Diagnosis and Management of Headache: A Review

Efficacy and safety of simple analgesics for acute treatment of episodic tension-type headache in adults: a network meta-analysis

OBJECTIVE

Tension-type headache is the most common type of primary headache and results in a huge socioeconomic burden. This network meta-analysis (NMA) aimed to compare the efficacy and safety of simple analgesics for the treatment of episodic tension-type headache (ETTH) in adults.

METHODS

We searched the Cochrane Library, PubMed, Web of Science, Embase, Chinese BioMedical Literature database and International Clinical Trials Registry Platform databases for eligible randomized clinical trials reporting the efficacy and/or safety of simple analgesics. A Bayesian NMA was performed to compare relative efficacy and safety. The surface under the cumulative ranking curve (SUCRA) was calculated to rank interventions. PROSPERO registration number: CRD42018090554.

RESULTS

We highlighted six studies including 3507 patients. For the 2 h pain-free rate, the SUCRA ranking was ibuprofen > diclofenac-K > ketoprofen > acetaminophen > naproxen > placebo. All drugs except naproxen reported a higher 2 h pain-free rate than placebo, with a risk ratio (RR) of 2.86 (95% credible interval, CrI: 1.62-5.42) for ibuprofen and 2.61 (1.53-4.88) for diclofenac-K. For adverse events rate, the SUCRA ranking was: metamizol > diclofenac-K > ibuprofen > lumiracoxib > placebo > aspirin > acetaminophen > naproxen > ketoprofen. The adverse event rates of all analgesics were no higher than those of placebo, except for ketoprofen. Moreover, all drugs were superior to placebo in the global assessment of efficacy. In particular, the RR of lumiracoxib was 2.47 (1.57-4.57). Global heterogeneity I2 between the studies was low.

CONCLUSIONS

Simple analgesics are considered more effective and safe as a placebo for ETTH in adults. Our results suggest that ibuprofen and diclofenac-K may be the two best treatment options for patients with ETTH from a comprehensive point of view (both high-quality evidence).

Artificial Intelligence and Virtual Reality in Headache Disorder Diagnosis, Classification, and Management

PURPOSE OF REVIEW

This review provides an overview of the current and future role of artificial intelligence (AI) and virtual reality (VR) in addressing the complexities inherent to the diagnosis, classification, and management of headache disorders.

RECENT FINDINGS

Through machine learning and natural language processing approaches, AI offers unprecedented opportunities to identify patterns within complex and voluminous datasets, including brain imaging data. This technology has demonstrated promise in optimizing diagnostic approaches to headache disorders and automating their classification, an attribute particularly beneficial for non-specialist providers. Furthermore, AI can enhance headache disorder management by enabling the forecasting of acute events of interest, such as migraine headaches or medication overuse, and by guiding treatment selection based on insights from predictive modeling. Additionally, AI may facilitate the streamlining of treatment efficacy monitoring and enable the automation of real-time treatment parameter adjustments. VR technology, on the other hand, offers controllable and immersive experiences, thus providing a unique avenue for the investigation of the sensory-perceptual symptomatology associated with certain headache disorders. Moreover, recent studies suggest that VR, combined with biofeedback, may serve as a viable adjunct to conventional treatment. Addressing challenges to the widespread adoption of AI and VR in headache medicine, including reimbursement policies and data privacy concerns, mandates collaborative efforts from stakeholders to enable the equitable, safe, and effective utilization of these technologies in advancing headache disorder care. This review highlights the potential of AI and VR to support precise diagnostics, automate classification, and enhance management strategies for headache disorders.

The Role of the Combination Paracetamol/Caffeine in Treatment of Acute Migraine Pain: A Narrative Review

INTRODUCTION

Thirty years ago, the first migraine-specific drugs (triptans) appeared. Today two new categories (gepants and ditans) are marketed for acute migraine treatment. That said, is there still a role for conventional therapy? The aim of the present narrative review is to provide an expert overview examining the possible role of the combination paracetamol/caffeine in treatment of acute migraine pain.

METHODS

To understand possible settings for more appropriate use of paracetamol/caffeine (1000 mg/130 mg) in treatment of acute migraine, a structured literature search was performed using the PubMed database by a panel of experts from major Italian headache centers; articles not referring to migraine pain were excluded from this review; review articles were prioritized.

RESULTS

Overall response, even to newer specific and selective trigeminal targeted drugs (TTTs), is not over 60%; thus, there is still room for conventional therapies in acute migraine treatment. The panel identified settings in which the use of paracetamol/caffeine combination to treat acute migraine attacks might offer benefit considering the consolidated use through years, despite the lack of studies directly addressing the efficacy of paracetamol/caffeine in the identified populations: subjects > 65 years of age; presence of cardiovascular (CV) comorbidities; TTTs non-responders; pregnancy and breastfeeding; subjects < 18 years of age; paracetamol/caffeine as add-on therapy.

CONCLUSIONS

Paracetamol is included in the World Health Organization (WHO) essential drug list and has a high level of popularity among patients. Caffeine enhances the analgesic effect of other drugs including paracetamol. In early treatment of acute migraine pain, prescribing physicians might consider using the paracetamol/caffeine combination among other options.

Benchmarking State-of-the-Art Large Language Models for Migraine Patient Education: A Comparison of Performances on the Responses to Common Queries

UNSTRUCTURED

Migraine, a frequent and highly disabling disorder, necessitates enhanced education of individuals with migraine to mitigate this global burden. The rapidly evolving field of large language models (LLMs) presents a promising avenue for assisting in migraine patient education. This study aims to assess the potential of LLMs in this context by evaluating the accuracy of responses from five leading LLMs, including OpenAI's ChatGPT 3.5 and 4.0, Google Bard, Meta Llama2, and Anthropic Claude2, in addressing 30 commonly asked migraine-related queries. We found that LLMs demonstrated varied levels of accuracy. ChatGPT-4.0 provided 96.7% appropriate responses, while other chatbots provided 83.3% to 90% appropriate responses (Pearson's chi-squared test, P=0.481). Additionally, Google Bard had a 'poor' rating proportion of 6.7%, other LLMs had 3.3% (Pearson's chi-squared test, P=0.961). This study underscores the potential of LLMs to accurately address common migraine-related queries. Such findings could advance AI-assisted education for individuals with migraine, providing insights for a holistic approach to migraine management.

New perspectives on migraine treatment: a review of the mechanisms and effects of complementary and alternative therapies

Migraine is a prevalent and disabling neurovascular disorder, with women being more susceptible, characterized by unilateral throbbing headache, often accompanied by nausea and vomiting, and often associated with various comorbidities such as brain and cardiovascular diseases, which can have a serious impact on quality of life. Although nonsteroidal anti-inflammatory drugs (NSAIDs) are the main first-line medications for the treatment of pain, long-term use often leads to side effects and drug addiction, which emphasizes the need to investigate alternative pain management strategies with fewer adverse effects. Complementary and alternative medicine is a viable pain intervention often used in conjunction with traditional medications, including acupuncture, herbs, moxibustion, transcutaneous electrical stimulation, bio-supplements, and acupressure, which offer non-pharmacological alternatives that are now viable pain management options. This review focuses on the mechanistic doctrine of migraine generation and the role and potential mechanisms of Complementary and Alternative Therapies (CAT) in the treatment of migraine, summarizes the research evidences for CAT as an adjunct or alternative to conventional therapies for migraine, and focuses on the potential of novel migraine therapies (calcitonin gene-related peptide (CGRP) antagonists and pituitary adenylyl cyclase-activating peptide (PACAP) antagonists) with the aim of evaluating CAT therapies as adjunctive or alternative therapies to conventional migraine treatment, thereby providing a broader perspective on migraine management and the design of treatment programs for more effective pain management.

Headache in Brain Tumors

The prevalence of brain tumors in patients with headache is very low; however, 48% to 71% of patients with brain tumors experience headache. The clinical presentation of headache in brain tumors varies according to age; intracranial pressure; tumor location, type, and progression; headache history; and treatment. Brain tumor-associated headaches can be caused by local and distant traction on pain-sensitive cranial structures, mass effect caused by the enlarging tumor and cerebral edema, infarction, hemorrhage, hydrocephalus, and tumor secretion. This article reviews the current findings related to epidemiologic details, clinical manifestations, mechanisms, diagnostic approaches, and management of headache in association with brain tumors.

Acupuncture versus tricyclic antidepressants in the prophylactic treatment of tension-type headaches: an indirect treatment comparison meta-analysis

BACKGROUND

Acupuncture showed better improvement than sham acupuncture in reducing attack frequency of tension-type headache (TTH), but its effectiveness relative to first-line drugs for TTH is unknown, which impedes the recommendation of acupuncture for patients who are intolerant to drugs for TTH. We aimed to estimate the relative effectiveness between acupuncture and tricyclic antidepressants (TCAs) through indirect treatment comparison (ITC) meta-analysis.

METHODS

We searched Ovid Medline, Embase, and Cochrane Library from database inception until April 13, 2023. Randomized controlled trials of TCAs or acupuncture in the prevention of TTH in adults were included. The primary outcome was headache frequency. The secondary outcomes were headache intensity, responder rate, and adverse event rate. Bayesian random-effect models were used to perform ITC meta-analysis, and confidence of evidence was evaluated by using the GRADE approach.

RESULTS

A total of 34 trials involving 4426 participants were included. Acupuncture had similar effect with TCAs in decreasing TTH frequency (amitriptyline: mean difference [MD] -1.29, 95% CI -5.28 to 3.02; amitriptylinoxide: MD -0.05, 95% CI -6.86 to 7.06) and reducing TTH intensity (amitriptyline: MD 2.35, 95% CI -1.20 to 5.78; clomipramine: MD 1.83, 95% CI -4.23 to 8.20). Amitriptyline had a higher rate of adverse events than acupuncture (OR 4.73, 95% CI 1.42 to 14.23).

