A recap of the promising new science presented at the AHS Scientific Meeting

By Chris Caiazza and Donna Gutterman, PharmD, Curriculum Developers for the American Headache Society

The American Headache Society was proud to host the 59th Annual Scientific Meeting in Boston from June 7-11. More than 1,100 medical professionals met for the four-day program, which included more than 100 educational sessions ranging in topics from Abortive and Preventive Pharmacotherapy to the Women’s Leadership Development Course. The meeting was centered on the theme of Finding Balance Between Science/Research and Clinical Practice. From start to finish, attendees were reminded that the everyday needs of headache patients and the people who care for them are just as important as the often-miraculous achievements of scientific research.

Highlights from the 59th Annual Scientific Meeting

Prevent the Attacks From Actually Happening?

At last year’s Scientific Meeting, a number of experts in headache medicine presented preliminary findings showing that a new class of medications—antibodies targeting calcitonin gene-related peptide (CGRP)—appeared to be highly effective at preventing migraine attacks.1-3 They assured attendees that efforts to confirm their exciting results were already underway, and that they’d be back with findings from large studies that would establish CGRP-based treatments as a major step forward in migraine prevention.

This year, researchers delivered. They presented the results of more than a dozen clinical studies of antibodies targeting CGRP.4 Without exception, the new studies confirmed:

  • This new class of preventive medications is highly effective and safe
  • They work well against all types of migraine—episodic migraine, migraine with and without aura, and chronic migraine

People who study and treat patients with migraine have always dreamed about a treatment that could switch off the machinery of migraine, something to prevent the attacks from actually happening in the first place. CGRP monoclonal antibodies are the first mechanism-based migraine preventive treatment developed specifically for the disease. The depth and breadth of the evidence presented at this year’s meeting suggests we’re in a genuine watershed moment in migraine. For people with migraine who continue to struggle after trying a range of treatments, the prospect that these new medications may become available in the near-term is incredibly exciting.

Not Just Little Adults

If you ask most healthcare professionals to describe migraine pain (where it hurts and what kind of pain), the most common answer would probably be that it affects one side of the head and has a pulsating quality. For most adult patients, they’d be on solid ground. But for anyone younger than 26 years old, a new study1 suggests that is rarely the case. When children, adolescents, and young adults were shown a diagram of a head and given various terms to choose from, the top three were “throbbing,” “pounding,” and “pressing”1. In fact, most young patients said migraine pain affects both sides of the head, and pulsating didn’t even make the top three for descriptions of pain. More research is needed to understand when and why the most common pain characteristics change, and diagnostic guidelines for migraine in children may need to be revisited.1

Many adults with migraine can tell when an attack is on the way. These warning signals, known as premonitory symptoms, happen hours to days before an attack starts.2 The most common include yawning, neck stiffness, fatigue, food cravings, increased urination, and mood changes.3 New research into this phenomenon in children and adolescents found that the most common premonitory symptoms were fatigue (68.4%) and mood changes (56.7%)—slightly different than the adults. Girls were more likely to have premonitory symptoms than boys (41% vs 32%), but there were no differences by type of migraine (with vs without aura) or between younger children and adolescents. The researchers believe linking this information with data about the start of attacks may help them refine approaches to treatment.3

In headache medicine, the main goal of preventive migraine treatment is to cut the number of attacks in half, ideally to no more than one per week.4 But when young migraine patients and their parents hear the word “preventive,” their expectations of treatment may exceed those of their healthcare providers. According to a new study,5 nearly 40 percent say their primary goal is to stop attacks completely. To address this discrepancy and avoid disappointment all around—which can cause patients to abandon a preventive regimen—the authors recommend discussing expectations about preventive treatments before beginning therapy.5

Adolescence can be a challenging time in life. For tweens and teens with migraine and few choices when it comes to treatment, this year’s meeting brought a small dose of good news. A new study found that a nasal spray known to work in adults, zolmitriptan (Zomig®), is also effective in patients between the ages of 12 and 17.6 More than 1600 patients were included, and researchers found that two hours after taking a 5-mg dose of zolmitriptan, the spray had eliminated migraine pain more effectively than placebo. Since it worked just as well in 12-year olds as it did in 17-year olds, nearly all adolescent migraine patients just got a safe and effective option for treating their attacks.6

