Ticagrelor Therapy for RefrACTORy Migraine Study

Study Overview
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Brief Summary
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This is a prospective, open-label, single-arm pilot study treating 40 subjects to assess the hypothesis that P2Y, G protein-coupled 12 (P2Y12) inhibition with Brilinta/ticagrelor (90 mg by mouth (PO) twice a day) reduces episodic and/or chronic migraine headache symptoms in patients with right to left shunt. Headache frequency while on Brilinta/ticagrelor will be compared with the documented baseline for each subject. If the Brilinta/ticagrelor therapy was effective (> 50% reduction in monthly headache days), the subject could elect to continue therapy for an additional two months (56 days), while continuing to complete daily headache logs.

Detailed Description
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Migraine headaches are poorly understood, and can be severely debilitating. Many types of drugs have been tried in migraine sufferers including anti-depressants, anti-seizure medications, blood pressure medicines and others. The investigators have shown that in a small number of patients, a certain type of blood thinner (Clopidogrel) can reduce or eliminate migraine headaches in patients who also have a hole in the heart wall that allows flow from the right side of the heart to the left. Ticagrelor is a blood thinning drug which works in the same way as the clopidogrel, but is broken down by the body differently and thus allows everyone to use it. The investigators wish to test this medication to see if it works as well, or better than the clopidogrel.

Official Title
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Ticagrelor Therapy for RefrACTORy Migraine Study Pilot (TRACTOR)

Conditions
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Migraine, Headache, Migraine Headache

Intervention / Treatment
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* Drug: Ticagrelor 90 mg twice per day


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: At least one year history of Episodic or Chronic migraine headache symptoms At least 6 headache days per month Subject able to complete online daily headache log Exclusion Criteria: Inability to understand the study or history of non-compliance with medical advice Currently taking a P2Y12 inhibitor Known hypersensitivity to Brilinta/ticagrelor History of stroke/transient ischemic attack (TIA) in the previous 6 months Active bleeding from any site Active peptic ulcer disease or upper gastrointestinal (GI) bleeding within six (6) months Migraine onset after 50 years of age Renal impairment: Creatinine Clearance < 60 cc/min Severe hepatic impairment with total bilirubin > 3.0 mg/dL Thrombocytopenia with platelet count < 100,000 / ul History of intracranial hemorrhage Contraindications to blood thinner therapy or history of major bleeding episode while taking blood thinner therapy Need for chronic oral anti-coagulation therapy (i.e. Atrial Fibrillation) Need for chronic anti-platelet therapy (i.e. drug-eluting (DE) Stent), including daily aspirin use Need for daily nonsteroidal anti-inflammatory drug (NSAID) use Need for daily carbamazepine therapy or other strong CYP3A inhibitors or potent CYP3A inducers Need for simvastatin or lovastatin greater than 40 mg daily Symptomatic bradycardia or syncope Pregnancy or currently breast-feeding, or plan to become pregnant during the study period Planned surgery during the study time-frame Previously implanted patent foramen ovale (PFO), atrial septal defect (ASD), pacemaker, inferior vena cava filter, or left atrial appendage closure device

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 65 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Ticagrelor 90 mg twice per day<br>Interventions include the following: All participants will have a loading dose of Ticagrelor (Brilinta) 180 mg administered in the office at the time of enrollment. Thereafter, for 28 days, Ticagrelor 90 mg tablet will be taken once in the morning and once in the evening, as close to 12 hours apart as possible. Each day, the subject will receive a text message reminder to login to the website, to record her/his headache activity. | Drug: Ticagrelor 90 mg twice per day<br>* Patients will be loaded with 180 mg of Ticagrelor during the enrollment office visit and provided with a 28 day supply of Ticagrelor, 90 mg twice per day. P2Y12 reactivity unit (PRU) testing will be conducted at 7-14 days. If the patient has a positive response, they will have the option of continued access of Ticagrelor 180 mg for another 2 months. Participants will be reminded via text message daily to complete a headache survey on line in order to track their headaches.<br>* Other names: Brilinta;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Total Number of Responders | A participant will be considered to have achieved the primary efficacy endpoint (a Responder) if she/he has >50% reduction in the number of monthly headache days during the month of therapy compared with participant's own baseline. If there is < 50% reduction in the number of migraine days, she/he will be considered a Non-Responder. | 1 month from baseline | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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headache, chronic, migraine, right to left shunt