Mohtashem Samsam, MD, PhD
Associate Professor, Department of Medicine
Burnett School of Biomedical Sciences (BSBS), College of Medicine, University of Central Florida, 4000 Central Florida Blvd., HPA-II, 320, Orlando, FL, 32816, USA, Tel. 1- 407- 823 4810; Fax: 1- 407- 823 3095; E-mail: Mohtashem.Samsam@ucf.edu
Migraine is believed to be a brain disorder, a deficiency of sensory modulation, and probably a system failure of normal sensory processing of the brainstem that regulates the vascular tone and the pain in migraine.1,2 Although the aura phase of migraine is believed to be due to cortical spreading depression, a similar mechanism of neuronal excitation is believed to be the trigger for migraine while the headache phase of migraine seems to involve the trigeminovascular system consisting of mainly trigeminal nerve and meningeal vessels.
Observations of Dr. Goadsby and several investigators using imaging studies suggest that the trigger phase of migraine is initiated by neuronal hyperexcitability and activation of the brainstem, hypothalamus, and the brain, and that activation is often unaffected even after relief of the headache by antimigraine drugs.3,4,5
A major part of the dura mater specially the supratentorial part of dura is innervated by the trigeminal nerve, mainly the ophthalmic branch. The Trigeminal Ganglionic (TG) neurons contain several neurotransmitters and neuromodulators among them glutamic acid and various neuropeptides including the calcitonin gene-related peptide.6,7 Several neuropeptides co-exist together in TG sensory neurons and may be released at the first central trigeminal synapses in the brainstem upon stimulation,8 but clinically, significant CGRP increase has been seen in migraine patients.9,10 CGRP administration in human provoked a migraine-like attack in migraine patients11 and CGRP-antagonists alleviated the headache to a comparable level to other potent anti-migraine drugs such as sumatriptan.12 Currently, some of the first choice antimigraine drugs include the triptan family drugs that are the serotonin receptor agonists (5-HT1B/D), and the Non-steroid anti-inflammatory drugs (NSAIDs) according to the “European Federation of Neurological Societies (EFNS)”.13 Please see14,15,16 for a comprehensive review of the triptan family drugs and their receptors, and see5,17 for a brief review of several other drugs that are being used for the treatment of migraine including their actions, effects and side effects.
However, research in the treatment of migraine is one of the active fields of the neurological research and several studies in recent years focused on new and alternative treatment strategies including antagonizing CGRP receptors and/or blocking the CGRP activity by mAbs against CGRP and/or its receptor.
Calcitonin gene-related peptide consists of 37 amino acid detected by alternative processing of Ribonucleic acid (RNA) transcripts from the calcitonin gene which result in the production of distinct messenger RNA (mRNAs) that encodes the hormone calcitonin.18
There are two forms of CGRP in humans: the α-CGRP and the β-CGRP that are derived from different genes that differ in 3 amino acids but show similar functions.19 The α-CGRP is expressed in sensory neurons including the trigeminal ganglion and is the relevant one in migraine pathophysiology while the β-CGRP is expressed in the enteric nervous system and in hypophysis and its role in migraine is not known.20,21,22
There is a wide anatomical distribution of CGRP in the body including the central and peripheral nervous system and is involved in many functions including nociception, glucose uptake, and stimulation of glycolysis in the skeletal muscles.23 CGRP is a potent vasodilator in human and rat and may mediate hyperemia in some pathological conditions.24
