chronic and treatment resistant migraine patients. METHODS A total of 177 treatment resistant CM patients were started on erenumab (70 mg or 140 mg subcutaneous injection every 4 weeks) in our three specialist Headache Clinics. Of these, 174 had their first injection between December 2018 and October 2019. All patients were evaluated with the following PROM: the Headache Impact Test- 6, Migraine Associated Disability Assessment test and Migraine-Specific QoL Questionnaire, before starting treatment with erenumab and at intervals of 3-12 months after starting treatment. The decision to continue treatment was based on subjective clinical improvement of at least 30% (as reported by the patient), supported with diaries and QoL questionnaires. We present here the QoL measurements for this group of 177 patients. Prior preventive migraine treatments included conventional oral prophylactic medications (such as topiramate, candesartan, propranolol, or amitriptyline), at least two cycles of PREEMPT protocol onabotulinumtoxin A or (in a small number of cases) neuromodulation with single pulse Transcranial Magnetic Stimulation. RESULTS Of the 177 patients who started treatment with erenumab, 68/177 (38.4%) stopped during the first year, either due to lack of efficacy (no significant benefit or only minimal improvement) and/or possible side effects. 109/177 (61.6%) patients reported clinically significant improvement after 6-12 months and wished to stay on treatment. Twelve of these 109 patients subsequently stopped treatment in the period between 1 year and up to June 2021 (mainly due to a worsening of their migraine). Therefore, a total of 97/177 patients (54.8%) remained on treatment as of June 2021 (duration of treatment 17-30 months, median of 25 months). CONCLUSION Approximately 55% of treatment resistant or difficult to treat CM patients who trialled erenumab in our clinics reported a subjective benefit and were still on treatment after 17-30 months.
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Affiliation(s)
- Emma Troy
- grid.414315.60000 0004 0617 6058Department of Neurology, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland
| | - Arif A. Shrukalla
- grid.414315.60000 0004 0617 6058Department of Neurology, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland
| | - Alina Buture
- grid.411596.e0000 0004 0488 8430Dublin Neurological Institute, Department of Neurology, Mater Hospital, Eccles Street, Dublin 7, Ireland
| | - Katie Conaty
- grid.414315.60000 0004 0617 6058Department of Neurology, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland
| | - Esther Macken
- grid.411596.e0000 0004 0488 8430Dublin Neurological Institute, Department of Neurology, Mater Hospital, Eccles Street, Dublin 7, Ireland
| | - Roisin Lonergan
- grid.411596.e0000 0004 0488 8430Dublin Neurological Institute, Department of Neurology, Mater Hospital, Eccles Street, Dublin 7, Ireland
| | - Jane Melling
- grid.411596.e0000 0004 0488 8430Dublin Neurological Institute, Department of Neurology, Mater Hospital, Eccles Street, Dublin 7, Ireland
| | - Niamh Long
- grid.414315.60000 0004 0617 6058Department of Neurology, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland
| | - Eamonn Shaikh
- grid.414315.60000 0004 0617 6058Department of Neurology, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland
| | - Kieran Birrane
- Independent Statistical Consultant, Wilton, Cork, Ireland
| | - Esther M. Tomkins
- grid.414315.60000 0004 0617 6058Department of Neurology, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland
| | - Peter J. Goadsby
- grid.19006.3e0000 0000 9632 6718NIHR SLaM Clinical Research Facility at King’s, King’s College London, UK and Department of Neurology, University of California, Los Angeles, CA Los Angeles, USA
| | - Martin H. Ruttledge
- grid.414315.60000 0004 0617 6058Department of Neurology, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland
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Nascimento TD, Kim DJ, Chrabol C, Lim M, Hu XS, DaSilva AF. Management of Episodic Migraine with Neuromodulation: A Case Report. Dent Clin North Am 2023; 67:157-171. [PMID: 36404076 DOI: 10.1016/j.cden.2022.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Migraine is a highly prevalent neurovascular disorder that affects approximately 15% of the global population. Migraine attacks are a complex cascade of neurologic events that lead to debilitating symptoms and are often associated with inhibitory behavior. The constellation of severe signs and symptoms during the ictal phase (headache attack) makes migraine the third most common cause of disability globally in both sexes under the age of 50. Misuse of pharmaceuticals, such as opiates, can lead to devastating outcomes and exacerbation of pain and headache attacks. A safe and well-tolerated non-pharmacological research approach is high-definition transcranial direct current stimulation over the M1.
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Affiliation(s)
- Thiago D Nascimento
- Department of Biologic and Materials Sciences & Prosthodontics, University of Michigan School of Dentistry, Ann Arbor, MI, USA; Michigan Neuroscience Institute (MNI), Headache & Orofacial Pain Effort (H.O.P.E.) Laboratory, 205 Zina Pitcher Pl, Room 1027, Ann Arbor, MI 48109, USA
| | - Dajung J Kim
- Department of Biologic and Materials Sciences & Prosthodontics, University of Michigan School of Dentistry, Ann Arbor, MI, USA; Michigan Neuroscience Institute (MNI), Headache & Orofacial Pain Effort (H.O.P.E.) Laboratory, 205 Zina Pitcher Pl, Room 1027, Ann Arbor, MI 48109, USA
| | - Conrad Chrabol
- Department of Biologic and Materials Sciences & Prosthodontics, University of Michigan School of Dentistry, Ann Arbor, MI, USA; Michigan Neuroscience Institute (MNI), Headache & Orofacial Pain Effort (H.O.P.E.) Laboratory, 205 Zina Pitcher Pl, Room 1027, Ann Arbor, MI 48109, USA
| | - Manyoel Lim
- Department of Biologic and Materials Sciences & Prosthodontics, University of Michigan School of Dentistry, Ann Arbor, MI, USA; Michigan Neuroscience Institute (MNI), Headache & Orofacial Pain Effort (H.O.P.E.) Laboratory, 205 Zina Pitcher Pl, Room 1027, Ann Arbor, MI 48109, USA
| | - Xiao-Su Hu
- Department of Biologic and Materials Sciences & Prosthodontics, University of Michigan School of Dentistry, Ann Arbor, MI, USA; Michigan Neuroscience Institute (MNI), Headache & Orofacial Pain Effort (H.O.P.E.) Laboratory, 205 Zina Pitcher Pl, Room 1027, Ann Arbor, MI 48109, USA
| | - Alexandre F DaSilva
- Department of Biologic and Materials Sciences & Prosthodontics, University of Michigan School of Dentistry, Ann Arbor, MI, USA; Michigan Neuroscience Institute (MNI), Headache & Orofacial Pain Effort (H.O.P.E.) Laboratory, 205 Zina Pitcher Pl, Room 1027, Ann Arbor, MI 48109, USA.
