Prophylaxis of migraine: general principles and patient acceptance

Validity, reliability, and sensitivity to change of the Arabic version of the Migraine-Specific Quality-of-Life Questionnaire after prophylactic treatment

BACKGROUND

The Migraine-Specific Quality-of-Life Questionnaire version 2.1 (MSQ 2.1) is one of the most frequently used tools in assessing the impact of migraine in clinical practice and in migraine research. This work aimed to examine the reliability and validity of the Arabic version of the MSQ 2.1 in Arabic-speaking patients with migraine and to assess its ability to detect subtle changes in quality of life after receiving prophylactic migraine medications.

METHODS

This multicenter prospective observational study was conducted with 140 patients experiencing migraine and indicated for prophylactic medications. Headache assessment was done at baseline and 3 months after receiving prophylactic medications using the Arabic version of MSQ 2.1, Headache Impact Test (HIT-6), and visual analog scale (VAS). The MSQ 2.1 was repeated 1 week after the first visit to a group of patients (n = 70) to assess test-retest reliability.

RESULTS

Cronbach's alpha for the MSQ 2.1 was 0.973, indicating excellent internal consistency. The intraclass correlation coefficient (average measure) was 0.99, indicating excellent test-retest reliability. There were statistically significant correlations between the MSQ 2.1 total score and monthly migraine days, VAS, and HIT-6 scores before and 3 months after prophylactic medications. The receiver operating characteristic curve revealed that an increase of 8.5 in the total score of the MSQ 2.1 represents the minimally important change that means significant improvement (area under the curve = 0.785, sensitivity = 0.861, specificity = 0.656, p < 0.001).

CONCLUSION

The Arabic version of the MSQ 2.1 is a valid, reliable, and sensitive tool that can precisely assess the impact of migraine on quality of life.

MigraineTracker: Examining Patient Experiences with Goal-Directed Self-Tracking for a Chronic Health Condition

Self-tracking and personal informatics offer important potential in chronic condition management, but such potential is often undermined by difficulty in aligning self-tracking tools to an individual's goals. Informed by prior proposals of goal-directed tracking, we designed and developed MigraineTracker, a prototype app that emphasizes explicit expression of goals for migraine-related self-tracking. We then examined migraine patient experiences in a deployment study for an average of 12+ months, including a total of 50 interview sessions with 10 patients working with 3 different clinicians. Patients were able to express multiple types of goals, evolve their goals over time, align tracking to their goals, personalize their tracking, reflect in the context of their goals, and gain insights that enabled understanding, communication, and action. We discuss how these results highlight the importance of accounting for distinct and concurrent goals in personal informatics together with implications for the design of future goal-directed personal informatics tools.

Sustained response of galcanezumab in migraine prevention: Patient-level data from a post hoc analysis in patients with episodic or chronic migraine

OBJECTIVE

To evaluate, at population and individual patient levels, the sustained response of reduction in migraine headache days in patients with migraine treated with galcanezumab.

METHODS

This was a post hoc analysis of double-blind galcanezumab studies in patients with migraine: two 6-month episodic migraine (EM; EVOLVE-1/EVOLVE-2), one 3-month chronic migraine (CM; REGAIN), and one 3-month treatment-resistant migraine (CONQUER). Patients received monthly subcutaneous galcanezumab 120 mg (after 240 mg initial loading dose), galcanezumab 240 mg, or placebo. In the EM and CM studies, the proportions of patients with ≥50% and ≥75% (EM only) reduction from baseline in average monthly migraine headache days from Months 1 to 3 and Months 4 to 6 were evaluated. A mean monthly response rate was estimated. The sustained effect was defined as maintaining ≥50% response for ≥3 consecutive months in the patient-level data for EM and CM.

RESULTS

A total of 3348 patients with EM or CM from the EVOLVE-1/EVOLVE-2 (placebo, n = 894, galcanezumab, n = 879), REGAIN (placebo, n = 558, galcanezumab, n = 555), and CONQUER (EM: placebo, n = 132, galcanezumab, n = 137; CM: placebo, n = 98, galcanezumab, n = 95) studies were included. Patients were predominantly female, White, and had monthly migraine headache day averages ranging from 9.1 to 9.5 days (EM) and 18.1 to 19.6 days (CM). In patients with EM and CM, 19.0% and 22.6% of galcanezumab-treated patients, respectively, had significantly higher maintenance of ≥50% response for all months in the double-blind period compared to 8.0% and 1.5% of placebo-treated patients. The odds ratios (OR) of achieving clinical response for EM and CM were double with galcanezumab (OR = 3.0 [95% CI 1.8, 4.8] and OR = 6.3 [95% CI 1.7, 22.7], respectively). At the individual patient level, of patients who had ≥75% response at Month 3 in the galcanezumab 120 and 240 mg dose groups and placebo group, 39.9% (55/138) and 43.0% (61/142), respectively, of galcanezumab-treated patients maintained ≥75% response during Months 4-6 compared to 32.7% (51/156) with placebo.

CONCLUSION

More galcanezumab-treated patients achieved ≥50% response within the first 3 months of treatment compared to placebo; responses were sustained during Months 4-6. The odds of achieving ≥50% response were double with galcanezumab.

QuEChERS-assisted ion pair chromatography/fluorescence detection method for determination of antimigraine combination therapy in rabbit plasma samples: Application to a pharmacokinetic study

Antimigraine combination therapy has shown significant effectiveness in relieving pain, as well as reducing the frequency, duration, and severity of migraine attacks if compared to a single migraine medication. This work represents the first analytical investigation for emphasizing the synergistic effect of combining ophthalmic beta blockers with triptans in migraine treatment. The presented study was conducted to investigate the pharmacokinetic profile of almotriptan (ALM), a serotonin (5-HT1B/1D) receptor agonist used to treat migraine, when coadministered with timolol (TIM) or verapamil (VER) which are considered as an adjuvant therapy in migraine prevention. Ion pair chromatography (IPC) with online fluorescence detection was applied to simultaneously detect and quantify the binary mixtures of ALM/TIM and ALM/VER in rabbit plasma samples. The separation was achieved using a Platinum C18 analytical column with a mobile phase composed of methanol: 35 mmol L-1 phosphate buffer solution containing 10 mmol L-1 SDS at pH = 6.8 (60:40 v/v). Several parameters were evaluated during the optimization of separation conditions including mobile phase composition, buffer concentration, buffer pH and concentration of ion pair reagent. A thorough investigation of the retention mechanism was performed, and the results showed that Coulomb forces were the main contributors to the overall retention mechanism, which may be hydrophobically assisted. QuEChERS extraction technique was utilized to extract the investigated drugs from plasma samples and a detailed study was carried out to optimize partition/extraction solvents, pH, extraction salts, sample volume and clean-up step. The method had a limit of detection and quantitation of 5.6 and 16.9 ng mL-1 for ALM in ALM/TIM mixture and 2.5 and 7.6 ng mL-1 for ALM in ALM/VER mixture, with an overall recovery not less than 95.22%. This newly proposed method offers a faster alternative to existing chromatographic methods for extraction and determination of ALM in binary mixtures with TIM or VER in rabbit plasma and provides a platform for studying pharmacokinetic parameters. The coadministration of either TIM or VER with ALM resulted in a notable rise in Cmax (maximum plasma concentration) and AUC (area under the plasma concentration-time curve) of ALM, implying possible alterations in the absorption and overall exposure of ALM.

Emerging drugs for the preventive treatment of migraine: a review of CGRP monoclonal antibodies and gepants trials

INTRODUCTION

Migraine is a leading cause of years lived with disability and preventive strategies represent a mainstay to reduce health-related disability and improve quality of life of migraine patients. Until a few years ago, migraine prevention was based on drugs developed for other clinical indications and relocated in the migraine therapeutic armamentarium, characterized by unfavourable tolerability profiles. The advent of monoclonal antibodies against Calcitonin Gene-Related Peptide (CGRP) and gepants, CGRP receptor antagonists, has been a turning point in migraine prevention owing to advantageous efficacy, safety and tolerability profiles.Nevertheless, while in an ideal scenario a drug characterized by significant greater efficacy and tolerability compared to existing therapeutic strategies should be adopted as a first-line treatment, cost-effectiveness analyses available for monoclonal antibodies against CGRP pathway tend to limit their administration to more severe migraine phenotypes.

AREAS COVERED

The present narrative review aim to provide a critical appraisal of phase II and III CGRP-mAbs and gepants trials to analyse their use in clinical practice.

EXPERT OPINION

Despite monoclonal antibodies against CGRP pathway and gepants can be undoubtedly considered top-of-the-range treatments, there are still issues deserving to be addressed in the coming years as the risk of off-target effects as well as their economic sustainability based on the considerable migraine burden.

Erenumab efficacy in migraine headache prophylaxis: A systematic review

OBJECTIVE

This systematic review aims to show the efficiency of Erenumab in the preventive therapy of episodic and chronic migraine, which is still under research.

