Migraine

"I am now on 'speaking terms' with my migraine monster" - patient experiences in acceptance-based cognitive behavioral therapy delivered via the internet for migraine: a randomized controlled pilot study using a mixed-method approach

Migraine is a common neurological disorder globally. Migraines, with or without aura, are episodic and recurring with symptom-free periods. Frequent and prolonged attacks can lead to chronic migraine. This pilot randomized controlled trial (RCT) aimed to evaluate feasibility of therapist-guided, acceptance-based internet cognitive behavioral therapy (iCBT) as an adjunct to standard medical care for migraine patients in Swedish primary healthcare settings using a mixed methods approach. Participants (treatment n = 15, control n = 14) underwent qualitative and quantitative assessments to evaluate feasibility, acceptance, and initial treatment effects. Interviews with participants (n = 7) indicate that most participants had struggled with migraines for decades and expressed dissatisfaction with the limited medical care. They found the flexible, digital format particularly helpful, praising its accessibility and structured learning. While they appreciated the comprehensive content, some faced challenges with the psychological language and the program pace. Post-treatment, participants reported emotional and behavioral changes, and better migraine management. Seventy-two percent of the 29 participants completed both baseline and 3-month follow-up measures. On average, participants completed 7.7 modules, with 60% completing all 10 modules. Promising effect size indicated a reduction in migraine days during the three-month follow-up. Both qualitative and quantitative data support the feasibility and acceptability of the intervention in primary care settings.

Assessing blood pressure changes and hypertension-related outcomes in patients with migraine treated with erenumab: A systematic review and meta-analysis

OBJECTIVES/BACKGROUND

We aimed to systematically review and summarize evidence on the effects of erenumab on systemic blood pressure (BP) in patients with migraine (International Prospective Register of Systematic Reviews ID: CRD42024571056). US Prescribing Information for erenumab was updated to include the potential risk of hypertension, although randomized trials did not link it previously. The association of this monoclonal antibody with an elevated vascular risk remains uncertain.

METHODS

Embase, PubMed, and the Cochrane databases were searched up to June 18, 2024 for studies examining the impact of erenumab on BP in patients with migraine. I2 statistics and prediction intervals (PIs) were applied to assess heterogeneity, and sensitivity and subgroup analyses were used to explore it. Data were collected using mean difference (MD) or proportion of events. The risk of bias of the included studies was assessed with the Cochrane Risk of Bias tool.

RESULTS

Systolic (MD = 0.86, 95% confidence interval [CI] = -1.02 to 2.73, p = 0.370, I2 = 63%) and diastolic (MD = 1.33, 95% CI = -0.05 to 2.72, p = 0.060, I2 = 69%) BP measures did not significantly differ between after and before erenumab treatment. This lack of significant difference persisted at 3 and 12 months. The leave-one-out technique did not change heterogeneity. The proportion of participants presenting worsening BP appears to be 22.04% (95% CI = 11.12-38.98, PI = 0.54-93.60), with 56.40% corresponding to nonhypertensive individuals at baseline. The incidence of patients starting antihypertensive medications during the study was 3.96% (95% CI = 1.30-11.42, PI = 0.02-90.04), of which 62.88% corresponded to nonhypertensive patients at baseline.

CONCLUSION

We did not find an association of erenumab with significant increases in systemic BP. There is a considerable degree of fragility in the current evidence available. The decision to prescribe erenumab, especially for patients with multiple comorbidities and risk factors for hypertension, must be made weighing the risks and benefits. Further studies are needed to confirm these findings.

Association between migraine, migraine subtype, and adverse pregnancy outcomes: A systematic review and meta-analysis

INTRODUCTION

Migraine is one of the most prevalent conditions worldwide. This systematic review aimed to evaluate the association between migraine, its subtypes, and adverse pregnancy outcomes.

MATERIAL AND METHODS

Eligible cohort and retrospective case-control studies were included from PubMed and Embase databases from their inception to May 2024. Adverse pregnancy outcomes of interest were preeclampsia, preterm birth, low birthweight, small for gestational age, and placental abruption. Study quality was assessed using the Newcastle-Ottawa Scale. Meta-analyses of the outcomes with their odds ratios (ORs) and adjusted ORs (aOR), including a 95% confidence interval (CI), were performed using RevMan. Outcomes were pooled using random effects models, with separate analyses for cohort and retrospective case-control studies. The protocol was registered with PROSPERO (no. CRD42023404759).

RESULTS

This meta-analysis included 19 studies (11 cohort and 8 retrospective case-control) encompassing 1 420 690 deliveries. Significant associations were observed between migraine and increased risk of preeclampsia (cohort: aOR 1.28 [95% CI: 1.11-1.47], I2 = 0%), (retrospective case-control: aOR 3.4 [95% CI: 1.81-6.4], I2 = 83%) and preterm birth (cohort: aOR 1.30 [95% CI: 1.17-1.44], I2 = 11%). The meta-analyses of adjusted data on low birthweight and small for gestational age were inconsistent with respect to statistical significance (cohort: aOR 1.27 [95% CI: 0.89-1.82], I2 = 36% and cohort: aOR 1.07 [95% CI: 1.03-1.12], I2 = 0%, respectively). In addition, migraine without aura (MO) (cohort: OR 1.62 [95% CI: 1.30-2.01], I2 = 0%; retrospective case-control: aOR 4.91 [95% CI: 2.78-8.67], I2 = 0%) and migraine with aura (MA) (cohort: OR 2.06 [95% CI: 1-4.27], I2 = 29%) were significantly associated with the risk of preeclampsia. Similarly, MO (cohort: OR 1.28 [95% CI: 1.11-1.49], I2 = 0%) and MA (cohort: OR 1.25 [95% CI: 1.07-1.47], I2 = 0%) were associated with preterm birth risk.

CONCLUSIONS

Pregnant women with migraines have a higher risk of preeclampsia and preterm birth compared with those without migraines. Migraine could be associated with an increased risk of low birth weight and small for gestational age. Sub-analyses indicate an elevated risk of preeclampsia and preterm birth across migraine subtypes. Notably, no previous meta-analyses have differentiated between migraine subtypes. Additional studies are needed to strengthen these findings.

Tolerability of repetitive dihydroergotamine infusions paired with an adjustment in preventive treatment strategy in chronic headache disorders in children and youth

BACKGROUND

In adults, intravenous (IV) dihydroergotamine (DHE) has been shown to be effective at improving medium term outcomes in patients with chronic headache disorders. The IV formulation is utilized given its superior bioavailability. We aim to assess the safety and effectiveness of repetitive IV DHE infusions paired with an adjustment of a preventive treatment strategy within children and youth with chronic headache disorders.

METHODS

A retrospective chart review was conducted of children and youth diagnosed with a chronic headache disorder who were admitted for DHE from January 2014 - October 2020. Patients completed a 5-day, standardized protocol. A new preventive was started one week after discharge. Data were collected from pre- and post-admission clinic notes. Safety and tolerability were assessed. Results were evaluated using descriptive statistics and compared with paired t-tests.

RESULTS

One hundred and eighty-seven patients were included for review. Sixty-eight percent (127) had chronic migraine (CM), 20% (37) new daily persistent headache (NDPH) and 12% (23) persistent headache attributed to head trauma (PHHT). The median (range) age was 16 years (7-21), and median (range) number of previous preventive trials was 4 (0-21). At follow-up, patients with CM had a significant decrease in headache days per month from 28.6 to 26.3 days (95% CI -4.1 to -1.3) p < 0.001, baseline headache intensity decreased from 5.9/10 to 5.3/10 (95% CI -1.3 to -0.1) p = 0.006, number of severe headache days per month decreased from 11.5 to 7.9 days (95% CI -6.5 to -2.3), p < 0.001, and monthly days of acute medication use from 12.1 to 9.8 days (95% CI -4.5 to -0.7) p = 0.002. In patients with NDPH there were significant decreases in baseline headache intensity from 6.4/10 to 5.3/10 (95% CI -1.7 to -0.3) p = 0.005 and monthly days of acute medication usage from 9.2 days to 5.9 days (95% CI -7.8 to -0.1) p = 0.043. Patients with PHHT had a significant decrease in headache days per month from 29 to 24 days (95% CI -9.4 to -0.7) p = 0.031. The most common side effects were nausea (85%) and mild leg cramping (60%).

CONCLUSION

Repetitive DHE infusions followed by preventive treatment adjustment was well tolerated and significantly reduced headache frequency, baseline intensity, number of severe days and/or acute medication usage in children and youth with refractory headache disorders.

Real-World Insights into the Effectiveness and Tolerability of OnabotulinumtoxinA in Chronic Migraine: A Long-Term Evaluation of up to 11 Years

BACKGROUND

Chronic migraine (CM) is a debilitating neurological disorder that imposes substantial burdens on individuals and society, including diminished quality of life and increased healthcare utilization. While the efficacy of botulinum neurotoxin type A (BoNT-A) has been demonstrated in controlled trials, this longitudinal, real-world study offers unprecedented evidence of its long-term benefits, with patients followed for a median of 15 months (interquartile range: 6-36 months) and up to 11 years.

METHODS

This retrospective analysis included 579 patients diagnosed with CM who were newly treated with BoNT-A, according to the PREEMPT protocol, receiving injections every 12 weeks at doses of 155-195 units across 31-39 sites. Outcomes were assessed through changes in monthly headache days, frequency, symptomatic medication use, and migraine-related disability using Migraine Disability Assessment (MIDAS) scores up to 60 months from recruitment. Safety was evaluated by recording treatment-emergent adverse events (TEAEs), with a focus on long-term tolerability and subgroup variability.

RESULTS

Patients showed sustained improvements, with the mean number of monthly headache days decreasing from 22.7 to 5.5, and symptomatic medication use dropping from 33.4 to 3.7 mean doses at 60 months. Additionally, over 60% of patients improved from severe (MIDAS Grade IV) to minimal disability (MIDAS Grade I). Subgroup analysis revealed variability in response rates, emphasizing the need for personalized approaches. TEAEs were predominantly mild, with no new adverse events reported after 36 months, supporting the long-term safety of BoNT-A in real-world settings.

CONCLUSIONS

This real-world study provides significant evidence for the long-term efficacy, safety, and tolerability of BoNT-A in the preventive treatment of CM. The findings highlight the importance of real-world data to account for patient variability and tailoring treatment strategies.

