Diagnosis and treatment of disorders of intracranial pressure: consensus statement of the Spanish Society of Neurology's Headache Study Group

Primary intracranial pressure disorders include idiopathic intracranial hypertension and spontaneous intracranial hypotension. Remarkable advances have been made in the diagnosis and treatment of these 2entities in recent years. Therefore, the Spanish Society of Neurology's Headache Study Group (GECSEN) deemed it necessary to prepare this consensus statement, including diagnostic and therapeutic algorithms to facilitate and improve the management of these disorders in clinical practice. This document was created by a committee of experts belonging to GECSEN, and is based on a systematic review of the literature, incorporating the experience of the participants, and establishes practical recommendations with levels of evidence and grades of recommendation.

[New therapeutic era for migraine attacks with recently approved monoclonal antibodies, ditans and gepants]

Treatment of migraine attacks is advised in all patients, using non-steroidal anti-inflammatory drugs when the pain is mild and triptans when the pain intensity is moderate-severe. However, the effectiveness of these drugs is moderate, a high percentage of patients have side effects, and triptans are contraindicated in people with a history of stroke, ischaemic heart disease or poorly controlled hypertension. Hence, there is an urgent need for new therapeutic alternatives. In recent years, new drugs for migraine attacks have become available, most notably ditans (lasmiditan) and gepants (ubrogepant and rimegepant). Furthermore, eptinezumab, which has been approved for the preventive treatment of migraine in adults, has also been used for migraine attacks. This manuscript reviews the efficacy and safety results of the new drugs for migraines that will soon be on the market.

Characterisation of the management of patients with migraine in the primary care setting in Spain. Analysis of the results of the European My-LIFE anamnesis project

INTRODUCTION

Migraine affects more than 4.5 million people in Spain, resulting in a considerable socioeconomic impact. Although national and international guidelines have been published, the management of patients with migraine, especially those with chronic migraine, is inadequate.

SUBJECTS AND METHODS

We conducted a survey among 40 primary care (PC) physicians in Spain as part of a European project involving 201 physicians from 5 countries.

RESULTS

Most participants issued diagnoses of episodic migraine and chronic migraine (93% vs 65%); 82.5% indicated that they did not refer these patients to specialists, and 100% of PC physicians stated that they were responsible for patient follow-up. The main tools used in PC for diagnosis and follow-up were clinical interviews, medical histories, and the patient diaries. Our data revealed that the treatments prescribed were not in accordance with the national and international guidelines. Participants who did not refer patients estimated that only 48% of patients received preventive treatment, and that the assessment of efficacy was based on patient perception. Seventy percent of respondents indicated a need for migraine training. Finally, 100% of participants considered that a guide for medical history taking and referral would be essential or useful for the management of migraine in PC.

CONCLUSIONS

The survey results revealed a need for training and guidance in PC to improve the diagnosis and management of patients with migraine, particularly chronic migraine.

Calcitonin gene-related peptide in migraine: from pathophysiology to treatment

INTRODUCTION

It has been observed in recent years that levels of such molecules as calcitonin gene-related peptide (CGRP) and, to a lesser extent, the pituitary adenylate cyclase-activating peptide are elevated during migraine attacks and in chronic migraine, both in the cerebrospinal fluid and in the serum. Pharmacological reduction of these proteins is clinically significant, with an improvement in patients' migraines. It therefore seems logical that one of the main lines of migraine research should be based on the role of CGRP in the pathophysiology of this entity.

DEVELOPMENT

The Spanish Society of Neurology's Headache Study Group decided to draft this document in order to address the evidence on such important issues as the role of CGRP in the pathophysiology of migraine and the mechanism of action of monoclonal antibodies and gepants; and to critically analyse the results of different studies and the profile of patients eligible for treatment with monoclonal antibodies, and the impact in terms of pharmacoeconomics.

CONCLUSIONS

The clinical development of gepants, which are CGRP antagonists, for the acute treatment of migraine attacks, and CGRP ligand and receptor monoclonal antibodies offer promising results for these patients.

Calcitonin gene-related peptide in migraine: from pathophysiology to treatment

INTRODUCTION

It has been observed in recent years that levels of such molecules as calcitonin gene-related peptide (CGRP) and, to a lesser extent, the pituitary adenylate cyclase-activating peptide are elevated during migraine attacks and in chronic migraine, both in the cerebrospinal fluid and in the serum. Pharmacological reduction of these proteins is clinically significant, with an improvement in patients' migraines. It therefore seems logical that one of the main lines of migraine research should be based on the role of CGRP in the pathophysiology of this entity.

DEVELOPMENT

The Spanish Society of Neurology's Headache Study Group decided to draft this document in order to address the evidence on such important issues as the role of CGRP in the pathophysiology of migraine and the mechanism of action of monoclonal antibodies and gepants; and to critically analyse the results of different studies and the profile of patients eligible for treatment with monoclonal antibodies, and the impact in terms of pharmacoeconomics.

