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Reuter U, Goadsby PJ, Ferrari MD, Da Silva Lima GP, Mondal S, Kalim J, Hasan F, Wen S, Arkuszewski M, Pandhi S, Stites T, Lanteri-Minet M. Efficacy and Safety of Erenumab in Participants With Episodic Migraine in Whom 2-4 Prior Preventive Treatments Had Failed: LIBERTY 3-Year Study. Neurology 2024; 102:e209349. [PMID: 38669638 DOI: 10.1212/wnl.0000000000209349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The LIBERTY study assessed the efficacy and safety of erenumab in participants with episodic migraine (EM) and 2-4 prior preventive treatment failures. The results have been presented after 3 years of erenumab exposure in its open-label extension phase (OLEP). METHODS Participants completing the 12-week double-blind treatment phase (DBTP) of the LIBERTY study could enter the OLEP and receive 140 mg of erenumab once monthly for 3 years. The main outcomes included the proportion of participants achieving ≥50% reduction in monthly migraine days (MMDs), the mean MMD change from baseline, and tolerability and safety. RESULTS Overall, 240/246 (97.6%) participants entered the OLEP and 168/240 (70.0%) completed the study (85/118 continuing erenumab [n = 1 lost during follow-up]; 83/122 switching from placebo [n = 2 lost during follow-up]). In the overall population, 79/151 participants (52.3%) with valid data points achieved ≥50% reduction in MMDs at week 168 (i.e., responders). In the continuous erenumab group, 35/117 participants (29.9%) were ≥50% responders at week 12 of the DBTP and 26/35 (74.3%) remained ≥50% responders in at least half of OLEP visits. Of the 82/117 participants (70.1%) not achieving responder status at week 12 in the continuous erenumab group, 17/82 (20.7%) converted to ≥50% responders in at least half of OLEP visits. Of 103/120 participants (85.8%) not achieving responder status at week 12 in the placebo-erenumab group, 42/103 (40.8%) converted to ≥50% responders in at least half of OLEP visits after switching to erenumab. Overall, the mean (SD) MMD change from baseline showed sustained improvement over 3 years (-4.4 [3.9] days at week 168). The most common treatment-emergent AEs (per 100 person-years) were nasopharyngitis (28.8), influenza (7.5), and back pain (5.8). Overall, 9.6% (3.9 per 100 person-years) and 6.7% (2.7 per 100 person-years) of participants reported events of treatment-emergent hypertension and constipation, respectively. The safety and tolerability profile remained consistent with earlier studies. DISCUSSION Erenumab (140 mg) showed sustained efficacy over 3 years in participants with EM and 2-4 prior preventive treatment failures. No new safety signals were observed. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov Identifier: NCT03096834.
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Affiliation(s)
- Uwe Reuter
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Peter J Goadsby
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Michel D Ferrari
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Gabriel Paiva Da Silva Lima
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Subhayan Mondal
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Jawed Kalim
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Fatima Hasan
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Shihua Wen
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Michal Arkuszewski
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Shaloo Pandhi
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Tracy Stites
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Michel Lanteri-Minet
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
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Oliveira R, Gil-Gouveia R, Puledda F. CGRP-targeted medication in chronic migraine - systematic review. J Headache Pain 2024; 25:51. [PMID: 38575868 PMCID: PMC10996229 DOI: 10.1186/s10194-024-01753-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 03/18/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Chronic migraine is a highly debilitating condition that is often difficult to manage, particularly in the presence of medication overuse headache. Drugs targeting the calcitonin gene-related peptide (CGRP), or its receptor have shown promising results in treating this disorder. METHODS We searched Pubmed and Embase to identify randomized clinical trials and real-world studies reporting on the use of medication targeting the calcitonin gene-related peptide in patients with chronic migraine. RESULTS A total of 270 records were identified. Nineteen studies qualified for the qualitative analysis. Most studies reported on monoclonal antibodies targeting CGRP (anti-CGRP mAbs), that overall prove to be effective in decreasing monthly migraine days by half in about 27.6-61.4% of the patients. Conversion from chronic to episodic migraine was seen in 40.88% of the cases, and 29-88% of the patients stopped medication overuse. Obesity seems to be the main negative predictor of response to anti-CGRP mAbs. There is no evidence to suggest the superiority of one anti-CGRP mAb. Despite the lack of strong evidence, the combination of anti-CGRP medication with onabotulinumtoxinA in chronic migraine is likely to bring benefits for resistant cases. Atogepant is the first gepant to demonstrate a significant decrease in monthly migraine days compared to placebo in a recent trial. Further, anti-CGRP mAb and gepants have a good safety profile. CONCLUSION There is strong evidence from randomized trials and real-world data to suggest that drugs targeting CGRP are a safe and effective treatment for chronic migraine.
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Affiliation(s)
- Renato Oliveira
- Headache Group, Wolfson SPaRRC, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 9PJ, UK
- Neurology Department, Barking, Havering and Redbridge University Hospitals NHS Foundation Trust, London, UK
| | - Raquel Gil-Gouveia
- Hospital da Luz Headache Center, Neurology Department, Hospital da Luz Lisboa, Lisbon, Portugal
- Center for Interdisciplinary Research in Health, Universidade Católica Portuguesa, Lisbon, Portugal
| | - Francesca Puledda
- Headache Group, Wolfson SPaRRC, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 9PJ, UK.
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3
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Guerzoni S, Castro FL, Brovia D, Baraldi C, Pani L. Evaluation of the risk of hypertension in patients treated with anti-CGRP monoclonal antibodies in a real-life study. Neurol Sci 2024; 45:1661-1668. [PMID: 37926748 DOI: 10.1007/s10072-023-07167-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/25/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE To explore the rate of hypertension incoming in patients treated with monoclonal antibodies against the calcitonin gene-related peptide. BACKGROUND The monoclonal antibodies blocking the calcitonin gene-related peptide are unquestionable effective in the prevention of migraine. Despite this, the development of hypertension has been detected in some patients. METHODS This was a retrospective study conducted at the University Hospital of Modena. Patients were visited quarterly up to 1 year. RESULTS Globally, no significant increase in the blood pressure was detected. The 5.7% of the patients developed a significant increase in their blood pressure. In particular, patients with a pre-existing hypertension were more likely to have a significant increase in the blood pressure. CONCLUSION The risk of developing hypertension during a treatment with anti-calcitonin gene-related peptide monoclonal antibodies seems low. Anyway, patients with a pre-existing hypertension should be cautiously monitored because they are more likely to develop hypertension.
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Affiliation(s)
- Simona Guerzoni
- Digital and Predictive Medicine, Pharmacology and Clinical Metabolic Toxicology-Headache Center and Drug Abuse-Laboratory of Clinical Pharmacology and Pharmacogenomics; Department of Specialist Medicines, AOU Policlinico di Modena, Modena, Italy
| | - Flavia Lo Castro
- Digital and Predictive Medicine, Pharmacology and Clinical Metabolic Toxicology-Headache Center and Drug Abuse-Laboratory of Clinical Pharmacology and Pharmacogenomics; Department of Specialist Medicines, AOU Policlinico di Modena, Modena, Italy.
| | - Daria Brovia
- Digital and Predictive Medicine, Pharmacology and Clinical Metabolic Toxicology-Headache Center and Drug Abuse-Laboratory of Clinical Pharmacology and Pharmacogenomics; Department of Specialist Medicines, AOU Policlinico di Modena, Modena, Italy
| | - Carlo Baraldi
- Pharmacology Unit; Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Luca Pani
- Digital and Predictive Medicine, Pharmacology and Clinical Metabolic Toxicology-Headache Center and Drug Abuse-Laboratory of Clinical Pharmacology and Pharmacogenomics; Department of Specialist Medicines, AOU Policlinico di Modena, Modena, Italy
- Pharmacology Unit; Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Department of Psychiatry and Behavioral Sciences, University of Miami, Coral Gables, USA
- VeraSci, Durham, USA
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Croop R, Berman G, Kudrow D, Mullin K, Thiry A, Lovegren M, L'Italien G, Lipton RB. A multicenter, open-label long-term safety study of rimegepant for the acute treatment of migraine. Cephalalgia 2024; 44:3331024241232944. [PMID: 38659334 DOI: 10.1177/03331024241232944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
BACKGROUND The present study evaluated the long-term safety and tolerability of rimegepant, an orally administered small molecule calcitonin gene-related peptide receptor antagonist, in people with migraine. METHODS This multicenter, long-term, open-label safety study included adults (≥18 years) with ≥1 year history of migraine who were sequentially enrolled into three groups: participants in the first two groups had either 2-8 or 9-14 moderate to severe migraine attacks per month by history and treated as needed (pro re nata [PRN]) with one rimegepant 75 mg oral tablet up to once per calendar day for 52 weeks (PRN 2-8 and PRN 9-14); a third group, included to collect safety data during higher-frequency dosing, had 4-14 moderate to severe migraine attacks per month by history and who took one rimegepant tablet every other day as scheduled dosing plus PRN dosing of one rimegepant tablet for migraine attacks of any severity on nonscheduled dosing days for 12 weeks (every other day (EOD) + PRN). RESULTS Overall, 1800 participants self-administered rimegepant (PRN 2-8: n = 1033; PRN 9-14: n = 481; EOD + PRN: n = 286). The most common on-treatment adverse events (AEs) were upper respiratory tract infection (8.8%), nasopharyngitis (6.8%) and sinusitis (5.1%). Most AEs were mild or moderate and considered unrelated to rimegepant. Serious AEs considered possibly (n = 1) or unlikely (n = 9) related to rimegepant were reported in ten (0.6%) participants. No signal of drug-induced liver injury because of rimegepant was identified. CONCLUSIONS Rimegepant 75 mg up to once per day as EOD + PRN for 12 weeks or PRN for up to 52 weeks was safe and well tolerated. No signal of hepatotoxicity, potential drug abuse, or medication-overuse headache was identified.Trial registration: Clinicaltrials.gov: NCT03266588.
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Affiliation(s)
| | - Gary Berman
- Clinical Research Institute, Inc., Minneapolis, MN, USA
| | - David Kudrow
- California Medical Clinic for Headache, Santa Monica, CA, USA
| | - Kathleen Mullin
- New England Institute for Neurology and Headache, Stamford, CT, USA
| | | | | | | | - Richard B Lipton
- Albert Einstein College of Medicine and the Montefiore Headache Center, Bronx, NY, USA
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Aoh Y, Hou TW, Yang CC, Chang CM, Chen SP, Tsai IJ, Cheng CW, Yang CP. Update on gepants for the treatment of chronic migraine. J Chin Med Assoc 2024; 87:350-356. [PMID: 38349136 DOI: 10.1097/jcma.0000000000001070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2024] Open
Abstract
Chronic migraine (CM) is a profoundly debilitating condition that has detrimental clinical and social outcomes. Over the past two decades, novel small-molecule calcitonin gene-related peptide (CGRP) receptor antagonists, known as gepants, and CGRP monoclonal antibodies (mAbs) have been developed, ushering in a new era of migraine-specific treatment. In this review, we discuss the literature investigating the role of gepants for the treatment of CM. Numerous completed and ongoing clinical studies have conclusively demonstrated the safety, tolerability, and efficacy of several gepants for the acute treatment of migraine. However, preventive trials involving gepants have focused on patients with episodic migraine, with atogepant being the only gepant approved for CM prevention by the US Food and Drug Administration at the time of writing. Although some preliminary positive results have been reported, further research is still required to achieve additional advancements in the future. In summary, the effectiveness of gepants for treating individuals with CM are highly expected. This review highlights the development and current progress of gepants for the treatment of CM, focusing both on their role as acute abortive agents and preventive measures and on their concomitant use with other antimigraine medications, such as CGRP mAbs or triptans.
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Affiliation(s)
- Yu Aoh
- Department of Neurology, China Medical University Hospital, Taichung, Taiwan, ROC
| | - Tsung-Wei Hou
- Department of Neurology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Cheng-Chia Yang
- Department of Healthcare Administration, Asia University, Taichung, Taiwan, ROC
| | - Ching-Mao Chang
- Center for Traditional Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Traditional Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Pin Chen
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Translational Research, Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Brain Research Center & School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - I-Ju Tsai
- Department of Medical Research, Kuang Tien General Hospital, Taichung, Taiwan, ROC
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan, ROC
| | - Chin-Wen Cheng
- Department of Neurology, Kuang Tien General Hospital, Taichung, Taiwan, ROC
| | - Chun-Pai Yang
- Department of Neurology, Kuang Tien General Hospital, Taichung, Taiwan, ROC
- Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan, ROC
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Chhabra N, Mead-Harvey C, Dodoo CA, Iser C, Taylor H, Chaudhary H, Vanood A, Dodick DW. Blood pressure elevation in erenumab-treated patients with migraine: A retrospective real-world experience. Headache 2024; 64:233-242. [PMID: 38411625 DOI: 10.1111/head.14679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 01/23/2024] [Accepted: 01/25/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND Erenumab is a monoclonal antibody that targets the calcitonin gene-related peptide (CGRP) receptor and is approved for the preventative treatment of migraine in adults. CGRP is involved in the regulation of vasomotor tone under physiologic and pathologic conditions, including hypertension. While there has not been evidence of hypertension in preclinical models or clinical trials, post-marketing data suggest erenumab may be associated with hypertension. This led to a warning in the United States Food and Drug Administration prescribing information for erenumab. OBJECTIVE To determine the frequency of worsening blood pressure (BP) after initiation of erenumab in patients with migraine and how this is associated with hypertension. METHODS This is an observational retrospective cohort study evaluating patients at a tertiary headache or neurology department. Systolic and diastolic BPs were compared between the initial visit prior to initiation of erenumab, and follow-up visit while on erenumab. Worsening BP was defined as moving from a lower stage to a higher stage of BP, as defined by the American Heart Association. Serious adverse vascular events were also recorded. RESULTS A total of 335 patients were included in the final analysis (mean [SD] age of 45.7 [14.40] years, 83.9% [281/335] female). At baseline, 20.9% (70/335) of patients had a prior diagnosis of hypertension. The median (interquartile range) time to follow-up appointment from initial appointment was 20.5 (13.3-35.3) weeks. The mean (SD) BP at baseline was systolic 124.7 (15) mmHg and diastolic 77 (11) mmHg, and at follow-up was systolic 124.0 (15) mmHg and diastolic 77.8 (9) mmHg. Overall, 23.3% (78/335) of all patients had worsening BP, whereas 13/225 (3.9%) patients had improvement in their BP. Patients with atrial fibrillation were more likely to develop worsening BP (odds ratio, 4.9, 95% confidence interval 1.12-21.4; p = 0.035). There was no association between worsening BP and pre-existing hypertension, sex, body mass index, or age. One patient had non-ST elevation myocardial infarction attributed to a hypertensive emergency while on erenumab. CONCLUSION We found that 23.3% of patients initiated on erenumab may have developed worsening BP, suggesting the need for BP monitoring in patients initiated on erenumab.
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Affiliation(s)
- Nikita Chhabra
- Department of Neurology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Carolyn Mead-Harvey
- Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, Arizona, USA
| | - Christopher A Dodoo
- Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, Arizona, USA
| | - Courtney Iser
- Department of Neurology, Mercy Clinic, Oklahoma City, Oklahoma, USA
| | - Hallie Taylor
- Department of Neurology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Hira Chaudhary
- Department of Neurology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Aimen Vanood
- Department of Neurology, Mayo Clinic, Scottsdale, Arizona, USA
| | - David W Dodick
- Department of Neurology, Mayo Clinic, Scottsdale, Arizona, USA
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7
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Ashina M, Hoffmann J, Ashina H, Hay DL, Flores-Montanez Y, Do TP, De Icco R, Dodick DW. Pharmacotherapies for Migraine and Translating Evidence From Bench to Bedside. Mayo Clin Proc 2024; 99:285-299. [PMID: 38180396 DOI: 10.1016/j.mayocp.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 06/02/2023] [Accepted: 07/11/2023] [Indexed: 01/06/2024]
Abstract
Migraine is a ubiquitous neurologic disorder that afflicts more than 1 billion people worldwide. Recommended therapeutic strategies include the use of acute and, if needed, preventive medications. During the past 2 decades, tremendous progress has been made in better understanding the molecular mechanisms underlying migraine pathogenesis, which in turn has resulted in the advent of novel medications targeting signaling molecule calcitonin gene-related peptide or its receptor. Here, we provide an update on the rational use of pharmacotherapies for migraine to facilitate more informed clinical decision-making. We then discuss the scientific discoveries that led to the advent of new medications targeting calcitonin gene-related peptide signaling. Last, we conclude with recent advances that are being made to identify novel drug targets for migraine.