The headache phase of migraine is believed to be caused by vasodilation of cranial vessels activating the trigeminal and other sensory nerves,25,26,27,28 although migraine has been reported without the initial dilatation of the middle cerebral artery29 and even during cerebral hypoperfusion.29,30,31,32
CGRP Receptor and its Localization in the Nervous System
CGRP receptor has an unusual structure and consists of a hetero-oligomeric complex with a transmembrane Gs protein-coupled receptor, the “Calcitonin receptor-like receptor (CLR)” and an accessory protein known as the “Receptor activity-modifying protein 1 (RAMP1)” which is necessary to transport CLR to the plasma membrane. Both the CLR and RAMP1 subunits have extracellular domains that interact with one another and together form a complex for the peptide-binding site.33,34,35,36 The extracellular domain of RAMP1 is very important for the binding of CGRP-receptor antagonist molecules to the CGRP receptors37 and function of RAMP1 is crucial for the activity of CGRP receptor in the trigeminal ganglion.38 Another related structure of the CGRP receptor is the Receptor Component Protein (RCP) which is crucial for signaling pathway and determines the G-protein to which the receptor should be coupled with.29,35
The CLR acts as a receptor for either CGRP or adrenomedullin, depending on which members of RAMPs are expressed. RAMP1 is a CGRP receptor at the cell surface and acts as a mature glycoprotein as well. RAMP2-transported receptors are adrenomedullin receptors and are core-glycosylated molecules.33,39
Although originally two CGRP receptors (1 and 2) were recognized40 the nomenclature changed later and the “CGRP(1)” receptor is now known as the “CGRP” receptor.17,41
Various signaling molecules and second messengers are involved following the CGRP receptor activation. These include the CGRP activation of ATP-sensitive K+ channels42 or large-conductance Ca+2-activated K+ channels43 with a subsequent increase of intracellular cAMP44 leading to vasodilation and headache. Nitric oxide activation of CGRP release in trigeminal ganglion neuronal cell culture however involves extracellular calcium and T-type calcium channels.45
CGRP receptor (both CLR/RAMP1 components) mRNA and protein are expressed in several regions of the CNS including the spinal cord and spinal trigeminal nucleus, area postrema, pineal gland, parts of hypothalamus, periaqueductal gray matter, pontine raphe nuclei and the gracile nucleus although the RAMP1 mRNA was also detected in several regions of the brainstem and that CGRP receptor was found in areas that were not supported by BBB.46
CGRP receptor is also expressed in the cerebellum.47 Localization of the CGRP receptor in the tigeminovascular system seems to be on the central trigeminal nerve endings, dural blood vessels and mast cells, and trigeminal ganglion48,49 as well as dorsal horn secondary neurons.50 Please see22,46,51 for a comprehensive review of the CGRP receptor sites. CNS glial cells such as astrocytes and microglial cell52 and Schwann cells49 also express CGRP receptors as well.
CGRP Receptor Antagonists in the Treatment of Migraine
One of the important properties of CGRP-antagonist drugs such as BIBN4096BS is that it prevents the CGRP-mediated vasodilation or activation of trigeminovascular afferents53 without the vasoconstrictor activities which is an advantage in patients with coronary heart disease or in patients with second rebound attack, see53,54 for review.
The discovery of CGRP-antagonist drugs the “gepant” family, in the last decade was a breakthrough in migraine treatment research due to their lack of vasoconstrictive activity compared to some “triptan” family drugs. One of the first drugs, the BIBN4096BS, also known as olcegepant, prevents the CGRP-mediated vasodilation or activation of trigeminovascular afferents12 and presumably inhibits the central CGRP receptors.
