Davida F. Kruger, MSN, APN-BC, BC-ADM
Ms. Kruger has been a certified nurse practitioner in diabetes at Henry Ford Health System in Detroit, MI, for more than 35 years. Ms. Kruger has been a co-investigator on numerous studies of diabetes interventions and care, including the National Institutes of Health–funded multicenter EDIC and ACCORD trials.

She is a past Chair of the American Diabetes Association (ADA) Research Foundation and has served on the ADA Research Policy Committee. She is also an ADA Past President (Health Care and Education). She has also served as editor-in-chief of 2 American Diabetes Association (ADA) journals, Diabetes Spectrum and Clinical Diabetes.

Our diabetes clinic in Detroit is ground zero for diabetes care and education.

High-risk obstetrician gynecologists, cardiologists, nephrologists, and primary care providers, which are all specialties seeing more patients with type 2 diabetes (T2D) comorbidities, are coming to us or sharing patient cases to learn more about diabetes care, newer medications, and the technology needed to help disease management. Considering the complexity of the disease, its comorbidities, the long list of medications, and the human skills required to help these individuals, our clinic has long considered that patients are better served by a team of providers with experience in the intricacies and nuances of this chronic disease.

With over 40 years in the trenches, I can write without equivocation that the treatment of patients with diabetes requires a team approach involving diabetes educators, nurse practitioners, physician assistants, pharmacists, physicians, and nutritionists, who have long known that diabetes is a serious, deadly disease. 

Some facts to prove my point: 
When I started treating people with  diabetes, 4% of the US population had the disease. Life expectancy was about 74 years. Today, 11% of the population has diabetes, and life expectancy is closer to 78 years. Longer life, for someone with diabetes, means more time with kidney disease, cardiovascular problems, neuropathy, macular degeneration, and more.T2D is no longer just an adult disease. We are treating T2D in a much younger population. The Centers for Disease Control and Prevention says from 2002 to 2015, the incidence rate for people <20 years rose 4.8% per year. 
In 2019, the World Health Organization said that 16,300 people < 25 years old died from diabetes, and most of these deaths were from type 1 diabetes.
If we maintain the status quo, between now and 2050, 33% of the adult population in this country could have this disease. 
Our clinic has enrolled  at least 3500 patients with some type of diabetes. 

The list of therapies ─ and more importantly the different classes of therapies ─ has grown significantly since the time when sulfonylureas, metformin, and insulin were the only therapies available. Today, there are at least 9 classes of medications to treat type 2 diabetes. 

Considering that patients with T2D, most of whom are overweight or obese, also have heart disease, kidney disease, and more, the collective input from various kinds of healthcare providers to discuss how these medications can work together, or not, is beyond beneficial. The literature shows that a multidisciplinary team improves patient outcomes in the T2D population. The literature also shows that despite therapeutic advances, most of these patients have disease that is not well controlled, for a variety of reasons.

Patients and Attitudes
I was riding in an elevator with a rheumatologist a few years ago. He told me that my patients were all “fat” and “responsible for their situation.” I told him an elevator ride could not cover the amount of education he needed, so I invited him to call me. There are many reasons why people develop T2D and carrying too much weight is a significant one. We tell our patients that this extra weight puts stress on the natural production of insulin. The result is that less organic insulin is produced so more manufactured insulin is prescribed, and this puts weight on the patient. 

Patients have busy lives, and those with diabetes are no different; their lives get in the way of managing their disease. Some need to remember to take 3 or 4 injections a day. They forget an injection at lunch because their routine has been disrupted; they forget at bedtime because they fell asleep on the sofa. Or they had to feed their children dinner quickly to make it to a teacher’s meeting, so they forgot their medication. But it is vital that they maintain their insulin injection schedule. Research says missing 2.1 meal-related injections a week increases glycated hemoglobin (A1c) by 0.3% to 0.4%.

Most people with T2D will eventually need insulin. For someone with diabetes – and for their family members – hypoglycemia is a real fear. Hypoglycemia has significant physical (eg, irregular heartbeat, shakiness) and mental (eg, anxiety, irritability) effects. In response, patients can treat themselves with glucose tablets or simple carbohydrates (between 15 and 30 g). If the patient is unconscious, the family may need to use injectable glucagon. This is where the benefits of a continuous glucose monitor come in.
Patients can see the hypoglycemic state they are approaching so they can treat a low blood glucose level on their own before others need to. 

Our clinic members focus on having open, honest conversations with our patients about how their lives affect their diabetes. We encourage them to choose a nutrition plan or see our dietitian. Some do phenomenally well with plans like Weight Watchers, but others do not. Whatever they choose, our dietitians aim to help them stay on it, with weekly check-ins, teleconferences, and appointments.

Communication goes both ways. Our patients tell us constantly that they do not want another medication. Diabetes is an expensive disease, and most of our patients take at least 5 medications, prescribed by nephrologists, cardiologists, endocrinologists, and family physicians. Our clinical pharmacists and other team members try to find ways to bring those costs down; sometimes we cannot.

Some Pointers
It is not a bad idea to keep a flowchart on your phone that details which diabetes drug is applicable under which circumstances, and when it is not applicable. While most are complementary, a list would detail how each of the new medications work, how they work together and how they benefit patients.

Some wisdom learned in the trenches: 

• Do not shy away from starting a newly diagnosed patient on metformin and a second agent. The American Diabetes Association guidelines say that more intensive initial treatment can be beneficial. If the patient’s  A1c is elevated, consider using 2 medications upon diagnosis. 
• Using a sulfonylurea, which stimulates insulin secretion, as a second-line therapy alone can increase risk of myocardial infarction, all-cause mortality, and severe hypoglycemia (hazard ratios, 1.26, 1.28, and 7.60, respectively); these medications also cause weight gain. The sulfonylureas put pressure on the beta cells to work harder. More importantly, we do not know what these medications do to the cardiovascular system in the long term.
• If the patient has cardiovascular disease, then, in combination with metformin, use a glucagon-like peptide 1 receptor agonist (GLP-1) or a sodium-glucose cotransporter 2 (SGLT2) inhibitor. If the patient has kidney disease, start with an SGLT2 inhibitor. And yes, you can prescribe both at the same time. 
• SGLT2 inhibitors lower glucose levels by preventing the kidneys from reabsorbing glucose. The GLP-1 agonists encourage insulin production and inhibit glucagon secretion  after meals. Neither of these medications are known to add weight; they are linked with weight loss. 
• If your patient is on a dipeptidyl peptidase 4 (DPP-4) inhibitor and is moving to a GLP-1 receptor agonist, stop the DDP-4 before starting the GLP-1 since both target the incretin system to control blood glucose levels.

