Redefining migraine prevention: early treatment with anti-CGRP monoclonal antibodies enhances response in the real world.

BACKGROUND: Anti-CGRP monoclonal antibodies (anti-CGRP MAbs) are approved and available treatments for migraine prevention. Patients do not respond alike and many countries have reimbursement policies, which hinder treatments to those who might respond. This study aimed to investigate clinical factors associated with good and excellent response to anti-CGRP MAbs at 6 months. METHODS: European multicentre, prospective, real-world study, including high-frequency episodic or chronic migraine (CM) patients treated since March 2018 with anti-CGRP MAbs. We defined good and excellent responses as ≥50% and ≥75% reduction in monthly headache days (MHD) at 6 months, respectively. Generalised mixed-effect regression models (GLMMs) were used to identify variables independently associated with treatment response. RESULTS: Of the 5818 included patients, 82.3% were females and the median age was 48.0 (40.0-55.0) years. At baseline, the median of MHD was 20.0 (14.0-28.0) days/months and 72.2% had a diagnosis of CM. At 6 months (n=4963), 56.5% (2804/4963) were good responders and 26.7% (1324/4963) were excellent responders. In the GLMM model, older age (1.08 (95% CI 1.02 to 1.15), p=0.016), the presence of unilateral pain (1.39 (95% CI 1.21 to 1.60), p<0.001), the absence of depression (0.840 (95% CI 0.731 to 0.966), p=0.014), less monthly migraine days (0.923 (95% CI 0.862 to 0.989), p=0.023) and lower Migraine Disability Assessment at baseline (0.874 (95% CI 0.819 to 0.932), p<0.001) were predictors of good response (AUC of 0.648 (95% CI 0.616 to 0.680)). These variables were also significant predictors of excellent response (AUC of 0.691 (95% CI 0.651 to 0.731)). Sex was not significant in the GLMM models. CONCLUSIONS: This is the largest real-world study of migraine patients treated with anti-CGRP MAbs. It provides evidence that higher migraine frequency and greater disability at baseline reduce the likelihood of responding to anti-CGRP MAbs, informing physicians and policy-makers on the need for an earlier treatment in order to offer the best chance of treatment success.

Is erenumab an efficient alternative for the prevention of episodic and chronic migraine in Spain? Results of a cost-effectiveness analysis.

BACKGROUND: The reimbursement of erenumab in Spain and other European countries is currently restricted because of the cost of this novel therapy to patients with migraine who have experienced previous failures to traditional preventive treatments. However, this reimbursement policy should be preferably based on cost-effectiveness studies, among other criteria. This study performed a cost-effectiveness analysis of erenumab versus topiramate for the prophylactic treatment of episodic migraine (EM) and versus placebo for chronic migraine (CM). METHODS: A Markov model with a 10-year time horizon, from the perspective of the Spanish National Healthcare System, was constructed based on data from responder and non-responder patients. A responder was defined as having a minimum 50% reduction in the number of monthly migraine days (MMD). A hypothetical cohort of patients with EM with one or more prior preventive treatment failures and patients with CM with more than two treatment failures was considered. The effectiveness score was measured as an incremental cost per quality-adjusted life year (QALY) gained and cost per migraine day (MD) avoided. Data from clinical outcomes and patient characteristics were obtained from erenumab clinical trials (NCT02066415, STRIVE, ARISE, LIBERTY and HER-MES). Deterministic and probabilistic sensitivity analyses were performed to validate the robustness of the model. RESULTS: After a 10-year follow-up, the estimated QALYs were 5.88 and 6.11 for patients with EM treated with topiramate and erenumab, respectively. Erenumab showed an incremental cost per patient of €4,420 vs topiramate. For CM patients, erenumab resulted in 0.756 QALYs gained vs placebo; and an incremental cost of €1,814. Patients treated with erenumab achieved reductions in MD for both EM and CM (172 and 568 MDs, respectively). The incremental cost per QALY gained with erenumab was below the Spanish threshold of €30,000/QALY for both health and societal perspectives (EM €19,122/QALY and CM €2,398/QALY). CONCLUSIONS: Erenumab is cost-effective versus topiramate as a preventive treatment for EM and versus placebo for patients with CM from the perspective of the Spanish National Health System.

Eptinezumab for the preventive treatment of episodic and chronic migraine: a narrative review.

