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Reina-Varona Á, Madroñero-Miguel B, Fierro-Marrero J, Paris-Alemany A, La Touche R. Efficacy of various exercise interventions for migraine treatment: A systematic review and network meta-analysis. Headache 2024. [PMID: 38597252 DOI: 10.1111/head.14696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/29/2023] [Accepted: 01/02/2024] [Indexed: 04/11/2024]
Abstract
OBJECTIVE To compare various exercise modalities' efficacy on migraine frequency, intensity, duration, and disability. BACKGROUND Exercise has been shown to be an effective intervention to reduce migraine symptoms and disability; however, no clear evidence exists regarding the most effective exercise modalities for migraine treatment. METHODS A systematic review was performed in PubMed, PEDro, Web of Science, and Google Scholar. Clinical trials that analyzed the efficacy of various exercise modalities in addressing the frequency, intensity, duration, and disability of patients with migraine were included. Eight network meta-analyses based on frequentist (F) and Bayesian (B) models were developed to estimate the direct and indirect evidence of various exercise modalities. Standardized mean difference (SMD) and 95% confidence (CI) and credible intervals (CrI) were calculated for each treatment effect based on Hedge's g and p scores to rank the modalities. RESULTS We included 28 studies with 1501 migraine participants. Yoga (F: SMD -1.30; 95% CI -2.09, -0.51; B: SMD -1.33; 95% CrI -2.21, -0.45), high-intensity aerobic exercise (F: SMD -1.30; 95% CI -2.21, -0.39; B: SMD -1.17; 95% CrI -2.20, -0.20) and moderate-intensity continuous aerobic exercise (F: SMD -1.01; 95% CI -1.63, -0.39; B: SMD -1.06; 95% CrI -1.74, -0.38) were significantly superior to pharmacological treatment alone for decreasing migraine frequency based on both models. Only yoga (F: SMD -1.40; 95% CI -2.41, -0.39; B: SMD -1.41; 95% CrI -2.54, -0.27) was significantly superior to pharmacological treatment alone for reducing migraine intensity. For diminishing migraine duration, high-intensity aerobic exercise (F: SMD -1.64; 95% CI -2.43, -0.85; B: SMD -1.56; 95% CrI -2.59, -0.63) and moderate-intensity continuous aerobic exercise (SMD -0.96; 95% CI -1.50, -0.41; B: SMD -1.00; 95% CrI -1.71, -0.31) were superior to pharmacological treatment alone. CONCLUSION Very low-quality evidence showed that yoga, high- and moderate-intensity aerobic exercises were the best interventions for reducing migraine frequency and intensity; high- and moderate-intensity aerobic exercises were best for decreasing migraine duration; and moderate-intensity aerobic exercise was best for diminishing disability.
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Affiliation(s)
- Álvaro Reina-Varona
- Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Madrid, Spain
- Motion in Brains Research Group, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Madrid, Spain
- PhD Program in Medicine and Surgery, Doctoral School, Universidad Autónoma de Madrid, Madrid, Spain
| | - Beatriz Madroñero-Miguel
- Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Madrid, Spain
| | - José Fierro-Marrero
- Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Madrid, Spain
- Motion in Brains Research Group, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Madrid, Spain
- PhD Program in Medicine and Surgery, Doctoral School, Universidad Autónoma de Madrid, Madrid, Spain
| | - Alba Paris-Alemany
- Motion in Brains Research Group, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Madrid, Spain
- Instituto de Dolor Craneofacial y Neuromusculoesquelético (INDCRAN), Madrid, Spain
- Departamento de Radiología, Rehabilitación y Fisioterapia, Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, Madrid, Spain
| | - Roy La Touche
- Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Madrid, Spain
- Motion in Brains Research Group, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Madrid, Spain
- Instituto de Dolor Craneofacial y Neuromusculoesquelético (INDCRAN), Madrid, Spain
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Chatterjee JH, Blume HK. Triptans in the Acute Migraine Management of Children and Adolescents: An Update. Curr Pain Headache Rep 2024:10.1007/s11916-024-01213-x. [PMID: 38581536 DOI: 10.1007/s11916-024-01213-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2024] [Indexed: 04/08/2024]
Abstract
PURPOSE OF REVIEW To summarize recent findings regarding triptan use in the acute treatment of pediatric migraine. RECENT FINDINGS Prevalence of pediatric migraine is rising. The American Headache Society and American Academy of Neurology updated guidelines to provide evidence-based recommendations for the treatment of acute migraine in youth. In the setting of a dearth of new randomized controlled trials (RCTs), we review current guidelines, triptan use in the emergency department, and an era of secondary analyses. Measuring the efficacy of triptans in pediatric migraine has been challenged by high placebo response rates. Secondary analyses, combining data from multiple RCTs, support that triptans are safe and effective in the treatment of migraine. Triptans are a vital tool and the only FDA-approved migraine-specific treatment available in pediatrics. There is a need for further studies and funding support in pediatric headache medicine.
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Affiliation(s)
- Jessica Hauser Chatterjee
- University of Washington School of Medicine, Department of Neurology, Division of Child Neurology and Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, WA, USA.
| | - Heidi K Blume
- Child Neurology, Seattle Children's Hospital, 4800 Sand Point Way NE, MB 7.420 Box 5371, Seattle, WA, 98105, USA
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Deng X, Zhou L, Liang C, Shang X, Hui X, Liu W, Liang S, Wang Y, Xu M, Guo K, Yang K, Li X. Comparison of effectiveness and safety of lasmiditan and CGRP-antagonists for the acute treatment of migraine in adults: systematic review and network meta-analysis of randomised trials. J Headache Pain 2024; 25:16. [PMID: 38311738 PMCID: PMC10840250 DOI: 10.1186/s10194-024-01723-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 01/22/2024] [Indexed: 02/06/2024] Open
Abstract
OBJECTIVE To compare the outcomes associated with the use of lasmiditan, rimegepant, ubrogepant, and zavegepant for the acute management of migraine headaches. METHODS We searched four electronic databases from database inception to August 31, 2023, to identify randomized controlled trials (RCTs) that report efficacy and safety for the acute treatment of migraine. The risk of bias in the included RCTs was evaluated according to the Cochrane tool, and the certainty of evidence using the CINeMA approach. We conducted frequentist network meta-analyses (NMA) to summarise the evidence. Data were analyzed using R-4.3.1. RESULTS A total of 18 eligible studies including 10 different types of interventions with 22,429 migraine patients were included. NMA results showed that compared to ubrogepant (25 mg and 50 mg) and zavegepant, lasmiditan (100 mg and 200 mg) exhibits an elevated probability of achieving pain relief within a 2-hour interval. Similarly, relative to zavegepant, rimegepant (75 mg) and ubrogepant (50 mg and 100 mg) demonstrate an enhanced likelihood of sustaining pain relief over a 24-hour period. Furthermore, in contrast to ubrogepant (25 mg) and lasmiditan (50 mg), rimegepant (75 mg) presents a heightened probability of achieving freedom from photophobia within 2 h. Regarding safety, lasmiditan carries the highest risk of adverse events, which are associated with an increased incidence of adverse effects, including dizziness, somnolence, asthenia, paresthesia, and fatigue. CONCLUSIONS In this NMA, a spectrum of evidence ranging from very low to high levels underscores the favorable efficacy and tolerability of rimegepant 75 mg and ubrogepant 100 mg, positioning them as potential candidates for the acute management of migraine. Concurrently, lasmiditan (100 mg and 200 mg) exhibits notable efficacy, albeit accompanied by an increased susceptibility to adverse events. These findings should still be approached with caution, primarily due to the intrinsic limitations associated with indirect comparisons.
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Affiliation(s)
- Xinxin Deng
- Health Technology Assessment Center/Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, 199 Donggang West Road, Lanzhou, 730000, China
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, 199 Donggang West Road, Lanzhou, 730000, China
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, 730000, China
| | - Liying Zhou
- Health Technology Assessment Center/Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, 199 Donggang West Road, Lanzhou, 730000, China
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, 199 Donggang West Road, Lanzhou, 730000, China
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, 730000, China
| | - Cui Liang
- Health Technology Assessment Center/Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, 199 Donggang West Road, Lanzhou, 730000, China
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, 199 Donggang West Road, Lanzhou, 730000, China
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, 730000, China
| | - Xue Shang
- School of Public Health and Emergency Management, Southern University of Science and Technology, Shenzhen, China
| | - Xu Hui
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, 199 Donggang West Road, Lanzhou, 730000, China
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, 730000, China
| | - Wendi Liu
- Health Technology Assessment Center/Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, 199 Donggang West Road, Lanzhou, 730000, China
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, 199 Donggang West Road, Lanzhou, 730000, China
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, 730000, China
| | - Shanshan Liang
- Health Technology Assessment Center/Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, 199 Donggang West Road, Lanzhou, 730000, China
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, 199 Donggang West Road, Lanzhou, 730000, China
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, 730000, China
| | - Yongsheng Wang
- Health Technology Assessment Center/Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, 199 Donggang West Road, Lanzhou, 730000, China
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, 199 Donggang West Road, Lanzhou, 730000, China
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, 730000, China
| | - Meng Xu
- Health Technology Assessment Center/Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, 199 Donggang West Road, Lanzhou, 730000, China
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, 199 Donggang West Road, Lanzhou, 730000, China
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, 730000, China
| | - Kangle Guo
- Department of infection management, Gansu Provincial Hospital, Lanzhou, 730000, China
| | - Kehu Yang
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, 199 Donggang West Road, Lanzhou, 730000, China.
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, 730000, China.
| | - Xiuxia Li
- Health Technology Assessment Center/Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, 199 Donggang West Road, Lanzhou, 730000, China.
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, 199 Donggang West Road, Lanzhou, 730000, China.
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, 730000, China.
