User login
Headache Strongly Linked to Attempted, Completed Suicide
Headache, including migraine, tension-type, trigeminal autonomic cephalalgia (TAC), and posttraumatic stress headache are significantly associated with both attempted and completed suicide, results of a large study suggested.
The risk for attempted and completed suicide was more than threefold higher for individuals with posttraumatic headache and about twofold higher for those with TAC than their counterparts without headache.
Even those with tension-type headache, one of the milder headache types, carried nearly a twofold increased risk for attempted suicide vs the comparison group with no headache.
First author Holly Elser, MD, MPH, PhD, a resident physician in the Department of Neurology at the University of Pennsylvania, Philadelphia, told Medscape Medical News that the findings were “quite striking” and underscore the importance of screening for suicide risk even in patients with mild headache.
The findings were published online on February 3 in JAMA Neurology.
Common, Disabling
With an estimated global lifetime prevalence of 67%, headache disorders are a leading cause of productivity loss, work absences, and short-term disability.
The mechanisms linking headache disorders to suicide remain unclear for several reasons, the investigators noted.
First, the relationship between headache and psychiatric comorbidities may be complex and bidirectional, with psychiatric symptoms potentially exacerbating headache severity and frequency, the investigators noted.
Secondly, research has shown a consistent link between chronic pain and suicidality, even after adjusting for comorbid psychiatric conditions. Finally, disruptions in serotonergic pathways and increased production of inflammatory cytokines may contribute to both headache disorders and psychiatric symptoms, suggesting a shared biological basis.
The mechanisms linking headache disorders to suicide remain unclear for several reasons, the investigators noted.
First, the relationship between headache and psychiatric comorbidities may be complex and bidirectional, with psychiatric symptoms potentially exacerbating headache severity and frequency, the investigators noted.
Secondly, research has shown a consistent link between chronic pain and suicidality, even after adjusting for comorbid psychiatric conditions. Finally, disruptions in serotonergic pathways and increased production of inflammatory cytokines may contribute to both headache disorders and psychiatric symptoms, suggesting a shared biological basis.
“Patients diagnosed with headache with comorbid psychiatric symptoms may benefit in particular from comanagement with behavioral health specialists,” she added.
Not ‘Just Headaches’
In an interview with Medscape Medical News, Fred Cohen, MD, an assistant professor of medicine and neurology at the Icahn School of Medicine at Mount Sinai Hospital, New York City, shared his perspective on the findings. Cohen, who was not involved in the study agreed with Elser’s point and incorporated screening into his practice.
“As part of my routine at every new patient appointment, I conduct screenings for depression and suicide risk. If a patient responds affirmatively to any of these questions, I make sure they get connected to the mental health resources they need,” Cohen said.
At least one of his patients per week screens positive for depression, he noted.
“Primary headaches, including migraine and trigeminal autonomic cephalalgias, are a significant source of disability and suffering,” said Cohen, adding that migraine, in particular, is the leading cause of disability worldwide among women aged 18-50 years. “These conditions are often misunderstood and dismissed as ‘just headaches,’ when in reality, they are much more complex and debilitating.”
Given that depression and anxiety are common co-occurring conditions with primary headache disorders, he said, “depression screenings should be standard practice when evaluating patients with headaches.”
The study’s limitations include dependence on diagnosis codes, which are prone to misclassification, and lack of information about headache chronicity and severity, which could have affected the findings.
There was no information provided about study funding. Elser and Cohen reported no relevant financial relationships.
Headache, including migraine, tension-type, trigeminal autonomic cephalalgia (TAC), and posttraumatic stress headache are significantly associated with both attempted and completed suicide, results of a large study suggested.
The risk for attempted and completed suicide was more than threefold higher for individuals with posttraumatic headache and about twofold higher for those with TAC than their counterparts without headache.
Even those with tension-type headache, one of the milder headache types, carried nearly a twofold increased risk for attempted suicide vs the comparison group with no headache.
First author Holly Elser, MD, MPH, PhD, a resident physician in the Department of Neurology at the University of Pennsylvania, Philadelphia, told Medscape Medical News that the findings were “quite striking” and underscore the importance of screening for suicide risk even in patients with mild headache.
The findings were published online on February 3 in JAMA Neurology.
Common, Disabling
With an estimated global lifetime prevalence of 67%, headache disorders are a leading cause of productivity loss, work absences, and short-term disability.
The mechanisms linking headache disorders to suicide remain unclear for several reasons, the investigators noted.
First, the relationship between headache and psychiatric comorbidities may be complex and bidirectional, with psychiatric symptoms potentially exacerbating headache severity and frequency, the investigators noted.
Secondly, research has shown a consistent link between chronic pain and suicidality, even after adjusting for comorbid psychiatric conditions. Finally, disruptions in serotonergic pathways and increased production of inflammatory cytokines may contribute to both headache disorders and psychiatric symptoms, suggesting a shared biological basis.
The mechanisms linking headache disorders to suicide remain unclear for several reasons, the investigators noted.
First, the relationship between headache and psychiatric comorbidities may be complex and bidirectional, with psychiatric symptoms potentially exacerbating headache severity and frequency, the investigators noted.
Secondly, research has shown a consistent link between chronic pain and suicidality, even after adjusting for comorbid psychiatric conditions. Finally, disruptions in serotonergic pathways and increased production of inflammatory cytokines may contribute to both headache disorders and psychiatric symptoms, suggesting a shared biological basis.
“Patients diagnosed with headache with comorbid psychiatric symptoms may benefit in particular from comanagement with behavioral health specialists,” she added.
Not ‘Just Headaches’
In an interview with Medscape Medical News, Fred Cohen, MD, an assistant professor of medicine and neurology at the Icahn School of Medicine at Mount Sinai Hospital, New York City, shared his perspective on the findings. Cohen, who was not involved in the study agreed with Elser’s point and incorporated screening into his practice.
“As part of my routine at every new patient appointment, I conduct screenings for depression and suicide risk. If a patient responds affirmatively to any of these questions, I make sure they get connected to the mental health resources they need,” Cohen said.
At least one of his patients per week screens positive for depression, he noted.
“Primary headaches, including migraine and trigeminal autonomic cephalalgias, are a significant source of disability and suffering,” said Cohen, adding that migraine, in particular, is the leading cause of disability worldwide among women aged 18-50 years. “These conditions are often misunderstood and dismissed as ‘just headaches,’ when in reality, they are much more complex and debilitating.”
Given that depression and anxiety are common co-occurring conditions with primary headache disorders, he said, “depression screenings should be standard practice when evaluating patients with headaches.”
The study’s limitations include dependence on diagnosis codes, which are prone to misclassification, and lack of information about headache chronicity and severity, which could have affected the findings.
There was no information provided about study funding. Elser and Cohen reported no relevant financial relationships.
Headache, including migraine, tension-type, trigeminal autonomic cephalalgia (TAC), and posttraumatic stress headache are significantly associated with both attempted and completed suicide, results of a large study suggested.
The risk for attempted and completed suicide was more than threefold higher for individuals with posttraumatic headache and about twofold higher for those with TAC than their counterparts without headache.
Even those with tension-type headache, one of the milder headache types, carried nearly a twofold increased risk for attempted suicide vs the comparison group with no headache.
First author Holly Elser, MD, MPH, PhD, a resident physician in the Department of Neurology at the University of Pennsylvania, Philadelphia, told Medscape Medical News that the findings were “quite striking” and underscore the importance of screening for suicide risk even in patients with mild headache.
The findings were published online on February 3 in JAMA Neurology.
Common, Disabling
With an estimated global lifetime prevalence of 67%, headache disorders are a leading cause of productivity loss, work absences, and short-term disability.
The mechanisms linking headache disorders to suicide remain unclear for several reasons, the investigators noted.
First, the relationship between headache and psychiatric comorbidities may be complex and bidirectional, with psychiatric symptoms potentially exacerbating headache severity and frequency, the investigators noted.
Secondly, research has shown a consistent link between chronic pain and suicidality, even after adjusting for comorbid psychiatric conditions. Finally, disruptions in serotonergic pathways and increased production of inflammatory cytokines may contribute to both headache disorders and psychiatric symptoms, suggesting a shared biological basis.
The mechanisms linking headache disorders to suicide remain unclear for several reasons, the investigators noted.
First, the relationship between headache and psychiatric comorbidities may be complex and bidirectional, with psychiatric symptoms potentially exacerbating headache severity and frequency, the investigators noted.
Secondly, research has shown a consistent link between chronic pain and suicidality, even after adjusting for comorbid psychiatric conditions. Finally, disruptions in serotonergic pathways and increased production of inflammatory cytokines may contribute to both headache disorders and psychiatric symptoms, suggesting a shared biological basis.
“Patients diagnosed with headache with comorbid psychiatric symptoms may benefit in particular from comanagement with behavioral health specialists,” she added.
Not ‘Just Headaches’
In an interview with Medscape Medical News, Fred Cohen, MD, an assistant professor of medicine and neurology at the Icahn School of Medicine at Mount Sinai Hospital, New York City, shared his perspective on the findings. Cohen, who was not involved in the study agreed with Elser’s point and incorporated screening into his practice.
“As part of my routine at every new patient appointment, I conduct screenings for depression and suicide risk. If a patient responds affirmatively to any of these questions, I make sure they get connected to the mental health resources they need,” Cohen said.
At least one of his patients per week screens positive for depression, he noted.
“Primary headaches, including migraine and trigeminal autonomic cephalalgias, are a significant source of disability and suffering,” said Cohen, adding that migraine, in particular, is the leading cause of disability worldwide among women aged 18-50 years. “These conditions are often misunderstood and dismissed as ‘just headaches,’ when in reality, they are much more complex and debilitating.”
Given that depression and anxiety are common co-occurring conditions with primary headache disorders, he said, “depression screenings should be standard practice when evaluating patients with headaches.”
The study’s limitations include dependence on diagnosis codes, which are prone to misclassification, and lack of information about headache chronicity and severity, which could have affected the findings.
There was no information provided about study funding. Elser and Cohen reported no relevant financial relationships.
