Migraine

Major sex differences in migraine prevalence among occupational categories: a cross-sectional study using UK Biobank

Background

Migraine represents one of the most prevalent neurological conditions worldwide. It is a disabling condition with high impact on the working situation of migraineurs. Interestingly, gender-related differences regarding an association of migraine with important occupational characteristics has been hardly studied.

Methods

The current study scrutinizes gender-specific differences in the prevalence of migraine across a broad spectrum of occupational categories, shedding also light on associations with important job-related features such as shift work, job satisfaction, and physical activity. The study included data from 415 712 participants from the UK Biobank cohort, using the official ICD10 diagnosis of migraine and other health conditions as selection criteria. Prevalence ratios of migraineurs compared to healthy controls among different occupational categories and job-related variables were estimated using log-binomial regression analyses. Statistical models were adjusted for important sociodemographic features such as age, BMI, ethnicity, education and neuroticism. To better highlight specific differences between men and women we stratified by sex.

Results

We detected a differential prevalence pattern of migraine in relation to different job categories between men and women. Especially in men, migraine appears to be more prevalent in highly physically demanding occupations (PR 1.38, 95% CI [0.93, 2.04]). Furthermore, migraine is also more prevalent in jobs that frequently involve shift or night shift work compared to healthy controls. Interestingly, this prevalence is especially high in women (shift work PR 1.45, 95% CI [1.14, 1.83], night shift work PR 1.46, 95% CI [0.93, 2.31]).

Conclusion

Our results show that migraine is genderdependently associated with physically demanding jobs and shift working.

Migraine and Stroke: In Search of Shared Pathways, Mechanisms, and Risk Factors

Migraines are one of the emerging causes of disabilities experienced worldwide, and strokes are the second leading cause of death globally. Migraines with aura have been reported to be associated with a higher risk of ischemic strokes, whereas hemorrhagic strokes are more closely associated with migraines without aura, possible mechanisms that link migraines to strokes. These can be categorized into vascular mechanisms such as vasospasm, endothelial and platelet dysfunction, and alteration in the vessel wall seen in migraineurs, further perpetrated by vascular risk factors such as hypertension and hyperlipidemias. Cerebral hypoperfusion that occurs in migraines can cause an electrical aberrance, leading to a phenomenon known as "spreading depression" which can contribute to strokes. In this review, we discuss bloodstream elevation in procoagulants such as antiphospholipid antibodies, homocysteine, von Willebrand factor, and prothrombin. Maintaining pregnant women who actively experience migraines with aura under close observation may be of some value in achieving better outcomes. Women who experience migraines after starting hormonal contraception are at a higher risk of experiencing strokes and stand to benefit from being switched to non-hormonal methods. In this article, we discuss the mechanisms linking migraines and strokes, briefly discuss the pathogenesis, and explore the risk factors contributing to the association therein. In addition, we examine the relationship between migraines and ischemic strokes, as well as hemorrhagic strokes, and review management considerations.

Depressive symptoms during early adulthood and the development of physical multimorbidity in the UK: an observational cohort study

BACKGROUND

An understanding of whether early-life depression is associated with physical multimorbidity could be instrumental for the development of preventive measures and the integrated management of depression. We therefore aimed to map out the cumulative incidence of physical multimorbidity over adulthood, and to determine the association between the presence of depressive symptoms during early adulthood and the development of physical multimorbidity in middle age.

METHODS

In this observational cohort study, we used pooled data from the 1958 National Child Development Study (NCDS) and the 1970 British Cohort Study (BCS). Cohort waves were pooled in each decade of adult life available (when cohort members were aged 26 years in the BCS and 23 years in the NCDS [baseline]; 34 years in the BCS and 33 years in the NCDS [age 34 BCS/33 NCDS]; 42 years in the BCS and NCDS [age 42 BCS/NCDS]; and 46 years in the BCS and 50 years in the NCDS [age 46 BCS/50 NCDS]). We included participants who had completed the nine-item Malaise Inventory at baseline, and did not have a history of physical multimorbidity, any physical multimorbidity at baseline, or the presence of depressive symptoms before the development of physical multimorbidity. The presence of depressive symptoms was determined using the nine-item Malaise Inventory (cutoff score ≥4). Physical multimorbidity was defined as having at least two measures of any of the following ten self-reported groups of long-term conditions: asthma or bronchitis; backache; bladder or kidney conditions; cancer; cardiovascular conditions; convulsions or epilepsy; diabetes; hearing conditions; migraine; and stomach, bowel, or gall conditions. Cumulative incidence (with 95% CI) of physical multimorbidity was calculated for each decade considered after baseline, with physical multimorbidity being assessed as both a dichotomous and categorical variable. The association between depressive symptoms and the development of physical multimorbidity was assessed using adjusted relative risk ratios (with 95% CIs).

FINDINGS

Analyses included 15 845 participants, of whom 4001 (25·25%; 95% CI 24·57-25·93) had depressive symptoms at baseline and 11 844 (74·75%; 74·07-75·42) did not. The cumulative incidence of physical multimorbidity (dichotomous) ranged over the study period from 2263 (18·44%; 95% CI 17·75-18·14) of 12 273 participants at age 34 BCS/33 NCDS, to 4496 (42·90%; 41·95-43·85) of 10 481 participants at age 46 BCS/50 NCDS, and was consistently higher in participants with depressive symptoms at baseline. The adjusted relative risk of physical multimorbidity was higher in participants with depressive symptoms than in those without and remained stable over the study period (adjusted relative rate ratio 1·67, 95% CI 1·50-1·87, at age 34 BCS/33 NCDS; 1·63, 1·48-1·79, at age 42 BCS/NCDS; and 1·58, 1·43-1·73, at age 46 BCS/50 NCDS).

INTERPRETATION

The presence of depressive symptoms during early adulthood is associated with an increased risk of the development of physical multimorbidity in middle age. Although further research about the drivers of this relationship is needed, these results could help to enhance the integrated management of individuals with depressive symptoms and the development of preventive strategies to reduce the effect and burden of physical multimorbidity.

FUNDING

UK Medical Research Council and Guy's Charity.

Association Between Asthma and Migraine: A Systematic Review and Meta-Analysis of Observational Studies

Objectives: The purpose of this study was to determine the association between asthma and migraine and assess the risk for migraine in patients with asthma. Methods: We systematically searched the Cochrane Library, PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), and Excerpta Medica dataBASE (EMBASE) databases from inception to September 26, 2021, for indexed observational studies that examined either the odds or risk of migraine in subjects with asthma. The qualities of the included studies were evaluated using the Newcastle-Ottawa Scale. A random-effects meta-analysis was performed to calculate the odds ratio for case-control and cross-sectional studies and the risk ratio for cohort studies. Results: Seven observational studies (four cross-sectional and three cohort studies) with a total of 549,534 study subjects were included in this systematic review and meta-analysis and selected for data extraction. Four articles were considered to be of moderate quality; other studies were considered to be of high quality. Asthma was associated with increased odds (OR, 1.85; 95%CI, 1.39-2.45) and risk of migraine (RR, 1.70; 95%CI, 1.52-1.90). Conclusions: The available evidence that supports the existence of an association between asthma and migraine is limited. Clinicians should be aware that patients with asthma show both increased prevalence and incidence of migraine. Further studies are warranted to further clarify the relationship between asthma and migraine. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=185881, identifier: CRD42020185881.

Tracking tDCS induced grey matter changes in episodic migraine: a randomized controlled trial

BACKGROUND

Occipital transcranial direct current stimulation (tDCS) is an effective and safe treatment for migraine attack prevention. Structural brain alterations have been found in migraineurs in regions related to pain modulation and perception, including occipital areas. However, whether these structural alterations can be dynamically modulated through tDCS treatment is understudied.

OBJECTIVE

To track longitudinally grey matter volume changes in occipital areas in episodic migraineurs during and up to five months after occipital tDCS treatment in a single-blind, and sham-controlled study.

METHODS

24 episodic migraineurs were randomized to either receive verum or sham occipital tDCS treatment for 28 days. To investigate dynamic grey matter volume changes patients underwent structural MRI at baseline (prior to treatment), 1.5 months and 5.5 months (after completion of treatment). 31 healthy controls were scanned with the same MRI protocol. Morphometry measures assessed rate of changes over time and between groups by means of tensor-based morphometry.

RESULTS

Before treatment, migraineurs reported 5.6 monthly migraine days on average. A cross-sectional analysis revealed grey matter volume increases in the left lingual gyrus in migraineurs compared to controls. Four weeks of tDCS application led to a reduction of 1.9 migraine days/month and was paralleled by grey matter volume decreases in the left lingual gyrus in the treatment group; its extent overlapping with that seen at baseline.

CONCLUSION

This study shows that migraineurs have increased grey matter volume in the lingual gyrus, which can be modified by tDCS. Tracking structural plasticity in migraineurs provides a potential neuroimaging biomarker for treatment monitoring.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT03237754 . Registered 03 August 2017 - retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03237754 .

Treatment of chronic migraine and neck pain with cognitive-behavioral therapy. Case report

The article presents a case of a patient with chronic migraine, neck pain, drug-induced headache and generalized anxiety disorder. We analyzed the relationship between migraines and neck pain. The article discusses the interdisciplinary treatment of chronic migraine, which included educational conversation, detoxification therapy, rational relief of migraine attacks, preventive pharmacotherapy and cognitive-behavioral therapy. The latter allowed to change the patient's perception of the disease, reduce anxiety and catastrophization of pain, cope with fears, stop taking benzodiazepines, reduce the intake of pain relievers, and increase daily activity and productivity at work. Clinical efficacy (reduction in the frequency of headaches per month by 50% or more) was achieved after 3 months of treatment. Long-term (12 months) follow-up of the patient showed long-term clinical effect of the interdisciplinary treatment.