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Affiliation(s)
- Messoud Ashina
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Danish Knowledge Center on Headache Disorders, Glostrup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Jan Hoffmann
- Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology & Neuroscience.), King's College Hospital, London, United Kingdom; NIHR-Wellcome Trust King's Clinical Research Facility/SLaM Biomedical Research Centre, King's College Hospital, London, United Kingdom
| | - Håkan Ashina
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Anaesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Brain and Spinal Cord Injury, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Debbie L Hay
- Department of Pharmacology and Toxicology, University of Otago, Dunedin, New Zealand
| | - Yadira Flores-Montanez
- BIDMC Comprehensive Headache Center, Department of Neurology and Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA; University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
| | - Thien Phu Do
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Danish Knowledge Center on Headache Disorders, Glostrup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Roberto De Icco
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy; Headache Science and Neurorehabilitation Center, IRCCS Mondino Foundation, Pavia, Italy
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Mínguez-Olaondo A, López-Bravo A, Quintas S, Nieves-Castellanos C, Layos-Romero A, Belvís R, Irimia P, Díaz-Insa S. [New therapeutic era for migraine attacks with recently approved monoclonal antibodies, ditans and gepants]. Rev Neurol 2024; 78:47-57. [PMID: 38223948 DOI: 10.33588/rn.7802.2023176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
Treatment of migraine attacks is advised in all patients, using non-steroidal anti-inflammatory drugs when the pain is mild and triptans when the pain intensity is moderate-severe. However, the effectiveness of these drugs is moderate, a high percentage of patients have side effects, and triptans are contraindicated in people with a history of stroke, ischaemic heart disease or poorly controlled hypertension. Hence, there is an urgent need for new therapeutic alternatives. In recent years, new drugs for migraine attacks have become available, most notably ditans (lasmiditan) and gepants (ubrogepant and rimegepant). Furthermore, eptinezumab, which has been approved for the preventive treatment of migraine in adults, has also been used for migraine attacks. This manuscript reviews the efficacy and safety results of the new drugs for migraines that will soon be on the market.
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Affiliation(s)
- A Mínguez-Olaondo
- Instituto de Investigación Sanitaria Biogipuzkoa, Donostia-San Sebastián, España
- Athenea Neuroclinics, Donostia-San Sebastián, España
- Hospital Universitario Donostia-Osakidetza, Donostia-San Sebastián, España
- Universidad de Deusto, Donostia-San Sebastián, España
| | - A López-Bravo
- Hospital Reina Sofía, Tudela, España
- Instituto de Investigación Sanitaria Aragón, Zaragoza, España
| | - S Quintas
- Hospital Universitario de La Princesa, Madrid, España
| | - C Nieves-Castellanos
- Hospital Universitario y Politécnico La Fe, Valencia, España
- Instituto de Investigación Sanitaria La Fe, Valencia, España
| | | | - R Belvís
- Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, España
| | - P Irimia
- Universidad de Navarra, Pamplona, España
| | - S Díaz-Insa
- Hospital Universitario y Politécnico La Fe, Valencia, España
- Instituto de Investigación Sanitaria La Fe, Valencia, España
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Finelli F, Catalano A, De Lisa M, Ferraro GA, Genovese S, Giuzio F, Salvia R, Scieuzo C, Sinicropi MS, Svolacchia F, Vassallo A, Santarsiere A, Saturnino C. CGRP Antagonism and Ketogenic Diet in the Treatment of Migraine. Medicina (Kaunas) 2024; 60:163. [PMID: 38256423 PMCID: PMC10820088 DOI: 10.3390/medicina60010163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/08/2024] [Accepted: 01/12/2024] [Indexed: 01/24/2024]
Abstract
The study of migraine is based on the complexity of the pathology, both at the pathophysiological and epidemiological levels. Although it affects more than a billion people worldwide, it is often underestimated and underreported by patients. Migraine must not be confused with a simple headache; it is a serious and disabling disease that causes considerable limitations in the daily life of afflicted people, including social, work, and emotional effects. Therefore, it causes a daily state of suffering and discomfort. It is important to point out that this pathology not only has a decisive impact on the quality of life of those who suffer from it but also on their families and, more generally, on society as a whole. The clinical picture of migraine is complex, with debilitating unilateral or bilateral head pain, and is often associated with characteristic symptoms such as nausea, vomiting, photophobia, and phonophobia. Hormonal, environmental, psychological, dietary, or other factors can trigger it. The present review focuses on the analysis of the physiopathological and pharmacological aspects of migraine, up to the correct dietary approach, with specific nutritional interventions aimed at modulating the symptoms. Based on the symptoms that the patient experiences, targeted and specific therapy is chosen to reduce the frequency and severity of migraine attacks. Specifically, the role of calcitonin gene-related peptide (CGRP) in the pathogenesis of migraine is analyzed, along with the drugs that effectively target the corresponding receptor. Particularly, CGRP receptor antagonists (gepants) are very effective drugs in the treatment of migraine, given their high diffusion in the brain. Moreover, following a ketogenic diet for only one or two months has been demonstrated to reduce migraine attacks. In this review, we highlight the diverse facets of migraine, from its physiopathological and pharmacological aspects to prevention and therapy.
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Affiliation(s)
- Francesca Finelli
- U.O.C. Pediatrics -S. Giuseppe Moscati Hospital, 83100 Avellino, Italy;
| | - Alessia Catalano
- Department of Pharmacy-Drug Sciences, University of Bari “Aldo Moro”, 70126 Bari, Italy;
| | - Michele De Lisa
- U.O.C. Hygiene, Epidemiology and Public Health Department ASP, 85100 Potenza, Italy;
| | - Giuseppe Andrea Ferraro
- Plastic and Reconstructive Surgery Unit, Multidisciplinary Department of Medical-Surgical and Dental Specialties, University of Campania Luigi Vanvitelli, 80138 Naples, Italy;
| | - Sabino Genovese
- Department of Agriculture, Faculty of Viticulture and Oenology, Federico II University, 83100 Avellino, Italy;
| | - Federica Giuzio
- Department of Sciences, University of Basilicata, 85100 Potenza, Italy; (R.S.); (C.S.); (A.V.); (A.S.); (C.S.)
- U.O.C. Primary Care and Territorial Health, Social and Health Department, State Hospital, 47893 San Marino, San Marino
- Spinoff TNCKILLERS s.r.l., University of Basilicata, 85100 Potenza, Italy
| | - Rosanna Salvia
- Department of Sciences, University of Basilicata, 85100 Potenza, Italy; (R.S.); (C.S.); (A.V.); (A.S.); (C.S.)
- Spinoff XFlies s.r.l., University of Basilicata, 85100 Potenza, Italy
| | - Carmen Scieuzo
- Department of Sciences, University of Basilicata, 85100 Potenza, Italy; (R.S.); (C.S.); (A.V.); (A.S.); (C.S.)
- Spinoff XFlies s.r.l., University of Basilicata, 85100 Potenza, Italy
| | - Maria Stefania Sinicropi
- Department of Pharmacy and Health and Nutrition Sciences, University of Calabria, 87036 Arcavacata di Rende, Italy;
| | | | - Antonio Vassallo
- Department of Sciences, University of Basilicata, 85100 Potenza, Italy; (R.S.); (C.S.); (A.V.); (A.S.); (C.S.)
- Spinoff XFlies s.r.l., University of Basilicata, 85100 Potenza, Italy
| | - Alessandro Santarsiere
- Department of Sciences, University of Basilicata, 85100 Potenza, Italy; (R.S.); (C.S.); (A.V.); (A.S.); (C.S.)
| | - Carmela Saturnino
- Department of Sciences, University of Basilicata, 85100 Potenza, Italy; (R.S.); (C.S.); (A.V.); (A.S.); (C.S.)
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Caronna E, Alpuente A, Torres-Ferrus M, Pozo-Rosich P. CGRP monoclonal antibodies and CGRP receptor antagonists (Gepants) in migraine prevention. Handb Clin Neurol 2024; 199:107-124. [PMID: 38307640 DOI: 10.1016/b978-0-12-823357-3.00024-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/04/2024]
Abstract
Migraine is a prevalent and disabling neurological disease. Its preventive treatment for decades has been rather limited due to the absence of disease-specific therapies with limited efficacy and tolerability. The advances made in migraine research have led to the discovery of the calcitonin gene-related peptide (CGRP) and its role in migraine pathophysiology. CGRP is a neuropeptide that acts as potent vasodilator and is involved in pain processing. Increased levels of plasma CGRP have been observed during migraine attacks as well as interictally when comparing patients with migraine and healthy controls. In the last years, two classes of drugs antagonizing CGRP have therefore been developed as the first migraine-specific preventive treatments: anti-CGRP monoclonal antibodies (mAbs) and gepants. Four mAbs have been approved: erenumab, galcanezumab, fremanezumab, and eptinezumab. Gepants are small molecules that antagonize the CGRP receptor; currently only rimegepant and atogepant have been approved for migraine prevention. These new drugs have demonstrated efficacy and safety in clinical trials for both episodic and chronic migraine, and results from their real-world experience are being increasingly reported in literature. In this review, we provide an overview of anti-CGRP drugs and their placement in migraine prevention.
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Affiliation(s)
- Edoardo Caronna
- Headache and Neurological Pain Research Group, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain; Headache Unit, Neurology Department, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Alicia Alpuente
- Headache and Neurological Pain Research Group, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain; Headache Unit, Neurology Department, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Marta Torres-Ferrus
- Headache and Neurological Pain Research Group, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain; Headache Unit, Neurology Department, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Patricia Pozo-Rosich
- Headache and Neurological Pain Research Group, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain; Headache Unit, Neurology Department, Hospital Universitario Vall d'Hebron, Barcelona, Spain.
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11
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Younis S, Latysheva NV, Danilov AB, Ashina M. CGRP receptor antagonists (gepants). Handb Clin Neurol 2024; 199:51-66. [PMID: 38307667 DOI: 10.1016/b978-0-12-823357-3.00033-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/04/2024]
Abstract
Small molecule calcitonin gene-related peptide (CGRP) receptor antagonists are commonly referred to as gepants. The first generation of gepants provided the first line of evidence of CGRP-mediated antimigraine medication in 2004-2011. However, further development was halted due to either lack of oral availability or concerns of hepatotoxicity. More than 15 years later, the first second generation of gepants, ubrogepant and rimegepant, are now approved for the acute treatment of migraine with or without aura. Furthermore, a novel and promising third-generation gepant, zavegepant, has recently been approved as well. In this chapter, we review the evidence supporting the effectiveness, safety, and tolerability of gepants for the acute treatment of migraine. Furthermore, we discuss the potential limitations and future directions of this class of migraine-specific medication.
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Affiliation(s)
- Samaira Younis
- Danish Headache Center & Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Nina V Latysheva
- Department of Neurology, Institute for Professional Education, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Alexey B Danilov
- Department of Neurology, Institute for Professional Education, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Messoud Ashina
- Danish Headache Center & Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Danish Knowledge Center On Headache Disorders, Rigshospitalet Glostrup, Glostrup, Denmark.
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Bentivegna E, Galastri S, Onan D, Martelletti P. Unmet Needs in the Acute Treatment of Migraine. Adv Ther 2024; 41:1-13. [PMID: 37943442 PMCID: PMC10796525 DOI: 10.1007/s12325-023-02650-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 08/16/2023] [Indexed: 11/10/2023]
Abstract
Migraine represents the most common neurologic disorder, ranking second among the world's causes of disability [expressed as years lived with disability (YLDs)]. Patients often do not receive the best therapy because of safety issues, tolerance, and prescription accessibility. General practitioners are not always educated about the disease, and specialists are few and often difficult to reach. Therapies are limited and have many side effects that can impede the prescription. Prophylactic therapy is recommended in case of four or more headaches a month, eight or more headache days a month, debilitating headaches, and medication-overuse headaches. The available therapeutic options are in constant development. The classic one consists of non-specific drugs: β-blockers, tricyclics, antiepileptics, and botulinum toxin. Monoclonal antibodies targeting the calcitonin gene receptor (CGRP) peptide or its receptor are the only ones specifically designed to treat migraine. Their efficiency and convenient safety profile have been demonstrated in a number of trials versus both placebo and classic therapies. The treatment of acute migraine attack consists of medications designed to affect the painful symptoms. For over 30 years, the cornerstones of treatment in clinical practice have continued to be represented by triptans and non-steroidal anti-inflammatory drugs (NSAIDs), with the well-know related adverse effects. Opioids are used inappropriately and overprescribed. Polytherapy is strongly not recommended but is still a common practice because treatment is not optimized and thus not efficient. Great promise comes from gepants, also targeting CGRP, and ditans, 5-HT1F receptor agonists. They seem to outweigh the risk of medication overuse headache because of their efficacy and rapid onset and have no cardiovascular contraindications. Nonetheless, these points remain to be confirmed. Although therapies have been implemented in the last years, significant unmet treatment needs remain a reality in patients' lives. This commentary aims to identify the most important unmet needs in the acute treatment of migraine, analyzing the current status of available therapies and their limits. We also analyzed some of the prophylactic therapies available, especially focusing on anti-CGRP monoclonal antibodies, to better understand the importance of setting a therapeutic strategy that includes the two modes, both acute and prophylactic, to reach the best result. We hope that having an overview of the shortcomings will help to provide constructive ideas for improvement.
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Affiliation(s)
- Enrico Bentivegna
- Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Sapienza University, Via di Grottarossa 1035-1039, 00189, Rome, Italy.
| | - Silvia Galastri
- Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Sapienza University, Via di Grottarossa 1035-1039, 00189, Rome, Italy
| | - Dilara Onan
- Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Sapienza University, Via di Grottarossa 1035-1039, 00189, Rome, Italy
- Back and Neck Health Unit, Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Sapienza University, Via di Grottarossa 1035-1039, 00189, Rome, Italy
- Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy
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Garelja ML, Alexander TI, Bennie A, Nimick M, Petersen J, Walker CS, Hay DL. Pharmacological characterisation of erenumab, Aimovig, at two calcitonin gene-related peptide responsive receptors. Br J Pharmacol 2024; 181:142-161. [PMID: 37580864 PMCID: PMC10840612 DOI: 10.1111/bph.16218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 06/30/2023] [Accepted: 08/02/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND AND PURPOSE Calcitonin gene-related peptide (CGRP) is involved in migraine pathophysiology. CGRP can signal through two receptors. The canonical CGRP receptor comprises the calcitonin receptor-like receptor and receptor activity-modifying protein 1 (RAMP1); the AMY1 receptor comprises the calcitonin receptor with RAMP1. Drugs that reduce CGRP activity, such as receptor antagonists, are approved for the treatment and prevention of migraine. Despite being designed to target the canonical CGRP receptor, emerging evidence suggests that these antagonists, including erenumab (a monoclonal antibody antagonist) can also antagonise the AMY1 receptor. However, it is difficult to estimate its selectivity because direct comparisons between receptors under matched conditions have not been made. We therefore characterised erenumab at both CGRP-responsive receptors with multiple ligands, including αCGRP and βCGRP. EXPERIMENTAL APPROACH Erenumab antagonism was quantified through IC50 and pKB experiments, measuring cAMP production. We used SK-N-MC cells which endogenously express the human CGRP receptor, and HEK293S and Cos7 cells transiently transfected to express either human CGRP or AMY1 receptors. KEY RESULTS Erenumab antagonised both the CGRP and AMY1 receptors with an ~20-120-fold preference for the CGRP receptor, depending on the cells, agonist, analytical approach and/or assay format. Erenumab antagonised both forms of CGRP equally, and appeared to act as a competitive reversible antagonist at both receptors. CONCLUSION AND IMPLICATIONS Despite being designed to target the CGRP receptor, erenumab can antagonise the AMY1 receptor. Its ability to antagonise CGRP activity at both receptors may be useful in better understanding the clinical profile of erenumab.