Olcegepant is a potent anti-migraine drug that has been examined on human arteries.55,56,57,58,59 The BIBN4096BS was shown to block the responses evoked by stimulants such as α-CGRP and capsaicin, or transcranial electrical stimulation of perivascular trigeminal nerve60 which reduces the increased dural blood flow without changing basal vascular parameters,61,62 whereas sumatriptan reduced only the vasodilation induced by electrical stimulation.17,60 One important advantage of olcegepant over the triptan family drugs is that it doesn’t constrict the coronary arteries.55,63,64
Olcegepant has been shown to inhibit CGRP receptor in the trigeminal nucleus suggesting a similar central nervous system mechanism as well in treatment of migraine.65 Another drug in this class, the MK-0974 (telcagepant) is another effective CGRP receptor antagonist when administered orally for the acute treatment of migraine.66
Both olcegepant (iv) in phase I, phase II and telcagepant (oral) in phase III have been used in migraine clinical trials.66,67,68,69 The efficacy of the CGRP antagonists in the central modulation of pain in the hypothalamus has also been reported by Goadsby and colleagues.5,70 A major side effect of these drugs is hepatic toxicity and elevated transaminase levels71 although the presumably high doses of olcegepant and telcagepant alleviating the migraine symptoms are not so high after all.72 A newer CGRP antagonist “BI44370TA” was reported to have a lower frequency of adverse effects in its phase II clinical trials.73 It seems that the CGRP antagonists can act on CGRP receptors however it is uncertain whether they act on peripheral or central sites or both in migraine.72
Please see74,75,76,77 for a comprehensive review on the CGRP and its functions, receptors, and the implication of CGRP-receptor antagonists as a novel approach in the treatment of migraine attacks. A recent report comparing the dose-response curve for the efficacy and adverse effect of several serotonin receptor (5-HT1B/D) agonist drugs such as triptans or Lasmiditan (5-HT1F antagonist) and the CGRP-receptor antagonists such as telcagepant, BI 44370 TA, MK-3207, and BMS-927711 indicates that the dose-response curve for efficacy of triptans is flat while their adverse effects increase by increasing the doses. While Lasmiditan and the CGRP-receptor antagonist drugs had also a flat dose-response curve, the efficacy-tolerability profile of the triptans is more favorable than others.78
Nevertheless, these newer drugs may have advantage in those patients that are triptan non-responders or with coronary heart disease or in patients with second rebound attack.53,54,78 So far five different CGRP-receptor antagonist drugs with proof of efficacy have been used for the treatment of migraine but were discontinued due to hepatic toxicity and other side effects.79,80,81,82
Therefore, search for newer drugs against CGRP did not stop but this time, efforts were on developing antibodies against CGRP and it receptors.
Monoclonal Antibodies against CGRP and its Receptor in the Treatment of Migraine Headaches
Antibodies against viruses have long considered as effective preventive methods in viral infections.85,86 Antibodies against biological antigens (in this case, CGRP) can bind proteins and neutralize their effect (block the activity) whether being free in the circulation or membrane-bound and possibly intracellular proteins.
Monoclonal antibodies (mAbs) against CGRP and its receptors are newer drugs that have emerged in recent years87 Table 1. Several investigators have been studying three mAbs for the prevention of episodic migraine and one mAb for the prevention of chronic migraine in the last couple of years.87 The main idea was to remove the excess peripheral CGRP released from the perivascular nerve endings and for the anti-CGRP receptor antibodies to prevent the CGRP signalling cascade.82,83
Currently, three anti-CGRP mAbs have been developed that are in clinical trials. These include the LY2951742 (by Eli Lilly and Company), ALD-403 (by Alde Biopharmaceuticals) and TEV-48125 (LBR-101) developed by Teva Pharmaceuticals. The other class of mAb is against CGRP receptor complex, the AMG 334, developed by Amgen.