Nummular Headache Linked to Range of Secondary Causes
A rare coin-shaped headache long viewed as a primary headache disorder frequently has underlying causes, according to new research, and clinicians should refer people who present with it for imaging.
First described in 2003, nummular or coin-shaped headache comprises an intermittent or constant pain limited to a rounded region between 1 and 6 cm in diameter. Classed as a primary headache by the International Classification of Headache Disorders (ICHD-3), it usually occurs in the parietal, or top rear, region of the head.
Now, a group of Spanish researchers has revised 20 years’ worth of cases, representing the largest series to date, and found a wide variety of causes, some of which, they say, had not been reported before in connection to this headache type.
For their research, published online in Headache, Antonio Sánchez-Soblechero, MD, and colleagues at the University Hospital Gregorio Marañón in Madrid, Spain, looked at clinical and imaging findings from 131 patients (67% women, median age at onset 52) seen from 2002 to 2022 at their center, seeking to identify any differences among primary and secondary or symptomatic coin-shaped headache cases. All patients underwent cranial MRI, CT, or both.
Altogether, 26% of the nummular headaches (n = 34) were found associated with trauma, vascular malformations, cranial bone disorders, neoplasia, arachnoid cysts, hypertension, aneurysm, or skin disorders including, in one case, a psoriasis plaque. Hypertension, aneurysm, and psoriasis were not previously described as causes of this headache, the authors said.
The definition of a nummular headache includes that secondary causes need to be excluded, according to the ICHD-3. The study authors proposed that “definite” secondary cases should meet ICHD-3 diagnostic criteria for nummular headache as well as for secondary headache, while “probable” cases meet all criteria for the former and all but one of the criteria for the latter. In their study, eight patients met the proposed criteria for “definite,” while the rest were deemed “probable” secondary cases.
Headache symptoms remained similar regardless of etiology, Sánchez-Soblechero and colleagues found, but coin-shaped headaches deemed to have secondary etiologies were significantly more likely to be associated with previous headache, remote head trauma, and longer symptom duration. The authors described treatments, including surgical interventions, for cases with secondary causes.
Preventive treatment was more effective in patients with determined causes for their headaches, Sánchez-Soblechero and colleagues found, with 72% seeing their monthly headache days halved, compared with just 30% of patients in whom a cause was not identified.
“The presence of any previous headache or remote head trauma may suggest a diagnosis of symptomatic nummular headache; however, as certain nummular headache might be an early symptom of intracranial mass lesions, neuroimaging is necessary. Finding the cause of nummular headache is essential to offer the most effective targeted treatment,” the investigators wrote in their analysis.
Primary Headache or Secondary?
In an interview, neurologist and headache specialist Nina Riggins, MD, PhD, of VA Palo Alto Health Care in California, praised the new findings as underscoring the importance of a thorough clinical approach.
“What this study shows is applicable to many primary headache disorders, whether migraine or cluster or nummular,” Riggins said. “Secondary headache can look like all of these headache types.”
Understanding what should be done to rule out secondary causes of headache is key for the correct diagnosis, she said. “In cases of coin-shaped headache, one should do a detailed neurological exam, consider imaging, check blood pressure, do blood work, and consider exams to exclude autoimmune psoriasis and other disorders as appropriate.”
Despite the inherent limits of its retrospective, single-center design, the study by Sánchez-Soblechero and colleagues is “extremely helpful in emphasizing that we should not dismiss [nummular headache] because it’s a little area of 1-6 centimeters,” Riggins said. “We absolutely have to make sure that we have ruled out secondary causes.” And while it would be useful to have evidence from prospective studies of nummular headache, “with such a rare headache, it’s hard. That’s why it’s so precious to have a study like this one, with 131 patients.”
Riggins acknowledged that the study emphasized the challenges of classifying and diagnosing nummular headache. The ICHD, last revised in 2018, “is a living, breathing document,” she said. “The idea is that as we learn more about headache disorders over time, this may mean changing some primary headaches to secondary, but we are clearly not there with this research: Most participants did not have a secondary cause for their coin-shaped headache.”
For now, Riggins said, “I think it’s best to keep classification straightforward for primary and secondary headache. It’s helpful for my day-to-day clinic life to have this neat division in place. But we do have to exclude secondary headache whenever possible in order to say that this is primary headache.”
Sánchez-Soblechero and coauthors disclosed no financial conflicts of interest related to their findings. Riggins disclosed consulting work for Gerson Lehrman Group, receiving research support from electroCore, Theranica, and Eli Lilly, and serving on advisory boards for Theranica, Teva Pharmaceuticals, Lundbeck, and Amneal Pharmaceuticals.
A version of this article appeared on Medscape.com.
A rare coin-shaped headache long viewed as a primary headache disorder frequently has underlying causes, according to new research, and clinicians should refer people who present with it for imaging.
First described in 2003, nummular or coin-shaped headache comprises an intermittent or constant pain limited to a rounded region between 1 and 6 cm in diameter. Classed as a primary headache by the International Classification of Headache Disorders (ICHD-3), it usually occurs in the parietal, or top rear, region of the head.
Now, a group of Spanish researchers has revised 20 years’ worth of cases, representing the largest series to date, and found a wide variety of causes, some of which, they say, had not been reported before in connection to this headache type.
For their research, published online in Headache, Antonio Sánchez-Soblechero, MD, and colleagues at the University Hospital Gregorio Marañón in Madrid, Spain, looked at clinical and imaging findings from 131 patients (67% women, median age at onset 52) seen from 2002 to 2022 at their center, seeking to identify any differences among primary and secondary or symptomatic coin-shaped headache cases. All patients underwent cranial MRI, CT, or both.
Altogether, 26% of the nummular headaches (n = 34) were found associated with trauma, vascular malformations, cranial bone disorders, neoplasia, arachnoid cysts, hypertension, aneurysm, or skin disorders including, in one case, a psoriasis plaque. Hypertension, aneurysm, and psoriasis were not previously described as causes of this headache, the authors said.
The definition of a nummular headache includes that secondary causes need to be excluded, according to the ICHD-3. The study authors proposed that “definite” secondary cases should meet ICHD-3 diagnostic criteria for nummular headache as well as for secondary headache, while “probable” cases meet all criteria for the former and all but one of the criteria for the latter. In their study, eight patients met the proposed criteria for “definite,” while the rest were deemed “probable” secondary cases.
Headache symptoms remained similar regardless of etiology, Sánchez-Soblechero and colleagues found, but coin-shaped headaches deemed to have secondary etiologies were significantly more likely to be associated with previous headache, remote head trauma, and longer symptom duration. The authors described treatments, including surgical interventions, for cases with secondary causes.
Preventive treatment was more effective in patients with determined causes for their headaches, Sánchez-Soblechero and colleagues found, with 72% seeing their monthly headache days halved, compared with just 30% of patients in whom a cause was not identified.
“The presence of any previous headache or remote head trauma may suggest a diagnosis of symptomatic nummular headache; however, as certain nummular headache might be an early symptom of intracranial mass lesions, neuroimaging is necessary. Finding the cause of nummular headache is essential to offer the most effective targeted treatment,” the investigators wrote in their analysis.
Primary Headache or Secondary?
In an interview, neurologist and headache specialist Nina Riggins, MD, PhD, of VA Palo Alto Health Care in California, praised the new findings as underscoring the importance of a thorough clinical approach.
“What this study shows is applicable to many primary headache disorders, whether migraine or cluster or nummular,” Riggins said. “Secondary headache can look like all of these headache types.”
Understanding what should be done to rule out secondary causes of headache is key for the correct diagnosis, she said. “In cases of coin-shaped headache, one should do a detailed neurological exam, consider imaging, check blood pressure, do blood work, and consider exams to exclude autoimmune psoriasis and other disorders as appropriate.”
Despite the inherent limits of its retrospective, single-center design, the study by Sánchez-Soblechero and colleagues is “extremely helpful in emphasizing that we should not dismiss [nummular headache] because it’s a little area of 1-6 centimeters,” Riggins said. “We absolutely have to make sure that we have ruled out secondary causes.” And while it would be useful to have evidence from prospective studies of nummular headache, “with such a rare headache, it’s hard. That’s why it’s so precious to have a study like this one, with 131 patients.”
Riggins acknowledged that the study emphasized the challenges of classifying and diagnosing nummular headache. The ICHD, last revised in 2018, “is a living, breathing document,” she said. “The idea is that as we learn more about headache disorders over time, this may mean changing some primary headaches to secondary, but we are clearly not there with this research: Most participants did not have a secondary cause for their coin-shaped headache.”
For now, Riggins said, “I think it’s best to keep classification straightforward for primary and secondary headache. It’s helpful for my day-to-day clinic life to have this neat division in place. But we do have to exclude secondary headache whenever possible in order to say that this is primary headache.”
Sánchez-Soblechero and coauthors disclosed no financial conflicts of interest related to their findings. Riggins disclosed consulting work for Gerson Lehrman Group, receiving research support from electroCore, Theranica, and Eli Lilly, and serving on advisory boards for Theranica, Teva Pharmaceuticals, Lundbeck, and Amneal Pharmaceuticals.
A version of this article appeared on Medscape.com.
A rare coin-shaped headache long viewed as a primary headache disorder frequently has underlying causes, according to new research, and clinicians should refer people who present with it for imaging.
First described in 2003, nummular or coin-shaped headache comprises an intermittent or constant pain limited to a rounded region between 1 and 6 cm in diameter. Classed as a primary headache by the International Classification of Headache Disorders (ICHD-3), it usually occurs in the parietal, or top rear, region of the head.
Now, a group of Spanish researchers has revised 20 years’ worth of cases, representing the largest series to date, and found a wide variety of causes, some of which, they say, had not been reported before in connection to this headache type.
For their research, published online in Headache, Antonio Sánchez-Soblechero, MD, and colleagues at the University Hospital Gregorio Marañón in Madrid, Spain, looked at clinical and imaging findings from 131 patients (67% women, median age at onset 52) seen from 2002 to 2022 at their center, seeking to identify any differences among primary and secondary or symptomatic coin-shaped headache cases. All patients underwent cranial MRI, CT, or both.