BACKGROUND

Migraine is a chronic neurovascular disorder that causes disability and a social burden. There are various medications used for migraine prevention regimens, most of which have unwanted side effects and aren't often quite effective. Erenumab is a monoclonal antibody that targets calcitonin gene-related peptide receptors and was recently approved by the Food and Drug Administration for migraine prevention.

METHODS

For this systematic review, we searched through Scopus and PubMed databases using "Erenumab" or "AMG 334" and "migraine" as keywords, and all the studies from 2016 to March 18, 2022, were included. Original English articles assessing any outcomes referring to the efficacy of Erenumab in migraine headache treatment were included in this study.

RESULTS

We found 53 out of 605 papers eligible to be investigated. Erenumab in both dosages of 70 mg and 140 mg could decrease the mean of monthly migraine days and monthly acute migraine-specific medication days. Erenumab also has a higher rate of ≥ 50 %, ≥ 75 %, and 100 % reduction in monthly migraine days from the baseline in different regions. The efficacy of Erenumab was initiated in the first week of administration and sustained throughout and after treatment. Erenumab was also potent in the treatment of migraine with allodynia, aura, prior preventive therapy failure, medication overuse headache, and menstrual migraine. Erenumab also had favorable outcomes in combination therapy with other preventive drugs like Onabotulinumtoxin-A.

CONCLUSION

Erenumab had remarkable efficacy in the short and long-term treatment of episodic and chronic migraine, notably the patients with difficult-to-treat migraine headaches.

Expert consensus established around flexible, individualized migraine treatment utilizing a modified Delphi panel

OBJECTIVE

To characterize treatment decision-making processes and formalize consensus regarding key factors headache specialists consider in treatment decisions for patients with migraine, considering novel therapies.

BACKGROUND

Migraine therapies have long been subject to binary classification, acute versus preventive, due to limitations of available drugs. The emergence of novel therapies that can be used more flexibly creates an opportunity to rethink this binary classification. To determine the role of these novel therapies in treatment, it is critical to understand whether existing guidelines reflect clinical practice and to establish consensus around factors driving management.

METHODS

A three-round modified Delphi process was conducted with migraine clinical experts. Round 1 consisted of an online questionnaire; Round 2 involved an online discussion of aggregated Round 1 results; and Round 3 allowed participants to revise Round 1 responses, incorporating Round 2 insights. Questions elicited likelihood ratings (0 = highly unlikely to 100 = highly likely), rankings, and estimates on treatment decision-making.

RESULTS

Nineteen experts completed three Delphi rounds. Experts strongly agreed on definitions for "acute" (median = 100, inter-quartile range [IQR] = 5) and "preventive" treatment (median = 90, IQR = 15), but noted a need for treatment customization for patients (median = 100, IQR = 6). Experts noted certain aspects of guidelines may no longer apply based on established tolerability and efficacy of newer acute and preventive agents (median = 91, IQR = 17). Further, experts agreed on a treatment category referred to as "situational prevention" (or "short-term prevention") for patients with reliable and predictable migraine triggers (median = 100, IQR = 10) or time-limited periods when headache avoidance is important (median = 100, IQR = 12).

CONCLUSIONS

Using the modified Delphi method, a panel of migraine experts identified the importance of customizing treatment for people with migraine and the utility of "situational prevention," given the ability of new treatment options to meet this need and the potential to clinically identify patients and time periods when this approach would add value.

Development of the functional assessment of migraine scale using a patient guided approach

PURPOSE

A better understanding of the multi-dimensional burden and impact of migraine has grown over recent years, yet the tools used to measure these concepts have not been updated to reflect such findings. Additionally, due to the increase in the number of both prophylactic and acute therapeutic options for migraine, a comprehensive assessment of treatment response is necessary. The goal of this project was to develop a patient guided outcome measure which evaluates patient identified efficacy factors when appraising migraine treatment response.

METHODS

A group of patients with migraine (N = 10) were given an in-person semi-structured interview collecting information regarding a patient's perspective on meaningful response to headache and migraine treatment. Using the patient information collected during these interviews, a set of questions aimed at evaluating meaningful response were developed. Two additional groups (N = 100, 200) of patients with migraine then provided feedback on the drafted questions in an online setting.

RESULTS

Interviews indicated thematic areas of interest to patients with migraine are not commonly assessed on popular measures. Over two hundred items were developed to assess thematic areas indicated by patients. Factor analysis used on the focus groups' results led to the development of an 18-item scale (Functional Assessment of Migraine Scale-Research: FAMS-R) that assesses the impact of migraine on a patient and shows the potential to measure treatment response.

CONCLUSION

The FAMS portrays promising results at measuring a multi-faceted migraine treatment response and disease impact.

Discrete Choice Experiment to Understand Japanese Patients' and Physicians' Preferences for Preventive Treatments for Migraine

INTRODUCTION

Self-injectable calcitonin gene-related peptide (CGRP) monoclonal antibody (mAb) auto-injectors and non-CGRP oral medications are currently available for migraine prevention in Japan. This study elicited the preferences for self-injectable CGRP mAbs and non-CGRP oral medications and determined differences in the relative importance of auto-injector attributes for patients and physicians in Japan.

METHODS

Japanese adults with episodic (EM) or chronic (CM) migraine and physicians who treat migraine completed an online discrete choice experiment (DCE), asking participants to choose a hypothetical treatment they preferred between two self-injectable CGRP mAb auto-injectors and a non-CGRP oral medication. The treatments were described by seven treatment attributes, with attribute levels varying between questions. DCE data were analyzed using a random-constant logit model to estimate relative attribution importance (RAI) scores and predicted choice probabilities (PCP) of CGRP mAb profiles.

RESULTS

A total of 601 patients (79.2% with EM, 60.1% female, mean age: 40.3 years) and 219 physicians (mean length of practice: 18.3 years) completed the DCE. About half (50.5%) of patients favored CGRP mAb auto-injectors, while others were skeptical of (20.2%) or averse (29.3%) to them. Patients most valued needle removal (RAI = 33.8%), shorter injection duration (RAI = 32.1%), and auto-injector base shape and need for skin pinching (RAI = 23.2%). Most physicians (87.8%) favored auto-injectors over non-CGRP oral medications. Physicians most valued less-frequent dosing RAI = 32.7%), shorter injection duration (30.4%), and longer storage outside the fridge (RAI = 20.3%). A profile comparable to galcanezumab showed a higher likelihood of being chosen by patients (PCP = 42.8%) than profiles comparable to erenumab (PCP = 28.4%) and fremanezumab (PCP = 28.8%). The PCPs of the three profiles were similar among physicians.

CONCLUSION

Many patients and physicians preferred CGRP mAb auto-injectors over non-CGRP oral medications and preferred a treatment profile similar to galcanezumab. Our results may encourage physicians in Japan to consider patient preferences when recommending migraine preventive treatments.

Revisiting Migraine: The Evolving Pathophysiology and the Expanding Management Armamentarium

Migraine affects about one billion people worldwide yearly and is one of the most common neurologic illnesses, with a high prevalence and morbidity, particularly among young adults and females. Migraine is associated with many comorbidities, including stress, sleep difficulties, and suicidal ideation. Migraine, despite its widespread occurrence, is underdiagnosed and undertreated. Because of the complicated and primarily unknown mechanisms of migraine formation, several social and biological risk factors, such as hormone imbalances, genetic and epigenetic impacts, and cardiovascular, neurological, and autoimmune illnesses, have been proposed. Through the mid-20th century diversion of the now-defunct vascular theory, the pathophysiology of migraine has developed from a historical study of the "humours" to a distinct entity as a neurological disorder. The range of therapeutic targets has broadened significantly, increasing the number of specialized clinical trials. Understanding the biology of migraine through careful research has resulted in the identification of major therapeutic classes: (i) triptans, serotonin 5-HT1B/1D receptor agonists, (ii) gepants, calcitonin gene-related peptide (CGRP) receptor antagonists, (iii) ditans, 5-HT1F receptor agonists, (iv) CGRP monoclonal antibodies, and (v) glurants, mGlu5 modulators, with further targets being explored. This review provides a comprehensive overview of the most recent literature on epidemiology and risk factors and exposes knowledge gaps.

A multicenter, open-label, phase 3 study to evaluate the safety of fremanezumab for migraine, subcutaneously self-administered with an auto-injection device at institutional sites and at home

BACKGROUND

Fremanezumab is a humanized monoclonal antibody against calcitonin gene-related peptide for subcutaneous use to suppress migraine attacks. A phase 3 study was conducted to investigate the safety of autoinjector (AI)-assisted self-injection of fremanezumab 225 mg.

RESEARCH DESIGN AND METHODS

The multicenter, open-label study involving 71 patients with migraine was conducted between June 2020 and November 2020 at ten institutions in Japan. The study consisted of a 4-week (28-day) screening period and an 8-week (57-day) treatment period. According to the investigator's instructions, all patients successfully performed self-injection for 4 weeks at the institutional site and at home and maintained eDiaries of their headaches. The primary endpoint was safety of the drug based on treatment-emergent adverse events (TEAEs).