CONCLUSIONS

The clinical development of gepants, which are CGRP antagonists, for the acute treatment of migraine attacks, and CGRP ligand and receptor monoclonal antibodies offer promising results for these patients.

1st Post-European Headache Federation Meeting: a review of the latest developments presented at the 2020 European Headache Federation Congress

INTRODUCTION

After the European Headache Federation (EHF) Congress, renowned Spanish neurologists specialised in migraine presented the most significant latest developments in research in this field at the Post-EHF Meeting.

DEVELOPMENT

The main data presented concerning the treatment of chronic and episodic migraine were addressed, with attention paid more specifically to those related to preventive treatments and real-life experience in the management of the disease. An important review was carried out of the new therapeutic targets and the possibilities they offer in terms of understanding the pathophysiology of migraine and its treatment. An update was also presented of the latest developments in the treatment of migraine with fremanezumab, a monoclonal antibody recently authorised by the European Medicines Agency. Participants were also given an update on the latest developments in basic research on the pathology, as well as an overview of the symptoms of migraine and COVID-19. Finally, the repercussions of migraine in terms of its burden on the care and economic resources of the health system were addressed, along with its impact on society.

CONCLUSIONS

The meeting summarised the content presented at the 14th EHF Congress, which took place in late June/early July 2020.

The impact of allodynia on the efficacy of almotriptan when given early in migraine: data from the "Act when mild" study

The objective of this study was to evaluate the impact of allodynia on treatment outcomes in the patients with acute migraine treated in the "Act when Mild" (AwM) study. AwM, a randomized placebo-controlled trial, studied almotriptan 12.5 mg in the early treatment (within 1 hr) of acute migraine when the pain was still mild, and investigated clinical outcomes in the presence or absence of allodynia, which was prospectively recorded using patient questionnaires. Of the total population, 39% (n = 404) reported allodynia that did not alter the efficacy of almotriptan administered for early/mild pain in terms of 2-hr pain-free rates (53.9% for allodynic patients vs. 52.5% for nonallodynic patients). Similarly, sustained pain-free rates were 47.2% versus 45.5%, and migraine duration 1.40 versus 1.54 hr, respectively. However, allodynia impaired the effectiveness of almotriptan in the patients with moderate/severe pain in terms of longer migraine duration, fewer patients achieving pain-free status, and more requiring rescue medication. In conclusion, the lack of effect of allodynia on the efficacy of almotriptan given for early/mild migraine pain might help explain the improved outcomes associated with the early-treatment strategy in AwM. Moreover, the data suggest that pain intensity is the main driver of triptan response, and not the presence or absence of allodynia.

Efficacy of almotriptan in early intervention for treatment of acute migraine in a primary care setting: the START study

AIMS

The benefits of taking almotriptan early for acute migraine when pain is mild have clearly been demonstrated in the neurology setting. The aim of this study was to determine whether similar benefits with early intervention of almotriptan can be achieved in everyday general practice, where most migraineurs are managed.

METHODS

In this European, prospective, observational study, patients were asked to treat up to three migraine attacks over a 2-month period with almotriptan 12.5 mg administered within 1 h of pain onset and when pain was mild (early + mild intervention group).

RESULTS

A total of 501 patients were enrolled in primary care centres across Spain, France and Italy. The intention-to-treat analysis involved 454 patients who reported 1174 migraine attacks, with early intervention being used in 138 of these attacks. A greater proportion of patients who took almotriptan early + mild for their first migraine attack (n = 42) were pain free at 2 h compared with those in the non-early + mild intervention group (n = 410) (62% vs. 35%; p < 0.001). Similar results were obtained for all migraine attacks comparison [65% (n = 138) vs. 38% (n = 1036); p < 0.001]. Other secondary end-points were also significantly in favour of early + mild treatment, including sustained pain free (SPF), SPF with no adverse events (SNAE), and time lost because of migraine (all p < 0.001). Almotriptan was well tolerated with no serious adverse events reported.

CONCLUSIONS

In the primary care setting, early intervention with almotriptan for treatment of migraine provides significant clinical benefits compared with delaying treatment and/or waiting until pain intensity has progressed beyond mild.

[Pharyngeal-cervical-brachial variant of Guillain-Barré syndrome: a well-defined clinical condition with a heterogeneous immunological profile]

INTRODUCTION

The pharyngeal-cervical-brachial variant of Guillain-Barre syndrome (GBS) is rare. This variant has its own specific clinical aspects but a heterogeneous immunological profile.

CASE REPORT

A 38-year-old male who presented progressive symptoms of dysphagia, dysphonia and weakness hindering movement of the upper limbs. Two weeks earlier, the patient had presented acute self-limiting diarrhoea. He displayed predominantly right-side bilateral peripheral facial paresis, and paresis of the 9th and 12th cranial nerves and upper limbs (proximal 0/5, distal 1/5), although strength in the lower limbs was not compromised; sensitivity was preserved and deep tendon reflexes were diminished (0 in the upper limbs and + in the lower extremities). At 24 hours after admission, he suffered severe respiratory distress and had to be moved to the Intensive Care Unit with invasive mechanical ventilation. An electronystagmography/electromyogram study revealed severe demyelinating damage that predominantly involved the brain, but also included a small axonal component. The most striking immunological finding was the presence of positive IgG anti-GQ1b, IgM anti-GMI and IgM anti-asialo GM1 titres.

