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Lucchese S, Daripa B, Pulimamidi S. A Retrospective Comparison of Onabotulinum Toxin A and Incobotulinum Toxin A in Terms of Efficacy, Tolerability, Duration of Effect, and Pain on Injection Administration Site for the Treatment of Chronic Migraine. Cureus 2024; 16:e53969. [PMID: 38468997 PMCID: PMC10927020 DOI: 10.7759/cureus.53969] [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] [Accepted: 02/10/2024] [Indexed: 03/13/2024] Open
Abstract
Background Onabotulinum toxin A (OnA) is a well-tolerated and effective treatment for chronic migraine (CM). However, based on research indications that incobotulinum toxin A (InA) would be equally effective, a Veterans Health Administration medical center mandated a two-year trial of InA as a more cost-effective alternative to OnA. Although InA is used for many similar indications as OnA, it is not Food and Drug Administration-approved for treating CM, and complications occurred in several patients with CM following this treatment change. We conducted this retrospective analysis to evaluate differences in the efficacy of OnA and InA and identify the reasons for the adverse effects of InA in some of these patients. Methods We performed a retrospective review of 42 patients who had been effectively treated with OnA and were then switched to InA. The differences between treatment responses to OnA and InA were assessed through the evaluation of pain on injection, number of headache days, and duration of action. Patients received injections at 10- to 13-week intervals. Those who reported severe pain on injection of InA were switched back to OnA. Results Severe burning pain on InA injection was reported by 38% of patients (nine males and seven females, i.e., a total of 16 patients out of 42 patients). One male patient reported the same degree of pain from both InA and OnA injections. A total of 66.7% of women with obesity and 83.3% of men with obesity or diabetes experienced severe pain on injection. Neither migraine suppression nor the duration of effect was significantly different between OnA and InA. Conclusions OnA is better tolerated than InA in the treatment of CM. InA appears to effectively suppress migraines, but some patients complain of a severe localized burning sensation during the injections. Some of these patients, all of whom were previously treated with OnA, requested to switch back to OnA. This suggested that InA is not equivalent to OnA in terms of tolerability and effectiveness. The present study found 2.38% of patients experienced an insufficient duration of effect with InA, and none with OnA. However, these lower rates may, in part, be due to variability in injection intervals in this sample, which could be because of scheduling considerations at the Harry S. Truman Veterans Health Administration Medical Center. In cases where OnA fails because of the development of antibodies, it might be reasonable to switch to InA treatment. Reformulation of InA with a pH-buffered solution may eliminate the difference in pain on injection. InA would then be a good alternative to OnA for treating CM.
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Affiliation(s)
- Scott Lucchese
- Neurology/Headache Medicine, University of Arkansas for Medical Sciences, Little Rock, USA
- Neurology, University of Missouri School of Medicine, Columbia, USA
| | - Bob Daripa
- Internal Medicine/Neurology, Singapore General Hospital, Singapore, SGP
- Neurology, University Hospital, Columbia, USA
- Internal Medicine/Neurology, Grant Medical College and Sir J.J. Group of Hospitals, Mumbai, IND
| | - Shruthi Pulimamidi
- Internal Medicine, University of Missouri School of Medicine, Columbia, USA
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Lucchese S, Daripa B, Pulimamidi S. Onabotulinum toxin A vs. incobotulinum toxin A for the treatment of chronic migraine: a retrospective review. RESEARCH SQUARE 2023:rs.3.rs-2624326. [PMID: 36993755 PMCID: PMC10055501 DOI: 10.21203/rs.3.rs-2624326/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Background Onabotulinum toxin A (OnA) is a well-tolerated and effective treatment for chronic migraine (CM). However, based on research indications that incobotulinum toxin A (InA) would be equally effective, a Veterans' Health Administration Medical Center mandated a 2-year trial of InA as more cost-effective alternative to OnA. Although InA is used for many similar indications as OnA, it is not Food and Drug Administration approved for treating CM, and complications occurred in several patients with CM following this treatment change. We conducted this retrospective analysis to evaluate differences in the efficacy of OnA and InA and identify the reasons for the adverse effects of InA in some of these patients. Methods We performed a retrospective review of 42 patients who had been effectively treated with OnA and were then switched to InA. The differences between treatment responses to OnA and InA were assessed through the evaluation of pain on injection, number of headache days, and duration of action. Patients received injections at 10- to 13-week intervals. Those who reported excessive pain on injection of InA were switched back to OnA. Findings Severe burning pain on injection was reported by 16 (38%) patients for InA only and by 1 (2%) patient for both InA and OnA. Neither migraine suppression nor the duration of effect was significantly different between OnA and InA. Conclusions Reformulation of InA with a pH-buffered solution may eliminate the difference in pain on injection. InA would then be a good alternative to OnA for treating CM.