RESULTS

Treatment-emergent adverse events were more frequent after at-home injection than after at-site injection, but they were mainly injection site reactions and mostly mild. The safety profile was comparable, raising no concerns compared with what has been reported in previous studies. Both migraine days and headache days were decreased considerably.

CONCLUSIONS

Overall, AI-assisted, at-home self-injection of fremanezumab was found to be generally safe and well-tolerated. This injection strategy is considered clinically meaningful in view of improved utility of and adherence to the drug.

The effects of phytosomal curcumin supplementation on clinical symptoms, and inflammatory and oxidative stress biomarkers in patients with migraine: A protocol for a randomized double-blind placebo-controlled trial

Objective

Migraine is one of the most common diseases. Curcumin with anti-oxidative and anti-neuroinflammatory properties might have beneficial effects in migraine patients. This study will be conducted to evaluate the effects of a phytosomal preparation of curcumin on clinical signs, oxidative stress, and inflammatory parameters in patients with migraine.

Materials and Methods

This is a randomized, double-blind, placebo-controlled, clinical trial in which, 60 patients with migraine will be assigned to receive a daily dose of 250 mg of phytosomal curcumin for 8 weeks (intervention group) or 250 mg maltodextrin as a placebo for the same duration (control group). Before and after the study, frequency, duration, and severity of the attacks, quality of life and sleep, mood status, high-sensitivity C-reactive protein (hs-CRP), Nitric Oxide (NO), and oxidative stress factors will be measured.

Conclusion

It seems that phytosomal formulation of curcumin (a solid dispersion preparation of curcumin with phosphatidylserine) with high bioavailability, can cross the blood-brain barrier (BBB) and result in decreased neuroinflammation, oxidative stress, and neurotoxicity. This way, phytosomal curcumin might lead to reduction of headaches and other complications of migraine and increase the quality of life of patients with migraine.

The Functional Assessment of Migraine Scale development datasets

The Functional Assessment of Migraine Scale (FAMS) is a newly developed questionnaire that allows patients to indicate their response to migraine treatment [1]. The datasets provided in this article were collected on patients with migraine using survey methodology in two rounds of data collection. In the first dataset (n = 100), patients were shown 210 proposed questions for the FAMS and rated their usefulness and/or relevance for assessing their treatment response [2]. Using factor analyses, the best items were selected for the second data collection (n = 200). Patients completed the final proposed 72 items along with two other popular measures of migraine assessment [3]. Both datasets include demographic and migraine related information (gender, race, medication, number of headache and migraine days). These data provide a wealth of information about the number and types of medications a patient with migraine may take, coupled with information about their perceived response to treatment with those medications. Because the FAMS was developed to assess a wide range of concerns voiced by patients, this data offers new insights into a large health population beyond the normal scope of research studies.

Preventive Medication Use among Adults Aged 40 and over in the United States: National Health and Nutrition Examination Survey, 2015-2018

OBJECTIVES

1. To estimate the prevalence of preventive medication use among adults in the United States (US); 2. To identify the socioeconomic, demographic and clinical factors associated with preventive prescription medication use; 3. To identify the diagnoses associated with preventive prescription medication use.

METHODS

Data from two cycles of the National Health and Nutrition Examination Survey, 2015-2016 and 2017-2018, are analyzed.

RESULTS

Among US adults aged 40 years or older (N = 7634), 31% use a preventive medication. Specifically, 27% of them use aspirin and 9% use other preventive prescription medications. Among those who use other preventive prescription medications, 27% report using one of the cardiovascular agents and 24% reported using anticoagulants and/or antiplatelet agents. High percentages of preventive prescription medication users report using medications to prevent heart attacks/myocardial infarctions (25%) or blood clots (23%). Uninsured adults are less likely to use preventive medications (OR: 0.656; p-value = 0.009) as compared with their counterparts with private insurance. On the other hand, older adults and those with diabetes, heart disease, arthritis and hypertension are more likely to use preventive medications. Furthermore, past smokers and adults who never smoked are more likely to use preventive medications as compared with those who currently smoke.

CONCLUSION

Policies are needed to increase access to preventive care for uninsured adults. Further research needs to review the benefits and harms of the chronic use of preventive medication among older adults in the US.

Factors Associated with Over-the-Counter Analgesic Overuse among Individuals Experiencing Headache

The prevalence of chronic daily headache (CDH) worldwide is 4−5%. Treatment for CDH with prophylaxis and abortive medications is often delayed, increasing disease severity. Consequently, increased usage of over-the-counter (OTC) analgesics can lead to medication overuse headache (MOH). This study aimed to assess factors affecting OTC analgesic overuse causing headaches. Methodology: A cross-sectional structured survey was conducted using voluntary response sampling. Among 1177 respondents, 459 individuals with headache were enrolled in the study. Results: Most participants were female (73.5%), almost half were aged 20−39 years (48.1%), and over half used OTC analgesics (56%). A significant association was found between OTC analgesic overuse and factors, such as chronic disease (p = 0.007), working status (p = 0.015), smoking (p = 0.02), headache frequency >15 days per month (p = 0.000), migraine-type headache (p = 0.01), preventive medicine use (p = 0.018), and emergency department visit (p = 0.018). Conclusion: OTC analgesic overuse among individuals with headache is affected by several factors, including the presence of chronic diseases, working status, smoking, and migraine-type headaches. However, preventive medicine and emergency department visits were considered to have protective effects. Health care providers should screen patients for MOH, increase their awareness, and follow MOH guidelines to treat chronic headache.

A real-world study of acute and preventive medication use, adherence, and persistence in patients prescribed fremanezumab in the United States

Background

Following approval of fremanezumab for the prevention of migraine in adults, health care decision makers are interested in understanding real-world clinical characteristics and treatment patterns among patients initiating fremanezumab therapy.

Methods

Data were obtained for this retrospective (pre-post) study from the Veradigm Health Insights database. The study period was January 1, 2014, to June 30, 2019. Patients were included if they were aged ≥ 18 years; had ≥ 1 migraine diagnosis during the study period; and had a medication record for fremanezumab on or after diagnosis during the identification period (September 1, 2018–December 31, 2018). Treatment patterns, including adherence, persistence, and utilization of acute and preventive migraine medication prescriptions, were evaluated.

Results

Of 987 patients initiating fremanezumab during the study period, 738 (74.8%) were adherent to fremanezumab by proportion of days covered (PDC; ≥ 80%) and 780 (79.0%) were adherent by medication possession ratio (MPR; ≥ 80%). A total of 746 (75.6%) patients were persistent for ≥ 6 months. Quarterly fremanezumab (n = 186) was associated with higher rates of adherence versus monthly fremanezumab (n = 801) by PDC (quarterly, 91.3%; monthly, 84.9%; P < 0.001) and MPR (quarterly, 92.2%; monthly, 87.9%; P = 0.006) and higher persistence at ≥ 6 months (quarterly, 82.8%; monthly, 73.9%; P = 0.011). After fremanezumab initiation, patients who were persistent for ≥ 6 months experienced significant reductions from baseline in the mean monthly number of acute and preventive migraine medication prescriptions (P < 0.001). Subgroup analyses in patients with comorbid depression and anxiety showed meaningful real-world benefits based on significant reductions in the number of patients who were prescribed antidepressants (baseline, 68.6%; follow-up, 56.4%; P = 0.0025) and anxiolytic medications (baseline, 55.0%; follow-up, 47.2%; P = 0.037), respectively. In a subgroup of patients with comorbid hypertension at baseline, fremanezumab treatment resulted in nonsignificant reductions in blood pressure.

Conclusions

Overall, adherence and persistence to fremanezumab in this real-world study was high in patients with migraine, with higher rates observed for quarterly fremanezumab. Patients who were persistent for ≥ 6 months experienced significant reductions in acute and preventive migraine medication use, while a subgroup of migraine patients with comorbid depression and anxiety at baseline showed significant reductions in antidepressant and anxiolytic medication use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10194-022-01413-z.

Early onset of efficacy with fremanezumab in patients with episodic and chronic migraine: subanalysis of two phase 2b/3 trials in Japanese and Korean patients

Background

Early onset of action has become recognized as an important efficacy feature of preventive migraine treatment, which can help overcome adherence issues commonly associated with older medications. Preventive treatments that target the calcitonin gene-related peptide (CGRP) or the CGRP receptor have been previously shown to provide early onset of action.

Methods

This subanalysis of primary endpoints of two separate phase 2b/3 studies sought to determine the onset of action of fremanezumab in Japanese and Korean patients with episodic migraine (EM) and chronic migraine (CM).