CONCLUSIONS

The pharyngeal-cervical-brachial variant is a clinical condition with its own clinical characteristics and well-established diagnostic criteria that allow it to be distinguished from the other variants of GBS. Our case highlights the wide clinical spectrum of acute inflammatory demyelinating polyradiculoneuropathies and the important degree of heterogeneity that exists as regards the immunological parameters.

[Symptomatic treatment of migraine with zolmitriptan: experience with 82 patients]

OBJECTIVES

To analyze our experience with the new, 5 mg intranasal formulation of zolmitriptan in the symptomatic treatment of migraine attacks.

PATIENTS AND METHODS

This series includes 82 patients who had treated an average of 7 migraine attacks. Eighty patients had taken oral triptans and 20 subcutaneous sumatriptan. The main reasons for using nasal zolmitriptan were: poor efficacy of oral triptans (41.5 % of the patients), use of subcutaneous sumatriptan (24.4%) or medical criteria (34.5%).

RESULTS

Among the 80 patients who had been treated with oral triptans, 50 (62.5 %) preferred nasal zolmitriptan, 14 (17.5 %) oral triptans and the remaining 16 (20 %) did not express any preference. The main reasons for this preference were shorter speed of action and better efficacy. Within those 20 patients who were using subcutaneous sumatriptan, 8 (40 %) preferred subcutaneous sumatriptan, 5 (25%) nasal zolmitriptan and 7 (35%) did not express any preference. The reasons for preference of intranasal zolmitriptan over subcutaneous sumatriptan were greater convenience, better tolerability and lower price. A total of 55 patients noticed efficacy within 60 min. Half experienced at least one adverse event, always mild. The most frequent were local: bad taste (n=23) or nasal irritation/itching (n=8).

CONCLUSIONS

The new intranasal formulation of 5 mg zolmitriptan is a good option for the symptomatic treatment of migraine, which could be considered as an intermediate between oral triptans and the subcutaneous formulation of sumatriptan.

[Neurocutaneous melanosis]

INTRODUCTION

Neurocutaneous melanosis is an infrequent condition characterized by the presence of numerous gigantic cutaneous naevi and melanocytic infiltration of the central nervous system and/or the leptomeningeal layers. Different clinical features may be seen: endocranial hypertension due to hydrocephalus, cranial nerve paralysis, myelopathy, convulsive seizures, etc. The prognosis is considered to be malignant. Only positive CNS histological findings confirm the diagnosis.

CLINICAL CASE

We present the case of a man with cutaneous lesions compatible with the diagnosis of neurocutaneous melanosis since birth, with benign self-limiting epilepsy in early childhood. Cerebral CT and MR scans were normal until the age of 17, when hipper-signal lesions appeared on MR, infiltrating the leptomeninges of the deep temporal pole and anterior aspect of the cerebral peduncles, which suggested the presence of melanocytes in the CNS.

CONCLUSIONS

There are cases of neurocutaneous melanosis with a good medium-term prognosis and benign manifestations until infiltration of the CNS occurs. Then they start to show the classical behavior of cases with a malignant prognosis. MR should be included as part of the diagnostic criteria for neurocutaneous melanosis. MR should be done periodically in patients with cutaneous lesions suggestive of this condition.

[Epileptic seizures during sleep]

Introduction. Epileptic crises presenting exclusively during sleep are rare and pose more problems of diagnosis than do crises of diurnal presentation.

PATIENTS

We present the clinical and electroencephalographic data of 20 patients with exclusively sleep-induced epileptic crises, evaluating not only the type of crises and the diagnosis of the particular syndrome, but also the response to treatment and prognosis. The patients studied were over 17 years old, had only nocturnal crises and were followed up for a period of three years. An EEG done during sleep and cerebral CT scan were available in all cases and a cranial MR was available in two cases. Diagnosis was made using clinical data and the sleep EEG.

RESULTS

The majority (40%) had temporal lobe epilepsy. In two patients (10%) occipital paroxysms were found. In all cases both the neurological examination and the mental state were normal. The sleep EEG was pathological in 75% of the cases. Only three of the twenty patients had changes on the CT scan. Monotherapeutic antiepileptic treatment completely controlled the crises in 15 patients.

CONCLUSIONS

We wish to emphasize the usefulness and importance of the sleep EEG in defining the syndrome affecting these patients, the diagnostic difficulties in sleep epilepsy, the good response to antiepileptic treatment and the high incidence of recurrence if antiepileptic treatment is no longer given. In view of all these factors we believe that sleep epilepsy may be considered to be a syndrome of epilepsy.