Migraine Treatment: Towards New Pharmacological Targets

The relevance of cortical thickness in migraine sufferers and implications to therapy

INTRODUCTION

Advanced neuroimaging studies have strongly contributed to clarify the gaps in the knowledge about migraine pathophysiology. Cortical thickness has garnered significant interest reflecting physiological processes such as gray matter neurogenesis and synaptic pruning, as well as pathophysiological mechanisms like neurodegeneration or plasticity changes associated with aging and disease. Evidence on cortical thickness highlights significant variability, likely due to migraine clinical complexity but also to methodological issues. Nevertheless, changes in the cortical thickness of areas involved in pain perception and modulation, as well as in cognitive and emotional attributes of pain experiences, have been consistently demonstrated reinforcing the concept of a dysfunctional neuro-limbic pain network in migraine.

AREAS COVERED

This review summarizes the available findings from advanced structural neuroimaging investigations, highlighting the most relevant findings and how they have contributed to the advancement in our understanding of migraine pathophysiology. This review is based on a literature search using PubMed along with the keyword 'migraine' combined with 'cortical thickness.'

EXPERT OPINION

Presently, it is challenging to ascertain whether the structural changes in migraine represent a primary phenomenon or the result of pain experience. Nevertheless, longitudinal neuroimaging studies have highlighted a role for treatments that, even if short-term, modulate cortical thickness, while also promoting the idea of structural changes as biomarkers.

Medical comorbidities in adults newly diagnosed with multiple sclerosis and clinically isolated syndrome: An observational study exploring prevalence, risk factors, and outcomes

BACKGROUND

Comorbidity is common in people with MS (PwMS) and clinically isolated syndrome (CIS), but research exploring factors associated with comorbidity and impacts on health outcomes in newly diagnosed PwMS and CIS is limited. This study aimed to (1) report the prevalence of medical comorbidities in newly diagnosed PwMS and CIS, (2) explore the relationship between comorbidity and demographic factors, (3) examine the relationship between comorbidities and outcomes one year following diagnosis, accounting for baseline outcomes to assess change over time, and (4) explore if these relationships differ with comorbidity treatment.

METHODS

Secondary analysis of data collected from a longitudinal, observational study of adults newly diagnosed with MS or CIS 1 month and 12 months after diagnosis (N = 230). Statistical methods included point biserial, Chi-squared, ANCOVA, and multivariate linear regression.

RESULTS

The most common comorbidities within the first year following diagnosis were mental health (32.9 %), vascular (32 %), neurological (22.5 %), and musculoskeletal (9.1 %). Age and race were associated with hypertension and heart trouble, respectively. After one year, mental health comorbidity was associated with higher fatigue scores, musculoskeletal and neurological comorbidity with higher pain interference, and neurological comorbidity with less exercise, after accounting baseline for fatigue, pain interference and exercise. Those with treated neurological conditions had worse pain interference compared to those with untreated conditions.

CONCLUSIONS

Mental health, neurological, and musculoskeletal comorbidities were common within the first year following diagnosis, and were associated with worse fatigue and pain, and decreased exercise. Future research should explore how early treatment of comorbidities may impact outcomes and disease progression.

Exploring the therapeutic potential of TRPC channels in chronic pain: An investigation into their mechanisms, functions, and prospects

Transient Receptor Potential Canonical (TRPC) channels have received more attention in recent years for their role of in the pathophysiology of chronic pain. These non-selective cation channels, which are predominantly present on cell membranes, play a pivotal role in regulating both physiological and pathological processes. Research advances have shown the critical role of TRPC channels in a variety of chronic pain, including neuropathic, inflammatory, and visceral pain. Activation of TRPC channels increases neuronal excitability, amplifying and prolonging pain signals. Moreover, these channels collaborate with other ion channels and receptors to form complexes that augment the transmission and perception of pain. As research advances, our understanding of TRPC channels' regulation mechanisms and signaling pathways improves. An expanding variety of TRPC modulators has been identified as promising therapeutic agents for chronic pain, opening up novel treatment options. Nevertheless, the diversity and complexity of TRPC channels present challenges in drug development, highlighting the importance of full understanding of their unique properties and activities. This review aims to provide a thorough evaluation of recent breakthrough in TRPC channels research related to chronic pain, with a focus on their mechanisms, functions, and prospective therapeutic application. By integrating existing research findings, we seek to bring new viewpoints and approaches for chronic pain management.