Patients' and Health Care Workers' Perception of Migraine Images on the Internet: Cross-sectional Survey Study

BACKGROUND

The representation of migraine in the media is stereotypical. Standard images of migraine attacks display stylish young women holding their head in a pain pose. This representation may contribute to the social stigmatization of patients with migraine.

OBJECTIVE

We aimed to analyze how patients with migraine and health care workers perceive online images of migraine.

METHODS

The study consisted of an anonymous web-based survey of patients with migraine at the Headache Center of Charité - Universitätsmedizin Berlin (migraine group) and employees and students at our university (health care group). A total of 10 frequently used Adobe Stock photos of migraine attacks were presented to the participants. Each photo was rated on a scale of 0% to 100% based on how closely it resembled a realistic migraine attack (realism score). Patients with migraine also indicated how much each photo corresponded to their own experience of migraine as a percentage (representation score). We calculated the mean realism and representation scores for all photos and conducted further analyses using the categories male or female models, younger or older models, and unilateral or bilateral pain pose.

RESULTS

A total of 367 patients with migraine and 331 health care employees and students completed the survey. In both groups, the mean realism score was <50% (migraine group: 47.8%, SD 18.3%; health care group: 46.0%, SD 16.2%). Patients with migraine identified their own migraine experience in these photos to a lesser degree (mean representation score 44.4%, SD 19.8%; P<.001 when compared to the realism score). Patients and health care workers considered photos with male models to be more realistic than photos with females (P<.001) and photos with older models to be more realistic than those with younger people (P<.001). In the health care group only, a bilateral pain posture was deemed more realistic than a unilateral pose (P<.001).

CONCLUSIONS

Standard images of migraine attacks are considered only slightly or moderately realistic by patients and health care workers. Some characteristics perceived as more realistic such as male sex or older age are in contrast with migraine epidemiology. A more accurate representation of migraine in the media could help to raise awareness for migraine and reduce the associated stigma.

Effects of the Dietary Approaches to Stop Hypertension (DASH) diet on clinical, quality of life, and mental health outcomes in women with migraine: A randomised controlled trial

The relationship between the Dietary Approaches to Stop Hypertension (DASH) diet and clinical, quality of life, and mental health outcomes in migraine is unknown. To address this knowledge gap, we conducted a parallel-group, randomised controlled trial to evaluate the effect of the DASH diet on these health outcomes in women with migraine. Of 102 eligible women (20-50 years), 51 randomised to the DASH and 51 to the usual dietary advice (control) groups completed a 12-week intervention. The DASH diet was designed using a 7-day menu cycle to provide 15-20% of total daily energy requirements from proteins, 25-30% from fats, and 55-60% from carbohydrates. Dietary records and serum vitamin C levels were used to assess women's compliance with the DASH diet. The clinical symptoms of migraine (i.e., frequency, duration, severity) and quality of life and mental health (i.e., depression, anxiety, stress) outcomes were assessed in groups pre-and post-intervention. We observed greater decreases in the frequency (-3.00 vs. -1.40, P=0.025) and severity (-1.76 vs. -0.59, P<0.001) of migraine in the DASH vs. control group post-intervention. Similarly, the DASH group exhibited a tendency toward greater decreases in migraine duration (-0.58 vs -0.33 days, P=0.053) and had lower scores of depression (-4.50 vs. -2.73, P=0.019) and stress (-5.84 vs -2.98, P=0.011) vs. controls. However, the quality of life and anxiety outcomes remained comparable in groups post-intervention. Together, evidence supports the benefits of the DASH diet on improving migraine health outcomes in reproductive-aged women. Further research is needed to confirm our findings.

Safety and Risk of Medication Overuse Headache in Lasmiditan and Second-Generation Gepants: A Rapid Review

The treatment of migraine is often complicated by insufficient headache relief, a miscellany of side effects and the risk of developing Medication Overuse Headache (MOH). Novel acute therapies have been recently developed and are now in the early post-marketing phase. Lasmiditan is a highly selective serotonin receptor agonist that binds to the 5-HT_1F receptor, while ubrogepant and rimegepant antagonize the calcitonin gene-related peptide receptor. All three medications are now prescribed in a real-world setting, and an adequate level of knowledge is the starting point for rational use. In this rapid systematic review, we have established what is known about lasmiditan, ubrogepant and rimegepant, highlighting the most relevant safety aspects available from published studies and speculating about their risk of MOH.

A retrospective cohort study of clinical factors, visit patterns, and demographic factors associated with use of remote communications in patients with headache

OBJECTIVE

To identify the characteristics associated with high utilization of remote communications (RCs) in patients with headache.

BACKGROUND

Patients with headache frequently communicate with their providers using secure portal messaging and telephone calls. However, clinical and demographic factors as well as visit patterns associated with RC utilization remain poorly characterized.

METHODS

We retrospectively analyzed data from patients with headache who were evaluated in the ambulatory neurology faculty practice at the Icahn School of Medicine at Mount Sinai in New York between January 1 and June 30, 2019. We extracted clinical and demographic characteristics, total office visits, secure MyChart portal messages, and telephone encounters from our institutional data warehouse. We defined high RC and MyChart utilization as the top tertile of RC and MyChart message volume, respectively, and assessed the relationship between patient characteristics and high RC (primary outcome), as well as high MyChart utilization (secondary outcome). We characterized the relationship between clinicodemographic characteristics and the ratio of MyChart messages to total RCs (secondary outcome).

RESULTS

We identified 1390 patients, of whom 477 (34.3%) were high RC utilizers and 321 (23.1%) were high MyChart utilizers. High RC utilizers generated 3306/3921 (84.3%) RCs. The presence of chronic headache (aOR 2.31, 95% CI 1.75-3.03, p < 0.0001), cluster headache (aOR 18.3, 95% CI 5.0-71.7, p = 0.001), and migraine (aOR 3.82, 95% CI 1.93-9.3, p = 0.011) was associated with high RC utilization. Patients ≥65 years of age were less likely to engage in MyChart messaging as a proportion of RC (191/680, 28.1%) compared with patients 18-30 years of age (243/620, 39.2%, p = 0.049) and 30-64 years of age (1172/2721, 43.1%, p < 0.0001).

CONCLUSIONS

A minority of patients with headache (477/1390; 34.3%) generated the majority (3306/3921; 84.3%) of RCs. Our findings should be validated in external patient cohorts with the objective of developing strategies to optimize RC utilization.

Neuroscience Education as Therapy for Migraine and Overlapping Pain Conditions: A Scoping Review

BACKGROUND

Neuroscience education therapy (NET) has been successfully used for numerous overlapping pain conditions, but few studies have investigated NET for migraine.

OBJECTIVE

We sought to 1) review the literature on NET used for the treatment of various pain conditions to assess how NET has been studied thus far and 2) recommend considerations for future research of NET for the treatment of migraine.

DESIGN/METHODS

Following the PRISMA guideline for scoping reviews, co-author (TR), a medical librarian, searched the MEDLINE, PsychInfo, Embase, and Cochrane Central Clinical Trials Registry databases for peer-reviewed articles describing NET to treat migraine and other chronic pain conditions. Each citation was reviewed by two trained independent reviewers. Conflicts were resolved through consensus.

RESULTS

Overall, a NET curriculum consists of the following topics: pain does not equate to injury, pain is generated in the brain, perception, genetics, reward systems, fear, brain plasticity, and placebo/nocebo effects. Delivered through individual, group, or a combination of individual and group sessions, NET treatments often incorporate exercise programs and/or components of other evidence-based behavioral treatments. NET has significantly reduced catastrophizing, kinesiophobia, pain intensity, and disability in overlapping pain conditions. In migraine-specific studies, when implemented together with traditional pharmacological treatments, NET has emerged as a promising therapy by reducing migraine days, pain intensity and duration, and acute medication intake.

CONCLUSION

NET is an established treatment for pain conditions, and future research should focus on refining NET for migraine, examining delivery modality, dosage, components of other behavioral therapies to integrate, and migraine-specific NET curricula.

The impact of a digital platform on migraine patient-centered outcome research. Evaluation of midolordecabeza.org, a headache website in Spanish

OBJECTIVE

This internet survey aimed to analyze the activity of midolordecabeza.org, a specialized website for headache stakeholders.

BACKGROUND

eHealth tools, such as websites, can be educational for stakeholders of a specific disease, such as patients. This is particularly helpful in chronic disorders such as migraine. eHealth also enhances patient-centered outcome research. The website midolordecabeza.org has the stated aim of organizing key information on headache making it accessible and useful for all stakeholders, and, eventually promoting patient participation.

METHODS

We analyzed Google Analytics (GA) data to study the web's activity, traffic source, geographical distribution of access, registered-user behavior, electronic device performance, and temporary references with greater web activity.

RESULTS

From January 2015 until December 2020, the website registered 1,121,585 visitors, 1,775,953 sessions, and a total of 3,833,144 views with an average time per session of nearly 2 min. Higher data traffic has been registered in Spanish-speaking countries such as Spain (33.3%; 591,256/1,775,953), where Spain's regions with higher views were statistically significantly correlated with the nationwide migraine prevalence (ρ = 0.505; p = 0.039). In regard to social behavior, returning users were statistically significantly associated with being a woman (84.0%; 5696/6781), and they predominantly acceded from organic searches (50.6%; 3434/6781). When answering available open surveys, 72.5% (1827/2520) described their migraine as a disabling disease with high impact on their daily tasks and 64.4% (14,016/21,764) were unaware of what their headache diagnosis is.

