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Tulbah AS, Elkomy MH, Zaki RM, Eid HM, Eissa EM, Ali AA, Yassin HA, Aldosari BN, Naguib IA, Hassan AH. Novel nasal niosomes loaded with lacosamide and coated with chitosan: A possible pathway to target the brain to control partial-onset seizures. Int J Pharm X 2023; 6:100206. [PMID: 37637477 PMCID: PMC10458293 DOI: 10.1016/j.ijpx.2023.100206] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 08/09/2023] [Accepted: 08/11/2023] [Indexed: 08/29/2023] Open
Abstract
This work aimed to develop and produce lacosamide-loaded niosomes coated with chitosan (LCA-CTS-NSM) using a thin-film hydration method and the Box-Behnken design. The effect of three independent factors (Span 60 amount, chitosan concentration, and cholesterol amount) on vesicle size, entrapment efficiency, zeta potential, and cumulative release (8 h) was studied. The optimal formulation of LCA-CTS-NSM was chosen from the design space and assessed for morphology, in vitro release, nasal diffusion, stability, tolerability, and in vivo biodistribution for brain targeting after intranasal delivery. The vesicle size, entrapment, surface charge, and in vitro release of the optimal formula were found to be 194.3 nm, 58.3%, +35.6 mV, and 81.3%, respectively. Besides, it exhibits sustained release behavior, enhanced nasal diffusion, and improved physical stability. Histopathological testing revealed no evidence of toxicity or structural damage to the nasal mucosa. It demonstrated significantly more brain distribution than the drug solution. Overall, the data is encouraging since it points to the potential for non-invasive intranasal administration of LCA as an alternative to oral or parenteral routes.
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Affiliation(s)
- Alaa S. Tulbah
- Department of Pharmaceutics, College of Pharmacy, Umm Al-Qura University, Makkah 21955, Saudi Arabia
| | - Mohammed H. Elkomy
- Department of Pharmaceutics, College of Pharmacy, Jouf University, Sakaka 72341, Saudi Arabia
| | - Randa Mohammed Zaki
- Department of Pharmaceutics, College of Pharmacy, Prince Sattam Bin Abdulaziz University, P.O. Box 173, Al-Kharj 11942, Saudi Arabia
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Beni-Suef University, Beni-Suef 62511, Egypt
| | - Hussein M. Eid
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Beni-Suef University, Beni-Suef 62511, Egypt
| | - Essam M. Eissa
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Beni-Suef University, Beni-Suef 62511, Egypt
| | - Adel A. Ali
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Beni-Suef University, Beni-Suef 62511, Egypt
| | - Heba A. Yassin
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Sinai University (Arish campus), Arish, Egypt
| | - Basmah Nasser Aldosari
- Department of Pharmaceutics, College of Pharmacy, King Saud University, P.O. Box 2457, Riyadh 11451, Saudi Arabia
| | - Ibrahim A. Naguib
- Department of Pharmaceutical Chemistry, College of Pharmacy, Taif University, P.O. Box 11099, Taif 21944, Saudi Arabia
| | - Amira H. Hassan
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Beni-Suef University, Beni-Suef 62511, Egypt
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2
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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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3
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Cavusoglu D, Olgac Dundar N, Oztekin O, Arican P, Gencpinar P, Baran M. A Neurological Appearance of Celiac Disease: Is There Any Associated Factor? Pediatr Emerg Care 2021; 37:303-307. [PMID: 32195978 DOI: 10.1097/pec.0000000000001918] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Celiac disease may present with one or more neurological signs and/or symptoms. We aimed to define the incidence of accompanying neurological manifestations in children diagnosed as having celiac disease. METHODS The prospective study included 146 children diagnosed as having celiac disease. The medical records (presentation symptoms, clinical findings, serological test, duodenal biopsy results, lack/deficiency of vitamin, tissue type, accompanying autoimmune disorders) and demographic data of all patients were also reviewed. RESULTS Thirty-five (23.9%) of the 146 celiac patients exhibited one or more neurological findings. Headache (11.6%) and dizziness (6.1%) were the most common symptoms among neurological manifestations. There was a significant difference between the patients with and without neurological manifestations in terms of sex, biopsy result, and tissue type (P < 0.05). Moreover, there was a statistically significant difference between tissue types of the patients with and without headache (P < 0.05). We found that grade 3a by Marsh classification was the most common type among the patients with and without neurological findings in celiac disease. On neuroimaging evaluation of patients, 1 patient with chronic focal ischemic lesion, 1 patient with Chiari type 1 malformation, and 1 patient with subcortical white matter changes were identified. CONCLUSIONS Pathophysiology of neurological involvement in celiac disease is liable for various neurological findings. This study contributes to data suggesting that female sex, mild histopathological form, and human leukocyte antigen DQ2 heterozygosity are related to neurological manifestations, and also human leukocyte antigen DQ2 heterozygosity is associated with headache in celiac disease.
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Affiliation(s)
- Dilek Cavusoglu
- From the Department of Pediatric Neurology, Faculty of Medicine, Afyon Kocatepe University, Afyon
| | - Nihal Olgac Dundar
- Department of Pediatric Neurology, Faculty of Medicine, İzmir Katip Çelebi University
| | | | | | - Pinar Gencpinar
- Department of Pediatric Neurology, Faculty of Medicine, İzmir Katip Çelebi University
| | - Masallah Baran
- Pediatric Gastroenterology, Hepatology and Nutrition, Tepecik Education and Research Hospital, Izmir, Turkey
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4
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McAlindon TE, Driban JB, Roberts MB, Duryea J, Haugen IK, Schaefer LF, Smith SE, Mathiessen A, Eaton C. Erosive Hand Osteoarthritis: Incidence and Predictive Characteristics among Participants in the Osteoarthritis Initiative. Arthritis Rheumatol 2021; 73:2015-2024. [PMID: 33844453 DOI: 10.1002/art.41757] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 04/01/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate age, sex, race, osteoarthritis severity, metabolic factors, and bone health as risk factors for incident erosive hand osteoarthritis (EHOA) at baseline and over 48-month period. METHODS This study was a longitudinal cohort design including participants from the Osteoarthritis Initiative with complete hand radiographs from baseline and 48-month visits who were eligible at baseline for incident EHOA. Individuals were classified as having EHOA if they had Kellgren-Lawrence (KL) grade≥2 in at least one interphalangeal joint on two different fingers and central erosion in at least one joint. RESULTS Of the 3365 individuals identified without prevalent EHOA at baseline, 86 (2.6%) developed EHOA during the 48-month period. Risk factors included being older [relative risk (RR) per standard deviation=0.76 (95% confidence interval 0.59, 0.98)], female [RR=1.73 (1.05, 2.85)], greater osteoarthritis severity (sum of KL grade 13.9 vs. 5.3, p<0.001) and less cortical width (1.38 vs 1.52 mm, p<0.001). After 48 months, people who developed EHOA were characterized by greater progressions of radiographic osteoarthritis (i.e., joint space narrowing, KL grade progression [RRs = 1.35 to 1.9] and loss of cortical thickness [RR = 1.23], adjusted for age, sex, race, body mass index, and baseline osteoarthritis severity (sum KL scores). CONCLUSION These findings present EHOA as a disorder of advanced age and female sex, strongly associated with severity of articular structural damage and its progression. Individuals who develop EHOA have thinner bones prior to EHOA development and as it progresses, suggesting EHOA as a disorder of skeletal frailty.
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Affiliation(s)
- Timothy E McAlindon
- Division of Rheumatology, Allergy, and Immunology, Tufts Medical Center, Boston, MA, USA
| | - Jeffrey B Driban
- Division of Rheumatology, Allergy, and Immunology, Tufts Medical Center, Boston, MA, USA
| | - Mary B Roberts
- Care New England Medical Group/Primary Care and Specialty Services, Pawtucket, RI, USA
| | - Jeffrey Duryea
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ida K Haugen
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Lena F Schaefer
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stacy E Smith
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexander Mathiessen
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Charles Eaton
- Care New England Medical Group/Primary Care and Specialty Services, Pawtucket, RI, USA
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Bongiovanni D, Benedetto C, Corvisieri S, Del Favero C, Orlandi F, Allais G, Sinigaglia S, Fadda M. Effectiveness of ketogenic diet in treatment of patients with refractory chronic migraine. Neurol Sci 2021; 42:3865-3870. [PMID: 33527209 DOI: 10.1007/s10072-021-05078-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 01/18/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Ketogenic diet (KD) is based on restriction of carbohydrate intake. Metabolism is forced to obtain energy starting from β-oxidation of fatty acids which, turned into ketone bodies, can also be used by central nervous system (CNS). KD use in treatment of chronic migraine has recently been considered. We set out to verify modification of symptoms in patients with refractory chronic migraine in response to KD. METHODS Fifty patients were enrolled of which 38 completed the procedures the study and 23 were considered in the statistics. All of the patients considered in our study were affected by medication overuse headache (MOH). They were on a KD for 3 months. The following parameters have been checked at t = 0 and every 30 days for 6 months: migraine episode length (n. hours/day), frequency (n. days/month), level of pain of every episode measured on a scale from 1 to 3 (1 = mild; 2 = moderate; 3 = severe), and n. analgesic drugs taken/month. RESULTS Days with symptoms decreased from 30 (median value) to 7.5 with p < 0.0001. The duration of the migraine episodes decreased from 24 h (median value) to 5.5 h with p < 0.0016. The patients' pain level, initially at maximum value for 83% of the participants, improved for 55% of them (p < 0.0024). The number of drugs taken in a month decreased from 30 doses (median value) to 6 doses. CONCLUSIONS It can be stated that a 3-month KD resulted in a reduction of painful symptoms of drug refractory chronic migraine. This result may suggest an improvement in quality of life of the patients, even without a tabulated data collection.
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Affiliation(s)
- Daria Bongiovanni
- Endocrinology and Metabolism Unit, Humanitas Gradenigo, Turin, Italy
| | - Chiara Benedetto
- Women's Headache Center, Department of Surgical Sciences, University of Turin, Turin, Italy
| | | | | | - Fabio Orlandi
- Endocrinology and Metabolism Unit, Humanitas Gradenigo, Turin, Italy
| | - Gianni Allais
- Women's Headache Center, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Silvia Sinigaglia
- Women's Headache Center, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Maurizio Fadda
- Clinical Nutrition Unit, City of Health and Science, Turin, Italy.
