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Robblee J, Orlova YY, Ahn AH, Ali AS, Birlea M, Charleston L, Singh NN, Souza MNP. Real-world approaches to outpatient treatment of status migrainosus: A survey study. Headache 2024. [PMID: 38957119 DOI: 10.1111/head.14769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/16/2024] [Accepted: 04/21/2024] [Indexed: 07/04/2024]
Abstract
OBJECTIVES Identify how the American Headache Society (AHS) membership manages status migrainosus (SM) among outpatients. BACKGROUND SM is defined as a debilitating migraine attack lasting more than 72 h. There is no standard of care for SM, including whether a 72-h duration is required before the attack can be treated as SM. METHODS The Refractory Headache Special Interest Group from AHS developed a four-question survey distributed to AHS members enquiring (1) whether they treat severe refractory migraine attacks the same as SM regardless of duration, (2) what their first step in SM management is, (3) what the top three medications they use for SM are, and (4) whether they are United Council for Neurologic Subspecialties (UCNS) certified. The survey was conducted in January 2022. Descriptive statistical analyses were performed. RESULTS Responses were received from 196 of 1859 (10.5%) AHS members; 64.3% were UCNS certified in headache management. Respondents treated 69.4% (136/196) of patients with a severe refractory migraine attack as SM before the 72-h period had elapsed. Most (76.0%, 149/196) chose "treat remotely using outpatient medications at home" as the first step, 11.2% (22/196) preferred procedures, 6.1% (12/196) favored an infusion center, 6.1% (12/196) sent patients to the emergency department (ED) or urgent care, and 0.5% (1/196) preferred direct hospital admission. The top five preferred medications were as follows: (1) corticosteroids (71.4%, 140/196), (2) nonsteroidal anti-inflammatory drugs (NSAIDs) (50.1%, 99/196), (3) neuroleptics (46.9%, 92/196), (4) triptans (30.6%, 60/196), and (5) dihydroergotamine (DHE) (21.4%, 42/196). CONCLUSIONS Healthcare professionals with expertise in headache medicine typically treated severe migraine attacks early and did not wait 72 h to fulfill the diagnostic criteria for SM. Outpatient management with one or more medications for home use was preferred by most respondents; few opted for ED referrals. Finally, corticosteroids, NSAIDs, neuroleptics, triptans, and DHE were the top five preferred treatments for home SM management.
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Affiliation(s)
- Jennifer Robblee
- Department of Neurology, Lewis Headache Center, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Yulia Y Orlova
- Department of Neurology, University of Florida, Gainesville, Florida, USA
| | - Andrew H Ahn
- Global Specialty R&D, Neuroscience at Teva Pharmaceuticals, West Chester, Pennsylvania, USA
| | - Ashhar S Ali
- Department of Neurology, Henry Ford Health System, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Marius Birlea
- Department of Neurology, University of Colorado Denver SOM, Aurora, Colorado, USA
| | - Larry Charleston
- Department of Neurology and Ophthalmology, Michigan State University College of Human Medicine, East Lansing, Michigan, USA
| | - Niranjan N Singh
- Department of Neurology, University of Missouri, St. Louis, Missouri, USA
| | - Marcio Nattan P Souza
- Department of Neurology, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
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Zilberg G, Parpounas AK, Warren AL, Fiorillo B, Provasi D, Filizola M, Wacker D. Structural insights into the unexpected agonism of tetracyclic antidepressants at serotonin receptors 5-HT 1eR and 5-HT 1FR. SCIENCE ADVANCES 2024; 10:eadk4855. [PMID: 38630816 PMCID: PMC11023502 DOI: 10.1126/sciadv.adk4855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 03/15/2024] [Indexed: 04/19/2024]
Abstract
Serotonin [5-hydroxytryptamine (5-HT)] acts via 13 different receptors in humans. Of these receptor subtypes, all but 5-HT1eR have confirmed roles in native tissue and are validated drug targets. Despite 5-HT1eR's therapeutic potential and plausible druggability, the mechanisms of its activation remain elusive. To illuminate 5-HT1eR's pharmacology in relation to the highly homologous 5-HT1FR, we screened a library of aminergic receptor ligands at both receptors and observe 5-HT1eR/5-HT1FR agonism by multicyclic drugs described as pan-antagonists at 5-HT receptors. Potent agonism by tetracyclic antidepressants mianserin, setiptiline, and mirtazapine suggests a mechanism for their clinically observed antimigraine properties. Using cryo-EM and mutagenesis studies, we uncover and characterize unique agonist-like binding poses of mianserin and setiptiline at 5-HT1eR distinct from similar drug scaffolds in inactive-state 5-HTR structures. Together with computational studies, our data suggest that these binding poses alongside receptor-specific allosteric coupling in 5-HT1eR and 5-HT1FR contribute to the agonist activity of these antidepressants.