While years in the making, new medications and technologies now available for T2D have given healthcare providers more options for their patients, and patients have better opportunities to achieve their treatment goals. 
 

Davida F. Kruger, MSN, APN-BC, BC-ADM
Ms. Kruger has been a certified nurse practitioner in diabetes at Henry Ford Health System in Detroit, MI, for more than 35 years. Ms. Kruger has been a co-investigator on numerous studies of diabetes interventions and care, including the National Institutes of Health–funded multicenter EDIC and ACCORD trials.

She is a past Chair of the American Diabetes Association (ADA) Research Foundation and has served on the ADA Research Policy Committee. She is also an ADA Past President (Health Care and Education). She has also served as editor-in-chief of 2 American Diabetes Association (ADA) journals, Diabetes Spectrum and Clinical Diabetes.

Our diabetes clinic in Detroit is ground zero for diabetes care and education.

High-risk obstetrician gynecologists, cardiologists, nephrologists, and primary care providers, which are all specialties seeing more patients with type 2 diabetes (T2D) comorbidities, are coming to us or sharing patient cases to learn more about diabetes care, newer medications, and the technology needed to help disease management. Considering the complexity of the disease, its comorbidities, the long list of medications, and the human skills required to help these individuals, our clinic has long considered that patients are better served by a team of providers with experience in the intricacies and nuances of this chronic disease.

With over 40 years in the trenches, I can write without equivocation that the treatment of patients with diabetes requires a team approach involving diabetes educators, nurse practitioners, physician assistants, pharmacists, physicians, and nutritionists, who have long known that diabetes is a serious, deadly disease. 

Some facts to prove my point: 
When I started treating people with  diabetes, 4% of the US population had the disease. Life expectancy was about 74 years. Today, 11% of the population has diabetes, and life expectancy is closer to 78 years. Longer life, for someone with diabetes, means more time with kidney disease, cardiovascular problems, neuropathy, macular degeneration, and more.T2D is no longer just an adult disease. We are treating T2D in a much younger population. The Centers for Disease Control and Prevention says from 2002 to 2015, the incidence rate for people <20 years rose 4.8% per year. 
In 2019, the World Health Organization said that 16,300 people < 25 years old died from diabetes, and most of these deaths were from type 1 diabetes.
If we maintain the status quo, between now and 2050, 33% of the adult population in this country could have this disease. 
Our clinic has enrolled  at least 3500 patients with some type of diabetes. 

The list of therapies ─ and more importantly the different classes of therapies ─ has grown significantly since the time when sulfonylureas, metformin, and insulin were the only therapies available. Today, there are at least 9 classes of medications to treat type 2 diabetes. 

Considering that patients with T2D, most of whom are overweight or obese, also have heart disease, kidney disease, and more, the collective input from various kinds of healthcare providers to discuss how these medications can work together, or not, is beyond beneficial. The literature shows that a multidisciplinary team improves patient outcomes in the T2D population. The literature also shows that despite therapeutic advances, most of these patients have disease that is not well controlled, for a variety of reasons.

Patients and Attitudes
I was riding in an elevator with a rheumatologist a few years ago. He told me that my patients were all “fat” and “responsible for their situation.” I told him an elevator ride could not cover the amount of education he needed, so I invited him to call me. There are many reasons why people develop T2D and carrying too much weight is a significant one. We tell our patients that this extra weight puts stress on the natural production of insulin. The result is that less organic insulin is produced so more manufactured insulin is prescribed, and this puts weight on the patient. 

Patients have busy lives, and those with diabetes are no different; their lives get in the way of managing their disease. Some need to remember to take 3 or 4 injections a day. They forget an injection at lunch because their routine has been disrupted; they forget at bedtime because they fell asleep on the sofa. Or they had to feed their children dinner quickly to make it to a teacher’s meeting, so they forgot their medication. But it is vital that they maintain their insulin injection schedule. Research says missing 2.1 meal-related injections a week increases glycated hemoglobin (A1c) by 0.3% to 0.4%.

Most people with T2D will eventually need insulin. For someone with diabetes – and for their family members – hypoglycemia is a real fear. Hypoglycemia has significant physical (eg, irregular heartbeat, shakiness) and mental (eg, anxiety, irritability) effects. In response, patients can treat themselves with glucose tablets or simple carbohydrates (between 15 and 30 g). If the patient is unconscious, the family may need to use injectable glucagon. This is where the benefits of a continuous glucose monitor come in.
Patients can see the hypoglycemic state they are approaching so they can treat a low blood glucose level on their own before others need to. 

Our clinic members focus on having open, honest conversations with our patients about how their lives affect their diabetes. We encourage them to choose a nutrition plan or see our dietitian. Some do phenomenally well with plans like Weight Watchers, but others do not. Whatever they choose, our dietitians aim to help them stay on it, with weekly check-ins, teleconferences, and appointments.

Communication goes both ways. Our patients tell us constantly that they do not want another medication. Diabetes is an expensive disease, and most of our patients take at least 5 medications, prescribed by nephrologists, cardiologists, endocrinologists, and family physicians. Our clinical pharmacists and other team members try to find ways to bring those costs down; sometimes we cannot.

Some Pointers
It is not a bad idea to keep a flowchart on your phone that details which diabetes drug is applicable under which circumstances, and when it is not applicable. While most are complementary, a list would detail how each of the new medications work, how they work together and how they benefit patients.

Some wisdom learned in the trenches: 

• Do not shy away from starting a newly diagnosed patient on metformin and a second agent. The American Diabetes Association guidelines say that more intensive initial treatment can be beneficial. If the patient’s  A1c is elevated, consider using 2 medications upon diagnosis. 
• Using a sulfonylurea, which stimulates insulin secretion, as a second-line therapy alone can increase risk of myocardial infarction, all-cause mortality, and severe hypoglycemia (hazard ratios, 1.26, 1.28, and 7.60, respectively); these medications also cause weight gain. The sulfonylureas put pressure on the beta cells to work harder. More importantly, we do not know what these medications do to the cardiovascular system in the long term.
• If the patient has cardiovascular disease, then, in combination with metformin, use a glucagon-like peptide 1 receptor agonist (GLP-1) or a sodium-glucose cotransporter 2 (SGLT2) inhibitor. If the patient has kidney disease, start with an SGLT2 inhibitor. And yes, you can prescribe both at the same time. 
• SGLT2 inhibitors lower glucose levels by preventing the kidneys from reabsorbing glucose. The GLP-1 agonists encourage insulin production and inhibit glucagon secretion  after meals. Neither of these medications are known to add weight; they are linked with weight loss. 
• If your patient is on a dipeptidyl peptidase 4 (DPP-4) inhibitor and is moving to a GLP-1 receptor agonist, stop the DDP-4 before starting the GLP-1 since both target the incretin system to control blood glucose levels.