Eptinezumab, a monoclonal antibody that targets calcitonin gene-related peptide (CGRP), was recently approved in Europe for the prophylactic treatment of migraine in adults who have at least four migraine days a month. Eptinezumab is administered by intravenous infusion every 12 weeks. During recent months, a considerable amount of evidence from eptinezumab trials has been published. The aim of this review is to describe the existing evidence on the tolerability, safety and efficacy of eptinezumab in patients with migraine. Data from randomized (PROMISE-1, PROMISE-2, RELIEF and DELIVER) and open-label (PREVAIL) phase 3 clinical trials have demonstrated the favorable effect of eptinezumab in migraine symptoms from first day of treatment. These studies showed that eptinezumab results in an overall reduction in mean monthly migraine days (MMDs), increases in the ≥50% and ≥ 75% migraine responder rates (MRRs) and improvements in patient-reported outcome measures in both patients with episodic migraine (EM) and with chronic migraine (CM), including patients who failed previous preventive treatments. The RELIEF trial also showed that eptinezumab, within 2 h of administration, reduced headache pain, migraine-associated symptoms and acute medication use when administered during a migraine attack. Eptinezumab benefits manifested as early as day 1 after dosing and with the subsequent doses lasted up to at least 2 years. Treatment-emergent adverse events reported by ≥2% of patients included upper respiratory tract infection and fatigue. Current evidence demonstrates that eptinezumab has a potent, fast-acting, sustained migraine preventive effect in patients with EM and CM. Eptinezumab has also shown to be well tolerated, supporting its use in the treatment of patients with migraine and inclusion in the current migraine therapeutic options.

Migraine treatment consensus document of the Spanish Society of Neurology (SEN), Spanish Society of Family and Community Medicine (SEMFYC), Society of Primary Care Medicine (SEMERGEN) and Spanish Association of Migraine and Headache (AEMICE) on migraine treatment. / Documento de consenso de la Sociedad Española de Neurología (SEN), Sociedad Española de Medicina de Familia y Comunitaria (SEMFYC), Sociedad de Medicina de Atención Primaria (SEMERGEN) y Asociación Española de Migraña y Cefalea (AEMICE) sobre el tratamiento de la migraña.

Migraine is a disease with a high prevalence and incidence, in addition to being highly disabling, causing a great impact on the patient's quality of life at a personal, family and work level, but also social, given its high expense due to its direct (care) and indirect (presenteeism and work absenteeism) costs. The multiple and recent developments in its pathophysiological knowledge and in its therapy require updating and, therefore, in this article the Spanish scientific societies most involved in its study and treatment (SEN, SEMFYC and SEMERGEN), together with the Association Spanish Association for Patients with Migraine and other Headaches (AEMICE), we have developed these updated care recommendations. We reviewed the treatment of migraine attacks, which consisted mainly of the use of NSAIDs and triptans, to which ditans and gepants have been added. We also discuss preventive treatment consisting of oral preventive drugs, botulinum toxin, and treatments that block the action of calcitonin-related peptide (CGRP). Finally, we emphasize that pharmacological treatments must be complementary to carrying out general measures consisting of identifying and managing/deletion the precipitating factors of the attacks and the chronicizing factors, controlling the comorbidities of migraine and eliminating analgesic overuse.

Long-term safety of OnabotulinumtoxinA treatment in chronic migraine patients: a five-year retrospective study.

Background: Real-world studies have shown the sustained therapeutic effect and favourable safety profile of OnabotulinumtoxinA (BoNTA) in the long term and up to 4 years of treatment in chronic migraine (CM). This study aims to assess the safety profile and efficacy of BoNTA in CM after 5 years of treatment in a real-life setting. Methods: We performed a retrospective chart review of patients with CM in relation to BoNTA treatment for more than 5 years in 19 Spanish headache clinics. We excluded patients who discontinued treatment due to lack of efficacy or poor tolerability. Results: 489 patients were included [mean age 49, 82.8% women]. The mean age of onset of migraine was 21.8 years; patients had CM with a mean of 6.4 years (20.8% fulfilled the aura criteria). At baseline, patients reported a mean of 24.7 monthly headache days (MHDs) and 15.7 monthly migraine days (MMDs). In relation to effectiveness, the responder rate was 59.1% and the mean reduction in MMDs was 9.4 days (15.7 to 6.3 days; p < 0.001). The MHDs were also reduced by 14.9 days (24.7 to 9.8 days; p < 0.001). Regarding the side effects, 17.5% experienced neck pain, 17.3% headache, 8.5% eyelid ptosis, 7.5% temporal muscle atrophy and 3.2% trapezius muscle atrophy. Furthermore, after longer-term exposure exceeding 5 years, there were no serious adverse events (AE) or treatment discontinuation because of safety or tolerability issues. Conclusion: Treatment with BoNTA led to sustained reductions in migraine frequency, even after long-term exposure exceeding 5 years, with no evidence of new safety concerns.