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10
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Goenka A, Fonseca LD. Rate and Predictors of Intractable Status Migrainosus among Patients Aged 13-18 Years. Neurohospitalist 2023; 13:5-12. [PMID: 36531843 PMCID: PMC9755617 DOI: 10.1177/19418744221124646] [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: 01/03/2024] Open
Abstract
Purpose To assess associations for intractable status migrainosus in the pediatric inpatient setting. Methods A retrospective cohort study of 1,805 patients presenting to the pediatric hospital in Dayton, Ohio with status migrainosus from 2017 to 2022, was performed. Among 1,805 patients, 159 received 3 lines of sequentially more aggressive abortive migraine treatment and were included in this analysis. Responders and non-responders were categorized based on a visual analogue scale (VAS) of pain scores from time of admission to discharge with responders having a reduction of 50% or greater in VAS. Patient demographic information, migraine history, headache type, medication history, self-reported pain, anxiety level and co-morbidities were assessed. Results Out of 159 patients, 125 (78.6%) achieved the target pain control with decrease in VAS pain score by ≥ 50% from the baseline. The remaining 34/159 (21.4%) patients remained refractory to treatment. Non-responder patients had a longer hospital stay (6.1 days) and greater readmission rate within 7 days (17.6%) compared to responders (4.7 days and .8% respectively). Among the non-responder patients, 14/34 (41.2%) had attention-deficit/hyperactivity disorder (ADHD) compared to the responder group in which 17/125 (13.6%) had ADHD. Among patients who had comorbidity of anxiety, non-responders had greater severe generalized anxiety disorder (GAD-7 ≥15) (6/14, 42.9%) than responders (2/39, 5.1%). Conclusion ADHD and severe GAD are associated with poorer response to treatment in pediatric patients with refractory migraine admitted for inpatient therapy. This study highlights the prolonged hospital stay and modest clinical outcomes seen with intractable migraine in 13-18-year-old pediatric patients.
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Affiliation(s)
- Ajay Goenka
- Department of Neurology, Dayton Children's Hospital, Dayton, OH, USA
- Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
| | - Laura D Fonseca
- Department of Neurology, Dayton Children's Hospital, Dayton, OH, USA
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11
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Andreou AP, Fuccaro M, Hill B, Murphy M, Caponnetto V, Kilner R, Lambru G. Two-year effectiveness of erenumab in resistant chronic migraine: a prospective real-world analysis. J Headache Pain 2022; 23:139. [PMID: 36333710 PMCID: PMC9635079 DOI: 10.1186/s10194-022-01507-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 09/12/2022] [Indexed: 11/06/2022] Open
Abstract
Background Controlled and real-world evidence have demonstrated the efficacy of calcitonin gene related peptide (CGRP) monoclonal antibodies (MABs) in migraine. However, data on the over-one-year sustained effectiveness of CGRP MABs in resistant chronic migraine (CM) is sparse. Methods This is a two-year real-world prospective analysis of an ongoing single centre audit conducted in patients with resistant CM. Patients received monthly erenumab for six months before assessing its effectiveness. Responders were considered those who achieved at least 30% reduction in monthly migraine days (MMD) by month 6, compared to baseline. Secondary outcomes were also analysed, including changes of the Headache Impact Test version 6 (HIT-6). Results One hundred sixty-four patients [135 (82.3%) females; mean age 46 SD 14) years] were included in the audit and 160 patients analysed. Patients had failed a mean of 8.4 preventive treatments at baseline. At month 6, 76 patients (48%) were 30% responders to erenumab, 50 patients (31%) were 50% responders and 25 (15%) were 75% responders. The mean reduction in MMD at month 6 was 7.5 days compared to baseline (P < 0.001). At month 12 and month 18, 61 patients (38%) and 52 patients (33%) remained 30% responders respectively. At month 24, 36 patients (23%) remained 30% responders, 25 patients (16%) and 13 patients (8%) were respectively 50% and 75% responders. Compared to 95% of patients at baseline, at months 6, 12 and 24, 46%, 29% and 16% of responders respectively had severe disability. At least one adverse event at month 6, 12, 18 and 24 was reported by 49%, 19%, 11% and 3% of patients. By month 6, 13% of patients discontinued the treatment because of side effects, often constipation. Conclusions Long-term sustained effectiveness of erenumab was reported only by a minority of resistant CM patients. Although more research in resistant migraine is needed, Erenumab can provide long-term meaningful reduction in migraine load and migraine-related disability in some patients.
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Affiliation(s)
- Anna P. Andreou
- grid.13097.3c0000 0001 2322 6764Institute of Psychiatry, Psychology and Neuroscience, Headache Research-Wolfson CARD, King’s College London, London, UK
| | - Matteo Fuccaro
- grid.420545.20000 0004 0489 3985Headache and Facial Pain Service, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Bethany Hill
- grid.420545.20000 0004 0489 3985Headache and Facial Pain Service, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Madeleine Murphy
- grid.420545.20000 0004 0489 3985Headache and Facial Pain Service, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Valeria Caponnetto
- grid.158820.60000 0004 1757 2611Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, L’Aquila, Italy
| | - Rachael Kilner
- grid.420545.20000 0004 0489 3985Headache and Facial Pain Service, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Giorgio Lambru
- grid.420545.20000 0004 0489 3985Headache and Facial Pain Service, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
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12
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Xin B, Xie K, Luo G, Yao M. Long-Term Follow-Up Safety and Effectiveness of CT-Guided Radiofrequency Thermocoagulation of Sphenopalatine Ganglion in Refractory Headache Treatment. Pain Ther 2022; 11:1011-1023. [PMID: 35793048 PMCID: PMC9314503 DOI: 10.1007/s40122-022-00401-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 05/26/2022] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE The purpose of this study was to evaluate the effectiveness and safety of computed tomography (CT)-guided radiofrequency thermocoagulation (RFTA) of the sphenopalatine ganglion (SPG) for patients with refractory headache. METHODS A total of 14 patients with refractory migraine and 10 patients with cluster headache (CH) who underwent CT-guided SPG RF between May 2019 and August 2021 at the Jiaxing First Hospital, located in Jiaxing City, Zhejiang Province, China, were included and analyzed in this retrospective cohort study. Pain score, sleep quality scores, and treatment effects were observed before operation as well as 1 day and 1, 3, 6, 12, and 24 months after surgery. Also, the incidence of facial numbness at different timepoints after operation was evaluated. RESULTS The frequency and duration of attacks decreased after treatment in patients with migraine, and the shortening of the cluster period and the prolongation of the remission period after treatment in patients with CH indicated that the treatment was effective. The numeric rating scale (NRS) ranged from 0 to 10, where 0 meant no pain and 10 meant the worst imaginable pain. The NRS of patients at 1 day and 1, 3, 6, 12, and 24 months after surgery was significantly lower than before operation (P < 0.05). The treatment of patients with migraine and CH was effective. The overall incidence of numbness in patients with migraine and the total incidence of numbness in patients with CH was recorded. The total incidence of numbness decreased gradually, but no significant difference was detected in the incidence of numbness between the two groups (P > 0.05). No serious adverse reactions, such as orthostatic hypertension, intracranial infection, and visual disturbance, occurred in the patients after operation. CONCLUSION CT-guided RFTA of the SPG significantly relieves headache symptoms in patients with refractory migraine and CH. It has the advantages of rapid onset, long duration, and a safe and reliable treatment process, making it worthy of clinical application.