CONCLUSION

Acupuncture had similar effect as TCAs in reducing headache frequency of TTH, and acupuncture had a lower adverse events rate than amitriptyline, as shown by very low certainty of evidence.

Readability analysis and concept mapping of PROMs used for headache disorders

OBJECTIVE

To assess the readability and the comprehensiveness of patient-reported outcome measures (PROMs) utilized in primary headache disorders literature.

BACKGROUND

As the health-care landscape has evolved toward a patient-centric model, numerous PROMs have been developed to capture treatment outcomes in patients with headache disorders. For these PROMs to advance our understanding of headache disorders and their treatment impact, they must be easy to understand (i.e., reading grade level 6 or less) and comprehensively capture what matters to patients with headache. The aim of this study was to (a) assess the readability of PROMs utilized in headache disorders literature, and (b) assess the comprehensiveness of PROMs by mapping their content to a health-related quality of life framework.

METHODS

In this scoping review, recently published systematic reviews were used to identify PROMs used in primary headache disorders literature. Readability analysis was performed at the level of individual items and full PROM using established readability metrics. The content of the PROMs was mapped against a health-related quality-of-life framework by two independent reviewers.

RESULTS

In total, 22 PROMs (15 headache disorders related, 7 generic) were included. The median reading grade level varied between 7.1 (interquartile range [IQR] 6.3-7.8) and 12.7 (IQR 11.8-13.2). None of the PROMs were below the recommended reading grade level for patient-facing material (grade 6). Three PROMs, the Migraine-Treatment Assessment Questionnaire, the Eurolight, and the European Quality of Life 5 Dimensions 3 Level Version, were between reading grade levels 7 and 8; the remaining 19 PROMs were above reading grade level 8. In total, the PROMs included 425 items. Most items (n = 134, 32%) assessed physical function (e.g., work, activities of daily living). The remaining items assessed physical symptoms (n = 127, 30%; e.g., pain, nausea), treatment effects on symptoms (n = 65, 15%; e.g., accompanying symptoms relief, headache relief), treatment impact (n = 56, 13%; e.g., function, side effects), psychological well-being (n = 41, 10%; e.g., anger, frustration), social well-being (n = 29, 7%; e.g., missing out on social activities, relationships), psychological impact (n = 14, 3%; e.g., feeling [not] in control, feeling like a burden), and sexual well-being (n = 3, 1%; e.g., sexual activity, sexual interest). Some of the items pertained to treatment (n = 27, 6%), of which most were about treatment type and use (n = 12, 3%; e.g., medication, botulinum toxin), treatment access (n = 10, 2%; e.g., health-care utilization, cost of medication), and treatment experience (n = 9, 2%; e.g., treatment satisfaction, confidence in treatment).

CONCLUSION

The PROMs used in studies of headache disorders may be challenging for some patients to understand, leading to inaccurate or missing data. Furthermore, no available PROM comprehensively measures the health-related quality-of-life impact of headache disorders or their treatment, resulting in a limited understanding of patient-reported outcomes. The development of an easy-to-understand, comprehensive, and validated headache disorders-specific PROM is warranted.

Research hotspots and trends on acupuncture treatment for headache: a bibliometric analysis from 2003 to 2023

Background

While acupuncture treatment has gained extensive usage in addressing headaches, there remains a notable gap in the literature analysis for this field. Therefore, this study aims to conduct a literature review using Citespace, VOSviewer, and Bibliometrix, aiming to examine the current status, strengths, and potential future directions in the utilization of acupuncture for headache treatment.

Methods

Relevant literature on acupuncture treatment for headaches between 2003 and 2023 was retrieved from the Web of Science (WoS) core database. Utilizing CiteSpace 6.1.R6, VOSviewer 1.6.18, and Bibliometrix 4.1.4, we conducted bibliometric analyses across various categories, including countries/regions, institutions, authors, journals, references, and keywords.

Results

A total of 808 research reports were included. China and the United States have significantly contributed to this field. Chengdu University of Chinese Medicine holds the record for the highest number of published papers. Liu Lu has the highest publication output, while Linde K has the highest citation rate. MEDICINE leads in publication frequency, while CEPHALALGIA holds the highest citation rate. The Long-term Effect of Acupuncture for Migraine Prophylaxis a Randomized Clinical Trial is the most cited reference. Migraine was the most researched type. Filiform needle acupuncture was the most widely used stimulation method. The safety and efficacy of acupuncture have received significant attention. Modern mechanism research shows that depression, brain functional connectivity, and neuroimaging technology have become research hotspots in the acupuncture treatment of headaches.

Conclusion

Acupuncture treatment for headaches has established a stable trend with a promising developmental trajectory. Research in this field mainly focuses on different acupuncture prevention and treatment for various types of headaches, the safety and efficacy of acupuncture, etc. Research on the mechanism of action mainly focuses on interpreting bidirectional and holistic regulation between pain and emotion by acupuncture and the regulation of brain function connection and neuroimaging technology by acupuncture. Future research should expand on the advantages and indications of acupuncture treatment for different headaches and their modern mechanisms.

Evaluating Ubrogepant-related adverse events using the FDA adverse event reporting system

BACKGROUND

Migraine has a high prevalence in the population and accounts for 12% of primary headaches. Ubrogepant is used for the treatment of acute migraine, and although some clinical trials have demonstrated the safety of Ubrogepant, its long-term safety in a large sample of the population remains to be investigated.

METHODS

We collected data from the US Food and Drug Administration Adverse Event Reporting System (FAERS) database. We used reporting odds ratio (ROR), the proportional reporting ratio (PRR), the information component (IC) and the empirical Bayes geometric mean (EBGM) to evaluate Ubrogepant-induced adverse events (AEs).

RESULTS

We screened out 2,067 reports of Ubrogepant as primary suspected (PS) and 6,190 reports of Ubrogepant-induced AEs as PS. Our results showed that Ubrogepant-induced AEs targeted 4 system organ classes (SOCs), detected 32 Preferred terms (PTs) signals in 9 SOCs, including common Ubrogepant label consistent with Migraine, Nausea, Somnolence, Paraesthesia oral and Dizziness, It also includes the AEs of Hemiparesis, Mental impairment, Dysstasia, Tinnitus, Chest pain, Cold sweat, Neck pain, etc. that have not been demonstrated in previous studies.

CONCLUSIONS

Our study identified new AEs that have not been reported, which provides a new guidance to deepen the comprehension of the safety of Ubrogepant.

Association Between Smartphone Usage and Primary Headaches in Taif, Saudi Arabia: A Hospital-Based Study

Background Integrating smartphones into human life has transformed various daily activities. Numerous symptoms, including headaches, have been linked to smartphone use. The excessive use of these devices raises significant health concerns. This study aimed to investigate the relationship between smartphone use and the progression, type, and severity of primary headaches, as well as the necessity for both abortive and prophylactic medications in treating such conditions. Materials and methods In this study, we utilized a cross-sectional survey involving 403 participants aged 14 years and older, all experiencing primary headaches and seeking care at three governmental hospitals in Taif, Saudi Arabia. The participants were divided into two groups based on their smartphone usage: high and low smartphone users. Data were collected through a hospital-based questionnaire administered across the three centers. Descriptive analysis and Pearson chi-square tests were conducted using IBM SPSS Statistics for Windows, Version 21 (released 2012; IBM Corp., Armonk, New York, United States). Results Of the participants, 128 (31.8%) were classified as low users, while 275 (68.2%) were identified as high users. The most frequently reported type of headache was undiagnosed headache, among 109 (27%), followed by migraine, at 86 (21.3%). Headaches were severe in 112 (40.9%) of cases and moderate in 134 (48.9%) of users. Around 62 (72.1%) of participants diagnosed with migraine reported a severe impact on their daily lives. In terms of medication usage, 166 (60.6%) of participants reported consuming zero to five pills monthly, while 52 (19%) reported taking more than 10 pills monthly. Additionally, 58 (21.2%) of participants utilized prophylactic medications. Conclusion No significant association was observed between smartphone use and the impact of headaches. Notably, pain severity was higher among low smartphone users who reported a high intake of medications. Migraine was the most severe and intense headache type. On average, the participants consumed fewer than five pills per month.

Headache Management in Individuals with Brain Tumor

Headache occurs commonly in individuals diagnosed with cerebral neoplasm. Though the features of a brain tumor-associated headache may vary, a progressive nature of headache and a change in headache phenotype from a prior primary headache disorder often are identified. Pathophysiologic mechanisms proposed for headache associated with brain tumor include headache related to traction on pain-sensitive structures, activation of central and peripheral pain processes, and complications from surgical, chemotherapeutic and/or radiotherapy treatment(s). Optimization of headache management is important for an individual's quality of life. Treatments are based upon patient-specific goals of care and may include tumor-targeted medical and surgical interventions, as well as a multimodal headache treatment approach incorporating acute and preventive medications, nutraceuticals, neuromodulation devices, behavioral interventions, anesthetic nerve blocks, and lifestyles changes.

Disease-Related Factors Associated with Acupuncture Response in Patients with Chronic Tension-Type Headache: A Secondary Analysis of A Randomized Controlled Trial

OBJECTIVE

To explore the demographic and disease-related factors associated with acupuncture response in patients with chronic tension-type headache (CTTH).

METHODS

Using data from a randomized clinical trial (218 cases) consisting of 4 weeks of baseline assessment, 8 weeks of treatment, and 24 weeks of follow-up, participants were regrouped into responders (at least a 50% reduction in monthly headache days at week 16 compared with baseline) and non-responders. Twenty-three demographic and disease-related factors associated with acupuncture response in 183 participants were analyzed by multivariable logistic regression.