Nueva era terapéutica para el ataque de migraña con los recientemente aprobados anticuerpos monoclonales, ditanes y gepantes / New therapeutic era for migraine attacks with recently approved monoclonal antibodies, ditans and gepants

El tratamiento de los ataques de migraña se aconseja en todos los pacientes, utilizando antiinflamatorios no esteroideos cuando el dolor es leve y triptanes cuando la intensidad del dolor es moderada-grave. Sin embargo, la efectividad de estos fármacos es modesta, un porcentaje elevado de pacientes presenta efectos secundarios y los triptanes están contraindicados en las personas con antecedentes de ictus, cardiopatía isquémica o hipertensión mal controlada. Por tanto, es imprescindible disponer de nuevas alternativas terapéuticas. En los últimos años han ido apareciendo nuevos fármacos para los ataques de migraña, entre los que destacan los ditanes (lasmiditán) y los gepantes (ubrogepant y rimegepant). Por otro lado, el eptinezumab, que ha sido aprobado para el tratamiento preventivo de la migraña en adultos, se ha utilizado también para los ataques de migraña. En este manuscrito se revisan los resultados de eficacia y seguridad de los nuevos fármacos para los ataques de migraña que se comercializarán próximamente. (AU)

Treatment of migraine attacks is advised in all patients, using non-steroidal anti-inflammatory drugs when the pain is mild and triptans when the pain intensity is moderate-severe. However, the effectiveness of these drugs is moderate, a high percentage of patients have side effects, and triptans are contraindicated in people with a history of stroke, ischaemic heart disease or poorly controlled hypertension. Hence, there is an urgent need for new therapeutic alternatives. In recent years, new drugs for migraine attacks have become available, most notably ditans (lasmiditan) and gepants (ubrogepant and rimegepant). Furthermore, eptinezumab, which has been approved for the preventive treatment of migraine in adults, has also been used for migraine attacks. This manuscript reviews the efficacy and safety results of the new drugs for migraines that will soon be on the market. (AU)

Fisioterapia en cefalea tensional. ¿Debe recomendarse a nuestros pacientes? / Physiotherapy in tension type headaches. Should it be recommended?

No disponible

Recomendaciones de uso de anticuerpos monoclonales para el tratamiento de la migraña del grupo de consenso de Navarra y Aragón / Recommendations on the use of monoclonal antibodies for treating migraine. Consensus group of Navarre and Aragon

No disponible

Grasa epicárdica en la población general de mediana edad y su asociación con el síndrome metabólico / Epicardial adipose tissue in the general middle-aged population and its association with metabolic syndrome

Introducción y objetivos: Actualmente hay cada vez más interés en el tejido adiposo epicárdico (TAE) como marcador de enfermedad cardiovascular. Nuestro objetivo es describir el TAE medido por ecocardiograma, y determinar su asociación con el síndrome metabólico (SM), dentro del estudio poblacional RIVANA. Métodos: Se incluyó a 880 sujetos de 45 a 74 años (492 con SM según la definición armonizada). Se realizó una exploración física y se tomó una muestra sanguínea para obtener el perfil bioquímico. Se midió el espesor del TAE con ecocardiografía transtorácica al final de la sístole. Resultados: Entre los sujetos sin SM, la prevalencia de TAE ≥ 5 mm aumentaba significativamente con la edad (> 65 frente a 45-54 años, OR = 8,22; IC95%, 3,90-17,35; p lineal < 0,001). El TAE se asoció significativamente con el SM (5.o frente a 1.er quintil, OR = 3,26; IC95%, 1,59-6,71; p lineal = 0,001). Respecto a los criterios individuales, el TAE se asoció independientemente con los criterios colesterol unido a lipoproteínas de alta densidad bajo (5.o frente a 1.er quintil, OR = 2,65; IC95%, 1,16-6,05; p lineal = 0,028), triglicéridos altos (5.o frente a 1.er quintil, OR = 2,22; IC95%, 1,26-3,90; p lineal = 0,003) y elevado perímetro abdominal (5.o frente a 1.er quintil, OR = 6,85; IC95%, 2,91-16,11; p lineal < 0,001). Conclusiones En una submuestra de la población general, la grasa epicárdica aumentó significativa e independientemente con la edad, y su incremento se asoció independientemente con el SM, el colesterol unido a lipoproteínas de alta densidad bajo, los triglicéridos altos y un elevado perímetro abdominal (AU)

