Epidemiology, Demographics, Triptan Contraindications, and Prescription Patterns of Patients with Migraine: A German Claims Database Study

Cost-effectiveness of rimegepant oral lyophilisate compared to best supportive care for the acute treatment of migraine in the UK

AIMS

Migraine is the most common disabling headache disorder and is characterized by recurrent throbbing head pain and symptoms of photophobia, phonophobia, nausea, and vomiting. Rimegepant 75 mg, an oral lyophilisate calcitonin gene-related peptide antagonist, is the first treatment approved for both the acute and preventative treatment of migraine, and the first acute therapy approved in over 20-years. The objective was to assess the cost-utility of rimegepant compared with best supportive care (BSC) in the UK, for the acute treatment of migraine in the adults with inadequate symptom relief after taking at least 2 triptans, or for whom triptans are contraindicated or not tolerated.

MATERIALS AND METHODS

A de novo model was developed to estimate incremental costs and quality-adjusted life years (QALYs), structured as a decision tree followed by Markov model. Patients received rimegepant or BSC for a migraine attack and were assessed for response (pain relief at 2-h). Responders and non-responders followed different pain trajectories over 48-h cycles. Non-responders discontinued treatment while responders continued treatment for subsequent attacks, with a proportion discontinuing over time. Data sources included a post-hoc pooled analysis of the phase 3 acute rimegepant trials (NCT03235479, NCT03237845, NCT03461757), and a long-term safety study (NCT03266588). The analysis was conducted from the perspective of the UK National Health Service and Personal Social Services over a 20-year time horizon.

RESULTS

Rimegepant resulted in an incremental cost-utility ratio (ICUR) of £10,309 per QALY gained vs BSC, which is cost-effectiveness at a willingness to pay threshold of £30,000/QALY. Rimegepant generated +0.44 incremental QALYs and higher incremental lifetime costs (£4,492). Improved QALYs for rimegepant were a result of less time spent with severe and moderate headache pain.

CONCLUSION

This study highlights the economic value of rimegepant which was found to be cost-effective for the acute treatment of migraine in adults unsuitable for triptans.

Triptan non-response in specialized headache care: cross-sectional data from the DMKG Headache Registry

BACKGROUND

Triptans are effective for many migraine patients, but some do not experience adequate efficacy and tolerability. The European Headache Federation (EHF) has proposed that patients with lack of efficacy and/or tolerability of ≥ 2 triptans ('triptan resistance') could be considered eligible for treatment with the novel medications from the ditan and gepant groups. There is little data on the frequency of 'triptan resistance'.

METHODS

We used patient self-report data from the German Migraine and Headache Society (DMKG) Headache Registry to assess triptan response and triptan efficacy and/or tolerability failure.

RESULTS

A total of 2284 adult migraine patients (females: 85.4%, age: 39.4 ± 12.8 years) were included. 42.5% (n = 970) had failed ≥ 1 triptan, 13.1% (n = 300) had failed ≥ 2 triptans (meeting the EHF definition of 'triptan resistance'), and 3.9% (n = 88) had failed ≥ 3 triptans. Compared to triptan responders (current use, no failure, n = 597), triptan non-responders had significantly more severe migraine (higher frequency (p < 0.001), intensity (p < 0.05), and disability (p < 0.001)), that further increased with the level of triptan failure. Responders rates were highest for nasal and oral zolmitriptan, oral eletriptan and subcutaneous sumatriptan.

CONCLUSION

In the present setting (specialized headache care in Germany), 13.1% of the patients had failed ≥ 2 triptans. Triptan failure was associated with increased migraine severity and disability, emphasizing the importance of establishing an effective and tolerable acute migraine medication. Acute treatment optimization might include switching to one of the triptans with the highest responder rates and/or to a different acute medication class.

TRIAL REGISTRATION

The DMKG Headache Registry is registered with the German Clinical Trials Register (DRKS 00021081).