CONCLUSIONS

Spanish-speaking patients with migraine around the world increasingly visited the headache-specialized website midolordecabeza.org using different electronic devices, showing great interest in their disease. This website allowed them to get updated information on their disease, share clinical data with physicians, and finally express their concerns.

Underuse of Behavioral Treatments for Headache: a Narrative Review Examining Societal and Cultural Factors

Migraine affects over 40 million Americans and is the world's second most disabling condition. As the majority of medical care for migraine occurs in primary care settings, not in neurology nor headache subspecialty practices, healthcare system interventions should focus on primary care. Though there is grade A evidence for behavioral treatment (e.g., biofeedback, cognitive behavioral therapy (CBT), and relaxation techniques) for migraine, these treatments are underutilized. Behavioral treatments may be a valuable alternative to opioids, which remain widely used for migraine, despite the US opioid epidemic and guidelines that recommend against them. Identifying and removing barriers to the use of headache behavioral therapy could help reduce the disability as well as the personal and social costs of migraine. These techniques will have their greatest impact if offered in primary care settings to the lower socioeconomic status groups at greatest risk for migraine. We review the societal and cultural challenges that impose barriers to optimal use of non-pharmacological treatment services. These barriers include insufficient knowledge of migraine/headache behavioral treatments and insufficient availability of clinicians trained in non-pharmacological treatment delivery; limited access in underserved communities; financial burden; and stigma associated with both headache and mental health diagnoses and treatment. For each barrier, we discuss potential approaches to minimizing its effect and thus enhancing non-pharmacological treatment utilization.Case ExampleA 25-year-old graduate student with a prior history of headaches in college is attending school in the evenings while working a full-time job. Now, his headaches have significant nausea and photophobia. They are twice weekly and are disabling enough that he is unable to complete homework assignments. He does not understand why the headaches occur on Saturdays when he pushes through all week to get through his examinations that take place on Friday evenings. He tried two different migraine preventive medications, but neither led to the 50% reduction in headache days his doctor had hoped for. His doctor had suggested cognitive behavioral therapy (CBT) before initiating the medications, but he had been too busy to attend the appointments, and the challenges in finding an in-network provider proved difficult. Now with the worsening headaches, he opted for the CBT and by the fifth week had already noted improvements in his headache frequency and intensity.

Did she have an epidural? The long-term consequences of postdural puncture headache and the role of unintended dural puncture

OBJECTIVE

This narrative literature review examines the long-term impact of postdural puncture headache (PDPH) in postpartum women following an unintended dural puncture (UDP) with a large bore needle commonly used for epidural catheter placement. It seeks to bridge the knowledge gap for the neurologist as to the mounting body of obstetric anesthesia literature on the development of chronic headache after PDPH with this unique needle.

BACKGROUND

Headache is the most common complication of dural puncture, and the risk is greatest in the parturient population. Preexisting risk factors for this population include youth and sex, and after UDP with a large bore needle, almost 70%-80% report a headache. Additionally, there appears to be a significant cohort who experience long-term, persistent headache after UDP.

METHODS

We performed a narrative review of literature using PubMed, searching terms that included long-term follow-up after UDP with a large bore needle in the postpartum population.

RESULTS

In women who had UDP with a large bore needle used for epidural catheter placement at delivery, the rate of chronic debilitating headache is around 30% in the months following delivery and may persist for up to a year or longer.

CONCLUSION

Based on the existing literature, we have mounting evidence that UDP with the large bore needle used to place an epidural catheter should be understood as a high-risk inciting event for the development of long-term headaches not simply a high risk of acute PDPH. Additionally, consideration should be given to stratifying the etiology of PDPH, based on needle type, and recognizing the entity of chronic PDPH, thus allowing for improvements in research and diagnosis.

Headache disability, lifestyle factors, health perception, and mental disorder symptoms: a cross-sectional analysis of the 2013 National Health Survey in Brazil

OBJECTIVE

To evaluate the past 2-week headache disability and explore its association with lifestyle factors, health perception, and mental disorder symptoms in the PNS 2013 survey.

BACKGROUND

The prevalence of headache disorders has been associated with lifestyle factors, mental disorders, and health perception. However, less is known regarding their influence on headache-related disability.

METHODS

In a cross-sectional analysis, chi-squared tests and logistic regression models computed the associations between headache-related disability (defined as days lost from work, school, or household chores in the past 2 weeks) and the variables of interest, compared to other disease-related disabilities groups or no day lost group. The adjusted models controlled for the effects of age, sex, income, and educational levels.

RESULTS

In the sample aged ≥ 18 years (n = 145,580), 10,728 (7.4%) participants reported any disease-related disability in the past 2 weeks (median interquartile range (IQR) for age = 47 (33-59) years, 62% women), with the median (IQR) days lost = 5 (2-14). Headache disability represented 5.3% (572/10,728) of all diseases, constituting the 4th most prevalent disease-related disability [median (IQR) days lost = 3 (3-4)]. Among people aged 18-25 years, headache disorders ranked 2nd as the most prevalent disability (13%), headache-related disability positively associated with physical inactivity, poorer health perception, and frequent mental disorders symptoms, and negatively associated with overweight, obesity, and alcohol consumption.

CONCLUSION

Headache disability represents a leading cause of disease-related disability in Brazil and associates with unhealthy lifestyle factors, poorer health perception, and frequent mental disorder symptoms.

Early Experiences in Switching between Monoclonal Antibodies in Patients with Nonresponsive Migraine in Spain: A Case Series

Monoclonal antibodies targeting the calcitonin gene-related peptide have been introduced into the therapeutic arsenal of migraine prophylaxis. Clinical trials report similar efficacy between them, and there is no evidence of switching to another one after failure. We aim to describe our experience in switching from erenumab to galcanezumab after therapeutic failure. We retrospectively reviewed 30 migraine patients who received monoclonal antibodies, with 15 of them switched after failure to achieve reduction in migraine days per month ≥30%. A ≥30% reduction in migraine days per month compared to baseline was observed in 8/15 (4/15 ≥ 50%) patients after switch. Some nonresponsive patients may benefit from switching between monoclonal antibodies with different therapeutic targets.

Neck Active Movements Assessment in Women with Episodic and Chronic Migraine

We aimed to compare movement parameters and muscle activity during active cervical spine movements between women with episodic or chronic migraine and asymptomatic control. We also assessed the correlations between cervical movement measures with neck-related disability and kinesiophobia. Women with episodic (n = 27; EM) or chronic (n = 27; CM) migraine and headache-free controls (n = 27; CG) performed active cervical movements. Cervical range of motion, angular velocity, and percentage of muscular activation were calculated in a blinded fashion. Compared to CG, the EM and CM groups presented a reduced total range of motion (p < 0.05). Reduced mean angular velocity of cervical movement was also observed in both EM and CM compared to CG (p < 0.05). Total cervical range of motion and mean angular velocity showed weak correlations with disability (r = −0.25 and −0.30, respectively; p < 0.05) and weak-to-moderate correlations with kinesiophobia (r = −0.30 and −0.40, respectively; p < 0.05). No significant correlation was observed between headache features and total cervical range of motion or mean angular velocity (p > 0.05). No differences in the percentage of activation of both flexors and extensors cervical muscles during active neck movements were seen (p > 0.05). In conclusion, episodic and chronic migraines were associated with less mobility and less velocity of neck movements, without differences within muscle activity. Neck disability and kinesiophobia are negative and weakly associated with cervical movement.

Association Between Insomnia and Migraine Risk: A Case-Control and Bidirectional Mendelian Randomization Study

Background

The causal relationship between insomnia and migraine is contradictory and no study has been carried out among the Chinese population to date.

Methods

In this case, we conducted a case–control study and a bidirectional mendelian randomization (MR) analysis to determine whether insomnia is causally related to the development of migraine. The instrumental variables for insomnia were derived from the largest genome-wide association study of 1,331,010 participants, while the genetic instruments for migraine were available from the largest meta-analysis of migraine with 59,674 cases and 316,078 controls.

Results

In case–control study, subjects with insomnia have significantly higher risk of migraine (OR=4.29, 95% CI: 3.21–5.74, P<0.001), compared with those without insomnia. The bidirectional two-sample MR analysis revealed that insomnia was significantly associated with higher risk of migraine (OR=1.24, 95% CI: 1.11–1.38, P=1.01×10-4), and the results were validated in the UK Biobank data. The results showed no indication for directional pleiotropy effects as assessed by the MR-Egger intercept (P>0.05).

Conclusion

Conclusively, our study highlighted that increased migraine risk was confined to subjects with a genetic pre-disposition to insomnia, and these findings had potential implications for improving the sleep quality to reduce the burden of migraine.

Percutaneous Interventional Strategies for Migraine Prevention: A Systematic Review and Practice Guideline

OBJECTIVE

To systematically evaluate the efficacy and effectiveness of percutaneous interventional treatments for prevention of migraine through a qualitative and (when possible) quantitative analysis.

METHODS

An expert panel was asked to develop recommendations for the multidisciplinary preventive treatment of migraine, including interventional strategies. The committee conducted a systematic review and (when evidence was sufficient) a meta-analytic review using GRADE criteria and the modified Cochrane risk of bias analysis available in the Covidence data management program. Clinical questions addressed adults with migraine who should be offered prevention. Examined outcomes included headache days, acute medication use, and functional impairment. Acute management of migraine was outside the scope of this guideline.

RESULTS

The committee screened 1195 studies and assessed 352 by full text, yielding 16 randomized controlled trials that met inclusion criteria.