Introduction and objectives: There is currently increasing interest in epicardial adipose tissue (EAT) as a marker of cardiovascular disease. Our purpose was to describe EAT, measured by transthoracic echocardiography, and to assess its association with metabolic syndrome (MS) in the RIVANA population-based study. Methods: Physical examination was performed in 880 participants aged 45 to 74 years (492 of them with MS according to the harmonized definition). Fasting glucose, high-density lipoprotein cholesterol, triglyceride, and C-reactive protein concentrations were determined in a blood sample. In all participants, EAT thickness was measured with transthoracic echocardiography at end-systole. Results: Among participants without MS, the prevalence of EAT ≥ 5 mm significantly increased with age (OR > 65 years vs 45-54 years = 8.22; 95%CI, 3.90-17.35; P for trend < .001). Increasing EAT quintiles were significantly associated with MS (OR fifth quintile vs first quintile = 3.26; 95%CI, 1.59-6.71; P for trend = .001). Considering the different MS criteria, increasing quintiles of EAT were independently associated with low high-density lipoprotein cholesterol (OR fifth quintile vs first quintile = 2.65; 95%CI, 1.16-6.05; P for trend = .028), high triglycerides (OR fifth quintile vs first quintile = 2.22; 95%CI, 1.26-3.90; P for trend = .003), and elevated waist circumference (OR fifth quintile vs first quintile = 6.85; 95%CI, 2.91-16.11; P for trend < .001). Conclusions: In a subsample of the general population, EAT measured by echocardiography increased significantly and independently with age. Increased EAT thickness was independently associated with MS and with low high-density lipoprotein cholesterol, high triglycerides, and elevated waist circumference as individual criteria (AU)

Guía para el tratamiento preventivo del ictus isquémico y AIT (II). Recomendaciones según subtipo etiológico / Guidelines for the preventive treatment of ischaemic stroke and TIA (II). Recommendations according to aetiological sub-type

FUNDAMENTO Y OBJETIVO: Actualizar las guías terapéuticas del Comité ad hoc del Grupo de Estudio de Enfermedades Cerebrovasculares de la SEN en el tratamiento preventivo de ictus isquémico (II) y ataque isquémico transitorio (AIT). MÉTODOS: Revisión de evidencias disponibles sobre la prevención del ictus isquémico y AIT en función del subtipo etiológico. Los niveles de evidencia y grados de recomendación se han basado en la clasificación del Centro de Medicina Basada en la Evidencia. RESULTADOS: En el II de origen aterotrombótico reducen el riesgo de recurrencias el tratamiento antiagregante y los procedimientos revascularizadores en casos seleccionados de estenosis carotidea ipsilateral (70-99%). La prevención de II de origen cardioembólico (fibrilación auricular, valvulopatías, prótesis valvulares y en infarto de miocardio con trombo mural) se basa en el uso de anticoagulantes orales. En el II de origen inhabitual, las terapias preventivas dependerán de la etiología; en la trombosis venosa cerebral la anticoagulación oral es eficaz. CONCLUSIONES: Se concluye con recomendaciones de práctica clínica en prevención de ictus isquémico y AIT adaptadas al subtipo etiológico de II que ha presentado el paciente

BACKGROUND AND OBJECTIVE: To update the ad hoc Committee of the Cerebrovascular Diseases Study Group of The Spanish Neurological Society guidelines on prevention of ischaemic stroke (IS) and Transient Ischaemic Attack (TIA). METHODS: We reviewed the available evidence on ischaemic stroke and TIA prevention according to aetiological subtype. Levels of evidence and recommendation levels are based on the classification of the Centre for Evidence-Based Medicine. RESULTS: In atherothrombotic IS, antiplatelet therapy and revascularization procedures in selected cases of ipsilateral carotid stenosis (70%-90%) reduce the risk of recurrences. In cardioembolic IS (atrial fibrillation, valvular diseases, prosthetic valves and myocardial infarction with mural thrombus) prevention is based on the use of oral anticoagulants. Preventive therapies for uncommon causes of IS will depend on the aetiology. In the case of cerebral venous thrombosis oral anticoagulation is effective. CONCLUSIONS: We conclude with recommendations for clinical practice in prevention of IS according to the aetiological subtype presented by the patient

Guía de actuación clínica en la hemorragia subaracnoidea. Sistemática diagnóstica y tratamiento / Clinical management guidelines for subarachnoid haemorrhage. Diagnosis and treatment

