Migraine headache disability and health-related quality-of-life: a population-based case-control study from England

Orexins and primary headaches: an overview of the neurobiology and clinical impact

INTRODUCTION

Primary headaches, including migraines and cluster headaches, are highly prevalent disorders that significantly impact quality of life. Several factors suggest a key role for the hypothalamus, including neuroimaging studies, attack periodicity, and the presence of altered homeostatic regulation. The orexins are two neuropeptides synthesized almost exclusively in the lateral hypothalamus with widespread projections across the central nervous system. They are involved in an array of functions including homeostatic regulation and nociception, suggesting a potential role in primary headaches.

AREAS COVERED

This review summarizes current knowledge of the neurobiology of orexins, their involvement in sleep-wake regulation, nociception, and functions relevant to the associated symptomology of headache disorders. Preclinical reports of the antinociceptive effects of orexin-A in preclinical models are discussed, as well as clinical evidence for the potential involvement of the orexinergic system in headache.

EXPERT OPINION

Several lines of evidence support the targeted modulation of orexinergic signaling in primary headaches. Critically, orexins A and B, acting differentially via the orexin 1 and 2 receptors, respectively, demonstrate differential effects on trigeminal pain processing, indicating why dual-receptor antagonists failed to show clinical efficacy. The authors propose that orexin 1 receptor agonists or positive allosteric modulators should be the focus of future research.

Structural equation modeling for identifying the drivers of health-related quality of life improvement experienced by patients with migraine receiving eptinezumab

BACKGROUND

As new migraine therapies emerge, it is crucial for measures to capture the complexities of health-related quality of life (HRQoL) improvement beyond improvements in monthly migraine day (MMD) reduction. Investigations into the correlations between MMD reduction, symptom management, and HRQoL are lacking, particularly those that focus on improvements in canonical symptoms and improvement in patient-identified most-bothersome symptoms (PI-MBS), in patients treated with eptinezumab. This exploratory analysis identified efficacy measures mediating the effect of eptinezumab on HRQoL improvements in patients with migraine.

METHODS

Data from the DELIVER study of patients with 2-4 prior preventive migraine treatment failures (NCT04418765) were inputted to two structural equation models describing sources of HRQoL improvement via Migraine-Specific Quality-of-Life Questionnaire (MSQ) scores. A single latent variable was defined to represent HRQoL and describe the sources of HRQoL in DELIVER. One model included all migraine symptoms while the second model included the PI-MBS as the only migraine symptom. Mediating variables capturing different aspects of efficacy included MMDs, other canonical symptoms, and PI-MBS.

RESULTS

In the first model, reductions in MMDs and other canonical symptoms accounted for 35% (standardized effect size [SES] - 0.11) and 25% (SES - 0.08) of HRQoL improvement, respectively, with 41% (SES - 0.13) of improvement comprising "direct treatment effect," i.e., unexplained by mediators. In the second model, substantial HRQoL improvement with eptinezumab (86%; SES - 0.26) is due to MMD reduction (17%; SES - 0.05) and change in PI-MBS (69%; SES - 0.21).

CONCLUSIONS

Improvements in HRQoL experienced by patients treated with eptinezumab can be substantially explained by its effect on migraine frequency and PI-MBS. Therefore, in addition to MMD reduction, healthcare providers should discuss PI-MBS improvements, since this may impact HRQoL. Health technology policymakers should consider implications of these findings in economic evaluation, as they point to alternative measurement of quality-adjusted life years to capture fully treatment benefits in cost-utility analyses.

TRIAL REGISTRATION

ClinicalTrials.gov (Identifier: NCT04418765 ; EudraCT (Identifier: 2019-004497-25; URL: https://www.clinicaltrialsregister.eu/ctr-search/search?query=2019-004497-25 ).

Impact of monthly headache days on migraine-related quality of life: Results from the Chronic Migraine Epidemiology and Outcomes (CaMEO) study

OBJECTIVE

To characterize the direct impact of monthly headache days (MHDs) on health-related quality of life (HRQoL) in people with migraine and the potential mediating effects of anxiety, depression, and allodynia.

BACKGROUND

Although the general relationship between increased migraine frequency (i.e., MHDs) and reduced HRQoL is well established, the degree to which reduced HRQoL is due to a direct effect of increased MHDs or attributable to mediating factors remains uncertain.

METHODS

Cross-sectional baseline data from participants with migraine who completed the Core and Comorbidities/Endophenotypes modules in the 2012-2013 US Chronic Migraine Epidemiology and Outcomes (CaMEO) study, a longitudinal web-based survey study, were analyzed. The potential contribution of depression, anxiety, and/or allodynia to the observed effects of MHDs on HRQoL as measured by the Migraine-Specific Quality-of-Life Questionnaire version 2.1 (MSQ) was evaluated.

RESULTS

A total of 12,715 respondents were included in the analyses. The MSQ domain scores demonstrated progressive declines with increasing MHD categories (B = -1.23 to -0.60; p < 0.001). The observed HRQoL decrements associated with increasing MHDs were partially mediated by the presence of depression, anxiety, and allodynia. The MHD values predicted 24.0%-32.4% of the observed variation in the MSQ domains. Depression mediated 15.2%-24.3%, allodynia mediated 9.6%-16.1%, and anxiety mediated 2.3%-6.0% of the observed MHD effects on the MSQ.

CONCLUSIONS

Increased MHD values were associated with lower MSQ scores; the impact of MHDs on the MSQ domain scores was partially mediated by the presence of depression, anxiety, and allodynia. MHDs remain the predominant driver of the MSQ variation; moreover, most of the variation in the MSQ remains unexplained by the variables we analyzed. Future longitudinal analyses and studies may help clarify the contribution of MHDs, comorbidities, and other factors to changes in HRQoL.

Problem of headache: A cross-sectional study

Objectives

To assess the medical students, interns, general practitioners, and family physicians' perception of neurological and otolaryngeal causes of headaches.

Materials and Methods

A prospective, qualitative, questionnaire-based cross-sectional study took place. Five hundred and seventy-one senior medical students, interns, general practitioners (GPs), and family physicians from different geographical regions in Saudi Arabia were involved in the study. An online questionnaire is used to estimate the respondents' knowledge regarding neurological and otolaryngeal causes of headaches. The obtained data were statistically analyzed using SPSS version 21.

Results

Five hundred and seventy-one participants were involved in the study. They were 377 females and 194 males with a female-to-male ratio of 1.9:1. Most of them were medical students (69.9%). However, medical interns, general practitioners, and family physicians' respondents were (17.3%), (7.5%), and (5.3%), respectively. They constituted different geographical regions of Saudi Arabia. An average level of knowledge about headaches was recorded in (55%) of the participants, while (42.7%) had a good level of knowledge about its etiologies.

Conclusions

A considerable percentage of the current study population has average knowledge about neurological and otolaryngeal factors of headache. It is advocated that the current national medical curriculum be thoroughly reviewed and clear referral pathways must be established to have better management of these cases.

The use of clinical scales and PROMs in headache disorders and migraine, summarizing their dissemination and operationalization

Measurements are an essential aspect of scientific research. This review will present clinical scales and patient-reported outcome measures (PROMs) for headache disorders and migraine that have been endorsed by the International Headache Society (IHS) and are intended for use by both physicians and researchers. A clinical scale is a tool to assess a patient's condition or symptoms in a standardized and quantifiable way. Clinical scales are often used in research settings and can be used to track a patient's progress over time, monitor the effectiveness of treatment, and make decisions. They can be self-administered or completed by a healthcare professional. PROMs are tools used to evaluate a patient's health status, symptoms, and quality of life. These measures are completed by the patient and provide valuable information about the patient's perspective and experience of their condition. PROMs are increasingly used in clinical practice and research to improve patient-centered care, patient engagement, and shared decision-making. This review also briefly covers the creation process, testing for reliability and validity, and interpreting the results of the use of clinical scales and PROMs in clinical and research settings in headache disorders. The first step in creating a clinical scale or PROM is to define the purpose of the scale and the population it is intended to assess. The next step is to identify the domains or areas that the scale will assess. Then, the items or questions that will be included in the scale need to be developed. These items should be relevant to the defined purpose and population of the scale and should be worded clearly and concisely. After the items have been developed, the scale or PROM can be administered to a sample of individuals in the target population. This allows researchers to assess the reliability and validity of the scale or PROM, as well as to make any necessary revisions.

Clinical benefits and economic cost-savings of Remote Electrical Neuromodulation (REN) for migraine prevention

AIMS

Assess the clinical benefits and associated direct and indirect cost-savings from Remote Electrical Neuromodulation (REN) for migraine prevention.

METHODS

REN, a prescribed, wearable, FDA-cleared neuromodulation-device for the acute and/or treatment of migraine, recently demonstrated efficacy for migraine prevention when used every-other-day, in a prospective, randomized, double-blind, placebo-controlled, multi-center study. Following baseline (4-weeks), subjects underwent treatment with REN (or placebo; 8-weeks), and electronically reported migraine symptoms and acute treatments daily. Therapeutic-gain was the between-groups difference (REN minus placebo) in change from baseline to the second month of intervention. Health-economics impact was derived as cost-savings associated with REN's clinical benefits.

