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The Journal of Headache and Pain Aug 2023The monoclonal antibodies (mAbs) blocking the calcitonin-gene related peptide (CGRP) pathway, collectively called here "anti-CGRP/rec mAbs", have dramatically improved... (Review)
Review
The monoclonal antibodies (mAbs) blocking the calcitonin-gene related peptide (CGRP) pathway, collectively called here "anti-CGRP/rec mAbs", have dramatically improved preventive migraine treatment. Although their efficacy and tolerability were proven in a number of randomized controlled trials (RCTs) and, maybe even more convincingly, in real world settings, a number of open questions remain. In this narrative review, we will analyze published data allowing insight in some of the uncertainties related to the use of anti-CGRP/rec mAbs in clinical practice: their differential efficacy in migraine subtypes, outcome predictors, switching between molecules, use in children and adolescents, long-term treatment adherence and persistence, effect persistence after discontinuation, combined treatment with botulinum toxin or gepants, added-value and cost effectiveness, effectiveness in other headache types, and potential contraindications based on known physiological effects of CGRP. While recent studies have already provided hints for some of these questions, many of them will not find reliable and definitive answers before larger studies, registries or dedicated RCTs are available.
Topics: Child; Humans; Adolescent; Calcitonin Gene-Related Peptide; Antibodies, Monoclonal; Calcitonin; Migraine Disorders; Receptors, Calcitonin Gene-Related Peptide
PubMed: 37528353
DOI: 10.1186/s10194-023-01637-7 -
Cells Dec 2022To perform a systematic review of real-world outcomes for anti-CGRP-mAbs. (Review)
Review
OBJECTIVE
To perform a systematic review of real-world outcomes for anti-CGRP-mAbs.
METHODS
Following the PRISMA guidelines, we searched PubMed for real-world data of erenumab, galcanezumab, fremanezumab, or eptinezumab in patients with migraines.
RESULTS
We identified 134 publications (89 retrospective), comprising 10 pharmaco-epidemiologic and 83 clinic-based studies, 38 case reports, and 3 other articles. None of the clinic-based studies provided follow-up data over more than one year in more than 200 patients. Findings suggest that there are reductions in health insurance claims and days with sick-leave as well as better treatment adherence with anti-CGRP-mAbs. Effectiveness, reported in 77 clinic-based studies, was comparable to randomized controlled trials. A treatment pause was associated with an increase in migraine frequency, and switching to another antibody resulted in a better response in some of the patients. Adverse events and safety issues were addressed in 86 papers, including 24 single case reports.
CONCLUSION
Real-world data on anti-CGRP-mAbs are limited by retrospective data collection, small patient numbers, and short follow-up periods. The majority of papers seem to support good effectiveness and tolerability of anti-CGRP-mAbs in the real-world setting. There is an unmet need for large prospective real-world studies providing long-term follow-ups of patients treated with anti-CGRP-mAbs.
Topics: Humans; Calcitonin Gene-Related Peptide; Prospective Studies; Retrospective Studies; Antibodies, Monoclonal; Migraine Disorders
PubMed: 36611935
DOI: 10.3390/cells12010143 -
Journal of Vestibular Research :... 2021This paper describes the diagnostic criteria for "Vestibular Migraine of Childhood", "probable Vestibular Migraine of Childhood" and "Recurrent Vertigo of Childhood" as...
Vestibular Migraine of Childhood and Recurrent Vertigo of Childhood: Diagnostic criteria Consensus document of the Committee for the Classification of Vestibular Disorders of the Bárány Society and the International Headache Society.