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Affiliation(s)
- Michael L. Garelja
- Department of Pharmacology and Toxicology, University of Otago, Dunedin, 9016, New Zealand
- Maurice Wilkins Centre for Molecular Biodiscovery, University of Auckland, Auckland, 1010, New Zealand
| | - Tyla I. Alexander
- Department of Pharmacology and Toxicology, University of Otago, Dunedin, 9016, New Zealand
- Maurice Wilkins Centre for Molecular Biodiscovery, University of Auckland, Auckland, 1010, New Zealand
| | - Amy Bennie
- Department of Pharmacology and Toxicology, University of Otago, Dunedin, 9016, New Zealand
| | - Mhairi Nimick
- Department of Pharmacology and Toxicology, University of Otago, Dunedin, 9016, New Zealand
| | - Jakeb Petersen
- School of Biological Sciences, University of Auckland, Auckland, 1010, New Zealand
| | - Christopher S. Walker
- Maurice Wilkins Centre for Molecular Biodiscovery, University of Auckland, Auckland, 1010, New Zealand
- School of Biological Sciences, University of Auckland, Auckland, 1010, New Zealand
| | - Debbie L. Hay
- Department of Pharmacology and Toxicology, University of Otago, Dunedin, 9016, New Zealand
- Maurice Wilkins Centre for Molecular Biodiscovery, University of Auckland, Auckland, 1010, New Zealand
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Moore E, Bell IM, Fraley ME, Burgey CS, White RB, Li CC, Regan CP, Danziger A, McGaraughty SP, Naseri Kouzehgarani G, Salvatore C, Banerjee P. Pharmacologic characterization of atogepant: A potent and selective calcitonin gene-related peptide receptor antagonist. Cephalalgia 2024; 44:3331024231226186. [PMID: 38215228 DOI: 10.1177/03331024231226186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2024]
Abstract
BACKGROUND The trigeminal sensory neuropeptide calcitonin gene-related peptide (CGRP) is identified as an essential element in migraine pathogenesis. METHODS In vitro and in vivo studies evaluated pharmacologic properties of the CGRP receptor antagonist atogepant. Radioligand binding using 125I-CGRP and cyclic adenosine monophosphate (cAMP) accumulation assays were conducted in human embryonic kidney 293 cells to assess affinity, functional potency and selectivity. Atogepant in vivo potency was assessed in the rat nitroglycerine model of facial allodynia and primate capsaicin-induced dermal vasodilation (CIDV) pharmacodynamic model. Cerebrospinal fluid/brain penetration and behavioral effects of chronic dosing and upon withdrawal were evaluated in rats. RESULTS Atogepant exhibited high human CGRP receptor-binding affinity and potently inhibited human α-CGRP-stimulated cAMP responses. Atogepant exhibited significant affinity for the amylin1 receptor but lacked appreciable affinities for adrenomedullin, calcitonin and other known neurotransmitter receptor targets. Atogepant dose-dependently inhibited facial allodynia in the rat nitroglycerine model and produced significant CIDV inhibition in primates. Brain penetration and behavioral/physical signs during chronic dosing and abrupt withdrawal were minimal in rats. CONCLUSIONS Atogepant is a competitive antagonist with high affinity, potency and selectivity for the human CGRP receptor. Atogepant demonstrated a potent, concentration-dependent exposure/efficacy relationship between atogepant plasma concentrations and inhibition of CGRP-dependent effects.
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15
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Waliszewska-Prosół M, Vuralli D, Martelletti P. What to do with non-responders to CGRP(r) monoclonal antibodies: switch to another or move to gepants? J Headache Pain 2023; 24:163. [PMID: 38053061 DOI: 10.1186/s10194-023-01698-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Indexed: 12/07/2023] Open
Abstract
In this editorial we aim to provide potential therapeutic options in patients who do not benefit from treatment with CGRP(r) monoclonal antibodies. Based on current real-life studies and analysis of practical and economic aspects, we will analyze the potential benefits of changing CGRP-targeted treatment.
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Affiliation(s)
| | - Doga Vuralli
- Department of Neurology and Algology, Neuroscience and Neurotechnology Center of Excellence (NÖROM), Faculty of Medicine, Neuropsychiatry Center, Gazi University, Ankara, Turkey
| | - Paolo Martelletti
- School of Health Sciences, UnitelmaSapienza University of Rome, Rome, Italy
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16
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Kowacs PA, Sampaio Rocha-Filho PA, Peres MFP, Edvinsson L. The history and rationale of the development of new drugs for migraine treatment. Arq Neuropsiquiatr 2023; 81:1084-1097. [PMID: 38157876 PMCID: PMC10756794 DOI: 10.1055/s-0043-1777723] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 11/21/2023] [Indexed: 01/03/2024]
Abstract
Migraine is one of the most prevalent and disabling diseases in the world. Migraine attack treatments and prophylactic treatments of this disease are essential to lessen its individual, social, and economic impact. This is a narrative review of the main drugs used for treating migraine, as well as the experimental models and the theoretical frameworks that led to their development. Ergot derivatives, triptans, non-steroid anti-inflammatory drugs, tricyclic antidepressants, beta-blockers,: flunarizine,: valproic acid,: topiramate, onabotulinumtoxin A, ditans, monoclonal antibodies against CGRP and its receptor, and gepants are discussed. Possible therapeutic targets for the development of new drugs that are under development are also addressed. Many of the drugs currently in use for treating migraine were developed for the treatment of other diseases, but have proven effective for the treatment of migraine, expanding knowledge about the disease. With a better understanding of the pathophysiology of migraine, new drugs have been and continue to be developed specifically for the treatment of this disease.
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Affiliation(s)
- Pedro André Kowacs
- Instituto de Neurologia de Curitiba, Serviço de Neurologia, Curitiba PR, Brazil.
- Universidade Federal do Paraná, Complexo Hospital de Clínicas, Unidade do Sistema Nervoso, Curitiba PR, Brazil.
| | - Pedro Augusto Sampaio Rocha-Filho
- Universidade Federal de Pernambuco, Centro de Ciências Médicas, Divisão de Neuropsiquiatria, Recife PE, Brazil.
- Universidade de Pernambuco, Hospital Universitário Oswaldo Cruz, Clínica de Cefaleia, Recife PE, Brazil.
| | | | - Lars Edvinsson
- Lund University, Institute of Clinical Sciences, 22185 Lund, Sweden.
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Montalbetti N, Dalghi MG, Parakala-Jain T, Clayton D, Apodaca G, Carattino MD. Antinociceptive effect of the calcitonin gene-related peptide receptor antagonist BIBN4096BS in mice with bacterial cystitis. Am J Physiol Renal Physiol 2023; 325:F779-F791. [PMID: 37823199 PMCID: PMC10878727 DOI: 10.1152/ajprenal.00217.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/25/2023] [Accepted: 10/09/2023] [Indexed: 10/13/2023] Open
Abstract
Patients with urinary tract infections (UTIs) suffer from urinary frequency, urgency, dysuria, and suprapubic pain, but the mechanisms by which bladder afferents sense the presence of uropathogens and encode this information is not well understood. Calcitonin gene-related peptide (CGRP) is a 37-mer neuropeptide found in a subset of bladder afferents that terminate primarily in the lamina propria. Here, we report that the CGRP receptor antagonist BIBN4096BS lessens lower urinary tract symptoms and prevents the development of pelvic allodynia in mice inoculated with uropathogenic Escherichia coli (UPEC) without altering urine bacterial loads or the host immune response to the infection. These findings indicate that CGRP facilitates the processing of noxious/inflammatory stimuli during UPEC infection. Using fluorescent in situ hybridization, we identified a population of suburothelial fibroblasts in the lamina propria, a region where afferent fibers containing CGRP terminate, that expresses the canonical CGRP receptor components Calcrl and Ramp1. We propose that these fibroblasts, in conjunction with CGRP+ afferents, form a circuit that senses substances released during the infection and transmit this noxious information to the central nervous system.NEW & NOTEWORTHY Afferent C fibers release neuropeptides including calcitonin gene-related peptide (CGRP). Here, we show that the specific CGRP receptor antagonist, BIBN409BS, ameliorates lower urinary tract symptoms and pelvic allodynia in mice inoculated with uropathogenic E. coli. Using fluorescent in situ hybridization, we identified a population of suburothelial fibroblasts in the lamina propria that expresses the canonical CGRP receptor. Our findings indicate that CGRP contributes to the transmission of nociceptive information arising from the bladder.
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Affiliation(s)
- Nicolas Montalbetti
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Marianela G Dalghi
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Tanmay Parakala-Jain
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Dennis Clayton
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Gerard Apodaca
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Department of Cell Biology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Marcelo D Carattino
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Department of Cell Biology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
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Tana C, Cipollone F, Giamberardino MA, Martelletti P. New drugs targeting calcitonin gene-related peptide for the management of migraines. Expert Opin Emerg Drugs 2023; 28:233-240. [PMID: 37996401 DOI: 10.1080/14728214.2023.2288334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 11/22/2023] [Indexed: 11/25/2023]
Abstract
INTRODUCTION Significant advances in migraine research have contributed to the development of new drugs for the treatment of migraine. Monoclonal antibodies (mAbs) against Calcitonin Gene-Related Peptide (CGRP) or its receptor and CGRP receptor antagonists (gepants) have been associated with a good safety profile and resulted in an overall efficacy in reducing the number of monthly migraine days both in episodic and chronic forms of migraine. AREAS COVERED The results from main investigation studies (phase 2 or 3) of CGRP-targeting drugs (both anti-CGRP mAbs and gepants) are reported in this expert-opinion review. EXPERT OPINION The introduction of new drugs targeting CGRP is a significant breakthrough in the migraine field, and represents a new generation of therapeutic agents that are available to manage migraine. The evaluation of efficacy and safety in the long-term follow-up and the development of trials comparing the available drugs could improve the current knowledge. The economic sustainability of these drugs remains to be clarified, and a cost-cutting campaign should be promoted based on the high burden of migraine.
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Affiliation(s)
- Claudio Tana
- Headache Center, Geriatrics Clinic, SS Annunziata Hospital of Chieti, Chieti, Italy
| | - Francesco Cipollone
- Department of Medicine and Science of Aging, Medical Clinic, SS. Annunziata Hospital of Chieti, "G. D'Annunzio" University of Chieti, Chieti, Italy
| | - Maria Adele Giamberardino
- Headache Center, Geriatrics Clinic, SS Annunziata Hospital of Chieti, Chieti, Italy
- Department of Medicine and Science of Aging and CAST, G. D'Annunzio University of Chieti, Chieti, Italy
| | - Paolo Martelletti
- School of Health Sciences, Unitelma Sapienza University of Rome, Rome, Italy
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Zhou Z, Urman R, Gill K, Park AS, Vuvu F, Patel LB, Lu J, Wade RL, Frerichs L, Bensink ME. Treatment patterns for patients initiating novel acute migraine specific medications (nAMSMs) in the context of monoclonal antibodies (mAbs) targeting the calcitonin gene-related peptide (CGRP) pathway. J Headache Pain 2023; 24:153. [PMID: 37946113 PMCID: PMC10634163 DOI: 10.1186/s10194-023-01678-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 10/10/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND New acute and preventive migraine medications are available, but data on current treatment patterns are limited. This study describes migraine treatment patterns among patients initiating novel acute migraine specific medications (nAMSMs), overall and by prior use of anti-calcitonin gene-related peptide (CGRP) pathway monoclonal antibodies (mAbs). METHODS In this retrospective cohort study using IQVIA open-source pharmacy and medical claims data, we identified patients with ≥ 1 claim for a nAMSM (ubrogepant, rimegepant, lasmiditan) between 01/01/2020 and 09/30/2020 (index period). Patients were indexed on their first nAMSM claim and stratified into 2 cohorts: patients with prior mAb use (≥ 1 claim for erenumab, fremanezumab, galcanezumab in the 6-month pre-index period) or patients without prior mAb use. Treatment patterns were assessed during the 6-month post-index period. RESULTS Overall, 78,574 patients were identified (63% indexed on ubrogepant, 34% on rimegepant, and 3% on lasmiditan) with 26,656 patients (34%) having had prior mAb use. In the pre-index period, 79% of patients used non-mAb preventive medications and 75% of patients used acute medications. Following the index nAMSM claim, 65% of patients had ≥ 1 refill and 21% had ≥ 4 refills of their index nAMSM; 10% of patients switched to another nAMSM. Post-index mAb use was observed in 82% of patients with a prior mAb and 15% of patients without. Among patients with pre- and post-index use of acute medications, 38% discontinued ≥ 1 acute medication class in the post-index period. Among patients with concomitant use of traditional preventive medications at index, 30% discontinued ≥ 1 concomitant preventive anti-migraine medication in the post-index period. CONCLUSIONS Most patients initiating nAMSMs had prior treatment with acute and preventive medications. Approximately one-third of patients had prior treatment with anti-CGRP pathway mAbs. After starting nAMSMs, more than one-third of patients discontinued at least one traditional acute medication and one-third of patients discontinued at least one traditional preventive medication. Despite nAMSM initiation, most patients with prior anti-CGRP pathway mAb use continued mAb use. Around 15% of patients without a prior mAb newly started a mAb. These results provide insight into how nAMSMs and mAbs have been integrated into clinical management of migraine in the real-world.
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Lanteri-Minet M, Fabre R, Martin C, Pradat K, Alchaar A, Bozzolo E, Duchene ML, Van Obberghen EK, Donnet A, Fontaine D. One-year prospective real-world assessment of effectiveness and safety of erenumab in migraine prevention: results of the French FHU INOVPAIN registry study. J Headache Pain 2023; 24:152. [PMID: 37940860 PMCID: PMC10633983 DOI: 10.1186/s10194-023-01680-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 10/16/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Randomized clinical trials have demonstrated efficacy and safety of erenumab. The aim of this study is to evaluate the effectiveness and safety of erenumab in a real-world setting in French patients with migraine associated with extreme unmet needs. METHODS This is a one year-prospective real-word study with enrolment of all consecutive adult patients included in the FHU InovPain registry who participated in a compassionate erenumab use program. RESULTS Of 144 patients included, 140 patients (82.1% female / mean age of 50.9 ± 11.4) received at least one dose of erenumab and were concerned by effectiveness and safety assessment. All patients had failed 11 oral preventive treatments. Most of them suffered from chronic migraine (88.6%) and presented a medication overuse (90.7%) at baseline. Thirty-eight (27.1%) discontinued treatment during the 12-month follow-up, with 22 (15.7%), 11 (7.9%) and 5 (3.6%) patients before 3, 6 or 9 months of treatment. The proportion of ≥ 50% responders at M3, M6, M9 and M12 was 74/140 (52.9%), 69/118 (58.5%), 61/107 (57.0%) and 60/102 (58.8%) respectively. At M3, the rate of reversion from chronic migraine to episodic migraine was 57.3% and the rate of transition from medication overuse to non-overuse was 46.5%. For monthly migraine days, the median (IQR) was 18.0 (13.0-26.0), 9.0 (5.0-17.0), 7.5 (5.0-14.0), 8.0 (5.0-12.5) and 8.0 (5.0-12.0) at M0, M3, M6, M9 and M12 respectively. For HIT-6 score, the median (IQR) was 68.0 (63.8-73.3), 60.0 (54.0-65.0), 60.0 (50.3-53.0), 59.0 (50.0-63.0) and 58.0 (50.0-62.9) at M0, M3, M6, M9 and M12 respectively. Fifty-three (37.9%) patients reported at least one of the following adverse events: cutaneous erythema and/or pain at the injection site for 42 (30%) patients, constipation for 22 (15.7%) patients, muscle spasm for 2 (1.4%) patients, alopecia for one (0.7%) patient and blood pressure increase in one (0.7%) patient. There was no serious adverse event. One female patient became pregnant after 5 months of exposure to erenumab with a safe evolution after treatment discontinuation. CONCLUSION This first French real-world study related to migraine prevention with CGRP-mAbs confirms effectiveness and safety of erenumab in patients with extreme unmet needs.
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Affiliation(s)
- M Lanteri-Minet
- Pain Department and FHU InovPain, CHU Nice and Côte Azur University, Hôpital Cimiez, 4 Rue Reine Victoria, 06003, Nice, France.