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Affiliation(s)
- Bingyue Xin
- The Second Affiliated Hospital & Yuying Children’s Hospital of Wenzhou Medical University/The Second School of Medicine, Wenzhou Medical University, No. 109 West Xueyuan Road, Wenzhou City, Zhejiang China ,Department of Anesthesiology and Pain Research Center, The First Hospital of Jiaxing or The Affiliated Hospital of Jiaxing University, No. 1882 South Zhonghuan Road, Jiaxing City, Zhejiang China
| | - Keyue Xie
- The Second Clinical Medical College, Zhejiang Chinese Medicine University, No. 548 Binwen Road, Hangzhou City, Zhejiang China ,Department of Anesthesiology and Pain Research Center, The First Hospital of Jiaxing or The Affiliated Hospital of Jiaxing University, No. 1882 South Zhonghuan Road, Jiaxing City, Zhejiang China
| | - Ge Luo
- Department of Anesthesiology and Pain Research Center, The First Hospital of Jiaxing or The Affiliated Hospital of Jiaxing University, No. 1882 South Zhonghuan Road, Jiaxing City, Zhejiang China
| | - Ming Yao
- The Second Affiliated Hospital & Yuying Children’s Hospital of Wenzhou Medical University/The Second School of Medicine, Wenzhou Medical University, No. 109 West Xueyuan Road, Wenzhou City, Zhejiang China ,Department of Anesthesiology and Pain Research Center, The First Hospital of Jiaxing or The Affiliated Hospital of Jiaxing University, No. 1882 South Zhonghuan Road, Jiaxing City, Zhejiang China
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13
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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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Abstract
BACKGROUND Refractory chronic migraine is a common and debilitating neurologic condition, affecting over 8 million people in the United States. It is associated with billions of dollars in lost productivity annually. Novel medical (anti-calcitonin gene-related peptide antibodies) and surgical treatment modalities have emerged for chronic migraine in recent years. The current study investigated the cost-utility of surgical versus medical management of refractory chronic migraine. METHODS A Markov cohort analysis using hybrid Monte Carlo patient simulation was performed to compare surgical decompression versus erenumab for the treatment of refractory chronic migraine in adults. Both societal and payer perspectives were considered. Primary model outcomes included incremental cost-effectiveness ratio, or cost per quality-adjusted life-year gained. RESULTS Over a 5-year period, migraine surgery was associated with an increase of 0.2 quality-adjusted life-year per patient when compared to erenumab. In terms of costs, the results demonstrated a $19,337 decrease in direct medical costs and a $491 decrease in indirect costs (productivity lost) for the surgery cohort compared to erenumab. Because surgery improved quality of life and decreased costs compared to erenumab, even when considering revision surgery needs, surgery was the overall dominant treatment in terms of cost-effectiveness. Sensitivity analyses demonstrated that surgery was cost-effective compared to erenumab when patients required therapy for at least 1 year. CONCLUSIONS Surgical deactivation of migraine trigger sites may pose a cost-effective approach to treating refractory chronic migraine in adults. This is especially the case when patients are anticipated to require therapy for more than 1 year.
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15
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Lekontseva O, Wang M, Amoozegar F. Predictors of clinical response to erenumab in patients with migraine. CEPHALALGIA REPORTS 2022. [DOI: 10.1177/25158163221128185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Anti-CGRP monoclonal antibodies have emerged as efficacious preventive therapies for some, but not all patients with migraine. It is not yet fully understood what predicts treatment response. Objective: To identify factors associated with good or poor response to erenumab, the first available CGRP monoclonal antibody. Methods: A chart review of patients with migraine from a large headache center who received at least three 4-weekly doses of erenumab between 2018 and 2020 was conducted. Clinical variables were compared between erenumab responders (defined as ≥30% reduction in monthly headache or migraine days at 3 months) and non-responders via logistic regression analyses. Results: Among 90 enrolled patients, 62.2% were erenumab responders and 37.8% non-responders. A significantly larger proportion of non-responders were unemployed (58.8% vs. 28.6%), had complex diagnosis (chronic migraine overlapping another primary or secondary headache) (47.1% vs. 14.3%), higher monthly headache days (30 vs. 25.5) and migraine days (20 vs. 12), a higher frequency of daily headache (76.5% vs. 48.2%), and failed more preventive therapies (5.5 vs. 3). Based on logistic regressions, erenumab responsiveness did not significantly associate with duration of migraine, presence of aura, medication overuse, number of concurrent preventives, response to onabotulinumtoxinA or triptans, or certain comorbidities and substance use. Conclusions: This work may help improve selection of patients who may benefit from erenumab, but further prospective research studies are needed.
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Affiliation(s)
- Olga Lekontseva
- Calgary Headache Assessment and Management Program, Alberta Health Services and University of Calgary, Calgary, AB, Canada
| | - Meng Wang
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Farnaz Amoozegar
- Calgary Headache Assessment and Management Program, Alberta Health Services and University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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16
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Özaltun MF, Geyik S, Yılmaz ŞG. Screening for Copy Number Variations of the 15q13.3 Hotspot in CHRNA7 Gene and Expression in Patients with Migraines. Curr Issues Mol Biol 2021; 43:1090-1113. [PMID: 34563047 PMCID: PMC8929100 DOI: 10.3390/cimb43020078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 08/24/2021] [Accepted: 09/02/2021] [Indexed: 12/02/2022] Open
Abstract
Background: a migraine is a neurological disease. Copy number variation (CNV) is a phenomenon in which parts of the genome are repeated. We investigated the effects of the CNV and gene expression at the location 15q13.3 in the Cholinergic Receptor Nicotinic Alpha 7 Subunit (CHRNA7) gene, which we believe to be effective in the migraine clinic. Methods: we evaluated changes in CHRNA7 gene expression levels and CNV of 15q13.3 in patients with migraine (n = 102, with aura, n = 43; without aura, n = 59) according to healthy controls (n = 120) by q-PCR. The data obtained were analyzed against the reference telomerase reverse transcriptase (TERT) gene with the double copy number by standard curve analysis. Copy numbers were graded as a normal copy (2), gain (2>), and loss (<2). Results: we analyzed using the 2−ΔΔCT calculation method. The CHRNA7 gene was significantly downregulated in patients (p < 0.05). The analysis of CNV in the CHRNA7 gene was statistically significant in the patient group, according to healthy controls (p < 0.05). A decreased copy number indicates a dosage loss. However, no significant difference was observed among gain, normal, and loss copy numbers and expression values in patients (p > 0.05). The change in CNV was not associated with the downregulation of the CHRNA7 gene. Conclusion: Downregulation of the CHRNA7 gene may contribute to the formation of migraine by inactivation of the alpha-7 nicotinic receptor (α7nAChR). The association of CNV gains and losses with migraines will lead to better understanding of the molecular mechanisms and pathogenesis, to better define the disease, to be used as a treatment target.