While years in the making, new medications and technologies now available for T2D have given healthcare providers more options for their patients, and patients have better opportunities to achieve their treatment goals. 
 

Davida F. Kruger, MSN, APN-BC, BC-ADM
Ms. Kruger has been a certified nurse practitioner in diabetes at Henry Ford Health System in Detroit, MI, for more than 35 years. Ms. Kruger has been a co-investigator on numerous studies of diabetes interventions and care, including the National Institutes of Health–funded multicenter EDIC and ACCORD trials.

She is a past Chair of the American Diabetes Association (ADA) Research Foundation and has served on the ADA Research Policy Committee. She is also an ADA Past President (Health Care and Education). She has also served as editor-in-chief of 2 American Diabetes Association (ADA) journals, Diabetes Spectrum and Clinical Diabetes.

Our diabetes clinic in Detroit is ground zero for diabetes care and education.

High-risk obstetrician gynecologists, cardiologists, nephrologists, and primary care providers, which are all specialties seeing more patients with type 2 diabetes (T2D) comorbidities, are coming to us or sharing patient cases to learn more about diabetes care, newer medications, and the technology needed to help disease management. Considering the complexity of the disease, its comorbidities, the long list of medications, and the human skills required to help these individuals, our clinic has long considered that patients are better served by a team of providers with experience in the intricacies and nuances of this chronic disease.

With over 40 years in the trenches, I can write without equivocation that the treatment of patients with diabetes requires a team approach involving diabetes educators, nurse practitioners, physician assistants, pharmacists, physicians, and nutritionists, who have long known that diabetes is a serious, deadly disease. 

Some facts to prove my point: 
When I started treating people with  diabetes, 4% of the US population had the disease. Life expectancy was about 74 years. Today, 11% of the population has diabetes, and life expectancy is closer to 78 years. Longer life, for someone with diabetes, means more time with kidney disease, cardiovascular problems, neuropathy, macular degeneration, and more.T2D is no longer just an adult disease. We are treating T2D in a much younger population. The Centers for Disease Control and Prevention says from 2002 to 2015, the incidence rate for people <20 years rose 4.8% per year. 
In 2019, the World Health Organization said that 16,300 people < 25 years old died from diabetes, and most of these deaths were from type 1 diabetes.
If we maintain the status quo, between now and 2050, 33% of the adult population in this country could have this disease. 
Our clinic has enrolled  at least 3500 patients with some type of diabetes. 

The list of therapies ─ and more importantly the different classes of therapies ─ has grown significantly since the time when sulfonylureas, metformin, and insulin were the only therapies available. Today, there are at least 9 classes of medications to treat type 2 diabetes. 

Considering that patients with T2D, most of whom are overweight or obese, also have heart disease, kidney disease, and more, the collective input from various kinds of healthcare providers to discuss how these medications can work together, or not, is beyond beneficial. The literature shows that a multidisciplinary team improves patient outcomes in the T2D population. The literature also shows that despite therapeutic advances, most of these patients have disease that is not well controlled, for a variety of reasons.

Patients and Attitudes
I was riding in an elevator with a rheumatologist a few years ago. He told me that my patients were all “fat” and “responsible for their situation.” I told him an elevator ride could not cover the amount of education he needed, so I invited him to call me. There are many reasons why people develop T2D and carrying too much weight is a significant one. We tell our patients that this extra weight puts stress on the natural production of insulin. The result is that less organic insulin is produced so more manufactured insulin is prescribed, and this puts weight on the patient. 

Patients have busy lives, and those with diabetes are no different; their lives get in the way of managing their disease. Some need to remember to take 3 or 4 injections a day. They forget an injection at lunch because their routine has been disrupted; they forget at bedtime because they fell asleep on the sofa. Or they had to feed their children dinner quickly to make it to a teacher’s meeting, so they forgot their medication. But it is vital that they maintain their insulin injection schedule. Research says missing 2.1 meal-related injections a week increases glycated hemoglobin (A1c) by 0.3% to 0.4%.

Most people with T2D will eventually need insulin. For someone with diabetes – and for their family members – hypoglycemia is a real fear. Hypoglycemia has significant physical (eg, irregular heartbeat, shakiness) and mental (eg, anxiety, irritability) effects. In response, patients can treat themselves with glucose tablets or simple carbohydrates (between 15 and 30 g). If the patient is unconscious, the family may need to use injectable glucagon. This is where the benefits of a continuous glucose monitor come in.
Patients can see the hypoglycemic state they are approaching so they can treat a low blood glucose level on their own before others need to. 

Our clinic members focus on having open, honest conversations with our patients about how their lives affect their diabetes. We encourage them to choose a nutrition plan or see our dietitian. Some do phenomenally well with plans like Weight Watchers, but others do not. Whatever they choose, our dietitians aim to help them stay on it, with weekly check-ins, teleconferences, and appointments.

Communication goes both ways. Our patients tell us constantly that they do not want another medication. Diabetes is an expensive disease, and most of our patients take at least 5 medications, prescribed by nephrologists, cardiologists, endocrinologists, and family physicians. Our clinical pharmacists and other team members try to find ways to bring those costs down; sometimes we cannot.

Some Pointers
It is not a bad idea to keep a flowchart on your phone that details which diabetes drug is applicable under which circumstances, and when it is not applicable. While most are complementary, a list would detail how each of the new medications work, how they work together and how they benefit patients.

