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The patient used either frovatriptan, sumatriptan injections or eletriptan with successful pain mitigation between 3C8? days a month

The patient used either frovatriptan, sumatriptan injections or eletriptan with successful pain mitigation between 3C8? days a month. by suppression of CGRP. Thus, small and unnoticeable bruises may be aggravated instead in patients with tendency to bruise caused by for instance fish oil supplements. strong class=”kwd-title” Keywords: Migraine, Erenumab, CGRP monoclonal antibody, Fish oil, Ecchymosis, Bleeding, Hemostasis Background Treatment with monoclonal antibodies against calcitonin gene-related peptide (CGRP) is a new generation of mechanism-based preventive antimigraine therapy. CGRP is a vasoactive peptide found naturally in the organism, including the trigeminovascular system. Intravenous infusion of CGRP causes migraine attacks [1]. Erenumab, a CGRP receptor antibody, is effective against chronic migraine and has relatively few side effects [2] compared to the conventional antimigraine drugs. The most common adverse events include constipation, muscle spasms itching, injection site pain, nasopharyngitis, and upper respiratory tract infections [3]. Here, we present the first case of increased tendency of ecchymosis in a chronic migraine patient treated with a monoclonal CGRP receptor antibody, erenumab. Case presentation In November 2019, a 41-year old Caucasian female with chronic migraine, was started on preventive antimigraine treatment with 140?mg subcutaneous erenumab every 4?weeks. At the time of treatment start the patient had 16 headache days a month of which 12 was migraine days. The patient used either frovatriptan, sumatriptan injections or eletriptan with successful pain mitigation between 3C8?days NSC 95397 a month. She suffered from migraine without aura since childhood but was otherwise healthy, except rare occasional small unnoticeable bruises during the past 4C5?years without relationship to traumas. She had no family history of hemostasis disorders. She had previously been treated with various antimigraine prophylactics, including antihypertensive drugs (candesartan, lisinopril, metoprolol), anticonvulsants (topiramate, lamotrigine) as well as botulinum toxin type A, flunarizine, riboflavin, and magnesium without effective reduction in migraine days. At the 3-month follow-up there was a significant reduction in headache (50%) and migraine (50%) days at month 3. The patient NSC 95397 reported mild constipation as well as an increased tendency to bruise without the patient having any recollection of any traumas. The spontaneous bruising occurred primarily on her lower legs and thighs, but also on her upper arms and had no spatial relation to the injections site of the erenumab as the patient reported she always injected in her stomach. The patient reported no bruising in the injection site. Moreover, the patient had no fever or general aches. Blood samples showed normal platelet count (198??109/L) and aggregation, thromboelastography, APTT (29 secs) and INR (1.0). The patient denied any trauma, tendency to bleed from mucous membranes, affected menstrual cycle, or use of aspirin, NSAIDs or other blood thinners. We advised the patient to pause erenumab treatment, but she wanted to continue because of the excellent effect on her headache and migraine. Thus, she continued with erenumab treatment, but was lowered to a dose of 70?mg as part of standard treatment procedure at the Danish Headache Center. After another 5?weeks, the patient contacted the headache center because of extreme aggravation of the bruising tendency as she woke up with a 16?cm??8?cm NSC 95397 ecchymosis on each thigh (Fig.?1). Open in a separate window Fig. 1 Ecchymoses on the patients upper left thigh with A patients hand for scale, and B with a ruler Again, she was thoroughly interviewed and denied trauma, local pain, itching etc. Review of her use of medication, revealed a daily use of fish oil supplements for many years which the patient did not regard as medication. She reassured, that she had never experienced Rabbit Polyclonal to Claudin 2 similar tendency to bruise. As the fish oil was suspected of having an interaction with erenumab causing hemostatic disturbances, the patient was advised to NSC 95397 immediately stop the use of fish oil supplement, as she was not willing to discontinue erenumab. The patient was discussed with a hematologist who advised a referral to the dermatologists for skin biopsy if no improvement was seen after cessation of the NSC 95397 fish oil. However, the patient had no.