1
|
Arsava EM, Topcuoglu MA, Ay I, Liebler E, Ay H. Abstract WMP5: Non-invasive Vagus Nerve Stimulation For The Acute Treatment Of Ischemic Or Hemorrhagic Stroke. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.wmp5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
This first-in-human randomized, blinded, sham-controlled, multicenter study assessed the safety and feasibility of non-invasive vagus nerve stimulation (nVNS) for the acute treatment of ischemic and hemorrhagic stroke. Potential efficacy was also assessed.
Methods:
Eligible participants admitted to nine clinical sites received standard care for acute stroke and were randomly assigned to low-dose nVNS, sham (2-minute stimulation applied to the skin overlying the vagus nerve every 10 minutes for an hour; 7 stimulations) or high-dose nVNS (2-minute stimulation every 10 minutes during hour 1 and hour 5; 14 stimulations) within 6 hours of stroke onset. Safety endpoints included severe bradycardia (≤50 beats/min) or significant hypotension (≥20-mm Hg reduction in arterial blood pressure) evaluated at 2 and 5 minutes after each stimulation and 30 minutes after the final stimulation. Feasibility was measured as the proportion of eligible patients in whom nVNS could be initiated within 6 hours of stroke onset and the ability to deliver scheduled stimulations per protocol. Efficacy measurements included absolute and relative infarct growth 24 hours poststroke compared to baseline and the proportion of patients with an NIH Stroke Scale (NIHSS) score of ≤4 or a ≥8-point improvement at 24 hours.
Results:
Sixty-eight patients with ischemic (n=60) or hemorrhagic (n=8) stroke completed the study. Baseline characteristics did not differ between sham (n=24) and nVNS (n=44). No significant bradycardia (2.9% of sham vs 3.1% of nVNS;
p
=0.965) or hypotension (1.1% of sham vs 2.5% of nVNS;
p
=0.145) occurred with nVNS. No deaths, acute coronary syndrome, symptomatic intracerebral hemorrhage, or stimulation site reactions were noted. All patients received 100% of intended stimulations per protocol. Clinical efficacy measures were similar between sham and total nVNS. Relative infarct growth, measured by diffusion weighted imaging, in the high dose nVNS group (63.3%) was lower than in the sham group (185.8%;
p
=0.05).
Conclusions:
This study suggests that nVNS is safe and feasible for the acute treatment for ischemic and hemorrhagic stroke. Possible efficacy is suggested by a decrease in relative infarct growth.
Collapse
Affiliation(s)
| | | | - Ilknur Ay
- Massachusetts General Hosp, Boston, MA
| | | | - Hakan Ay
- Massachusetts General Hosp, Boston, MA
| |
Collapse
|
2
|
Abstract
Introduction:
Non-invasive vagus nerve stimulation (nVNS) reduces infarct volume after transient ischemia in rats. Here, we tested the effect of nVNS in intracerebral hemorrhage (ICH) and permanent ischemic brain injury models.
Methods:
ICH was induced by whole blood (n=24) or collagenase (n=24) injection into the striatum of adult male and female Wistar rats. 1-hour sham stimulation (n=16) or nVNS (n=32) was initiated 30 minutes after injection. Spontaneous circling, hindlimb retraction, and grasp ability were tested at 24 hours to measure functional deficit. Rats were euthanized 24 hours or one week after injury, and brain tissue was processed for water content analysis (n=24) and histology (n=24), respectively. Permanent ischemia was induced by filament occlusion of the right middle cerebral artery in adult male Wistar rats (n=18). Sham stimulation and nVNS initiated 30 minutes after the induction of ischemia were applied for 1 hour and 3 hours (n=6 per group). Rats were euthanized 24 hours later to measure infarct volume.
Results:
1-hour nVNS was associated with a non-significant reduction in hematoma volume in both models of ICH (Fig). Animals treated with nVNS demonstrated better functional outcome at 24 hours after ICH (
p
=0.042). There was no difference in brain edema between control and active treatment arms in both models of ICH. 3-hour nVNS reduced infarct volume by 21% in permanent ischemia (
p
=0.047, Fig).
Conclusion:
The results of this study support prior evidence that nVNS may have a therapeutic potential in ischemic stroke. nVNS is currently being evaluated in two clinical studies (NCT03733431 and NCT04050501) for the treatment of acute ischemic stroke. The lack of adverse events in two different models of ICH in this study suggests that nVNS could be safely administered as early as an ambulatory setting before the stroke etiology (ischemic vs. hemorrhagic) has been determined.
Collapse
Affiliation(s)
- Ilknur Ay
- Massachusetts General Hosp, Charleston, MA
| | | | - Hakan Ay
- Massachusetts General Hosp, Charleston, MA
| |
Collapse
|
3
|
Najib U, Smith T, Hindiyeh N, Saper J, Nye B, Ashina S, McClure CK, Marmura MJ, Chase S, Liebler E, Lipton RB. Non-invasive vagus nerve stimulation for prevention of migraine: The multicenter, randomized, double-blind, sham-controlled PREMIUM II trial. Cephalalgia 2022; 42:560-569. [PMID: 35001643 DOI: 10.1177/03331024211068813] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIM Evaluate the efficacy and safety of non-invasive vagus nerve stimulation for migraine prevention. METHODS After completing a 4-week diary run-in period, adults who had migraine with or without aura were randomly assigned to receive active non-invasive vagus nerve stimulation or sham therapy during a 12-week double-blind period. RESULTS Of 336 enrolled participants, 113 (active, n = 56; sham, n = 57) completed ≥70 days of the double-blind period and were ≥66% adherent with treatment, comprising the prespecified modified intention-to-treat population. The COVID-19 pandemic led to early trial termination, and the population was ∼60% smaller than the statistical target for full power. Mean reduction in monthly migraine days (primary endpoint) was 3.12 for the active group and 2.29 days for the sham group (difference, -0.83; p = 0.2329). Responder rate (i.e. the percentage of participants with a ≥50% reduction in migraine days) was greater in the active group (44.87%) than the sham group (26.81%; p = 0.0481). Prespecified subgroup analysis suggested that participants with aura responded preferentially. No serious device-related adverse events were reported. CONCLUSIONS These results suggest clinical utility of non-invasive vagus nerve stimulation for migraine prevention, particularly for patients who have migraine with aura, and reinforce the well-established safety and tolerability profile of this therapy.Trial Registration: ClinicalTrials.gov (NCT03716505).
Collapse
Affiliation(s)
- Umer Najib
- WVU Headache Center, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA
| | | | - Nada Hindiyeh
- Stanford University Medical Center, Palo Alto, CA, USA
| | - Joel Saper
- Michigan Head Pain and Neurological Institute, Ann Arbor, MI, USA
| | - Barbara Nye
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Sait Ashina
- Beth Israel Deaconess Medical Center, Department of Neurology, Harvard Medical School, Boston, MA, USA
| | | | - Michael J Marmura
- Thomas Jefferson University, Department of Neurology, Jefferson Headache Center, Philadelphia, PA, USA
| | - Serena Chase
- Chase Advocate Consulting, LLC, Cocoa Beach, FL, USA
| | | | | |
Collapse
|
4
|
Silberstein SD, Yuan H, Najib U, Ailani J, Morais ALD, Mathew PG, Liebler E, Tassorelli C, Diener HC. Non-invasive vagus nerve stimulation for primary headache: A clinical update. Cephalalgia 2020; 40:1370-1384. [PMID: 32718243 DOI: 10.1177/0333102420941864] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Non-invasive vagus nerve stimulation (nVNS) is a proven treatment for cluster headache and migraine. Several possible mechanisms of action by which nVNS mitigates headache have been identified. Methods We conducted a narrative review of recent scientific and clinical research into nVNS for headache, including findings from mechanistic studies and their possible relationships to the clinical effects of nVNS. Results Findings from animal and human studies have provided possible mechanistic explanations for nVNS efficacy in headache involving four core areas: Autonomic nervous system functions; cortical spreading depression inhibition; neurotransmitter regulation; and nociceptive modulation. We discuss how overlap and interplay among these areas may underlie the utility of nVNS in the context of clinical evidence supporting its safety and efficacy as acute and preventive therapy for both cluster headache and migraine. Possible future nVNS applications are also discussed. Conclusion Significant progress over the past several years has yielded valuable mechanistic and clinical evidence that, combined with the excellent safety and tolerability profile of nVNS, suggests that it should be considered a first-line treatment for both acute and preventive treatment of cluster headache, an effective option for acute treatment of migraine, and a highly relevant, practical option for migraine prevention.
Collapse
Affiliation(s)
- Stephen D Silberstein
- Jefferson Headache Center, Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Hsiangkuo Yuan
- Jefferson Headache Center, Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Umer Najib
- Department of Neurology, West Virginia University, Morgantown, West Virginia, USA
| | - Jessica Ailani
- Medstar Georgetown University Hospital, Washington, DC, USA
| | - Andreia Lopes de Morais
- Neurovascular Research Laboratory, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts, USA
| | - Paul G Mathew
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Brigham & Women's Hospital, Boston, Massachusetts, USA
- Department of Neurology, Harvard Vanguard Medical Associates, Braintree, Massachusetts, USA
| | - Eric Liebler
- electroCore, Inc., Basking Ridge, New Jersey, USA
| | - Cristina Tassorelli
- Headache Science Center, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Hans-Christoph Diener
- Institute for Medical Informatics, Biometry and Epidemiology, Medical Faculty of the University of Duisburg-Essen, Essen, Germany
| |
Collapse
|
5
|
Staats P, Giannakopoulos G, Blake J, Liebler E, Levy RM. The Use of Non-invasive Vagus Nerve Stimulation to Treat Respiratory Symptoms Associated With COVID-19: A Theoretical Hypothesis and Early Clinical Experience. Neuromodulation 2020; 23:784-788. [PMID: 32342609 PMCID: PMC7267613 DOI: 10.1111/ner.13172] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 04/23/2020] [Accepted: 04/23/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a pandemic with no specific therapeutic agents and substantial mortality, and finding new treatments is critical. Most cases are mild, but a significant minority of patients develop moderate to severe respiratory symptoms, with the most severe cases requiring intensive care and/or ventilator support. This respiratory compromise appears to be due to a hyperimmune reaction, often called a cytokine storm. Vagus nerve stimulation has been demonstrated to block production of cytokines in sepsis and other medical conditions. We hypothesize that non-invasive vagus nerve stimulation (nVNS) might provide clinical benefits in patients with respiratory symptoms similar to those associated with COVID-19. MATERIALS AND METHODS Information on two case reports was obtained via email correspondence and phone interviews with the patients. RESULTS Both patients reported clinically meaningful benefits from nVNS therapy. In case 1, the patient used nVNS to expedite symptomatic recovery at home after hospital discharge and was able to discontinue use of opioid and cough suppressant medications. In case 2, the patient experienced immediate and consistent relief from symptoms of chest tightness and shortness of breath, as well as an improved ability to clear his lungs. CONCLUSIONS Preliminary observations and a strong scientific foundation suggest that nVNS might provide clinical benefits in patients with COVID-19 via multiple mechanisms.