Middle meningeal artery embolization in migraine: From concept to reality

Migraine is a common neurological disorder that primarily affects young adults. Despite the availability of multiple therapeutic options for patients with intractable migraine, a significant proportion of these patients remain refractory to treatment, highlighting the importance for novel therapies. In this study, we comprehensively assessed the role of the middle meningeal artery (MMA) in the management of intractable migraine. Although the exact pathophysiology of migraine remains a subject of debate, the neurovascular theory of migraine has gained attention recently following multiple studies assessing the role of the MMA in migraine pathophysiology. In addition, the successful utilization of lidocaine both through intravenous injection and directly into the MMA, as well as favorable results observed in the form of headache relief following MMA embolization (MMAE) in patients with chronic subdural hematoma, has further substantiated the neurovascular theory hypothesis. In this study, we evaluated the current evidence, potential trends, role of other injection medications, as well as risks and limitations of MMAE in the management of patients with refractory migraine. Intractable migraine is a complex condition that often requires multimodal management. MMAE has emerged as a promising, novel therapeutic technique that may help reduce pain and minimize the need for additional treatments. However, further prospective and randomized trials are still necessary for further validation.

Adrenomedullin-mediated depressor response with visceral afferent-specific membrane depolarization in isolated nodose ganglion neurons from adult female rat

Adrenomedullin (ADM) is an endogenous and vasoactive neuropeptide that possesses potent central/peripheral regulations on blood pressure (BP) and sex-related vasodilation under physiological conditions. However, the role of ADM on baroreflex afferent function is largely unknown. Here, BP was monitored in adult female rats while ADM was microinjected into the nodose ganglion (NG); Fluorescent intensity against ADM was analyzed in the tissue level and membrane responses elicited by ADM were tested in identified NG neurons isolated from adult female rats with gap-free protocol under current-clamp mode with or without ADM antagonist. The results showed that BP was reduced by ADM (30-300 nM) concentration-dependently; myelinated (HCN1-positive) neurons showed significantly higher fluorescent intensity against ADM antibody vs. unmyelinated (HCN1-negative) neurons. Interestingly, patch-clamp data indicated that membrane potential was not changed in 50 % (6/12) of identified A-types, only 4/12 was hyperpolarized by 30 nM ADM, while 100 nM ADM induced brief hyperpolarization followed by depolarization in 2/12 of recordings; Robustly, ADM depolarized 100 % tested myelinated Ah-type neurons with dramatic and concentration-dependent repetitive discharges; While, a majority (8/9) of unmyelinated C-types were depolarized and few with repetitive dischargers. By application of ADM (22-52), the depolarization elicited by ADM 100 nM was partially or completely abolished in Ah-types or C-types, respectively. These datasets demonstrated for the first time that baroreflex afferents especially female-distributed subpopulation of Ah-types would be a key player in ADM-mediated depressor response unveiling the dominate role of peripheral ADM in neurocontrol of hypotension via baroreflex afferent function and gender-dependent vasodilation promoted by female sex steroid.

Hallmarks of primary headache: part 1 - migraine

BACKGROUND AND AIM

Migraine is a common disabling conditions which, globally, affects 15.2% of the population. It is the second cause of health loss in terms of years lived with disability, the first among women. Despite being so common, it is poorly recognised and too often undertreated. Specialty centres and neurologists with specific expertise on headache disorders have the knowledge to provide specific care: however, those who do not regularly treat patients with migraine will benefit from a synopsis on the most relevant and updated information about this condition. This paper presents a comprehensive view on the hallmarks of migraine, from genetics and diagnostic markers, up to treatments and societal impact, and reports the elements that identify migraine specific features.