The ALD 403: Is a humanized Anti-CGRP mAb that has been used for episodic and chronic migraine, please see company’s website.88 It has completed phase 189-90 study and is in phase 2.91 It has a half-life of approximately 31 days and has finalized positive proof-of-concept in phase 2a with a single i.v. dose of 1000 mg that can be repeated every 3-month.92 The safety of the drug was assessed at 12 weeks after the infusion; the primary efficacy endpoint was observation of changes in the frequency of migraine days from the baseline to weeks 5-8 among adult patients age 18-55 years who had 9-10 days of headache per month where 8-9 of them qualified for migraine days.82,92 Patients treated with ALD403 had a mean decrease of 5.6 migraine days between baseline and weeks 5-8 compared to the placebo group who had a decrease of 4.6 migraine days in the 3rd month (1 day difference).82,92 The difference in the first month was 5.6 versus 3.9 days between the ALD403 group and the placebo (1.7 days difference).82,92 These results showed the efficacy of ALD403 and there was no safety concern with the i.v. injection of 1000 mg of this mAb against CGRP.92 Some side effects included infections of the upper respiratory, or urinary tracts, back pain, fatigue, nausea and vomiting that were seen in 57% of the 81 patients treated with ALD403 but were also seen in 52% of the 82 individuals who received the placebo treatment.92
LY2951742: Is another humanized anti-CGRP mAb (Lilly’s clinical development pipeline)93 with a half-life of 28 days94 that has completed phase 1 clinical trials for the treatment of episodic and chronic migraine95,96 and was tested in phase 2 clinical trials.97 This phase 2 proof-of concept included randomized, double blind, placebo controlled investigations in 35 centres in the United States.94
The safety of the drug was assessed at 12 weeks treatment period after subcutaneous administration of 150 mg of this mAb twice per month (once every 2 weeks) for 12 weeks.94 The primary endpoint was observation of changes in the number of migraine headache days per 28-day period that were evaluated at 9-12 weeks (although follow up assessment continued over 24 weeks as well) among adult patients age 18-65 years having 4-14 days of migraine headache per month.94 Patients treated with LY2951742 had a mean decrease of 4.2 (62.5% decrease) migraine headache days between baseline and week 12 compared to the placebo group who had a decrease of 3 migraine days (42.3%).94 This study indicated that LY2951742 may be beneficial in prevention of migraine.94
Adverse effects such as pain and erythema or both at the injection site (20% versus 6% in placebo group), upper respiratory tract infections (17% versus 9% in placebo group) and abdominal pain (6% versus 3% in placebo group) were more frequent in the LY2951742 treated group than the placebo treated group.94 Another effort was also determining the dose selection for phase 2 studies.98 LY2951742 is currently in clinical trial phase 3 for treatment of episodic cluster headache.99
TEV-48125: Also known as LBR-101 (with a former identity: RN-307) is also a humanized anti-CGRP mAb for treatment of episodic and chronic migraine (Teva Pharmaceutical Industries Ltd.)100 and has a half-life of about 45 days, the longest among the anti-CGRP mAbs.101 Its safety profiles were demonstrated through six phase one studies.102 Studies in monkeys established the safety and tolerability of LBR-101 and appeared to have no significant effect in cardiovascular and haemodynamic parameters.103 Clinical studies used 0.2-2000 mg given as a single dose (a one hour i.v. infusion) once (on day 1), or up to 300 mg given twice (day 1 and day 14) to human subjects.104 These doses were well tolerated and overt safety concerns were not noticed.82 TEV-48125 is currently in two phase 2b clinical trials, administered as a 1-month run-in phase followed by randomization and monthly subcutaneously injections for 3 months.82 TEVA company announced the successful completion a phase 2b clinical trial using TEV-48125, meeting the primary and secondary endpoints in both chronic and episodic migraine study after a single dose injection which was significantly higher than placebo and resulted in significant reduction of both the number of monthly cumulative headache hours, and the number of headache days of at least moderate severity relative to baseline.105 No significant cardiovascular or liver function adverse effects were seen compared to the placebo receiving control group, please see82,104 for details of the studies and a comprehensive review.
AMG 334: Is a CGRP-receptor mAb, indicated in Amgen media news release106 that has completed phase 1107-109 and is in its phase 2 clinical trials.110,111,112 A few recent reports113 and those of Amgen released results (reported by PRNewswire) of a global phase 2 clinical trial (which was also presented in the 17th congress of the International Headache Society, Valencia, Spain) indicate that this fully human mAb, the AMG 334 seems to have significantly decreased the mean migraine days per month in episodic migraine patients.114,115 These studies are currently ongoing but please see references112,113 for more details of AMG 334 studies that has been released so far.
Biological Role of CGRP in Homeostasis
So far we discussed the CGRP being a neurotransmitter/neuromodulator that mediates vasodilation peripherally and acting on its receptor on central neurons but it is important to discuss some other biological roles of CGRP in the body.