RESULTS

Out of 248 subjects randomized (128 active, 120 placebo), 179 (95:84) qualified for modifiedintention-to-treat (mITT) analysis. Significant therapeutic gains favoring REN vs placebo were found (Tepper et al., 2023), including mean (±SD) reduction in number of acute medication days (3.4 ± 0.4 vs 1.2 ± 0.5; gain = 2.2; p = 0.001) and presenteeism days (2.7 ± 0.3 vs 1.1 ± 0.4; p = 0.001). Mean changes of provider visits (reduction of 0.09 ± 0.1 vs increase of 0.08 ± 0.2; p = 0.297), and reduction of absenteeism days (0.07 ± 0.1 vs 0.07 ± 0.2; p = 0.997) were not significant. Mean annual cost-saving for one patient using REN for migraine prevention estimated $10,000 (±$1,777) from reductions in these four clinical outcomes relative to baseline without REN treatment. Extrapolated to a hypothetical US commercial health-plan of one-million covered lives, assuming the national prevalence of migraine patients on preventive treatment, annual mean (±SE) cost-saving from using REN migraine prevention estimated $560.0 million (±$99.5 million) from reduction in direct and indirect metrics measured.

LIMITATIONS

Clinical and cost-savings benefits presented are conservative, assessed only from endpoints measured in the clinical trial. Moreover, some of the endpoints had only scarce or no occurrences during the study period.

CONCLUSIONS

Demonstrated significant and meaningful clinical, and cost-savings benefits for patients, health insurance systems, and employers, from utilizing REN for migraine prevention.

Perceived Stress and Impact on Role Functioning in University Students with Migraine-Like Headaches during COVID-19

Migraines, a chronic disease, can be debilitating in university students, affecting their academic performance, attendance, and social interactions. The purpose of this study was to identify the impact of COVID-19 on the role functioning and perceived stress levels of students suffering from migraine-like headaches.

METHODS

Two identical cross-sectional surveys were sent to students in Fall 2019 and Spring 2021 at a mid-sized university in the U.S. The students were queried on the headache impact scale (HIT-6) and perceived stress scale (PSS-10). Associations between the migraine-like headaches, severity of the headaches, stress levels, and headache impacts on the individuals' role functioning were analyzed.

RESULTS

The average age of the respondents (n = 721) was 20.81 ± 4.32 years in 2019 and (n = 520) 20.95 ± 3.19 years in 2021. A difference (p = 0.044) was found in the HIT-6 score <49 category. The other categories of the HIT-6 and the PSS-10 were not significant.

CONCLUSIONS

During COVID-19, more students answered that their migraine-like headaches had lower impacts on their role functioning, thus suggesting that the students were having less severe migraines. A trend was seen for student's stress levels, indicating a decrease from 2019 to 2021. Furthermore, our results showed that the impact of headaches and stress levels slightly declined throughout the pandemic.

Eptinezumab improved patient-reported outcomes in patients with migraine and medication-overuse headache: Subgroup analysis of the randomized PROMISE-2 trial

OBJECTIVE

To evaluate the effect of eptinezumab on patient-reported outcomes in patients with chronic migraine (CM) and medication-overuse headache (MOH).

BACKGROUND

MOH is a secondary headache disorder commonly occurring in patients with CM and associated with functional and psychological impairments. Medication overuse and monthly headache and migraine days were reduced with eptinezumab compared with placebo as published previously; however, these outcomes do not fully capture the burden of migraine and treatment effect.

METHODS

PROMISE-2 was a phase 3, randomized, double-blind, placebo-controlled trial in adults with CM. Patients were randomized (1:1:1) to receive eptinezumab 100 mg, eptinezumab 300 mg, or placebo (up to 2 doses, 12 weeks apart). Patients completed the following patient-reported outcomes: 6-item Headache Impact Test (HIT-6), Patient Global Impression of Change (PGIC), patient-identified most bothersome symptom (PI-MBS), and 36-item Short-Form Health Survey (SF-36).

RESULTS

A total of 431 CM patients (139, 147, and 145 patients in the eptinezumab 100 mg, eptinezumab 300 mg, and placebo groups, respectively) had MOH diagnosed at screening (40.2% of the total PROMISE-2 population [n = 1072]). In CM with MOH patients, both doses of eptinezumab were associated with clinically meaningful improvements in mean HIT-6 total scores by week 4 and remained improved throughout the 24-week study. Responder rates for individual HIT-6 items were greater with eptinezumab than with placebo at all time points. At week 12, almost twice as many eptinezumab-treated patients indicated the PGIC was "much" or "very much" improved (58.5% [79/135, 100 mg] and 67.4% [95/147, 300 mg] vs. 35.8% [48/134, placebo]). Patients in the eptinezumab groups showed numerically greater improvements over placebo in the PI-MBS and SF-36 scores.

CONCLUSIONS

This subgroup analysis in patients with CM/MOH at baseline suggests that eptinezumab treatment is associated with early, sustained, and clinically meaningful improvements in patient-reported outcomes.

Burden of migraine in Brazil: A cross-sectional real-world study

OBJECTIVE

To assess the burden and consequences of migraine in Brazil in terms of health-related quality of life (HRQoL), work productivity and daily activities, and healthcare resource utilization (HRU).

BACKGROUND

Despite existing data on how migraine affects populations worldwide, there are limited data on the burden of migraine in Latin America.

METHODS

This cross-sectional study used patient-reported data from the 2018 Brazil National Health and Wellness Survey. HRQoL scores (EuroQol 5-dimension 5-level [EQ-5D-5L]; 36-item Short Form Health Survey, version 2 [SF-36v2]; and Short Form 6-dimension [SF-6D]), impairments to work productivity and daily activities (Work Productivity and Activity Impairment questionnaire), and all-cause HRU were compared between migraine respondents and matched non-migraine controls.

RESULTS

Of the 12,000 total respondents in the survey database, 1643 self-reported a physician diagnosis of migraine and were propensity score matched 1:1 with controls without migraine. HRQoL was lower in patients with migraine versus non-migraine controls, with significantly lower SF-36v2 physical (mean [± SD] 50.3 [7.5] vs. 52.0 [7.6]) and mental component (mean [± SD] 42.9 [10.2] vs. 46.0 [9.9]) summary scores and SF-6D (mean [± SD] 0.7 [0.1] vs. 0.7 [0.1]) and EQ-5D-5L (mean [± SD] 0.7 [0.2] vs. 0.8 [0.2]) utility scores (all p < 0.001). Patients with migraine reported higher levels of work productivity loss (mean [± SD], 40.6% [31.4%] vs. 28.6% [30.9%], including absenteeism 12.8% [19.1%] vs. 8.4% [17.1%] and presenteeism 35.0% [28.7%] vs. 24.8% [28.0%]; all p < 0.001); activity impairment (mean [± SD] 36.0% [28.8%] vs. 25.5% [28.1%]; p < 0.001); and significantly higher HRU in the past 6 months (healthcare provider and emergency department visits [mean [± SD] 7.2 [9.5] vs. 4.5 [6.3] and 1.7 [3.8] vs. 0.9 [2.2]; both p < 0.001] and hospitalizations [mean [± SD] 0.4 [2.7] vs. 0.2 [1.1]; p = 0.002]) than controls.

CONCLUSION

Migraine is associated with poorer HRQoL, higher all-cause HRU, and greater activity impairment and work productivity loss versus non-migraine controls in Brazil.

Impact of fremanezumab on disability outcomes in patients with episodic and chronic migraine: a pooled analysis of phase 3 studies

Background

Migraine is the second leading cause of disability worldwide. Although many preventive treatments reduce migraine frequency and severity, it is unclear whether these treatments reduce migraine-related disability in a clinically meaningful way. This pooled analysis evaluated the ability of fremanezumab to reduce migraine-related disability, based on responses and shifts in severity in patient-reported disability outcomes.

Methods

This pooled analysis included 3 double-blind phase 3 trials (HALO EM, HALO CM, FOCUS) in which patients with episodic or chronic migraine were randomly assigned 1:1:1 to quarterly or monthly fremanezumab or matched placebo for 12 weeks. Migraine-related disability was assessed using the 6-item Headache Impact Test (HIT-6) and Migraine Disability Assessment (MIDAS) questionnaires. A clinically meaningful improvement in disability was defined per American Headache Society guidelines: for HIT-6, a ≥ 5-point reduction; for MIDAS, a ≥ 5-point reduction when baseline score was 11 to 20 or ≥ 30% reduction when baseline score was > 20. Proportions of patients who demonstrated shifts in severity for each outcome were also evaluated.