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Wu X, Li W, Luo Z, Chen Y. A comprehensive comparison of the safety and efficacy of drugs in the treatment of idiopathic pulmonary fibrosis: a network meta-analysis based on randomized controlled trials. BMC Pulm Med 2024; 24:58. [PMID: 38281037 PMCID: PMC10822186 DOI: 10.1186/s12890-024-02861-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 01/10/2024] [Indexed: 01/29/2024] Open
Abstract
OBJECTIVE Randomized controlled trials(RCTs) of multiple drugs for Idiopathic pulmonary fibrosis(IPF) have been reported and achieved a certain degree of efficacy, however, the difference in safety and efficacy of them for IPF is not yet well understood. The aim of this network meta-analysis is to assess their safety and efficacy in the treatment of IPF and differences in this safety and efficacy comprehensively. METHODS The PubMed, EMbase, CENTRAL and MEDLINE were retrieved to find out the RCTs of drugs in the treatment of IPF. The retrieval date is from construction to November 10, 2022. Stata 14.0 and RevMan 5.3 was used for statistical analysis. REGISTRATION NUMBER CRD42023385689. RESULTS Twenty-four studies with a total of 6208 patients were finally included, including RCTs of 13 drugs. The results of safety showed that there' s no difference in the incidence of SAEs of 13 drugs treated with IPF compared to placebo (P>0.05), and it's also found that Warfarin had a higher all-cause mortality for IPF than placebo (OR = 5.63, 95% CI [1.54 to 20.55]). SUCRA' s scatterplot showed that Pirfenidone, Nintedanib, Sildenafil and Imatinib were lower than placebo, and Warfarin, Ambrisentan and N-acetylcysteine were higher than placebo. The results of effectiveness showed that Nintedanib (MD = -0.08, 95% CI [-0.12 to -0.04]) improved FVC (L)absolute change from baseline in patients better than placebo, and Nintedanib (OR=1.81, 95% CI [1.23 to 2.66]), Pirfenidone (OR=1.85, 95%CI [1.26 to 2.71]) and Pamrevlumab (OR=4.11, 95% CI [1.25 to 13.58]) improved the proportion of patients with a decline in FVC ≥10% predicted better than placebo. SUCRA' s scatterplot showed that Pamrevlumab, Pirfenidone and Nintedanib were lower than placebo, and Warfarin and Ambrisentan were higher than placebo. CONCLUSION Compared with other drugs, Nintedanib and Pirfenidone can significantly slow the decline of lung function in patients with IPF, and the safety is higher. Therefore, they can be further promoted in clinical practice. Warfarin and Ambrisentan shouldn't be used clinically for IPF as the safety and efficacy of them are poor compared to other drugs and placebo. Pamrevlumab may become important drugs for the treatment of IPF in the future.
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Affiliation(s)
- Xiaozheng Wu
- Department of Preclinical medicine, Guizhou University of Traditional Chinese Medicine, Guiyang, 510025, China
| | - Wen Li
- Department of Preclinical medicine, Guizhou University of Traditional Chinese Medicine, Guiyang, 510025, China
| | - Zhenliang Luo
- Department of Preclinical medicine, Guizhou University of Traditional Chinese Medicine, Guiyang, 510025, China
| | - Yunzhi Chen
- Department of Preclinical medicine, Guizhou University of Traditional Chinese Medicine, Guiyang, 510025, China.
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Friedman SA, Robbins MS. Millions of Migraine Attacks, Many Answers, More Questions. Neurology 2023; 101:1089-1090. [PMID: 38030396 DOI: 10.1212/wnl.0000000000208084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
In the landscape of migraine treatment, many unanswered questions remain-particularly, which medications are most effective as acute agents and for which patients? Given the heterogeneity of patients, clinicians' practice, and the integration of new agents into migraine care, this is an ambitious question to address.1 At the same time, this question is crucial both because proper acute treatment is an important metric of quality of care and such treatments are woefully underused in the general population.2,3.
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Affiliation(s)
- Sarah A Friedman
- From the Department of Neurology, NewYork-Presbyterian and Weill Cornell Medicine, New York, NY
| | - Matthew S Robbins
- From the Department of Neurology, NewYork-Presbyterian and Weill Cornell Medicine, New York, NY
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Chiang CC, Fang X, Horvath Z, Cadiou F, Urani A, Poh W, Narimatsu H, Cheng Y, Dodick DW. Simultaneous Comparisons of 25 Acute Migraine Medications Based on 10 Million Users' Self-Reported Records From a Smartphone Application. Neurology 2023; 101:e2560-e2570. [PMID: 38030397 PMCID: PMC10791049 DOI: 10.1212/wnl.0000000000207964] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 10/03/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Many acute treatment options exist for migraine. However, large-scale, head-to-head comparisons of treatment effectiveness from real-world patient experience reports are lacking. METHODS This is a retrospective analysis of 10,842,795 migraine attack records extracted from an e-diary smartphone application between June 30, 2014, and July 2, 2020. We analyzed 25 acute medications among 7 classes-acetaminophen, nonsteroid anti-inflammatory drugs (NSAIDs), triptans, combination analgesics, ergots, antiemetics, and opioids. Gepants and ditan were not included in this analysis. Different doses and formulations of each medication, according to the generic names, were combined in this analysis. We used a 2-level nested logistic regression model to analyze the odds ratio (OR) of treatment effectiveness of each medication by adjusting concurrent medications and the covariance within the same user. Subgroup analyses were conducted for users in the United States, the United Kingdom, and Canada. RESULTS Our final analysis included 4,777,524 medication-outcome pairs from 3,119,517 migraine attacks among 278,006 users. Triptans (mean OR 4.8), ergots (mean OR 3.02), and antiemetics (mean OR 2.67) were the top 3 classes of medications with the highest effectiveness, followed by opioids (mean OR 2.49), NSAIDs (other than ibuprofen, mean OR 1.94), combination analgesics (acetaminophen/acetylsalicylic acid/caffeine) (OR 1.69, 95% CI 1.67-1.71), others (OR 1.49, 95% CI 1.47-1.50), and acetaminophen (OR 0.83, 95% CI 0.83-0.84), using ibuprofen as the reference. Individual medications with the highest ORs were eletriptan (OR 6.1, 95% CI 6.0-6.3), zolmitriptan (OR 5.7, 95% CI 5.6-5.8), and sumatriptan (OR 5.2, 95% CI 5.2-5.3). The ORs of acetaminophen, NSAIDS, combination analgesics, and opioids were mostly around or less than 1, suggesting similar or lower reported effectiveness compared with ibuprofen. The ORs for 24 medications, except that of acetylsalicylic acid, achieved statistical significance with p < 0.0001, and our nested logistic regression model achieved an area under the curve (AUC) of 0.849. Country-specific subgroup analyses revealed similar ORs of each medication and AUC (United States 0.849, United Kingdom 0.864, and Canada 0.842), demonstrating the robustness of our analysis. DISCUSSION Using a big data approach, we analyzed patient-generated real-time records of 10 million migraine attacks and conducted simultaneous head-to-head comparisons of 25 acute migraine medications. Our findings that triptans, ergots, and antiemetics are the most effective classes of medications align with the guideline recommendations and offer generalizable insights to complement clinical practice. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that for patients with migraine, selected acute medications (e.g., triptans, ergots, antiemetics) are associated with higher odds of user-rated positive response than ibuprofen.