Altogether, 26% of the nummular headaches (n = 34) were found associated with trauma, vascular malformations, cranial bone disorders, neoplasia, arachnoid cysts, hypertension, aneurysm, or skin disorders including, in one case, a psoriasis plaque. Hypertension, aneurysm, and psoriasis were not previously described as causes of this headache, the authors said.
The definition of a nummular headache includes that secondary causes need to be excluded, according to the ICHD-3. The study authors proposed that “definite” secondary cases should meet ICHD-3 diagnostic criteria for nummular headache as well as for secondary headache, while “probable” cases meet all criteria for the former and all but one of the criteria for the latter. In their study, eight patients met the proposed criteria for “definite,” while the rest were deemed “probable” secondary cases.
Headache symptoms remained similar regardless of etiology, Sánchez-Soblechero and colleagues found, but coin-shaped headaches deemed to have secondary etiologies were significantly more likely to be associated with previous headache, remote head trauma, and longer symptom duration. The authors described treatments, including surgical interventions, for cases with secondary causes.
Preventive treatment was more effective in patients with determined causes for their headaches, Sánchez-Soblechero and colleagues found, with 72% seeing their monthly headache days halved, compared with just 30% of patients in whom a cause was not identified.
“The presence of any previous headache or remote head trauma may suggest a diagnosis of symptomatic nummular headache; however, as certain nummular headache might be an early symptom of intracranial mass lesions, neuroimaging is necessary. Finding the cause of nummular headache is essential to offer the most effective targeted treatment,” the investigators wrote in their analysis.
Primary Headache or Secondary?
In an interview, neurologist and headache specialist Nina Riggins, MD, PhD, of VA Palo Alto Health Care in California, praised the new findings as underscoring the importance of a thorough clinical approach.
“What this study shows is applicable to many primary headache disorders, whether migraine or cluster or nummular,” Riggins said. “Secondary headache can look like all of these headache types.”
Understanding what should be done to rule out secondary causes of headache is key for the correct diagnosis, she said. “In cases of coin-shaped headache, one should do a detailed neurological exam, consider imaging, check blood pressure, do blood work, and consider exams to exclude autoimmune psoriasis and other disorders as appropriate.”
Despite the inherent limits of its retrospective, single-center design, the study by Sánchez-Soblechero and colleagues is “extremely helpful in emphasizing that we should not dismiss [nummular headache] because it’s a little area of 1-6 centimeters,” Riggins said. “We absolutely have to make sure that we have ruled out secondary causes.” And while it would be useful to have evidence from prospective studies of nummular headache, “with such a rare headache, it’s hard. That’s why it’s so precious to have a study like this one, with 131 patients.”
Riggins acknowledged that the study emphasized the challenges of classifying and diagnosing nummular headache. The ICHD, last revised in 2018, “is a living, breathing document,” she said. “The idea is that as we learn more about headache disorders over time, this may mean changing some primary headaches to secondary, but we are clearly not there with this research: Most participants did not have a secondary cause for their coin-shaped headache.”
For now, Riggins said, “I think it’s best to keep classification straightforward for primary and secondary headache. It’s helpful for my day-to-day clinic life to have this neat division in place. But we do have to exclude secondary headache whenever possible in order to say that this is primary headache.”
Sánchez-Soblechero and coauthors disclosed no financial conflicts of interest related to their findings. Riggins disclosed consulting work for Gerson Lehrman Group, receiving research support from electroCore, Theranica, and Eli Lilly, and serving on advisory boards for Theranica, Teva Pharmaceuticals, Lundbeck, and Amneal Pharmaceuticals.
A version of this article appeared on Medscape.com.
FROM HEADACHE
Pharmacologic Treatment of Chronic Migraine: A Revolution in Progress
Pharmacologic Treatment of Chronic Migraine: A Revolution in Progress
 (1) (1).jpg)
In assessing chronic medical disorders that adversely affect quality of life, including disorders such as malaria, acquired immunodeficiency syndrome, and sickle cell anemia, the World Health Organization has ranked migraine as the number 1 disorder for women. The diagnosis of chronic migraine (CM) implies an established history of migraine, including 15 or more days of headache per month. This clinical variant accounts for a disproportionate share of the public health burden generally imposed by migraine. One of the great paradoxes of migraine is that, despite this outsized burden, as few as 5% of the millions of Americans with CM seek medical attention, are diagnosed accurately, and receive appropriate therapy.
Why is this? The answer lies in part with the relatively recent formal recognition of CM as a distinct primary headache disorder. Not until the 2006 revision of the International Classification of Headache Disorders were widely accepted diagnostic criteria for CM available. Without such criteria in place, meaningful clinical research (and therapeutic research in particular) is impossible. As recently as 2009, we consequently lacked any evidence-based therapies for suppression of CM. In what may be a therapeutic revolution unrivaled in almost any other area of clinical medicine, within 15 years we have identified and introduced into general clinical practice no fewer than 6 new evidence-based therapies for suppression of CM that are safe, generally well tolerated, and effective. Those therapies are onabotulinumtoxin A, an orally administered atogepant, the 3 subcutaneously self-administered anti–calcitonin gene-related peptide (CGRP) monoclonal antibodies (erenumab, galcanezumab, and fremanezumab), and the intravenously administered anti-CGRP monoclonal antibody eptinenzumab. A seventh and older therapy, topiramate, could be included in that group, except tolerability issues reduce its utility.
As we presently lack adequate active vs active comparator trials, at this point there is no “best” among these 6 CM therapies. Each is effective in reducing migraine burden substantially in a large proportion of patients. In many cases, the onset of the positive treatment response is gratifyingly rapid. Are they disease-modifying therapies (DMTs) that, in addition to suppressing symptoms, can alter the disorder’s biologic underpinnings and its long-term course? Put another way, does their benefit extend beyond the period of time the patient is actively on treatment? Given their relative newness, the answer is unknown. However, preliminary evidence suggests that onabotulinumtoxin A may qualify as a DMT. The US Food and Drug Administration indicated onabotulinumtoxin A for CM in 2010, and it is the first of the group introduced into clinical practice.
Complicating clinical use of these 6 therapies for suppression of CM have been various proscriptions emanating from the health care insurance industry. Chief among these has been the oft-encountered mandate that, for 1 of these 6 evidence-based treatments to be authorized for coverage, the patient with CM first must fail an “adequate” trial of multiple older, generic, and less costly therapies commonly used for prophylaxis in episodic migraine. But, with the exception of frequently difficult-to-tolerate topiramate, these therapies have no meaningful evidence base for use in CM. Furthermore, some limited evidence suggests that the efficacy of the evidence-based treatments may be less robust in patients whose CM has been longstanding. Therefore, spending many months prescribing a succession of therapies lacking an evidence base seems counterproductive and contrary to the patient’s best interests, when evidence-based therapies are available. In addition, the higher cost of evidence-based therapies may be offset by their reduction in the direct medical costs that result from clinical improvement.
The American Headache Society (AHS) recently published a position statement recommending that the CGRP-targeting medications─both the small molecule gepants and the large molecule monoclonal antibodies─be considered first-line treatment for migraine prevention. An estimated 40% of patients with migraine require prevention therapy. The soundness of the AHS recommendation is especially evident in the sizeable subset of that population with CM; for treatment of CM, this list of recommended first-line therapies logically can be extended to include onabotulinumtoxin A. In their consensus statement the AHS acknowledged the relatively higher cost of these therapies but noted the resulting reduction in direct and indirect costs could justify their use.
Migraine ranks near or at the top of the list of chronic medical disorders that adversely impact public health. CM, a common variant of migraine, is particularly adept at eroding quality of life. Presently available are 6 safe and typically well-tolerated therapies, known to be effective for treating CM and potentially capable of modifying its long-term course. Although the cost of these exceeds the cost of older generic therapies commonly used for migraine prophylaxis, those older therapies generally lack any meaningful evidence base for use in CM. In addition, prescription of these older therapies may delay easing the CM patient’s migraine burden without any associated reduction in long-term net cost. Both medically and financially, a strong case can be made for designating these 6 medications as first-line therapy for CM. Insurers, the ball is now in your court.
1Department of Neurology, Inova Health/the University of Virginia School of Medicine
2Department of Neurology, UCLA School of Medicine, Los Angeles
Disclosures:
Dr John Rothrock is a specialty care physician board certified in neurology and vascular neurology at Inova Health System. He joined Inova in 2022 and has been practicing since 1984.
Dr Rothrock is actively receiving funding for an educational grant from AbbVie and funding for clinical research from AbbVie, Lundbeck, and Ipsen.
Dr Alan Rapoport is a past-president of the International Headache Society (IHS) and is also the founder and Director-Emeritus of The New England Center for Headache in Stamford, Connecticut. Dr Rapoport does not have any financial disclosures.
Corresponding Author:
John Rothrock, MD
rothrockjf@gmail.com
1Department of Neurology, Inova Health/the University of Virginia School of Medicine
2Department of Neurology, UCLA School of Medicine, Los Angeles
Disclosures:
Dr John Rothrock is a specialty care physician board certified in neurology and vascular neurology at Inova Health System. He joined Inova in 2022 and has been practicing since 1984.
Dr Rothrock is actively receiving funding for an educational grant from AbbVie and funding for clinical research from AbbVie, Lundbeck, and Ipsen.
Dr Alan Rapoport is a past-president of the International Headache Society (IHS) and is also the founder and Director-Emeritus of The New England Center for Headache in Stamford, Connecticut. Dr Rapoport does not have any financial disclosures.
Corresponding Author:
John Rothrock, MD
rothrockjf@gmail.com
1Department of Neurology, Inova Health/the University of Virginia School of Medicine
2Department of Neurology, UCLA School of Medicine, Los Angeles
Disclosures:
Dr John Rothrock is a specialty care physician board certified in neurology and vascular neurology at Inova Health System. He joined Inova in 2022 and has been practicing since 1984.