Disparities in the Readability and Quality of Online Patient Education Materials for Neurotoxin and Surgical Treatment of Chronic Migraine

The present study aims to evaluate the readability, content quality, and technical quality of online patient educational materials related to surgical intervention and neurotoxin treatment for chronic migraines. An online search using 10 search terms that corresponded to "surgical deactivation" or "neurotoxin treatment" was conducted. For each search term, the first 20 unique results were screened for online patient educational materials related to migraine treatment. Readability, content quality, and technical quality were assessed. Website-specific characteristics, including discussion of insurance coverage, photos, and videos were recorded. Analyses were performed across website types and between broad categories of search terms. Overall, 127 online patient educational materials were included (52% academic/hospital, 29.1% online health reference, 13.4% private practice, and 5.5% other). The average reading grade level was 10.8, which was found to be significantly higher than the AMA/NIH-recommended sixth-grade benchmark (P<0.001). Across website types, academic/hospital websites had a higher reading level than online health reference websites (11.5 vs. 9.7, P<0.001). Online health reference websites had significantly higher content quality scores than both academic/hospital and private practice websites (P<0.001). Notably, online patient educational materials within the "neurotoxin treatment" category were found to have a lower reading grade level (10.1 vs. 11.4) and an increased content quality score compared with those categorized within "surgical deactivation" (P<0.05). Online patient educational materials had a significantly higher reading level than the recommended sixth-grade level. Further efforts must be made to ensure online patient educational materials related to treatments for chronic migraines are accessible.

Clinical characteristics and treatment of patients hospitalized with status migrainosus: a retrospective analysis

BACKGROUNDS

Status Migrainosus is not rare, but there is still very little research data on this aspect, and treatment and diagnosis face huge challenges.

OBJECTS

The purpose of this study was to characterize the clinical characteristics and current treatment status of status migrainosus patients hospitalized in the Department of Neurology.

METHODS

This retrospective study examined patients with status migrainosus who were hospitalized in the Department of Neurology at a tertiary hospital in Chengdu, China, from August 1, 2015, to July 31, 2024. This study analyzed the demographic characteristics, clinical features, and treatment approaches of these status migrainosus patients.

RESULTS

Among the 1,237 patients hospitalized with a primary complaint of headache, 26 were ultimately diagnosed with status migrainosus. Of these status migrainosus patients, 21 patients with complete information were analyzed. The cohort predominantly consisted of middle-aged women, with most reporting moderate to severe headache intensity. The most common triggers identified were lack of sleep (66.7%) and mood disorders (42.8%). The average duration of status migrainosus was 9.3 days. In terms of treatment, NSAIDs were the most frequently administered (95.2%). During hospitalization, the most commonly used oral analgesics were NSAIDs and triptans, while intravenous treatments primarily included dexamethasone and valproic acid. 87.5% (14 out of 16) of the patients received preventive migraine treatment following discharge.

CONCLUSION

The clinical characteristics of Status Migrainosus are generally similar to those of episodic migraine. Treatment to terminate the headache attack often requires the combined use of multiple drugs.

Safety of Onabotulinumtoxin-A for Chronic Migraine During Pregnancy and Breastfeeding: A Narrative Review

Onabotulinumtoxin-A (onabotA) is a neurotoxin widely used for several indications, including chronic migraine (CM) preventive treatment, due to its well-demonstrated efficacy, tolerability, and safety. However, onabotA safety during pregnancy and breastfeeding remains unclear, as these populations are typically excluded from clinical trials. The action of onabotA starts locally at the injection sites, modulating the pain pathway with minimal systemic absorption, which theoretically minimizes risks to the fetus or breastfeeding infant. Preclinical studies demonstrate that onabotA does not distribute systemically in significant amounts after administration, although adverse fetal outcomes in rats and rabbits were reported when injected at high doses. Limited human data suggest that onabotA exposure during pregnancy may not be associated with major malformations or significant adverse outcomes for the fetus, especially when used at therapeutic doses for migraine prevention during the first trimester or earlier. Data on breastfeeding are even scarcer but indicate a low likelihood of drug transfer into breast milk. This narrative review highlights the available evidence on the use of onabotA in pregnancy and breastfeeding women, including real-word evidence, with a focus on the use for CM.

Fixed combination of palmitoylethanolamide and melatonin in preventive therapy of migraine: results from a randomized clinical trial

Introduction

Migraines are neurological disorders which significantly impact quality of life. Current pharmacological treatments often have adverse effects, prompting the search for alternatives with fewer side effects. Several studies have described the antimigraine properties of palmitoylethanolamide (PEA) and melatonin.

Materials and methods

Our research assessed the efficacy of the association of hydrodispersible PEA (1,200 mg) and melatonin (0.2 mg) by a randomized, three-month, double-blind, placebo-controlled trial (PEATONIDE®; n = 30 patients; placebo; n = 30 patients). The participants were recruited by "I.N.B.B. Consortium" in Italy. The primary outcome was the reduction of migraine frequency, while secondary outcomes included the reduction of intensity, duration, and grade of disability. The parameters were assessed by a self-reported daily headache diary.

Results

The formulation displayed a significant reduction in frequency (T3 months: 2.2 ± 0.4 MMDs; T0 baseline: 3.4 ± 0.5 MMDs, ***p < 0.001 vs baseline T0) and duration, intensity, disability, and incidence of associated symptoms of migraine attacks after 3 months of treatment. No adverse effects were observed during the treatment. In addition, a significant mitigation of migraine-related symptomatology was observed.

Conclusion

These findings suggest that PEATONIDE® may be a promising adjunctive approach for migraine management. However, given the relatively small sample size, further large-scale and multicenter trials are needed to confirm its clinical applicability in broader migraine population.

Rates and risk factors for migraine progression using multiple definitions of progression: Results of the longitudinal OVERCOME (US) study

OBJECTIVE

To estimate rates of migraine progression and assess predictors of progression in a large, longitudinal cohort study using the traditional definition and two alternative definitions of migraine progression.

BACKGROUND

Traditionally, migraine progression is defined as moving from episodic migraine (EM) with ≤ 14 monthly headache days (MHD) to chronic migraine (CM) with ≥ 15 MHDs of which 8 are attributable to migraine. This definition does not take into account changes in the full range of potential headache days, disability, or impact on function.

METHODS

The Observational Survey of the Epidemiology, Treatment, and Care of Migraine (OVERCOME) study identified, characterized, and followed a representative sample of adults with migraine in the United States. Migraine was defined based on the International Classification of Headache Disorders, 3rd edition (ICHD-3) criteria. We estimated rates of migraine progression at 1 year of follow-up using three definitions: (1) traditional EM-to-CM transition, (2) increase of ≥ 5 MHDs (MHD progression), and (3) increase of ≥ 5 points on the Migraine Disability Assessment (MIDAS) scale (MIDAS progression). The analysis identified sociodemographic, clinical, and migraine-related characteristics associated with each definition of progression from a set of 67 candidates and then determined the association with progression for each candidate predictor and each definition of progression.

RESULTS

A total of 11,634 participants met ICHD-3 criteria for migraine at baseline and completed the 1-year follow-up survey. The average age was 48.2 years, and average years living with migraine was 22.8 years. The sample was 75.6% female (8793/11,634), 84.4% White (9814/11,634), 6.5% Black (757/11,634), and 7.6% Hispanic (889/11,634). The majority (89.2%, 10,374/11,634) had EM at baseline, and among these, 4.7% progressed to CM over 1 year of follow-up. Rates of progression at 1 year were higher using other definitions of progression, with 9.6% (1087/11,329) reporting an increase in ≥ 5 MHDs and 21.7% (2519/11,630) reporting an increase of ≥ 5 MIDAS points. Across all three definitions of progression, ever taking preventive medications for migraine placed people at lower odds of progressing (odds ratio [95% confidence interval]: EM-to-CM transition, 0.7 [0.57-0.85]; MHD progression, 0.9 [0.75-1.00]; MIDAS progression, 0.8 [0.73-0.91]), while the presence of depression placed people at higher odds of progressing (odds ratio [95% confidence interval]: EM-to-CM transition, 1.3 [1.05-1.69]; MHD progression, 1.4 [1.21-1.67]; MIDAS progression, 1.2 [1.04-1.34]).

CONCLUSION

This work expands the concept of migraine progression, exploring two alternative definitions that modify the potential range of MHD changes and take disability into account. This analysis identified never having used preventive medications for migraine and presence of depression as risk factors across all three definitions of progression. This work may more accurately identify persons with progression and at risk of migraine progression, setting the stage for trials of preventive intervention and ultimately more effective practice.

Knowledge of the genetics of human pain gained over the last decade from next-generation sequencing

Next-generation sequencing (NGS) technologies have revolutionized pain research by providing comprehensive insights into genetic variation across the genome. Recent studies have expanded the known spectrum of mutations in genes such as SCN9A and NTRK1, which are commonly mutated in hereditary sensory neuropathies. NGS has uncovered critical alternative splicing events and facilitated single-cell transcriptomics, revealing cellular heterogeneity within tissues. An NGS-based classifier predicted extremely high opioid requirements with 80 % accuracy, highlighting the importance of tailoring opioid therapy based on genetic profiles. Key genes such as GDF5, COL11A1, and TRPV1 have been linked to osteoarthritis risk and pain sensitivity, while HLA-DRB1, TNF, and P2X7 play critical roles in inflammation and pain modulation in rheumatoid arthritis. Innovative tools, such as an atlas of the somatosensory system in neuropathic pain, have been developed based on NGS data, focusing on the dorsal root and trigeminal ganglia. This approach allows the analysis of cellular changes during the development of chronic pain. In the study of rare variants, NGS outperforms single nucleotide variant candidate studies and classical genome-wide association approaches. The complex data generated by NGS enables integrated multi-omics approaches, allowing deeper exploration of the molecular and cellular basis of pain perception. In addition, the characterization of non-coding RNAs has opened new therapeutic avenues. NGS-based pain research faces challenges related to complex data analysis and interpretation of rare genetic variants with unknown biological functions. Nevertheless, NGS offers significant potential for improving personalized pain management and highlights the need for interdisciplinary collaboration to translate findings into clinical practice.

Association between obstructive sleep apnea and migraine: A United States population-based cohort study

OBJECTIVE

To determine the association between obstructive sleep apnea (OSA) and the incidence of migraine using a large population-based dataset, as well as to identify the at-risk target groups.

