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MigraineNCT05046119

Psychological and Biological Markers of Refractory Migraine

An observational study of Migraine, run by IRCCS National Neurological Institute "C. Mondino" Foundation at 1 site in Italy.

Unknown status

Status not confirmed. The sponsor has not verified this record for over two years, so it may be out of date.

Official record
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Trial summary

The term "refractory" migraine describes a particularly aggressive form of the disease in which the patient does not benefit from any of the preventive therapies with the various classes of drugs available, including treatment with monoclonal antibodies directed against Calcitonin Gene Related Peptide (CGRP). Read more about this study

Who is it for?
Ages 18 to 65 years
Conditions the study is for
Migraine
How many people
80 participants
Where
1 siteItaly
Study dates
15 Sep 2021to 15 Sep 2024
Phase
Observational
Are there results?
None posted in the registry

Key requirements

Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.

  • Ages 18 to 65 years
  • All sexes
  • No healthy volunteers
  • Adult, Older adult

Study population: Eighty participants with EM and CM will be recruited at the Headache Science and Neurorehabilitation Centre of the IRCCS Mondino Foundation. The diagnosis of EM and CM is formulated according to the guidelines of the ICHD-III version (EM or CM with previous failure to at least 3 of the following classes of antimigraine preventive drugs :beta-blockers, antidepressants, calcium antagonists and, for CM, onabotulinumtoxinA).

Who may be able to join

  • Clinical characteristics that meet the criteria of the current International Headache Classification for Migraine or Chronic Migraine.
  • Age >18, <65 years of both sexes
  • At least 8 days of migraine/month and Migraine Disability Assessment Questionnaire (MIDAS) score greater than 11 at baseline*.
  • Lack of benefit or intolerance or contraindication to at least three classes of drugs for the preventive therapy of migraine*.
  • Drug Italian Agency (AIFA) criteria for the prescription of monoclonal antibodies directed against CGRP.

Who cannot join

  • dementia, psychosis, mental retardation
  • women of childbearing age without contraceptive protection, pregnant and lactating women

Trial locations and contacts

1 site in 1 country.

Italy1 site
  • Headache Science Center

    Pavia, 27100

Other trials in Italy

About this study

Official title: Factors Associated With Migraine Refractoriness to Preventive Treatments: Psychological Aspects and Relationship With Components of the Endocannabinoid System

The term "refractory" migraine describes a particularly aggressive form of the disease in which the patient does not benefit from any of the preventive therapies with the various classes of drugs available, including treatment with monoclonal antibodies directed against Calcitonin Gene Related Peptide (CGRP).

Anxiety, depressive symptoms, somatization, and pain hypersensitivity are significantly more prevalent in refractory migraineurs than in non-refractory subjects who benefit from preventive therapies, suggesting that these symptoms may contribute to treatment refractoriness. Recently, in a preliminary study on the efficacy of a CGRP-targeting monoclonal antibody in Chronic Migraine (CM) patients with at least 3 failures to previous preventive treatments, the investigators showed a higher prevalence of psychological disturbances in those who did respond to the monoclonal antibody compared with the responders. These data, although preliminary, point to a more psychologically complicated picture in non-responder patients compared with responders. To date, however, no neurobiological evaluations are available to explain how psychological comorbidities may contribute to treatment refractoriness. Isolated clinical evidence and growing pre-clinical evidence suggests a role for the endocannabinoid system in migraine. Hence, the present study aims to identify psychological and biological factors associated with refractory migraine. The investigators' hypothesis is that patients presenting with psychological disorders may bear an associated dysfunction of the endocannabinoid system, which makes them more resistant to migraine preventive therapies, including monoclonal antibodies directed against CGRP.

Read the detailed description

Migraine is a common and highly disabling condition, representing the second-leading cause of disability in the global ranking of most disabling diseases . In the majority of individuals, the disease manifests as episodic (EM), with attacks recurring weekly or monthly. In a smaller (2-3% of the general population), but still significant portion of patients, migraine becomes chronic, i.e., occurring on at least 15 days per month (CM).

Previous studies have shown that CM patients are characterized by the presence of multiple psychiatric comorbidities compared with subjects with episodic migraine and healthy controls. In recent years, it has also been shown that among the neurobiological systems involved in the genesis and development of mental disorders, the endocannabinoid system (ES) appears to play an active role. In particular, patients with these disorders are characterized, at the level of peripheral cells, by a gene alteration of cannabinoid receptors.

