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Raffaelli B, Do TP, Ashina H, Snellman J, Maio-Twofoot T, Ashina M. Induction of cGMP-mediated migraine attacks is independent of CGRP receptor activation. Cephalalgia 2024; 44:3331024241259489. [PMID: 38850034 DOI: 10.1177/03331024241259489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024]
Abstract
BACKGROUND The cAMP and cGMP pathways are implicated in the initiation of migraine attacks, but their interactions remain unclear. Calcitonin gene-related peptide (CGRP) triggers migraine attacks via cAMP, whereas the phosphodiesterase-5 inhibitor sildenafil induces migraine attacks via cGMP. Our objective was to investigate whether sildenafil could induce migraine attacks in individuals with migraine pre-treated with the CGRP-receptor antibody erenumab. METHODS In this randomized, double-blind, placebo-controlled, cross-over study, adults with migraine without aura received a single subcutaneous injection of 140 mg erenumab on day 1. They were then randomized to receive sildenafil 100 mg or placebo on two experimental days, each separated by at least one week, between days 8 and 21. The primary endpoint was the difference in the incidence of migraine attacks between sildenafil and placebo during the 12-h observation period after administration. RESULTS In total, 16 participants completed the study. Ten participants (63%) experienced a migraine attack within 12 h after sildenafil administration compared to three (19%) after placebo (p = 0.016). The median headache intensity was higher after sildenafil than after placebo (area under the curve (AUC) for the 12-h observation period, p = 0.026). Furthermore, sildenafil induced a significant decrease in mean arterial blood pressure (AUC, p = 0.026) and a simultaneous increase in heart rate (AUC, p < 0.001) during the first hour after administration compared to placebo. CONCLUSION These findings provide evidence that migraine induction via the cGMP pathway can occur even under CGRP receptor blockade. TRIAL REGISTRATION ClinicalTrials.gov: Identifier NCT05889455.
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Affiliation(s)
- Bianca Raffaelli
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Clinician Scientist Program, Berlin Institute of Health at Charité (BIH), Berlin, Germany
| | - Thien Phu Do
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Håkan Ashina
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Translational Research Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | | | | | - Messoud Ashina
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Robblee J, Hakim SM, Reynolds JM, Monteith TS, Zhang N, Barad M. Nonspecific oral medications versus anti-calcitonin gene-related peptide monoclonal antibodies for migraine: A systematic review and meta-analysis of randomized controlled trials. Headache 2024; 64:547-572. [PMID: 38634515 DOI: 10.1111/head.14693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 02/22/2024] [Accepted: 02/22/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVE To compare calcitonin gene-related peptide monoclonal antibodies (CGRP mAbs) versus nonspecific oral migraine preventives (NOEPs). BACKGROUND Insurers mandate step therapy with NOEPs before approving CGRP mAbs. METHODS Databases were searched for class I or II randomized controlled trials (RCTs) comparing CGRP mAbs or NOEPs versus placebo for migraine prevention in adults. The primary outcome measure was monthly migraine days (MMD) or moderate to severe headache days. RESULTS Twelve RCTs for CGRP mAbs, 5 RCTs for topiramate, and 3 RCTs for divalproex were included in the meta-analysis. There was high certainty that CGRP mAbs are more effective than placebo, with weighted mean difference (WMD; 95% confidence interval) of -1.64 (-1.99 to -1.28) MMD, which is compatible with small effect size (Cohen's d -0.25 [-0.34 to -0.16]). Certainty of evidence that topiramate or divalproex is more effective than placebo was very low and low, respectively (WMD -1.45 [-1.52 to -1.38] and -1.65 [-2.30 to -1.00], respectively; Cohen's d -1.25 [-2.47 to -0.03] and -0.48 [-0.67 to -0.29], respectively). Trial sequential analysis showed that information size was adequate and that CGRP mAbs had clear benefit versus placebo. Network meta-analysis showed no statistically significant difference between CGRP mAbs and topiramate (WMD -0.19 [-0.56 to 0.17]) or divalproex (0.01 [-0.73 to 0.75]). No significant difference was seen between topiramate or divalproex (0.21 [-0.45 to 0.86]). CONCLUSIONS There is high certainty that CGRP mAbs are more effective than placebo, but the effect size is small. When feasible, CGRP mAbs may be prescribed as first-line preventives; topiramate or divalproex could be as effective but are less well tolerated. The findings of this study support the recently published 2024 position of the American Headache Society on the use of CGRP mAbs as the first-line treatment.
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Affiliation(s)
- Jennifer Robblee
- Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Sameh M Hakim
- Department of Anesthesiology, Intensive Care, and Pain Management, Ain Shams University Faculty of Medicine, Cairo, Egypt
| | - John M Reynolds
- The Louis Calder Memorial Library, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Teshamae S Monteith
- Division of Headache, Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Niushen Zhang
- Department of Neurology & Neurological Sciences, Stanford Health Care, Stanford, California, USA
| | - Meredith Barad
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Health Care, Stanford, California, USA
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Pozo-Rosich P, Dolezil D, Paemeleire K, Stepien A, Stude P, Snellman J, Arkuszewski M, Stites T, Ritter S, Lopez Lopez C, Maca J, Ferraris M, Gil-Gouveia R. Early Use of Erenumab vs Nonspecific Oral Migraine Preventives: The APPRAISE Randomized Clinical Trial. JAMA Neurol 2024; 81:461-470. [PMID: 38526461 PMCID: PMC10964163 DOI: 10.1001/jamaneurol.2024.0368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/13/2023] [Indexed: 03/26/2024]
Abstract
Importance Patients with migraine often cycle through multiple nonspecific preventive medications due to poor tolerability and/or inadequate efficacy leading to low adherence and increased disease burden. Objective To compare the efficacy, tolerability, patient adherence, and patient satisfaction between erenumab and nonspecific oral migraine preventive medications (OMPMs) in patients with episodic migraine (EM) who had previously failed 1 or 2 preventive treatments. Design, Setting, and Participants The 12-month prospective, interventional, global, multicenter, active-controlled, randomized clinical trial comparing sustained benefit of 2 treatment paradigms (erenumab qm vs oral prophylactics) in adult episodic migraine patients (APPRAISE) trial was a 12-month open-label, multicenter, active-controlled, phase 4 randomized clinical trial conducted from May 15, 2019, to October 1, 2021. This pragmatic trial was conducted at 84 centers across 17 countries. Overall, participants 18 years or older with a 12-month or longer history of migraine, and 4 or more but fewer than 15 monthly migraine days (MMDs) were included. Interventions Patients were randomized (2:1) to receive erenumab or OMPMs. Dose adjustment was permitted (label dependent). Main Outcomes and Measures The primary end point was the proportion of patients completing 1 year of the initially assigned treatment and achieving a reduction of 50% or greater from baseline in MMDs at month 12. Secondary end points included the cumulative mean change from baseline in MMDs during the treatment period and the proportion of responders according to the Patients' Global Impression of Change (PGIC) scale at month 12 for patients taking the initially assigned treatment. Results A total of 866 patients were screened, of whom 245 failed the screening and 621 completed the screening and baseline period. Of the 621 randomized patients (mean [SD] age, 41.3 [11.2] years; 545 female [87.8%]; 413 [66.5%] in the erenumab group; 208 [33.5%] in the OMPM group), 523 (84.2%) completed the treatment phase, and 98 (15.8%) discontinued the study. At month 12, significantly more patients assigned to erenumab vs OMPM achieved the primary end point (232 of 413 [56.2%] vs 35 of 208 [16.8%]; odds ratio [OR], 6.48; 95% CI, 4.28-9.82; P <.001). Compared with OMPMs, treatment with erenumab showed higher responder rate (314 of 413 [76.0%] vs 39 of 208 [18.8%]; OR, 13.75; 95% CI, 9.08-20.83; P <.001) on the PGIC scale (≥5 at month 12). Significant reduction in cumulative average MMDs was reported with erenumab treatment vs OMPM treatment (-4.32 vs -2.65; treatment difference [SE]: -1.67 [0.35] days; P < .001). Substantially fewer patients in the erenumab arm compared with the OMPM arm switched medication (9 of 413 [2.2%] vs 72 of 208 [34.6%]) and discontinued treatment due to adverse events (12 of 408 [2.9%] vs 48 of 206 [23.3%]). No new safety signals were identified. Conclusions and Relevance Results of this randomized clinical trial demonstrated that earlier use of erenumab in patients with EM who failed 1 or 2 previous preventive treatments provided greater and sustained efficacy, safety, and adherence than continuous OMPM. Trial Registration ClinicalTrials.gov Identifier: NCT03927144.
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Affiliation(s)
- Patricia Pozo-Rosich
- Headache and Neurological Pain Research Group, Vall d’Hebron Institute of Research (VHIR), Department of Medicine, Universitat Autònoma de Barcelona, Spain
- Headache Unit, Neurology Department, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - David Dolezil
- Headache Center, Dado Medical sro, Prague, Czech Republic
| | - Koen Paemeleire
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Adam Stepien
- Department of Neurology, Military Institute of Medicine-National Research Institute, Warsaw, Poland
| | | | | | | | - Tracy Stites
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Shannon Ritter
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | | | - Jeff Maca
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | | | - Raquel Gil-Gouveia
- Hospital da Luz Headache Center, Neurology Department, Hospital da Luz, Lisboa, Portugal
- Center for Interdisciplinary Research in Health, Universidade Católica Portuguesa, Lisboa, Portugal
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Reuter U, Goadsby PJ, Ferrari MD, Da Silva Lima GP, Mondal S, Kalim J, Hasan F, Wen S, Arkuszewski M, Pandhi S, Stites T, Lanteri-Minet M. Efficacy and Safety of Erenumab in Participants With Episodic Migraine in Whom 2-4 Prior Preventive Treatments Had Failed: LIBERTY 3-Year Study. Neurology 2024; 102:e209349. [PMID: 38669638 DOI: 10.1212/wnl.0000000000209349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The LIBERTY study assessed the efficacy and safety of erenumab in participants with episodic migraine (EM) and 2-4 prior preventive treatment failures. The results have been presented after 3 years of erenumab exposure in its open-label extension phase (OLEP). METHODS Participants completing the 12-week double-blind treatment phase (DBTP) of the LIBERTY study could enter the OLEP and receive 140 mg of erenumab once monthly for 3 years. The main outcomes included the proportion of participants achieving ≥50% reduction in monthly migraine days (MMDs), the mean MMD change from baseline, and tolerability and safety. RESULTS Overall, 240/246 (97.6%) participants entered the OLEP and 168/240 (70.0%) completed the study (85/118 continuing erenumab [n = 1 lost during follow-up]; 83/122 switching from placebo [n = 2 lost during follow-up]). In the overall population, 79/151 participants (52.3%) with valid data points achieved ≥50% reduction in MMDs at week 168 (i.e., responders). In the continuous erenumab group, 35/117 participants (29.9%) were ≥50% responders at week 12 of the DBTP and 26/35 (74.3%) remained ≥50% responders in at least half of OLEP visits. Of the 82/117 participants (70.1%) not achieving responder status at week 12 in the continuous erenumab group, 17/82 (20.7%) converted to ≥50% responders in at least half of OLEP visits. Of 103/120 participants (85.8%) not achieving responder status at week 12 in the placebo-erenumab group, 42/103 (40.8%) converted to ≥50% responders in at least half of OLEP visits after switching to erenumab. Overall, the mean (SD) MMD change from baseline showed sustained improvement over 3 years (-4.4 [3.9] days at week 168). The most common treatment-emergent AEs (per 100 person-years) were nasopharyngitis (28.8), influenza (7.5), and back pain (5.8). Overall, 9.6% (3.9 per 100 person-years) and 6.7% (2.7 per 100 person-years) of participants reported events of treatment-emergent hypertension and constipation, respectively. The safety and tolerability profile remained consistent with earlier studies. DISCUSSION Erenumab (140 mg) showed sustained efficacy over 3 years in participants with EM and 2-4 prior preventive treatment failures. No new safety signals were observed. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov Identifier: NCT03096834.
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Affiliation(s)
- Uwe Reuter
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Peter J Goadsby
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Michel D Ferrari
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Gabriel Paiva Da Silva Lima
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Subhayan Mondal
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Jawed Kalim
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Fatima Hasan
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Shihua Wen
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Michal Arkuszewski
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Shaloo Pandhi
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Tracy Stites
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Michel Lanteri-Minet
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
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Cho S, Kim BK. Long-Term Outcome After Discontinuation of CGRP-Targeting Therapy for Migraine. Curr Pain Headache Rep 2024:10.1007/s11916-024-01259-x. [PMID: 38683278 DOI: 10.1007/s11916-024-01259-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2024] [Indexed: 05/01/2024]
Abstract
PURPOSE OF REVIEW Calcitonin gene-related peptide (CGRP)-targeting agents are potential candidates for disease-modifying migraine drugs. However, most studies on CGRP-targeting agents have assessed efficacy outcomes rather than long-term effects after discontinuation. This review aimed to synthesize and scrutinize the latest clinical data on the outcomes after the discontinuation of CGRP-targeting therapy in patients with episodic and chronic migraine, with a particular focus on chronic migraine. RECENT FINDINGS Real-world studies involving patients with migraine have reported consistent findings of worsened headache frequency and quality of life after the discontinuation of CGRP monoclonal antibodies (CGRP mAbs). Although many patients maintain improvements for up to 4 months after discontinuation compared to baseline (before starting CGRP mAbs), no studies have evaluated the effects of stopping treatment for > 5 months, which is the five-half-life of CGRP mAbs. Several studies have suggested that patients treated with CGRP receptor mAbs experience more rapid deterioration than those treated with CGRP ligand mAbs after discontinuing CGRP mAbs. The results of real-world studies suggest that for many patients with migraine, the benefits of CGRP mAbs diminish months after discontinuation. Therefore, anti-CGRP therapies may not be considered disease-modifying. However, the comprehensive assessment of the disease-modifying potential of these drugs requires studies with extended treatment and cessation durations.
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Affiliation(s)
- Soohyun Cho
- Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu, Korea
| | - Byung-Kun Kim
- Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea.