BACKGROUND

Epidemiological and biochemical studies have provided evidence for the close connection between sleep disorders and migraine. Understanding the connections between OSA and migraine, as well as their shared risk factors, may provide new perspectives on the pathophysiology of both OSA and migraine and novel approaches to managing and treating these conditions.

METHODS

This retrospective cohort study used data from the TriNetX network from 2010 to 2021. We compared 196,864 adult participants with OSA to a group of 196,864 participants who had never been diagnosed with OSA (1:1 propensity score-matching for age, sex, race, comorbidities, and body mass index [BMI] categories) in relation to the risk of incident migraine. We performed subgroup analyses based on age (18-39, 40-59, ≥60 years), sex (female, male), race (White, Black or African American, Asian), BMI categories (<18.5, 18.5-24.9, 25-29.9, ≥30 kg/m2), and the presence of hypoxemia (yes, no). Sensitivity analyses were performed to validate our findings.

RESULTS

During the follow-up period, 12,613 (6.4%) and 6356 participants (3.2%) developed migraine in the OSA and non-OSA cohorts, respectively. Patients with OSA were found to have a 1.85-fold risk (hazard ratio [HR] 1.85; 95% confidence interval [CI] 1.79-1.90) of incident migraine when compared to those without OSA, after accounting for age, sex, race, and baseline comorbidities. The results were consistent in sensitivity analyses (test-negative design: HR 1.39, 95% CI 1.28-1.49) and also cross-validated in a different dataset from TriNetX (Global Collaborative Research Network: HR 1.88, 95% CI 1.82-1.93). The results of subgroup analysis by sex, age, race, BMI categories, and the presence of hypoxemia were generally consistent.

CONCLUSION

We found OSA to be associated with an elevated risk of developing migraine using a large United States nationwide database, and the association was generalizable across sex, age, race, and BMI categories. Our results suggest that awareness of migraine should be increased among patients with OSA. The findings also encourage further research to clarify the role of obesity and overweight in the relationship between OSA and migraine, as well as the potential benefits of body weight control for those with these two comorbid conditions.

Associations of comorbid headache disorders and depression with leisure-time physical activity among 14,088 adults in The Brazilian Longitudinal Study of Adult Health

BACKGROUND

While headache disorders are linked to low physical activity levels, the impact of depression on this relationship is unclear.

OBJECTIVE

To assess how single and comorbid diagnoses of migraine and tension-type headache (TTH) interact with depression and leisure-time physical activity (LTPA) levels in The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

METHODS

In this cross-sectional analysis based on the ELSA-Brasil baseline data, the relationship of migraine, TTH (both assessed with the International Classification of Headache Disorders, Second Edition), and depression (assessed with the Clinical Interview Schedule-Revised) with LTPA levels (International Physical Activity Questionnaire) was investigated by employing linear regression models. Models were adjusted for sociodemographic, lifestyle, and clinical covariates, and interaction terms were created to examine additive effects of comorbid conditions.

RESULTS

Among 14,088 participants, 54.4% (7668/14,088) were female, prevalence rates were: TTH = 39.6% (5573/14,088), migraine = 27.0% (3806/14,088), depression = 0.7% (94/14,088), depression + TTH = 1.1% (148/14,088), and depression + migraine = 2.5% (356/14,088). The mean (standard deviation) LTPA levels across the groups were: no headache + no depression = 148.7 (183.0) min/week, TTH = 133.5 (170.1) min/week, migraine = 110.3 (154.8) min/week, depression = 76.5 (146.3) min/week, depression + TTH = 84.5 (127.7) min/week, and depression + migraine = 64.3 (123.2) min/week. Negative associations were found for depression (β = -55.1, 95% confidence interval [CI] -93.6 to -17.0; p = 0.005), migraine (β = -24.7, 95% CI -33.2 to -15.4; p < 0.001), and TTH (β = -15.5, 95% CI -23.1 to -7.6; p < 0.001) with LTPA. No interaction effect was observed for depression + TTH (β = 36.0, 95% CI -12.6 to 84.6; p = 0.147) and depression + migraine (β = 31.7, 95% CI -11.3 to 74.7; p = 0.149), indicating no additive effect of comorbid conditions on LTPA levels. After adjusting for headache attack frequency, only depression + migraine remained negatively associated with LTPA (β = -38.7, 95% CI -71.6 to -5.8; p = 0.021).

CONCLUSIONS

Headache disorders and depression were independently and inversely associated with LTPA, with the strongest effects seen in depression alone or comorbid with migraine.

Internet use May be associated with the severity of headache in migraine patients: results from a Hungarian tertiary headache center

BACKGROUND

Migraine as a prevalent primary headache disorder affects mainly the young population. Migraines worsen the quality of life and are responsible for the main cause of disability worldwide. Apart from the well-known lifestyle factors, the spread of digitalization seems to influence the frequency as well as the severity of migraine attacks, however clinical studies are still lacking. Here we present a prospective single-center cross-sectional study focusing on the possible negative effects of being online and problematic internet use on the severity of headache during migraine attacks taking many covariates into account.

METHODS

Migraine patients were recruited from the Headache Outpatient Clinic of the Department of Neurology, University of Szeged, Szeged, Hungary. Socio-demographic data, medical history of migraine, severity of migraine attacks and details of online activities were recorded as well as online questionnaires focusing on internet addiction.

RESULTS

A total of 192 patients (n = 166 female; n = 26 male) completed the online questionnaire package. After the setup of a logistic regression among socio-demographic data age > 45 years (odds ratio, OR = 1.101), being married (OR = 1.584), number of children > 2 (OR = 1.227), secondary employment (OR = 2.349), while related to being online only nighttime internet use (OR = 1.330) was significantly associated with the severity of migraine attacks.

CONCLUSION

This study is among the first clinical studies focusing on the unfavorable effects of online activities on the severity of headache in migraine patients. Clinicians should be aware the negative effect of being online as a potential non-pharmacological aspect of migraine treatment.

Cognition, mental health, and quality of life in patients with chronic and episodic migraine during the interictal period

INTRODUCTION

Migraine is a highly prevalent and disabling condition, not only due to its painful symptoms but also because of its significant impact on mental health and cognitive functioning, leading to a considerable deterioration in quality of life. This study aimed to evaluate the cognitive profile, mental health, and quality of life in patients with chronic and episodic migraine during the interictal period, and to explore their relationship with sociodemographic and clinical variables.

METHOD

This observational, descriptive, cross-sectional analytical study included 60 patients diagnosed with chronic or episodic migraine, who were enrolled in a health program for headache patients between 2010 and 2016. Cognitive function, anxiety and/or depression symptoms, and quality of life during the interictal period were assessed. Descriptive analyses were conducted, and associations were evaluated by configuring primary (type of migraine) and alternative events (cognitive impairment, depression and/or anxiety, and poor quality of life).

RESULTS

The mean age of the participants was 45 years (SD ± 8), with 83.3% being women and 93.3% belonging to middle and low socioeconomic strata. Of the 60 patients, 83.3% (50) were diagnosed with chronic migraine, while the remaining had episodic migraine. The use of one or more cognition-altering medications was observed in 90% of patients with chronic migraine and 60% of those with episodic migraine (p = 0.02). Anxiety was more prevalent in patients with episodic migraine, whereas depression was more common among those with chronic migraine. Female gender, middle socioeconomic status, and longer disease duration were significantly associated with chronic migraine. Among the 57 patients who completed the Mini-Mental State Examination, 38.6% had cognitive impairment, which decreased with longer migraine duration and better social interaction. Memory and selective attention were the most affected cognitive domains in both groups. No significant associations were found for the other variables after adjusting for confounders.

CONCLUSIONS

Chronic migraine significantly impacts mental health, cognition, and quality of life, with depression and cognitive impairments being prevalent. Social interaction and longer disease duration may protect against cognitive decline, highlighting the need for multidisciplinary, personalized interventions addressing neurological and psychosocial challenges.

Guidelines of the International Headache Society for Real-World Evidence studies in migraine and cluster headache

Real-world evidence studies are an important tool for investigating the effectiveness, safety and tolerability of treatments for headache disorders in clinical practice. These studies use data generated from routine clinical practice from a variety of sources and can help to identify unmet needs in headache care and guide new therapies, including populations not always included in randomized clinical trials of different ages, comorbidities, and concomitant stable treatments. Real-world evidence pertains to the clinical evidence surrounding the utilization, as well as the potential advantages or drawbacks of treatment, which is extracted through an analysis of real-world data. Real-world evidence studies can present unique challenges, including timing of data collection (prospective vs retrospective), data selection, data quality issues and potential biases (selection, confounding factors, etc.). The International Headache Society has developed these guidelines for optimizing the design and conduct of real-world evidence studies, and therefore the strength and reliability of their output.

Acute Headache Diagnosis and Management

A clinician's goal when encountering acute headaches is to distinguish primary and secondary headache disorders. A comprehensive history, screening for warning signs of secondary headache, and a physical examination can help determine if further workup is necessary. While neurodiagnostic testing is not indicated for individuals with a history of primary headache disorders with typical symptoms, individuals with atypical signs or symptoms may warrant brain imaging with MRI brain, CT head, CT angiogram, CTV, MRV, conventional cerebral angiography, spine imaging, and/or lumbar puncture. Secondary headaches should be treated for their underlying cause. Primary headache disorders have specific evidence-based treatments that can help with acute pain relief.

Future Applications of Central Neuromodulation and Neurophysiological Testing in Cyclic Vomiting Syndrome

BACKGROUND

Cyclic vomiting syndrome (CVS) is defined by its episodic patterning. Furthermore, CVS is associated with other episodic disorders such as migraine and epilepsy. Indeed, many of the medications that are known to be useful for prophylaxis and abortive therapy in CVS are also effective in preventing and aborting migraines and seizures. These observations strongly suggest that CVS has a neural basis, but the precise pathophysiological mechanisms that operate in CVS remain unclear.

PURPOSE

This brief review describes recent neurophysiological insights and opportunities to further advance the understanding of pathophysiological neural mechanisms that are present in patients with CVS. These insights are poised to translate into the next generation of neurotherapeutic strategies for CVS using central neuromodulation. Additionally, the development of neurophysiological tests of neural excitability could be positioned to shape management decisions in future CVS care.

The Chronic Headache Self-Efficacy Scale: Development and assessment of measurement properties

OBJECTIVE

To develop and assess the psychometrics of the Chronic Headache Self-Efficacy Scale (CHASE).