This paper describes the diagnostic criteria for "Vestibular Migraine of Childhood", "probable Vestibular Migraine of Childhood" and "Recurrent Vertigo of Childhood" as put forth by the Committee for the Classification of Vestibular Disorders of the Bárány Society (ICVD) and the Migraine Classification subgroup of the International Headache Society. Migraine plays an important role in some subgroups of children with recurrent vertigo. In this classification paper a spectrum of three disorders is described in which the migraine component varies from definite to possibly absent. These three disorders are: Vestibular Migraine of Childhood, probable Vestibular Migraine of Childhood and Recurrent Vertigo of Childhood. The criteria for Vestibular Migraine of Childhood (VMC) include (A) at least five episodes with vestibular symptoms of moderate or severe intensity, lasting between five minutes and 72 hours, (B) a current or past history of migraine with or without aura, and (C) at least half of episodes are associated with at least one migraine feature. Probable Vestibular Migraine of Childhood (probable VMC) is considered when at least three episodes with vestibular symptoms of moderate or severe intensity, lasting between five minutes and 72 hours, are accompanied by at least criterion B or C from the VMC criteria. Recurrent Vertigo of Childhood (RVC) is diagnosed in case of at least three episodes with vestibular symptoms of moderate or severe intensity, lasting between 1 minute and 72 hours, and none of the criteria B and C for VMC are applicable. For all disorders, the age of the individual needs to be below 18 years old. It is recommended that future research should particularly focus on RVC, in order to investigate and identify possible subtypes and its links or its absence thereof with migraine.
Topics: Adolescent; Child; Consensus; Dizziness; Headache; Humans; Migraine Disorders; Vertigo
PubMed: 33386837
DOI: 10.3233/VES-200003 -
The Journal of Clinical Psychiatry Nov 2021Many preclinical and clinical studies have examined the potential benefits of ginger extracts for a range of medical disorders. Ginger has been found to reduce both pain...
Many preclinical and clinical studies have examined the potential benefits of ginger extracts for a range of medical disorders. Ginger has been found to reduce both pain and nausea and has therefore also been studied in the context of migraine headache. One randomized controlled trial (RCT) found that ginger was no better than placebo for the prevention of migraine episodes. One meta-analysis (pooled N = 227) found that, relative to placebo, ginger was associated with a higher proportion of patients who were pain free 2 hours after treatment (risk ratio [RR], 1.79; 95% confidence interval [CI], 1.04-3.09; 2 RCTs). In this meta-analysis, relative to placebo, ginger reduced the risk of migraine-related nausea and vomiting (RR, 0.48; 95% CI, 0.30-0.77; 3 RCTs) and was not associated with an increased risk of adverse events (RR, 0.80; 95% CI, 0.46-1.41; 3 RCTs). No other RCT data are available. Such an evidence base is clearly too small for formal recommendations to be possible. It is suggested that raw ginger or proprietary ginger extracts may be useful as a home remedy for patients who experience an episode of migraine and who, for whatever reason, cannot take established first-line treatments for acute migraine. How ginger thus used compares with established treatments for migraine is presently unknown. Finally, it must be remembered that the chemical constituents of ginger will vary across source and extract; so, when an extract of ginger is studied, the findings of the study can be generalized only to that extract and, possibly, to other extracts with a similar composition.
Topics: Analgesics; Zingiber officinale; Humans; Meta-Analysis as Topic; Migraine Disorders; Phytotherapy; Plant Preparations; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 34851560
DOI: 10.4088/JCP.21f14325 -
Cephalalgia : An International Journal... Apr 2024Many risk factors have been associated with migraine progression, including insufficient and ineffective utilization of migraine medications; however, they have been... (Review)
Review
BACKGROUND
Many risk factors have been associated with migraine progression, including insufficient and ineffective utilization of migraine medications; however, they have been inadequately explored. This has resulted in suboptimal usage of medications without effective altering of prescribing recommendations for patients, posing a risk for migraine chronification.
METHODS
Our aim is to conduct a comprehensive review of the available evidence regarding the underuse of migraine medications, both acute and preventive. The term "underuse" includes, but is not limited to: (1) ineffective use of appropriate and inappropriate medication; (2) underutilization; (3) inappropriate timing of usage; and (4) patient dissatisfaction with medication.