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Affiliation(s)
- Mehmet Fatih Özaltun
- Department of Neurology, Gaziantep University, Gaziantep 27310, Turkey; (M.F.Ö.); (S.G.)
| | - Sırma Geyik
- Department of Neurology, Gaziantep University, Gaziantep 27310, Turkey; (M.F.Ö.); (S.G.)
| | - Şenay Görücü Yılmaz
- Department of Nutrition and Dietetics, Gaziantep University, Gaziantep 27310, Turkey
- Correspondence: or ; Tel.: +90-(342)-360-1200; Fax: +90-(342)-360-8795
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17
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Cheng F, Ahmed F. OnabotulinumtoxinA for the prophylactic treatment of headaches in adult patients with chronic migraine: a safety evaluation. Expert Opin Drug Saf 2021; 20:1275-1289. [PMID: 34187265 DOI: 10.1080/14740338.2021.1948531] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Existing oral prophylaxis for chronic migraine (CM) are often ineffective or poorly tolerated. OnabotulinumtoxinA (onabotA) is approved for headache prophylaxis in CM and ameliorates headaches in patients refractory to multiple preventatives.Areas covered: We appraise evidence regarding action mechanisms, pharmacodynamics, and pharmacokinetics of onabotA in CM prophylaxis. We critically evaluate salient clinical and real-world studies demonstrating its efficacy in improving multiple aspects of CM. We discuss onabotA safety, tolerability, and adverse events (AEs) for CM prophylaxis from clinical trials, post-authorization studies and meta-analyses, including novel pregnancy safety data and comparisons with oral prophylactics. We explore areas of future interest, particularly onabotA safety and efficacy in the context of novel antibody-based prophylaxis.Expert opinion: Clinical and real-world evidence demonstrate onabotA safety, tolerability and efficacy for CM prophylaxis. Most AEs are mild/moderate and self-limiting, with few serious AEs and no treatment-related deaths. Common AEs include neck pain, ptosis, muscle weakness, and stiffness. Modifying existing responder-criteria enables more patients to benefit from onabotA. OnabotA shows superior safety and efficacy to oral preventatives, and appears safe in pregnancy. Future pregnancy-risk register will clarify pregnancy and lactation safety further. Future research comparing onabotA safety and efficacy with newly emergent antibody-based prophylaxis is keenly awaited.
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Affiliation(s)
- Fan Cheng
- Department of Neurosciences, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Fayyaz Ahmed
- Department of Neurosciences, Hull University Teaching Hospitals NHS Trust, Hull, UK
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18
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Ramsden CE, Zamora D, Faurot KR, MacIntosh B, Horowitz M, Keyes GS, Yuan ZX, Miller V, Lynch C, Honvoh G, Park J, Levy R, Domenichiello AF, Johnston A, Majchrzak-Hong S, Hibbeln JR, Barrow DA, Loewke J, Davis JM, Mannes A, Palsson OS, Suchindran CM, Gaylord SA, Mann JD. Dietary alteration of n-3 and n-6 fatty acids for headache reduction in adults with migraine: randomized controlled trial. BMJ 2021; 374:n1448. [PMID: 34526307 PMCID: PMC8244542 DOI: 10.1136/bmj.n1448] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To determine whether dietary interventions that increase n-3 fatty acids with and without reduction in n-6 linoleic acid can alter circulating lipid mediators implicated in headache pathogenesis, and decrease headache in adults with migraine. DESIGN Three arm, parallel group, randomized, modified double blind, controlled trial. SETTING Ambulatory, academic medical center in the United States over 16 weeks. PARTICIPANTS 182 participants (88% women, mean age 38 years) with migraines on 5-20 days per month (67% met criteria for chronic migraine). INTERVENTIONS Three diets designed with eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and linoleic acid altered as controlled variables: H3 diet (n=61)-increase EPA+DHA to 1.5 g/day and maintain linoleic acid at around 7% of energy; H3-L6 diet (n=61)-increase n-3 EPA+DHA to 1.5 g/day and decrease linoleic acid to ≤1.8% of energy; control diet (n=60)-maintain EPA+DHA at <150 mg/day and linoleic acid at around 7% of energy. All participants received foods accounting for two thirds of daily food energy and continued usual care. MAIN OUTCOME MEASURES The primary endpoints (week 16) were the antinociceptive mediator 17-hydroxydocosahexaenoic acid (17-HDHA) in blood and the headache impact test (HIT-6), a six item questionnaire assessing headache impact on quality of life. Headache frequency was assessed daily with an electronic diary. RESULTS In intention-to-treat analyses (n=182), the H3-L6 and H3 diets increased circulating 17-HDHA (log ng/mL) compared with the control diet (baseline-adjusted mean difference 0.6, 95% confidence interval 0.2 to 0.9; 0.7, 0.4 to 1.1, respectively). The observed improvement in HIT-6 scores in the H3-L6 and H3 groups was not statistically significant (-1.6, -4.2 to 1.0, and -1.5, -4.2 to 1.2, respectively). Compared with the control diet, the H3-L6 and H3 diets decreased total headache hours per day (-1.7, -2.5 to -0.9, and -1.3, -2.1 to -0.5, respectively), moderate to severe headache hours per day (-0.8, -1.2 to -0.4, and -0.7, -1.1 to -0.3, respectively), and headache days per month (-4.0, -5.2 to -2.7, and -2.0, -3.3 to -0.7, respectively). The H3-L6 diet decreased headache days per month more than the H3 diet (-2.0, -3.2 to -0.8), suggesting additional benefit from lowering dietary linoleic acid. The H3-L6 and H3 diets altered n-3 and n-6 fatty acids and several of their nociceptive oxylipin derivatives in plasma, serum, erythrocytes or immune cells, but did not alter classic headache mediators calcitonin gene related peptide and prostaglandin E2. CONCLUSIONS The H3-L6 and H3 interventions altered bioactive mediators implicated in headache pathogenesis and decreased frequency and severity of headaches, but did not significantly improve quality of life. TRIAL REGISTRATION ClinicalTrials.gov NCT02012790.
