RE-START: Exploring the effectiveness of anti-calcitonin gene-related peptide resumption after discontinuation in migraine

BACKGROUND AND PURPOSE

According to the latest European guidelines, discontinuation of monoclonal antibodies against calcitonin gene-related peptide (anti-CGRP MAb) may be considered after 12-18 months of treatment. However, some patients may worsen after discontinuation. In this study, we assessed the response following treatment resumption.

METHODS

This was a prospective study conducted in 14 Headache Units in Spain. We included patients with response to anti-CGRP MAb with clinical worsening after withdrawal and resumption of treatment. Numbers of monthly migraine days (MMD) and monthly headache days (MHD) were obtained at four time points: before starting anti-CGRP MAb (T-baseline); last month of first treatment period (T-suspension); month of restart due to worsening (T-worsening); and 3 months after resumption (T-reintroduction). The response rate to resumption was calculated. Possible differences among periods were analysed according to MMD and MHD.

RESULTS

A total of 360 patients, 82% women, with a median (interquartile range [IQR]) age at migraine onset of 18 (12) years. The median (IQR) MHD at T-baseline was 20 (13) and MMD was 5 (6); at T-suspension, the median (IQR) MHD was 5 (6) and MMD was 4 (5); at T-worsening, the median (IQR) MHD was 16 (13) and MMD was 12 (6); and at T-reintroduction, the median (IQR) MHD was 8 (8) and MHD was 5 (5). In the second period of treatment, a 50% response rate was achieved by 57.4% of patients in MHD and 65.8% in MMD. Multivariate models showed significant differences in MHD between the third month after reintroduction and last month before suspension of first treatment period (p < 0.001).

CONCLUSION

The results suggest that anti-CGRP MAb therapy is effective after reintroduction. However, 3 months after resumption, one third of the sample reached the same improvement as after the first treatment period.

Patient preference in migraine therapy

OBJECTIVE

To assess patient preference for almotriptan 12.5 mg vs rizatriptan 10 mg for the acute treatment of migraine.

METHODS

Randomized, multicenter, open-label, crossover trial in which triptan-naïve patients treated two moderate/severe migraine attacks, the first with one triptan and the second with the other: 183 patients took rizatriptan followed by almotriptan and 189 treated in the reverse order. Patient preference was assessed with a self-administered questionnaire.

RESULTS

Of those recording a preference (209), 54.5% preferred almotriptan, but statistical significance was not achieved. The main reason for preference for one or the other triptan was efficacy: 43% of patients preferring almotriptan gave faster headache relief as the reason and 34% cited faster return to normal activities. The corresponding values for rizatriptan were 47% and 38%. A significantly greater proportion of those preferring almotriptan cited fewer adverse events (AEs) as the reason. Almotriptan and rizatriptan were of comparable efficacy and both treatments were well tolerated; 9% of patients experienced AEs probably or possibly related to study medication after almotriptan vs 14% after rizatriptan. Almotriptan was associated with a significantly lower incidence of triptan-associated AEs in triptan-naïve patients (8.5% vs 18% with rizatriptan).

CONCLUSION

Physicians should use information from meta-analyses and preference studies like this one to aid in the selection of a triptan with a high likelihood of providing rapid, sustained relief from pain coupled with an absence of AEs. About 55% of patients recording a preference in this trial preferred almotriptan, perhaps because of its combination of good efficacy and lower incidence of triptan-associated AEs.