OBJETIVO: Actualización de la guía para el diagnóstico y tratamiento de la hemorragia subaracnoidea de la Sociedad Española de Neurología. MATERIAL Y MÉTODOS: Revisión y análisis de la bibliografía existente. Se establecen recomendaciones en función del nivel de evidencia que ofrecen los estudios revisados. RESULTADOS: La causa más frecuente de hemorragia subaracnoidea espontánea (HSA) es la rotura de un aneurisma cerebral. Su incidencia se sitúa en torno 9 casos por 100.000 habitantes/año y supone un 5% de todos los ictus. La hipertensión arterial y el tabaquismo son sus principales factores de riesgo. Se ha de realizar el tratamiento en centros especializados. Se debe considerar el ingreso en unidades de ictus de aquellos pacientes con HSA y buena situación clínica inicial (grados I y II en la escala de Hunt y Hess). Se recomienda la exclusión precoz de la circulación del aneurisma. El estudio diagnóstico de elección es la tomografía computarizada (TC) craneal sin contraste. Si esta es negativa y persiste la sospecha clínica se aconseja realizar una punción lumbar. Los estudios de elección para identificar la fuente de sangrado son la resonancia magnética (RM) y la angiografía. Los estudios ultrasonográficos son útiles para el diagnóstico y seguimiento del vasoespasmo. Se recomienda el nimodipino para la prevención de la isquemia cerebral diferida. La terapia hipertensiva y el intervencionismo neurovascular pueden plantearse para tratar el vasoespasmo establecido. CONCLUSIONES: La HSA es una enfermedad grave y compleja que debe ser atendida en centros especializados, con suficiente experiencia para abordar el proceso diagnóstico y terapéutico

OBJECTIVE: To update the Spanish Society of Neurology's guidelines for subarachnoid haemorrhage diagnosis and treatment. MATERIAL AND METHODS: A review and analysis of the existing literature. Recommendations are given based on the level of evidence for each study reviewed. RESULTS: The most common cause of spontaneous subarachnoid haemorrhage (SAH) is cerebral aneurysm rupture. Its estimated incidence in Spain is 9/100 000 inhabitants/year with a relative frequency of approximately 5% of all strokes. Hypertension and smoking are the main risk factors. Stroke patients require treatment in a specialised centre. Admission to a stroke unit should be considered for SAH patients whose initial clinical condition is good (Grades I or II on the Hunt and Hess scale). We recommend early exclusion of aneurysms from the circulation. The diagnostic study of choice for SAH is brain CT (computed tomography) without contrast. If the test is negative and SAH is still suspected, a lumbar puncture should then be performed. The diagnostic tests recommended in order to determine the source of the haemorrhage are MRI (magnetic resonance imaging) and angiography. Doppler ultrasonography studies are very useful for diagnosing and monitoring vasospasm. Nimodipine is recommended for preventing delayed cerebral ischaemia. Blood pressure treatment and neurovascular intervention may be considered in treating refractory vasospasm. CONCLUSIONS: SAH is a severe and complex disease which must be managed in specialised centres by professionals with ample experience in relevant diagnostic and therapeutic processes

¿Realmente es beneficioso usar las dosis de OnabotulinumtoxinA del estudio PREEMPT? / What is the optimal dose for the prophylactic treatment of chronic migraine patients?

Introducción. La OnabotulinumtoxinA (OnabotA) está indicada para el tratamiento preventivo de los pacientes con diagnóstico de migraña crónica. Existe cierta controversia acerca de cuál es la dosis mínima eficaz de OnabotA. Objetivo. Determinar cuál es la dosis más adecuada de OnabotA para el tratamiento de la migraña crónica. Desarrollo. Se revisan los estudios controlados frente a placebo, que han evaluado la eficacia y seguridad de OnabotA para el tratamiento de la migraña, prestando especial atención a las dosis de toxina utilizadas. En los diferentes ensayos clínicos llevados a cabo antes del año 2010 se utilizaron distintos protocolos de infiltración. La experiencia obtenida de los estudios previos permitió definir un protocolo de infiltración que se utilizó en el programa PREEMPT, y que demostró que el tratamiento con OnabotA es seguro y eficaz en pacientes con migraña crónica. La dosis elegida en los ensayos PREEMPT 1 y 2 fue de 155-195 U, al observarse en los estudios en fase II que la dosis de 75 U no era eficaz y que la utilización de 150-200 U aumentaba la eficacia sin incrementar los efectos adversos. Además de la dosis, el paradigma de inyección PREEMPT también establece de manera detallada los puntos de inyección y la metodología de infiltración. Conclusiones. La evidencia científica disponible hasta la fecha sustenta que la dosis más adecuada para el tratamiento de la migraña crónica es la utilización de al menos 150 U de OnabotA, y que la infiltración debe realizarse con la metodología definida en el paradigma de inyección PREEMPT (AU)