Dr Rothrock is actively receiving funding for an educational grant from AbbVie and funding for clinical research from AbbVie, Lundbeck, and Ipsen.
Dr Alan Rapoport is a past-president of the International Headache Society (IHS) and is also the founder and Director-Emeritus of The New England Center for Headache in Stamford, Connecticut. Dr Rapoport does not have any financial disclosures.
Corresponding Author:
John Rothrock, MD
rothrockjf@gmail.com
In assessing chronic medical disorders that adversely affect quality of life, including disorders such as malaria, acquired immunodeficiency syndrome, and sickle cell anemia, the World Health Organization has ranked migraine as the number 1 disorder for women. The diagnosis of chronic migraine (CM) implies an established history of migraine, including 15 or more days of headache per month. This clinical variant accounts for a disproportionate share of the public health burden generally imposed by migraine. One of the great paradoxes of migraine is that, despite this outsized burden, as few as 5% of the millions of Americans with CM seek medical attention, are diagnosed accurately, and receive appropriate therapy.
Why is this? The answer lies in part with the relatively recent formal recognition of CM as a distinct primary headache disorder. Not until the 2006 revision of the International Classification of Headache Disorders were widely accepted diagnostic criteria for CM available. Without such criteria in place, meaningful clinical research (and therapeutic research in particular) is impossible. As recently as 2009, we consequently lacked any evidence-based therapies for suppression of CM. In what may be a therapeutic revolution unrivaled in almost any other area of clinical medicine, within 15 years we have identified and introduced into general clinical practice no fewer than 6 new evidence-based therapies for suppression of CM that are safe, generally well tolerated, and effective. Those therapies are onabotulinumtoxin A, an orally administered atogepant, the 3 subcutaneously self-administered anti–calcitonin gene-related peptide (CGRP) monoclonal antibodies (erenumab, galcanezumab, and fremanezumab), and the intravenously administered anti-CGRP monoclonal antibody eptinenzumab. A seventh and older therapy, topiramate, could be included in that group, except tolerability issues reduce its utility.
As we presently lack adequate active vs active comparator trials, at this point there is no “best” among these 6 CM therapies. Each is effective in reducing migraine burden substantially in a large proportion of patients. In many cases, the onset of the positive treatment response is gratifyingly rapid. Are they disease-modifying therapies (DMTs) that, in addition to suppressing symptoms, can alter the disorder’s biologic underpinnings and its long-term course? Put another way, does their benefit extend beyond the period of time the patient is actively on treatment? Given their relative newness, the answer is unknown. However, preliminary evidence suggests that onabotulinumtoxin A may qualify as a DMT. The US Food and Drug Administration indicated onabotulinumtoxin A for CM in 2010, and it is the first of the group introduced into clinical practice.
Complicating clinical use of these 6 therapies for suppression of CM have been various proscriptions emanating from the health care insurance industry. Chief among these has been the oft-encountered mandate that, for 1 of these 6 evidence-based treatments to be authorized for coverage, the patient with CM first must fail an “adequate” trial of multiple older, generic, and less costly therapies commonly used for prophylaxis in episodic migraine. But, with the exception of frequently difficult-to-tolerate topiramate, these therapies have no meaningful evidence base for use in CM. Furthermore, some limited evidence suggests that the efficacy of the evidence-based treatments may be less robust in patients whose CM has been longstanding. Therefore, spending many months prescribing a succession of therapies lacking an evidence base seems counterproductive and contrary to the patient’s best interests, when evidence-based therapies are available. In addition, the higher cost of evidence-based therapies may be offset by their reduction in the direct medical costs that result from clinical improvement.
The American Headache Society (AHS) recently published a position statement recommending that the CGRP-targeting medications─both the small molecule gepants and the large molecule monoclonal antibodies─be considered first-line treatment for migraine prevention. An estimated 40% of patients with migraine require prevention therapy. The soundness of the AHS recommendation is especially evident in the sizeable subset of that population with CM; for treatment of CM, this list of recommended first-line therapies logically can be extended to include onabotulinumtoxin A. In their consensus statement the AHS acknowledged the relatively higher cost of these therapies but noted the resulting reduction in direct and indirect costs could justify their use.
Migraine ranks near or at the top of the list of chronic medical disorders that adversely impact public health. CM, a common variant of migraine, is particularly adept at eroding quality of life. Presently available are 6 safe and typically well-tolerated therapies, known to be effective for treating CM and potentially capable of modifying its long-term course. Although the cost of these exceeds the cost of older generic therapies commonly used for migraine prophylaxis, those older therapies generally lack any meaningful evidence base for use in CM. In addition, prescription of these older therapies may delay easing the CM patient’s migraine burden without any associated reduction in long-term net cost. Both medically and financially, a strong case can be made for designating these 6 medications as first-line therapy for CM. Insurers, the ball is now in your court.
In assessing chronic medical disorders that adversely affect quality of life, including disorders such as malaria, acquired immunodeficiency syndrome, and sickle cell anemia, the World Health Organization has ranked migraine as the number 1 disorder for women. The diagnosis of chronic migraine (CM) implies an established history of migraine, including 15 or more days of headache per month. This clinical variant accounts for a disproportionate share of the public health burden generally imposed by migraine. One of the great paradoxes of migraine is that, despite this outsized burden, as few as 5% of the millions of Americans with CM seek medical attention, are diagnosed accurately, and receive appropriate therapy.
Why is this? The answer lies in part with the relatively recent formal recognition of CM as a distinct primary headache disorder. Not until the 2006 revision of the International Classification of Headache Disorders were widely accepted diagnostic criteria for CM available. Without such criteria in place, meaningful clinical research (and therapeutic research in particular) is impossible. As recently as 2009, we consequently lacked any evidence-based therapies for suppression of CM. In what may be a therapeutic revolution unrivaled in almost any other area of clinical medicine, within 15 years we have identified and introduced into general clinical practice no fewer than 6 new evidence-based therapies for suppression of CM that are safe, generally well tolerated, and effective. Those therapies are onabotulinumtoxin A, an orally administered atogepant, the 3 subcutaneously self-administered anti–calcitonin gene-related peptide (CGRP) monoclonal antibodies (erenumab, galcanezumab, and fremanezumab), and the intravenously administered anti-CGRP monoclonal antibody eptinenzumab. A seventh and older therapy, topiramate, could be included in that group, except tolerability issues reduce its utility.
As we presently lack adequate active vs active comparator trials, at this point there is no “best” among these 6 CM therapies. Each is effective in reducing migraine burden substantially in a large proportion of patients. In many cases, the onset of the positive treatment response is gratifyingly rapid. Are they disease-modifying therapies (DMTs) that, in addition to suppressing symptoms, can alter the disorder’s biologic underpinnings and its long-term course? Put another way, does their benefit extend beyond the period of time the patient is actively on treatment? Given their relative newness, the answer is unknown. However, preliminary evidence suggests that onabotulinumtoxin A may qualify as a DMT. The US Food and Drug Administration indicated onabotulinumtoxin A for CM in 2010, and it is the first of the group introduced into clinical practice.
Complicating clinical use of these 6 therapies for suppression of CM have been various proscriptions emanating from the health care insurance industry. Chief among these has been the oft-encountered mandate that, for 1 of these 6 evidence-based treatments to be authorized for coverage, the patient with CM first must fail an “adequate” trial of multiple older, generic, and less costly therapies commonly used for prophylaxis in episodic migraine. But, with the exception of frequently difficult-to-tolerate topiramate, these therapies have no meaningful evidence base for use in CM. Furthermore, some limited evidence suggests that the efficacy of the evidence-based treatments may be less robust in patients whose CM has been longstanding. Therefore, spending many months prescribing a succession of therapies lacking an evidence base seems counterproductive and contrary to the patient’s best interests, when evidence-based therapies are available. In addition, the higher cost of evidence-based therapies may be offset by their reduction in the direct medical costs that result from clinical improvement.
The American Headache Society (AHS) recently published a position statement recommending that the CGRP-targeting medications─both the small molecule gepants and the large molecule monoclonal antibodies─be considered first-line treatment for migraine prevention. An estimated 40% of patients with migraine require prevention therapy. The soundness of the AHS recommendation is especially evident in the sizeable subset of that population with CM; for treatment of CM, this list of recommended first-line therapies logically can be extended to include onabotulinumtoxin A. In their consensus statement the AHS acknowledged the relatively higher cost of these therapies but noted the resulting reduction in direct and indirect costs could justify their use.
Migraine ranks near or at the top of the list of chronic medical disorders that adversely impact public health. CM, a common variant of migraine, is particularly adept at eroding quality of life. Presently available are 6 safe and typically well-tolerated therapies, known to be effective for treating CM and potentially capable of modifying its long-term course. Although the cost of these exceeds the cost of older generic therapies commonly used for migraine prophylaxis, those older therapies generally lack any meaningful evidence base for use in CM. In addition, prescription of these older therapies may delay easing the CM patient’s migraine burden without any associated reduction in long-term net cost. Both medically and financially, a strong case can be made for designating these 6 medications as first-line therapy for CM. Insurers, the ball is now in your court.
Pharmacologic Treatment of Chronic Migraine: A Revolution in Progress
Pharmacologic Treatment of Chronic Migraine: A Revolution in Progress
No Benefit to High-Dose IV Vs Oral Steroids in Giant Cell Arteritis
TOPLINE:
In patients with giant cell arteritis (GCA), intravenous methylprednisolone compared with oral glucocorticoids alone does not improve visual acuity and increases the risk for diabetes within the first year. Survival rates do not differ with these two treatments.
METHODOLOGY:
- Researchers conducted a population-based retrospective study at three centers in Sweden to assess the clinical characteristics, treatment-related toxicity, and mortality in patients with GCA who were receiving high-dose intravenous methylprednisolone.
- A total of 419 patients with biopsy-confirmed GCA (mean age at diagnosis, 75 years; 69% women) diagnosed from 2004 to 2019 were included.
- Patients were treated with either intravenous methylprednisolone (n = 111) at a dose of 500-1000 mg per day for 3 consecutive days or oral glucocorticoids alone (n = 308).