Collapse
|
6
|
Diener HC, Goadsby PJ, Ashina M, Al-Karagholi MAM, Sinclair A, Mitsikostas D, Magis D, Pozo-Rosich P, Irimia Sieira P, Làinez MJA, Gaul C, Silver N, Hoffmann J, Marin J, Liebler E, Ferrari MD. Non-invasive vagus nerve stimulation (nVNS) for the preventive treatment of episodic migraine: The multicentre, double-blind, randomised, sham-controlled PREMIUM trial. Cephalalgia 2019; 39:1475-1487. [PMID: 31522546 PMCID: PMC6791025 DOI: 10.1177/0333102419876920] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [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: 07/23/2019] [Revised: 08/14/2019] [Accepted: 08/23/2019] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Non-invasive vagus nerve stimulation (nVNS; gammaCore®) has the potential to prevent migraine days in patients with migraine on the basis of mechanistic rationale and pilot clinical data. METHODS This multicentre study included a 4-week run-in period, a 12-week double-blind period of randomised treatment with nVNS or sham, and a 24-week open-label period of nVNS. Patients were to administer two 120-second stimulations bilaterally to the neck three times daily (6-8 hours apart). RESULTS Of 477 enrolled patients, 332 comprised the intent-to-treat (ITT) population. Mean reductions in migraine days per month (primary outcome) were 2.26 for nVNS (n = 165; baseline, 7.9 days) and 1.80 for sham (n = 167; baseline, 8.1 days) (p = 0.15). Results were similar across other outcomes. Upon observation of suboptimal adherence rates, post hoc analysis of patients with ≥ 67% adherence per month demonstrated significant differences between nVNS (n = 138) and sham (n = 140) for outcomes including reduction in migraine days (2.27 vs. 1.53; p = 0.043); therapeutic gains were greater in patients with aura than in those without aura. Most nVNS device-related adverse events were mild and transient, with application site discomfort being the most common. CONCLUSIONS Preventive nVNS treatment in episodic migraine was not superior to sham stimulation in the ITT population. The "sham" device inadvertently provided a level of active vagus nerve stimulation. Post hoc analysis showed significant effects of nVNS in treatment-adherent patients. Study identification and registration: PREMIUM; NCT02378844; https://clinicaltrials.gov/ct2/show/NCT02378844.
Collapse
Affiliation(s)
| | - Peter J Goadsby
- NIHR-Wellcome Trust King's Clinical Research Facility, King's College London, London, UK
| | - Messoud Ashina
- Danish Headache Center, Rigshospitalet Glostrup, University of Copenhagen, Copenhagen, Denmark
| | | | - Alexandra Sinclair
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Dimos Mitsikostas
- 1st Neurology Department, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Delphine Magis
- Neurology Department and Pain Clinic, CHR East Belgium, Liège, Belgium
| | - Patricia Pozo-Rosich
- Headache Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Headache Research Group, Vall d'Hebron Research Institute, Universitat Autonoma de Barcelona, Barcelona, Spain
| | | | - Miguel JA Làinez
- Catholic University of Valencia, University Clinic Hospital, Valencia, Spain
| | - Charly Gaul
- Migraine and Headache Clinic, Königstein, Germany
| | | | - Jan Hoffmann
- NIHR-Wellcome Trust King's Clinical Research Facility, King's College London, London, UK
| | - Juana Marin
- NIHR-Wellcome Trust King's Clinical Research Facility, King's College London, London, UK
| | - Eric Liebler
- electroCore, Inc., Basking Ridge, New Jersey, USA
| | | |
Collapse
|
7
|
Vargas B, Liebler E, Bunt S, Supent-Bell C. Rationale and design for a randomized, single-center, double-blind, sham-controlled study of non-invasive vagus nerve stimulation for treatment of post-traumatic headache. Neurology 2019. [DOI: 10.1212/wnl.0000000000008354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
ObjectiveEvaluate the efficacy and safety of non-invasive vagus nerve stimulation (nVNS) for the treatment of post-traumatic headache (PTH).BackgroundWorldwide, ∼69 million people per year sustain a traumatic brain injury (TBI), many of whom develop PTH. Clinicians often treat PTH with drugs approved for primary headache disorders, and many patients self-treat with over-the-counter agents but have inadequate pain relief. There has been little study of therapies for PTH, and safe, effective treatments are needed.Design/MethodsThis randomized, double-blind, sham-controlled, parallel-group pilot study is enrolling adults who present 1–4 weeks after a head injury, meet International Classification of Headache Disorders 3rd edition (ICHD-3) criteria for acute headache attributed to mild TBI, and have ≥2 headaches/week with a migraine or probable migraine phenotype. After a 2-week run-in period, subjects are randomly assigned (1:1 allocation) to receive daily preventive therapy and as-needed acute treatment with nVNS or a sham device. Preventive therapy consists of two 120-second stimulations 3 times daily. Acute treatment comprises 2 stimulations at headache onset and 2 stimulations 20 minutes after the start of initial treatment. Subjects are not to use acute rescue medication for 120 minutes post-treatment. One North American site will enroll ≤80 subjects. The expected duration is 12 months (enrollment, 9 months; participation, 14 weeks).ResultsThe primary effectiveness end point is decrease in pain (on a 7-point scale) 60 minutes post-treatment for all treated headache attacks. Secondary end points include decrease in the frequency of headache days between the run-in period and the last 2 weeks of the double-blind period and responder rates (ie, percentages of subjects with ≥50% decrease in attack frequency). The primary safety end point is the incidence of treatment-related serious adverse events.ConclusionsThis study will assess the efficacy and safety of nVNS as a novel therapy for PTH.
Collapse
|
8
|
Reuter U, McClure C, Liebler E, Pozo-Rosich P. Non-invasive neuromodulation for migraine and cluster headache: a systematic review of clinical trials. J Neurol Neurosurg Psychiatry 2019; 90:796-804. [PMID: 30824632 PMCID: PMC6585264 DOI: 10.1136/jnnp-2018-320113] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 01/21/2019] [Accepted: 01/22/2019] [Indexed: 02/05/2023]
Abstract
Non-invasive neuromodulation therapies for migraine and cluster headache are a practical and safe alternative to pharmacologics. Comparisons of these therapies are difficult because of the heterogeneity in study designs. In this systematic review of clinical trials, the scientific rigour and clinical relevance of the available data were assessed to inform clinical decisions about non-invasive neuromodulation. PubMed, Cochrane Library and ClinicalTrials.gov databases and the WHO's International Clinical Trials Registry Platform were searched for relevant clinical studies of non-invasive neuromodulation devices for migraine and cluster headache (1 January 1990 to 31 January 2018), and 71 were identified. This analysis compared study designs using recommendations of the International Headache Society for pharmacological clinical trials, the only available guidelines for migraine and cluster headache. Non-invasive vagus nerve stimulation (nVNS), single-transcranial magnetic stimulation and external trigeminal nerve stimulation (all with regulatory clearance) were well studied compared with the other devices, for which studies frequently lacked proper blinding, sham controls and sufficient population sizes. nVNS studies demonstrated the most consistent adherence to available guidelines. Studies of all neuromodulation devices should strive to achieve the same high level of scientific rigour to allow for proper comparison across devices. Device-specific guidelines for migraine and cluster headache will be soon available, but adherence to current guidelines for pharmacological trials will remain a key consideration for investigators and clinicians.
Collapse
Affiliation(s)
- Uwe Reuter
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Candace McClure
- North American Science Associates, Minneapolis, Minnesota, USA
| | - Eric Liebler
- electroCore, Inc, Basking Ridge, New Jersey, USA
| | - Patricia Pozo-Rosich
- Headache and Craniofacial Pain Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Headache Research Group, VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
| |
Collapse
|
9
|
De Icco R, Bitetto V, Martinelli D, Allena M, Guaschino E, Bottiroli S, Liebler E, Tassorelli C, Sances G. Noninvasive peripheral vagal nerve stimulation prevents migraine aura: A case report. Cephalalgia Reports 2019. [DOI: 10.1177/2515816319855607] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
We describe a patient affected by migraine with visual and somatosensory aura, whose symptoms were consistently attenuated by noninvasive peripheral vagal nerve stimulation (nVNS) in multiple prospectively recorded attacks. When compared with the current standard of care, nVNS significantly reduced the duration of visual aura in all the attacks ( n = 5) and prevented the somatosensory aura in three of the five attacks. The overall duration of nVNS-treated auras was 19.0 ± 4.2 min, significantly shorter than the duration of aura in attacks treated with standard of care (103.8 ± 10.3 min). This single-case study requires confirmation in a larger sample size, but we believe that this first report is suggestive of likely efficacy given the relatively high number of treated attacks and the consistent effect of nVNS.