RECOMMENDATIONS/CONCLUSIONS

As informed by evidence related to the preselected outcomes, adverse event profile, cost, and values and preferences of patients, onabotulinumtoxinA received a strong recommendation for chronic migraine prevention and a weak recommendation against use for episodic migraine prevention. Greater occipital nerve blocks received a weak recommendation for chronic migraine prevention. For greater occipital nerve block, steroid received a weak recommendation against use vs local anesthetic alone. Occipital nerve with supraorbital nerve blocks, sphenopalatine ganglion blocks, cervical spine percutaneous interventions, and implantable stimulation all received weak recommendations for chronic migraine prevention. The committee found insufficient evidence to assess trigger point injections in migraine prevention and highly discouraged use of intrathecal medication.

Race, ethnicity, and other sociodemographic characteristics of patients with hospital admission for migraine in the United States

BACKGROUND

Despite the growing awareness across the general population, migraine is often underdiagnosed and undertreated in socially and economically marginalized groups. The present study aimed to investigate the differential effects of race and income on other sociodemographic data and hospital length of stay in patients admitted to hospital with a primary diagnosis of migraine headache.

METHODS

We utilized the Nationwide Inpatient Sample (NIS) database to identify patients admitted to the hospital from 2004 to 2017 with primary diagnosis of migraine. Information on demographic and length of stay data was obtained. Only patients older than 18 years were selected and age outliers were excluded. Race groups were identified as "White", "Black", "Asian or Pacific Islander", "Native American", or "Other ethnic group", as originally reported in the NIS database. Income was identified as the estimated median household income of residents in the patient's ZIP Code.

RESULTS

A total of 106,761,737 valid cases were identified. After applying our case inclusion criteria, only 61453 (median age= 42 years, range= 18-78 years) were included. Patients identified as "Black", "Hispanic" or "Native Americans" were more likely to have lower household income (p < 0.001), whereas higher income was found for the patients identified as "White"", even when men and women were considered separately (p < 0.001). No effects of race and/or household income was found on the length of stay in hospital.

IMPLICATIONS

The occurrence of migraine diagnosis on hospital admission in the USA can be impacted by dramatic culturally driven patient-clinician communication differences between ethnic groups.

Comparison of cervical muscle isometric force between migraine subgroups or migraine-associated neck pain: a controlled study

This study aimed to verify if migraine frequency or migraine-associated neck pain were associated with a reduction of normalized force and altered electromyographic activity during maximal cervical muscle isometric contractions. Additionally, it aimed to assess the correlation of normalized isometric force with years with migraine, headache frequency, headache intensity, migraine-related disability, and severity of cutaneous allodynia. The sample comprises 71 women with migraine (40/31 episodic/chronic, 42/18 with/without neck pain) and 32 women without headache. Cervical muscle isometric force in flexion, extension, and lateral flexion was assessed synchronized with the acquisition of superficial electromyography from the cervical muscles. Women with episodic migraine presented lower normalized isometric force in extension, flexion, and right and left lateral flexions than controls (P < 0.05). Women with migraine and neck pain exhibited lower cervical extension and right/left lateral-flexions normalized isometric force than controls (P < 0.05). No significant differences were observed in antagonist activity. Normalized isometric force in all directions showed weak to moderate correlations with the severity of self-reported symptoms of cutaneous allodynia (- 0.25 ≥ r ≥ - 0.39). No additional linear correlation with clinical migraine features was observed. In conclusion, cervical muscle weakness may be associated with episodic migraine and neck pain concurrent with migraine attacks without altered antagonist activity. Additionally, it may also be related to the severity of cutaneous allodynia.

The chronobiology of migraine: a systematic review

BACKGROUND

The paroxysmal nature of migraine is a hallmark of the disease. Some patients report increased attack frequency at certain seasons or towards the end of the week, while others experience diurnal variations of migraine attack onset. This systematic review investigates the chronobiology of migraine and its relation to the periodicity of attacks in existing literature to further understand the oscillating nature of migraine.

MAIN BODY

PubMed and Embase were systematically searched and screened for eligible articles with outcome measures relating to a circadian, weekly or seasonal distribution of migraine attacks. We found that the majority of studies reported morning hours (6 am-12 pm) as the peak time of onset for migraine attacks. More studies reported Saturday as weekly peak day of attack. There was no clear seasonal variation of migraine due to methodological differences (primarily related to location), however four out of five studies conducted in Norway reported the same yearly peak time indicating a possible seasonal periodicity phenomenon of migraine.

CONCLUSIONS

The findings of the current review suggest a possible role of chronobiologic rhythms to the periodicity of migraine attacks. Future studies are, however, still needed to provide more knowledge of the oscillating nature of migraine.

The effects of the dietary approaches to stop hypertension (DASH) diet on oxidative stress and clinical indices of migraine patients: a randomized controlled trial

AIMS

The relationship between the Dietary Approaches to Stop Hypertension (DASH) diet and oxidative stress (OS) in patients diagnosed with migraine is unknown and remains to be examined. Hence, we conducted a parallel-group, randomized controlled trial to investigate this issue.

METHODS

Of the 102 women who met all the inclusion criteria, 51 individuals were randomized to the DASH diet group and 51 to the usual dietary advice group to receive allocated intervention for three months. In order to assess the compliance of participants to the DASH diet, dietary records, and serum vitamin C levels were examined. Parameters of OS status (e.g. nitric oxide (NO), total antioxidant capacity (TAC), total oxidative status (TOS), malondialdehyde (MDA), and oxidative stress index (OSI)) and clinical indices of migraine (e.g. migraine index (MI), headache dairy result (HDR), and migraine headache index score (MHIS)) were assessed at the beginning and the end of the study.

RESULTS

There was a significant reduction in NO (-5.75 vs. + 4.18, P = 0.025) and TOS (-1.55 vs. + 0.71, P = 0.034), and a marginally significant reduction in OSI (-0.10 vs. + 0.14, P = 0.060) in the DASH group compared with the control. Compliance with the DASH diet resulted in a significant decrease in the score of MI (-31.33 vs. - 15.09), HDR (-5.04 vs. -2.51), and MHIS (-44.21 vs. -26.74). Moreover, no significant change was observed in TAC, MDA, and total thiol content.

CONCLUSION

This type of dietary approach can be considered as a complementary treatment for migraine patients, also further investigations are needed to replicate our findings.Trial registration: Iranian Registry of Clinical Trials identifier: IRCT20121216011763N38.

OnabotulinumtoxinA Improves Quality of Life in Chronic Migraine: The PREDICT Study

BACKGROUND

The PREDICT study assessed real-world, long-term health-related quality of life in adults with chronic migraine (CM) receiving onabotulinumtoxinA.

METHODS

Canadian, multicenter, prospective, observational study in adults naïve to onabotulinumtoxinA for CM. OnabotulinumtoxinA (155-195 U) was administered every 12 weeks over 2 years (≤7 treatment cycles). Primary endpoint: mean change in Migraine-Specific Quality of Life Questionnaire (MSQ) at treatment 4 (Tx4) versus baseline. Secondary endpoints: mean change in MSQ at final visit versus baseline, and headache days.

RESULTS

184 participants (average age 45 years; 84.8% female; 94.6% Caucasian) received ≥1 onabotulinumtoxinA treatment; 150 participants completed 4 treatments (1 year) and 123 completed all 7 treatment cycles (2 years). Mean (SD) onabotulinumtoxinA dose per treatment cycle was 171 (18) U and treatment interval was 13.2 (1.8) weeks. Baseline mean (SD) 20.9 (6.7) headache days/month decreased (Tx1: -3.5 [6.3]; Tx4: -6.5 [6.6]; p < 0.0001 versus baseline). Mean (SD) increased from baseline in MSQ at Tx4 (restrictive: 21.5 [24.3], preventive: 19.5 [24.7], emotional: 22.9 [32.9]) and the final visit (restrictive: 21.3 [23.0], preventive: 19.2 [23.7], emotional: 27.4 [30.7]), exceeding minimal important differences (all p < 0.0001). Seventy-seven (41.8%) participants reported 168 treatment-emergent adverse events (TEAEs); 38 TEAEs (12.0%) were considered treatment-related. Four (2.2%) participants reported six serious TEAEs; none were considered treatment-related. No new safety signals were identified.

CONCLUSIONS

Real-world evidence from PREDICT demonstrates that onabotulinumtoxinA for CM in Canada improved MSQ scores and reduced headache frequency and severity, adding to the body of evidence on the long-term safety and effectiveness of onabotulinumtoxinA for CM.

Learning the full impact of migraine through patient voices: A qualitative study

OBJECTIVE

To better characterize the ways that migraine affects multiple domains of life.

BACKGROUND

Further understanding of migraine burden is needed.

METHODS

Adults with migraine randomized to mindfulness-based stress reduction or headache education arms (n = 81) in two separate randomized clinical trials participated in semistructured in-person qualitative interviews conducted after the interventions. Interviews queried participants on migraine impact on life and were audio-recorded, transcribed, and summarized into a framework matrix. A master codebook was created until meaning saturation was reached and magnitude coding established code frequency. Themes and subthemes were identified using a constructivist grounded theory approach.