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De Andres J, Formicola GL, Rubio-Haro R, De Andres-Serrano C. Updated management of occipital nerve stimulator lead migration: case report of a technical challenge. Scand J Pain 2021; 21:415-420. [PMID: 34387963 DOI: 10.1515/sjpain-2020-0135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 12/01/2020] [Indexed: 11/15/2022]
Abstract
Electrode migration is a challenge, even with adequate anchoring techniques, due to the high mechanical stress on components of occipital nerve stimulation (ONS) for headache disorders. When a lead displacement of an ONS implant is diagnosed, there are currently different approaches described for its management. Nevertheless current neuromodulation devices are designed like a continuum of components without any intermediate connector, and if a lead displacement is diagnosed, the solution is the complete removal of the electrode from its placement, and its repositioning through an ex-novo procedure. The described technique can allow ONS leads to be revised while minimizing the need to reopen incisions over the IPG, thus improving patients' intraoperative and postoperative discomfort, shortening surgical time and medical costs, reasonably reducing the incidence of infective postoperative complications.
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Affiliation(s)
- Jose De Andres
- Anesthesia, Critical Care and Multidisciplinary Pain Management Department, Valencia University General Hospital, Avda. Tres Cruces, s/n 46014, Valencia, Spain.,Anesthesia Unit, Surgical Specialties Department, School of Medicine, University of Valencia, Valencia, Spain
| | - Giuseppe Luca Formicola
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Pain Management Department of Valencia University General Hospital, Milan, Italy
| | - Ruben Rubio-Haro
- Anesthesia Critical Care and Pain Management Department, Valencia University General Hospital, Valencia, Spain
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Gonçalves J, Alves G, Fonseca C, Carona A, Bicker J, Falcão A, Fortuna A. Is intranasal administration an opportunity for direct brain delivery of lacosamide? Eur J Pharm Sci 2020; 157:105632. [PMID: 33152466 DOI: 10.1016/j.ejps.2020.105632] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 10/20/2020] [Accepted: 10/26/2020] [Indexed: 02/06/2023]
Abstract
Lacosamide is well-known as an effective and safe anticonvulsant drug. Nevertheless, there is also evidence of anti-epileptogenic, neuroprotective and antinociceptive properties of lacosamide. It is currently available as oral and intravenous (IV) formulations, and its brain concentrations and therapeutic effects depend on its passage across the blood-brain barrier (BBB). Therefore, to circumvent the restrictive BBB, we herein evaluated the intranasal (IN) administration of lacosamide. Nasal thermoreversible gels were screened in vitro for their influence on the viability of human nasal septum (RPMI 2650) and lung adenocarcinoma (Calu-3) cells. According to the Alamar Blue test, the in situ gel composed of Pluronic F-127 (22.5%, w/v) and Carbopol 974P (0.2%, w/v) did not affect cell viability, which remained higher than 85%, within the concentration range of lacosamide. The in situ gel was intranasally administered to healthy male CD-1 mice (8.33 mg/kg) to describe the pharmacokinetic profiles of lacosamide in plasma, brain, lung and kidney and compare them with those obtained after IV administration of the same dose. Accordingly, IN administration allowed a fast (tmax in plasma: 5 min) and complete systemic absorption of lacosamide (absolute bioavailability: 120.46%). Interestingly, IN lacosamide demonstrated higher exposure (given by the AUCt) in the brain (425.44 µg.min/mL versus 274.49 µg.min/mL), but lower exposure in kidneys (357.56 µg.min/mL versus 762.61 µg.min/mL), in comparison to IV administration. These findings, together with the tmax in brain of 15 min, a drug targeting efficiency (DTE) of 128.67% and a direct transport percentage of 22.28%, evidence that part of lacosamide reaches the brain directly after nasal administration, even though penetration into the brain from the systemic circulation seems to be the major determinant of brain exposure. Importantly, lacosamide concentrations found in lungs following IN administration were considerably higher than those observed after IV injection, until 30 min post-dosing (p < 0.05). Nevertheless, attained drug concentrations were lower than those tested in vitro in the Calu-3 cell line (1-100 µM), indicating that adverse effects are unlikely to occur in vivo. Hence, it seems that the proposed IN route has potential to be a suitable and valuable strategy for the brain delivery of lacosamide in emergency conditions and for the chronic treatment of epilepsy and other neurological diseases.
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Affiliation(s)
- Joana Gonçalves
- Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal; Coimbra Institute for Biomedical Imaging and Translational Research, University of Coimbra, Coimbra, Portugal
| | - Gilberto Alves
- CICS-UBI - Health Sciences Research Centre, University of Beira Interior, Covilhã, Portugal
| | - Carla Fonseca
- Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal
| | - Andreia Carona
- Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal; Coimbra Institute for Biomedical Imaging and Translational Research, University of Coimbra, Coimbra, Portugal
| | - Joana Bicker
- Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal; Coimbra Institute for Biomedical Imaging and Translational Research, University of Coimbra, Coimbra, Portugal
| | - Amílcar Falcão
- Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal; Coimbra Institute for Biomedical Imaging and Translational Research, University of Coimbra, Coimbra, Portugal
| | - Ana Fortuna
- Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal; Coimbra Institute for Biomedical Imaging and Translational Research, University of Coimbra, Coimbra, Portugal.
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Chaliha DR, Vaccarezza M, Takechi R, Lam V, Visser E, Drummond P, Mamo JCL. A Paradoxical Vasodilatory Nutraceutical Intervention for Prevention and Attenuation of Migraine-A Hypothetical Review. Nutrients 2020; 12:E2487. [PMID: 32824835 PMCID: PMC7468811 DOI: 10.3390/nu12082487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/14/2020] [Accepted: 08/15/2020] [Indexed: 02/07/2023] Open
Abstract
Studies suggest that migraine pain has a vascular component. The prevailing dogma is that peripheral vasoconstriction activates baroreceptors in central, large arteries. Dilatation of central vessels stimulates nociceptors and induces cortical spreading depression. Studies investigating nitric oxide (NO) donors support the indicated hypothesis that pain is amplified when acutely administered. In this review, we provide an alternate hypothesis which, if substantiated, may provide therapeutic opportunities for attenuating migraine frequency and severity. We suggest that in migraines, heightened sympathetic tone results in progressive central microvascular constriction. Suboptimal parenchymal blood flow, we suggest, activates nociceptors and triggers headache pain onset. Administration of NO donors could paradoxically promote constriction of the microvasculature as a consequence of larger upstream central artery vasodilatation. Inhibitors of NO production are reported to alleviate migraine pain. We describe how constriction of larger upstream arteries, induced by NO synthesis inhibitors, may result in a compensatory dilatory response of the microvasculature. The restoration of central capillary blood flow may be the primary mechanism for pain relief. Attenuating the propensity for central capillary constriction and promoting a more dilatory phenotype may reduce frequency and severity of migraines. Here, we propose consideration of two dietary nutraceuticals for reducing migraine risk: L-arginine and aged garlic extracts.
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Affiliation(s)
- Devahuti Rai Chaliha
- Curtin Health Innovation Research Institute, Curtin University, Kent St., Bentley 6102, Australia; (D.R.C.); (M.V.); (R.T.); (V.L.)
- School of Public Health, Faculty of Health Sciences, Curtin University, Kent St., Bentley 6102, Australia
| | - Mauro Vaccarezza
- Curtin Health Innovation Research Institute, Curtin University, Kent St., Bentley 6102, Australia; (D.R.C.); (M.V.); (R.T.); (V.L.)
- School of Pharmacy and Biomedical Sciences, Faculty of Health Sciences, Curtin University, Kent St., Bentley 6102, Australia
| | - Ryu Takechi
- Curtin Health Innovation Research Institute, Curtin University, Kent St., Bentley 6102, Australia; (D.R.C.); (M.V.); (R.T.); (V.L.)
- School of Public Health, Faculty of Health Sciences, Curtin University, Kent St., Bentley 6102, Australia
| | - Virginie Lam
- Curtin Health Innovation Research Institute, Curtin University, Kent St., Bentley 6102, Australia; (D.R.C.); (M.V.); (R.T.); (V.L.)
- School of Public Health, Faculty of Health Sciences, Curtin University, Kent St., Bentley 6102, Australia
| | - Eric Visser
- School of Medicine, University of Notre Dame, Fremantle 6160, Australia;
| | - Peter Drummond
- College of Science, Health, Engineering and Education (SHEE), Murdoch University, Murdoch 6150, Australia;
| | - John Charles Louis Mamo
- Curtin Health Innovation Research Institute, Curtin University, Kent St., Bentley 6102, Australia; (D.R.C.); (M.V.); (R.T.); (V.L.)
- School of Public Health, Faculty of Health Sciences, Curtin University, Kent St., Bentley 6102, Australia
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Arzani M, Jahromi SR, Ghorbani Z, Vahabizad F, Martelletti P, Ghaemi A, Sacco S, Togha M. Gut-brain Axis and migraine headache: a comprehensive review. J Headache Pain 2020; 21:15. [PMID: 32054443 PMCID: PMC7020496 DOI: 10.1186/s10194-020-1078-9] [Citation(s) in RCA: 154] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 01/23/2020] [Indexed: 02/08/2023] Open
Abstract
The terminology "gut-brain axis "points out a bidirectional relationship between the GI system and the central nervous system (CNS). To date, several researches have shown that migraine is associated with some gastrointestinal (GI) disorders such as Helicobacter pylori (HP) infection, irritable bowel syndrome (IBS), and celiac disease (CD). The present review article aims to discuss the direct and indirect evidence suggesting relationships between migraine and the gut-brain axis. However, the mechanisms explaining how the gut and the brain may interact in patients with migraine are not entirely clear. Studies suggest that this interaction seems to be influenced by multiple factors such as inflammatory mediators (IL-1β, IL-6, IL-8, and TNF-α), gut microbiota profile, neuropeptides and serotonin pathway, stress hormones and nutritional substances. Neuropeptides including CGRP, SP, VIP, NPY are thought to have antimicrobial impact on a variety of the gut bacterial strains and thus speculated to be involved in the bidirectional relationship between the gut and the brain. According to the current knowledge, migraine headache in patients harboring HP might be improved following the bacteria eradication. Migraineurs with long headache history and high headache frequency have a higher chance of being diagnosed with IBS. IBS and migraine share some similarities and can alter gut microflora composition and thereby may affect the gut-brain axis and inflammatory status. Migraine has been also associated with CD and the condition should be searched particularly in patients with migraine with occipital and parieto-occipital calcification at brain neuroimaging. In those patients, gluten-free diet can also be effective in reducing migraine frequency. It has also been proposed that migraine may be improved by dietary approaches with beneficial effects on gut microbiota and gut-brain axis including appropriate consumption of fiber per day, adhering to a low glycemic index diet, supplementation with vitamin D, omega-3 and probiotics as well as weight loss dietary plans for overweight and obese patients.