Some wisdom learned in the trenches: 

• Do not shy away from starting a newly diagnosed patient on metformin and a second agent. The American Diabetes Association guidelines say that more intensive initial treatment can be beneficial. If the patient’s  A1c is elevated, consider using 2 medications upon diagnosis. 
• Using a sulfonylurea, which stimulates insulin secretion, as a second-line therapy alone can increase risk of myocardial infarction, all-cause mortality, and severe hypoglycemia (hazard ratios, 1.26, 1.28, and 7.60, respectively); these medications also cause weight gain. The sulfonylureas put pressure on the beta cells to work harder. More importantly, we do not know what these medications do to the cardiovascular system in the long term.
• If the patient has cardiovascular disease, then, in combination with metformin, use a glucagon-like peptide 1 receptor agonist (GLP-1) or a sodium-glucose cotransporter 2 (SGLT2) inhibitor. If the patient has kidney disease, start with an SGLT2 inhibitor. And yes, you can prescribe both at the same time. 
• SGLT2 inhibitors lower glucose levels by preventing the kidneys from reabsorbing glucose. The GLP-1 agonists encourage insulin production and inhibit glucagon secretion  after meals. Neither of these medications are known to add weight; they are linked with weight loss. 
• If your patient is on a dipeptidyl peptidase 4 (DPP-4) inhibitor and is moving to a GLP-1 receptor agonist, stop the DDP-4 before starting the GLP-1 since both target the incretin system to control blood glucose levels.

While years in the making, new medications and technologies now available for T2D have given healthcare providers more options for their patients, and patients have better opportunities to achieve their treatment goals. 
 

Key clinical point: The prevalence of migraine is higher in children and adolescents with attention deficit hyperactivity disorder (ADHD) vs those without.

Major finding: The risk of developing migraine was significantly higher in patients with ADHD than in matched controls (adjusted hazard ratio [aHR] 1.92; 95% CI 1.64-2.31) with the risk being prominent in children (aHR 2.01; 95% CI 1.63-2.49) and adolescents (aHR 1.94; 95% CI 1.35-2.79) but not in young adults with ADHD.

Study details: This was a nationwide longitudinal case-cohort study including 81,441 patients (including children, adolescents, and young adults aged 3-11, 12-17, and 18-29 years, respectively) with ADHD and 81,441 matched controls without ADHD.

Disclosures: The study was supported by grants from Taipei Veterans General Hospital; Kaohsiung Veterans General Hospital; Yen Tjing Ling Medical Foundation; and the Ministry of Science and Technology, Taiwan. The authors declared no conflicts of interest.

Source: Hsu T-W et al. Attention deficit hyperactivity disorder and risk of migraine: A nationwide longitudinal study. Headache. 2022 (May 6). Doi:  10.1111/head.14306

Key clinical point: The prevalence of migraine is higher in children and adolescents with attention deficit hyperactivity disorder (ADHD) vs those without.

Major finding: The risk of developing migraine was significantly higher in patients with ADHD than in matched controls (adjusted hazard ratio [aHR] 1.92; 95% CI 1.64-2.31) with the risk being prominent in children (aHR 2.01; 95% CI 1.63-2.49) and adolescents (aHR 1.94; 95% CI 1.35-2.79) but not in young adults with ADHD.

Study details: This was a nationwide longitudinal case-cohort study including 81,441 patients (including children, adolescents, and young adults aged 3-11, 12-17, and 18-29 years, respectively) with ADHD and 81,441 matched controls without ADHD.

Disclosures: The study was supported by grants from Taipei Veterans General Hospital; Kaohsiung Veterans General Hospital; Yen Tjing Ling Medical Foundation; and the Ministry of Science and Technology, Taiwan. The authors declared no conflicts of interest.

Source: Hsu T-W et al. Attention deficit hyperactivity disorder and risk of migraine: A nationwide longitudinal study. Headache. 2022 (May 6). Doi:  10.1111/head.14306

Key clinical point: The prevalence of migraine is higher in children and adolescents with attention deficit hyperactivity disorder (ADHD) vs those without.

Major finding: The risk of developing migraine was significantly higher in patients with ADHD than in matched controls (adjusted hazard ratio [aHR] 1.92; 95% CI 1.64-2.31) with the risk being prominent in children (aHR 2.01; 95% CI 1.63-2.49) and adolescents (aHR 1.94; 95% CI 1.35-2.79) but not in young adults with ADHD.

Study details: This was a nationwide longitudinal case-cohort study including 81,441 patients (including children, adolescents, and young adults aged 3-11, 12-17, and 18-29 years, respectively) with ADHD and 81,441 matched controls without ADHD.

Disclosures: The study was supported by grants from Taipei Veterans General Hospital; Kaohsiung Veterans General Hospital; Yen Tjing Ling Medical Foundation; and the Ministry of Science and Technology, Taiwan. The authors declared no conflicts of interest.

Source: Hsu T-W et al. Attention deficit hyperactivity disorder and risk of migraine: A nationwide longitudinal study. Headache. 2022 (May 6). Doi:  10.1111/head.14306

Key clinical point: Interictal levels of plasma glutamate are elevated in patients with episodic migraine (EM) and chronic migraine (CM), thus qualifying it as a potential marker for both EM and CM.

Major finding: Plasma glutamate levels were significantly higher in patients with EM (49.73 μmol/L [95% CI 40.82-66.12] ) and CM (58.70 μmol/L [95% CI 44.64-72.46]) vs control participants (38.79 μmol/L [95% CI 29.50-53.60]; P < .001).

Study details: This single-center study included 240 women aged 19-65 years, of which 98 had EM, 92 had CM, and 50 were nonmigraine control participants.

Disclosures: The study was supported by a National Research Foundation of Korea (NRF) grant from the Korean government. MK Chu declared serving as a site investigator for a multicenter trial and an advisory member for and receiving lecture honoraria and grants from various organizations, including NRF.

Source: Park CG, Chu MK. Interictal plasma glutamate levels are elevated in individuals with episodic and chronic migraine. Sci Rep. 2022;12:6921 (Apr 28). Doi: 10.1038/s41598-022-10883-9

Key clinical point: Interictal levels of plasma glutamate are elevated in patients with episodic migraine (EM) and chronic migraine (CM), thus qualifying it as a potential marker for both EM and CM.

Major finding: Plasma glutamate levels were significantly higher in patients with EM (49.73 μmol/L [95% CI 40.82-66.12] ) and CM (58.70 μmol/L [95% CI 44.64-72.46]) vs control participants (38.79 μmol/L [95% CI 29.50-53.60]; P < .001).

Study details: This single-center study included 240 women aged 19-65 years, of which 98 had EM, 92 had CM, and 50 were nonmigraine control participants.

