What´s left and new in the management of migraine?

2021 ◽  
pp. 1-23
Author(s):  
Oihane Goñi ◽  
◽  
Leire Leache ◽  
Esther Lacalle ◽  
Maria Teresa Acin ◽  
...  
Keyword(s):  
Health Service ◽  
Botulinum Toxin A ◽  
Preventive Treatment ◽  
Poor Response ◽  
Symptomatic Treatment ◽  
Episodic Migraine ◽  
Prescription Database ◽  
First Line ◽  
First Choice ◽  
Service Data

INTRODUCTION Migraine is a neurological disorder that generally manifests in the form of headache. The treatment of migraine is based on changes in lifestyle, symptomatic treatment and preventive therapies. The pharmacotherapeutic approach to migraine is based on widely-used drugs and novel drugs, which include monoclonal antibodies (mAbs), which emerge as an alternative for patients with poor response to standard preventive treatments. PURPOSE The objective of this study is to assess the efficacy and safety of the medications employed for the symptomatic and preventive treatment of migraine. Another objective is to determine its place in therapeutics and identify the best treatment based on the type of migraine and characteristics of the patient. METHODS A A search was performed of clinical practice guidelines, documents from regulatory agencies, systematic reviews and primary studies assessing symptomatic and preventive treatments of migraine. Data related to the use of triptans in Navarra, Spain, was extracted from the prescription database of the Navarre Health Service. Data about patients receiving mAb therapy in our community and their progress was extracted from electronic medical records and the Navarre Health Service pharmacotherapy management system. CONCLUSIONS The symptomatic treatment of choice for mild-moderate migraine includes non-steroidal anti-inflammatory drugs (NSAIDs), whereas triptans are frequently reserved for moderate-severe migraine. Oral drugs are the first-line preventive treatment, with ß-blockers and topiramate as the first choice. Botulinum toxin A is used in patients with chronic migraine who are unresponsive to oral preventive therapies. mAbs emerge as an alternative to prevent chronic or episodic migraine in patients unresponsive to previous treatments. These treatments, however, have a modest efficacy as compared to placebo. In addition, no comparative studies have been published to date about other first-line preventive therapies. The long-term safety and efficacy of mAbs have not yet been established, and their cost is high. MAbs are funded by the public health system only as fourth-line prophylactic therapy for chronic or high-frequency episodic migraine.

scholarly journals Consensus of the Hellenic Headache Society on the diagnosis and treatment of migraine

2019 ◽  
Vol 20 (1) ◽  
Author(s):  
Evangelos Kouremenos ◽  
◽  
Chrysa Arvaniti ◽  
Theodoros S. Constantinidis ◽  
Ermioni Giannouli ◽  
...  
Keyword(s):  
Chronic Migraine ◽  
Botulinum Toxin Type A ◽  
Good Clinical Practice ◽  
Symptomatic Treatment ◽  
Episodic Migraine ◽  
Diagnosis And Treatment ◽  
High Dose ◽  
Migraine Prevention ◽  
Regulatory Affairs ◽  
First Choice

AbstractMore than 0.6 million people suffer from disabling migraines in Greece causing a dramatic work loss, but only a small proportion of migraineurs attend headache centres, most of them being treated by non-experts. On behalf of the Hellenic Headache Society, we report here a consensus on the diagnosis and treatment of adult migraine that is based on the recent guidelines of the European Headache Federation, on the principles of Good Clinical Practice and on the Greek regulatory affairs. The purposes are three-fold: (1) to increase awareness for migraine in Greece; (2) to support Greek practitioners who are treating migraineurs; and (3) to help Greek migraineurs to get the most appropriate treatment. For mild migraine, symptomatic treatment with high dose simple analgesics is suggested, while for moderate to severe migraines triptans or non-steroidal anti-inflammatory drugs, or both, should be administered following an individually tailored therapeutic strategy. A rescue acute treatment option should always be advised. For episodic migraine prevention, metoprolol (50–200 mg/d), propranolol (40–240 mg/d), flunarizine (5–10 mg/d), valproate (500–1800 mg/d), topiramate (25–100 mg/d) and candesartan (16–32 mg/d) are the drugs of first choice. For chronic migraine prevention topiramate (100-200 mg/d), valproate (500–1800 mg/d), flunarizine (5–10 mg/d) and venlafaxine (150 mg/d) may be used, but the evidence is very limited. Botulinum toxin type A and monoclonal antibodies targeting the CGRP pathway (anti-CGRP mAbs) are recommended for patients suffering from chronic migraine (with or without medication overuse) who failed or did not tolerate two previous treatments. Anti-CGRP mAbs are also suggested for patients suffering from high frequency episodic migraine (≥8 migraine days per month and less than 14) who failed or did not tolerate two previous treatments.