Collapse
Affiliation(s)
- Roberto De Icco
- Headache Science Centre, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Vito Bitetto
- Headache Science Centre, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Daniele Martinelli
- Headache Science Centre, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Marta Allena
- Headache Science Centre, IRCCS Mondino Foundation, Pavia, Italy
| | - Elena Guaschino
- Headache Science Centre, IRCCS Mondino Foundation, Pavia, Italy
| | - Sara Bottiroli
- Headache Science Centre, IRCCS Mondino Foundation, Pavia, Italy
- Faculty of Law, Giustino Fortunato University, Benevento, Italy
| | | | - Cristina Tassorelli
- Headache Science Centre, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Grazia Sances
- Headache Science Centre, IRCCS Mondino Foundation, Pavia, Italy
| |
Collapse
|
10
|
de Coo IF, Marin JC, Silberstein SD, Friedman DI, Gaul C, McClure CK, Tyagi A, Liebler E, Tepper SJ, Ferrari MD, Goadsby PJ. Differential efficacy of non-invasive vagus nerve stimulation for the acute treatment of episodic and chronic cluster headache: A meta-analysis. Cephalalgia 2019; 39:967-977. [PMID: 31246132 PMCID: PMC6637721 DOI: 10.1177/0333102419856607] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Two randomized, double-blind, sham-controlled trials (ACT1, ACT2) evaluated non-invasive vagus nerve stimulation (nVNS) as acute treatment for cluster headache. We analyzed pooled ACT1/ACT2 data to increase statistical power and gain insight into the differential efficacy of nVNS in episodic and chronic cluster headache. METHODS Data extracted from ACT1 and ACT2 were pooled using a fixed-effects model. Main outcome measures were the primary endpoints of each study. This was the proportion of participants whose first treated attack improved from moderate (2), severe (3), or very severe (4) pain intensity to mild (1) or nil (0) for ACT1 and the proportion of treated attacks whose pain intensity improved from 2-4 to 0 for ACT2. RESULTS The pooled population included 225 participants (episodic: n = 112; chronic: n = 113) from ACT1 (n = 133) and ACT2 (n = 92) in the nVNS (n = 108) and sham (n = 117) groups. Interaction was shown between treatment group and cluster headache subtype (p < 0.05). nVNS was superior to sham in episodic but not chronic cluster headache (both endpoints p < 0.01). Only four patients discontinued the studies due to adverse events. CONCLUSIONS nVNS is a well-tolerated and effective acute treatment for episodic cluster headache. TRIAL REGISTRATION The studies were registered at clinicaltrials.gov (ACT1: NCT01792817; ACT2: NCT01958125).
Collapse
Affiliation(s)
- Ilse F de Coo
- 1 Leiden University Medical Centre, Leiden, the Netherlands
| | - Juana Ca Marin
- 2 NIHR-Wellcome Trust King's Clinical Research Facility, King's College London, UK
| | | | - Deborah I Friedman
- 4 Department of Neurology, University of Texas Southwestern, Dallas, TX, USA
| | - Charly Gaul
- 5 Migraine and Headache Clinic, Königstein, Germany
| | | | - Alok Tyagi
- 7 Neurology Department, The Southern Hospital, Glasgow, UK
| | | | | | | | - Peter J Goadsby
- 2 NIHR-Wellcome Trust King's Clinical Research Facility, King's College London, UK
| |
Collapse
|
11
|
Grazzi L, Tassorelli C, de Tommaso M, Pierangeli G, Martelletti P, Rainero I, Geppetti P, Ambrosini A, Sarchielli P, Liebler E, Barbanti P. Correction to: Practical and clinical utility of non-invasive vagus nerve stimulation (nVNS) for the acute treatment of migraine: a post hoc analysis of the randomized, sham-controlled, double-blind PRESTO trial. J Headache Pain 2019; 20:1. [PMID: 30616570 PMCID: PMC6734483 DOI: 10.1186/s10194-018-0948-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 11/14/2018] [Indexed: 12/21/2022] Open
Affiliation(s)
- Licia Grazzi
- Neuroalgology Unit, Carlo Besta Neurological Institute and Foundation, Milan, Italy. .,Department of Fondazione IRCCS Istituto Neurologico C. Besta, U.O. Neurologia III - Cefalee e Neuroalgologia, Via Celoria 11, 20133, Milan, Italy.
| | - Cristina Tassorelli
- Headache Science Centre, IRCCS C. Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Marina de Tommaso
- Neurophysiology and Pain Unit, University of Bari Aldo Moro, Bari, Italy
| | - Giulia Pierangeli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | | | | | | | - Paola Sarchielli
- Neurologic Clinic, Santa Maria della Misericordia Hospital, Perugia, Italy
| | | | - Piero Barbanti
- Headache and Pain Unit, IRCCS San Raffaele Pisana, Rome, Italy
| | | |
Collapse
|
12
|
Martelletti P, Barbanti P, Grazzi L, Pierangeli G, Rainero I, Geppetti P, Ambrosini A, Sarchielli P, Tassorelli C, Liebler E, de Tommaso M. Correction to: Consistent effects of non-invasive vagus nerve stimulation (nVNS) for the acute treatment of migraine: additional findings from the randomized, sham-controlled, double-blind PRESTO trial. J Headache Pain 2018; 19:120. [PMID: 30563446 PMCID: PMC6755543 DOI: 10.1186/s10194-018-0949-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 11/14/2018] [Indexed: 12/01/2022] Open
Affiliation(s)
- Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Piero Barbanti
- Headache and Pain Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Pisana, Rome, Italy
| | - Licia Grazzi
- Neuroalgology Unit, Carlo Besta Neurological Institute and Foundation, Milan, Italy
| | - Giulia Pierangeli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | | | | | | | - Paola Sarchielli
- Neurologic Clinic, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Cristina Tassorelli
- Headache Science Centre, IRCCS C. Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | | | - Marina de Tommaso
- Neurophysiology and Pain Unit, University of Bari Aldo Moro, Bari, Italy
| | | |
Collapse
|
13
|
Marin J, Giffin N, Consiglio E, McClure C, Liebler E, Davies B. Non-invasive vagus nerve stimulation for treatment of cluster headache: early UK clinical experience. J Headache Pain 2018; 19:114. [PMID: 30470171 PMCID: PMC6755582 DOI: 10.1186/s10194-018-0936-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 10/18/2018] [Indexed: 01/03/2023] Open
Abstract
Background Evidence supports the use of non-invasive vagus nerve stimulation (nVNS; gammaCore®) as a promising therapeutic option for patients with cluster headache (CH). We conducted this audit of real-world data from patients with CH, the majority of whom were treatment refractory, to explore early UK clinical experience with nVNS used acutely, preventively, or both. Methods We retrospectively analysed data from 30 patients with CH (29 chronic, 1 episodic) who submitted individual funding requests for nVNS to the National Health Service. All patients had responded to adjunctive nVNS therapy during an evaluation period (typical duration, 3–6 months). Data collected from patient interviews, treatment diaries, and physician notes were summarised with descriptive statistics. Paired t tests were used to examine statistical significance. Results The mean (SD) CH attack frequency decreased from 26.6 (17.1) attacks/wk. before initiation of nVNS therapy to 9.5 (11.0) attacks/wk. (P < 0.01) afterward. Mean (SD) attack duration decreased from 51.9 (36.7) minutes to 29.4 (28.5) minutes (P < 0.01), and mean (SD) attack severity (rated on a 10-point scale) decreased from 7.8 (2.3) to 6.0 (2.6) (P < 0.01). Use of abortive treatments also decreased. Favourable changes in the use of preventive medication were also observed. No serious device-related adverse events were reported. Conclusions Significant decreases in attack frequency, severity, and duration were observed in these patients with CH who did not respond to or were intolerant of multiple preventive and/or acute treatments. These real-world findings complement evidence from clinical trials demonstrating the efficacy and safety of nVNS in CH. Electronic supplementary material The online version of this article (10.1186/s10194-018-0936-1) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Juana Marin
- Wellcome Foundation Building, King's College Hospital, London, SE5 9PJ, UK.
| | - Nicola Giffin
- Royal United Hospital, Coombe Park, Bath, BA1 3NG, UK
| | | | - Candace McClure
- North American Science Associates, Inc., 400 US-169, Minneapolis, MN, 55441, USA
| | - Eric Liebler
- electroCore, Inc., 150 Allen Road, Suite 201, Basking Ridge, NJ, 07920, USA
| | - Brendan Davies
- University Hospitals of North Midlands, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
| |
Collapse
|
14
|
Martelletti P, Barbanti P, Grazzi L, Pierangeli G, Rainero I, Geppetti P, Ambrosini A, Sarchielli P, Tassorelli C, Liebler E, de Tommaso M. Consistent effects of non-invasive vagus nerve stimulation (nVNS) for the acute treatment of migraine: additional findings from the randomized, sham-controlled, double-blind PRESTO trial. J Headache Pain 2018; 19:101. [PMID: 30382909 PMCID: PMC6755599 DOI: 10.1186/s10194-018-0929-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 10/03/2018] [Indexed: 12/21/2022] Open
Abstract
Background Non-invasive vagus nerve stimulation (nVNS) has been shown to be practical, safe, and well tolerated for treating primary headache disorders. The recent multicenter, randomized, double-blind, sham-controlled PRESTO trial provided Class I evidence that for patients with episodic migraine, nVNS significantly increases the probability of having mild pain or being pain-free 2 h post stimulation. We report additional pre-defined secondary and other end points from PRESTO that demonstrate the consistency and durability of nVNS efficacy across a broad range of outcomes. Methods After a 4-week observation period, 248 patients with episodic migraine with/without aura were randomly assigned to acute treatment of migraine attacks with nVNS (n = 122) or a sham device (n = 126) during a double-blind period lasting 4 weeks (or until the patient had treated 5 attacks). All patients received nVNS therapy during the subsequent 4-week/5-attack open-label period. Results The intent-to-treat population consisted of 243 patients. The nVNS group (n = 120) had a significantly greater percentage of attacks treated during the double-blind period that were pain-free at 60 (P = 0.005) and 120 min (P = 0.026) than the sham group (n = 123) did. Similar results were seen for attacks with pain relief at 60 (P = 0.025) and 120 min (P = 0.018). For the first attack and all attacks, the nVNS group had significantly greater decreases (vs sham) in pain score from baseline to 60 min (P = 0.029); the decrease was also significantly greater for nVNS at 120 min for the first attack (P = 0.011). Results during the open-label period were consistent with those of the nVNS group during the double-blind period. The incidence of adverse events (AEs) and adverse device effects was low across all study periods, and no serious AEs occurred. Conclusions These results further demonstrate that nVNS is an effective and reliable acute treatment for multiple migraine attacks, which can be used safely while preserving the patient’s option to use traditional acute medications as rescue therapy, possibly decreasing the risk of medication overuse. Together with its practicality and optimal tolerability profile, these findings suggest nVNS has value as a front-line option for acute treatment of migraine. Trial registration ClinicalTrials.gov identifier: NCT02686034.
