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Migraine: Current Concepts and Emerging Therapies Vascular Pharmacology 43 (2005) 176 – 187 www.elsevier.com/locate/vph Migraine: Current concepts and emerging therapies D.K. Arulmozhi a,b,*, A. Veeranjaneyulu a, S.L. Bodhankar b aNew Chemical Entity Research, Lupin Research Park, Village Nande, Taluk Mulshi, Pune 411 042, Maharashtra, India bDepartment of Pharmacology, Bharati Vidyapeeth, Poona College of Pharmacy, Pune 411 038, Maharashtra, India Received 23 April 2005; received in revised form 17 June 2005; accepted 11 July 2005 Abstract Migraine is a recurrent incapacitating neurovascular disorder characterized by attacks of debilitating pain associated with photophobia, phonophobia, nausea and vomiting. Migraine affects a substantial fraction of world population and is a major cause of disability in the work place. Though the pathophysiology of migraine is still unclear three major theories proposed with regard to the mechanisms of migraine are vascular (due to cerebral vasodilatation), neurological (abnormal neurological firing which causes the spreading depression and migraine) and neurogenic dural inflammation (release of inflammatory neuropeptides). The modern understanding of the pathogenesis of migraine is based on the concept that it is a neurovascular disorder. The drugs used in the treatment of migraine either abolish the acute migraine headache or aim its prevention. The last decade has witnessed the advent of Sumatriptan and the Ftriptan_ class of 5-HT1B/1D receptor agonists which have well established efficacy in treating migraine. Currently prophylactic treatments for migraine include calcium channel blockers, 5-HT2 receptor antagonists, beta adrenoceptor blockers and g-amino butyric acid (GABA) agonists. Unfortunately, many of these treatments are non specific and not always effective. Despite such progress, in view of the complexity of the etiology of migraine, it still remains undiagnosed and available therapies are underused. In this article, the diverse pieces of evidence that have linked the different theories of migraine with its pathophysiology are reviewed. Furthermore, the present therapeutic targets and futuristic approaches for the acute and prophylactic treatment of migraine, with a special emphasis to calcitonin gene-related peptide, are critically evaluated. D 2005 Published by Elsevier Inc. Keywords: Migraine; CGRP; Serotonin; Triptan 1. Introduction towards attacks and the cranial circulatory phenomenon appears to be secondary to a primary central nervous system Migraine is a chronic, often debilitating disease that disorder. affects 12% of the general population. This episodic brain The Headache Classification Committee of the Interna- disorder is characterized by unilateral throbbing headache tional Headache Society (IHS) published the classification lasting from 4 h to 3 days. Associated symptoms include and diagnostic criteria for headache disorders (International nausea vomiting and sensitivity to light, sound and head Headache Society, 2004). The terms Fcommon migraine_ movements (Silberstein, 2004). A working definition of and Fclassical migraine_ have been replaced by Fmigraine migraine is benign recurring headache and/or neurological without aura_ and Fmigraine with aura_ respectively. These dysfunction usually attended by pain-free interludes and operational criteria have been validated by different often provoked by stereotyped stimuli. Migraine is more approaches and have enabled to distinguish different head- common in females, with a hereditary predisposition ache entities in a reliable manner. Migraine apparently a global disorder, occurring in all races, cultures and geographical locations. Current figures * Corresponding author. Department of Pharmacology, New Chemical Entity Research, Lupin Research Park, Village Nande, Taluk Mulshi, Pune suggest that 18% of women and six percent of men suffer 411 042, Maharashtra, India. Tel.: +91 20 2512 6161; fax: +91 20 2512 6298. from migraine and those numbers are increasing. The Center E-mail address: [email protected] (D.K. Arulmozhi). for Disease Control reported a 60% increase in the disease 1537-1891/$ - see front matter D 2005 Published by Elsevier Inc. doi:10.1016/j.vph.2005.07.001 D.K. Arulmozhi et al. / Vascular Pharmacology 43 (2005) 176–187 177 from 1980 to 1989. The highest incidence of migraine Table 1 occurs between the ages of 20 and 35 and often associated Diagnostic criteria of migraine with a positive family history of the disease (Liption and Migraine without aura Bigal, 2005). A. At least 5 attacks fulfilling B–D B. Headache attacks, lasting 4–72 h (untreated or unsuccessfully treated) Migraine has an enormous impact on society. Recent C. Headache has at least two of the following characteristics studies have evaluated the