Abortive migraine article migraine awareness Migraine preventative migraine research migraine treatment Visual snow

What is on the horizon with migraines – with Dr. Goadsby

Discussion with Dr. Goadsby about new migraine research and treatments both preventatively and acutely on the horizon.

I had a short chat with Dr. Goadsby, MD, PhD, FAHS on June 16, 2017. Unfortunately, it was the day of a rather wicked migraine so I hope he forgives my befuddlement. I am not at my verbal best with high migraine pain. Or thinking. I had just taken my triptan and had that sensation of immense brain slowing. ‘pudding brain’ syndrome I call it. I must say, to talk about migraines one doesn’t need to have a migraine, but my brain apparently disagreed. Forgive me for the long post, but this is important mind-blowing research we have in the migraine research field these days.

Nevertheless, this is a great research time when it comes to migraines and there is a lot on the horizon to talk about. I also had the pleasure to hear his webcast for the 59th Annual Scientific Meeting Highlight which was quite informative as well as on the new research coming out. And, oh my, the research. Dr. Goadsby is the American Headache Society’s Scientific Program Chair, a Professor of Neurology at King’s College London and University of California, San Francisco. His research interests are in the mechanisms of primary headache disorders (migraines and cluster headaches).

“It’s not just hope in a vague sort of way, it’s very concrete. It’s hope nearly delivered,” Peter Goadsby, MD, PhD, professor of neurology at King’s College London, United Kingdom, and the University of California, San Francisco, told Medscape Medical News. (Medscape)

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PREVENTATIVE TREATMENT

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CGRP monoclonal antibodies are quite literally, as Dr. Goadsby said, in the webcast a ‘migraine treatment for migraine patients’. He stated via the webcast that all the study results were positive and that there were 6 trials in Phase III and 2 Phase III for chronic migraines. He stated via the webcast all were ‘well tolerated’. As well as the fact, over half of the patients are seeing an over 50% response rate!

Me: So, recently with research, we are coming out with the first migraine preventative in CGRP medication, can you tell us how this works?

Dr. Goadsby: Well, there are two levels of how it works. It’s crystal clear, the medicine we’ve talking about, are antibodies to either CGRP the peptide protein in the blood or to the receptor, the place in the body where it acts, and by being antibodies, they bind or mop up, or vacuum up, all the CGRP in the blood or they block the receptor, the part of the body where it acts, to the CGRP… CGRP is clearly key to the migraine process and by blocking it, migraines is prevented.

When I mentioned the lack of side effects Dr. Goadsby confirmed there is 5% showing irritation at the injection site itself but “Nothing is emerging from the careful monitoring of the side effects.”

Dr. Goadsby: You’re a migraine person, yes?

Me: Oh, yes. Very much so, yes.

Dr. Goadsby: Have you been on a preventative?

Me: I’ve been on many. Yes.

Dr. Goadsby: Yes, Okay. So many of the conversations you have had with migraine doctors have been about when you put on weight, when your exercise tolerance will go down, when your blood pressure will drop, whether you will have trouble sleeping…, etc, etc. You can think of all the things people have said of the years. I realize that it’s almost; its almost breathtaking when I say to you that these medication have none of those side effects. 

(Take a pause to just think about all those side effects. An extra pause to think about all that weight gain. And, yes, breathtaking it is indeed.)

Me: Yes, it’s astonishing, really. Its’ astonishing to me.

Dr. Goadsby:  I agree with you. I think that, when I talk about it to people who don’t have migraine they kind of don’t get how big that is. Then when I talk to someone who’s got migraine, he’s got a number of preventatives and you tell him here is something that doesn’t have any of the things we just talked about for two to twenty years. This person will think ‘this guy must be kidding, he’s joking or something… what’s he not telling me?’

Dr. Goadsby: If I was you, I’d be skeptical. Be optimistically skeptical because, well, because, I’m saying that because it is four companies and they are attacking the same pathway so if there is any systematic side effects of attacking the pathway you got four times as many chances because all of the company’s going to notice them and nothing is turning up in any of them. I find that reassuring and I think a patient can find that reassuring if not just one company is doing one set of studies but all companies in sets of studies and all have the same result. Just quite reassuring.

When I asked about the response rates for 50% reduction in chronic migraine trials Dr. Goadsby said, “Between 28 and 57%” and I expressed that seemed high since chronic migraines seem so difficult to treat. In my personal experience, of course. But, of course, this isn’t off-label medication we are talking about anymore, is it? As Dr. Goadsby said we were dealing with ‘hand me down stuff’ before so this is an entirely different story.