- INSERM U1107 Migraine and Trigeminal Pain, Auvergne University, Clermont-Ferrand, France.
| | - R Fabre
- Pain Department and FHU InovPain, CHU Nice and Côte Azur University, Hôpital Cimiez, 4 Rue Reine Victoria, 06003, Nice, France
- Public Health Department, CHU Nice and Côte Azur University, Nice, France
| | - C Martin
- Pain Department and FHU InovPain, CHU Nice and Côte Azur University, Hôpital Cimiez, 4 Rue Reine Victoria, 06003, Nice, France
| | - K Pradat
- Pain Department and FHU InovPain, CHU Nice and Côte Azur University, Hôpital Cimiez, 4 Rue Reine Victoria, 06003, Nice, France
| | - A Alchaar
- Pain Department and FHU InovPain, CHU Nice and Côte Azur University, Hôpital Cimiez, 4 Rue Reine Victoria, 06003, Nice, France
| | - E Bozzolo
- Pain Department and FHU InovPain, CHU Nice and Côte Azur University, Hôpital Cimiez, 4 Rue Reine Victoria, 06003, Nice, France
| | - M L Duchene
- Cinical Pharmacy Departement, CHU Nice and Côte Azur University, Nice, France
| | - E K Van Obberghen
- Pain Department and FHU InovPain, CHU Nice and Côte Azur University, Hôpital Cimiez, 4 Rue Reine Victoria, 06003, Nice, France
| | - A Donnet
- Pain Departement, Timone Hospital, APHM, Marseille, France
| | - D Fontaine
- Neurosurgery Department and FHU InovPain, CHU Nice and Côte Azur University, Nice, France
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Filippi M, Messina R, Bartezaghi M, Cetta I, Colombo B, Grazzi L, Martinelli D, Ornello R, Pichiecchio A, Raimondi D, Russo A, Sacco S, Splendiani A, Tassorelli C, Turrini R, Valsasina P, Rocca MA. The effect of erenumab on brain network function in episodic migraine patients: a randomized, placebo-controlled clinical trial (RESET BRAIN). J Neurol 2023; 270:5600-5612. [PMID: 37550498 PMCID: PMC10576673 DOI: 10.1007/s00415-023-11879-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/12/2023] [Accepted: 07/12/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND We aimed to explore whether erenumab, a monoclonal antibody targeting the calcitonin gene-related peptide receptor, could exert a central effect on brain network function in migraine, and investigate the persistence of such an effect following treatment discontinuation. METHODS This was a randomized, double-blind, placebo-controlled, multicenter trial with a crossover design performed in adult episodic migraine patients with previous treatment failure. Patients were randomized (1:1) to 12 weeks of erenumab 140 mg or placebo, followed by a 12-week crossover. Resting state (RS) functional connectivity (FC) changes of brain networks involved in migraine were investigated using a seed-based correlation approach. RESULTS Sixty-one patients were randomized to treatment. In each treatment sequence, 27 patients completed the visit at week 12. Forty-four enrolled patients, 22 in each treatment sequence, completed the study procedures with no major protocol violations. We observed a carry-over effect of erenumab during the placebo treatment and therefore data analysis was performed as a parallel comparison of erenumab vs placebo of the first 12 weeks of treatment. From baseline to week 12, compared to placebo, patients receiving erenumab showed RS FC changes within the cerebellar, thalamic and periaqueductal gray matter networks, significantly associated with clinical improvement. Compared to non-responders, patients achieving a 50% reduction in migraine days had distinct patterns of thalamic and visual network RS FC. Brain RS FC changes reversed when erenumab was stopped. A lower baseline RS FC of the pontine network identified patients responding to erenumab. CONCLUSION Erenumab modulates RS FC of networks involved in migraine pathophysiology. In line with clinical response, erenumab-induced brain RS FC changes tend to reverse when treatment is stopped.
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Affiliation(s)
- Massimo Filippi
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy.
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.
- Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.
- Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy.
- Vita-Salute San Raffaele University, Milan, Italy.
| | - Roberta Messina
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | | | - Ilaria Cetta
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Bruno Colombo
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Licia Grazzi
- Neuroalgology Unit, Headache Center Fondazione IRCCS Istituto Neurologico "Carlo Besta", Milan, Italy
| | - Daniele Martinelli
- Headache Science and Rehabilitation Center, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Raffaele Ornello
- Department Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Anna Pichiecchio
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Neuroradiology Department, Advanced Imaging and Radiomics Center, IRCCS Mondino Foundation, Pavia, Italy
| | | | - Antonio Russo
- Department of Advanced Medical and Surgical Sciences (DAMSS), Headache Center, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Simona Sacco
- Department Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Alessandra Splendiani
- Department Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Cristina Tassorelli
- Headache Science and Rehabilitation Center, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | | | - Paola Valsasina
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
| | - Maria Assunta Rocca
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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VanderPluym JH, Victorio MCC, Oakley CB, Rastogi RG, Orr SL. Beyond the Guidelines: A Narrative Review of Treatments on the Horizon for Migraine in Children and Adolescents. Neurology 2023; 101:788-797. [PMID: 37604658 PMCID: PMC10634646 DOI: 10.1212/wnl.0000000000207677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 06/06/2023] [Indexed: 08/23/2023] Open
Abstract
Migraine is common in children and adolescents and can cause significant disability. There are relatively limited evidence-based treatment options available, especially when compared with treatment of migraine in adults. The Pediatric Research Equity Act requires the study of a new drug or biologic in pediatric populations. As such it is mandatory that the newest migraine treatment options available for adults be evaluated in children and adolescents. It will take years before results from clinical trials in pediatric patients become available. In the meantime, there is eagerness among clinicians to seek out the existing evidence that may help provide clarity on utilization of the newer migraine therapies in children and adolescents because many of the currently available, guideline-recommended treatments do not provide benefit for all patients. In this narrative review, the literature regarding onabotulinumtoxinA, neuromodulatory devices, calcitonin gene-related peptide (CGRP) monoclonal antibodies, 5-hydroxytryptamine (1F) agonists (i.e., ditans), and CGRP small-molecule receptor antagonists (i.e., gepants) for the treatment of migraine in children and adolescents will be summarized.
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Affiliation(s)
- Juliana H VanderPluym
- From the Department of Neurology (J.H.V.), Mayo Clinic, Scottsdale, AZ; Division of Neurology (M.C.C.V.), NeuroDevelopmental Science Center, Akron Children's Hospital, OH; Department of Neurology (C.B.O.), Johns Hopkins University School of Medicine, Baltimore, MD; Division of Neurology (R.G.R.), Barrow Neurological Institute at Phoenix Children's Hospital, AZ; Department of Child Health and Neurology (R.G.R.), University of Arizona College of Medicine-Phoenix; Departments of Pediatrics (S.L.O.), Community Health Sciences, and Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta; and Department of Neurology (S.L.O.), Alberta Children's Hospital, Calgary, Canada.
| | - M Cristina C Victorio
- From the Department of Neurology (J.H.V.), Mayo Clinic, Scottsdale, AZ; Division of Neurology (M.C.C.V.), NeuroDevelopmental Science Center, Akron Children's Hospital, OH; Department of Neurology (C.B.O.), Johns Hopkins University School of Medicine, Baltimore, MD; Division of Neurology (R.G.R.), Barrow Neurological Institute at Phoenix Children's Hospital, AZ; Department of Child Health and Neurology (R.G.R.), University of Arizona College of Medicine-Phoenix; Departments of Pediatrics (S.L.O.), Community Health Sciences, and Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta; and Department of Neurology (S.L.O.), Alberta Children's Hospital, Calgary, Canada
| | - Christopher B Oakley
- From the Department of Neurology (J.H.V.), Mayo Clinic, Scottsdale, AZ; Division of Neurology (M.C.C.V.), NeuroDevelopmental Science Center, Akron Children's Hospital, OH; Department of Neurology (C.B.O.), Johns Hopkins University School of Medicine, Baltimore, MD; Division of Neurology (R.G.R.), Barrow Neurological Institute at Phoenix Children's Hospital, AZ; Department of Child Health and Neurology (R.G.R.), University of Arizona College of Medicine-Phoenix; Departments of Pediatrics (S.L.O.), Community Health Sciences, and Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta; and Department of Neurology (S.L.O.), Alberta Children's Hospital, Calgary, Canada
| | - Reena G Rastogi
- From the Department of Neurology (J.H.V.), Mayo Clinic, Scottsdale, AZ; Division of Neurology (M.C.C.V.), NeuroDevelopmental Science Center, Akron Children's Hospital, OH; Department of Neurology (C.B.O.), Johns Hopkins University School of Medicine, Baltimore, MD; Division of Neurology (R.G.R.), Barrow Neurological Institute at Phoenix Children's Hospital, AZ; Department of Child Health and Neurology (R.G.R.), University of Arizona College of Medicine-Phoenix; Departments of Pediatrics (S.L.O.), Community Health Sciences, and Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta; and Department of Neurology (S.L.O.), Alberta Children's Hospital, Calgary, Canada
| | - Serena L Orr
- From the Department of Neurology (J.H.V.), Mayo Clinic, Scottsdale, AZ; Division of Neurology (M.C.C.V.), NeuroDevelopmental Science Center, Akron Children's Hospital, OH; Department of Neurology (C.B.O.), Johns Hopkins University School of Medicine, Baltimore, MD; Division of Neurology (R.G.R.), Barrow Neurological Institute at Phoenix Children's Hospital, AZ; Department of Child Health and Neurology (R.G.R.), University of Arizona College of Medicine-Phoenix; Departments of Pediatrics (S.L.O.), Community Health Sciences, and Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta; and Department of Neurology (S.L.O.), Alberta Children's Hospital, Calgary, Canada
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Hong JB, Lange KS, Fitzek M, Overeem LH, Triller P, Siebert A, Reuter U, Raffaelli B. Impact of a reimbursement policy change on treatment with erenumab in migraine - a real-world experience from Germany. J Headache Pain 2023; 24:144. [PMID: 37899428 PMCID: PMC10614330 DOI: 10.1186/s10194-023-01682-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 10/18/2023] [Indexed: 10/31/2023] Open
Abstract
BACKGROUND Monoclonal antibodies (mAbs) targeting the Calcitonin Gene-Related Peptide (CGRP) pathway are safe and effective treatments for migraine prevention. However, the high cost of these novel therapies has led to reimbursement policies requiring patients to try multiple traditional preventives before access. In Germany, a recent change in insurance policy significantly expanded coverage for the CGRP receptor mAb erenumab, enabling migraine patients who failed just one prior prophylactic medication to receive this mAb. Here, we compare the clinical response to treatment with erenumab in migraine patients treated using the old and new coverage policy. METHODS In this retrospective cohort study, we included CGRP-mAb naïve patients with episodic or chronic migraine, who started erenumab at our headache center according to either the old or the new insurance policy and received at least 3 consecutive injections. Headache diaries and electronic documentation were used to evaluate reductions in monthly headache and migraine days (MHD and MMD) and ≥ 50% and ≥ 30% responder rates at month 3 (weeks 9-12) of treatment. RESULTS We included 146 patients who received erenumab according to the old policy and 63 patients that were treated using the new policy. At weeks 9-12 of treatment, 37.7% of the old policy group had a 50% or greater reduction in MHD, compared to 63.5% of the new policy group (P < 0.001). Mean reduction in MHD was 5.02 days (SD = 5.46) and 6.67 days (SD = 5.32, P = 0.045) in the old and new policy cohort, respectively. After propensity score matching, the marginal effect of the new policy on treatment outcome was 2.29 days (standard error, SE: 0.715, P = 0.001) more reduction in MHD, and 30.1% (SE: 10.6%, P = 0.005) increase in ≥ 50% response rate for MHD. CONCLUSIONS Starting erenumab earlier in the course of migraine progression in a real-world setting may lead to a better response than starting after multiple failed prophylactic attempts. Continually gathering real-world evidence may help policymakers in deciding how readily to cover CGRP-targeted therapies in migraine prevention.
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Affiliation(s)
- Ja Bin Hong
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Mira Fitzek
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Paul Triller
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Anke Siebert
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Uwe Reuter
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Universitätsmedizin Greifswald, Greifswald, Germany
| | - Bianca Raffaelli
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.
- Clinician Scientist Program, Berlin Institute of Health (BIH) at Charité, Berlin, Germany.
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Jinesh S. Pharmaceutical aspects of novel CGRP inhibitors used in the prophylaxis and treatment of migraine. Inflammopharmacology 2023; 31:2245-2251. [PMID: 37421480 DOI: 10.1007/s10787-023-01276-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 06/21/2023] [Indexed: 07/10/2023]
Abstract
Migraine is one of the most prevalent neurological disorders known to have an immense adverse socio-economic impact. Neurogenic inflammation is thought to mediate migraine, and CGRP is known to be released during acute attacks of migraine that causes vasodilation in extracerebral arteries. Hence, CGRP is believed to play a key role in triggering migraine. Although there are several classes of medications used in the prevention and treatment of migraine pain, targeted therapies are fewer. Therefore, CGRP receptor inhibitors which bind to CGRP receptors in the cranial vasculature have been developed as drugs for migraine therapy. In this review article, we describe the basic pathophysiologic mechanism that causes migraine headaches and the pharmacotherapeutic aspects of CGRP inhibitors available for clinical use. For the purpose of this review, a search was performed on the pharmacological, pharmacokinetic, pharmaceutical, and therapeutic aspects of the FDA-approved CGRP inhibitors viz. erenumab, ubrogepant, rimegepant, atogepant, eptinezumab, fremanezumab, and galcanezumab in UpToDate database and PubMed beginning year 2000. Based on the data collected, a risk-benefit comparison of different classes of novel CGRP inhibitors available for clinical use is provided. This comparative review may help the healthcare providers in choosing the best pharmacotherapeutic agent for their patients based on patient-specific information.
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Cho S, Kim BK. Update of Gepants in the Treatment of Chronic Migraine. Curr Pain Headache Rep 2023; 27:561-569. [PMID: 37656319 DOI: 10.1007/s11916-023-01167-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE OF REVIEW Despite the unmet therapeutic needs of patients with chronic migraine (CM) and/or medication overuse, available treatment options are limited. Recently, four calcitonin gene-related peptide receptor antagonists, known as gepants, have been approved for the treatment of migraine. This review focuses on the preventive treatment of CM with gepants and highlights recent findings. RECENT FINDINGS Two randomized controlled trials (RCTs) have shown promising results for rimegepant and atogepant as preventive treatments for CM. In an RCT targeting patients with CM, atogepant demonstrated a significant reduction in the mean monthly migraine days, irrespective of acute medication overuse. Moreover, the patients reported no significant safety concerns and exhibited good tolerance to treatment. These findings highlight the potential of gepants as a new and effective therapeutic option for patients with CM and/or medication overuse. Gepant use will help improve the management and quality of life of individuals with this debilitating condition.
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Affiliation(s)
- Soohyun Cho
- Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu, Korea
| | - Byung-Kun Kim
- Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea.
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Moskatel LS, Zhang N. The Role of Step Therapy in the Treatment of Migraine. Curr Pain Headache Rep 2023; 27:571-577. [PMID: 37542597 DOI: 10.1007/s11916-023-01155-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2023] [Indexed: 08/07/2023]
Abstract
PURPOSE OF REVIEW This review examines recent evidence and applies bioethical principles to evaluate the benefits and risks of using step therapy in the treatment of migraine. RECENT FINDINGS With the CGRP mAbs, gepants, and lasmiditan now on the market for up to 5 years, new research, including network meta-analyses and long-term use studies, can evaluate the comparative efficacy, tolerability, and adherence of these medications relative to older acute and preventive medications for the treatment of migraine. Deciding how medications are chosen for patients requires accounting for many factors including sustainability, efficacy, tolerability, and preference. Newer research can help give clarity on the appropriateness of gating certain treatment options behind others.
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Affiliation(s)
- Leon S Moskatel
- Division of Headache, Department of Neurology and Neurological Sciences, Stanford University, 211 Quarry Road, Suite #206, Palo Alto, CA, 94304, USA.
| | - Niushen Zhang
- Division of Headache, Department of Neurology and Neurological Sciences, Stanford University, 211 Quarry Road, Suite #206, Palo Alto, CA, 94304, USA
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Barbanti P, Aurilia C, Egeo G, Torelli P, Proietti S, Cevoli S, Bonassi S. Late Response to Anti-CGRP Monoclonal Antibodies in Migraine: A Multicenter Prospective Observational Study. Neurology 2023; 101:482-488. [PMID: 37072224 PMCID: PMC10513886 DOI: 10.1212/wnl.0000000000207292] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 02/28/2023] [Indexed: 04/20/2023] Open
Abstract
OBJECTIVES To assess the frequency and characteristics of late responders (>12 weeks) to monoclonal antibodies (mAbs) targeting the calcitonin gene-related peptide (CGRP). METHODS This is a multicenter (n = 16) prospective real-life study considering all consecutive adults with high-frequency or chronic migraine treated with anti-CGRP mAbs for ≥24 weeks. We defined responder patients with a ≥50% reduction from baseline in monthly migraine/headache days at weeks 9-12 and late responders as those achieving a ≥50% reduction only afterward. RESULTS A total of 771 people with migraine completed ≥24 weeks of anti-CGRP mAb treatment. Responders at 12 weeks were 65.6% (506/771) of the patients, while nonresponders were 34.4% (265/771). A total of 146 of the 265 nonresponders (55.1%) at 12 weeks responded afterward (late responders): they differed from responders for a higher BMI (+0.78, 95% CI [0.10; 1.45]; p = 0.024), more frequent treatment failures (+0.52, 95% CI [0.09; 0.95]; p = 0.017) and psychiatric comorbidities (+10.1%, 95% CI [0.1; 0.20]; p = 0.041), and less common unilateral pain, alone (-10,9%, 95% CI [-20.5; -1.2]; p = 0.025) or in combination with unilateral cranial autonomic symptoms (-12.3%, 95% CI [-20.2;-3.9]; p = 0.006) or allodynia (-10.7, 95% CI [-18.2; -3.2]; p = 0.01). DISCUSSION Half of nonresponders to anti-CGRP mAbs at 12 weeks are indeed late responders. Efficacy of anti-CGRP mAbs should be assessed at 24 weeks while treatment duration should be extended beyond 12 months.