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Affiliation(s)
- Gregory Zilberg
- Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Alexandra K. Parpounas
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Audrey L. Warren
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Bianca Fiorillo
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Davide Provasi
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Marta Filizola
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Daniel Wacker
- Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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3
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Zilberg G, Parpounas AK, Warren AL, Fiorillo B, Provasi D, Filizola M, Wacker D. Structural Insights into the Unexpected Agonism of Tetracyclic Antidepressants at Serotonin Receptors 5-HT1eR and 5-HT1FR. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.10.05.561100. [PMID: 37986777 PMCID: PMC10659432 DOI: 10.1101/2023.10.05.561100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
Serotonin (5-hydroxytryptamine, 5-HT) acts via 13 different receptors in humans. Of these receptor subtypes, all but 5-HT1eR have confirmed roles in native tissue and are validated drug targets. Despite 5-HT1eR's therapeutic potential and plausible druggability, the mechanisms of its activation remain elusive. To illuminate 5-HT1eR's pharmacology in relation to the highly homologous 5-HT1FR, we screened a library of aminergic receptor ligands at both receptors and observe 5-HT1e/1FR agonism by multicyclic drugs described as pan-antagonists at 5-HT receptors. Potent agonism by tetracyclic antidepressants mianserin, setiptiline, and mirtazapine suggests a mechanism for their clinically observed anti-migraine properties. Using cryoEM and mutagenesis studies, we uncover and characterize unique agonist-like binding poses of mianserin and setiptiline at 5-HT1eR distinct from similar drug scaffolds in inactive-state 5-HTR structures. Together with computational studies, our data suggest that these binding poses alongside receptor-specific allosteric coupling in 5-HT1eR and 5-HT1FR contribute to the agonist activity of these antidepressants.
