Moving closer to the ideal migraine acute treatment
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THERAPEUTICAL SCENARIOS IN HEADACHES
Moving closer to the ideal migraine acute treatment Sabina Cevoli 1 & Umberto Pensato 2 & Valentina Favoni 1
# Fondazione Società Italiana di Neurologia 2020
Migraine is a complex disorder affecting mostly young individuals, and it is considered one of the most common disabling neurological conditions. Thus, all migraineurs require an effective acute treatment to relieve headache attacks and prevent the risk of progression from episodic to chronic migraine that is associated with noneffective acute treatments. Nowadays, although a wide range of acute medications are available, there are several limiting factors, as follows: (i) potential ineffectiveness, (ii) side effects, (iii) contraindications, and (iv) risk to develop medication overuse headache (MOH). Accordingly, almost half of migraineurs are not satisfied with their current therapy that, at present, includes analgesics, NSAIDs, triptans, and ergots [1]. Driven from this unmet need, the increasing understanding of molecular mechanisms underlying migraine pathophysiology has led to development of different new drugs targeting CGRP and 5-HT, finally broadening the therapeutic armamentarium. Ditans and gepants are promising new classes for acute migraine medications in development. Several selective 5-HT1F agonists (ditans) have been developed in recent years in clinical trials. Among them, lasmiditan was approved in the USA for the acute treatment of migraine with or without aura in adults. RCTs have demonstrated that oral doses of lasmiditan (50–200 mg) is efficacious, safe, and generally well tolerated for the acute treatment of migraine [2, 3]. The percentage of patients with 2-h pain freedom in trials ranges from 28.2 to 38.8%. The most reported adverse events were dizziness, paresthesia, somnolence, fatigue, nausea, lethargy, and vertigo. Interestingly, lasmiditan does not cause vasoconstriction, and its safety has been extensively investigated, with
* Sabina Cevoli [email protected] 1
IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Bellaria, Via Altura 3, 40129 Bologna, Italy
2
Department of Biomedical and NeuroMotor Sciences (DiBiNeM), Alma Mater Studiorum - University of Bologna Italy, Bologna, Italy
no increase in frequency of cardiovascular treatmentemergent adverse events. These findings make lasmiditan an attractive option for individuals who cannot use triptans for cardiovascular reasons (e.g., uncontrolled hypertension or coronary artery disease) [2, 3]. The second new class of acute migraine medications is gepants that are small molecule CGRP receptor antagonists. Among these, ubrogepant and rimegepant are still in development. Ubrogepant is administrated orally with 25–100 mg doses. The percentage of patients with 2-h pain freedom in trials ranges from 19.2 to 19.6%. The most commonly reported adverse events (in less than 5% of patients) were nausea, somnolence, and dry mouth [2, 3]. The other CGRP receptor antagonist on development is rimegepant. The percentage of patients with 2-h pai
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