RESULTS

Despite most participants being treated with acute and/or prophylactic medications, 90% (73/81) reported migraine had a negative impact on overall life, with 68% (55/81) endorsing specific domains of life impacted and 52% (42/81) describing impact on emotional health. Six main themes of migraine impact emerged: (1) global negative impact on overall life; (2) impact on emotional health; (3) impact on cognitive function; (4) impact on specific domains of life (work/career, family, social); (5) fear and avoidance (pain catastrophizing and anticipatory anxiety); and (6) internalized and externalized stigma. Participants reported how migraine (a) controls life, (b) makes life difficult, and (c) causes disability during attacks, with participants (d) experiencing a lack of control and/or (e) attempting to push through despite migraine. Emotional health was affected through (a) isolation, (b) anxiety, (c) frustration/anger, (d) guilt, (e) mood changes/irritability, and (f) depression/hopelessness. Cognitive function was affected through concentration and communication difficulties.

CONCLUSIONS

Migraine has a global negative impact on overall life, cognitive and emotional health, work, family, and social life. Migraine contributes to isolation, frustration, guilt, fear, avoidance behavior, and stigma. A greater understanding of the deep burden of this chronic neurological disease is needed to effectively target and treat what is most important to those living with migraine.

Scientific Knowledge Graph of Acupuncture for Migraine: A Bibliometric Analysis from 2000 to 2019

OBJECTIVE

This study aims to explore the trend and knowledge mapping of acupuncture for migraine through bibliometrics.

METHODS

It retrieved the literature on acupuncture for migraine in the Web of Science database from 2000 to 2019, and then resorted to CiteSpace to conduct bibliometric analysis to attain the knowledge mapping.

RESULTS

The total number of publications each year has increased year by year, and the average annual growth rate from 2000 to 2009 was 15.57%, while from 2010 to 2019 was 6.35%, with a faster growth rate from 2000 to 2009. According to the cluster analysis of institutions, authors, cited references, and keywords, 10, 7, 12, and 10 categories were gained from 2000 to 2019. The most productive countries, institutions, and authors are the USA and China, Technical University of Munich and Beijing University of Chinese Medicine, Linde K and Liang FR from 2000 to 2019, whose frequency is 119/103, 28/24, and 28/24, respectively. However, the most important of them are Canada, Sichuan University, and Witt CM. Owing to their highest centrality, they are 0.86, 0.54, and 0.27 separately. Moreover, cited references that contributed to the most co-citations are Linde K (2005), yet, the most vital cited reference is Karst M (2001). Keywords such as migraine, acupuncture, headache, pain, and randomized controlled trial are the most frequently used. However, needle acupuncture is the crucial keyword. In the cluster analysis of institutions, authors, cited references, and keywords from 2000 to 2019, the largest cluster categories are #0 migraine prophylaxis, #1 randomized controlled trial, #0 episodic migraine, and #0 topiramate treatment. Then, randomized controlled trials of acupuncture prevention and treatment of migraine are the most important research content in this field.

CONCLUSION

Through the bibliometric analysis of the research on acupuncture for migraine in the Web of Science database in the past 20 years, the trends and the Knowledge Graph of the country, institution, author, cited reference, and the keyword are acquired, which have an important guiding significance for quickly and accurately positioning the key information in the field.

Dietary alteration of n-3 and n-6 fatty acids for headache reduction in adults with migraine: randomized controlled trial

OBJECTIVE

To determine whether dietary interventions that increase n-3 fatty acids with and without reduction in n-6 linoleic acid can alter circulating lipid mediators implicated in headache pathogenesis, and decrease headache in adults with migraine.

DESIGN

Three arm, parallel group, randomized, modified double blind, controlled trial.

SETTING

Ambulatory, academic medical center in the United States over 16 weeks.

PARTICIPANTS

182 participants (88% women, mean age 38 years) with migraines on 5-20 days per month (67% met criteria for chronic migraine).

INTERVENTIONS

Three diets designed with eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and linoleic acid altered as controlled variables: H3 diet (n=61)-increase EPA+DHA to 1.5 g/day and maintain linoleic acid at around 7% of energy; H3-L6 diet (n=61)-increase n-3 EPA+DHA to 1.5 g/day and decrease linoleic acid to ≤1.8% of energy; control diet (n=60)-maintain EPA+DHA at <150 mg/day and linoleic acid at around 7% of energy. All participants received foods accounting for two thirds of daily food energy and continued usual care.

MAIN OUTCOME MEASURES

The primary endpoints (week 16) were the antinociceptive mediator 17-hydroxydocosahexaenoic acid (17-HDHA) in blood and the headache impact test (HIT-6), a six item questionnaire assessing headache impact on quality of life. Headache frequency was assessed daily with an electronic diary.

RESULTS

In intention-to-treat analyses (n=182), the H3-L6 and H3 diets increased circulating 17-HDHA (log ng/mL) compared with the control diet (baseline-adjusted mean difference 0.6, 95% confidence interval 0.2 to 0.9; 0.7, 0.4 to 1.1, respectively). The observed improvement in HIT-6 scores in the H3-L6 and H3 groups was not statistically significant (-1.6, -4.2 to 1.0, and -1.5, -4.2 to 1.2, respectively). Compared with the control diet, the H3-L6 and H3 diets decreased total headache hours per day (-1.7, -2.5 to -0.9, and -1.3, -2.1 to -0.5, respectively), moderate to severe headache hours per day (-0.8, -1.2 to -0.4, and -0.7, -1.1 to -0.3, respectively), and headache days per month (-4.0, -5.2 to -2.7, and -2.0, -3.3 to -0.7, respectively). The H3-L6 diet decreased headache days per month more than the H3 diet (-2.0, -3.2 to -0.8), suggesting additional benefit from lowering dietary linoleic acid. The H3-L6 and H3 diets altered n-3 and n-6 fatty acids and several of their nociceptive oxylipin derivatives in plasma, serum, erythrocytes or immune cells, but did not alter classic headache mediators calcitonin gene related peptide and prostaglandin E2.

CONCLUSIONS

The H3-L6 and H3 interventions altered bioactive mediators implicated in headache pathogenesis and decreased frequency and severity of headaches, but did not significantly improve quality of life.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02012790.

The current state of headache medicine education in the United States and Canada: An observational, survey-based study of neurology clerkship directors and curriculum deans

OBJECTIVE

To investigate the current headache medicine education paradigm in allopathic and osteopathic medical schools in the United States and Canada.

BACKGROUND

There is a disparity in the number of clinicians specially trained to treat patients with headache disorders and the number of people who have them. Early education and exposure to headache medicine is crucial to address this disparity. However, the current state of headache education within medical schools across the United States and Canada is unknown.

METHODS

The authors created a medical student headache education survey, which is a 20-question REDCap survey that was distributed via email to the neurology clerkship director, curriculum dean, or similar role at each US and Canadian MD or DO conferring medical school. The email listserv was created using the American Academy of Neurology Clerkship Directory, the Association of American Medical Colleges Organization Directory, the American Association of College of Osteopathic Medicine Organization Directory, manual searches of the institutions' websites, and phone calls and emails to administrators as needed.

RESULTS

Of the 249 individuals contacted, 78 completed the survey, yielding a response rate of 31.3%. Of those responses, 84.6% of respondents (66/78) reported that their institution has at least one mandatory session on headache disorders. Many of these sessions (72.7% (48/78)) occurred during preclinical training, and 74.2% (49/78) occurred as part of the clinical curricula. Of respondents, 44.9% (39/78) reported that their institutions coordinate headache education across training levels (i.e., from preclinical to clinical), and only 17.9% (14/78) coordinate across clinical rotations. The most common topics covered were headache red flags, migraine, pharmacologic management, and differentiating primary versus secondary headache. 65.4% of respondents (51/78) felt that the preclinical headache curriculum prepares their students for the clinical experience, and 55.1% (43/78) felt that medical students were learning enough about headache medicine at their institution. Barriers to educating medical students about headache included insufficient time during courses, lack of administrative support in curricula development, lack of available resources, and lack of student interest. Case-based learning modules and online lectures were the most desired educational materials to improve medical student headache education at their institution.

CONCLUSIONS

The majority of medical schools report incorporating headache medicine education into preclinical or clinical curricula and cover a range of topics in headache medicine. Yet there remains a lack of consistency, with some reporting limited headache education, citing barriers such as lack of administrative support and available educational resources. There is also variation in what is being taught at the medical student level. Future projects should aim to address said barriers, with the goal of providing a standardized headache medicine curriculum for use across medical schools.

Effects of combining manual therapy, neck muscle exercises, and therapeutic pain neuroscience education in patients with migraine: a study protocol for a randomized clinical trial

BACKGROUND

Non-pharmacological approaches for the management of migraine exhibit low to moderate effectiveness due to a lack of high-quality randomized clinical trials. In fact, previous studies applied isolated techniques, which were not representative of common clinical practice. A multimodal approach for migraine may benefit these patients more than isolated approaches. This randomized clinical trial aims to determine the effectiveness of a multimodal protocol combining manual therapy, exercise, and therapeutic pain neuroscience education versus the application of manual therapy or pain neuroscience education alone in patients with migraine.

METHODS

This clinical trial will include 75 individuals of both sexes, aged between 18 and 55 years, with migraine. Participants will be randomized into three groups: the therapeutic pain neuroscience education (TPNE; n = 25) group, the manual therapy (MT; n = 25) group, and the multimodal (MM; n = 25) group. The TPNE group will receive one orientation session on migraine and pain self-management, and recommendations for daily active stretching and walking, with subsequent therapist monitoring. The MT group will receive manual therapies targeting musculoskeletal disorders of the cervical spine. The MM group will receive manual therapies targeting musculoskeletal disorders of the cervical spine, active neck exercises, and therapeutic pain neuroscience education. The treatment period will last 12 weeks. The primary outcome will be the headache impact, measured using the Headache Impact Test (HIT-6). Secondary outcomes will include migraine frequency and intensity, cervical mobility and strength parameters, neck pain-related disability, kinesiophobia, cutaneous allodynia, pain-related catastrophizing, quality of life, and self-perception of change. All outcomes will be evaluated at the fourth, eighth, and twelfth weeks of the treatment period. Primary and secondary clinical outcomes, such as headache impact, frequency, and intensity, will also be evaluated at the 1-, 2-, and 4-month follow-ups.