scholarly journals Patients and general practitioners assessment of the main outcomes employed in the acute and preventive treatment of migraine: a cross sectional study

BMC Neurology ◽  
2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Javier Trigo-López ◽  
Ángel Luis Guerrero-Peral ◽  
Álvaro Sierra ◽  
Enrique Martínez-Pías ◽  
María Gutiérrez-Sánchez ◽  
...  
Keyword(s):  
General Practitioners ◽  
Preventive Treatment ◽  
Symptomatic Treatment ◽  
Episodic Migraine ◽  
Cross Sectional Study ◽  
Important Variable ◽  
Migraine Treatment ◽  
Cross Sectional ◽  
Sustained Effect ◽  
Action Time

Abstract Background We aim to describe and compare patients and general practitioners’ opinions about the different variables related to acute and preventive treatment for migraine. Patients and methods An observational descriptive study was performed. Patients with episodic migraine and general practitioners, from our healthcare area, were invited to answer a survey about the different variables related to migraine treatment. They were asked for their opinions on the different variables, and to consider the desired efficacy in percentage terms and the desired action times of treatment. Results Fifty-five patients and fifty-five general practitioners were selected. Effectiveness was considered the most important variable for symptomatic and preventive treatment. Cost was considered the least important variable. Patients desired percentage of efficacy was 84.0% (±16.7%) for symptomatic treatment and 79.9% (±17.1%) for preventive treatment. General practitioners desired percentage of efficacy was 75.0% (±14.0) for symptomatic treatment and 70.4% (±14.3) for preventive treatment. For symptomatic treatment the desired action time for pain cessation was selected as 27.5 min (±13.8) for patients and 24.0 min (±18.3) for GPs. For preventive treatment the desired action time for effect was 7.1 days (±4.5) for patients and 13.9 days (±8.9) for general practitioners. Conclusion The most important endpoints were, for acute: effectiveness, a short action time and a persistent effect. For prophylactic: effectiveness, sustained effect and tolerability. Both patients and general practitioners agreed on the most and least preferred endpoints. Desired percentage of efficacy was above 75% for both symptomatic and preventive treatment; and the desired action time was below 30 min for acute treatment and 2 weeks for preventive treatment.

scholarly journals AHR-dependent genes and response to MTX therapy in rheumatoid arthritis patients

2021 ◽  
Author(s):  
Anna Wajda ◽  
Ewa Walczuk ◽  
Barbara Stypińska ◽  
Jakub Lach ◽  
Danat Yermakovich ◽  
...  
Keyword(s):  
Rheumatoid Arthritis ◽  
Lymphoblastic Leukemia ◽  
Mrna Level ◽  
Poor Response ◽  
Evolutionary Analysis ◽  
First Line ◽  
Aryl Hydrocarbon ◽  
First Line Therapy ◽  
Genes Expression ◽  
Ahr Gene

AbstractMethotrexate (MTX) is the first-line therapy for rheumatoid arthritis. Nevertheless, MTX resistance is quite a common issue in clinical practice. There are some premises that aryl hydrocarbon receptor (AhR) gene battery may take part in MTX metabolism. In the present retrospective study, we analyzed genes expression of AHR genes battery associated with MTX metabolism in whole blood of RA patients with good and poor response to MTX treatment. Additionally, sequencing, genotyping and bioinformatics analysis of AHR repressor gene (AHRR) c.565C > G (rs2292596) and c.1933G > C (rs34453673) have been performed. Theoretically, both changes may have an impact on H3K36me3 and H3K27me3. Evolutionary analysis revealed that rs2292596 may be possibly damaging. Allele G in rs2292596 and DAS28 seems to be associated with a higher risk of poor response to MTX treatment in RA. RA patients with poor response to MTX treatment revealed upregulated AhR and SLC19A1 mRNA level. Treatment with IL-6 inhibitor may be helpful to overcome the low-dose MTX resistance. Analysis of gene expression revealed possible another cause of poor response to MTX treatment which is different from that observed in the case of acute lymphoblastic leukemia.

scholarly journals Treatment of COVID-19 with Chloroquine: Implication for Malaria Chemotherapy Using ACTs in Disease Endemic Countries

2020 ◽  
Author(s):  
Neils Ben Quashie ◽  
Nancy Odurowah Duah-Quashie
Keyword(s):  
Intermittent Preventive Treatment ◽  
Preventive Treatment ◽  
World Health ◽  
Cross Resistance ◽  
Drug Resistant ◽  
Combination Therapies ◽  
Parasite Resistance ◽  
Demand And Supply ◽  
First Choice ◽  
Health Organization