Several studies reported the involvement of SE in immune responses, psychological processes, transduction of neurobiological signals and pain, including migraine pain. Recently it has been shown that the peripheral gene expression of enzymes involved in the metabolism of anandamide (AEA) and 2-aciglycerol (2-AG), the two best known endocannabinoids, is altered in migraine patients, but more markedly in the chronic subtype, suggesting a role for these lipid molecules not only in the pathophysiology of the disease, but also in its exacerbation. The role of CGRP in the pathophysiology of migraine has now been demonstrated, although the mechanism of action at both peripheral and central levels and its possible interactions with other pathways are not completely known.

The term "refractory" migraine describes a particularly aggressive form of the disease in which the patient does not benefit from any of the preventive therapies with the various classes of drugs available, including treatment with monoclonal antibodies directed against CGRP (Consensus document of the European Headache Federation).

Anxiety, depressive symptoms, somatization, and pain hypersensitivity are significantly more prevalent in refractory migraineurs than in non-refractory subjects who benefit from preventive therapies, suggesting that these symptoms may contribute to treatment refractoriness. Recently, in a preliminary study regarding the efficacy of monoclonal antibody targeting CGRP in CM patients refractory to at least three preventive therapies,the investigators showed a higher prevalence of personality disorders (77% vs 37%) in those who were not responding to treatment at 1 year (non-responders: reduction in migraine days <50%), compared with those who were responding (responders: reduction in migraine days ≥50%). Non-responders were also characterized by a higher prevalence of anxiety spectrum disorders and more stressful events than responders. These data, although preliminary, point to a more psychologically complicated picture in non-responder patients compared with responders. To date, however, no neurobiological data are available to explain how psychological comorbidities may contribute to treatment refractoriness.

In this frame, the present study aims to identify psychological and potential biochemical/molecular factors associated with refractory migraine. The investigators' hypothesis is that patients presenting with psychological disorders may bear an associated dysfunction of the endocannabinoid system, which makes them more resistant to migraine preventive therapies, including monoclonal antibodies directed against CGRP.

There will be a screening phase of one month in which patients will complete a daily headache diary in which they will note the occurrence, intensity and duration of attacks, as well as the use of symptomatic drugs. At baseline patients will undergo the psychological and biochemical/molecular evaluation. Subjects will then be treated with one of the three commercially available monoclonal antibodies targeting CGRP and will continue to record the characteristics of attacks and the use of symptomatic drugs in their headache diary. Follow-up visits are foreseen after 3 and 6 months of treatment. At 6 months, patients will be divided into 2 groups (responder or not responder to the treatment) depending on the reduction of monthly migraine days in the previous 3 months (>50% and <50%, respectively).

The patients who failed to respond to the treatment will be considered refractory.

Psychological evaluation: All patients will be evaluated by psychological interview and by adopting the DSM-V criteria for personality disturbances, anxiety and mood disorders. All patients will also be administered the Hospital Anxiety and Depression Scale (HADS) the Toronto Alexithymia Scale 20 (TAS-20), severity of dependence questionnaires (Severity Dependence Scale - SDS - and Leeds Dependence Questionnaire - LDQ), questionnaires related to Childhood trauma and Stressful life events.

Conditions
Migraine
Keywords
Migraine, Refractoriness, Monoclonal antibodies directed against CGRP, Psychological disturbances, Endocannabinoid system
Medical subject headings
Migraine Disorders

What is being measured

The primary outcome is the main question the study is designed to answer.

  1. Personality disorders

    To evaluate the association of refractory migraine with personality disorders (according to Diagnostic and Statistical Manual of mental disorders - DSM V criteria) in subjects with resistant migraine undergoing therapy with monoclonal antibodies directed against CGRP.

    Measured: Change from baseline to 3-month to 6-month

Secondary outcomes (7)
  1. Hospital Anxiety and Depression Scale (HADS)

    The HADS is a fourteen item scale that generates: seven of the items relate to anxiety and seven relate to depression. Each item on the questionnaire is scored from 0-3. Higher scores are worst outcomes

    Measured: Baseline, pre-receiving the treatment

  2. Toronto Alexitimia Scale 20 (TAS-20)

    The TAS is a 20-item instrument that is one of the most commonly used measures of alexithymia. The TAS-20 uses cutoff scoring: equal to or less than 51 = non-alexithymia, equal to or greater than 61 = alexithymia. Scores of 52 to 60 = possible alexithymia.

