Headache News

This section is updated monthly and provides commentary and summaries of interesting headache research.

November 2018

 

Lane R, Davies P. Post traumatic headache (PTH) in a cohort of UK compensation claimants. Cephalalgia 2018 Nov 8 [Epub ahead of print].

 

Background: Post traumatic headache frequently results in headache. This study examines the characteristics of post traumatic headache in compensation claimants.

 

Results: In this observational study 116 consecutive medicolegal notes were reviewed. 88 had suffered from head and neck injury, 21 only neck injury and 7 “other injuries”. 94% of head injuries were classified as mild. Patients with neck injuries were equally likely to develop post traumatic headache as those with head and neck injuries. Patients with “other injuries” did not develop headache. 25% of patients with head and neck injury denied developing headache. Post traumatic headache correlated strongly with a background of previous primary headache (p<0.0001). 90% of post traumatic headache displayed the same seminology as migraine or probable migraine. 40% of patients has received no treatment for headache in primary care.

 

Conclusion: This study suggests that post traumatic headache is essentially “migraine” triggered by neck or head concussion.

 

For patients: In the absence of any significant structural cause, post traumatic headache should be managed as (chronic) migraine, especially if there is a previous background of primary headache.

October 2018

 

Grazzi L, Tassorelli C, de Tommaso M, Pierangeli G, Martelletti P, Rainero I, Geppetti P, Ambrosini A1, Sarchielli P, Liebler E, Barbanti P; PRESTO Study Group. Practical and clinical utility of non-invasive vagus nerve stimulation (nVNS) for the acute treatment of migraine: a post hoc analysis of the randomized, sham-controlled, double-blind PRESTO trial. J Headache Pain 2018;19:98

 

Background: The PRESTO study provided evidence that patients with episodic migraine benefit from non-invasive vagus nerve stimulation (gammaCore®). In this study additional data from the PRESTO study was examined. Patients recorded pain intensity for treated migraine attacks on a 4-point scale and whether acute medication was required.

 

Results: A significantly higher percentage of patients who used gammaCore® at the time of attacks (n = 120) vs sham (n = 123) reported a ≥ 1-point decrease in pain intensity at 30 min (32.2% vs 18.5%, P = 0.020), 60 min (38.8% vs 24.0%, P = 0.017), and 120 min (46.8% vs 26.2%, P = 0.002) after the first attack. The proportion of patients who did not require rescue medication was significantly higher with gammaCore® than with sham for the first attack (59.3% vs 41.9%, P = 0.013) and all attacks (52.3% vs 37.3%, P = 0.008). When initial pain intensity was mild, the percentage of patients with no pain after treatment was significantly higher with gammaCore® than with sham at 60 min (37.0% vs 21.2%, P = 0.025).

 

Conclusion: This post hoc analysis demonstrated that use with gammaCore® quickly and consistently reduced pain intensity while decreasing rescue medication use. 

 

For patients: This study demonstates the clinical benefits provided by gammaCore® use in the treatment of episodic migraine and therefore has the potential to reduce use of acute pharmacologic medications and their associated adverse events.

September 2018

 

Vikelis M, Argyriou AA, Dermitzakis EV, Spingos KC, Makris N, Kararizou E. Sustained onabotulinumtoxinA therapeutic benefits in patients with chronic migraine over 3 years treatment. J Headache Pain. 2018;19:87.

 

Background: This study assessed whether there is a sustained benefit and good safety with repeated onabotulinumtoxinA (Botox) sessions in chronic migraine over more than three years of treatment. 65 patients with chronic migraine were prospectively followed over 3 years of treatment.

 

Results: 56 (86%) of 65 patients continued Botox over three years. Comparisons were made between data collected during the first and last 3 months of the study. By the end of the 3 years there was a reduction in monthly mean headache days (3.4 ± 1.7 vs 7.2 ± 3.8; P < 0.001). Headaches were also noted to be less severe and patients took acute painkillers on less days (2.8 ± 1.3 vs 4.7 ± 3.2; P < 0.001). Botox was safe and well tolerated with low rates of adverse events or drop-outs.

 

Conclusion: Long-term treatment with Botox proved to be effective, safe and well tolerated over three years. 

 

For patients: This is reassuring news for patients already receiving Botox and supports continued use where appropriate. 

August 2018

 

Buse DC, Lipton RB, Hallström Y, Reuter U, Tepper SJ, Zhang F, Sapra S, Picard H, Mikol DD, Lenz RA. Migraine-related disability, impact, and health-related quality of life among patients with episodic migraine receiving preventive treatment with erenumab. Cephalalgia 2018 Aug 7. [Epub ahead of print]

 

Background: Erenumab (Aimovig) is a fully human monoclonal antibody that inhibits calcitonin gene-related peptide (CGRP) receptor. CGRP is important in the pathogenesis of migraine. Erenumab is given as a subcutaneous injection every 4 weeks (1 month). This study looked at migraine-related disability, impact, and health-related quality of life among patients with episodic migraine in patients given Erenumab.

 

Results: This was a phase 3, 6-month, double blinded, placebo-controlled study. 955 patients were randomized to receive Erenumab 70 mg (n = 317), Erenumab 140 mg (n = 319), or placebo (n = 319). Patients completed an eDiary during the baseline and double-blind treatment phases and specific questionnaires, including the modified (monthly) Migraine Disability Assessment Questionnaire; Headache Impact Test; and Migraine-Specific Quality of Life Questionnaire-role function-restrictive (MSQ-RFR), -role function-preventive (MSQ-RFP), and -emotional function (MSQ-EF). Erenumab versus placebo resulted in significantly greater improvements in all patient-reported outcomes. Improvements occurred rapidly and were maintained over 6 months of treatment. Between-group differences from placebo over months 4-6 for the 70- and 140-mg dose groups were, respectively, -2.1 and -2.8 for modified (monthly) Migraine Disability Assessment Questionnaire, -2.1 and -2.3 for Headache Impact Test, 5.1 and 6.5 for MSQ-RFR, 4.2 and 5.4 for MSQ-RFP, and 5.2 and 6.7 for MSQ-EF ( p < 0.001 for all). Erenumab also significantly reduced the proportion of patients with severe and very severe migraine-related disability and increased the proportion of patients with clinically meaningful improvements in migraine-related impact and health-related quality of life.