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Affiliation(s)
- Mahsa Arzani
- Headache Department, Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Soodeh Razeghi Jahromi
- Department of Clinical Nutrition and Dietetics, Faculty of Nutrition and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zeinab Ghorbani
- Cardiovascular Diseases Research Center, Department of Cardiology, Heshmat Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Fahimeh Vahabizad
- Headache Department, Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
- Headache Department, Neurology Ward, Sina University Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Amir Ghaemi
- Department of Virology, Pasteur Institute of Iran, Tehran, Iran
| | - Simona Sacco
- Neuroscience section - Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy.
| | - Mansoureh Togha
- Headache Department, Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran.
- Headache Department, Neurology Ward, Sina University Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
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10
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Levetiracetam as preventive treatment in adults with migraine: an up-to-date systematic review and quantitative meta-analysis. Eur J Clin Pharmacol 2019; 76:161-174. [DOI: 10.1007/s00228-019-02790-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 10/25/2019] [Indexed: 01/21/2023]
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11
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Ruff DD, Ford JH, Tockhorn-Heidenreich A, Sexson M, Govindan S, Pearlman EM, Wang SJ, Khan A, Aurora SK. Efficacy of galcanezumab in patients with chronic migraine and a history of preventive treatment failure. Cephalalgia 2019; 39:931-944. [DOI: 10.1177/0333102419847957] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Efficacy of galcanezumab in chronic migraine has been demonstrated in a pivotal Phase 3 study. Here, we assess efficacy in patients who have failed ≥2 and ≥1 prior migraine preventives for efficacy and/or safety reasons, and in those who never failed. Study design/methods REGAIN (NCT02614261) was a Phase 3, randomized, double-blind, placebo-controlled study in patients with chronic migraine. Patients were randomized 2:1:1 to receive placebo, galcanezumab 120 mg/240 mg once monthly during a double-blind treatment period lasting three months. Subgroup analyses were conducted among patients who failed ≥2 and ≥1 prior preventives and who never failed previously. Outcomes assessed were change from baseline in number of monthly migraine headache days, proportion of patients with ≥50% and ≥75% response (reduction in monthly migraine headache days), change in number of monthly migraine headache days with acute medication use and change in patient functioning per Migraine-Specific Quality of Life Questionnaire Role Function Restrictive (MSQ RF-R) domain score. Results Treatment with galcanezumab versus placebo resulted in significant improvements ( p < 0.01) in overall reduction (Months 1–3) from baseline in the number of monthly migraine headache days in patients with prior failures (LS mean change [SE]: ≥2 prior failures: galcanezumab 120 mg: −5.35 (0.71); galcanezumab 240 mg: −2.77 (0.66); placebo: −1.01 (0.54); ≥1 prior failures: galcanezumab 120 mg: −5.53 (0.60), galcanezumab 240 mg: −3.53 (0.59); placebo: −2.02 (0.49). Similarly, significant results were seen with galcanezumab versus placebo for ≥50% and ≥75% response rates, reductions in acute medication use and improvements in MSQ RF-R domain score. In the subgroup with no prior preventive failures, results were statistically significant for the 240 mg galcanezumab group versus placebo on all outcome measures, and for the 120 mg group on the reduction in migraine headache days with acute medication use. There was also a higher placebo response observed in the patients with no prior preventive failures. Conclusion Galcanezumab is consistently efficacious versus placebo in reducing monthly migraine headache days and several other key outcomes in patients with chronic migraine who have failed ≥2 or ≥1 preventives previously. In the subgroup with no prior failures, greater numerical differences were seen with galcanezumab, but statistical separation from placebo varied by dose and outcome. Clinicaltrials.gov identifier number NCT02614261.
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Affiliation(s)
| | | | | | | | - Sriram Govindan
- Eli Lilly Services India Private Limited, Bengaluru, Karnataka, India
| | | | - Shuu-Jiun Wang
- Brain Research Center, National Yang-Ming University, Taipei
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei
| | - Arif Khan
- Northwest Clinical Research Center, Bellevue, WA, USA
- Duke University School of Medicine, Durham, NC, USA
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12
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Targeting the orexinergic system: Mainly but not only for sleep-wakefulness therapies. ALEXANDRIA JOURNAL OF MEDICINE 2019. [DOI: 10.1016/j.ajme.2014.07.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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13
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Han L, Liu Y, Xiong H, Hong P. CGRP monoclonal antibody for preventive treatment of chronic migraine: An update of meta-analysis. Brain Behav 2019; 9:e01215. [PMID: 30656853 PMCID: PMC6379644 DOI: 10.1002/brb3.1215] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 12/09/2018] [Accepted: 12/23/2018] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND CGRP monoclonal antibody (mAb) is a promising preventive treatment for episodic migraine and has been approved by US FDA recently. But the treatments for chronic migraine are rare. Therefore, we performed meta-analysis to assess the efficacy and safety of CGRP mAbs in preventing chronic migraine. METHODS Database including Cochrane Library and PubMed were systematically searched for randomized controlled trials (RCTs) which are about CGRP mAb in preventing treatment of chronic migraine. Evaluating the bias and quality of RCTs was carried out according to the Cochrane collaboration's tool for assessing risk of bias. The data analysis was carried out by reviewer manager 5.2. RESULTS Totally, 6 articles enrolled in the present meta-analysis, including 4 independent clinical trials and 3,166 patients. After pooled analysis, it indicated that CGRP mAb improved 50% responder rate (OR = 2.42, 95% CI = [2.04, 2.87], I2 = 0%, p < 0.00001) and 75% responder rate (OR = 1.95, 95% CI = [1.30, 2.91], I2 = 0%, p = 0.001), as compared with placebo. And there was no difference in incidence of adverse events between CGRP mAb group and placebo group except incidence of injection site discomfort. CONCLUSIONS CGRP mAb is an effective and safety preventive treatment for chronic migraine.
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Affiliation(s)
- Lin Han
- Department of Geriatrics, West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Yao Liu
- Xindu Hospital of Traditional Chinese Medicine, Chengdu, China
| | - Hai Xiong
- Department of Geriatrics, West China Fourth Hospital, Sichuan University, Chengdu, China.,Tibet University Medical College, Lasha, China
| | - Peiwei Hong
- Department of Geriatrics, West China Fourth Hospital, Sichuan University, Chengdu, China
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Lambru G, Andreou AP, Guglielmetti M, Martelletti P. Emerging drugs for migraine treatment: an update. Expert Opin Emerg Drugs 2018; 23:301-318. [PMID: 30484333 DOI: 10.1080/14728214.2018.1552939] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Migraine is a very frequent and disabling neurological disorder. The current treatment options are old, generally poorly tolerated and not migraine-specific, reflecting the low priority of migraine research and highlighting the vast unmet need in its management. Areas covered: Advancement in the understanding of migraine pathophysiological mechanisms and identification of novel potentially meaningful targets have resulted in a multitude of emerging acute and preventive treatments. Here we review the known putative migraine pathophysiological mechanisms in order to understand the rationale of the most promising novel treatments targeting the Calcitonin-Gene-Related Peptide receptor and ligand and the 5 hydroxytryptamine (5-HT)1F receptor. Key findings on the phase II and phase III clinical trials on these treatments will be summarized. Furthermore, a critical analysis on failed trials of potentially meaningful targets such the nitric oxide and the orexinergic pathways will be conducted. Future perspective will be outlined. Expert opinion: The recent approval of Erenumab and Fremanezumab is a major milestone in the therapy of migraine since the approval of triptans. Several more studies are needed to fully understand the clinical potential, long-term safety and cost-effectiveness of these therapies. This paramount achievement should stimulate the development of further research in the migraine field.
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Affiliation(s)
- Giorgio Lambru
- a The Headache Centre, Pain Management and Neuromodulation , Guy's and St Thomas NHS Foundation Trust , London , UK.,b The Wolfson CARD, Institute of Psychology, Psychiatry and Neuroscience , King's College London , London , UK
| | - Anna P Andreou
- a The Headache Centre, Pain Management and Neuromodulation , Guy's and St Thomas NHS Foundation Trust , London , UK.,b The Wolfson CARD, Institute of Psychology, Psychiatry and Neuroscience , King's College London , London , UK
| | - Martina Guglielmetti
- c Department of Clinical and Molecular Medicine , Sapienza" University, "Sant'Andrea" Hospital, Regional Referral Headache Centre , Rome , Italy
| | - Paolo Martelletti
- c Department of Clinical and Molecular Medicine , Sapienza" University, "Sant'Andrea" Hospital, Regional Referral Headache Centre , Rome , Italy
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15
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Aydinlar EI, Dikmen PY, Kosak S, Kocaman AS. OnabotulinumtoxinA effectiveness on chronic migraine, negative emotional states and sleep quality: a single-center prospective cohort study. J Headache Pain 2017; 18:23. [PMID: 28213829 PMCID: PMC5315653 DOI: 10.1186/s10194-017-0723-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 01/13/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND OnabotulinumtoxinA (OnabotA) is considered effective in in patients with chronic migraine (CM) who failed on traditional therapies. This study was designed to evaluate the effect of OnabotA injection series on migraine outcome, negative emotional states and sleep quality in patients with CM. METHODS A total of 190 patients with CM (mean (SD) age: 39.3 (10.2) years; 87.9% were female) were included. Data on Pittsburgh sleep quality index (PSQI), headache frequency and severity, number of analgesics used, Migraine Disability Assessment Scale. (MIDAS) scores and Depression, Anxiety and Stress Scale (DASS-21) were evaluated at baseline (visit 1) and 4 consecutive follow up visits, each conducted after OnabotA injection series; at week 12 (visit 2), week 24 (visit 3), week 36 (visit 4) and week 48 (visit 5) to evaluate change from baseline to follow up. RESULTS From baseline to visit 5, significant decrease was noted in least square (LS) mean headache frequency (from 19.5 to 8.4, p = 0.002), headache severity (from 8.1 to 6.1, p = 0.017), number of analgesics (from 26.9 to 10.4, p = 0.023) and MIDAS scores (from 67.3 to 18.5, p < 0.001). No significant change from baseline was noted in global PSOI and DASS-21 scores throughout the study. CONCLUSIONS Our findings revealed that OnabotA therapy was associated with significant improvement in migraine outcome leading to decrease in headache frequency and severity, number of analgesics used and MIDAS scores. While no significant change was noted in overall sleep quality and prevalence of negative emotional states, patients without negative emotional states at baseline showed improved sleep quality throughout the study.