MAIN RESULTS

The most relevant hallmark of migraine is that it has common and individual features together. Besides the known clinical manifestations, migraine presentation is heterogeneous with regard to frequency of attacks, presence of aura, response to therapy, associated comorbidities or other symptoms, which likely reflect migraine heterogeneous genetic and molecular basis. The amount of therapies for acute and for prophylactic treatment is really wide, and one of the difficulties is with finding the best treatment for the single patient. In addition to this, patients carry out different daily life activities, and might show lifestyle habits which are not entirely adequate to manage migraine day by day. Education will be more and more important as a strategy of brain health promotion, because this will enable reducing the amount of subjects needing specialty care, thus leaving it to those who require it in reason of refractory condition or presence of comorbidities.

CONCLUSIONS

Recognizing the hallmarks of migraine and the features of single patients enables prescribing specific pharmacological and non-pharmacological treatments. Medical research on headaches today particularly suffers from the syndrome of single-disease approach, but it is important to have a cross-sectional and joint vision with other close specialties, in order to treat our patients with a comprehensive approach that a heterogeneous condition like migraine requires.

Identifying novel proteins for migraine by integrating proteomes from blood and CSF with genome-wide association data

BACKGROUND

Proteome-wide Mendelian randomization studies have been increasingly utilized to identify potential drug targets for diseases. We aimed to identify potential therapeutic targets for migraine and its subtypes through the application of Mendelian randomization and co-localization analysis methods.

METHODS

We utilized cis-protein quantitative trait loci data for 1378 plasma proteins available from two studies with 7213 individuals and 35,559 individuals, respectively. Summary data for migraine and its subtypes were obtained from a genetic study involving up to 1,339,303 individuals. Proteins that passed both the discovery and validation Mendelian randomization analysis, sensitivity analysis, heterogeneity test, and pleiotropy test, were associated with ≥2 outcomes, and received strong support from co-localization analysis (PP.H4.abf ≥0.80) and were classified as tier 1 proteins.

RESULTS

We identified three tier 1 proteins (LRP11, ITIH1, and ADGRF5), whose genes have not been previously identified as causal genes for migraine in genetic studies. LRP11 was significantly associated with the risk of any migraine (OR [odds ratio] = 0.968, 95% CI [confidence interval] = 0.955-0.981, p = 1.27 × 10-6) and significantly/suggestively associated with three migraine subtypes. ITIH1 was significantly associated with the risk of any migraine (OR = 1.044, 95% CI = 1.024-1.065, p = 1.08 × 10-5) and migraine with visual disturbances. ADGRF5 was significantly associated with the risk of any migraine (OR = 0.964, 95% CI = 0.946-0.982, p = 8.74 × 10-5) and suggestively associated with migraine with aura. The effects of LRP11 and ADGRF5 were further replicated using cerebrospinal fluid protein data. Apart from ADGRF5, there was no evidence of potential adverse consequences when modulating the plasma levels. We also identified another four proteins (PLCG1, ARHGAP25, CHGA, and MANBA) with no potential adverse consequences when modulating the plasma levels, and their genes were not reported by previous genetic studies.

CONCLUSIONS

We found compelling evidence for two proteins and suggestive evidence for four proteins that could be promising targets for migraine treatment without significant adverse consequences. The corresponding genes were not reported in previous genetic studies. Future studies are needed to confirm the causal role of these proteins and explore the underlying mechanisms.

Atogepant: Mechanism of action, clinical and translational science

Since the discovery of calcitonin gene-related peptide (CGRP) in 1982, its integral role in migraine pathophysiology, specifically migraine pain, has been demonstrated through cumulative scientific discoveries that have led to the development and approval of migraine-specific therapeutics. Today, eight drugs, including monoclonal antibodies and small molecule CGRP receptor antagonists, known as gepants, have received approval for acute or preventive treatment of migraine. The primary mechanism of these drugs is to block CGRP signaling, thus preventing CGRP-mediated nociception and neurogenic inflammation. Here, we focus on atogepant, a highly potent and selective gepant and the first and only oral medication approved for the preventive treatment of both episodic and chronic migraine in adults. In this article, we summarize the role of CGRP in migraine pathophysiology and the mechanism of action of atogepant. In addition, we provide an overview of atogepant's pharmacology and the key clinical trials and outcomes that have demonstrated the safety and efficacy of atogepant.