Patient-reported migraine-specific quality of life, activity impairment and headache impact with once-daily atogepant for preventive treatment of migraine in a randomized, 52-week trial

Prevalence, Treatment, and Unmet Needs of Migraine in the Middle East: A Systematic Review

INTRODUCTION

Migraine is a debilitating neurological disorder characterized by recurrent throbbing, moderate-to-severe headaches that disrupt daily chores, leisure, and social activities of patients, impacting their overall quality of life (QoL). Despite the high disease burden, there is a scarcity of data on migraines within the Middle East (ME) region. Thus, a systematic literature review (SLR) was conducted to examine epidemiological data, treatment patterns, QoL, and unmet needs regarding migraines in the ME region.

METHODS

Electronic searches were carried out using the MEDLINE® and Embase® databases via the OvidSP® platform for articles published prior to April 2024. The inclusion and exclusion criteria for the selection of studies were based on the Patients, Intervention, Comparator, Outcomes, and Study design framework, which identified 42 studies.

RESULTS

The prevalence of migraines reported from the region ranged between 2.6 and 32%, and the average age of patients with migraines reported in these studies ranged from 27 to 37.5 years. The data indicated a gender disparity in migraine prevalence, with women exhibiting a 2- to 2.5-fold higher prevalence. Common comorbidities reported were depression, anxiety, and irritable bowel disease. Migraines significantly impact patients' physical and emotional well-being, leading to disabilities and loss of productivity. The most common triggers of migraines were sleep disorders, dietary habits, and stress. The current treatment landscape for acute migraines encompasses anti-inflammatory agents, analgesics, triptans, ditans, calcitonin-gene-related peptides, and antiemetics. However, migraines in the region are often underestimated, underreported, and undertreated. Several unmet needs persist in the region, including delayed referral along with delayed diagnosis, misdiagnosis, poor treatment adherence, limited accessibility to treatments, and a lack of awareness among health care providers and patients.

CONCLUSIONS

The SLR highlights knowledge gaps in clinical aspects and the treatment of migraines and enables clinicians to make informed decisions to ensure optimal patient outcomes in diverse clinical settings.

Combining treatments for migraine prophylaxis: the state-of-the-art

Combination treatments for migraine prophylaxis present a promising approach to addressing the diverse and complex mechanisms underlying migraine. This review explores the potential of combining oral conventional prophylactics, onabotulinumtoxin A, monoclonal antibodies (mAbs) targeting the calcitonin gene-related peptide (CGRP) pathway, and small molecule CGRP receptor antagonists (gepants). Among the most promising strategies, dual CGRP inhibition through mAbs and gepants may enhance efficacy by targeting both the CGRP peptide and its receptor, while the combination of onabotulinumtoxin A with CGRP treatments offers synergistic pain relief. Oral non-CGRP treatments, which are accessible and often prescribed for patients with comorbid conditions, provide an affordable and practical option in combination regimens. Despite the potential of these combinations, there is a lack of evidence to support their widespread inclusion in clinical guidelines. The high cost of certain combinations, such as onabotulinumtoxin A with a CGRP mAb or dual anti-CGRP mAbs, presents feasibility challenges. Further large-scale trials are needed to establish safe and effective combination protocols and solidify their role in clinical practice, particularly for treatment-resistant patients.

Profile of Sensory Integration Disorders in Migraine Patients-New Perspectives of Therapy

Background: The involvement of sensory integration disorders in the pathophysiology of migraine has been suggested. This study aims to analyze the relationship between symptoms of sensory integration disorders and migraine in a broad scope, including all sensory domains, and examine its impact on migraine attacks. Methods: The study included 372 people diagnosed with migraine. The Daniel Travis Questionnaire was used to assess symptoms of sensory integration disorders and their severity across six domains. The relationships between the severity of these symptoms and headache features, as well as accompanying headache symptoms, were the subject of statistical analysis. Results: Current impairment in all sensory domains was significantly associated with headaches exacerbated by everyday life activities. A significant inverse relationship was found between the occurrence of throbbing headaches and symptoms of sensory integration disorders in terms of current sensory discrimination, current motor skills, and current emotional/social skills. Past under-responsiveness and past disturbances in emotional/social abilities were significantly associated with migraine aura. Conclusions: The severity of symptoms of sensory integration disorders affects the clinical picture of migraine. The significant association between migraine and emotional/social disorders, as well as under-responsiveness in the past, needs further research to assess whether this is a cause-and-effect relationship. There is a need for in-depth diagnostics of sensory integration disorders in migraine patients, which could be an additional target of their therapy.

The preclinical discovery and development of atogepant for migraine prophylaxis

INTRODUCTION

Atogepant is a selective calcitonin gene-related peptide (CGRP) receptor antagonist that is utilized in adults for the prevention of episodic and chronic migraine. Cumulative findings support the involvement of CGRP in migraine pathophysiology, and atogepant functions by competitively antagonizing CGRP receptors, which results in the inhibition of trigeminovascular nociception. The mechanism of action addresses the cause of migraine pain, providing an effective preventive treatment option.

AREAS COVERED

The key milestones in its development, including preclinical achievements, phase I, II, and III clinical trials, and regulatory approvals are reviewed. Additionally, clinical efficacy, safety profile, and tolerability of atogepant are discussed. The literature review is based on a comprehensive search of English peer-reviewed articles from various electronic databases, including PubMed and ClinicalTrials.gov.

EXPERT OPINION

The development of atogepant represents a significant breakthrough in migraine prevention, particularly due to its improved safety profile that reduces the risk of liver injury, which was a major limitation of first-generation gepants. Drug-drug interaction studies with atogepant highlight the necessity for more inclusive study populations. Given that migraine disproportionately affects females, future clinical development programs should include diverse patient demographics to ensure the findings are generalizable to all individuals suffering from migraine.

The effect of selenium supplementation on oxidative stress, clinical symptoms and mental health status in patients with migraine: a study protocol for a double-blinded randomized clinical trial

BACKGROUND

Despite a number of recommended strategies, effective treatment of migraine remains elusive. Given the role of oxidative stress in the pathogenesis of migraine, selenium, as an antioxidant nutrient, may have a beneficial effect on migraine outcomes. However, no study has explored the effects of selenium supplementation on migraine symptoms, oxidative stress biomarkers, and mental health. Therefore, this randomized, double-blinded, placebo-controlled clinical trial aims to examine the effects of selenium supplementation among migraine patients.

METHODS

Seventy-two migraine patients will receive either 200 µg/day selenium supplement (n = 36) or placebo (n = 36) for 12 weeks in a randomized, double-blinded, placebo-controlled study. The severity, frequency, and duration of headaches, mental health indices including depression, anxiety, and distress, and quality of life, as well as biomarkers of oxidative stress such as nitric oxide (NO), malondialdehyde (MDA), total antioxidant capacity (TAC), and total oxidant status (TOS), will be measured at the baseline and end of the study. The intention-to-treat (ITT) approach will be used to estimate missing values. One-way analysis of covariance (ANCOVA) will be performed to detect the effect of selenium supplementation on outcome variables.

DISCUSSION

Oxidative stress is recognized as a key contributor to migraine pathogenesis. Selenium is an essential trace element with antioxidant properties, capable of crossing the blood-brain barrier (BBB), holding promise to alleviate the oxidative stress and neurotoxicity. Thus, selenium may beneficially affect clinical symptoms and oxidative stress as well as the quality of life in migraine patients.

TRIAL REGISTRATION

This trial was registered in the Iranian Registry of Clinical Trials ( https://www.irct.ir/ ) on 27 May 2023 with the code number IRCT20121216011763N60.