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CGRP: Calcitonin gene
related peptide
-
37 amino acid peptides
-
Very specific target
“What excites me is the
biology is giving credibility to the field”
This step forward in research and
knowledge about migraine will bring new people into the field.
CGRP
-
Aimovig – monoclonal antibodies – binds
to receptor
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Ajovy & Emgality – goes directly to peptide itself (mops it up)
Block pathway and just that
pathway.
Side effects – limits?
“It’s a marker of how
disabling migraine is. The fact doctors will inform patients of side effects
and patients still say.. .oh ill take one of those. The disorder is still worse
than the horrible side effect symptoms."
Response?
-
Some super responders
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Some high expectations – show no response
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Some failed 7-8 treatments and now doing so much
better.
Eptinezumab (IV drug)
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Targets
the peptide, not receptor (mops up the receptor)
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Onset of action is key
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Think twice for cardiovascular patients and
those with hemiplegic/basilar migraine. Caution rather than specific data
telling us it’s not safe.
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CGRP is fine to use with other drugs such as
Botox and topiramate.
Neuromodulation devices?
-
Devices that don’t interfere with reproductive
process is a good idea
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Migraine demographic – women – peaks at age of
40 – escalating migraine in 20’s and 30’s
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Very helpful tools to use
Cefaly: Branches of
trigeminal nerve
Gammacore: vagus nerve – inputs into pain – cluster
headache patients
Stms: Cortex- brain matter how it interreacts with
the thalamus
Treatment works directly for
attack and no MOH. Might as well use it daily as a preventative.
Nerivio: new device to be worn on the arm (acute).
Distraction from pain.
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Body ignores the fact you’re wearing clothes
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Brain selecting what to attend to and filters
out signals such as that you are wearing shoes for example.
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Stimulate arm via the Nerivio – filter out other
signals – pain in head is perceived as less.
Acute meds?
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Ditans
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Reyvow (Lasmiditan): serotonin 1F receptor
antagonist (only on nerves. Turn off pain nerves, no vasal constriction). Side
effects – dizzy but no chest tightness like some experience on triptans.
Gepant?
-
Antagonist
-
CGRP receptor blocker. Small molecule. They come
on and off and compete with CGRP.
Gepant VS
triptan for acute therapy?
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Gepant: 20% pain free within 2 hours (<2%
side effects)
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Triptan: 30% pain free within 2 hours (30% experience
some side effects)
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Gepant appears to be very well tolerated so
far
-
Prevention with Gepant? Potential to use daily
as shouldn’t be a problem with MOH.
“What sort
of month is it when you don’t know what you can do because of triptan days. Moving
towards an era when you can do what you want to do.”
Final
thoughts from Professor Goadsby
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Maintain a new optimism. “if someone says you
have tried everything, it might be true today but next week or in a month or
two that’s almost certainly going to be incorrect”.
Never give
up hope. Its not just a word to use. The science and the effort that’s going on
is turning hope into reality. It will change, just stick with it.
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