Disclosures: The study was supported by a National Research Foundation of Korea (NRF) grant from the Korean government. MK Chu declared serving as a site investigator for a multicenter trial and an advisory member for and receiving lecture honoraria and grants from various organizations, including NRF.

Source: Park CG, Chu MK. Interictal plasma glutamate levels are elevated in individuals with episodic and chronic migraine. Sci Rep. 2022;12:6921 (Apr 28). Doi: 10.1038/s41598-022-10883-9

Key clinical point: Interictal levels of plasma glutamate are elevated in patients with episodic migraine (EM) and chronic migraine (CM), thus qualifying it as a potential marker for both EM and CM.

Major finding: Plasma glutamate levels were significantly higher in patients with EM (49.73 μmol/L [95% CI 40.82-66.12] ) and CM (58.70 μmol/L [95% CI 44.64-72.46]) vs control participants (38.79 μmol/L [95% CI 29.50-53.60]; P < .001).

Study details: This single-center study included 240 women aged 19-65 years, of which 98 had EM, 92 had CM, and 50 were nonmigraine control participants.

Disclosures: The study was supported by a National Research Foundation of Korea (NRF) grant from the Korean government. MK Chu declared serving as a site investigator for a multicenter trial and an advisory member for and receiving lecture honoraria and grants from various organizations, including NRF.

Source: Park CG, Chu MK. Interictal plasma glutamate levels are elevated in individuals with episodic and chronic migraine. Sci Rep. 2022;12:6921 (Apr 28). Doi: 10.1038/s41598-022-10883-9

Key clinical point: Adherence and persistence to fremanezumab was high among patients with migraine, especially for quarterly vs monthly dosing.

Major finding: After 6 months of fremanezumab initiation, the mean proportion of days covered (PDC) and medication possession ratio (MPR) were 86.1% and 88.7% respectively, with 74.8% and 79.0% of patients being classified as higher adherers by PDC (≥80%) and MPR (≥80%), respectively. Quarterly vs monthly fremanezumab was associated with significantly higher adherence (P ≤ .006) and mean persistence rates (P = .011).

Study details: This was a retrospective study including 987 adult patients with ≥1 migraine diagnosis during the study period who received fremanezumab on or after diagnosis.

Disclosures: The study was sponsored by Teva Pharmaceuticals. Some authors reported being current orformer employees of Teva.

Source: Krasenbaum LJ et al. A real-world study of acute and preventive medication use, adherence, and persistence in patients prescribed fremanezumab in the United States. J Headache Pain. 2022;23:54 (May 4). Doi: 10.1186/s10194-022-01413-z

Key clinical point: Adherence and persistence to fremanezumab was high among patients with migraine, especially for quarterly vs monthly dosing.

Major finding: After 6 months of fremanezumab initiation, the mean proportion of days covered (PDC) and medication possession ratio (MPR) were 86.1% and 88.7% respectively, with 74.8% and 79.0% of patients being classified as higher adherers by PDC (≥80%) and MPR (≥80%), respectively. Quarterly vs monthly fremanezumab was associated with significantly higher adherence (P ≤ .006) and mean persistence rates (P = .011).

Study details: This was a retrospective study including 987 adult patients with ≥1 migraine diagnosis during the study period who received fremanezumab on or after diagnosis.

Disclosures: The study was sponsored by Teva Pharmaceuticals. Some authors reported being current orformer employees of Teva.

Source: Krasenbaum LJ et al. A real-world study of acute and preventive medication use, adherence, and persistence in patients prescribed fremanezumab in the United States. J Headache Pain. 2022;23:54 (May 4). Doi: 10.1186/s10194-022-01413-z

Key clinical point: Adherence and persistence to fremanezumab was high among patients with migraine, especially for quarterly vs monthly dosing.

Major finding: After 6 months of fremanezumab initiation, the mean proportion of days covered (PDC) and medication possession ratio (MPR) were 86.1% and 88.7% respectively, with 74.8% and 79.0% of patients being classified as higher adherers by PDC (≥80%) and MPR (≥80%), respectively. Quarterly vs monthly fremanezumab was associated with significantly higher adherence (P ≤ .006) and mean persistence rates (P = .011).

Study details: This was a retrospective study including 987 adult patients with ≥1 migraine diagnosis during the study period who received fremanezumab on or after diagnosis.

Disclosures: The study was sponsored by Teva Pharmaceuticals. Some authors reported being current orformer employees of Teva.

Source: Krasenbaum LJ et al. A real-world study of acute and preventive medication use, adherence, and persistence in patients prescribed fremanezumab in the United States. J Headache Pain. 2022;23:54 (May 4). Doi: 10.1186/s10194-022-01413-z

Key clinical point: With self-reported migraine being associated with 26% higher odds of adverse pregnancy outcomes (APO), it may be a significant risk factor for APO.

Major finding: After adjusting for confounding factors, women with migraine showed increased odds of any APO (adjusted odds ratio 1.26; 95% CI 1.12-1.41).

Study details: This was a multicenter prospective study, nuMoM2b, including 9450 nulliparous singleton pregnant women in early gestation, of which 1752 self-reported migraine at the first-trimester visit.

Disclosures: The nuMoM2b study was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Case Western Reserve University, and Columbia University, among others. EC Miller and NA Bello declared receiving financial support from various sources.

Source: Miller EC et al. Migraine and adverse pregnancy outcomes: the nuMoM2b study. Am J Obstet Gynecol. 2022 (May 2). Doi: 10.1016/j.ajog.2022.04.049

Key clinical point: With self-reported migraine being associated with 26% higher odds of adverse pregnancy outcomes (APO), it may be a significant risk factor for APO.

Major finding: After adjusting for confounding factors, women with migraine showed increased odds of any APO (adjusted odds ratio 1.26; 95% CI 1.12-1.41).

Study details: This was a multicenter prospective study, nuMoM2b, including 9450 nulliparous singleton pregnant women in early gestation, of which 1752 self-reported migraine at the first-trimester visit.

Disclosures: The nuMoM2b study was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Case Western Reserve University, and Columbia University, among others. EC Miller and NA Bello declared receiving financial support from various sources.

Source: Miller EC et al. Migraine and adverse pregnancy outcomes: the nuMoM2b study. Am J Obstet Gynecol. 2022 (May 2). Doi: 10.1016/j.ajog.2022.04.049

Key clinical point: With self-reported migraine being associated with 26% higher odds of adverse pregnancy outcomes (APO), it may be a significant risk factor for APO.