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Affiliation(s)
- Elif Ilgaz Aydinlar
- Department of Neurology, Acibadem University School of Medicine, Içerenkoy, Kayisdagi Cd, 34752 Atasehir/Istanbul, Turkey
| | - Pinar Yalinay Dikmen
- Department of Neurology, Acibadem University School of Medicine, Içerenkoy, Kayisdagi Cd, 34752 Atasehir/Istanbul, Turkey
| | - Seda Kosak
- Department of Neurology, Acibadem University School of Medicine, Içerenkoy, Kayisdagi Cd, 34752 Atasehir/Istanbul, Turkey
| | - Ayse Sagduyu Kocaman
- Department of Neurology, Acibadem University School of Medicine, Içerenkoy, Kayisdagi Cd, 34752 Atasehir/Istanbul, Turkey
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16
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Petrarca L, Nenna R. Headache and Celiac Disease: An Increasingly Investigated Association. Headache 2017; 56:1520-1521. [PMID: 27699778 DOI: 10.1111/head.12958] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 04/08/2016] [Indexed: 12/19/2022]
Affiliation(s)
- Laura Petrarca
- Department of Paediatrics and Paediatric Neuropsychiatry, "Sapienza" University of Rome, Rome, Italy
| | - Raffaella Nenna
- Department of Paediatrics and Paediatric Neuropsychiatry, "Sapienza" University of Rome, Rome, Italy
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17
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Santoro A, Fontana A, Miscio AM, Zarrelli MM, Copetti M, Leone MA. Quarterly repeat cycles of onabotulinumtoxinA in chronic migraine patients: the benefits of the prolonged treatment on the continuous responders and quality-of-life conversion rate in a real-life setting. Neurol Sci 2017; 38:1779-1789. [PMID: 28726049 PMCID: PMC5605581 DOI: 10.1007/s10072-017-3054-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 06/30/2017] [Indexed: 12/14/2022]
Abstract
OnabotulinumtoxinA was approved for treatment of chronic migraine (CM) after publication of Phase 3 Research Evaluating Migraine Prophylaxis Therapy (PREEMPT) trials. However, the PREEMPT trials lasted only up to 1 year. The main aim of our retrospective study was to evaluate whether a prolonged treatment of onabotulinumtoxinA (18 months, six quarterly cycles) will sustain or further improve the efficacy results and the quality of life achieved at 6 and 12 months. Patients were adults with CM with or without overuse of drugs, with at least six regularly repeat onabotulinumtoxinA treatments, administered according to the PREEMPT protocol. The outcomes were investigated after 6, 12, and 18 months of treatment with respect to baseline and with respect to each previous study time point. Headache days and hours, and dosage of headache medication taken with latency period, were collected from the patients daily. Quality of life was evaluated by means of the Migraine Disability Assessment (MIDAS) questionnaire. At each study time point, the proportion of responder patients with respect to baseline was evaluated. For all measures, the baseline data were referred to the previous month before starting. Forty-seven patients were evaluated. Our data show a decrease in the monthly headache days and hours, at each study evaluation, with respect to the previous one. They showed that beyond the first year, a statistically significant difference in the monthly days of headache compared at 18 vs. 12 months is observed. A significantly higher proportion of patients (with a response greater than 75% decrease from baseline in the frequency of headache days and hours) was observed at month 18 compared to month 12. The proportion of patients in MIDAS grade I increased over time, and a statistically significant improvement in MIDAS I score was obtained from month 12 to month 18. A positive modification in the consumption of analgesics over time was observed (p for trend <0.001). The mean acute drug latency strongly decreased over time. Our study confirmed that onabotulinumtoxinA is an effective treatment to reduce headache-related disability and improve patients' quality of life, highlighting that upon repeated administration, the therapy efficacy increases significantly and a progressive trend of "first-time response" is observed for the entire period under consideration.
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Affiliation(s)
- Antonio Santoro
- Unit of Neurology, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, FG, Italy.
| | - Andrea Fontana
- Unit of Biostatistics, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, FG, Italy
| | - Anna M Miscio
- Unit of Neurology, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, FG, Italy
| | - Michele M Zarrelli
- Unit of Neurology, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, FG, Italy
| | - Massimiliano Copetti
- Unit of Biostatistics, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, FG, Italy
| | - Maurizio A Leone
- Unit of Neurology, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, FG, Italy
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18
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Raffaelli B, Israel H, Neeb L, Reuter U. The safety and efficacy of the 5-HT 1F receptor agonist lasmiditan in the acute treatment of migraine. Expert Opin Pharmacother 2017; 18:1409-1415. [PMID: 28749698 DOI: 10.1080/14656566.2017.1361406] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 07/21/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Migraine is among the most disabling disorders worldwide, with a significant therapeutic need. Triptans are drugs of choice in the acute attack treatment, but they are contraindicated in patients with vascular conditions due to their potential vasoconstrictive properties. Further limitations include side effects, inconsistency in therapeutic action and possible non-response. Lasmiditan, a highly selective 5-HT1F receptor agonist, is a novel acute anti-migraine substance devoid of vasoconstriction. Areas covered: This article reviews the clinical efficacy and safety of oral and intravenous lasmiditan as a possible acute migraine treatment. We analyze all currently available results in Phase I to III studies. Expert opinion: Lasmiditan is a promising acute migraine therapy, in particular for patients at cardiovascular risk. Phase II and the first Phase III clinical trials show a significant better headache response in comparison to placebo. The efficacy of lasmiditan proves that vasoconstriction is not essential for acute migraine therapy and thereby points, in addition to a well-established trigeminal contribution, to central neuronal mechanisms in migraine pathophysiology. Lasmiditan penetrates the blood-brain barrier and CNS associated adverse events are common, but mostly in mild to moderate severity. The results of long-term Phase III studies will determine if these adverse events represent a limitation in clinical practice.
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Affiliation(s)
- Bianca Raffaelli
- a Department of Neurology , Charité Universitätsmedizin Berlin , Berlin , Germany
| | - Heike Israel
- a Department of Neurology , Charité Universitätsmedizin Berlin , Berlin , Germany
| | - Lars Neeb
- a Department of Neurology , Charité Universitätsmedizin Berlin , Berlin , Germany
| | - Uwe Reuter
- a Department of Neurology , Charité Universitätsmedizin Berlin , Berlin , Germany
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19
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Hou YC, Lai CH. The Relief Effects of Ramelteon on Refractory Chronic Migraine: A Case Report. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE : THE OFFICIAL SCIENTIFIC JOURNAL OF THE KOREAN COLLEGE OF NEUROPSYCHOPHARMACOLOGY 2016; 14:405-406. [PMID: 27776398 PMCID: PMC5083936 DOI: 10.9758/cpn.2016.14.4.405] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 03/24/2016] [Accepted: 04/23/2016] [Indexed: 11/18/2022]
Abstract
The selective melatonin receptor agonism effect of ramelteon is useful for insomnia. Here we wanted to present a refractory chronic migraine case, who had significant improvements in migraine after using ramelteon. The possible mechanism for the ramelteon in the migraine relief might be related to melatonin effects.
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Affiliation(s)
- Yi-Cheng Hou
- Department of Nutrition, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan, ROC
| | - Chien-Han Lai
- Department of Psychiatry, Cheng Hsin General Hospital, Taipei, Taiwan, ROC.,Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan, ROC
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20
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Koçer A. Greater occipital nerve blocks in the treatment of refractory chronic migraine: An observational report of nine cases. World J Clin Cases 2016; 4:323-327. [PMID: 27803914 PMCID: PMC5067495 DOI: 10.12998/wjcc.v4.i10.323] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 07/17/2016] [Accepted: 08/08/2016] [Indexed: 02/05/2023] Open
Abstract
AIM To report the effects of greater occipital nerve (GON) blocks on refractory chronic migraine headache.
METHODS Nine patients who were receiving the conventionally accepted preventive therapies underwent treatment with repeated GON block to control chronic migraine resistant to other treatments. GON blocking with lidocaine and normal saline mixture was administered by the same physician at hospital once a month (for three times in total). Patients were assessed before the injection and every month thereafter for pain frequency and severity, number of times analgesics were used and any appearant side effects during a 6 mo follow-up.
RESULTS Eight of nine patients reported a marked decrease in frequency and severity of migraine attacks in comparison to their baseline symptoms; one reported no significant change (not more than 50%) from baseline and did not accept the second injection. GON block resulted in considerable reduction in pain frequency and severity and need to use analgesics up to three months after the injection in the present cases. The patients did not report any adverse effects.
CONCLUSION Hereby we noticed a remarkable success with refractory chronic migraine patients. We believe that this intervention can result in rapid relief of pain with the effects lasting for perhaps several weeks or even months. Further controlled clinical trials are warranted to evaluate the effect of GON block in the treatment of refractory migraine cases.
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Abstract
Chronic daily headache (CDH) is a common neurological condition that affects 1-4% of the general population. Recent epidemiological studies have shown that CDH is mainly represented by chronic migraine (CM). Owing to the frequent headaches, associated symptoms, and comorbid conditions associated with CDH/CM, disability, quality of life (QoL), economic burden, and treatment outcome have become important personal and social issues. There have been several studies assessing the disability, QoL, and economic burden associated with CDH/CM. These studies, conducted in different settings, consistently reported significantly higher disability and economic burden and lower QoL among CDH/CM patients compared to patients with episodic headache (EH) or episodic migraine (EM). Treatment outcome of CDH/CM is often poor. In this review, we describe and summarize the results of relevant studies performed to date.