11 Years After the Injury. . .Still Badly Hurt

It’s well known that veterans who suffer a traumatic brain injury (TBI) have to live with the after-effects of war long after they return to non-combat life—and the burden can be staggering. Now, new research shows that veterans who experienced a TBI while deployed in Afghanistan or Iraq are more likely to have severe, disabling headaches than those who did not have a TBI while deployed.1

In this study, severe headaches were defined as those causing a 50% to 90% decrease in activity that left patients able to do only the most essential tasks.1 Disabling headaches caused total avoidance of activity and required bedrest. The investigators found veterans in the TBI group were about three times as likely to have severe, disabling headaches as those in the non-TBI group (75% vs 25%). The difference between the groups remained the same, even up to 11 years after the injury first occurred.1

These new findings reinforce a painful lesson. Veterans who experience a TBI while deployed are at high risk of major long-term negative impact on their lives and their families because of debilitating headaches.

Headache Relief, No Medication

Medication isn’t the best choice for every headache patient. Some can get by with lifestyle modifications (diet and exercise), many dislike injections or can’t swallow tablets and capsules, and others simply don’t like the thought of taking pharmaceutical remedies for health problems. Researchers have developed a number of devices to treat headaches in these patients, and several of them presented the results of their studies at the meeting.

One study showed a technique that works on the structures of the inner ear—called “Non-Invasive Caloric Vestibular Stimulation” (nCVS for short)—can prevent episodic migraine attacks.1 The device involves a headset similar to music headphones, and it has aluminum earpieces to conduct heat and a control unit that powers the device and allows patients to start treatments. Patients who used the nCVS device every day for two 18-minute sessions averaged three fewer attacks per month after three months. Patients using a sham device did not have any improvement. No serious or unexpected adverse events were reported.1

Non-Invasive Caloric Vestibular Stimulation (nCVS)
Non-Invasive Caloric Vestibular Stimulation (nCVS)

Another device that can be used to treat migraine, this time using “transcranial magnetic stimulation” (TMS) to deliver a brief magnetic field pulse to certain areas of the brain, was tested for the prevention of migraine attacks with or without aura in the ESPOUSE  study.2 Participants used four pulses twice daily to prevent attacks, and three pulses at 15-minute intervals repeated up to three times to treat attacks when they occurred. After three months, users of the device had 31% fewer attacks than they did before starting the study. About 19% of participants reported adverse events, such as lightheadedness, tingling, and tinnitus, though none was serious.2

SpringTMS device
SpringTMS device

New research in patients with cluster headache, a rare and extremely painful headache disorder, showed that gammaCore®—a device that delivers electrical impulses through the skin to a branch of the vagus nerve, a major nerve that connects the brain with many areas of the body—can be very effective in reducing the pain of a cluster attack.3 In this study, compared with a sham device, episodic cluster headache patients using the gammaCore® were eight times as likely to have no pain after 15 minutes of treatment. In patients with chronic cluster headache, there were no significant differences between the device and sham treatment. About one in five patients experienced an adverse event after using the gammaCore®, but none of them was considered serious.3

gammaCore device
gammaCore device

Confirmed: AHS Guidance on Emergency Treatment of Migraine

When patients show up at the emergency room with severe head pain, doctors first make sure it’s not a life-threatening problem, like a stroke or brain hemorrhage. One those are ruled out, they try to figure out what kind of headache might be responsible. If they decide it’s migraine, about 1 in 4 patients is given an opioid drug called hydromorphone.1

The problem? There were no high-quality studies supporting the use of hydromorphone in the emergency treatment of migraine. However, doctors at two emergency departments in New York City have now remedied that situation with a randomized, double-blind study.2 Patients visiting the emergency department with migraine were given intravenous injections of hydromorphone or an antipsychotic (prochlorperazine). They found that, after only one dose of study medication, the antipsychotic relieved pain for at least 48 hours in about twice as many patients as the opioid (60% versus 31%). The results were so obvious that the trial was stopped early as it would have been unethical to keep giving patients the less effective opioid treatment.

These findings support the American Headache Society’s treatment recommendations for adults presenting to the emergency department with acute migraine: Because of a lack of evidence showing efficacy and concerns about side effects, avoid opioids and use intravenous prochlorperazine or subcutaneous sumatriptan.3 Perhaps even more important, they are a powerful reminder that evidence-based medicine and patient care should always walk hand-in-hand, striving to find the balance between science/research and clinical practice.