- Ischemic visual complications considered to indicate visual involvement were confirmed by an ophthalmologist, and data on visual acuity were collected from ophthalmologic clinic records at initial consultations and follow-up at 3-18 months.
TAKEAWAY:
- Despite a tendency toward improvement, no significant difference in visual acuity was observed with intravenous methylprednisolone compared with oral glucocorticoids.
- Patients treated with intravenous methylprednisolone had a higher risk for newly diagnosed diabetes within a year of GCA diagnosis (odds ratio [OR], 2.59; P = .01).
- The risk for diabetes remained elevated even after adjustment for the cumulative oral glucocorticoid dose at 3 months (adjusted OR, 3.30; P = .01).
- Survival rates did not significantly differ between the treatment groups over a mean follow-up of 6.6 years.
IN PRACTICE:
“In this study on the use of intravenous methylprednisolone treatment in GCA, we found no evidence of a beneficial effect in improving visual acuity or enabling more rapid tapering of the oral glucocorticoid dose,” the authors wrote. “The use of IVMP [intravenous methylprednisolone] was associated with an increased risk of diabetes during the first year compared with oral GC [glucocorticoid], raising questions about the value of IVMP in GCA treatment.”
SOURCE:
The study, led by Hampus Henningson, Department of Clinical Sciences, Rheumatology, Lund University, Lund, Sweden, was published online in Rheumatology.
LIMITATIONS:
The retrospective nature of the study may have resulted in missing data and difficulty in accurately quantifying the cumulative glucocorticoid doses. The study did not validate the diagnoses of comorbidities but relied solely on diagnostic codes.
DISCLOSURES:
This study was supported by the Swedish Research Council, Swedish Rheumatism Association, Swedish Medical Society, Alfred Österlund’s Foundation, and King Gustaf V’s 80-year foundation. The authors declared no conflicts of interest.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
TOPLINE:
In patients with giant cell arteritis (GCA), intravenous methylprednisolone compared with oral glucocorticoids alone does not improve visual acuity and increases the risk for diabetes within the first year. Survival rates do not differ with these two treatments.
METHODOLOGY:
- Researchers conducted a population-based retrospective study at three centers in Sweden to assess the clinical characteristics, treatment-related toxicity, and mortality in patients with GCA who were receiving high-dose intravenous methylprednisolone.
- A total of 419 patients with biopsy-confirmed GCA (mean age at diagnosis, 75 years; 69% women) diagnosed from 2004 to 2019 were included.
- Patients were treated with either intravenous methylprednisolone (n = 111) at a dose of 500-1000 mg per day for 3 consecutive days or oral glucocorticoids alone (n = 308).
- Ischemic visual complications considered to indicate visual involvement were confirmed by an ophthalmologist, and data on visual acuity were collected from ophthalmologic clinic records at initial consultations and follow-up at 3-18 months.
TAKEAWAY:
- Despite a tendency toward improvement, no significant difference in visual acuity was observed with intravenous methylprednisolone compared with oral glucocorticoids.
- Patients treated with intravenous methylprednisolone had a higher risk for newly diagnosed diabetes within a year of GCA diagnosis (odds ratio [OR], 2.59; P = .01).
- The risk for diabetes remained elevated even after adjustment for the cumulative oral glucocorticoid dose at 3 months (adjusted OR, 3.30; P = .01).
- Survival rates did not significantly differ between the treatment groups over a mean follow-up of 6.6 years.
IN PRACTICE:
“In this study on the use of intravenous methylprednisolone treatment in GCA, we found no evidence of a beneficial effect in improving visual acuity or enabling more rapid tapering of the oral glucocorticoid dose,” the authors wrote. “The use of IVMP [intravenous methylprednisolone] was associated with an increased risk of diabetes during the first year compared with oral GC [glucocorticoid], raising questions about the value of IVMP in GCA treatment.”
SOURCE:
The study, led by Hampus Henningson, Department of Clinical Sciences, Rheumatology, Lund University, Lund, Sweden, was published online in Rheumatology.
LIMITATIONS:
The retrospective nature of the study may have resulted in missing data and difficulty in accurately quantifying the cumulative glucocorticoid doses. The study did not validate the diagnoses of comorbidities but relied solely on diagnostic codes.
DISCLOSURES:
This study was supported by the Swedish Research Council, Swedish Rheumatism Association, Swedish Medical Society, Alfred Österlund’s Foundation, and King Gustaf V’s 80-year foundation. The authors declared no conflicts of interest.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
TOPLINE:
In patients with giant cell arteritis (GCA), intravenous methylprednisolone compared with oral glucocorticoids alone does not improve visual acuity and increases the risk for diabetes within the first year. Survival rates do not differ with these two treatments.
METHODOLOGY:
- Researchers conducted a population-based retrospective study at three centers in Sweden to assess the clinical characteristics, treatment-related toxicity, and mortality in patients with GCA who were receiving high-dose intravenous methylprednisolone.
- A total of 419 patients with biopsy-confirmed GCA (mean age at diagnosis, 75 years; 69% women) diagnosed from 2004 to 2019 were included.
- Patients were treated with either intravenous methylprednisolone (n = 111) at a dose of 500-1000 mg per day for 3 consecutive days or oral glucocorticoids alone (n = 308).
- Ischemic visual complications considered to indicate visual involvement were confirmed by an ophthalmologist, and data on visual acuity were collected from ophthalmologic clinic records at initial consultations and follow-up at 3-18 months.
TAKEAWAY:
- Despite a tendency toward improvement, no significant difference in visual acuity was observed with intravenous methylprednisolone compared with oral glucocorticoids.
- Patients treated with intravenous methylprednisolone had a higher risk for newly diagnosed diabetes within a year of GCA diagnosis (odds ratio [OR], 2.59; P = .01).
- The risk for diabetes remained elevated even after adjustment for the cumulative oral glucocorticoid dose at 3 months (adjusted OR, 3.30; P = .01).
- Survival rates did not significantly differ between the treatment groups over a mean follow-up of 6.6 years.
IN PRACTICE:
“In this study on the use of intravenous methylprednisolone treatment in GCA, we found no evidence of a beneficial effect in improving visual acuity or enabling more rapid tapering of the oral glucocorticoid dose,” the authors wrote. “The use of IVMP [intravenous methylprednisolone] was associated with an increased risk of diabetes during the first year compared with oral GC [glucocorticoid], raising questions about the value of IVMP in GCA treatment.”
SOURCE:
The study, led by Hampus Henningson, Department of Clinical Sciences, Rheumatology, Lund University, Lund, Sweden, was published online in Rheumatology.
LIMITATIONS:
The retrospective nature of the study may have resulted in missing data and difficulty in accurately quantifying the cumulative glucocorticoid doses. The study did not validate the diagnoses of comorbidities but relied solely on diagnostic codes.
DISCLOSURES:
This study was supported by the Swedish Research Council, Swedish Rheumatism Association, Swedish Medical Society, Alfred Österlund’s Foundation, and King Gustaf V’s 80-year foundation. The authors declared no conflicts of interest.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
Commentary: Comparing Migraine Treatments, November 2024
With increasing options for migraine therapy, the right choice for each patient might not be clear. And many individual patients could experience relief from any of the different choices, meaning that there is often more than one “right” answer when it comes to selecting a migraine treatment approach for each patient. Triptans and nonsteroidal anti-inflammatory drugs (NSAIDs), which have been around for decades, have shown consistent success in treating migraine episodes. Newer therapies could be safer for patients who have contraindications to triptans or NSAIDs, and these newer medications could be more effective for some patients, but we are still trying to fully understand which types of patients. Studies aimed at reaching conclusions regarding comparisons between triptans, calcitonin gene-related peptide inhibitors (CGRPi), and other treatments can help us determine which of the different categories of treatments are most effective for certain migraine populations (age or migraine subtype) or indications (acute vs preventive therapy).
A review published in 2023 in Aging and Disease described several markers of aging that are associated with migraine, including epigenetic aging and oxidative stress.2 The review authors noted that markers of cellular senescence (ie, irreversible inhibition of cellular division) were increased in association with migraine. Additionally, endothelial progenitor cells, which reflect an increased ability for cell renewal, were decreased among migraine patients compared with the control group.
Telomeres, composed of nucleotides, are part of chromosome structures, serving to protect the molecular integrity of DNA. It has been established that shortened telomeres, often considered a reflection of aging and a marker of high potential for genetic and cellular damage, are a risk factor for physiologic changes that occur with the aging process. The 2024 Scientific Reports cross-sectional study included data from 6169 participants in the National Health and Nutrition Survey (NHANES) from 1999 to 2002.1 The researchers used statistical analysis to determine whether there was an age-influenced telomere length in relation to migraine. They found that “telomere length was inversely associated with migraine risk in those aged 20-50 years, while no relationship was observed in those aged > 50 years.” The significance of this association among the younger group, but not among the older group, is not clear.
The limited research regarding the links between migraine and physiologic markers of aging has not untangled cause-and-effect distinctions. And while there is no evidence that preventing or treating migraine could slow down these pro-aging molecular processes, we do know that the distress of migraine episodes contributes to pain, anxiety, stress, depression, and sleep disruption. Given that we can’t change a patient’s hereditary predisposition to migraines, we can make an effort to alleviate the impact of migraine by using the tools that we have.
An article published in September 2024 in the BMJ described the results of a meta-analysis that included “137 randomized controlled trials with 89,445 participants allocated to 1 of 17 active interventions or placebo.”3 Treatments included NSAIDs, paracetamol, triptans, and CGRPi. The authors observed that triptans “had the best profiles and were more efficacious” than other treatment categories, including CGRPi. Interestingly, they observed that eletriptan and ibuprofen performed better for sustained pain freedom. Efficacy and sustained relief are crucial for patients with migraine, and for those who experience relief with simple over-the-counter ibuprofen, it makes sense to avoid making changes. But for those who are not getting the relief they need with established migraine therapies, trying the newer medications, such as CGRPi, could provide a solution. It is also important to keep in mind that triptans are contraindicated for some patients, such as those with a high-risk cardiovascular profile. Additionally, some patients may have contraindications to NSAIDs.