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Naghdi S, Underwood M, Brown A, Matharu M, Duncan C, Davies N, Aksentyte A, Mistry H. Adverse and serious adverse events incidence of pharmacological interventions for managing chronic and episodic migraine in adults: a systematic review. BMJ Neurol Open 2024; 6:e000616. [PMID: 38646505 PMCID: PMC11029425 DOI: 10.1136/bmjno-2023-000616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 04/01/2024] [Indexed: 04/23/2024] Open
Abstract
Background Migraine is the second most common prevalent disorder worldwide and is a top cause of disability with a substantial economic burden. Many preventive migraine medications have notable side effects that affect different body organs. Method We systematically searched for published randomised controlled trials (RCTs) using terms for migraine/headache and preventive medications. Using eligibility criteria, two reviewers independently assessed the articles. Cochrane risk-of-bias tool was applied to assess the quality of the studies. Data were classified by system organ class (SOC). Results Thirty-two RCTs with 21 780 participants met the eligibility criteria for the incidence of adverse events (AEs). Additionally, 33 RCTs with 22 615 participants were included to synthesise the incidence of serious AEs (SAEs). The percentage of attributed AEs and SAEs to each SOC for 10 preventive drugs with different dosing regimens was calculated. Amitriptyline and topiramate had a higher incidence of nervous system disorders; Topiramate was also associated with a higher incidence of psychiatric disorders. All drugs showed a certain incidence of infections and infestations, with Onabotulinumtoxin A (BTA) having the lowest rate. BTA had a higher incidence of musculoskeletal disorders than the other drugs. Calcitonin gene-related peptide (CGRP) monoclonal antibodies (MAbs) such as fremanezumab and galcanezumab were linked to more general disorders and administration site conditions than other drugs. Conclusion Notably, the observed harm to SOCs varies among these preventive drugs. We suggest conducting head-to-head RCTs to evaluate the safety profile of oral medications, BTA, and CGRP MAbs in episodic and/or chronic migraine populations. PROSPERO registration number CRD42021265993.
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Affiliation(s)
- Seyran Naghdi
- Warwick Clinical Trials Unit, University of Warwick, Warwick Medical School, Coventry, UK
| | - Martin Underwood
- Warwick Clinical Trials Unit, University of Warwick, Warwick Medical School, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, Coventry, UK
| | - Anna Brown
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Manjit Matharu
- Headache Group, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK
| | - Callum Duncan
- Department of Neurology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Natasha Davies
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Aiva Aksentyte
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Hema Mistry
- Warwick Clinical Trials Unit, University of Warwick, Warwick Medical School, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, Coventry, UK
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Montisano DA, Giossi R, Canella M, Altamura C, Marcosano M, Vernieri F, Raggi A, Grazzi L. Reducing the Impact of Headache and Allodynia Score in Chronic Migraine: An Exploratory Analysis from the Real-World Effectiveness of Anti-CGRP Monoclonal Antibodies Compared to Onabotulinum Toxin A (RAMO) Study. Toxins (Basel) 2024; 16:178. [PMID: 38668603 PMCID: PMC11054793 DOI: 10.3390/toxins16040178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 03/22/2024] [Accepted: 03/28/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Chronic migraine (CM) is a disabling and hard-to-treat condition, associated with high disability and high cost. Among the preventive treatments, botulinum toxin A (BoNT-a) and monoclonal antibodies against the calcitonin gene-related protein (anti-CGRP mAbs) are the only disease-specific ones. The assessment of the disease burden is complex, and among others, tools such as the allodynia symptoms checklist (ASC-12) and headache impact test (HIT-6) are very useful. This exploratory study analysed the impact of these two therapies on migraine burden. METHODS The RAMO study was a multicentre, observational, retrospective investigation conducted in two headache centres: the Fondazione IRCCS Istituto Neurologico Carlo Besta (Milan) and the Fondazione Policlinico Campus Bio-Medico (Rome). This study involved patients with chronic migraine treated with mAbs or BoNT-A. We conducted a subgroup exploratory analysis on HIT-6 and ASC-12 scores in the two groups. The Wilcoxon rank-sum test, Fisher's exact test, and ANOVA were performed. RESULTS Of 126 patients, 36 on mAbs and 90 on BoNT-A had at least one available follow-up. mAbs resulted in a mean reduction of -11.1 and -11.4 points, respectively, in the HIT-6 at 6 and 12 months, while BoNT-A was reduced -3.2 and -3.6 points, respectively; the mAbs arm resulted in mean reductions in ASC-12 at 6 and 12 months of follow-up of -5.2 and -6.0 points, respectively, while BoNT-A showed lesser mean changes of -0.5 and -0.9 points, respectively. The adjusted analysis confirmed our results. CONCLUSIONS In this exploratory analysis, anti-CGRP mAbs showed superior effectiveness for HIT-6 and ASC12 compared to BoNT-A. Reductions in terms of month headache days (MHD), migraine disability assessment test (MIDAS), and migraine acute medications (MAM) were clinically relevant for both treatments.
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Affiliation(s)
- Danilo Antonio Montisano
- Neuroalgology Unit and Headache Center, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria, 11, 20133 Milan, Italy
| | - Riccardo Giossi
- Poison Control Center and Clinical Pharmacology Unit, Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy
- Department of Research and Clinical Development, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria, 11, 20133 Milan, Italy
| | - Mattia Canella
- Department of Medical Biotechnology and Translational Medicine, Postgraduate School of Clinical Pharmacology and Toxicology, Università degli Studi di Milano, Via Vanvitelli, 32, 20129 Milan, Italy
- Neuroimmunology and Neuromuscular Disease Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy
| | - Claudia Altamura
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| | - Marilena Marcosano
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| | - Fabrizio Vernieri
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| | - Alberto Raggi
- Neurology, Public Health and Disability Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20131 Milan, Italy
| | - Licia Grazzi
- Neuroalgology Unit and Headache Center, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria, 11, 20133 Milan, Italy
- SC Neuroalgologia–Centro Cefalee, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy
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Rattanawong W, Rapoport A, Srikiatkhachorn A. Medication "underuse" headache. Cephalalgia 2024; 44:3331024241245658. [PMID: 38613233 DOI: 10.1177/03331024241245658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
BACKGROUND Many risk factors have been associated with migraine progression, including insufficient and ineffective utilization of migraine medications; however, they have been inadequately explored. This has resulted in suboptimal usage of medications without effective altering of prescribing recommendations for patients, posing a risk for migraine chronification. METHODS Our aim is to conduct a comprehensive review of the available evidence regarding the underuse of migraine medications, both acute and preventive. The term "underuse" includes, but is not limited to: (1) ineffective use of appropriate and inappropriate medication; (2) underutilization; (3) inappropriate timing of usage; and (4) patient dissatisfaction with medication. RESULTS The underuse of both acute and preventive medications has been shown to contribute to the progression of migraine. In terms of acute medication, chronification occurs as a result of insufficient drug use, including failure of the prescriber to select the appropriate type based on pain intensity and disability, patients taking medication too late (more than 60 minutes after the onset or after central sensitization has occurred as evidenced by allodynia), and discontinuation because of lack of effect or intolerable side effects. The underlying cause of inadequate effectiveness of acute medication lies in its inability to halt the propagation of peripheral activation to central sensitization in a timely manner. For oral and injectable preventive migraine medications, insufficient efficacy and intolerable side effects have led to poor adherence and discontinuation with subsequent progression of migraine. The underlying pathophysiology here is rooted in the repetitive stimulation of afferent sensory pain fibers, followed by ascending brainstem pain pathways plus dysfunction of the endogenous descending brainstem pain inhibitory pathway. Although anti-calcitonin gene-related peptide (CGRP) medications partially address pain caused by the above factors, including decreased efficacy and tolerability from conventional therapy, some patients do not respond well to this treatment. Research suggests that initiating preventive anti-CGRP treatment at an early stage (during low frequency episodic migraine attacks) is more beneficial than commencing it during high frequency episodic attacks or when chronic migraine has begun. CONCLUSIONS The term "medication underuse" is underrecognized, but it holds significant importance. Optimal usage of acute care and preventive migraine medications could potentially prevent migraine chronification and improve the treatment of migraine attacks.
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Affiliation(s)
- Wanakorn Rattanawong
- Faculty of Medicine, King Mongkut's Institute of Technology Ladkrabang, Bangkok, Thailand
| | - Alan Rapoport
- Department of Neurology, The David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Anan Srikiatkhachorn
- Faculty of Medicine, King Mongkut's Institute of Technology Ladkrabang, Bangkok, Thailand
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Pellesi L, Do TP, Hougaard A. Pharmacological management of migraine: current strategies and future directions. Expert Opin Pharmacother 2024; 25:673-683. [PMID: 38720629 DOI: 10.1080/14656566.2024.2349791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 04/26/2024] [Indexed: 06/12/2024]
Abstract
INTRODUCTION Migraine is a complex neurological disorder that affects a significant portion of the global population. As traditional pharmacological approaches often fall short in alleviating symptoms, the development of innovative therapies has garnered significant interest. This text aims to summarize the current pharmacological options for managing migraine and to explore the potential impact of novel therapies. AREAS COVERED We focused on conventional treatments, emerging therapies, and novel compounds in clinical development, including therapies targeting the trigeminovascular system, cannabis-based therapies, hormonal and metabolic therapies, and other options. English peer-reviewed articles were searched in PubMed, Scopus, and ClinicalTrials.gov electronic databases. EXPERT OPINION Several novel treatment options for migraine have become available in recent years. Emerging pharmacological therapies targeting the trigeminovascular system, cannabis-based therapies, hormonal and metabolic interventions, and other emerging treatment modalities, may prove to be valuable for the treatment of migraine. Further research, clinical trials, and substantiated evidence are necessary to validate the efficacy, safety, and long-term outcomes of these therapeutic options.
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Affiliation(s)
- Lanfranco Pellesi
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Thien Phu Do
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Neurology, Danish Knowledge Center on Headache Disorders, Glostrup, Denmark
- Department of Clinical Medicine, Faculty of Medical and Health Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Neurology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Anders Hougaard
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Medical and Health Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Neurology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
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10
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Lipton RB. Preventive Treatment of Migraine. Continuum (Minneap Minn) 2024; 30:364-378. [PMID: 38568488 DOI: 10.1212/con.0000000000001418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
OBJECTIVE This article describes strategies for the preventive treatment of migraine including the emerging role of calcitonin gene-related peptide (CGRP)-targeted therapies and introduces novel paradigms for the preventive treatment of migraine. LATEST DEVELOPMENTS Multiple migraine medications targeting CGRP have been introduced since 2018, including injectable monoclonal antibodies (ie, eptinezumab, erenumab, fremanezumab, and galcanezumab) and oral small-molecule CGRP receptor antagonists (ie, ubrogepant, rimegepant, atogepant, and zavegepant). With the exceptions of ubrogepant and zavegepant, which are approved only as acute treatments, all of these agents have demonstrated efficacy in the preventive treatment of migraine; the monoclonal antibodies and atogepant have evidence of effectiveness in adults with either episodic or chronic migraine. The safety and tolerability profiles of CGRP-targeted therapies in migraine are favorable. ESSENTIAL POINTS The goals of preventive migraine therapy include reducing the frequency, severity, duration, and disability associated with attacks, reducing the need for acute treatment and the risk of medication overuse, enhancing self-efficacy and health-related quality of life, and reducing headache-related distress and interictal burden. Six drugs targeting CGRP (four monoclonal antibodies and two gepants) are now available for the preventive treatment of episodic migraine in adults. The efficacy of CGRP-targeted medications in the acute and preventive treatment of migraine, together with good safety and tolerability, has led to the emergence of new approaches to preventive treatment.
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11
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Charles AC, Digre KB, Goadsby PJ, Robbins MS, Hershey A. Calcitonin gene-related peptide-targeting therapies are a first-line option for the prevention of migraine: An American Headache Society position statement update. Headache 2024; 64:333-341. [PMID: 38466028 DOI: 10.1111/head.14692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 02/20/2024] [Accepted: 02/22/2024] [Indexed: 03/12/2024]
Abstract
OBJECTIVE To provide a position statement update from The American Headache Society specifically regarding therapies targeting calcitonin gene-related peptide (CGRP) for the prevention of migraine. BACKGROUND All migraine preventive therapies previously considered to be first-line treatments were developed for other indications and adopted later for migraine. Adherence to these therapies is often poor due to issues with efficacy and tolerability. Multiple new migraine-specific therapies have been developed based on a broad foundation of pre-clinical and clinical evidence showing that CGRP plays a key role in the pathogenesis of migraine. These CGRP-targeting therapies have had a transformational impact on the management of migraine but are still not widely considered to be first-line approaches. METHODS Evidence regarding migraine preventive therapies including primary and secondary endpoints from randomized placebo-controlled clinical trials, post hoc analyses and open-label extensions of these trials, and prospective and retrospective observational studies were collected from a variety of sources including PubMed, Google Scholar, and ClinicalTrials.gov. The results and conclusions based upon these results were reviewed and discussed by the Board of Directors of The American Headache Society to confirm consistency with clinical experience and to achieve consensus. RESULTS The evidence for the efficacy, tolerability, and safety of CGRP-targeting migraine preventive therapies (the monoclonal antibodies: erenumab, fremanezumab, galcanezumab, and eptinezumab, and the gepants: rimegepant and atogepant) is substantial, and vastly exceeds that for any other preventive treatment approach. The evidence remains consistent across different individual CGRP-targeting treatments and is corroborated by extensive "real-world" clinical experience. The data indicates that the efficacy and tolerability of CGRP-targeting therapies are equal to or greater than those of previous first-line therapies and that serious adverse events associated with CGRP-targeting therapies are rare. CONCLUSION The CGRP-targeting therapies should be considered as a first-line approach for migraine prevention along with previous first-line treatments without a requirement for prior failure of other classes of migraine preventive treatment.
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Affiliation(s)
- Andrew C Charles
- Department of Neurology, UCLA Goldberg Migraine Program, Los Angeles, California, USA
| | - Kathleen B Digre
- Departments of Neurology and Ophthalmology, University of Utah, Salt Lake City, Utah, USA
| | - Peter J Goadsby
- Department of Neurology, UCLA Goldberg Migraine Program, Los Angeles, California, USA
- King's College London, London, UK
| | - Matthew S Robbins
- Department of Neurology, Weill Cornell Medical College, New York, New York, USA
| | - Andrew Hershey
- Department of Pediatrics and Neurology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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12
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Rikos D, Vikelis M, Dermitzakis EV, Soldatos P, Rallis D, Rudolf J, Andreou AP, Argyriou AA. Reporting Quality and Risk of Bias Analysis of Published RCTs Assessing Anti-CGRP Monoclonal Antibodies in Migraine Prophylaxis: A Systematic Review. J Clin Med 2024; 13:1964. [PMID: 38610729 PMCID: PMC11012539 DOI: 10.3390/jcm13071964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 03/19/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
Objective: Phase II/III randomized clinical trials (RCTs) are vulnerable to many types of bias beyond randomization. Insights into the reporting quality of RCTs involving migraine patients treated with monoclonal antibodies targeting the calcitonin gene-related peptide system (anti-CGRP MAbs) are currently lacking. Our aim was to analyze the reporting quality of phase II/III RCTs involving migraine patients treated with anti-CGRP MAbs. Methods: A systematic search was performed on the PubMed and EMBASE databases, according to PRISMA guidelines, for relevant RCTs in either episodic or chronic migraine prevention. Additionally, an adapted version of the 2010 CONSORT statement checklist was utilized. The ROBvis online tool was used to document the risk of bias. Results: From the initially identified 179 articles, we finally found 31 RCTs that were eligible for evaluation. The average CONSORT compliance was 88.7% (69.7-100%), while 93.5% (N = 29) of the articles had a compliance greater than 75%. Twenty-eight CONSORT items were reported in more than 75% of the articles. The average compliance of the analyzed RCTs was 93.9% for Galcanezumab, 91.3% for Fremanezumab, followed by 85.4% for Erenumab and Eptinezumab studies. Implementation of the ROB2 tool showed some concerning "missing information" arising from the inadequate reporting. Specifically, 50% of the studies (N = 16) were categorized as having inadequate information regarding the randomization process. Conclusions: Adequate reporting quality was disclosed in the evaluated RCTs with anti-CGRP MAbs in migraine prevention. However, some methodological issues need to be highlighted to be addressed in future studies assessing the efficacy of new molecules targeting CGRP or other candidate pathways implicated in migraine pathophysiology.