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Affiliation(s)
- Christopher E Ramsden
- Lipid Peroxidation Unit, Laboratory of Clinical Investigation, National Institute on Aging, Baltimore, MD, USA
- Intramural Program of the National Institute on Alcohol Abuse and Alcoholism, NIH, Bethesda, MD, USA
- Department of Physical Medicine and Rehabilitation, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Daisy Zamora
- Lipid Peroxidation Unit, Laboratory of Clinical Investigation, National Institute on Aging, Baltimore, MD, USA
- Department of Psychiatry, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Keturah R Faurot
- Department of Physical Medicine and Rehabilitation, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Beth MacIntosh
- Department of Physical Medicine and Rehabilitation, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Metabolic and Nutrition Research Core, UNC Medical Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mark Horowitz
- Lipid Peroxidation Unit, Laboratory of Clinical Investigation, National Institute on Aging, Baltimore, MD, USA
| | - Gregory S Keyes
- Lipid Peroxidation Unit, Laboratory of Clinical Investigation, National Institute on Aging, Baltimore, MD, USA
| | - Zhi-Xin Yuan
- Lipid Peroxidation Unit, Laboratory of Clinical Investigation, National Institute on Aging, Baltimore, MD, USA
| | - Vanessa Miller
- Department of Physical Medicine and Rehabilitation, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Chanee Lynch
- Department of Physical Medicine and Rehabilitation, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Gilson Honvoh
- Department of Physical Medicine and Rehabilitation, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jinyoung Park
- Department of Physical Medicine and Rehabilitation, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Russell Levy
- Cytokine Analysis Core, UNC Adams School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Anthony F Domenichiello
- Lipid Peroxidation Unit, Laboratory of Clinical Investigation, National Institute on Aging, Baltimore, MD, USA
| | - Angela Johnston
- Department of Physical Medicine and Rehabilitation, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sharon Majchrzak-Hong
- Intramural Program of the National Institute on Alcohol Abuse and Alcoholism, NIH, Bethesda, MD, USA
| | - Joseph R Hibbeln
- Intramural Program of the National Institute on Alcohol Abuse and Alcoholism, NIH, Bethesda, MD, USA
| | - David A Barrow
- Cytokine Analysis Core, UNC Adams School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - James Loewke
- Intramural Program of the National Institute on Alcohol Abuse and Alcoholism, NIH, Bethesda, MD, USA
| | - John M Davis
- Department of Psychiatry, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Andrew Mannes
- Department of Perioperative Medicine, NIH Clinical Center, Bethesda, MD, USA
| | - Olafur S Palsson
- Department of Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Chirayath M Suchindran
- Department of Biostatistics, Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Susan A Gaylord
- Department of Physical Medicine and Rehabilitation, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - J Douglas Mann
- Department of Neurology, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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19
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Al-Kaisy A, Palmisani S, Carganillo R, Wesley S, Pang D, Rotte A, Santos A, Lambru G. Safety and Efficacy of 10 kHz Spinal Cord Stimulation for the Treatment of Refractory Chronic Migraine: A Prospective Long-Term Open-Label Study. Neuromodulation 2021; 25:103-113. [PMID: 34110663 DOI: 10.1111/ner.13465] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 04/06/2021] [Accepted: 05/04/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND Refractory chronic migraine (rCM) is a highly disabling condition for which novel safe and effective treatments are needed. Safety and long-term efficacy of paresthesia-free high cervical 10 kHz spinal cord stimulation (SCS) were here prospectively evaluated for the treatment of rCM. MATERIALS AND METHODS Twenty adults with rCM (mean numbers of preventive treatments failed: 12.2 ± 3.1) were enrolled in this single-center, open-label, prospective study and implanted with a 10 kHz SCS system (Senza™ system, Nevro Corp.), with the distal tip of the lead(s) positioned epidurally at the C2 vertebral level. Safety and effectiveness outcomes, such as adverse events, headache and migraine reductions, responder rates, Migraine Disability Assessment (MIDAS), Headache Impact Test-6 (HIT-6), and Migraine-Specific Quality-of-Life (MSQ), were captured up to 52 weeks after implantation. RESULTS Compared to baseline, at 52 weeks postimplantation, there was a significant reduction of mean monthly migraine days (MMD) by 9.3 days (p < 0.001). Sixty percent and 50% of patients obtained respectively at least 30% and at least 50% reduction in mean MMD. By week 52, 50% of patients' chronic pattern converted to an episodic pattern. The proportion of subjects classified with severe headache-related disability on the HIT-6, decreased from 100% to 60% at week 52. Meaningful improvements of headache-related quality of life measured by the MSQ scale were observed with mean gain of 24.9 ± 23.1 (p < 0.001) points at 52 weeks. No unanticipated adverse device effects occurred. No patients required any additional device surgical revision. CONCLUSION 10 kHz SCS may a be safe and effective neurostimulation option for rCM patients. The paresthesia-free waveform constitutes an unprecedented advantage for future methodologically sound sham-controlled studies in headache neuromodulation.
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Affiliation(s)
- Adnan Al-Kaisy
- Pain & Neuromodulation Academic Research Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Stefano Palmisani
- Pain & Neuromodulation Academic Research Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Roy Carganillo
- Pain & Neuromodulation Academic Research Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Samuel Wesley
- Pain & Neuromodulation Academic Research Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - David Pang
- Pain & Neuromodulation Academic Research Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | | | | | - Giorgio Lambru
- The Headache Service, Pain Management and Neuromodulation Centre Guy's & St Thomas' NHS Foundation Trust, London, UK
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20
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Alqahtani M, Barmherzig R, Lagman-Bartolome AM. Approach to Pediatric Intractable Migraine. Curr Neurol Neurosci Rep 2021; 21:38. [PMID: 34089140 DOI: 10.1007/s11910-021-01128-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW Intractable migraine in children and adolescents is a significant cause of disability and decreased quality of life (QoL) in this population. Challenges include lack of unifying definition for intractable migraine, and limited data on best-practice management in this age group, with most current treatment pathways extrapolated from adult studies or expert consensus. RECENT FINDINGS A comprehensive approach in the evaluation and management of intractable migraine in this age group encompasses excluding secondary causes of headache; making an accurate diagnosis; identifying and appropriately managing modifiable risk factors; and initiating appropriate pharmacologic therapy to reduce disability, improve health-related quality of life, reduce risk of progression, and develop adaptive pain coping strategies. Several strategies for management of pediatric intractable migraine including use of acute medications, bridge therapy in outpatient setting, emerging therapies for preventive therapy, and a stepwise combination therapy for management of pediatric intractable migraine in emergency and inpatient setting are presented based on available clinical data, safety/tolerability, availability, cost-effectiveness, and expert consensus. This descriptive review of the available literature focuses on approach to therapy for acute intractable migraine in a pediatric population including outpatient, emergency department (ED), and inpatient management.
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Affiliation(s)
- Mohammed Alqahtani
- Division of Neurology, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
| | - Rebecca Barmherzig
- Pediatric Headache Program, Division of Neurology, Children's Hospital of Philadelphia (CHOP), 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Ana Marissa Lagman-Bartolome
- Division of Neurology, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada. .,Centre for Headache, Women's College Hospital, University of Toronto, 76 Grenville Street, Toronto, Ontario, M5B1S2, Canada.