Results

In EM patients (n = 357), both fremanezumab quarterly and fremanezumab monthly led to greater reductions in weekly migraine days (days/week) than placebo from the first week after the initial injection and thereafter during the remainder of the study period. Similarly, CM patients (n = 571) had a greater reduction in headache days of at least moderate severity (days/week) with fremanezumab (total) than placebo. The percentage of patients with a migraine day (EM) or headache day at least moderate severity (CM) was lower in those treated with fremanezumab than placebo and this effect was apparent from as early as Day 2 (1 day after first injection).

Conclusions

These results suggest that fremanezumab has an early onset of action, as noted in previous post hoc analyses of anti-CGRP monoclonal antibodies.

Trial registration

ClinicalTrials.gov. NCT03303092, Registered 5 October 2017, NCT03303079, Registered 5 October 2017.

Headache for ophthalmologists: current advances in headache understanding and management

Patients with headache and head pain are often referred to ophthalmologists. These symptoms can either be associated with underlying ophthalmic conditions, or more often are headache disorders unrelated to the eyes. Understanding the phenotype of the headache is critical for advice, safe discharge or onward referral. This review will provide an update on the criteria for common headache disorders that are often seen by ophthalmology and embrace disorders associated with ophthalmic diseases. It will also describe the changing management of migraine and outline recent therapies that are currently available.

Galcanezumab Provides Consistent Efficacy Throughout the Dosing Interval Among Patients with Episodic and Chronic Migraine: A Post Hoc Analysis

Introduction

The consistency of the treatment effect of galcanezumab throughout the dosing interval is examined in patients with episodic and chronic migraine.

Methods

This study was a post hoc analysis of clinical trial data from episodic (EVOLVE-1; EVOLVE-2; both 6-month duration) and chronic (REGAIN; 3-month duration) migraine double-blind trials evaluating the efficacy of a once-monthly injection of galcanezumab 120 mg relative to placebo. Adults with episodic (placebo, n = 894; galcanezumab, n = 444) or chronic migraine (placebo, n = 558; galcanezumab, n = 278) were included. Mean change from baseline in weekly migraine headache days, averaged across all months for each week of the dosing interval, was compared between groups and within the galcanezumab group during weeks 1 and 4. Additional analyses examined the mean difference from placebo in weekly migraine headache days and a day-by-day analysis.

Results

Weekly migraine headache day reduction was significantly greater with galcanezumab relative to placebo every week (P < 0.001) and did not differ during weeks 1 and 4 for those with episodic (P = 0.740) or chronic migraine (P = 0.231) taking galcanezumab. Estimated probabilities of migraine on day 2 and day 30 did not differ for those with episodic (P = 0.61) or chronic migraine (P = 0.616) taking galcanezumab.

Conclusion

This analysis demonstrates once monthly galcanezumab exhibits consistent efficacy throughout the dosing interval among the population of patients with migraine in three clinical trials evaluating the efficacy of galcanezumab. There is no evidence from these trials that the effect of galcanezumab “wears off” at the end of the dosing interval.

Trial Registration

ClinicalTrials.gov identifier: EVOLVE-1 (NCT02614183); EVOLVE-2 (NCT02614196); REGAIN (NCT02614261).

Genetics, pathophysiology, diagnosis, treatment, management, and prevention of migraine

Migraine is a neurological ailment that is characterized by severe throbbing unilateral headache and associated with nausea, photophobia, phonophobia and vomiting. A full and clear mechanism of the pathogenesis of migraine, though studied extensively, has not been established yet. The current available information indicates an intracranial network activation that culminates in the sensitization of the trigemino-vascular system, release of inflammatory markers, and initiation of meningeal-like inflammatory reaction that is sensed as headache. Genetic factors might play a significant role in deciding an individual's susceptibility to migraine. Twin studies have revealed that a single gene polymorphism can lead to migraine in individuals with a monogenic migraine disorder. In this review, we describe recent advancements in the genetics, pathophysiology, diagnosis, treatment, management, and prevention of migraine. We also discuss the potential roles of genetic and abnormal factors, including some of the metabolic triggering factors that result in migraine attacks. This review will help to accumulate current knowledge about migraine and understanding of its pathophysiology, and provides up-to-date prevention strategies.

Effectiveness of erenumab and onabotulinumtoxinA on acute medication usage and health care resource utilization as migraine prevention in the United States

BACKGROUND: Migraine is a common neurological disease that can have a substantial impact on patients' lives and on society. Erenumab, a fully human monoclonal antibody that targets the calcitonin gene-related peptide receptor, was specifically developed for migraine prevention. The efficacy of erenumab has been established in several clinical trials; however, the real-world comparative effectiveness of erenumab has not been fully investigated. OBJECTIVE: To evaluate the real-world impact of erenumab and onabotulinumtoxinA on acute medication usage and health care resource utilization (HCRU) among patients with migraine in the United States. METHODS: This retrospective US claims analysis (Optum's deidentified Clinformatics Data Mart Database) evaluated patients aged at least 18 years diagnosed with migraine who initiated erenumab or onabotulinumtoxinA between May 1, 2018, and September 30, 2019 (index date: first erenumab/onabotulinumtoxinA claim). Cohorts were matched 1:1 using the propensity score (PS) method (greedy match with caliper = 0.1). Stratification was performed based on gender, chronic migraine without aura diagnosis, onabotulinumtoxinA use, and acute/preventive drug use. The impact of erenumab and onabotulinumtoxinA on acute medication usage and HCRU was assessed in the 6-month post-index period. An exploratory analysis assessed the impact of erenumab and onabotulinumtoxinA on a composite endpoint of: (1) outpatient visit with a migraine diagnosis and associated acute medication claim, (2) hospital admission with a primary migraine diagnosis, or (3) emergency department visit with a primary migraine diagnosis. PS-matched data were used for comparative analyses; logistic regression with covariate adjustment was used for dichotomous variables, and a negative binomial model was used for count variables, with odds ratios or rate ratios (RRs) and 95% CIs calculated. RESULTS: Following stratified PS matching, 1,338 patients were included in both cohorts. At 6 months, the adjusted average number of claims per person for any acute medication was significantly lower in the erenumab cohort (1.13 vs 1.29 in the onabotulinumtoxinA cohort; RR = 0.88; 95% CI = 0.80-0.96; P = 0.0069), although the difference in the number of claims for triptans and barbiturates was statistically nonsignificant. The adjusted average number of all-cause and migraine-specific visits per person to health care providers was generally lower in the erenumab cohort compared with the onabotulinumtoxinA cohort. Patients in the erenumab cohort had a significantly lower number of composite events (0.44 vs 0.69 in the onabotulinumtoxinA cohort; RR = 0.63; 95% CI = 0.56-0.71; P < 0.0001). Similarly, the adjusted proportion of patients with any of the 3 composite events was lower in the erenumab cohort (31.7% vs 44.3% in the onabotulinumtoxinA cohort; OR = 0.59; 95% CI = 0.49-0.70; P < 0.0001). CONCLUSIONS: In this retrospective claims analysis study, erenumab significantly reduced acute medication usage (opioids and nonsteroidal anti-inflammatory drugs; any acute medication when analyzed together) and HCRU to a greater extent than onabotulinumtoxinA. DISCLOSURES: This study was supported by Novartis Pharma AG. Novartis employees contributed to the study design, analysis of the data, and the decision to publish the results. Fang, Abdrabboh, Glassberg, Vo, and Ferraris are employed by Novartis. Zhou and Shen are employed by KMK Consulting, Inc., which received funding from Novartis to conduct the study. Tepper reports grants from Allergan, Amgen, ElectroCore, Eli Lilly, Lundbeck, Neurolief, Novartis, Satsuma, and Zosano, outside the submitted work; personal fees from Dartmouth-Hitchcock Medical Center, American Headache Society, Thomas Jefferson University, Aeon, Align Strategies, Allergan/AbbVie, Alphasights, Amgen, Aperture Venture Partners, Aralez Pharmaceuticals Canada, Axsome Therapeutics, Becker Pharmaceutical Consulting, BioDelivery Sciences International, Biohaven, ClearView Healthcare Partners, CoolTech, CRG, Currax, Decision Resources, DeepBench, DRG, Eli Lilly, Equinox, ExpertConnect, GLG, Guidepoint Global Healthcare Consultancy Group, Health Science Communications, HMP Communications, Impel, InteractiveForums, M3 Global Research, Magellan Rx Management, Medicxi, Navigant Consulting, Neurorelief, Nordic BioTech, Novartis, Pulmatrix, Reckner Healthcare, Relevale, SAI MedPartners, Satsuma, Slingshot Insights, Spherix Global Insights, Sudler and Hennessey, Synapse Medical Communications, System Analytic, Teva, Theranica, Thought Leader Select, Trinity Partners, XOC, Zosano, Krog and Partners, and Lundbeck, outside the submitted work; and CME honoraria from American Academy of Neurology, American Headache Society, Cleveland Clinic Foundation, Diamond Headache Clinic, Elsevier, Forefront Collaborative, Hamilton General Hospital, Ontario, Canada, Headache Cooperative of New England, Henry Ford Hospital, Detroit, Inova, Medical Learning Institute PeerView, Medical Education Speakers Network, Miller Medical Communications, North American Center for CME, Physicians' Education Resource, Rockpointe, ScientiaCME, WebMD/Medscape. The abstract and poster of these results were presented at The Migraine Trust Virtual Symposium (MTIS), October 3-9, 2020.