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Affiliation(s)
| | - Michail Vikelis
- Headache Clinic, Mediterraneo Hospital, 16675 Athens, Greece;
| | | | | | - Dimitrios Rallis
- Department of Neurology, Tzaneio General Hospital of Piraeus, 18536 Athens, Greece;
| | - Jobst Rudolf
- Department of Neurology, Papageorgiou General Hospital of Thessaloniki, 54645 Thessaloniki, Greece;
| | - Anna P. Andreou
- Headache Centre, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 9RT, UK;
- Headache Research-Wolfson Sensory, Pain and Regeneration Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE1 1LU, UK
| | - Andreas A. Argyriou
- Headache Outpatient Clinic, Department of Neurology, Agios Andreas General Hospital of Patras, 26335 Patras, Greece;
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Pozo-Rosich P, Poveda JL, Crespo C, Martínez M, Rodríguez JM, Irimia P. Is erenumab an efficient alternative for the prevention of episodic and chronic migraine in Spain? Results of a cost-effectiveness analysis. J Headache Pain 2024; 25:40. [PMID: 38491460 PMCID: PMC10943917 DOI: 10.1186/s10194-024-01747-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 03/07/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND The reimbursement of erenumab in Spain and other European countries is currently restricted because of the cost of this novel therapy to patients with migraine who have experienced previous failures to traditional preventive treatments. However, this reimbursement policy should be preferably based on cost-effectiveness studies, among other criteria. This study performed a cost-effectiveness analysis of erenumab versus topiramate for the prophylactic treatment of episodic migraine (EM) and versus placebo for chronic migraine (CM). METHODS A Markov model with a 10-year time horizon, from the perspective of the Spanish National Healthcare System, was constructed based on data from responder and non-responder patients. A responder was defined as having a minimum 50% reduction in the number of monthly migraine days (MMD). A hypothetical cohort of patients with EM with one or more prior preventive treatment failures and patients with CM with more than two treatment failures was considered. The effectiveness score was measured as an incremental cost per quality-adjusted life year (QALY) gained and cost per migraine day (MD) avoided. Data from clinical outcomes and patient characteristics were obtained from erenumab clinical trials (NCT02066415, STRIVE, ARISE, LIBERTY and HER-MES). Deterministic and probabilistic sensitivity analyses were performed to validate the robustness of the model. RESULTS After a 10-year follow-up, the estimated QALYs were 5.88 and 6.11 for patients with EM treated with topiramate and erenumab, respectively. Erenumab showed an incremental cost per patient of €4,420 vs topiramate. For CM patients, erenumab resulted in 0.756 QALYs gained vs placebo; and an incremental cost of €1,814. Patients treated with erenumab achieved reductions in MD for both EM and CM (172 and 568 MDs, respectively). The incremental cost per QALY gained with erenumab was below the Spanish threshold of €30,000/QALY for both health and societal perspectives (EM €19,122/QALY and CM €2,398/QALY). CONCLUSIONS Erenumab is cost-effective versus topiramate as a preventive treatment for EM and versus placebo for patients with CM from the perspective of the Spanish National Health System.
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Affiliation(s)
- Patricia Pozo-Rosich
- Neurology Department, Headache Unit, Valld'Hebron University Hospital, Ps. Vall d'Hebron 119-12, 08035, Barcelona, Spain.
- Headache Research Group, Medicine Departament, VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - José Luis Poveda
- Pharmacy Department, Hospital Universitari I Politècnic La Fe, Valencia, Spain
| | - Carlos Crespo
- Axentiva Solutions, Barcelona, Spain
- G.M. Statistics Department, Universidad de Barcelona, Barcelona, Spain
| | | | | | - Pablo Irimia
- Department of Neurology, Headache Unit, Clínica Universidad de Navarra, Pamplona, Spain
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Hershey AD, Paiva da Silva Lima G, Pannacciulli N, Mackowski M, Koukakis R, McVige JW. Pharmacokinetics and safety of erenumab in pediatric patients with migraine: A phase I, randomized, open-label, multiple-dose study. Clin Transl Sci 2024; 17:e13755. [PMID: 38476099 PMCID: PMC10933636 DOI: 10.1111/cts.13755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/14/2024] Open
Abstract
Erenumab, a fully human monoclonal antibody targeting the calcitonin gene-related peptide receptor, is efficacious and safe for prevention of attacks of migraine in adults. This phase I, randomized, open-label, multiple-dose study evaluated the safety, tolerability, and pharmacokinetics (PK) of erenumab in children and adolescents with migraine. The initial treatment phase lasted 12 weeks, followed by an optional 40-week extension phase for adolescents. Primary end points were PK of erenumab, incidence of treatment-emergent adverse events (TEAEs), and changes in clinical and laboratory assessments. Participants received erenumab 35 mg (n = 4), 70 mg (n = 17), or 140 mg (n = 32) q4w. The mean age was 14.1 years. Of the 53 participants, 48 (90.6%) completed the initial treatment phase and 36 (67.9%) received erenumab during the extension phase. Mean exposures to erenumab based on the maximum observed concentration and the area under the drug concentration-time curve during the dosing interval increased approximately dose-proportionally. A total of 42 participants (79.2%) reported TEAEs (307.2 per 100 participant-years); and four (7.5%) reported serious TEAEs not considered treatment-related. The most common TEAEs were upper respiratory tract infection, headache, and vomiting. No clinically significant changes were reported in vital signs, electrocardiograms, and laboratory and neurological assessments. Overall, the observed PK profile of erenumab in children and adolescents with migraine is consistent with that in adults when body weight differences are taken into consideration. The safety profile of erenumab in children and adolescents is consistent with that in adults.
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Affiliation(s)
- Andrew D. Hershey
- Cincinnati Children's Hospital Medical Center and University of Cincinnati College of MedicineCincinnatiOhioUSA
| | | | | | - Mia Mackowski
- Amgen Inc., One Amgen Center DriveThousand OaksCaliforniaUSA
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15
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Diener HC, May A. New migraine drugs: A critical appraisal of the reason why the majority of migraine patients do not receive an adequate medication. Cephalalgia 2024; 44:3331024241228605. [PMID: 38520255 DOI: 10.1177/03331024241228605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2024]
Abstract
The last three decades have produced several novel and efficient medications to treat migraine attacks and reduce attack frequency. Additionally, promising approaches for the development of acute therapy and migraine prophylaxis continue to be pursued. At the same time as we witness the development of better and more efficient medications with continuously fewer side effects, we also realise that the high cost of such therapies means that only a minority of migraine patients who could benefit from these medications can afford them. Furthermore, information on cost-effectiveness is still lacking. Here, we compare availiable data, highlight open questions and suggest trials to close knowledge gaps. With good reason, our medicine is evidence-based. However, if this evidence is not collected, our decisions will continue to be based on marketing and assumptions. At the moment, we are not doing justice to our patients.
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Affiliation(s)
- Hans Christoph Diener
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology (IMIBE), Faculty of Medicine, University Duisburg-Essen, Essen, Germany
| | - Arne May
- Department of Systems Neuroscience, University Hamburg, Hamburg, Germany
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Lazaro-Hernandez C, Caronna E, Rosell-Mirmi J, Gallardo VJ, Alpuente A, Torres-Ferrus M, Pozo-Rosich P. Early and annual projected savings from anti-CGRP monoclonal antibodies in migraine prevention: a cost-benefit analysis in the working-age population. J Headache Pain 2024; 25:21. [PMID: 38347485 PMCID: PMC10860274 DOI: 10.1186/s10194-024-01727-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 01/28/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Migraine is one of the main causes of disability worldwide. Anti-CGRP monoclonal antibodies (MAbs) have proven to be safe and efficacious as preventive migraine treatments. However, their use is restricted in many countries due to their apparently high cost. Cost-benefit studies are needed. OBJECTIVE To study the cost-benefit of anti-CGRP MAbs in working-age patients with migraine. METHODS This is a prospective cohort study of consecutive migraine patients treated with anti-CGRP MAbs (erenumab, fremanezumab and galcanezumab) following National reimbursement policy in a specialized headache clinic. Migraine characteristics and the work impact scale (WPAI) were compared between baseline (M0) and after 3 (M3) and 6 months (M6) of treatment. Using WPAI and the municipal average hourly wage, we calculated indirect costs (absenteeism and presenteeism) at each time point. Direct costs (emergency visits, acute medication use) were also analysed. A cost-benefit study was performed considering the different costs and savings of treating with MAbs. Based on these data an annual projection was conducted. RESULTS From 256 treated working-age patients, 148 were employed (89.2% women; mean age 48.0 ± 8.5 years), of which 41.2% (61/148) were responders (> 50% reduction in monthly headache days (MHD)). Statistically significant reductions between M0 and M3/M6 were found in absenteeism (p < 0.001) and presenteeism (p < 0.001). Average savings in indirect costs per patient at M3 were absenteeism 105.4 euros/month and presenteeism 394.3 euros/month, similar for M6. Considering the monthly cost of anti-CGRP MAbs, the cost-benefit analysis showed savings of 159.8 euros per patient at M3, with an annual projected savings of 639.2 euros/patient. Both responders and partial responders (30-50% reduction in MHD) presented a positive cost-benefit balance. The overall savings of the cohort at M3/M6 compensated the negative cost-benefit balance for non-responders (< 30% reduction in MHD). CONCLUSION Anti-CGRP MAbs have a positive impact in the workforce significantly reducing absenteeism and presenteeism. In Spain, this benefit overcomes the expenses derived from their use already at 3 months and is potentially sustainable at longer term; also in patients who are only partial responders, prompting reconsideration of current reimbursement criteria and motivating the extension of similar cost-benefit studies in other countries.
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Affiliation(s)
| | - Edoardo Caronna
- Headache Clinic, Neurology Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Headache and Neurological Pain Research Group, Vall d'Hebron Research Institute, Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Joana Rosell-Mirmi
- Headache and Neurological Pain Research Group, Vall d'Hebron Research Institute, Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Victor J Gallardo
- Headache and Neurological Pain Research Group, Vall d'Hebron Research Institute, Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alicia Alpuente
- Headache Clinic, Neurology Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Headache and Neurological Pain Research Group, Vall d'Hebron Research Institute, Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marta Torres-Ferrus
- Headache Clinic, Neurology Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Headache and Neurological Pain Research Group, Vall d'Hebron Research Institute, Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Patricia Pozo-Rosich
- Headache Clinic, Neurology Department, Vall d'Hebron University Hospital, Barcelona, Spain.
- Headache and Neurological Pain Research Group, Vall d'Hebron Research Institute, Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.
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Grazzi L, Giossi R, Montisano DA, Canella M, Marcosano M, Altamura C, Vernieri F. Real-world effectiveness of Anti-CGRP monoclonal antibodies compared to OnabotulinumtoxinA (RAMO) in chronic migraine: a retrospective, observational, multicenter, cohort study. J Headache Pain 2024; 25:14. [PMID: 38308209 PMCID: PMC10836018 DOI: 10.1186/s10194-024-01721-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 01/17/2024] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND Chronic migraine (CM) is a disabling condition with high prevalence in the general population. Until the recent approval of monoclonal antibodies targeting the calcitonin gene-related peptide (Anti-CGRP mAbs), OnabotulinumtoxinA (BoNT-A) was the only treatment specifically approved for CM prophylaxis. Direct comparisons between the two treatments are not available so far. METHODS We performed an observational, retrospective, multicenter study in Italy to compare the real-world effectiveness of Anti-CGRP mAbs and BoNT-A. Patients with CM who had received either treatment according to Italian prescribing regulations were extracted from available clinical databases. Efficacy outcomes included the change from baseline in monthly headache days (MHD), MIgraine Disability ASsessment test (MIDAS), and monthly acute medications (MAM) evaluated at 6 and 12 months of follow-up. The primary outcome was MHD change from baseline at 12 months. Safety outcomes included serious adverse events (SAE) and treatment discontinuation. Unadjusted and adjusted models were used for the analyses. RESULTS Two hundred sixteen potentially eligible patients were screened; 183 (86 Anti-CGRP mAbs; 97 BoNT-A) were included. One hundred seventy-one (80 Anti-CGRP mAbs; 91 BoNT-A) and 154 (69 Anti-CGRP mAbs; 85 BoNT-A) patients were included in the efficacy analysis at 6 and 12 months of follow-up, respectively. Anti-CGRP mAbs and BoNT-A both resulted in a mean MHD reduction at 6 (-11.5 and -7.2 days, respectively; unadjusted mean difference -4.3; 95%CI -6.6 to -2.0; p = 0.0003) and 12 months (-11.9 and -7.6, respectively; unadjusted mean difference -4.4; 95%CI -6.8 to -2.0; p = 0.0002) of follow-up. Similar results were observed after adjusting for baseline confounders. Anti-CGRP mAbs showed a significant MIDAS (-31.7 and -19.2 points, p = 0.0001 and p = 0.0296, respectively) and MAM reduction (-5.1 and -3.1 administrations, p = 0.0023 and p = 0.0574, respectively) compared to BoNT-A at 6 and 12 months. No SAEs were reported. One patient receiving fremanezumab discontinued treatment due to arthralgia. Treatment discontinuations, mainly for inefficacy, were comparable. CONCLUSION Both Anti-CGRP mAbs and BoNT-A were effective in CM patients with Anti-CGRP mAbs presenting higher effect magnitude, with comparable safety. Still, BoNT-A remains a valuable option for CM patients with contraindications to Anti-CGRP mAbs or for frail categories who are candidates to local therapy with limited risk of systemic administration.
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Affiliation(s)
- Licia Grazzi
- Headache Center, Neuroalgology Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria, 11, Milan, 20133, Italy
| | - Riccardo Giossi
- Poison Control Center and Clinical Pharmacology Unit, Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, Milan, 20162, Italy.