RESULTS

One hundred and nineteen (65.0%) participants were classified as responders. Four factors were significantly independently associated with acupuncture response, including treatment assignment, headache intensity at baseline, and 2 domains [general health (GH) and social functioning (SF)] from the 36-Item Short Form Health Survey quality of life questionnaire. Treatment assignment was associated with non-response: participants receiving true acupuncture were 3-time more likely to achieve a CTTH response than those receiving superficial acupuncture [odds ratio (OR) 0.322, 95% confidence interval (CI) 0.162 to 0.625, P=0.001]. Compared with patients with mild-intensity headache, patients with moderate-intensity headache were twice as likely to respond to acupuncture (OR 2.001, 95% CI 1.020 to 4.011, P=0.046). The likelihood of non-response increased by 4.5% with each unit increase in the GH grade (OR 0.955, 95% CI 0.917 to 0.993, P=0.024) while decreased by 3.8% with each unit increase in the SF grade (OR 1.038, 95% CI 1.009 to 1.069, P=0.011).

CONCLUSIONS

Greater headache intensity, lower GH score, and higher SF score were associated with better acupuncture responses in CTTH patients. These 3 factors require independent validation as predictors of acupuncture effectiveness in CTTH.

The World Health Organization Intersectoral Global Action Plan on Epilepsy and Other Neurological Disorders and the headache revolution: from headache burden to a global action plan for headache disorders

The World Health Organization (WHO) Intersectoral Global Action Plan on Epilepsy and Other Neurological Disorders was developed by WHO to address the worldwide challenges and gaps in provision of care and services for people with epilepsy and other neurological disorders and to ensure a comprehensive, coordinated response across sectors to the burden of neurologic diseases and to promote brain health across life-course. Headache disorders constitute the second most burdensome of all neurological diseases after stroke, but the first if young and midlife adults are taken into account. Despite the availability of a range of treatments, disability associated with headache disorders, and with migraine, remains very high. In addition, there are inequalities between high-income and low and middle income countries in access to medical care. In line with several brain health initiatives following the WHOiGAP resolution, herein we tailor the main pillars of the action plan to headache disorders: (1) raising policy prioritization and strengthen governance; (2) providing effective, timely and responsive diagnosis, treatment and care; (3) implementing strategies for promotion and prevention; (4) fostering research and innovation and strengthen information systems. Specific targets for future policy actions are proposed. The Global Action Plan triggered a revolution in neurology, not only by increasing public awareness of brain disorders and brain health but also by boosting the number of neurologists in training, raising research funding and making neurology a public health priority for policy makers. Reducing the burden of headache disorders will not only improve the quality of life and wellbeing of people with headache but also reduce the burden of neurological disorders increasing global brain health and, thus, global population health.

What Are the Predictors for and Psychosocial Correlates of Chronic Headache After Moderate to Severe Traumatic Brain Injury?

OBJECTIVE

Although headache (HA) is a common sequela of traumatic brain injury (TBI), early predictors of chronic HA after moderate to severe TBI are not well established, and the relationship chronic HA has with psychosocial functioning is understudied. Thus, we sought to (1) determine demographic and injury predictors of chronic HA 1 or more years after moderate to severe TBI and (2) examine associations between chronic HA and psychosocial outcomes.

SETTING

Community.

PARTICIPANTS

Participants in the TBI Model System (TBIMS) with moderate to severe TBI who consented for additional chronic pain questionnaires at the time of TBIMS follow-up.

DESIGN

Multisite, observational cohort study using LASSO (least absolute shrinkage and selection operator) regression for prediction modeling and independent t tests for psychosocial associations.

MAIN OUTCOME MEASURES

Chronic HA after TBI at year 1 or 2 postinjury and more remotely (5 or more years).

RESULTS

The LASSO model for chronic HA at 1 to 2 years achieved acceptable predictability (cross-validated area under the curve [AUC] = 0.70). At 5 or more years, predictability was nearly acceptable (cross-validated AUC = 0.68), but much more complex, with more than twice as many variables contributing. Injury characteristics had stronger predictive value at postinjury years 1 to 2 versus 5 or more years, especially sustained intracranial pressure elevation (odds ratio [OR] = 3.8) and skull fragments on head computed tomography (CT) (OR = 2.5). Additional TBI(s) was a risk factor at both time frames, as were multiple socioeconomic characteristics, including lower education level, younger age, female gender, and Black race. Lower education level was a particularly strong predictor at 5 or more years (OR up to 3.5). Emotional and participation outcomes were broadly poorer among persons with chronic HA after moderate to severe TBI.

CONCLUSIONS

Among people with moderate to severe TBI, chronic HA is associated with significant psychosocial burden. The identified risk factors will enable targeted clinical screening and monitoring strategies to enhance clinical care pathways that could lead to better outcomes. They may also be useful as stratification or covariates in future clinical trial research on treatments.

Radiofrequency ablation of the occipital nerves for treatment of neuralgias and headache

OBJECTIVE

The purpose of this study was to retrospectively assess the efficacy of radiofrequency ablation (RFA) therapy as a treatment for occipital neuralgias and headaches at health clinics in the United States between January 1, 2015 and June 20, 2022. We hypothesize that RFA is a minimally invasive treatment that provides significant pain relief long-term for occipital neuralgias and associated headaches.

METHODS

This retrospective analysis studies data collected from 277 occipital nerve RFA patients who had adequate pre-procedure and post-procedure follow-up for data analysis. Data collected includes the patient's age, biological sex, BMI, headache diagnosis, pre-procedure, and post-procedure pain score using the visual analog scale (VAS), subjective percent improvement in symptom(s), and duration of symptom relief. Statistical analysis used SPSS software, version 26 (IBM), using a paired t-test to assess the significance between pre and post-occipital RFA therapy pain scores. p-values were significant if found to be ≤0.05.

RESULTS

The mean pre-procedure pain score before RFA therapy for patients who completed at least 6 months of follow-up was 5.57 (SD = 1.87) and the mean post-procedure pain score after RFA therapy was 2.39 (SD = 2.42). The improvement in pain scores between pre-procedure and post-procedure was statistically significant with a p-value < 0.001. The mean patient-reported percent improvement in pain following RFA therapy was 63.53% (SD = 36.37). The mean duration of pain improvement was 253.9 days after the initiation of therapy (SD = 300.5). When excluding patients who did not have any relief following their RFA procedure, the average pre-procedure pain score was 5.54 (SD = 1.81) and post-procedure pain score was 1.71 (SD = 1.81) with a p-value < 0.001.

CONCLUSION

This study demonstrates the minimally invasive, safe, and effective treatment of RFA in patients with refractory occipital neuralgias and headaches. Additional studies are necessary to illuminate ideal patient characteristics for RFA treatment and the potential for procedural complications and long-term side effects associated with occipital nerve RFA therapy.

Palliative Care and Care Partner Support in Neuro-oncology

ABSTRACT

The journey for a patient with a brain tumor and their loved ones can be extremely challenging due to the high burden of physical symptoms and the emotional distress caused by the diagnosis. Optimizing quality of life by addressing symptoms and reducing this emotional distress can improve treatment tolerance and outcomes and alleviate care partner distress and burden. Symptoms in patients with central nervous system (CNS) tumors can vary in onset and intensity, ranging from headaches, seizures, and focal weakness to emotional distress and cognitive dysfunction. Additionally, care partners may demonstrate distress due to the high burden of care and need appropriate support structures and access to resources to alleviate this stress. Evidence-based recommendations are unfortunately limited given the lack of high-quality research in this area, but patients living with CNS tumors and their loved ones can benefit from early and routine symptom identification and management, compassionate and transparent communication, and practical guidance for the future. These principles are part of palliative care, a field of medicine focused on alleviating suffering in patients with serious, chronic illness. Clinicians involved in the care of patients with CNS tumors must be educated in these important primary palliative care principles. This article focuses on key symptom management, strategies for high-quality communication, a discussion of advance care planning, and an overview of end-of-life care.

Headaches treatment with EMG biofeedback: a focused systematic review and meta-analysis

INTRODUCTION

The aim of this paper was to present an up-to-date evaluation of the efficacy of EMG-biofeedback (EMG-BFB) for primary headaches and to address possible mediators of outcome.

EVIDENCE ACQUISITION

PubMed, Scopus, Embase and Pedro databases were searched from inception to May 1, 2023. All randomized controlled trials (RCT) studies using an EMG-BFB to treat headache have been included in this systematic review. The current systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations and was registered in the PROSPERO database (CRD42022312827). Methodological quality was assessed through the Risk of Bias tool 2 (RoB 2). The effect sizes and 95% confidence interval (CI) were calculated by random-effect models on frequency, intensity, and duration variables. Egger regression and the Begg-Mazumdar rank correlation test were used for publication bias.

EVIDENCE SYNTHESIS

A total of 3059 articles were identified through the database searches. 29 articles, involving 1342 participants, met the inclusion criteria for the systematic review; of them, 4 were included in the meta-analysis. Ten studies reported a significant improvement in the EMG-BFB group with respect to the control group. Meta-analyses show a reduction in the intensity of attacks in patients subjected to EMG-BFB (ES 0.21 [(95% CI=-0.02; 0.44), P value=0.07] based on 293 patients).

CONCLUSIONS

EMG-BFB represents a non-pharmacological approach to headache treatment as shown via qualitative synthesis, despite not impressive results, this technique can be particularly useful in paediatric or in adult patients who cannot undergo drug therapies. Quantitative synthesis revealed a promising effect in the intensity of headaches attacks. Moreover, no significant effect was found about the effectiveness of EMG-BFB in the reduction of frequency and durations of headache attacks. Future studies with new multimodal technologic assessment and following RCT guidelines can unmask the potentiality of EMG-BFB in the treatment of headache.

