Migraine

Microstructural changes of basal ganglia in migraine with restless legs syndrome: findings from a neuroimaging study

In this study, it is planned to investigate the integrity of the basal ganglia structures in migraineurs with restless legs syndrome (RLS) to explore this relationship. In this study, 58 patients who were diagnosed migraine and 51 healthy controls (HCs) were included. Patients diagnosed with migraine were divided into two groups: Group I (migraine without RLS) and Group II (migraine with RLS). The integrity of basal ganglia was evaluated with region of interest diffusion tensor imaging method which allows us to assess microstructural changes of the tissue. The mean age of the patients was 35.98 ± 7.92 years, and the mean age of the HCs was 33.84 ± 11.06. 84.5% (n = 49) of the patients were female and 15.5% (n = 9) were male. 82.4% (n = 42) of the HCs were female, 17.6% (n = 9) were male. The number of  the patients without RLS was 41 (Group I), and the number of the patients with RLS was 17 (Group II). When basal ganglia structures were compared between groups of the patients with and without RLS, the fractional anisotropy (FA) value of the left putamen differed (Group I: 0.30 ± 0.06 vs. Group II: 0.25 ± 0.7, p = 0.01). The significant relationship was found attack frequency and presence of RLS with left putamen FA values according to multiple regression analysis. It was determined in this study that the changes in the microstructure of putamen, one of the basal ganglia structures, may be associated with the presence of RLS in migraineurs.

Risk of Stroke in Migrainous Women, a Hidden Association: A Systematic Review

Migraine-a term used to describe a unilateral throbbing headache has shown growing evidence of being linked to different types of strokes-particularly ischemic and hemorrhagic. This study aims to identify and summarize the relationship between migraine and the incidents of stroke in women of child-bearing age. This systematic review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search was done using PubMed, the British Medical Journal (BMJ), Cochrane library, Google Scholar, and ScienceDirect databases up until March 15, 2022. Studies were chosen based on the listed eligibility criteria: English-language, observational studies, systematic reviews, articles, and meta-analyses, which included stroke patients and migraine patients, and the possible link between these two conditions. In addition, quality assessment was done using assessment tools like Scale for the Assessment of Narrative Review Articles (SANRA), Assessment of multiple systematic reviews (AMSTAR), and Newcastle-Ottawa Scale (NOS) criteria. The initial search generated 245 studies. Fourteen studies were included in the final selection - one case-control, four cohort studies, seven systematic reviews with meta-analyses, and two narrative reviews. Strokes-particularly ischemic-were found to be linked to the incidents of migraine in women. The risks of a stroke increased if a woman was a smoker, under 45, and uses oral contraceptives regularly. In addition, the use of nonsteroidal anti-inflammatory drugs (NSAIDs), genetic predisposition, and metabolic dysfunction was linked to increased incidents of hemorrhagic strokes-which proved to be rarer but more fatal due to their serious underlying pathophysiologies.

Efficacy of contralateral acupuncture in women with migraine without aura: protocol for a randomised controlled trial

INTRODUCTION

Migraine is a common neurological disorder with a higher prevalence occurring in women. Migraine without aura (MwoA) is the most common type of migraine. In recent years, the safety and effectiveness of acupuncture for migraines have been internationally recognised. Contralateral acupuncture (CAT) (Jùcì) is an ancient classic acupuncture technique from Huang Di Nei Jing that refers to the acupoints on the right side (healthy side) selected for diseases on the left (affected side) and vice versa. Some studies have shown that efficacy of CAT on the painful disorder is even better than ipsilateral acupuncture (IAT), but there remains a lack of high-quality evidence to support it.

METHODS AND ANALYSIS

This is a single-centre, randomised and sham-controlled clinical trial in China with three parallel groups that aim to evaluate the efficacy of CAT in women with unilateral MwoA. 243 participants will be randomly divided into the experimental group (CAT group), control group 1 (IAT group) and control group 2 (sham acupuncture group) (1:1:1 allocation ratio). Each group will be given 30-minute treatment sessions, once every other day, approximately three times per week, for a total of 24 treatments and follow-up visits two times. The primary outcome is the changes in days of migraine attacks. The secondary outcomes are frequency of migraine attacks, intensity of migraine, migraine duration, the dose of intake of acute medication, the Migraine-Specific Quality of Life Questionnaire, the Migraine Disability Assessment Score, the Headache Impact Test-6 and the Pittsburgh Sleep Quality Index. The data will be collected at the baseline time (week 0), end of treatment (week 4-8) and the follow-up time (week 12-16). Adverse events will be collected and recorded during each treatment.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Ethics Committee of the Sports Trauma Specialist Hospital of Yunnan Province (2021-01). All participants will provide written informed consent before randomisation. The results of this study will be published in a peer-reviewed journal and presented at conferences.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registration Center (ChiCTR2100051479).

Advances in pharmacotherapy for the prophylactic treatment of resistant and refractory migraine

INTRODUCTION

Refractory migraine is associated with low quality of life and great socioeconomic burden. Despite high need for effective, tolerable preventive therapies, there has been little research on potential therapeutic options. Monoclonal antibodies (mAbs) against Calcitonin Gene-Related Peptide (CGRP) are the first preventive therapeutic approach for migraine based on the underlying pathophysiology.

AREAS COVERED

Following a brief introduction into the term 'refractory migraine,' the authors reviewavailable treatment options, focusing on current phase III trials of substances acting on the CGRP pathway.

EXPERT OPINION

No uniform definition for refractory migraine is available. The vast majority of proposals recommend treatment failure of 2-4 drug classes as a key diagnostic criterion. Phase III studies on CGRP-(receptor) mAbs demonstrated excellent efficacy and tolerability in patients with chronic and episodic migraine including subjects with multiple unsuccessful conventional therapy attempts. However, more comparator trials showing superiority of mAbs versus oral preventatives, such as the HER-MEs study are needed. In summary, with the CGRP antibodies, a group of drugs has entered the market which will most likely not only significantly improve the quality of life of many individual migraine patients but could also reduce indirect health-care costs associated with migraine by reducing recurrent medical consultations.

Migraine in the workplace

Migraine is prevalent, disabling, and peaks during people's peak productive years. The impact of migraine on people's professional lives, work productivity, and interpersonal relationships at work eventually affects everyone, has a significant detrimental effect on people with migraine, and a huge cost in terms of lost productivity. People with migraine want to work, so they do their best to work despite the varied migraine related and associated symptoms. Most of migraine-related productivity loss (89%) is due to presenteeism. People are less than half effective during a migraine attack due to the pain, migraine symptoms, attack unpredictability, migraine comorbidities, emotional impact, under-diagnosis and under-management, and the stigma. Migraine-related productivity loss may negatively affect people's career choice, job status and/or security, financial status, work relationships, mood, and confidence. Migraine is estimated to represent 16% of total US workforce presenteeism. Thankfully, there are ways to help support people with migraine in the workplace and increase their productivity such as: workplace migraine education programs, workplace migraine education and management programs, migraine-friendly work environment, migraine treatment optimization and advocacy. The example of the successful workplace migraine education and management program developed and run in collaboration between Fujitsu, the Japanase Headache Society, and the International Headache Society Global Patient Advocacy Coalition is discussed.

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Migraine-related productivity loss is costly to people with migraine, to employers, and to everyone in one way or another.

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Workplace migraine education and/or management programs and migraine-friendly environment help people with migraine at work.

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Neurologists can help support their patients in the workplace and get involved in advocacy in many ways.

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)