Prevention is another important aspect of migraine care. A September 2024 article in Headache: The Journal of Head and Face Pain used a retrospective cohort analysis of Patient-Reported Outcomes Measurement Information System (PROMIS) data, which included 1245 patients using a variety of migraine preventive therapies: antidepressants, antiseizure medications, beta-blockers, and CGRPi.4 The researchers reported that patients taking “CGRPi had a statistically significant reduction in pain T-scores (60.4 [standard deviation (SD) 7.4] to 58.4 [SD 8.2], p = 0.003), especially those who switched from other preventative medications to CGRPi.” This, along with the BMJ meta-analysis,3 helps in assessing relative benefits for treatments of acute migraine episodes and for migraine prevention. However, the efficacy of various types of therapy highlights the value of considering all options for each patient.
Individual patient characteristics, particularly contraindications, also play an important role in guiding therapeutic selection. And trial and error remain part of migraine treatment, given that there are no pretesting determinants that can predict treatment success for individual patients. We need to emphasize to patients that effective migraine therapy is obtainable and important — for comfort, quality of life, and possibly overall healthy aging.
References
- Geng D, Liu H, Wang H, Wang H. Telomere length exhibits inverse association with migraine among Americans aged 20-50 years, without implications beyond age 50: a cross-sectional study. Sci Rep. 2024;14:22597. Source
- Fila M, Pawlowska E, Szczepanska J, Blasiak J. Different aspects of aging in migraine. Aging Dis. 2023;14:6. Source
- Karlsson WK, Ostinelli EG, Zhuang ZA, et al. Comparative effects of drug interventions for the acute management of migraine episodes in adults: Systematic review and network meta-analysis. BMJ. 2024;386:e080107. Source
- Peasah SK, Soh YH, Huang Y, Nguyen J, Hanmer J, Good C. Patient reported outcomes and real-world use of calcitonin gene-related peptide medications in migraine. Headache. Published online September 30, 202 Source
With increasing options for migraine therapy, the right choice for each patient might not be clear. And many individual patients could experience relief from any of the different choices, meaning that there is often more than one “right” answer when it comes to selecting a migraine treatment approach for each patient. Triptans and nonsteroidal anti-inflammatory drugs (NSAIDs), which have been around for decades, have shown consistent success in treating migraine episodes. Newer therapies could be safer for patients who have contraindications to triptans or NSAIDs, and these newer medications could be more effective for some patients, but we are still trying to fully understand which types of patients. Studies aimed at reaching conclusions regarding comparisons between triptans, calcitonin gene-related peptide inhibitors (CGRPi), and other treatments can help us determine which of the different categories of treatments are most effective for certain migraine populations (age or migraine subtype) or indications (acute vs preventive therapy).
A review published in 2023 in Aging and Disease described several markers of aging that are associated with migraine, including epigenetic aging and oxidative stress.2 The review authors noted that markers of cellular senescence (ie, irreversible inhibition of cellular division) were increased in association with migraine. Additionally, endothelial progenitor cells, which reflect an increased ability for cell renewal, were decreased among migraine patients compared with the control group.
Telomeres, composed of nucleotides, are part of chromosome structures, serving to protect the molecular integrity of DNA. It has been established that shortened telomeres, often considered a reflection of aging and a marker of high potential for genetic and cellular damage, are a risk factor for physiologic changes that occur with the aging process. The 2024 Scientific Reports cross-sectional study included data from 6169 participants in the National Health and Nutrition Survey (NHANES) from 1999 to 2002.1 The researchers used statistical analysis to determine whether there was an age-influenced telomere length in relation to migraine. They found that “telomere length was inversely associated with migraine risk in those aged 20-50 years, while no relationship was observed in those aged > 50 years.” The significance of this association among the younger group, but not among the older group, is not clear.
The limited research regarding the links between migraine and physiologic markers of aging has not untangled cause-and-effect distinctions. And while there is no evidence that preventing or treating migraine could slow down these pro-aging molecular processes, we do know that the distress of migraine episodes contributes to pain, anxiety, stress, depression, and sleep disruption. Given that we can’t change a patient’s hereditary predisposition to migraines, we can make an effort to alleviate the impact of migraine by using the tools that we have.
An article published in September 2024 in the BMJ described the results of a meta-analysis that included “137 randomized controlled trials with 89,445 participants allocated to 1 of 17 active interventions or placebo.”3 Treatments included NSAIDs, paracetamol, triptans, and CGRPi. The authors observed that triptans “had the best profiles and were more efficacious” than other treatment categories, including CGRPi. Interestingly, they observed that eletriptan and ibuprofen performed better for sustained pain freedom. Efficacy and sustained relief are crucial for patients with migraine, and for those who experience relief with simple over-the-counter ibuprofen, it makes sense to avoid making changes. But for those who are not getting the relief they need with established migraine therapies, trying the newer medications, such as CGRPi, could provide a solution. It is also important to keep in mind that triptans are contraindicated for some patients, such as those with a high-risk cardiovascular profile. Additionally, some patients may have contraindications to NSAIDs.
Prevention is another important aspect of migraine care. A September 2024 article in Headache: The Journal of Head and Face Pain used a retrospective cohort analysis of Patient-Reported Outcomes Measurement Information System (PROMIS) data, which included 1245 patients using a variety of migraine preventive therapies: antidepressants, antiseizure medications, beta-blockers, and CGRPi.4 The researchers reported that patients taking “CGRPi had a statistically significant reduction in pain T-scores (60.4 [standard deviation (SD) 7.4] to 58.4 [SD 8.2], p = 0.003), especially those who switched from other preventative medications to CGRPi.” This, along with the BMJ meta-analysis,3 helps in assessing relative benefits for treatments of acute migraine episodes and for migraine prevention. However, the efficacy of various types of therapy highlights the value of considering all options for each patient.
Individual patient characteristics, particularly contraindications, also play an important role in guiding therapeutic selection. And trial and error remain part of migraine treatment, given that there are no pretesting determinants that can predict treatment success for individual patients. We need to emphasize to patients that effective migraine therapy is obtainable and important — for comfort, quality of life, and possibly overall healthy aging.
References
- Geng D, Liu H, Wang H, Wang H. Telomere length exhibits inverse association with migraine among Americans aged 20-50 years, without implications beyond age 50: a cross-sectional study. Sci Rep. 2024;14:22597. Source
- Fila M, Pawlowska E, Szczepanska J, Blasiak J. Different aspects of aging in migraine. Aging Dis. 2023;14:6. Source
- Karlsson WK, Ostinelli EG, Zhuang ZA, et al. Comparative effects of drug interventions for the acute management of migraine episodes in adults: Systematic review and network meta-analysis. BMJ. 2024;386:e080107. Source
- Peasah SK, Soh YH, Huang Y, Nguyen J, Hanmer J, Good C. Patient reported outcomes and real-world use of calcitonin gene-related peptide medications in migraine. Headache. Published online September 30, 202 Source
With increasing options for migraine therapy, the right choice for each patient might not be clear. And many individual patients could experience relief from any of the different choices, meaning that there is often more than one “right” answer when it comes to selecting a migraine treatment approach for each patient. Triptans and nonsteroidal anti-inflammatory drugs (NSAIDs), which have been around for decades, have shown consistent success in treating migraine episodes. Newer therapies could be safer for patients who have contraindications to triptans or NSAIDs, and these newer medications could be more effective for some patients, but we are still trying to fully understand which types of patients. Studies aimed at reaching conclusions regarding comparisons between triptans, calcitonin gene-related peptide inhibitors (CGRPi), and other treatments can help us determine which of the different categories of treatments are most effective for certain migraine populations (age or migraine subtype) or indications (acute vs preventive therapy).
A review published in 2023 in Aging and Disease described several markers of aging that are associated with migraine, including epigenetic aging and oxidative stress.2 The review authors noted that markers of cellular senescence (ie, irreversible inhibition of cellular division) were increased in association with migraine. Additionally, endothelial progenitor cells, which reflect an increased ability for cell renewal, were decreased among migraine patients compared with the control group.
Telomeres, composed of nucleotides, are part of chromosome structures, serving to protect the molecular integrity of DNA. It has been established that shortened telomeres, often considered a reflection of aging and a marker of high potential for genetic and cellular damage, are a risk factor for physiologic changes that occur with the aging process. The 2024 Scientific Reports cross-sectional study included data from 6169 participants in the National Health and Nutrition Survey (NHANES) from 1999 to 2002.1 The researchers used statistical analysis to determine whether there was an age-influenced telomere length in relation to migraine. They found that “telomere length was inversely associated with migraine risk in those aged 20-50 years, while no relationship was observed in those aged > 50 years.” The significance of this association among the younger group, but not among the older group, is not clear.
The limited research regarding the links between migraine and physiologic markers of aging has not untangled cause-and-effect distinctions. And while there is no evidence that preventing or treating migraine could slow down these pro-aging molecular processes, we do know that the distress of migraine episodes contributes to pain, anxiety, stress, depression, and sleep disruption. Given that we can’t change a patient’s hereditary predisposition to migraines, we can make an effort to alleviate the impact of migraine by using the tools that we have.
An article published in September 2024 in the BMJ described the results of a meta-analysis that included “137 randomized controlled trials with 89,445 participants allocated to 1 of 17 active interventions or placebo.”3 Treatments included NSAIDs, paracetamol, triptans, and CGRPi. The authors observed that triptans “had the best profiles and were more efficacious” than other treatment categories, including CGRPi. Interestingly, they observed that eletriptan and ibuprofen performed better for sustained pain freedom. Efficacy and sustained relief are crucial for patients with migraine, and for those who experience relief with simple over-the-counter ibuprofen, it makes sense to avoid making changes. But for those who are not getting the relief they need with established migraine therapies, trying the newer medications, such as CGRPi, could provide a solution. It is also important to keep in mind that triptans are contraindicated for some patients, such as those with a high-risk cardiovascular profile. Additionally, some patients may have contraindications to NSAIDs.