 

Conclusion: Erenumab reduced migraine disability and impact and improved patients' health-related quality of life, reinforcing its role as a promising new therapy for migraine prevention.

 

For patients: Erenumab (Aimovig) will be available for private prescription in the UK from mid-September. Patients with 4 or more migraines per month can be considered for treatment. Some patients with chronic migraine may also be able to receive it on the NHS in certain hospitals. A review by NICE of Erenumab has been delayed until next summer.

July 2018

 

Snoer A, Lund N, Beske R, Hagedorn A, Jensen RH, Barloese M. Cluster headache beyond the pain phase: A prospective study of 500 attacks. Neurology 2018 Jul 27 [Epub ahead of Print].

 

Background: Cluster headache is the most painful condition known to medical science. Typically headaches are daily and occur in bouts over several weeks or months. In between bouts patients are often headache free. The majority of cluster attacks are less than 60 minutes. In between attacks patients are usually symptom free. In this study the authors investigate what symptoms patients describe before (preictal), during (ictal) and after (postictal) cluster headaches.

 

Results: In total 500 attacks from 57 patients were described. Preictal symptoms were described in approximately half of patients and included: problems with concentration; restlessness; and changes in mood. A quarter of patients described autonomic symptoms (e.g. lacrimation) 10 minutes before attacks. Postictally approximately a third of patients described fatigue, decreased energy and concentration difficulties, that on average lasted 60 minutes.

 

Conclusions: Preictal and postictal symptoms are very common in patients with cluster headache.

 

For patients: Forewarned is forearmed. Knowledge that a cluster headache is about to occur may potentially enable earlier abortive intervention in some patients.

June 2018

 

Tassorelli C, Grazzi L, de Tommaso M, Pierangeli G, Martelletti P, Rainero I, Dorlas S, Geppetti P, Ambrosini A, Sarchielli P, Liebler E, Barbanti P, PRESTO Study Group. Noninvasive vagus nerve stimulation as acute therapy for migraine: The randomized PRESTO study. Neurology 2018 June 15 [Epub ahead of Print].

 

Background: This study evaluated the efficacy, safety and tolerability of noninvasive vagus nerve stimulation (with the gammaCore device) for the acute treatment of migraine. This was a double-blinded, randomized, sham-controlled study.

 

Results: 248 patients with episodic migraine, with and without aura were evaluated. Subjects were randomized to use either gammaCore or sham within 20-minutes of onset of pain. Subjects who received gammaCore were significantly more likely to pain free compared to sham at 30-minutes (12.7% vs 4.2%; p=0.012) and 60-minutes (21.0% vs 10.0%; p=0.023). At 120-minutes there was no significant difference between gammaCore and sham (30.4% vs 19.7%; p=0.067).

 

Conclusions: gammaCore is effective, well tolerated and safe for treatment of acute migraine in some patients.

 

For patients: gammaCore has not yet been approved by NICE and therefore at present is not readily available on the NHS. Hopefully, the PRESTO study and future studies will provide the level of evidence that is required by NICE for approval. More research is required to determine which patients are most likely to benefit from gammaCore.

June 2018

 

Karsan N, Palethorpe D, Rattanawong W, Marin Jc, Bhoa R, Goadsby PJ. Flunarizine in migraine-related headache prevention: results from 200 patients treated in the UK. Eur J Neurol. 2018;25:811-817.

 

Background: Flunarizine is a calcium antagonist, which has been been used to prevent migraine for over 25-years. Although not licenced for use in the UK, it is widely used across Europe and Asia. It should be avoided in patients with depression and Parkinson's disease and related disorder.

 

Results: A cohort of 200 patients receiving Flunarizine was studied in patients with migraine-related headache, including new daily persistent headache with migrainous features. 76% of patients benefited. Doses up to 15mg/day were generally well tolerated, although 10.5% stopped due to adverse events. The most common adverse events were tiredness, mood change and weight gain.

 

Conclusions: There is evidence for use of Flunarizine in migraine.

 

For patients: NICE recognizes that Flunarizine is useful in migraine, but it remains unlicenced. GPs are therefore often unable to prescribe Flunarizine.

May 2018

 

Dodick DW, Ashina M, Brandes JL, Kudrow D, Lanteri-Minet M, Osipova V, Palmer K, Picard H, Mikol DD, Lenz RA. ARISE: A Phase 3 randomized trial of erenumab for episodic migraine. Cephalalgia 2018;38:1026-1037.

 

Background: Calcitonin-Gene-Related-Peptide (CGRP) plays an important role in the pathogenesis of migraine. Erenumab is a fully human monoclonal antibody of the CGRP receptor. Blocking CGRP or its receptor has been shown to reduce migraine.

 

Results: Patients receiving Erenumab had less headache days per month than placebo (-2.9 vs -1.8). A higher proportion of patients receiving Erenumab also reported  ≥ 50% reduction in monthly migraine days (39.7% vs 29.5%). Safety and adverse event profiles were similar for Erenumab and placebo.

 

Conclusions: Erenumab significantly reduces migraine frequency and appears to be safe.

 

For patients: Erenumab is currently being reviewed by NICE, but is unlikely to be available until 2019.