In the lung and respiratory airways, in addition to CGRP expression of the sensory neurons innervating the airways, blood vessels and lymphoid tissue,116 CGRP is also localized in specialized epithelial (neuroendocrine) cells in the lungs and is involved in regulation of vascular tone,117 protection of the bronchial tree, the anti-inflammatory responses and tissue repair.118 Ablation of sensory nerve fibers leads to a significant increase in inflammatory responses, and congenital CGRP-knockout mice have increased reperfusion-induced tissue inflammatory activities.119 In the gastrointestinal (GI) tract, stimulation of sensory nerves reduces reperfusion-induced liver injury and stressed-induced gastric mucosal injury in rodents presumably by CGRP-induced increase in the expression of prostacyclin [PGI(2)] and attenuation of inflammatory responses such as tissue Tumor Necrosis Factor (TNF) increase and tissue accumulation of neutrophils.119
CGRP is a negative regulator of innate immune responses by inhibiting the antigen presenting cells such as macrophages and dendritic cells, blocking their capacity to produce proinflammatory cytokines.120,121 This effect of CGRP is mediated by production of Interleukin-10 (IL-10) and IL-10 independent processes that stimulate the expression of the inducible cAMP early repressor (International Confederation of Energy Regulators (ICER)) and inhibition of NF-ΚB, although in sepsis this effect of CGRP may complicate the situation.121 A central role for intestinal dendritic cells in neuroimmune communication and similar roles for neuropeptides including CGRP in the skin, lung and GI tract has also been proposed.122
The Toll-like receptor 4 (TLR4), a bacterial gram negative receptor, can activate the Vanilloid receptor 1 (transient receptor potential action channel subfamily V member 1, TRPV1) and result in the release of CGRP and its anti-inflammatory effects in the intestine.123
CGRP expressing nerve fibers in the GI tract are involved in pain, GI motility and secretion, defense against irritants, and wound healing of ulceration, presumably acting via TRPV1 receptor.124 The central action of CGRP controls the GI motor function and intestinal motility including the migrating motor complexes.125
CGRP and TRPV1 (and some other neuropeptides and receptors/channels) are also involved in the neural plasticity of almost all parts of GI tract including the liver and pancreas during pathological conditions.126
CGRP release from the mesenteric perivascular nerve fibers increases the induction of pannexin-1-formed channel opening (hemichannels) which results in reduction of pannexin-1 and endothelial Nitric Oxide Synthase (eNOS) expression, and CGRP blockade increases the eNOS expression significantly.127 These channels are important in the regulation of blood brain barrier as well.
There are evidences that CGRP expressing fibers of trigeminal ganglion innervate the pineal gland in several mammalian species.128 Pineal gland is known to regulate hypothalamus, the command center for the control of autonomic and endocrine activities. Although this might be involved in the autonomic responses of pain following activation of the trigeminovascular system.
There is even a role for CGRP in the neuromuscular transmission. CGRP seems to significantly stimulate the calcium (Ca++) channels at the sarcoplasmic reticulum leading to Ca++ release into the cytosol of the skeletal muscle and also stimulate the Ca++ channels at the sarcolemma to a lesser extent.129
CGRP expression increases in injured motor neurons and is believed to activate neuroglial cells such as astrocytes and microglial cells in the CNS which is believed to be responsible for tissue remodeling and repair.52
Several anti-migraine drugs have been developed in the past three decades. Tremendous efforts by brave scientists, clinicians, drug companies, and patients (for clinical trials) in this field has contributed to the significant achievements so far and this effort continues until various treatment options for migraine are found.
Although CGRP has several important roles in human body, increases in its levels in the blood of migraine patients has been linked with the headache. Therefore, inhibiting its activities by means of CGRP-receptor antagonists and/or monoclonal antibodies against CGRP or its receptor has been a focus of more than a decade of research to find another alternative treatment to alleviate the pain of migraine specially on those who are non-respondent to other drugs and also find a more convenient type of medication that patients could take once a month or so and become pain free.