Abstract Based on reports of parasite resistance and on World Health Organization recommendation, chloroquine was replaced with the artemisinin-based combination therapies (ACTs) as the first choice of drugs for the treatment of uncomplicated malaria. Disuse of chloroquine led to restoration of drug-sensitive parasite to some extent in certain countries. Ever since chloroquine and hydroxychloroquine were touted as potential treatment for coronavirus disease 2019 (COVID-19), there has been a dramatic surge in demand for the drugs. Even in areas where chloroquine is proscribed, there has been an unexpected increase in demand and supply of the drug. This situation is quite worrying as the indiscriminate use of chloroquine may produce drug-resistant parasites which may impact negatively on the efficacy of amodiaquine due to cross-resistance. Amodiaquine is a partner drug in one of the ACTs and in some of the drugs used for intermittent preventive treatment. We herein discuss the consequences of the escalated use of chloroquine in the management of COVID-19 on chemotherapy or chemoprevention of malaria and offer an advice. We speculate that parasite strains resistant to chloroquine will escalate due to the increased and indiscriminate use of the drug and consequently lead to cross-resistance with amodiaquine which is present in some drug schemes aforementioned. Under the circumstance, the anticipated hope of reverting to the use of the ‘resurrected chloroquine’ to manage malaria in future is likely to diminish. The use of chloroquine and its derivatives for the management of COVID-19 should be controlled.

scholarly journals Factors Predicting the Success of Adhesiolysis Using a Steerable Catheter in Lumbar Failed Back Surgery Syndrome: A Retrospective Study

2021 ◽  
Vol 10 (5) ◽  
pp. 913
Author(s):  
Ji Yeong Kim ◽  
Yong Ho Lee ◽  
Subin Yoo ◽  
Ji Young Kim ◽  
Mina Joo ◽  
...  
Keyword(s):  
Poor Response ◽  
Failed Back Surgery Syndrome ◽  
Foraminal Stenosis ◽  
Outer Diameter ◽  
Lumbar Surgery ◽  
First Line ◽  
Failed Back Surgery ◽  
Back Surgery ◽  
Reasonable Evidence ◽  
Reduction Effect

Failed back surgery syndrome (FBSS) is a commonly encountered disease after lumbar surgery. There are many cases where it is difficult to choose a treatment because no specific cause can be found. Nevertheless, according to recent reports, adhesiolysis has shown reasonable evidence. However, considering its poor cost-effectiveness, adhesiolysis cannot be used as the first line of treatment. FBSS patients often suffer from chronic pain; accordingly, they become frustrated when this treatment produces a poor response. Therefore, before the procedure, the target group must be selected carefully. We sought to identify the pre-procedure factors predicting the effect of adhesiolysis in FBSS. A total of 150 patients were evaluated and analyzed retrospectively. Of these 150 patients, 69 were classified as responders three months after the procedure (46%). The outer diameter of the catheter during the procedure and grade of foraminal stenosis were correlated with the procedure effect. In conclusion, of the 2.1 mm diameter of the catheter, 1.7 mm of it was used during the procedure, and the milder the foraminal stenosis, the greater the pain reduction effect was three months after the procedure.

scholarly journals Identifying Cutaneous Allodynia in Chronic Migraine Using a Practical Clinical Method

Cephalalgia ◽  
2007 ◽  
Vol 27 (2) ◽  
pp. 111-117 ◽  
Author(s):  
A Ashkenazi ◽  
M Sholtzow ◽  
JW Shaw ◽  
R Burstein ◽  
WB Young
Keyword(s):  
Chronic Migraine ◽  
Demographic Data ◽  
Poor Response ◽  
Practical Method ◽  
Episodic Migraine ◽  
Entire Study ◽  
Clinical Method ◽  
Cutaneous Allodynia ◽  
History Of ◽  
Acute Headache

Cutaneous allodynia is common in migraine. In the majority of previous studies on allodynia in migraine, only patients with episodic migraine (EM) were included. Little is known on patterns of allodynia in chronic migraine (CM). Since the presence of allodynia is associated with a poor response to triptans, a clinically practical method to test migraine patients for allodynia would be useful to the clinician. The aim of this study was to assess the prevalence of dynamic mechanical (brush) allodynia (BA) in CM, using a clinically practical method. Eighty-nine CM patients were prospectively recruited. Patients were given a structured questionnaire regarding demographic data and migraine characteristics. Allodynia was tested using a 10 x 10-cm gauze pad to brush various areas of the skin lightly. The prevalence of BA in the entire study population and in different patient subgroups was calculated. BA was present in 42.7% (38/89) of the patients. The presence of allodynia was unrelated to age, disease duration or to the occurrence of an acute headache exacerbation at the time of testing. Allodynia was positively associated with a history of migraine aura. BA was most common in the cephalic area, but was also seen in cervical dermatomes. BA is common in CM and, unlike in EM, is not significantly affected by the occurrence of an acute headache exacerbation. This suggests that central trigeminovascular neurons are chronically sensitized in patients experiencing migraine headache >15 days per month. The testing of BA in the clinical setting is possible using a simple and brief approach. It allows the clinician to determine whether the patient is sensitized, a diagnosis that affects treatment decisions.

