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