Collapse
Affiliation(s)
- Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Piero Barbanti
- Headache and Pain Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Pisana, Rome, Italy
| | - Licia Grazzi
- Neuroalgology Unit, Carlo Besta Neurological Institute and Foundation, Milan, Italy
| | - Giulia Pierangeli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | | | | | | | - Paola Sarchielli
- Neurologic Clinic, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Cristina Tassorelli
- Headache Science Centre, IRCCS C. Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | | | - Marina de Tommaso
- Neurophysiology and Pain Unit, University of Bari Aldo Moro, Bari, Italy
| | | |
Collapse
|
15
|
Grazzi L, Tassorelli C, de Tommaso M, Pierangeli G, Martelletti P, Rainero I, Geppetti P, Ambrosini A, Sarchielli P, Liebler E, Barbanti P. Practical and clinical utility of non-invasive vagus nerve stimulation (nVNS) for the acute treatment of migraine: a post hoc analysis of the randomized, sham-controlled, double-blind PRESTO trial. J Headache Pain 2018; 19:98. [PMID: 30340460 PMCID: PMC6742918 DOI: 10.1186/s10194-018-0928-1] [Citation(s) in RCA: 15] [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: 08/10/2018] [Accepted: 10/03/2018] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND The PRESTO study of non-invasive vagus nerve stimulation (nVNS; gammaCore®) featured key primary and secondary end points recommended by the International Headache Society to provide Class I evidence that for patients with an episodic migraine, nVNS significantly increases the probability of having mild pain or being pain-free 2 h post stimulation. Here, we examined additional data from PRESTO to provide further insights into the practical utility of nVNS by evaluating its ability to consistently deliver clinically meaningful improvements in pain intensity while reducing the need for rescue medication. METHODS Patients recorded pain intensity for treated migraine attacks on a 4-point scale. Data were examined to compare nVNS and sham with regard to the percentage of patients who benefited by at least 1 point in pain intensity. We also assessed the percentage of attacks that required rescue medication and pain-free rates stratified by pain intensity at treatment initiation. RESULTS A significantly higher percentage of patients who used acute nVNS treatment (n = 120) vs sham (n = 123) reported a ≥ 1-point decrease in pain intensity at 30 min (nVNS, 32.2%; sham, 18.5%; P = 0.020), 60 min (nVNS, 38.8%; sham, 24.0%; P = 0.017), and 120 min (nVNS, 46.8%; sham, 26.2%; P = 0.002) after the first attack. Similar significant results were seen when assessing the benefit in all attacks. The proportion of patients who did not require rescue medication was significantly higher with nVNS than with sham for the first attack (nVNS, 59.3%; sham, 41.9%; P = 0.013) and all attacks (nVNS, 52.3%; sham, 37.3%; P = 0.008). When initial pain intensity was mild, the percentage of patients with no pain after treatment was significantly higher with nVNS than with sham at 60 min (all attacks: nVNS, 37.0%; sham, 21.2%; P = 0.025) and 120 min (first attack: nVNS, 50.0%; sham, 25.0%; P = 0.018; all attacks: nVNS, 46.7%; sham, 30.1%; P = 0.037). CONCLUSIONS This post hoc analysis demonstrated that acute nVNS treatment quickly and consistently reduced pain intensity while decreasing rescue medication use. These clinical benefits provide guidance in the optimal use of nVNS in everyday practice, which can potentially reduce use of acute pharmacologic medications and their associated adverse events. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02686034 .
Collapse
Affiliation(s)
- Licia Grazzi
- Neuroalgology Unit, Carlo Besta Neurological Institute and Foundation, Milan, Italy
- Department of Fondazione IRCCS Istituto Neurologico C. Besta, U.O. Neurologia III – Cefalee e Neuroalgologia, Via Celoria 11, 20133 Milan, Italy
| | - Cristina Tassorelli
- Headache Science Centre, IRCCS C. Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Marina de Tommaso
- Neurophysiology and Pain Unit, University of Bari Aldo Moro, Bari, Italy
| | - Giulia Pierangeli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | | | | | | | - Paola Sarchielli
- Neurologic Clinic, Santa Maria della Misericordia Hospital, Perugia, Italy
| | | | - Piero Barbanti
- Headache and Pain Unit, IRCCS San Raffaele Pisana, Rome, Italy
| |
Collapse
|
16
|
Vecchio E, Bassez I, Ricci K, Tassorelli C, Liebler E, de Tommaso M. Effect of Non-invasive Vagus Nerve Stimulation on Resting-State Electroencephalography and Laser-Evoked Potentials in Migraine Patients: Mechanistic Insights. Front Hum Neurosci 2018; 12:366. [PMID: 30271335 PMCID: PMC6146235 DOI: 10.3389/fnhum.2018.00366] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Accepted: 08/28/2018] [Indexed: 12/24/2022] Open
Abstract
A recent multicenter trial provided Class I evidence that for patients with an episodic migraine, non-invasive vagus nerve stimulation (nVNS) significantly increases the probability of having mild pain or being pain-free 2 h post-stimulation. Here we aimed to investigate the potential effect of nVNS in the modulation of spontaneous and pain related bioelectrical activity in a subgroup of migraine patients enrolled in the PRESTO trial by using resting-state electroencephalography and trigeminal laser-evoked potentials (LEPs). LEPs were recorded for 27 migraine patients who received active or sham nVNS over the cervical vagus nerve. We measured power values for frequencies between 1–100 Hz in a resting-state condition and the latency and amplitude of N1, N2, and P2 components of LEPs in a basal condition during and after active or sham vagus nerve stimulation (T0, T1, T2). The P2 evoked by the right and the left trigeminal branch was smaller during active nVNS. The sham device also attenuated the P2 amplitude evoked by the left trigeminal branch at T1 and T2, but this attenuation did not reach significance. No changes were observed for N1 amplitude, N1, N2, P2 latency, or pain rating. nVNS induced an increase of EEG power in both slow and fast rhythms, but this effect was not significant as compared to the sham device. These findings suggest that nVNS acts on the cortical areas that are responsible for trigeminal pain control and pave the ground for future studies aimed at confirming the possible correlations with clinical outcomes, including the effect on symptoms that are directly correlated with trigeminal pain processing and modulation.
Collapse
Affiliation(s)
- Eleonora Vecchio
- Applied Neurophysiology and Pain Unit, SMBNOS Department, Polyclinic General Hospital, Bari Aldo Moro University, Bari, Italy
| | - Iege Bassez
- Department of Data Analysis, Ghent University, Ghent, Belgium
| | - Katia Ricci
- Applied Neurophysiology and Pain Unit, SMBNOS Department, Polyclinic General Hospital, Bari Aldo Moro University, Bari, Italy
| | - Cristina Tassorelli
- Headache Science Center, C. Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Eric Liebler
- electroCore LLC, Basking Ridge, NJ, United States
| | - Marina de Tommaso
- Applied Neurophysiology and Pain Unit, SMBNOS Department, Polyclinic General Hospital, Bari Aldo Moro University, Bari, Italy
| |
Collapse
|
17
|
Tassorelli C, Grazzi L, de Tommaso M, Pierangeli G, Martelletti P, Rainero I, Dorlas S, Geppetti P, Ambrosini A, Sarchielli P, Liebler E, Barbanti P. Noninvasive vagus nerve stimulation as acute therapy for migraine: The randomized PRESTO study. Neurology 2018; 91:e364-e373. [PMID: 29907608 PMCID: PMC6070381 DOI: 10.1212/wnl.0000000000005857] [Citation(s) in RCA: 152] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 04/11/2018] [Indexed: 01/03/2023] Open
Abstract
Objective To evaluate the efficacy, safety, and tolerability of noninvasive vagus nerve stimulation (nVNS; gammaCore; electroCore, LLC, Basking Ridge, NJ) for the acute treatment of migraine in a multicenter, double-blind, randomized, sham-controlled trial. Methods A total of 248 participants with episodic migraine with/without aura were randomized to receive nVNS or sham within 20 minutes from pain onset. Participants were to repeat treatment if pain had not improved in 15 minutes. Results nVNS (n = 120) was superior to sham (n = 123) for pain freedom at 30 minutes (12.7% vs 4.2%; p = 0.012) and 60 minutes (21.0% vs 10.0%; p = 0.023) but not at 120 minutes (30.4% vs 19.7%; p = 0.067; primary endpoint; logistic regression) after the first treated attack. A post hoc repeated-measures test provided further insight into the therapeutic benefit of nVNS through 30, 60, and 120 minutes (odds ratio 2.3; 95% confidence interval 1.2, 4.4; p = 0.012). nVNS demonstrated benefits across other endpoints including pain relief at 120 minutes and was safe and well-tolerated. Conclusion This randomized sham-controlled trial supports the abortive efficacy of nVNS as early as 30 minutes and up to 60 minutes after an attack. Findings also suggest effective pain relief, tolerability, and practicality of nVNS for the acute treatment of episodic migraine. ClinicalTrials.gov identifier NCT02686034. Classification of evidence This study provides Class I evidence that for patients with an episodic migraine, nVNS significantly increases the probability of having mild pain or being pain-free 2 hours poststimulation (absolute difference 13.2%).