Results

For patients with baseline MIDAS scores of 11 to 20 (n = 234), significantly higher proportions achieved 5-point reductions from baseline in MIDAS scores with fremanezumab (quarterly, 71%; monthly, 70%) compared with placebo (49%; both P ≤ 0.01). For patients with baseline MIDAS scores of > 20 (n = 1266), proportions achieving ≥30% reduction from baseline in MIDAS scores were also significantly higher with fremanezumab (quarterly, 69%; monthly, 79%) compared with placebo (58%; both P < 0.001). For HIT-6 scores, proportions of patients achieving 5-point reductions from baseline were significantly higher with fremanezumab (quarterly, 53%; monthly, 55%) compared with placebo (39%; both P < 0.0001). Proportions of patients with shifts of 1 to 3 grades down in MIDAS or HIT-6 disability severity were significantly greater with quarterly and monthly fremanezumab compared with placebo (all P < 0.0001).

Conclusion

Fremanezumab demonstrated clinically meaningful improvements in disability severity in this pooled analysis.

Trial registrations

HALO CM, NCT02621931; HALO EM, NCT02629861; FOCUS, NCT03308968.

Pineal cyst management: A single-institution experience spanning two decades

Background:

Pineal cysts (PCs) are benign lesions commonly found on intracranial imaging. Despite their high prevalence, there is no clear consensus on the most appropriate management of patients with PCs, especially those with symptomatic nonhydrocephalic cysts.

Methods:

A retrospective analysis was performed on 142 patients with PCs (103 surgical cases and 39 conservatively managed cases). Data were examined, including clinical presentation, imaging findings, ophthalmological status, natural course, postoperative outcomes, and complications.

Results:

Surgical group: the most common symptom was headache (92%), followed by signs of intracranial hypertension due to hydrocephalus (22%). New radiological feature of PCs was found in 11 patients. From 71 patients with long-term follow-up, headache completely resolved in 44 (62%) patients; marked improvement was observed in 20 (29%); in 7 (9%) – headache remained unchanged. The most common postoperative complication was neuro-ophthalmological disorders (23%), with a tendency for resolution in the long-term follow-up period. Neuro-ophthalmological symptoms at last follow-up included upward gaze palsy (6%) and skew deviation (5%), followed by convergence disorders (3%) and eyelid-retraction (2%). Natural course group: PC size remained stable in 34 (87%) patients during the follow-up period. The patient’s gender or age was not a significant predictor of cyst growth (P = 0.4, P = 0.56).

Conclusion:

The majority of patients with a newly diagnosed PC remain clinically and radiologically stable. Patients with nonhydrocephalic PCs and intractable headaches experience significant relief in headache symptoms, but are at risk of mild to moderate neuro-ophthalmological disorders. The natural course of PCs and factors promoting their growth still remains poorly defined.

The Impact of Migraine Disease on Work Productivity and Quality of Life Among the Adults in Riyadh, Saudi Arabia

Background: Migraine is a chronic unilateral headache associated with nausea and vomiting. According to the World Health Organization, it is listed as the 19th disabling disease. Multiple studies found an inverse relationship between the frequency of the attacks and the low quality of life score. Roughly, one-third of migraine attacks occur during workdays, with a higher incidence of reduced productivity and missed days among chronic patients (>15 headache days per month).

Objective: The objective of this article was to determine the migraine impact on work productivity and quality of life in Riyadh's general population in Saudi Arabia.

Materials and methods: A cross-sectional study was conducted among participants suspected or diagnosed with migraine in Riyadh, Saudi Arabia. The survey measured the quality of life with the effect of migraine headaches by the Migraine Specific Quality of Life Questionnaire (MSQ). Patients suspected of migraines were asked to complete the ID Migraine™ three-item screening test.

Results: In this study, we were able to collect data from 223 patients diagnosed with migraine. Among the participants, 99.1% of them were Saudi Arabian, and 93.7% were females. Moreover, 33.6% of the participants were included in the study upon their self-report and 66.4% according to the ID migraine assessment. The mean scores of limitations of the patients’ performance, interrupting normal activities, and emotions were 51.83, 57.11, and 59.94, respectively.

Conclusion: Our study confirmed the results reported in previous studies that migraine has a negative impact on the quality of life of the patients and their ability to work. An awareness program should be conducted to increase the awareness of the importance of the early diagnosis of migraine.

How to Motivate SARS-CoV-2 Convalescents to Receive a Booster Vaccination? Influence on Vaccination Willingness

(1) Background: Booster vaccinations for SARS-CoV-2 convalescents are essential for achieving herd immunity. For the first time, this study examined the influencing factors of vaccination willingness among SARS-CoV-2 infected individuals and identified vaccination-hesitant subgroups. (2) Methods: Individuals with positive SARS-CoV-2 PCR results were recruited by telephone. They completed an online questionnaire during their home isolation in Germany. This questionnaire assessed the vaccination willingness and its influencing factors. (3) Results: 224 home-isolated individuals with acute SARS-CoV-2 infection were included in the study. Vaccination willingness of home-isolated SARS-CoV-2 infected individuals with asymptomatic or moderate course was 54%. The following factors were associated with significantly lower vaccination willingness: younger age, foreign nationality, low income, low trust in vaccination effectiveness, fear of negative vaccination effects, low trust in the governmental pandemic management, low subjective informativeness about SARS-CoV-2, support of conspiracy theories. (4) Conclusions: The vaccination willingness of home-isolated SARS-CoV-2 infected individuals with asymptomatic or moderate symptomatic course was low. Motivational vaccination campaigns should be adapted to individuals with acute SARS-CoV-2 infection and consider the vaccination-hesitant groups. Vaccination education should be demand-driven, low-threshold, begin during the acute infection phase, and be guided for example by the established 5C model ("confidence, complacency, constraints, calculation, collective responsibility").

The preventive effect of the combination of atorvastatin and nortriptyline in migraine-type headache: a randomized, triple-blind, placebo-controlled trial

BACKGROUND AND PURPOSE

Migraine ranked as the eighth cause of disability worldwide. Statins with anti-inflammatory and vasodilatory endothelial effects have been introduced as an option for the prevention of migraine-type headaches. The current study aimed to assess the efficacy and tolerability of atorvastatin for the prevention of migraine in adults.

METHOD

This prospective, triple-blind, randomized controlled clinical trial was performed in adult migraineurs from mid-July 2019 to late-April 2020. Patients were randomly assigned to receive atorvastatin or placebo in combination with nortriptyline for 24-weeks. The frequency of headache was the primary outcome, and intensity of the headache and quality of life (QOL) were the secondary outcomes for this study.

RESULTS

With 34 patients in each arm, 68 patients with migraines based on the International Headache Society (IHS) criteria were enrolled in the study. At week 24, patients in the atorvastatin group experienced significantly fewer migraine attacks than the placebo group (P-value = 0.004). Moreover, there were significant differences between the two groups in QOL at follow-up intervals of 14 (P-value = 0.001) and 24 (P-value < 0.001) weeks. However, no significant difference was observed in the intensity of headache was observed in both groups (P-value > 0.05). The most common adverse effects in intervention and control groups were constipation and insomnia, respectively.

CONCLUSION

In patients with migraine, prophylaxis with atorvastatin significantly improved the frequency of headache and QOL over 24 weeks compared with placebo with no effect on the intensity of headache. Statins seem to be a potential promising drug for prophylaxis of migraine headaches.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Is it possible to sort the disability of individuals with migraine based on the International Classification of Functioning, Disability and Health? — A Scoping Review

PurposeTo identify the most frequent outcomes related to disability assessed in individuals with migraine and to correlate these findings with the categories of International Classification of Functioning, Disability and Health.Material and methodThis scoping review was developed based on studies with adult population (18-55 years) of both sexes and assessing the disability generated by migraine. We included studies in which patients had a diagnosis of migraine based on International Classification of Headache Disorders.Results52 articles were found with 42 outcomes related to 17 categories of International Classification of Functioning, Disability and Health, including the four main components of the classification, with seven categories in "Body Functions", one in "Body Structures", four in “Activities and Participation” and five in "Environmental Factors".ConclusionThe findings show that disabilities, activity limitation, or participation restriction generated by migraine can be classified by International Classification of Functioning, Disability and Health. The components "body functions", "environmental factors" and "activities and participation" were the most identified in the present study. Thus, this classification is important to classify the disability caused by migraine and to guide a rehabilitation more focused onthe patient's real demands, as well as directing the research involving this population.

Effects of CYP3A4 and P-glycoprotein inhibition or induction on the pharmacokinetics of ubrogepant in healthy adults: Two phase 1, open-label, fixed-sequence, single-center, crossover trials

Background:

Ubrogepant is metabolized by cytochrome P450 3A4 (CYP3A4) and is a P-glycoprotein (P-gp) substrate.

Objective:

To assess effects of multiple-dose moderate-strong CYP3A4 and strong P-gp inhibitors and inducers on ubrogepant pharmacokinetic (PK) parameters.