BACKGROUND: Patients with migraine, particularly with multiple prior preventive treatment failures, often have high rates of acute headache medication use and are at risk for overuse (acute or symptomatic headache medication use between 10 and 15 days per month [depending on the medication] for > 3 months). Furthermore, these patients have greater health care resource utilization (HCRU). OBJECTIVE: To examine acute headache medication use and HCRU with galcanezumab compared with placebo in a population with multiple prior migraine preventive treatment failures. METHODS: In the 3-month double-blind phase, patients with episodic or chronic migraine and treatment failures to 2 to 4 standard-of-care migraine preventive categories (lack of effectiveness or safety/tolerability) received galcanezumab 120 mg/month (following a 240-mg loading dose) or placebo; an optional 3 month open-label phase followed. Acute headache medication use (monthly days with acute headache medication utilization) was self-reported daily. The change from baseline in monthly days with acute headache medication used a mixed-model repeated measures analysis. HCRU was reported at baseline (for the previous 6 months) and at monthly visits. Migraine-related HCRU rates were evaluated in the total population per 100 patient-years. RESULTS: Of the 462 patients (galcanezumab n=232, placebo n=230), baseline mean days/month of acute headache medication was 12.3; 44.8% had acute headache medication overuse. Across months 1-3, least squares (LS) mean reductions in acute headache medication use were greater for the galcanezumab group (4.2) compared with placebo (0.9); the LS mean difference was 3.4 (95% CI = 2.7-4.1; P < 0.0001). Greater reductions in the galcanezumab group were observed as early as month 1; statistical separation continued at months 2 and 3 (all P < 0.0001). During the open-label phase, reductions from baseline ranged from 4.7 to 5.3 days and were similar in patients who transitioned from placebo to patients continuing galcanezumab. Reductions from baseline of migraine-specific health care visits (double-blind phase) were numerically greater with galcanezumab than placebo (215.5 vs 155.3). Patients switching to galcanezumab had reductions (212.9 days) similar to patients continuing galcanezumab (222.6 days). Migraine-specific emergency department visits decreased by two-thirds at month 3 in the galcanezumab group compared with nearly no reduction in the placebo group that experienced a similar reduction during the open-label phase. For both groups, migraine-specific hospitalizations were less than 2 per 100 patient-years. CONCLUSIONS: These results demonstrate that galcanezumab has the potential to reduce acute headache medication use and overuse and HCRU in patients with prior migraine preventive treatment failures. DISCLOSURES: Data were presented in part as a poster presentation at the 14th European Headache Congress (European Headache Federation), Virtual Meeting, July 3-5, 2020. Dr Ambrosini is on the advisory board for Eli Lilly and Company and received honorarium from Teva, Novartis, and Eli Lilly and Company. Dr Estemalik is on the advisory boards for Eli Lilly and Company, Lundbeck, and Allergan and the speakers' bureau for Teva, Lundbeck, Eli Lilly and Company, Allergan, and Biohaven. He received consulting fees from Eli Lilly and Company, Teva, Lundbeck, and Allergan and support for attending meetings and/or travel from Eli Lilly and Company, Allergan, Biohaven, Teva, and Lundbeck. Dr Pascual received research support from Instituto de Salud Carlos III, Ministry of Economy, Spain. He was also on advisory boards for Allergan, Amgen-Novartis, Eli Lilly and Company, and Stendhal and received consulting fees or honoraria from Allegan, Eli Lilly and Company, Novartis-Amgen, and Teva. Dr Rettiganti is an employee of Eli Lilly and Company and/or one of its subsidiaries, Indianapolis, IN. She is also a minor stock and restricted stockholder of Eli Lilly and Company. Mr. Stroud and Ms. Day are employees of Eli Lilly and Company and/or one of its subsidiaries, Indianapolis, IN. Dr Ford is an employee of and holds stock of Eli Lilly and Company and/or one of its subsidiaries, Indianapolis, IN. She also received support for attending meetings and/or travel from Eli Lilly and Company.

Telemedicine application to headache: a critical review

BACKGROUND

Migraine affects more than a billion people all over the world and requires critical employment of healthcare resources. Telemedicine could be a reasonable tool to manage people suffering from headaches, and it received a big push from the COVID-19 pandemic.

OBJECTIVE

This review aims to propose a practical approach for the virtual management of these patients.

METHODS

To do this, we conducted a literature search, including 32 articles relevant to the topic treated in this review.

RESULTS

The most challenging step in telemedicine applied to practical neurology remains the clinical assessment, but through a careful headache history and a recently proposed entirely virtual neurological assessment, this hitch can be easily overcome. Electronic diary compilations and virtual administration of disability-measuring scales, conversely, are the key features of effective long-term follow-up although we do not have apps that met the criteria of scientific reliability. Furthermore, tele-rehabilitation seems to be effective and has demonstrated to be a solution to alternatively treat chronic patients at home, and can be considered part of the remote management of headache patients. Moreover, virtual management of headaches finds an application in specific communities of patients, as pediatric patients and for rural communities of low- and middle-income countries suffer from health disparities, with inadequate resources and knowledge gaps.

CONCLUSION

Telemedicine could be promising for patients with no regular or convenient access to headache specialists and seems to be a priority in managing migraine patients to avoid non-urgent hospitalizations.

Burden of disease and lifestyle habits in adolescents and young adults prone to frequent episodic migraine: A secondary comparative analysis

The objective of this study was to assess the burden of disease and prevalence of lifestyle factors for adolescents and young adults with frequent episodic migraine. We conducted a secondary comparative analysis of data collected during two previous studies. Inclusion criteria for this analysis were age 15-35 years, 15 to 44 migraine episodes within 12 weeks, and completeness of Migraine Disability Assessment and lifestyle questionnaire data. Datasets of 37 adults (median age [interquartile range]: 25 [6]) and 27 adolescents (median age [interquartile range]: 15 [1]) were analyzed. 81% (n = 30) of adults reported severe disability (16% [n = 3] of adolescents; p < 0.001). Headache frequency (24 vs. 17 days; p = 0.005) and prevalence of regular analgesic use (60% [n = 22] vs. 18% [n = 5]; p = 0.002) were significantly higher in adults. In adults, sleep duration on weekdays was significantly lower (8.5 vs. 10 h; p < 0.001). Any consumption of caffeine tended to be higher in adolescents and alcohol consumption tended to be higher in adults (p > 0.05). This study underlines the importance of educating adolescents and young adults with migraine about lifestyle habits that are likely to interfere with the condition.

Cold intervention for relieving migraine symptoms: A systematic review and meta-analysis

AIMS

To evaluate the effectiveness of the cold intervention on relieving migraine symptoms among adult patients with migraine.

DESIGNS

A systematic review and meta-analysis of randomised controlled trials (RCT) and non-RCT studies were performed.

DATA SOURCES

We searched five electronic databases including Cochrane Library and Cochrane CENTRAL, Embase, MEDLINE, Scopus and CINAHL from the date of inception to March 2021.

REVIEW METHODS

Research was eligible for the systematic review if they included adult patients with migraine, using cold regimen as intervention, and outcomes measuring the symptom alleviation of migraine. Two researchers independently conducted the searching process and data extraction. The certainty of evidence was assessed using GRADE approach to the main outcomes was used. The PRISMA checklist was used to assure the quality and transparency of report.

RESULTS

Six studies (4 RCTs and 2 non-RCTs) met the inclusion criteria. The cold interventions on migraine alleviation include a cold-gel headband, cold-gel cap, intraoral cooling, skin temperature biofeedback and cold wrap accompanied by massage. Compared to non-cold regimens, the cold interventions had a short-term effect on reducing migraine pain rated on the Visual Analog Scale (VAS) score at 30 min after intervention (Std. mean difference [SMD] -3.21; 95% CI -5.94, -0.48). Compared to the non-cold regimens, the cold interventions had marginal long-term effects on relieving migraine pain VAS score (SMD -0.44; 95% CI -0.91, 0.03) and nausea (SMD -0.56; 95% CI -1.17, 0.04) (24 h after intervention). The GRADE indicated that the certainty of evidence was rated from very low to moderate. Insufficient results on the outcomes of nausea and vomiting were discovered for the meta-analysis.

CONCLUSIONS

Cold intervention is an effective regimen to reduce migraine pain instantly. The long-term effect of cold interventions on migraine is not demonstrated. The effects of cold interventions on nausea and vomiting need more studies to verify.

Why are CGRP monoclonal antibodies not yet the first line treatment in migraine prevention?

Migraine is a prevalent disorder and a cause of high disability, influenced by modifiable and non-modifiable risk factors. Comorbid and psychiatric illnesses are prevalent in migraine patients and should be considered when choosing preventive drugs. There have been unforeseen problems with the use of preventive treatment of migraine with oral drugs, mainly due to side-effects that cannot be tolerated and lack of efficacy, leading to high discontinuation rates. Anti-CGRP monoclonal antibodies (mAbs) have shown better tolerance profiles, based on the low dropout rates in clinical trials due to adverse events. First-line therapy is a term most expressed in some medical specialties that adopt standardized protocol treatments and may not be suitable for treating migraine. Regarding efficacy, mAbs don't seem to perform much better than the current prophylactic oral drugs in reduction of monthly migraine days compared to placebo. Monoclonal antibodies against CGRP pathway have been prescribed recently, which raises some concern about their safety in the long term. Only side effects observation will confirm whether CGRP blockade causes susceptibility to severe side-effects, at least to specific subpopulations. CGRP may play a role in regulating uteroplacental blood flow and myometrial and uterine relaxation, as well as blood pressure control, raising the suspicion that its blockade could cause complications during pregnancy. Recent guidelines retain the recommendation of starting preventive treatment of migraine with oral drugs. Both the fact that it is new and costs are the reason why guidelines recommend the prescription of mAbs only after failure of at least two oral drugs.

OnabotulinumtoxinA Reduces Health Resource Utilization in Chronic Migraine: PREDICT Study

BACKGROUND

PREDICT was a Canadian, multicenter, prospective, observational study in adults naïve to onabotulinumtoxinA treatment for chronic migraine (CM). We descriptively assess health resource utilization, work productivity, and acute medication use.