    Measured: Baseline, pre-receiving the treatment

  3. Childhood traumas questionnaire

    The Childhood Trauma Questionnaire (CTQ) is a retrospective, self-report measure that was developed to provide a brief, reliable, and valid assessment of a broad range of traumatic experiences in childhood. It contains 70 items arranged according to four factors: physical and emotional abuse, emotional neglect, sexual abuse, and physical neglect. Responses are quantified on a 5-point Likert-type scale according to the frequency with which experiences occurred, with 1 = "never true" and 5 = "very often true.

    Measured: Baseline, pre-receiving the treatment

  4. Stressful life events questionnaire (SLESQ)

    SLESQ is a 13-item self-report measure for non-treatment seeking samples that assesses lifetime exposure to traumatic events. Eleven specific and two general categories of events, such as a life-threatening accident, physical and sexual abuse, witness to another person being killed or assaulted, are examined. For each event, respondents are asked to indicate whether the event occurred ("yes" or "no"), their age at time of the event, as well as other specific items related to the event, such as the frequency, duration, whether anyone died, or was hospitalization, etc.

    Measured: Baseline, pre-receiving the treatment

  5. The Leeds Dependence Questionnaire (LDQ)

    The LDQ has been developed as part of a treatment evaluation package. The LDQ is a 10-item, self completion questionnaire designed to measure dependence upon a variety of substances. All items are scored 0-1-2-3.

    Measured: Baseline, pre-receiving the treatment

  6. Severity of Dependence Scale (SDS)

    The Severity of Dependence Scale (SDS) is a 5-item self-administered questionnaire that provides a score indicating the severity of dependence on drugs. Higher scores are worst outcomes

    Measured: Baseline, pre-receiving the treatment

  7. Endocannabinoid System (ES)

    Main components of the ES at the peripheral level

    Measured: Baseline, pre-receiving the treatment

Timeline

From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.

  1. First posted16 Sep 2021
  2. Study start15 Sep 2021 (estimated)
  3. Primary completion15 Sep 2024 (estimated)
  4. Study completion15 Sep 2024 (estimated)

Resources

More details

For doctors and researchers: how the study is designed, who runs it, and its registry IDs.

Study design
Study type
Observational
Observational model
Cohort
Time perspective
Prospective
Enrolment
80 participants (estimated)
IDs, dates and publications
ClinicalTrials.gov ID
NCT05046119
Sponsor's protocol ID
ReMi2021
Status last verified
Aug 2021
First submitted
2 Sep 2021
Last updated
16 Sep 2021
Results posted
No
Data monitoring committee
No
Individual data sharing
No

Publications

  • Ashton CH, Moore PB. Endocannabinoid system dysfunction in mood and related disorders. Acta Psychiatr Scand. 2011 Oct;124(4):250-61. doi: 10.1111/j.1600-0447.2011.01687.x. Epub 2011 Mar 9.

    PubMed 21916860
  • Bottiroli S, Galli F, Viana M, De Icco R, Bitetto V, Allena M, Pazzi S, Sances G, Tassorelli C. Negative Short-Term Outcome of Detoxification Therapy in Chronic Migraine With Medication Overuse Headache: Role for Early Life Traumatic Experiences and Recent Stressful Events. Front Neurol. 2019 Mar 7;10:173. doi: 10.3389/fneur.2019.00173. eCollection 2019.

    PubMed 30899242
  • Bottiroli S, Galli F, Viana M, Sances G, Tassorelli C. Traumatic Experiences, Stressful Events, and Alexithymia in Chronic Migraine With Medication Overuse. Front Psychol. 2018 May 14;9:704. doi: 10.3389/fpsyg.2018.00704. eCollection 2018.

    PubMed 29867669
  • Bottiroli S, Viana M, Sances G, Ghiotto N, Guaschino E, Galli F, Vegni E, Pazzi S, Nappi G, Tassorelli C. Psychological factors associated with failure of detoxification treatment in chronic headache associated with medication overuse. Cephalalgia. 2016 Dec;36(14):1356-1365. doi: 10.1177/0333102416631960. Epub 2016 Feb 15.

    PubMed 26879321
  • Cupini LM, Bari M, Battista N, Argiro G, Finazzi-Agro A, Calabresi P, Maccarrone M. Biochemical changes in endocannabinoid system are expressed in platelets of female but not male migraineurs. Cephalalgia. 2006 Mar;26(3):277-81. doi: 10.1111/j.1468-2982.2005.01031.x.