- Department of Research and Clinical Development, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria, 11, Milan, 20133, Italy.
| | - Danilo Antonio Montisano
- Headache Center, Neuroalgology Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria, 11, Milan, 20133, Italy
| | - Mattia Canella
- Department of Medical Biotechnology and Translational Medicine, Postgraduate School of Clinical Pharmacology and Toxicology, Università degli Studi di Milano, Via Vanvitelli, 32, Milan, 20129, Italy
- Neuroimmunology and Neuromuscular Diseases Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, 20133, Italy
| | - Marilena Marcosano
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, Roma, 00128, Italy
- Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, Roma, 00128, Italy
| | - Claudia Altamura
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, Roma, 00128, Italy
- Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, Roma, 00128, Italy
| | - Fabrizio Vernieri
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, Roma, 00128, Italy
- Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, Roma, 00128, Italy
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Ashina M, Hoffmann J, Ashina H, Hay DL, Flores-Montanez Y, Do TP, De Icco R, Dodick DW. Pharmacotherapies for Migraine and Translating Evidence From Bench to Bedside. Mayo Clin Proc 2024; 99:285-299. [PMID: 38180396 DOI: 10.1016/j.mayocp.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 06/02/2023] [Accepted: 07/11/2023] [Indexed: 01/06/2024]
Abstract
Migraine is a ubiquitous neurologic disorder that afflicts more than 1 billion people worldwide. Recommended therapeutic strategies include the use of acute and, if needed, preventive medications. During the past 2 decades, tremendous progress has been made in better understanding the molecular mechanisms underlying migraine pathogenesis, which in turn has resulted in the advent of novel medications targeting signaling molecule calcitonin gene-related peptide or its receptor. Here, we provide an update on the rational use of pharmacotherapies for migraine to facilitate more informed clinical decision-making. We then discuss the scientific discoveries that led to the advent of new medications targeting calcitonin gene-related peptide signaling. Last, we conclude with recent advances that are being made to identify novel drug targets for migraine.
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Affiliation(s)
- Messoud Ashina
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Danish Knowledge Center on Headache Disorders, Glostrup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Jan Hoffmann
- Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology & Neuroscience.), King's College Hospital, London, United Kingdom; NIHR-Wellcome Trust King's Clinical Research Facility/SLaM Biomedical Research Centre, King's College Hospital, London, United Kingdom
| | - Håkan Ashina
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Anaesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Brain and Spinal Cord Injury, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Debbie L Hay
- Department of Pharmacology and Toxicology, University of Otago, Dunedin, New Zealand
| | - Yadira Flores-Montanez
- BIDMC Comprehensive Headache Center, Department of Neurology and Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA; University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
| | - Thien Phu Do
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Danish Knowledge Center on Headache Disorders, Glostrup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Roberto De Icco
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy; Headache Science and Neurorehabilitation Center, IRCCS Mondino Foundation, Pavia, Italy
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Schwedt TJ, Myers Oakes TM, Martinez JM, Vargas BB, Pandey H, Pearlman EM, Richardson DR, Varnado OJ, Cobas Meyer M, Goadsby PJ. Comparing the Efficacy and Safety of Galcanezumab Versus Rimegepant for Prevention of Episodic Migraine: Results from a Randomized, Controlled Clinical Trial. Neurol Ther 2024; 13:85-105. [PMID: 37948006 PMCID: PMC10787669 DOI: 10.1007/s40120-023-00562-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 10/24/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION There have been no prior trials directly comparing the efficacy of different calcitonin gene-related peptide (CGRP) antagonists for migraine prevention. Reported are the results from the first head-to-head study of two CGRP antagonists, galcanezumab (monoclonal antibody) versus rimegepant (gepant), for the prevention of episodic migraine. METHODS In this 3-month, double-blind, double-dummy study, participants were randomized (1:1) to subcutaneous (SC) galcanezumab 120 mg per month (after a 240 mg loading dose) and a placebo oral disintegrating tablet (ODT) every other day (q.o.d.) or to rimegepant 75 mg ODT q.o.d. and a monthly SC placebo. The primary endpoint was the proportion of participants with a ≥ 50% reduction in migraine headache days per month from baseline across the 3-month double-blind treatment period. Key secondary endpoints were overall mean change from baseline in: migraine headache days per month across 3 months and at month 3, 2, and 1; migraine headache days per month with acute migraine medication use; Migraine-Specific Quality of Life Questionnaire Role Function-Restrictive domain score at month 3; and a ≥ 75% and 100% reduction from baseline in migraine headache days per month across 3 months. RESULTS Of 580 randomized participants (galcanezumab: 287, rimegepant: 293; mean age: 42 years), 83% were female and 81% Caucasian. Galcanezumab was not superior to rimegepant in achieving a ≥ 50% reduction from baseline in migraine headache days per month (62% versus 61% respectively; P = 0.70). Given the pre-specified multiple testing procedure, key secondary endpoints cannot be considered statistically significant. Overall, treatment-emergent adverse events were reported by 21% of participants, with no significant differences between study intervention groups. CONCLUSIONS Galcanezumab was not superior to rimegepant for the primary endpoint; however, both interventions demonstrated efficacy as preventive treatments in participants with episodic migraine. The efficacy and safety profiles observed in galcanezumab-treated participants were consistent with previous studies. TRIAL REGISTRATION ClinTrials.gov-NCT05127486 (I5Q-MC-CGBD).
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Peter J Goadsby
- NIHR King's Clinical Research Facility and Headache Group, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Wolfson SPRRC, London, UK
- Department of Neurology, University of California, Los Angeles, CA, USA
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20
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Yang C, Zhang Y. Efficacy and Safety of Rimegepant for Migraine Patients: A Meta-analysis of Randomized Controlled Studies. Clin Neuropharmacol 2024; 47:7-11. [PMID: 37909676 DOI: 10.1097/wnf.0000000000000576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
OBJECTIVES Rimegepant may have some potential in treating migraine, and this meta-analysis aims to study the efficacy and safety of rimegepant for migraine patients. METHODS We have searched several databases including PubMed, Embase, Web of Science, EBSCO, and Cochrane Library databases and selected the randomized controlled trials comparing the efficacy of rimegepant versus placebo for migraine patients. This meta-analysis was conducted using the random- or fixed-effect model based on the heterogeneity. RESULTS Three randomized controlled trials were included in this meta-analysis. Compared with placebo in migraine patients, rimegepant treatment was associated with substantially improved freedom from pain at 2 hours (odds ratio [OR], 2.10; 95% confidence interval [CI], 1.69-2.59; P < 0.00001), pain relief at 2 hours (OR, 1.93; 95% CI, 1.65 to 2.25; P < 0.00001), freedom from the most bothersome symptom at 2 hours (OR, 1.61; 95% CI, 1.35-1.91; P < 0.00001), ability to function normally at 2 hours (OR, 1.69; 95% CI, 1.42-2.01; P < 0.00001), sustained freedom from pain at 24 hours (OR, 2.88; 95% CI, 1.74-4.78; P < 0.0001), sustained pain relief at 24 hours (OR, 2.31; 95% CI, 1.96-2.72; P < 0.00001), and no rescue medication (OR, 2.42; 95% CI, 2.02-2.90; P < 0.00001) but showed no obvious impact on adverse events (OR, 1.27; 95% CI, 1.01-1.60; P = 0.04). CONCLUSIONS Rimegepant may be effective and safe for the treatment of migraine patients.
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Affiliation(s)
| | - Yue Zhang
- Department of Stomatology, Affiliated Hospital of Beihua University, Jilin, China
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21
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Bjørk MH, Borkenhagen S, Oteiza F, Dueland AN, Sørgaard FE, Saether EM, Bugge C. Comparative retention and effectiveness of migraine preventive treatments: A nationwide registry-based cohort study. Eur J Neurol 2024; 31:e16062. [PMID: 37754544 DOI: 10.1111/ene.16062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 07/28/2023] [Accepted: 08/30/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND AND PURPOSE Little is known about the comparative effects of migraine preventive drugs. We aimed to estimate treatment retention and effectiveness of migraine preventive drugs in a nationwide registry-based cohort study in Norway between 2010 and 2020. METHODS We assessed retention, defined as the number of uninterrupted treatment days, and effectiveness, defined as the reduction in filled triptan prescriptions during four 90-day periods after the first preventive prescription, compared to a 90-day baseline period. We compared retention and efficacy for different drugs against beta blockers. Comparative retention was estimated with hazard ratios (HRs), adjusted for covariates, using Cox regression, and effectiveness as odds ratios (ORs) using logistic regression, with propensity-weighted adjustment for covariates. RESULTS We identified 104,072 migraine patients, 81,890 of whom were female (78.69%) and whose mean (standard deviation) age was 44.60 (15.61) years. Compared to beta blockers, botulinum toxin (HR 0.43, 95% confidence interval [CI] 0.42-0.44) and calcitonin gene-related peptide pathway antibodies (CGRPabs; HR 0.63, 95% CI 0.59-0.66) were the least likely to be discontinued, while clonidine (HR 2.95, 95% CI 2.88-3.02) and topiramate (HR 1.34, 95% CI 1.31-1.37) were the most likely to be discontinued. Patients on simvastatin, CGRPabs, and amitriptyline were more likely to achieve a clinically significant reduction in triptan use during the first 90 days of treatment, with propensity score-adjusted ORs of 1.28 (95% CI 1.19-1.38), 1.23 (95% CI 0.79-1.90), and 1.13 (95% CI 1.08-1.17), respectively. CONCLUSIONS We found a favorable effect of CGRPabs, amitriptyline, and simvastatin compared with beta blockers, while topiramate and clonidine were associated with poorer outcomes.
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Affiliation(s)
- Marte H Bjørk
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
- NorHEAD, Norwegian Headache Research Centre, Norwegian University of Science and Technology, Trondheim, Norway
| | | | | | - Aud N Dueland
- Sandvika Nevrosenter, Sandvika, Norway
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | | | | | - Christoffer Bugge
- Oslo Economics, Oslo, Norway
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
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Alsaadi T, Kayed DM, Al-Madani A, Hassan AM, Terruzzi A, Krieger D, Riachi N, Sarathchandran P, Al-Rukn S. Consensus-Based Recommendations on the Use of CGRP-Based Therapies for Migraine Prevention in the UAE. Neurol Ther 2023; 12:1845-1865. [PMID: 37792218 PMCID: PMC10630270 DOI: 10.1007/s40120-023-00550-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 09/19/2023] [Indexed: 10/05/2023] Open
Abstract
INTRODUCTION Migraine is a common debilitating neurological disorder affecting a large proportion of the general population. Calcitonin gene-related peptide (CGRP), a 37-amino acid neuropeptide, plays a key role in the pathophysiology of migraine, and the development of therapies targeting the anti-CGRP pathway has revolutionized the field of migraine treatment. METHODS An expert task force of neurologists in the United Arab Emirates (UAE) developed and critically assessed recommendations on the use of CGRP-based therapies in migraine treatment and management in the UAE, based on available published literature. A consensus was reached for each statement by means of an open-voting process, based on a predefined agreement level of at least 60%. RESULTS The consensus recommendations advocate the need for guidelines for the appropriate use of CGRP-based therapies by defining patient cohorts and appropriate monitoring of therapeutic response as well as standardizing the initiation, assessment, and cessation of treatment. The consensus recommendations were primarily formulated on the basis of international studies, because of the limited availability of regional and local data. As such, they may also act as guidelines for global healthcare providers. CONCLUSIONS These are the first consensus recommendations for the UAE that address the use of CGRP-based therapies in the treatment and management of migraine, integrating both clinical evidence and medical expertise to enhance clinical judgment and decision-making.
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Affiliation(s)
- Taoufik Alsaadi
- Department of Neurology, American Center for Psychiatry and Neurology, Abu Dhabi, UAE.
| | - Deeb M Kayed
- Neurology Department, Mediclinic City Hospital, Dubai, UAE
| | | | | | | | - Derk Krieger
- Neurology Department, Mediclinic Parkview Hospital, Dubai, UAE
| | - Naji Riachi
- Sheikh Shakhbout Medical City, Khalifa University College of Medicine and Health Sciences, Abu Dhabi, UAE
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Altamura C, Brunelli N, Marcosano M, Alesina A, Fofi L, Vernieri F. Eptinezumab for the Prevention of Migraine: Clinical Utility, Patient Preferences and Selection - A Narrative Review. Ther Clin Risk Manag 2023; 19:959-971. [PMID: 38023625 PMCID: PMC10680459 DOI: 10.2147/tcrm.s263824] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 11/18/2023] [Indexed: 12/01/2023] Open
Abstract
The new Calcitonin Gene-Related Peptide (CGRP)-targeted therapies have proven high efficacy and tolerability in episodic and chronic migraine. Eptinezumab is a humanized monoclonal antibody that selectively binds CGRP with high affinity. Eptinezumab was approved by the Food and Drug Administration on February 21st, 2020, for the preventive treatment of migraine in adults. It is administered intravenously over 30 minutes with a standard dose of 100 mg and has a T-max of 30 minutes-1 hour and a half-life of 27 days. These pharmacological properties allow for a very rapid onset of effect and a quarterly administration. It is the first time that a preventive treatment for migraine can be offered as an intravenous administration. As the range of therapeutic possibilities in migraine is expanding, the treatment process must include common decision-making, where physicians should explain in detail to patients the different characteristics of treatment options beyond efficacy and side effects. Patients can now express a preference on a range of opportunities: pharmacological versus non-pharmacological approaches, route of administration, frequency of administration, efficacy, rapidity, side effects, costs, the possibility of titration or dosing, and durability of effectiveness at suspension. Also, patient preferences can be influenced by age, country, migraine severity, and earlier experience with CGRP-targeted therapies. Besides, adherence may be influenced by several factors, including route and the schedule of administration. This narrative review describes a new perspective from the patient's point of view. Clinicians should ally with patients to select treatments that meet each patient's needs and thus apply a tailored approach, addressing not only headaches. In this way, physicians would care for the patients globally and stand out their preferences on different aspects of treatment. Besides, healthcare professionals shall be aware that patients' beliefs about therapies are subject to change with increasing experience with new therapeutic approaches.
