Redefining migraine prevention: early treatment with anti-CGRP monoclonal antibodies enhances response in the real world

BACKGROUND

Anti-CGRP monoclonal antibodies (anti-CGRP MAbs) are approved and available treatments for migraine prevention. Patients do not respond alike and many countries have reimbursement policies, which hinder treatments to those who might respond. This study aimed to investigate clinical factors associated with good and excellent response to anti-CGRP MAbs at 6 months.

METHODS

European multicentre, prospective, real-world study, including high-frequency episodic or chronic migraine (CM) patients treated since March 2018 with anti-CGRP MAbs. We defined good and excellent responses as ≥50% and ≥75% reduction in monthly headache days (MHD) at 6 months, respectively. Generalised mixed-effect regression models (GLMMs) were used to identify variables independently associated with treatment response.

RESULTS

Of the 5818 included patients, 82.3% were females and the median age was 48.0 (40.0-55.0) years. At baseline, the median of MHD was 20.0 (14.0-28.0) days/months and 72.2% had a diagnosis of CM. At 6 months (n=4963), 56.5% (2804/4963) were good responders and 26.7% (1324/4963) were excellent responders. In the GLMM model, older age (1.08 (95% CI 1.02 to 1.15), p=0.016), the presence of unilateral pain (1.39 (95% CI 1.21 to 1.60), p<0.001), the absence of depression (0.840 (95% CI 0.731 to 0.966), p=0.014), less monthly migraine days (0.923 (95% CI 0.862 to 0.989), p=0.023) and lower Migraine Disability Assessment at baseline (0.874 (95% CI 0.819 to 0.932), p<0.001) were predictors of good response (AUC of 0.648 (95% CI 0.616 to 0.680)). These variables were also significant predictors of excellent response (AUC of 0.691 (95% CI 0.651 to 0.731)). Sex was not significant in the GLMM models.

CONCLUSIONS

This is the largest real-world study of migraine patients treated with anti-CGRP MAbs. It provides evidence that higher migraine frequency and greater disability at baseline reduce the likelihood of responding to anti-CGRP MAbs, informing physicians and policy-makers on the need for an earlier treatment in order to offer the best chance of treatment success.

Somatosensory Profiling of Patients With Cluster Headache: A Systematic Review and Meta-analysis

The objectives were 1) to synthesize quantitative sensory testing results in cluster headache (CH) patients and to identify somatosensory differences from healthy subjects (HS), and 2) between symptomatic and asymptomatic sides in CH patients. Two independent reviewers conducted a literature search in MEDLINE, EMBASE, Web of Science, and CINAHL databases. Studies with observational designs were included. Methodological quality and risk of bias were assessed with the Newcastle Ottawa Scale. The selected studies underwent qualitative and quantitative analyses. The qualitative analysis showed inconsistent findings among multiple studies. Meta-analysis showed lower pressure pain thresholds (PPTs) on the symptomatic side of CH patients than HS in V2 (standardized mean difference [SMD] -1.01 [95% confidence interval (CI) -1.79, -.23], P = .01, I2 = 73%, n = 114), V3 (SMD -1 [95% CI -1.54, .45], P < .01, I2 = 82%, n = 354), and cervical region (SMD -1.25 [95% CI -2.07, -.44], P < .01, I2 = 84%, n = 194). Furthermore, lower PPTs than those detected in HS were found on the asymptomatic side in V3 (SMD -.77 [95% CI -1.27, -.27], P < .01, I2 = 79%, n = 354) and in the cervical region (SMD -1.13 [95% CI -1.97, -.3], P < .01, I2 = 85%, n = 194). However, no differences were found in V1 or the extratrigeminal points between these groups. No significant changes were found between symptomatic and asymptomatic sides in trigeminal and extratrigeminal regions. Mechanical hyperalgesia in the trigemino-cervical region of patients with CH could suggest the presence of central pain mechanisms. These results are of clinical relevance because their presence could be associated with a poorer prognosis, chronification, and treatment response. PERSPECTIVES: This study provides consistent findings on the somatosensory profile characterizing patients with CH. Clinicians should assess PPTs and other quantitative sensory testing variables in the trigeminal and extratrigeminal (cervical) regions.

Evaluation of the burden of migraine on the partner's lifestyle

BACKGROUND

Despite the number of research studies regarding the individual burden of migraine, few studies have examined its impact on the patients' partners. We aim to assess migraine effects on the patients' partners on sentimental relationship, children relationship, friendship, and work, as well as the caregiver burden, anxiety and/or depression.