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22
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Chua AL, Silberstein S. Inhaled drug therapy development for the treatment of migraine. Expert Opin Pharmacother 2016; 17:1733-43. [DOI: 10.1080/14656566.2016.1203901] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Abigail L. Chua
- Jefferson Headache Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Stephen Silberstein
- Jefferson Headache Center, Thomas Jefferson University, Philadelphia, PA, USA
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23
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Negro A, Curto M, Lionetto L, Giamberardino MA, Martelletti P. Chronic migraine treatment: from OnabotulinumtoxinA onwards. Expert Rev Neurother 2016; 16:1217-27. [DOI: 10.1080/14737175.2016.1200973] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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24
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Affaitati G, Martelletti P, Lopopolo M, Tana C, Massimini F, Cipollone F, Lapenna D, Giamberardino MA, Costantini R. Use of Nonsteroidal Anti-Inflammatory Drugs for Symptomatic Treatment of Episodic Headache. Pain Pract 2016; 17:392-401. [PMID: 27207273 DOI: 10.1111/papr.12461] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 03/11/2016] [Accepted: 04/08/2016] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Primary headaches have high epidemiologic impact but their symptomatic treatment often remains problematic. Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently used, but their modality of employment and efficacy/differential efficacy are highly variable. This study investigated current NSAID use for episodic headache at an Italian headache center (January 2000 to February 2013). METHODS A retrospective evaluation was performed on 6,443 patient records: migraine (n = 2,330), tension-type headache (TTH; n = 807), and migraine plus TTH (n = 3,306). RESULTS Among migraine patients, 80% had used NSAIDs in the past year. Preferences were: nimesulide (57%), ketoprofen (25%), and ibuprofen (24%); complete efficacy was significantly higher than incomplete/absent efficacy (P < 0.0001). NSAIDs were replaced with triptans in 53% of patients at first visit; after 1 year there was a spontaneous significant return to NSAIDs (56%; P < 0.0005). Among TTH patients, 90% were NSAID users; preferences were: nimesulide (48%), ketoprofen (47%), and diclofenac (19%), with significantly higher complete vs. incomplete/absent efficacy (nimesulide and ketoprofen, P < 0.02). Replacement with analgesics was performed in 24% of patients; after 1 year, there was a 29% return to NSAIDs. Among migraine plus TTH patients, 89% were NSAID users. Preferences were: nimesulide (44%), ibuprofen (42%), and ketoprofen (38%), with significantly higher complete vs. incomplete/absent efficacy (0.001 < P < 0.0001). Replacement with analgesics was performed in 31% of patients; after 1 year, there was a 37% return to NSAIDs. CONCLUSIONS Nonsteroidal anti-inflammatory drug use in headache was higher than could be hypothesized based on guidelines, with NSAID preferences not entirely coinciding with international recommendations. This outcome suggests the need for greater awareness of all treatment options in headache by both patients and physicians.
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Affiliation(s)
- Giannapia Affaitati
- Department of Medicine and Science of Aging, Headache Center, Geriatrics Clinic and Ce.S.I.-MeT, "G. D'Annunzio" University of Chieti, Chieti, Italy
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Regional Referral Headache Centre, "Sant'Andrea" Hospital, "Sapienza" University, Rome, Italy
| | - Mariangela Lopopolo
- Department of Medicine and Science of Aging, Headache Center, Geriatrics Clinic and Ce.S.I.-MeT, "G. D'Annunzio" University of Chieti, Chieti, Italy
| | - Claudio Tana
- Internal Medicine Unit, Guastalla Hospital, AUSL Reggio Emilia, Reggio Emilia, Italy
| | - Francesca Massimini
- Institute of Clinical Pathology, "G. D'Annunzio" University of Chieti, Chieti, Italy
| | - Francesco Cipollone
- Department of Medicine and Science of Aging, Headache Center, Geriatrics Clinic and Ce.S.I.-MeT, "G. D'Annunzio" University of Chieti, Chieti, Italy
| | - Domenico Lapenna
- Department of Medicine and Science of Aging, "G. D'Annunzio" University of Chieti, Chieti, Italy
| | - Maria Adele Giamberardino
- Department of Medicine and Science of Aging, Headache Center, Geriatrics Clinic and Ce.S.I.-MeT, "G. D'Annunzio" University of Chieti, Chieti, Italy
| | - Raffaele Costantini
- Institute of Surgical Pathology, "G. D'Annunzio" University of Chieti, Chieti, Italy
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25
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Nenna R, Petrarca L, Verdecchia P, Florio M, Pietropaoli N, Mastrogiorgio G, Bavastrelli M, Bonamico M, Cucchiara S. Celiac disease in a large cohort of children and adolescents with recurrent headache: A retrospective study. Dig Liver Dis 2016; 48:495-498. [PMID: 26826905 DOI: 10.1016/j.dld.2015.12.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 11/23/2015] [Accepted: 12/27/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND The clinical picture of celiac disease is changing with the emergence of subclinical forms and growing evidence reporting associated neurological disorders. AIMS To establish the prevalence of celiac disease in children suffering from recurrent headache. METHODS In our retrospective study we collected charts from 1131 children attending our tertiary care Centre for Paediatric Headache over the period 2001-2012. They were screened for celiac disease and positive patients were referred to our Operative Unit for Coeliac disease and confirmed positive children underwent upper endoscopy with multiple duodenal biopsies. Celiac children started a gluten-free diet. RESULTS 883 children (481 females; median age, 9.8 years, range 3-19) performed celiac disease screening, and among them, 11 children (7 females; median age, 8.2 years, range: 4.8-13.9) were diagnosed with celiac disease. Seven children (5 females, median age, 11.9 years, range: 10.3-13.9) had been diagnosed as celiac prior to the neurological evaluation. The prevalence of celiac disease in our sample is 2.04% vs. 1.2% of the general population (p=0.034). CONCLUSIONS Our study demonstrates, on a large series, that celiac disease prevalence is doubled in patients with chronic headache. Screening for celiac disease could be advised as part of the diagnostic work-up in these paediatric patients, particularly among pharmacological non-responders.
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Affiliation(s)
- Raffaella Nenna
- Department of Paediatrics and Infant Neuropsychiatry, "Sapienza" University of Rome, Rome, Italy.
| | - Laura Petrarca
- Department of Paediatrics and Infant Neuropsychiatry, "Sapienza" University of Rome, Rome, Italy
| | - Paola Verdecchia
- Department of Paediatrics and Infant Neuropsychiatry, "Sapienza" University of Rome, Rome, Italy
| | - Matteo Florio
- Department of Paediatrics and Infant Neuropsychiatry, "Sapienza" University of Rome, Rome, Italy
| | - Nicoletta Pietropaoli
- Department of Paediatrics and Infant Neuropsychiatry, "Sapienza" University of Rome, Rome, Italy
| | - Gerarda Mastrogiorgio
- Department of Paediatrics and Infant Neuropsychiatry, "Sapienza" University of Rome, Rome, Italy
| | - Maria Bavastrelli
- Department of Paediatrics and Infant Neuropsychiatry, "Sapienza" University of Rome, Rome, Italy
| | - Margherita Bonamico
- Department of Paediatrics and Infant Neuropsychiatry, "Sapienza" University of Rome, Rome, Italy
| | - Salvatore Cucchiara
- Department of Paediatrics and Infant Neuropsychiatry, "Sapienza" University of Rome, Rome, Italy
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Curto M, Lionetto L, Negro A, Capi M, Fazio F, Giamberardino MA, Simmaco M, Nicoletti F, Martelletti P. Altered kynurenine pathway metabolites in serum of chronic migraine patients. J Headache Pain 2016; 17:47. [PMID: 27130315 PMCID: PMC4851673 DOI: 10.1186/s10194-016-0638-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Accepted: 04/12/2016] [Indexed: 02/07/2023] Open
Abstract
Background Activation of glutamate (Glu) receptors plays a key role in the pathophysiology of migraine. Both NMDA and metabotropic Glu receptors are activated or inhibited by metabolites of the kynurenine pathway, such as kynureninic acid (KYNA), quinolinic acid (QUINA), and xanthurenic acid (XA). In spite of the extensive research carried out on KYNA and other kynurenine metabolites in experimental models of migraine, no studies have ever been carried out in humans. Here, we measured all metabolites of the kynurenine pathway in the serum of patients affected by chronic migraine (CM) and age- and gender-matched healthy controls. Methods We assessed serum levels of tryptophan (Trp), L-kynurenine (KYN), KYNA, anthranilic acid (ANA), 3-hydroxyanthranilic acid (3-HANA), 3-hydroxykynirenine (3-HK), XA, QUINA, and 5-hydroxyindolacetic acid (5-HIAA) in 119 patients affected by CM (ICHD-3beta criteria) and 84 age-matched healthy subjects. Patients with psychiatric co-morbidities, systemic inflammatory, endocrine or neurological disorders, and mental retardation were excluded. Serum levels of all metabolites were assayed using liquid chromatography/tandem mass spectrometry (LC-MS/MS). Results LC-MS/MS analysis of kynurenine metabolites showed significant reductions in the levels of KYN (−32 %), KYNA (−25 %), 3-HK (−49 %), 3-HANA (−63 %), 5-HIAA (−36 %) and QUINA (−80 %) in the serum of the CM patients, as compared to healthy controls. Conversely, levels of Trp, ANA and XA were significantly increased in CM patients (+5 %, +339 % and +28 %, respectively). Conclusions These findings suggest that in migraine KYN is unidirectionally metabolized into ANA at expenses of KYNA and 3-HK. The reduction in the levels of KYNA, which behaves as a competitive antagonist of the glycine site of NMDA receptors, is consistent with the hypothesis that NMDA receptors are overactive in migraine. The increase in XA, a putative activator of Glu2 receptors, may represent a compensatory event aimed at reinforcing endogenous analgesic mechanisms. The large increase in the levels of ANA encourages research aimed at establishing whether ANA has any role in the regulation of nociceptive transmission.