Methods:

Two phase 1, open-label, fixed-sequence, single-center, crossover trials enrolled healthy adults to receive ubrogepant 20 mg with/without verapamil 240 mg (a moderate CYP3A4 inhibitor) or ketoconazole 400 mg (a strong CYP3A4 and P-gp transporter inhibitor) (Study A), or ubrogepant 100 mg with/without rifampin 600 mg (a strong CYP3A4 inducer and P-gp inducer) (Study B). Outcomes included ubrogepant PK parameters (area under plasma concentration-time curve, time 0 through infinity [AUC0-∞], peak plasma concentration [Cmax]), and safety (treatment-emergent adverse events [TEAEs]). PK parameters were compared between ubrogepant with/without coadministered medications using linear mixed-effects models. Cmax and AUC0-∞ least-squares geometric mean ratios (GMR) of ubrogepant with/without coadministration were constructed.

Results:

Twelve participants enrolled in Study A and 30 in Study B. AUC0-∞ and Cmax GMR (90% CI) were 3.53 (3.32–3.75) and 2.80 (2.48–3.15), respectively, for ubrogepant with verapamil; 9.65 (7.27–12.81) and 5.32 (4.19–6.76) with ketoconazole; and 0.22 (0.20–0.24) and 0.31 (0.27–0.36) with rifampin. TEAEs were predominantly mild; no treatment-related serious TEAEs or TEAE-related discontinuations occurred.

Conclusion:

The PK of ubrogepant were significantly affected by the concomitant use of CYP3A4 moderate-strong inhibitors and strong inducers.

Healthcare Expenditures Associated With Comorbid Anxiety and Depression Among Adults With Migraine

Introduction: Depression and anxiety are common among patients with migraine and usually associated with a humanistic and financial burden. This study aims to examine the direct healthcare expenditures among adults with migraine alone or with comorbid anxiety and/or depression. Methods: This was a retrospective cross-sectional study using 2012, 2014, and 2016 Medical Expenditure Panel Survey data. Adult patients aged ≥22 years with migraine headache were included in the study. The direct healthcare expenditures of four migraine groups (migraine alone, migraine and anxiety, migraine and depression, and migraine and both conditions) were compared. Results: There were 1,556 patients who met the inclusion criteria and eventually enrolled in the study. Approximately 42% of the study sample had migraine with comorbid depression and/or anxiety (16.1% have depression, 12.3% have anxiety disorder, and 13.9% have both). The mean total healthcare expenditures of adults with migraine alone ($6,461) were significantly lower than those with comorbid depression and anxiety ($11,102), comorbid anxiety ($10,817), and comorbid depression ($14,577). Migraine with comorbid anxiety and depression was significantly associated with incremental costs of $1,027 in outpatient and $662 emergency room healthcare expenditures and prescription drug compared to the migraine alone group. Conclusions: The healthcare expenditures associated with migraine with comorbid depression and/or anxiety are significantly higher than those without mental health comorbidities. Therefore, regular depression and anxiety screening for patients with migraine may help reduce the healthcare expenditures associated with depression and/or anxiety comorbidities and improve the quality of care.

Effects of fremanezumab in patients with chronic migraine and comorbid depression: Subgroup analysis of the randomized HALO CM study

Objective

To evaluate the efficacy of fremanezumab in patients with chronic migraine (CM) and moderate to severe depression.

Background

Fremanezumab, a fully humanized monoclonal antibody that selectively targets calcitonin gene–related peptide, has been approved for the preventive treatment of migraine in adults. CM and depression are highly comorbid.

Methods

The 12‐week, Phase 3 HALO trial randomized patients with CM to fremanezumab quarterly (675 mg/placebo/placebo), fremanezumab monthly (675/225/225 mg), or placebo. Post hoc analyses evaluated the effects of fremanezumab in patients with moderate to severe depression (baseline 9‐item Patient Health Questionnaire sum score ≥10) on monthly number of headache days of at least moderate severity; monthly migraine days; Patient Global Impression of Change (PGIC); 6‐item Headache Impact Test (HIT‐6) scores; and depression.

Results

For the 219/1121 (19.5%) patients with moderate to severe depression at baseline, fremanezumab was associated with a significant reduction in monthly number of headache days of at least moderate severity for active treatment versus placebo (least‐squares mean change ± standard error for quarterly dosing: −5.3 ± 0.77; for monthly dosing: −5.5 ± 0.72; and for placebo: −2.2 ± 0.81; both p < 0.001). More patients achieved a ≥50% reduction in headache days of at least moderate severity with fremanezumab (quarterly: 31/78 [39.7%]; monthly: 39/96 [40.6%]) than placebo (9/67 [13.4%]; both p < 0.001). Compared with placebo, fremanezumab improved PGIC and HIT‐6 scores.

Conclusions

Fremanezumab demonstrated efficacy in the preventive treatment of CM and reduced headache impact in patients with comorbid depression.

Demographic and clinical characteristics of prevention-eligible patients with migraine in the US: a linked national survey and administrative claims database study

OBJECTIVE

To characterize burden of migraine in prevention-eligible patients compared with prevention non-eligible patients in the United States (US). Receipt of preventive therapy was also examined among prevention-eligible patients.

METHODS

This retrospective study utilized data from the 2017 US National Health and Wellness Survey linked with medical and pharmacy claims. Patients aged ≥18 years who self-reported experiencing migraine and had confirmed evidence of migraine (≥1 medical or pharmacy claim) were included. Prevention eligibility was based on number of headache days in the past 30 days (prevention-eligible: ≥4 and prevention non-eligible: <4). Descriptive statistics summarized study variables; bivariate and multivariable analyses were conducted to examine the association of prevention-eligibility status with outcomes.

RESULTS

Analyses included 450 patients, 291 (65%) prevention-eligible, and of these 56 (19%) received preventive therapy. Overall, patients were 42.98 ± 14.51 years old; 84% were female. Prevention-eligible patients reported significantly more migraine headache days in the past 6 months (29.27 ± 37.96 vs. 8.61 ± 7.88), had lower mental component summary scores (35.80 ± 2.73 vs. 37.90 ± 2.96), and more presenteeism (47.30 ± 2.98% vs. 37.90 ± 2.60%), overall work impairment (46.30 ± 2.87% vs. 37.90 ± 2.55%) and activity days missed due to migraine (8.16 ± 3.05 vs. 3.82 ± 1.58) than prevention non-eligible patients (all p<.001). Prevention-eligible patients receiving preventive therapy reported more migraine headache days during the past month (9.21 ± 7.99 vs. 6.06 ± 7.10; p=.002) and activity days lost due to migraine (18.39 ± 28.08 vs. 10.69 ± 21.43, p=.015) than those not receiving preventive therapy.

CONCLUSIONS

Prevention-eligible patients experience greater burden due to migraine, including more headache days, worse health-related quality-of-life, and greater work and activity impairment than prevention non-eligible patients.

Systematic review of outcomes and endpoints in preventive migraine clinical trials

BACKGROUND

Over the last six decades (earliest included publication from 1959), clinical trials of migraine preventive treatments have led to the regulatory approval of many medications and devices. Despite similar clinical goals, the outcomes and endpoints used in these trials are broad and not well standardized.

OBJECTIVE

To describe results from a systematic literature review focused on outcomes and endpoints used in preventive migraine clinical trials.

METHOD

A systematic literature review, following a pre-specified (unregistered) protocol developed to adhere to recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, was conducted to characterize the endpoints and outcomes used in preventive migraine clinical trials. Predetermined terms were searched in PubMed on October 28, 2019. Data related to trial design, subject characteristics, outcomes, and endpoints reported in each publication were extracted. Descriptive summaries of these features were tabulated for the recent subset of publications, published during or after 1988, that were randomized, blinded, and focused on pharmacological or device therapies for the preventive treatment of migraine.

RESULTS

The initial literature search identified 1506 publications, of which 757 publications were eligible for data extraction. Of specific clinical interest were the recent subset of 268 articles (268/757, 35.4%) fulfilling the targeted criteria. Results showed that the outcomes used to define endpoints varied substantially across publications. For example, in the recent subset of publications, 68.7% (184/268) of the publications examined ≥1 migraine-specific outcome, 39.6% (106/268) examined ≥1 headache-specific outcome, 50.7% (136/268) examined ≥1 acute/rescue medication use outcome, 40.3% (108/268) examined ≥1 headache-related patient-reported outcome measure (PROM), and 22.0% (59/268) examined ≥1 non-headache-specific PROM. Furthermore, the definition of the endpoints used (e.g., change from baseline, fixed timepoint comparisons, categorization of "responders" to treatment based on wide variety of "responder definitions") also differed across publications.

CONCLUSION

Publications from clinical trials of preventive migraine pharmacologic and device treatments differed in terms of study design, endpoint definitions, and how endpoints and outcomes were measured. Although there were common outcomes and endpoints used across publications, no clear "standardized" set of endpoints and outcomes emerged. The inconsistencies in endpoints and outcomes within this literature suggest that the development of a uniform set of outcomes and endpoints could improve the clinical meaningfulness of clinical trial results, facilitate cross-trial comparisons and better inform patient care. This standard set of outcomes and endpoints should be statistically robust and informed by the priorities of various stakeholders, most importantly, the needs and preferences of people living with migraine.