Introduction. OnabotulinumtoxinA (OnabotA) is indicated for headache prophylaxis in patients with chronic migraine. However, there is some controversy about what is the minimum effective dose for treating chronic migraine patients. Aim. To determine the optimal dose of OnabotA for the prophylactic treatment of patients with chronic migraine. Development. We performed a literature review of the randomized, double blind, placebo-controlled studies that have evaluated the safety and efficacy of OnabotA as headache prophylactic treatment in migraine patients. In the studies conducted before the PREEMPT clinical programme, a variety of dose ranges and infiltration paradigms were used. Initial phase II studies of OnabotA in chronic daily headache showed that those patients treated with 150 U had significant mean reductions from baseline in headache frequency compared with placebo, and this benefit was not observed for patients treated with 75 U. The experience from previous studies allowed to define an injection paradigm and dose range (155-195 U) that was used in the PREEMPT clinical trials. PREEMPT studies demonstrate that OnabotA is a safe an effective prophylactic treatment for chronic migraine. Conclusions. Available evidence to date supports that the optimal dose for the treatment of chronic migraine patients is the use of at least 150 U of OnabotA, that should be administered according to the PREEMPT injection paradigm (AU)

Factores predictores de respuesta al tratamiento con onabotulinumtoxina A en la migraña refractaria / Predictive factors of the response to treatment with onabotulinumtoxinA in refractory migraine

Objetivo. Identificar las características clínicas que predicen una respuesta favorable al tratamiento con onabotulinumtoxina A (OnabotA) en pacientes con migraña refractaria. Pacientes y métodos. Estudio retrospectivo de pacientes con migraña refractaria que recibieron al menos dos infiltraciones de OnabotA entre los años 2008 y 2012. Los pacientes fueron divididos en respondedores y no respondedores a OnabotA y se compararon entre ambos grupos, y de forma retrospectiva, una serie de características clínicas consideradas predictoras de respuesta en estudios previos: localización unilateral de la cefalea, presencia de tensión muscular pericraneal, tipo de dolor (implosivo, explosivo u ocular), tiempo de evolución de la migraña (menor o mayor de 10 años) y abuso de medicación analgésica. Resultados. Se incluyeron 39 pacientes (35 mujeres) con una edad media de 46 años. En 18 pacientes (46,2%) se observó una reducción mayor del 50% en el número de días de cefalea/mes (pacientes respondedores). Al analizar las d ferentes características de la migraña, se observó que todas ellas fueron igualmente prevalentes en los pacientes respondedores y en los no respondedores (p > 0,05): localización unilateral (66,7% frente a 66,6%, respectivamente), dolor implosivo (27,8% frente a 38,1%), presencia de tensión muscular pericraneal (33,3% frente a 38,1%), tiempo de evolución de la migraña mayor de 10 años (77,8% frente a 69,2%) y presencia de abuso de medicación analgésica (50% frente a 81%). Conclusión. En esta serie de pacientes no se ha identificado ningún rasgo clínico que permita predecir en pacientes con migraña refractaria una respuesta favorable al tratamiento con OnabotA (AU)

Aim. To identify the clinical features that predict a favourable response to onabotulinumtoxinA (OnabotA) treatment in patients with refractory migraine. Patients and methods. Retrospective analysis of patients with refractory migraine who underwent at least two pericranial injections of OnabotA between 2008 and 2012. Patients were divided into responders and non-responders. Some clinical features including unilateral location of headache, presence of pericranial muscle tension, type of pain (imploding or exploding), duration of migraine (less than or greater than 10 years) and medication overuse were compared between the two groups. Results. 39 patients were included (35 women) with a mean age of 46 years. 18 patients (46.2%) showed a greater than 50% reduction in the number of headache days/month (responders). When analyzing the different features of migraine, we observed that all were equally prevalent in responders and non-responders (p > 0.05): unilateral location (66.7% vs 66.6% respectively), implosive ain (27.8% vs 38.1%), presence of pericranial muscle tension (33.3% vs 38.1%), duration of migraine more than 10 years (77.8% vs 69.2%) and presence of medication overuse (50% vs 81%). Conclusion. We failed to identify any clinical feature in our patients with refractory migraine that predicts a favourable response to OnabotA treatment (AU)

Los triptanes en la práctica clínica: eficacia, tolerancia y satisfacción del paciente con los fármacos (estudio TRIPRACLI) / Triptans in clinical practice: effectiveness, tolerance and patient’s satisfaction with medication (TRIPRACLI study)