Collapse
Affiliation(s)
- Cristina Tassorelli
- From the Headache Science Centre (C.T.), IRCCS C. Mondino Foundation, Pavia; University of Pavia (C.T.); Headache Center (L.G.), Carlo Besta Neurological Institute and Foundation, Milan; Neurophysiology and Pain Unit (M.d.T.), University of Bari Aldo Moro; Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) (G.P.), Istituto delle Scienze Neurologiche di Bologna; Department of Clinical and Molecular Medicine (P.M.), Sapienza University, Rome; Department of Neuroscience (I.R.), University of Turin, Italy; MedLogix Communications, LLC (S.D.), Itasca IL; Headache Centre (P.G.), University Hospital of Careggi, Florence; IRCCS Neuromed (A.A.), Pozzilli (IS); Neurologic Clinic (P.S.), Santa Maria della Misericordia Hospital, Perugia, Italy; electroCore, LLC (E.L.), Basking Ridge, NJ; and Headache and Pain Unit (P.B.), IRCCS San Raffaele Pisana, Rome, Italy.
| | - Licia Grazzi
- From the Headache Science Centre (C.T.), IRCCS C. Mondino Foundation, Pavia; University of Pavia (C.T.); Headache Center (L.G.), Carlo Besta Neurological Institute and Foundation, Milan; Neurophysiology and Pain Unit (M.d.T.), University of Bari Aldo Moro; Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) (G.P.), Istituto delle Scienze Neurologiche di Bologna; Department of Clinical and Molecular Medicine (P.M.), Sapienza University, Rome; Department of Neuroscience (I.R.), University of Turin, Italy; MedLogix Communications, LLC (S.D.), Itasca IL; Headache Centre (P.G.), University Hospital of Careggi, Florence; IRCCS Neuromed (A.A.), Pozzilli (IS); Neurologic Clinic (P.S.), Santa Maria della Misericordia Hospital, Perugia, Italy; electroCore, LLC (E.L.), Basking Ridge, NJ; and Headache and Pain Unit (P.B.), IRCCS San Raffaele Pisana, Rome, Italy
| | - Marina de Tommaso
- From the Headache Science Centre (C.T.), IRCCS C. Mondino Foundation, Pavia; University of Pavia (C.T.); Headache Center (L.G.), Carlo Besta Neurological Institute and Foundation, Milan; Neurophysiology and Pain Unit (M.d.T.), University of Bari Aldo Moro; Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) (G.P.), Istituto delle Scienze Neurologiche di Bologna; Department of Clinical and Molecular Medicine (P.M.), Sapienza University, Rome; Department of Neuroscience (I.R.), University of Turin, Italy; MedLogix Communications, LLC (S.D.), Itasca IL; Headache Centre (P.G.), University Hospital of Careggi, Florence; IRCCS Neuromed (A.A.), Pozzilli (IS); Neurologic Clinic (P.S.), Santa Maria della Misericordia Hospital, Perugia, Italy; electroCore, LLC (E.L.), Basking Ridge, NJ; and Headache and Pain Unit (P.B.), IRCCS San Raffaele Pisana, Rome, Italy
| | - Giulia Pierangeli
- From the Headache Science Centre (C.T.), IRCCS C. Mondino Foundation, Pavia; University of Pavia (C.T.); Headache Center (L.G.), Carlo Besta Neurological Institute and Foundation, Milan; Neurophysiology and Pain Unit (M.d.T.), University of Bari Aldo Moro; Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) (G.P.), Istituto delle Scienze Neurologiche di Bologna; Department of Clinical and Molecular Medicine (P.M.), Sapienza University, Rome; Department of Neuroscience (I.R.), University of Turin, Italy; MedLogix Communications, LLC (S.D.), Itasca IL; Headache Centre (P.G.), University Hospital of Careggi, Florence; IRCCS Neuromed (A.A.), Pozzilli (IS); Neurologic Clinic (P.S.), Santa Maria della Misericordia Hospital, Perugia, Italy; electroCore, LLC (E.L.), Basking Ridge, NJ; and Headache and Pain Unit (P.B.), IRCCS San Raffaele Pisana, Rome, Italy
| | - Paolo Martelletti
- From the Headache Science Centre (C.T.), IRCCS C. Mondino Foundation, Pavia; University of Pavia (C.T.); Headache Center (L.G.), Carlo Besta Neurological Institute and Foundation, Milan; Neurophysiology and Pain Unit (M.d.T.), University of Bari Aldo Moro; Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) (G.P.), Istituto delle Scienze Neurologiche di Bologna; Department of Clinical and Molecular Medicine (P.M.), Sapienza University, Rome; Department of Neuroscience (I.R.), University of Turin, Italy; MedLogix Communications, LLC (S.D.), Itasca IL; Headache Centre (P.G.), University Hospital of Careggi, Florence; IRCCS Neuromed (A.A.), Pozzilli (IS); Neurologic Clinic (P.S.), Santa Maria della Misericordia Hospital, Perugia, Italy; electroCore, LLC (E.L.), Basking Ridge, NJ; and Headache and Pain Unit (P.B.), IRCCS San Raffaele Pisana, Rome, Italy
| | - Innocenzo Rainero
- From the Headache Science Centre (C.T.), IRCCS C. Mondino Foundation, Pavia; University of Pavia (C.T.); Headache Center (L.G.), Carlo Besta Neurological Institute and Foundation, Milan; Neurophysiology and Pain Unit (M.d.T.), University of Bari Aldo Moro; Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) (G.P.), Istituto delle Scienze Neurologiche di Bologna; Department of Clinical and Molecular Medicine (P.M.), Sapienza University, Rome; Department of Neuroscience (I.R.), University of Turin, Italy; MedLogix Communications, LLC (S.D.), Itasca IL; Headache Centre (P.G.), University Hospital of Careggi, Florence; IRCCS Neuromed (A.A.), Pozzilli (IS); Neurologic Clinic (P.S.), Santa Maria della Misericordia Hospital, Perugia, Italy; electroCore, LLC (E.L.), Basking Ridge, NJ; and Headache and Pain Unit (P.B.), IRCCS San Raffaele Pisana, Rome, Italy
| | - Stefanie Dorlas
- From the Headache Science Centre (C.T.), IRCCS C. Mondino Foundation, Pavia; University of Pavia (C.T.); Headache Center (L.G.), Carlo Besta Neurological Institute and Foundation, Milan; Neurophysiology and Pain Unit (M.d.T.), University of Bari Aldo Moro; Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) (G.P.), Istituto delle Scienze Neurologiche di Bologna; Department of Clinical and Molecular Medicine (P.M.), Sapienza University, Rome; Department of Neuroscience (I.R.), University of Turin, Italy; MedLogix Communications, LLC (S.D.), Itasca IL; Headache Centre (P.G.), University Hospital of Careggi, Florence; IRCCS Neuromed (A.A.), Pozzilli (IS); Neurologic Clinic (P.S.), Santa Maria della Misericordia Hospital, Perugia, Italy; electroCore, LLC (E.L.), Basking Ridge, NJ; and Headache and Pain Unit (P.B.), IRCCS San Raffaele Pisana, Rome, Italy
| | - Pierangelo Geppetti
- From the Headache Science Centre (C.T.), IRCCS C. Mondino Foundation, Pavia; University of Pavia (C.T.); Headache Center (L.G.), Carlo Besta Neurological Institute and Foundation, Milan; Neurophysiology and Pain Unit (M.d.T.), University of Bari Aldo Moro; Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) (G.P.), Istituto delle Scienze Neurologiche di Bologna; Department of Clinical and Molecular Medicine (P.M.), Sapienza University, Rome; Department of Neuroscience (I.R.), University of Turin, Italy; MedLogix Communications, LLC (S.D.), Itasca IL; Headache Centre (P.G.), University Hospital of Careggi, Florence; IRCCS Neuromed (A.A.), Pozzilli (IS); Neurologic Clinic (P.S.), Santa Maria della Misericordia Hospital, Perugia, Italy; electroCore, LLC (E.L.), Basking Ridge, NJ; and Headache and Pain Unit (P.B.), IRCCS San Raffaele Pisana, Rome, Italy
| | - Anna Ambrosini
- From the Headache Science Centre (C.T.), IRCCS C. Mondino Foundation, Pavia; University of Pavia (C.T.); Headache Center (L.G.), Carlo Besta Neurological Institute and Foundation, Milan; Neurophysiology and Pain Unit (M.d.T.), University of Bari Aldo Moro; Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) (G.P.), Istituto delle Scienze Neurologiche di Bologna; Department of Clinical and Molecular Medicine (P.M.), Sapienza University, Rome; Department of Neuroscience (I.R.), University of Turin, Italy; MedLogix Communications, LLC (S.D.), Itasca IL; Headache Centre (P.G.), University Hospital of Careggi, Florence; IRCCS Neuromed (A.A.), Pozzilli (IS); Neurologic Clinic (P.S.), Santa Maria della Misericordia Hospital, Perugia, Italy; electroCore, LLC (E.L.), Basking Ridge, NJ; and Headache and Pain Unit (P.B.), IRCCS San Raffaele Pisana, Rome, Italy
| | - Paola Sarchielli
- From the Headache Science Centre (C.T.), IRCCS C. Mondino Foundation, Pavia; University of Pavia (C.T.); Headache Center (L.G.), Carlo Besta Neurological Institute and Foundation, Milan; Neurophysiology and Pain Unit (M.d.T.), University of Bari Aldo Moro; Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) (G.P.), Istituto delle Scienze Neurologiche di Bologna; Department of Clinical and Molecular Medicine (P.M.), Sapienza University, Rome; Department of Neuroscience (I.R.), University of Turin, Italy; MedLogix Communications, LLC (S.D.), Itasca IL; Headache Centre (P.G.), University Hospital of Careggi, Florence; IRCCS Neuromed (A.A.), Pozzilli (IS); Neurologic Clinic (P.S.), Santa Maria della Misericordia Hospital, Perugia, Italy; electroCore, LLC (E.L.), Basking Ridge, NJ; and Headache and Pain Unit (P.B.), IRCCS San Raffaele Pisana, Rome, Italy
| | - Eric Liebler
- From the Headache Science Centre (C.T.), IRCCS C. Mondino Foundation, Pavia; University of Pavia (C.T.); Headache Center (L.G.), Carlo Besta Neurological Institute and Foundation, Milan; Neurophysiology and Pain Unit (M.d.T.), University of Bari Aldo Moro; Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) (G.P.), Istituto delle Scienze Neurologiche di Bologna; Department of Clinical and Molecular Medicine (P.M.), Sapienza University, Rome; Department of Neuroscience (I.R.), University of Turin, Italy; MedLogix Communications, LLC (S.D.), Itasca IL; Headache Centre (P.G.), University Hospital of Careggi, Florence; IRCCS Neuromed (A.A.), Pozzilli (IS); Neurologic Clinic (P.S.), Santa Maria della Misericordia Hospital, Perugia, Italy; electroCore, LLC (E.L.), Basking Ridge, NJ; and Headache and Pain Unit (P.B.), IRCCS San Raffaele Pisana, Rome, Italy
| | - Piero Barbanti