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Affiliation(s)
- Piero Barbanti
- From the Headache and Pain Unit (P.B., C.A., G.E.), IRCCS San Raffaele Roma; San Raffaele University (P.B., S.B.), Rome; Unit of Neurology, Department of Medicine and Surgery (P.T.), Headache Center, University of Parma, Parma; Clinical and Molecular Epidemiology (S.P.), IRCCS San Raffaele Roma; IRCCS Istituto delle Scienze Neurologiche di Bologna (S.C.), Bologna, Italy.
| | - Cinzia Aurilia
- From the Headache and Pain Unit (P.B., C.A., G.E.), IRCCS San Raffaele Roma; San Raffaele University (P.B., S.B.), Rome; Unit of Neurology, Department of Medicine and Surgery (P.T.), Headache Center, University of Parma, Parma; Clinical and Molecular Epidemiology (S.P.), IRCCS San Raffaele Roma; IRCCS Istituto delle Scienze Neurologiche di Bologna (S.C.), Bologna, Italy
| | - Gabriella Egeo
- From the Headache and Pain Unit (P.B., C.A., G.E.), IRCCS San Raffaele Roma; San Raffaele University (P.B., S.B.), Rome; Unit of Neurology, Department of Medicine and Surgery (P.T.), Headache Center, University of Parma, Parma; Clinical and Molecular Epidemiology (S.P.), IRCCS San Raffaele Roma; IRCCS Istituto delle Scienze Neurologiche di Bologna (S.C.), Bologna, Italy
| | - Paola Torelli
- From the Headache and Pain Unit (P.B., C.A., G.E.), IRCCS San Raffaele Roma; San Raffaele University (P.B., S.B.), Rome; Unit of Neurology, Department of Medicine and Surgery (P.T.), Headache Center, University of Parma, Parma; Clinical and Molecular Epidemiology (S.P.), IRCCS San Raffaele Roma; IRCCS Istituto delle Scienze Neurologiche di Bologna (S.C.), Bologna, Italy
| | - Stefania Proietti
- From the Headache and Pain Unit (P.B., C.A., G.E.), IRCCS San Raffaele Roma; San Raffaele University (P.B., S.B.), Rome; Unit of Neurology, Department of Medicine and Surgery (P.T.), Headache Center, University of Parma, Parma; Clinical and Molecular Epidemiology (S.P.), IRCCS San Raffaele Roma; IRCCS Istituto delle Scienze Neurologiche di Bologna (S.C.), Bologna, Italy
| | - Sabina Cevoli
- From the Headache and Pain Unit (P.B., C.A., G.E.), IRCCS San Raffaele Roma; San Raffaele University (P.B., S.B.), Rome; Unit of Neurology, Department of Medicine and Surgery (P.T.), Headache Center, University of Parma, Parma; Clinical and Molecular Epidemiology (S.P.), IRCCS San Raffaele Roma; IRCCS Istituto delle Scienze Neurologiche di Bologna (S.C.), Bologna, Italy
| | - Stefano Bonassi
- From the Headache and Pain Unit (P.B., C.A., G.E.), IRCCS San Raffaele Roma; San Raffaele University (P.B., S.B.), Rome; Unit of Neurology, Department of Medicine and Surgery (P.T.), Headache Center, University of Parma, Parma; Clinical and Molecular Epidemiology (S.P.), IRCCS San Raffaele Roma; IRCCS Istituto delle Scienze Neurologiche di Bologna (S.C.), Bologna, Italy
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Labastida-Ramírez A, Caronna E, Gollion C, Stanyer E, Dapkute A, Braniste D, Naghshineh H, Meksa L, Chkhitunidze N, Gudadze T, Pozo-Rosich P, Burstein R, Hoffmann J. Mode and site of action of therapies targeting CGRP signaling. J Headache Pain 2023; 24:125. [PMID: 37691118 PMCID: PMC10494408 DOI: 10.1186/s10194-023-01644-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 08/01/2023] [Indexed: 09/12/2023] Open
Abstract
Targeting CGRP has proved to be efficacious, tolerable, and safe to treat migraine; however, many patients with migraine do not benefit from drugs that antagonize the CGRPergic system. Therefore, this review focuses on summarizing the general pharmacology of the different types of treatments currently available, which target directly or indirectly the CGRP receptor or its ligand. Moreover, the latest evidence regarding the selectivity and site of action of CGRP small molecule antagonists (gepants) and monoclonal antibodies is critically discussed. Finally, the reasons behind non-responders to anti-CGRP drugs and rationale for combining and/or switching between these therapies are addressed.
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Affiliation(s)
- Alejandro Labastida-Ramírez
- Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE1 1UL, UK
| | - Edoardo Caronna
- Headache Unit, Neurology Department, Vall d'Hebron Universitary Hospital, Barcelona, Spain
- Headache Research Group, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Cédric Gollion
- Department of Neurology, University Hospital of Toulouse, Toulouse, France
| | - Emily Stanyer
- Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE1 1UL, UK
- Nuffield Department of Clinical Neurosciences, Sleep and Circadian Neuroscience Institute, University of Oxford, Oxford, UK
| | | | - Diana Braniste
- Institute of Neurology and Neurosurgery, Diomid Gherman, Chișinău, Moldova
- State University of Medicine and Pharmacy, Nicolae Testemițanu, Moldova
| | - Hoda Naghshineh
- Headache Department, Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Science, Tehran, Iran
| | - Liga Meksa
- Headache Unit, Neurology and Neurosurgery Department, Riga East University Hospital Gailezers, Riga, Latvia
| | | | - Tamari Gudadze
- Department of Neurology, Christian Hospital Unna, Unna, Germany
| | - Patricia Pozo-Rosich
- Headache Unit, Neurology Department, Vall d'Hebron Universitary Hospital, Barcelona, Spain
- Headache Research Group, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Rami Burstein
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Anesthesia, Harvard Medical School, Boston, MA, USA
- Center for Life Science, Room 649, 3 Blackfan Circle, Boston, MA, 02215, USA
| | - Jan Hoffmann
- Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE1 1UL, UK.
- NIHR-Wellcome Trust King's Clinical Research Facility/SLaM Biomedical Research Centre, King's College Hospital, London, UK.
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Abstract
This Viewpoint describes the relevance of sex-specific differences in the treatment of migraine, including in evidence from trials of CGRP therapeutics, and the clinical implications for decision-making in practice and trial design.
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Affiliation(s)
- Frank Porreca
- Department of Pharmacology, University of Arizona, Tucson
- Mayo Clinic Arizona, Phoenix
| | - David W Dodick
- Mayo Clinic Arizona, Phoenix
- Atria Academy of Science and Medicine, New York, New York
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Li D, Abreu J, Tepper SJ. A Brief Review of Gepants. Curr Pain Headache Rep 2023; 27:479-488. [PMID: 37531032 DOI: 10.1007/s11916-023-01142-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2023] [Indexed: 08/03/2023]
Abstract
PURPOSE OF REVIEW Gepants are small molecules that antagonize calcitonin gene-related peptide (CGRP) receptors. Due to their favorable side effect profile and versatility in treating headaches acutely and preventively, gepants are preferred over triptans. We will cover the indications for the four FDA-approved gepants in adults: rimegepant, atogepant, ubrogepant, and zavegepant. This review will illustrate how gepants will continue to revolutionize the acute and preventive treatment of headaches. RECENT FINDINGS Gepants are now available in oral tablet, dissolving tablet, and intra-nasal spray formulations. Recent studies have shown promising utility in treating the pre-headache or prodromal phase. They have favorable tolerability, no evidence for association with medication overuse, and remain a safer alternative in those who have cerebrovascular risk factors. Additional research is needed to explore occurrence of Raynaud's phenomenon in participants treated with gepants, as it has been associated with CGRP monoclonal antibodies, but are not extensively studied in gepants. Gepants are expected to play a significant role in the next generation of migraine treatments.
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Affiliation(s)
- Diana Li
- Dartmouth Headache Center, Neurology Department, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA.
| | - Jessica Abreu
- Dartmouth Headache Center, Neurology Department, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA
| | - Stewart J Tepper
- Dartmouth Headache Center, Neurology Department, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA
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Lipton RB, Halker Singh RB, Mechtler L, McVige J, Ma J, Yu SY, Stokes J, Dabruzzo B, Gandhi P, Ashina M. Patient-reported migraine-specific quality of life, activity impairment and headache impact with once-daily atogepant for preventive treatment of migraine in a randomized, 52-week trial. Cephalalgia 2023; 51:3331024231190296. [PMID: 37638400 DOI: 10.1177/03331024231190296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
BACKGROUND Atogepant is an oral, small-molecule, calcitonin gene-related peptide receptor antagonist for the preventive treatment of episodic migraine. METHODS In this 52-week, multicenter, randomized, open-label trial, adults with 4-14 monthly migraine days received atogepant 60 mg once-daily or standard care. Health outcome endpoints collected from participants randomized to atogepant included change from baseline in Migraine-Specific Quality of Life Questionnaire version 2.1 (MSQ v2.1) Role Function-Restrictive (RFR), Role Function-Preventive (RFP) and Emotional Function (EF) domain scores, change in Activity Impairment in Migraine-Diary (AIM-D) Performance of Daily Activities (PDA) and Physical Impairment (PI) domain scores, and change in Headache Impact Test-6 (HIT-6) total score. RESULTS Of 744 randomized participants, 521 received atogepant 60 mg in the modified intent-to-treat population. Least-squares mean changes from baseline in MSQ-RFR score were 30.02 (95% confidence interval = 28.16-31.87) at week 12 and 34.70 (95% confidence interval = 32.74-36.66) at week 52. Improvements were also observed in other MSQ domains, AIM-D PDA, PI and HIT-6 total scores. A ≥5-point improvement from baseline in HIT-6 score was observed in 59.9% of participants at week 4 and 80.8% of participants at week 52. CONCLUSION Over 52 weeks, atogepant 60 mg once-daily was associated with sustained improvements in quality of life and reductions in activity impairment and headache impact.Trial Registration: NCT03700320.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Messoud Ashina
- Danish Headache Center, Rigshospitalet Glostrup, University of Copenhagen, Denmark
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32
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Tepper SJ, Lipton RB, Silberstein SD, Kudrow D, Ashina M, Reuter U, Dodick DW, Wang A, Cheng S, Klatt J, Mikol DD. Long-term efficacy and safety of erenumab in patients with chronic migraine and acute medication overuse: A subgroup analysis. Headache 2023; 63:730-742. [PMID: 37313616 DOI: 10.1111/head.14536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 05/02/2023] [Accepted: 05/03/2023] [Indexed: 06/15/2023]
Abstract
OBJECTIVE Assess the long-term efficacy and safety of erenumab in patients with chronic migraine with acute medication overuse. BACKGROUND Overuse of acute medication in patients with chronic migraine has been linked to greater pain intensity and disability and may diminish the effectiveness of preventive therapies. METHODS This 52-week open-label extension study followed a 12-week double-blind placebo-controlled study in which patients with chronic migraine were randomized 3:2:2 to placebo or once-monthly erenumab 70 mg or 140 mg. Patients were stratified by region and medication overuse status. Patients received erenumab 70 mg or 140 mg throughout or switched from erenumab 70 to 140 mg (based on protocol amendment to augment safety data at higher dose). Efficacy was assessed in patients with and without medication overuse at parent study baseline. RESULTS Of 609 patients enrolled in the extension study, 252/609 (41.4%) met the criteria for medication overuse at parent study baseline. At Week 52, the mean change in monthly migraine days from parent study baseline was -9.3 (95% confidence interval: -10.4, -8.1 days) in the medication overuse subgroup versus -9.3 (-10.1, -8.5 days) in the non-medication overuse subgroup (combined erenumab doses); proportion of patients achieving ≥50% reduction in monthly migraine days at Week 52 was 55.9% (90/161; 48.2%, 63.3%) versus 61.3% (136/222; 54.7%, 67.4%), respectively. Among baseline users of acute migraine-specific medication, the mean change in monthly migraine-specific medication days at Week 52 was -7.4 (-8.3, -6.4 days) in the medication overuse subgroup versus -5.4 (-6.1, -4.7 days) in the non-medication overuse subgroup. Most patients (197/298; 66.1%) in the medication overuse subgroup transitioned to non-overuse status by Week 52. Erenumab 140 mg was associated with numerically greater efficacy than erenumab 70 mg across all endpoints. No new safety signals were identified. CONCLUSION Long-term erenumab treatment demonstrated sustained efficacy and safety in patients with chronic migraine with and without acute medication overuse.
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Affiliation(s)
- Stewart J Tepper
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | | | - Stephen D Silberstein
- Jefferson Headache Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - David Kudrow
- California Medical Clinic for Headache, Santa Monica, California, USA
| | - Messoud Ashina
- Department of Neurology, Danish Headache Center, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Uwe Reuter
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Universitätsmedizin Greifswald, Greifswald, Germany
| | - David W Dodick
- Department of Neurology, Mayo Clinic, Scottsdale, Arizona, USA
| | | | | | - Jan Klatt
- Novartis Pharma AG, Basel, Switzerland
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Bagherzadeh-Fard M, Amin Yazdanifar M, Sadeghalvad M, Rezaei N. Erenumab efficacy in migraine headache prophylaxis: A systematic review. Int Immunopharmacol 2023; 117:109366. [PMID: 37012858 DOI: 10.1016/j.intimp.2022.109366] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 09/25/2022] [Accepted: 10/15/2022] [Indexed: 03/11/2023]
Abstract
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.
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Affiliation(s)
- Mahsa Bagherzadeh-Fard
- Qom University of Medical Sciences, Qom, Iran; Systematic Review and Meta-Analysis Expert Group (SRMEG), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Mohammad Amin Yazdanifar
- Qom University of Medical Sciences, Qom, Iran; Systematic Review and Meta-Analysis Expert Group (SRMEG), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Mona Sadeghalvad
- Systematic Review and Meta-Analysis Expert Group (SRMEG), Universal Scientific Education and Research Network (USERN), Tehran, Iran; Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Nima Rezaei
- Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran; Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran,Iran; Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.
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34
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Fumal A, Timmermans G. [Integrating new migraine treatments into clinical practice. Part 2 : preventive treatment]. Rev Med Liege 2023; 78:89-98. [PMID: 36799326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Migraine is the most common neurological disorder and can be very debilitating. While traditional (and older) oral preventive treatments have helped numerous patients to date, their therapeutic efficacy is often low, and adverse event profiles are troublesome. However, the coupled progress of biochemistry and molecular biology as well as the application of advanced drug design methods have led to a therapeutic renewal with, in particular, the advent of monoclonal antibodies blocking CGRP («Calcitonin Gene- Related-Peptide») transmission. We provide an overview of the preventive pharmacologic options with both older oral treatments and new ones such as botulinum toxin and the newly marketed CGRP monoclonal antibodies. The latter seem particularly interesting because they have an effectiveness at least equivalent to most oral treatments with much better tolerance and compliance. Unfortunately, their very high cost confines them to a fourth line of therapy in Belgium, a disappointment for both specialists in migraine therapy and patients who suffer from frequent migraine crisis. We finally propose a rational (and Belgian) pharmacological approach of migraine preventive treatment.
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Affiliation(s)
- Arnaud Fumal
- Service Universitaire de Neurologie, Centre de Recherche des Céphalées, Hôpital de la Citadelle, Liège, Belgique
| | - Gregory Timmermans
- Service Universitaire de Neurologie, Centre de Recherche des Céphalées, Hôpital de la Citadelle, Liège, Belgique
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35
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George N, Tepper SJ. Novel Migraine Treatments: A Review. J Oral Facial Pain Headache 2023; 37:25-32. [PMID: 36917235 PMCID: PMC10586574 DOI: 10.11607/ofph.3163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
Aims: To present a review of the mechanisms of action, available clinical data, and safety profiles of novel migraine therapeutics to inform practice. Methods: PubMed, Medline, and Google Scholar were searched for randomized controlled trials (24 publications), review articles (15 publications), and other pertinent literature (16 publications) discussing the novel migraine therapeutics available between the years 2010 and 2021. All publications were reviewed to assess the mechanism of action, relevant clinical data, and side effect profile for each novel treatment. Therapeutic gain was also recorded in studies that included a placebo arm. Results: A total of 55 studies were included in the final analysis. In the preventive treatment of migraine, novel medications target calcitonin gene-related peptide (CGRP) and fall into either the monoclonal anti-CGRP or gepant class. For the acute treatment of migraine, novel medications fall into either the ditan or gepant class. Several medical devices have been developed for the acute and preventive treatment of migraine. Conclusion: Novel therapeutics are available for both the prevention and acute treatment of migraine headaches. These new medications and neuromodulatory devices appear overall to be safe and effective in the management of migraine headaches.