BACKGROUND

Existing scales assess self-efficacy in coping strategies and management of symptoms and triggers but do not measure other important self-efficacy domains, such as performing daily activities and socializing in patients with chronic daily headache (CDH).

METHODS

The study had two phases: (i) Development of the 14-item CHASE, with items derived from patients with CDH and a multidisciplinary healthcare team; (ii) longitudinal observational study for psychometric evaluation. Participants with CDH (N = 79) completed the CHASE, Headache Management Self-Efficacy Scale (HMSE), six-item Headache Impact Test-6 (HIT-6), and 12-item Short Form Health Survey (SF-12) at baseline, 24-72 h after baseline, and 12 weeks after baseline. The Global Rating of Change (GROC) assessed perceived change in symptoms. We assessed internal consistency, day-to-day reliability, convergent and known group discriminant validity, dimensionality, and responsiveness via minimal clinical important difference (MCID).

RESULTS

For day-to-day reliability, the CHASE intraclass correlation coefficient was 0.68 (95% confidence interval 0.49-0.81), with standard error of measurement and minimal detectable change of 10.3% and 24%, respectively. The CHASE had two independent factors (total R2 = 54.5%) that can be combined into a single score (Cronbach's alpha internal consistency 0.88). For convergent validity, the CHASE score was related to the HIT-6, HMSE, and SF-12 (R2: 0.17-0.29, all p < 0.001). For known group discriminant validity, individuals with an active headache had a lower CHASE score than those without (mean [standard deviation] 47.7 [17.3]% vs. 57.2 [19.8]%, p < 0.001). Classification and regression tree analysis showed the MCID for meaningful positive symptom change on the GROC was a CHASE change of >8% or CHASE change of 8% with baseline CHASE >67%.

CONCLUSION

The CHASE is a reliable and valid questionnaire for assessing self-efficacy in performing daily activities, socializing, managing headache symptoms and triggers, and guiding treatment plans for patients with CDH.

IDO1 modulates pain sensitivity and comorbid anxiety in chronic migraine through microglial activation and synaptic pruning

BACKGROUND

Chronic migraine is a prevalent and potentially debilitating neurological disorder that is often comorbid with mental health conditions (such as anxiety and depression), but the underlying mechanisms linking these conditions remain poorly understood. Indoleamine 2,3-dioxygenase 1 (IDO1) has been implicated in inflammatory processes, including neuroinflammation and pain. However, its role as a link between neuroinflammation and pain sensitization in chronic migraine is not well defined.

METHODS

Male mice were used to establish a model of chronic migraine by recurrent intraperitoneal injections of nitroglycerin (NTG, 10 mg/kg). Using pharmacological approaches, transgenic strategies and adeno-associated virus (AAV) intervention, we investigated the role of IDO1 in pain sensitization and migraine-related mood disorders in an NTG-induced chronic migraine mouse model. We employed a combination of immunoblotting, immunohistochemistry, three-dimensional reconstruction, RNA sequencing, electrophysiology, in vivo fiber photometry, and behavioral assays to elucidate the underlying mechanisms involved.

RESULTS

Our findings demonstrated that pharmacological inhibition and genetic knockout of IDO1 significantly alleviated pain sensitivity in a chronic migraine model. Neuronal activity in the anterior cingulate cortex (ACC) was evaluated with in vitro c-Fos immunostaining as well as in vivo fiber photometry, and a shift in the excitation/inhibition (E/I) balance toward excitation was observed through whole-cell patch clamp recording. Notably, IDO1 expression was increased in the ACC, and AAV-mediated IDO1 knockdown in the ACC rescued pain sensitivity, electrophysiological E/I balance changes, and anxiety-like behavior in chronic migraine model mice. Furthermore, IDO1 regulated microglial activation and pruning of neuronal synapses in the ACC. IDO1's microglial pruning function appears to be mediated through the interferon (IFN) signaling pathway, and the behavioral changes induced by IDO1 knockdown in the ACC could be reversed by activating this pathway.

CONCLUSIONS

Our findings revealed that microglial IDO1 in the ACC drives pain sensitization and anxiety in chronic migraine, highlighting IDO1 as a potential therapeutic target for chronic migraine treatment.

The quality and reliability of online video resources concerning patient education for migraine treatment in China Mainland: an electronic media-based study

BACKGROUND

Migraine is an extremely prevalent and disabling primary neurological disease worldwide. Although multiple forms of patient education for migraine management have been employed in the past decades, the quality and reliability of headache-related online videos targeting migraine patients remained unclear, particularly those in China. Therefore, in this study, our research team aimed to explore the overall quality and credibility of online videos concerning patient education on migraine treatment in China Mainland.

METHODS

A total of 182 online videos concerning migraine treatment were retrieved from four most popular Chinese language online video platforms, including Douyin, BiliBili, Haokan Video, and Xigua Video. Our research team collected the producer identity and basic information of these videos, and then used two major score instruments, i.e., the Global Quality Score (GQS) scale and the DISCERN questionnaire, to evaluate the quality and reliability of its content. Subsequently, overall descriptive analysis and detailed comparison among specific video platforms and producers were performed. Finally, using the Spearman correlation coefficient, we also explored the potential correlation between video general information and video quality and reliability.

RESULTS

The overall quality and reliability of the migraine-related information provided by online videos were poor, yet those uploaded to Douyin were relatively more satisfactory. Among all study videos, 10 encouraged patients to keep a headache diary, 12 warned about the risk of medication overuse, and 32 emphasized the preventive treatment of chronic migraine. However, the treatment recommendations proposed by video creators were highly heterogenous, with the most frequently mentioned pharmacological, non-pharmacological, and traditional Chinese medicine measures being Triptans (n = 57, 31.3%), massage (n = 40, 22.0%), and acupuncture (n = 31, 17.0%), respectively. We also observed slight positive correlations between video quality and the numbers of likes and comments received.

CONCLUSIONS

The results of our research revealed that the quality and reliability of Chinese language online videos focused on patient education for migraine treatment were inadequate, suggesting that viewers should treat these contents with caution. However, the prospects for video-based patient education remain promising. Implementing appropriate strategies, such as strengthening regulations on health-related videos and instituting a review process conducted by medical professionals, may elevate the overall quality and trustworthiness of medical information shared through online video platforms.

Migraine and MRI: uncovering potential associations

OBJECTIVE

This study aims to investigate the association between patients with migraine headaches and brain magnetic resonance imaging (MRI) findings.

BACKGROUND

Migraine is a frequently encountered primary headache disorder with a disproportionate female predominance. Diagnosis is usually based on the patient's clinical history with neuroimaging reserved for severe or atypical presentations to exclude other pathologies. Migraine patients often experience a profound impact on their quality of life.

METHODS

A retrospective study was conducted at King Abdullah University Hospital, Jordan, involving patients with a clinical diagnosis of migraine who had undergone MRI brain imaging between January 2021 to March 2023. Descriptive data were documented, with two independent neuro-radiologists interpreting MRI findings.

RESULTS

Our study included 670 migraine patients (510 females; mean age, 40.3 years). White matter hyperintensity lesions were found in 309 patients (46.1%), significantly affecting older age groups with a mean age of 46.8 years (p > 0.001). Additionally, gender played a role, with a higher prevalence of these lesions in female migraine patients, accounting for 79.6% (p = 0.05). Multiple logistic regression analysis proved age to be an independent risk factor for the presence of white matter hyperintensity lesions (OR: 1.0688, 95% CI: 1.0546-1.0831, p > 0.001).

CONCLUSION

White matter hyperintensity lesions were seen in the MRI imaging of a subset of migraine patients. Patients with these lesions tend to be older and of female gender. However, the clinical significance of these findings remains unclear.

A narrative review of autophagy in migraine

Background and objective

Autophagy is a natural process regulated by autophagy-related genes in eukaryotic cells that involves the degradation of cytoplasmic proteins and old or damaged organelles via the lysosomal pathway to help maintain cell homeostasis. Previous studies have suggested a potential association between autophagy and migraine, while the underlying mechanisms remain unclear. This review seeks to evaluate the possible involvement of autophagy in the pathophysiology of migraine, aiming to clarify its role and implications for future research and therapeutic strategies.

Methods

A search in PubMed was conducted for English-language articles until December 5, 2024. Key terms of "autophagy," "migraine," "microglia," "neurogenic inflammation," "central sensitization," "mitophagy" and "neuropathic pain" in different combinations.

Results

In the context of migraine, the activation of the phosphoinositide 3-kinase (PI3K)/protein kinase B (PKB/Akt) signaling pathway exerts a direct influence on the mammalian target of rapamycin (mTOR), leading to a reduction in autophagy levels. Moreover, the stimulation of purinergic ligand-gated ion channel type 7 receptor (P2X7R) in microglia can hinder autophagy by interfering with the fusion of autophagosomes and lysosomes, which impedes the degradation of substrates within the autophagolysosome. Increased levels of calcitonin gene-related peptide (CGRP) may also modulate autophagy through the Akt/mTOR or protein kinase A (PKA)/mTOR signaling pathways. Additionally, research indicates that mitophagy may be partially impaired in individuals suffering from migraine. Furthermore, autophagy could contribute to the dysregulation of synaptic plasticity by influencing the processes of long-term potentiation (LTP) and long-term depression (LTD), both of which are associated with central sensitization in chronic migraine.

Conclusion

These findings suggest that autophagy may play an important role in the pathophysiology of migraine, particularly in its development and central sensitization. Research on autophagy modulators related to migraine will provide valuable insights for treatment strategies.

Unmet needs in the management of migraine in Greece from the perspective of medical experts: a Delphi consensus

Introduction

Migraine is a chronic, debilitating neurological disorder affecting billions worldwide. While not life-threatening, migraine patients experience significant unmet needs in diagnosis and management. Addressing these challenges could result in improvement of patient outcomes and reduction of the socioeconomic burden migraine imposes on individuals, healthcare system and the society.

Objective

This survey aimed to capture in Greece the perspective of medical experts (neurologists) specializing in migraine management regarding the socioeconomic burden of migraine and the unmet needs in diagnosis and treatment.

Methods

An online Delphi-based survey was conducted with 13 neurologists, experts in migraine. The survey consisted of 55 statements derived from literature research, regarding the burden of disease, diagnosis, treatment and unmet needs. Participants' level of agreement for each statement was measured through a 5-point Likert scale ("Strongly Agree," "Agree," "Neither Agree nor Disagree," "Disagree" and "Strongly Disagree"). Three rounds of voting were conducted to achieve consensus. The consensus threshold was set at 70% of responses, focusing on "Strongly Agree"/ "Agree" or "Disagree"/ "Strongly Disagree."