Pharmacokinetics and safety of ubrogepant when coadministered with calcitonin gene-related peptide-targeted monoclonal antibody migraine preventives in participants with migraine: A randomized phase 1b drug-drug interaction study

Objective

To evaluate the impact of two calcitonin gene–related peptide (CGRP)‐targeted monoclonal antibodies (mAbs), erenumab and galcanezumab, on the pharmacokinetic (PK) profile, safety, and tolerability of ubrogepant.

Background

People taking CGRP‐targeted mAbs for migraine prevention sometimes take ubrogepant, an oral small‐molecule CGRP receptor antagonist, for acute treatment of breakthrough migraine attacks.

Design

In this two‐arm, multicenter, open‐label, phase 1b trial, adults with migraine were randomized to arm 1 (ubrogepant ± erenumab) or arm 2 (ubrogepant ± galcanezumab). The PK profile of ubrogepant was characterized for administration before and 4 days after CGRP‐targeted mAb injection. Participants received single‐dose ubrogepant 100 mg on day 1, subcutaneous erenumab 140 mg (arm 1) or galcanezumab 240 mg (arm 2) on day 8, and ubrogepant 100 mg once daily on days 12–15. In each study arm, serial blood samples were drawn on days 1 and 12 for measurement of plasma ubrogepant concentrations. The primary outcomes were area under the plasma ubrogepant concentration–time curve (AUC) from time 0 to t post‐dose (AUC_0–t) and from time 0 to infinity (AUC_0–inf), and maximum plasma concentration (C_max) of ubrogepant when ubrogepant was administered before or after a single dose of erenumab or galcanezumab. Vital signs and laboratory parameters were monitored.

Results

Forty participants enrolled (20 per arm; mean [standard deviation] ages, 32.2 [8.9] and 38.4 [8.8] years; 50% [10/20] and 60% [12/20] female in arms 1 and 2, respectively). There were no significant differences in ubrogepant C_max after versus before erenumab administration (geometric least‐squares mean [LSM] ratio, 1.04 [90% CI, 0.93–1.16]), and no significant differences in AUC_0–t (1.06 [0.96–1.16]) or AUC_0–inf (1.05 [0.96–1.15]). Similarly, ubrogepant C_max (1.00 [90% CI, 0.82–1.20]), AUC_0–t (1.05 [0.90–1.23]), and AUC_0–inf (1.05 [0.90–1.22]) geometric LSM ratios were statistically equivalent after galcanezumab versus ubrogepant alone. Treatment‐emergent adverse events (TEAEs) were similar to those reported with each treatment alone. No serious TEAEs, TEAEs leading to discontinuation, or clinically relevant changes in laboratory parameters or vital signs were reported.

Conclusions

The PK profile of ubrogepant was not significantly changed and no safety concerns were identified when ubrogepant was coadministered with erenumab or galcanezumab.

Treatment of headache disorders with acupuncture: a 6-year retrospective study

OBJECTIVE

Existing systematic reviews and meta-analyses indicate that acupuncture has similar clinical effectiveness in the prevention of headache disorders (HDs) as drug therapy, but with fewer side effects. As such, examining acupuncture's use in a pragmatic, real-world setting would be valuable. The purpose of this study was to compare the effects of acupuncture and prophylactic drug treatment (PDT) on headache frequency in patients with HDs, under real-world clinical conditions.

METHODS

Retrospective cohort study of patients with HDs referred to a pain clinic, using electronic health record data. Patients continued with tertiary care (treatment of acute headache attacks and lifestyle, meditation, exercise and dietary instructions) with PDT, or received 12 sessions of acupuncture over 3 months, instead of PDT under conditions of tertiary care. The primary outcome data were the number of days with headache per month, and groups were compared at baseline and at the end of the third month of treatment.

RESULTS

Data were analysed for 482 patients with HDs. The number of headache days per month decreased by 3.7 (standard deviation (SD) = 2.9) days in the acupuncture group versus 2.9 (SD = 2.3) in the PDT group (p = 0.007). The proportion of responders was 39.5% versus 16.3% (p < 0.001). The number needed to treat was 4 (95% confidence interval = 3-7).

CONCLUSION

Our study has shown that patients with HDs in tertiary care who opted for treatment with acupuncture appeared to receive similar clinical benefits to those that chose PDT, suggesting these treatments may be similarly effective of the prevention of headache in a real-world clinical setting.

Renin-Angiotensin-Aldosterone System and Migraine: A Systematic Review of Human Studies

Migraine is a common neurologic condition marked by recurrent episodes of headache. Its pathophysiology is highly complex involving neuronal, inflammatory and vascular mechanisms. The Renin-Angiotensin System (RAS) can modulate all these mechanism, being a potential pharmacological target for migraine treatment. We carried out a systematic review of the studies evaluating the involvement of RAS in patients with migraine. There is evidence from genetic studies exploring the relation between migraine and RAS-related genes and from clinical trials evaluating the efficacy of Angiotensin II Type 1 (AT1) receptor antagonists and angiotensin converting enzyme inhibitors in migraine prophylaxis. RAS seems to play a role in the pathophysiology of migraine, but more direct evidence is still missing.

Optimal treatment strategy of fremanezumab in migraine prevention: a systematic review with network meta-analysis of randomized clinical trials

Identifying the optimal fremanezumab treatment strategy is crucial in treating patients with migraines. The optimal strategy was investigated by assessing the cumulative 50% reduction rate (50%CRR), cumulative 75% reduction rate (75%CRR), reduction in the number of migraine days, treatment-related adverse events, and serious adverse events in patients treated with fremanezumab 225 mg monthly (225 mg), 675 mg monthly (675 mg), 900 mg monthly (900 mg), a single high dose of 675 mg (S675mg), 675 mg at baseline with 225 mg monthly (675/225 mg), and placebo. Biomedical databases were searched for randomized controlled trials on this topic, and data were individually extracted. Risk ratios and mean differences were used to present the pooled results. The surface under the cumulative ranking curve (SUCRA) was used to determine the effects of the medication strategies of fremanezumab. Five trials (n = 3404) were used to form a six-node network meta-analysis. All fremanezumab medication strategies displayed significantly higher cumulative 50% reduction rates than the placebo. The SUCRA revealed that treatment with 675 mg yielded the highest 50%CRR value (mean rank = 2.5). S675 mg was the only treatment with significantly higher 75%CRR reduction rate than placebo, whereas the SUCRA for 225 mg displayed the highest mean rank (2.2). Moreover, 225 mg (mean rank = 2.2) and S675 mg (mean rank = 2.2) presented lower probabilities of serious adverse events. Collectively, S675mg and 225 mg exhibited the optimal balance between efficacy and safety within three months. Long-term efficacy and safety remain unclear, and future studies should further evaluate the long-term outcomes.

The Health and Productivity Burden of Migraines in Australia

OBJECTIVE

This study aimed to quantify the health and productivity burden of migraines in Australia, measured by quality-adjusted life years (QALYs), productivity-adjusted life years (PALYs, a novel measure of productivity), and associated health-care and broader economic costs.

METHODS

A Markov state-transition model was constructed to simulate follow-up of Australians aged 20-64 years over the next 10 years. The model was first run using current prevalence estimates of migraine. It was then rerun assuming that people with migraine hypothetically did not have the condition. Differences in outcomes between the 2 model simulations represented the health and productivity burden attributable to migraine. All data inputs were obtained from published sources. Gross domestic product (GDP) per equivalent full-time worker in Australia was used to reflect the cost of each PALY (AU$177,092). Future costs and outcomes were discounted by 5% annually.

RESULTS

Currently, 1,274,319 million (8.5%) Australians aged 20-64 years have migraine. Over the next 10 years, migraine was predicted to lead to a loss of 2,577,783 (95% confidence interval [CI] 2,054,980 to 3,000,784) QALYs among this cohort (2.02 per person and 2.43% of total QALYs), and AU$1.67 (95% CI $1.16 to $2.37) billion in health-care costs (AU$1313 per person, 95% CI $914 to $1862). There would also be 384,740 (95% CI 299,102 to 479,803) PALYs lost (0.30 per person and 0.53% of total PALYs), resulting in AU$68.13 (95% CI $44.42 to $98.25) billion of lost GDP (AU$53,467 per person, 95% CI $34,855 to $77,102).

CONCLUSION

Migraines impose a substantial health and economic burden on Australians of working age. Funding interventions that reduce the prevalence of migraines and/or its effects are likely to provide sound return on investment.