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Rollo E, Romozzi M, Vollono C, Calabresi P, Geppetti P, Iannone LF. Antiseizure Medications for the Prophylaxis of Migraine during the Anti- CGRP Drugs Era. Curr Neuropharmacol 2023; 21:1767-1785. [PMID: 36582062 PMCID: PMC10514541 DOI: 10.2174/1570159x21666221228095256] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/26/2022] [Accepted: 12/01/2022] [Indexed: 12/31/2022] Open
Abstract
Migraine and epilepsy are fundamentally distinct disorders that can frequently coexist in the same patient. These two conditions significantly differ in diagnosis and therapy but share some widely- used preventive treatments. Antiseizure medications (ASMs) are the mainstay of therapy for epilepsy, and about thirty different ASMs are available to date. ASMs are widely prescribed for other neurological and non-neurological conditions, including migraine. However, only topiramate and valproic acid/valproate currently have an indication for migraine prophylaxis supported by high-quality evidence. Although without specifically approved indications and with a low level of evidence or recommendation, several other ASMs are used for migraine prophylaxis. Understanding ASM antimigraine mechanisms, including their ability to affect the pro-migraine calcitonin gene-related peptide (CGRP) signaling pathway and other pathways, may be instrumental in identifying the specific targets of their antimigraine efficacy and may increase awareness of the neurobiological differences between epilepsy and migraine. Several new ASMs are under clinical testing or have been approved for epilepsy in recent years, providing novel potential drugs for migraine prevention to enrich the treatment armamentarium and drugs that inhibit the CGRP pathway.
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Affiliation(s)
- Eleonora Rollo
- Dipartimento Universitario di Neuroscienze, University Cattolica del Sacro Cuore, Rome, Italy
| | - Marina Romozzi
- Dipartimento Universitario di Neuroscienze, University Cattolica del Sacro Cuore, Rome, Italy
| | - Catello Vollono
- Dipartimento Universitario di Neuroscienze, University Cattolica del Sacro Cuore, Rome, Italy
- Neurofisiopatologia, Dipartimento di Scienze dell’invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Paolo Calabresi
- Dipartimento Universitario di Neuroscienze, University Cattolica del Sacro Cuore, Rome, Italy
- Neurologia, Dipartimento di Scienze dell’invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Pierangelo Geppetti
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Florence, Italy
- Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, Florence, Italy
| | - Luigi F. Iannone
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Florence, Italy
- Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, Florence, Italy
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Ailani J, Kaiser EA, Mathew PG, McAllister P, Russo AF, Vélez C, Ramajo AP, Abdrabboh A, Xu C, Rasmussen S, Tepper SJ. Role of Calcitonin Gene-Related Peptide on the Gastrointestinal Symptoms of Migraine-Clinical Considerations: A Narrative Review. Neurology 2022; 99:841-853. [PMID: 36127137 PMCID: PMC9651456 DOI: 10.1212/wnl.0000000000201332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 08/16/2022] [Indexed: 11/15/2022] Open
Abstract
Calcitonin gene-related peptide (CGRP) is involved in several of the pathophysiologic processes underpinning migraine attacks. Therapies that target CGRP or its receptor have shown efficacy as preventive or acute treatments for migraine. Two small-molecule CGRP receptor antagonists (rimegepant and ubrogepant) are approved for the acute treatment of migraine, and 4 monoclonal antibodies (eptinezumab, erenumab, fremanezumab, and galcanezumab) are approved for migraine prevention; erenumab targets the canonical CGRP receptor, the others CGRP ligand. CGRP plays a role in gastrointestinal nociception, inflammation, gastric acid secretion, and motility. Nausea and vomiting are among the gastrointestinal symptoms associated with migraine, but individuals with migraine may also experience functional upper and lower gastrointestinal comorbidities, such as gastroesophageal reflux disease, gastroparesis, functional diarrhea or constipation, and irritable bowel syndrome. Although gastrointestinal symptoms in migraine can be treatment-related, they may also be attributable to increased CGRP. In this review, we summarize the epidemiologic evidence for associations between migraine and gastrointestinal disorders, consider the possible physiologic role of CGRP in these associations, and review the clinical occurrence of gastrointestinal events in patients with migraine receiving CGRP-based therapies and other migraine treatments. Because patients with migraine are at an increased risk of comorbid and treatment-related gastrointestinal effects, we also propose a patient-management strategy to mitigate these effects.
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Affiliation(s)
- Jessica Ailani
- From the Department of Neurology (J.A.), Medstar Georgetown University Hospital, Washington, DC; Department of Neurology (E.A.K.), University of Pennsylvania, Philadelphia, PA; Harvard Medical School (P.G.M.), Boston, MA; Department of Neurology (P.G.M.), Brigham & Women's Hospital, Boston, MA; Department of Neurology (P.G.M.), Harvard Vanguard Medical Associates, Braintree, MA; New England Institute for Neurology and Headache (P.G.M., P.M.), Stamford, CT; Departments of Molecular Physiology and Biophysics (A.F.R.), Neurology, University of Iowa, Iowa City, IA; Center for the Prevention and Treatment of Visual Loss (A.F.R.), Iowa VA Health Care System, Iowa City, IA; Center for Neurointestinal Health (A.F.R., C.V.), Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA; Oxford PharmaGenesis (A.P.R.), Oxford, United Kingdom; Novartis Pharmaceuticals Corporation (A.A.), East Hanover, NJ; Amgen Neuroscience (C.X., S.R.), Thousand Oaks, CA; and Geisel School of Medicine at Dartmouth (S.J.T.), Hanover, NH.
| | - Eric A Kaiser
- From the Department of Neurology (J.A.), Medstar Georgetown University Hospital, Washington, DC; Department of Neurology (E.A.K.), University of Pennsylvania, Philadelphia, PA; Harvard Medical School (P.G.M.), Boston, MA; Department of Neurology (P.G.M.), Brigham & Women's Hospital, Boston, MA; Department of Neurology (P.G.M.), Harvard Vanguard Medical Associates, Braintree, MA; New England Institute for Neurology and Headache (P.G.M., P.M.), Stamford, CT; Departments of Molecular Physiology and Biophysics (A.F.R.), Neurology, University of Iowa, Iowa City, IA; Center for the Prevention and Treatment of Visual Loss (A.F.R.), Iowa VA Health Care System, Iowa City, IA; Center for Neurointestinal Health (A.F.R., C.V.), Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA; Oxford PharmaGenesis (A.P.R.), Oxford, United Kingdom; Novartis Pharmaceuticals Corporation (A.A.), East Hanover, NJ; Amgen Neuroscience (C.X., S.R.), Thousand Oaks, CA; and Geisel School of Medicine at Dartmouth (S.J.T.), Hanover, NH
| | - Paul G Mathew
- From the Department of Neurology (J.A.), Medstar Georgetown University Hospital, Washington, DC; Department of Neurology (E.A.K.), University of Pennsylvania, Philadelphia, PA; Harvard Medical School (P.G.M.), Boston, MA; Department of Neurology (P.G.M.), Brigham & Women's Hospital, Boston, MA; Department of Neurology (P.G.M.), Harvard Vanguard Medical Associates, Braintree, MA; New England Institute for Neurology and Headache (P.G.M., P.M.), Stamford, CT; Departments of Molecular Physiology and Biophysics (A.F.R.), Neurology, University of Iowa, Iowa City, IA; Center for the Prevention and Treatment of Visual Loss (A.F.R.), Iowa VA Health Care System, Iowa City, IA; Center for Neurointestinal Health (A.F.R., C.V.), Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA; Oxford PharmaGenesis (A.P.R.), Oxford, United Kingdom; Novartis Pharmaceuticals Corporation (A.A.), East Hanover, NJ; Amgen Neuroscience (C.X., S.R.), Thousand Oaks, CA; and Geisel School of Medicine at Dartmouth (S.J.T.), Hanover, NH
| | - Peter McAllister
- From the Department of Neurology (J.A.), Medstar Georgetown University Hospital, Washington, DC; Department of Neurology (E.A.K.), University of Pennsylvania, Philadelphia, PA; Harvard Medical School (P.G.M.), Boston, MA; Department of Neurology (P.G.M.), Brigham & Women's Hospital, Boston, MA; Department of Neurology (P.G.M.), Harvard Vanguard Medical Associates, Braintree, MA; New England Institute for Neurology and Headache (P.G.M., P.M.), Stamford, CT; Departments of Molecular Physiology and Biophysics (A.F.R.), Neurology, University of Iowa, Iowa City, IA; Center for the Prevention and Treatment of Visual Loss (A.F.R.), Iowa VA Health Care System, Iowa City, IA; Center for Neurointestinal Health (A.F.R., C.V.), Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA; Oxford PharmaGenesis (A.P.R.), Oxford, United Kingdom; Novartis Pharmaceuticals Corporation (A.A.), East Hanover, NJ; Amgen Neuroscience (C.X., S.R.), Thousand Oaks, CA; and Geisel School of Medicine at Dartmouth (S.J.T.), Hanover, NH
| | - Andrew F Russo
- From the Department of Neurology (J.A.), Medstar Georgetown University Hospital, Washington, DC; Department of Neurology (E.A.K.), University of Pennsylvania, Philadelphia, PA; Harvard Medical School (P.G.M.), Boston, MA; Department of Neurology (P.G.M.), Brigham & Women's Hospital, Boston, MA; Department of Neurology (P.G.M.), Harvard Vanguard Medical Associates, Braintree, MA; New England Institute for Neurology and Headache (P.G.M., P.M.), Stamford, CT; Departments of Molecular Physiology and Biophysics (A.F.R.), Neurology, University of Iowa, Iowa City, IA; Center for the Prevention and Treatment of Visual Loss (A.F.R.), Iowa VA Health Care System, Iowa City, IA; Center for Neurointestinal Health (A.F.R., C.V.), Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA; Oxford PharmaGenesis (A.P.R.), Oxford, United Kingdom; Novartis Pharmaceuticals Corporation (A.A.), East Hanover, NJ; Amgen Neuroscience (C.X., S.R.), Thousand Oaks, CA; and Geisel School of Medicine at Dartmouth (S.J.T.), Hanover, NH
| | - Christopher Vélez
- From the Department of Neurology (J.A.), Medstar Georgetown University Hospital, Washington, DC; Department of Neurology (E.A.K.), University of Pennsylvania, Philadelphia, PA; Harvard Medical School (P.G.M.), Boston, MA; Department of Neurology (P.G.M.), Brigham & Women's Hospital, Boston, MA; Department of Neurology (P.G.M.), Harvard Vanguard Medical Associates, Braintree, MA; New England Institute for Neurology and Headache (P.G.M., P.M.), Stamford, CT; Departments of Molecular Physiology and Biophysics (A.F.R.), Neurology, University of Iowa, Iowa City, IA; Center for the Prevention and Treatment of Visual Loss (A.F.R.), Iowa VA Health Care System, Iowa City, IA; Center for Neurointestinal Health (A.F.R., C.V.), Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA; Oxford PharmaGenesis (A.P.R.), Oxford, United Kingdom; Novartis Pharmaceuticals Corporation (A.A.), East Hanover, NJ; Amgen Neuroscience (C.X., S.R.), Thousand Oaks, CA; and Geisel School of Medicine at Dartmouth (S.J.T.), Hanover, NH
| | - Angela Pozo Ramajo
- From the Department of Neurology (J.A.), Medstar Georgetown University Hospital, Washington, DC; Department of Neurology (E.A.K.), University of Pennsylvania, Philadelphia, PA; Harvard Medical School (P.G.M.), Boston, MA; Department of Neurology (P.G.M.), Brigham & Women's Hospital, Boston, MA; Department of Neurology (P.G.M.), Harvard Vanguard Medical Associates, Braintree, MA; New England Institute for Neurology and Headache (P.G.M., P.M.), Stamford, CT; Departments of Molecular Physiology and Biophysics (A.F.R.), Neurology, University of Iowa, Iowa City, IA; Center for the Prevention and Treatment of Visual Loss (A.F.R.), Iowa VA Health Care System, Iowa City, IA; Center for Neurointestinal Health (A.F.R., C.V.), Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA; Oxford PharmaGenesis (A.P.R.), Oxford, United Kingdom; Novartis Pharmaceuticals Corporation (A.A.), East Hanover, NJ; Amgen Neuroscience (C.X., S.R.), Thousand Oaks, CA; and Geisel School of Medicine at Dartmouth (S.J.T.), Hanover, NH
| | - Ahmad Abdrabboh
- From the Department of Neurology (J.A.), Medstar Georgetown University Hospital, Washington, DC; Department of Neurology (E.A.K.), University of Pennsylvania, Philadelphia, PA; Harvard Medical School (P.G.M.), Boston, MA; Department of Neurology (P.G.M.), Brigham & Women's Hospital, Boston, MA; Department of Neurology (P.G.M.), Harvard Vanguard Medical Associates, Braintree, MA; New England Institute for Neurology and Headache (P.G.M., P.M.), Stamford, CT; Departments of Molecular Physiology and Biophysics (A.F.R.), Neurology, University of Iowa, Iowa City, IA; Center for the Prevention and Treatment of Visual Loss (A.F.R.), Iowa VA Health Care System, Iowa City, IA; Center for Neurointestinal Health (A.F.R., C.V.), Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA; Oxford PharmaGenesis (A.P.R.), Oxford, United Kingdom; Novartis Pharmaceuticals Corporation (A.A.), East Hanover, NJ; Amgen Neuroscience (C.X., S.R.), Thousand Oaks, CA; and Geisel School of Medicine at Dartmouth (S.J.T.), Hanover, NH
| | - Cen Xu
- From the Department of Neurology (J.A.), Medstar Georgetown University Hospital, Washington, DC; Department of Neurology (E.A.K.), University of Pennsylvania, Philadelphia, PA; Harvard Medical School (P.G.M.), Boston, MA; Department of Neurology (P.G.M.), Brigham & Women's Hospital, Boston, MA; Department of Neurology (P.G.M.), Harvard Vanguard Medical Associates, Braintree, MA; New England Institute for Neurology and Headache (P.G.M., P.M.), Stamford, CT; Departments of Molecular Physiology and Biophysics (A.F.R.), Neurology, University of Iowa, Iowa City, IA; Center for the Prevention and Treatment of Visual Loss (A.F.R.), Iowa VA Health Care System, Iowa City, IA; Center for Neurointestinal Health (A.F.R., C.V.), Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA; Oxford PharmaGenesis (A.P.R.), Oxford, United Kingdom; Novartis Pharmaceuticals Corporation (A.A.), East Hanover, NJ; Amgen Neuroscience (C.X., S.R.), Thousand Oaks, CA; and Geisel School of Medicine at Dartmouth (S.J.T.), Hanover, NH
| | - Soeren Rasmussen
- From the Department of Neurology (J.A.), Medstar Georgetown University Hospital, Washington, DC; Department of Neurology (E.A.K.), University of Pennsylvania, Philadelphia, PA; Harvard Medical School (P.G.M.), Boston, MA; Department of Neurology (P.G.M.), Brigham & Women's Hospital, Boston, MA; Department of Neurology (P.G.M.), Harvard Vanguard Medical Associates, Braintree, MA; New England Institute for Neurology and Headache (P.G.M., P.M.), Stamford, CT; Departments of Molecular Physiology and Biophysics (A.F.R.), Neurology, University of Iowa, Iowa City, IA; Center for the Prevention and Treatment of Visual Loss (A.F.R.), Iowa VA Health Care System, Iowa City, IA; Center for Neurointestinal Health (A.F.R., C.V.), Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA; Oxford PharmaGenesis (A.P.R.), Oxford, United Kingdom; Novartis Pharmaceuticals Corporation (A.A.), East Hanover, NJ; Amgen Neuroscience (C.X., S.R.), Thousand Oaks, CA; and Geisel School of Medicine at Dartmouth (S.J.T.), Hanover, NH
| | - Stewart J Tepper
- From the Department of Neurology (J.A.), Medstar Georgetown University Hospital, Washington, DC; Department of Neurology (E.A.K.), University of Pennsylvania, Philadelphia, PA; Harvard Medical School (P.G.M.), Boston, MA; Department of Neurology (P.G.M.), Brigham & Women's Hospital, Boston, MA; Department of Neurology (P.G.M.), Harvard Vanguard Medical Associates, Braintree, MA; New England Institute for Neurology and Headache (P.G.M., P.M.), Stamford, CT; Departments of Molecular Physiology and Biophysics (A.F.R.), Neurology, University of Iowa, Iowa City, IA; Center for the Prevention and Treatment of Visual Loss (A.F.R.), Iowa VA Health Care System, Iowa City, IA; Center for Neurointestinal Health (A.F.R., C.V.), Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA; Oxford PharmaGenesis (A.P.R.), Oxford, United Kingdom; Novartis Pharmaceuticals Corporation (A.A.), East Hanover, NJ; Amgen Neuroscience (C.X., S.R.), Thousand Oaks, CA; and Geisel School of Medicine at Dartmouth (S.J.T.), Hanover, NH
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Varnado OJ, Hoyt M, Ye W, Nicholson R. Patient characteristics and treatment utilization among patients with migraine initiating self-injectable calcitonin gene-related peptide monoclonal antibody and novel acute medication. Curr Med Res Opin 2022; 38:1451-1457. [PMID: 35762152 DOI: 10.1080/03007995.2022.2091333] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE This study describes patient characteristics and utilization of recently approved novel acute medication and calcitonin gene-related peptide (CGRP) monoclonal antibodies. METHODS This retrospective observational study utilized the IBM MarketScan Research Database and Optum's Clinformatics Data Mart from May 2017 through December 2020 (index period). Adult patients initiating self-injectable CGRP monoclonal antibodies (mAbs) (erenumab, fremanezumab, galcanezumab) and novel acute migraine medications (lasmiditan, rimegepant, ubrogepant) with: (a) ≥3 months overlap between the index medication and second medication initiated along with it; (b) ≥1 claim for migraine diagnosis; and (c) continuous medical and pharmacy benefits 12 months pre- and 3 months post-index were included. Data are presented descriptively. RESULTS A total of 2840 patients from the MarketScan database and 657 patients from the Optum database were included. Identified patients' (MarketScan/Optum) mean age was 44.7/51.2 years; they were mostly women (88.8%/87.7%); a majority had a chronic migraine diagnosis (64.4%/71.4%) and were prescribed both preventive and acute treatments for migraine in the pre-index period. Most patients received a combination of both preventive and acute medications binding CGRP receptors (43.6%/59.0%) or preventive medication binding CGRP ligands and acute medication binding CGRP receptors (51.9%/34.9%). Mean (SD) number of days of concomitant use of CGRP and novel acute medications were: MarketScan, 29.1 (18.7); Optum, 31.8 (20.4). Prescribing patterns were similar across healthcare provider types within each database. CONCLUSIONS Understanding patient characteristics and treatment utilization patterns among patients prescribed both a CGRP mAb and novel acute medication may provide valuable insight regarding migraine treatment selection for healthcare decision makers.