Major finding: After adjusting for confounding factors, women with migraine showed increased odds of any APO (adjusted odds ratio 1.26; 95% CI 1.12-1.41).

Study details: This was a multicenter prospective study, nuMoM2b, including 9450 nulliparous singleton pregnant women in early gestation, of which 1752 self-reported migraine at the first-trimester visit.

Disclosures: The nuMoM2b study was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Case Western Reserve University, and Columbia University, among others. EC Miller and NA Bello declared receiving financial support from various sources.

Source: Miller EC et al. Migraine and adverse pregnancy outcomes: the nuMoM2b study. Am J Obstet Gynecol. 2022 (May 2). Doi: 10.1016/j.ajog.2022.04.049

Key clinical point: Self-administered single-dose subcutaneous (SC) injection of diclofenac sodium (50 mg/mL) complexed with hydroxypropyl-β-cyclodextrin (HPβCD) is safe and effective for the treatment of acute migraine attacks in patients with moderate-to-severe migraine pain.

Major finding: After 2 hours of injection, 46.7% of patients were pain-free in the 50 mg diclofenac/HPβCD group, with the percentage being significantly higher than that in the placebo group (16.1%; P = .01). Most treatment-emergent adverse events were mild.

Study details: The findings are from a multicenter, phase 2, dose-finding pilot study including 122 adult patients experiencing 2-8 migraine attacks/month with moderate-to-severe pain who were randomly assigned to receive diclofenac/HPβCD (25, 50, or 75 mg) or placebo.

Disclosures: The study was sponsored by IBSA Institut Biochimique S.A. (Switzerland). Some authors declared serving as advisory board members, consultants, or speakers, or receiving honoraria for clinical investigation studies, travel and research grants, or personal fees from various sources.

Source: Geppetti P et al. Self-administered subcutaneous diclofenac sodium in acute migraine attack: A randomized, double-blind, placebo-controlled dose-finding pilot study. Cephalalgia. 2022 (Apr 26). Doi: 10.1177/03331024221093712

Key clinical point: Self-administered single-dose subcutaneous (SC) injection of diclofenac sodium (50 mg/mL) complexed with hydroxypropyl-β-cyclodextrin (HPβCD) is safe and effective for the treatment of acute migraine attacks in patients with moderate-to-severe migraine pain.

Major finding: After 2 hours of injection, 46.7% of patients were pain-free in the 50 mg diclofenac/HPβCD group, with the percentage being significantly higher than that in the placebo group (16.1%; P = .01). Most treatment-emergent adverse events were mild.

Study details: The findings are from a multicenter, phase 2, dose-finding pilot study including 122 adult patients experiencing 2-8 migraine attacks/month with moderate-to-severe pain who were randomly assigned to receive diclofenac/HPβCD (25, 50, or 75 mg) or placebo.

Disclosures: The study was sponsored by IBSA Institut Biochimique S.A. (Switzerland). Some authors declared serving as advisory board members, consultants, or speakers, or receiving honoraria for clinical investigation studies, travel and research grants, or personal fees from various sources.

Source: Geppetti P et al. Self-administered subcutaneous diclofenac sodium in acute migraine attack: A randomized, double-blind, placebo-controlled dose-finding pilot study. Cephalalgia. 2022 (Apr 26). Doi: 10.1177/03331024221093712

Key clinical point: Self-administered single-dose subcutaneous (SC) injection of diclofenac sodium (50 mg/mL) complexed with hydroxypropyl-β-cyclodextrin (HPβCD) is safe and effective for the treatment of acute migraine attacks in patients with moderate-to-severe migraine pain.

Major finding: After 2 hours of injection, 46.7% of patients were pain-free in the 50 mg diclofenac/HPβCD group, with the percentage being significantly higher than that in the placebo group (16.1%; P = .01). Most treatment-emergent adverse events were mild.

Study details: The findings are from a multicenter, phase 2, dose-finding pilot study including 122 adult patients experiencing 2-8 migraine attacks/month with moderate-to-severe pain who were randomly assigned to receive diclofenac/HPβCD (25, 50, or 75 mg) or placebo.

Disclosures: The study was sponsored by IBSA Institut Biochimique S.A. (Switzerland). Some authors declared serving as advisory board members, consultants, or speakers, or receiving honoraria for clinical investigation studies, travel and research grants, or personal fees from various sources.

Source: Geppetti P et al. Self-administered subcutaneous diclofenac sodium in acute migraine attack: A randomized, double-blind, placebo-controlled dose-finding pilot study. Cephalalgia. 2022 (Apr 26). Doi: 10.1177/03331024221093712

Key clinical point: Compared with placebo, ubrogepant therapy provides favorable 2-hour outcomes, as measured by functional disability, medication satisfaction, and impression of overall change in migraine, in patients with migraine who are triptan insufficient responders (TIR).

Major finding: At 2 hours after initial dose of ubrogepant vs placebo, significantly greater proportion of patients reported no disability (38% vs 29%; odds ratio [OR] 1.5; P = .048), treatment satisfaction (33% vs 21%; OR 1.8; P = .006), and improvement in migraine (30% vs 18%; OR 2.0; P = .006).

Study details: This post hoc analysis included 1799 patients with migraine with or without aura from the phase 3 ACHIEVE I and ACHIEVE II trials who were self-reported TIR and received 50 mg ubrogepant (n = 887) or placebo (n = 912).

Disclosures: The study was funded by Allergan (before acquisition by AbbVie). Some authors declared serving as consultants or advisory board members and receiving research support, honoraria, or royalties from various sources, including AbbVie/Allergan. The other authors are current or former employees and stockholders of AbbVie.

Source: Lipton RB et al. Functionality, satisfaction, and global impression of change with ubrogepant for the acute treatment of migraine in triptan insufficient responders: A post hoc analysis of the ACHIEVE I and ACHIEVE II randomized trials. J Headache Pain. 2022;23:50 (Apr 25). Doi: 10.1186/s10194-022-01419-7

Key clinical point: Compared with placebo, ubrogepant therapy provides favorable 2-hour outcomes, as measured by functional disability, medication satisfaction, and impression of overall change in migraine, in patients with migraine who are triptan insufficient responders (TIR).