METHODS

OnabotulinumtoxinA (155-195 U) was administered every 12 weeks over 2 years (≤7 treatment cycles). Participants completed a 4-item health resource utilization questionnaire and 6-item Work Productivity and Activity Impairment Questionnaire: Specific Health Problem V2.0. Acute medication use was recorded in daily headache diaries. Treatment-emergent adverse events were recorded throughout the study.

RESULTS

A total of 197 participants were enrolled, and 184 received ≥1 treatment with onabotulinumtoxinA and were included in the analysis. Between baseline and the final visit, there were decreases in the percentage of participants who reported headache-related healthcare professional visit(s) (96.2% to 76.8%) and those who received headache-related diagnostic testing (37.5% to 9.9%). Reductions from baseline were also observed in the mean number of headache-related visits to an emergency room/urgent care clinic (2.5 to 1.4) and median headache-related hospital admissions (4.0 to 1.0). OnabotulinumtoxinA improved work productivity and reduced the mean (standard deviation) number of hours missed from work over a 7-day period (6.1 [9.7] to 3.0 [6.8]). Mean (standard deviation) acute medication use decreased from baseline (15.2 [7.6] to 9.1 [6.5] days). No new safety signals were identified.

CONCLUSIONS

Real-world evidence from PREDICT demonstrates that onabotulinumtoxinA treatment for CM in the Canadian population reduces health resource utilization and acute medication use and improves workplace productivity, supporting the long-term benefits of using onabotulinumtoxinA for CM.

Practical Insights on the Identification and Management of Patients with Chronic Migraine

Chronic migraine (CM) is one of the most disabling diseases, and it is commonly misdiagnosed and mistreated. Despite the importance of a timely and accurate diagnosis for the effective management of CM, recent surveys have shown that only 20–25% of individuals with CM receive a correct diagnosis. The obvious consequences of misdiagnosed CM are prolongation of symptoms and their associated effects on disability and health-related quality of life. Additionally, mistreatment of CM can lead to acute medication overuse headache with escalation of headache and end organ damage. Ideally, a diagnosis of CM should be made in the primary care setting, based on a thorough medical history including detailed descriptions of headaches occurring earlier in life as well as current headaches, and the range of headaches (not just the worst headaches). In our experience, it is often equally informative to ask the patient about the number of headache-free days (HFDs) and no accompanying symptoms (i.e., crystal-clear days) to quantify headache days and accurately estimate headache frequency/impact. Headache frequency is important, as this count is one key means of diagnosing CM, which requires ≥ 15 headache days/month, noting that these do not need to be migraine days. A headache day is defined as more than 4 h a day of headache. Comorbidities are common in CM and may affect the treatment choice and increase disability. Every CM patient should be offered a preventive migraine treatment. In this commentary, we provide practical insights and tips for diagnosing CM and cover issues of medication overuse, patient communication, diagnostic testing, and when to make a referral. Our key message to physicians for a patient who comes to the clinic with frequent disabling headaches having features of migraine is to assume CM until proven otherwise.

High-frequency repetitive transcranial magnetic stimulation at dorsolateral prefrontal cortex for migraine prevention: A systematic review and meta-analysis

OBJECTIVE

To evaluate the efficacy of high-frequency repetitive transcranial magnetic stimulation over dorsolateral prefrontal cortex as a migraine prevention by conducting a systematic review and meta-analysis.

BACKGROUND

The efficacy of high-frequency repetitive transcranial magnetic stimulation over dorsolateral prefrontal cortex as preventive migraine treatment remains debatable.

METHODS

PubMed, Scopus, CINAHL, CENTRAL, and BioMed Central databases were searched from their inception until December 2020. Randomised trials comparing high-frequency repetitive transcranial magnetic stimulation over dorsolateral prefrontal cortex with sham for migraine prevention were included. The risk of bias was assessed using the Cochrane guidelines. Headache days, pain intensity, acute medication intake, and disability were extracted as study outcomes and the mean difference with a random-effects model was used to determine the effect size.

RESULTS

Meta-analysis revealed that high-frequency repetitive transcranial magnetic stimulation over dorsolateral prefrontal cortex significantly reduced acute medication intake (Mean Difference = 9.78, p = 0.02, 95%CI: 1.60, 17.96, p = 0.02) and functional disability (Mean Difference = 8.00, p < 0.05, 95%CI: 4.21, 11.79). However, no differences were found in headache days and pain intensity reduction, although there was a slight trend favouring high-frequency repetitive transcranial magnetic stimulation.

CONCLUSION

High-frequency repetitive transcranial magnetic stimulation over dorsolateral prefrontal cortex may be effective in reducing acute medication intake and disability. However, more studies are needed to strengthen this preliminary evidence.

An Exponential Curve Relationship Between Serum Urate and Migraine: A Cross-Section Study From NHANES

Background

Migraine is a common neurological disease and an important cause of disability worldwide. Serum urate is the end product of purine metabolism in Homo sapiens and other hominoids. Previous studies about the serum urate level in migraine were contradictory. Hence, we present a cross-section study to clarify the association between serum urate and migraine and explore the dose effect of serum urate on migraine.

Materials and Methods

The data for this cross-section study were acquired from the National Health and Nutrition Examination Survey (NHANES). A diagnosis of migraine was made through patient the self-reported and prescription medication. For data analysis, the weighted linear regression model, weighted chi-square test, logistic regression models, smooth curve fittings, and the two-piecewise linear regression model were utilized for data analysis. All data analysis was conducted on Empower software.

Results

Totally, 18,637 participants were enrolled in this study, of which 208 were migraineurs. The rest were set as control. There existed a statistically significant difference in mean age (p = 0.0389), gender (p< 0.0001), race (p< 0.0001), data release cycle (p = 0.048), drug usage, blood albumin (p< 0.0001), blood total protein (p< 0.0001), hemoglobin (p< 0.0001), serum iron (p< 0.0001), and serum urate (p< 0.0001) between the two groups. According to logistic regression models, there existed no consistent linear relationship between serum urate and migraine before (model 1: odd ratio (OR) = 0.83, p = 0.0004) or after adjusting for confounders (model 2: OR = 0.96, p = 0.5198; model 3: OR = 0.84, p = 0.0184). However, smooth curve fittings found an exponential curve relationship between serum urate and migraine. Furthermore, when serum urate was more than 7.8 mg/dl, higher serum urate was correlated with higher migraine occurrence (model 1: OR = 1.54, p = 0.0022; model 2: OR = 1.51, p = 0.0050; model 3: OR = 1.77, p = 0.0348). Besides, 8 out of the 208 migraineurs had a serum urate higher than 7.8 mg/dl.

Conclusions

In conclusion, there existed an exponential curve relationship between serum urate and migraine, with an infliction point of 7.8 mg/dl. When serum urate was more than 7.8 mg/dl, increased serum urate was correlated with higher migraine occurrence.

Integrative, Interventional, and Non-invasive Approaches for the Treatment for Migraine During Pregnancy

PURPOSE OF REVIEW

While most women with migraine improve during pregnancy, a subset may remain unchanged or even become more severe. Given the limited evidence for the use of prescription medications during pregnancy, many look to other treatment modalities. We seek to review complementary and integrative medicine, procedural interventions, and neurostimulation to empower women with safe and effective treatment options during pregnancy.

RECENT FINDINGS

Migraine treatment during pregnancy remains controversial. While evidence is limited, prospective and retrospective reviews, as well as clinical experience support the use of nutraceuticals, procedural interventions, and neurostimulation during pregnancy when the appropriate risks and benefits are weighed. Empowering patients with information on complementary and integrative medicine, as well as non-systemic and interventional treatments, may help to reduce anxiety and headache burden during pregnancy. Various nutraceuticals have shown promise for the preventive management of migraine. Non-systemic interventions such as trigger point injections and peripheral and sphenopalatine nerve blocks offer effective treatment options with minimal side-effects. Options for neurostimulation have expanded in recent years and may offer safe and effective non-pharmacologic options for the management of migraine. It is imperative that providers do not minimize migraine during pregnancy and become aware of the treatment modalities available to help guide women through this experience.