The efficacy of magnesium oxide and sodium valproate in prevention of migraine headache: a randomized, controlled, double-blind, crossover study

Migraine is a disabling disorder that affects the quality of life of patients. Different medications have been used in prevention of migraine headache. In this study, we evaluated the effectiveness of magnesium oxide in comparison with valproate sodium in preventing migraine headache attacks. This is a single-center, randomized, controlled, crossover trial which is double-blind, 24-week, 2-sequence, 2-period, 2-treatment. After patient randomization into two sequences, the intervention group received magnesium oxide 500 mg and the control group received valproate sodium 400 mg two tablets each day (every 12 h) for 8 weeks. The primary efficacy variable was reduction in the number of migraine attacks and number of days with moderate or severe headache and hours with headache (duration) per month in the final of 8 weeks in comparison with baseline. Seventy patients were randomized and seven dropped out, leaving 63 for analysis. In an intention-to-treat analysis, 31 patients were in group 1 (magnesium oxide-valproate) and 32 patients were in group 2 (valproate-magnesium oxide). The mean number of migraine attacks and days per month was 1.72 ± 1.18 and 2.09 ± 1.70, with a mean duration of 15.50 ± 21.80 h in magnesium group and 1.27 ± 1.27 and 2.22 ± 1.96, with a mean duration 13.38 ± 14.10 in valproate group. This study has shown that 500 mg magnesium oxide appears to be effective in migraine prophylaxis similar to valproate sodium without significant adverse effect.

Patent Foramen Ovale Closure: State of the Art

Patent foramen ovale (PFO) is a common abnormality affecting between 20% and 34% of the adult population. For most people, it is a benign finding; however, in some people, the PFO can open widely to enable paradoxical embolus to transit from the venous to arterial circulation, which is associated with stroke and systemic embolisation. Percutaneous closure of the PFO in patients with cryptogenic stroke has been undertaken for a number of years, and a number of purpose-specific septal occluders have been marketed. Recent randomised control trials have demonstrated that closure of PFO in patients with cryptogenic stroke is associated with reduced rates of recurrent stroke. After a brief overview of the anatomy of a PFO, this article considers the evidence for PFO closure in cryptogenic stroke. The article also addresses other potential indications for closure, including systemic arterial embolisation, decompression sickness, platypnoea–orthodeoxia syndrome and migraine with aura. The article lays out the pre-procedural investigations and preparation for the procedure. Finally, the article gives an overview of the procedure itself, including discussion of closure devices.

Humanistic and economic burden of depression and anxiety among adults with migraine: A systematic review

BACKGROUND

Depression and anxiety are well-recognized comorbid health conditions among adults with migraine due to their humanistic and economic burden. This review was conducted to systematically assess the humanistic and economic burden of comorbid depression and/or anxiety disorder among adults with migraine.

METHODS

A systematic literature search was conducted using MEDLINE and CINAHL via EBSCO, EMBASE, and Cochrane Database of Systematic Reviews via OVID. Studies evaluating the humanistic burden and the economic burden of comorbid depression and anxiety among adults with migraine that were published in peer-reviewed English language journals from inception until January 2020 were included.

RESULTS

Out of the 640 identified articles, 23 studies were found eligible and included in this review. Regarding the humanistic burden, health-related quality of life (HRQoL) was examined by 11 studies, 7 studies examined disability, while 2 studies evaluated both HRQoL and disability measures. These studies reported an association between depression and/or anxiety and lower HRQoL and higher disability among adults with migraine. Regarding the economic burden, only three studies were identified and all concluded that depression and/or anxiety are significantly associated with higher healthcare expenditures and utilization among adults with migraine.

CONCLUSIONS

Results of this review highlight the substantial burden of depression and/or anxiety for adults with migraine. Healthcare providers need to identify and treat anxiety and depression for patients living with migraine.

A Nomogram for the Prediction of Cessation of Migraine Among Patients With Patent Foramen Ovale After Percutaneous Closure

Objective: This study aimed to develop and validate a nomogram to predict cessation of patent foramen ovale (PFO) patients with migraine headache after percutaneous closure.

Methods: A total of 247 eligible patients with PFO and migraine after percutaneous closure between May, 2016 and May, 2018 were divided into a development cohort (n = 149) and a validation cohort (n = 98). The primary end point was cessation of migraine at follow-up of 1 year after the procedure measured by the Migraine Disability Assessment Score (MIDAS). In the development cohort, the LASSO regression was used data dimension reduction. A multivariable logistic regression analysis was used to develop the predicting nomogram. The performance of the nomogram was assessed by concordance index (C-index), calibration and clinical usefulness. The results were validated in the validation cohort.

Results: Migraine with aura, history of antiplatelet, and the right-to-left shunt (RLS) at rest were identified as significant predictors based on the analysis of multivariate logistic regression. The nomogram incorporating these variables showed good calibration and discrimination in the development cohort with C-index of 0.906 (95% CI: 0.847–0.965), which was confirmed using the validation cohort with C-index of 0.827 (95% CI: 0.751–0.903). The nomogram showed good agreement between prediction by nomogram and actual observation. Furthermore, the decision curve indicated that the novel nomogram was clinically useful.

Conclusion: The novel nomogram showed favorable predictive accuracy for cessation of migraine among patients with PFO after percutaneous closure and might provide constructive guidance in clinical decision making.

Criterion-related validity in a sample of migraine outpatients: the diagnostic criteria for psychosomatic research

OBJECTIVE

The Diagnostic Criteria for Psychosomatic Research (DCPR) are those of psychosomatic syndromes that did not find room in the classical taxonomy. More recently, the DCPR were updated, called DCPR-revised (DCPR-R). The present study was conducted to test the criterion-related validity of the DCPR-R.

METHODS

Two hundred consecutive subjects were enrolled at the Headache Center of Careggi University Hospital (Italy): 100 subjects had a diagnosis of chronic migraine (CM) and 100 had a diagnosis of episodic migraine (EM). Participants received a clinical assessment, which included the DCPR-revised Semi-Structured Interview (DCPR-R SSI), the Structured Clinical Interview for DSM-5 (SCID-5), and the psychosocial index (PSI).

RESULTS

Forty-seven subjects (23.5%) had at least one DSM-5 diagnosis: major depressive disorder (8.5%; n = 17) and agoraphobia (7.5%; n = 15) were the most frequent. One hundred and ten subjects (55%) reported a DCPR-R diagnosis: allostatic overload (29%; n = 58) and type A behavior (10.5%; n = 21) were the most frequent. When the incremental validity of the DCPR system over the DSM system was tested using PSI subscales as the criterion variable, the DCPR-R increased up to 0.11-0.24 the amount of explained variance. Subjects with at least one DCPR-R diagnosis showed lower PSI well-being scores (p = .001), higher PSI stress scores (p < .001), and higher PSI psychological distress scores (p = .008) than subjects without a DCPR-R diagnosis.

CONCLUSION

The DCPR-R showed a good criterion-related validity in migraine outpatients. Thus, they might be implemented, together with the DSM-5, in the assessment of migraine subjects.

Development and Implementation of the Integrative Toolbox for Headache Management

Patients with migraine are interested in integrative therapies and overall wellness. They also suffer from social isolation as they try to manage a chronic medical condition. We implemented a three-part workshop structured as a group visit that teaches multiple integrative therapies from specialists and offers a chance for shared support and learning.

Shift work and migraine: A systematic review

OBJECTIVES

Migraine is a chronic neurological disorder characterized by recurrent attacks of headache, mainly affecting the working age population with a great socioeconomic impact. The etiology of migraine is still uncertain, and various individual and/or environmental risk factors have been suggested as triggers of the attacks, including irregularities in the sleep-wake rhythm. In this perspective, it is possible that shift and night work, affecting circadian rhythms, may play a key function in the disease pathogenesis. Therefore, aim of this review was to provide an overview on the possible association between shift works and migraine development or clinical outcomes.

METHODS

A systematic review of literature studies available in Pubmed, Scopus, and ISI Web of Science databases, addressing the possible shift work-migraine relationship was performed.

RESULTS

Conflicting data emerged from the revised studies. Some results supported a positive association between migraine prevalence and shift works, according to peculiar job tasks, seniority in shift works, specific work schedules, and number of night shifts performed in a month. However, other investigations failed to confirm such findings.

CONCLUSIONS

The limited number of available studies, their cross-sectional nature, the different criteria employed for migraine diagnosis, and the various shift work schedules analyzed, together with exposure to other confounding factors on workplace do not allow to extrapolate definite conclusions on shift work-migraine relationship. From an occupational health perspective, further studies appear necessary to better understand such exposure-disease association and possibly define risk assessment and management strategies to protect the health of susceptible and/or migraine affected workers.

Is Mindfulness-Based Stress Reduction a Promising and Feasible Intervention for Patients Suffering from Migraine? A Randomized Controlled Pilot Trial

AIM

We performed a pilot study in order to evaluate the feasibility and to estimate effect sizes of mindfulness-based stress reduction (MBSR) in a sample of patients suffering from migraine.