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Affiliation(s)
- Chia-Chun Chiang
- From the Department of Neurology (C.-C.C.), Mayo Clinic, Rochester, MN; Graduate School of Health Innovation (X.F., H.N.), Kanagawa University of Human Services, Kawasaki; IBM Client Engineering (X.F.), Banking Financial Market Unit, Chuo-Ku, Tokyo, Japan; Healint Pte. Ltd. (Z.H., F.C., A.U., W.P.), Singapore; Cancer Prevention and Cancer Control Division (H.N.), Kanagawa Cancer Center Research Institute; Department of Genetic Medicine (H.N.), Kanagawa Cancer Center, Yokohama, Japan; Department of Statistics (Y.C.), University of Pittsburgh, PA; and Department of Neurology (D.W.D.), Mayo Clinic, Scottsdale, AZ
| | - Xuemin Fang
- From the Department of Neurology (C.-C.C.), Mayo Clinic, Rochester, MN; Graduate School of Health Innovation (X.F., H.N.), Kanagawa University of Human Services, Kawasaki; IBM Client Engineering (X.F.), Banking Financial Market Unit, Chuo-Ku, Tokyo, Japan; Healint Pte. Ltd. (Z.H., F.C., A.U., W.P.), Singapore; Cancer Prevention and Cancer Control Division (H.N.), Kanagawa Cancer Center Research Institute; Department of Genetic Medicine (H.N.), Kanagawa Cancer Center, Yokohama, Japan; Department of Statistics (Y.C.), University of Pittsburgh, PA; and Department of Neurology (D.W.D.), Mayo Clinic, Scottsdale, AZ
| | - Zsolt Horvath
- From the Department of Neurology (C.-C.C.), Mayo Clinic, Rochester, MN; Graduate School of Health Innovation (X.F., H.N.), Kanagawa University of Human Services, Kawasaki; IBM Client Engineering (X.F.), Banking Financial Market Unit, Chuo-Ku, Tokyo, Japan; Healint Pte. Ltd. (Z.H., F.C., A.U., W.P.), Singapore; Cancer Prevention and Cancer Control Division (H.N.), Kanagawa Cancer Center Research Institute; Department of Genetic Medicine (H.N.), Kanagawa Cancer Center, Yokohama, Japan; Department of Statistics (Y.C.), University of Pittsburgh, PA; and Department of Neurology (D.W.D.), Mayo Clinic, Scottsdale, AZ
| | - Francois Cadiou
- From the Department of Neurology (C.-C.C.), Mayo Clinic, Rochester, MN; Graduate School of Health Innovation (X.F., H.N.), Kanagawa University of Human Services, Kawasaki; IBM Client Engineering (X.F.), Banking Financial Market Unit, Chuo-Ku, Tokyo, Japan; Healint Pte. Ltd. (Z.H., F.C., A.U., W.P.), Singapore; Cancer Prevention and Cancer Control Division (H.N.), Kanagawa Cancer Center Research Institute; Department of Genetic Medicine (H.N.), Kanagawa Cancer Center, Yokohama, Japan; Department of Statistics (Y.C.), University of Pittsburgh, PA; and Department of Neurology (D.W.D.), Mayo Clinic, Scottsdale, AZ
| | - Alexandre Urani
- From the Department of Neurology (C.-C.C.), Mayo Clinic, Rochester, MN; Graduate School of Health Innovation (X.F., H.N.), Kanagawa University of Human Services, Kawasaki; IBM Client Engineering (X.F.), Banking Financial Market Unit, Chuo-Ku, Tokyo, Japan; Healint Pte. Ltd. (Z.H., F.C., A.U., W.P.), Singapore; Cancer Prevention and Cancer Control Division (H.N.), Kanagawa Cancer Center Research Institute; Department of Genetic Medicine (H.N.), Kanagawa Cancer Center, Yokohama, Japan; Department of Statistics (Y.C.), University of Pittsburgh, PA; and Department of Neurology (D.W.D.), Mayo Clinic, Scottsdale, AZ
| | - Weijie Poh
- From the Department of Neurology (C.-C.C.), Mayo Clinic, Rochester, MN; Graduate School of Health Innovation (X.F., H.N.), Kanagawa University of Human Services, Kawasaki; IBM Client Engineering (X.F.), Banking Financial Market Unit, Chuo-Ku, Tokyo, Japan; Healint Pte. Ltd. (Z.H., F.C., A.U., W.P.), Singapore; Cancer Prevention and Cancer Control Division (H.N.), Kanagawa Cancer Center Research Institute; Department of Genetic Medicine (H.N.), Kanagawa Cancer Center, Yokohama, Japan; Department of Statistics (Y.C.), University of Pittsburgh, PA; and Department of Neurology (D.W.D.), Mayo Clinic, Scottsdale, AZ
| | - Hiroto Narimatsu
- From the Department of Neurology (C.-C.C.), Mayo Clinic, Rochester, MN; Graduate School of Health Innovation (X.F., H.N.), Kanagawa University of Human Services, Kawasaki; IBM Client Engineering (X.F.), Banking Financial Market Unit, Chuo-Ku, Tokyo, Japan; Healint Pte. Ltd. (Z.H., F.C., A.U., W.P.), Singapore; Cancer Prevention and Cancer Control Division (H.N.), Kanagawa Cancer Center Research Institute; Department of Genetic Medicine (H.N.), Kanagawa Cancer Center, Yokohama, Japan; Department of Statistics (Y.C.), University of Pittsburgh, PA; and Department of Neurology (D.W.D.), Mayo Clinic, Scottsdale, AZ
| | - Yu Cheng
- From the Department of Neurology (C.-C.C.), Mayo Clinic, Rochester, MN; Graduate School of Health Innovation (X.F., H.N.), Kanagawa University of Human Services, Kawasaki; IBM Client Engineering (X.F.), Banking Financial Market Unit, Chuo-Ku, Tokyo, Japan; Healint Pte. Ltd. (Z.H., F.C., A.U., W.P.), Singapore; Cancer Prevention and Cancer Control Division (H.N.), Kanagawa Cancer Center Research Institute; Department of Genetic Medicine (H.N.), Kanagawa Cancer Center, Yokohama, Japan; Department of Statistics (Y.C.), University of Pittsburgh, PA; and Department of Neurology (D.W.D.), Mayo Clinic, Scottsdale, AZ
| | - David W Dodick
- From the Department of Neurology (C.-C.C.), Mayo Clinic, Rochester, MN; Graduate School of Health Innovation (X.F., H.N.), Kanagawa University of Human Services, Kawasaki; IBM Client Engineering (X.F.), Banking Financial Market Unit, Chuo-Ku, Tokyo, Japan; Healint Pte. Ltd. (Z.H., F.C., A.U., W.P.), Singapore; Cancer Prevention and Cancer Control Division (H.N.), Kanagawa Cancer Center Research Institute; Department of Genetic Medicine (H.N.), Kanagawa Cancer Center, Yokohama, Japan; Department of Statistics (Y.C.), University of Pittsburgh, PA; and Department of Neurology (D.W.D.), Mayo Clinic, Scottsdale, AZ
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Cortel-LeBlanc MA, Orr SL, Dunn M, James D, Cortel-LeBlanc A. Managing and Preventing Migraine in the Emergency Department: A Review. Ann Emerg Med 2023; 82:732-751. [PMID: 37436346 DOI: 10.1016/j.annemergmed.2023.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/24/2023] [Accepted: 05/25/2023] [Indexed: 07/13/2023]
Abstract
Migraine is a leading cause of disability worldwide, and acute migraine attacks are a common reason for patients to seek care in the emergency department (ED). There have been recent advancements in the care of patients with migraine, specifically emerging evidence for nerve blocks and new pharmacological classes of medications like gepants and ditans. This article serves as a comprehensive review of migraine in the ED, including diagnosis and management of acute complications of migraine (eg, status migrainosus, migrainous infarct, persistent aura without infarction, and aura-triggered seizure) and use of evidence-based migraine-specific treatments in the ED. It highlights the role of migraine preventive medications and provides a framework for emergency physicians to prescribe them to eligible patients. Finally, it evaluates the evidence for nerve blocks in the treatment of migraine and introduces the possible role of gepants and ditans in the care of patients with migraine in the ED.
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Affiliation(s)
- Miguel A Cortel-LeBlanc
- Department of Emergency Medicine, Queensway Carleton Hospital, Ottawa, ON, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada; Institut du Savoir Montfort, Ottawa, ON, Canada; 360 Concussion Care, Ottawa, ON, Canada.
| | - Serena L Orr
- Departments of Pediatrics, Community Health Sciences, and Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Maeghan Dunn
- Department of Emergency Medicine, Queensway Carleton Hospital, Ottawa, ON, Canada
| | - Daniel James
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada; Department of Emergency Medicine, The Ottawa Hospital, Ottawa, ON, Canada; Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Achelle Cortel-LeBlanc
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada; Institut du Savoir Montfort, Ottawa, ON, Canada; 360 Concussion Care, Ottawa, ON, Canada; Division of Neurology, Department of Medicine, Queensway Carleton Hospital, Ottawa, ON, Canada
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8
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Dighriri IM, Nazel S, Alharthi AM, Altowairqi NA, Albariqi AM, Tohari MA, Alameer AA, Alsaran AK, ALshammari FR, AlMutairi NF, Alsubaie FM, Alharbi TA. A Comprehensive Review of the Mechanism, Efficacy, Safety, and Tolerability of Ubrogepant in the Treatment of Migraine. Cureus 2023; 15:e48160. [PMID: 38046695 PMCID: PMC10693258 DOI: 10.7759/cureus.48160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2023] [Indexed: 12/05/2023] Open
Abstract
Ubrogepant is an innovative medication designed for the acute treatment of migraine, a debilitating neurological condition that profoundly impairs quality of life, productivity, and social interactions. This comprehensive review assesses the efficacy, safety, tolerability, and mechanism of action of ubrogepant through a rigorous methodology, including an in-depth literature review from reputable databases like PubMed, Web of Science, Embase, Scopus, and Cochrane. Classified as a calcitonin gene-related peptide (CGRP) receptor antagonist, ubrogepant has emerged as a potential revolutionary medication for migraine treatment. CGRP is a peptide integral to migraine pathophysiology, and its blockade has demonstrated great therapeutic potential. Unlike triptans, known for their cardiovascular risks, ubrogepant lacks vasoconstrictive properties, making it a safer alternative for a broader patient population. Ubrogepant offers significant potential for pain relief, symptom reduction, and restoration of normal function during a migraine attack, and it outperforms placebo in terms of efficacy. It also presents favorable safety, with generally mild adverse drug events (ADEs), such as nausea, dizziness, and somnolence, similar to placebo effects. Consistent results from clinical trials confirm its tolerability, with minor ADEs and no safety alerts for the tested doses, indicating that ubrogepant is a safe and well-tolerated option for migraine treatment. As an effective oral medication, ubrogepant could be an alternative to traditional acute migraine treatments. Its benefits include a unique mechanism of action, rapid onset, and favorable safety profile. However, specific contraindications, such as hypersensitivity, severe hepatic impairment, concurrent use of CYP3A4 inhibitors, pregnancy or breastfeeding, and uncontrolled hypertension, require caution or avoidance of ubrogepant. Despite these limitations, ubrogepant signals a promising new direction in migraine therapeutics.
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Affiliation(s)
| | - Shahad Nazel
- Faculty of Pharmacy, Princess Nourah Bint Abdulrahman University, Riyadh, SAU
| | | | | | - Aqeel M Albariqi
- Department of Pharmacy, Bariq Primary Health Care Center, Bariq, SAU
| | - Mona A Tohari
- Department of Pharmacy, Alhada Armed Forces Hospital, Taif, SAU
| | | | - Amjad K Alsaran
- Department of Pharmacy, Specialized Medical Center Hospital, Riyadh, SAU
| | | | - Naif F AlMutairi
- Department of Pharmacy, Maternity and Children Hospital, Buraydah, SAU
| | - Fahad M Alsubaie
- Department of Pharmacy, King Abdulaziz Specialist Hospital, Taif, SAU
| | - Turki A Alharbi
- Department of Pharmacy, Al Rass General Hospital, Al Rass, SAU
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9
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Wells-Gatnik WD, Martelletti P. Gepants in the acute management of migraine. Pain Manag 2023; 13:627-630. [PMID: 37942638 DOI: 10.2217/pmt-2023-0106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023] Open
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10
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Jinesh S. Pharmaceutical aspects of novel CGRP inhibitors used in the prophylaxis and treatment of migraine. Inflammopharmacology 2023; 31:2245-2251. [PMID: 37421480 DOI: 10.1007/s10787-023-01276-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 06/21/2023] [Indexed: 07/10/2023]
Abstract
Migraine is one of the most prevalent neurological disorders known to have an immense adverse socio-economic impact. Neurogenic inflammation is thought to mediate migraine, and CGRP is known to be released during acute attacks of migraine that causes vasodilation in extracerebral arteries. Hence, CGRP is believed to play a key role in triggering migraine. Although there are several classes of medications used in the prevention and treatment of migraine pain, targeted therapies are fewer. Therefore, CGRP receptor inhibitors which bind to CGRP receptors in the cranial vasculature have been developed as drugs for migraine therapy. In this review article, we describe the basic pathophysiologic mechanism that causes migraine headaches and the pharmacotherapeutic aspects of CGRP inhibitors available for clinical use. For the purpose of this review, a search was performed on the pharmacological, pharmacokinetic, pharmaceutical, and therapeutic aspects of the FDA-approved CGRP inhibitors viz. erenumab, ubrogepant, rimegepant, atogepant, eptinezumab, fremanezumab, and galcanezumab in UpToDate database and PubMed beginning year 2000. Based on the data collected, a risk-benefit comparison of different classes of novel CGRP inhibitors available for clinical use is provided. This comparative review may help the healthcare providers in choosing the best pharmacotherapeutic agent for their patients based on patient-specific information.