Dural Immune Cells, CGRP, and Migraine

Migraine is the most common neurological disorder in the world, affecting 12% of the population. Migraine involves the central nervous system, trigeminal nerves and meninges. Recent advances have shown that targeting calcitonin gene-related peptide (CGRP) through either antibodies or small molecule receptor antagonists is effective at reducing episodic and chronic migraine episodes, but these therapeutics are not effective in all patients. This suggests that migraine does not have a singular molecular cause but is likely due to dysregulated physiology of multiple mechanisms. An often-overlooked part of migraine is the potential involvement of the immune system. Clinical studies have shown that migraine patients may have dysregulation in their immune system, with abnormal plasma cytokine levels either during the attack or at baseline. In addition, those who are immunocompromised appear to be at a higher risk of migraine-like disorders. A recent study showed that migraine caused changes to transcription of immune genes in the blood, even following treatment with sumatriptan. The dura mater is densely packed with macrophages, mast and dendritic cells, and they have been found to associate with meningeal blood vessels and trigeminal afferent endings. Recent work in mice shows activation and morphological changes of these cells in rodents following the migraine trigger cortical spreading depression. Importantly, each of these immune cell types can respond directly to CGRP. Since immune cells make up a large portion of the dura, have functional responses to CGRP, and interact with trigeminal afferents, CGRP actions on the dural immune system are likely to play key roles in migraine.

Real-time ultrasound-guided stellate ganglion block for migraine: an observational study

Objective

To observe whether ultrasound-guided stellate ganglion block (SGB) can effectively relieve migraine pain and improve the quality of migraine patients’ life.

Methods

81 patients with migraines were enrolled in this study. The patients received SGB with 6 ml of 0.15% ropivacaine once every week for four times. Migraine was assessed with the Migraine Disability Assessment Scale (MIDAS) at baseline and three-months follow-up (Tm). The numerical rating scale (NRS) score at baseline, one day after treatment (Td) and Tm, the frequency of analgesic use in 3 months and the side effects were also recorded at the same time.

Results

The NRS score of migraine subjects decreased significantly from 7.0 (2.0) to 3.0 (1.0) at Td and 2.0 (2.0) at Tm (vs baseline, P < 0.01). The MIDAS total scores were 14.0 (10.5) at baseline and 7.0 (4.5) at Tm (P < 0.001). During the three months, the frequency of analgesic consumption was decreased from 6.2 ± 2.8 to 1.9 ± 1.8. There were no serious side effects.

Conclusions

This study confirmed that ultrasound-guided SGB is an effective method to treat migraines. This technique can reduce pain and disability and then improve the quality of life of patients with migraines.

Headache in the Workplace: Analysis of Factors Influencing Headaches in Terms of Productivity and Health

Headache is a very common condition that can have a significant impact on work. This study aimed to assess the prevalence of headaches and their impact on a sample of 1076 workers from 18 small companies operating in different sectors. The workers who volunteered to participate were asked to fill in the Headache Impact Test-6 (HIT-6) and answer questions designed to assess stressful and traumatic factors potentially associated with headaches. The volunteers subsequently underwent a medical examination and tests for diagnosing metabolic syndrome. Out of the 1044 workers who completed the questionnaire (participation rate = 97%), 509 (48.8%) reported suffering from headaches. In a multivariate logistic regression model, female gender, recent bereavement, intrusive leadership, and sleep problems were significantly associated with headaches. In univariate logistic regression models, headache intensity was associated with an increased risk of anxiety (OR 1.10; CI95% 1.09; 1.12) and depression (OR 1.09; CI95% 1.08; 1.11). Headache impact was also associated with the risk of metabolic syndrome (OR 1.02; CI95% 1.00, 1.04), obesity (OR 1.02, CI95% 1.01; 1.03), and reduced HDL cholesterol (OR 1.03; CI95% 1.01; 1.04). The impact of headache calls for intervention in the workplace not only to promote a prompt diagnosis of the different forms of headaches but also to improve work organization, leadership style, and the quality of sleep.

Effectiveness of yoga therapy for migraine: A meta-analysis of randomized controlled studies

INTRODUCTION

The efficacy of yoga therapy for migraine remains controversial. We conduct this meta-analysis to explore the influence of yoga therapy on the treatment efficacy of migraine.

METHODS

We have searched PubMed, EMbase, Web of science, EBSCO and Cochrane library databases through February 2021, and included randomized controlled trials (RCTs) assessing the efficacy of yoga therapy for migraine attack.

RESULTS

Five RCTs involving 356 patients were included in the meta-analysis. Overall, compared with control group for migraine, yoga therapy was associated with substantially reduced headache frequency headache frequency (SMD = -1.43; 95% CI = -2.23 to -0.64; P = 0.0004) and HIT-6 score (SMD = -2.19; 95% CI = -4.09 to -0.28; P = 0.02), but revealed no obvious influence on pain intensity (SMD = -1.37; 95% CI = -2.76 to 0.01; P = 0.05) or McGill Pain Questionnaire (SMD = -2.09; 95% CI = -6.39 to 2.22; P = 0.34).

CONCLUSIONS

Yoga therapy may benefit to reduce the headache frequency of migraine patients.

Clinical Evidence of Cannabinoids in Migraine: A Narrative Review

The endocannabinoid system (ECS) influences many biological functions, and hence, its pharmacological modulation may be useful for several disorders, such as migraine. Preclinical studies have demonstrated that the ECS is involved in the modulation of trigeminal excitability. Additionally, clinical data have suggested that an endocannabinoid deficiency is associated with migraine. Given these data, phytocannabinoids, as well as synthetic cannabinoids, have been tried as migraine treatments. In this narrative review, the current clinical evidence of potential ECS involvement in migraine pathogenesis is summarized. Furthermore, studies exploring the clinical effects of phytocannabinoids and synthetic cannabinoids on migraine patients are reviewed.

Review on Headache Related to Dietary Supplements

PURPOSE OF REVIEW

The lifetime prevalence of headaches is 96%. Approximately 11% of the adult population worldwide has a migraine headache. Migraine is a complex disorder that is more than a simple headache. So far, many underlying mechanisms, i.e. inflammatory, vascular, neurogenic have been hypothesized. In recent years evidences proposed that an energy deficit due to changes in mitochondrial function contributes to migraine pathophysiology as an upstream disorder. Recent insights suggested that the coexistence of sensory-stimuli surplus and energy-reserve shortage activate the trigeminovascular system. Some nutrients are considered as essential elements in mitochondrial bioenergetics and some others are known as natural immuno-modulatory components. Also, evidence showed their beneficial effect in headache prophylaxis and treatment. In present study, we aimed to review the available data in this field.

RECENT FINDINGS

Vitamin B group, magnesium, and Coenzyme Q10 (CoQ10) are well-known for their function in mitochondrial energy metabolism. On the other hand, studies support their beneficial role in controlling migraine headache symptoms. For instance, daily intake of 400-milligram riboflavin for 3 months resulted in more than 50% reduction in migraine attacks in more than half of the consumers. According to recent evidence, vitamin D and Omega-3 which are considered as famous immune-modulatory compounds are also reported to be effective in migraine prophylaxis. For example, every 22% reduction in migraine headache occurrence was reported for every 5 ng/ml rise in serum vitamin D. Supplementation with vitamin B group, CoQ10, magnesium, vitamin D and Omega-3 could be considered as an effective, less costly strategy in headache/migraine prophylaxis.

The Bidirectional Link Between Sleep Disturbances and Traumatic Brain Injury Symptoms: A Role for Glymphatic Dysfunction?

Mild traumatic brain injury (mTBI), often referred to as concussion, is a major cause of morbidity and mortality worldwide. Sleep disturbances are common after mTBI. Moreover, subjects who develop subjective sleep complaints after mTBI also report more severe somatic, mental health, and cognitive impairment and take longer to recover from mTBI sequelae. Despite many previous studies addressing the role of sleep in post-mTBI morbidity, the mechanisms linking sleep to recovery after mTBI remain poorly understood. The glymphatic system is a brainwide network that supports fluid movement through the cerebral parenchyma and the clearance of interstitial solutes and wastes from the brain. Notably, the glymphatic system is active primarily during sleep. Clearance of cellular byproducts related to somatic, mental health, and neurodegenerative processes (e.g., amyloid-β and tau, among others) depends in part on intact glymphatic function, which becomes impaired after mTBI. In this viewpoint, we review the current knowledge regarding the association between sleep disturbances and post-mTBI symptoms. We also discuss the role of glymphatic dysfunction as a potential link between mTBI, sleep disruption, and posttraumatic morbidity. We outline a model where glymphatic dysfunction and sleep disruption caused by mTBI may have an additive effect on waste clearance, leading to cerebral dysfunction and impaired recovery. Finally, we review the novel techniques being developed to examine glymphatic function in humans and explore potential interventions to alter glymphatic exchange that may offer a novel therapeutic approach to those experiencing poor sleep and prolonged symptoms after mTBI.

Behavioral Management of Episodic Migraine: Maintaining a Healthy Consistent Lifestyle

PURPOSE OF REVIEW

To describe the most recent findings related to lifestyle behaviors and migraine.