Results

Most experts agreed on statements emphasizing on financial and social impact of the disease and its epidemiology. However, consensus was not reached on statements concerning patient preferences for treatment administration, treatment adherence, opioid use, and frequency of visits to neurologists. Consensus was reached on the need for better healthcare professional training and the development of effective, safe treatments.

Conclusion

This survey highlighted the challenges of prompt diagnosis and effective management of migraine. Addressing these needs requires patient-centered approaches, enhanced healthcare-provider training, tailored therapeutic interventions, and advanced communication platforms.

Chronic Migraine in Adults

This JAMA Insights explores the prevalence of episodic and chronic migraine in adults and acute and preventive treatments for migraine, such as novel calcitonin gene-related peptide receptor antagonists.

Lasmiditan ameliorates serotonergic itch in mice: Possible involvement of 5-HT1F receptors

Previously, some allergic conditions involving pruritus have been linked to migraine, raising the possibility that migraine and itching may be governed by similar underlying mechanisms. We aimed to investigate the efficacy of Lasmiditan, a highly selective agonist of the 5-hydroxytryptamine 1F (5-HT1F) receptor and a recently approved medication for the treatment of migraine headaches, in ameliorating serotonergic itching. Forty animals were employed in the present study (n = 40). Eight animals were randomly assigned to each of the following study groups (n = 8, in each group): (1) "Normal Saline": This group was given intradermal injections of normal saline (2) "5-HT": The animals were injected with intradermal 5-HT, which was used to induce itching. (3) "Lasmiditan 0.3", "Lasmiditan 1", and "Lasmiditan 3" groups: injected with 5-HT as well as intraperitoneal Lasmiditan at different dose levels (0.3, 1, and 3 mg/kg, respectively). Scratching behavior was recorded for 60 min, and the skin tissue of three mice was sampled at the end of the behavioral experiment to assess the levels of TLR-4, IL-31, 5-HT1F receptor, CGRP & TRPV4. In the present study, we found that Lasmiditan when administered at 1 mg/kg effectively reduced serotonin-induced itching compared to the "5-HT" group (P < 0.0001). Following the administration of Lasmiditan (1 mg/kg), the expression levels of the 5-HT1F receptor significantly increased (P < 0.01). Further, the levels of TLR-4, IL-31, CGRP & TRPV4 were substantially reduced upon the administration of Lasmiditan (1 mg/kg). We found that Lasmiditan is effective in reducing serotonergic itch in mice through its interaction with the 5-HT1F receptor in the skin tissue of mice.

The Proteomic Analysis of Chronic Migraine Exosomes Reveals Disease Patterns and Potential Biomarkers

Exosomes have been identified as optimal biomarkers to screen for multiple diseases. However, few studies focus on the abundant exosome population isolated from plasma of migraine. This study investigated whether proteins in abundant exosomes can aid in the diagnosis of chronic migraine (CM). Plasma exosomes were collected by centrifugation, from which protein samples were extracted. A pilot study (CM, 18; episodic migraine (EM), 26) followed by a second dataset (CM, 26; EM, 16; tension-type headache (TTH), 20; control, 22) was applied to establish a diagnostic model of CM. We employed proteomics based on liquid chromatography-tandem mass spectrometry (LC-MS/MS) to search for potential candidate biomarkers in plasma exosomes from CM patients. In total, 530 proteins in plasma exosomes were co-detected. Among them, 13 proteins were found significantly dysregulated between the plasma exosomes of CM patients and other groups. The receiver operating characteristic curve analysis revealed a combination of six proteins (upregulated: RAP2B, AK1, BID, DAG1, PICALM, PSMB2) could distinguish CM patients with high accuracy. Linear correlation analysis showed that the combination was significantly correlated with Headache Impact Test (HIT-6) scores (assessing the negative impact of headaches on normal daily activity). The RT-qPCR results showed the same trends in CM models with nitroglycerin as the exosomal protein sequencing results. These data revealed dysregulated proteins in plasma exosomes of CM, and the combination of plasma exosomal proteins RAP2B, AK1, BID, DAG1, PICALM, and PSMB2 could serve as a novel candidate biomarker for CM diagnosis.

Understanding Data and Opportunities Focused on Value: A Single-Center Experience in Headache Care

Background and Objectives

Headache syndromes are highly prevalent, disabling, and costly. Our goals were to (1) describe headache care delivery and costs in a system and (2) identify opportunities for the system to collect, organize, or analyze health care data to facilitate value-based headache care delivery.

Methods

We performed a descriptive, retrospective cohort study using data from a large integrated health system (July 2018-July 2021). We assigned individuals into a reference (REF) or headache group based on headache-related ICD diagnoses. The primary exposure variable, applied to the headache group, was the headache specialty seen most after the incident headache diagnosis: primary care (PC), neurology (NEU), or headache subspecialist (HS). Outcomes of interest were per member per month all-cause costs, per episode costs, all-cause utilization, and headache utilization. Variables included age, sex, insurance contract, and the Adjusted Clinical Groups (ACG) concurrent risk score. We calculated univariate statistics for clinical indicators and outcomes for each group. For outcome variables, we also report these statistics after adjustment for ACG risk score.

Results

We identified 22,700 (14%) individuals in the headache groups and 138,818 (86%) individuals in the reference group (REF). Within the headache groups, 84% received care from PC, 14% from NEU, and 2% from HS. The average ACG risk scores increased across exposure groups. In both unadjusted and after risk adjustment analyses, total cost of care (TCOC) was highest in NEU and HS, and the largest drivers of TCOC were outpatient facility costs, followed by inpatient facility costs. HS had the highest pharmacy and professional costs. After risk adjustment, all-cause inpatient admissions and headache-related ED visits were roughly similar, although there was increasing use of outpatient PC and NEU visits across exposure groups.

Discussion

Individuals seen by a NEU or HS had higher medical morbidity, higher health care utilization, and higher costs than those who receive care from PC. Outcome data were either not available or not structured to determine the value of neurologic expertise in headache care or within a particular headache care pathway. To clarify neurology's value in primary headache disorders, we encourage health system leaders to adopt an economic evaluation framework.

Methodological challenges in using screening tools for depression in migraine: A systematic review

BACKGROUND

Depression is frequently described to occur in migraine, and depression screening questionnaires are commonly used to evaluate depressive symptoms in patients with migraine. The present study aimed to investigate how the most common depression screening tools are used in migraine studies to determine whether they are applied and interpreted correctly.

METHODS

PubMed was systematically searched, and we included any study using the Beck Depression Inventory (BDI), Patient Health Questionnaire-9 (PHQ-9), Hospital Anxiety Depression Scale (HADS) or Hamilton Depression Rating Scale (HAM-D). The study included adults diagnosed with migraine based on the International Classification of Headache Disorders (ICHD-2 or ICHD-3).

RESULTS

The literature search generated 78 studies. Thirty-five (45%) of the included studies used a depression screening tool as evidence of depression. This applied to 53, 46, 47 and 13% of studies using PHQ, BDI, HADS and HAM-D, respectively. Only one study out of 35 confirmed the diagnosis with a diagnostic interview. The data presentation and interpretation across the studies was highly heterogeneous.

CONCLUSIONS

Screening tools as evidence of depression in patients with migraine may lead to inaccurate estimates of depression among migraine patients. There is a need for guidelines on and validation of depression screening tools in patients with migraine.

Comparison of the Efficacy of Propranolol Versus Valsartan in the Prevention of Migraine: A Randomized Controlled Trial

BACKGROUND

Migraine is a prevalent episodic headache that affects approximately 14%-15% of the global population. Since valsartan is an antihypertensive drug, it is hypothesized that taking valsartan can prevent migraine attacks in patients with the condition. This study aimed to determine the efficacy of propranolol versus valsartan in preventing migraine attacks.

MATERIAL AND METHODS

This randomized controlled trial was conducted on 56 patients with migraine from a neurology clinic. Patients were divided into two equal groups of 28 individuals, after providing informed consent. The patients then received either propranolol or valsartan treatment. The intensity and frequency of migraines were compared before and after treatment in both study groups.

RESULTS

The patients' mean age was 32.78 years old (±6.9 SD), and 64% of the patients were female. After a 1-month treatment period, the results showed that valsartan patients experienced significantly fewer severe migraine attacks compared to propranolol patients.

CONCLUSION

According to the results of the present study, valsartan may be at least as effective as propranolol and perhaps more effective on some measures.

Development of the Migraine-Related Stigma (MiRS) Questionnaire: Results of the OVERCOME (US) Study

BACKGROUND

Stigma is emerging as an important social contributor to migraine-related disability and other outcomes. Currently, there are no published validated measures of migraine-specific measures of stigma.

OBJECTIVES

This secondary post hoc analysis of a cross-sectional cohort study aimed to develop a questionnaire to evaluate migraine-related stigma.

METHODS

Based on focus group discussions among persons with migraine and literature review, a panel of migraine experts iteratively developed 12 candidate items for the migraine-related stigma (MiRS) questionnaire, which aims to measure if and how people living with migraine perceive they are viewed in a stigmatizing manner by others. The United States ObserVational survey of the Epidemiology tReatment and Care Of MigrainE (OVERCOME) study identified people with active migraine within a demographically representative United States (US) adult sample and administered the novel MiRS questionnaire in addition to questionnaires assessing sociodemographics, monthly headache days, and migraine disability score (Migraine Disability Assessment) among other data. Exploratory factor analysis was then utilized to evaluate the structure of the MiRS items and determine the Cronbach's alpha described internal consistency of the factors.

RESULTS

This exploratory factor analysis was a secondary post hoc analysis of a cross-sectional cohort study derived from the OVERCOME population-based web survey, which was conducted in a United States sample of 61,932 adults with migraine. The mean (standard deviation) age was 41.7 (14.8) years, 74.5% (n = 46,122) were female, and 70.3% (n = 43,564) identified as White. Two factors were identified: MiRS-external perception of Secondary Gain (eigenvalue = 21.5, percentage of total variance = 88.9%) and MiRS-external perception of Minimizing Burden of migraine (eigenvalue = 2.7, percentage of total variance = 11.1%). The two factors were correlated (r = 0.66) and a non-orthogonal varimax rotation showed that eight items loaded onto the MiRS-Secondary Gain factor, and four items loaded onto the MiRS-Minimizing Burden factor.