I’ll give one example he mentioned during the webcast for chronic migraines. He mentioned the chronic migraine trial for  eptinezumab (ALD403, Alder Biopharmaceuticals) with an end point of 75% reduction and the results were 33% of the 300mg group and 31% of the 100 mg group. He said 55% had a 50% reduction rate, with the 50% end point. This study stuck out for me. Really, for chronic migraines I am stunned and deeply excited.

Dr. Goadsby: Sometimes, you got to start with the patient perspective here. It doesn’t matter if I’m not excited. I am excited. It really doesn’t matter. It’s interesting with a, as what you, talk with yourself. It is very interesting to hear what the perspective it is of someone whose actually standing to better from what is going on.

(Trust me when I say, we are all too excited by what is going on. The very fact this is designed for migraines to treat migraines is a breakthrough of epic proportions.)

Dr: Goadsby: That is the issue with having chronic migraine. … It’s a life destroying thing to live with. So having the new class of medicine will help that, that’s not nothing to discuss that.

 

I did ask about if the studies are also seeing a decrease in intensity but all the data isn’t in yet, and Dr. Goadsby suspects the answer will be yes, but the answer is not firm on that one yet.

Dr. Goadsby: I think it’s safe to say that it will be good for people who do spectacularly well and it’ll be good for people who do pretty well. Probably, good for people who will be disappointed. … I don’t think this solves everyone’s problems. It does two really important things, it solves some people’s problems, and that’s really important. The second things, it shows everybody in industry, government, research, people that this is a, you know, that migraine people are not crazy and that this is a {solvable} problem. So you can make an effort, you can build on this to help the people who won’t respond. And this development proves that its possible. ( part in {} couldn’t be read from my notes, basing it on context there. Notes said retractable.)

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See more on CGRP here.

ACUTE TREATMENTS

There is in fact new Acute treatments out that Dr. Goadsby mentioned to me and I heard him mention likewise in his discussion via during the 59th Annual Scientific Meeting Highlight Webcast.

One is of particular interest to many people I know who do not respond to triptans or cannot take them due to adverse effects, stroke, heart attack or blood pressure risks.

He mentioned during the webcast that not only do these studies now involve looking at the pain but also the resolution of the ‘most bothersome symptom’ such as nausea or vertigo such as the case may be. Quite appropriate when you think about it, since symptoms can be just as debilitating.

He states in my interview, “Yes, it’s actually extraordinary…What happened with the abortive side is almost getting ignored by what’s happening in the preventive side”.

  • “Lasmiditan (200 mg and 100 mg) Compared to Placebo for Acute Treatment of Migraine”
    This randomized, double-blind, placebo-controlled study included 1,545 participants who were suffering a migraine attack that resulted in at least moderate disability (Migraine Disability Assessment Score [MIDAS] >11). The findings showed that significantly more participants were free of headache pain and the most bothersome symptom (nausea, or aversion to loud sounds or light) two hours after treatment with the investigational medicine lasmiditan compared to placebo. Lasmiditan was generally well tolerated, with no participants discontinuing the medication because of an adverse event. AHS

In regards to Lasmiditan Dr. Goadsby stated,

Dr: Goadsby: … it doesn’t have any effect on blood vessels. So to break the question, we don’t think blood vessels are important in migraine at all, which nobody does… So it runs now in the blood vessel risk, that with triptans, the triptans with vasoconstriction risk that people opting out to take triptans or have vascular problems or the side effect problems. This is gonna be quite welcome, an addition to the options we have.

Me: Very much so, yes, because the triptans do have a lot of side effects and a lot of people are contradicted for it, right?

Dr. Goadsby: Well, I feel, to that response there are people who cannot, contraindicated and all the contraindications will go away with this treatment. That’s quite, that’s quite a big deal as well. We see that the fullness of their, the options.

(I have to say, I get rare side effects from triptans and have to take them, well, rarely. So this is going to be quite a benefit in my life. And for several people I know who have had strokes or never did respond to triptans at all or have Basilar and HM migraines.)

The second Dr. Goadsby said is a ‘mirconeedle array’, which is a better injection method and rapid absorption.