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Affiliation(s)
| | - Bob Daripa
- Grant Medical College & Sir J.J. Group of Government Hospitals
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Hemasian H, Abedini F, Arab A, Khorvash F. A novel technique of botulinum toxin injection around skull sutures for chronic migraine: A randomized controlled clinical trial. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2022; 27:85. [PMID: 36685024 PMCID: PMC9854915 DOI: 10.4103/jrms.jrms_372_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 04/25/2022] [Accepted: 05/30/2022] [Indexed: 11/27/2022]
Abstract
Background Migraine is a chronic headache manifested with attacks. Here we aimed to evaluate and compare the efficacy of 15-point Dysport injection with 31-point Xeomin injections. Materials and Methods This is a randomized clinical trial performed in 2020-2021 in Isfahan on patients with refractory chronic migraine. A total number of 60 patients entered the study. The pain of patients was also determined using headache impact test (HIT) questionnaire. Patients were randomized into two groups: Group 1 underwent 31-point Xeomin injection and Group 2 underwent 1 vial of Dysport injection into 15 points of the scalp. Results Our study revealed that the data regarding aura, nausea, vomit, photosensitivity, sensitivity to sounds and smells did not change significantly between two groups compared to the beginning of the study. Frequency, duration, intensity of headaches, and the mean HIT score of all patients improved significantly within 3 months after interventions. Comparing both groups showed no significant differences (P > 0.05). HIT score was decreased from 21.26 ± 3.58 before intervention to 15.51 ± 4.58 after 3 months in Group 1 and 22.23 ± 2.59-10.33 ± 2.26 in Group 2. In both groups, these changes were statistically significant (P < 0.001). Although we found more decrease of HIT score in Group 2 comparing with Group 1 (10.33 ± 2.26 vs. 15.51 ± 4.58), this difference was not statistically significant (P = 0.12). Conclusion Although Xeomin and Dysport injections are both effective and reduced pain in patients with chronic migraine, our new technique is probably better than the standard technique. Because the injection points are halved, increase patients comfort and reduce overall cost.
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Affiliation(s)
- Helia Hemasian
- Department of Neurology, School of Medicine, Firouzgar Hospital, Iran University of Medical Science, Tehran, Iran
| | - Faezeh Abedini
- Department of Neurology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Arman Arab
- Department of Community Nutrition, School of Nutrition and Food Science, Food Security Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fariborz Khorvash
- Department of Neurology, School of Medicine, Firouzgar Hospital, Iran University of Medical Science, Tehran, Iran,Address for correspondence: Dr. Fariborz Khorvash, Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran. E-mail:
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Botulinum Toxin in the Treatment of Headache. Toxins (Basel) 2020; 12:toxins12120803. [PMID: 33348571 PMCID: PMC7766412 DOI: 10.3390/toxins12120803] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 12/08/2020] [Accepted: 12/11/2020] [Indexed: 12/20/2022] Open
Abstract
Botulinum toxin type A has been used in the treatment of chronic migraine for over a decade and has become established as a well-tolerated option for the preventive therapy of chronic migraine. Ongoing research is gradually shedding light on its mechanism of action in migraine prevention. Given that its mechanism of action is quite different from that of the new monoclonal antibodies directed against calcitonin gene-related peptide (CGRP) or its receptor, it is unlikely to be displaced to any major extent by them. Both will likely remain as important tools for patients with chronic migraine and the clinicians assisting them. New types of botulinum toxin selective for sensory pain neurons may well be discovered or produced by recombinant DNA techniques in the coming decade, and this may greatly enhance its therapeutic usefulness. This review summarizes the evolution of botulinum toxin use in headache management over the past several decades and its role in the preventive treatment of chronic migraine and other headache disorders.
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Abstract
Botulinum neurotoxin (BoNT) is an effective treatment for many neurologic disorders. This article gives a comprehensive overview of the clinical applications of BoNT across the field of neurology.
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Affiliation(s)
- Shannon Y Chiu
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, 3009 SW Williston Road, Gainesville, FL 32608, USA
| | - Matthew R Burns
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, 3009 SW Williston Road, Gainesville, FL 32608, USA
| | - Irene A Malaty
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, 3009 SW Williston Road, Gainesville, FL 32608, USA.
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Introduction to the Toxins Special Issue on Botulinum Neurotoxins in the Nervous System: Future Challenges for Novel Indications. Toxins (Basel) 2020; 12:toxins12090601. [PMID: 32957443 PMCID: PMC7551742 DOI: 10.3390/toxins12090601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 09/14/2020] [Indexed: 11/18/2022] Open
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Urits I, Gress K, Charipova K, Zamarripa AM, Patel PM, Lassiter G, Jung JW, Kaye AD, Viswanath O. Pharmacological options for the treatment of chronic migraine pain. Best Pract Res Clin Anaesthesiol 2020; 34:383-407. [PMID: 33004155 DOI: 10.1016/j.bpa.2020.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/03/2020] [Indexed: 12/29/2022]
Abstract
Migraine is a debilitating neurological condition with symptoms typically consisting of unilateral and pulsating headache, sensitivity to sensory stimuli, nausea, and vomiting. The World Health Organization (WHO) reports that migraine is the third most prevalent medical disorder and second most disabling neurological condition in the world. There are several options for preventive migraine treatments that include, but are not limited to, anticonvulsants, antidepressants, beta blockers, calcium channel blockers, botulinum toxins, NSAIDs, riboflavin, and magnesium. Patients may also benefit from adjunct nonpharmacological options in the comprehensive prevention of migraines, such as cognitive behavior therapy, relaxation therapies, biofeedback, lifestyle guidance, and education. Preventative therapies are an essential component of the overall approach to the pharmacological treatment of migraine. Comparative studies of newer therapies are needed to help patients receive the best treatment option for chronic migraine pain.