CONCLUSION

This population-based study of >60,000 people with migraine allowed the development and validation of the first migraine-specific measure of perceived external stigma for people with migraine. This study demonstrated that MiRS consists of two internally consistent subscales: Secondary Gain and Minimizing Burden. This may be a useful tool for quantifying perceived migraine-related stigma to understand determinants of migraine-related stigma and test interventions to reduce perceived migraine-related stigma.

Effects of proton pump inhibitor (PPI) use on migraine - a critical review

BACKGROUND

Proton pump inhibitor (PPI) drugs are widely used and are among the most significant achievements of modern pharmacology. Their primary purpose is treating and preventing gastric acid-related disorders. Migraine and PPI intake are prevalent, and many people are affected by both. In the last few years, a potential link between PPI intake and the development of headaches-especially migraine-has come to increased attention. In this review, we critically examine the scientific data concerning the co-occurrence of these two entities.

FINDINGS

There seems to be a possible link between the use of PPIs and the occurrence of headache, especially migraine, suggesting a pathophysiological connection on several levels. Moreover, PPI use is only partially without side effects, even if these may not occur immediately. Whether the relation is causative or merely co-existential is currently not yet clear. The influence of genetics, environment, gut microbiome, medication intake and evolution of headache is multidirectional.

CONCLUSION

A relation between the prevalence of migraine and the use of PPIs on a population and personal level seems likely. Although PPIs have many advantages, they should be prescribed with caution, especially in patients who suffer from headaches and migraine. In this narrative review, we aim to critically evaluate existing data and offer a potential approach to accurately identify any connections and interactions, leading to a better understanding of how these conditions may influence each other.

The Mechanism of Acupuncture Therapy for Migraine: A Systematic Review of Animal Studies on Rats

Background

Acupuncture has long been used for migraine treatment as it is convenient for use and has remarkable efficacy. The acupuncture-based comprehensive treatment plan has been widely recognized for migraine prevention and treatment. However, the mechanism underlying acupuncture efficacy in migraine treatment is not yet completely understood. Our goal is to systematically analyze and evaluate this efficacy mechanism in migraine treatment-related basic research.

Methods

To retrieve animal experiments investigating the action mechanism of acupuncture in migraine treatment, We conducted a literature search in major databases, the search period was the inception of each database to April 1, 2024. Literature was screened and data were extracted independently based on predefined inclusion and exclusion criteria. The animal models, acupuncture points, and acupuncture methods specified in the included studies were statistically analyzed and summarized. Furthermore, the potential action mechanisms of acupuncture were discussed.

Results

In total, 20 animal experimental studies were included in the present analysis, and all of these studies used rats. In the order of frequency of use, the migraine animal models employed in the searched studies were the dural stimulation model, the nitroglycerin model, and the cortical spreading depression model. The primary acupuncture points selected were Fengchi (GB20) and Yanglingquan (GB34), and electroacupuncture was the most frequently used acupuncture method. The action mechanism of acupuncture underlying migraine treatment primarily involves regulating the descending pain modulatory system and inhibiting neurotransmitters such as CGRP, SP, and 5-HT, as well as microglial cell activation. It also reduces the levels of inflammatory cytokines, thereby mitigating neurogenic inflammation and improving central sensitization.

Conclusion

Acupuncture exerts its therapeutic effect on migraine by regulating neurotransmitter release, inhibiting inflammatory responses, modulating central analgesic mechanisms, and suppressing glial cell activation. However, further in-depth exploration is needed in the study of the mechanisms underlying acupuncture treatment for migraine.

Bridging Gaps in Migraine Management: A Comprehensive Review of Conventional Treatments, Natural Supplements, Complementary Therapies, and Lifestyle Modifications

Background: Migraine, a complex neurological condition, poses significant challenges for both sufferers and healthcare providers. While prescription medications play a vital role in managing migraine attacks, the quest for natural, non-pharmacological alternatives has garnered increasing interest. This review explores the efficacy and safety of natural supplements as treatments for migraine relief, comparing them with conventional prescription medications. Methods: The review delves into herbal supplements, clinical studies on natural remedies, aromatherapy, dietary influences, and lifestyle modifications in the context of migraine management in several databases. Results: The findings shed light on the potential of natural supplements as complementary or alternative approaches to traditional migraine therapies, offering insights into a holistic and personalized treatment paradigm for migraine sufferers. Conclusions: Natural supplements have gained attention as potential treatments for migraine relief, often perceived as safer alternatives to conventional medications.

Development and validation of a diagnostic model for migraine without aura in inpatients

Objectives

This study aimed to develop and validate a robust predictive model for accurately identifying migraine without aura (MWoA) individuals from migraine patients.

Methods

We recruited 637 migraine patients, randomizing them into training and validation cohorts. Participant's medical data were collected such as demographic data (age, gender, self-reported headache characteristics) and clinical details including symptoms, triggers, and comorbidities. The model stability, which was developed using multivariable logistic regression, was tested by the internal validation cohort. Model efficacy was evaluated using the area under the receiver operating characteristic curve (AUC), alongside with nomogram, calibration curve, and decision curve analysis (DCA).

Results

The study included 477 females (average age 46.62 ± 15.64) and 160 males (average age 39.78 ± 19.53). A total of 397 individuals met the criteria for MWoA. Key predictors in the regression model included patent foramen ovale (PFO) (OR = 2.30, p = 0.01), blurred vision (OR = 0.40, p = 0.001), dizziness (OR = 0.16, p < 0.01), and anxiety/depression (OR = 0.41, p = 0.02). Common symptoms like nausea (OR = 0.79, p = 0.43) and vomiting (OR = 0.64, p = 0.17) were not statistically significant predictors for MWoA. The AUC values were 79.1% and 82.8% in the training and validation cohorts, respectively, with good calibration in both.

Conclusion

The predictive model developed and validated in this study demonstrates significant efficacy in identifying MWoA. Our findings highlight PFO as a potential key risk factor, underscoring its importance for early prevention, screening, and diagnosis of MWoA.

Examining the Effect of Intramuscular versus Intravenous Metoclopramide for Treatment of Acute Headaches to Expedite Throughput in the Emergency Department

BACKGROUND

Numerous therapies exist for both prophylactic and abortive treatments of migraine headache symptoms. Although many of these treatments are nonspecific to migraine headache, they show sufficient evidence and have garnered significant medical professional consensus for off-label use to treat acute migraine headache. One antiemetic known to be particularly effective in ceasing migraine headache symptoms is metoclopramide.

OBJECTIVE

The purpose of this study is to examine the difference between intramuscular (i.m.) vs. intravenous (i.v.) metoclopramide on emergency department (ED) length of stay (LOS) and pain relief in patients presenting with presumed migraine headache. As a secondary outcome, we also assess the efficacy in treating subjective pain between these groups.

METHODS

This was a single-center, retrospective study of adult ED patients presenting between January 2020 and September 2022 with a principal diagnosis of acute migraine or nonspecific headache and receiving i.m. or i.v. metoclopramide during their visit. Propensity matching was utilized to balance covariates between the i.m. and i.v. groups and adjust for confounding factors, including adjuvant therapies.

RESULTS

LOS was decreased when i.m. metoclopramide was utilized as opposed to i.v. metoclopramide, both prior to and after propensity matching. Prior to propensity score matching, patients who received i.m. metoclopramide had a median LOS of 67 min (interquartile range [IQR] 42.50, 99.50), and patients with i.v. administration had a median LOS of 168 min (IQR 137, 234) (median difference = 102, 95% confidence interval [CI] 93-112, r = 0.44, p < 0.001). After propensity matching, median LOS for i.m. administration was 73 min (IQR 47, 103) and i.v. administration was 166 min (IQR 129, 259) (median difference = 97, 95% CI 81-144, r = 0.68, p < 0.001). A 95% CI was utilized for all outcomes. There was no significant difference in pain reduction between the two groups.

CONCLUSION

Intramuscular administration of metoclopramide for the treatment of acute headache in the ED is associated with a decreased median LOS compared with i.v. administration with similar clinical efficacy.

Association between serum vitamin D and severe headache or migraine: A population-based analysis

BACKGROUND

Vitamin D is thought to play a role in the development of migraine, but the nature of the relationship is still not fully understood. Although some studies have shown an association between vitamin D deficiency and migraine, other studies have had inconsistent or inconclusive results. Therefore, further research is needed to better understand the relationship between vitamin D and migraine headaches.

METHODS

We selected 9142 participants from the 2001-2004 National Health and Nutrition Examination Survey (NHANES). In our study, the term "serum vitamin D" refers to the concentration of 25OHD2 + 25OHD3 (nmol/L) in the blood. Migraine was assessed based on self-reports in the miscellaneous pain section of the NHANES questionnaire. Associations between vitamin D and the risk of migraine were examined using multiple logistic regression, smoothed curve fitting, and stratified analyses.

RESULTS

In our study, 20.53% of the participants suffered from migraine. The prevalence of migraine was higher in those with lower serum vitamin D levels. Participants in the highest quartile of serum vitamin D levels were found to have a 16% lower prevalence than those in the lowest quartile in the fully adjusted model (OR = 0.84, 95% CI 0.71-0.99). This result was supported by stratified analysis and smoothed curve fitting.

CONCLUSION

Our study showed a significant negative correlation between serum vitamin D levels and the prevalence of migraine in American adults.

Effects of ligustrazine on energy metabolism in migraine rats based on mitochondria-inflammation pathway

OBJECTIVE

To evaluate the effects of Ligustrazine (Lig) on nitroglycerin-induced migraine and explore the mechanism through the mitochondria-inflammation pathway.

METHODS

Rats were divided into control, model, Lig(50 mg/kg) + Erastin, Lig(100 mg/kg), Lig(50 mg/kg), and Zolmitriptan groups. Nitroglycerin (NTG) was administered through injection to trigger a migraine. The following parameters were measured: mechanical pain threshold, mitochondrial morphology, levels of reactive oxygen species (ROS), mitochondrial membrane potential (MMP), Adenosine triphosphate (ATP), and Nitric oxide (NO). The neuronal nitric oxide synthase (nNOS), transient receptor potential A1 (TRPA1), interleukin 1 beta (IL-1β), nuclear factor-kappaB (NF-κB), and calcitonin gene-related peptide (CGRP) were detected by Western blotting and immunohistochemistry.