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Affiliation(s)
| | - Maggie Hoyt
- Eli Lilly and Company, Indianapolis, IN, USA
| | - Wenyu Ye
- Eli Lilly and Company, Indianapolis, IN, USA
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Lau CI, Wang YF. 2022 Taiwan Guidelines for Acute Treatment of Migraine. Acta Neurol Taiwan 2022; 31(2):89-113. [PMID: 36153693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
The Taiwan Headache Society published its guidelines for acute migraine treatment in 2017. Since then, emerging drugs and treatment options have developed rapidly. The migraine-specific drugs gepants and ditans and several noninvasive neuromodulation devices have been approved for use in Europe and the United States. Although not all emerging drugs and treatment options have been approved for use in Taiwan, keeping pace with international trends and updating treatment guidelines are imperative. Therefore, the Treatment Guideline Subcommittee of the Taiwan Headache Society reviewed the quality of recent trials, evaluated the corresponding grade of evidence, and appraised the reported clinical efficacy to reach a new consensus. To ensure that the updated Taiwan guidelines are appropriate and feasible, the subcommittee also referred to the guidelines from the United States, Europe, Canada, and other countries concerning the main roles, recommendation levels, clinical efficacy, and adverse reactions of drugs for the acute migraine treatment. Several types of drugs are currently available for acute migraine treatment in Taiwan. These drugs can be categorized into migraine-specific and migraine-non-specific. Among them, migraine-specific triptans (oral or nasal spray formulations) and migraine-nonspecific acetaminophen and NSAIDs (diclofenac, ibuprofen, naproxen) are highly recommended because they are supported by strong evidence and demonstrate high efficacy. Prochlorperazine injection has been upgraded to a highly recommended level because of the rich clinical experience for this treatment. Ergotamine/caffeine remains a second-line drug because of its lower specificity and efficacy compared with triptans. High-dose aspirin was downgraded to rescue treatment because of potential gastrointestinal side effects. Although evidence supports the combination of oral tramadol and acetaminophen, this combination should be used as a rescue treatment due to concerns about dependence. Evidence supporting the use of intravenous tramadol or morphine is insufficient; therefore, their use is not recommended. As for non-pharmacological approaches, there are only limited controlled data. The choice of treatment for acute migraine attacks should follow the concept of "stratified care." For mild to moderate migraine attacks, oral NSAIDs are the first choice, with combination analgesics, intravenous/intramuscular NSAIDs as alternatives. For moderate to severe attacks, oral or nasal spray triptans and ergotamine/caffeine compounds are recommended and should be administered in the early stage of migraine attacks. Antiemetics can be used as supplements to alleviate nausea and vomiting. Other emerging migraine-specific drugs, such as gepants or ditans, may also have a role in the future. Notably, a combination of a triptan and a NSAID yielded a better efficacy compared with either therapy alone. Parenteral steroids and fluid supply are the first-line treatment for status migrainosus. Acetaminophen is suitable for mild to moderate migraine attacks and remains the first choice for children and pregnant women. To prevent medication overuse headache, the use of acute treatment should be limited to a maximum of 2 days per week. Key words: acute migraine treatment, evidence-based medicine, treatment guidelines, triptans, ergotamine, neuromodulation.
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Affiliation(s)
- Chi Ieong Lau
- Dementia Center, Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Yen-Feng Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
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Jiang Y, Huang ZL. Recent advances in targeting calcitonin gene-related peptide for the treatment of menstrual migraine: A narrative review. Medicine (Baltimore) 2022; 101:e29361. [PMID: 35713436 PMCID: PMC9276107 DOI: 10.1097/md.0000000000029361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 04/08/2022] [Indexed: 11/26/2022] Open
Abstract
Menstrual migraine (MM) has a longer duration and higher drug resistance than non-perimenstrual migraine. Calcitonin gene-related peptide (CGRP) and CGRP receptors are expressed in the peripheral and central nervous systems throughout the trigeminovascular system. The CGRP/CGRP receptor axis plays an important role in sensory physiology and pharmacology. CGRP receptor antagonists and anti-CGRP monoclonal antibodies (mAbs) have shown consistent efficacy and tolerability in the prevention of chronic or episodic migraine and are now approved for clinical use. However, few studies have reported the use of these drugs in MM, and no specific treatment for MM has been approved. This review aimed to shed light on the recent advances in targeting calcitonin gene-related peptides for the treatment of menstrual migraines in PubMed. In this review, we first discuss the axis of the CGRP/CGRP receptor. We then discuss the role of CGRP receptor antagonists and anti-CGRP mAbs in MM treatment. Finally, we discuss the role of the combination of anti-CGRP mAbs and CGRP receptor antagonists in migraine treatment and the drugs that inhibit CGRP release. Altogether, the anti-CGRP mAbs or CGRP receptor antagonists showed good efficacy and safety in the treatment of MM.
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Cohen F, Yuan H, Silberstein SD. Calcitonin Gene-Related Peptide (CGRP)-Targeted Monoclonal Antibodies and Antagonists in Migraine: Current Evidence and Rationale. BioDrugs 2022; 36:341-358. [PMID: 35476215 PMCID: PMC9043885 DOI: 10.1007/s40259-022-00530-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2022] [Indexed: 12/25/2022]
Abstract
Calcitonin gene-related peptide (CGRP), a 37 amino-acid neuropeptide found mostly in peptidergic sensory C-fibers, has been suggested to be implicated in the pathogenesis of migraine, which is one of the most common neurological disorders seen in medical practice, affecting almost 16% of the US population. While previously thought to be a vascular condition, migraine attacks are the result of neurogenic inflammation and peripheral/central sensitization through dysfunctional activation of the trigeminovascular system. To date, two classes of therapeutic agents have been developed to interrupt the function of CGRP: CGRP-targeted monoclonal antibodies (mAbs) and small-molecule antagonists (gepants). There are currently four CGRP-targeted mAbs and three gepants that are US Food and Drug Administration (FDA) approved for the treatment of migraine. Multiple phase II and III studies have established the efficacies and tolerability of these treatments. Previously, we reviewed the fundamental role of CGRP in migraine pathogenesis. Here, we discuss in depth the clinical evidence (randomized controlled trials and real-world studies), safety, and tolerability of CGRP-targeted mAbs and gepants for treating migraine.
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Affiliation(s)
- Fred Cohen
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, 900 Walnut Street, Suite 200, Philadelphia, PA, 19107, USA
| | - Hsiangkuo Yuan
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, 900 Walnut Street, Suite 200, Philadelphia, PA, 19107, USA
| | - Stephen D Silberstein
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, 900 Walnut Street, Suite 200, Philadelphia, PA, 19107, USA.
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Kubota GT. It is time anti-CGRP monoclonal antibodies be considered first-line prophylaxis for migraine. Arq Neuropsiquiatr 2022; 80:218-226. [PMID: 35976302 PMCID: PMC9491437 DOI: 10.1590/0004-282x-anp-2022-s112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 04/29/2022] [Indexed: 06/15/2023]
Abstract
The result of more than thirty years of research, anti-CGRP monoclonal antibodies are currently the state of the art for migraine preventive therapy. Their efficacy and safety, supported by an already large and growing body of evidence, are added by many other advantages: an early onset of action, favorable posology, negligible pharmacological interaction, and a broad-reaching efficacy in many challenging clinical contexts. When compared to standard prophylactics, these novel medications seem at least as efficacious, clearly more tolerable and, consequently, with a superior adherence profile. Furthermore, recently published analyses indicate that they are cost-effective, especially among those with chronic migraine. Yet, current guidelines endorse their use only after multiple other preventives have failed or have been deemed not tolerable. Although this recommendation may have been sensible at first, the now available data strongly point that time has come for anti-CGRP monoclonal antibodies to be acknowledged as first-line treatments for migraine patients with severe disability. For these individuals, delaying treatment until several other alternatives have failed incurs in significant losses, both economically and to many relevant aspects of their lives.
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Affiliation(s)
- Gabriel Taricani Kubota
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil
- Instituto do Câncer do Estado de São Paulo, São Paulo SP, Brazil
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Abstract
Remarkable advancements have been made in the field of migraine pathophysiology and pharmacotherapy over the past decade. Understanding the molecular mechanism of calcitonin gene-related peptide (CGRP) has led to the discovery of a novel class of drugs, CGRP functional blocking monoclonal antibodies (mAbs), for migraine prevention. CGRP is a neuropeptide inherently involved in migraine physiology where its receptors are found dispersed throughout the central and peripheral nervous systems. CGRP-targeted mAbs are effective in the preventive treatment of both chronic and episodic migraine. The advantages of mAbs over oral migraine preventives are numerous. Favorable attributes of the mAbs include high affinity and selectivity for CGRP molecular targets, long-circulating plasma half-lives, and limited risk for nonspecific hepatic and renal toxicity. This pharmacological profile leads to fewer off-target (side) effects and drug-drug interactions rendering mAbs an attractive alternative to traditional small molecule therapies, especially for the preventive treatment of migraine. MAbs display minimal drug interaction thus are excellent for patients prescribed with multiple medications. However, the long-term safety of CGRP blockade is incompletely known, and CGRP mAbs use should be avoided during pregnancy. CGRP mAbs represent a radical shift in preventing chronic and episodic migraine.
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Affiliation(s)
- Fred Cohen
- Department of Neurology, Jefferson Headache Center, Thomas Jefferson University, 900 Walnut Street, Suite 200, Philadelphia, PA, 19107, USA
| | - Hsiangkuo Yuan
- Department of Neurology, Jefferson Headache Center, Thomas Jefferson University, 900 Walnut Street, Suite 200, Philadelphia, PA, 19107, USA
| | - E M G DePoy
- Department of Neurology, Jefferson Headache Center, Thomas Jefferson University, 900 Walnut Street, Suite 200, Philadelphia, PA, 19107, USA
| | - Stephen D Silberstein
- Department of Neurology, Jefferson Headache Center, Thomas Jefferson University, 900 Walnut Street, Suite 200, Philadelphia, PA, 19107, USA.
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Blumenfeld AM, Knievel K, Manack Adams A, Severt L, Butler M, Lai H, Dodick DW. Ubrogepant Is Safe and Efficacious in Participants Taking Concomitant Preventive Medication for Migraine: A Pooled Analysis of Phase 3 Trials. Adv Ther 2022; 39:692-705. [PMID: 34874514 PMCID: PMC8799553 DOI: 10.1007/s12325-021-01923-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 09/14/2021] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Ubrogepant is a calcitonin gene-related peptide receptor antagonist indicated for acute treatment of migraine that can be used to treat breakthrough attacks in individuals taking preventive treatment for migraine. We evaluated the impact of preventive medication use on the efficacy and safety of ubrogepant for the acute treatment of migraine. METHODS This was an analysis of pooled efficacy data from the ACHIEVE I and ACHIEVE II phase 3 trials, in which efficacy of ubrogepant was assessed at 2 h after taking study medication for pain freedom, absence of most bothersome symptom (MBS), and pain relief. In addition, a long-term safety (LTS) extension trial was completed where safety was assessed on the basis of incidence and severity of treatment-emergent adverse events (TEAEs). Outcomes were compared between participants with or without prior (within 6 months) preventive medication use (anticonvulsants, beta blockers, antidepressants, or onabotulinumtoxinA). For efficacy analyses, data were pooled across ACHIEVE trials for the 50 mg and placebo groups; for safety analyses, data for all dose groups (50 mg and 100 mg) in the LTS trial were pooled. RESULTS Preventive treatments were used by 417 of 2247 (18.6%) participants analyzed in the ACHIEVE trials and by 143 of 813 (17.5%) participants in the LTS trial. Responder rates for all outcomes were similar between participants with or without preventive treatment within each dose group (p > 0.05). No significant differences were noted across the different preventive medications. Rates and types of TEAEs were similar between participants with or without preventive treatment. No serious treatment-related adverse events were reported. CONCLUSION Efficacy and safety of ubrogepant for the acute treatment of migraine were similar between participants with or without prior or current use of concomitant preventive medication. TRIAL REGISTRATION ClinicalTrials.gov identifiers: NCT02828020 (ACHIEVE I), NCT02867709 (ACHIEVE II), and NCT02873221 (long-term safety trial).
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Affiliation(s)
- Andrew M Blumenfeld
- Headache Center of Southern California, 6010 Hidden Valley Rd #200, Carlsbad, CA, 92011, USA.
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Abstract
Migraine is a common and disabling neurological disorder, with several manifestations, of which pain is just one. Despite its worldwide prevalence, there remains a paucity of targeted and effective treatments for the condition, leaving many of those affected underserved by available treatments. Work over the last 30+ years has recently led to the emergence of the first targeted acute and preventive treatments in our practice since the triptan era in the early 1990s, which are changing the landscape of migraine treatment. These include the monoclonal antibodies targeting calcitonin gene-related peptide or its receptor. Evolving work on novel therapeutic targets, as well as continuing to exploit drugs used in other disorders that may also have a therapeutic effect in migraine, is likely to lead to more and more treatments being able to be offered to migraineurs. Future work involves the development of agents that lack vasoconstrictive effects, such as lasmiditan, do not contribute to medication overuse, such as the gepants, and do not interact with other drugs that may be used for the disorder, as well as agents that can act both acutely and preventively, thereby utilising the quantum between acute and preventive drug effects which has been demonstrated with different migraine drugs before. Here we discuss the evolution of oral migraine treatments over the last 5 years, including those that have gained regulatory approval and reached clinical practice, those in development and potential other targets for the future.
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Affiliation(s)
- Nazia Karsan
- Headache Group, School of Neuroscience, Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- NIHR King's Clinical Research Facility and South London and Maudsley Biomedical Research Centre, Wellcome Foundation Building, King's College Hospital, London, SE5 9PJ, UK
| | - Peter J Goadsby
- Headache Group, School of Neuroscience, Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
- NIHR King's Clinical Research Facility and South London and Maudsley Biomedical Research Centre, Wellcome Foundation Building, King's College Hospital, London, SE5 9PJ, UK.