There is so much promising new science on the horizon, and we are more confident than ever that a breakthrough is coming. To stay up-to-date on what’s going on in migraine research and clinical trials, visit our website and subscribe to our email list.

 

References

Prevent the Attacks From Actually Happening?

  1. Dodick DW, Goadsby PJ, Spierings EL, Scherer JC, Sweeney SP, Grayzel DS. Safety and efficacy of LY2951742, a monoclonal antibody to calcitonin gene-related peptide, for the prevention of migraine: a phase 2, randomised, double-blind, placebo-controlled study. Lancet Neurol. 2014;13:885–892.
  2. Voss T, Lipton RB, Dodick DW, et al. A phase IIb randomized, double-blind, placebo-controlled trial of ubrogepant for the acute treatment of migraine. Cephalalgia. 2016;36(9):887-898.
  3. Bigal ME, Dodick DW, Krymchantowski AV, et al. TEV-48125 for the preventive treatment of chronic migraine: Efficacy at early time points. Neurology. 2016;87(1):41-48.
  4. Various authors. Program Abstracts: The 59th Annual American Headache Society Meeting. Headache. 2017;57 Suppl 3:113-226.

Not Just Little Adults

  1. Ludwick A. Headache disorders in children and adolescents. Program Abstracts: The 59th Annual American Headache Society Meeting. Headache. 2017;57 Suppl 3:113-226.
  2. The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013;33(9):629-808.
  3. Pakalnis A. Premonitory symptoms in pediatric migraine: a prospective study. Program Abstracts: The 59th Annual American Headache Society Meeting. Headache. 2017;57 Suppl 3:113-226.
  4. Szperka C. Pediatric patient and parent goals and preferences for preventive headache treatment. Program Abstracts: The 59th Annual American Headache Society Meeting. Headache. 2017;57 Suppl 3:113-226.
  5. Silberstein S, Tfelt-Hansen P, Dodick DW, et al. Guidelines for controlled trials of prophylactic treatment of chronic migraine in adults. Cephalalgia. 2008;28(5):484-495.
  6. Winner P, Floam S. Efficacy of zolmitriptan nasal spray for the treatment of acute migraine in adolescents: subgroup analysis by age. Program Abstracts: The 59th Annual American Headache Society Meeting. Headache. 2017;57 Suppl 3:113-226.

11 Years After the Injury. . .Still Badly Hurt

  1. Couch J. Headache severity in veterans deployed to Afghanistan or Iraq wars at 2-11 years after traumatic brain injury. Program Abstracts: The 59th Annual American Headache Society Meeting. Headache. 2017;57 Suppl 3:113-226.

Headache Relief, No Medication

  1. Balaban C. Multi-sensory neuromodulation of migraine: a role for vestibular stimulation. Program Abstracts: The 59th Annual American Headache Society Meeting. Headache. 2017;57 Suppl 3:113-226.
  2. Starling A. A multicenter, prospective, single arm, open label, post-market, observational study to evaluate the use of sTMS in reduction of migraine headache (ESPOUSE Study). Program Abstracts: The 59th Annual American Headache Society Meeting. Headache. 2017;57 Suppl 3:113-226.
  3. Liebler E. Non-invasive vagus nerve stimulation for the acute treatment of episodic and chronic cluster headache: findings from the randomized, double-blind, sham-controlled ACT2 study. Program Abstracts: The 59th Annual American Headache Society Meeting. Headache. 2017;57 Suppl 3:113-226.

Confirmed: AHS Guidance on Emergency Treatment of Migraine

  1. Friedman BW, West J, Vinson DR, Minen MT, Restivo A, Gallagher EJ. Current management of migraine in US emergency departments: an analysis of the National Hospital Ambulatory Medical Care Survey. Cephalalgia. 2015;35(4):301-309.
  2. Friedman B. A randomized study of prochlorperazine versus hydromorphone for acute migraine. Program Abstracts: The 59th Annual American Headache Society Meeting. Headache. 2017;57 Suppl 3:113-226.
  3. Orr SL, Friedman BW, Christie S, et al. Management of adults with acute migraine in the emergency department: the American Headache Society evidence assessment of parenteral pharmacotherapies. Headache. 2016;56(6):911-940.