Changes in Health-Related Quality of Life in Patients with Therapy-Resistant Migraine during Treatment with Erenumab in an Ambulatory Care Setting

Migraine preventive treatment with the CGRP-receptor monoclonal antibody Erenumab can positively impact health-related quality of life (HRQoL) and disease-associated disability. Patient-reported outcome measures (PROMs) are a valuable additional datapoint to real-world evidence covering how treatment affects physical, mental, and social domains of patients' lives. In this real-world, single-center retrospective observational cohort study, we analyzed clinical performance indicators and PROMs for migraine patients who failed at least four other preventive medications and received Erenumab over the course of one year. Endpoints were the average monthly migraine days as well as PROMs including the MIDAS, EQ-5D-VAS and PROMIS-29. Data were collected digitally via the software heartbeat ONE in an ambulatory care setting as part of the clinical routine. A total of 145 patients treated with Erenumab provided data for 12 months. After 12 months, the median number of monthly migraine days decreased from 9 to 7 days. A clinically relevant reduction in migraine days by ≥30% was reported by 40% of the patients. The migraine-specific MIDAS score, the EQ-5D-VAS measuring the overall health status and all PROMIS domains, except sleep disturbance, changed significantly, reflecting a positive disease progression. This study highlights how patients with a treatment-resistant migraine in an outpatient setting benefit from a preventive treatment with Erenumab. A decrease in migraine days and an increase in HRQoL was maintained over one year. It also underscores the significance of collecting real-world evidence, including PROMs, as an integral component of the healthcare cycle, as such data can reveal additional factors relevant to treatment.

Perception of typical migraine images on the internet: Comparison between a metropolis and a smaller rural city in Germany

The medial portrayal of migraine is often stereotypical and inaccurate but reflects how society perceives migraine. The discrepancy between others' views and the reality of affected individuals may negatively affect access to treatment and the disease course of patients with migraine. This study aimed to investigate whether images presented in the media as typical migraine attacks are perceived as realistic and representative by migraine patients in Rostock, a smaller town in rural Germany, and compare the results to those from Berlin, a large metropolis. We performed an online survey in Rostock. Migraine patients were shown ten images of migraine attacks, which were among the most downloaded stock pictures on the internet under the search term "migraine". They rated on a scale of 0-100 to what extent the pictures were realistic for migraine attacks (realism score), representative of their own migraine (representation score), or the society's view of migraine (society score). In addition, we compared our results with a recently published study from the metropolitan region of Berlin. A total of 174 migraine patients completed our survey. Mean (SD) realism, representation, and society scores were 59.9 (17.5), 56.7 (18.3), and 58.4 (17.1) respectively. Images of older patients were perceived as significantly more realistic and representative than those of younger patients (P < .001). Patients in Rostock (rural region) rated the images as significantly more realistic and representative than survey participants in Berlin (metropolis). Migraine patients in a rural region found typical migraine images only moderately realistic and representative but to a higher degree than their counterparts from a metropolis.

Efficacy of rimegepant for the acute treatment of migraine based on triptan treatment experience: Pooled results from three phase 3 randomized clinical trials

BACKGROUND

This post-hoc analysis from three phase 3 treatment trials of rimegepant 75 mg - an oral small molecule calcitonin gene-related peptide receptor antagonist for acute and preventive treatment of migraine - assessed efficacy in adults with migraine based on triptan treatment experience.

METHODS

Participants were assigned to one of four groups based on triptan treatment experience: insufficient response (e.g. lack of efficacy and/or poor tolerability) to 1 triptan, insufficient response to ≥2 triptans, current triptan users, and triptan-naïve participants. The co-primary efficacy endpoints were pain freedom and most bothersome symptom freedom at two hours postdose.

RESULTS

In the three trials (N = 3507; rimegepant n = 1749, placebo n = 1758), 1235 (35.2%) participants had a history of insufficient response to 1 triptan (n = 910 [25.9%]) or ≥2 triptans (n = 325 [9.3%]), and 2272 (64.8%) had no history of insufficient response to triptans (current use = 595 [17.0%], naïve = 1677 [47.8%]). Rimegepant was effective on the co-primary endpoints in all subgroups (p ≤ 0.013), except for freedom from the most bothersome symptom in the triptan-naïve group (p = 0.06). No differences on co-primary endpoints were found in pairwise comparisons of rimegepant-treated participants.