- Department of Neurology, University of California, Los Angeles, USA.
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Abstract
BACKGROUND Atogepant is an oral, small-molecule, calcitonin gene-related peptide receptor antagonist that is being investigated for the preventive treatment of migraine. METHODS In a phase 3, double-blind trial, we randomly assigned adults with 4 to 14 migraine days per month in a 1:1:1:1 ratio to receive a once-daily dose of oral atogepant (10 mg, 30 mg, or 60 mg) or placebo for 12 weeks. The primary end point was the change from baseline in the mean number of migraine days per month across the 12 weeks. Secondary end points included headache days per month, a reduction from baseline of at least 50% in the 3-month average of migraine days per month, quality of life, and scores on the Activity Impairment in Migraine-Diary (AIM-D). RESULTS A total of 2270 participants were screened, 910 were enrolled, and 873 were included in the efficacy analysis; 214 were assigned to the 10-mg atogepant group, 223 to the 30-mg atogepant group, 222 to the 60-mg atogepant group, and 214 to the placebo group. The mean number of migraine days per month at baseline ranged from 7.5 to 7.9 in the four groups. The changes from baseline across 12 weeks were -3.7 days with 10-mg atogepant, -3.9 days with 30-mg atogepant, -4.2 days with 60-mg atogepant, and -2.5 days with placebo. The mean differences from placebo in the change from baseline were -1.2 days with 10-mg atogepant (95% confidence interval [CI], -1.8 to -0.6), -1.4 days with 30-mg atogepant (95% CI, -1.9 to -0.8), and -1.7 days with 60-mg atogepant (95% CI, -2.3 to -1.2) (P<0.001 for all comparisons with placebo). Results for the secondary end points favored atogepant over placebo with the exceptions of the AIM-D Performance of Daily Activities score and the AIM-D Physical Impairment score for the 10-mg dose. The most common adverse events were constipation (6.9 to 7.7% across atogepant doses) and nausea (4.4 to 6.1% across atogepant doses). Serious adverse events included one case each of asthma and optic neuritis in the 10-mg atogepant group. CONCLUSIONS Oral atogepant once daily was effective in reducing the number of migraine days and headache days over a period of 12 weeks. Adverse events included constipation and nausea. Longer and larger trials are needed to determine the effect and safety of atogepant for migraine prevention. (Funded by Allergan; ADVANCE ClinicalTrials.gov number, NCT03777059.).
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Affiliation(s)
- Jessica Ailani
- From MedStar Georgetown University Hospital, Washington, DC (J.A.); Albert Einstein College of Medicine and Montefiore Headache Center, New York (R.B.L.); the National Institute for Health Research-Wellcome Trust King's Clinical Research Facility, King's College London, London (P.J.G.); the Department of Neurology, University of California, Los Angeles, Los Angeles (P.J.G.); and AbbVie, Madison, NJ (H.G., R.M., L.S., M.F., J.M.T.)
| | - Richard B Lipton
- From MedStar Georgetown University Hospital, Washington, DC (J.A.); Albert Einstein College of Medicine and Montefiore Headache Center, New York (R.B.L.); the National Institute for Health Research-Wellcome Trust King's Clinical Research Facility, King's College London, London (P.J.G.); the Department of Neurology, University of California, Los Angeles, Los Angeles (P.J.G.); and AbbVie, Madison, NJ (H.G., R.M., L.S., M.F., J.M.T.)
| | - Peter J Goadsby
- From MedStar Georgetown University Hospital, Washington, DC (J.A.); Albert Einstein College of Medicine and Montefiore Headache Center, New York (R.B.L.); the National Institute for Health Research-Wellcome Trust King's Clinical Research Facility, King's College London, London (P.J.G.); the Department of Neurology, University of California, Los Angeles, Los Angeles (P.J.G.); and AbbVie, Madison, NJ (H.G., R.M., L.S., M.F., J.M.T.)
| | - Hua Guo
- From MedStar Georgetown University Hospital, Washington, DC (J.A.); Albert Einstein College of Medicine and Montefiore Headache Center, New York (R.B.L.); the National Institute for Health Research-Wellcome Trust King's Clinical Research Facility, King's College London, London (P.J.G.); the Department of Neurology, University of California, Los Angeles, Los Angeles (P.J.G.); and AbbVie, Madison, NJ (H.G., R.M., L.S., M.F., J.M.T.)
| | - Rosa Miceli
- From MedStar Georgetown University Hospital, Washington, DC (J.A.); Albert Einstein College of Medicine and Montefiore Headache Center, New York (R.B.L.); the National Institute for Health Research-Wellcome Trust King's Clinical Research Facility, King's College London, London (P.J.G.); the Department of Neurology, University of California, Los Angeles, Los Angeles (P.J.G.); and AbbVie, Madison, NJ (H.G., R.M., L.S., M.F., J.M.T.)
| | - Lawrence Severt
- From MedStar Georgetown University Hospital, Washington, DC (J.A.); Albert Einstein College of Medicine and Montefiore Headache Center, New York (R.B.L.); the National Institute for Health Research-Wellcome Trust King's Clinical Research Facility, King's College London, London (P.J.G.); the Department of Neurology, University of California, Los Angeles, Los Angeles (P.J.G.); and AbbVie, Madison, NJ (H.G., R.M., L.S., M.F., J.M.T.)
| | - Michelle Finnegan
- From MedStar Georgetown University Hospital, Washington, DC (J.A.); Albert Einstein College of Medicine and Montefiore Headache Center, New York (R.B.L.); the National Institute for Health Research-Wellcome Trust King's Clinical Research Facility, King's College London, London (P.J.G.); the Department of Neurology, University of California, Los Angeles, Los Angeles (P.J.G.); and AbbVie, Madison, NJ (H.G., R.M., L.S., M.F., J.M.T.)
| | - Joel M Trugman
- From MedStar Georgetown University Hospital, Washington, DC (J.A.); Albert Einstein College of Medicine and Montefiore Headache Center, New York (R.B.L.); the National Institute for Health Research-Wellcome Trust King's Clinical Research Facility, King's College London, London (P.J.G.); the Department of Neurology, University of California, Los Angeles, Los Angeles (P.J.G.); and AbbVie, Madison, NJ (H.G., R.M., L.S., M.F., J.M.T.)
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Abstract
BACKGROUND Reversible cerebral vasoconstriction syndrome is normally triggered by vasoactive compounds or illicit drugs. A new type of migraine preventive medication blocks calcitonin gene-related peptide utilizing monoclonal antibodies. Calcitonin gene-related peptide is a potent vasodilator for the cerebrovascular system. Could blocking calcitonin gene-related peptide be a trigger for cerebral artery vasospasm in patients susceptible to developing reversible cerebral vasoconstriction syndrome (migraine patients) or in individuals using vasoactive compounds? We present a case of reversible cerebral vasoconstriction syndrome occurring after calcitonin gene-related peptide monoclonal antibody treatment. CASE REPORT A 43-year -old woman with a history of episodic migraine developed an acute headache with orgasm two days after taking her second injection of erenumab. Ten days after erenumab injection she developed a thunderclap headache while completing a high intensity workout. These new headaches were only left sided. Computed tomography angiography demonstrated mild to moderate areas of narrowing involving the left middle and anterior cerebral arteries, concerning for reversible cerebral vasoconstriction syndrome. She denied exposure to any known reversible cerebral vasoconstriction syndrome precipitant medication or illicit drugs. She did endorse recent exposure to high altitude prior to erenumab therapy. She was started on verapamil 40 mg three times per day and her headache ceased within 24 h of initiating treatment. A repeat CT angiogram completed 4 weeks after the initial study noted resolution of the areas of vessel stenosis. CONCLUSION A case of reversible cerebral vasoconstriction syndrome developing after treatment with a calcitonin gene-related peptide monoclonal antibody is presented. The timing of the new type of headache occurring 2 days post erenumab injection suggests a possible cause and effect relationship. Reversible cerebral vasoconstriction syndrome as a possible treatment-related complication to the usage of calcitonin gene-related peptide monoclonal antibodies needs to be studied further.
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Affiliation(s)
| | - Alok A Bhatt
- Department of Neuroradiology, Mayo Clinic, FL, USA
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Ailani J, Burch RC, Robbins MS. The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice. Headache 2021; 61:1021-1039. [PMID: 34160823 DOI: 10.1111/head.14153] [Citation(s) in RCA: 231] [Impact Index Per Article: 77.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/04/2021] [Accepted: 05/09/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To incorporate recent research findings, expert consensus, and patient perspectives into updated guidance on the use of new acute and preventive treatments for migraine in adults. BACKGROUND The American Headache Society previously published a Consensus Statement on the use of newly introduced treatments for adults with migraine. This update, which is based on the expanded evidence base and emerging expert consensus concerning postapproval usage, provides practical recommendations in the absence of a formal guideline. METHODS This update involved four steps: (1) review of data about the efficacy, safety, and clinical use of migraine treatments introduced since the previous Statement was published; (2) incorporation of these data into a proposed update; (3) review and commentary by the Board of Directors of the American Headache Society and patients and advocates associated with the American Migraine Foundation; (4) consideration of these collective insights and integration into an updated Consensus Statement. RESULTS Since the last Consensus Statement, no evidence has emerged to alter the established principles of either acute or preventive treatment. Newly introduced acute treatments include two small-molecule calcitonin gene-related peptide (CGRP) receptor antagonists (ubrogepant, rimegepant); a serotonin (5-HT1F ) agonist (lasmiditan); a nonsteroidal anti-inflammatory drug (celecoxib oral solution); and a neuromodulatory device (remote electrical neuromodulation). New preventive treatments include an intravenous anti-CGRP ligand monoclonal antibody (eptinezumab). Several modalities, including neuromodulation (electrical trigeminal nerve stimulation, noninvasive vagus nerve stimulation, single-pulse transcranial magnetic stimulation) and biobehavioral therapy (cognitive behavioral therapy, biofeedback, relaxation therapies, mindfulness-based therapies, acceptance and commitment therapy) may be appropriate for either acute and/or preventive treatment; a neuromodulation device may be appropriate for acute migraine treatment only (remote electrical neuromodulation). CONCLUSIONS The integration of new treatments into clinical practice should be informed by the potential for benefit relative to established therapies, as well as by the characteristics and preferences of individual patients.
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Affiliation(s)
- Jessica Ailani
- Department of Neurology, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Rebecca C Burch
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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VanderPluym JH, Halker Singh RB, Urtecho M, Morrow AS, Nayfeh T, Torres Roldan VD, Farah MH, Hasan B, Saadi S, Shah S, Abd-Rabu R, Daraz L, Prokop LJ, Murad MH, Wang Z. Acute Treatments for Episodic Migraine in Adults: A Systematic Review and Meta-analysis. JAMA 2021; 325:2357-2369. [PMID: 34128998 PMCID: PMC8207243 DOI: 10.1001/jama.2021.7939] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Migraine is common and can be associated with significant morbidity, and several treatment options exist for acute therapy. OBJECTIVE To evaluate the benefits and harms associated with acute treatments for episodic migraine in adults. DATA SOURCES Multiple databases from database inception to February 24, 2021. STUDY SELECTION Randomized clinical trials and systematic reviews that assessed effectiveness or harms of acute therapy for migraine attacks. DATA EXTRACTION AND SYNTHESIS Independent reviewers selected studies and extracted data. Meta-analysis was performed with the DerSimonian-Laird random-effects model with Hartung-Knapp-Sidik-Jonkman variance correction or by using a fixed-effect model based on the Mantel-Haenszel method if the number of studies was small. MAIN OUTCOMES AND MEASURES The main outcomes included pain freedom, pain relief, sustained pain freedom, sustained pain relief, and adverse events. The strength of evidence (SOE) was graded with the Agency for Healthcare Research and Quality Methods Guide for Effectiveness and Comparative Effectiveness Reviews. FINDINGS Evidence on triptans and nonsteroidal anti-inflammatory drugs was summarized from 15 systematic reviews. For other interventions, 115 randomized clinical trials with 28 803 patients were included. Compared with placebo, triptans and nonsteroidal anti-inflammatory drugs used individually were significantly associated with reduced pain at 2 hours and 1 day (moderate to high SOE) and increased risk of mild and transient adverse events. Compared with placebo, calcitonin gene-related peptide receptor antagonists (low to high SOE), lasmiditan (5-HT1F receptor agonist; high SOE), dihydroergotamine (moderate to high SOE), ergotamine plus caffeine (moderate SOE), acetaminophen (moderate SOE), antiemetics (low SOE), butorphanol (low SOE), and tramadol in combination with acetaminophen (low SOE) were significantly associated with pain reduction and increase in mild adverse events. The findings for opioids were based on low or insufficient SOE. Several nonpharmacologic treatments were significantly associated with improved pain, including remote electrical neuromodulation (moderate SOE), transcranial magnetic stimulation (low SOE), external trigeminal nerve stimulation (low SOE), and noninvasive vagus nerve stimulation (moderate SOE). No significant difference in adverse events was found between nonpharmacologic treatments and sham. CONCLUSIONS AND RELEVANCE There are several acute treatments for migraine, with varying strength of supporting evidence. Use of triptans, nonsteroidal anti-inflammatory drugs, acetaminophen, dihydroergotamine, calcitonin gene-related peptide antagonists, lasmiditan, and some nonpharmacologic treatments was associated with improved pain and function. The evidence for many other interventions, including opioids, was limited.
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Affiliation(s)
- Juliana H. VanderPluym
- Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota
- Department of Neurology, Mayo Clinic, Scottsdale, Arizona
| | - Rashmi B. Halker Singh
- Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota
- Department of Neurology, Mayo Clinic, Scottsdale, Arizona
| | - Meritxell Urtecho
- Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Allison S. Morrow
- Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Tarek Nayfeh
- Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Victor D. Torres Roldan
- Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Magdoleen H. Farah
- Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Bashar Hasan
- Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Samer Saadi
- Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Sahrish Shah
- Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Rami Abd-Rabu
- Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Lubna Daraz
- Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Larry J. Prokop
- Department of Library–Public Services, Mayo Clinic, Rochester, Minnesota
| | - Mohammad Hassan Murad
- Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Zhen Wang
- Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, Minnesota
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50
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Abstract
IMPORTANCE Approximately 90% of people in the US experience headache during their lifetime. Migraine is the second leading cause of years lived with disability worldwide. OBSERVATIONS Primary headache disorders are defined as headaches that are unrelated to an underlying medical condition and are categorized into 4 groups: migraine, tension-type headache, trigeminal autonomic cephalalgias, and other primary headache disorders. Studies evaluating prevalence in more than 100 000 people reported that tension-type headache affected 38% of the population, while migraine affected 12% and was the most disabling. Secondary headache disorders are defined as headaches due to an underlying medical condition and are classified according to whether they are due to vascular, neoplastic, infectious, or intracranial pressure/volume causes. Patients presenting with headache should be evaluated to determine whether their headache is most likely a primary or a secondary headache disorder. They should be evaluated for symptoms or signs that suggest an urgent medical problem such as an abrupt onset, neurologic signs, age 50 years and older, presence of cancer or immunosuppression, and provocation by physical activities or postural changes. Acute migraine treatment includes acetaminophen, nonsteroidal anti-inflammatory drugs, and combination products that include caffeine. Patients not responsive to these treatments may require migraine-specific treatments including triptans (5-HT1B/D agonists), which eliminate pain in 20% to 30% of patients by 2 hours, but are accompanied by adverse effects such as transient flushing, tightness, or tingling in the upper body in 25% of patients. Patients with or at high risk for cardiovascular disease should avoid triptans because of vasoconstrictive properties. Acute treatments with gepants, antagonists to receptors for the inflammatory neuropeptide calcitonin gene-related peptide, such as rimegepant or ubrogepant, can eliminate headache symptoms for 2 hours in 20% of patients but have adverse effects of nausea and dry mouth in 1% to 4% of patients. A 5-HT1F agonist, lasmiditan, is also available for acute migraine treatment and appears safe in patients with cardiovascular risk factors. Preventive treatments include antihypertensives, antiepileptics, antidepressants, calcitonin gene-related peptide monoclonal antibodies, and onabotulinumtoxinA, which reduce migraine by 1 to 3 days per month relative to placebo. CONCLUSIONS AND RELEVANCE Headache disorders affect approximately 90% of people during their lifetime. Among primary headache disorders, migraine is most debilitating and can be treated acutely with analgesics, nonsteroidal anti-inflammatory drugs, triptans, gepants, and lasmiditan.
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Affiliation(s)
- Matthew S Robbins
- Department of Neurology, Weill Cornell Medical College, New York, New York
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