Metabolic and toxicological considerations regarding CGRP mAbs and CGRP antagonists to treat migraine in COVID-19 patients: a narrative review

INTRODUCTION

Migraine pharmacological therapies targeting calcitonin gene-related peptide (CGRP), including monoclonal antibodies and gepants, have shown clinical effect and optimal tolerability. Interactions between treatments of COVID-19 and CGRP-related drugs have not been reviewed.

AREAS COVERED

An overview of CGRP, a description of the characteristics of each CGRP-related drug and its response predictors, COVID-19 and its treatment, the interactions between CGRP-related drugs and COVID-19 treatment, COVID-19 and vaccination-induced headache, and the neurological consequences of Covid-19.

EXPERT OPINION

Clinicians should be careful about using gepants for COVID-19 patients, due to the potential drug interactions with drugs metabolized via CYP3A4 cytochrome. In particular, COVID-19 treatment (especially nirmatrelvir packaged with ritonavir, as Paxlovid) should be considered cautiously. It is advisable to stop or adjust the dose (10 mg atogepant when used for episodic migraine) of gepants when using Paxlovid (except for zavegepant). CGRP moncolconal antibodies (CGRP-mAbs) do not have drug - drug interactions, but a few days' interval between a COVID-19 vaccination and the use of CGRP mAbs is recommended to allow the accurate identification of the possible adverse effects, such as injection site reaction. Covid-19- and vaccination-related headache are known to occur. Whether CGRP-related drugs would be of benefit in these circumstances is not yet known.

Migraine signaling pathways: purine metabolites that regulate migraine and predispose migraineurs to headache

Migraine is a debilitating disorder that afflicts over 1 billion people worldwide, involving attacks that result in a throbbing and pulsating headache. Migraine is thought to be a neurovascular event associated with vasoconstriction, vasodilation, and neuronal activation. Understanding signaling in migraine pathology is central to the development of therapeutics for migraine prophylaxis and for mitigation of migraine in the prodrome phase before pain sets in. The fact that both vasoactivity and neural sensitization are involved in migraine indicates that agonists which promote these phenomena may very well be involved in migraine pathology. One such group of agonists is the purines, in particular, adenosine phosphates and their metabolites. This manuscript explores what is known about the relationship between these metabolites and migraine pathology and explores the potential for such relationships through their known signaling pathways. Reported receptor involvement in vasoaction and nociception.

Headache Characteristics and Their Influencing Factors Among Pregnant Women in Saudi Arabia: A Survey Study

Background Headache disorders, particularly migraines, significantly impact public health globally. The Global Burden of Disease (GBD) report highlights migraines as the second leading cause of disability worldwide, especially among women under 50. Hormonal changes, particularly estrogen, play a role in primary headaches like migraines, and this connection becomes important during pregnancy due to physiological changes.  Materials and methods A cross-sectional survey was conducted among pregnant women in Saudi Arabia to assess the characteristics of the headaches and explore their influencing factors. The study initiated the data collection process across various regions of Saudi Arabia from February 2023 to July 2023. Participants included pregnant women aged 18 or above residing in Saudi Arabia. Data were collected through an online self-administered survey with multiple-choice questions. Descriptive analysis and Pearson Chi-Square tests were performed using IBM SPSS Statistics version 25 (IBM Corp., Armonk, USA). Results A study surveyed 411 pregnant women to investigate the characteristics of headaches during pregnancy. The majority of participants were Saudi nationals 381 (92.7%) and 242 (58.9%) aged 18-30 and 357 (86.9%) resided in urban areas. Around 72 (17.5%) reported having chronic diseases. Results showed that 246 (59.9%) of pregnant women were diagnosed with headaches before pregnancy, with migraines being the most common type by 145 (35.3%). Headache frequency increased during pregnancy for 171 (41.6%) of participants, and the majority 275 (66.9%) experienced headaches lasting 0-3 hours. Nausea 219 (53.3%) and holo-cranial pain 112 (27.3%) were common accompanying symptoms. Conclusion This study provides valuable insights into the burden of headaches among pregnant women in Saudi Arabia, emphasizing the importance of improved healthcare practices and educational initiatives to effectively address this issue.

Non-Pharmacological Pain Treatment of Patients with Myofascial Pain Syndrome of the Masticatory Muscles-Case Series

Myofascial pain is the most common cause of chronic pain in the masticatory region and can be assessed through clinical analysis and muscle palpation. Generally, it appears with headache and orofacial pain associated with sensitive points (trigger points) due to the excessive contraction of the masticatory muscle fibers. The study aims to evaluate how a correct treatment of myofascial pain can improve the life quality of affected patients. In this case series, 300 patients with myofascial pain were divided into two groups: 150 with intra- and extra-articular disorders and 150 with only extra-articular disorder. Each group included 75 males and 75 females. All the patients were treated with gnathological therapy through passive aligners and biofeedback exercises for four months. They underwent pain assessment (through a visual analogue scale and muscular palpation test) before, during, and after the treatment, as well as nuclear magnetic resonance of the temporomandibular joint before and after the gnathological treatment. The treatment considerably reduced the pain in all patients, without drugs, in four months according to the visual analogue scales and the palpation test. The temporomandibular magnetic resonance in each patient was similar before and after the gnathological treatment. The improvement in pain did not depend on a change in the relationship between the articular condyle and the disc.

Frequency and risk factors for headache disability: A population-based cross-sectional study in Egypt

BACKGROUND

A headache is a very common condition that can have a significant impact on one's quality of life. It is one of the leading causes of years lived with disability worldwide. The objective of the study was to determine the prevalence of primary headache disability, its characteristics, risk factors and its impact on daily life.

MATERIALS AND METHODS

A cross-sectional study was conducted in Fayoum governorate. The sample size was 1909 participants. A multistage random sample technique was used to select adults aged above 18 years. A self-structured questionnaire solicited information on sociodemographic characteristics, headache characteristics, and the headache disability index. SPSS v 22.0 was used for data analysis.

RESULTS

Headaches caused complete disability in 19.5% of the study group, and 76.8% developed severe disability. Participants who reported that they had a headache more than once a week were; 44.5% had moderate pain and 40.2% had more intense pain. About 55% complained of attacks rather than continuous headache and were more likely to have a degree of complete disability, (P = 0.001). A statistically significant association was found between living in urban areas, working in professional occupations, complaining of severe headache in the form of an attack and seeking medical advice, with high scores of headache disability.

CONCLUSION

Headache is a condition that affects the entire population in a way that causes high levels of disability. Good management is necessary for the reduction of the adverse effects of headaches on the health of the population. This should focus on raising public awareness by means of education and on the provision of basic healthcare.

Effectiveness of Calcitonin Gene-Related Peptide Monoclonal Antibodies in the Prevention of Migraine: A Systematic Review and Meta-Analysis of Observational Cohort Studies

BACKGROUND AND OBJECTIVE

Migraine is a neurological disorder characterized by episodes of moderate-to-severe headache. The emergence of drugs derived from monoclonal antibodies specific for the calcitonin gene has brought forth a therapeutic option for patients in whom the traditional treatments have failed. This study aimed to evaluate the clinical effectiveness of calcitonin gene-related peptide antibodies in the prevention of migraine through a systematic review and meta-analysis of observational cohort studies.

METHODS

A literature search for evidence was performed in electronic databases for observational studies that evaluated adult patients with migraine receiving calcitonin gene-related peptide receptor antagonists (e.g. erenumab, fremanezumab, galcanezumab and eptinezumab) and reported effectiveness outcomes (mean reduction in monthly migraine/headache days, and proportion of patients with 50% or greater reduction in migraine/headache days).

RESULTS

During the screening process, 47 records were included for data extraction and qualitative and quantitative analyses. The overall rate of patients with a reduction of at least 50% of mean monthly migraine days was 54% (95% CI 49-59%), and overall mean monthly migraine reduction was about 7.7 days (95% CI 8.4-7.0 days). Regarding the outcome ≥ 50% reduction in mean monthly headache reduction, the overall rate of patients with a reduction of at least 50% was 57% (95% CI 48-64%), and the overall mean monthly headache reduction was approximately 8.8 days (95% CI 10.1-7.5 days). Subgroup analyses considering the drug treatment used and type of migraine were consistent with previous results.

CONCLUSIONS

The use of calcitonin gene-related peptide antibodies in real-world studies to prevent migraine demonstrates promising effectiveness outcomes, in agreement with those reported in previously published randomized clinical trial reports.

Pharmacological Management of Orofacial Pain

Orofacial pain is a category of complex disorders, including musculoskeletal, neuropathic and neurovascular disorders, that greatly affect the quality of life of the patient. These disorders are within the fields of dentistry and medicine and management can be challenging, requiring a referral to an orofacial pain specialist, essential for adequate evaluation, diagnosis, and care. Management is specific to the diagnosis and a treatment plan is developed with diverse pharmacological and non-pharmacological modalities. The pharmacological management of orofacial pain encompasses a vast array of medication classes and approaches. This includes anti-inflammatory drugs, muscle relaxants, anticonvulsants, antidepressants, and anesthetics. In addition, as adjunct therapy, different injections can be integrated into the management plan depending on the diagnosis and needs. These include trigger point injections, temporomandibular joint (TMJ) injections, and neurotoxin injections with botulinum toxin and nerve blocks. Multidisciplinary management is key for optimal care. New and safer therapeutic targets exclusively for the management of orofacial pain disorders are needed to offer better care for this patient population.