Prevention is another important aspect of migraine care. A September 2024 article in Headache: The Journal of Head and Face Pain used a retrospective cohort analysis of Patient-Reported Outcomes Measurement Information System (PROMIS) data, which included 1245 patients using a variety of migraine preventive therapies: antidepressants, antiseizure medications, beta-blockers, and CGRPi.4 The researchers reported that patients taking “CGRPi had a statistically significant reduction in pain T-scores (60.4 [standard deviation (SD) 7.4] to 58.4 [SD 8.2], p = 0.003), especially those who switched from other preventative medications to CGRPi.” This, along with the BMJ meta-analysis,3 helps in assessing relative benefits for treatments of acute migraine episodes and for migraine prevention. However, the efficacy of various types of therapy highlights the value of considering all options for each patient.
Individual patient characteristics, particularly contraindications, also play an important role in guiding therapeutic selection. And trial and error remain part of migraine treatment, given that there are no pretesting determinants that can predict treatment success for individual patients. We need to emphasize to patients that effective migraine therapy is obtainable and important — for comfort, quality of life, and possibly overall healthy aging.
References
- Geng D, Liu H, Wang H, Wang H. Telomere length exhibits inverse association with migraine among Americans aged 20-50 years, without implications beyond age 50: a cross-sectional study. Sci Rep. 2024;14:22597. Source
- Fila M, Pawlowska E, Szczepanska J, Blasiak J. Different aspects of aging in migraine. Aging Dis. 2023;14:6. Source
- Karlsson WK, Ostinelli EG, Zhuang ZA, et al. Comparative effects of drug interventions for the acute management of migraine episodes in adults: Systematic review and network meta-analysis. BMJ. 2024;386:e080107. Source
- Peasah SK, Soh YH, Huang Y, Nguyen J, Hanmer J, Good C. Patient reported outcomes and real-world use of calcitonin gene-related peptide medications in migraine. Headache. Published online September 30, 202 Source
Diabetes and Migraine May Have a Bidirectional Link
Key clinical point: Diabetes may have a bidirectional association with migraine risk. Type 1 diabetes (T1D) reduced the risk for migraine, whereas migraine without aura increased the risk for diabetes.
Major findings: Diabetes did not significantly affect the overall risk for migraine (odds ratio [OR], 0.85; P = .13). However, individuals with T1D had a lower risk for migraine (OR, 0.48; P = .002) than those without diabetes. Conversely, migraine did not significantly increase the risk for diabetes (OR, 1.00, P = .99), but individuals with migraine without aura had a higher risk for diabetes (OR, 1.19; P = .03) than those without migraine.
Study details: This meta-analysis included eight cross-sectional studies (131,361 patients with diabetes and 1,005,604 patients with migraine) and four cohort studies (103,205 patients with diabetes and 32,197 patients with migraine).
Disclosure: The study was funded by the Ministry of Health & Welfare, Republic of Korea, and the National Research Foundation of Korea. One author is a junior editor at The Journal of Headache and Pain, and another serves on its board and has received grants from the Korea Health Industry Development Institute.
Source: Ha WS, Nguyen VK, Chu MK. Epidemiological linkage between migraine and diabetes mellitus: A systematic review and meta-analysis. J Headache Pain. 2024;25:158. Source
Key clinical point: Diabetes may have a bidirectional association with migraine risk. Type 1 diabetes (T1D) reduced the risk for migraine, whereas migraine without aura increased the risk for diabetes.
Major findings: Diabetes did not significantly affect the overall risk for migraine (odds ratio [OR], 0.85; P = .13). However, individuals with T1D had a lower risk for migraine (OR, 0.48; P = .002) than those without diabetes. Conversely, migraine did not significantly increase the risk for diabetes (OR, 1.00, P = .99), but individuals with migraine without aura had a higher risk for diabetes (OR, 1.19; P = .03) than those without migraine.
Study details: This meta-analysis included eight cross-sectional studies (131,361 patients with diabetes and 1,005,604 patients with migraine) and four cohort studies (103,205 patients with diabetes and 32,197 patients with migraine).
Disclosure: The study was funded by the Ministry of Health & Welfare, Republic of Korea, and the National Research Foundation of Korea. One author is a junior editor at The Journal of Headache and Pain, and another serves on its board and has received grants from the Korea Health Industry Development Institute.
Source: Ha WS, Nguyen VK, Chu MK. Epidemiological linkage between migraine and diabetes mellitus: A systematic review and meta-analysis. J Headache Pain. 2024;25:158. Source
Key clinical point: Diabetes may have a bidirectional association with migraine risk. Type 1 diabetes (T1D) reduced the risk for migraine, whereas migraine without aura increased the risk for diabetes.
Major findings: Diabetes did not significantly affect the overall risk for migraine (odds ratio [OR], 0.85; P = .13). However, individuals with T1D had a lower risk for migraine (OR, 0.48; P = .002) than those without diabetes. Conversely, migraine did not significantly increase the risk for diabetes (OR, 1.00, P = .99), but individuals with migraine without aura had a higher risk for diabetes (OR, 1.19; P = .03) than those without migraine.
Study details: This meta-analysis included eight cross-sectional studies (131,361 patients with diabetes and 1,005,604 patients with migraine) and four cohort studies (103,205 patients with diabetes and 32,197 patients with migraine).
Disclosure: The study was funded by the Ministry of Health & Welfare, Republic of Korea, and the National Research Foundation of Korea. One author is a junior editor at The Journal of Headache and Pain, and another serves on its board and has received grants from the Korea Health Industry Development Institute.
Source: Ha WS, Nguyen VK, Chu MK. Epidemiological linkage between migraine and diabetes mellitus: A systematic review and meta-analysis. J Headache Pain. 2024;25:158. Source
Long-Term Safety of Dihydroergotamine Nasal Powder for Acute Treatment of Migraine
Key clinical point: Dihydroergotamine (DHE) nasal powder was well tolerated over the long term for the acute treatment of migraine.
Major findings: Treatment-emergent adverse events were reported in 48.5% of the participants, with nasal discomfort being the most common (11.3%). No deaths were reported. A serious adverse event related to treatment occurred in only one participant who did not disclose contraindications to DHE, and 4.4% of the participants discontinued the use of DHE. There were no new safety concerns.
Study details: The ASCEND trial involved 344 adults aged 18-65 years with a history of 4-12 migraine attacks per month for at least 1 year. Participants self-administered DHE (5.2 mg) as needed, with a maximum of 12 doses per month, for 1 year.
Disclosure: This study was funded by Satsuma Pharmaceuticals, Inc. Two authors declared being employees and stockholders of Satsuma, and others declared having ties with various sources, including Satsuma.
Sources: Tepper SJ, Albrecht D, Ailani J. Kirby L, Strom S, Rapoport AM. Long-term (12-Month) safety and tolerability of STS101 (dihydroergotamine nasal powder) in the acute treatment of migraine: Data from the phase 3 open-label ASCEND study. CNS Drugs. Published online October 7, 2024. Source
Key clinical point: Dihydroergotamine (DHE) nasal powder was well tolerated over the long term for the acute treatment of migraine.
Major findings: Treatment-emergent adverse events were reported in 48.5% of the participants, with nasal discomfort being the most common (11.3%). No deaths were reported. A serious adverse event related to treatment occurred in only one participant who did not disclose contraindications to DHE, and 4.4% of the participants discontinued the use of DHE. There were no new safety concerns.
Study details: The ASCEND trial involved 344 adults aged 18-65 years with a history of 4-12 migraine attacks per month for at least 1 year. Participants self-administered DHE (5.2 mg) as needed, with a maximum of 12 doses per month, for 1 year.
Disclosure: This study was funded by Satsuma Pharmaceuticals, Inc. Two authors declared being employees and stockholders of Satsuma, and others declared having ties with various sources, including Satsuma.
Sources: Tepper SJ, Albrecht D, Ailani J. Kirby L, Strom S, Rapoport AM. Long-term (12-Month) safety and tolerability of STS101 (dihydroergotamine nasal powder) in the acute treatment of migraine: Data from the phase 3 open-label ASCEND study. CNS Drugs. Published online October 7, 2024. Source
Key clinical point: Dihydroergotamine (DHE) nasal powder was well tolerated over the long term for the acute treatment of migraine.
Major findings: Treatment-emergent adverse events were reported in 48.5% of the participants, with nasal discomfort being the most common (11.3%). No deaths were reported. A serious adverse event related to treatment occurred in only one participant who did not disclose contraindications to DHE, and 4.4% of the participants discontinued the use of DHE. There were no new safety concerns.
Study details: The ASCEND trial involved 344 adults aged 18-65 years with a history of 4-12 migraine attacks per month for at least 1 year. Participants self-administered DHE (5.2 mg) as needed, with a maximum of 12 doses per month, for 1 year.
Disclosure: This study was funded by Satsuma Pharmaceuticals, Inc. Two authors declared being employees and stockholders of Satsuma, and others declared having ties with various sources, including Satsuma.
Sources: Tepper SJ, Albrecht D, Ailani J. Kirby L, Strom S, Rapoport AM. Long-term (12-Month) safety and tolerability of STS101 (dihydroergotamine nasal powder) in the acute treatment of migraine: Data from the phase 3 open-label ASCEND study. CNS Drugs. Published online October 7, 2024. Source
CGRP Inhibitors Outperform Other Migraine-Preventive Medications
Key clinical point: Patients with migraine who received calcitonin gene-related peptide inhibitors (CGRPi) showed improved pain reduction compared with those on other preventative medications.
Major findings: Patients who received only CGRPi or switched to CGRPi had significant reductions in mean pain scores (−2.0 and −2.7, respectively; both P < .001), whereas those on other migraine-preventative medications did not. Patients adhering to CGRPi, including those who received only CGRPi (−3.1; P = .005) and those who switched from other medications to CGRPi (−3.7; P = .002), had significantly reduced pain scores; however, no reduction in pain scores was noted in patients not adhering to CGRPi.