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Affiliation(s)
- Martina Curto
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA. .,Department of Molecular Medicine, Sant'Andrea Medical Center, Sapienza University, Via di Grottarossa 1035-1039, Rome, 00189, Italy.
| | | | - Andrea Negro
- Department of Molecular Medicine, Sant'Andrea Medical Center, Sapienza University, Via di Grottarossa 1035-1039, Rome, 00189, Italy.,Regional referral headache center, Sant'Andrea Hospital, Rome, Italy
| | - Matilde Capi
- Advanced Molecular Diagnostics, IDI-IRCSS, Rome, Italy
| | | | - Maria Adele Giamberardino
- Headache Center and Geriatrics Clinic, Department of Medicine and Science of Aging, "G. D'Annunzio" University, Chieti, Italy
| | | | - Ferdinando Nicoletti
- IRCCS Neuromed, Pozzilli, Italy.,Department of Physiology and Pharmacology, Sapienza University, Rome, Italy
| | - Paolo Martelletti
- Department of Molecular Medicine, Sant'Andrea Medical Center, Sapienza University, Via di Grottarossa 1035-1039, Rome, 00189, Italy.,Regional referral headache center, Sant'Andrea Hospital, Rome, Italy
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Hong P, Liu Y. Calcitonin gene-related peptide antagonism for acute treatment of migraine: a meta-analysis. Int J Neurosci 2016; 127:20-27. [DOI: 10.3109/00207454.2015.1137915] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Negro A, Curto M, Lionetto L, Martelletti P. A two years open-label prospective study of OnabotulinumtoxinA 195 U in medication overuse headache: a real-world experience. J Headache Pain 2016; 17:1. [PMID: 26792662 PMCID: PMC4720620 DOI: 10.1186/s10194-016-0591-3] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 01/13/2016] [Indexed: 02/04/2023] Open
Abstract
Background The efficacy and safety of OnabotulinumtoxinA (BOTOX®) in adults with chronic migraine (CM) were demonstrated in the PREEMPT program. However, the dosage used in this study was flexible from 155 U to 195 U at the physician’s discretion. Therefore, the objective of this prospective study was to compare the efficacy and safety of OnabotulinumtoxinA 195 U vs. 155 U for the treatment of CM and medication overuse headache (MOH) during a 2-year period. Methods We prospectively evaluated the mean reduction in headache days, migraine days, acute pain medication intake days and Headache Impact Test (HIT)-6 score in 172 patients injected with OnabotulinumtoxinA 195 U. Successively, we compared the efficacy measures with data of 155 patients injected with OnabotulinumtoxinA 155 U and followed up for 2 years. All patients were affected by CM and MOH, and failed one or more previous detoxification and preventative therapies. Results Both OnabotulinumtoxinA 195 U and 155 U reduced significantly the number of headache and migraine days, acute pain medication intake days and HIT-6 score, when compared with the baseline measures. Nevertheless, OnabotulinumtoxinA 195 U proved to be superior of 155 U in all efficacy measures since the first injection and for all the 2 years of treatment, with the exception of the reduction in pain medication intake days that resulted significantly larger with 195 U only after the 4th injection. The safety and tolerability of the two doses were similar and treatment related adverse events were transient and mild-moderate. Conclusions This study represents the largest and longest post-marketing studies of doses comparison with OnabotulinumtoxinA in a real-life clinical setting. Here, we demonstrate the superior efficacy of OnabotulinumtoxinA 195 U compared to 155 U in CM patients with MOH during a 2-year treatment period with similar safety and tolerability profile. Electronic supplementary material The online version of this article (doi:10.1186/s10194-016-0591-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Andrea Negro
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy. .,Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy. .,Molecular Medicine Department, Sant'Andrea Hospital, Sapienza University, Via di Grottarossa, 1035-1039, Rome, Italy.
| | - Martina Curto
- Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy.,Department of Psychiatry, Harvard Medical School, Boston, MA, USA.,Bipolar & Psychotic Disorders Program, McLean Hospital, Belmont, MA, USA
| | - Luana Lionetto
- Advanced Molecular Diagnostics Unit, IDI Istituto Dermopatico dell'Immacolata-IRCSS, 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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Kinfe TM, Pintea B, Roeske S, Güresir Á, Güresir E, Vatter H. Percutaneous nerve field stimulation (PENS) of the occipital region as a possible predictor for occipital nerve stimulation (ONS) responsiveness in refractory headache disorders? A feasibility study. Cephalalgia 2015; 36:779-89. [DOI: 10.1177/0333102415613765] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 09/18/2015] [Indexed: 12/26/2022]
Abstract
Background Occipital nerve stimulation (ONS) has been reported to diminish pain levels in intractable chronic headache syndromes of different origin. No reliable objective markers exist to predict ONS responsiveness. This study investigated the predictive value of occipital percutaneous nerve field stimulation (PENS) prior to ONS. Methods This trial included 12 patients (CCH, CM, PTH, CH) with chronic refractory headache syndromes eligible for ONS. Repetitive PENS (3 × /10 days) was performed and the headache severity/frequency monitored over four weeks before ONS implantation. Further assessment of PENS/ONS outcomes were stimulation-related complications, perception/tolerance stimulation threshold, the Migraine Disability Scale (MIDAS) and the Beck Depression Inventory (BDI). Results All PENS responders benefited from ONS. Of the seven PENS-nonresponders with VAS 6.1(±1.1), six experienced significant pain relief from ONS after three months and one patient failed the PENS/ONS trial (VAS 3.7 (±1.6)); (95% CI 3.6 to 5.7, p < 0.001). The VAS baseline was 8.4 (±0.5) and decreased significantly (50% reduction in severity/frequency) in five patients after PENS, while seven failed to improve (VAS 4.9 (±1.1); (95% CI 2.5 to 4.5, p < 0.001). BDI baseline (from 22.6 (±4.2) to 10.6 (±5.9) (95% CI 7.4 to 16.6, p < 0.001)) and MIDAS baseline (from 143.9 (±14.5) to 72.8 (±28.7) (95% CI 1.17 to 2.3, p < 0.001)) significantly declined after ONS. No PENS/ONS-related complications occurred. Conclusions Presurgical applied occipital PENS failed to identify ONS responders sufficiently according to our study protocol, thus requiring further specific investigations to determine its predictive usefulness.
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Affiliation(s)
- TM Kinfe
- Division of Functional Neurosurgery, Stereotaxy and Neuromodulation, Department of Neurosurgery, University of Bonn Medical Center, Germany
| | - B Pintea
- Department of Neurosurgery, University Hospital, RFW University, Germany
| | - S Roeske
- DZNE, German Center for Neurodegenerative Disease, Bonn, Germany
| | - Á Güresir
- Department of Neurosurgery, University Hospital, RFW University, Germany
| | - E Güresir
- Department of Neurosurgery, University Hospital, RFW University, Germany
| | - H Vatter
- Department of Neurosurgery, University Hospital, RFW University, Germany
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Cairns BE, Gazerani P. Botulinum neurotoxin A for chronic migraine headaches: does it work and how? Pain Manag 2015; 4:377-80. [PMID: 25494688 DOI: 10.2217/pmt.14.30] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Brian E Cairns
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, V6T 1Z3, Canada
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Giamberardino MA, Mitsikostas DD, Martelletti P. Update on Medication-Overuse Headache and Its Treatment. Curr Treat Options Neurol 2015; 17:368. [PMID: 26139553 DOI: 10.1007/s11940-015-0368-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OPINION STATEMENT Medication-overuse headache-i.e., a too-frequent consumption of acute headache medications leading to increased headache frequency and reduced effectiveness of acute and preventive treatments-is a serious medical condition whose pathophysiology still remains incompletely known, which is reflected into a lack of mechanism-based treatments. The first mandatory step in the therapeutic strategy remains withdrawal of the abused drug, preferably abrupt, in concomitance with a detoxification pharmacological regimen to lessen withdrawal symptoms. Intravenous hydration, antiemetics, corticosteroids (prednisone), tranquilizers (benzodiazepine), neuroleptics, and rescue medication (another analgesic than the overused) should be delivered in various combinations, on an inpatient (hospitalization and day hospital) basis or outpatient basis, depending on the characteristics of the specific patient and type of overuse. Inpatient withdrawal should be preferred in barbiturate and opioid overuse, in concomitant depression, or, in general, in patients who have difficulty in stopping the overused medication as outpatients. In contrast, in overuse limited to simple analgesics in highly motivated patients, without high levels of depression and/or anxiety, home detoxification should be chosen. Re-prophylaxis should immediately follow detoxification, ideally with local injections of onabotulinumtoxinA every 3 months or topiramate orally for at least 3 months. Adequate information to patients about the risks of a too-frequent consumption of symptomatic headache medications is essential and should constantly parallel treatment to help preventing relapse after detoxification and re-prophylaxis.
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Affiliation(s)
- Maria Adele Giamberardino
- Headache Center and Geriatrics Clinic, Department of Medicine and Science of Aging, "G. D'Annunzio" University, via Carlo de Tocco n. 3, 66100, Chieti, Italy,
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Sadeghian H, Motiei-Langroudi R. Comparison of Levetiracetam and sodium Valproate in migraine prophylaxis: A randomized placebo-controlled study. Ann Indian Acad Neurol 2015; 18:45-8. [PMID: 25745310 PMCID: PMC4350213 DOI: 10.4103/0972-2327.144290] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2014] [Revised: 07/15/2014] [Accepted: 09/01/2014] [Indexed: 02/07/2023] Open
Abstract
Background: Migraine is a chronic and disabling disorder. Treatment of migraine often comprises of symptomatic (abortive) and preventive (prophylactic) treatment. The current drugs used in migraine prophylaxis include antidepressant drugs (Serotonin Reuptake Inhibitors, Tricyclic antidepressants), and anti-epileptic drugs (valproate, gabapentin, etc). Objective: The objective of our study was to assess the efficacy and tolerability of levetiracetam in adult migraine prophylaxis, compared to valproate and placebo. Materials and Methods: We conducted a prospective, randomized, placebo-controlled study. A total of 85 patients were randomized to receive levetiracetam 500 mg/d (n = 27), valproate 500 mg/d (n = 32) or placebo (n = 26). The patients were evaluated for treatment efficacy after 6 months. Efficacy was assessed as a more than 50% decrease in headache frequency. Results: In levetiracetam group, 17 (63.0%) patients experienced a more than 50% decrease in headache frequency, while this efficacy number was 21 (65.6%) for valproate group and 4 (15.4%) for placebo group. The difference was not statistically significant between levetiracetam and valproate, while it was significant when comparing either levetiracetam or valproate to placebo. Conclusion: Compared to placebo, levetiracetam offers improvement in headache frequency in patients with migraine. The efficacy of levetiracetam in migraine prophylaxis is comparable to currently used drugs such as valproate.