Identifying causal genes for migraine by integrating the proteome and transcriptome

BACKGROUND

While previous genome-wide association studies (GWAS) have identified multiple risk variants for migraine, there is a lack of evidence about how these variants contribute to the development of migraine. We employed an integrative pipeline to efficiently transform genetic associations to identify causal genes for migraine.

METHODS

We conducted a proteome-wide association study (PWAS) by combining data from the migraine GWAS data with proteomic data from the human brain and plasma to identify proteins that may play a role in the risk of developing migraine. We also combined data from GWAS of migraine with a novel joint-tissue imputation (JTI) prediction model of 17 migraine-related human tissues to conduct transcriptome-wide association studies (TWAS) together with the fine mapping method FOCUS to identify disease-associated genes.

RESULTS

We identified 13 genes in the human brain and plasma proteome that modulate migraine risk by regulating protein abundance. In addition, 62 associated genes not reported in previous migraine TWAS studies were identified by our analysis of migraine using TWAS and fine mapping. Five genes including ICA1L, TREX1, STAT6, UFL1, and B3GNT8 showed significant associations with migraine at both the proteome and transcriptome, these genes are mainly expressed in ependymal cells, neurons, and glial cells, and are potential target genes for prevention of neuronal signaling and inflammatory responses in the pathogenesis of migraine.

CONCLUSIONS

Our proteomic and transcriptome findings have identified disease-associated genes that may give new insights into the pathogenesis and potential therapeutic targets for migraine.

Migraine and cardiovascular disease: what cardiologists should know

Migraine is a chronic neurovascular disease with a complex, not fully understood pathophysiology with multiple causes. People with migraine suffer from recurrent moderate to severe headache attacks varying from 4 to 72 h. The prevalence of migraine is two to three times higher in women compared with men. Importantly, it is the most disabling disease in women <50 years of age due to a high number of years lived with disability, resulting in a very high global socioeconomic burden. Robust evidence exists on the association between migraine with aura and increased incidence of cardiovascular disease (CVD), in particular ischaemic stroke. People with migraine with aura have an increased risk of atrial fibrillation, myocardial infarction, and cardiovascular death compared with those without migraine. Ongoing studies investigate the relation between migraine and angina with non-obstructive coronary arteries and migraine patients with patent foramen ovale. Medication for the treatment of migraine can be preventative medication, such as beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, antiepileptics, antidepressants, some of the long-acting calcitonin gene-related peptide receptor antagonists, or monoclonal antibodies against calcitonin gene-related peptide or its receptor, or acute medication, such as triptans and calcitonin gene-related peptide receptor antagonists. However, these medications might raise concerns when migraine patients also have CVD due to possible (coronary) side effects. Specifically, knowledge gaps remain for the contraindication to newer treatments for migraine. All cardiologists will encounter patients with CVD and migraine. This state-of-the-art review will outline the basic pathophysiology of migraine and the associations between migraine and CVD, discuss current therapies, and propose future directions for research.

Neurosarcoidosis With Multi-Organ Involvement: A Case Report and Literature Review

Sarcoidosis is a multisystemic disease that, in rare cases, can involve the central nervous system (CNS). We present a case of sarcoidosis with intracranial and multi-organ involvement. The patient presented with a one-month history of headaches. Imaging revealed leptomeningeal nodular enhancement (LNE), and a PET/CT scan of the chest and abdomen showed bilateral hilar, retroperitoneal, and inguinal lymphadenopathy. The diagnosis of sarcoidosis was confirmed by an ultrasound-guided inguinal lymph node biopsy. The patient was started on a combination of corticosteroids and immunosuppressive drugs, with a gradual improvement in symptoms and radiological findings over several months.

Duality in response of intracranial vessels to nitroglycerin revealed in rats by imaging photoplethysmography

Among numerous approaches to the study of migraine, the nitroglycerin (NTG) model occupies a prominent place, but there is relatively insufficient information about how NTG affects intracranial vessels. In this study we aim to assess the effects of NTG on blood-flow parameters in meningeal vessels measured by imaging photoplethysmography (iPPG) in animal experiments. An amplitude of the pulsatile component (APC) of iPPG waveform was assessed before and within 2.5 h after the NTG administration in saline (n = 13) or sumatriptan (n = 12) pretreatment anesthetized rats in conditions of a closed cranial window. In animals of both groups, NTG caused a steady decrease in blood pressure. In 7 rats of the saline group, NTG resulted in progressive increase in APC, whereas decrease in APC was observed in other 6 rats. In all animals in the sumatriptan group, NTG administration was accompanied exclusively by an increase in APC. Diametrically opposite changes in APC due to NTG indicate a dual effect of this drug on meningeal vasomotor activity. Sumatriptan acts as a synergist of the NTG vasodilating action. The results we obtained contribute to understanding the interaction of vasoactive drugs in the study of the headache pathophysiology and methods of its therapy.

Efficacy of acupuncture for tension-type headache prophylaxis: systematic review and meta-analysis with trial sequential analysis

BACKGROUND

Acupuncture has been shown to reduce tension-type headache (TTH) frequency in previous studies. Nevertheless, repeated significance testing might inflate type I error. We aimed to verify the effectiveness and safety of acupuncture in reducing TTH frequency by meta-analysis and trial sequential analysis (TSA).

METHODS

Ovid Medline, Embase, and Cochrane Library were searched until September 29, 2022. Randomized controlled trials comparing acupuncture with sham acupuncture, no acupuncture, or other active therapies in adults with TTH were included. The primary outcome was TTH frequency. The secondary outcomes were responder rate and adverse event.

RESULTS

Fourteen studies involving 2795 participants were included. Acupuncture had more reduction than sham acupuncture in TTH frequency, both after treatment (standardized mean difference [SMD] - 0.80, 95% CI - 1.36 to - 0.24, P = 0.005) and at the follow-up period (SMD - 1.33, 95% CI - 2.18 to - 0.49, P = 0.002), while TSA showed the included sample size did not exceed required information size (RIS). Acupuncture was superior over no acupuncture after treatment (SMD - 0.52, 95% CI - 0.63 to - 0.41, P < 0.001), and cumulative sample size reached RIS. In terms of responder rate, acupuncture had a higher responder rate compared with sham acupuncture both after treatment (relative ratio [RR] 1.28, 95% CI 1.12 to 1.46, P = 0.0003) and the follow-up period (RR 1.37, 95% CI 1.19 to 1.58, P < 0.0001), but the sample size is inadequate.

CONCLUSION

Acupuncture is an efficacious and safe treatment for TTH prevention, but this conclusion might be limited by the generally very low to low quality evidence. TSA suggested that high-quality trials are needed to verify the efficacy and safety of acupuncture compared to sham acupuncture.

Clinical Potential of Adrenomedullin Signaling in the Cardiovascular System

Numerous clinical studies have revealed the utility of circulating AM (adrenomedullin) or MR-proAM (mid-regional proAM 45-92) as an effective prognostic and diagnostic biomarker for a variety of cardiovascular-related pathophysiologies. Thus, there is strong supporting evidence encouraging the exploration of the AM-CLR (calcitonin receptor-like receptor) signaling pathway as a therapeutic target. This is further bolstered because several drugs targeting the shared CGRP (calcitonin gene-related peptide)-CLR pathway are already Food and Drug Administration-approved and on the market for the treatment of migraine. In this review, we summarize the AM-CLR signaling pathway and its modulatory mechanisms and provide an overview of the current understanding of the physiological and pathological roles of AM-CLR signaling and the yet untapped potentials of AM as a biomarker or therapeutic target in cardiac and vascular diseases and provide an outlook on the recently emerged strategies that may provide further boost to the possible clinical applications of AM signaling.

A Review of Neurological Symptoms in Long COVID and Clinical Management

Long COVID is a clinical diagnosis generally referring to the persistence or development of new symptoms, affecting multiple organ systems after SARS-CoV-2 COVID-19 infection. Long COVID is thought to affect ∼20% of people after infection, including all age ranges and severity of infection. Fatigue, postexertional malaise, and respiratory and cardiac symptoms are commonly described. Neurological symptoms such as cognitive changes, sensory disturbances, headaches, and dysautonomia are common as well. The underlying pathophysiology remains unclear but immune dysregulation, autoimmunity, persistent viral reservoirs, and microvascular dysfunction have been implicated. As there are no tests at this time to diagnose long COVID, work-up should be focused on assessing reversible or treatable causes of symptoms. Furthermore, no treatments for long COVID currently exist, and management remains focused on a multimodal approach and symptom management, with many people showing improvement in symptoms over time.

L-arginine and aged garlic extract for the prevention of migraine: a study protocol for a randomised, double-blind, placebo-controlled, phase-II trial (LARGE trial)

Background

Migraine is a common and distressing neurological condition characterised by recurrent throbbing headaches, nausea and heightened sensitivity to light and sound. Accumulating evidence suggests that cerebral arteries dilate during migraine, causing distal microvessels to constrict, which could activate nociceptors and cause onset of headache pain. If so, preventing or attenuating chronic microvascular constriction, and promoting a dilatory phenotype, may reduce frequency and/or severity of migraines. The primary aim of the L-Arginine and Aged Garlic Extract (LARGE) trial is to investigate whether oral treatment with dietary nutraceuticals, L-arginine and aged garlic extract (AGE), both systemic vasodilatory agents, will alleviate migraine frequency, duration and severity in adults with chronic frequent episodic migraines.

Methods

The study is a randomised double-blind placebo-controlled phase-II single-site clinical trial conducted in Perth, Australia. The target sample is to recruit 240 participants diagnosed with chronic frequent episodic migraines between 18 and 80 years of age. Participants will be randomised to one of four treatment groups for 14 weeks (placebo induction for 2 weeks, followed by 12 weeks on one of the respective treatment arms): placebo, L-arginine, AGE, or a combination of L-arginine and AGE. The doses of L-arginine and AGE are 1.5 g and 1 g daily, respectively. The primary outcome is to assess migraine response using change in migraine frequency and intensity between baseline and 12 weeks. Secondary outcomes include the impact of L-arginine and/or AGE on photosensitivity, retinal vessel changes, and blood biomarker concentrations of vascular tone, following a 12-week intervention.