Effect of fremanezumab on quality of life and productivity in patients with chronic migraine

OBJECTIVE

To evaluate fremanezumab quarterly or monthly vs placebo on health-related quality of life, health status, patients' global impression of change, and productivity in patients with chronic migraine (CM).

METHODS

HALO CM was a double-blind, placebo-controlled trial in patients with CM. Patients were randomized 1:1:1 to treatment with fremanezumab quarterly (675 mg at baseline, placebo at weeks 4 and 8), fremanezumab monthly (225 mg at baseline, weeks 4 and 8), or placebo. This article assessed the effect of treatment with fremanezumab on health-related quality of life and productivity using the following prespecified assessments: the Migraine-Specific Quality of Life (MSQoL) questionnaire at baseline and weeks 4, 8, and 12; Patient Global Impression of Change (PGIC) questionnaire at weeks 4, 8, and 12; and EuroQoL 5-dimension, 5-response level (EQ-5D-5L) questionnaire and Work Productivity and Activity Impairment: General Health (WPAI:GH) questionnaire at baseline and week 12.

RESULTS

The full analysis set included 1,121 patients: 375 patients with quarterly dosing, 375 with monthly dosing, and 371 with placebo. Fremanezumab quarterly and monthly was associated with significant improvements over placebo in change from baseline mean scores in MSQoL domains (all, p < 0.05) to week 12. At week 12, fremanezumab also showed significant improvements in EQ-5D-5L visual analog scale (p < 0.05) and PGIC scores (p < 0.0001) as well as significant reductions from baseline in WPAI:GH scores (p < 0.01) and presenteeism (impairment while working; p < 0.05) vs placebo.

CONCLUSIONS

Fremanezumab quarterly or monthly was associated with improvement over placebo in migraine-specific quality of life, overall health status, patients' global impression of change with treatment, and productivity in patients with CM.

CLINICALTRIALSGOV IDENTIFIER

NCT02621931.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that in patients with CM, treatment with fremanezumab quarterly or monthly is associated with improvements in health-related quality of life and productivity.

An Evidence-Based Review of Fremanezumab for the Treatment of Migraine

Migraine headache is a common, chronic, debilitating disease with a complex etiology. Current therapy for migraine headache comprises either treatments targeting acute migraine pain or prophylactic therapy aimed at increasing the length of time between migraine episodes. Recent evidence suggests that calcium gene-related peptide (CGRP) is a critical component in the pathogenesis of migraines. Fremanezumab, a monoclonal antibody against CGRP, was recently approved by the Food and Drug Administration (FDA) after multiple studies showed that it was well-tolerated, safe, and effective in the treatment of migraines. Further research is needed to elucidate the long-term effects of fremanezumab and CGRP-antagonists in general, and additional data is required in less healthy patients to estimate its effects in these populations and potentially increase the eligible group of recipients. This is a comprehensive review of the current literature on the efficacy and safety of fremanezumab for the treatment of chronic migraine. In this review we provide an update on the epidemiology, pathogenesis, diagnosis, and current treatment of migraine, and summarize the evidence for fremanezumab as a treatment for migraine.

Calcitonin Gene-Related Peptide (CGRP) Antagonists and Their Use in Migraines

Migraine is highly prevalent and associated with a large socio-economic burden in the United States. Current preventive medications have variable efficacy and their use is often limited by intolerable side effects. Calcitonin gene-related peptide (CGRP) has been identified as an integral part of migraine pathophysiology. There are currently seven CGRP antagonists under investigation, all of which are undergoing or have completed phase 3 clinical trials. Three of the investigated CGRP antagonists are approved for use within and outside of the United States. The trials have resulted in positive efficacy and safety data. The purpose of this review is to evaluate the seven CGRP antagonists and their future place in therapy.

The organizations of specialized medical care for patients with headache

Primary headaches are common diseases in the clinical practice. Affecting the active, able-bodied population, impairing the quality of life and causing social maladjustment, they are of immense social significance. The medical care for patients with headaches ought to be complex and include a patient’s educational program, rational pharmaceutical therapy, detection and correction of comorbid functional disorders, nonpharmaceutical therapy. Despite an adequate therapy, the treatment satisfaction remains low and stimulates development of individualized treatment algorithms, that take into account the patient’s personal characteristics. They should be applicable both for the self treatment and for the use in the neurological and general practice.

Are antimigraine drugs that influence CGRP levels justified?

Migraine is one of the most common disorders found in everyday clinical practice. Although migraines are not directly life-threatening or permanently disabling, the severity of the pain and symptoms that characterize a migraine attack often prevent normal work and cause difficulties in everyday life. Migraines also affect the patient's family, who often experience stress and depression in response to the patient's condition. Available therapy, used in both acute and chronic treatments, might not provide sufficient improvement. Due to problems like therapy inefficacy, side effects, and intolerance, patients often stop treatments. Recent studies have indicated that drugs that act through calcitonin gene-related peptide (CGRP) can significantly improve migraine therapy. Here, we review results from currently available clinical trials on CGRP receptor antagonists and anti-CGRP monoclonal antibodies.

Real-world treatment patterns and patient-reported outcomes in episodic and chronic migraine in Japan: analysis of data from the Adelphi migraine disease specific programme

Background

In Japan, detailed information on the characteristics, disease burden, and treatment patterns of people living with migraine is limited. The aim of this study was to compare clinical characteristics, disease burden, and treatment patterns in people with episodic migraine (EM) or chronic migraine (CM) using real-world data from clinical practice in Japan.

Methods

This was an analysis of data collected in 2014 by the Adelphi Migraine Disease Specific Programme, a cross-sectional survey of physicians and their consulting adult patients in Japan, using physician and patient questionnaires. We report patient demographics, prescribed treatment, work productivity, and quality-of-life data for people with CM (≥15 headache days/month) or EM (not fulfilling CM criteria). In descriptive analyses, continuous and categorical measures were assessed using t-tests and Chi-squared tests, respectively.

Results

Physicians provided data for 977 patients (mean age 44.5 years; 77.2% female; 94.5% with EM, 5.5% with CM). A total of 634/977 (64.9%) invited patients (600 with EM; 34 with CM) also provided data. Acute therapy was currently being prescribed in 93.7% and 100% of patients with EM and CM, respectively (p = 0.069); corresponding percentages for current preventive therapy prescriptions were 40.5% and 68.5% (p < 0.001). According to physicians who provided data, preventive therapy was used at least once by significantly fewer patients with EM than with CM (42.3% vs. 68.5%, respectively; p < 0.001). Among patients who provided physicians with information on issues with their current therapy (acute therapy: n = 668 with EM, n = 38 with CM; preventive therapy: n = 295 with EM, n = 21 with CM), lack of efficacy was the most frequently identified problem (acute therapy: EM 35.3%, CM 39.5% [p = 0.833]; preventive therapy: EM 35.3%, CM 52.4% [p = 0.131]). Moderate-to-severe headache-related disability (Migraine Disability Assessment total score ≥ 11) was reported by significantly fewer patients with EM than with CM (21.0% vs. 60.0%, respectively; p < 0.001) among patients who provided data.

Conclusions

Preventive treatment patterns in people with EM versus CM differ in Japan, with both types of migraine posing notable disease burdens. Our findings demonstrate that more effective migraine therapies are required to reduce the burden of the disease.

Electronic supplementary material

The online version of this article (10.1186/s10194-019-1012-1) contains supplementary material, which is available to authorized users.

The Role of Anti-calcitonin Gene-related Peptide in Migraine and its Implication in Developing Countries: A Reasonable Option to Consider Despite Higher Cost

Migraine is among the commonest causes of headache in all ages. It is the second most common cause of neurological disability. Currently, antihypertensive, antidepressants and antiepileptic drugs are reasonable preventable medications for chronic migraine. Despite the higher levels of stigma associated with this disease, fewer attempts were made in past regarding the treatment options for chronic migraine. Recently, a novelty treatment was introduced known as calcitonin gene-related peptide (CGRP) monoclonal antibodies as a possible mechanism for the prevention of migraine attacks. CGRP played an important role in the etiology of migraine headaches and was considered as the major peptide behind the cause of the headache disorders. We have reviewed the benefits of these monoclonal antibodies in terms of their efficacy and adverse effects with the available treatment choices. These drugs showed superior results when compared to the placebo and were considered generally safe in the majority of clinical trials. Earlier versions of CGRP antagonists, known as gepants, were less tolerable due to their tendency to cause liver and cardiovascular complications. Thus, in comparison to the earlier gepants, these CGRP monoclonal antibodies were safer and demonstrated excellent tolerability. Short-term side effects were only limited to mild-moderate injection site rash or pruritus, however, their long-term side effects are still unknown. Despite the higher cost of these drugs, we have analyzed the applicability of this drug in the developing countries. Although the quality-adjusted life year (QALY) gained per cost of the drug is still expensive and majority of people may not afford, its excellent tolerability and less adverse effects should also be considered a reason to implement this drug, particularly for resource-limited countries. Moreover, these medications could also become a prototype for future inventions and creations (cost-effective versions for resource-limited countries). In conclusion, this review suggests that CGRP monoclonal antibodies are safer and excellent alternate option for patients with chronic migraine as it has better efficacy, tolerability, and provides a hope to reduce the stigma associated with migraine. All these benefits should be the deciding factors when opting for this treatment and the decision should not be made solely on the socioeconomic status.