DISCUSSION

The results of this randomized clinical trial may provide high-quality clinical evidence of the effects of non-pharmacological treatment options for the management of migraine.

TRIAL REGISTRATION

This study was registered under the access code RBR-7s22c75 in the Registro Brasileiro de Ensaios Clínicos (ReBEC) in December 2020.

A pilot study of the feasibility of a Swedish multimodal group intervention for severe migraine—The migraine patient school

Objectives:

To evaluate a multidisciplinary group intervention, the migraine patient school (MPS), for patients with severe, mostly chronic migraine.

Method:

A 13-week group intervention program including seven sessions of patient education, practical body awareness and relaxation exercises, and home assignments was performed in small groups with 5–11 participants. Four groups were consecutively included from spring 2014 to fall 2015. Headache diaries and standardized and study-specific questionnaires were used for evaluation at baseline before MPS (pre-interventional phase), and at follow-up.

Results:

Twenty-four of 30 included patients completed the study, i.e. attended ≥ four sessions. Most participants found it rewarding to participate in the MPS and easy to take part in, understand and complete home assignments. Validated standardized questionnaires delivered before, and after (follow-up) MPS showed that the impact on life (HIT-6) and avoidance behavior (PIPS-A) were significantly improved whereas quality of life (MSQL), anxiety and depression (HAD) and perceived stress (PSS-14) did not show a statistically significant change.

Conclusion:

The Migraine patient school with a multimodal educational and behavioral group intervention program was feasible to perform and seem to benefit patients with severe (high-frequency or chronic) migraine.

Noninvasive Neuromodulation in Headache: An Update

Background

Migraine is a common disabling primary headache condition. Although strives have been made in treatment, there remains an unmet need for safe, effective acute, and preventative treatments. The promising concept of neuromodulation of relevant neuronal targets in a noninvasive fashion for the treatment of primary headache disorders has led to the trial of numerous devices over the years.

Objective

We aimed to review the evidence on current neuromodulation treatments available for the management of primary headache disorders.

Methods

Randomized controlled trial as well as open-label and real-world studies on central and peripheral cephalic and noncephalic neuromodulation modalities in primary headaches were critically reviewed.

Results

The current evidence suggests a role of single-pulse transcranial magnetic stimulation, supraorbital nerve stimulation, and remote noncephalic electrical stimulation as migraine abortive treatments, with stronger evidence in episodic rather than in chronic migraine. Single-pulse transcranial magnetic stimulation and supraorbital nerve stimulation also hold promising evidence in episodic migraine prevention and initial positive evidence in chronic migraine prevention. More evidence should clarify the therapeutic role of the external vagus nerve stimulation and transcranial direct current stimulation in migraine. However, external vagus nerve stimulation may be effective in the acute treatment of episodic but not chronic cluster headache, in the prevention of hemicrania continua and paroxysmal hemicrania but not of short-lasting neuralgiform headache attacks. The difficulty in setting up sham-controlled studies has thus far prevented the publication of robust trials. This limitation along with the cost of these therapies has meant that their use is limited in most countries.

Conclusion

Neuromodulation is a promising nonpharmacological treatment approach for primary headaches. More studies with appropriate blinding strategies and reduction of device cost may allow more widespread approval of these treatments and in turn increase clinician's experience in neuromodulation.

Changes and Associations between Cervical Range of Motion, Pain, Temporomandibular Joint Range of Motion and Quality of Life in Individuals with Migraine Applying Physiotherapy: A Pilot Study

Background and Objectives: The aim of this study was to assess the effects of physiotherapy with aerobic exercise together with temporomandibular joint range of motion exercises (supervised) and physiotherapy with aerobic exercise only (unsupervised), also to review the correlations between neck movements, pain, temporomandibular joint range of motion movements and quality of life in individuals with migraine. Methods: The flexion, extension and lateral flexion of the cervical spine were measured in degrees with a mechanical goniometer and pressure pain thresholds with algometer. Quality of life was assessed with the SF-36 questionnaire and temporomandibular joint range of motion with a centimeter. Results: The study showed statistically significant cervical flexion results in both groups (p < 0.05), masticatory muscle results and temporomandibular joint range of motion between the groups (p < 0.05). A correlation between left upper trapezius muscle pain and cervical lateral flexion was observed in the intervention group. Physical activity correlated with cervical extension, activity limitation due to physical ailments and general health. A correlation between temporomandibular joint and right-side masticatory muscles pain was found. A correlation between upper trapezius muscle pain and left- as well as right-side temporalis muscles were found in the control group. Strong correlations were found between pain and activity limitation due to physical ailments and emotional state. The temporomandibular joint range of motion strongly correlated with activity limitation due to physical ailments. Conclusions: Physiotherapy based on aerobic exercises together with temporomandibular joint exercises was more effective than physiotherapy based on aerobic exercise for decreasing pain, increasing pressure pain thresholds and cervical range of motion.

Ubrogepant for the Acute Treatment of Migraine: Pooled Efficacy, Safety, and Tolerability From the ACHIEVE I and ACHIEVE II Phase 3 Randomized Trials

INTRODUCTION

Ubrogepant is an oral, small-molecule calcitonin gene-related peptide receptor antagonist approved for the acute treatment of migraine. The efficacy and safety of ubrogepant were demonstrated in two pivotal phase 3, single-attack, randomized, placebo-controlled trials (ACHIEVE I and ACHIEVE II).

METHODS

We conducted a post hoc analysis of pooled data from the ACHIEVE trials to evaluate the efficacy, safety, and tolerability of ubrogepant 50 mg (the only dose evaluated in both trials) versus placebo across a large population of participants with migraine. The coprimary efficacy outcomes were pain freedom and absence of the most bothersome migraine-associated symptom (including photophobia, phonophobia, and nausea) at 2 h post dose. Secondary outcomes included pain relief at 2 h post dose, sustained pain relief and pain freedom from 2 to 24 h, and absence of specific migraine-associated symptoms at 2 h post dose.

RESULTS

A total of 2240 eligible participants were randomized to placebo (n = 1122) or ubrogepant 50 mg (n = 1118) in the ACHIEVE trials. Pain freedom at 2 h was reported in 13.0% of participants in the pooled placebo group and 20.5% in the pooled ubrogepant 50 mg group (odds ratio [OR] 1.72; 95% confidence interval [CI] 1.34, 2.22; P < 0.001). Absence of the most bothersome migraine-associated symptom at 2 h was reported by 27.6% in the pooled placebo group and by 38.7% in the pooled ubrogepant 50 mg group (OR 1.68; 95% CI 1.37, 2.05; P < 0.001). Adverse events (AEs) within 48 h after the initial or optional second dose were reported by 11.5 and 11.2% of participants in the pooled placebo and pooled ubrogepant 50 mg groups, respectively. The most common AE was nausea (1.8 and 1.9%, respectively). No serious AEs related to treatment or discontinuations due to AEs were reported.

CONCLUSION

These results further support the efficacy, safety, and tolerability of ubrogepant for the acute treatment of migraine.

TRIAL REGISTRATION

ClinicalTrials.gov Identifiers: ACHIEVE I: NCT02828020; ACHIEVE II: NCT02867709.

Preventive Migraine Treatment

PURPOSE OF REVIEW

This article provides an overview of preventive interventions for migraine, including when to start and how to choose a treatment, pharmacologic options (both older oral treatments and new monoclonal antibodies to calcitonin gene-related peptide [CGRP] or its receptor), nonpharmacologic treatment such as neuromodulation, and preventive treatment of refractory migraine.

RECENT FINDINGS

The migraine preventive treatment landscape has been transformed by the development of monoclonal antibodies targeting CGRP or its receptor. These treatments, which are given subcutaneously or intravenously monthly or quarterly, have high efficacy and were well tolerated in clinical trials. Emerging real-world studies have found higher rates of adverse events than were seen in clinical trials. They are currently recommended for use if two traditional preventive therapies have proven inadequate. Since the commonly cited 2012 American Headache Society/American Academy of Neurology migraine prevention guidelines were released, clinical trials supporting the preventive use of lisinopril, candesartan, and memantine have been published. Neuromodulation devices, including external trigeminal nerve stimulation and single-pulse transcranial magnetic stimulation devices, have modest evidence to support preventive use. The American Headache Society/American Academy of Neurology guidelines for the preventive treatment of migraine are currently being updated. A new class of oral CGRP receptor antagonists (gepants) is being tested for migraine prevention.

SUMMARY

Successful preventive treatment of migraine reduces disease burden and improves quality of life. Many pharmacologic and nonpharmacologic treatment options are available for the prevention of migraine, including newer therapies aimed at the CGRP pathway as well as older treatments with good evidence for efficacy. Multiple treatment trials may be required to find the best preventive for an individual patient.

Acute and Preventive Management of Migraine during Menstruation and Menopause

Migraine course is influenced by female reproductive milestones, including menstruation and perimenopause; menstrual migraine (MM) represents a distinct clinical entity. Increased susceptibility to migraine during menstruation and in perimenopause is probably due to fluctuations in estrogen levels. The present review provides suggestions for the treatment of MM and perimenopausal migraine. MM is characterized by long, severe, and poorly treatable headaches, for which the use of long-acting triptans and/or combined treatment with triptans and common analgesics is advisable. Short-term prophylaxis with triptans and/or estrogen treatment is another viable option in women with regular menstrual cycles or treated with combined hormonal contraceptives; conventional prevention may also be considered depending on the attack-related disability and the presence of attacks unrelated to menstruation. In women with perimenopausal migraine, hormonal treatments should aim at avoiding estrogen fluctuations. Future research on migraine treatments will benefit from the ascertainment of the interplay between female sex hormones and the mechanisms of migraine pathogenesis, including the calcitonin gene-related peptide pathway.