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Affiliation(s)
- Ivan Urits
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, USA.
| | - Kyle Gress
- Georgetown University School of Medicine, Washington, DC, USA
| | | | - Alec M Zamarripa
- University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ, USA
| | - Parth M Patel
- University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ, USA
| | - Grace Lassiter
- Georgetown University School of Medicine, Washington, DC, USA
| | - Jai Won Jung
- Georgetown University School of Medicine, Washington, DC, USA
| | - Alan D Kaye
- Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA
| | - Omar Viswanath
- University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ, USA; Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, USA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ, USA
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Ferrari MD, Diener HC, Ning X, Galic M, Cohen JM, Yang R, Mueller M, Ahn AH, Schwartz YC, Grozinski-Wolff M, Janka L, Ashina M. Fremanezumab versus placebo for migraine prevention in patients with documented failure to up to four migraine preventive medication classes (FOCUS): a randomised, double-blind, placebo-controlled, phase 3b trial. Lancet 2019; 394:1030-1040. [PMID: 31427046 DOI: 10.1016/s0140-6736(19)31946-4] [Citation(s) in RCA: 224] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 07/30/2019] [Accepted: 08/01/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Antibodies targeting calcitonin gene-related peptide (CGRP) or its receptor have shown efficacy in the prevention of migraine attacks. We investigated the efficacy and tolerability of fremanezumab, a fully humanised CGRP antibody, in patients with migraine who had previously not responded to two to four classes of migraine preventive medications. METHODS The randomised, double-blind, placebo-controlled, parallel-group, phase 3b FOCUS trial was done at 104 sites (including hospitals, medical centres, research institutes, and group practice clinics) across Belgium, the Czech Republic, Denmark, Finland, France, Germany, Italy, the Netherlands, Poland, Spain, Sweden, Switzerland, the UK, and the USA. We enrolled participants aged 18-70 years with episodic or chronic migraine who had documented failure to two to four classes of migraine preventive medications in the past 10 years. Failure was defined as no clinically meaningful improvement after at least 3 months of therapy at a stable dose, as per the treating physician's judgment; discontinuation because of adverse events that made treatment intolerable; or treatment contraindicated or unsuitable for the preventive treatment of migraine for the patient. Participants were randomly assigned (1:1:1) by electronic interactive response technology to subcutaneously administered quarterly fremanezumab (month 1, 675 mg; months 2 and 3: placebo), monthly fremanezumab (month 1: 225 mg in episodic migraine and 675 mg in chronic migraine; months 2 and 3: 225 mg in both migraine subgroups), or matched monthly placebo for 12 weeks. The primary outcome was mean change from baseline in the monthly average number of migraine days during the 12-week treatment period. This trial is registered with ClinicalTrials.gov, number NCT03308968, and is now completed. FINDINGS Between Nov 10, 2017, and July 6, 2018, 838 participants with episodic (329 [39%]) or chronic (509 [61%]) migraine were randomly assigned to placebo (n=279), quarterly fremanezumab (n=276), or monthly fremanezumab (n=283). Reductions from baseline in monthly average migraine days over 12 weeks were greater versus placebo (least-squares mean [LSM] change -0·6 [SE 0·3]) with quarterly fremanezumab (LSM change -3·7 [0·3]; LSM difference vs placebo -3·1 [95% CI -3·8 to -2·4]; p<0·0001) and with monthly fremanezumab (LSM change -4·1 [0·34]; LSM difference vs placebo -3·5 [-4·2 to -2·8]; p<0·0001). Adverse events were similar for placebo and fremanezumab. Serious adverse events were reported in four (1%) of 277 participants with placebo, two (<1%) of 276 with quarterly fremanezumab, and four (1%) of 285 with monthly fremanezumab. INTERPRETATION Fremanezumab was effective and well tolerated in patients with difficult-to-treat migraine who had previously not responded to up to four classes of migraine preventive medications. FUNDING Teva Pharmaceuticals.
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Affiliation(s)
| | | | | | - Maja Galic
- Teva Pharmaceuticals, Amsterdam, Netherlands
| | | | - Ronghua Yang
- Teva Pharmaceuticals Industries, Frazer, PA, USA
| | | | - Andrew H Ahn
- Teva Pharmaceuticals Industries, Frazer, PA, USA
| | | | | | | | - Messoud Ashina
- Danish Headache Centre, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
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