Discussion

The protocol describes the oral administration of 2 nutraceutical-based interventions as possible prophylactic treatments for chronic frequent episodic migraines, with potential for direct clinical translation of outcomes. Potential limitations of the study include the fixed-dose design of each treatment arm and that in vivo neuroimaging methods, such as magnetic resonance imaging (MRI), will not be conducted to determine putative cerebro-vasodilatory changes to coincide with the outcome measures. Dose-response studies may be indicated.

Trial registration

The trial was retrospectively registered with the Australian New Zealand Clinical Trials Registry ACTRN12621001476820 (Universal Trial Number: U1111-1268-1117) on 04/08/2021. This is protocol version 1, submitted on 25/11/2022.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-023-03149-y.

Predictors of treatment-response to caffeine combination products, acetaminophen, acetylsalicylic acid (aspirin), and nonsteroidal anti-inflammatory drugs in acute treatment of episodic migraine

OBJECTIVE

To identify predictors of acute treatment optimization for migraine with "over-the-counter" (OTC) or prescription nonsteroidal anti-inflammatory drugs (NSAIDs) as well as other widely used OTCs including acetaminophen, caffeine combination products (CCP), and acetylsalicylic acid (ASA, aspirin) among people with episodic migraine and to develop models that predict treatment response to each class of OTCs.

BACKGROUND

Efficacy of acute OTC medications for migraine varies greatly. Identifying predictors of treatment response to particular classes of medication is a step toward evidence-based personalized therapy.

METHODS

For this prediction model development study, we used data from 2224 participants from the American Migraine Prevalence and Prevention (AMPP) study who were aged ≥18 years, met criteria for migraine, had <15 monthly headache days, and reported being on monotherapy for acute migraine attacks with one of the following classes medications: CCP (N = 711), acetaminophen (N = 643), ASA (N = 110), and prescription or OTC NSAIDs (N = 760). The primary outcome measures of treatment optimization were adequate 2-h pain freedom (2hPF) and adequate 24-h pain relief (24hPR), which were defined by responses of half the time or more to the relevant items on the Migraine Treatment Optimization Questionnaire-6.

RESULTS

The mean (SD) age of the participants was 46.2 (13.1) years, 79.4% (1765/2224) were female, 43.7% (972/2224) reported adequate 2hPF, and 46.1% (1025/2224) reported adequate 24hPR. Those taking CCP had better 2hPF and 24PR outcomes. For those taking NSAIDs, better outcomes were associated with lower average pain intensity (2hPF: odds ratio [OR] 0.89, 95% confidence interval [CI] 0.80-0.99; 24PR: OR 0.86, 95% CI 0.77-0.96), cutaneous allodynia (2hPF: OR 0.92, 95% CI 0.89-0.96; 24PR: OR 0.91, 95% CI 0.87-0.95), depressive symptoms (2hPF: OR 0.95, 95% CI 0.92-0.98; 24PR: OR 0.95, 95% CI 0.91-0.99), and Migraine Disability Assessment Scale (MIDAS) grade (2hPF: OR 0.76, 95% CI 0.64-0.90; 24PR: OR 0.79, 95% CI 0.65-0.95). Adequate 2hPF for those taking CCP was associated with male gender (OR 1.83, 95% CI 1.21-2.77), lower average pain intensity (OR 0.80, 95% CI 0.70-0.91), lower cutaneous allodynia (OR 0.94, 95% CI 0.90-0.97), and lower Migraine Symptom Severity Scale Score (MSSS; OR 0.91, 95% CI 0.86-0.97). Adequate 24hPR for those taking CCP was associated with lower average pain intensity (OR 0.85, 95% CI 0.75-0.96), lower cutaneous allodynia (OR 0.92, 95% CI 0.89-0.96), and lower MIDAS grade (OR 0.81, 95% CI 0.68-0.96). Participants who were married (OR 1.51, 95% CI 1.05-2.19), had lower average pain intensity (OR 0.79, 95% CI 0.70-0.89), lower MSSS (OR 0.93, 95% CI 0.88-0.99), less depression (OR 0.96, 95% CI 0.93-0.99), and lower MIDAS grade (OR 0.72, 95% CI 0.59-0.87) had adequate 2hPF after taking acetaminophen. Participants who were married (OR 1.50, 95% CI 1.02-2.21), had lower pain intensity (OR 0.78, 95% CI 0.69-0.88), less depression (OR 0.95, 95% CI 0.91-0.98) and lower MIDAS grade (OR 0.53, 95% CI 0.42-0.67) had higher 24hPR following use of acetaminophen. A lower MSSS was the only factor associated with higher 2hPF and 24PR after using ASA (OR 0.78, 95% CI 0.67-0.92 and OR 0.79, 95% CI 0.67-0.93). Predictive models had modest performance in identifying responders to each class of OTC.

CONCLUSION

A large subgroup of people with migraine had an inadequate response to their usual acute OTC migraine treatment 2- and 24-h after dosing. These findings suggest a need to improve OTC treatment for some and to offer prescription acute medications for others. Predictive models identified several factors associated with better treatment-response in each OTC class. Selecting OTC treatment based on factors predictive of treatment optimization might improve patient outcomes.

Rimegepant: A Review in the Acute Treatment and Preventive Treatment of Migraine

Rimegepant [Nurtec^® ODT (USA); Vydura^® (EU)] is a calcitonin gene-related peptide (CGRP) receptor antagonist approved for the acute treatment of migraine with or without aura in adults, and for the preventive treatment of episodic migraine in adults. Rimegepant is available as an orally disintegrating tablet (ODT), which offers convenience and a potentially faster response time than the conventional tablet formulation. In pivotal phase III trials, rimegepant was more effective than placebo at relieving pain and the most bothersome symptom when taken as needed for the acute treatment of migraine. Rimegepant was also more effective than placebo at reducing the number of monthly migraine days when taken every other day for the preventive treatment of migraine. The beneficial effects of rimegepant in reducing migraine frequency and improving quality of life were maintained over the longer term (up to 52 weeks). Rimegepant was generally well tolerated, with no evidence of hepatotoxicity or cardiovascular toxicity in clinical trials. As the first dual agent approved for both treatment and prevention of migraine, rimegepant represents a useful option for the management of migraine in adults.

The effect of bright light therapy in migraine patients with sleep disturbance: A prospective, observational cohort study protocol

Background

Migraine is a common disabling disorder, and its substantial burden is associated with a considerable negative impact on the patients' quality of life. Moreover, aging patients with migraine have more cognitive complaints. Additionally, the elderly are more likely to have sleep disturbances, which may also predict the risk of incident dementia. Migraines are reported to be closely associated with sleep and circadian rhythms. Sleep disturbance is a well-known trigger for migraine episodes; moreover, shift work or jet lag reportedly triggers some migraines. The hypothalamus is thought to be the migraine generator; sleep and circadian activity rhythm are also controlled by the hypothalamus. Evidence suggests an influence of both sleep and circadian system on migraine. Previously, light therapy has been show to stabilize sleep architecture and further improve insomnia related to circadian rhythm disorders. However, the beneficial effect of light therapy on migraine with sleep disturbance has not yet been determined. We aim to explore the effects of light therapy for migraine combined with sleep disturbance.

Methods and analysis

This project is a 2-year, randomized, double-blind, placebo-controlled clinical trial. The study design includes a 4-week monitoring period (baseline and pretest), a 4-week treatment period, and a posttest. The study participants will undergo assessments on headache frequency and severity and subjective and objective (wrist actigraphy and polysomnography) sleep disturbances, and quality of life and a series of blood tests for serum biomarkers.

Discussion

This study will establish evidence-based alternative medicine for the preventive effect of bright light therapy in migraine patients with sleep disturbances. Moreover, our data will be useful to comprehend the biochemical mechanism of light therapy in migraine prevention.Clinical Trial Registration: ClinicalTrials.gov, identifier NCT04890691.

Resting-state abnormalities in functional connectivity of the default mode network in migraine: A meta-analysis

Migraine-a disabling neurological disorder, imposes a tremendous burden on societies. To reduce the economic and health toll of the disease, insight into its pathophysiological mechanism is key to improving treatment and prevention. Resting-state functional magnetic resonance imaging (rs-fMRI) studies suggest abnormal functional connectivity (FC) within the default mode network (DMN) in migraine patients. This implies that DMN connectivity change may represent a biomarker for migraine. However, the FC abnormalities appear inconsistent which hinders our understanding of the potential neuropathology. Therefore, we performed a meta-analysis of the FC within the DMN in migraine patients in the resting state to identify the common FC abnormalities. With efficient search and selection strategies, nine studies (published before July, 2022) were retrieved, containing 204 migraine patients and 199 healthy subjects. We meta-analyzed the data using the Anisotropic Effect Size version of Signed Differential Mapping (AES-SDM) method. Compared with healthy subjects, migraine patients showed increased connectivity in the right calcarine gyrus, left inferior occipital gyrus, left postcentral gyrus, right cerebellum, right parahippocampal gyrus, and right posterior cingulate gyrus, while decreased connectivity in the right postcentral gyrus, left superior frontal gyrus, right superior occipital gyrus, right orbital inferior frontal gyrus, left middle occipital gyrus, left middle frontal gyrus and left inferior frontal gyrus. These results provide a new perspective for the study of the pathophysiology of migraine and facilitate a more targeted treatment of migraine in the future.