The Efficacy of Shinbaro for the Preventive Treatment of Migraine: A Pilot Study

OBJECTIVE

To investigate the therapeutic potential and efficacy of Shinbaro, an herbal medication for inflammatory diseases and bone disorders, as a preventive treatment of migraine.

METHODS

In this prospective, interventional, single-arm, pre-post study, 37 migraine patients took 600mg bid of Shinbaro for 12 weeks. At 4-week intervals, the migraine frequency and the rescue medications frequency were measured from each patient's headache diary. The modified Migraine Disability Assessment (MIDAS) questionnaires to assess migraine associated disabilities were also completed at each visit. The serum calcitonin gene-related peptide (CGRP) concentrations before and after 12 weeks of Shinbaro administration were compared.

RESULTS

The monthly migraine frequency was significantly reduced from 20.5 days at baseline to 16.4 days at week 12 (P =0.003), and 22% of the participants showed ≥ 50% reduction. The frequency reduction was observed by week 4 (P =0.035) and continuously occurred through week 8 (P =0.001) and week 12 (P =0.003). The rescue medications frequency also decreased significantly from 17.4 days at baseline to 13.2 days at week 12 (P =0.035). Lastly, the serum CGRP concentration dropped from 434.6 pg/mL at baseline to 371.4 pg/mL at week 12, which was statistically significant (P <0.001).

CONCLUSIONS

Shinbaro demonstrated prophylactic effects in migraine patients, significantly reducing their mean migraine frequency, rescue medications frequency, and the serum CGRP concentration after 12 weeks of treatment. This study is registered in Clinical Research Information Service, Seoul National University Hospital Clinical Research Institute (IRB No. 1604-138-758).

New Trends in Migraine Pharmacology: Targeting Calcitonin Gene-Related Peptide (CGRP) With Monoclonal Antibodies

Migraine is a common neurologic disorder characterized by attacks consisting of unilateral, throbbing headache accompanied by photophobia, phonophobia, and nausea which remarkably reduces the patients' quality of life. Not migraine-specific non-steroidal anti-inflammatory drugs (NSAIDs) are effective in patients affected by mild episodic migraine whilst in moderate or severe episodic migraine and in chronic migraineurs triptans and preventative therapies are needed. Since these treatments are endowed with serious side effects and have limited effectiveness new pharmacological approaches have been investigated. The demonstrated pivotal role of calcitonin gene-related peptide (CGRP) has fostered the development of CGRP antagonists, unfortunately endowed with liver toxicity, and monoclonal antibodies (mAbs) toward circulating CGRP released during migraine attack or targeting its receptor. Currently, four mAbs, eptinezumab, fremanezumab, galcanezumab for CGRP and erenumab for CGRP canonical receptor, have been studied in clinical trials for episodic and chronic migraine. Apart from the proven effectiveness, these antibodies have resulted well tolerated and could improve the compliance of the patients due to their long half-lives allowing less frequent administrations. This study aims at investigating the still poorly clear pathogenesis of migraine and the potential role of anti-CGRP mAbs in the scenario of prophylaxis of migraine.

Long-term treatment patterns of prophylactic and acute migraine medications and incidence of opioid-related adverse events in patients with migraine

Objectives

To describe long-term treatment patterns in migraine patients initiating prophylactic therapy and to evaluate acute medication use and adverse events associated with opioids.

Methods

This study used the 2005–2014 IBM MarketScan® databases to evaluate migraine patients initiating prophylactic medication. Outcome measures included persistence with prophylactic migraine medications over 2–5 years. Acute medication use and gastrointestinal-related adverse events and opioid abuse following opioid use were evaluated. Cox proportional hazards models were used to evaluate predictors of non-persistence and predictors of gastrointestinal-related AEs and opioid abuse associated with long-term opioid use.

Results

In total, 147,832 patients were analyzed. Non-persistence was observed in 90% of patients; 39% switched, 30% restarted, and 31% discontinued treatment. Over the follow-up, 59.9% of patients received triptans, 66.6% non-steroidal anti-inflammatory drugs, 77.4% opioids, and 2.6% ergotamines. Among opioid users, 16.6% experienced nausea/vomiting, 12.2% had constipation, and 10.4% had diarrhea. Opioid abuse was reported in <1% of opioid users. Gastrointestinal-related adverse events increased with increasing number of days’ supply of opioids.

Conclusions

Non-persistence to prophylactic treatment was frequent among migraine patients. Opioid use was common in migraine patients and the risk of gastrointestinal-related adverse events and opioid abuse increased with long-term use of opioids. These results suggest a need for more effective prophylactic migraine treatments.

Analysis of Initial Nonresponders to Galcanezumab in Patients With Episodic or Chronic Migraine: Results From the EVOLVE-1, EVOLVE-2, and REGAIN Randomized, Double-Blind, Placebo-Controlled Studies

OBJECTIVE

To examine the likelihood of response with continued galcanezumab treatment in patients with episodic or chronic migraine without initial clinical improvement.

BACKGROUND

A percentage of patients with migraine may require additional time on pharmacotherapy but discontinue treatment prematurely. Additionally, recognizing when continued treatment is unlikely to provide improvement limits unnecessary exposure.

METHODS

Post hoc analysis of response after continued galcanezumab treatment was conducted in a subset of patients with episodic (N = 879) and chronic (N = 555) migraine who did not achieve "good" early improvement (episodic, ≥50% reduction in baseline migraine headache days [MHD] and chronic, ≥30% reduction) after 1 month of dosing (NR-1; episodic, n = 450 and chronic, n = 306). This subset was categorized by level of reduction in MHD during 1 month of treatment: "modest" (>30% to <50% fewer MHD for episodic and >10% to <30% fewer MHD for chronic), "limited" (episodic only; >10% to ≤30% fewer MHD), or "minimal/no" early improvement (≤10% fewer MHD to ≤10% more MHD), or "worsening" (>10% more MHD). The percentages of patients having "better" (≥75% fewer MHD for episodic and ≥50% for chronic), "good," or "little-to-no" (≤10% fewer MHD) response during the remaining treatment period were calculated for each category. Similarly, the subset of NR-1 patients who did not achieve "good" early improvement after 2 months of treatment (NR-2; episodic, n = 290 and chronic, n = 240) were categorized by level of their average monthly reduction across 1 and 2 months using similar categories.

RESULTS

Of NR-1 patients with episodic migraine having "modest" early improvement, 62% (96/155) achieved "good" and 20% (31/155) achieved "better" responses with continued treatment. A percentage of patients with "limited" (43%; 46/108) or "minimal/no" (34%; 29/85) early improvement, or "worsening" (20%; 20/102) achieved a "good" response after continued treatment. A percentage of NR-1 patients with chronic migraine having "modest" early improvement achieved "good" (38%; 44/116) and "better" (13%; 15/116) responses with continued treatment. A "good" response was achieved for a percentage of patients with "minimal/no" early improvement (17%; 23/133). Similar patterns were observed for the NR-2 subset, though percentages were lower.

CONCLUSIONS

Galcanezumab-treated patients with episodic or chronic migraine without response following 1 or 2 months of treatment appear to have a reasonable likelihood of continued improvement in months following initial treatment and this opportunity is more likely in patients showing greater early improvements. While a small percentage of patients with episodic or chronic migraine who experienced worsening in the number of MHD following initial treatment responded with continued treatment, most do not show substantial reduction in MHD. Overall benefit of therapy should be determined collaboratively between the patient and physician.

100% Response Rate to Galcanezumab in Patients With Episodic Migraine: A Post Hoc Analysis of the Results From Phase 3, Randomized, Double-Blind, Placebo-Controlled EVOLVE-1 and EVOLVE-2 Studies

Objective

To characterize adult patients with episodic migraine who achieved 100% response to galcanezumab treatment.

Background

Galcanezumab is a humanized monoclonal antibody that selectively binds to the calcitonin gene‐related peptide (CGRP) and has demonstrated efficacy in reducing migraine headache days (MHD) in patients with episodic and chronic migraine.

Methods

A post hoc analysis of the proportion of patients with 100% response (100% reduction from baseline in monthly MHD) was calculated for each month from pooled data of 2 double‐blind, 6‐month galcanezumab studies in patients with episodic migraine (4 to 14 MHD and ≥2 migraine attacks per month at baseline). The patients were randomized (1:1:2) to monthly subcutaneous galcanezumab, 120 mg (after 240 mg initial loading dose) or 240 mg, or placebo. A generalized linear mixed model with effects for baseline MHD, treatment, month, and treatment‐by‐month interaction was used to estimate the mean monthly response rate.