METHODS

A cross-sectional observational study was conducted through online questionnaire from patients' partners with migraine followed-up in five Headache Units. Questions about the four areas of interest and two scales (Hospital Anxiety and Depression Scale and Zarit's scale) were included. Scores were compared against the population prevalence.

RESULTS

One hundred fifty-five answers were analyzed. Among the patient's partners 135/155 (87.1%) were men, with a mean age of 45.6 ± 10.1 years. Migraine's main effects on partners were observed on the sentimental relationship and items concerning children and friendships, with a minor impact at work. Partners showed a moderate burden (12/155 = 7.7% [4.1%-13.1%]), and a higher moderate-severe anxiety rate (23/155 = 14.8% [9.6%-21.4%]), and similar depression rate (5/155 = 3.2% [1.1%-7.3%]) compared to the National Health Survey.

CONCLUSIONS

The burden of migraine impacts the partners' personal relationship, children care, friendship and work. Moreover, certain migraine partners showed a moderate burden according to Zarit's scale and higher anxiety levels than the Spanish population.

Preventive treatment of refractory chronic cluster headache: systematic review and meta-analysis

BACKGROUND

Preventive treatment for refractory chronic cluster headache (rCCH) is challenging and many therapies have been tried.

OBJECTIVE

To study what could be considered the therapy of choice in rCCH through a systematic review and meta-analysis.

METHODS

This review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The protocol was registered in PROSPERO (ID CRD42021290983). A systematic search was performed in MEDLINE, Embase, Cochrane, clinicaltrials.gov, and the WHO's-International-Clinical-Trials-Registry-Platform. Studies on the preventive treatment for rCCH as defined by the European Headache Federation consensus statement were included. A meta-analysis of the pooled response rate was conducted for the different therapies.

RESULTS

Of 336 results, 45 were eligible for inclusion. Most articles studied the effect of neuromodulation as a preventive treatment for rCCH. The most studied neuromodulation technique was occipital nerve stimulation (ONS), with a pooled response rate in the meta-analysis of 57.3% (95% CI 0.481-0.665). Deep brain stimulation (DBS) was the second most studied treatment with a pooled response rate of 77.0% (95% CI 0.594-0.957). DBS results were more heterogeneous than ONS, which could be related to the different stimulation targets in DBS studies, and reported more serious adverse events than in ONS studies. The remaining therapies (anti-CGRP pathway drugs, warfarin, ketamine-magnesium infusions, serial occipital nerve blocks, clomiphene, onabotulinum toxin A, ketogenic diet, sphenopalatine ganglion radiofrequency or stimulation, vagus nerve stimulation, percutaneous bioelectric current stimulation, upper cervical cord stimulation, and vidian neurectomy) present weaker results or have less quality of evidence.

CONCLUSIONS

The results of this systematic review and meta-analysis suggest that ONS could be the first therapeutic strategy for patients with rCCH based on the current evidence.

Migraine with Brainstem Aura Associated with SCN2A Mutation: A Case Report

Background Migraine with brainstem aura (MBA) is a rare subtype of migraine with aura that associates headache with paroxysmal episodes of ataxia, dysarthria, and diplopia among other symptoms attributed to brainstem involvement. The manifestation of this disease in the absence of typical aura symptoms (i.e., fully reversible visual, sensory and/or speech/language symptoms) is even more infrequent.

Case Report In this article, we reported a case of a 16-year-old male patient with MBA associated with a sodium voltage-gated channel alpha subunit 2 (SCN2A) de novo mutation. The patient did not have typical aura symptoms. Ataxia was the most prominent clinical feature, leading to initial diagnosis of episodic ataxia. Patient responded partially to treatment with onabotulinum toxin A.

Conclusion MBA needs to be taken into consideration in the differential diagnosis of recurrent ataxia, even in the absence of typical aura symptoms. Finding a de novo SCN2A mutation in our patient helps in further understanding of MBA genetics.

Post-COVID-19 persistent headache: A multicentric 9-months follow-up study of 905 patients

BACKGROUND

Headache is a frequent symptoms of coronavirus disease 2019 (COVID-19). Its long-term evolution remains unknown. We aim to evaluate the long-term duration of headache in patients that presented headache during the acute phase of COVID-19.

METHODS

This is a post-hoc multicenter ambisective study including patients from six different third-level hospitals between 1 March and 27 April 2020. Patients completed 9 months of neurological follow-up.