Introducción y objetivos. Conocer en nuestro medio la eficacia, tolerabilidad y satisfacción del paciente migrañoso con diferentes triptanes en función de las características de sus crisis e intentar establecer un modelo predictivo para recomendar uno u otro en función de dichas características. Pacientes y métodos. Estudio retrospectivo observacional multicéntrico en unidades de cefalea. Se incluyen pacientes con migraña que utilizan un mismo triptán para el tratamiento de sus crisis. Se analizan datos de preferencia, eficacia, rapidez y tolerancia. Resultados. Se analizan 160 pacientes (88 mujeres), con una edad media de 42,92 años. Los triptanes más utilizados fueron eletriptán, almotriptán y rizatriptán. Tanto pacientes como médicos mostraron un alto grado de satisfacción (88% y 65%, respectivamente) con el triptán utilizado. En las encuestas de preferencia, los pacientes preferían el triptán actual sobre el previo (83%) o fármacos no específicos (93%). La valoración global en una escala analógica visual estuvo por encima de 7 para todos los triptanes, sin diferencias entre ellos. Al analizar la utilización de un determinado triptán en función de las características de las crisis, no se encontraron diferencias estadísticamente significativas. Conclusiones. En este grupo seleccionado de pacientes, los triptanes son un tratamiento por el que los pacientes muestran un alto grado de satisfacción. Aunque no existen diferencias globales en las puntuaciones entre los diferentes triptanes, el hecho de que determinados triptanes sean más utilizados por los pacientes después de experiencias previas con otros sugiere una mayor eficacia por su parte. No hemos encontrado ningún parámetro que prediga la utilización de un determinado triptán(AU)

Introduction and aims. This study was aimed determining the effectiveness, tolerance and satisfaction of patients with migraine as regards different triptans, according to the characteristics of their attacks. At the same time it sought to establish a predictive model that can be used to recommend one or another, depending on those characteristics. Patients and methods. Retrospective observation-based study conducted in headache units in a number of different centres. Patients included in the study were those with migraine who used the same triptan to treat their attacks. Data concerning preference, effectiveness, speed and tolerance were analysed. Results. The analysis included 160 patients (88 females), with a mean age of 42.92 years. The most commonly used triptans were eletriptan, almotriptan and rizatriptan. Both patients and doctors reported a high degree of satisfaction (88% and 65%) with the triptan that was used. In the surveys on preference, patients preferred their current triptan to the previous one (83%) or to non-specific drugs. The overall score on a visual analogue scale was above 7 for all the triptans, without any differences from one to another. On analysing the use of a particular triptan depending on the characteristics of the attacks, no statistically significant differences were found. Conclusions. In this selected group of patients, triptans are a treatment that patients claim to be very satisfied with. Although there are no overall differences in the scores among different triptans, the fact that certain triptans are used more by patients after previous experiences with others suggests that they are more effective. We did not find any parameter that predicts the use of a particular triptan(AU)

Migraña crónica: definición, epidemiología, factores de riesgo y tratamiento / Chronic migraine: definition, epidemiology, risk factors and treatment

Introducción. La migraña crónica es la complicación más frecuente de la migraña. Se define por la presencia de cefalea 15 o más días al mes, de los que al menos ocho deben cumplir criterios de migraña sin aura durante al menos tres meses, en ausencia de abuso de medicación y no atribuibles a otra causa. Desarrollo. Su prevalencia oscila entre el 1-3% de la población, y su incidencia se ha estimado en un 2,5% anual. Producede cuatro a seis veces más discapacidad, disminución de la productividad y alteración de la calidad de vida que la migrañaepisódica. El desarrollo de migraña crónica se ha asociado con varios factores de riesgo no modificables (sexo femenino, estatus socioeconómico y nivel educativo bajos) y modificables (ansiedad, depresión, apnea del sueño/ronquido, obesidad,consumo de analgésicos y cafeína). Los pacientes con migraña crónica sufren dolor crónico, ansiedad o depresión con una frecuencia 2-3 veces superior a la migraña episódica. Su abordaje requiere la identificación y el manejo de los factores de riesgo que predisponen a su desarrollo, deshabituación de analgésicos cuando hay abuso, tratamiento específico de lascrisis de migraña y tratamiento preventivo. Entre los fármacos preventivos, el topiramato y la Onabotulinumtoxin A handemostrado, en grandes ensayos clínicos controlados frente a placebo, su eficacia en esta complicación de la migraña. Conclusiones. La migraña crónica es una entidad frecuente que requiere un manejo global cuyos objetivos son reducir la frecuencia de las crisis, la discapacidad asociada y mejorar la calidad de vida de los pacientes (AU)