- From the Headache Science Centre (C.T.), IRCCS C. Mondino Foundation, Pavia; University of Pavia (C.T.); Headache Center (L.G.), Carlo Besta Neurological Institute and Foundation, Milan; Neurophysiology and Pain Unit (M.d.T.), University of Bari Aldo Moro; Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) (G.P.), Istituto delle Scienze Neurologiche di Bologna; Department of Clinical and Molecular Medicine (P.M.), Sapienza University, Rome; Department of Neuroscience (I.R.), University of Turin, Italy; MedLogix Communications, LLC (S.D.), Itasca IL; Headache Centre (P.G.), University Hospital of Careggi, Florence; IRCCS Neuromed (A.A.), Pozzilli (IS); Neurologic Clinic (P.S.), Santa Maria della Misericordia Hospital, Perugia, Italy; electroCore, LLC (E.L.), Basking Ridge, NJ; and Headache and Pain Unit (P.B.), IRCCS San Raffaele Pisana, Rome, Italy
| | | |
Collapse
|
18
|
Goadsby PJ, de Coo IF, Silver N, Tyagi A, Ahmed F, Gaul C, Jensen RH, Diener HC, Solbach K, Straube A, Liebler E, Marin JCA, Ferrari MD. Non-invasive vagus nerve stimulation for the acute treatment of episodic and chronic cluster headache: A randomized, double-blind, sham-controlled ACT2 study. Cephalalgia 2018; 38:959-969. [PMID: 29231763 PMCID: PMC5896689 DOI: 10.1177/0333102417744362] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 10/26/2017] [Accepted: 10/30/2017] [Indexed: 01/03/2023]
Abstract
Background Clinical observations and results from recent studies support the use of non-invasive vagus nerve stimulation (nVNS) for treating cluster headache (CH) attacks. This study compared nVNS with a sham device for acute treatment in patients with episodic or chronic CH (eCH, cCH). Methods After completing a 1-week run-in period, subjects were randomly assigned (1:1) to receive nVNS or sham therapy during a 2-week double-blind period. The primary efficacy endpoint was the proportion of all treated attacks that achieved pain-free status within 15 minutes after treatment initiation, without rescue treatment. Results The Full Analysis Set comprised 48 nVNS-treated (14 eCH, 34 cCH) and 44 sham-treated (13 eCH, 31 cCH) subjects. For the primary endpoint, nVNS (14%) and sham (12%) treatments were not significantly different for the total cohort. In the eCH subgroup, nVNS (48%) was superior to sham (6%; p < 0.01). No significant differences between nVNS (5%) and sham (13%) were seen in the cCH subgroup. Conclusions Combing both eCH and cCH patients, nVNS was no different to sham. For the treatment of CH attacks, nVNS was superior to sham therapy in eCH but not in cCH. These results confirm and extend previous findings regarding the efficacy, safety, and tolerability of nVNS for the acute treatment of eCH.
Collapse
Affiliation(s)
- Peter J Goadsby
- NIHR-Wellcome Trust King’s Clinical
Research Facility, King’s College Hospital, London, UK
| | - Ilse F de Coo
- Leiden University Medical Centre,
Leiden, the Netherlands
| | - Nicholas Silver
- The Walton Centre for Neurology and
Neurosurgery, Liverpool, UK
| | - Alok Tyagi
- Queen Elizabeth University Hospital
Glasgow, Glasgow, UK
| | | | - Charly Gaul
- Migraine and Headache Clinic,
Königstein, Germany
| | | | | | | | - Andreas Straube
- Department of Neurology, University
Hospital, LMU Munich, Munich, Germany
| | | | - Juana CA Marin
- NIHR-Wellcome Trust King’s Clinical
Research Facility, King’s College Hospital, London, UK
| | | |
Collapse
|
19
|
De Icco R, Martinelli D, Bitetto V, Fresia M, Liebler E, Sandrini G, Tassorelli C. Peripheral vagal nerve stimulation modulates the nociceptive withdrawal reflex in healthy subjects: A randomized, cross-over, sham-controlled study. Cephalalgia 2017; 38:1658-1664. [PMID: 29154689 DOI: 10.1177/0333102417742347] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Introduction The mechanism of action of non-invasive vagal nerve stimulation in the treatment of migraine is elusive. We studied its effect in a human model of pain, the nociceptive withdrawal reflex. Methods We enrolled 10 healthy subjects who underwent active non-invasive vagal nerve stimulation and sham treatment in a randomized, cross-over, sham-controlled study. Non-invasive vagal nerve stimulation was delivered with gammaCore®. The assessment of the nociceptive withdrawal reflex was performed at baseline (T0) and at 5 (T5) and 30 (T30) minutes after stimulation. Results Non-invasive vagal nerve stimulation significantly increased the reflex threshold to single stimulus at both T5 and T30 and the temporal summation threshold at T30. Sham treatment did not modify any parameters. Discussion These findings are consistent with a modulation of central descending pathways for pain control. An altered spinal and supraspinal control of pain has been described in primary headache, so this effect may partially explain the therapeutic effect of non-invasive vagal nerve stimulation.
Collapse
Affiliation(s)
- Roberto De Icco
- 1 Headache Science Centre, C. Mondino National Neurological Institute, Pavia, Italy.,2 Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Daniele Martinelli
- 1 Headache Science Centre, C. Mondino National Neurological Institute, Pavia, Italy.,2 Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Vito Bitetto
- 1 Headache Science Centre, C. Mondino National Neurological Institute, Pavia, Italy
| | - Mauro Fresia
- 1 Headache Science Centre, C. Mondino National Neurological Institute, Pavia, Italy
| | | | - Giorgio Sandrini
- 1 Headache Science Centre, C. Mondino National Neurological Institute, Pavia, Italy.,2 Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Cristina Tassorelli
- 1 Headache Science Centre, C. Mondino National Neurological Institute, Pavia, Italy.,2 Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| |
Collapse
|
20
|
Paulon E, Nastou D, Jaboli F, Marin J, Liebler E, Epstein O. Proof of concept: short-term non-invasive cervical vagus nerve stimulation in patients with drug-refractory gastroparesis. Frontline Gastroenterol 2017; 8:325-330. [PMID: 29067158 PMCID: PMC5641854 DOI: 10.1136/flgastro-2017-100809] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 03/17/2017] [Accepted: 04/02/2017] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Gastric electric stimulation (GES) is a treatment approach to refractory gastroparesis, possibly acting centrally via afferent vagus nerve stimulation (VNS). Non-invasive VNS (nVNS) is a potential alternative to GES that could eliminate the safety risks of or identify likely responders to implantable neurostimulators. OBJECTIVE This open-label proof-of-concept study assessed the effects of nVNS in patients with severe drug-refractory gastroparesis. METHODS Patients used the Gastroparesis Cardinal Symptom Index (GCSI) to grade symptoms in diaries daily for 2 weeks before treatment (baseline) and during ≥3 weeks of nVNS therapy. Adverse events (AEs) were also diarised. Treatment was self-administered using an nVNS device (gammaCore, electroCore) and consisted of 120 s stimulations to the vagus nerve in the neck (two stimulations to each side three times daily during weeks 1 and 2; three stimulations to each side three times daily during week 3 and beyond). Response was defined as a ≥1 point decrease from baseline in GCSI score. RESULTS Thirty-five patients enrolled; 23 were compliant with study procedures and were included in the analysis; 7 continued treatment beyond 3 weeks. Response rates were 35% (8/23) at 3 weeks and 43% (10/23) for the duration of therapy (3-6 weeks). For the entire cohort and the 10 responders, improvements from baseline were noted for mean total GCSI and GCSI subscale scores (nausea/vomiting, postprandial fullness/early satiety, bloating). No serious AEs were reported. CONCLUSIONS These preliminary results provide a signal that nVNS may be useful for treating refractory gastroparesis. Larger controlled studies are warranted.
Collapse
Affiliation(s)
- Emma Paulon
- Royal Free London NHS Foundation Trust, London, UK
| | | | | | - Juana Marin
- NIHR-Wellcome Trust Clinical Research Facility, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
| | - Eric Liebler
- electroCore, LLC, Basking Ridge, New Jersey, USA
| | - Owen Epstein
- Royal Free London NHS Foundation Trust, London, UK
| |
Collapse
|
21
|
Gaul C, Magis D, Liebler E, Straube A. Effects of non-invasive vagus nerve stimulation on attack frequency over time and expanded response rates in patients with chronic cluster headache: a post hoc analysis of the randomised, controlled PREVA study. J Headache Pain 2017; 18:22. [PMID: 28197844 PMCID: PMC5309191 DOI: 10.1186/s10194-017-0731-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 02/07/2017] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND In the PREVention and Acute treatment of chronic cluster headache (PREVA) study, attack frequency reductions from baseline were significantly more pronounced with non-invasive vagus nerve stimulation plus standard of care (nVNS + SoC) than with SoC alone. Given the intensely painful and frequent nature of chronic cluster headache attacks, additional patient-centric outcomes, including the time to and level of therapeutic response, were evaluated in a post hoc analysis of the PREVA study. FINDINGS After a 2-week baseline phase, 97 patients with chronic cluster headache entered a 4-week randomised phase to receive nVNS + SoC (n = 48) or SoC alone (n = 49). All 92 patients who continued into a 4-week extension phase received nVNS + SoC. Compared with SoC alone, nVNS + SoC led to a significantly lower mean weekly attack frequency by week 2 of the randomised phase; the attack frequency remained significantly lower in the nVNS + SoC group through week 3 of the extension phase (P < 0.02). Attack frequencies in the nVNS + SoC group were significantly lower at all study time points than they were at baseline (P < 0.05). Response rates were significantly greater with nVNS + SoC than with SoC alone when response was defined as attack frequency reductions of ≥25%, ≥50%, and ≥75% from baseline (≥25% and ≥50%, P < 0.001; ≥75%, P = 0.009). The 100% response rate was 8% with nVNS + SoC and 0% with SoC alone. CONCLUSIONS Prophylactic nVNS led to rapid, significant, and sustained reductions in chronic cluster headache attack frequency within 2 weeks after its addition to SoC and was associated with significantly higher ≥25%, ≥50%, and ≥75% response rates than SoC alone. The rapid decrease in weekly attack frequency justifies a 4-week trial period to identify responders to nVNS, with a high degree of confidence, among patients with chronic cluster headache.