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21
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Vernieri F, Altamura C, Brunelli N, Costa CM, Aurilia C, Egeo G, Fofi L, Favoni V, Pierangeli G, Lovati C, Aguggia M, d'Onofrio F, Doretti A, Di Fiore P, Finocchi C, Rao R, Bono F, Ranieri A, Albanese M, Cevoli S, Barbanti P. Galcanezumab for the prevention of high frequency episodic and chronic migraine in real life in Italy: a multicenter prospective cohort study (the GARLIT study). J Headache Pain 2021; 22:35. [PMID: 33941080 PMCID: PMC8091153 DOI: 10.1186/s10194-021-01247-1] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 04/16/2021] [Indexed: 12/19/2022] Open
Abstract
Background The clinical benefit of galcanezumab, demonstrated in randomized clinical trials (RCTs), remains to be quantified in real life. This study aimed at evaluating the effectiveness, safety and tolerability of galcanezumab in the prevention of high-frequency episodic migraine (HFEM) and chronic migraine (CM) in a real-life setting. Methods This multicenter prospective observational cohort study was conducted between November 2019 and January 2021 at 13 Italian headache centers. Consecutive adult HFEM and CM patients clinically eligible were enrolled and treated with galcanezumab subcutaneous injection 120 mg monthly with the first loading dose of 240 mg. The primary endpoint was the change in monthly migraine days (MMDs) in HFEM and monthly headache days (MHDs) in CM patients after 6 months of therapy (V6). Secondary endpoints were the Numerical Rating Scale (NRS), monthly painkiller intake (MPI), HIT-6 and MIDAS scores changes, ≥50% responder rates (RR), the conversion rate from CM to episodic migraine (EM) and Medication Overuse (MO) discontinuation. Results One hundred sixty-three patients (80.5% female, 47.1 ± 11.7 years, 79.8% CM) were included. At V6, MMDs reduced by 8 days in HFEM and MHDs by 13 days in CM patients (both p < .001). NRS, MPI, HIT-6 and MIDAS scores significantly decreased (p < .001). Ten patients (6.1%) dropped out for inefficacy and classified as non-responders. Patients with ≥50%RRs, i.e. responders, were 76.5% in the HFEM and 63.5% in the CM group at V6. Among CM patients, the V6 responders presented a lower body mass index (p = .018) and had failed a lower number of preventive treatments (p = .013) than non-responders. At V6, 77.2% of CM patients converted to EM, and 82.0% ceased MO. Adverse events, none serious, were reported in up to 10.3% of patients during evaluation times. Conclusions Galcanezumab in real life was safe, well tolerated and seemed more effective than in RCTs. Normal weight and a low number of failed preventives were positively associated with galcanezumab effectiveness in CM patients. Trial registration ClinicalTrials.govNCT04803513.
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Affiliation(s)
- Fabrizio Vernieri
- Headache and Neurosonology Unit, Campus Bio-Medico University Hospital, Via Alvaro del Portillo, 200, 00128, Rome, Italy.
| | - Claudia Altamura
- Headache and Neurosonology Unit, Campus Bio-Medico University Hospital, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - Nicoletta Brunelli
- Headache and Neurosonology Unit, Campus Bio-Medico University Hospital, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - Carmelina Maria Costa
- Headache and Neurosonology Unit, Campus Bio-Medico University Hospital, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - Cinzia Aurilia
- Headache and Pain Unit, IRCCS San Raffaele Pisana, Rome, Italy
| | - Gabriella Egeo
- Headache and Pain Unit, IRCCS San Raffaele Pisana, Rome, Italy
| | - Luisa Fofi
- Headache and Pain Unit, IRCCS San Raffaele Pisana, Rome, Italy
| | - Valentina Favoni
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Giulia Pierangeli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Carlo Lovati
- Headache Center, Neurology Unit, University Hospital L. Sacco, Milan, Italy
| | - Marco Aguggia
- Neurology and Stroke Unit, Asti Hospital, Asti, Italy
| | | | - Alberto Doretti
- Department of Neurology, Stroke Unit and Laboratory of Neuroscience, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Paola Di Fiore
- Headache Center, Neurology and Stroke Unit, S. Carlo Borromeo Hospital, Milan, Italy
| | | | - Renata Rao
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Francesco Bono
- Center for Headache and Intracranial Pressure Disorders, Neurology Unit, A.O.U. Mater Domini, Catanzaro, Italy
| | - Angelo Ranieri
- Headache Centre, Neurology and Stroke Unit, A. Cardarelli Hospital, Naples, Italy
| | - Maria Albanese
- Headache Center, Neurology Unit, Tor Vergata University Hospital, Rome, Italy.,Department of Systems Medicine, Tor Vergata University, Rome, Italy
| | - Sabina Cevoli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Piero Barbanti
- Headache and Pain Unit, IRCCS San Raffaele Pisana, Rome, Italy.,San Raffaele University, Rome, Italy
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22
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Donnet A, Ducros A, Radat F, Allaf B, Chouette I, Lanteri-Minet M. Severe migraine and its control: A proposal for definitions and consequences for care. Rev Neurol (Paris) 2021; 177:924-934. [PMID: 33810839 DOI: 10.1016/j.neurol.2020.11.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/19/2020] [Accepted: 11/26/2020] [Indexed: 12/13/2022]
Abstract
Currently many patients with severe migraine do not receive appropriate treatment and are never referred to specialist headache centres. On the other hand, specialist headache centres are frequently attended by patients whose migraines could be managed adequately in the community. One reason for this may be the absence of standardised definitions of migraine severity and control and of a treatment algorithm for orientating difficult-to-treat patients to specialist headache centres. Based on a review of the relevant literature and consensus meetings, proposals have been made for these items. We propose that migraine should be considered severe if headache frequency is at least eight migraine days per month or, if headaches are less frequent, the HIT-6 score is ≥60 or ≥50% of headaches require complete interruption of activity. The proposed definition of migraine control is defined on the basis of appropriate response to acute headache therapy and to preventative therapy. A treatment algorithm is proposed to assess migraine control regularly and to adapt therapy accordingly. These proposals may contribute to developing and testing strategies for management of severe disease with appropriate and effective preventive treatment strategies. With the anticipated introduction of new possibilities for migraine prevention in the near future, the time is ripe for a holistic approach to migraine management.
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Affiliation(s)
- Anne Donnet
- Centre d'évaluation et de traitement de la douleur, CHU de la Timone, Marseille, France; Neuro-Dol Inserm U1107, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Anne Ducros
- Service de Neurologie, CHU Gui de Chauliac, Montpellier, France
| | - Françoise Radat
- Unité de traitement de la douleur chronique, CHU de Bordeaux, Bordeaux, France
| | | | | | - Michel Lanteri-Minet
- Neuro-Dol Inserm U1107, Université Clermont Auvergne, Clermont-Ferrand, France; Département d'évaluation et de traitement de la douleur CHU de Nice, FHU InovPain Université Côte Azur, Nice, France.