    PubMed 16472333
  • Cupini LM, Costa C, Sarchielli P, Bari M, Battista N, Eusebi P, Calabresi P, Maccarrone M. Degradation of endocannabinoids in chronic migraine and medication overuse headache. Neurobiol Dis. 2008 May;30(2):186-9. doi: 10.1016/j.nbd.2008.01.003. Epub 2008 Feb 1.

    PubMed 18358734
  • De Icco R, Greco R, Demartini C, Vergobbi P, Zanaboni A, Tumelero E, Reggiani A, Realini N, Sances G, Grillo V, Allena M, Tassorelli C. Spinal nociceptive sensitization and plasma palmitoylethanolamide levels during experimentally induced migraine attacks. Pain. 2021 Sep 1;162(9):2376-2385. doi: 10.1097/j.pain.0000000000002223.

    PubMed 33587406
  • Iani L, Lauriola M, Costantini M. A confirmatory bifactor analysis of the Hospital Anxiety and Depression Scale in an Italian community sample. Health Qual Life Outcomes. 2014 Jun 5;12:84. doi: 10.1186/1477-7525-12-84.

    PubMed 24902622
  • Ibarra-Lecue I, Pilar-Cuellar F, Muguruza C, Florensa-Zanuy E, Diaz A, Uriguen L, Castro E, Pazos A, Callado LF. The endocannabinoid system in mental disorders: Evidence from human brain studies. Biochem Pharmacol. 2018 Nov;157:97-107. doi: 10.1016/j.bcp.2018.07.009. Epub 2018 Jul 17.

    PubMed 30026022
  • Sacco S, Braschinsky M, Ducros A, Lampl C, Little P, van den Brink AM, Pozo-Rosich P, Reuter U, de la Torre ER, Sanchez Del Rio M, Sinclair AJ, Katsarava Z, Martelletti P. European headache federation consensus on the definition of resistant and refractory migraine : Developed with the endorsement of the European Migraine & Headache Alliance (EMHA). J Headache Pain. 2020 Jun 16;21(1):76. doi: 10.1186/s10194-020-01130-5.

    PubMed 32546227
  • Sarchielli P, Pini LA, Coppola F, Rossi C, Baldi A, Mancini ML, Calabresi P. Endocannabinoids in chronic migraine: CSF findings suggest a system failure. Neuropsychopharmacology. 2007 Jun;32(6):1384-90. doi: 10.1038/sj.npp.1301246. Epub 2006 Nov 22.

    PubMed 17119542
  • Tassorelli C, Greco R, Silberstein SD. The endocannabinoid system in migraine: from bench to pharmacy and back. Curr Opin Neurol. 2019 Jun;32(3):405-412. doi: 10.1097/WCO.0000000000000688.

    PubMed 30883435
  • Viana M, Bottiroli S, Sances G, Ghiotto N, Allena M, Guaschino E, Nappi G, Tassorelli C. Factors associated to chronic migraine with medication overuse: A cross-sectional study. Cephalalgia. 2018 Dec;38(14):2045-2057. doi: 10.1177/0333102418761047. Epub 2018 Apr 10.

    PubMed 29635935

Questions about this trial

What is this clinical trial studying?

An observational study of Migraine, run by IRCCS National Neurological Institute "C. Mondino" Foundation at 1 site in Italy.

The full registered description is in the About this study section and the official record.

Who may be eligible to take part?

The sponsor lists 5 inclusion and 2 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.

Is this clinical trial currently recruiting?

The record says: status not confirmed, as of the sponsor's last update on 16 Sep 2021. Status can change between updates, so confirm with the study contact before making plans.

Where is the study taking place?

The record lists 1 site in Italy. Whether a site is taking part right now should be confirmed with that site. See every site.

What are the possible benefits and risks?

They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.

Are results available for this study?

Results are not available in the source record.

How can a doctor refer a patient or contact the research team?

Contact Cinzia Fattore (0039 (0)382380385, cinzia.fattore@mondino.it), or a site near the patient. AzTrials does not enrol participants or take referrals.

What does the primary outcome measure?

Personality disorders (time frame: Change from baseline to 3-month to 6-month). It is what the study was designed to measure, not a finding.

Where can I read the original study information?

On the ClinicalTrials.gov record for NCT05046119, which also lists 13 linked publications.

Does a listing mean the treatment is approved or proven to work?

No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.

How often is this information updated?

AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 16 Sep 2021.

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