  • Effectiveness and Safety of a New Zolmitriptan Rapid Absorption Microneedle Array (M207) for the Acute Treatment of Migraine (The Zotrip Study)”
    This randomized, double-blind, placebo-controlled study evaluated a new, microneedle array delivery system called M207 for the medication zolmitraptan in 321 adults suffering from a migraine headache with or without aura. The findings showed that, two hours after treatment, significantly more participants were free of pain and the most bothersome symptom (nausea, or aversion to loud sounds or light) with M207 treatment compared to placebo. M207 was well tolerated. Application-site adverse events included redness, swelling and bruising, which cleared within 24 hours in most participants. AHS

He mentions, “Apparently, it’s been tolerated. That’s big.”

VISUAL SNOW

As you know, I am particularly interested in Visual Snow research and I had a chance to ask him briefly a puzzling question I had about that. Visual Snow being the visual phenomena of static in the vision (constant flickering dots, can be warping and pulsing). Also occurs with floaters, blue field entoptic phenomenon, photopsia, afterimages and trailers, photophobia, impaired night vision, and tinnitus. But before I get to that I would like to outline his research into the subject because it is rather a breakthrough in the area. Visual Snow back in the day, when in fact I was diagnosed, was considered to be one of two things a) a persistent migraine aura if you had migraines, and b) the result of drug use. The research done stated that Visual Snow itself is a separate disorder separate from persistent migraine auras and unrelated to drug use. That was in the study ‘Visual snow’ – a disorder distinct from persistent migraine aura. Quite amazing at the time, I assure you.

A further study found the location in the brain and what was going on with Visual Snow “The hypermetabolic lingual gyrus confirms a brain dysfunction in patients with “visual snow.” The metabolic pattern differs from interictal migraine with some similarities to migrainous photophobia. The findings support the view that “visual snow,” migraine, and typical migraine aura are distinct syndromes with shared pathophysiological mechanisms that need to be addressed in order to develop rational treatment strategies for this disabling condition.” And Here is a review of recent information on the subject. It is a fascinating and visually disruptive phenomena that can be quite disabling in some. What is puzzling is that people with VS are highly comorbid with migraines, as in many of them have migraines.

What I have always been curious to know is why there is such a high percentage of people with Visual Snow that have migraines. It is extremely high. Why is that I wondered? What connection is there? So I asked Dr. Goadsby just that.

Dr. Goadsby: …there’s two possibilities, one that visual snow and migraine biology is somehow related. It’s not like visual snow behaves like aura of migraine. It’s possible that biology is related. It’s also possible that the brain disorder, that brain disease that migraine patients have to sensitivity to change, sensitivity to difference, makes visual snow more problematic for them. So to these examples, many people with migraine are sensitive to light when they have an attack, now,… because their brain doesn’t filter light for them. Now if you have mild visual snow and you have migraine you might be bothered more by  the visual snow, so its biological interaction, or simply one condition makes another condition more troublesome, it is an unknown thing. We’re very interested in that. … There’s something going on. There’s something going on, but I can’t tell you yet. It isn’t all worked out yet

Dr. Goadsby said at this time there is no research suggesting medication or treatment.As of 2012, the statistic was 92% of people not responding to medication but predominately medication was and still is migraine preventatives.

 

It was indeed a pleasure to watch the webcast with Dr.Goadsby and to personally speak with him for a bit to hear about all these spectacular things that could make our lives so much better in the near future. I am so glad he made the time for me, even with my less than stellar communication skills that day. It genuinely gives us some hope and I must say we could all use a little hope to carry on, couldn’t we? This research, as he said, is breathtaking to me. The CGRP in results and the fact there is no side effects. Both of those I look forward to in ways I have a difficult time expressing. I could list all the side effects I have had and it would be longer than this post. And the new acute medication, also and amazing breakthrough for people who seriously could benefit from that. So many cannot take them for various reasons and that will be life-altering for them. It was great Dr. Goadsby could spend a little time with me, us, to share these new things on the horizons for us migraineurs.

This is what we have all been waiting for. HOPE.

 

*I didn’t discuss these findings with him, but they were mentioned in the webcast. The studies on babies with colic and migraine, and TBI and migraine.

 

 

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6 comments

  1. Lasmiditan isn’t one I’d come across so this intrigued me. I think there’s a lot to be said for accompanying debilitating symptoms with migraines, such as the nausea. I take triptans and find they can help a little with the nausea but I get this strange sensation, almost like it’s in my sinuses and I can’t quite describe it (along with some of the pudding syndrome you describe!) A fascinating read, thank you.x

    Liked by 1 person

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