CONCLUSIONS

Rimegepant was effective for the acute treatment of migraine in adults with a history of insufficient response to 1 or ≥2 triptans and in current triptan users. Efficacy on co-primary endpoints did not differ based on the number of insufficient triptan responses.Trial registration: Clinicaltrials.gov: NCT03235479, NCT03237845, NCT03461757.

Evaluation of simple antioxidant blood parameters in patients with migraine

Background

The study aims to investigate the role of serum albumin (ALB) and creatinine (CRE), bilirubin (BIL), and uric acid (UA) as major intravascular antioxidants in migraine.

Methods

We enrolled 148 patients with migraine and 150 age- and sex-matched healthy controls. The serum levels of ALB, TBIL, CRE, and UA were measured in patients with migraine of different subtypes. The risk of migraine was assessed by multiple stepwise logistic regression analysis.

Results

The serum levels of ALB, total BIL (TBIL), CRE, and UA were significantly lower in the migraine group than in the HC group (p < 0.05). The ALB and UA levels were lower during migraine attack periods (p < 0.05). There were no statistically significant differences observed in serum ALB, TBIL, CRE, and UA levels between aura/without aura and episodic/chronic migraine subtypes (p > 0.05). The multiple stepwise logistic regression revealed that ALB [odds ratio (OR) 0.79, 95% confidence interval (CI) 0.69–0.89, p < 0.001], TBIL (OR 0.61, 95% CI 0.5–0.75, p < 0.001), and UA (OR 0.97, 95% CI 0.96–0.99, p = 0.014) were independently associated with migraine. In addition, the serum levels of ALB, TBIL, and UA were significantly lower in the migraine group when compared by sex.

Conclusion

The serum levels of UA, TBIL, ALB, and CRE were lower in the patients with migraine, indicating a lower antioxidant status. In addition, ALB, TBIL, and UA were independently related to migraine. These results could provide insights into the possible role of oxidative stress in the pathogenesis of migraine.

Compritol-Based Nanostrucutured Lipid Carriers (NLCs) for Augmentation of Zolmitriptan Bioavailability via the Transdermal Route: In Vitro Optimization, Ex Vivo Permeation, In Vivo Pharmacokinetic Study

Migraine is a severe neurovascular disease manifested mainly as unilateral throbbing headaches. Triptans are agonists for serotonin receptors. Zolmitriptan (ZMP) is a biopharmaceutics classification system (BCS) class III medication with an absolute oral bioavailability of less than 40%. As a result, our research intended to increase ZMP bioavailability by developing transdermal nanostructured lipid carriers (NLCs). NLCs were prepared utilizing a combination of hot melt emulsification and high-speed stirring in a 3² full factorial design. The studied variables were liquid lipid type (X₁) and surfactant type (X₂). The developed NLCs were evaluated in terms of particle size (Y₁, nm), polydispersity index (Y₂, PDI), zeta potential (Y₃, mV), entrapment efficacy (Y₄, %) and amount released after 6 h (Q6h, Y₅, %). At 1% Mygliol as liquid lipid component and 1% Span 20 as surfactant, the optimized formula (NLC9) showed a minimum particle size (138 ± 7.07 nm), minimum polydispersity index (0.39 ± 0.001), acceptable zeta potential (−22.1 ± 0.80), maximum entrapment efficiency (73 ± 0.10%) and maximum amount released after 6 h (83.22 ± 0.10%). The optimized formula was then incorporated into gel preparation (HPMC) to improve the system stability and ease of application. Then, the pharmacokinetic study was conducted on rabbits in a cross-over design. The calculated parameters showed a higher area under the curve (AUC_0–24, AUC_0–∞ (ng·h/mL)) of the developed ZMP-NLCs loaded gel, with a 1.76-fold increase in bioavailability in comparison to the orally administered marketed product (Zomig^®). A histopathological examination revealed the safety of the developed nanoparticles. The declared results highlight the potential of utilizing the proposed NLCs for the transdermal delivery of ZMP to improve the drug bioavailability.