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11
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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] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [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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12
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Moskatel LS, Zhang N. The Role of Step Therapy in the Treatment of Migraine. Curr Pain Headache Rep 2023; 27:571-577. [PMID: 37542597 DOI: 10.1007/s11916-023-01155-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2023] [Indexed: 08/07/2023]
Abstract
PURPOSE OF REVIEW This review examines recent evidence and applies bioethical principles to evaluate the benefits and risks of using step therapy in the treatment of migraine. RECENT FINDINGS With the CGRP mAbs, gepants, and lasmiditan now on the market for up to 5 years, new research, including network meta-analyses and long-term use studies, can evaluate the comparative efficacy, tolerability, and adherence of these medications relative to older acute and preventive medications for the treatment of migraine. Deciding how medications are chosen for patients requires accounting for many factors including sustainability, efficacy, tolerability, and preference. Newer research can help give clarity on the appropriateness of gating certain treatment options behind others.
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Affiliation(s)
- Leon S Moskatel
- Division of Headache, Department of Neurology and Neurological Sciences, Stanford University, 211 Quarry Road, Suite #206, Palo Alto, CA, 94304, USA.
| | - Niushen Zhang
- Division of Headache, Department of Neurology and Neurological Sciences, Stanford University, 211 Quarry Road, Suite #206, Palo Alto, CA, 94304, USA
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13
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Li G, Duan S, Zhu T, Ren Z, Xia H, Wang Z, Liu L, Liu Z. Efficacy and safety of intranasal agents for the acute treatment of migraine: a systematic review and network meta-analysis. J Headache Pain 2023; 24:129. [PMID: 37723470 PMCID: PMC10506288 DOI: 10.1186/s10194-023-01662-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 08/28/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Intranasal agents may be ideal for the treatment of migraine patients. Many new acute intranasal-specific therapies have been developed, but few of them have been directly compared. The aim of this network meta-analysis (NMA) was to compare the efficacy and safety of various intranasal agents for the treatment of acute migraine in adult patients. METHODS The Cochrane Register of Controlled Trials, Embase, and PubMed were searched from inception to 15 August 2023. Randomized controlled trials (RCTs) using intranasal agents (no restrictions on dose, formulation, dosing regimen or timing of the first dose) to treat adult patients with acute migraine were included. The primary efficacy endpoint was pain freedom at 2 h, and the primary safety endpoint was adverse events (AEs). The analysis process followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS Nineteen studies (21 RCTs, 9738 participants) were included. Compared to the placebo, 5 mg of zolmitriptan using a conventional liquid nasal spray device was the most effective for pain freedom at 2 h [odds ratio (OR): 4.67, 95% confidence interval (CI): 3.43 to 6.43] and 24 h (OR: 5.49, 95% CI: 3.58 to 8.42) among all the interventions. Butorphanol nasal spray 1 mg was the most effective (OR: 8.62, 95% CI: 1.11 to 66.92) for pain freedom at 1 h, but with low-quality evidence. DFN-02 presented the highest freedom from nausea (OR: 4.95, 95% CI: 1.29 to 19.01) and phonophobia (OR: 5.36, 95% CI: 1.67 to 17.22) at 2 h, albeit with lower odds of achieving complete pain freedom. ROX-828 showed the highest improvement in freedom from photophobia at 2 h (OR: 4.03, 95% CI: 1.66 to 9.81). Dihydroergotamine nasal spray was significantly associated with the highest risk of AEs (OR: 9.65, 95% CI: 4.39 to 21.22) and was not recommended for routine use. Zavegepant nasal spray demonstrated the lowest risk of AEs (OR: 2.04, 95% CI: 1.37 to 3.03). The results of sensitivity analyses for the primary endpoints (pain freedom at 2 h and AEs) were generally consistent with those of the base case model. CONCLUSIONS Compared with other new intranasal-specific therapies in treating migraine attacks, zolmitriptan nasal spray 5 mg was the most effective agent for pain freedom at 2 h. Zavegepant nasal spray 10 mg had the fewest adverse side effects.
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Affiliation(s)
- Guanglu Li
- Graduate School of Beijing, University of Chinese Medicine, Beijing, China
- Department of Neurology, China-Japan Friendship Hospital, Beijing, China
| | - Shaojie Duan
- Department of Geriatrics, Taizhou Central Hospital (Taizhou University Hospital), Taizhou, China
| | - Tiantian Zhu
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhiying Ren
- Graduate School of Beijing, University of Chinese Medicine, Beijing, China
- Department of Neurology, China-Japan Friendship Hospital, Beijing, China
| | - Hui Xia
- Graduate School of Beijing, University of Chinese Medicine, Beijing, China
- Department of Neurology, China-Japan Friendship Hospital, Beijing, China
| | - Ziyao Wang
- Graduate School of Beijing, University of Chinese Medicine, Beijing, China
- Department of Neurology, China-Japan Friendship Hospital, Beijing, China
| | - Lei Liu
- Department of Neurology, China-Japan Friendship Hospital, Beijing, China.
| | - Zunjing Liu
- Department of Neurology, Peking University People's Hospital, Beijing, China.
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Labastida-Ramírez A, Caronna E, Gollion C, Stanyer E, Dapkute A, Braniste D, Naghshineh H, Meksa L, Chkhitunidze N, Gudadze T, Pozo-Rosich P, Burstein R, Hoffmann J. Mode and site of action of therapies targeting CGRP signaling. J Headache Pain 2023; 24:125. [PMID: 37691118 PMCID: PMC10494408 DOI: 10.1186/s10194-023-01644-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 08/01/2023] [Indexed: 09/12/2023] Open
Abstract
Targeting CGRP has proved to be efficacious, tolerable, and safe to treat migraine; however, many patients with migraine do not benefit from drugs that antagonize the CGRPergic system. Therefore, this review focuses on summarizing the general pharmacology of the different types of treatments currently available, which target directly or indirectly the CGRP receptor or its ligand. Moreover, the latest evidence regarding the selectivity and site of action of CGRP small molecule antagonists (gepants) and monoclonal antibodies is critically discussed. Finally, the reasons behind non-responders to anti-CGRP drugs and rationale for combining and/or switching between these therapies are addressed.
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Affiliation(s)
- Alejandro Labastida-Ramírez
- Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE1 1UL, UK
| | - Edoardo Caronna
- Headache Unit, Neurology Department, Vall d'Hebron Universitary Hospital, Barcelona, Spain
- Headache Research Group, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Cédric Gollion
- Department of Neurology, University Hospital of Toulouse, Toulouse, France
| | - Emily Stanyer
- Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE1 1UL, UK
- Nuffield Department of Clinical Neurosciences, Sleep and Circadian Neuroscience Institute, University of Oxford, Oxford, UK
| | | | - Diana Braniste
- Institute of Neurology and Neurosurgery, Diomid Gherman, Chișinău, Moldova
- State University of Medicine and Pharmacy, Nicolae Testemițanu, Moldova
| | - Hoda Naghshineh
- Headache Department, Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Science, Tehran, Iran
| | - Liga Meksa
- Headache Unit, Neurology and Neurosurgery Department, Riga East University Hospital Gailezers, Riga, Latvia
| | | | - Tamari Gudadze
- Department of Neurology, Christian Hospital Unna, Unna, Germany
| | - Patricia Pozo-Rosich
- Headache Unit, Neurology Department, Vall d'Hebron Universitary Hospital, Barcelona, Spain
- Headache Research Group, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Rami Burstein
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Anesthesia, Harvard Medical School, Boston, MA, USA
- Center for Life Science, Room 649, 3 Blackfan Circle, Boston, MA, 02215, USA
| | - Jan Hoffmann
- Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE1 1UL, UK.
- NIHR-Wellcome Trust King's Clinical Research Facility/SLaM Biomedical Research Centre, King's College Hospital, London, UK.
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15
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Zhang H, Qi JZ, Zhang ZH. Comparative efficacy of different treatments for menstrual migraine: a systematic review and network meta-analysis. J Headache Pain 2023; 24:81. [PMID: 37400775 DOI: 10.1186/s10194-023-01625-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 06/28/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND Menstrual migraine is a subtype of migraine disease that is typically more disabling, longer-lasting, and more challenging to treat. The purpose of this network meta-analysis (NMA) is to compare the relative efficacy of treatments for menstrual migraine. METHODS We systematically searched databases, including PubMed, EMBASE, and Cochrane, and included all eligible randomized controlled trials in the study. We conducted the statistical analysis using Stata version 14.0, based on the frequentist framework. We used the Cochrane Risk of Bias tool for randomized trials version 2 (RoB2) to assess the risk of bias of the included studies. RESULTS This network meta-analysis included 14 randomized controlled trials with 4601 patients. For short-term prophylaxis, frovatriptan 2.5 mg twice daily had the highest probability of effectiveness [OR = 1.87 (95% CI: 1.48 to 2.38)] compared to placebo. For acute treatment, the results showed that sumatriptan 100 mg [OR = 4.32 (95% CI: 2.95 to 6.34)] was the most effective treatment compared to placebo. CONCLUSIONS These findings suggest that frovatriptan 2.5 mg twice daily was best for short-term prevention, sumatriptan 100 mg were best for acute treatment. More high-quality randomized trials are required to determine the most effective treatment.