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Affiliation(s)
- Homa Sadeghian
- Department of Radiology, Neurovascular Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts, USA
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Gentile G, Negro A, D'Alonzo L, Aimati L, Simmaco M, Martelletti P, Borro M. Lack of association between oxidative stress-related gene polymorphisms and chronic migraine in an Italian population. Expert Rev Neurother 2015; 15:215-25. [PMID: 25585507 DOI: 10.1586/14737175.2015.1001748] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Migraine patients present increased risks of vascular diseases such as high blood pressure, insulin resistance, metabolic syndrome, stroke and coronary heart disease. Oxidative stress (OS) is increasingly being studied in relation to the pathophysiology of migraine, stimulated by the described association with the most frequent migraine comorbidities. Because many of the gene-encoded players of the OS balance are characterized by functional polymorphisms, it is supposed that the individual genomic profile could affect susceptibility to OS and to related pathophysiological conditions. This study aimed to characterize a panel of 10 polymorphisms in 8 OS-related genes in a chronic migraine (CM) population and healthy controls, to recognize a genetic risk in the process of migraine chronification. The sample consisted of 45 healthy women and 96 women diagnosed with CM. No deviations from the Hardy-Weinberg equilibrium were detected, or in the overall population, or in the CM group or in the control group.
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Affiliation(s)
- Giovanna Gentile
- Advanced Molecular Diagnostics Unit, Sant'Andrea Hospital, Rome, Italy
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Reuter U, Israel H, Neeb L. The pharmacological profile and clinical prospects of the oral 5-HT1F receptor agonist lasmiditan in the acute treatment of migraine. Ther Adv Neurol Disord 2015; 8:46-54. [PMID: 25584073 PMCID: PMC4286941 DOI: 10.1177/1756285614562419] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
More than 20 years have passed without the launch of a new substance class for acute migraine therapy. Triptans were the latest class of substances which successfully passed all developmental stages with a significant antimigraine efficacy and a sufficient safety profile. New drugs with a better adverse event profile and at least similar efficacy are needed for migraine subjects who cannot tolerate triptans for attack treatment. Lasmiditan is a novel highly specific 5-HT1F receptor agonist currently in clinical trials for acute migraine therapy and devoid of vasoconstriction in coronary arteries as determined in a surrogate assay. In both phase II randomized, placebo-controlled trials in acute migraine the primary endpoint was met. For the intravenous formulation a clear dose-dependent effect on headaches could be determined. Lasmiditan tablets in doses of 50-400 mg show significant headache relief after 2 hours compared with placebo and improved accompanying symptoms. This substance is chemically clearly different from other antimigraine drugs, which is also reflected by its dose-dependent adverse event profile chiefly including dizziness, vertigo, paresthesia and fatigue. Adverse events are usually linked to the central nervous system. Future phase III clinical trials with an active triptan comparator or in a preferential trial design will allow a better comparison of lasmiditan and triptans. They will also determine whether lasmiditan will become available to the migraine patient.
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Affiliation(s)
- Uwe Reuter
- Hochschulambulanz und Klinik für Neurologie, Charité-Universitätsmedizin Berlin, Chariteplatz 1, 10117 Berlin, Germany
| | - Heike Israel
- Department of Neurology, Charite Universitätsmedizin Berlin, Berlin, Germany
| | - Lars Neeb
- Department of Neurology, Charite Universitätsmedizin Berlin, Berlin, Germany
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Abstract
Global Burden of Disease 2010 study considers migraine as one of the most important noncommunicable diseases in the world, classifying it third in terms of global prevalence (14.70%): it sums up the 54.19% of all the years of life lived with disabilities caused by the rest of all neurological disorders. This Editorial provides an historical excursus of old and new-entry molecules in migraine therapeutic area. Drugs for acute treatment such as triptans date back to the early 1990s with the appearance of sumatriptan and the following six triptans in the years immediately after (zolmitriptan, rizatriptan, naratriptan, eletriptan, almotriptan, frovatriptan). Prophylaxis drugs, dedicated to patients with medium/high frequency of crises, show as last entries topiramate and botulinum toxin type A. The use of this preventative group, with its intrinsic limits, is mandatory to reduce the risk of migraine chronification, a highly harmful clinical phenomenon that produces as its natural consequence the medication overuse headache. The development of new acute and preventative compounds, such as 5HT (serotonin) 1F receptor (5-HT1F) agonist lasmiditan, calcitonin gene related peptide (CGRP) peptide receptor antagonists, anti-CGRP monoclonal antibodies (LY2951742, ALD403, LBR101) and anti-CGRP-r monoclonal antibody (AMG334), is warranted and might be soon completed in order to offer new opportunities to migraine patients.
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Affiliation(s)
- Paolo Martelletti
- Sapienza University, Department of Clinical and Molecular Medicine , Via di Grottarossa 1035, I - 00189 Rome , Italy +39 06 33 77 51 11 ; +39 06 33 77 51 10 ;
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Sabato D, Lionetto L, Martelletti P. The therapeutic potential of novel anti-migraine acute therapies. Expert Opin Investig Drugs 2014; 24:141-4. [PMID: 25391253 DOI: 10.1517/13543784.2015.983223] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Migraine is a highly disabling neurovascular disorder. 'The complex and multifactorial properties of migraine pathogenesis provide the opportunity to identify new therapeutic targets from a wide range of receptors. AREAS COVERED In this editorial, the authors focus on future pharmacological interventions for acute migraine including: 5-HT receptors and their agonists, calcitonin gene-related peptide receptors and their antagonists, PAC1 receptors and their antagonists, glutamate receptors and some of their antagonists as well as transient receptor potential channels and their antagonists. The authors also discuss preventative treatments for migraine that are currently in development. EXPERT OPINION Future pharmaceutical research that looks at the well-known mechanisms involved in the pathophysiology of migraine should aim to overcome the existing limitations of each pharmacological class and their side effects. There has lately been particular interest in the role of glutamate receptors, particularly metabotropic glutamate receptors, in the pathophysiology of migraine. These receptors may be potentially viable drug targets for migraine in the future.
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Affiliation(s)
- Donata Sabato
- Sapienza University, Department of Clinical and Molecular Medicine , Rome , Italy
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Tajti J, Csáti A, Vécsei L. Novel strategies for the treatment of migraine attacks via the CGRP, serotonin, dopamine, PAC1, and NMDA receptors. Expert Opin Drug Metab Toxicol 2014; 10:1509-20. [PMID: 25253587 DOI: 10.1517/17425255.2014.963554] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Migraine is a common, paroxysmal, and disabling primary headache with a high personal and socioeconomic impact. It involves ∼ 16% of the general population. During the years, a number of hypotheses have been put forward concerning the exact pathomechanism, but the final solution is still undiscovered. AREAS COVERED Although the origin is enigmatic, parallel therapeutic efforts have been developed. Current attack therapy does not meet the expectations of the patients or the doctors. This article, based on a PubMed search, reviews the novel pharmacological possibilities that influence the peripheral and central sensitization involved in the disease. EXPERT OPINION In order to overcome the therapeutic insufficiency, a calcitonin gene-related peptide receptor antagonist without the side-effect of liver transaminase elevation is required. Another therapeutic option is to develop a neurally acting antimigraine agent, such as a serotonin-1F receptor agonist, with low adverse central nervous system events. Development of a potent dopamine receptor antagonist is necessary to diminish the premonitory symptoms of migraine. A further option is to decrease the headache intensity with a pituitary adenylate cyclase-activating polypeptide type 1 receptor blocker which can cross the blood-brain barrier. Finally, synthetic kynurenine analogues are required to block the pain transmission in the activated trigeminal system.
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Affiliation(s)
- János Tajti
- University of Szeged, Department of Neurology , Semmelweis u. 6, H-6725, Szeged , Hungary
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Martelletti P, Katsarava Z, Lampl C, Magis D, Bendtsen L, Negro A, Russell MB, Mitsikostas DDD, Jensen RH. Refractory chronic migraine: a consensus statement on clinical definition from the European Headache Federation. J Headache Pain 2014; 15:47. [PMID: 25169882 PMCID: PMC4237793 DOI: 10.1186/1129-2377-15-47] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 07/29/2014] [Indexed: 12/14/2022] Open
Abstract
The debate on the clinical definition of refractory Chronic Migraine (rCM) is still far to be concluded. The importance to create a clinical framing of these rCM patients resides in the complete disability they show, in the high risk of serious adverse events from acute and preventative drugs and in the uncontrolled application of therapeutic techniques not yet validated. The European Headache Federation Expert Group on rCM presents hereby the updated definition criteria for this harmful subset of headache disorders. This attempt wants to be the first impulse towards the correct identification of these patients, the correct application of innovative therapeutic techniques and lastly aim to be acknowledged as clinical entity in the next definitive version of the International Classification of Headache Disorders 3 (ICHD-3 beta).
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Affiliation(s)
- Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy.
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Efficacy of Zhengtian Pill for migraine prophylaxis: A randomized, multicenter, double-blind, placebo-controlled, parallel-group study. Eur J Integr Med 2014. [DOI: 10.1016/j.eujim.2014.01.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Calcitonin Gene-Related Peptide Targeted Immunotherapy for Migraine: Progress and Challenges in Treating Headache. BioDrugs 2014; 28:237-44. [DOI: 10.1007/s40259-014-0083-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Watanabe Y, Takashima R, Iwanami H, Suzuki S, Igarashi H, Hirata K. [Management of chronic migraine in Japan]. Rinsho Shinkeigaku 2013; 23:1228-30. [PMID: 24291939 DOI: 10.5692/clinicalneurol.53.1228] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Japanese Headache Society and the Japanese Society of Neurology has published the 2013 guidelines for the diagnosis and treatment of chronic headache. A new CQ has been set up in the guidelines on the topic of "How to treat chronic migraine." In the past, lomerizine was the only prophylactic medication of migraine that was eligible under insurance coverage. However, afterward in 2010, valproate was added to the list of antimigraine medications approved under insurance coverage, followed by propranolol, amitriptyline, and verapamil, with rapid advances in the treatment of migraine. Valproate, topiramate (not approved under insurance coverage until date), and amitriptyline could potentially be used in the treatment of chronic migraine in Japan; further, considering the clinical outcomes thus far, lomerizine could also be added to the list. As a drug for migraine prophylaxis, valproate is contraindicated in pregnant women and needs to be used with caution.