Major finding: At 2 hours after initial dose of ubrogepant vs placebo, significantly greater proportion of patients reported no disability (38% vs 29%; odds ratio [OR] 1.5; P = .048), treatment satisfaction (33% vs 21%; OR 1.8; P = .006), and improvement in migraine (30% vs 18%; OR 2.0; P = .006).

Study details: This post hoc analysis included 1799 patients with migraine with or without aura from the phase 3 ACHIEVE I and ACHIEVE II trials who were self-reported TIR and received 50 mg ubrogepant (n = 887) or placebo (n = 912).

Disclosures: The study was funded by Allergan (before acquisition by AbbVie). Some authors declared serving as consultants or advisory board members and receiving research support, honoraria, or royalties from various sources, including AbbVie/Allergan. The other authors are current or former employees and stockholders of AbbVie.

Source: Lipton RB et al. Functionality, satisfaction, and global impression of change with ubrogepant for the acute treatment of migraine in triptan insufficient responders: A post hoc analysis of the ACHIEVE I and ACHIEVE II randomized trials. J Headache Pain. 2022;23:50 (Apr 25). Doi: 10.1186/s10194-022-01419-7

Key clinical point: Compared with placebo, ubrogepant therapy provides favorable 2-hour outcomes, as measured by functional disability, medication satisfaction, and impression of overall change in migraine, in patients with migraine who are triptan insufficient responders (TIR).

Major finding: At 2 hours after initial dose of ubrogepant vs placebo, significantly greater proportion of patients reported no disability (38% vs 29%; odds ratio [OR] 1.5; P = .048), treatment satisfaction (33% vs 21%; OR 1.8; P = .006), and improvement in migraine (30% vs 18%; OR 2.0; P = .006).

Study details: This post hoc analysis included 1799 patients with migraine with or without aura from the phase 3 ACHIEVE I and ACHIEVE II trials who were self-reported TIR and received 50 mg ubrogepant (n = 887) or placebo (n = 912).

Disclosures: The study was funded by Allergan (before acquisition by AbbVie). Some authors declared serving as consultants or advisory board members and receiving research support, honoraria, or royalties from various sources, including AbbVie/Allergan. The other authors are current or former employees and stockholders of AbbVie.

Source: Lipton RB et al. Functionality, satisfaction, and global impression of change with ubrogepant for the acute treatment of migraine in triptan insufficient responders: A post hoc analysis of the ACHIEVE I and ACHIEVE II randomized trials. J Headache Pain. 2022;23:50 (Apr 25). Doi: 10.1186/s10194-022-01419-7

Key clinical point: In treatment-resistant episodic or chronic migraine, galcanezumab therapy can help achieve a clinically meaningful reduction in monthly acute headache medication use.

Major finding: Galcanezumab vs. placebo led to a significantly greater least-squares mean reduction in monthly acute headache medication use from 1 to 3 months (4.2 vs 0.8 days; P < .0001). At 6 months, the monthly acute headache medication use was similar between the groups.

Study details: The data come from the phase 3 CONQUER study including 462 patients with treatment-resistant episodic or chronic migraine who were randomly assigned to receive galcanezumab (n = 232) or placebo (n = 230) in the double-blind phase (months 1-3), followed by galcanezumab in the open-label phase (months 4-6).

Disclosures: The study was sponsored by Eli Lilly and Company. Some authors declared being on the advisory board or speakers’ bureau for and receiving consulting fees, speaker fees, honoraria, or travel support from various sources, including Eli Lilly. The other authors are employees or stockholders of Eli Lilly or one of its subsidiaries.

Source: Ambrosini A et al. Changes in acute headache medication use and health care resource utilization: Results from a randomized, double-blind, placebo-controlled clinical trial evaluating galcanezumab in adults with treatment-resistant migraine (CONQUER). J Manag Care Spec Pharm. 2022 (Apr 22). Doi: 10.18553/jmcp.2022.21375

Key clinical point: In treatment-resistant episodic or chronic migraine, galcanezumab therapy can help achieve a clinically meaningful reduction in monthly acute headache medication use.

Major finding: Galcanezumab vs. placebo led to a significantly greater least-squares mean reduction in monthly acute headache medication use from 1 to 3 months (4.2 vs 0.8 days; P < .0001). At 6 months, the monthly acute headache medication use was similar between the groups.

Study details: The data come from the phase 3 CONQUER study including 462 patients with treatment-resistant episodic or chronic migraine who were randomly assigned to receive galcanezumab (n = 232) or placebo (n = 230) in the double-blind phase (months 1-3), followed by galcanezumab in the open-label phase (months 4-6).

Disclosures: The study was sponsored by Eli Lilly and Company. Some authors declared being on the advisory board or speakers’ bureau for and receiving consulting fees, speaker fees, honoraria, or travel support from various sources, including Eli Lilly. The other authors are employees or stockholders of Eli Lilly or one of its subsidiaries.

Source: Ambrosini A et al. Changes in acute headache medication use and health care resource utilization: Results from a randomized, double-blind, placebo-controlled clinical trial evaluating galcanezumab in adults with treatment-resistant migraine (CONQUER). J Manag Care Spec Pharm. 2022 (Apr 22). Doi: 10.18553/jmcp.2022.21375

Key clinical point: In treatment-resistant episodic or chronic migraine, galcanezumab therapy can help achieve a clinically meaningful reduction in monthly acute headache medication use.

Major finding: Galcanezumab vs. placebo led to a significantly greater least-squares mean reduction in monthly acute headache medication use from 1 to 3 months (4.2 vs 0.8 days; P < .0001). At 6 months, the monthly acute headache medication use was similar between the groups.

Study details: The data come from the phase 3 CONQUER study including 462 patients with treatment-resistant episodic or chronic migraine who were randomly assigned to receive galcanezumab (n = 232) or placebo (n = 230) in the double-blind phase (months 1-3), followed by galcanezumab in the open-label phase (months 4-6).

Disclosures: The study was sponsored by Eli Lilly and Company. Some authors declared being on the advisory board or speakers’ bureau for and receiving consulting fees, speaker fees, honoraria, or travel support from various sources, including Eli Lilly. The other authors are employees or stockholders of Eli Lilly or one of its subsidiaries.

Source: Ambrosini A et al. Changes in acute headache medication use and health care resource utilization: Results from a randomized, double-blind, placebo-controlled clinical trial evaluating galcanezumab in adults with treatment-resistant migraine (CONQUER). J Manag Care Spec Pharm. 2022 (Apr 22). Doi: 10.18553/jmcp.2022.21375

Key clinical point: A second dose of eptinezumab may be beneficial in patients with migraine who exhibit a suboptimal first-dose response.