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Affiliation(s)
- Claudia Altamura
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, 00128, Italy
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
| | - Nicoletta Brunelli
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, 00128, Italy
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
| | - Marilena Marcosano
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, 00128, Italy
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
| | - Alessandro Alesina
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, 00128, Italy
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
| | - Luisa Fofi
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, 00128, Italy
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
| | - Fabrizio Vernieri
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, 00128, Italy
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
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Vernieri F, Brunelli N, Guerzoni S, Iannone LF, Baraldi C, Rao R, Schiano di Cola F, Ornello R, Cevoli S, Lovati C, Albanese M, Perrotta A, Cetta I, Rossi SS, Taranta V, Filippi M, Geppetti P, Sacco S, Altamura C. Retreating migraine patients in the second year with monoclonal antibodies anti-CGRP pathway: the multicenter prospective cohort RE-DO study. J Neurol 2023; 270:5436-5448. [PMID: 37468621 DOI: 10.1007/s00415-023-11872-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 07/10/2023] [Accepted: 07/10/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND The outcome of migraine patients retreated with monoclonal antibodies (mAbs) targeting the calcitonin gene-related peptide (anti-CGRP) or its receptor (anti-CGRPr) is not completely known. METHODS This multicentric prospective observational cohort study assessed monthly migraine days (MMDs), migraine acute medication intake (MAMI), and HIT-6 at baseline, after 90-112 days (Rev-1), after 84-90 days since Rev-1 (Rev-2) and 30 days after the last injection of anti-CGRP/CGRPr mAbs (Year-end), in the first and the second year after a discontinuation period. RESULTS We enrolled 226 patients (79.6% with chronic migraine; 55.3% on erenumab and 44.7% on galcanezumab or fremanezumab). MMDs, MAMI, and HIT-6-did not differ at the respective first and second-year evaluations in the entire cohort, and comparing anti-CGRP with anti-CGRPr Abs. MMDs (18.1 ± 7.8 vs. 3.4 ± 7.8), MAMI (26.7 ± 28.3 vs.17.7 ± 17.2), and HIT-6 scores (63.1 ± 5.9 vs. 67.1 ± 10.3) were lower in the second year than in the pre-treatment baseline (consistently, p < 0.0001). Second-year baseline MMDs were lower in patients on anti-CGRP mAbs (p = 0.001) and with lower pre-treatment baseline MMDs (p ≤ 0.001). CONCLUSION Anti-CGRP/CGRPr mAbs are effective in the second as in the first year. The use of anti-CGRP or CGRPr mAbs influenced the second-year baseline MMDs, but their effectiveness did not differ during the two treatment years.
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Affiliation(s)
- Fabrizio Vernieri
- Unità Cefalee e Neurosonologia, Fondazione Policlinico Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy.
- Neurologia, Dipartimento di Medicina e Chirurgia, Università Campus Bio-Medico di Roma, Rome, Italy.
| | - Nicoletta Brunelli
- Unità Cefalee e Neurosonologia, Fondazione Policlinico Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - Simona Guerzoni
- Digital and Predictive Medicine, Pharmacology and Clinical Metabolic Toxicology, Headache Center and Drug Abuse, Laboratory of Clinical Pharmacology and Pharmacogenomics, Department of Specialist Medicines, AOU Policlinico di Modena, Modena, Italy
| | - Luigi Francesco Iannone
- Headache Center, Section of Clinical Pharmacology and Oncology, Department of Health Sciences, Careggi University Hospital, University of Florence, Florence, Italy
| | - Carlo Baraldi
- Digital and Predictive Medicine, Pharmacology and Clinical Metabolic Toxicology, Headache Center and Drug Abuse, Laboratory of Clinical Pharmacology and Pharmacogenomics, Department of Specialist Medicines, AOU Policlinico di Modena, Modena, Italy
| | - Renata Rao
- Headache Center, ASST Spedali Civili of Brescia, Department Continuity of Care and Fragility, Department of Clinical and Experimental Sciences, Neurological Clinic, University of Brescia, Brescia, Italy
| | - Francesca Schiano di Cola
- Headache Center, ASST Spedali Civili of Brescia, Department Continuity of Care and Fragility, Department of Clinical and Experimental Sciences, Neurological Clinic, University of Brescia, Brescia, Italy
| | - Raffaele Ornello
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Sabina Cevoli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Carlo Lovati
- Headache Center, Neurology Unit, L. Sacco University Hospital, Milan, Italy
| | - Maria Albanese
- Neurology Unit, Headache Center, Tor Vergata University Hospital, Rome, Italy
- Department of Systems Medicine, Tor Vergata University, Rome, Italy
| | | | - Ilaria Cetta
- Neuroimaging Research Unit, Division of Neuroscience; Neurology Unit and Neurophysiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Sergio Soeren Rossi
- Neurologia, Dipartimento di Medicina e Chirurgia, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Valentina Taranta
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Massimo Filippi
- Neuroimaging Research Unit, Division of Neuroscience; Neurology Unit and Neurophysiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Pierangelo Geppetti
- Headache Center, Section of Clinical Pharmacology and Oncology, Department of Health Sciences, Careggi University Hospital, University of Florence, Florence, Italy
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Claudia Altamura
- Unità Cefalee e Neurosonologia, Fondazione Policlinico Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
- Neurologia, Dipartimento di Medicina e Chirurgia, Università Campus Bio-Medico di Roma, Rome, Italy
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Hong JB, Lange KS, Fitzek M, Overeem LH, Triller P, Siebert A, Reuter U, Raffaelli B. Impact of a reimbursement policy change on treatment with erenumab in migraine - a real-world experience from Germany. J Headache Pain 2023; 24:144. [PMID: 37899428 PMCID: PMC10614330 DOI: 10.1186/s10194-023-01682-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 10/18/2023] [Indexed: 10/31/2023] Open
Abstract
BACKGROUND Monoclonal antibodies (mAbs) targeting the Calcitonin Gene-Related Peptide (CGRP) pathway are safe and effective treatments for migraine prevention. However, the high cost of these novel therapies has led to reimbursement policies requiring patients to try multiple traditional preventives before access. In Germany, a recent change in insurance policy significantly expanded coverage for the CGRP receptor mAb erenumab, enabling migraine patients who failed just one prior prophylactic medication to receive this mAb. Here, we compare the clinical response to treatment with erenumab in migraine patients treated using the old and new coverage policy. METHODS In this retrospective cohort study, we included CGRP-mAb naïve patients with episodic or chronic migraine, who started erenumab at our headache center according to either the old or the new insurance policy and received at least 3 consecutive injections. Headache diaries and electronic documentation were used to evaluate reductions in monthly headache and migraine days (MHD and MMD) and ≥ 50% and ≥ 30% responder rates at month 3 (weeks 9-12) of treatment. RESULTS We included 146 patients who received erenumab according to the old policy and 63 patients that were treated using the new policy. At weeks 9-12 of treatment, 37.7% of the old policy group had a 50% or greater reduction in MHD, compared to 63.5% of the new policy group (P < 0.001). Mean reduction in MHD was 5.02 days (SD = 5.46) and 6.67 days (SD = 5.32, P = 0.045) in the old and new policy cohort, respectively. After propensity score matching, the marginal effect of the new policy on treatment outcome was 2.29 days (standard error, SE: 0.715, P = 0.001) more reduction in MHD, and 30.1% (SE: 10.6%, P = 0.005) increase in ≥ 50% response rate for MHD. CONCLUSIONS Starting erenumab earlier in the course of migraine progression in a real-world setting may lead to a better response than starting after multiple failed prophylactic attempts. Continually gathering real-world evidence may help policymakers in deciding how readily to cover CGRP-targeted therapies in migraine prevention.
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Affiliation(s)
- Ja Bin Hong
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Mira Fitzek
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Paul Triller
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Anke Siebert
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Uwe Reuter
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Universitätsmedizin Greifswald, Greifswald, Germany
| | - Bianca Raffaelli
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.
- Clinician Scientist Program, Berlin Institute of Health (BIH) at Charité, Berlin, Germany.
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26
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Raffaelli B, García-Azorín D, Boucherie DM, Amin FM, Deligianni CI, Gil-Gouveia R, Kirsh S, Lampl C, Sacco S, Uluduz D, Versijpt J, MaassenVanDenBrink A, Zeraatkar D, Sanchez-Del-Rio M, Reuter U. European Headache Federation (EHF) critical reappraisal and meta-analysis of oral drugs in migraine prevention - part 3: topiramate. J Headache Pain 2023; 24:134. [PMID: 37814223 PMCID: PMC10563338 DOI: 10.1186/s10194-023-01671-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 09/25/2023] [Indexed: 10/11/2023] Open
Abstract
OBJECTIVE Topiramate is a repurposed first-line treatment for migraine prophylaxis. The aim of this systematic review and meta-analysis is to critically re-appraise the existing evidence supporting the efficacy and tolerability of topiramate. METHODS A systematic search in MEDLINE, EMBASE, Cochrane CENTRAL, and ClinicalTrials.gov was performed for trials of pharmacological treatment in migraine prophylaxis as of August 13, 2022, following the Preferred Reporting Items for Systematic Reviews (PRISMA). Randomized controlled trials in adult patients that used topiramate for the prophylactic treatment of migraine, with placebo as active comparator, were included. Two reviewers independently screened the retrieved studies and extracted all data. Outcomes of interest were the 50% responder rates, the reduction in monthly migraine days, and adverse events leading to treatment discontinuation. Results were pooled and meta-analyzed, with sensitivity analysis based on the risk of bias of the studies, the monthly migraine days at baseline, and the previous use of other prophylactic treatments. Certainty evidence was judged according to the GRADE framework. RESULTS Eight out of 10,826 studies fulfilled the inclusion/exclusion criteria, accounting for 2,610 randomized patients. Six studies included patients with episodic migraine and two with chronic migraine. Topiramate dose ranged from 50 to 200 mg/day, and all studies included a placebo arm. There was a high certainty that topiramate: 1) increased the proportion of patients who achieved a 50% responder rate in monthly migraine days, compared to placebo [relative risk: 1.61 (95% confidence interval (CI): 1.29-2.01); absolute risk difference: 168 more per 1,000 (95% CI: 80 to 278 more)]; 2) was associated with 0.99 (95% CI: 1.41-0.58) fewer migraine days than placebo; 3) and had a higher proportion of patients with adverse events leading to treatment discontinuation [absolute risk difference 80 patients more per 1,000 (95% CI: 20 to 140 more patients)]. CONCLUSIONS There is high-quality evidence of the efficacy of topiramate in the prophylaxis of migraine, albeit its use poses a risk of adverse events that may lead to treatment discontinuation, with a negative effect on patient satisfaction and adherence to care.
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Affiliation(s)
- Bianca Raffaelli
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Clinician Scientist Program, Berlin Institute of Health at Charité (BIH), Berlin, Germany
| | - David García-Azorín
- Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Deirdre M Boucherie
- Department of Internal Medicine, Division of Vascular Medicine and Pharmacology, Erasmus MC Medical Center, Rotterdam, the Netherlands
| | - Faisal Mohammad Amin
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Brain and Spinal Cord Injury, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | | | - Raquel Gil-Gouveia
- Hospital da Luz Headache Center, Neurology Department, Hospital da Luz Lisboa, Lisbon, Portugal
- Center for Interdisciplinary Research in Health, Universidade Católica Portuguesa, Lisbon, Portugal
| | - Sarah Kirsh
- Department of Anesthesia and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Christian Lampl
- Department of Neurology and Stroke Unit, Konventhospital Barmherzige Brüder Linz, Linz, Austria
- Headache Medical Center Linz, Linz, Austria
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Derya Uluduz
- Department of Neurology Istanbul Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Jan Versijpt
- Department of Neurology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Antoinette MaassenVanDenBrink
- Department of Internal Medicine, Division of Vascular Medicine and Pharmacology, Erasmus MC Medical Center, Rotterdam, the Netherlands
| | - Dena Zeraatkar
- Department of Anesthesia and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | | | - Uwe Reuter
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany.
- Universitätsmedizin Greifswald, Greifswald, Germany.
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Juhasz G, Gecse K, Baksa D. Towards precision medicine in migraine: Recent therapeutic advances and potential biomarkers to understand heterogeneity and treatment response. Pharmacol Ther 2023; 250:108523. [PMID: 37657674 DOI: 10.1016/j.pharmthera.2023.108523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 08/11/2023] [Accepted: 08/29/2023] [Indexed: 09/03/2023]
Abstract
After 35 years since the introduction of the International Classification of Headache Disorders (ICHD), we are living in the era of the second great revolution in migraine therapies. First, discoveries of triptans provided a breakthrough in acute migraine treatment utilizing bench-to-bedside research results on the role of serotonin in migraine. Next, the discovery of the role of neuropeptides, more specifically calcitonin gene-related peptide (CGRP) in migraine attack led to the development of anti-CGRP therapies that are effective both in acute and preventive treatment, and are also able to reduce migraine-related burden. Here, we reviewed the most recent clinical studies and real-world data on available migraine-specific medications, including triptans, ditants, gepants and anti-CGRP monoclonal antibodies. Novel drug targets, such as PACAP and amylins were also discussed. To address the main challenges of migraine therapy, the high heterogeneity of people with migraine, the prevalent presence of various comorbid disorders, and the insufficient medical care of migraine patients were covered. Promising novel approaches from the fields of omics, blood and saliva biomarker, imaging and provocation studies might bring solutions for these challenges with the potential to identify further drug targets, distinguish more homogeneous patient subgroups, contribute to more optimal drug selection strategies, and detect biomarkers in association with headache features or predicting treatment efficacy. In the future, the combined analysis of data of different biomarker modalities with machine learning algorithms may serve precision medicine in migraine treatment.
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Affiliation(s)
- Gabriella Juhasz
- Department of Pharmacodynamics, Faculty of Pharmaceutical Sciences, Semmelweis University, Budapest, Hungary; NAP3.0 Neuropsychopharmacology Research Group, Hungarian Brain Research Program, Semmelweis University, Budapest, Hungary.
| | - Kinga Gecse
- Department of Pharmacodynamics, Faculty of Pharmaceutical Sciences, Semmelweis University, Budapest, Hungary; NAP3.0 Neuropsychopharmacology Research Group, Hungarian Brain Research Program, Semmelweis University, Budapest, Hungary
| | - Daniel Baksa
- Department of Pharmacodynamics, Faculty of Pharmaceutical Sciences, Semmelweis University, Budapest, Hungary; NAP3.0 Neuropsychopharmacology Research Group, Hungarian Brain Research Program, Semmelweis University, Budapest, Hungary; Department of Personality and Clinical Psychology, Institute of Psychology, Faculty of Humanities and Social Sciences, Pazmany Peter Catholic University, Budapest, Hungary
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Aleksovska K, Hershey AD, Deen M, Icco RD, Lee MJ, Diener HC. Efficacy and safety of monoclonal antibodies targeting CGRP in migraine prevention. GRADE tables elaborated by the ad hoc working group of the International Headache Society. Cephalalgia 2023; 43:3331024231206162. [PMID: 37879637 DOI: 10.1177/03331024231206162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
OBJECTIVES Grading of Recommendations, Assessment Development and Evaluation (GRADE) tables were created using a standardized and independent assessment of the efficacy and side effects of treatments with monoclonal antibodies (mAb) against calcitonin gene-related peptide (CGRP) or the CGRP receptor for the prevention of migraine. We hope to provide support for author groups writing national or regional treatment or management guidelines for migraine prevention. METHODS We formulated patient/population, intervention, comparison and outcomes (PICO) questions for the efficacy and safety of mAb against CGRP or the CGRP-receptor for the prevention of migraine attacks. We performed a systematic literature research for randomized studies with eptinezumab, erenumab, fremanezumab and galcanezumab and a pooled analysis was done, using RevMan 5.4 software. For dichotomous outcomes we used risk ratio, and for continuous outcomes we used the mean difference to compare and summarize the evidence between groups. The evidence across studies, for each outcome, except serious adverse events, was assessed using GRADE evidence tables. Additionally, we report the serious adverse effects in the tables of the characteristics of the studies. RESULTS All mAb are superior to placebo for the reduction in monthly migraine days (days in which a headache consistent with migraine occurred) in participants with episodic and chronic migraine. There are no major differences between the mAb. CONCLUSIONS The GRADE evidence summary tables provided will support author groups to write treatment guidelines for the prevention of migraine with mAb.