METHOD

Migraine patients (n = 62, mean age 44 years, 92% female) were randomly allocated to either MBSR or an active control intervention based on progressive muscle relaxation and psychoeducation. The primary outcome was the number of migraine days per month assessed by headache diaries covering one month before and one month after the intervention. Secondary outcomes included functional impairment, use of medication, psychological symptoms, quality of life, pain acceptance, pain self-efficacy, pain perception and self-attributed mindfulness. To measure feasibility, questionnaires assessing study compliance and contentment were administered.

RESULTS

The primary outcome migraine frequency showed no significant group difference. Compared to the control group, the MBSR group showed greater improvements in variables of psychological symptoms, pain self-efficacy and sensory pain perception. Within the MBSR condition, all variables showed significant improvements over the course span with effect sizes ranging from d = 0.37 to 0.81, apart from the primary outcome (27% reduction in migraine days, p = 0.07). Compliance and contentment rates were good, supporting the feasibility of the MBSR intervention.

CONCLUSION

Overall, participants in the MBSR group showed more adaptive coping strategies and decreased levels of psychological impairment compared to the control group, indicating a reduced impact of migraine on their everyday lives. It is concluded that this feasibility study demonstrates the ability of mindfulness-based interventions to reduce suffering in patients with migraine.

The burden of headache disorders in the Eastern Mediterranean Region, 1990-2016: findings from the Global Burden of Disease study 2016

Objectives

Using the findings of the Global Burden of Disease Study (GBD), we report the burden of primary headache disorders in the Eastern Mediterranean Region (EMR) from 1990 to 2016.

Methods

We modelled headache disorders using DisMod-MR 2.1 Bayesian meta-regression tool to ensure consistency between prevalence, incidence, and remission. Years lived with disability (YLDs) were calculated by multiplying prevalence and disability weight (DW) of migraine and tension-type headache (TTH). We assumed primary headache disorders as non-fatal, so their YLD is equal to disability-adjusted life years (DALYs).

Results

Migraine and TTH were the second and twentieth leading causes of YLDs in EMR. Between 1990 and 2016, the absolute YLD numbers of migraine and TTH increased from 2.3 million (95% uncertainty interval (UI): 1.5–3.2) to 4.7 million (95%UI: 3–6.5) and from 383 thousand (95%UI: 240–562) to 816 thousand (95%UI: 516–1221), respectively. During the same period, age-standardised YLD rates of migraine and TTH in EMR increased by 0.7% and 2.5%, respectively, in comparison to a small decrease in the global rates (0.2% decrease in migraine and TTH). The bulk of burden due to headache occurred in the 30–49 year age group, with a peak at ages 35–44 years. The age-standardised YLD rates of both headache disorders were higher in women with female to male ratio of 1.69 for migraine and 1.38 for TTH. All countries of the EMR except for Somalia and Djibouti had higher age-standardised YLD rates for migraine and TTH in compare to the global rates. Libya and Saudi Arabia had the highest increase in age-standardised YLD rates of migraine and TTH, respectively.

Conclusion

The findings of this study show that primary headache disorders are a major and a growing cause of disability in EMR. Since 1990, burden of primary headache disorders has constantly been higher in EMR compared to rest of the world, which indicates that health systems in EMR must focus further on developing and implementing preventive and management strategies to control headache.

Electronic supplementary material

The online version of this article (10.1186/s10194-019-0990-3) contains supplementary material, which is available to authorized users.

Mental Pain Questionnaire: An item response theory analysis

BACKGROUND

The Mental Pain Questionnaire (MPQ) is a self-report questionnaire developed to assess mental pain. The aim of the present study was to test the clinimetric properties of the MPQ.

METHODS

A sample of 200 migraine outpatients were enrolled; homogeneity of MPQ was assessed by Mokken Analysis; item-level severity and item-level sensitivity were calculated via Two-Parameter Logistic model; Total Information Function was evaluated to assess reliability of MPQ; internal consistency was calculated via Cronbach's alpha and Sijtsma and Molenaar rho; sensitivity and specificity were assessed via Receiver Operating Characteristic curves.

RESULTS

The MPQ showed unidimensional factor structure; satisfactory homogeneity of the item and total score, except items 4 ("my pain is everywhere") and 6 ("I cannot understand why I feel this pain"); good discrimination, except item 7 ("I feel empty"); low information provided by items 4, 6, 7; good reliability for mild and high levels of mental pain; poor reliability for low levels of mental pain; acceptable internal consistency; acceptable sensitivity and specificity.

LIMITATIONS

The sample size is barely sufficient to calculate item parameters; it is a monocentric study that enrolled outpatients from a tertiary facility; the study enrolled migraine outpatients not affected by other medical disease.

CONCLUSIONS

The MPQ showed good psychometric properties. Items 4, 6, 7 should be considered with caution when migraine patients are evaluated. A score of at least 3 indicates mental pain clinically relevant, a score of at least 2 indicates distress. These data are preliminary and refer to migraine patients, results might be different in psychiatric populations.

Beta-blockers for the prevention of headache in adults, a systematic review and meta-analysis

BACKGROUND

Headaches are a common source of pain and suffering. The study's purpose was to assess beta-blockers efficacy in preventing migraine and tension-type headache.

METHODS

Cochrane Register of Controlled Trials; MEDLINE; EMBASE; ISI Web of Science, clinical trial registries, CNKI, Wanfang and CQVIP were searched through 21 August 2018, for randomized trials in which at least one comparison was a beta-blocker for the prevention of migraine or tension-type headache in adults. The primary outcome, headache frequency per month, was extracted in duplicate and pooled using random effects models.

DATA SYNTHESIS

This study included 108 randomized controlled trials, 50 placebo-controlled and 58 comparative effectiveness trials. Compared to placebo, propranolol reduced episodic migraine headaches by 1.5 headaches/month at 8 weeks (95% CI: -2.3 to -0.65) and was more likely to reduce headaches by 50% (RR: 1.4, 95% CI: 1.1-1.7). Trial Sequential Analysis (TSA) found that these outcomes were unlikely to be due to a Type I error. A network analysis suggested that beta-blocker's benefit for episodic migraines may be a class effect. Trials comparing beta-blockers to other interventions were largely single, underpowered trials. Propranolol was comparable to other medications known to be effective including flunarizine, topiramate and valproate. For chronic migraine, propranolol was more likely to reduce headaches by at least 50% (RR: 2.0, 95% CI: 1.0-4.3). There was only one trial of beta-blockers for tension-type headache.

CONCLUSIONS

There is high quality evidence that propranolol is better than placebo for episodic migraine headache. Other comparisons were underpowered, rated as low-quality based on only including single trials, making definitive conclusions about comparative effectiveness impossible. There were few trials examining beta-blocker effectiveness for chronic migraine or tension-type headache though there was limited evidence of benefit.

REGISTRATION

Prospero (ID: CRD42017050335).

Patent Foramen Ovale Closure in 2019

Patent foramen ovale (PFO) is a common abnormality affecting between 20% and 34% of the adult population. For most people it is a benign finding; however, in some the PFO can open widely, enabling a paradoxical embolus to transit from the venous to arterial circulation, which is associated with stroke and systemic embolisation. Percutaneous closure of PFO in patients with cryptogenic stroke has been undertaken for a number of years, and a number of purpose-specific septal occluders have been marketed. Recent randomised controlled trials have demonstrated that closure of PFO in patients with cryptogenic stroke is associated with reduced rates of recurrent stroke. After a brief overview of the anatomy of a PFO, this review considers the evidence for PFO closure in cryptogenic stroke. The review also addresses other potential indications for closure, including systemic embolisation, decompression sickness, platypnoea-orthodeoxia syndrome and migraine with aura. It lays out the pre-procedural investigations and preparation for the procedure. Finally, it gives an overview of the procedure itself, including discussion of closure devices.

Migraine, tension-type headache, and depression among Saudi female students in Taif University

BACKGROUND

Studies done in Saudi Arabia showed a high prevalence of headache among university students. Limited research was done to assess the relationship between headache and psychiatric disorders. The aim of this study was to assess the prevalence and association between migraine, tension-type headache, and depression among Saudi female students in Taif University.

PARTICIPANTS AND METHODS

A cross-sectional study using self-administered questionnaires about headache and depression was conducted at the Taif University on 1340 female students in the academic year 2016-2017. The Beck Depression Inventory, the ID Migraine™ screening tool, and the criteria of the International Headache Society were used to investigate the depressive symptoms and headache types.

RESULTS

The self-reported headache prevalence was 68.4%, and the prevalence of migraine, tension-type headache (TTH), and depression was 32.5%, 29.5%, and 6.2%, respectively. The main migraine trigger was stress or anxiety; 86.6% of migraineurs had a positive family history, and only 11.9% sought medical care for headache. Of students with TTH, 61.1% reported family history and only 12.4% sought medical care. Paracetamol was the commonly used analgesic for all headache types. Medical students and students in older grades showed significantly higher levels of all headache types. Depression prevalence was significantly higher among migraineurs and students who suffered higher headache frequencies.