Headache in Workers: A Matched Case-Control Study

A case−control study including 446 workers reporting headaches (cases; 136 males and 310 females, mean age 46.71 ± 10.84 years) and 446 age- and sex-matched colleagues without headaches (controls; mean age 45.44 ± 10.13) was conducted in the second half of 2020 in a sample drawn from socio health and commercial services companies to investigate the association of headache with lifestyle, metabolic, and work-related factors. Workers suffering from headache reported higher body weight (OR: 1.92, 95% CI: 1.46−2.53, p < 0.001), higher blood cholesterol (OR: 2.01, 95% CI: 1.46−2.77, p < 0.001), triglyceride (OR: 2.01, 95% CI: 1.20−3.35, p < 0.01), blood glucose (OR: 1.91, 95% CI: 1.16−3.24, p < 0.01), and blood pressure levels (OR: 1.76, 95% CI: 1.23−2.52, p < 0.01). In the year preceding the survey, cases had experienced a higher frequency of workplace violence (OR: 2.29, 95% CI: 1.25−4.20, p < 0.01 for physical aggression, OR: 2.22, 95% CI: 1.45−3.41, p < 0.001 for threat, OR: 2.74, 95% CI: 1.72−4.38, p < 0.001 for harassment) and were more frequently distressed (effort/reward ratio > 1) (OR: 1.82, 95% CI: 1.39−2.40, p < 0.001) than the controls. Compared to the controls, cases also had higher scores on anxiety and depression scales, lower scores on happiness, and lower levels of sleep quality (p < 0.001). The association of headaches with metabolic and mental health problems suggests that monitoring headaches in the workplace could help to identify workers at risk of impairment.

Effects on neuromodulation, acupuncture, and aerobic exercises on migraine and tension-type headache outcomes: A systematic review and meta-analysis

BACKGROUND

Headache disorders are common diseases that cause a social burden. This systematic review and meta-analysis aimed to evaluate the effects of various non-pharmacological treatments to address or prevent acute headaches, including neuromodulation, acupuncture, and aerobic exercises in patients with episodic migraine and tension-type headache (TTH).

METHODS

We performed a systematic search of the electronic databases PubMed, Cochrane Library, Embase, China National Knowledge Infrastructure, WANFANG MEDICINE ONLINE, and Chinese Medical Journal database using Stata/SE 14.0 to obtain weighted mean differences (WMDs). The outcomes included monthly headache days, headache intensity, headache duration, days per month of acute medication use, and the Medical Outcomes Study 36-Item Short-Form Health Survey.

RESULTS

Of 872 identified articles, 27 were included in the meta-analysis. Neuromodulation was associated with reduced headache days (WMD: -1.274, 95% CI [-1.914, -0.634], P < .001), duration (WMD: -2.2, 95% CI [-3.32, -0.107], P < .001) and medication consumption (WMD: -1.808, 95% CI [-2.546, -1.071], P < .001) in cases of migraine. Acupuncture was associated with the alleviation of headache days (WMD: -0.677, 95% CI [-0.932, -0.422], P < .001) and intensity (WMD: -0.893, 95% CI [-1.573, -0.212], P = .01) in cases of migraine and acute medication use (WMD: -3.29, 95% CI [-4.86, -1.72], P < .001) in cases of TTH. Aerobic exercise was associated with reduced headache duration (WMD: -5.1, 95% CI [-8.97, -1.22], P = .01) in cases of TTH. The risk of bias for included articles was moderate.

CONCLUSIONS

There is low- and moderate-quality evidence that neuromodulation, acupuncture, and aerobic exercises are associated with attenuated headache symptoms in patients with episodic migraine or TTH. However, high-quality studies are needed to draw more detailed conclusions.

PAC1, VPAC1, and VPAC2 Receptor Expression in Rat and Human Trigeminal Ganglia: Characterization of PACAP-Responsive Receptor Antibodies

Pituitary adenylate cyclase-activating peptide (PACAP) is a neuropeptide expressed in the trigeminal ganglia (TG). The TG conducts nociceptive signals in the head and may play roles in migraine. PACAP infusion provokes headaches in healthy individuals and migraine-like attacks in patients; however, it is not clear whether targeting this system could be therapeutically efficacious. To effectively target the PACAP system, an understanding of PACAP receptor distribution is required. Therefore, this study aimed to characterize commercially available antibodies and use these to detect PACAP-responsive receptors in the TG. Antibodies were initially validated in receptor transfected cell models and then used to explore receptor expression in rat and human TG. Antibodies were identified that could detect PACAP-responsive receptors, including the first antibody to differentiate between the PAC_1n and PAC_1s receptor splice variants. PAC₁, VPAC₁, and VPAC₂ receptor-like immunoreactivity were observed in subpopulations of both neuronal and glial-like cells in the TG. In this study, PAC₁, VPAC₁, and VPAC₂ receptors were detected in the TG, suggesting they are all potential targets to treat migraine. These antibodies may be useful tools to help elucidate PACAP-responsive receptor expression in tissues. However, most antibodies exhibited limitations, requiring the use of multiple methodologies and the careful inclusion of controls.

Migraine in the context of chronic primary pain, chronic overlapping pain disorders, and functional somatic disorders: A narrative review

OBJECTIVE

To contextualize migraine as the most common primary headache disorder in relation to other chronic primary pain and non-pain functional somatic and mental conditions.

BACKGROUND

Migraine is increasingly understood as a sensory processing disorder within a broader spectrum of symptom disorders. This has implications for diagnosis and treatment.

METHOD

Narrative review based on a search of the literature of the last 15 years on the overlap of migraine with other symptom disorders.

RESULTS

Migraine as the prototypical primary headache disorder not only comprises many non-headache symptoms in itself, it also shows high comorbidity with other chronic pain and non-pain conditions (e.g., fibromyalgia syndrome, irritable bowel syndrome, functional non-epileptic seizures, depression, anxiety, and posttraumatic stress disorder). Such "symptom disorders" share several etiological factors (e.g., female preponderance, psychological vulnerability) and psychophysiological mechanisms (e.g., altered sensory processing, pain expectancy). These facts are acknowledged by several recent integrative conceptualizations such as chronic primary pain, chronic overlapping pain conditions, or functional somatic disorders. Accordingly, migraine management increasingly addresses the total symptom burden and individual contributors to symptom experience, and thus incorporates centrally acting pharmacological and non-pharmacological, that is, psychological and behavioral, treatment approaches.

CONCLUSIONS

Migraine and also other primary headache disorders should be seen as particular phenotypes within a broader spectrum of symptom perception and processing disorders that require integrative diagnostics and treatment. A harmonization of classifications and better interdisciplinary collaboration are desirable.

The Impact of Workplace Violence on Headache and Sleep Problems in Nurses

Workplace violence (WV) is a significant occupational hazard for nurses. Previous studies have shown that WV has a reciprocal relationship with occupational stress. Headaches and sleep problems are early neuropsychological signs of distress. This cross-sectional study aims to ascertain the frequency of physical or verbal assaults on nurses and to study the association of WV with headaches and sleep problems. During their regular medical examination in the workplace, 550 nurses and nursing assistants (105 males, 19.1%; mean age 48.02 ± 9.98 years) were asked to fill in a standardized questionnaire containing the Violent Incident Form (VIF) concerning the episodes of violence experienced, the Headache Impact Test (HIT-6) regarding headaches, and the Pittsburgh Sleep Quality Inventory (PSQI) on sleep quality. Occupational stress was measured using the Effort/Reward Imbalance questionnaire (ERI). Physical and non-physical violence experienced in the previous year was reported by 7.5% and 17.5% of workers, respectively. In the univariate logistic regression models, the workers who experienced violence had an increased risk of headaches and sleep problems. After adjusting for sex, age, job type, and ERI, the relationship between physical violence and headaches remained significant (adjusted odds ratio aOR = 2.25; confidence interval CI95% = 1.11; 4.57). All forms of WV were significantly associated with poor sleep in a multivariate logistic regression model adjusted for sex, age, job type, and ERI (aOR = 2.35 CI95% = 1.44; 3.85). WV was also associated with the impact of headaches and with sleep quality. WV prevention may reduce the frequency of lasting psychoneurological symptoms, such as headaches and poor sleep quality, that interfere with the ability to work.

Managing migraine on the frontline: Identifying disease, understanding burden, and incorporating CGRP pathway-targeting therapies in primary care

Migraine is a common neurologic disorder with clinical phenotypes encompassing a variety of symptoms which all contribute to the burden felt by patients. In addition to negative impacts on a patient's quality of life, migraine has both direct medical costs and indirect costs related to missed work and decreased productivity that affect individuals as well as society at large. Unfortunately, migraine diagnoses are often missed, and many patients do not receive appropriate treatment. Primary care providers are in a key position to provide timely diagnosis and effectively manage migraine for many patients. This review aims to be a guide for improving migraine management in the primary care setting by providing strategies to overcome common challenges in migraine diagnosis; summarizing current knowledge on the mechanism of action, efficacy, and safety of calcitonin gene-related peptide (CGRP) pathway-targeting therapies; and reviewing approaches to incorporate traditional and emerging treatment options into a patient-centric migraine management strategy.

Practice guidelines for the treatment of acute migraine and chronic knee osteoarthritis with paracetamol: an expert appraisal on evolution over time between scientific societies

BACKGROUND

Paracetamol is the commonest analgesic worldwide in primary care. Despite evidence-based recommendations for management of acute and chronic pain with paracetamol, practices seem to vary considerably in its modalities of use, with or without restrictions, between renowned scientific societies and over time.

OBJECTIVE

Qualitative assessment of similarities, differences, and changes over time in guidelines for paracetamol use in acute and chronic pain.