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Affiliation(s)
- Katina Aleksovska
- Department of Neurology, Ss. Cyril and Methodius University, Skopje, Macedonia
| | - Andrew D Hershey
- Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, USA
| | - Marie Deen
- Department of Neurology, Danish Headache Center, Rigshospitalet - Glostrup, Glostrup, Denmark
| | - Robert de Icco
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Headache Science & Neurorehabilitation Center, IRCCS Mondino Foundation, Pavia, Italy
| | - Mi Ji Lee
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
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Sharma P, Joshi RV, Pritchard R, Xu K, Eicher MA. Therapeutic Antibodies in Medicine. Molecules 2023; 28:6438. [PMID: 37764213 PMCID: PMC10535987 DOI: 10.3390/molecules28186438] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 08/05/2023] [Accepted: 08/28/2023] [Indexed: 09/29/2023] Open
Abstract
Antibody engineering has developed into a wide-reaching field, impacting a multitude of industries, most notably healthcare and diagnostics. The seminal work on developing the first monoclonal antibody four decades ago has witnessed exponential growth in the last 10-15 years, where regulators have approved monoclonal antibodies as therapeutics and for several diagnostic applications, including the remarkable attention it garnered during the pandemic. In recent years, antibodies have become the fastest-growing class of biological drugs approved for the treatment of a wide range of diseases, from cancer to autoimmune conditions. This review discusses the field of therapeutic antibodies as it stands today. It summarizes and outlines the clinical relevance and application of therapeutic antibodies in treating a landscape of diseases in different disciplines of medicine. It discusses the nomenclature, various approaches to antibody therapies, and the evolution of antibody therapeutics. It also discusses the risk profile and adverse immune reactions associated with the antibodies and sheds light on future applications and perspectives in antibody drug discovery.
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Affiliation(s)
- Prerna Sharma
- Geisinger Commonwealth School of Medicine, Scranton, PA 18509, USA
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30
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Peng KP, Burish MJ. Management of cluster headache: Treatments and their mechanisms. Cephalalgia 2023; 43:3331024231196808. [PMID: 37652457 DOI: 10.1177/03331024231196808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
BACKGROUND The management of cluster headache is similar to that of other primary headache disorders and can be broadly divided into acute and preventive treatments. Acute treatments for cluster headache are primarily delivered via rapid, non-oral routes (such as inhalation, nasal, or subcutaneous) while preventives include a variety of unrelated treatments such as corticosteroids, verapamil, and galcanezumab. Neuromodulation is becoming an increasingly popular option, both non-invasively such as vagus nerve stimulation when medical treatment is contraindicated or side effects are intolerable, and invasively such as occipital nerve stimulation when medical treatment is ineffective. Clinically, this collection of treatment types provides a range of options for the informed clinician. Scientifically, this collection provides important insights into disease mechanisms. METHODS Two authors performed independent narrative reviews of the literature on guideline recommendations, clinical trials, real-world data, and mechanistic studies. RESULTS Cluster headache is treated with acute treatments, bridge treatments, and preventive treatments. Common first-line treatments include subcutaneous sumatriptan and high-flow oxygen as acute treatments, corticosteroids (oral or suboccipital injections) as bridge treatments, and verapamil as a preventive treatment. Some newer acute (non-invasive vagus nerve stimulation) and preventive (galcanezumab) treatments have excellent clinical trial data for episodic cluster headache, while other newer treatments (occipital nerve stimulation) have been specifically tested in treatment-refractory chronic cluster headache. Most treatments are suspected to act on the trigeminovascular system, the autonomic system, or the hypothalamus. CONCLUSIONS The first-line treatments have not changed in recent years, but new treatments have provided additional options for patients.
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Affiliation(s)
- Kuan-Po Peng
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mark J Burish
- Department of Neurosurgery, UTHealth Houston, Houston, Texas, USA
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31
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Schoenen J, Van Dycke A, Versijpt J, Paemeleire K. Ten open questions in migraine prophylaxis with monoclonal antibodies blocking the calcitonin-gene related peptide pathway: a narrative review. J Headache Pain 2023; 24:99. [PMID: 37528353 PMCID: PMC10391994 DOI: 10.1186/s10194-023-01637-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 07/21/2023] [Indexed: 08/03/2023] Open
Abstract
The monoclonal antibodies (mAbs) blocking the calcitonin-gene related peptide (CGRP) pathway, collectively called here "anti-CGRP/rec mAbs", have dramatically improved preventive migraine treatment. Although their efficacy and tolerability were proven in a number of randomized controlled trials (RCTs) and, maybe even more convincingly, in real world settings, a number of open questions remain. In this narrative review, we will analyze published data allowing insight in some of the uncertainties related to the use of anti-CGRP/rec mAbs in clinical practice: their differential efficacy in migraine subtypes, outcome predictors, switching between molecules, use in children and adolescents, long-term treatment adherence and persistence, effect persistence after discontinuation, combined treatment with botulinum toxin or gepants, added-value and cost effectiveness, effectiveness in other headache types, and potential contraindications based on known physiological effects of CGRP. While recent studies have already provided hints for some of these questions, many of them will not find reliable and definitive answers before larger studies, registries or dedicated RCTs are available.
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Affiliation(s)
- Jean Schoenen
- Headache Research Unit, Department of Neurology‑Citadelle Hospital, University of Liège, Boulevard du 12 ème de Ligne 1, Liège, 4000, Belgium.
| | - Annelies Van Dycke
- Department of Neurology, General Hospital Sint-Jan Bruges, Ruddershove 10, Bruges, 8000, Belgium
| | - Jan Versijpt
- Department of Neurology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, Brussels, 1090, Belgium
| | - Koen Paemeleire
- Department of Neurology, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, 9000, Belgium
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Vikelis M, Dermitzakis EV, Xiromerisiou G, Rallis D, Soldatos P, Litsardopoulos P, Rikos D, Argyriou AA. Effects of Fremanezumab on Psychiatric Comorbidities in Difficult-to-Treat Patients with Chronic Migraine: Post Hoc Analysis of a Prospective, Multicenter, Real-World Greek Registry. J Clin Med 2023; 12:4526. [PMID: 37445560 DOI: 10.3390/jcm12134526] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 07/03/2023] [Accepted: 07/04/2023] [Indexed: 07/15/2023] Open
Abstract
OBJECTIVE this post hoc analysis aimed to evaluate the efficacy of fremanezumab in difficult-to-treat chronic migraine (CM) patients with and without psychiatric comorbidities (PCs), mainly anxiety and/or depression. METHODS We assessed data from CM patients with and without PCs who failed at least 3 preventives and eventually received at least 3 consecutive monthly doses of fremanezumab 225 mg. Outcomes included the crude response (≥50% reduction in monthly headache days (MHDs)) rates to fremanezumab from the baseline to the last clinical follow-up. The changes in MHDs; MHDs of moderate/greater severity; monthly days with intake of abortive medication; and the proportion of patients' changing status from with PCs to decreased/without PCs were also compared. Disability and quality of life (QOL) outcomes were also assessed. RESULTS Of 107 patients enrolled, 65 (60.7%) had baseline PCs. The percentage of patients with (n = 38/65; 58.5%) and without (n = 28/42; 66.6%) PCs that achieved a ≥50% reduction in MHDs with fremanezumab was comparable (p = 0.41), whereas MHDs were significantly reduced (difference vs. baseline) in both patients with PCs (mean -8.9 (standard error: 6.8); p < 0.001) and without PCs (-9.8 (7.5); p < 0.001). Both groups experienced significant improvements in all other efficacy, disability, and QOL outcomes at comparable rates, including in MHD reduction. A significant proportion of fremanezumab-treated patients with baseline PCs de-escalated in corresponding severities or even reverted to no PCs (28/65; 43.1%) post-fremanezumab. CONCLUSIONS fremanezumab appears to be effective as a preventive treatment in difficult-to-treat CM patients with and without PCs while also being beneficial in reducing the severity of comorbid anxiety and/or depression.
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Affiliation(s)
- Michail Vikelis
- Headache Clinic, Mediterraneo Hospital, 16675 Athens, Greece
| | | | - Georgia Xiromerisiou
- Department of Neurology, University Hospital of Larissa, University of Thessaly, 41110 Larissa, Greece
| | - Dimitrios Rallis
- Department of Neurology, Tzaneio General Hospital of Piraeus, 18536 Athens, Greece
| | | | - Pantelis Litsardopoulos
- Headache Outpatient Clinic, Department of Neurology, Agios Andreas State General Hospital of Patras, 26335 Patras, Greece
| | | | - Andreas A Argyriou
- Headache Outpatient Clinic, Department of Neurology, Agios Andreas State General Hospital of Patras, 26335 Patras, Greece
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Wells-Gatnik W, Martelletti P. Antiseizure medications as migraine preventatives: a call for action for a teratogenic and neurodevelopmental risk removal. Expert Opin Drug Saf 2023; 22:777-781. [PMID: 37575009 DOI: 10.1080/14740338.2023.2247963] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/26/2023] [Accepted: 08/11/2023] [Indexed: 08/15/2023]
Abstract
INTRODUCTION A recent study has demonstrated an increased risk of neurodevelopmental disorders, including autism spectrum disorder, in individuals exposed to either valproate or topiramate monotherapy. Regulatory bodies have initiated a review to reassess the safety of topiramate exposure during pregnancy. These novel findings raise concerns regarding the recommendation of antiseizure medications in women of childbearing potential. This manuscript highlights current research defining concerns specific to the use of valproate and topiramate in women of childbearing potential. AREAS COVERED This manuscript summarizes recent findings regarding the safety of valproate and topiramate when compared to alternative therapies for the preventative treatment of migraine in women of childbearing potential. The studies included in this review were selected following a comprehensive literature review of multiple relevant databases. All studies that were published within the past 15 years were considered for inclusion. EXPERT OPINION The use of valproate and topiramate in women of childbearing potential should be highly discouraged. Our recommendations include a review of current prescribing guidelines, further public education regarding the neurodevelopmental and congenital risks associated with the use of valproate and topiramate, and an appeal for further research defining the safety of alternative medications for migraine prevention when intrauterine exposure is possible.
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Affiliation(s)
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
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34
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Diener HC, Gaul C. [Drug therapy of the acute migraine attack and prophylaxis of migraine]. Dtsch Med Wochenschr 2023; 148:678-684. [PMID: 37216943 DOI: 10.1055/a-1857-3887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Migraine has a prevalence of 10 % in Germany, making it the most common neurological disorder. Migraine is a prevalent disorder not only for neurologist, it's an everyday topic for general physicians and internal medicine as well. Acute migraine attacks are treated with analgesics or triptans. In case of frequent migraine attacks, there is an indication for medicinal and non-pharmacological migraine prophylaxis. Medications include beta-blockers, flunarizine, anticonvulsants, amitriptyline or, in the case of chronic migraine, onabotulinumtoxinA. If these drugs are not effective, are not tolerated or contraindicated, monoclonal antibodies against calcitonin gene-related peptide (CGRP) or the CGRP receptor can be used.
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35
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Lampl C, MaassenVanDenBrink A, Deligianni CI, Gil-Gouveia R, Jassal T, Sanchez-Del-Rio M, Reuter U, Uluduz D, Versijpt J, Zeraatkar D, Sacco S. The comparative effectiveness of migraine preventive drugs: a systematic review and network meta-analysis. J Headache Pain 2023; 24:56. [PMID: 37208596 DOI: 10.1186/s10194-023-01594-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 05/10/2023] [Indexed: 05/21/2023] Open
Abstract
OBJECTIVE While there are several trials that support the efficacy of various drugs for migraine prophylaxis against placebo, there is limited evidence addressing the comparative safety and efficacy of these drugs. We conducted a systematic review and network meta-analysis to facilitate comparison between drugs for migraine prophylaxis. METHODS We searched MEDLINE, EMBASE, CENTRAL, and clinicaltrials.gov from inception to August 13, 2022, for randomized trials of pharmacological treatments for migraine prophylaxis in adults. Reviewers worked independently and in duplicate to screen references, extract data, and assess risk of bias. We performed a frequentist random-effects network meta-analysis and rated the certainty (quality) of evidence as either high, moderate, low, or very low using the GRADE approach. RESULTS We identified 74 eligible trials, reporting on 32,990 patients. We found high certainty evidence that monoclonal antibodies acting on the calcitonin gene related peptide or its receptor (CGRP(r)mAbs), gepants, and topiramate increase the proportion of patients who experience a 50% or more reduction in monthly migraine days, compared to placebo. We found moderate certainty evidence that beta-blockers, valproate, and amitriptyline increase the proportion of patients who experience a 50% or more reduction in monthly migraine days, and low certainty evidence that gabapentin may not be different from placebo. We found high certainty evidence that, compared to placebo, valproate and amitriptyline lead to substantial adverse events leading to discontinuation, moderate certainty evidence that topiramate, beta-blockers, and gabapentin increase adverse events leading to discontinuation, and moderate to high certainty evidence that (CGRP(r)mAbs) and gepants do not increase adverse events. CONCLUSIONS (CGRP(r)mAbs) have the best safety and efficacy profile of all drugs for migraine prophylaxis, followed closely by gepants.
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Affiliation(s)
- Christian Lampl
- Department of Neurology, Konventhospital Barmherzige Brüder Linz, Linz, Austria.