Results

The analysis included 1739 patients treated with galcanezumab, 120 mg (n = 436) or 240 mg (n = 428), or placebo (n = 875). The mean monthly 100% response rate on an average month in the 6‐month double‐blind phase was greater for galcanezumab 120 mg (13.5%) and 240 mg (14.3%) groups vs placebo (5.9%) with odds ratios of 2.5 (95% confidence interval [CI] 1.9, 3.2) and 2.6 (95% CI 2.0, 3.4), respectively (P < .001). The rate of 100% monthly response increased at each month over the 6‐month double‐blind phase with higher rates for galcanezumab dose groups (9 to 21%) than placebo (2 to 10%) (P < .02). Evaluation of 100% response by the number of months showed a greater proportion of galcanezumab‐treated patients in either dose group, compared to placebo, were able to achieve a 100% response (P < .001 up to 3 months); however, though greater than placebo, few galcanezumab patients had ≥4 months of 100% response (P < .02). The proportions of patients with 100% response were greatest in the last 3 months of the treatment. Considering the average number days between nonconsecutive MHD across the 6‐month period (not just during the times of 100% response), the duration of migraine headache‐free periods in the galcanezumab groups was 29 days for those with at least 1 month of 100% response and 55 days for those with at least 3 months of 100% response. This gap was approximately 6 to 11 times greater than the mean gap of 5 days observed at baseline.

Conclusions

More than a third of the patients with episodic migraine treated with galcanezumab 120 mg or 240 mg achieved 100% response for at least 1 month. More patients had 100% monthly response in the last 3 months of the 6‐month double‐blind period. For those with 100% response for at least 1 month, the average time between nonconsecutive MHD for the entire treatment period was nearly 1 month and approached 2 months for patients with 3 or more months of 100% response.

Early onset of efficacy with erenumab in patients with episodic and chronic migraine

Background

Subcutaneous erenumab reduced monthly migraine days and increased the likelihood of achieving a ≥ 50% reduction at all monthly assessment points tested in 2 pivotal trials in episodic migraine (EM) and chronic migraine (CM). Early efficacy of migraine preventive medications is an important treatment characteristic to patients. Delays in achievement of efficacy can result in failed adherence. The objective of these post-hoc analyses were to evaluate efficacy in the first 4 weeks after initial subcutaneous administration of erenumab 70 mg, erenumab 140 mg, or placebo.

Methods

There is no generally accepted methodology to measure onset of action for migraine preventive medications. We used a comprehensive approach with data from both studies to evaluate change from baseline in weekly migraine days (WMD), achievement of ≥ 50% reduction in WMD, and proportion of patients experiencing migraine measured on a daily basis. The 7-day moving averages were overlaid with observed data.

Results

In both studies (EM: N = 955; CM: N = 667), there was evidence of onset of efficacy of erenumab vs. placebo during the first week of treatment, which in some cases reached nominal significance. For EM the changes in WMD were (least squares mean [LSM] [95% CI]): placebo, − 0.1 (− 0.3, 0.0); erenumab 70 mg, − 0.3 (− 0.5, − 0.2) p = 0.130; erenumab 140 mg, − 0.6 (− 0.7, − 0.4) p < 0.001. For CM the changes were: placebo, − 0.5 (− 0.8, − 0.3); erenumab 70 mg, − 0.9 (− 1.2, − 0.7) p = 0.047; erenumab 140 mg, − 0.8 (− 1.1, − 0.5) p = 0.18. Achievement of ≥ 50% reduction in WMD was observed as early as Week 1 (adjusted OR [95% CI] erenumab vs placebo) in EM: erenumab 70 mg, 1.3 (1.0, 1.9) p = 0.097; erenumab 140 mg, 2.0 (1.4, 2.7) p < 0.001. A similar outcome was observed for CM: erenumab 70 mg, 1.8 (1.1, 2.8) p = 0.011; erenumab 140 mg, 1.9 (1.2, 2.9) p = 0.009. Seven-day moving averages of observed data showed each treatment arm differed from placebo by Week 1 (OR [95% CI]): in EM Day 3 for erenumab 140 mg, 0.7 (0.5, 1.0) p = 0.031 and at Day 7 for 70 mg, 0.6 (0.4, 0.8) p = 0.002; in CM: Day 6 for erenumab 70 mg, 0.6 (0.4, 0.9) p = 0.022 and at Day 7 for 140 mg, 0.7 (0.4, 1.0); p = 0.038.

Conclusion

Erenumab showed early onset of efficacy with separation from placebo within the first week of treatment in both chronic and episodic migraine patients.

Comorbidity of Migraine and Epilepsy in Pediatrics: A Review

Migraine and epilepsy are classified as chronic paroxysmal neurologic disorders sharing many clinical features, as well as possible treatment options. This review highlights the similarities between migraine and epilepsy in pediatrics, focusing on epidemiologic, pathophysiological, genetic, clinical, and pharmacologic aspects. Despite the fact that several syndromes share symptoms of both migraine and epilepsy, further research is needed to clarify the pathophysiological and genetic basis of their comorbidity. Drugs used for prophylactic therapy of migraine and epilepsy have similar pharmacologic properties. The role of epileptic pharmacotherapy in the prophylaxis of migraine is assessed, including the use of conventional antiepileptic drugs, calcium channel blockers, and nonpharmacologic methods such as dietary therapy, supplements, and vagal nerve stimulation. Further randomized, controlled clinical trials assessing pharmacologic and nonpharmacologic methods for the treatment of both disorders are essential, in order to initiate new therapeutic approaches.

Sustained onabotulinumtoxinA therapeutic benefits in patients with chronic migraine over 3 years of treatment

Background

Evidence on whether the therapeutic effect and good safety profile of onabotulinumtoxinA (Botox®) in chronic migraine (CM) patients is maintained over long term treatment is still limited. We herein aimed at assessing whether there is a sustained benefit and good safety with repeated onabotulinumtoxinA sessions in CM over more than three years of treatment.

Methods

We prospectively enrolled 65 CM patients, who were classified as responders after three sessions of onabotulinumtoxinA and were eligible to further continue treatment. Data documenting longitudinal changes from the trimester after the third onabotulinumtoxinA administration (T1) to the trimester after completing two years of treatment (T2) and eventually to the trimester after completing three years of treatment (T3) in (i) mean number of monthly headache days (ii) migraine severity as expressed by the mean number of days with peak headache intensity of > 4/10, and (iii) mean number of days with use of any acute headache medication, were prospectively collected from patients’ headache diaries.

Results

A total of 56 (86.1%) of 65 patients achieved to attain onabotulinumtoxinA over three years. At T3, a significant reduction in mean monthly headache days was evident, compared to T1 (3.4 ± 1.7 vs 7.2 ± 3.8; P < 0.001) with diminished mean number of monthly days with peak headache intensity of more than 4/10 and a significant change in days using acute headache medications per month between T1 and T3 (2.8 ± 1.3 vs 4.7 ± 3.2; P < 0.001). Significant changes were also noticed in all efficacy variables from T2 to T3. Therapy was safe and well tolerated with low rates of adverse events or drop-outs.

Conclusion

The long -term treatment with onabotulinumtoxinA proved effective, safe and well tolerated over three years. Our findings support the strategy to consistently deliver sessions of use of onabotulinumtoxinΑ over long time in CM patients (Trial registration NTC03606356, registered retrospectively, 28 July 2018).

Headache and Its Management in Patients With Multiple Sclerosis

PURPOSE OF REVIEW

The purpose of this review was to discuss the prevalence, impact, pathophysiology, and treatment of headaches (H/As) in patients with multiple sclerosis (MS).

RECENT FINDINGS

Headaches and multiple sclerosis are more common in women than in men with the ratio of female to male being 3:1. It is not entirely clear if there is a correlation or an incidental comorbidity of two neurological conditions. A review of the literature shows a variable prevalence of H/As in MS patients. Using the International Classification of Headache Disorders (ICHD) criteria, the primary type of H/As, especially migraine, is the most common type seen in patients with MS. One of the theories of the pathophysiologic mechanisms of migraine in MS patients is inflammation leading to demyelinating lesions in the pain-producing centers in the midbrain. Secondary H/As due to MS medications such as interferons are also frequently present. H/As can be a cause for significant comorbidity in patients with MS. The treatment of H/As in patients with MS should be addressed in the same fashion as in the non-MS population, which is a combination of pharmacological and non-pharmacological methods. Preventive medicines for the H/As should be carefully selected because of their side effect profiles. Acute attacks of migraines can be treated with medications such as triptans. Patients with MS who have migraine H/As should be educated about the phenomenon of overuse H/As, keeping headache journals, avoiding stress, and monitoring sleeping habits. The presence of depression in patients with MS and migraine affects quality of life (QOL) and should also be addressed for better outcomes.