RECENT FINDINGS

An individualized conceptualization of how lifestyle factors impact migraine activity has increased our understanding of the role of behavioral interventions for episodic migraine. Healthy diets of several types have been associated with migraine attack reduction, whereas disruptions in diet like skipping meals are associated with migraine attack onset. Both aerobic activity and lower intensity yoga interventions show promise for migraine prevention. Sleep disruption has been associated with migraine day and may have a bi-directional relationship. Both increases and decreases in stress have been associated with migraine activity. Evidence is converging around the principle that highly unusual disruptions in daily routine are particularly associated with migraine attack onset and that a consistent healthy lifestyle is a key feature of effective behavioral migraine prevention strategies.

Effectiveness and safety of erenumab and galcanezumab in the prevention of chronic and episodic migraine: A retrospective cohort study

WHAT IS KNOWN AND OBJECTIVE?: Erenumab and galcanezumab have shown great results for migraine prevention. However, strict inclusion criteria, absence of concomitant medication and selective outcome report of clinical trials may sometimes be barely representative of the real-world daily practice. Therefore, this study was designed to evaluate effectiveness and safety of these two monoclonal antibodies targeting calcitonin gene-related peptide in real-world patients. METHODS: This observational, retrospective study evaluated the effectiveness and safety of erenumab 140 mg and galcanezumab 120 mg in 142 real-world patients who had previously not responded to three well-established pharmacological alternatives for migraine prevention. To do so, a combination of objective parameters (monthly headache days and acute migraine-specific medication days) and subjective measurements (Migraine Disability Assessment questionnaire, Headache Impact Test and Visual Analogue Scale), validated for clinical research in migraine, were assessed during clinical interview. RESULTS AND DISCUSSION: Findings here reported show that erenumab and galcanezumab reduced monthly headache days, acute migraine specific medication days per month, Headache Impact Test score, Migraine Disability Assessment Test score and Visual Analogue Scale score after 3 and 6 doses (p < 0.01). Additionally, more than 25% of the patients enrolled in the study experienced a reduction by a half in monthly headache days, and more than 50% of the patients also reported a reduction by a half in the number of migraine specific medication days. Both treatments exhibited a great safety profile, rarely leading to discontinuation because of poor tolerance. WHAT IS NEW AND CONCLUSIONS?: Altogether, these results support previous real-life studies regarding effectiveness and safety and provide an interesting insight in how these preventive therapies are also effective in patients diagnosed with difficult to treat migraine who have previously failed, at least, three different drug classes stablished by current neurology guidelines for migraine prevention. Moreover, these data may suggest that erenumab and galcanezumab are able to not only diminish frequency, but also migraine intensity, and that it should be also considered as an effectiveness measure in line with other authors suggestion.

Erenumab efficacy predictors for chronic migraine

The diagnosis of chronic migraine (CM) is made when there are 15 or more days of headache per month in a patient with migraine. Approximately 2.5% of patients with episodic migraine develop chronic migraine, which is more difficult to treat and often leads to drug-induced headache (LIH). Such patients are rarely included in clinical trials. Aim. To analyze in clinical practice the effectiveness of the CGRP monoclonal antibody erenumab after 6 months of therapy in patients with CM with and without LIHD, and to evaluate possible predictors of the effectiveness of prophylactic therapy. Materials and methods. The study included 47 patients with CM taking erenumab at a dose of 70 mg monthly for at least 3 months. Patients completed a headache diary throughout the study. The 12-item Allodynia Symptom Checklist (ACS-12) was used to assess the presence of allodynia. After 6 months of therapy, the efficacy and safety of treatment, the presence of LAH and possible predictors of efficacy were evaluated. Results. After 6 months of therapy, 22 (78.6%) patients no longer met the criteria for LIHD. The factors that positively influenced the outcome of therapy were the absence of allodynia (p0.05), the presence of photo- and phonophobia, and the one-sidedness of pain (p0.05). The age and number of days with headache in patients with HM before treatment did not have a statistically significant effect on the effect of therapy. The presence of LIHD did not statistically significantly affect the outcome of therapy. Conclusion. CGRP monoclonal antibodies are reasonable in patients with LIHD. The presence of LIHD does not affect the efficacy of erenumab prophylactic therapy, the presence of allodynia may be a predictor of failure, and the unilaterality of pain and irritability to light and sound indicate likely efficacy. Real-world studies with a large cohort of patients and longer durations of therapy are required to confirm these results.

Association between dietary acid load and clinical features of migraine headaches among Iranian individuals

There is limited evidence regarding the possible role of dietary acid load (DAL) in the pathophysiology of migraine headaches. Therefore, we sought to examine DAL in relation to the clinical features of migraine including headache frequency, severity and duration, headache impact test-6 (HIT-6), and serum levels of nitric oxide (NO). In the present cross-sectional study, 262 patients (38 men and 224 women aged 20–50 years) were recruited through a simple random sampling method. Dietary intakes were obtained by using a validated 168-item semi-quantitative food frequency questionnaire (FFQ). DAL was then calculated by two different methods; potential renal acid load (PRAL) and net endogenous acid production (NEAP). In total, 262 patients with a mean (SE) age of 36.1 (0.53) and a BMI of 25.55 (0.21) were included in the current study. After controlling for potential confounders, a higher DAL was positively associated with headache frequency in those with the highest DAL score compared to the lowest (PRAL; β = 2.33; 95% CI 0.78, 3.88; NEAP; β = 1.74; 95% CI 0.13, 3.34). Increasing NEAP from 28.96 to 35.89 resulted in a 3.43 and 2.74 increment in HIT-6 scores in the crude (95% CI 1.35, 5.52) and fully-adjusted models (95% CI 0.40, 5.07), respectively. Moreover, a higher dietary PRAL was significantly associated with migraine-related disability, as shown by HIT-6, in subjects of the third tertile compared to those in the first tertile after controlling for confounders (β = 2.42; 95% CI 0.13, 4.70). In conclusion, our study highlighted the importance of the acid–base properties of a diet in the pathophysiology of migraine headaches. However, further well-designed studies are needed to confirm our findings.

A Comprehensive Review of Yoga Research in 2020

Objectives: Accumulated evidence garnered in the last few decades has highlighted the role of yoga in health and disease. The overwhelming mortality and morbidity mediated by noncommunicable epidemics such as heart disease and cancer have fostered a search for mechanisms to attenuate them. Despite overwhelming success in acute care, the efficacy of modern medicines has been limited on this front. Yoga is one of the integrative therapies that has come to light as having a substantial role in preventing and mitigating such disorders. It thus seems trite to analyze and discuss the research advancements in yoga for 2020. The present review attempts to distill recent research highlights from voluminous literature generated in 2020. Methods: This review was conducted on the articles published or assigned to an issue in 2020. The authors searched the PubMed database for clinical studies published in the English language, using yoga (including meditation) as the intervention, and having an adequate description of the intervention. Then, they extracted data from each study into a standardized Google sheet. Results: A total of 1149 citations were retrieved in the initial search. Of these, 46 studies met eligibility criteria and were finally included. The studies were predominantly on mental health and neuropsychology, addressing various issues such as anxiety, postural balance, migraine, academic performance, and childhood neglect. Anxiety, stress, and depression were other common denominators. Eight studies were on cardiorespiratory systems, including exercise capacity, cardiac rehabilitation, myocardial infarction, and hypertension. Three studies were on diabetes, evaluating the effect of yoga. Five studies focused on cognition, health status, and autonomic regulation and few others included cancers, infertility, ulcerative colitis, urinary incontinence, restless leg syndrome, rheumatoid arthritis, chronic pain, and metabolic syndrome. Finally, most studies were on noncommunicable diseases with one exception, human immunodeficiency virus; two randomized controlled trials were dedicated to it. Conclusions: Yoga has been studied under a wide variety of clinicopathological conditions in the year 2020. This landscape review intends to provide an idea of the role of yoga in various clinical conditions and its future therapeutic implications.

Global, regional, and national burden of migraine in 204 countries and territories, 1990 to 2019

ABSTRACT

Data from the Global Burden of Disease Study 2019 were used to report the burden of migraine in 204 countries and territories during the period 1990 to 2019, through a systematic analysis of point prevalence, annual incidence, and years lived with disability (YLD). In 2019, the global age-standardised point prevalence and annual incidence rate of migraine were 14,107.3 (95% Uncertainty Interval [UI] 12,270.3-16,239) and 1142.5 (95% UI 995.9-1289.4) per 100,000, an increase of 1.7% (95% UI 0.7%-2.8%) and 2.1% (95% UI 1.1%-2.8%) since 1990, respectively. Moreover, the global age-standardised YLD rate in 2019 was 525.5 (95% UI 78.8-1194), an increase of 1.5% (95% UI -4.4% to 3.3%) since 1990. The global point prevalence of migraine in 2019 was higher in females and increased by age up to the 40 to 44 age group, then decreased with increased age. Belgium (22,400.6 [95% UI: 19,305.2-26,215.8]), Italy (20,337.7 [95% UI: 17,724.7-23,405.8]), and Germany (19,436.4 [95% UI: 16,806.2-22,810.3]) had the 3 highest age-standardised point prevalence rates for migraine in 2019. In conclusion, there were large intercountry differences in the burden of migraine, and this burden increased significantly across the measurement period. These findings suggest that migraine care needs to be included within the health system to increase population awareness regarding the probable risk factors and treatment strategies especially among young adults and middle-aged women, as well as to increase the data on migraines.