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Affiliation(s)
- Gregory Zilberg
- Department of Neuroscience, Icahn School of Medicine at Mount Sinai; New York, New York 10029
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai; New York, New York 10029
| | - Alexandra K. Parpounas
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai; New York, New York 10029
| | - Audrey L. Warren
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai; New York, New York 10029
| | - Bianca Fiorillo
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai; New York, New York 10029
| | - Davide Provasi
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai; New York, New York 10029
| | - Marta Filizola
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai; New York, New York 10029
| | - Daniel Wacker
- Department of Neuroscience, Icahn School of Medicine at Mount Sinai; New York, New York 10029
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai; New York, New York 10029
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai; New York, New York 10029
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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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Chauhan A, Singh J, Sangwan N, Singh H, Prakash A, Medhi B, Avti PK. Designing the 5HT 2BR structure and its modulation as a therapeutic target for repurposing approach in drug-resistant epilepsy. Epilepsy Res 2023; 194:107168. [PMID: 37302343 DOI: 10.1016/j.eplepsyres.2023.107168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/24/2023] [Accepted: 05/22/2023] [Indexed: 06/13/2023]
Abstract
The study intends to repurpose FDA drugs and investigate the mechanism of (5HT2BR) activation by comprehending inter-residue interactions. The 5HT2BR is a novel thread, and its role in reducing seizures in Dravet syndrome is emerging. The crystal structure (5HT2BR) is a chimera with mutations; hence 3D-structure is modeled (4IB4: 5HT2BRM). The structure is cross-validated to simulate the human receptor using enrichment analysis (ROC: 0.79) and SAVESv6.0. Virtual screening of 2456 approved drugs yielded the best hits that are subjected to MM/GBSA and molecular dynamic (MD) simulations. The 2 top drugs Cabergoline (-53.44 kcal/mol) and Methylergonovine (-40.42 kcal/mol), display strong binding affinity, and ADMET/SAR analysis also suggests their non-mutagenic or non-carcinogenic nature. Methylergonovine has a weaker binding affinity and lower potency than standards [Ergotamine (agonist) and Methysergide (antagonist)] due to its higher Ki (1.32 M) and Kd (6.44 ×10-8 M) values. Compared to standards, Cabergoline has moderate binding affinity and potency [Ki = 0.85 M and Kd = 5.53 × 10-8 M]. The top 2 drugs primarily interact with conserved residues (ASP135, LEU209, GLY221, ALA225, and THR140) as in agonists, unlike the antagonist. The top 2 drugs, upon binding to the 5HT2BRM, modify the helices VI, V, and III and shift the RMSD 2.48 Å and 3.07 Å. LEU209 forms a latch with residues 207-214 (forms a lid) in the 5HT2BRM receptor, which enhances agonist binding and prevents drug escape. Methylergonovine and Cabergoline interact more stongly with ALA225 than the antagonist. The post-MD analysis of Cabergoline suggests a better MM/GBSA value (-89.21 kcal/mol) than Methylergonovine (-63.54 kcal/mol). In this study, Cabergoline and Methylergonovine's agonistic mechanism and solid binding properties suggest their strong role in regulating the 5HT2BR and might target drug-resistant epilepsy.
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Affiliation(s)
| | | | | | | | - Ajay Prakash
- Department of Pharmacology, PGIMER, Chandigarh, India
| | - Bikash Medhi
- Department of Pharmacology, PGIMER, Chandigarh, India
| | - Pramod K Avti
- Department of Biophysics, PGIMER, Chandigarh, India.
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Navas-Sánchez FJ, Fernández-Pena A, Martín de Blas D, Alemán-Gómez Y, Marcos-Vidal L, Guzmán-de-Villoria JA, Fernández-García P, Romero J, Catalina I, Lillo L, Muñoz-Blanco JL, Ordoñez-Ugalde A, Quintáns B, Pardo J, Sobrido MJ, Carmona S, Grandas F, Desco M. Thalamic atrophy in patients with pure hereditary spastic paraplegia type 4. J Neurol 2021; 268:2429-2440. [PMID: 33507371 DOI: 10.1007/s00415-020-10387-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 12/22/2020] [Accepted: 12/23/2020] [Indexed: 01/18/2023]
Abstract
SPG4 is an autosomal dominant pure form of hereditary spastic paraplegia (HSP) caused by mutations in the SPAST gene. HSP is considered an upper motor neuron disorder characterized by progressive spasticity and weakness of the lower limbs caused by degeneration of the corticospinal tract. In other neurodegenerative motor disorders, the thalamus and basal ganglia are affected, with a considerable impact on disease progression. However, only a few works have studied these brain structures in HSP, mainly in complex forms of this disease. Our research aims to detect potential alterations in the volume and shape of the thalamus and various basal ganglia structures by comparing 12 patients with pure HSP and 18 healthy controls. We used two neuroimaging procedures: automated segmentation of the subcortical structures (thalamus, hippocampus, caudate nucleus, globus pallidus, and putamen) in native space and shape analysis of the structures. We found a significant reduction in thalamic volume bilaterally, as well as an inward deformation, mainly in the sensory-motor thalamic regions in patients with pure HSP and a mutation in SPG4. We also observed a significant negative correlation between the shape of the thalamus and clinical scores (the Spastic Paraplegia Rating Scale score and disease duration). Moreover, we found a 'Group × Age' interaction that was closely related to the severity of the disease. No differences in volume or in shape were found in the remaining subcortical structures studied. Our results suggest that changes in structure of the thalamus could be an imaging biomarker of disease progression in pHSP.