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Affiliation(s)
- Han Zhang
- The Second School of Clinical Medicine, Anhui Medical University, Hefei, 230032, China
| | - Jian-Zhi Qi
- The Second School of Clinical Medicine, Anhui Medical University, Hefei, 230032, China
| | - Zhi-Hua Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, 230032, China.
- Center for Evidence Based Medicine, Anhui Medical University, Hefei, 230032, China.
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16
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Anderson CC, VanderPluym JH. Profile of Lasmiditan in the Acute Treatment of Migraine in Adults: Design, Development, and Place in Therapy. Drug Des Devel Ther 2023; 17:1979-1993. [PMID: 37426628 PMCID: PMC10327670 DOI: 10.2147/dddt.s380440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/26/2023] [Indexed: 07/11/2023] Open
Abstract
Migraine is a common neurological disorder that is present in a large proportion of the global population. It is estimated to occur in around 20.7% of women and 10.7% of men in the United States. The pathophysiology of migraine is a major focus of research, and medications have been developed to interrupt the processes that generate headache and other bothersome symptoms of migraine attacks. The triptan class of medications acts as a direct agonist at the 5-HT1B/D receptor but its use is limited by contraindications for those with coronary or cerebrovascular disease. Lasmiditan is a first-in-class agonist at the 5-HT1F serotonin receptor that does not appear to generate vasoconstriction. This article reviews the design, development, and place in therapy for lasmiditan. A narrative review of the literature using the Ovid MEDLINE database was performed. The rationale behind the development of lasmiditan and pre-clinical, proof-of-concept, Phase II, pivotal, Phase III trials and post-hoc data is covered. Additionally, the efficacy and safety of lasmiditan when compared to other acute treatments in migraine is described, including lasmiditan's side effect profile and status as a Schedule V substance. Further, head-to-head studies of lasmiditan compared with other acute treatments are required.
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17
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La Touche R, Fierro-Marrero J, Sánchez-Ruíz I, Rodríguez de Rivera-Romero B, Cabrera-López CD, Lerma-Lara S, Requejo-Salinas N, de Asís-Fernández F, Elizagaray-García I, Fernández-Carnero J, Matesanz-García L, Pardo-Montero J, Paris-Alemany A, Reina-Varona Á. Prescription of therapeutic exercise in migraine, an evidence-based clinical practice guideline. J Headache Pain 2023; 24:68. [PMID: 37286937 DOI: 10.1186/s10194-023-01571-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 03/24/2023] [Indexed: 06/09/2023] Open
Abstract
The main objective of this clinical practice guideline is to provide a series of recommendations for healthcare and exercise professionals, such as neurologists, physical therapists, and exercise physiologists, regarding exercise prescription for patients with migraine.This guideline was developed following the methodology and procedures recommended in the Appraisal of Guidelines for Research and Evaluation (AGREE). The quality of evidence and strength of recommendations were evaluated with the Scottish Intercollegiate Guidelines Network (SIGN). A systematic literature review was performed and an established appraisal process was employed to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development, and Evaluation methodology).The evaluation of the current evidence, the elaboration of the grades of recommendation, and their validation show a B grade of recommendation for aerobic exercise, moderate-continuous aerobic exercise, yoga, and exercise and lifestyle recommendations for the improvement of symptoms, disability, and quality of life in patients with migraine. Relaxation techniques, high-intensity interval training, low-intensity continuous aerobic exercise, exercise and relaxation techniques, Tai Chi, and resistance exercise obtained a C grade of recommendation for the improvement of migraine symptoms and disability.
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Affiliation(s)
- Roy La Touche
- Departamento de Fisioterapia, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Aravaca, Madrid, Spain
- Motion in Brains Research Group, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Aravaca, Madrid, Spain
- PhD Program in Medicine and Surgery. Doctoral School, Universidad Autónoma de Madrid, Madrid, Spain
- Instituto de Dolor Craneofacial y Neuromusculoesquelético (INDCRAN), Madrid, Spain
| | - José Fierro-Marrero
- Departamento de Fisioterapia, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Aravaca, Madrid, Spain
- Motion in Brains Research Group, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Aravaca, Madrid, Spain
| | - Irene Sánchez-Ruíz
- Departamento de Fisioterapia, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Aravaca, Madrid, Spain
| | - Borja Rodríguez de Rivera-Romero
- Departamento de Fisioterapia, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Aravaca, Madrid, Spain
| | - Carlos Donato Cabrera-López
- Departamento de Fisioterapia, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Aravaca, Madrid, Spain
| | - Sergio Lerma-Lara
- Departamento de Fisioterapia, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Aravaca, Madrid, Spain
- Motion in Brains Research Group, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Aravaca, Madrid, Spain
| | - Néstor Requejo-Salinas
- Departamento de Fisioterapia, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Aravaca, Madrid, Spain
- Motion in Brains Research Group, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Aravaca, Madrid, Spain
| | - Francisco de Asís-Fernández
- Departamento de Fisioterapia, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Aravaca, Madrid, Spain
- Research Group Breatherapy, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Aravaca, Madrid, Spain
| | - Ignacio Elizagaray-García
- Departamento de Fisioterapia, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Aravaca, Madrid, Spain
- Motion in Brains Research Group, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Aravaca, Madrid, Spain
- CranioSPain Research Group, Centro Superior de Estudios Universitarios La Salle, 28023, Madrid, Spain
| | - Josué Fernández-Carnero
- Motion in Brains Research Group, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Aravaca, Madrid, Spain
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Rey Juan Carlos University, 28922, Alcorcón, Spain
| | - Luís Matesanz-García
- Departamento de Fisioterapia, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Aravaca, Madrid, Spain
- CranioSPain Research Group, Centro Superior de Estudios Universitarios La Salle, 28023, Madrid, Spain
| | - Joaquín Pardo-Montero
- Departamento de Fisioterapia, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Aravaca, Madrid, Spain
- Motion in Brains Research Group, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Aravaca, Madrid, Spain
| | - Alba Paris-Alemany
- Motion in Brains Research Group, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Aravaca, Madrid, Spain.
- Instituto de Dolor Craneofacial y Neuromusculoesquelético (INDCRAN), Madrid, Spain.
- Department of Radiology, Rehabilitation and Physiotherapy. Faculty of Nursery, Physiotherapy and Podiatry, Complutense University of Madrid, Madrid, Spain.
| | - Álvaro Reina-Varona
- Departamento de Fisioterapia, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Aravaca, Madrid, Spain
- Motion in Brains Research Group, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Aravaca, Madrid, Spain
- PhD Program in Medicine and Surgery. Doctoral School, Universidad Autónoma de Madrid, Madrid, Spain
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18
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Messina R, Christensen RH, Cetta I, Ashina M, Filippi M. Imaging the brain and vascular reactions to headache treatments: a systematic review. J Headache Pain 2023; 24:58. [PMID: 37221469 DOI: 10.1186/s10194-023-01590-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 04/28/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Neuroimaging studies have made an important contribution to our understanding of headache pathophysiology. This systematic review aims to provide a comprehensive overview and critical appraisal of mechanisms of actions of headache treatments and potential biomarkers of treatment response disclosed by imaging studies. MAIN BODY We performed a systematic literature search on PubMed and Embase databases for imaging studies investigating central and vascular effects of pharmacological and non-pharmacological treatments used to abort and prevent headache attacks. Sixty-three studies were included in the final qualitative analysis. Of these, 54 investigated migraine patients, 4 cluster headache patients and 5 patients with medication overuse headache. Most studies used functional magnetic resonance imaging (MRI) (n = 33) or molecular imaging (n = 14). Eleven studies employed structural MRI and a few used arterial spin labeling (n = 3), magnetic resonance spectroscopy (n = 3) or magnetic resonance angiography (n = 2). Different imaging modalities were combined in eight studies. Despite of the variety of imaging approaches and results, some findings were consistent. This systematic review suggests that triptans may cross the blood-brain barrier to some extent, though perhaps not sufficiently to alter the intracranial cerebral blood flow. Acupuncture in migraine, neuromodulation in migraine and cluster headache patients, and medication withdrawal in patients with medication overuse headache could promote headache improvement by reverting headache-affected pain processing brain areas. Yet, there is currently no clear evidence for where each treatment acts, and no firm imaging predictors of efficacy. This is mainly due to a scarcity of studies and heterogeneous treatment schemes, study designs, subjects, and imaging techniques. In addition, most studies used small sample sizes and inadequate statistical approaches, which precludes generalizable conclusions. CONCLUSION Several aspects of headache treatments remain to be elucidated using imaging approaches, such as how pharmacological preventive therapies work, whether treatment-related brain changes may influence therapy effectiveness, and imaging biomarkers of clinical response. In the future, well-designed studies with homogeneous study populations, adequate sample sizes and statistical approaches are needed.
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Affiliation(s)
- R Messina
- Neuroimaging Research Unit, Division of Neuroscience and Neurology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy.
| | - R H Christensen
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Glostrup, Denmark
| | - I Cetta
- Neuroimaging Research Unit, Division of Neuroscience and Neurology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
| | - M Ashina
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Glostrup, Denmark
| | - M Filippi
- Neuroimaging Research Unit, Division of Neuroscience and Neurology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
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Abstract
Rimegepant [Nurtec® ODT (USA); Vydura® (EU)] is a calcitonin gene-related peptide (CGRP) receptor antagonist approved for the acute treatment of migraine with or without aura in adults, and for the preventive treatment of episodic migraine in adults. Rimegepant is available as an orally disintegrating tablet (ODT), which offers convenience and a potentially faster response time than the conventional tablet formulation. In pivotal phase III trials, rimegepant was more effective than placebo at relieving pain and the most bothersome symptom when taken as needed for the acute treatment of migraine. Rimegepant was also more effective than placebo at reducing the number of monthly migraine days when taken every other day for the preventive treatment of migraine. The beneficial effects of rimegepant in reducing migraine frequency and improving quality of life were maintained over the longer term (up to 52 weeks). Rimegepant was generally well tolerated, with no evidence of hepatotoxicity or cardiovascular toxicity in clinical trials. As the first dual agent approved for both treatment and prevention of migraine, rimegepant represents a useful option for the management of migraine in adults.
