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Medscape
a day ago
- Health
- Medscape
Migraine Expert Renews Call for Prompt, Effective Management
OTTAWA — Therapies that target calcitonin gene-related peptide (CGRP) should be used up front in the treatment and prevention of migraine because of their efficacy, safety, and potential to modify the disease course, an expert said. Speaking at the annual meeting of the Canadian Neurological Sciences Federation (CNSF) Congress 2025, David Dodick, MD, emeritus professor of neurology at Mayo Clinic in Phoenix, reiterated the appeal that was first published in an American Headache Society position statement: That migraine therapies that target CGRP become first-line treatments for migraine. A Bold Call Some of the available monoclonal antibodies to treat migraine include erenumab, fremanezumab, galcanezumab, and eptinezumab. The class of 'gepants' includes rimegepant and atogepant. All these treatments target CGRP. 'This was a type of expert consensus opinion,' Dodick told Medscape Medical News , referring to the 'rather bold' position statement. 'The real-world evidence supports what we saw in clinical trials, and we now know the safety profile of these [therapies] because we've had them for almost 8 years of use in clinical practice. They are not first-line [therapies] simply because of cost.' The largest prospective study on the use of anti-CGRP monoclonal antibodies demonstrated robust responses to these therapies. Because CGRP-targeting therapies are well tolerated, discontinuation due to adverse events is generally not a concern, and increased efficacy may be realized if patients stay the course with CGRP-targeting therapies, said Dodick. 'You can imagine that if people are able to tolerate them and stay on these drugs longer, then efficacy is cumulative over time. Adherence and compliance increase the response rate over time,' said Dodick. Early Treatment Vital 'It really does matter how early you get to the patient and treat them effectively, both from the standpoint of treating an individual episode of migraine and from the prevention standpoint: That is, treating the disease earlier,' said Dodick. 'The more frequent that migraines are, and the more you allow them to be frequent, the more likely they are to progress to a daily migraine, and the more difficult they are to manage.' In the US and Canada, patients with migraine must first fail other treatments before they are prescribed newer agents like CGRP monoclonal antibodies or gepants, and this requirement creates the potential for a lapse in care, noted Dodick. 'Patients can become discouraged and lost to follow-up if they fail one medicine and then two medicines,' which he said supports the case for first-line access to CGRP-targeting migraine therapies. High-Impact Agents The efficacy of migraine treatments that target CGRP is convincing, said Michael Hill, MD, professor of clinical neuroscience at the University of Calgary's Cumming School of Medicine, Calgary. 'For some patients, they can get back to living a relatively normal life,' said Hill, who also is CNSF president. 'It can be a remarkable evolution. They go from being nonfunctioning and not working to being fully functional again because their migraine is not chronic, or their recurrent migraines are not so disabling.' Seeing patients who are unable to access these therapies is disheartening, Hill told Medscape Medical News. 'It is hard to see them denied this therapy.' The preventive potential that these therapies could offer would certainly be welcome, Hill added. 'The idea that some of these people who start with simple migraine and progress to a chronic, refractory migraine state, and that these might actually be preventable with early treatment, is really exciting.' Episodic treatment of migraine has not altered the disease course. 'The focus on migraine therapy has been on acute treatment and not so much on this idea that you might prevent the evolving chronicity of the disease.'
Medscape
2 days ago
- Health
- Medscape
Use of Oral Steroids to Treat MS Relapse Is Growing
OTTAWA — The use of oral rather than intravenous (IV) steroids to respond to relapses in patients with relapsing-remitting multiple sclerosis (RRMS) is growing, a study suggested. The data, which were presented in a moderated poster session at the annual meeting of the Canadian Neurological Sciences Federation (CNSF) Congress 2025, indicate a decreasing reliance on steroids over time to manage relapses. Researchers retrospectively examined data from 2010 to 2022 from the MS database MuSicaL. Investigators identified 2413 eligible patients for their analysis, and 1086 had at least one attack or relapse. Of these 1086 patients, half (543) had used high-dose steroids for 818 attacks. Information on the route of high-dose steroids was known in 348 attacks. IV steroids were administered for 148 attacks (42.5%), and oral steroids for 208 (59.8%) attacks. Oral and IV steroids are considered to have equal efficacy, study author Jihad Al Kharbooshi, MD, a fourth-year adult neurology resident at London Health Sciences Centre in London, Ontario, told Medscape Medical News. 'There have been studies involving patients with RRMS who received IV and oral steroids. Both groups of patients were compared, and they found the same effect' in terms of efficacy, he added. A review paper published in 2013 cited several investigations that compared IV steroid management with oral steroid management. These investigations concluded that the routes managed relapses in patients with RRMS with comparable efficacy. 'The second objective [of the present study] was to see whether the patient's type of relapse had anything to do with oral versus IV steroids being used,' said Al Kharbooshi. The researchers found that patients who experienced a multifocal relapse, which is a more severe type of relapse, were more likely to receive IV steroids than oral steroids (39.3% vs 25.5%). 'If the physician perceived that the relapse was very serious, such that it may be a life-endangering situation, they may have chosen IV steroids,' said Al Kharbooshi. Clinicians may believe that IV steroids can better manage more severe relapses, he added. The researchers also analyzed the route of administration according to prescriber specialty. 'The specialty of the prescriber, whether a neurologist or another prescriber, didn't significantly influence the choice of route of high-dose steroids,' said Al Kharbooshi. Taking steroids orally offers the benefit of convenience for patients with MS who, if they live in remote areas, may not be able to access IV steroids easily, pointed out Al Kharbooshi. Maryam Nouri, MD, an associate professor of pediatric neurology at Western University in London, Ontario, who moderated the poster session, noted that the growing decline in the use of steroids to manage MS relapses likely results from the greater efficacy of emerging medical therapies for RRMS. 'There was a downward trend toward using steroids to begin with, which could indicate that patients with MS are not experiencing as many relapses,' said Nouri. 'This confirms that the treatment landscape of MS has changed, as there are a lot of patients who are starting with high-affinity therapies right from the get-go. It is probably that the number of relapses is declining to begin with, so patients are not requiring as many steroid therapies.' One limitation of the analysis is that investigators did not have information about the route of steroid use for a substantial proportion of relapses, said Nouri. The investigators acknowledged this shortcoming in their presentation. Still, the fact that oral steroid use has grown over time suggests that clinicians are giving more consideration to this route of administration, according to Nouri. 'It is positive news that people are feeling more comfortable about using oral steroids,' she said. But in her clinical experience and that of her colleagues, the IV route is still the route of choice for managing MS flares in the pediatric setting, given that the evidence supporting comparable efficacy of IV and oral routes comes from adult studies.