Study details: This retrospective study analyzed Patient Reported Outcomes Measurement Information System data for adults with migraine over 12 months, including 1245 patients on other preventive medications (antiseizures, antidepressants, or beta-blockers), 148 receiving only CGRPi, and 112 switching to CGRPi.
Disclosure: The study did not receive any funding. The authors declared no conflicts of interest.
Source: Peasah SK, Soh YH, Huang Y, Nguyen J, Hanmer J, Good C. Patient reported outcomes and the real-world use of calcitonin gene–related peptide medications in migraine. Headache. Published online September 30, 2024. Source
Key clinical point: Patients with migraine who received calcitonin gene-related peptide inhibitors (CGRPi) showed improved pain reduction compared with those on other preventative medications.
Major findings: Patients who received only CGRPi or switched to CGRPi had significant reductions in mean pain scores (−2.0 and −2.7, respectively; both P < .001), whereas those on other migraine-preventative medications did not. Patients adhering to CGRPi, including those who received only CGRPi (−3.1; P = .005) and those who switched from other medications to CGRPi (−3.7; P = .002), had significantly reduced pain scores; however, no reduction in pain scores was noted in patients not adhering to CGRPi.
Study details: This retrospective study analyzed Patient Reported Outcomes Measurement Information System data for adults with migraine over 12 months, including 1245 patients on other preventive medications (antiseizures, antidepressants, or beta-blockers), 148 receiving only CGRPi, and 112 switching to CGRPi.
Disclosure: The study did not receive any funding. The authors declared no conflicts of interest.
Source: Peasah SK, Soh YH, Huang Y, Nguyen J, Hanmer J, Good C. Patient reported outcomes and the real-world use of calcitonin gene–related peptide medications in migraine. Headache. Published online September 30, 2024. Source
Key clinical point: Patients with migraine who received calcitonin gene-related peptide inhibitors (CGRPi) showed improved pain reduction compared with those on other preventative medications.
Major findings: Patients who received only CGRPi or switched to CGRPi had significant reductions in mean pain scores (−2.0 and −2.7, respectively; both P < .001), whereas those on other migraine-preventative medications did not. Patients adhering to CGRPi, including those who received only CGRPi (−3.1; P = .005) and those who switched from other medications to CGRPi (−3.7; P = .002), had significantly reduced pain scores; however, no reduction in pain scores was noted in patients not adhering to CGRPi.
Study details: This retrospective study analyzed Patient Reported Outcomes Measurement Information System data for adults with migraine over 12 months, including 1245 patients on other preventive medications (antiseizures, antidepressants, or beta-blockers), 148 receiving only CGRPi, and 112 switching to CGRPi.
Disclosure: The study did not receive any funding. The authors declared no conflicts of interest.
Source: Peasah SK, Soh YH, Huang Y, Nguyen J, Hanmer J, Good C. Patient reported outcomes and the real-world use of calcitonin gene–related peptide medications in migraine. Headache. Published online September 30, 2024. Source
Ubrogepant Offers Relief From Acute Migraine
Key clinical point: Ubrogepant showed real-world effectiveness for the acute treatment of migraine, with increased treatment satisfaction and a strong intention to continue using the medication.
Major findings: A high proportion of patients reported using ubrogepant for relief from migraine, with satisfaction rates of 75.8% at 2 hours, 83.4% at 4 hours, and 78.5% at 24 hours. Additionally, 85.1% were satisfied with their ability to think clearly and 83.8% were satisfied with returning to normal function. Overall, 90.7% participants intended to continue using ubrogepant and 87.4% reported switching to ubrogepant due to inadequate response to previous migraine treatments.
Study details: This observational cross-sectional study included 302 adults who had received ubrogepant for the acute treatment of migraine within the preceding 14 days; 120 participants reported taking 50 mg ubrogepant and 182 reported taking 100 mg ubrogepant.
Disclosure: The study was funded by AbbVie. Four authors declared being current or former employees of AbbVie and may hold stock in the company. Several authors reported having ties with various sources.
Source: Shewale AR, Poh W, Reed ML, et al. Ubrogepant users' real-world experience: Patients on ubrogepant, characteristics, and outcomes (UNIVERSE) study. Headache. Published online September 26, 2024. Source
Key clinical point: Ubrogepant showed real-world effectiveness for the acute treatment of migraine, with increased treatment satisfaction and a strong intention to continue using the medication.
Major findings: A high proportion of patients reported using ubrogepant for relief from migraine, with satisfaction rates of 75.8% at 2 hours, 83.4% at 4 hours, and 78.5% at 24 hours. Additionally, 85.1% were satisfied with their ability to think clearly and 83.8% were satisfied with returning to normal function. Overall, 90.7% participants intended to continue using ubrogepant and 87.4% reported switching to ubrogepant due to inadequate response to previous migraine treatments.
Study details: This observational cross-sectional study included 302 adults who had received ubrogepant for the acute treatment of migraine within the preceding 14 days; 120 participants reported taking 50 mg ubrogepant and 182 reported taking 100 mg ubrogepant.
Disclosure: The study was funded by AbbVie. Four authors declared being current or former employees of AbbVie and may hold stock in the company. Several authors reported having ties with various sources.
Source: Shewale AR, Poh W, Reed ML, et al. Ubrogepant users' real-world experience: Patients on ubrogepant, characteristics, and outcomes (UNIVERSE) study. Headache. Published online September 26, 2024. Source
Key clinical point: Ubrogepant showed real-world effectiveness for the acute treatment of migraine, with increased treatment satisfaction and a strong intention to continue using the medication.
Major findings: A high proportion of patients reported using ubrogepant for relief from migraine, with satisfaction rates of 75.8% at 2 hours, 83.4% at 4 hours, and 78.5% at 24 hours. Additionally, 85.1% were satisfied with their ability to think clearly and 83.8% were satisfied with returning to normal function. Overall, 90.7% participants intended to continue using ubrogepant and 87.4% reported switching to ubrogepant due to inadequate response to previous migraine treatments.
Study details: This observational cross-sectional study included 302 adults who had received ubrogepant for the acute treatment of migraine within the preceding 14 days; 120 participants reported taking 50 mg ubrogepant and 182 reported taking 100 mg ubrogepant.
Disclosure: The study was funded by AbbVie. Four authors declared being current or former employees of AbbVie and may hold stock in the company. Several authors reported having ties with various sources.
Source: Shewale AR, Poh W, Reed ML, et al. Ubrogepant users' real-world experience: Patients on ubrogepant, characteristics, and outcomes (UNIVERSE) study. Headache. Published online September 26, 2024. Source
Serostatus and Increased Migraine Risk in Patients With Rheumatoid Arthritis
Key clinical point: Patients with rheumatoid arthritis (RA) had a higher risk for migraine than those without RA, irrespective of the RA serologic status.
Major findings: Patients with vs without RA had a 1.2-fold higher risk for migraine (adjusted hazard ratio (aHR), 1.21; 95% CI, 1.17-1.26). Both seropositive RA (aHR 1.20; 95% CI, 1.15-1.24) and seronegative RA (aHR, 1.26; 95% CI, 1.20-1.34) were associated with an increased risk for migraine. However, the risk was not significantly different between patients with seropositive RA and those with seronegative RA.
Study details: This longitudinal retrospective cohort study included 42,674 patients with RA (29,774 with seropositive RA and 12,900 with seronegative RA) and 213,370 age- and sex-matched control individuals without RA. Overall, 22,294 new migraine cases were reported during a mean follow-up of 4.4 years, following a 1-year lag period.
Disclosure: The study did not receive any funding. The authors declared no conflicts of interest.
Source: Kang S, Eun Y, Han K, et al. Heightened migraine risk in patients with rheumatoid arthritis: A national retrospective cohort study. Headache. Published online September 13, 2024. Source
Key clinical point: Patients with rheumatoid arthritis (RA) had a higher risk for migraine than those without RA, irrespective of the RA serologic status.
Major findings: Patients with vs without RA had a 1.2-fold higher risk for migraine (adjusted hazard ratio (aHR), 1.21; 95% CI, 1.17-1.26). Both seropositive RA (aHR 1.20; 95% CI, 1.15-1.24) and seronegative RA (aHR, 1.26; 95% CI, 1.20-1.34) were associated with an increased risk for migraine. However, the risk was not significantly different between patients with seropositive RA and those with seronegative RA.
Study details: This longitudinal retrospective cohort study included 42,674 patients with RA (29,774 with seropositive RA and 12,900 with seronegative RA) and 213,370 age- and sex-matched control individuals without RA. Overall, 22,294 new migraine cases were reported during a mean follow-up of 4.4 years, following a 1-year lag period.
Disclosure: The study did not receive any funding. The authors declared no conflicts of interest.
Source: Kang S, Eun Y, Han K, et al. Heightened migraine risk in patients with rheumatoid arthritis: A national retrospective cohort study. Headache. Published online September 13, 2024. Source
Key clinical point: Patients with rheumatoid arthritis (RA) had a higher risk for migraine than those without RA, irrespective of the RA serologic status.
Major findings: Patients with vs without RA had a 1.2-fold higher risk for migraine (adjusted hazard ratio (aHR), 1.21; 95% CI, 1.17-1.26). Both seropositive RA (aHR 1.20; 95% CI, 1.15-1.24) and seronegative RA (aHR, 1.26; 95% CI, 1.20-1.34) were associated with an increased risk for migraine. However, the risk was not significantly different between patients with seropositive RA and those with seronegative RA.
Study details: This longitudinal retrospective cohort study included 42,674 patients with RA (29,774 with seropositive RA and 12,900 with seronegative RA) and 213,370 age- and sex-matched control individuals without RA. Overall, 22,294 new migraine cases were reported during a mean follow-up of 4.4 years, following a 1-year lag period.
Disclosure: The study did not receive any funding. The authors declared no conflicts of interest.
Source: Kang S, Eun Y, Han K, et al. Heightened migraine risk in patients with rheumatoid arthritis: A national retrospective cohort study. Headache. Published online September 13, 2024. Source