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Affiliation(s)
- Francisco J Navas-Sánchez
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain. .,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain.
| | | | | | - Yasser Alemán-Gómez
- Department of Psychiatry, Centre Hospitalier Universitaire Vaudois, Prilly, Switzerland.,Department of Radiology, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland.,Medical Image Analysis Laboratory (MIAL), Centre D'Imagerie BioMédicale (CIBM), Lausanne, Switzerland
| | - Luís Marcos-Vidal
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain.,Medical Image Analysis Laboratory (MIAL), Centre D'Imagerie BioMédicale (CIBM), Lausanne, Switzerland
| | - Juan A Guzmán-de-Villoria
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain.,Servicio de Radiodiagnóstico, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Julia Romero
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Servicio de Radiodiagnóstico, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Irene Catalina
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Laura Lillo
- Hospital Ruber Internacional, Servicio de Neurología, Madrid, Spain.,Hospital Universitario Fundación Alcorcón, Servicio de Neurología Alcorcón, Madrid, Spain
| | - José L Muñoz-Blanco
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Andrés Ordoñez-Ugalde
- Laboratorio Biomolecular, Cuenca, Ecuador.,Unidad de Genética y Molecular, Hospital de Especialidades José Carrasco Arteaga, Cuenca, Ecuador.,Neurogenetics Group, FPGMX-IDIS, Santiago de Compostela, Spain
| | - Beatriz Quintáns
- Instituto de Investigación Sanitaria, Santiago de Compostela, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER-U711), Madrid, Spain.,Fundación Pública Galega de Medicina Xenómica, Santiago de Compostela, Spain
| | - Julio Pardo
- Departamento de Neurología, Hospital Clínico Universitario de Santiago de Compostela, A Coruña, Santiago de Compostela, Spain
| | - María-Jesús Sobrido
- Instituto de Investigación Sanitaria, Santiago de Compostela, Spain.,Hospital Clínico Universitario de A Coruña, SERGAS, Santiago de Compostela, Spain
| | - Susanna Carmona
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
| | - Francisco Grandas
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Manuel Desco
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain.,Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Madrid, Spain.,Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
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Abstract
PURPOSE OF REVIEW This article reviews treatment options for patients presenting with headache in the emergency department (ED) and for inpatients, including red flags and status migrainosus (SM). RECENT FINDINGS Most patients presenting with headache in the ED will have migraine, but red flags must be reviewed to rule out secondary headaches. SM refractory to home treatment is a common reason for ED presentation or inpatient admission, but high-quality treatment evidence is lacking. Common treatments include intravenous fluids, anti-dopaminergic agents with diphenhydramine, steroids, divalproex, nonsteroidal anti-inflammatory drugs, intravenous dihydroergotamine, and nerve blocks. Other therapies (e.g., ketamine and lidocaine) are used with limited or inconsistent evidence. There is evidence for inpatient behavioral management therapy. This article details red flags to review in the workup of headache presentation in the ED and provides a step-wise approach to ED and inpatient management. However, more studies are needed to better optimize care.
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Affiliation(s)
- Jennifer Robblee
- Jan and Tom Lewis Migraine Treatment Program, Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA.
| | - Kate W Grimsrud
- Cerebrovascular and Hospital Neurology, Penrose Neuroscience, Colorado Springs, CO, USA
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