Updates in Migraine, Cluster, and Posttraumatic Headache

Hans-Christoph Diener, MD, PhD


August 17, 2021

This transcript has been edited for clarity.

Dear colleagues, I am Christoph Diener from the University of Duisburg-Essen in Germany, with an overview of some of the most important neurology studies recently published. I'd like to specifically concentrate on studies dealing with headache. Although there were a number of other studies outside of this indication, most of them, unfortunately, were neutral or negative.

Patent Foramen Ovale and Migraine

Epidemiologic studies have shown that patients who have migraine with aura have a higher prevalence of patent foramen ovale (PFO). This is why interventional cardiologists propose to close a PFO to prevent migraine, although the three previous randomized trials looking at this were all negative.

We now have additional information from the CLOSE-MIG study in patients younger than 60 years with PFO-associated cryptogenic stroke. Of 473 patients randomized to either undergo PFO closure or receive antiplatelet therapy, 145 (mean age, 41.9 years; 58.6% women) had a history of migraine. After a mean follow-up of 5 years, PFO closure was not superior to aspirin at reducing the number of migraine attacks, disability due to migraine, or the intake of preventive medication. These results indicate that PFO closure is probably not effective and also signal that we have now very effective treatments to prevent migraine and migraine with aura.

Three Studies on the Effects of Monoclonal Antibodies

A study published in Cephalalgia investigated what happens if you terminate treatment with a monoclonal antibody against calcitonin gene-related peptide (CGRP) or the CGRP receptor. Investigators studied 52 patients who received treatment for 12 months, and then had it interrupted for another 3 months. Unfortunately, it turned out that migraine came back in the majority of these patients, and approximately 90% wanted to reinitiate the monoclonal antibody after 3 months. However, it should be noted that this was a population of severely affected patients, the majority of whom had chronic migraine.

Another study analyzed data from the World Health Organization's pharmacovigilance database to determine the effects of receiving treatment with a monoclonal antibody against CGRP in patients who became pregnant. Fortunately, the results were normal in the 85 cases where patients received this treatment while pregnant, with nothing unexpected occurring. Nevertheless, these monoclonal antibodies against CGRP or the CGRP receptor should be stopped if a female patient gets pregnant.

A separate meta-analysis performed an indirect comparison between the traditional migraine preventive drugs and the monoclonal antibodies. Investigators calculated the numbers needed to treat vs the number needed to harm. It turned out that propranolol and topiramate in episodic migraine, and topiramate and onabotulinumtoxinA in chronic migraine, provide inferior efficacy when compared against the monoclonal antibodies. Monoclonal antibodies also have much better tolerability. Unfortunately, as you know, monoclonal antibodies are still very expensive.

Real-World Evidence on Cluster Headache

The Danish Headache Survey reported the results of treating 400 patients with episodic or chronic cluster headache. They showed that the most effective treatment of cluster attacks is subcutaneous sumatriptan and inhalation of oxygen, which was more effective in episodic cluster headaches than in chronic cluster headache. Unfortunately, the therapy gets less effective with time.

In terms of preventive therapy, the most used drug was verapamil. But only approximately 60% of patients continued preventive medication in cluster headache, and fewer in chronic cluster headache.

Idiopathic Intracranial Hypertension and Bariatric Surgery

The final two studies are very interesting, the first of which deals with idiopathic intracranial hypertension. As you know, the most important risk factor for this condition is obesity.

In this study from the United Kingdom, investigators randomized 66 patients either to bariatric surgery or to management of food intake. They found that after 12 months bariatric surgery was clearly superior in terms of lowering cerebrospinal fluid opening pressure, improving visual function, and reducing headache days.

A Better Understanding of Posttraumatic Headache

Finally, in Lancet Neurology, we had a wonderful review paper on posttraumatic headache, which shows that we know very little about this condition. What the authors propose is that preventive therapy should be done according to the phenotype of posttraumatic headache. If this phenotype resembles migraine, then migraine preventive drugs should be used. If the phenotype looks like tension-type headache, then most probably amitriptyline should be used.

I think the most important message here is that patients who have posttraumatic headache for more than 4 weeks need to be referred to a neurologist or a headache specialist to deal with the headache and to prevent chronification of headache and medication overuse.

Ladies and gentlemen, a number of interesting studies on headache were published in May and June of this year. I am Christoph Diener from the medical faculty of the University Duisburg-Essen in Germany. Thank you very much for listening and watching.

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