- Headache Medical Center Linz, Linz, Austria.
| | | | | | - Raquel Gil-Gouveia
- Neurology Department, Hospital da Luz Headache Center, Hospital da Luz Lisboa, Lisbon, Portugal
- Center for Interdisciplinary Research in Health, Universidade Católica Portuguesa, Lisbon, Portugal
| | - Tanvir Jassal
- Department of Anesthesia and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | | | - Uwe Reuter
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Derya Uluduz
- Department of Neurology Istanbul Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Jan Versijpt
- Department of Neurology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Dena Zeraatkar
- Department of Anesthesia and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L´Aquila, L'Aquila, Italy
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Kaltseis K, Filippi V, Frank F, Eckhardt C, Schiefecker A, Broessner G. Monoclonal antibodies against CGRP (R): non-responders and switchers: real world data from an austrian case series. BMC Neurol 2023; 23:174. [PMID: 37118682 PMCID: PMC10142255 DOI: 10.1186/s12883-023-03203-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 04/10/2023] [Indexed: 04/30/2023] Open
Abstract
OBJECTIVE Assessement of the responder and non-responder rate to consecutive monoclonal CGRP-antibody (CGRP-mAb) treatment, the presence of side effects, analysis of predictors of response and loss-of-effectiveness evaluation over time. METHODS We conducted a retrospective analysis including 171 patients with episodic (EM) or chronic migraine (CM), who received one, two or three different CGRP-mAbs. Non-response was defined as ≤ 50% reduction of monthly migraine days (MMDs) in EM and ≤ 30% reduction of MMDs in CM after 3 months of treatment. RESULTS 123 (71.9%) responded to the first mAb. Side effects led to treatment discontinuation in 9 (5.3%) patients. Of the 26 patients who did not respond to the first mAb or experienced a loss of efficacy over time, 11 (42.3%) responded to the second and two (28.6%) of 7 to the third monoclonal antibody. Poor response to therapy was associated with a higher monthly migraine frequency (p = 0.028), a higher number of prior preventive migraine therapies (p = 0.011) and medication overuse (p = 0.022). CONCLUSION Our findings support mAb-class switch in non-responders or in patients experiencing a loss of effectiveness. The use of a third CGRP-mAb could be beneficial for some patients.
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Affiliation(s)
- Katharina Kaltseis
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Vera Filippi
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Florian Frank
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Christine Eckhardt
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Alois Schiefecker
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Gregor Broessner
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria.
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Bagherzadeh-Fard M, Amin Yazdanifar M, Sadeghalvad M, Rezaei N. Erenumab efficacy in migraine headache prophylaxis: A systematic review. Int Immunopharmacol 2023; 117:109366. [PMID: 37012858 DOI: 10.1016/j.intimp.2022.109366] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 09/25/2022] [Accepted: 10/15/2022] [Indexed: 03/11/2023]
Abstract
OBJECTIVE This systematic review aims to show the efficiency of Erenumab in the preventive therapy of episodic and chronic migraine, which is still under research. BACKGROUND Migraine is a chronic neurovascular disorder that causes disability and a social burden. There are various medications used for migraine prevention regimens, most of which have unwanted side effects and aren't often quite effective. Erenumab is a monoclonal antibody that targets calcitonin gene-related peptide receptors and was recently approved by the Food and Drug Administration for migraine prevention. METHODS For this systematic review, we searched through Scopus and PubMed databases using "Erenumab" or "AMG 334" and "migraine" as keywords, and all the studies from 2016 to March 18, 2022, were included. Original English articles assessing any outcomes referring to the efficacy of Erenumab in migraine headache treatment were included in this study. RESULTS We found 53 out of 605 papers eligible to be investigated. Erenumab in both dosages of 70 mg and 140 mg could decrease the mean of monthly migraine days and monthly acute migraine-specific medication days. Erenumab also has a higher rate of ≥ 50 %, ≥ 75 %, and 100 % reduction in monthly migraine days from the baseline in different regions. The efficacy of Erenumab was initiated in the first week of administration and sustained throughout and after treatment. Erenumab was also potent in the treatment of migraine with allodynia, aura, prior preventive therapy failure, medication overuse headache, and menstrual migraine. Erenumab also had favorable outcomes in combination therapy with other preventive drugs like Onabotulinumtoxin-A. CONCLUSION Erenumab had remarkable efficacy in the short and long-term treatment of episodic and chronic migraine, notably the patients with difficult-to-treat migraine headaches.
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Affiliation(s)
- Mahsa Bagherzadeh-Fard
- Qom University of Medical Sciences, Qom, Iran; Systematic Review and Meta-Analysis Expert Group (SRMEG), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Mohammad Amin Yazdanifar
- Qom University of Medical Sciences, Qom, Iran; Systematic Review and Meta-Analysis Expert Group (SRMEG), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Mona Sadeghalvad
- Systematic Review and Meta-Analysis Expert Group (SRMEG), Universal Scientific Education and Research Network (USERN), Tehran, Iran; Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Nima Rezaei
- Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran; Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran,Iran; Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.
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Haghdoost F, Puledda F, Garcia-Azorin D, Huessler EM, Messina R, Pozo-Rosich P. Evaluating the efficacy of CGRP mAbs and gepants for the preventive treatment of migraine: A systematic review and network meta-analysis of phase 3 randomised controlled trials. Cephalalgia 2023; 43:3331024231159366. [PMID: 36855951 DOI: 10.1177/03331024231159366] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Several novel treatments targeting the calcitonin gene-related peptide pathway have been developed for migraine. We evaluated the efficacy of these medications, including atogepant, rimegepant, erenumab, eptinezumab, fremanezumab, and galcanezumab, for the prevention of migraine via network meta-analysis. METHODS Databases, including MEDLINE via PubMed, EMBASE, and Cochrane central, were systematically reviewed, and all eligible phase 3 randomised controlled trials were included. RESULTS Nineteen studies (n = 14,584 participants) were included. Studies included episodic (n = 11) and chronic (n = 4) migraine or both (n = 4). All interventions, except for eptinzumab 30 mg, significantly reduced mean monthly migraine days compared to placebo. All medications had a higher ≥50% responder rate than placebo and results were statistically significant in those with the subcutaneous or intravenous route of administrations, but not with the oral one. All medications significantly reduced mean monthly headache days, although no data for this outcome was available for rimegepant, and mean monthly acute medication days, with no data for eptinezumab. CONCLUSION The results show that medications targeting calcitonin gene-related peptide were effective in preventing migraine compared to placebo. Considering limitations of single studies, different populations such as episodic and chronic migraine, and the absence of head-to-head trials, all novel treatments decreased mean monthly migraine and headache days, and showed higher 50%, 75% and 100% responder rates than placebo.Trial registration: PROSPERO registration: CRD42022310579.
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Affiliation(s)
- Faraidoon Haghdoost
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Francesca Puledda
- Headache Group, Wolfson CARD, SLaM Biomedical Research Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, National Institute for Health Research-Wellcome Trust King's Clinical Research Facility, King's College Hospital, London, United Kingdom
| | - David Garcia-Azorin
- Headache Unit, Department of Neurology, Hospital Clínico Universitario de Valladolid, Gerencia Regional de Salud de Castilla y Leon, Valladolid, Spain
| | - Eva-Maria Huessler
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Germany
| | - Roberta Messina
- Neuroimaging Research Unit and Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Patricia Pozo-Rosich
- Headache Unit and Headache and Neurological Pain Research Group, Neurology Department, Hospital Universitari Vall d'Hebron and VHIR, Barcelona, Spain
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Ihara K, Ohtani S, Watanabe N, Takahashi N, Miyazaki N, Ishizuchi K, Hori S, Takemura R, Nakahara J, Takizawa T. Predicting response to CGRP-monoclonal antibodies in patients with migraine in Japan: a single-centre retrospective observational study. J Headache Pain 2023; 24:23. [PMID: 36890436 PMCID: PMC9996919 DOI: 10.1186/s10194-023-01556-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 02/24/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Anti-calcitonin gene-related peptide monoclonal antibodies (CGRPmAbs) are a favourable option for patients with migraine who experience distressful headache disability and fail to respond to traditional preventive treatment options. However, since CGRPmAb has been available for only 2 years in Japan, the difference between good and poor responders remains unknown. We aimed to investigate the clinical characteristics of patients with migraine in Japan who responded well to CGRPmAb based on real-world data. METHODS We analysed patients who visited Keio University Hospital, Tokyo, Japan, between the 12th of August 2021 and 31st of August 2022, and were prescribed one of three CGRPmAbs (erenumab, galcanezumab, and fremanezumab) for more than 3 months. We recorded the patients' basic migraine characteristics, such as pain quality, monthly migraine days (MMD)/monthly headache days (MHD), and the number of prior treatment failures. We defined good responders as patients whose MMDs decreased by more than 50% after 3 months of treatment and other patients as poor responders. We compared the baseline migraine characteristics between the two groups and performed logistic regression analysis based on the items that showed statistically significant differences. RESULTS In total, 101 patients were considered eligible for the responder analysis (galcanezumab: 57 (56%), fremanezumab: 31 (31%), and erenumab: 13 (13%)). After 3 months of treatment, 55 (54%) patients achieved ≥ 50% reduction in MMDs. Comparisons between ≥ 50% responders and non-responders revealed that age was significantly higher (p = 0.003), and MHD and total prior treatment failures were significantly lower (p = 0.027, 0.040, respectively), in responders than in non-responders. Age was a positive predictive factor, and the total number of prior treatment failures and past medical history of immuno-rheumatologic diseases were negative predictive factors of CGRPmAb responsiveness in Japanese patients with migraine. CONCLUSIONS Patients with migraine who are older, with fewer prior treatment failures and no past history of immuno-rheumatologic disease, may respond well to CGRPmAbs.
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Affiliation(s)
- Keiko Ihara
- Department of Neurology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Seiya Ohtani
- Department of Neurology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.,Division of Drug Informatics, Keio Univiersity Faculty of Pharmacy, 1-5-30 Shibakouen, Minato-ku, Tokyo, 105-8512, Japan
| | - Narumi Watanabe
- Department of Neurology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Nobuyuki Takahashi
- Department of Neurology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Naoki Miyazaki
- Biostatistics Unit, Clinical and Translational Research Center, Keio University Hospital, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Kei Ishizuchi
- Department of Neurology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Satoko Hori
- Division of Drug Informatics, Keio Univiersity Faculty of Pharmacy, 1-5-30 Shibakouen, Minato-ku, Tokyo, 105-8512, Japan
| | - Ryo Takemura
- Biostatistics Unit, Clinical and Translational Research Center, Keio University Hospital, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Jin Nakahara
- Department of Neurology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Tsubasa Takizawa
- Department of Neurology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
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A nasal CGRP receptor antagonist for acute migraine therapy. Lancet Neurol 2023; 22:190-191. [PMID: 36804077 DOI: 10.1016/s1474-4422(23)00037-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 01/23/2023] [Indexed: 02/17/2023]
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Giffin NJ. Calcitonin gene-related peptide (CGRP) monoclonal antibodies for migraine. Pract Neurol 2023; 23:200-207. [PMID: 36754606 DOI: 10.1136/pn-2022-003592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2023] [Indexed: 02/10/2023]
Abstract
The introduction of calcitonin gene-related peptide monoclonal antibodies represents a step forward in preventive migraine treatment as the first agents to target the underlying pathogenesis of migraine. In trials they act more quickly, have better long-term adherence and appear to be better tolerated than other treatments. Major disadvantages are their high cost and unknown safety in pregnancy and in cardiovascular disease. To mitigate these concerns, they should be used according to guidance produced by professional bodies, with defined starting and stopping criteria. We do not yet know whether they are more effective than standard care; many patients may still be better treated by other means, in particular addressing lifestyle factors and medication-overuse headache.
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Tzankova V, Becker WJ, Chan TLH. Pharmacologic prevention of migraine. CMAJ 2023; 195:E187-E192. [PMID: 36746481 PMCID: PMC9904820 DOI: 10.1503/cmaj.221607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Affiliation(s)
- Velina Tzankova
- Division of Neurology, Department of Medicine (Tzankova), University of Toronto, Toronto, Ont.; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Becker), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Clinical Neurological Sciences (Chan), Western University, London, Ont
| | - Werner J Becker
- Division of Neurology, Department of Medicine (Tzankova), University of Toronto, Toronto, Ont.; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Becker), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Clinical Neurological Sciences (Chan), Western University, London, Ont
| | - Tommy L H Chan
- Division of Neurology, Department of Medicine (Tzankova), University of Toronto, Toronto, Ont.; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Becker), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Clinical Neurological Sciences (Chan), Western University, London, Ont.
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Raffaelli B, De Icco R, Corrado M, Terhart M, Ailani J. Open-label trials for CGRP-targeted drugs in migraine prevention: A narrative review. Cephalalgia 2023; 43:3331024221137091. [PMID: 36718044 DOI: 10.1177/03331024221137091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Calcitonin gene-related peptide-targeted drugs have proven safe and effective for migraine prevention in large randomized-controlled, double-blind trials with an average duration of six months. Open-label studies may provide additional information on the long-term safety and efficacy of these substances. METHODS We searched PubMed for open-label trials with calcitonin gene-related peptide(-receptor) monoclonal antibodies and calcitonin gene-related peptide-receptor antagonists. We summarized and critically analyzed the literature in a narrative way. RESULTS Overall, 13 open-label trials were included in this review (n = 4 for erenumab, n = 4 for galcanezumab, n = 3 for fremanezumab, n = 1 for eptinezumab, n = 1 for atogepant). Open-label trial duration ranged between 12 and 264 weeks. No safety concerns emerged, and the adverse events profile was similar to the double-blind study phase. Discontinuation rates were generally low with >75% of patients remaining in the trials after one year. Efficacy data showed a sustained reduction of migraine frequency throughout the trials, along with a lasting improvement in quality of life. CONCLUSIONS The open-label study program for calcitonin gene-related peptide-targeted migraine preventives confirms the favorable safety and efficacy profile of these drugs over time. Treatment adherence appears higher than with previous unspecific migraine preventives. Real-world data and post-marketing surveillance studies may corroborate and complement open-label results.
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Affiliation(s)
- Bianca Raffaelli
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany.,Clinician Scientist Program, Berlin Institute of Health, Berlin, Germany
| | - Roberto De Icco
- Headache Science & Neurorehabilitation Center, IRCCS Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Michele Corrado
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Maria Terhart
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jessica Ailani
- MedStar Georgetown University Hospital, Washington, DC, USA
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Kim N, Estrada J, Chow I, Ruseva A, Ramasamy A, Burudpakdee C, Blanchette CM. The Relative Value of Anti-Obesity Medications Compared to Similar Therapies. Clinicoecon Outcomes Res 2023; 15:51-62. [PMID: 36726966 PMCID: PMC9886521 DOI: 10.2147/ceor.s392276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 01/11/2023] [Indexed: 01/27/2023]
Abstract
Purpose To demonstrate a need for improved health insurance coverage for anti-obesity medications (AOMs) by comparing clinical and economic benefits of obesity treatments to covered medications for selected therapeutic areas. Methods Using a grey literature search, we identified and prioritized therapeutic areas and treatment analogues for comparison to obesity. A targeted literature review identified clinical and economic outcomes research across the therapeutic area analogues. Associated comorbidities, clinical evidence, indirect costs (ie, absenteeism and productivity loss), and direct medical costs were evaluated to determine the relative value of treating obesity. Results Four therapeutic areas/treatment analogues were selected for comparison to obesity: smoking cessation (varenicline), daytime sleepiness (modafinil), migraines (erenumab), and fibromyalgia (pregabalin). Obesity was associated with 17 comorbidities, more than migraine (9), smoking (8), daytime sleepiness (5), and fibromyalgia (2). Economic burden was greatest for obesity, followed by smoking, with yearly indirect and direct medical costs totaling $676 and $345 billion, respectively. AOMs resulted in cost savings of $2586 in direct medical costs per patient per year (PPPY), greater than that for varenicline at $930 PPPY, modafinil at $1045 PPPY, and erenumab at $468 PPPY; pregabalin utilization increased costs by $924 PPPY. AOMs were covered by 10-16% of United States health insurance plans, compared to 45-59% for the four comparators. Conclusion Compared to four therapeutic analogues, obesity represented the highest economic burden and was associated with more comorbidities. AOMs provide greater cost savings compared to selected analogues. However, AOMs have limited formulary coverage. Improved coverage of AOMs may increase access to these treatments and may help address the clinical and economic burden associated with obesity and its comorbidities.