The increased iron deposition of the gray matter over the whole brain in chronic migraine: an exploratory quantitative susceptibility mapping study

Background

Prior studies identified iron deposition in deep brain nuclei and the periaqueductal gray matter region in chronic migraine, and less is known about the cerebral iron deposition over the whole cerebral gray matter in CM. The aim of this case–control study is to investigate the cerebral iron deposition of gray matter in CM using an advanced quantitative susceptibility mapping.

Methods

A multi-echo gradient echo MR sequence was used to obtain raw quantitative susceptibility mapping data from 12 CM patients and 18 normal controls and the quantitative susceptibility mapping were reconstructed. Three dimensional T1 images were segmented and the gray matter mask was generated to extract the susceptibility value of gray matter over the whole brain. The independent t test and receiver operating characteristic curve Receiver operating characteristics was used to investigate the iron deposition changes in CM patients.

Results

CM presented a higher susceptibility value (1.44 × 10⁻³ ppm) compared with NC group (0.47 × 10⁻³ ppm) (p < 0.0001) over the whole cerebral gray matter. There was no correlation between susceptibility value and the clinical variables including disease duration, Visual Analog Scale (VAS), Migraine Disability Assessment Scale (MIDAS), Hamilton Anxiety Scale (HAMA), Hamilton Depression Scale (HAMD), and Montreal Cognitive Assessment (MoCA) scores (p > 0.05). ROC analysis demonstrated the susceptibility had a high diagnostic efficacy (AUC 0.949, sensitivity 77.78% and specificity 100%) in distinguishing CM from NC.

Conclusion

CM patients had increased iron deposition in total cerebral gray matter which could be considered as a potential diagnostic and evaluated imaging biomarker in CM.

Diagnosis, consultation, treatment, and impact of migraine in the US: Results of the OVERCOME (US) study

OBJECTIVE

The ObserVational survey of the Epidemiology, tReatment and Care of MigrainE (OVERCOME; United States) study is a multicohort, longitudinal web survey that assesses symptomatology, consulting, diagnosis, treatment, and impact of migraine in the United States.

BACKGROUND

Regularly updating population-based views of migraine in the United States provides a method for assessing the quality of ongoing migraine care and identifying unmet needs.

METHODS

The OVERCOME (US) 2018 migraine cohort involved: (I) creating a demographically representative sample of US adults using quota sampling (n = 97,478), (II) identifying people with active migraine in the past year via a validated migraine diagnostic questionnaire and/or self-reported medical diagnosis of migraine (n = 24,272), and (III) assessing consultation, diagnosis, and treatment of migraine (n = 21,143). The current manuscript evaluated whether those with low frequency episodic migraine (LFEM; 0-3 monthly headache days) differed from other categories on outcomes of interest.

RESULTS

Among the migraine cohort (n = 21,143), 19,888 (94.1%) met our International Classification of Headache Disorders, 3rd edition-based case definition of migraine and 12,905 (61.0%) self-reported a medical diagnosis of migraine. Respondents' mean (SD) age was 42.2 (15.0) years; 15,697 (74.2%) were women. Having at least moderate disability was common (n = 8965; 42.4%) and around half (n = 10,783; 51.0%) had consulted a medical professional for migraine care in the past year. Only 4792 (22.7%) of respondents were currently using a triptan. Overall, 8539 (40.4%) were eligible for migraine preventive medication and 3555 (16.8%) were currently using migraine preventive medication. Those with LFEM differed from moderate and high frequency episodic migraine and chronic migraine on nearly all measures of consulting, diagnosis, and treatment.

CONCLUSION

The OVERCOME (US) 2018 cohort revealed slow but steady progress in diagnosis and preventive treatment of migraine. However, despite significant impact among the population, many with migraine have unmet needs related to consulting for migraine, migraine diagnosis, and getting potentially beneficial migraine treatment. Moreover, it demonstrated the heterogeneity and varying unmet needs within episodic migraine.

No Causal Association Between Coffee Consumption and Risk of Migraine: A Mendelian Randomization Study

Background and Aims: Coffee consumption has been suggested to increase the risk of migraine. However, causality remains inconclusive. In the present study, we performed a two-sample Mendelian randomization (MR) analysis to investigate the causal relationship between coffee consumption and migraine.

Methods: We obtained nine single-nucleotide polymorphisms (SNPs) associated with coffee consumption at genome-wide significance (p < 5 × 10⁻⁸) from a large genome-wide association study (GWAS) based on the UK Biobank study (included 375,833 individuals). Summary-level data for any migraine (AM) and its subtypes (migraine with aura (MA) and migraine without aura (MO)) were obtained from the largest available GWAS of migraine conducted by the International Headache Genetics Consortium (IHGC) (included 59,674 cases and 316,078 controls). MR estimates were pooled using fixed-effect inverse-variance weighted (IVW) as the main method. Sensitivity analyses were further performed using weighted median, MR-Egger, and MR-PRESSO to assess the robustness of our findings.

Results: Genetically-predicted 50% increase of coffee consumption was not causally associated with the risk of AM (odds ratio (OR), 0.97; 95% confidence interval (CI), 0.83–1.14; p = 0.71), MA (OR, 0.81; 95%CI, 0.58, 1.12; p = 0.19), or MO (OR, 0.97; 95%CI, 0.72, 1.30; p = 0.83) in the fixed-effect IVW methods. Sensitivity analyses returned similar results. No directional pleiotropy was found.

Conclusion: This MR study does not support a causal relationship between genetically predicted coffee consumption and the risk of migraine. Coffee consumption is likely not a trigger nor a prevention strategy for migraine headaches.

Complementary and integrative medicine perspectives among veteran patients and VHA healthcare providers for the treatment of headache disorders: a qualitative study

Objective

To evaluate veteran patient and provider perceptions and preferences on complementary and integrative medicine (CIM) for headache management.

Background

The Veterans Health Administration (VHA) has spearheaded a Whole Health system of care focusing on CIM-based care for veteran patients. Less is known about patients’ and providers’ CIM perceptions and preferences for chronic headache management.

Methods

We conducted semi-structured interviews with 20 veteran patients diagnosed with headache and 43 clinical providers, across 12 VHA Headache Centers of Excellence (HCoE), from January 2019 to March 2020. We conducted thematic and case comparative analyses.

Results

Veteran patients and VHA clinical providers viewed CIM favorably for the treatment of chronic headache. Specific barriers to CIM approaches included: (1) A lack of personnel specialized in specific CIM approaches for timely access, and (2) variation in patient perceptions and responses to CIM treatment efficacy for headache management.

Conclusion

Veteran patients and VHA clinical providers in this study viewed CIM favorably as a safe addition to mainstream headache treatments. Advantages to CIM include favorable adverse effect profiles and patient autonomy over the treatment. By adding more CIM providers and resources throughout the VHA, CIM modalities may be recommended more routinely in the management of veterans with headache.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12906-022-03511-6.

Care Gaps and Recommendations in Vestibular Migraine: An Expert Panel Summit

Vestibular migraine (VM) is an increasingly recognized pathology yet remains as an underdiagnosed cause of vestibular disorders. While current diagnostic criteria are codified in the 2012 Barany Society document and included in the third edition of the international classification of headache disorders, the pathophysiology of this disorder is still elusive. The Association for Migraine Disorders hosted a multidisciplinary, international expert workshop in October 2020 and identified seven current care gaps that the scientific community needs to resolve, including a better understanding of the range of symptoms and phenotypes of VM, the lack of a diagnostic marker, a better understanding of pathophysiologic mechanisms, as well as the lack of clear recommendations for interventions (nonpharmacologic and pharmacologic) and finally, the need for specific outcome measures that will guide clinicians as well as research into the efficacy of interventions. The expert group issued several recommendations to address those areas including establishing a global VM registry, creating an improved diagnostic algorithm using available vestibular tests as well as others that are in development, conducting appropriate trials of high quality to validate current clinically available treatment and fostering collaborative efforts to elucidate the pathophysiologic mechanisms underlying VM, specifically the role of the trigemino-vascular pathways.