RESULTS
The underuse of both acute and preventive medications has been shown to contribute to the progression of migraine. In terms of acute medication, chronification occurs as a result of insufficient drug use, including failure of the prescriber to select the appropriate type based on pain intensity and disability, patients taking medication too late (more than 60 minutes after the onset or after central sensitization has occurred as evidenced by allodynia), and discontinuation because of lack of effect or intolerable side effects. The underlying cause of inadequate effectiveness of acute medication lies in its inability to halt the propagation of peripheral activation to central sensitization in a timely manner. For oral and injectable preventive migraine medications, insufficient efficacy and intolerable side effects have led to poor adherence and discontinuation with subsequent progression of migraine. The underlying pathophysiology here is rooted in the repetitive stimulation of afferent sensory pain fibers, followed by ascending brainstem pain pathways plus dysfunction of the endogenous descending brainstem pain inhibitory pathway. Although anti-calcitonin gene-related peptide (CGRP) medications partially address pain caused by the above factors, including decreased efficacy and tolerability from conventional therapy, some patients do not respond well to this treatment. Research suggests that initiating preventive anti-CGRP treatment at an early stage (during low frequency episodic migraine attacks) is more beneficial than commencing it during high frequency episodic attacks or when chronic migraine has begun.
CONCLUSIONS
The term "medication underuse" is underrecognized, but it holds significant importance. Optimal usage of acute care and preventive migraine medications could potentially prevent migraine chronification and improve the treatment of migraine attacks.
Topics: Humans; Headache; Migraine Disorders; Pain; Risk Factors; Brain Stem; Calcitonin Gene-Related Peptide
PubMed: 38613233
DOI: 10.1177/03331024241245658 -
Current Opinion in Neurology Jun 2024We performed a narrative review of the recent findings in epidemiology, clinical presentation, mechanisms and treatment of vestibular migraine. (Review)
Review
PURPOSE OF REVIEW
We performed a narrative review of the recent findings in epidemiology, clinical presentation, mechanisms and treatment of vestibular migraine.
RECENT FINDINGS
Vestibular migraine is an underdiagnosed condition that has a high prevalence among general, headache and neuro-otology clinics. Vestibular migraine has a bimodal presentation probably associated with a hormonal component in women. These patients could have a complex clinical phenotype including concomitant autonomic, inflammatory or connective tissue conditions that have a higher prevalence of psychological symptoms, which may mistakenly lead to a diagnosis of a functional neurological disorder. A high proportion of patients with postural perceptual persistent dizziness have a migraine phenotype. Independently of the clinical presentation and past medical history, patients with the vestibular migraine phenotype can respond to regular migraine preventive treatments, including those targeting the calcitonin gene-related peptide pathways.
SUMMARY
Vestibular migraine is an underdiagnosed migraine phenotype that shares the pathophysiological mechanisms of migraine, with growing interest in recent years. A thorough anamnesis is essential to increase sensitivity in patients with unknown cause of dizziness and migraine treatment should be considered (see supplemental video-abstract).
Topics: Humans; Dizziness; Migraine Disorders; Vertigo; Vestibular Diseases
PubMed: 38619053
DOI: 10.1097/WCO.0000000000001257 -
Cephalalgia : An International Journal... Dec 2023Migraine's astonishing prevalence and preserved genetic background contrast with the definition of a disease and the biological meaning of experiencing recurrent, severe... (Review)
Review
INTRODUCTION
Migraine's astonishing prevalence and preserved genetic background contrast with the definition of a disease and the biological meaning of experiencing recurrent, severe headache attacks is still puzzling.
METHODS
To provide a comprehensive explanation of the migraine evolutionary meaning, we review (i) the putative role of the autonomic nervous system in migraine attacks, (ii) the inter-ictal autonomic, functional, and metabolic signature of migraine patients, (iii) the bio-behavioral perspective of pain, and (iv) the allostatic perception of migraine chronification.