CONCLUSION

The study demonstrated a high prevalence of headache among the studied students and an association between headache and depression. The study calls for increasing awareness towards headache and the importance of seeking medical consultation. Management strategies should be planned for the observed headache and depression comorbidity.

Clinical relevance of atrial septal aneurysm and patent foramen ovale with migraine

AIM

To test the potential association between atrial septal aneurysm (ASA) and migraine in patent foramen ovale (PFO) closure patients through an observational, single-center, case-controlled study.

METHODS

We studied a total of 450 migraineurs who had right-to-left shunts and underwent PFO closure in a retrospective single-center non-randomized registry from February 2012 to October 2016 on the condition that they were aged 18-45 years old. Migraine was diagnosed according to the International Classification of Headache Disorders, 3^rd edition and evaluated using the Headache Impact Test-6 (HIT-6). All patients underwent preoperative transesophageal echocardiography, contrast transthoracic echocardiography, and computed tomography or magnetic resonance imaging examinations, with subsequent fluoroscopy-guided PFO closure. Based on whether they have ASA or not, the patients were divided into two groups: A (PFO with ASA, n = 80) and B (PFO without ASA, n = 370). Baseline characteristics and procedural and follow-up data were reviewed.

RESULTS

Compared to group B, group A had an increased frequency of ischemic lesions (11.3% vs 6.2%, P = 0.038) and migraine with aura (32.5% vs 21.1%, P = 0.040). The PFO size was significantly larger in group A (P = 0.007). There was no significant difference in HIT-6 scores between the two groups before and at the one-year follow-up after the PFO closure [61 (9) vs 63 (9), P = 0.227; 36 (13) vs 36 (10), P = 0.706].

CONCLUSION

Despite its small sample size, our study suggests that the prevalence of ASA in PFO with migraine patients is associated with ischemic stroke, larger PFO size, and migraine with aura.

Quantifying visual allodynia across migraine subtypes: the Leiden Visual Sensitivity Scale

Enhanced sensitivity to light (photophobia) and patterns is common in migraine and can be regarded as visual allodynia. We aimed to develop and validate a questionnaire to easily quantify sensitivity to light and patterns in large populations, and to assess and compare visual allodynia across different migraine subtypes and states. We developed the Leiden Visual Sensitivity Scale (L-VISS), a 9-item scale (score range 0-36 points), based on literature and patient interviews, and examined its construct validity. Furthermore, we assessed ictal and interictal visual sensitivity in episodic migraine with (n = 67) and without (n = 66) aura and chronic migraine with (n = 20) and without (n = 19) aura, and in healthy controls (n = 86). Differences between migraine subtypes and states were tested using a linear mixed model with 3 fixed factors (episodic/chronic, with/without aura, and ictal/interictal). Test-retest reliability and construct validity of L-VISS were good. Leiden Visual Sensitivity Scale scores correlated in the expected direction with light discomfort (Kendall's τ = -0.25) and pattern glare tests (τ = 0.35). Known-group comparisons confirmed its construct validity. Within migraine subtypes, L-VISS scores were higher in migraine with aura versus without aura and in chronic versus episodic migraine. The linear mixed model showed all factors affected the outcome (P < 0.001). The L-VISS is an easy-to-use scale to quantify and monitor the burden of bothersome visual sensitivity to light and patterns in large populations. There are remarkable ictal and interictal differences in visual allodynia across migraine subtypes, possibly reflecting dynamic differences in cortical excitability.

Patients' perspective on the burden of migraine in Europe: a cross-sectional analysis of survey data in France, Germany, Italy, Spain, and the United Kingdom

Background

Migraine is a distinct neurological disease that imposes a significant burden on patients, society, and the healthcare system. This study aimed to characterize the incremental burden of migraine in individuals who suffer from ≥4 monthly headache days (MHDs) by examining health-related quality of life (HRQoL), impairments to work productivity and daily activities, and healthcare resource utilization (HRU) in the EU5 (France, Germany, Italy, Spain, United Kingdom).

Methods

This retrospective cross-sectional study used data from the 2016 National Health and Wellness Survey (NHWS; N = 80,600). Short-Form 36-Item Health Survey, version 2 (SF-36v2) physical and mental component summary scores (PCS and MCS), Short-form-6D (SF-6D), and EuroQoL (EQ-5D), impairments to work productivity and daily activities (Work Productivity and Activity Impairment Questionnaire (WPAI), and HRU were compared between migraine respondents suffering from ≥4 MHDs (n = 218) and non-migraine controls (n = 218) by propensity score matching using sociodemographic characteristics. Chi-square, T-tests, and Mann-Whitney tests were performed to determine significant differences between the groups after propensity score matching.

Results

HRQoL was lower in migraine individuals suffering from ≥4 MHDs compared with non-migraine controls, with reduced SF-36v2 PCS (46.00 vs 50.51) and MCS (37.69 vs 44.82), SF-6D health state utility score (0.62 vs 0.71), and EQ-5D score (0.68 vs 0.81) (for all, p < 0.001). Respondents with migraine suffering from ≥4 MHDs also reported higher levels of absenteeism from work (14.43% vs 9.46%; p = 0.001), presenteeism (35.52% vs 20.97%), overall work impairment (38.70% vs 23.27%), and activity impairment (44.17% vs 27.75%) than non-migraine controls (for all, p < 0.001). Additionally, HRU was significantly higher for individuals with ≥4 MHDs compared to their matched controls. Consistently, migraine subgroups (4–7 MHDs, 8–14 MHDs and CM) had lower HRQoL, greater overall work and activity impairment, and higher HRU compared to non-migraine controls.

Conclusions

Migraine of ≥4 MHDs was associated with poorer HRQoL, greater work productivity loss, and higher HRU compared with non-migraine controls. The findings of the study suggest that an unmet need exists among individuals suffering from ≥4 MHDs in the EU5 suggesting the need for effective prophylactic treatments to lessen the humanistic and economic burden of migraine.

Predictors of Long-Term Temporomandibular Disorder Pain Intensity: An 8-Year Cohort Study

AIMS

To investigate, in individuals with pain-related temporomandibular disorder (TMD), the association of long-term pain intensity with baseline health-related quality of life (HRQoL) and jaw functional limitation.

METHODS

Of 513 cases with baseline pain-related TMD (masticatory muscle and/or temporomandibular joint [TMJ] pain), 273 were reevaluated after 8 years, and 258 of them had complete baseline data for Jaw Functional Limitation Scale (JFLS) scores and HRQoL measured by the Physical Component Summary (PCS) and Mental Component Summary (MCS) scores of the 12-item Short Form Health Survey and follow-up data for Characteristic Pain Intensity (CPI) from the Graded Chronic Pain Scale. Secondary analyses of existing data quantified the effects of primary (PCS, MCS) and secondary (JFLS) predictors on follow-up CPI by using multivariable linear regression. Sensitivity analyses considered differences between the included participants (n = 258) and those who were not included (n = 255) by using inverse probability weighting. Interactions of baseline predictors with age, sex, and baseline CPI were evaluated using multivariable linear regression.

RESULTS

The score for baseline PCS, but not MCS or JFLS, was associated with follow-up CPI (P = .012). One standard deviation (SD = 9.0)-higher baseline PCS score predicted an overall 3.2-point-lower follow-up CPI (95% confidence interval -5.8 to -0.7) after adjusting for age, sex, MCS, JFLS, and baseline CPI scores. However, the effect of PCS score was not uniform: the association between PCS and follow-up CPI scores was statistically significant for participants with baseline CPI ≥ 51.3/100 and clinically significant for participants with baseline CPI ≥ 68.7/100. Adjustment for TMD treatments and sensitivity analyses had negligible effect.

CONCLUSION

In participants with moderate to severe baseline TMD pain intensity, higher baseline physical HRQoL predicted lower TMD pain intensity at 8 years follow-up. PCS score could contribute to a multifactorial long-term TMD pain prediction model.

The relationship between alexithymia and headache impact: the role of somatization and pain catastrophizing

PURPOSE

The present study compared psychological factors (i.e., alexithymia, somatization, pain catastrophizing (PC), anxiety, and depression) and QOL for headache patients and headache-free individuals, and examined whether somatization and PC mediate the relationship between alexithymia and headache impact in headache patients.

METHODS

Study participants consisted of 123 headache patients from an outpatient clinic at a university hospital and 124 headache-free individuals in Daegu, Korea. The survey employed the somatization and anxiety subscales of the Symptom Checklist-90-revised, the Patient Health Questionnaire-9, Pain Catastrophizing Scale, Toronto Alexithymia Scale, Short-Form Health survey-8 (SF-8), and the Headache Impact Test-6.

RESULTS

Headache patients showed a higher level of all psychological factors and lower level of two summary scores (physical and mental health) as well as the seven dimensions of the SF-8 compared with headache-free individuals. Examination employing the SPSS Process macro found that the direct effect of alexithymia on headache impact was not significant after controlling for somatization and PC. The total indirect effects of alexithymia on headache impact were significant without anxiety and depression as covariates with the significant indirect effects of alexithymia on headache impact via somatization or via PC as well as via somatization and PC. However, after controlling for anxiety and depression, PC was the only significant pathway through which alexithymia was related to headache impact.