RESULTS

We included 905 patients. Their median age was 51 (IQR 45-65), 66.5% were female, and 52.7% had a prior history of primary headache. The median duration of headache was 14 (6-39) days; however, the headache persisted after 3 months in 19.0% (95% CI: 16.5-21.8%) and after 9 months in 16.0% (95% confidence interval: 13.7-18.7%). Headache intensity during the acute phase was associated with a more prolonged duration of headache (Hazard ratio 0.655; 95% confidence interval: 0.582-0.737).

CONCLUSION

The median duration of headache was 2 weeks, but in approximately a fifth of patients it became persistent and followed a chronic daily pattern.

Psychophysical testing in chronic migraine and chronic tension type headache: An observational study

BACKGROUND

Clinical presentation is the key to the diagnosis of patients with migraine and tension-type headache, but features may overlap when both become chronic. Psychophysical parameters may distinguish both conditions. We aimed to compare psychophysical aspects of patients with chronic migraine, chronic tension-type headache and headache-free controls, and to determine whether these can predict headache frequency.

METHODS

An examiner blinded to the diagnosis assessed 100 participants (chronic migraine (n = 38), chronic tension-type headache (n = 31) and controls (n = 31)). Assessed variables included painful area, pressure pain thresholds, temporal summation, cervical range of motion, neck posture, headache and neck impact, quality of life, and kinesiophobia. Comparison between groups was performed with one-way ANOVA and multiple linear regression was used to assess the headache frequency predictors.

RESULTS

We found differences of both headache groups compared to controls (p < 0.01), but not between headache groups. Neck disability was a significant predictor of headache frequency for chronic tension-type headache (adjusted R² = 0.14; β = 0.43; p = 0.03) and chronic migraine (adjusted R² = 0.18; β = 0.51; p < 0.01).

CONCLUSIONS

Chronic tension-type headache and chronic migraine showed similar psychophysical results, but were significantly worse when compared to controls. The psychophysical examination did not discriminate between headache types. The variable best explaining headache frequency for both headache types was neck disability.

Inter, intra-examiner reliability and validity of inertial sensors to measure the active cervical range of motion in patients with primary headache

We analyzed the inter- and intra-examiner reliability of Werium inertial sensors and the cervical range of motion (CROM) instrument for the measurement of active CROM (AcROM) in patients with primary headache. Another objective is to analyze the validity of the inertial sensors (Werium). The literature has reported symptomatology features in patients diagnosed with primary headache similar to that of patients with cervicogenic headache. The International Classification of Headache (ICHD-III) established the presence of reduced AcROM as a diagnostic criterion for cervicogenic headache. Several instruments are used for this measurement, with limitations in their applicability in daily clinical practice. A prospective longitudinal repeated measures study was conducted to assess the intra- and inter-rater reliability and validity of Werium inertial sensors in 20 adults with chronic primary headache. For the inter-rater analysis, the intraclass correlation coefficient (ICC) values were above 0.75 for all movements, indicating a good level of reliability. For the intra-rater results, the ICC values obtained by the Werium inertial sensors for all cervical movements were good for rater A (ICC >0.80) and rater B (ICC >0.84). For the validity, the ICCs obtained by the Werium inertial sensors compared with the CROM instrument for all cervical movements were moderate for both raters (ICC > 0.70, respectively). Values obtained in the standard error of measurement, minimum detectable change at 90% and limits of agreement also indicated good agreement. Werium inertial sensors have shown good to excellent reliability results, both intra- and inter-examiner (ICC > 0.75). Likewise, when the sensors were compared with another validated instrument (CROM device) they obtained high reliability results (ICC > 0.70). These results plus its relatively low price and ease of use allow us to recommend it in daily clinical practice to measure AcROM in patients with chronic primary headache.

Occipital Nerve Stimulation for Pain Modulation in Drug-Resistant Chronic Cluster Headache

Occipital nerve stimulation (ONS) is a surgical treatment proposed for drug-resistant chronic cluster headache (drCCH). Long-term series assessing its efficacy are scarce. We designed a retrospective observational study with consecutive sampling, evaluating the follow-up of 17 drCCH patients who underwent ONS. Our main endpoint was the reduction the rate of attacks per week. We also evaluated the pain intensity through the Visual Analogue Scale (VAS), patient overall perceived improvement and decrease in oral medication intake. After a median follow-up of 6.0 years (4.5–9.0), patients decreased from a median of 30 weekly attacks to 22.5 (5.6–37.5, p = 0.012), 7.5 at 1 year (p = 0.006) and 15.0 at the end of follow-up (p = 0.041). The VAS decreased from a median of 10.0 to 8.0 (p = 0.011) at three months, to 7.0 (p = 0.008) at twelve months and 7.0 (p = 0.003) at the end of the follow-up. A total of 23.5% had an overall perceived improvement of ≥70% at 3 months, 41.2% at 1 year and 27.8% at the end of follow-up. Reducing prophylactic oral medication was possible in 76.5% and it was stopped in 17.7%. Triptan use decreased in all the responder patients and 17.7% stopped its intake. A total of 41.2% presented mild adverse events. In conclusion, our long-term experience suggests that ONS could be an interesting option for drCCH-selected patients, as it is a beneficial and minimally invasive procedure with no serious adverse events.

