The Migraine World Summit Summary: Day 7

Day 7

Lars Edvinsson: Treatment spotlight: Anti CGRP treatments for migraine

How does CGRP work in the trigeminal system?

1990- CGRP discovered – only single molecule released during a migraine attack. (Himself and Prof Goadsby).

Monoclonal antibodies – way to produce something to block the CGRP.

1.Go to receptor and block receptor itself

2. Pacman style inactivates CGRP

CGRP – stored in the trigeminal ganglion – activated and then released into the head.

The monoclonal antibodies DON’T affect the release of CGRP. They either;

1.Block the receptor

2. Mop it up

Currently pending approval FDA & NICE.

*First CGRP antibody has actually been FDA approved since the summit (May 2018)

Clinical trials

CGRP antibody or CGRP antibody receptor

-        Fairly similar in effect

-        Side effects similar to placebo

-        Important to note that this is NOT a cure.

There have been some “super responders” – complete remission as a result of CGRP

treatment. These are a sub population but it is possible!

What can average patient expect?

-        No side effects

-        Cost is an issue (currently very expensive)

-        Blessing for those it does work for

-        Hard to predict who will have a really good outcome from it (very early stages)

Safe & effective is main priority at this stage.

Molecule for acute treatment coming soon too – hiccup along the way with that though (something bothered the liver).

Hopefully we will end up with; CGRP receptor blocker acute g-pant

Triptans block the release of CGRP so the combination of the two could work well together. CGRP won’t have the same side effect of triptans though.

Who is a good candidate for CGRP?

-        No particular group

-        No long-term results yet so hard to say

-        Pregnant woman/ children? Biology of CGRP means it should in theory be fine but need to learn more

*Interesting to note during the 2^nd & 3^rd trimester migraine disappears (level of CGRP elevated). Desensitizing CGRP. Then migraines back when they have the baby and CGRP normal.

Big pharmaceuticals have CGRP in the pipeline.

G-pants – oral – acute – separate class of drug

Antibodies – injection once a month – preventative- injection patients take themselves (subcutaneous injection)

CGRP receptor and CGRP receptor antibodies;

-        Phase 3 trials at last stage

-        Phase 4, further studies ongoing

Day 7

Richard Lipton: Treatment spotlight, Triptans & Rebound headaches

Medication overuse headache (MOH)- Secondary headache disorder like brain tumour etc.

Rebound headache/MOH basically the same thing.

Medications used to treat headache – when used too much can cause MOH headache disorder.

MO: More meds (opioids and narcotics etc)- worse head gets over time.

                                                              

MOH: Not meant to be judgmental. Just another factor causing headaches. Not addiction! Can be very difficult if in pattern of MOH.

How common?

-        MO: 1-2% of general population

-        About as common as epilepsy

Do I have it?

-        History/pattern (infrequent to frequent headaches)

-        Codeine for example (end of dosing interval headaches, pain comes back just before next dose)

-        Headache itself not being treated

-        Use of caffeine containing products

-        Profile: accelerating headache (more meds they take, over time, the worse the headache becomes.

-    Worse in morning and sometimes weekends (people have slept through usual dose of morning medication)

What medications are involved?

-        Triptans although hard to get hold of enough in a month

-        Occasionally with anti-inflammatories (less likely)

-        Opioids/barbiturates most troublesome

Acute medication should be taken 2-3 days MAX per week

Help – I take 5 days a week – what can I do?

-        Avoid triggers

-        Find a preventative that works

-        Take acute medication early but don’t take too much (really tricky in practice to do this) – much easier to achieve if you can reduce overall headache frequency with a preventative.

*Issue of people desperately trying to avoid MOH – end up delaying acute meds and then

take them too late and they don’t work.

Preventative meds – generally don’t cause MOH (sometimes a worsening when people come off

these drugs for a brief period).

What if I have more than one pain condition?

-        Research shows that pain disorders travel together

-        People who have pain in multiple bodily areas are more likely to suffer from headache and these people are more likely to have episodic migraine that turns to chronic

-        Preventatives

-        Physio

-        CBT

-        Tens machine

-        Antidepressants

-        Restrict acute number of days taking meds

-        Neuromodulation (2 FDA approved) can be good option for people with MOH to use on a daily basis but also for acute attacks instead of pain medication.