Migraine evolution after the cessation of CGRP(-receptor) antibody prophylaxis: a prospective, longitudinal cohort study

Background National and international guidelines recommend stopping migraine prophylaxis with CGRP(-receptor) monoclonal antibodies after 6–12 months of successful therapy. In this study, we aimed to analyze the course of migraine for four months after the cessation of CGRP(-receptor) antibodies use. Methods This longitudinal cohort study included patients with migraine who received a CGRP-(receptor) antibody for ≥8 months before treatment cessation. We analyzed headache data in the four-week period prior to mAb treatment initiation (baseline), in the month before the last mAb injection, in weeks 5–8 and 13–16 after last treatment. Primary endpoint of the study was the change of monthly migraine days from the month before last treatment to weeks 13–16. Secondary endpoints were changes in monthly headache days and monthly days with acute medication use. Results A total of 62 patients equally distributed between prophylaxis with the CGRP-receptor antibody erenumab and the CGRP antibodies galcanezumab or fremanezumab participated in the study. Patients reported 8.2 ± 6.6 monthly migraine days in the month before last treatment. Monthly migraine days gradually increased to 10.3 ± 6.8 in weeks 5–8 (p = 0.001) and to 12.5 ± 6.6 in weeks 13–16 (p < 0.001) after drug cessation. Monthly migraine days in weeks 13–16 were not different from baseline values (−0.8 ± 5.4; p > 0.999). Monthly headache days and monthly days with acute medication use showed a similar pattern. Conclusions The cessation of CGRP(-receptor) antibodies migraine prophylaxis was associated with a significant increase of migraine frequency and acute medication intake over time.

Early Experiences in Switching between Monoclonal Antibodies in Patients with Nonresponsive Migraine in Spain: A Case Series

Monoclonal antibodies targeting the calcitonin gene-related peptide have been introduced into the therapeutic arsenal of migraine prophylaxis. Clinical trials report similar efficacy between them, and there is no evidence of switching to another one after failure. We aim to describe our experience in switching from erenumab to galcanezumab after therapeutic failure. We retrospectively reviewed 30 migraine patients who received monoclonal antibodies, with 15 of them switched after failure to achieve reduction in migraine days per month ≥30%. A ≥30% reduction in migraine days per month compared to baseline was observed in 8/15 (4/15 ≥ 50%) patients after switch. Some nonresponsive patients may benefit from switching between monoclonal antibodies with different therapeutic targets.

Outcome of Topiramate in Migraine Prophylaxis

Background: Topiramate is an anti epileptic medication originally and one of the first line drugs for migraine prophylaxis.Objective: To assess outcome of Topiramate in migraine prophylaxis by evaluating reduction in frequency and/or severity of attacks and address most common adverse affect associated with it.Methods: A Descriptive, prospective hospital based study was conducted at Ibrahim Malik Hospital, National center of neurological disease and sciences within the period of October 2018 –May 2019. Data entered, cleaned, analyzed using SPSS version 25.0.Results: This study covered 32 study participants; the mean age (33 ± 10) years, with female predominance by 27 (84%).Nearly, half of them 15(47%) migraine triggered by weather changes, 13 (41%) menstruation. 17(53%) was suffering from headache > 24 months, and most of them 26(81%) used the OTC medications in the acute pain headache.Mean of frequency of attacks per month was reduce (6.1 base line to 3.2), in severity mean was (6.9 turn to 5). Reduction in Frequency of attacks there was significant in both number and severity (p value < 0.001) with no significant difference in (50 mg and 100mg dose). Concerning adverse effects 5(15.6%) didn’t complain of any, more than third 12(38%) experienced weight loss, 7(22%) both Abdominal/GIT symptoms and Dizziness, 5(16%) mood changes, 4(13%) both parathesia and decreased memory, 3(9%) both Anorexia and sleepiness.Conclusion: Topiramate is effective in reducing headache frequency and reasonably well tolerated in adult Sudanese patients with episodic migraine. This may provide good evidence to support its use in routine clinical management.

Acute Angle-Closure Crisis Secondary to Topiramate-Induced Ciliochoroidal Effusion With Underlying Plateau Iris Configuration

Objective: The development of ciliochoroidal effusions and secondary acute angle-closure crisis (AACC) is an uncommon side effect of topiramate, a common antiepileptic now FDA-approved for migraine prophylaxis. The mechanisms that underlie the development of ciliochoroidal effusions after topiramate use remain unclear. Materials and Methods: Ultrasound biomicroscopy (UBM) was also performed in all participants after stopping topiramate. Results: Six patient cases are presented with medication-induced AACC following the initiation or escalation of topiramate. Ciliochoroidal effusions were confirmed by gray-scale sonography in all patients at presentation. The images revealed either plateau iris configuration or atypical plateau iris configuration. Plateau iris configuration is defined by presence of an anteriorly rotated ciliary body processes and an absent posterior sulcus. Atypical plateau iris configuration refers to when the iris inserts directly into the ciliary body face. This case series, of medication-induced angle-closure crisis, suggests that plateau iris configuration is a shared anatomical feature in the development of topiramate-induced ciliochoroidal effusions.

Erenumab Discontinuation Following 12-Month Treatment: A Multicentric Observational Real-Life Study

ABSTRACTOBJECTIVE:to assess migraine outcome following twelve months treatment with erenumab and compare patients who underwent three months erenumab discontinuation following the first treatment cycle to those who continued monthly administrations.METHODS:this is a multicentric observational study in migraine patients in treatment with erenumab. Following a full 12 months treatment cycle (T12) patients could either continue or discontinue erenumab for at least three months. Patients who underwent treatment discontinuation were assessed following three months (T15) to decide whether to start re-treatment. Patients were then assessed following at T16 and T18.RESULTS:Thirty consecutive patients were enrolled. Nineteen patients underwent treatment suspension at T12 up to T15, whereas 11 continued phrophylaxis. At T15, patients who discontinued treatment documented significantly more migraine days (17.06±6.5 vs 4.8±2.5; p < 0.0001) and analgesics consumption (14.8±9.2 vs 4.6±2.5; p = 0.002), compared to those who continued treatment. Following re-treatment, at T16, patients who had previously undergone discontinuation documented a significant improvement in terms of migraine days (9.01±4.4 vs 17.06±6.5; p < 0.0001) and analgesics consumption (9.6±7.3 vs 14.8±9.2; p = 0.004). Such improvement was even greater at T18, comparable to T12.CONCLUSIONS:Following treatment discontinuation, a rapid migraine worsening was found, despite the high clinical response during treatment and at re-treatment, which might be secondary to an untimely interruption of a potentially disease modifying pharmacological intervention. Although clinical improvement was documented following retreatment, given the high frequency and degree of worsening during discontinuation, it seems plausible – even ethical – to re-evaluate current timing of discontinuation.CLASSIFICATION OF EVIDENCE:This study provides class III evidence that people with migraine discontinuing erenumab migraine prophylaxis after 12 months were more likely to have an increase in non-responder status and migraine days than those who continued treatment.