Monoclonal Antibodies Targeting CGRP: A Novel Treatment in Vestibular Migraine.

Background. Monoclonal antibodies (mAbs) directed against the calcitonin gene-related peptide (CGRP) or its receptor represented the first targeted and specialized approach to migraine prophylaxis. Nevertheless, they have been rarely considered in the treatment of vestibular migraine (VM). Our aim was to evaluate the effectiveness of anti-CGRP mAbs in VM patients who did not respond to conventional migraine treatments. Methods. Consecutive VM patients treated with erenumab were considered. As a comparison, we considered the same VM patients during conventional migraine treatments (i.e., propranolol, flunarizine, or valproic acid), which were tried before mAbs therapy. Videonystagmography, the Italian version of the Dizziness Handicap Inventory (DHI) questionnaire, and migraine days over the last 3 months were evaluated in all patients before and after treatments. Results. In the present retrospective study, we included 21 female and 2 male VM patients, mean age 45.2 years. All patients underwent contrast-enhanced magnetic resonance imaging that ruled out other causes of vertigo. The DHI questionnaire significantly improved after mAb therapy (p < 0.0001). Mean migraine days over the last 3 months were significantly reduced after treatment (p = 0.001). Videonystagmography was altered in 11 (48%) patients prior to monoclonal antibodies. We found vertical positional nystagmus in 9 patients and horizontal positional nystagmus in 2 patients. After the treatment, we found vertical positional nystagmus only in 1 patient (p = 0.002). When patients were treated with conventional therapies, there was no significant reduction in DHI, and instrumental vestibular examinations remained altered. Conclusions. VM patients using anti-CGRP mAbs experienced a reduction in the dizziness-derived handicap, as reported in the DHI questionnaire. Furthermore, these treatments were significantly associated with a normalization of vestibular instrumental analysis. These findings were not seen with conventional treatments. Treatment with anti-CGRP mAbs may be effective in VM patients who did not respond to conventional migraine treatments. These findings should be tested in large, randomized clinical trials.

Ratio Aß1-42:p-Tau: a Possible Diagnostic Tool in Differentiating Dementias.

BACKGROUND: Patients with Alzheimer's disease (AD) present a typical biochemical profile of biomarkers: low concentration of ß amyloid 1-42 (Aß1-42), high concentration of total Tau (t-Tau) and phosphorylated Tau at threonine 181 (p-Tau). Several neurodegenerative diseases may overlap with AD, both in regards to clinical symptoms and neuropathology. Many data suggest that Alzheimer's disease (AD) pathophysiology can be identified using biomarkers. It has been hypothesized that subjects with dementia due to AD showed low levels of Aß1-42 combined with the highest levels of total Tau and phosphorylated Tau; moreover, it has been hypothesized that the ratio Aß1-42:p-Tau further help in discriminating Alzheimer's disease from other diagnoses. The aim of this work is to verify this hypothesis in our cohort of patients and to investigate if the same ratio could be a sensitive index able to discriminate MCI due to neurodegenerative factors (MCId) from MCI due to vascular factors (MCIv). METHODS: Two hundred sixty-two patients meeting the NIA-AA and NINDS-AIREN criteria were diagnosed as follow: AD in 120 patients [mean age 71.6 (42 - 87)], FTD in 23 patients [mean age 67.3 (46 - 78)], LBD in 17 patients [mean age 73.2 (58 - 83)], VAD in 9 patients [mean age 71.2 (60 - 81)]. According to the criteria proposed by Petersen RC, 24 patients had the diagnosis of MCId [mean age 71.8 (59 - 81)], 38 MCIv [mean age 69.3 (55-82). The comparison between the ratio of Aß1-42/p-Tau among the six groups was done using t-test for independent samples. A p-value < 0.05 was considered to represent statistical significance. The ROC (Receiver Operating Characteristic) curve analysis was made using R-studio software. RESULTS: The ratio Aß1-42:p-Tau was significantly lower in AD and MCId with respect to all the other groups and the difference was also statistically significant between MCId and MCIv. CONCLUSIONS: Aß1-42:p-Tau ratio has potential for being implemented in the clinical routine for differential diagnosis between AD and other dementias and to distinguish underling pathology such as neurodegenerative or vascular disease.

Angiotensin II receptor blockers: a new possible treatment for chronic migraine?

The objective is to suggest a possible role of different angiotensin receptor blockers in the treatment of chronic migraine, especially in hypertensive subjects. Chronic migraine is a highly disabling disorder affecting between 1.4 and 2.2 % of the general population. Despite many pharmacological and non-pharmacological treatments proposed, the results are rather discouraging. Therefore, we believe that should be highlighted all the possible therapies that may lead to an improvement of the symptomatology. Particularly, data available on efficacy of ARBs in preventing chronic migraine are poor. Methods include case reports, literature review and discussion. We report three cases recently treated with angiotensin II receptor blockers that showed a significant improvement, never previously presented with more conventional treatments, including beta blockers. In all three cases, we obtained the reversibility from a chronic migraine to an episodic. Taking a cue from this observation, we consider desirable large controlled, randomized trials to assess the effectiveness of ARBs both in CM hypertensive patients and in patients who do not require anti-hypertensive therapy; furthermore are desirable comparative studies between the various ARB inhibitors to assay any intermolecular differences in efficacy.

Efficacy of oxygen inhalation in sumatriptan refractory "high altitude" cluster headache attacks.

We describe the case of a 40-year-old woman, affected by episodic cluster headache, who presented with a cluster headache triggered by exposure to high altitude. Her attacks were refractory to sumatriptan, very effective at sea level, but responded to oxygen. A pathophysiological mechanism is proposed.