RESULTS
Migraineurs have inter-ictal cortical hyperexcitability and metabolic dysfunction that predisposes to brain energetic imbalance. Multiple precipitating factors may lead to brain energy consumption over the migraine attack generation threshold. In response, the brain engenders adaptive, evolutionary conserved, autonomic-behavior responses through the antidromic activation of the trigeminovascular system. The sickness behavior and severe pain experienced during migraine attacks result in avoiding mental and physical activity, allowing brain energy restoration. Chronic exposure to stressors may result in an allostatic overload, leading to maladaptive chronic activation of these responses. In this bio-behavioral perspective, the chronification of migraine should be envisioned as a pathological process, whereas the migraine itself should not.
CONCLUSION
Migraine has an evolutionary (Darwinian) meaning.
Topics: Humans; Migraine Disorders; Brain; Pain; Autonomic Nervous System; Headache
PubMed: 38041827
DOI: 10.1177/03331024231209303 -
Pain Research & Management 2020
Topics: Humans; Migraine Disorders
PubMed: 32256911
DOI: 10.1155/2020/8958143 -
Current Pain and Headache Reports Apr 2022Migraine is and continues to be a significant medical issue in older adults. Migraine can have different characteristics in older adults and specific diagnostic and... (Review)
Review
PURPOSE OF REVIEW
Migraine is and continues to be a significant medical issue in older adults. Migraine can have different characteristics in older adults and specific diagnostic and treatment considerations need to be applied when managing headache and migraine in this population, which is increasing in both size and diversity. Contrary to widely held beliefs, migraine may not improve in older women following menopause and can have new onset in older age. The purpose of this review is to give an update on the diagnosis and treatment of episodic migraine in older adults.
RECENT FINDINGS
As the population ages, migraine in older adults will become a more significant public health issue. Migraine in older adults can present with different clinical symptoms than in a younger population and is primarily a diagnosis of exclusion in older adults. Migraine treatment considerations for older adults should include comorbidities and medication interactions. Recent findings suggest there are medications that should be avoided when treating seniors with migraine. The purpose of this review is to give an update on the most important aspects regarding the diagnosis and treatment of headache and migraine in older adults. In addition, recommendations will be made concerning medications that need careful consideration when prescribing to seniors.
Topics: Aged; Comorbidity; Female; Headache; Humans; Migraine Disorders
PubMed: 35384586
DOI: 10.1007/s11916-022-01029-7 -
Neurology India 2021The complex relationship between migraine and epilepsy has frequently been described to represent a clinical and electrographic "borderland." These two conditions share... (Review)
Review
BACKGROUND
The complex relationship between migraine and epilepsy has frequently been described to represent a clinical and electrographic "borderland." These two conditions share clinical expressions such as paroxysmal and chronic nature, as well as semiology, particularly visual phenomenon.
OBJECTIVE
We aimed to review the current literature on the overlapping phenomena of migraine and epilepsy.
MATERIALS AND METHODS
We searched the PubMed for relevant literature and conducted a narrative review on migraine and epilepsy.
RESULTS
Migraine and epilepsy share a complex and pathophysiologically intriguing relationship. The International Classification of Headache Disorders, 3 edition (ICHD-3) makes diagnostic provisions for migraine aura-triggered seizures (Subchapter 1.4.4) and headache attributed to epileptic seizure (Subchapter 7.6), the latter being further categorized as 7.6.1 Ictal epileptic headache, and 7.6.2 post-ictal headache. Neurological conditions such as certain channelopathies and epilepsy syndromes exhibit both conditions within their phenotypic spectrum, suggesting shared genetic and molecular underpinnings. Diagnostic confusion may arise, particularly between occipital epilepsy and the visual aura of migraine. Antiseizure medications may be effective for the treatment of migraines that occur in concert with epilepsy.
CONCLUSIONS
Migraine and epilepsy share several clinical features and have intertwined genetic and molecular underpinnings, which may contribute to common pathogenesis. Electroencephalography may be useful as a diagnostic tool in selected cases.
Topics: Electroencephalography; Epilepsy; Headache; Humans; Migraine Disorders; Seizures
PubMed: 34003153
DOI: 10.4103/0028-3886.315994