METHODS

We focused on two common pain conditions for which paracetamol is widely used: acute migraine and chronic knee osteoarthritis (OA). In 19 guidelines (10 for acute migraine, 9 for chronic knee OA) from 10 scientific societies (AAN/AHS, ACR/AF, CHS, EFNS, EHF/LTB, ESCEO, EULAR, SFEMC, SRF, OARSI) published between 1997 and 2021, methods, results and conclusions were compared, between guidelines and over time.

RESULTS

In acute migraine, there was a shift from no recommendation for paracetamol or recommendation only for mild attacks to recommendation for mild to moderate attacks in updated guidelines, without restriction for use for four of the five scientific societies. In knee OA, although updated guidelines generally used the GRADE system, recommendations remained heterogeneous between scientific societies: recommendation without or with restrictions, or not recommended. Consensus is lacking regarding long-course safety and efficacy in acute pain and pain at mobilization.

CONCLUSIONS

Most migraine guidelines now recommend paracetamol for mild to moderate pain. Knee OA guidelines vary on the use of paracetamol: a more holistic approach is needed for this condition, considering patient profile, disease stage, and pain management during physical activity to clarify its appropriate use.

Migraine may disturb sleep perception during sleep onset: a retrospective data analysis

STUDY OBJECTIVES

As sleep latency is an important factor in the diagnosis of many disorders, it is important to know whether the patient's self-reported evaluation of sleep latency corresponds with an objectively measured evaluation. Some studies indicate that patients usually overestimate their sleep latency. We sought to determine how comorbidities affect the patient's ability to assess their sleep latency.

METHODS

This was a retrospective study of 240 patients who had a polysomnography recorded at our sleep unit or at home in 2017-2020. Data on comorbidities were collected from hospital records.

RESULTS

Mean objective sleep latency (29.5 minutes, standard deviation [SD] 35.5) was significantly lower than self-reported sleep (37.4 minutes, SD 41.6) (P < .001). The patients who overestimated their sleep latency had higher mean apnea-hypopnea index (18.8 events/h, SD 21.6, vs 13.4 events/h, SD 12.8; P = .04) and higher mean sleep efficiency (81.7%, SD 13.6%, vs 75.2%, SD 13.9%; P = .004) than those who underestimated their sleep latency. There were significantly more patients with migraine in the overestimation group than in the underestimation group (20/159 patients vs 3/81 patients; P = .035). This difference was not observed in patients with headache without migraine (P = 1.000).

CONCLUSIONS

We hypothesize that migraine is markedly associated with overestimation of sleep latency. This overestimation was not observed in patients with other headache types. Further studies are needed to explore the relation between migraine and sleep onset misperception.

CITATION

Rantanen O, Hollmen M, Bachour A. Migraine may disturb sleep perception during sleep onset: a retrospective data analysis. J Clin Sleep Med. 2022;18(9):2113-2117.

Migraine disability, pain catastrophizing, and headache severity are associated with evoked pain and targeted by mind-body therapy

ABSTRACT

Meta-analysis suggests that migraine patients are no more sensitive to experimentally evoked pain than healthy control subjects. At the same time, studies have linked some migraine symptoms to quantitative sensory testing (QST) profiles. Unfortunately, previous studies associating migraine symptoms and QST have important methodological shortcomings, stemming from small sample sizes, and frequent use of univariate statistics for multivariate research questions. In the current study, we seek to address these limitations by using a large sample of episodic migraine patients (n = 103) and a multivariate analysis that associates pain ratings from many thermal intensities simultaneously with 12 clinical measures ranging from headache frequency to sleep abnormalities. We identified a single dimension of association between thermal QST and migraine symptoms that relates to pain ratings for all stimulus intensities and a subset of migraine symptoms relating to disability (Headache Impact Test 6 and Brief Pain Inventory interference), catastrophizing (Pain Catastrophizing Scale), and pain severity (average headache pain, Brief Pain Inventory severity, and Short-Form McGill Pain Questionnaire 2). Headache frequency, allodynia, affect, and sleep disturbances were unrelated to this dimension. Consistent with previous research, we did not observe any difference in QST ratings between migraine patients and healthy control subjects. Additionally, we found that the linear combination of symptoms related to QST was modified by the mind-body therapy enhanced mindfulness-based stress reduction (MBSR+). These results suggest that QST has a selective relationship with pain symptoms even in the absence of between-subjects differences between chronic pain patients and healthy control subjects.

Long-Term Follow-Up Safety and Effectiveness of CT-Guided Radiofrequency Thermocoagulation of Sphenopalatine Ganglion in Refractory Headache Treatment

OBJECTIVE

The purpose of this study was to evaluate the effectiveness and safety of computed tomography (CT)-guided radiofrequency thermocoagulation (RFTA) of the sphenopalatine ganglion (SPG) for patients with refractory headache.

METHODS

A total of 14 patients with refractory migraine and 10 patients with cluster headache (CH) who underwent CT-guided SPG RF between May 2019 and August 2021 at the Jiaxing First Hospital, located in Jiaxing City, Zhejiang Province, China, were included and analyzed in this retrospective cohort study. Pain score, sleep quality scores, and treatment effects were observed before operation as well as 1 day and 1, 3, 6, 12, and 24 months after surgery. Also, the incidence of facial numbness at different timepoints after operation was evaluated.

RESULTS

The frequency and duration of attacks decreased after treatment in patients with migraine, and the shortening of the cluster period and the prolongation of the remission period after treatment in patients with CH indicated that the treatment was effective. The numeric rating scale (NRS) ranged from 0 to 10, where 0 meant no pain and 10 meant the worst imaginable pain. The NRS of patients at 1 day and 1, 3, 6, 12, and 24 months after surgery was significantly lower than before operation (P < 0.05). The treatment of patients with migraine and CH was effective. The overall incidence of numbness in patients with migraine and the total incidence of numbness in patients with CH was recorded. The total incidence of numbness decreased gradually, but no significant difference was detected in the incidence of numbness between the two groups (P > 0.05). No serious adverse reactions, such as orthostatic hypertension, intracranial infection, and visual disturbance, occurred in the patients after operation.

CONCLUSION

CT-guided RFTA of the SPG significantly relieves headache symptoms in patients with refractory migraine and CH. It has the advantages of rapid onset, long duration, and a safe and reliable treatment process, making it worthy of clinical application.

A bibliometric analysis and visualization of tension-type headache

Background

Tension-type headache (TTH) is the most prevalent headache in the clinical practice, leading to impaired social activities, work-related disability, and heavy financial burdens. Previous studies have described possible inducement, potential pathophysiology, and clinical management of TTH; however, due to the lack of attention, literature involving bibliometric analysis is sporadic. Therefore, this study aimed to explore the current hotspots and future directions of the TTH field by bibliometric analysis.

Methods

By using CiteSpace and VOSviewer, literature regarding TTH between 2002 and 2021 from the Web of Science database was summarized and extracted. Annual publication trend, the most productive countries/regions and institutions, distribution of categories, co-citation of journals and references, and co-occurrence of keywords were analyzed.

Results

A total of 3,379 publications were included in the final visualization, indicating a stable trend in current research and a lack of breakthroughs over the past decades. These studies were mainly conducted in 120 countries/regions led by the United States and more than 600 institutions. Four eternal core themes were identified in TTH, including neurosciences, nursing, developmental psychology, and general/internal medicine. Cephalalgia ranked first, with the highest number of literature, and is the most influential journal in this area. Keyword analysis demonstrated that the similarities and differences between migraine and TTH, epidemiological studies, clinical double-blind trials, and potential populations have become key issues in the TTH field.

Conclusion

TTH has received less attention and breakthroughs in the past 20 years. To promote coordinated development between regions to fight headaches, cooperation and exchanges between countries and institutions are essential in the future. Relevant studies about headaches in children and adolescents, inducing factors such as emotional triggers and sleep disorders, concomitant diseases, possible pathogenesis, and headache treatments, are in the spotlight in recent years. This study offers a powerful roadmap for further research in this field.

Preventive and Therapeutic Effects of Low-Intensity Ultrasound Stimulation on Migraine in Rats

This study sought to systematically evaluate the prophylactic and therapeutic effects of low-intensity transcranial ultrasound stimulation on migraine in rats. We used video recordings to assess the head scratching behavior and laser speckle contrast imaging to record the changes in cerebral blood flow velocity of freely moving rats in a healthy group, migraine group, migraine group with ultrasound prevention, and migraine group with ultrasound therapy. Results demonstrated that (1) head scratching during migraine attacks in rats was accompanied by an decrease in cerebral blood flow; (2) both ultrasound prevention and therapy significantly reduced the number of head scratches but did not reduce the cerebral blood flow velocity; and (3) the number of head scratches in the ultrasound stimulation groups was not affected by the auditory effect. These results reveal that low-intensity ultrasound has the potential to be used clinically in the prevention and therapeutic treatment of migraine.

Effects of Continuous Infusion of Lidocaine under Ultrasound-Guided Cervical Sympathetic Ganglion Catheterization on Cerebral Hemodynamics and Thermal Imaging Characteristics of Head and Neck in Patients with Angioneurotic Headache

Angioneurotic headache is a common headache type in clinical treatment. At present, patients with nervous headache are mainly treated with oral western medicine in clinic, but it is usually difficult to obtain the ideal effect. In this study, we analyzed the effects of continuous lidocaine infusion through an ultrasound-guided cervical sympathetic ganglia (SG) catheter on cerebral hemodynamics and thermal imaging characteristics of head and neck in patients with angioneurotic headache and explored the clinical feasibility of this scheme. The results show that continuous infusion of lidocaine under ultrasound-guided SG catheterization can alleviate headache in patients with angioneurotic headache, which may be related to improving cerebral hemodynamics.