COMMENTARY

The Year in Migraine and Cluster Headache Research

Hans-Christoph Diener, MD, PhD

Disclosures

December 27, 2016

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Dear colleagues, I am Christoph Diener, senior professor of clinical neurosciences at the University of Essen, Germany. Today, I will give you a brief summary of what has happened in headache research in 2016.

A very important epidemiologic study was published from the Nurses' Health Study, which looked at 116,470 nurses, all of whom were healthy at the time.[1] About 17,500 of these nurses had a diagnosis of migraine. For the next 10 years, vascular events were recorded. It turned out that those with migraine have an increased risk not only for stroke, but also for myocardial infarction. The hazard ratios for myocardial infarction and stroke were 1.33 and 1.62, respectively. In absolute numbers, the risk for stroke and myocardial infarction is low, but we need to advise our female patients who have migraine to treat risk factors, such as stopping smoking and treating their hypertension.

Elsewhere, researchers performed a meta-analysis of more than 20,000 patients included in randomized trials to compare triptans with placebo and other treatments.[2] The rate of being pain-free after triptan intake was somewhere between 18% and 50%, which shows there is still room for improvement. In comparison with other migraine treatments, the triptans were superior to ergots, nonsteroidal anti-inflammatory drugs, aspirin, and acetaminophen/paracetamol. However, we still need better treatments, in particular for patients who have contraindications for triptans, such as those who have had a stroke or have coronary heart disease.

The biggest progress in migraine and cluster headache will be the use of antibodies against calcitonin gene-related peptides (CGRP), either against a molecule or the receptor. Phase 2 trials in episodic migraine[3] and chronic migraine[4] were published. The responder rate, defined as a reduction of migraine frequency of at least 50%, was achieved by one half of the patients. The most important issue here is safety and tolerability: The tolerability has been excellent. and there have basically been almost no side effects. All of these drugs are now in phase 3 randomized trials for episodic and chronic migraine, but also for episodic and chronic cluster headache. Hopefully, next year I will be able to tell you how effective and well tolerated these new drugs are.

We had two trials on migraine prevention with other drugs, both of which failed. One was with L-carnitine,[5] and the other was with the orexin antagonist filorexant.[6]

One important study investigated the optimal duration of botulinum toxin for the treatment for chronic migraine.[7] Investigators treated patients for 1 year and then stopped the treatment. It turned out that about one half of the patients did so well that they no longer needed botulinum toxin, whereas the other half deteriorated again and treatment had to be continued.

There was a published paper[8] on closure of patent foramen ovale (PFO) in patients who have migraine and migraine with aura. Both trials had a negative outcome similar to the MIST trial,[9] which was conducted almost 10 years ago. They all had a trend toward efficacy for patients with migraine with aura, but it was not statistically significant. I think PFO closure is not an option in migraine prevention.

There was also an interesting but small study in cluster headache to treat acute attacks with a civamide nasal spray, which seemed to be effective.[10] A phase 3 trial is now ongoing.

We had positive results for transcutaneous stimulation of the vagus nerve in cluster headache.[11] This method is safe and well tolerated, and is now being investigated in frequent episodic migraine, chronic migraine, and cluster headache, compared with sham stimulation.

Finally, there were data[12] showing that botulinum toxin might also be effective in patients with trigeminal neuralgia who cannot use or tolerate the usual treatment, such as with carbamazepine or pregabalin.

These are interesting results. Potentially the most important outcome will come next year, when we see the efficacy of CGRP antibodies or antibodies against the CGRP receptor.

Ladies and gentlemen, I am Christoph Diener from the Department of Neurology at the University of Essen in Germany. Thank you for listening.

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