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23
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Kim S, Bae DW, Park SG, Park JW. The impact of Pain-related emotions on migraine. Sci Rep 2021; 11:577. [PMID: 33436778 PMCID: PMC7804193 DOI: 10.1038/s41598-020-80094-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 12/14/2020] [Indexed: 02/07/2023] Open
Abstract
The response to pain is highly individual and can be influenced by complex emotional perception. This study aims to investigate the status of the pain-related emotional response, and the influence on headache characteristics and disability in migraine. We studied the pain-related emotional response in 145 consecutive migraine patients using the Pain Anxiety Symptoms Scale (PASS), the Pain Catastrophizing Scale (PCS), and the Pain Sensitivity Questionnaire (PSQ) and compared them with 106 healthy controls. We investigated the relationship between emotional factors and migraine characteristics. The effect of pain-related emotion on migraine-related disability assessed with the Headache Impact Test-6 (HIT-6) and the Migraine Disability Assessment (MIDAS). Migraine patients showed significantly higher scores on total PASS (p < 0.001), PCS (p < 0.001) and PSQ (p = 0.002) compared to the healthy controls. The HIT-6 was weakly correlated with PASS (r = 0.390, p < 0.001) and PCS (r = 0.354, p < 0.001). PASS-Total (p = 0.001), headache frequency (p = 0.003), and HADS-Anxiety (p = 0.028) were independent variables associated with HIT-6. Headache frequency (p < 0.001) was an independent variable associated with MIDAS. The structural equation model indicated that headache severity has direct loading on emotion and subsequently influenced migraine-related disability. Disability has a significant effect on the frequency of abortive medication use. Migraine patients have altered emotional responses to pain perception. Pain-related anxiety made an important contribution to headache-related disability. The present results suggest that the management of disability by considering various pain-related emotional factors may be necessary for the therapeutic aspects of migraine.
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Affiliation(s)
- Seonghoon Kim
- Department of Neurology, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dae-Woong Bae
- Department of Neurology, St. Vincent's hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang-Gue Park
- Department of Applied Statistics, Chung-Ang University, Seoul, Republic of Korea
| | - Jeong-Wook Park
- Department of Neurology, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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24
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Maselis K, Žekevičiūtė R, Vaitkus A. Refractoriness to drugs in migraine may be the result of developing anti-drug antibodies. Med Hypotheses 2020; 146:110459. [PMID: 33360448 DOI: 10.1016/j.mehy.2020.110459] [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: 10/26/2020] [Revised: 12/09/2020] [Accepted: 12/11/2020] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Migraine is a common neurological disease and is listed second among the most disabling health conditions worldwide. Refractory migraine (RM) is a term used to emphasize the unresponsiveness of migraine to various treatment options, encompassing both episodic refractory and chronic refractory migraine. In this paper we discuss various known and possible mechanisms of pharmacological refractoriness in RM, such as possible involvement of the gut microbiome, the blood-brain barrier, migraine genetics and various mechanisms of pharmacokinetic and pharmacodynamic tolerance. Development of medication-overuse headache as a secondary disorder following migraine is also considered. We argue that the available literature is insufficient to fully explain the mechanisms of refractoriness and we present our hypothesis. HYPOTHESIS Refractoriness to drugs in migraine may be the result of developing anti-drug antibodies. Most migraine drugs are small molecules, which cannot elicit an immune response on their own due to their size. However, such molecules can bind to peptide carriers in their vicinity, greatly increasing their immunogenicity. A small molecule possessing this binding ability is called a hapten. Haptens form hapten-carrier complexes (HCCs), which can evoke powerful immune responses. Immune reactions to HCCs are known to be predominantly 'drug allergies' or type 1 drug hypersensitivity reactions', usually resulting from IgE or non-IgE mediated mast cell degranulation. We argue that the immune reaction to HCCs can take shape in developing neutralizing anti-drug antibodies (ADA) in the form of IgG and IgA class antibodies. Since biological therapeutics, such as various monoclonal antibodies, face the issue of ADA-induced drug tolerance, HCCs, being similar in the sense that they carry peptide antigens, are of sufficient size and may be considerably immunogenic, can be responded to in a similar way by producing neutralizing ADA. Furthermore, we argue that such responses are expected to happen more frequently than is thought, due to IgG and IgA being prevalent antibodies, which utilize their neutralizing capabilities on regular basis. Finally, it is important to consider that neutralization reactions in normal immune responses are typically asymptomatic, with the only clinical expression being progressive drug tolerance. These cases may be overshadowed by the life-threatening cases of drug allergy induced anaphylaxis, possibly leading to neutralization reactions being underrecognized. DISCUSSION This hypothesis aims to stimulate more research regarding drug resistance, and if it receives support from empirical evidence, it may help further elucidate the mechanisms underlying refractory diseases and contribute to the development of more effective treatment of many disorders.
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Affiliation(s)
- K Maselis
- Hospital of Lithuanian, University of Health Sciences Kauno klinikos, Eivenių g. 2, Kaunas, Lithuania.
| | - R Žekevičiūtė
- Hospital of Lithuanian, University of Health Sciences Kauno klinikos, Eivenių g. 2, Kaunas, Lithuania
| | - A Vaitkus
- Lithuanian University of Health Sciences, Eivenių g. 2, Kaunas, Lithuania
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25
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Buse DC, Gandhi SK, Cohen JM, Ramirez-Campos V, Cloud B, Yang R, Cowan RP. Improvements across a range of patient-reported domains with fremanezumab treatment: results from a patient survey study. J Headache Pain 2020; 21:109. [PMID: 32887548 PMCID: PMC7487845 DOI: 10.1186/s10194-020-01177-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 08/18/2020] [Indexed: 12/13/2022] Open
Abstract
Background The long-term safety and efficacy of fremanezumab were evaluated in a 52-week extension study (NCT02638103). Patient satisfaction with fremanezumab, dosing preferences, and patient-reported outcomes were assessed in a subpopulation who completed the extension study and consented to a follow-up questionnaire. Methods In the extension study (N = 1842), adults with migraine were randomized to quarterly or monthly fremanezumab. After completing active treatment, patients answered a survey evaluating patient satisfaction, treatment and dosing preferences, and changes in patient-reported outcomes. Results Of the 557 patients who could have been contacted upon completing the extension study, 302 consented and 253 completed the survey. The mean (standard deviation) satisfaction rating for fremanezumab was 6.1 (1.4; 1 = “extremely dissatisfied” to 7 = “extremely satisfied”). Most patients (175 [69.2%]) preferred quarterly over monthly fremanezumab dosing. Among patients taking antiepileptics (most common class of prior preventive medication; n = 130), 91.5% preferred fremanezumab. Patients reported improvements in anxiety (74 [67.9%]), sleep quality (143 [56.5%]), and quality of time spent with others (210 [83.0%]) with fremanezumab. Conclusion In this study, treatment satisfaction with fremanezumab was high, most patients preferred quarterly fremanezumab dosing, and fremanezumab was generally preferred to prior preventive medications. Trial registration ClinicalTrials.gov NCT02638103 (HALO LTS), registered December 22, 2015.