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Affiliation(s)
- Hannah A Blair
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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20
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Gazerani P. Human Brain Organoids in Migraine Research: Pathogenesis and Drug Development. Int J Mol Sci 2023; 24. [PMID: 36834522 DOI: 10.3390/ijms24043113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 02/01/2023] [Accepted: 02/02/2023] [Indexed: 02/08/2023] Open
Abstract
Human organoids are small, self-organized, three-dimensional (3D) tissue cultures that have started to revolutionize medical science in terms of understanding disease, testing pharmacologically active compounds, and offering novel ways to treat disease. Organoids of the liver, kidney, intestine, lung, and brain have been developed in recent years. Human brain organoids are used for understanding pathogenesis and investigating therapeutic options for neurodevelopmental, neuropsychiatric, neurodegenerative, and neurological disorders. Theoretically, several brain disorders can be modeled with the aid of human brain organoids, and hence the potential exists for understanding migraine pathogenesis and its treatment with the aid of brain organoids. Migraine is considered a brain disorder with neurological and non-neurological abnormalities and symptoms. Both genetic and environmental factors play essential roles in migraine pathogenesis and its clinical manifestations. Several types of migraines are classified, for example, migraines with and without aura, and human brain organoids can be developed from patients with these types of migraines to study genetic factors (e.g., channelopathy in calcium channels) and environmental stressors (e.g., chemical and mechanical). In these models, drug candidates for therapeutic purposes can also be tested. Here, the potential and limitations of human brain organoids for studying migraine pathogenesis and its treatment are communicated to generate motivation and stimulate curiosity for further research. This must, however, be considered alongside the complexity of the concept of brain organoids and the neuroethical aspects of the topic. Interested researchers are invited to join the network for protocol development and testing the hypothesis presented here.
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21
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de Boer I, Verhagen IE, Souza MNP, Ashina M. Place of next generation acute migraine specific treatments among triptans, non-responders and contraindications to triptans and possible combination therapies. Cephalalgia 2023; 43:3331024221143773. [PMID: 36739516 DOI: 10.1177/03331024221143773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background: For many years triptans have been the cornerstone of acute migraine treatment. Nevertheless, treatment with triptans may not always be initiated due to contraindications (seen in approximately one fifth of patients) or inadequate response (seen in approximately one third of patients). New acute therapies, including 5-hydroxytryptamine (5-HT)1F receptor agonists, also known as ditans (lasmiditan) and small molecule antagonists of the calcitonin gene-related peptide receptor, also known as gepants (rimegepant and ubrogepant), may be an effective alternative. Methods: We searched Pubmed for keywords, summarized the literature and provided a comprehensive review on the place of next generation acute migraine specific treatments among triptans. Results and conclusion: Post-hoc analyses reported no differences in efficacy of gepants/ditans between responders and non-responders to triptans, but research is hampered by lack of consensus on the definition of non-responder. Due to (partially) overlapping mechanisms of action, it remains unknown whether combination therapy with lasmiditan, gepants and triptans will have added value over monotherapy. Preclinical studies and post-hoc analyses cautiously indicate that these new drugs are safe for patients with cardiovascular risk factors. However, long-term studies are needed to prove cardiovascular safety. The risk of developing medication overuse headache may differ between triptans, ditans and gepants, but further studies are needed to confirm this difference. Head-to-head randomized controlled trials of acute therapies and combinations of therapies are needed to determine their place in migraine treatment among established therapies.
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Affiliation(s)
- Irene de Boer
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - Iris Elsa Verhagen
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Messoud Ashina
- Department of Neurology, Rigshospitalet Glostrup, University of Copenhagen, Glostrup, Denmark
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22
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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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23
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Dong G, Kjærgaard NA, Shakibfar S, Sessa M. Ubrogepant and rimegepant: systematic review, meta-analysis, and meta-regression of clinical studies. Expert Opin Drug Saf 2023; 22:59-70. [PMID: 36737057 DOI: 10.1080/14740338.2023.2177270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES This study aimed at providing pooled estimates of the incidence of adverse drug reactions (ADRs) of ubrogepant and rimegepant and to use meta-regression to identify correlations between the occurrence of selected ADRs, socio-demographic, and clinical characteristics from data published in clinical studies. METHODS Ovid MEDLINE (up to 03/02/2022) was searched along with the references listed in the reviews identified with the research query. Random intercept and slope logistic regression models were used to estimate the logit transformation of the pooled incidence. To examine how selected clinical and socio-demographic characteristics correlated with the pooled incidence rates, we performed random-effects meta-regression. RESULTS Significant heterogeneity of incidence estimates was observed in clinical studies along with correlations between ADRs and the sociodemographic and clinical characteristics of patients exposed to ubrogepant. In particular, we observed a correlation between ubrogepant dosage and muscle strain and between Body Mass Index (BMI) and liver function values. For rimegepant, significant correlations were observed between age and infections and having aura symptoms at baseline and nausea/dizziness/diarrhea/muscle strain. CONCLUSION This study provided pooled incidence estimates of ubrogepant and rimegepant's ADRs and highlighted new safety aspects of the pharmacological treatment with ubrogepants and rimigepants from correlations obtained from the meta-regression.
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Affiliation(s)
- Guojun Dong
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Naoko Adachi Kjærgaard
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Saeed Shakibfar
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Maurizio Sessa
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
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24
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Cooper W, Ray S, Aurora SK, Shrewsbury SB, Fuller C, Davies G, Hoekman J. Delivery of Dihydroergotamine Mesylate to the Upper Nasal Space for the Acute Treatment of Migraine: Technology in Action. J Aerosol Med Pulm Drug Deliv 2022; 35:321-332. [PMID: 36108289 PMCID: PMC9807280 DOI: 10.1089/jamp.2022.0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Oral tablets account for the majority of medications used to acutely treat migraine, but relief can be limited by their rates of dissolution and absorption. The nose is an attractive alternative route of drug delivery since it provides patient convenience of at-home use, gastrointestinal (GI) avoidance, and rapid absorption of drugs into systemic circulation because of its large surface area. However, the site of drug deposition within the nasal cavity should be considered since it can influence drug absorption. Traditional nasal devices have been shown to target drug delivery to the lower nasal space where epithelium is not best-suited for drug absorption and where there is an increased likelihood of drug clearance due to nasal drip, swallowing, or mucociliary clearance, potentially resulting in variable absorption and suboptimal efficacy. Alternatively, the upper nasal space (UNS) offers a permeable, richly vascularized epithelium with a decreased likelihood of drug loss or clearance due to the anatomy of this area. Traditional nasal pumps deposit <5% of active drug into the UNS because of the nasal cavity's complex architecture. A new technology, Precision Olfactory Delivery (POD®), is a handheld, manually actuated, propellant-powered, administration device that delivers drug specifically to the UNS. A dihydroergotamine (DHE) mesylate product, INP104, utilizes POD technology to deliver drug to the UNS for the acute treatment of migraine. Results from clinical studies of INP104 demonstrate a favorable pharmacokinetic profile, consistent and predictable dosing, rapid systemic levels known to be effective (similar to other DHE mesylate clinical programs), safety and tolerability on the upper nasal mucosa, and high patient acceptance. POD technology may have the potential to overcome the limitations of traditional nasal delivery systems, while utilizing the nasal delivery benefits of GI tract avoidance, rapid onset, patient convenience, and ease of use.
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Affiliation(s)
- Wade Cooper
- Headache and Neuropathic Pain Program, University of Michigan, Ann Arbor, Michigan, USA
| | - Sutapa Ray
- Impel Pharmaceuticals, Seattle, Washington, USA
| | | | - Stephen B. Shrewsbury
- Impel Pharmaceuticals, Seattle, Washington, USA.,Address correspondence to: Stephen B. Shrewsbury, MB, ChB, Impel Pharmaceuticals, Seattle, WA 98119, USA
| | | | - Greg Davies
- Impel Pharmaceuticals, Seattle, Washington, USA
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25
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Rissardo JP, Caprara ALF. Gepants for Acute and Preventive Migraine Treatment: A Narrative Review. Brain Sci 2022; 12. [PMID: 36552072 DOI: 10.3390/brainsci12121612] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 11/11/2022] [Accepted: 11/22/2022] [Indexed: 11/27/2022] Open
Abstract
Calcitonin gene-related peptide (CGRP) antagonists are a class of medications that act as antagonists of the CGRP receptor or ligand. They can be divided into monoclonal antibodies and non-peptide small molecules, also known as gepants. CGRP antagonists were the first oral agents specifically designed to prevent migraines. The second generation of gepants includes rimegepant (BHV-3000, BMS-927711), ubrogepant (MK-1602), and atogepant (AGN-241689, MK-8031). Zavegepant (BHV-3500, BMS-742413) belongs to the third generation of gepants characterized by different administration routes. The chemical and pharmacological properties of this new generation of gepants were calculated. The clinical trials showed that the new generation of CGRP antagonists is effective for the acute and/or preventive treatment of migraines. No increased mortality risks were observed to be associated with the second- and third-generation gepants. Moreover, the majority of the serious adverse events reported probably occurred unrelated to the medications. Interesting facts about gepants were highlighted, such as potency, hepatotoxicity, concomitant use with monoclonal antibodies targeting the CGRP, comparative analysis with triptans, and the "acute and preventive" treatment of migraine. Further studies should include an elderly population and compare the medications inside this class and with triptans. There are still concerns regarding the long-term side effects of these medications, such as chronic vascular hemodynamic impairment. Meanwhile, careful pharmacovigilance and safety monitoring should be performed in the clinical practice use of gepants.