Female Gender Is Associated with a Higher Prevalence of Chronic Neck Pain, Chronic Low Back Pain, and Migraine: Results of the Spanish National Health Survey, 2017

OBJECTIVES

To assess the prevalence of chronic neck pain (CNP), chronic low back pain (CLBP), and migraine headache (MH) in the Spanish population and to identify sociodemographic and health-related variables associated with CNP, CLBP, and MH.

DESIGN

Observational study.

SETTING

Spain.

SUBJECTS

A total of 22,511 persons 18 years of age or older (10,304 males and 12,207 females) who participated in the 2017 Spanish National Health Survey.

METHODS

Stratified three-stage sampling was applied. CNP, CLBP, and MH were the dependent variables. The analysis was conducted separately by gender. Sociodemographic features, self-perceived health status, lifestyle habits, comorbidities, and pain features were analyzed by using logistic regression models.

RESULTS

Females reported a higher prevalence of CNP, CLBP, and MH (P < 0.001) than males. For both sexes, anxiety and/or depression and poor self-rated health were associated with a significantly increased prevalence of CNP, CLBP, and MH. For CNP and CLBP, the identified associated factors were older age and limitations to usual activity. For CNP and MH, the most common associated factor was comorbid respiratory disease.

CONCLUSIONS

Our study identified several factors associated with CNP, CLBP, and MH in Spanish female and male adults, with potential implications for health care providers.

The Efficacy of Herbal Supplements and Nutraceuticals for Prevention of Migraine: Can They Help?

Migraine is a common neurological disorder associated with or without aura. Although the pathophysiology of migraine is not very well understood, pro-inflammatory cytokines and oxidative stress biomarkers are found to be increased in migraine. Multiple studies have been done to see if alternative medicine such as herbal supplements and nutraceuticals are effective in the prevention and treatment of migraine headaches. This review aimed to evaluate the effect of supplements like coenzyme Q10, riboflavin (vitamin B2), feverfew, and magnesium on the frequency, severity, and duration of migraine attacks. We performed a thorough literature search using mainly PubMed. We included studies published in the last 10 years, those conducted among adult human participants 18-65 years of age, and those published in the English language. Based on the articles selected for the final review, we concluded that herbal supplements and nutraceuticals help reduce the frequency of migraine headaches; however, mixed results were seen regarding the severity and duration of headaches. Moreover, there were no concerning side effects with these supplements. Therefore, physicians can suggest herbal supplements to patients who experience adverse effects from pharmaceutical drugs and desire a more natural treatment.

A Single Supratherapeutic Dose of Atogepant Does Not Affect Cardiac Repolarization in Healthy Adults: Results From a Randomized, Single-Dose, Phase 1 Crossover Trial

Atogepant is a selective, oral calcitonin gene–related peptide receptor antagonist in development for preventive treatment of migraine. This randomized, double‐blind, phase 1 crossover study evaluated the cardiac repolarization effect of a single supratherapeutic (300 mg) atogepant dose vs placebo in healthy adults. Moxifloxacin 400 mg was the open‐label active control. The primary end point was a change from baseline in Fridericia‐corrected QT intervals (ΔQTcF). Sixty participants were randomized to atogepant 300 mg, placebo, and moxifloxacin; 59 (98.3%) completed all interventions. Assay sensitivity was confirmed: lower 90% confidence interval limit for QTcF interval change from baseline (ΔΔQTcF) for moxifloxacin was >5 millisecond vs placebo at prespecified 2‐, 3‐, and 4‐hour time points. Following single‐dose atogepant 300 mg, mean atogepant ΔΔQTcF and upper 90% confidence interval limits were lower than the 10‐millisecond threshold at all time points. Atogepant mean peak plasma concentration was 3197 ng/mL, area under the concentration‐time curve from time 0 to time t was 16 640 ng • h/mL, area under the concentration‐time curve from time 0 to 24 hours was 16 607 ng • h/mL, and median time to peak plasma concentration was 2.1 hours. The incidence of adverse events was low; no serious adverse events or elevations of liver enzymes were reported. Overall, a single supratherapeutic dose of atogepant was safe and did not impact cardiac repolarization in healthy participants.

Plasma calcitonin gene-related peptide (CGRP) in migraine and endometriosis during the menstrual cycle

OBJECTIVE

Migraine, endometriosis, and the comorbidity of both are frequent pain disorders of special relevance for women. The neuropeptide calcitonin gene-related peptide (CGRP) is critically involved in migraine, and circumstantial evidence suggests a role in endometriosis. We assessed CGRP levels at different times of menstrual cycle in four groups: healthy women, women with migraine or endometriosis and with the comorbidity of both.

METHODS

Women with episodic migraine and women with a histologically confirmed endometriosis were recruited from specialized centers. For CGRP determination with a commercial enzyme immunoassay kit, cubital vein blood samples were collected on menstrual cycle day 2 ± 2 (during menstruation) and on day 15 ± 2 (periovulatory period). The primary endpoint of the study was the absolute difference of CGRP plasma levels between the menstrual and the periovulatory phase of all study groups. Groups were compared using nonparametric test procedures.

RESULTS

A total of 124 women were included in the study. The change of CGRP plasma levels between menstruation and the periovulatory period was different between groups (p = 0.007). Women with comorbid migraine and endometriosis showed an increase of CGRP in the menstrual phase of +6.32 (interquartile range, IQR -3.64-13.60) compared to the periovulatory time, while healthy controls had a decrease of -10.14 (-22.54-0.91, p = 0.004). CGRP levels were different in the periovulatory phase among groups (p = 0.008), with highest values in healthy controls.

INTERPRETATION

CGRP levels change significantly during the menstrual cycle. Different patterns in women with the comorbidity point to a deviant regulation of CGRP release.

Identification of work accommodations and interventions associated with work productivity in adults with migraine: A scoping review

OBJECTIVE

To identify factors associated with work productivity in adults with migraine, and accommodations or interventions to improve productivity or the workplace environment for them.

METHODS

We conducted a scoping review by searching MEDLINE, Embase, PsycINFO, Cumulative Index of Nursing and Allied Heath Literature, and Web of Science from their inception to 14 October 2019 for studies of any design that assessed workplace productivity in adults with migraine.

RESULTS

We included 26 articles describing 24 studies after screening 4139 records. Five prospective cohort studies showed that education on managing migraine in the workplace was associated with an increase in productivity of 29-36%. Two studies showed that migraine education and management in the workplace were associated with increased productivity (absenteeism decreased by 50% in one study). One prospective cohort study showed that occupational health referrals were associated with more than 50% reduction in absenteeism. Autonomy, social support, and job satisfaction were positively associated with productivity, while quantitative demands, emotional demands, job instability, and non-conducive work environment triggers are negatively associated with productivity in workers with migraine.

CONCLUSION

Despite migraine being the second leading cause of disability worldwide, there is a paucity of strong data on migraine-related work factors associated with productivity.Registration: None (scoping review).

Network Pharmacology and Metabolomics Studies on Antimigraine Mechanisms of Da Chuan Xiong Fang (DCXF)

Background

Da Chuan Xiong Fang (DCXF) is a traditional Chinese medicine (TCM) formula used to treat migraines. Previously, we uncovered partial mechanisms involved in the therapeutic actions of DCXF on migraines.

Methods

In this study, we further elucidated its antimigraine mechanisms in vivo by using an integrated strategy coupling with network pharmacology and metabolomics techniques.

Results

Network pharmacology identified 33 genes linked with both migraine and DCXF, most of which were 5-hydroxytryptamine receptors, dopamine, and peptide receptors. The results of GO and KEGG enrichment analysis showed that DCXF significantly regulated tyrosine metabolism, tryptophan metabolism, dopamine metabolic process, glucose transmembrane transport, lipid metabolism, and fatty acid transport. The results of metabolomics analysis found that the metabolism of tryptophan and tyrosine in the brain tissue and energy and lipid metabolism of rats tended towards normal and reached normal levels after administering DCXF. The metabolomics and network pharmacology approaches demonstrated similar antimigraine effects of DCXF on endogenous neurotransmitters and overall trends in serum and brain tissue. Using both approaches, 62 hub genes were identified from the protein-protein interaction (PPI) network of DCXF and gene-metabolite interaction network, with hub genes and different metabolites in serum and brain tissue. The hub genes of DCXF, which were mostly linked with inflammation, might affect mainly neurotransmitters in serum and brain tissue metabolisms.

Conclusion

Network pharmacology and metabolomics study may help identify hub genes, metabolites, and possible pathways of disease and treatment. Additionally, two parts of the results were integrated to confirm each other. Their combination may help elucidate the relationship between hub genes and metabolites and provide the further understanding of TCM mechanisms.