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The calcitonin gene-related peptide receptor antagonist MK-8825 decreases spinal trigeminal activity during nitroglycerin infusion. J Headache Pain 2013; 14:93. [PMID: 24256609 PMCID: PMC3845525 DOI: 10.1186/1129-2377-14-93] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 11/16/2013] [Indexed: 01/04/2023] Open
Abstract
Background Calcitonin gene-related peptide (CGRP) and nitric oxide (NO) are regarded as key mediators in migraine and other primary headaches. Migraineurs respond to infusion of nitroglycerin with delayed headaches, and inhibition of CGRP receptors has been shown to be effective in migraine therapy. In animal experiments nitrovasodilators like nitroglycerin induced increases in spinal trigeminal activity, which were reversed after inhibition of CGRP receptors. In the present study we asked if CGRP receptor inhibition can also prevent spinal trigeminal activity induced by nitroglycerin. Methods In isoflurane anaesthetised rats extracellular recordings were made from neurons in the spinal trigeminal nucleus with meningeal afferent input. The non-peptide CGRP receptor inhibitor MK-8825 (5 mg/kg) dissolved in acidic saline (pH 3.3) was slowly infused into rats one hour prior to prolonged glyceryl trinitrate (nitroglycerin) infusion (250 μg/kg/h for two hours). Results After infusion of MK-8825 the activity of spinal trigeminal neurons with meningeal afferent input did not increase under continuous nitroglycerin infusion but decreased two hours later below baseline. In contrast, vehicle infusion followed by nitroglycerin was accompanied by a transient increase in activity. Conclusions CGRP receptors may be important in an early phase of nitroglycerin-induced central trigeminal activity. This finding may be relevant for nitroglycerin-induced headaches.
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Napoletano F, Lionetto L, Martelletti P. Sumatriptan in clinical practice: effectiveness in migraine and the problem of psychiatric comorbidity. Expert Opin Pharmacother 2013; 15:303-5. [PMID: 24206090 DOI: 10.1517/14656566.2014.858120] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Migraine is a multifactorial and disabling syndrome often in comorbidity with psychiatric illnesses. Triptans are the first-line treatment in acute attacks and the most effective drugs in various types of migraine. Sumatriptan was the first medication of this group. Thanks to multiple types of formulations that greatly increase patient's compliance, sumatriptan is so far the most commonly used drug for moderate-to-severe acute migraine attacks. Although generally safe and well tolerated, sumatriptan has to be carefully administered in patients suffering from various types of medical conditions (such as cardiovascular and cerebrovascular disease and some psychiatric illnesses) and/or treated with various medications (such as monoamine oxidase inhibitors and selective serotonin reuptake inhibitors). The administration of sumatriptan in some psychiatric condition in which serotonin plays an important role (i.e., major depressive disorder and obsessive-compulsive disorder) has been underestimated so far. In fact, at present, literature studies are few, with non-conclusive and often contrasting findings. Thus, sumatriptan should continue to be used with caution in patients diagnosed with psychiatric illness and/or treated with drugs where serotonin is crucially involved in, until further data demonstrating complete safety become available.
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Affiliation(s)
- Flavia Napoletano
- Sapienza University, Department of Clinical and Molecular Medicine , Rome , Italy
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Reddy DS. The pathophysiological and pharmacological basis of current drug treatment of migraine headache. Expert Rev Clin Pharmacol 2013; 6:271-88. [PMID: 23656340 DOI: 10.1586/ecp.13.14] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Migraine is a common neurological syndrome that affects approximately 10-20% of the population. The pathophysiology of migraine is unclear. 5-hydroxytriptamine is a key mediator in the pathogenesis of migraine and thus 5-HT1-receptor agonists are the principal drugs for acute migraine therapy. There are three classes of drugs for migraine: over-the-counter analgesics and nonsteroidal anti-inflammatory drugs for acute mild migraine, specific prescription drugs (triptans and ergot alkaloids) for acute severe migraine and pharmacological agents for prophylaxis of migraine. Sumatriptan, naratriptan and others, referred to as 'triptans', are the mainstay for acute treatment of migraine. Ergot alkaloids (ergotamine, dihydroergotamine) are used in patients with frequent, moderate migraine, but are less effective than triptans. There are several agents for prevention of migraine occurrence in patients with frequent or severe disabling migraine attacks. New drugs with improved efficacy and reduced side effects are needed for effective treatment and prevention of migraine.
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Affiliation(s)
- Doodipala Samba Reddy
- Department of Neuroscience and Experimental Therapeutics, College of Medicine, Texas A&M University Health Science Center, 8447 State Highway 47, Medical Research & Education Building, Bryan, TX 77807, USA.
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Neuromodulation of chronic headaches: position statement from the European Headache Federation. J Headache Pain 2013; 14:86. [PMID: 24144382 PMCID: PMC4231359 DOI: 10.1186/1129-2377-14-86] [Citation(s) in RCA: 128] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 09/20/2013] [Indexed: 01/19/2023] Open
Abstract
The medical treatment of patients with chronic primary headache syndromes (chronic migraine, chronic tension-type headache, chronic cluster headache, hemicrania continua) is challenging as serious side effects frequently complicate the course of medical treatment and some patients may be even medically intractable. When a definitive lack of responsiveness to conservative treatments is ascertained and medication overuse headache is excluded, neuromodulation options can be considered in selected cases. Here, the various invasive and non-invasive approaches, such as hypothalamic deep brain stimulation, occipital nerve stimulation, stimulation of sphenopalatine ganglion, cervical spinal cord stimulation, vagus nerve stimulation, transcranial direct current stimulation, repetitive transcranial magnetic stimulation, and transcutaneous electrical nerve stimulation are extensively published although proper RCT-based evidence is limited. The European Headache Federation herewith provides a consensus statement on the clinical use of neuromodulation in headache, based on theoretical background, clinical data, and side effect of each method. This international consensus further gives recommendations for future studies on these new approaches. In spite of a growing field of stimulation devices in headaches treatment, further controlled studies to validate, strengthen and disseminate the use of neurostimulation are clearly warranted. Consequently, until these data are available any neurostimulation device should only be used in patients with medically intractable syndromes from tertiary headache centers either as part of a valid study or have shown to be effective in such controlled studies with an acceptable side effect profile.
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Palmisani S, Al-Kaisy A, Arcioni R, Smith T, Negro A, Lambru G, Bandikatla V, Carson E, Martelletti P. A six year retrospective review of occipital nerve stimulation practice--controversies and challenges of an emerging technique for treating refractory headache syndromes. J Headache Pain 2013; 14:67. [PMID: 23919570 PMCID: PMC3751236 DOI: 10.1186/1129-2377-14-67] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Accepted: 07/28/2013] [Indexed: 11/28/2022] Open
Abstract
Background A retrospective review of patients treated with Occipital Nerve Stimulation (ONS) at two large tertiary referral centres has been audited in order to optimise future treatment pathways. Methods Patient’s medical records were retrospectively reviewed, and each patient was contacted by a trained headache expert to confirm clinical diagnosis and system efficacy. Results were compared to reported outcomes in current literature on ONS for primary headaches. Results Twenty-five patients underwent a trial of ONS between January 2007 and December 2012, and 23 patients went on to have permanent implantation of ONS. All 23 patients reached one-year follow/up, and 14 of them (61%) exceeded two years of follow-up. Seventeen of the 23 had refractory chronic migraine (rCM), and 3 refractory occipital neuralgia (ON). 11 of the 19 rCM patients had been referred with an incorrect headache diagnosis. Nine of the rCM patients (53%) reported 50% or more reduction in headache pain intensity and or frequency at long term follow-up (11–77 months). All 3 ON patients reported more than 50% reduction in pain intensity and/or frequency at 28–31 months. Ten (43%) subjects underwent surgical revision after an average of 11 ± 7 months from permanent implantation - in 90% of cases due to lead problems. Seven patients attended a specifically designed, multi-disciplinary, two-week pre-implant programme and showed improved scores across all measured psychological and functional parameters independent of response to subsequent ONS. Conclusions Our retrospective review: 1) confirms the long-term ONS success rate in refractory chronic headaches, consistent with previously published studies; 2) suggests that some headaches types may respond better to ONS than others (ON vs CM); 3) calls into question the role of trial stimulation in ONS; 4) confirms the high rate of complications related to the equipment not originally designed for ONS; 5) emphasises the need for specialist multidisciplinary care in these patients.
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Affiliation(s)
- Stefano Palmisani
- Pain Management & Neuromodulation Centre, Guy's & St Thomas NHS Trust, London, UK.
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Giacomozzi ARE, Vindas AP, Junior AADS, Bordini CA, Buonanotte CF, Roesler CADP, Brito CM, Perez C, Carvalho DDS, Macedo DDPD, Piovesan EJ, Sarmento EM, Melhado EM, Éckeli FD, Kowacs F, Sobrino F, Rabello GD, Rada G, Souza JAD, Casanovas JR, Durán JC, Calia LC, Medina LRP, Queiroz LPD, Ciciarelli MC, Valença MM, Cusicanqui M, Jimenez MKV, Goycochea MT, Peres MFP, Sandoval MVF, Vincent MB, Gomes MV, Diez M, Aranaga N, Barrientos N, Kowacs PA, Filho PFM. Latin American consensus on guidelines for chronic migraine treatment. ARQUIVOS DE NEURO-PSIQUIATRIA 2013; 71:478-86. [DOI: 10.1590/0004-282x20130066] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Accepted: 03/20/2013] [Indexed: 11/22/2022]
Abstract
Chronic migraine is a condition with significant prevalence all around the world and high socioeconomic impact, and its handling has been challenging neurologists. Developments for understanding its mechanisms and associated conditions, as well as that of new therapies, have been quick and important, a fact which has motivated the Latin American and Brazilian Headache Societies to prepare the present consensus. The treatment of chronic migraine should always be preceded by a careful diagnosis review; the detection of possible worsening factors and associated conditions; the stratification of seriousness/impossibility to treat; and monitoring establishment, with a pain diary. The present consensus deals with pharmacological and nonpharmacological forms of treatment to be used in chronic migraine.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Fernando Kowacs
- Universidade Federal de Ciências da Saúde de Porto Alegre, Brazil
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Negro A, Lionetto L, D'Alonzo L, Casolla B, Marsibilio F, Vignaroli G, Simmaco M, Martelletti P. Pharmacokinetic evaluation of almotriptan for the treatment of migraines. Expert Opin Drug Metab Toxicol 2013; 9:637-44. [DOI: 10.1517/17425255.2013.783012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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