Collapse
Affiliation(s)
- Charly Gaul
- Department of Headache and Facial Pain, Migraine and Headache Clinic, Ölmühlweg 31, Königstein im Taunus, 61462, Germany.
| | - Delphine Magis
- Headache Research Unit, University Department of Neurology, Centre Hospitalier Régional de la Citadelle, Boulevard du 12ème de Ligne 1, 4000, Liège, Belgium
| | - Eric Liebler
- electroCore, LLC, 150 Allen Road, Suite 201, Basking Ridge, 07920, NJ, USA
| | - Andreas Straube
- Department of Neurology, Ludwig-Maximilian University, Marchioninistr 15, Munich, D81377, Germany
| |
Collapse
|
22
|
Grazzi L, Egeo G, Calhoun AH, McClure CK, Liebler E, Barbanti P. Non-invasive Vagus Nerve Stimulation (nVNS) as mini-prophylaxis for menstrual/menstrually related migraine: an open-label study. J Headache Pain 2016; 17:91. [PMID: 27699586 PMCID: PMC5047863 DOI: 10.1186/s10194-016-0684-z] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 09/23/2016] [Indexed: 01/03/2023] Open
Abstract
Background Menstrual migraine and menstrually related migraine attacks are typically longer, more disabling, and less responsive to medications than non-menstrual attacks. The aim of this study was to evaluate the efficacy, safety, and tolerability of non-invasive vagus nerve stimulation for the prophylactic treatment of menstrual migraine/menstrually related migraine. Methods Fifty-six enrolled subjects (menstrual migraine, 9 %; menstrually related migraine, 91 %), 33 (59 %) of whom were receiving other prophylactic therapies, entered a 12-week baseline period. Fifty-one subjects subsequently entered a 12-week treatment period to receive open-label prophylactic non-invasive vagus nerve stimulation adjunctively (31/51; 61 %) or as monotherapy (20/51; 39 %) on day −3 before estimated onset of menses through day +3 after the end of menses. Results The number of menstrual migraine/menstrually related migraine days per month was significantly reduced from baseline (mean ± standard error, 7.2 ± 0.7 days) to the end of treatment (mean ± standard error, 4.7 ± 0.5 days; P < 0.001) (primary end point). Of all subjects, 39 % (95 % confidence interval: 26 %, 54 %) (20/51) had a ≥ 50 % reduction (secondary end point). For the other secondary end points, clinically meaningful reductions in analgesic use (mean change ± standard error, −3.3 ± 0.6 times per month; P < 0.001), 6-item Headache Impact Test score (mean change ± standard error, −3.1 ± 0.7; P < 0.001), and Migraine Disability Assessment score (mean change ± standard error, −11.9 ± 3.4; P < 0.001) were observed, along with a modest reduction in pain intensity (mean change ± standard error, −0.5 ± 0.2; P = 0.002). There were no safety/tolerability concerns. Conclusions These findings suggest that non-invasive vagus nerve stimulation is an effective treatment that reduces the number of menstrual migraine/menstrually related migraine days and analgesic use without safety/tolerability concerns in subjects with menstrual migraine/menstrually related migraine. Randomised controlled studies are warranted.
Collapse
Affiliation(s)
- Licia Grazzi
- Headache Center, Carlo Besta Neurological Institute and Foundation, Via Celoria 11, 20133, Milan, Italy
| | - Gabriella Egeo
- Headache and Pain Unit, Istituto di Ricovero e Cura a Carattere Scientifico, San Raffaele Pisana, Via della Pisana 235, 00163, Rome, Italy
| | - Anne H Calhoun
- Carolina Headache Institute, 6114 Fayetteville Rd., Suite 109, 27713, Durham, NC, USA
| | - Candace K McClure
- North American Science Associates Inc., 4050 Olson Memorial Highway, Suite 450, 55422, Minneapolis, MN, USA
| | - Eric Liebler
- electroCore, LLC, 150 Allen Road, Suite 201, 07920, Basking Ridge, NJ, USA
| | - Piero Barbanti
- Headache and Pain Unit, Istituto di Ricovero e Cura a Carattere Scientifico, San Raffaele Pisana, Via della Pisana 235, 00163, Rome, Italy.
| |
Collapse
|
23
|
Morris J, Straube A, Diener HC, Ahmed F, Silver N, Walker S, Liebler E, Gaul C. Cost-effectiveness analysis of non-invasive vagus nerve stimulation for the treatment of chronic cluster headache. J Headache Pain 2016; 17:43. [PMID: 27102120 PMCID: PMC4840129 DOI: 10.1186/s10194-016-0633-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 04/07/2016] [Indexed: 01/03/2023] Open
Abstract
Background Cluster headache (CH) is a debilitating condition that is generally associated with substantial health care costs. Few therapies are approved for abortive or prophylactic treatment. Results from the prospective, randomised, open-label PREVA study suggested that adjunctive treatment with a novel non-invasive vagus nerve stimulation (nVNS) device led to decreased attack frequency and abortive medication use in patients with chronic CH (cCH). Herein, we evaluate whether nVNS is cost-effective compared with the current standard of care (SoC) for cCH. Methods A pharmacoeconomic model from the German statutory health insurance perspective was developed to estimate the 1-year cost-effectiveness of nVNS + SoC (versus SoC alone) using data from PREVA. Short-term treatment response data were taken from the clinical trial; longer-term response was modelled under scenarios of response maintenance, constant rate of response loss, and diminishing rate of response loss. Health-related quality of life was estimated by modelling EQ-5D™ data from PREVA; benefits were defined as quality-adjusted life-years (QALY). Abortive medication use data from PREVA, along with costs for the nVNS device and abortive therapies (i.e. intranasal zolmitriptan, subcutaneous sumatriptan, and inhaled oxygen), were used to assess health care costs in the German setting. Results The analysis resulted in mean expected yearly costs of €7096.69 for nVNS + SoC and €7511.35 for SoC alone and mean QALY of 0.607 for nVNS + SoC and 0.522 for SoC alone, suggesting that nVNS generates greater health benefits for lower overall cost. Abortive medication costs were 23 % lower with nVNS + SoC than with SoC alone. In the alternative scenarios (i.e. constant rate of response loss and diminishing rate of response loss), nVNS + SoC was more effective and cost saving than SoC alone. Conclusions In all scenarios modelled from a German perspective, nVNS was cost-effective compared with current SoC, which suggests that adjunctive nVNS therapy provides economic benefits in the treatment of cCH. Notably, the current analysis included only costs associated with abortive treatments. Treatment with nVNS will likely promote further economic benefit when other potential sources of cost savings (e.g. reduced frequency of clinic visits) are considered. Trial registration Clinicaltrials.gov identifier NCT01701245, 03OCT2012.
Collapse
Affiliation(s)
- James Morris
- Cogentia Healthcare Consulting Ltd., Richmond House, 16-20 Regent Street, Cambridge, CB2 1DB, UK.
| | - Andreas Straube
- Ludwig Maximilian University of Munich, Marchioninistr 15, Munich, D81377, Germany
| | - Hans-Christoph Diener
- Department of Neurology and Headache Center, University Hospital Essen, Hufelandstrasse 55, 45122, Essen, Germany
| | - Fayyaz Ahmed
- Hull and Yorkshire Hospitals, Hull Royal Infirmary, Anlaby Road, Hull, HU3 2JZ, UK
| | - Nicholas Silver
- The Walton Centre for Neurology and Neurosurgery, Lower Lane, Liverpool, L9 7LJ, UK
| | - Simon Walker
- Cogentia Healthcare Consulting Ltd., Richmond House, 16-20 Regent Street, Cambridge, CB2 1DB, UK
| | - Eric Liebler
- electroCore, LLC, 150 Allen Road, Suite 201, Basking Ridge, NJ, 07920, USA
| | - Charly Gaul
- Department of Neurology and Headache Center, University Hospital Essen, Hufelandstrasse 55, 45122, Essen, Germany.,Migraine and Headache Clinic Königstein, Ölmühlweg 31, 61462, Königstein im Taunus, Germany
| |
Collapse
|
24
|
Barbanti P, Grazzi L, Egeo G, Padovan AM, Liebler E, Bussone G. Non-invasive vagus nerve stimulation for acute treatment of high-frequency and chronic migraine: an open-label study. J Headache Pain 2015; 16:61. [PMID: 26123825 PMCID: PMC4485661 DOI: 10.1186/s10194-015-0542-4] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 06/12/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The treatment of migraine headache is challenging given the lack of a standardized approach to care, unsatisfactory response rates, and medication overuse. Neuromodulation therapy has gained interest as an alternative to pharmacologic therapy for primary headache disorders. This study investigated the effects of non-invasive vagus nerve stimulation (nVNS) in patients with high-frequency episodic migraine (HFEM) and chronic migraine (CM). FINDINGS In this open-label, single-arm, multicenter study, patients with HFEM or CM self-treated up to 3 consecutive mild or moderate migraine attacks that occurred during a 2-week period by delivering two 120-s doses of nVNS at 3-min intervals to the right cervical branch of the vagus nerve. Of the 50 migraineurs enrolled (CM/HFEM: 36/14), 48 treated 131 attacks. The proportion of patients reporting pain relief, defined as a ≥50% reduction in visual analog scale (VAS) score, was 56.3% at 1 h and 64.6% at 2 h. Of these patients, 35.4% and 39.6% achieved pain-free status (VAS = 0) at 1 and 2 h, respectively. When all attacks (N = 131) were considered, the pain-relief rate was 38.2% at 1 h and 51.1% at 2 h, whereas the pain-free rate was 17.6% at 1 h and 22.9% at 2 h. Treatment with nVNS was safe and well tolerated. CONCLUSION Non-invasive vagus nerve stimulation may be effective as acute treatment for HFEM or CM and may help to reduce medication overuse and medication-associated adverse events.