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Affiliation(s)
- Dawn C Buse
- Albert Einstein College of Medicine, Bronx, NY, 10461, USA.
| | - Sanjay K Gandhi
- 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
| | | | | | - Ronghua Yang
- Teva Branded Pharmaceutical Products R&D, Inc., West Chester, PA, USA
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26
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Sacco S, Braschinsky M, Ducros A, Lampl C, Little P, van den Brink AM, Pozo-Rosich P, Reuter U, de la Torre ER, Sanchez Del Rio M, Sinclair AJ, Katsarava Z, Martelletti P. European headache federation consensus on the definition of resistant and refractory migraine : Developed with the endorsement of the European Migraine & Headache Alliance (EMHA). J Headache Pain 2020; 21:76. [PMID: 32546227 PMCID: PMC7296705 DOI: 10.1186/s10194-020-01130-5] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 05/25/2020] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Despite advances in the management of headache disorders, some patients with migraine do not experience adequate pain relief with acute and preventive treatments. It is the aim of the present document to provide a definition of those migraines which are difficult-to-treat, to create awareness of existence of this group of patients, to help Healthcare Authorities in understanding the implications, and to create a basis to develop a better pathophysiological understanding and to support further therapeutic advances. MAIN BODY Definitions were established with a consensus process using the Delphi method. Patients with migraine with or without aura or with chronic migraine can be defined as having resistant migraine and refractory migraine according to previous preventative failures. Resistant migraine is defined by having failed at least 3 classes of migraine preventatives and suffer from at least 8 debilitating headache days per month for at least 3 consecutive months without improvement; definition can be based on review of medical charts. Refractory migraine is defined by having failed all of the available preventatives and suffer from at least 8 debilitating headache days per month for at least 6 consecutive months. Drug failure may include lack of efficacy or lack of tolerability. Debilitating headache is defined as headache causing serious impairment to conduct activities of daily living despite the use of pain-relief drugs with established efficacy at the recommended dose and taken early during the attack; failure of at least two different triptans is required. CONCLUSIONS We hope, that the updated EHF definition will be able to solve the conflicts that have limited the use of definitions which have been put forward in the past. Only with a widely accepted definition, progresses in difficult-to-treat migraine can be achieved. This new definition has also the aim to increase the understanding of the impact of the migraine as a disease with all of its social, legal and healthcare implications. It is the hope of the EHF Expert Consensus Group that the proposed criteria will stimulate further clinical, scientific and social attention to patients who suffer from migraine which is difficult-to-treat.
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Affiliation(s)
- Simona Sacco
- Neuroscience section - Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, Via Vetoio, 67100, L'Aquila, Italy. .,Regional Referral Headache Center of the Abruzzo region, ASL Avezzano-Sulmona-L'Aquila, L'Aquila, Italy.
| | - Mark Braschinsky
- Headache Clinic, Department of Neurology, Tartu University Clinics, Tartu, Estonia
| | - Anne Ducros
- Headache Unit, Neurology Department, Montpellier University Hospital and Montpellier University, Montpellier, France
| | - Christian Lampl
- Department of Neurology, Headache Medical Centre Linz, Hospital Barmherzige Brüder, Centre of Integrative Medicine (ZiAM) Ordensklinikum Linz, Linz, Austria
| | - Patrick Little
- European Migraine & Headache Alliance (EMHA), Hendrik Ido Ambacht, The Netherlands
| | - Antoinette Maassen van den Brink
- Division of Pharmacology, Department of Internal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Patricia Pozo-Rosich
- Headache Unit, Neurology Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Headache and Neurological Pain Research Group, Vall d'Hebron Research Institute, Department de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Uwe Reuter
- Charité Universitätsmedizin Berlin, Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | | | - Alexandra J Sinclair
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Zaza Katsarava
- Evangelical Hospital Unna, Unna, Germany.,Departmentof Neurology, University of Duisburg-Essen, Essen, Germany.,EVEX Medical Corporation, Tbilisi, Georgia.,IM Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy.,Regional Referral Headache Center of the Lazio region, Sant'Andrea Hospital, Rome, Italy
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27
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Pellesi L, Do TP, Ashina H, Ashina M, Burstein R. Dual Therapy With Anti-CGRP Monoclonal Antibodies and Botulinum Toxin for Migraine Prevention: Is There a Rationale? Headache 2020; 60:1056-1065. [PMID: 32437038 DOI: 10.1111/head.13843] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 04/29/2020] [Accepted: 04/29/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To narratively review the pathophysiological rationale of dual therapy with anti-calcitonin gene-related peptide monoclonal antibodies and botulinum toxin type A in treatment-resistant chronic migraine prevention. BACKGROUND For the prevention of chronic migraine, several pharmacological therapies are available, including oral medications, botulinum toxin type A, and the newly approved monoclonal antibodies targeting calcitonin gene-related peptide or its receptor. However, monotherapy does not yield benefits in some affected individuals, which raises the question of whether dual therapy with monoclonal antibodies and botulinum toxin type A hold promise in patients with treatment-resistant chronic migraine. METHOD We searched MEDLINE for articles published from database inception to December 31st, 2019. Publications were largely selected from the past 10 years but commonly referenced and highly regarded older publications were not excluded. RESULTS Preclinical data suggest that anti-calcitonin gene-related peptide monoclonal antibodies and botulinum toxin type A have synergistic effects within the trigeminovascular system. Of note, findings indicate that fremanezumab - an antibody targeting the calcitonin gene-related peptide - mainly prevents the activation of Aδ-fibers, whereas botulinum toxin type A prevents the activation of C-fibers. CONCLUSION There is currently only indirect preclinical evidence to support a rationale for dual therapy with anti-calcitonin gene-related peptide monoclonal antibodies and botulinum toxin type A for chronic migraine prevention. Rigorous studies evaluating clinical efficacy, safety, and cost-effectiveness are needed.
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Affiliation(s)
- Lanfranco Pellesi
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Thien P Do
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Håkan Ashina
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Messoud Ashina
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Rami Burstein
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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28
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Chowdhury D, Datta D. Managing Migraine in the Times of COVID-19 Pandemic. Ann Indian Acad Neurol 2020; 23:S33-S39. [PMID: 32419752 PMCID: PMC7213033 DOI: 10.4103/aian.aian_296_20] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 04/13/2020] [Accepted: 04/13/2020] [Indexed: 12/22/2022] Open
Abstract
COVID-19 pandemic is an emerging, rapidly evolving situation. Migraine is one of the commonest and highly disabling chronic neurological diseases in the world. During the pandemic and lockdown, migraine patients are facing an enormous problem in getting optimum care because of difficulty in access, forced social isolation, and encountering a health system that is getting rapidly overwhelmed. It is important that they must be protected by minimizing their visits to the clinics and emergency departments. Paradoxically multiple triggers are in operation which is likely to increase their headache frequency. Hence physicians should be made aware of the new rules of the game in treating migraines during this time of the pandemic so that these patients get optimum treatment and care and don't feel left out. This review tries to answer a series of questions related to managing migraines in the times of COVID-19 pandemic.
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Affiliation(s)
- Debashish Chowdhury
- Department of Neurology, G B Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - Debabrata Datta
- Department of Neurology, G B Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
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