RESULTS

Compared with the model group, the Lig(100 mg/kg) and Lig(50 mg/kg) groups increased mechanical pain threshold as well as improved abnormal mitochondrial morphology. Moreover, compared with the model group, the Lig(100 mg/kg) and Lig(50 mg/kg) groups demonstrated reduced levels of ROS, and NO, and increased MMP, and ATP. Lig(100 mg/kg) and Lig(50 mg/kg) groups reduced inflammation and oxidative stress by inhibiting certain gene expressions. When Erastin was injected, the effectiveness of Lig decreased, indicating that Lig's therapeutic effect was related to the extent of mPTP opening.

CONCLUSION

The mitochondria-inflammation pathway plays a critical role in regulating migraine. Lig exerts anti-migraine effects primarily by modulating the mitochondria-inflammation pathway providing a novel perspective on migraine research that is beneficial for its clinical application.

Effect of erenumab on the reversion from chronic migraine to episodic migraine in an Asian population: A post hoc analysis of the DRAGON study

BACKGROUND

Erenumab is a fully human monoclonal antibody that selectively targets the calcitonin gene-related peptide receptor. It has been proven to be safe and efficacious in patients with episodic migraine (EM) and chronic migraine (CM) as demonstrated in phase 2 and 3 clinical trials including patients from Europe, Japan, and the United States. Reversion from CM to EM, as indicated by a reduction in the frequency of headache days, is an important indicator for efficacy outcome, though it has not been analyzed widely in patients with CM to date.

OBJECTIVE

Primary results of the DRAGON study demonstrated the efficacy and safety of erenumab in patients with CM from China and other Asian countries. This post hoc analysis evaluated the rate of reversion from CM to EM in the overall population and in subgroups of patients defined by baseline demographic and clinical characteristics (age, body mass index, gender, prior preventive treatment failure, medication overuse status, and disease duration).

METHODS

Reversion from CM to EM was defined as a reduction in headache frequency to < 45 headache days over the 12 weeks of the double-blind treatment period. In addition, migraine-related disability and disease impact on functional impairment were assessed within each treatment group in reverters and non-reverters using the Headache Impact Test-6 (HIT-6), Migraine Physical Function Impact Diary (MPFID), and modified Migraine Disability Assessment (mMIDAS).

RESULTS

Overall, 557 patients with CM were randomized to monthly erenumab 70 mg (n = 279) or placebo (n = 278), of whom 52.3% (146 of 279) treated with erenumab reverted from CM to EM compared to 41.0% (114 of 278) in the placebo group (odds ratio [OR] 1.59, 95% confidence interval: 1.1-2.2; p = 0.007). Treatment with erenumab resulted in a greater mean change (standard error) from baseline in the HIT-6 total score for reverters versus non-reverters compared to placebo (erenumab: -9.5 [0.6] vs. -5.1 [0.5]; placebo: -8.9 [0.7] vs. -4.9 [0.5]). A similar pattern was observed for mMIDAS score in erenumab treatment groups versus placebo (erenumab: -22.1 [1.2] vs. -6.3 [1.8]; placebo: -19.9 [1.3] vs. -7.9 [1.6]). Substantial improvements were reported in MPFID-Physical Impairment (PI) and Everyday Activities (EA) scores in reverters versus non-reverters in erenumab treatment groups (MPFID-PI: -5.9 [0.3] vs. -1.9 [0.6]; MPFID-EA: -7.9 [0.4] vs. -3.4 [0.6]) and in placebo (MPFID-PI: -5.4 [0.4] vs. -1.0 [0.5]; MPFID-EA: -7.1 [0.5] vs. -3.2 [0.5]).

CONCLUSIONS

This analysis demonstrated that a greater proportion of patients treated with erenumab reverted from CM to EM compared to patients treated with placebo. The reversion from CM to EM was reflected by the greater improvements in patient-reported outcomes in the erenumab group.

Migraine and its major subtypes - with and without aura are associated with polygenic scores for autism

BACKGROUND

Individuals with autism spectrum disorder (ASD) experience a wide array of neurological, psychiatric and medical comorbidities, yet little attention has been given to the potential link between ASD and migraine, one of the most prevalent neurological disorders worldwide. This study aimed to investigate whether a genetic predisposition for ASD is linked to migraine and its major subtypes, with and without aura. Additionally, potential moderator and mediators of the association between ASD and migraine were explored.

METHODS

Polygenic scores (PGS) for ASD were constructed based on the genome-wide association study by the Psychiatric Genomics Consortium, on the UK Biobank cohort dataset comprising 337,386 participants using PRSice-2. Regression analyses were performed to investigate the association of ASD PGS with migraine and its major subtypes, with and without aura. Sex was explored as a potential moderating factor. The mediation analyses took into consideration variables such as education, personality trait neuroticism, body mass index (BMI) and four categories of comorbidities (psychiatric, vascular, neurologic and others).

RESULTS

ASD PGS were significantly and positively associated with migraine (odds ratio (OR) = 1.04, 95% confidence interval (CI) = 1.02-1.05, p < 0.002), migraine without aura (OR = 1.05, 95% CI = 1.02-1.07, p < 0.002) and migraine with aura (OR = 1.05, 95% CI = 1.02-1.07, p < 0.002). No moderating effect of sex on the association between ASD PGS and migraine was observed. As for potential mediators, only the personality trait neuroticism significantly mediated the association between ASD PGS and migraine, with the proportion of effect mediated 8.75% (95% CI = 4-18%).

CONCLUSIONS

Our study suggests that individuals genetically predisposed to autism are at higher risk of experiencing migraine, including the two major subtypes, with and without aura. While emphasizing the complex shared genetic and pathophysiological interactions of these conditions, the role of personality trait neuroticism as a mediator of this relationship is highlighted.

Decrement of choroid vascularization during spontaneous migraine attacks: An optical coherence tomography angiography study

OBJECTIVE

This study aimed to analyze the microcirculation of the macula, the optic nerve, and the choroid in patients with migraine by optical coherence tomography angiography (OCTA) during spontaneous migraine attacks, comparing the findings with scans performed in the interictal period in the same subjects and healthy controls (HCs).

METHODS

In this case-crossover design study, patients diagnosed with migraine who underwent an OCTA during a migraine attack were enrolled. A cohort of HCs was recruited for comparison. Data from ocular and orthotic examinations and clinical and demographical information were collected. All subjects were imaged with Solix full range OCT, recording the following parameters: macular vessel density (VD), inside disc VD, peripapillary VD, disc whole image VD, fovea choriocapillaris VD, fovea VD, parafovea VD, peripapillary thickness, fovea thickness, parafovea thickness, macular full retinal thickness, and foveal avascular zone (FAZ).

RESULTS

Thirteen patients (26 eyes individually assessed) with a diagnosis of migraine were included (9 without aura [69.2%] and 4 with aura [30.7%], with a mean age of 25.2 ± 3.4 years) and scanned during the ictal and interictal phase. Fifteen age-matched HCs (30 eyes individually assessed) were included. The foveal choriocapillaris VD was significantly lower in the ictal phase (63.3 ± 2.47%) compared to the interictal phase in the same patients (64.9 ± 2.79%) (p = 0.0019). Comparing the ictal scans from migraine patients and HCs, the FAZ area was significantly larger, and the inside disc, fovea, and fovea choriocapillaris VDs were significantly lower.

CONCLUSION

The study demonstrated a dynamic decrement in choroidal vascularization in migraine patients during spontaneous migraine attacks.

Interictal burden in migraine patients at the outset of CGRP monoclonal antibody prevention

BACKGROUND

The total burden of migraine includes not only the episodes with headache pain but extends throughout the interictal periods. Interictal symptoms and associated psychological responses may profoundly impact well-being and drive treatment-seeking behavior.

METHODS

A cross-sectional online survey was conducted with participants aged ≥ 18 years, 250 with episodic migraine (EM) and 250 with chronic migraine (CM), having ≥ 4 monthly migraine headache days. All were naïve to galcanezumab or began ≤ 6 months before survey completion. The study evaluated factors associated with the Migraine Interictal Burden Scale (MIBS-4), including social determinants of health and well-being. Multiple linear regression, logistic regression, and random forests (RF) were used to explore predictors of MIBS-4.

RESULTS

The majority of participants (90%) were female with a mean (standard deviation) age of 40.6 (± 12.0) years and 18.1 (± 12.7) years since the first migraine episode. Sociodemographically, the EM and CM groups were similar. Common comorbidities were anxiety disorder (45%) and depression (44%). Migraine family history was reported in 59% of participants. MIBS-4 was correlated with a number of diverse variables, including well-being, anxiety sensitivity, income, aura symptoms, and the worst migraine pain in the year before starting galcanezumab. Linear and logistic regression identified years since the first symptom, worst migraine attack pain, premonitory symptoms, and income as significant predictors. RF explained more of the variance than multiple linear regression and introduced additional concepts to the prediction of MIBS, identifying well-being (WHO-5 total score), the WHO-5 item "cheerful and in good spirits," worry about exercise, and fear of missing social obligations as significant predictors. Socioeconomic status and income were also critical explanatory variables for interictal burden (IIB) based on regression modeling and RF. Still, income was the only variable significantly associated with IIB across regression and RF methods.

CONCLUSIONS

Interictal burden should be considered in the medical care of people with migraine. This additional burden is holistic, with psychosocial and socioeconomic elements in addition to residual symptoms. It is essential to consider this when assessing the impact of IIB.

The Long-Term Treatment of Drug-Resistant Migraine with the Modified Atkins Ketogenic Diet: A Single-Center, Retrospective Study

Despite advances in pharmacological therapies, migraine patients are often drug resistant. Further therapeutic options in this field are, therefore, desirable. Recent studies have highlighted the efficacy of ketogenic diet (KD) on improving migraine, but data on their long-term efficacy and safety are lacking. In this study, we retrospectively evaluated the long-term effectiveness of the modified Atkins ketogenic diet (MAD) in episodic or chronic drug-resistant migraine patients. 52 patients diagnosed with episodic or chronic drug-resistant migraine under modified Atkins ketogenic diet (MAD) were evaluated. In total, 41 patients followed the diet for 6 months and 33 for 12 months. After both 6 and 12 months, frequency, length, and intensity of migraine episodes, as well as the number of medications significantly decreased with respect to the start of the diet. Body mass index, high sensitivity PCR, diastolic blood pressure, fasting plasma insulin and HOMA index were also significantly reduced both after 6 and 12 months. No major metabolic changes were observed during MAD treatment. In conclusion, KD has been shown to be effective and safe in the long-term treatment of drug-resistant migraine. A high dropout rate still remains an important factor, which often limits its use.