The relationship between dietary nutrients patterns and intensity and duration of migraine headaches

Migraine is a complicated brain disorder which affects approximately 12 % of the population, whilst the presence of migraine headaches is typically higher in women than men. Several nutrients are posited to improve headache severity. The aim of this study was to investigate the relationship between dietary nutrients patterns and intensity and duration of migraine headaches. This cross-sectional study was conducted with 266 women. Physical activity, general characteristics, anthropometric values and dietary intake were collected. Nutrient patterns were derived using principal component analysis with varimax rotation, and based on the correlation matrix, after completing the 147 item semi-quantitative FFQ, we discerned three nutrients patterns. The validated Migraine Disability Assessment (MIDAS) questionnaire and visual analogue scale (VAS) were used for assessing migraine intensity. Duration of headaches were defined as the hours the participants had headache in 1 d in last month. ANOVA, χ2 and linear regression tests were used to interrogate the data. Linear regression showed there was a positive relationship between second pattern rich in vitamin B1, carbohydrate, vitamin B3, vitamin B9, protein, and total fibre and VAS and pain duration. Furthermore, there was an inverse relationship between MIDAS and the first nutrient pattern characterised by dietary Ca, vitamin A, vitamin K, vitamin C, vitamin B6, vitamin B2, and Mg among women. Furthermore, there was a positive significant association between vitamin D and B12 (pattern 3) and headache duration. Dietary nutrients patterns should be monitored closely in individuals suffering with migraine.

The beneficial effect of Alpha-lipoic acid supplementation as a potential adjunct treatment in episodic migraines

The current study was performed to evaluate the effects of alpha-lipoic acid (ALA) supplementation on lactate, nitric oxide (NO), vascular cell adhesion molecule-1 (VCAM-1) levels, and clinical symptoms in women with episodic migraines. Considering the inclusion and exclusion criteria, ninety-two women with episodic migraines participated in this randomized, double-blind, placebo-controlled, parallel-design trial. The participants were randomly assigned to receive either 300 mg/day ALA or placebo, twice per day for 12 weeks. The primary outcomes included headache severity, headache frequency per month, and duration of attacks and the secondary outcomes included lactate (a marker of mitochondrial function), NO, and VCAM-1 serum levels were measured at baseline and the end of the intervention. At the end of the study, there was a significant decrease in lactate serum levels (- 6.45 ± 0.82 mg/dl vs - 2.27 ± 1.17 mg/dl; P = 0.039) and VCAM-1 (- 2.02 ± 0.30 ng/ml vs - 1.21 ± 0.36 ng/ml; P = 0.025) in the ALA as compared to the placebo group. In addition, the severity (P < 0.001), frequency (P = 0.001), headache impact test (HIT-6) (P < 0.001), headache dairy results (HDR) (P = 0.003), and migraine headache index score (MHIS) (P < 0.001) had significantly decreased in the intervention as compared to the control group. No significant changes were observed for NO levels and duration of migraine pains. ALA supplementation can be considered a potential adjunct treatment in patients with migraine due to its improving mitochondrial and endothelial functions and clinical symptoms.

Outcomes of Endolymphatic Sac Surgery for Meniere's Disease with and without Comorbid Migraine

Purpose

To explore outcomes of endolymphatic sac surgery for patients with Meniere's disease with and without the comorbid condition of migraine.

Materials and Methods

A retrospective chart review of adult patients undergoing endolymphatic sac surgery at a single tertiary care center from 1987 to 2019 was performed. All adult patients who failed medical therapy and underwent primary endolymphatic sac surgery were included. The main outcome measures were vertigo control and functional level scale (FLS) score. Patient characteristics, comorbidities, and audiometric outcomes were tracked as well.

Results

Patients with Meniere's disease and migraine had a stronger association with psychiatric comorbidities (64.29% vs. 25.80%, p=0.01), shorter duration of vertigo episodes (143 vs. 393 min, p=0.02), and younger age (36.6 vs. 50.8 yr, p=0.005) at the time of endolymphatic sac surgery. Postoperative pure tone averages and word recognition scores were nearly identical to preoperative baselines. Class A vertigo control (47.92%) was most common, followed by class B vertigo control (31.25%). The FLS score improved from 4.2 to 2.8 (p < 0.001). Both patients with and without migraine had classes A-B vertigo control (66.67% vs. 80.95%) without any statistically significant difference (p=0.59). Of the patients who required secondary treatment (10.42%), none had migraine.

Conclusions

Endolymphatic sac surgery is an effective surgical intervention for Meniere's disease with and without migraine. Patients with comorbid migraine tend to be younger and present with psychiatric comorbidities.

Efficacy and Safety of Chuanxiong Qingnao Granule in Patients with Migraine: A Randomized, Double-Blind, Placebo-Controlled Trial

OBJECTIVE

To evaluate the efficacy and safety of Chuanxiong Qingnao Granule (CQG) to treat migraine.

METHOD

This study was a randomized, double-blind, placebo-controlled trial. All migraineurs were recruited and randomly assigned into a treatment group treated with CQG and a control group treated with a placebo. The whole research process included a 4-week baseline, 12-week intervention, and 12-week follow-up. The primary outcome was responder rate, defined as the percentage of migraineurs with 50% or more reduction in the frequency of migraine attack during treatment and posttreatment period compared with the baseline. The secondary outcomes were the number of migraine days, migraine attack frequency, visual analogue scale (VAS), Fatigue Severity Scale (FSS), Hamilton Depression Scale (HAMD), and Migraine Disability Assessment (MIDAS).

RESULTS

A total of 346 migraineurs completed the research and were included in the intention-treatment analyses. The response rates differed significantly between the treatment group and the control group (71.5% vs. 12.1% at week 12 and 83.1% vs. 3.4% at week 24). Attack frequency, days of headache attack, VAS, FSS, HAMD, and MIDAS decreased at week 12 in both groups with more reduction in the treatment group (P < 0.001). No severe adverse events were observed in this trial.

CONCLUSION

Chuanxiong Qingnao Granule can significantly improve headache symptoms in patients with migraine while improving disability, fatigue, and depression with a good safety profile.

Sex hormone-related polymorphisms in endometriosis and migraine: A narrative review

Some evidence indicates endometriosis and migraine have a common genetic predisposition in sex-hormone genes, which could have important implications for the treatment of these two heterogenous conditions. To date, the genes responsibility remains unknown. Based on the biological hypothesis that polymorphisms of genes involved in sex-hormone pathways may influence estrogen levels and phenotypes of both disorders, we did a literature search for candidate sex-hormone genes and genes involved in the metabolism of estradiol. The aim was to review the evidence for shared sex-hormone-related polymorphisms between endometriosis and migraine and provide an exhaustive overview of the current literature. We included case-control studies investigating associations between candidate sex-hormone-related genes and the disorders endometriosis and migraine, respectively. Results showed three overlapping sex-hormone-associated polymorphisms in estrogen receptor genes that are associated with both conditions. To confirm possible associations with other sex-hormone genes, larger studies are needed.

Off-label Uses of Selective Serotonin Reuptake Inhibitors (SSRIs)

Psychiatric drugs have primacy for off-label prescribing. Among those, selective serotonin reuptake inhibitors (SSRIs) are highly versatile and, therefore, widely prescribed. Moreover, they are commonly considered as having a better safety profile compared to other antidepressants. Thus, when it comes to off-label prescribing, SSRIs rank among the top positions. In this review, we present the state of the art of off-label applications of selective serotonin reuptake inhibitors, ranging from migraine prophylaxis to SARS-CoV-2 antiviral properties. Research on SSRIs provided significant evidence in the treatment of premature ejaculation, both with the on-label dapoxetine 30 mg and the off-label paroxetine 20 mg. However, other than a serotoninergic syndrome, serious conditions like increased bleeding rates, hyponatremia, hepatoxicity, and post-SSRIs sexual dysfunctions, are consistently more prominent when using such compounds. These insidious side effects might be frequently underestimated during common clinical practice, especially by nonpsychiatrists. Thus, some points must be addressed when using SSRIs. Among these, a psychiatric evaluation before every administration that falls outside the regulatory agencies-approved guidelines has to be considered mandatory. For these reasons, we aim with the present article to identify the risks of inappropriate uses and to advocate the need to actively boost research encouraging future clinical trials on this topic.

Treatment Patterns for Calcitonin Gene-Related Peptide Monoclonal Antibodies Including Galcanezumab versus Conventional Preventive Treatments for Migraine: A Retrospective US Claims Study

BACKGROUND

Most conventional, oral, preventive treatments for migraine are non-specific and ~50% of patients discontinue them within six months. In 2018, the Food and Drug Administration approved three preventive migraine treatments: monoclonal antibodies (mAb) targeting the calcitonin gene-related peptide (CGRP) pathway implicated in migraine; galcanezumab and fremanezumab which target CGRP ligand; and erenumab which targets CGRP receptor. Real-world treatment patterns for CGRP mAb are limited.

PURPOSE

To compare real-world treatment patterns for CGRP mAb, specifically galcanezumab versus standard-of-care (SOC) migraine preventive treatments.