Introduction. Chronic migraine is the most frequent complication of migraine. It is defined by the presence of headache on 15 or more days a month, of which at least eight must meet the criteria of migraine without aura for a minimum ofthree months. In addition they must not be due to medication abuse or attributable to any other cause.Development. The prevalence of chronic migraine ranges between 1-3% of the population and its incidence has been estimated to be 2.5% per year. It produces from four to six times more disability, decreased productivity and disruption of quality of life than episodic migraine. The development of chronic migraine has been associated with both non-modifiablerisk factors (being female, low socio-economic status and level of schooling) and modifiable risk factors (anxiety, depression, sleep apnoea/snoring, obesity, consumption of painkillers and caffeine). Patients with chronic migraine suffer from chronicpain, anxiety or depression two to three times more often than those with episodic migraine. Management requires identification and control of the risk factors that predispose patients to develop the condition, detoxification therapy in the event of abuse of analgesics, specific treatment for migraine attacks and preventive treatment. The effectiveness of the preventive drugs topiramate and Onabotulinumtoxin A in this complication of migraine has been proved in large-scaleplacebo-controlled clinical trials.Conclusions. Chronic migraine is a common condition that requires global management aimed at reducing the frequencyof the attacks, lowering the associated disability and improving the patients’ quality of life (AU)

Experiencia clínica del tratamiento con onabotulinumtoxin A en pacientes con migraña refractaria / Clinical experience of treatment with onabotulinumtoxin A in patients with refractory migraine

Objetivo. Mostrar nuestra experiencia en el tratamiento de onabotulinumtoxin A (OnabotA) en pacientes con migraña refractaria, tanto crónica como episódica frecuente (≥ 10 días/mes). Pacientes y métodos. Análisis retrospectivo de pacientes con migraña refractaria que habían recibido al menos dos infiltraciones de OnabotA siguiendo el protocolo PREEMPT entre los años 2008 y 2012. Se evaluó la eficacia de OnabotA comparando la situación basal y transcurridas entre 12-16 semanas después de la segunda infiltración, determinando: mejoría subjetiva de los pacientes, número de días con cefalea, consumo de fármacos preventivos y analgésicos, y efectos adversos. Resultados. Se identificaron 41 pacientes (37 mujeres, cuatro varones). Un 65,8% de los pacientes encontró mejoría subjetiva tras el tratamiento. Un 36,58% respondió al tratamiento con OnabotA (reducción > 50% en los días de cefalea). La diferencia entre los días al mes de cefalea antes de la primera infiltración (24,5 ± 7,3) y después de la segunda infiltración (17,4 ± 11,6), y la diferencia entre la dosis de analgésicos al mes antes de la primera infiltración (26,8 ± 23,1) y la de después de la segunda infiltración (16,7 ± 19,3) fueron significativas (p < 0,001). En el análisis por subgrupos, todas las diferencias fueron significativas, salvo en el caso de pacientes con migraña episódica frecuente refractaria, donde la reducción en los días al mes de cefalea no alcanzó la significación. Conclusión. El tratamiento con OnabotA es útil en pacientes con migraña refractaria crónica, y podría ser también beneficioso en migraña refractaria episódica frecuente (AU)

Aim. To analyse our experience in the treatment of refractory chronic migraine, episodic frequent refractory migraine (≥ 10 days/month), with onabotulinumtoxin A (OnabotA). Patients and methods. Retrospective analysis of patients with refractory migraine who underwent, at least two sessions of OnabotA pericranial injections following the PREEMPT protocol between 2008 and 2012. The efficacy of OnabotA was evaluated comparing the basal situation with 12-16 weeks after the second session. We analysed the subjective improvement f the patients, number of days with headache, preventive and abortive drugs consumption, and adverse effects. Results. Forty-one patients (37 women, 4 male) were identified. 65.8% patients experienced subjective improvement after OnabotA treatment. 36.58% responded (reduction of > 50% in headache days). Differences between days with headache before the first session (24.5 ± 7.3), and 12-16 weeks after the second session (17.4 ± 11.6), as well as the differences between the number of abortive drugs taken before the first session (26.8 ± 23.1) and 12-16 weeks after the second session (16.7 ± 19.3), were statistically significant (p < 0.001). Subgroups analysis showed that all differences were significant, xcept for the reduction of the number of days with headache in patients with episodic frequent refractory migraine. Conclusion. Our work shows that treatment with OnabotA is safe and useful in patients with episodic and chronic refractory migraine, including those patients with medication overuse headache (AU)

Migraña crónica y abuso de analgésicos / Chronic migraine and abuse of analgesics

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