Cluster headache, beyond the pain: a comparative cross-sectional study

OBJECTIVE

To compare the presence of allodynia, pain catastrophizing, and the impact of headaches on patients with cluster headache (CH) and healthy individuals. Our second aim was to analyze the relationship between catastrophism, psychological comorbidities, and the impact in CH.

METHODS

We designed this cross-sectional study to compare various factors among 47 patients diagnosed with CH and 40 healthy controls, and then focus on catastrophism, anxiety, depression, and impact in the CH group.

RESULTS

There were statistically significant differences between CH and the asymptomatic group in Allodynia Symptom Checklist (ASC) (p < 0.001), Pain Catastrophizing Scale (p < 0.001), and HIT-6 (p < 0.001) scores. We found a correlation among ASC, PCS, anxiety-depression, EuroQoL, and HIT-6 for the CH group. In this group, we observed a strong positive correlation between PCS and anxiety (rho = 0.69; p < 0.001), PCS and depression (rho = 0.62; p < 0.001) and depression and EuroQoL (rho = - 0.68; p < 0.001). The regression model showed that the combination of anxiety and HIT-6 was a significant predictor of PCS (adjusted R² = 0.52).

DISCUSSION

Our findings reveal significant differences regarding allodynia, pain catastrophism, and impact in CH group compared with controls. We found a significant relationship between psychological comorbidity, pain catastrophism, and quality of life in CH patients. Anxiety and HIT-6 were a predictor (adjusted R² = 52%) of pain catastrophism. Screening for these comorbidities should be implemented through a multidisciplinary approach.

Hyperalgesia and Central Sensitization Signs in Patients with Cluster Headache: A Cross-Sectional Study

OBJECTIVE

To investigate central sensitization (CS) in cluster headache (CH) and to evaluate its relationship with disease characteristics and psychological comorbidities.

DESIGN

Cross-sectional study.

SETTINGS

Whether CS occurs in CH, as it does in other primary headaches, is a subject of debate. Few studies have evaluated the presence of CS and its relationship with psychological comorbidities in patients with CH.

SUBJECTS

Twenty patients with episodic or chronic CH and 16 healthy controls were recruited.

METHODS

The variables evaluated included frequency, intensity and duration of headache attacks, pressure pain thresholds (PPTs) and wind-up (WU) ratios of pain bilaterally measured over trigeminal and extratrigeminal areas, and results of questionnaires regarding anxiety and depression (Hospital Anxiety and Depression Scale [HADS], Beck Depression Inventory [BDI], State-Trait Anxiety Inventory [STAI]), quality of life (Short Form-36 [SF-36]), headache impact (Headache Impact Test [HIT-6]), and allodynia (Allodynia Symptom Checklist [ASC]).

RESULTS

PPT levels were significantly lower in the CH group compared with the healthy participants (all tested points, P < 0.001). No differences were found in WU ratios between groups. However, differences in HADS (P < 0.01), BDI (P < 0.01), STAI (P < 0.01), SF-36 (P < 0.01), HIT-6 (P < 0.001), and ASC (P < 0.01) were observed between groups. The healthy group showed a moderate negative correlation between SF-36 and BDI (rho = -0.59, P = 0.03). Likewise, the CH group showed a moderate negative correlation between frequency and BDI (rho = -0.52, P = 0.03), a strong positive correlation between duration and HADS (rho = 0.86, P < 0.01), and a moderate negative correlation between intensity and PPT over symptomatic V1 (rho = -0.66, P < 0.01) and over asymptomatic V1 (rho = -0.65, P < 0.01). The CH group also showed a moderate negative correlation between SF-36 and anxiety and depression variables.

CONCLUSIONS

Our findings show that patients with CH have lower PPT levels at cranial and extracranial points, suggesting, as in other primary headaches, the presence of CS. We have also found a high prevalence of psychiatric comorbidities that correlate with the length and frequency of attacks. These findings highlight the importance of a multidisciplinary approach to the treatment of patients with CH.