scholarly journals Rituximab as a first-line preventive treatment in pediatric NMOSDs

2014 ◽  
Vol 1 (4) ◽  
pp. e46 ◽  
Author(s):  
Giulia Longoni ◽  
Brenda Banwell ◽  
Massimo Filippi ◽  
E. Ann Yeh
Keyword(s):  
Preventive Treatment ◽  
First Line

Use of biologicals in dermatology – following the agreed path or going off-piste? A brief report

2021 ◽  
Vol 10 (3) ◽  
pp. 141-144
Author(s):  
Michael Wilcock ◽  
Andrew Pothecary
Keyword(s):  
Medical Records ◽  
Treatment Cost ◽  
Biological Therapy ◽  
Severe Psoriasis ◽  
Small Scale ◽  
First Line ◽  
First Choice ◽  
Biological Medicine ◽  
Reasons For Use ◽  
Local Guideline

Introduction: Biological medicines are used to treat a range of conditions according to National Institute for Health and Care Excellence (NICE) technology appraisals. The annual drug treatment cost per patient per year varies depending on various factors, including newer or older biological, and availability of a biosimilar. Our biologicals pathway for dermatology (moderate or severe psoriasis) listed less expensive older biologicals (including biosimilars) early on in the treatment choices and more recently approved (and generally more expensive) choices lower down the pathway. Objective: We aimed to identify which biologicals or selective immunosuppressants were used first line in adult patients with moderate or severe psoriasis, and ascertain if the reasons for use of treatments other than adalimumab were in accordance with the locally agreed pathway. Methods: Medical records were reviewed for a sample of patients prescribed biologicals during late 2019 and early 2020. We identified patients who had commenced any treatment. Contact was made with lead dermatology nurses if needed. Results: There were 33 patients commenced on a biological – 17 had newly started biological therapy and 16 had switched from a prior biological therapy to a new therapy. Of the 17 new patients, two commenced apremilast (biological contraindicated), 10 commenced adalimumab, and five commenced other biologicals. Of these five who commenced other biologicals, two were on guselkumab, two on ustekinumab, and one on certolizumab. In all five instances there was a valid reason for not using adalimumab as first choice though this was not always explicit in the multidisciplinary team (MDT) documentation. Discussion: Though the number of psoriasis patients (17) newly starting a biological medicine was relatively small, it was reassuring that for five of these who commenced a subcutaneous biological other than adalimumab, there was a valid reason for this choice, though not always explicit in the MDT letter, which Dermatology will ensure is clear for future decisions. Hence going ‘off-piste’ was deemed justified. Conclusion: This very small-scale study found that the local guideline was followed with patients commencing treatments other than biosimilar adalimumab for valid reasons.

Different Doses of Erenumab for Preventive Treatment of Episodic Migraine: A Systematic Review and Network Meta-Analysis

2020 ◽  
Author(s):  
Yanbo Yang ◽  
Mingjia Chen ◽  
Zilan Wang ◽  
Yue Sun ◽  
Fan Jiang ◽  
...  
Keyword(s):  
Randomized Clinical Trials ◽  
Response Rate ◽  
Meta Analysis ◽  
Preventive Treatment ◽  
Episodic Migraine ◽  
Cochrane Library ◽  
Migraine Treatment ◽  
Increased Risk ◽  
Significant Difference ◽  
Safety Outcomes

Abstract Background Erenumab is a novel monoclonal calcitonin gene–related peptide receptor antibody that is used for the preventive treatment of migraine.Objectives To evaluate overall safety and efficacy and dose-response relationship of erenumab in patients with episodic migraine and patients with prior migraine treatment failures.Methods We searched randomized clinical trials on PUBMED, EMBASE database, and Cochrane Library database. A pair-wise meta-analysis and Bayesian network analysis were performed.Results For efficacy outcomes, the network meta-analysis suggests that compared with erenumab 70 mg, participants received erenumab 140 mg reported significantly decreased MSMD and increased 50% response rate, and erenumab was most likely to be ranked first for MMD, MSMD and 50% response rate. For safety outcomes, the network meta-analysis has found no significant difference between the 70 mg group and the 140 mg group measured by AE and SAE. For patients with ≥2 treatment failures, 140mg erenumab group, patients with ≥2 treatment failures reported significantly reduced MMD and MSMD, increased 50%, and 75% response rate, compared with placebo. For safety outcomes, no significant difference was found between 140 mg erenumab group and the placebo group.Conclusion Erenumab was effective in patients with episodic migraine. 140 mg erenumab was associated with better efficacy outcomes without increased risk for developing adverse events compared with 70 mg erenumab, and 140 mg erenumab was effective in patients with prior migraine treatment failures.Registration number: CRD42020198985

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