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26
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Gibler RC, Knestrick KE, Reidy BL, Lax DN, Powers SW. Management of Chronic Migraine in Children and Adolescents: Where are We in 2022? Pediatric Health Med Ther 2022; 13:309-323. [PMID: 36110896 PMCID: PMC9470380 DOI: 10.2147/phmt.s334744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/10/2022] [Indexed: 11/23/2022] Open
Abstract
Migraine is a neurological disorder that affects millions of children and adolescents worldwide. Chronic migraine is a subtype of migraine in which patients experience headaches for more days than not each month, with accompanying symptoms of phonophobia, photophobia, nausea or vomiting for most of these headaches. The burden and impact of chronic migraine in the daily lives of children and adolescents is substantial, requiring a holistic, multidisciplinary, and biopsychosocial approach to conceptualization and treatment. The purpose of this review is to provide a comprehensive “2022” overview of acute and preventive treatments for the management of chronic migraine in youth. We first describe diagnostic criteria for chronic migraine and highlight the state of evidence for acute and preventive treatment in children and adolescents. We then discuss emerging treatments currently receiving rigorous clinical research effort, special considerations for the treatment of chronic migraine in children and adolescents, and avenues for improving existing treatments and expanding access to evidence-based care.
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Affiliation(s)
- Robert C Gibler
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Correspondence: Robert C Gibler, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA, Email
| | - Kaelynn E Knestrick
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Brooke L Reidy
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Daniel N Lax
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Headache Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Scott W Powers
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Headache Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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27
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Viticchi G, Falsetti L, Silvestrini M, Bartolini M. Ditans: a new prospective for the therapy of migraine attack? Neurol Sci 2022; 43:5709-16. [PMID: 35816257 DOI: 10.1007/s10072-022-06260-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 07/03/2022] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Migraine attack is characterized by disabling pain and associated symptoms. Triptans represent the "gold standard" therapy, but cardiac subjects have significant limitations for this approach. New drug families are under consideration to expand therapeutic offerings, especially in the presence of contraindications or for non-responsive patients. This review aimed to analyze studies related to the category of "ditans," with a focus on lasmiditan, which is available for human use. MATERIALS AND METHODS We consulted PubMed/MEDLINE, Web of Science, and www. CLINICALTRIALS gov to find both original and review articles on the mechanism of action of 5-HT1F agonists in migraine, and for randomized, double-blind, placebo-controlled trials (RCTs) on the family of drugs called "ditans," with a focus on "lasmiditan," published in the time frame of 01-Jan-2010 to 31-Mar-2022. Only studies conducted in human subjects and published in English were included in this review. RESULTS We retrieved four RCTs (named SAMURAI, SPARTAN, GLADIATOR, and CENTURION) and several studies that analyzed the efficacy and safety of lasmiditan. Lasmiditan at increasing doses showed significant improvement in pain and most other troublesome symptoms at 2 h. Adverse events were mild and mainly represented by dizziness, vertigo, drowsiness, and fatigue. No vasoconstrictive effects were described, suggesting the use of ditans as a safe option in chronic cardio- and cerebro-vascular disease. DISCUSSION Lasmiditan could be a viable alternative to triptans, although further RCT studies and real-world evidence are needed to better understand its potential and possible adverse events in a larger population.
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Grazzi L. Mindfulness and other behavioral approaches. Neurol Sci 2022; 43:5745-5747. [DOI: 10.1007/s10072-022-06155-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 05/13/2022] [Indexed: 11/25/2022]
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Abstract
Calcitonin gene-related peptide (CGRP) is probably the most potent vasodilator in cerebral circulation. Forty years after its discovery, the new CGRP-targeted therapy monoclonal antibodies, and the small molecule gepants, are now available for clinical practice. While randomized controlled trials and real-world experience consistently demonstrated the high efficacy and tolerability of monoclonal antibodies, limited evidence is available to characterize gepants fully. Depending on pharmacokinetics, these CGRP receptor antagonists can be used for acute (ubrogepant, rimegepant, and the not yet approved zavegepant) or preventive (atogepant and rimegepant) migraine treatment. Randomized placebo-controlled trials demonstrated gepants efficacy in treating acute attacks to obtain 2 h pain freedom in about 20% of patients and pain relief in about 60%, while up to 60% of treated patients with episodic migraine may experience a 50% reduction in monthly migraine days. The most common treatment-related emergent adverse events were gastrointestinal (nausea, constipation) for the acute or preventive use. No vascular or hepatic concerns have emerged so far. More studies are ongoing to investigate gepant tolerability and safety also if associated with monoclonal antibodies targeting CGRP and other therapeutic classes. Gepants are also under investigation to treat other painful and non-painful conditions. Real-life studies are necessary to confirm the trials’ findings and investigate more practical clinical aspects.
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Affiliation(s)
- Claudia Altamura
- Headache and Neurosonology Unit, Neurology, Fondazione Policlinico Universitario Campus Bio-Medico Di Roma, 00128, Rome, Italy.
| | - Nicoletta Brunelli
- Headache and Neurosonology Unit, Neurology, Fondazione Policlinico Universitario Campus Bio-Medico Di Roma, 00128, Rome, Italy
| | - Marilena Marcosano
- Headache and Neurosonology Unit, Neurology, Fondazione Policlinico Universitario Campus Bio-Medico Di Roma, 00128, Rome, Italy
| | - Luisa Fofi
- Headache and Neurosonology Unit, Neurology, Fondazione Policlinico Universitario Campus Bio-Medico Di Roma, 00128, Rome, Italy
| | - Fabrizio Vernieri
- Headache and Neurosonology Unit, Neurology, Fondazione Policlinico Universitario Campus Bio-Medico Di Roma, 00128, Rome, Italy
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Bentivegna E, Luciani M, Ferrari V, Galastri S, Baldari F, Scarso F, Lamberti PA, Martelletti P. Recently approved and emerging drug options for migraine prophylaxis. Expert Opin Pharmacother 2022; 23:1325-1335. [PMID: 35850597 DOI: 10.1080/14656566.2022.2102420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION : Migraine occupies the first position regarding to the disability caused in female working population (15-49 years). Research in the field of prophylaxis of this pathology has made enormous strides in recent years. AREAS COVERED In this narrative review we retrace the most important scientific evidence regarding recently approved and emerging drug for prophylactic treatment of migraine. The purpose of this article is in fact to evaluate currently approved or emerging pharmacological agents for migraine prophylaxis. This review is based on literature published in peer review journal obtained through PubMed, Cochrane library, Clinicaltrials.gov and US FDA. EXPERT OPINION : Monoclonal antibodies (mAbs) that target the calcitonin gene-related peptide signalling pathway (CGRP) have marked an innovation in prophylactic migraine therapy. The combination of Onabotulinumtoxin-A (OBTA) and mAbs appears to be an effective, but costly, therapeutic option for resistant cases. New classes of molecules like gepants and ditans seem to give exceptional results. In addition, new prophylactic drugs are emerging with several targets: the pituitary adenylate cyclase-activating polypeptide (PACAP), ion channels, several receptors coupled to G proteins, orexin, and glutamate. All these therapies will implement and improve migraine management, as well as personalized medicine for each patient.
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Affiliation(s)
- Enrico Bentivegna
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | | | - Valeria Ferrari
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Silvia Galastri
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Francesco Baldari
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Francesco Scarso
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Piera A Lamberti
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy.,Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy
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Polavieja P, Belger M, Venkata SK, Wilhelm S, Johansson E. Relative efficacy of lasmiditan versus rimegepant and ubrogepant as acute treatments for migraine: network meta-analysis findings. J Headache Pain 2022; 23:76. [PMID: 35790906 PMCID: PMC9258126 DOI: 10.1186/s10194-022-01440-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 06/04/2022] [Indexed: 11/18/2022] Open
Abstract
Background In the absence of head-to-head trials, comprehensive evidence comparing onset of efficacy of novel agents for acute treatment of migraine is lacking. This study aimed to explore the relative efficacy of lasmiditan (serotonin [5-hydroxytryptamine] 1F receptor agonist) versus rimegepant and ubrogepant (calcitonin gene-related peptide antagonists) for the acute oral treatment of migraine through network meta-analysis (NMA). Methods Data included in the NMA were identified through a systematic literature search (conducted April 2018, updated May/December 2020) of phase II–IV, randomised controlled trials (RCTs) in adults with chronic/episodic migraine with/without aura. Treatments included: lasmiditan 50, 100, 200 mg; rimegepant 75 mg; ubrogepant 25, 50, 100 mg. Pairwise treatment comparisons from Bayesian fixed-effect/random-effects NMA, adjusted by baseline risk where appropriate, were conducted. Comparisons were reported as odds ratios with 95% credible intervals. Early-onset efficacy endpoints included: pain freedom at 2 hours and pain relief at 1 and 2 hours. Adverse drug reaction (ADR) profiles were summarised. Heterogeneity and inconsistency in the network were explored; sensitivity analyses investigated robustness of findings. Results Across 12 RCTs included in the base case, females represented >80% of included patients (mean age 37.9–45.7 years). Odds of achieving both pain freedom and pain relief at 2 hours were higher with lasmiditan 100 and 200 mg versus rimegepant 75 mg and ubrogepant 25 and 50 mg. Results for pain relief at 1 hour were consistent with those at 2 hours, but fewer comparisons were available. There were no statistically significant differences between lasmiditan 50 mg and ubrogepant or rimegepant for any outcome. Sensitivity analyses were in the same direction as base case analyses. Most commonly reported ADRs (incidence ≥2%) were: dizziness, fatigue, paraesthesia, sedation, nausea/vomiting and muscle weakness with lasmiditan; nausea with rimegepant; and nausea, somnolence and dry mouth with ubrogepant. Conclusions The efficacy findings of this indirect comparison indicate that lasmiditan 100 mg or 200 mg might be an appropriate acute treatment option for patients with migraine seeking a fast onset of action. Differently from rimegepant and ubrogepant, lasmiditan use is associated with mainly neurological events, which are mostly mild or moderate in severity and self-limiting. 350/350 words Supplementary Information The online version contains supplementary material available at 10.1186/s10194-022-01440-w.