Anti-CGRP treatment strategy is one of the alternative therapies to a number of drug treatment options currently available for the prophylaxis and treatment of headache in migraine. Currently, the first choice treatment options of migraine include the use of triptan [serotonin (5-HT1B/D)] receptor agonist family drugs and NSAIDs. A number of prophylactic drugs such as the Antiepileptic drugs (AEDs), betablockers, and Ca2+ channel blockers are currently being used to treat migraine. These are in addition to some other drugs and non-drug treatment options that are currently available to treat migraine headache. Nevertheless, research in the treatment of migraine is always looking for newer and more convenient, more efficient and more potent drugs or treatment strategies with fewer or no adverse effects.
Although promising, the CGRP-receptor antagonist drugs (the “gepant” family) were discontinued due to their side effects, especially the hepatotoxicity. Several other CGRP receptor antagonists such as MK-3207, BI 44370, BMS-846372 are still in clinical trials, please see77 for review. Search for newer anti-CGRP compounds with sufficient efficacy and less or no adverse effects continued in recent years.
It seems that blocking CGRP or its receptor alleviates the headache in migraine patients. A number of studies so far in phase one and phase 2, using mAbs against CGRP or its receptors have shown a decrease in the number of headache days per month while did not have a significant adverse effect although these studies are still ongoing at the moment. One important fact about CGRP mAbs is their half-life (and their clearance from the body) which is in the range of a few weeks. This is very good and convenient for migraine patients since with one injection or so per month they experience much less headache days per month although the clearance time of the mAbs from the body is also extended equally.
If proven effective with minimal or no significant adverse events after completing the clinical trials, mAbs against CGRP or its receptors will be another revolution like the triptan family drugs in the field of migraine treatment and will increase our abilities and options to treat migraine effectively. Some of the adverse events of mAbs against CGRP such as infections and abdominal pain seen in some patients may correspond to decrease or inhibition of biological activities of CGRP or activation of some other compensatory mechanisms. Therefore, long term use and monitoring of the patients would add more knowledge to our current understanding.
Such mAbs will certainly be beneficial in other painful or other conditions if their pathophysiology is similar.130 CGRP is among the four neuropeptides that were increased in the archived neonatal blood of infants who were later (after couple of years) diagnosed having Autism Spectrum Disorders (ASD) or mental retardation.131
It is not known why some neuropeptides are increased in ASD, but increased blood serotonin levels has been linked to loss of brain serotoninergic terminals via a negative feedback, disrupting the serotonin function leading to a compensatory increase in CGRP level in ASD patients.132,133,134 Although, several genes have been implicated in ASD135 environmental factors including GI abnormalities and immune imbalance might play a role in ASD136 and other psychological health problems.
The role of CGRP increase in ASD children is not very well known but both serotonin and CGRP are involved here as well. Some GI problems including diarrhea and abdominal pain in autistic children136,137,138,139 are due to various causes but the exact pathomechanism of GI problems in ASD children is not completely understood.140 It is however possible that anxiety, sensory over-responsivity and GI problems are interrelated phenomena in children with ASD.141
Several studies using CGRP knockout mice or other related studies have reported about the various roles of CGRP in pathological conditions in animal studies and results are indicative of some protective and some deleterious effects of CGRP in neuroprotection, immune activation or vascular structure and function.142,143,144,145,146,147,148,149,150
However, mAbs against CGRP in migraine treatment research should tell us more about the long term effect of CGRP inhibition.
Interestingly, inhibiting the TRPV1 receptor or interfering with CGRP activity may improve health and increase age longevity as shown in a recent study in mice151 and brought the ideas of “die another day”152 and “a long pain-free life”.153
Can mAbs against CGRP increase our longevity?
This paper has been written without external financial funding. There is no conflicts of interest.
The author’s salary is paid by the University of Central Florida, Orlando, FL, USA.
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