Major finding: Percent change in monthly migraine days (MMD) over weeks 1-12 (PROMISE-1: odds ratio [OR] 0.97; P = .0001; PROMISE-2: OR 0.94; P < .0001) and change in 6-item Headache Impact Test total score (only PROMISE-2: OR 0.92; P = .027) were observed to be significant first-dose predictors of second-dose response.

Study details: This post hoc analysis included patients with migraine (episodic [n = 416; PROMISE-1] and chronic [n = 479; PROMISE-2]), suboptimal response (<50% reduction from baseline in MMD across weeks 1-12), and patient-reported outcome data at weeks 12 and 24.

Disclosures: The study was sponsored by Lundbeck LLC, USA. Some authors declared serving as consultants, advisory board members, or speakers for and receiving speaker honoraria from various sources, including Lundbeck. The other authors are current orformer employees of H. Lundbeck A/S or its subsidiary/contracted service provider.

Source: Schim JD et al. Likelihood of response with subsequent dosing for patients with migraine and initial suboptimal response with eptinezumab: A post hoc analysis of two placebo-controlled randomized clinical trials. Headache. 2022 (May 6). Doi: 10.1111/head.14302

Key clinical point: A second dose of eptinezumab may be beneficial in patients with migraine who exhibit a suboptimal first-dose response.

Major finding: Percent change in monthly migraine days (MMD) over weeks 1-12 (PROMISE-1: odds ratio [OR] 0.97; P = .0001; PROMISE-2: OR 0.94; P < .0001) and change in 6-item Headache Impact Test total score (only PROMISE-2: OR 0.92; P = .027) were observed to be significant first-dose predictors of second-dose response.

Study details: This post hoc analysis included patients with migraine (episodic [n = 416; PROMISE-1] and chronic [n = 479; PROMISE-2]), suboptimal response (<50% reduction from baseline in MMD across weeks 1-12), and patient-reported outcome data at weeks 12 and 24.

Disclosures: The study was sponsored by Lundbeck LLC, USA. Some authors declared serving as consultants, advisory board members, or speakers for and receiving speaker honoraria from various sources, including Lundbeck. The other authors are current orformer employees of H. Lundbeck A/S or its subsidiary/contracted service provider.

Source: Schim JD et al. Likelihood of response with subsequent dosing for patients with migraine and initial suboptimal response with eptinezumab: A post hoc analysis of two placebo-controlled randomized clinical trials. Headache. 2022 (May 6). Doi: 10.1111/head.14302

Key clinical point: A second dose of eptinezumab may be beneficial in patients with migraine who exhibit a suboptimal first-dose response.

Major finding: Percent change in monthly migraine days (MMD) over weeks 1-12 (PROMISE-1: odds ratio [OR] 0.97; P = .0001; PROMISE-2: OR 0.94; P < .0001) and change in 6-item Headache Impact Test total score (only PROMISE-2: OR 0.92; P = .027) were observed to be significant first-dose predictors of second-dose response.

Study details: This post hoc analysis included patients with migraine (episodic [n = 416; PROMISE-1] and chronic [n = 479; PROMISE-2]), suboptimal response (<50% reduction from baseline in MMD across weeks 1-12), and patient-reported outcome data at weeks 12 and 24.

Disclosures: The study was sponsored by Lundbeck LLC, USA. Some authors declared serving as consultants, advisory board members, or speakers for and receiving speaker honoraria from various sources, including Lundbeck. The other authors are current orformer employees of H. Lundbeck A/S or its subsidiary/contracted service provider.

Source: Schim JD et al. Likelihood of response with subsequent dosing for patients with migraine and initial suboptimal response with eptinezumab: A post hoc analysis of two placebo-controlled randomized clinical trials. Headache. 2022 (May 6). Doi: 10.1111/head.14302

Key clinical point: Erenumab is effective in managing patients with treatment-resistant chronic migraine in a tertiary care setting without causing any serious adverse effects.

Major finding: At 3 and 6 months, erenumab significantly reduced the median monthly migraine days (MMD; −4 and −9 days, respectively; P < .001), with the MMD 50% responder rate at 3 months being 36%. No serious adverse events were observed.

Study details: This was a prospective study including 92 patients aged >18 years with chronic migraine and ≥3 prior migraine preventive treatment failures who received monthly 70 mg erenumab for 3 months.

Disclosures: The authors did not report any source of funding or conflict of interests.

Source: Khalil M et al. Erenumab in chronic migraine: Experience from a UK tertiary centre and comparison with other real-world evidence. Eur J Neurol. 2022 (Apr 21). Doi: 10.1111/ene.15364

Key clinical point: Erenumab is effective in managing patients with treatment-resistant chronic migraine in a tertiary care setting without causing any serious adverse effects.

Major finding: At 3 and 6 months, erenumab significantly reduced the median monthly migraine days (MMD; −4 and −9 days, respectively; P < .001), with the MMD 50% responder rate at 3 months being 36%. No serious adverse events were observed.

Study details: This was a prospective study including 92 patients aged >18 years with chronic migraine and ≥3 prior migraine preventive treatment failures who received monthly 70 mg erenumab for 3 months.

Disclosures: The authors did not report any source of funding or conflict of interests.

Source: Khalil M et al. Erenumab in chronic migraine: Experience from a UK tertiary centre and comparison with other real-world evidence. Eur J Neurol. 2022 (Apr 21). Doi: 10.1111/ene.15364

Key clinical point: Erenumab is effective in managing patients with treatment-resistant chronic migraine in a tertiary care setting without causing any serious adverse effects.

Major finding: At 3 and 6 months, erenumab significantly reduced the median monthly migraine days (MMD; −4 and −9 days, respectively; P < .001), with the MMD 50% responder rate at 3 months being 36%. No serious adverse events were observed.

Study details: This was a prospective study including 92 patients aged >18 years with chronic migraine and ≥3 prior migraine preventive treatment failures who received monthly 70 mg erenumab for 3 months.

Disclosures: The authors did not report any source of funding or conflict of interests.

Source: Khalil M et al. Erenumab in chronic migraine: Experience from a UK tertiary centre and comparison with other real-world evidence. Eur J Neurol. 2022 (Apr 21). Doi: 10.1111/ene.15364