PATIENTS AND METHODS

This retrospective, observational study included 12-month baseline and 6- and 12-month follow-up analyses using IBM^® MarketScan^® databases. Patients identified were aged ≥18 years with ≥1 claim (first claim=index) for CGRP mAb (erenumab, fremanezumab, or galcanezumab) or SOC preventives (eg, antiepileptics, beta-blockers, antidepressants, or onabotulinumtoxinA) as index drugs between May/01/2018 and June/30/2019. Propensity score matching was used to address confounding by observed covariates. Outcomes analyzed included proportion of days covered (PDC), persistence (≤60-day gap), and first non-index drug switch. Descriptive, chi-square (categorical), and t-test (continuous) analyses were conducted.

RESULTS

The study included 3082 (CGRP mAb versus SOC) and 421 (galcanezumab versus SOC) matched patient pairs with 12-month follow-up. Mean age across cohorts ranged 43.2-44.4 years (females: 85.7-88.6%). Compared with SOC, the CGRP mAb cohort had higher mean persistence (212.5 vs 131.9 days), adherence (PDC: 55.1% vs 35.2%), and more patients were adherent with PDC ≥80% (32.7% vs 18.7%) (all p <0.001). During 12-month follow-up, fewer patients discontinued CGRP mAb versus SOC (58.8% vs 77.6%, p <0.001). Galcanezumab versus SOC comparisons yielded similar results. In the CGRP mAb cohort, most switchers (28.3%) used galcanezumab as subsequent treatment. Largely similar results were observed for 6-month follow-up cohorts.

CONCLUSION

Patients on CGRP mAb and specifically galcanezumab showed higher adherence and persistence than patients on SOC migraine preventive treatments.

CE: Diagnosing and Managing Migraine

ABSTRACT

Roughly 90% of the U.S. population will develop a headache within their lifetime, and headache disorders account for more disability-adjusted life-years than all other neurologic disorders combined. Among primary headache disorders, the two most common are tension-type headache and migraine, with migraine identified as the most disabling. Here, the authors describe the importance of differentiating primary and secondary headache disorders and discuss the pathophysiology; clinical assessment; and outpatient management of the debilitating migraine headache, summarizing both acute and prophylactic treatment strategies that can substantially reduce associated disability.

Migraine History and Outcomes in Military Pilots and Flight Surgeons

BACKGROUND: Migraine is a common disorder with significant aeromedical implications. The variability and unpredictable nature of occurrences hampers accurate assessment of future risk. This uncertainty results in a necessarily conservative approach to aeromedical recommendations, which unfortunately may lead to over-restrictive dispositions. Limited long-term follow up information is available on migraine outcomes in pilots, particularly assessing for impact of potential modifiable aggravating factors.Methods: This retrospective study reviewed 159 U.S. Air Force pilots with migraine who had been granted aeromedical waivers. As a comparison group, 44 U.S. Air Force flight surgeons with migraine who had been granted aeromedical waivers were reviewed.Results: Migraine with aura and isolated migraine aura without headache accounted for the majority of migraine subtypes in both male and female subjects. Self-identified triggering factors were identified by 62% of subjects. The most commonly reported triggers were dietary factors, sleep disturbances, stress, caffeine intake, and hormonal factors. Sleep disturbances, stress, hormonal factors, and ethanol triggers were more frequently noted in female subjects. Self-reported positive response to trigger factor modification was noted in 54% of subjects. Subjects reported an average of only 3 migraine attacks in the previous year. Long-term follow up indicated continued aeromedical waiver in 91% of subjects.Discussion: The majority of subjects had migraine with aura or isolated migraine aura. Significant salutary response to modification of commonly-reported triggering factors was noted. These findings can be incorporated into individualized aeromedically-compatible management strategies to clarify symptom impact on aviation safety, improve symptom control, and increase the possibility of safe return to fly recommendations.Hesselbrock RR, Haynes JT. Migraine history and outcomes in military pilots and flight surgeons. Aerosp Med Hum Perform. 2022; 93(1):26-31.

Psychedelics in the Treatment of Headache and Chronic Pain Disorders

The therapeutic potential of psychedelics in headache and chronic pain disorders is documented over decades of anecdotal and early investigational reports, which have paved the way for the first controlled studies of psilocybin and lysergic acid diethylamide (LSD) in these disorders. The reported lasting clinical effects after limited dosing with psychedelics present a novel means for disease management, but considerable further study will be required to address disease-specific treatments, uncover mechanism(s) of action, and verify safety. In this chapter, these topics are reviewed with particular attention to the neurobiological systems that offer potential sources of psychedelics' unique clinical effects in headache and pain.

Migraine Headaches after Major Surgery with General or Neuraxial Anesthesia: A Nationwide Propensity-Score Matched Study

Migraine headaches can be provoked by surgical stress and vasoactive effects of anesthetics of general anesthesia in the perioperative period. However, it is unclear whether general anesthesia increases the migraine risk after major surgery. Incidence and risk factors of postoperative migraine are also largely unknown. We utilized reimbursement claims data of Taiwan’s National Health Insurance and performed propensity score matching analyses to compare the risk of postoperative migraine in patients without migraine initially who underwent general or neuraxial anesthesia. Multivariable logistic regressions were applied to calculate the adjusted odds ratio (aOR) and 95% confidence interval (CI) for migraine risk. A total of 68,131 matched pairs were analyzed. The overall incidence of migraine was 9.82 per 1000 person-years. General anesthesia was not associated with a greater risk of migraine compared with neuraxial anesthesia (aORs: 0.93, 95% CI: 0.80–1.09). This finding was consistent across subgroups of different migraine subtypes, uses of migraine medications, and varying postoperative periods. Influential factors for postoperative migraine were age (aOR: 0.99), sex (male vs. female, aOR: 0.50), pre-existing anxiety disorder (aOR: 2.43) or depressive disorder (aOR: 2.29), concurrent uses of systemic corticosteroids (aOR: 1.45), ephedrine (aOR: 1.45), and theophylline (aOR: 1.40), and number of emergency room visits before surgery. There was no difference in the risk of postoperative migraine between surgical patients undergoing general and neuraxial anesthesia. This study identified the risk factors for postoperative migraine headaches, which may provide an implication in facilitating early diagnoses and treatment.

Mindfulness-Based Cognitive Therapy as Migraine Intervention: a Randomized Waitlist Controlled Trial

BACKGROUND

Based on promising effects seen in a pilot study evaluating a generic mindfulness-based program for migraine, we developed a migraine-specific adaptation of the Mindfulness-Based Cognitive Therapy (MBCT) program. The aim of this study was to evaluate this program for feasibility and effectiveness in a randomized controlled trial.

METHOD

Fifty-four patients suffering from migraine were randomly allocated to either waitlist or the adapted MBCT. Outcomes were migraine-related parameters as well as variables of psychological functioning and coping. Assessment took place at baseline and post-intervention, for the intervention group also at follow-up (7 months). The effects of the intervention were analyzed by the use of ANCOVAs and linear mixed models.

RESULTS

With respect to migraine parameters we did not find a significant group difference in the primary outcome (headache-related impairment), but the intervention resulted in a significant reduction of headache frequency (p = .04). In the analysis of secondary outcomes, MBCT showed superiority in four out of eight psychological parameters (perceived stress, anxiety, rumination, catastrophizing) with small to medium effect sizes. The intervention proved to be feasible and participants reported high degrees of contentment and achievement of personal goals.

CONCLUSIONS

The migraine-specific MBCT program did not result in improvements with regard to headache-related impairment but showed a reduction in headache frequency as well as improved psychological functioning in secondary outcomes.

TRIAL REGISTRATION

This trial was registered in the German Trial Registry "Deutsches Register Klinischer Studien" (ID: DRKS00007477), which is a WHO-listed primary trial register.

Atogepant and sumatriptan: no clinically relevant drug-drug interactions in a randomized, open-label, crossover trial

Aim: To evaluate pharmacokinetic interactions of atogepant with sumatriptan, an open-label, randomized, crossover study was conducted. Patients & methods: Thirty healthy adults received atogepant 60 mg, sumatriptan 100 mg, or coadministered drugs. Primary end point was geometric mean ratios (GMRs) and 90% CIs of interventions for area under the plasma concentration-time curve from time 0 to t (AUC_0-t) or infinity (AUC_0-∞) and peak plasma concentration (C_max). Results: Atogepant GMRs for AUC_0-t and AUC_0-∞ versus with sumatriptan were within 90% CI 0.80-1.25, indicating no interaction; atogepant C_max was reduced by 22% (GMR: 0.78; 90% CI: 0.69-0.89) with sumatriptan. Sumatriptan GMRs for AUC_0-t, AUC_0-∞ and C_max versus with atogepant were within 90% CI 0.80-1.25. Conclusion: Atogepant with sumatriptan had no clinically relevant pharmacokinetic interactions.