Pathophysiological Bases of Comorbidity in Migraine

Despite that it is commonly accepted that migraine is a disorder of the nervous system with a prominent genetic basis, it is comorbid with a plethora of medical conditions. Several studies have found bidirectional comorbidity between migraine and different disorders including neurological, psychiatric, cardio- and cerebrovascular, gastrointestinal, metaboloendocrine, and immunological conditions. Each of these has its own genetic load and shares some common characteristics with migraine. The bidirectional mechanisms that are likely to underlie this extensive comorbidity between migraine and other diseases are manifold. Comorbid pathologies can induce and promote thalamocortical network dysexcitability, multi-organ transient or persistent pro-inflammatory state, and disproportionate energetic needs in a variable combination, which in turn may be causative mechanisms of the activation of an ample defensive system with includes the trigeminovascular system in conjunction with the neuroendocrine hypothalamic system. This strategy is designed to maintain brain homeostasis by regulating homeostatic needs, such as normal subcortico-cortical excitability, energy balance, osmoregulation, and emotional response. In this light, the treatment of migraine should always involves a multidisciplinary approach, aimed at identifying and, if necessary, eliminating possible risk and comorbidity factors.

Chronic Migraine and Medication Overuse Headache Worsening After OnabotulinumtoxinA Withdrawn Due to the Severe Acute Respiratory Syndrome-Coronavirus-2 Pandemic

Introduction: OnabotulinumtoxinA (BT-A) is a preventive treatment for chronic migraine (CM), which needs to be administered regularly by a trained clinician every 3 months. The spread of the severe acute respiratory syndrome coronavirus-2 pandemic has forced many patients to momentarily stop the scheduled BT-A injections. The goal of this study was to explore whether those patients experienced a worsening of their CM and, if any, the clinical predictors of migraine worsening after BT-A withdrawal.

Methods: This was a retrospective, multicenter study. Patients' clinical data were obtained from their clinical documentation stored at each center. In particular, the following variables were collected: the mean number of headache days in the last month (NHD), the average number of painkillers taken in the last month (AC), the average number of days in which patients took, at least, one painkiller in the last month (NDM), the average intensity of migraine using the numeric rating scale (NRS) score in the last month, and the average score obtained at the six-item Headache Impact Test. The variables mentioned earlier were compared before and after BT-A withdrawal.

Results: After BT-A suspension, there was a significant increase in the NHD (P = 0.0313, Kruskal–Wallis rank test), AC (P = 0.0421, Kruskal–Wallis rank test), NDM (P = 0.0394, paired t-test), NRS score (P = 0.0069, Kruskal–Wallis rank test), and six-item Headache Impact Test score (P = 0.0372, Kruskal–Wallis rank test). Patients who were not assuming other preventive treatments other than BT-A displayed similar results. Patients who experienced a >30% worsening in NHD after BT-A was withdrawn displayed a longer CM history (P = 0.001, Kruskal–Wallis rank test), a longer MOH duration (P = 0.0017, Kruskal–Wallis rank test), a higher AC value at the baseline (P = 0.0149, Kruskal–Wallis rank test), a higher NDM (P = 0.0024, t-test), and a higher average value of the NRS score (P = 0.0073, Kruskal–Wallis rank test).

Conclusion: BT-A withdrawn during severe acute respiratory syndrome coronavirus-2 pandemic was associated with a general worsening in patients suffering from CM, hence the need to continue BT-A injection to avoid patients' worsening.

Characteristics of Adults with Migraine in Alberta, Canada: A Population-Based Study

BACKGROUND

Migraine, including episodic migraine (EM) and chronic migraine (CM), is a common neurological disorder that imparts a substantial health burden.

OBJECTIVE

Understand the characteristics and treatment of EM and CM from a population-based perspective.

METHODS

This retrospective population-based cross-sectional study utilized administrative data from Alberta. Among those with a migraine diagnostic code, CM and EM were identified by an algorithm and through exclusion, respectively; characteristics and migraine medication use were examined with descriptive statistics.

RESULTS

From 79,076 adults with a migraine diagnostic code, 12,700 met the criteria for CM and 54,686 were considered to have EM. The majority of migraineurs were female, the most common comorbidity was depression, and individuals with CM had more comorbidities than EM. A larger proportion of individuals with CM versus EM were dispensed acute (80.6%: CM; 63.4%: EM) and preventative (58.0%: CM; 28.9%: EM) migraine medications over 1 year. Among those with a dispensation, individuals with CM had more acute (13.6 ± 32.2 vs. 4.6 ± 10.9 [mean ± standard deviation], 95% confidence interval [CI] 7.7-8.3), and preventative (12.6 ± 43.5 vs. 5.0 ± 12.6, 95% CI 6.9-8.4) migraine medication dispensations than EM, over 1-year. Opioids were commonly used in both groups (proportion of individuals dispensed an opioid over 1-year: 53.1%: CM; 25.7%: EM).

CONCLUSIONS

Individuals with EM and CM displayed characteristics and medication use patterns consistent with other reports. Application of this algorithm for CM may be a useful and efficient means of identifying subgroups of migraine using routinely collected health data in Canada.

Lasmiditan for the acute treatment of migraine

Migraine is a leading cause of morbidity and disability worldwide. Triptans were the first migraine-specific drug class developed and have proven efficacy in treatment of this neurological disease. They are however contraindicated in patients with cardiovascular disease and possibly others, owning to their vasoconstrictive properties. This review will focus on lasmiditan, which has been called the first 'ditan' and 'neurally acting anti-migraine agent', designed to selectively agonize the serotonin 5-HT_1F receptor subtype, providing anti-migraine effects without concomitant vasoconstriction. To date, lasmiditan has proven safe and effective for the acute treatment of migraine in two Phase II and four Phase III trials. Post hoc analysis revealed that the majority of treatment-emergent adverse events were CNS-related, mild-to-moderate in severity and self-limiting. The US FDA label recommends that patients not drive or operate machinery until at least 8 h after taking each dose of lasmiditan.

A device review of Relivion®: an external combined occipital and trigeminal neurostimulation (eCOT-NS) system for self-administered treatment of migraine and major depressive disorder

Introduction: Many patients with migraine are non-responsive or intolerant to pharmaceutical or surgical interventions. Peripheral nerve stimulation (PNS) offers a potential solution for these patients. This review discusses the external combined occipital and trigeminal neurostimulation (eCOT-NS) provided by the Relivion®, a multi-channel head-mounted device for self-administered PNS.Areas covered: Challenges and advantages of PNS systems for the treatment of migraine and depression are introduced, followed by an overall review of clinical evidence of the efficacy of the Relivion® system in treating migraine. The supporting smartphone app and cloud-based analytics which enable remote treatment management by the health care provider are also discussed. Recent empirical indications for the potency of this PNS combination for the treatment of depression are also summarized.Expert opinion: Relivion® is an eCOT-NS system, featuring Food and Drug Administration-approved, noninvasive, self-administered, customizable, multi-focal PNS for the treatment of migraine. In accordance with current telehealth trends, the Relivion® also enhances remote disease management and personalization using digital-monitoring, cloud-based technology, and artificial intelligence. As research on this system progresses, it may become the preferred treatment for the management of a number of neurological and psychiatric diseases, with migraine and major depressive disorders as precedents.

Pharmacokinetics and safety of ubrogepant when coadministered with calcitonin gene-related peptide-targeted monoclonal antibody migraine preventives in participants with migraine: A randomized phase 1b drug-drug interaction study

Objective

To evaluate the impact of two calcitonin gene–related peptide (CGRP)‐targeted monoclonal antibodies (mAbs), erenumab and galcanezumab, on the pharmacokinetic (PK) profile, safety, and tolerability of ubrogepant.

Background

People taking CGRP‐targeted mAbs for migraine prevention sometimes take ubrogepant, an oral small‐molecule CGRP receptor antagonist, for acute treatment of breakthrough migraine attacks.

Design

In this two‐arm, multicenter, open‐label, phase 1b trial, adults with migraine were randomized to arm 1 (ubrogepant ± erenumab) or arm 2 (ubrogepant ± galcanezumab). The PK profile of ubrogepant was characterized for administration before and 4 days after CGRP‐targeted mAb injection. Participants received single‐dose ubrogepant 100 mg on day 1, subcutaneous erenumab 140 mg (arm 1) or galcanezumab 240 mg (arm 2) on day 8, and ubrogepant 100 mg once daily on days 12–15. In each study arm, serial blood samples were drawn on days 1 and 12 for measurement of plasma ubrogepant concentrations. The primary outcomes were area under the plasma ubrogepant concentration–time curve (AUC) from time 0 to t post‐dose (AUC_0–t) and from time 0 to infinity (AUC_0–inf), and maximum plasma concentration (C_max) of ubrogepant when ubrogepant was administered before or after a single dose of erenumab or galcanezumab. Vital signs and laboratory parameters were monitored.

Results

Forty participants enrolled (20 per arm; mean [standard deviation] ages, 32.2 [8.9] and 38.4 [8.8] years; 50% [10/20] and 60% [12/20] female in arms 1 and 2, respectively). There were no significant differences in ubrogepant C_max after versus before erenumab administration (geometric least‐squares mean [LSM] ratio, 1.04 [90% CI, 0.93–1.16]), and no significant differences in AUC_0–t (1.06 [0.96–1.16]) or AUC_0–inf (1.05 [0.96–1.15]). Similarly, ubrogepant C_max (1.00 [90% CI, 0.82–1.20]), AUC_0–t (1.05 [0.90–1.23]), and AUC_0–inf (1.05 [0.90–1.22]) geometric LSM ratios were statistically equivalent after galcanezumab versus ubrogepant alone. Treatment‐emergent adverse events (TEAEs) were similar to those reported with each treatment alone. No serious TEAEs, TEAEs leading to discontinuation, or clinically relevant changes in laboratory parameters or vital signs were reported.

Conclusions

The PK profile of ubrogepant was not significantly changed and no safety concerns were identified when ubrogepant was coadministered with erenumab or galcanezumab.