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Affiliation(s)
- Nina Kim
- Novo Nordisk, Inc, Plainsboro, NJ, USA
| | | | | | - Aleksandrina Ruseva
- Novo Nordisk, Inc, Plainsboro, NJ, USA,Correspondence: Aleksandrina Ruseva, Novo Nordisk, Inc, 800 Scudders Mill Road, Plainsboro, NJ, 08536, USA, Tel +1 609-598-8146, Email
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Troy E, Shrukalla AA, Buture A, Conaty K, Macken E, Lonergan R, Melling J, Long N, Shaikh E, Birrane K, Tomkins EM, Goadsby PJ, Ruttledge MH. Medium-term real-world data for erenumab in 177 treatment resistant or difficult to treat chronic migraine patients: persistence and patient reported outcome measures after 17-30 months. J Headache Pain 2023; 24:5. [PMID: 36647006 PMCID: PMC9841480 DOI: 10.1186/s10194-022-01536-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 12/17/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Many migraine patients do not respond adequately to conventional preventive treatments and are therefore described as treatment/medically resistant or difficult to treat cases. Calcitonin gene-related peptide monoclonal antibodies are a relatively novel molecular treatment for episodic and chronic migraine that have been shown to be effective in short duration clinical trials in approximately 40-50% of all chronic migraine patients. Patient Related Outcome Measures (PROM) or Quality of Life (QoL) questionnaires are used to help measure response to treatment in migraine. Although some open label extension studies have become available for erenumab, there is a lack of real-world data pertaining to quality of life in the medium to long-term for chronic and treatment resistant migraine patients. METHODS A total of 177 treatment resistant CM patients were started on erenumab (70 mg or 140 mg subcutaneous injection every 4 weeks) in our three specialist Headache Clinics. Of these, 174 had their first injection between December 2018 and October 2019. All patients were evaluated with the following PROM: the Headache Impact Test- 6, Migraine Associated Disability Assessment test and Migraine-Specific QoL Questionnaire, before starting treatment with erenumab and at intervals of 3-12 months after starting treatment. The decision to continue treatment was based on subjective clinical improvement of at least 30% (as reported by the patient), supported with diaries and QoL questionnaires. We present here the QoL measurements for this group of 177 patients. Prior preventive migraine treatments included conventional oral prophylactic medications (such as topiramate, candesartan, propranolol, or amitriptyline), at least two cycles of PREEMPT protocol onabotulinumtoxin A or (in a small number of cases) neuromodulation with single pulse Transcranial Magnetic Stimulation. RESULTS Of the 177 patients who started treatment with erenumab, 68/177 (38.4%) stopped during the first year, either due to lack of efficacy (no significant benefit or only minimal improvement) and/or possible side effects. 109/177 (61.6%) patients reported clinically significant improvement after 6-12 months and wished to stay on treatment. Twelve of these 109 patients subsequently stopped treatment in the period between 1 year and up to June 2021 (mainly due to a worsening of their migraine). Therefore, a total of 97/177 patients (54.8%) remained on treatment as of June 2021 (duration of treatment 17-30 months, median of 25 months). CONCLUSION Approximately 55% of treatment resistant or difficult to treat CM patients who trialled erenumab in our clinics reported a subjective benefit and were still on treatment after 17-30 months.
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Affiliation(s)
- Emma Troy
- grid.414315.60000 0004 0617 6058Department of Neurology, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland
| | - Arif A. Shrukalla
- grid.414315.60000 0004 0617 6058Department of Neurology, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland
| | - Alina Buture
- grid.411596.e0000 0004 0488 8430Dublin Neurological Institute, Department of Neurology, Mater Hospital, Eccles Street, Dublin 7, Ireland
| | - Katie Conaty
- grid.414315.60000 0004 0617 6058Department of Neurology, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland
| | - Esther Macken
- grid.411596.e0000 0004 0488 8430Dublin Neurological Institute, Department of Neurology, Mater Hospital, Eccles Street, Dublin 7, Ireland
| | - Roisin Lonergan
- grid.411596.e0000 0004 0488 8430Dublin Neurological Institute, Department of Neurology, Mater Hospital, Eccles Street, Dublin 7, Ireland
| | - Jane Melling
- grid.411596.e0000 0004 0488 8430Dublin Neurological Institute, Department of Neurology, Mater Hospital, Eccles Street, Dublin 7, Ireland
| | - Niamh Long
- grid.414315.60000 0004 0617 6058Department of Neurology, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland
| | - Eamonn Shaikh
- grid.414315.60000 0004 0617 6058Department of Neurology, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland
| | - Kieran Birrane
- Independent Statistical Consultant, Wilton, Cork, Ireland
| | - Esther M. Tomkins
- grid.414315.60000 0004 0617 6058Department of Neurology, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland
| | - Peter J. Goadsby
- grid.19006.3e0000 0000 9632 6718NIHR SLaM Clinical Research Facility at King’s, King’s College London, UK and Department of Neurology, University of California, Los Angeles, CA Los Angeles, USA
| | - Martin H. Ruttledge
- grid.414315.60000 0004 0617 6058Department of Neurology, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland
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Headache research in 2022: advances and remaining challenges. Lancet Neurol 2023; 22:14-15. [PMID: 36517156 DOI: 10.1016/s1474-4422(22)00489-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 11/21/2022] [Indexed: 12/15/2022]
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Rollo E, Romozzi M, Vollono C, Calabresi P, Geppetti P, Iannone LF. Antiseizure Medications for the Prophylaxis of Migraine during the Anti- CGRP Drugs Era. Curr Neuropharmacol 2023; 21:1767-1785. [PMID: 36582062 PMCID: PMC10514541 DOI: 10.2174/1570159x21666221228095256] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/26/2022] [Accepted: 12/01/2022] [Indexed: 12/31/2022] Open
Abstract
Migraine and epilepsy are fundamentally distinct disorders that can frequently coexist in the same patient. These two conditions significantly differ in diagnosis and therapy but share some widely- used preventive treatments. Antiseizure medications (ASMs) are the mainstay of therapy for epilepsy, and about thirty different ASMs are available to date. ASMs are widely prescribed for other neurological and non-neurological conditions, including migraine. However, only topiramate and valproic acid/valproate currently have an indication for migraine prophylaxis supported by high-quality evidence. Although without specifically approved indications and with a low level of evidence or recommendation, several other ASMs are used for migraine prophylaxis. Understanding ASM antimigraine mechanisms, including their ability to affect the pro-migraine calcitonin gene-related peptide (CGRP) signaling pathway and other pathways, may be instrumental in identifying the specific targets of their antimigraine efficacy and may increase awareness of the neurobiological differences between epilepsy and migraine. Several new ASMs are under clinical testing or have been approved for epilepsy in recent years, providing novel potential drugs for migraine prevention to enrich the treatment armamentarium and drugs that inhibit the CGRP pathway.
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Affiliation(s)
- Eleonora Rollo
- Dipartimento Universitario di Neuroscienze, University Cattolica del Sacro Cuore, Rome, Italy
| | - Marina Romozzi
- Dipartimento Universitario di Neuroscienze, University Cattolica del Sacro Cuore, Rome, Italy
| | - Catello Vollono
- Dipartimento Universitario di Neuroscienze, University Cattolica del Sacro Cuore, Rome, Italy
- Neurofisiopatologia, Dipartimento di Scienze dell’invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Paolo Calabresi
- Dipartimento Universitario di Neuroscienze, University Cattolica del Sacro Cuore, Rome, Italy
- Neurologia, Dipartimento di Scienze dell’invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Pierangelo Geppetti
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Florence, Italy
- Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, Florence, Italy
| | - Luigi F. Iannone
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Florence, Italy
- Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, Florence, Italy
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[Consensus statement of the migraine and headache societies (DMKG, ÖKSG, and SKG) on the duration of pharmacological migraine prophylaxis]. Schmerz 2023; 37:5-16. [PMID: 36287263 PMCID: PMC9607711 DOI: 10.1007/s00482-022-00671-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/19/2022] [Accepted: 08/23/2022] [Indexed: 02/03/2023]
Abstract
Migraine is the most common neurological disorder and can be associated with a high degree of disability. In addition to non-pharmacological approaches to reduce migraine frequency, pharmacological migraine preventatives are available. Evidence-based guidelines from the German Migraine and Headache Society (DMKG), and German Society for Neurology (DGN), Austrian Headache Society (ÖKSG), and Swiss Headache Society (SKG) are available for indication and application. For therapy-relevant questions such as the duration of a pharmacological migraine prevention, no conclusions can be drawn from currently available study data. The aim of this review is to present a therapy consensus statement that integrates the current data situation and, where data are lacking, expert opinions. The resulting current recommendations on the duration of therapy for pharmacological migraine prophylaxis are shown here.
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Ehrlich M, Hentschke C, Sieder C, Maier-Peuschel M, Reuter U. Erenumab versus topiramate: post hoc efficacy analysis from the HER-MES study. J Headache Pain 2022; 23:141. [PMID: 36380284 PMCID: PMC9664641 DOI: 10.1186/s10194-022-01511-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 10/19/2022] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE HER-MES was the first head-to-head, phase 4 trial to assess the tolerability and effectiveness of erenumab against standard of care treatment (topiramate). This post hoc analysis compared the efficacy of erenumab with topiramate in patients who completed the trial on study medication. METHODS Post hoc sensitivity analysis was performed using the full analysis set. Outcomes assessed included the proportion of patients with a ≥50% reduction in monthly migraine days (MMD) from baseline (50% responder rate), over the last 3 months (months 4, 5, and 6) of the double-blind treatment phase (DBTP), the 50% responder rate during the first month of the DBTP, and change from baseline in MMD during the DBTP. Multiple imputation was done for efficacy values of patients who discontinued study treatment. RESULTS Patients (N = 777) were randomly assigned (1:1) to either 70 or 140 mg/month erenumab (N = 389) or 50-100 mg/day topiramate (N = 388). Of these, 334 patients (85.9%) receiving erenumab, and 231 patients (59.5%) receiving topiramate completed the DBTP on study medication. Patients on study medication until the end of the DBTP received a mean dose of 119 mg/month for erenumab and 92 mg/day for topiramate. At month 1, a significantly greater proportion of patients receiving erenumab (39.2%) reported ≥50% reduction in MMD from baseline compared with those receiving topiramate (24.0%; p < 0.001). In the last 3 months, a significantly larger proportion of patients receiving erenumab (60.3%) achieved ≥50% reduction in MMD from baseline compared with those receiving topiramate (43.3%; p < 0.001). Patients receiving erenumab demonstrated significantly greater reductions in MMD during the last 3 months from baseline versus those receiving topiramate (- 6.13 vs - 4.90; 95% CI: - 1.87 to - 0.61; p < 0.001). CONCLUSIONS This post hoc analysis demonstrated significantly superior efficacy of erenumab versus topiramate in achieving a ≥50% reduction in MMD with an early onset of efficacy. TRIAL REGISTRATION ClinicalTrials.gov NCT03828539 .
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Affiliation(s)
| | | | | | | | - Uwe Reuter
- Department of Neurology, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
- Universitätsmedizin Greifswald, Greifswald, Germany.
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Gui T, Li H, Zhu F, Wang Q, Zhou X, Xue Q. Different dosage regimens of erenumab for the treatment of migraine: A systematic review and meta-analysis of the efficacy and safety of randomized controlled trials. Headache 2022; 62:1281-1292. [PMID: 36373822 DOI: 10.1111/head.14423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Migraine is a worldwide epidemic neurological disorder that has a significant influence on the quality of life. Migraine attacks are considered to be related to a calcitonin gene-related peptide (CGRP) signaling molecule, and anti-CGRP medications are used to abort and prevent migraine attacks. Erenumab, a monoclonal antibody that targets the CGRP receptor, is the first migraine preventive medication approved by the US Food and Drug Administration. In the present study, we evaluate the efficacy and safety of erenumab. OBJECTIVE This study aims to systematically assess the efficacy and safety of erenumab as a migraine preventive treatment compared to a placebo. METHODS Randomized, placebo-controlled, single or double-blind trials were searched through MEDLINE, Embase, Cochrane Library, and ClinicalTrials.gov up to May 2022. The efficacy outcomes we collected include changes from baseline on monthly migraine days, monthly acute migraine-specific medication days, ≥50% responder rate, ≥75% responder rate, and 100% responder rate at week 12. Safety outcomes include treatment emergent adverse events, serious adverse events, and any adverse event that leads to discontinuation of treatment. The study was registered with PROSPERO (Registry number: CRD42022338861). RESULT In all eight included trials, we found that erenumab (28, 70, and 140 mg) is very effective and has a significantly greater reduction in baseline monthly migraine days (28 mg: mean difference [MD] = -1.1, 95% confidence interval [CI]: -2.0 to -0.2, p = 0.020; 70 mg: MD = -1.4, 95% CI: -1.8 to -1.1, p < 0.001, I2 = 26%; 140 mg: MD = -1.8, 95% CI: -2.1 to -1.4, p < 0.001, I2 = 0%) than placebo at week 12, especially with 140 mg. Otherwise, we found that there were no statistical differences in the occurrence of adverse events (7 mg: risk ratio [RR] = 0.9, 95% CI: 0.7 to 1.2, p = 0.570; 21 mg: RR = 1.0, 95% CI: 0.8 to 1.2, p = 0.730; 28 mg: RR = 0.9, 95% CI: 0.7 to 1.1, p = 0.340; 70 mg: RR = 1.0, 95% CI: 0.9 to 1.0, p = 0.230, I2 = 0%; 140 mg: RR = 1.0, 95% CI: 0.9 to 1.1, p = 0.880, I2 = 40%) between the erenumab and placebo groups. CONCLUSIONS In our study, we found that erenumab, especially at the dose of 140 mg, is an effective and well-tolerated preventive treatment for migraine.
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Affiliation(s)
- Tiantian Gui
- Department of Neurology, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Hao Li
- Department of Neurology, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Feng Zhu
- Department of Neurology, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Quan Wang
- Department of Neurology, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaoling Zhou
- Department of Neurology, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Qun Xue
- Department of Neurology, the First Affiliated Hospital of Soochow University, Suzhou, China
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