Collapse
Affiliation(s)
- Piero Barbanti
- Headache and Pain Unit, Department of Neurological Motor and Sensorial Sciences, IRCCS San Raffaele Pisana, Via della Pisana 235, 00163, Rome, Italy,
| | | | | | | | | | | |
Collapse
|
25
|
Fritzemeier J, Haas L, Liebler E, Moennig V, Greiser-Wilke I. The development of early vs. late onset mucosal disease is a consequence of two different pathogenic mechanisms. Arch Virol 1997; 142:1335-50. [PMID: 9267447 DOI: 10.1007/s007050050164] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [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: 02/05/2023]
Abstract
Bovine viral diarrhea (BVD) virus is the causative agent of fatal mucosal disease (MD) of cattle. Experimental induction of MD can be achieved by superinfection of calves persistently viremic with a noncytopathic (ncp) BVD virus using an antigenically similar cytopathic (cp) BVD virus. Here we describe the characterisation of BVD viruses isolated from three cases of experimentally induced MD. One animal developed clinical symptoms two weeks after superinfection (early onset MD), while the onset of disease in the other two cases occurred with a delay of months (late onset MD). Antigenic characterisation of the viruses was performed using a panel of monoclonal antibodies against the E2 glycoprotein. For genetic analysis, RT-PCR was applied to amplify specific insertions and duplications in the NS2-3 genomic region of the cp BVD viruses. In addition, these amplicons and fragments of the viral E2 genes were sequenced. The results showed that in the case of early onset MD the cp BVD virus isolated after begin of disease was identical to the one used for superinfection. In contrast, the cp BVD viruses isolated from the two animals with late onset MD were obviously the result of genetic recombinations between the persistent ncp and the superinfecting cp BVD viruses. We conclude that early and late onset MD are the consequence of different pathogenic mechanisms.
Collapse
Affiliation(s)
- J Fritzemeier
- Institute of Virology, Veterinary School Hannover, Germany
| | | | | | | | | |
Collapse
|
26
|
Enss ML, Wagner S, Liebler E, Coenen M, Hedrich HJ. Response of the germfree rat colonic mucosa to dietary endotoxins. J Exp Anim Sci 1996; 38:58-65. [PMID: 9226963] [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: 02/04/2023]
Abstract
Suggestive to induce an immunoreactive response in the colon mucosa of germfree rats 3 diets, autoclaved or gamma-irradiated, respectively, were administered to groups of 30 days old GF Ztm:SPRD rats. Diets and rats were studied in parallel after a feeding period of 20 days. The microbiological controls confirmed the sterility of diets and animals. The aqueous suspensions of one diet displayed obviously dead yeast and Gram positive and negative bacteria, which consistently were evident in colonic cast preparations of animals fed with this diet. These findings apparently were not related to the pathohistological alterations, observed in hematoxilin-eosin stained colon sections. However, dietary endotoxin concentrations between 0.6 and 10 micrograms LPS/g corresponded with the endotoxin concentrations in feces (0.3 to 3.1 micrograms LPS/g wet weight) and in colonic tissue (0.01 to 0.6 microgram LPS/g wet weight). These endotoxins obviously mediated a dose-dependent immunoreactive response of the colonic mucosa: in parallel to the dietary endotoxin content, the cellular infiltrations ranged from single mononuclear cells to severe, cell mediated, mucosal alteration. GF rats, used as an experimental animal model for inflammatory disorders of the intestine obviously necessitate diets with low endotoxin concentrations.
Collapse
Affiliation(s)
- M L Enss
- Institut for Laboratory Animal Science and Animal Facility, Medical School Hannover, Germany
| | | | | | | | | |
Collapse
|
27
|
Liebler E, Johannsen U, Pohlenz J. [The hemorrhagic form of acute bovine virus diarrhea: literature review and case report]. Tierarztl Prax 1995; 23:18-25. [PMID: 7792770] [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: 01/27/2023]
Abstract
Infection of cattle with certain strains of BVD-virus causes a severe thrombocytopenia. The most obvious clinical and pathological lesions are multiple hemorrhages. Until now, problems with the Hemorrhagic syndrome have been reported predominantly from veal calf operations in the U.S.A. This publication presents first a literature review about the Hemorrhagic syndrome. The current data are based upon retrospective studies of field cases and experimental infections. Afterwards clinical, pathological and virological findings from three herds of veal calves in Germany are reported in which hemorrhagic diathesis was observed in calves and BVD-virus was isolated from tissues of diseased calves. The findings in these herds closely resemble the ones described in the literature for the Hemorrhagic syndrome. Therefore, infection with BVD-virus should be considered as differential diagnoses in Germany too, when hemorrhagic diathesis is observed in cattle.
Collapse
Affiliation(s)
- E Liebler
- Institut für Pathologie, Tierärztlichen Hochschule Hannover
| | | | | |
Collapse
|
28
|
Moennig V, Greiser-Wilke I, Frey HR, Haas L, Liebler E, Pohlenz J, Liess B. Prolonged persistence of cytopathogenic bovine viral diarrhea virus (BVDV) in a persistently viremic cattle. Zentralbl Veterinarmed B 1993; 40:371-7. [PMID: 8237210 DOI: 10.1111/j.1439-0450.1993.tb00152.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
A bull persistently viremic with noncytopathogenic (ncp) BVDV was inoculated with the cytopathic (cp) BVDV strain TGAC, which had been found to be antigenically different from the endogenous ncpBVDV (ncpW8). Neutralizing antibodies against strains NADL and TGAC were detectable 12 days and four weeks post infection, respectively. The animal developed fever and diarrhea 15 weeks post infection. On days 3 and 8 after onset of diarrhea a cpBVDV (cpX) was isolated from feces. Antigenic analysis using monoclonal antibodies (MoAbs) showed that cpX and the endogenous ncpBVDV (ncpW8) had identical reactivity patterns except for one epitope that was neither expressed on TGAC nor on ncpW8. Using polymerase chain reaction analysis it was shown that both TGAC and cpX contained a p8 phi gene duplication combined with genomic insertions of identical size. Restriction enzyme analysis of the TGAC and cpX amplicons using four enzymes showed an identical cleavage pattern, except for HaeIII digestion where an additional fragment was observed with cpX. These results suggest that cpBVDV strain TGAC persisted in the viremic animal and apparently caused disease after 15 weeks.
Collapse
Affiliation(s)
- V Moennig
- Institute of Virology and Institute of Pathology, Hannover Veterinary School, Germany
| | | | | | | | | | | | | |
Collapse
|
29
|
Greiser-Wilke I, Liebler E, Haas L, Liess B, Pohlenz J, Moennig V. Distribution of cytopathogenic and noncytopathogenic bovine virus diarrhea virus in tissues from a calf with experimentally induced mucosal disease using antigenic and genetic markers. Arch Virol Suppl 1993; 7:295-302. [PMID: 8219810 DOI: 10.1007/978-3-7091-9300-6_22] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
A comparative analysis of the distribution of cytopathogenic (cp) and noncytopathogenic (ncp) bovine virus diarrhea disease (BVD) virus in tissues from a calf with experimentally induced mucosal disease was performed using immunohistology and polymerase chain reaction after reverse transcription (RT-PCR) of viral RNA. For immunohistology, an antigenic marker on the superinfecting cp BVD virus defined by a monoclonal antibody (mab) was used, and overall presence of antigen was assessed with a pestivirus specific mab. The primers selected for RT-PCR detected the genomic insertion in the p125 region of the superinfecting cp BVD virus. Both methods gave consistent results.
Collapse
Affiliation(s)
- I Greiser-Wilke
- Institute of Virology, Hannover Veterinary School, Federal Republic of Germany
| | | | | | | | | | | |
Collapse
|
30
|
Moennig V, Frey HR, Liebler E, Pohlenz J, Liess B. Reproduction of mucosal disease with cytopathogenic bovine viral diarrhoea virus selected in vitro. Vet Rec 1990; 127:200-3. [PMID: 2173245] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Isolates of non-cytopathogenic bovine viral diarrhoea (BVD) virus from 18 persistently infected calves from one herd were compared by using monoclonal antibodies directed against the major viral glycoprotein gp53. All the isolates displayed an almost identical reaction pattern. Based on this antigenic analysis three cytopathogenic BVD and three non-cytopathogenic BVD viruses closely related to the non-cytopathogenic BVD herd isolate were selected. Six of the persistently infected calves were inoculated with a pool of the three closely related cytopathogenic BVD viruses and two with a pool of the three non-cytopathogenic BVD viruses. In addition three animals were infected with one closely related cytopathogenic BVD strain (Indiana) and two animals with the antigenetically different cytopathogenic BVD viral strain A1138/69. Regardless of the inoculation route all the animals superinfected with closely related cytopathogenic BVD viruses developed the characteristic lesions of mucosal disease within 14 days of infection. Animals which were inoculated with non-cytopathogenic BVD viruses which closely resembled the herd isolate, or with cytopathogenic BVD viruses which did not resemble the herd isolate did not develop any signs of disease. However, the latter group produced antibodies to the superinfecting virus.
Collapse
Affiliation(s)
- V Moennig
- Institute of Virology, Hannover Veterinary School, Germany
| | | | | | | | | |
Collapse
|