Metabolomics integrated with mass spectrometry imaging reveals novel action of tetramethylpyrazine in migraine

Migraine as a common neurological disorder still lacks effective therapies. Tetramethylpyrazine (TMP) is the main bioactive component from Ligusticum chuanxiong hort., a traditional edible-medicinal herb. This study aimed to investigate the action of TMP on migraine by metabolomics with mass spectrometry imaging (MSI) analysis and molecular exploring, including random forest model analysis, KEGG enrichment analysis and metabolite-metabolite interaction network analysis. The results indicated that 26 key representative metabolic biomarkers were identified, especially γ-glu-cys, which were highly related to glutathione (GSH) metabolism. MSI found the abundance of eleven endogenous metabolites were modulated by TMP, particularly glucose, the most important energy metabolism molecule, and GSH were increased that maintains intracellular redox balance, which was consistent with activation of Nrf2 signals by TMP. These findings provide insights into the effectiveness of metabolomics integrated with MSI in explaining the metabolic mechanisms of TMP, and afford valuable information for healthy development of TMP in migraine.

Spinal manipulations for migraine: an updated systematic review and meta-analysis of randomized clinical trials

OBJECTIVE

This update of a systematic review evaluates the effectiveness of spinal manipulations as a treatment for migraine headaches.

BACKGROUND

Spinal manipulation therapy (SMT) is sometimes used to treat migraine headaches; however, the biological plausibility and safety of SMT have repeatedly been questioned.

METHODS

Amed, Embase, MEDLINE, CINAHL, Mantis, Index to Chiropractic Literature, and Cochrane Central were searched from inception to September 2023. Randomized clinical trials (RCTs) investigating spinal manipulations (performed by various healthcare professionals including physiotherapists, osteopaths, and chiropractors) for treating migraine headaches in human subjects were considered. Other types of manipulative therapy, i.e., cranial, visceral, and soft tissue were excluded. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to evaluate the certainty of evidence.

RESULTS

Three more RCTs were published since our first review; amounting to a total of 6 studies with 645 migraineurs meeting the inclusion criteria. Meta-analysis of six trials showed that, compared with various controls (placebo, drug therapy, usual care), SMT (with or without usual care) has no effect on migraine intensity/severity measured with a range of instruments (standardized mean difference [SMD] - 0.22, 95% confidence intervals [CI] - 0.65 to 0.21, very low certainty evidence), migraine duration (SMD - 0.10; 95% CI - 0.33 to 0.12, 4 trials, low certainty evidence), or emotional quality of life (SMD - 14.47; 95% CI - 31.59 to 2.66, 2 trials, low certainty evidence) at post-intervention. A meta-analysis of two trials showed that compared with various controls, SMT (with or without usual care) increased the risk of AEs (risk ratio [RR] 2.06; 95% CI 1.24 to 3.41, numbers needed to harm = 6; very low certainty evidence). The main reasons for downgrading the evidence were study limitations (studies judged to be at an unclear or high risk of bias), inconsistency (for pain intensity/severity), imprecision (small sizes and wide confidence intervals around effect estimates) and indirectness (methodological and clinical heterogeneity of populations, interventions, and comparators).

CONCLUSIONS

The effectiveness of SMT for the treatment of migraines remains unproven. Future, larger, more rigorous, and independently conducted studies might reduce the existing uncertainties.

Local Dynamic Stability of Trunk During Gait Can Detect Dynamic Imbalance in Subjects with Episodic Migraine

BACKGROUND/HYPOTHESIS

Motion sensitivity symptoms, such as dizziness or unsteadiness, are frequently reported as non-headache symptoms of migraine. Postural imbalance has been observed in subjects with vestibular migraine, chronic migraine, and aura. We aimed to assess the ability of largest Lyapunov's exponent for a short time series (sLLE), which reflects the ability to cope with internal perturbations during gait, to detect differences in local dynamic stability between individuals with migraine without aura (MO) with an episodic pattern between attacks and healthy subjects (HS).

METHODS

Trunk accelerations of 47 MO and 38 HS were recorded during gait using an inertial measurement unit. The discriminative ability of sLLE was assessed through receiver-operating characteristics curves and cutoff analysis. Partial correlation analysis was conducted between the clinical and gait variables, excluding the effects of gait speed.

RESULTS

MO showed higher sLLE values, and reduced pelvic rotation, pelvic tilt, and stride length values. sLLEML and pelvic rotation showed good ability to discriminate between MO and HS and were correlated with the perceived pain, migraine disability assessment score, and each other.

CONCLUSIONS

these findings may provide new insights into the postural balance control mechanism in subjects with MO and introduce the sLLEML as a potential measure of dynamic instability in MO.

Plasma pQTL and brain eQTL integration identifies PNKP as a therapeutic target and reveals mechanistic insights into migraine pathophysiology

BACKGROUND

Migraine is a prevalent neurological disorder affecting 14.1% of the global population. Despite advances in genetic research, further investigation is needed to identify therapeutic targets and better understand its mechanisms. In this study, we aimed to identify drug targets and explore the relationships between gene expression, protein levels, and migraine pathophysiology.

METHODS

We utilized cis-pQTL data from deCODE Genetics, combined with migraine GWAS data from the GERA + UKB cohort as the discovery cohort and the FinnGen R10 cohort as the replication cohort. SMR and MR analyses identified migraine-associated protein loci. Brain eQTL data from GTEx v8 and BrainMeta v2 were used to explore causal relationships between gene expression, protein levels, and migraine risk. Mediation analysis assessed the role of metabolites, and PheWAS evaluated potential side effects.

RESULTS

Four loci were identified: PNKP, MRVI1, CALCB, and INPP5B. PNKP and MRVI1 showed a high level of evidence and opposing effects at the gene and protein levels. PNKP gene expression in certain brain regions was protective against migraine, while its plasma protein levels were positively associated with migraine risk. MRVI1 showed protective effects at the protein level but had the opposite effect at the gene expression level. Mediation analysis revealed that the glutamate to pyruvate ratio and 3-CMPFP mediated PNKP's effects on migraine. PheWAS indicated associations between PNKP and body composition traits, suggesting drug safety considerations.

CONCLUSION

PNKP and MRVI1 exhibit dual mechanisms of action at the gene and protein levels, potentially involving distinct mechanistic pathways. Among them, PNKP emerges as a promising drug target for migraine treatment, supported by multi-layered validation.

Effectiveness of a Complementary Telehealth Education Program as a Preventive Treatment for Chronic Migraine: A Randomized Pilot Study

Background/Objectives: Chronic migraine (CM) is a neurological disorder that causes significant disability, loss of productivity, and economic burden. Preventive treatments, including pharmacological and educational interventions, are crucial for managing CM effectively. The aim of this study was to analyze whether adding a therapeutic telehealth education program (TTEP) to pharmacological treatment achieved a greater reduction in the number of headache days experienced by patients with CM. Methods: A randomized, double-blind, controlled pilot study with two parallel groups was performed. Patients with a diagnosis of CM and who were being treated with Botulinum Toxin were randomly assigned to either the EG (therapeutic education program about the neuroscience of pain, migraine, pain strategies, sleep habits, exercise, nutrition, postural habits, and relaxation strategies) or CG (general health recommendations with no specific content about migraine). The intervention lasted a total of eight weeks and was delivered via a telehealth application (APP). Headache frequency, migraine frequency, pain intensity, headache impact, allodynia, fear of movement, pain catastrophizing, chronic pain self-efficacy, anxiety and depression, sleep quality, and sedentary lifestyle were measured at baseline (M0), one month after the intervention started (M1), at the end of the intervention (M2), and one month after the intervention was completed for follow-up (M3). Results: In total, 48 patients participated. There were differences between the groups in the following outcomes in favor of EG for headache frequency at the one-month follow-up (p = 0.03; d = 0.681); chronic pain self-efficacy at post-treatment (p = 0.007; d = 0.885) and at the one-month follow-up (p < 0.001; d = 0.998); and sleep quality at post-treatment (p = 0.013; d = 0.786) and at the one-month follow-up (p < 0.001; d = 1.086). No differences existed between the groups for the other outcomes examined (p < 0.05). Conclusions: The use of TTEP reduced the number of headache days, improved sleep quality, and increased self-efficacy in managing pain. This pilot study suggests that the addition of a specialized TTPE to pharmacological treatments may be more effective than a general health recommendation program for migraine.

Migraine and the correlation between stroke: A systematic review and meta-analysis

BACKGROUND

This study aims to analyze and evaluate the correlation between migraines and the onset of stroke, and further explore whether migraines increase the risk of stroke.

METHODS

Two researchers independently conducted a comprehensive search of Chinese biomedical literature databases (CBM disc), PubMed, Embase, Cochrane Library, and Web of Science databases, using a combination of subject terms and free words. Literature that met the inclusion and exclusion criteria was selected, and quality assessment was performed using The Newcastle-Ottawa Scale (NOS). Data necessary for the study were extracted as effect size as needed, and meta-analysis was conducted using Review Manager 5.4 software and Stata 16 software to calculate the combined odds ratio and its 95% confidence interval. The relevant data were analyzed, and publication bias was evaluated.

RESULTS

After conducting a meta-analysis of the 9 final included articles, the heterogeneity test showed chi2 = 10.7, df = 8 (P = .22), I2 = 25%. Therefore, a fixed-effect model was used for analysis. The combined odds ratio (OR) for the risk of stroke in migraine patients compared to non-migraine patients was 2.04, with a 95% confidence interval [1.73, 2.4], which was statistically significant. In the analysis of migraine with aura, the respective ORs were 2.32 with a 95% CI of [1.70-3.18] and 1.77 with a 95% CI of [1.34-2.33]. Subgroup analysis of female migraine patients and young migraine patients showed statistically significant results, with ORs of 2.26 (95% CI [1.67-3.05]) and 2.39 (95% CI [1.9-3.01]), respectively. The relevant literature and results were evaluated for publication bias and assessed using the NOS, indicating the reliability of the results.

CONCLUSION

The results of the meta-analysis indicate that there is a certain relationship between migraine and the onset of stroke, and the results are relatively reliable. The analysis of migraine with aura shows that both the presence and absence of aura are associated with an increased risk of stroke. Subgroup analysis based on gender and age shows that the increased risk of stroke is associated with females and young individuals. However, due to the limited data in subgroup analysis, the above conclusions still require further research for validation.