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Affiliation(s)
- Pepa Polavieja
- Eli Lilly and Company, Indianapolis, Indiana, USA. .,, Avenida de la Industria 30, 28108, Alcobendas, Madrid, Spain.
| | - Mark Belger
- Eli Lilly and Company, Indianapolis, Indiana, USA
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Lee S, Staatz CE, Han N, Baek IH. Safety evaluation of oral calcitonin-gene-related peptide receptor antagonists in patients with acute migraine: a systematic review and meta-analysis. Eur J Clin Pharmacol 2022. [PMID: 35729340 DOI: 10.1007/s00228-022-03347-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/29/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Calcitonin gene-related peptide (CGRP) receptor antagonists have been suggested as novel treatments for acute migraine. This study aimed to use meta-analysis to compare the safety and tolerability of five existing oral CGRP receptor antagonists (BI44370TA, MK-3207, rimegepant, telcagepant, and ubrogepant) with that of a placebo or triptans against acute migraine. METHODS Five prominent databases were searched to identify randomized controlled trials on this topic. The primary safety outcomes of interest were any adverse events (AEs) and treatment-related adverse events (TRAEs), and secondary outcomes were individual events, namely diarrhea, dizziness, dry mouth, fatigue, nausea, paresthesia, somnolence, upper abdominal pain, and vomiting. RESULTS Fifteen studies met the eligibility criteria and were examined in detail. Although, compared to placebo, oral CGRP receptor antagonists significantly increased the incidence of any AEs (risk ratio [RR] = 1.15; 95% confidence interval [CI] = 1.07-1.23), there was no difference in the incidence of TRAEs (RR = 1.18; 95% CI = 1.00-1.38). Moreover, CGRP receptor antagonists were safer than triptans with respect to primary safety outcomes, such as any AEs (RR = 0.78; 95% CI = 0.63-0.98) and TRAEs (RR = 0.68; 95% CI = 0.58-0.79). CONCLUSION Despite oral CGRP receptor antagonists posing a significantly higher risk of AEs when compared to placebo, CGRP receptor antagonists have a favorable safety profile compared to triptans. Our findings inform strategies to enhance safety and tolerability in the treatment of acute migraine.
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Tondt J, Bays HE. Concomitant medications, functional foods, and supplements: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2022. Obes Pillars 2022; 2:100017. [PMID: 37990714 PMCID: PMC10661915 DOI: 10.1016/j.obpill.2022.100017] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 04/03/2022] [Indexed: 11/23/2023]
Abstract
Background This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) is intended to provide clinicians an overview of the body weight effects of concomitant medications (i.e., pharmacotherapies not specifically for the treatment of obesity) and functional foods, as well as adverse side effects of supplements sometimes used by patients with pre-obesity/obesity. Methods The scientific information for this CPS is based upon published scientific citations, clinical perspectives of OMA authors, and peer review by the Obesity Medicine Association leadership. Results This CPS outlines clinically relevant aspects of concomitant medications, functional foods, and many of the more common supplements as they relate to pre-obesity and obesity. Topics include a discussion of medications that may be associated with weight gain or loss, functional foods as they relate to obesity, and side effects of supplements (i.e., with a focus on supplements taken for weight loss). Special attention is given to the warnings and lack of regulation surrounding weight loss supplements. Conclusions This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) on concomitant medications, functional foods, and supplements is one of a series of OMA CPSs designed to assist clinicians in the care of patients with the disease of pre-obesity/obesity. Implementation of appropriate practices in these areas may improve the health of patients, especially those with adverse fat mass and adiposopathic metabolic consequences.
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Affiliation(s)
- Justin Tondt
- Department of Family and Community Medicine, Eastern Virginia Medical School, P.O. Box 1980, Norfolk, VA, 23501, USA
| | - Harold Edward Bays
- Louisville Metabolic and Atherosclerosis Research Center, 3288 Illinois Avenue, University of Louisville School of Medicine, Louisville, KY, 40213, USA
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Serra López-Matencio JM, Gago-Veiga AB, Gómez M, Alañón-Plaza E, Mejía GP, González-Gay MÁ, Castañeda S. Treatment of migraine with monoclonal antibodies. Expert Opin Biol Ther 2022; 22:707-716. [PMID: 35502612 DOI: 10.1080/14712598.2022.2072207] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION : In the few last years, a new family of drugs, anti-calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAbs), has been developed for migraine therapy. Anti-CGRP mAbs are highly effective, but the current limited experience with their use and their high-cost warrant establishing certain rules of use. AREAS COVERED The present review provides an overview of the management of migraine patients, especially those who are undergoing treatment with anti-CGRP mAbs. EXPERT OPINION Thanks to new research focused on the pathophysiology of migraine, and the discovery that CGRP plays a key role in its etiopathogenesis, new drugs targeting CGRP have been developed. These drugs have led to a paradigm shift, anticipating new and stimulating possibilities in migraine treatment. While physicians and patients are full of expectation about the advantages of this new family of drugs, there are still obstacles to overcome in order to make the best use of them. It is essential to form multidisciplinary teams that can identify patients who will benefit from these therapies, conducting cost-effective treatments. The follow-up of these therapies in the coming years is paramount due to the lack of experience in the management of these drugs and the peculiarity of disease evolution in migraine patients.
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Affiliation(s)
| | | | - Manuel Gómez
- Methodology Unit. Health Research Institute Princesa (IIS-IP), Madrid, Spain
| | | | - Gina Paola Mejía
- Pharmacology Department, Hospital Universitario de La Princesa, Madrid, Spain
| | - Miguel Ángel González-Gay
- Rheumatology Division, Hospital Universitario Marqués de Valdecilla, University of Cantabria, Av. de Valdecilla, 25; 39008 Santander, Santander, Spain
| | - Santos Castañeda
- Rheumatology Division, Hospital Universitario de La Princesa, c/ Diego de León 62, IIS-IP, Madrid, Spain.,Catedra UAM-Roche, EPID-Future, Medicine Department, Universidad Autónoma de Madrid (UAM), Madrid, Spain
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Cohen F, Yuan H, Silberstein SD. Calcitonin Gene-Related Peptide (CGRP)-Targeted Monoclonal Antibodies and Antagonists in Migraine: Current Evidence and Rationale. BioDrugs 2022; 36:341-358. [PMID: 35476215 PMCID: PMC9043885 DOI: 10.1007/s40259-022-00530-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2022] [Indexed: 12/25/2022]
Abstract
Calcitonin gene-related peptide (CGRP), a 37 amino-acid neuropeptide found mostly in peptidergic sensory C-fibers, has been suggested to be implicated in the pathogenesis of migraine, which is one of the most common neurological disorders seen in medical practice, affecting almost 16% of the US population. While previously thought to be a vascular condition, migraine attacks are the result of neurogenic inflammation and peripheral/central sensitization through dysfunctional activation of the trigeminovascular system. To date, two classes of therapeutic agents have been developed to interrupt the function of CGRP: CGRP-targeted monoclonal antibodies (mAbs) and small-molecule antagonists (gepants). There are currently four CGRP-targeted mAbs and three gepants that are US Food and Drug Administration (FDA) approved for the treatment of migraine. Multiple phase II and III studies have established the efficacies and tolerability of these treatments. Previously, we reviewed the fundamental role of CGRP in migraine pathogenesis. Here, we discuss in depth the clinical evidence (randomized controlled trials and real-world studies), safety, and tolerability of CGRP-targeted mAbs and gepants for treating migraine.
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Affiliation(s)
- Fred Cohen
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, 900 Walnut Street, Suite 200, Philadelphia, PA, 19107, USA
| | - Hsiangkuo Yuan
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, 900 Walnut Street, Suite 200, Philadelphia, PA, 19107, USA
| | - Stephen D Silberstein
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, 900 Walnut Street, Suite 200, Philadelphia, PA, 19107, USA.
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Sun K, Zhu J, Yan C, Li F, Kong F, Sun J, Sun X, Shi J, Wang Y. CGRP Regulates Nucleus Pulposus Cell Apoptosis and Inflammation via the MAPK/NF- κB Signaling Pathways during Intervertebral Disc Degeneration. Oxid Med Cell Longev 2021; 2021:2958584. [PMID: 34987701 DOI: 10.1155/2021/2958584] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 12/03/2021] [Indexed: 12/22/2022]
Abstract
Chronic low back pain (CLBP) has been proved to be the dominating cause of disability in patients with lumbar degenerative diseases. Of the various etiological factors, intervertebral disc degeneration (IVDD) has been the dominating cause. In the past few decades, the role and changes of nerve systems, especially the peripheral sensory fibers and their neurotransmitters, in the induction and progression of IVDD have attracted growing concerns. The expression of many neuropeptides, such as SP, NPY, and CGRP, in the nociceptive pathways is increased during the progression of IVDD and responsible for the discogenic pain. Here, the role of CGRP in the progression of IVDD was firstly investigated both in vitro and in vivo. Firstly, we confirmed that human degenerated intervertebral disc tissue exhibited elevated expression of CGRP and its receptor. Secondly, in vitro experiments suggested that CGRP could inhibit the proliferation and induce apoptosis in human nucleus pulposus (NP) cells, as well as promote inflammation and degenerated phenotypes through activating NF-κB and MAPK signaling pathways. Thirdly, CGRP receptor antagonist, Rimegepant, can ameliorate the adverse effects of CGRP imposed on NP cells, which were confirmed in vitro and in vivo. Our results will bring about a brand-new insight into the roles of neuromodulation in IVDD and related therapeutic attempts.
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