indirect and direct costs of 1. Unilateral localization migraine. Indirect costs include the aggregate effects of 2. Pulsating quality migraine on productivity at work (paid employment), in 3. Moderate to severe intensity performance of household work and in other roles. It was 4. Aggravation by walking stairs or similar routine physical activity D. During headache at least one of the following estimated that productivity losses due to migraine cost 1. Nausea and/or vomiting American employers $13 billion per year (Lipton et al., 2. Photophobia and phonophobia 2003). E. At least one of the following In the present review, the modern theories of migraine 1. History, physical- and neurological examinations do not suggest with respect to its diverse etiology as well the present association with head trauma, vascular or non-vascular disorders, use of or withdrawal from noxious substances, non-cephalic therapeutic targets and futuristic approaches for the acute infections, metabolic disorders or disorder or cranial or facial and prophylactic treatment of migraine are critically structures evaluated. 2. History and/or physical- and/or neurological examinations do suggest such disorder, but it is ruled out by appropriate investigations 3. Such disorder is present, but migraine attacks do not occur for the first time in close temporal relation with the disorder 2. Pathophysiology of migraine Migraine with aura 2.1. Clinical manifestations A. At least 2 attacks fulfilling B B. Migraine aura fulfills criteria for typical aura, hemiplegic aura, or Migraine is characterized by episodes of head pain that is basilar-type aura C. Not attributed to another disorder often throbbing and frequently unilateral and may be severe. In migraine without aura (previously known as common Typical aura migraine) attacks are usually associated with nausea, 1. Fully reversible visual, sensory, or speech symptoms (or any vomiting, or sensitivity to light, sound, or movement and combination) but no motor weakness when treated, the attacks typically last 4 to 72 h (Olesen and 2. Homonymous or bilateral visual symptoms including positive features (eg. Flicking of lights, spots, lines) or negative features (e.g. Loss of Lipton, 1994; Michel et al., 1993). A combination of vision), or unilateral sensory symptoms including positive features (e.g. features is required for the diagnosis, but not all features are Visual loss, pins and needles) or negative features (e.g. Numbness), or present in every attack or in every patient (Tables 1 and 2). any combination These symptoms do distinguish migraine from tension type 3. At least one of headache, the most common form of primary headache, a. At least one symptom develops gradually over a minimum of 5 min or different symptoms occur in succession or both which is characterized by the lack of associated features b. Each symptom lasts for at least 5 min and for no longer than 60 min (Silberstein, 2004). Any severe and recurrent headache is 4. Headache that meets criteria for migraine without aura begins during most likely a form of migraine and should be responsive to the aura or follows aura within 60 min antimigraine therapy (Lance, 2000). In 15% of patients migraine attacks are usually preceded or accompanied by transient focal neurotic symptoms, which are usually visual; 2.2. Genetics of migraine such patients have migraine with aura (previously known as classic migraine) (Rasmussen et al., 1992; Rasmussen and Migraine is best understood as primary disorder of pain Olesen, 1992). In a recent, large population-based study, (Silberstein, 2004). It is a form of neurovascular headache: 64% of patients with migraine had only migraine without a disorder in which neural events result in the dilation of aura, 18% had only migraine with aura and 13% had both blood vessels, which in turn, results in pain and further types of migraine (the remaining 5% had aura without nerve activation (Goadsby, 2001). Migraine is not caused headache). Thus, up to 31% of patients with migraine have by primary vascular event. Migraine attacks are episodic aura on some occasions (Launer et al., 1999), but clinicians and vary within and among the individuals. The variability who rely on the presence of aura for the diagnosis of is best explained by considering the biologic problem in migraine will miss many cases. migraine to be the dysfunction of an ion channel in the A recent survey by the World Health Organization aminergic brain stem nuclei that normally modulates (WHO), rates severe migraine, along with quadriplegia, sensory input and exerts neural influences on cranial psychosis, and dementia, as one of the most disabling vessels (Silberstein, 2004). There is thus ample evidence chronic disorders (Menken et al., 2000). This ranking for genetic liability
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