Reducing the Burden of Migraine: Safety and Efficacy of CGRP Pathway-Targeted Preventive Treatments.

Migraine is a highly disabling and often chronic neurological disease that affects more than one billion people globally. Preventive migraine treatment is recommended for individuals who have frequent and/or disabling attacks; however, many of the medications used for migraine prevention (e.g., antiepileptics, antidepressants, antihypertensives) were not specifically developed for migraine, and often have limited efficacy or poor tolerability. Four monoclonal antibodies targeting the calcitonin gene-related peptide (CGRP) pathway, which is believed to play a crucial role in the pathophysiology of migraine, have been approved by the US Food and Drug Administration for the preventive treatment of migraine in adults. All four migraine-specific treatments have demonstrated efficacy based on reductions in monthly days with migraine for patients with both episodic and chronic migraine, including those with comorbidities. They have also demonstrated favorable safety and tolerability profiles. Based on these accounts, CGRP pathway-targeted monoclonal antibodies have the potential to revolutionize preventive treatment for patients with migraine.

Hospital Burden of Migraine in United States Adults: A 15-year National Inpatient Sample Analysis.

BACKGROUND: Migraine headache is associated with high costs, but changes over time of inpatient burden in the United States are unknown. Understanding longitudinal trends is necessary to determine the costs of evolving inpatient treatments that target biological factors in the generation of pain such as vasodilation and aberrant activity of trigeminal neurotransmitters. We report the migraine hospital burden trend in the United States over 15 years. METHODS: Data from the Nationwide Inpatient Sample of the Hospitalization Cost and Utilization Project databases were analyzed from 1997 to 2012. Inpatient costs were reported in dollars for the cost to the institution, whereas charges reflect the amount billed. These parameters were trended and the average annual percent change was calculated to illustrate year-to-year changes. RESULTS: Overall discharges for migraine headache reached a low of 30,761 discharges in 1999, and peaked in 2012 with 54,510 discharges. Average length of stay decreased from 3.5 days in 1997 to 2.8 days in 2012. Total inpatient charges increased from $176 million in 1999 to $1.2 billion in 2012. Inpatient costs totaled $322 million in 2012, with an average daily cost of $2,111. CONCLUSIONS: Inpatient burden rapidly increased over the analyzed period, with hospital charges increasing from $5,939 per admission and $176 million nationwide in 1997, to $21,576 per admission and $1.2 billion nationwide in 2012. This trend provides context for research examining cost-effectiveness and quality of life benefits for current treatments. The study of these parameters together with better prevention and improved outpatient treatment may help alleviate the inpatient burden of migraine.

Isolated naratriptan-associated ischemic colitis.

We report a 41-year-old woman who developed histology- and colonoscopy-proven ischemic colitis with the use of naratriptan not exceeding the maximum 2 doses a day and 3 days per week and without a known medical or cardiovascular history. By exclusion of other causes of colonic ischemia, naratriptan was considered the sole causal agent. Discontinuation of naratriptan resulted in a complete clinical recovery. To date, our patient is the youngest known patient to develop ischemic colitis on isolated naratriptan in the setting of no known medical risk factors or predisposing medical condition. Even though triptans are commonly used for the abortive treatment of migraine headaches, such a reported side effect is rare; however, careful assessment and individual patient-based treatment is advised.

Migraine disability, healthcare utilization, and expenditures following treatment in a tertiary headache center.

Headache is among the most common disabling pain complaints. While many patients are managed in primary care or referral neurology practices, some patients have refractive situations that necessitate referral to a tertiary headache center. Increasing frequency of headache is strongly associated with increasing disability and workplace absenteeism as well as increased healthcare utilization. Previous studies have demonstrated that headache care in a dedicated tertiary center is associated with a decrease in headache frequency and improvement in other characteristics that persist over extended periods of time. Previous studies have not examined the impact of this treatment on subsequent healthcare utilization and associated expenditures. In this study we examined the changes in healthcare utilization and expenditures as well as the impact on disability and workplace productivity with treatment in a tertiary headache care center that used initial treatment settings of inpatient and outpatient care and considered the difference between those with episodic migraine and those with chronic migraine and its complications. Tertiary care was found to produce positive reductions in disability, healthcare utilization, and expenditures. These results suggest that earlier tertiary-level intervention may avoid the complications of migraine that occur in some patients and the increasing costs and utilization of care associated with higher disability.

Sumatriptan 6 mg subcutaneous as an effective migraine treatment in patients with cutaneous allodynia who historically fail to respond to oral triptans.

The objective of the study was to assess the efficacy of 6 mg subcutaneous (s.c.) sumatriptan to treat migraine and the relationship between response of migraine and cutaneous allodynia in a population of migraine patients who historically failed to respond to oral triptan medications. This was an open-label study consisting of patients with migraines who historically failed to respond to oral triptan medications. Forty-three patients were asked to treat three migraine attacks with 6 mg s.c. sumatriptan. The primary efficacy endpoint was the percentage of patients achieving relief of headache at 2 h. Ninety-one percent of the patients responded to a single dose of s.c. sumatriptan 6 mg. Fifty percent of all patients were pain-free by 2 h and over 30% had a 24-h sustained pain-free response. When administered within 90 min from the onset of migraine (i.e., during the developing phase of cutaneous allodynia), s.c. 6 mg sumatriptan proved to be effective despite the occurrence of allodynia in a group of patients, who historically had failed to respond to oral triptan medications. These findings suggest that the window of opportunity to treat allodynic patients with injectable triptans may be longer (up to 2 h) than with oral triptans (up to 1 h).

Optimizing migraine therapy: evidence-based and patient-centered care.

Migraine is a chronic, intermittently debilitating neurovascular condition that affects the physical, mental and social aspects of health-related quality of life. Primary care provider interactions with migraine sufferers are common, highlighting the need for clinicians to provide optimal therapy. A comprehensive therapy plan should encompass the whole patient, via a patient-physician partnership where goals and strategies are mutually established. Key treatments include nondrug approaches, such as education and lifestyle modifications, to reduce the occurrence of attacks, as well as acute medications to address the immediate need for relief during an attack. Routine assessment and adjustment of therapy based on data recorded by patient diaries is paramount. Clinical trials support the use of triptans and dihydroergotamine for moderate-to-severe migraine and nonsteroidal anti-inflammatory drugs (alone or in combination with antiemetics or caffeine) for mild-to-moderate migraine, as the treatments of choice to reduce pain and disability time in a cost-effective manner. Published evidence also endorses stratified care, where medication selection is geared towards disease severity, instead of step care, where nonspecific mediations are given to all patients. Thus, patients with significant migraine-induced debilitation, as assessed by tools, such as the Migraine Disability Assessment Scale or the Headache Impact Test, are prescribed migraine-specific agents from the onset of therapy, thereby avoiding the inherent failures of step care. For individuals experiencing a high frequency of attacks or routine debilitation, preventive medications are warranted.

Advances in migraine treatment.

Migraine is a common, incapacitating disorder that is underdiagnosed in clinical practice. Early and correct diagnosis of migraine is essential and can lead to significant improvements in a patient's quality of life. In the clinical practice setting, a screening tool can be used that can help differentiate migraine from other headache disorders. New research into the development of central sensitization and cutaneous allodynia in chronic migraine sufferers has led to an early treatment approach with triptans and other agents for acute migraine episodes. This approach results in greater 2-hour headache pain-free results. The use of botulinum toxin type A in the prophylaxis of migraine and mixed-headache types offers an alternative treatment in patients who may not have responded to other currently available migraine prophylactic agents.