Migraine is one of the most common diseases. More than one billion people worldwide suffer from this condition, which consists of recurrent attacks of headaches that are sometimes accompanied by vomiting, dizziness or hypersensitivity to light and sound. According to 2019 dataIn the past, migraine was the second leading cause of disability worldwide, and the first if only young women are taken into account. Although many new treatments have appeared in recent years that make it advisable to avoid giving up and go to the doctor in search of a diagnosis and relief, around 40% of patients are not satisfied with their treatment at the time of the attack.
Recently, an article that publishes the magazine Neurologythe journal of the American Academy of Neurology, has published the results of a trial of a drug for the time when a migraine sufferer knows an attack is coming but the pain is still mild or has not yet arrived. If the treatment is given at that time, disability and suffering are much less or can even be avoided. The study included 477 patients who were given ubrogepant, a drug that blocks CRGP, a substance that is released in excess during migraines, when they felt signs that they identify as announcing an attack, such as changes in vision and other sensations such as hunger, yawning or fatigue.
In the study, sponsored by AbbVie, the company that developed the drug, it was found that people who took it improved their ability to lead a normal life, without limitations. Compared with other patients who received a placebo, those who took ubrogepant were 66% more likely to remain functional for 24 hours, and were more than twice as likely to be satisfied with the treatment.
“These results are interesting because they focus attention on aspects such as disability. With this drug, patients return to their activities much sooner,” says Pablo Irimia, a neurologist at the University of Navarra Clinic. In addition, “this type of drug does not have the risk of worsening the frequency or intensity of attacks due to excessive use, as happens with other drugs,” adds Irimia. However, despite the scientific interest that these types of studies may have, the drug is not yet approved in Spain and it is likely that it will not be approved in the near future.
Drugs that block CGRP (calcitonin gene-related peptide) have transformed migraine treatment and improved the lives of many people. The first such treatments, which have been in use for just over five years, involved an injection of monoclonal antibodies every month or every three months, depending on the drug, to prevent migraines. Later, pill versions, called gepants, came along.
In the US, there are four approved gepants, including ubrogepant for the onset of an attack, but in Spain only atogepant, which is taken daily as a preventative for migraines, and rimegepante, which must be taken every 48 hours, are available and funded by Social Security. In an example of the complexity of the panorama with this type of medication, rimegepant can also be used at the beginning of an attack, for acute treatment, but the State does not fund it for that use and it should be paid for entirely by the patient.
The interest in drugs such as ubrogepant comes from an aspect of migraine about which little is known. According to Patricia Pozo-Rosich, head of the Headache and Craniofacial Pain Unit at the Vall d’Hebron University Hospital in Barcelona, “although a migraine attack is associated with the presence of pain, we know that attacks are not just that and begin up to 48 hours before the pain begins.” This onset, known as prodromal symptoms, is not always easy to identify. “Many patients say that chocolate gives them a migraine, but it is not the chocolate but the feeling of hunger,” Pozo-Rosich exemplifies. There are a series of symptoms, in addition to hunger, such as tiredness, yawning or fluid retention, which are among the most frequent, but there are dozens.
In order for drugs aimed at preventing migraines before they occur, such as ubrogepant, to be useful, it is important to have methods to identify the signs correctly. Ana Gago, head of the Headache Unit at the La Princesa University Hospital, comments that one of the criticisms made of the work published in Neurology on ubrogepant is that it selects a small group of patients who perfectly identify the symptoms prior to an attack. “There are patients who are good predictors, around a third, but there are more who do not identify the symptoms, because they are very nonspecific, although by explaining them, in consultation, you can reach 80%,” says Gago.
Gago is working with a team of engineers to create a system that is as objective as possible. “It is a bracelet that measures factors such as sweating or heart rate, among other hemodynamic variables, and it incorporates a machine learning system, and with it we are having a high percentage of success,” he says. With this type of more objective prediction system, drugs to prevent the attack before it reaches the pain phase, which is the most incapacitating, would be more useful.
Pozo-Rosich recalls that drugs such as those from the gepants family have changed people’s lives and “in an ideal world, if they were cheap, they would be much more widely available.” However, they are expensive, and in many cases people wait to try very cheap drugs, such as ibuprofen, before trying new medicines. In that ideal world, one could calculate the value of a person with migraine being able to return to work sooner or not ending up with a series of sick leaves until they are out of the market because their migraine was not treated in time.
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