CONCLUSIONS

Headache patients may benefit from interventions aiming at improving psychological factors in order to improve the functioning and QOL of headache patients.

The effect of maternal migraine headache on their children's quality of life

Migraine is an episodic disease characterized by a throbbing and generally unilateral headache, often accompanied by nausea, vomiting and light and sound sensitivity. Migraine is known to affect one's quality of life; not only the person with migraine but also his/her family and social environment are affected by this condition. Our study aimed to evaluate the effects of maternal migraine on children's quality of life. The patient group comprised 70 mothers with migraine diagnoses and their 111 healthy children, while 50 healthy mothers and their 86 children were included in this study as the control group. The Visual Analog Scale (VAS), Migraine Disability Assessment Scale, Beck Depression Index (BDI) and Beck Anxiety Index (BAI) were used for evaluation of mothers; 3 to 7-year old KINDL and 7- to 17-year-old KINDL-R Quality of Life Scales were used to evaluate the quality of life of children. The SPSS 21.0 program was used for statistical analysis and p < 0.05 was assumed to be statistically significant. The mean age of the migraine group was 37.09 ± 6.94 years, and the mean age of the control group was 38.2 ± 4.5. Symptoms of depression and anxiety were more frequently found in subjects with migraine (p < 0.05). In comparison with the control group: 3 to 7-year old KINDL total scores, self-esteem and school subscales, 7- to 17-year-old KINDL total scores, self-esteem and the social relationships subscale scores were lower in migraine group. It was found to be significant that VAS, BDI and BAI scores of the mothers were negatively correlated with the children's quality of life. Our study concluded that the presence of migraine-type headache in mothers worsen the relations in school, self-esteem and quality of life in younger children and social relations, relations in school and quality of life in older children. The maternal age, disease severity, and anxiety and depression symptoms were shown to predict the quality of life in children. Performing preventive interventions by individually assessing bio-psycho-social elements for the treatment of mothers with migraine will preserve other family member's and especially children's quality of life.

Disability, Quality of Life, and Pain Coping in Pediatric Migraine: An Observational Study

OBJECTIVES

The objective was to examine the relationship between disability, health-related quality of life (HrQoL), and pain coping in pediatric migraineurs.

METHOD

Eighty-five patients with migraine were recruited from Pediatric Neurology clinics. Participants completed the Pediatric Migraine Disability Assessment Scale, the Pediatric Quality of Life Inventory, the Pain Coping Questionnaire, and the Pain Catastrophizing Scale. Means were compared to published norms using t-tests. Spearman correlations and logistic regression were used to explore the relationships between the variables.

RESULTS

Mean HrQoL scores were lower than norms for controls and chronically ill pediatric patients ( P < .0001). Patients reported lower mean pain coping scores and higher mean pain catastrophizing scores than norms ( P < .0001). After controlling for age and sex, only the relationship between disability and HrQoL remained significant (OR = 0.91, 95% CI: 0.86-0.95).

CONCLUSION

Pediatric patients with migraine report lower HrQoL, fewer pain coping strategies and more catastrophizing than controls, while disability is inversely associated with HrQoL.

Neurophysiologic Correlates of Headache Pain in Subjects With Major Depressive Disorder

BACKGROUND

Headache pain is often comorbid with major depressive disorder (MDD) and is associated with greater symptom burden, disability, and suicidality. The biological correlates of headache pain in MDD, however, remain obscure. The purpose of this study was to examine the association between brain oscillatory activity and headache pain in MDD subjects.

METHODS

A total of 64 subjects with MDD who were free of psychoactive medications were evaluated for severity of headache pain in the past week. Brain function was assessed using resting-state quantitative electroencephalography (qEEG). We derived cordance in the theta (4-8 Hz) and alpha (8-12 Hz) frequency bands at each electrode, and examined correlations with headache pain in regions of interest while controlling for depression severity. Frontal and posterior asymmetry in alpha power was calculated in regions of interest.

RESULTS

Headache pain severity was associated with depression severity ( r = 0.447, P < .001). In bilateral frontal and right posterior regions, alpha cordance was significantly associated with headache intensity, including when controlling for depression severity. The direction of the correlation was positive anteriorly and negative posteriorly. Frontal left dominant alpha asymmetry correlated with severity of headache but not depression symptoms.

CONCLUSION

Alterations in brain oscillations identified by alpha cordance and alpha asymmetry may be associated with the pathophysiology of headache pain in depression. These findings should be prospectively confirmed.

Opioid Treatment of Migraine: Risk Factors and Behavioral Issues

Migraine can impact every aspect of a person's functioning. Psychological comorbidities, cognitive constructs, and behavioral responses to pain greatly impact the perception of migraine pain, treatment efficacy and outcome, and overall quality of life and functioning. Current considerations for migraine treatment emphasize the utility of the biopsychosocial model in understanding and treating migraine, noting both the importance of addressing psychological factors such as cognitive beliefs as well as psychiatric comorbidities. The guidelines for migraine treatment implicate opioid therapy as a second or third tier treatment. Guidelines and recommendations for the safe use of opioid medications among patients with chronic pain emphasize the importance of screening prior to prescribing opioid medications. Chronic opioid therapy has been shown to further levels of disability, decrease quality of life, and correlate to psychiatric comorbidities, concerns that are already present in migraine patients. While opioid treatment provides an alternative for persons with contraindications for alternative migraine treatments, it is critical that opioids be used sparingly and exclusively in conjunction with comprehensive assessment and integration of psychological treatment.

Ecological momentary assessment of the relationship between headache pain intensity and pain interference in women with migraine and obesity

Background

While pain intensity during migraine headache attacks is known to be a determinant of interference with daily activities, no study has evaluated: (a) the pain intensity-interference association in real-time on a per-headache basis, (b) multiple interference domains, and (c) factors that modify the association.

Methods

Participants were 116 women with overweight/obesity and migraine seeking behavioral treatment to lose weight and decrease headaches in the Women’s Health and Migraine trial. Ecological momentary assessment, via smartphone-based 28-day headache diary, and linear mixed-effects models were used to study associations between pain intensity and total- and domain-specific interference scores using the Brief Pain Inventory. Multiple factors (e.g. pain catastrophizing (PC) and headache management self-efficacy (HMSE)) were evaluated either as independent predictors or moderators of the pain intensity-interference relationship.

Results

Pain intensity predicted degree of pain interference across all domains either as a main effect (coeff = 0.61–0.78, p < 0.001) or interaction with PC, allodynia, and HMSE ( p < 0.05). Older age and greater allodynia consistently predicted higher interference, regardless of pain intensity (coeff = 0.04–0.19, p < 0.05).

Conclusions

Pain intensity is a consistent predictor of pain interference on migraine headache days. Allodynia, PC, and HMSE moderated the pain intensity-interference relationship, and may be promising targets for interventions to reduce pain interference.

Does complementary and alternative medicine (CAM) use reduce negative life impact of headaches for chronic migraineurs? A national survey

Background

Chronic migraine is a disabling condition that impacts multiple aspects of migraineurs’ lives. Although pharmacological treatments can help to treat the pain associated with migraine headache, chronic migraineurs often experience side-effects of pharmacological treatments. Those experiences may contribute to the observed growth in complementary and alternative medicine (CAM) use among migraineurs. Relatively little is known about the patterns of CAM treatment and the characteristics of chronic migraineurs. Therefore, the purpose of the present study is to investigate the characteristics of chronic migraineurs who use CAM treatment and the relationship among satisfaction with current CAM use, negative life impact, migraine outcomes, and psychiatric comorbidities among chronic migraineurs.

Methods

2907 participants were recruited from a well-known online migraine headache resource. All participants were US adults aged 18 years or older. Migraineurs are referred to this website through various routes (e.g., referral from healthcare providers, internet search, obtaining information from research papers, personal invitation from other users, and information shared on social media etc.). Participants completed a 30-min self-report-survey in the spring of 2014.

Results

Almost half of the participants reported that they are currently using more than three different CAM treatments even though the majority of the participants reported neutral or dissatisfied with their current CAM treatment. Chronic migraineurs who use CAM treatments were more likely to experience prolonged or frequent migraine headaches (p = .018, η² = .0021), and experience greater negative life impact from their headaches (p = .000, η² = .0172) compared to non-CAM users. CAM treatment satisfaction was inversely related to the number of psychiatric comorbidities, frequency of migraines, and number of migraine symptoms (p’s < .05). However, CAM treatment satisfaction was more strongly correlated with migraine outcomes than psychiatric comorbidities.

Conclusions

Chronic migraineurs often pursue multiple CAM treatments in spite of low levels of satisfaction with those treatments. Patients who experience relief from traditional treatments are less likely to seek the out additional CAM treatments. Thus it is often the sicker migraine patients who use CAM. More attention is needed to consider migraine treatment resistance, and psychological factors in planning the treatment of chronic migraineurs as those factors may play an important role in treatment choices by patients.