Unveiling the Public Economic Burden of Migraine in Argentina

Background: Migraine is a prevalent, underdiagnosed, highly debilitating neurological condition that affects individuals' quality of life and often negatively influences normal daily activities. Objectives: The study objective is to estimate the economic burden of migraine to the Argentine government by assessing the impact of the disease on tax revenue, absenteeism, and social support transfers. Methods: The analysis combines a cross-sectional model utilizing national demographic data and published migraine prevalence rates to estimate the annual burden for the entire migraine-affected cohort, and a longitudinal model assessing the average burden per individual from the age of 40, over a 20-year horizon. A fiscal framework based on generational accounting evaluated the impact of migraine on government finances. Sources of revenue such as direct and indirect taxes were weighted against elements of public expenditure (public sector absenteeism, healthcare expenses, and financial support) and compared with the general population. The effect of migraine on occupational outcomes was sourced from peer-reviewed publications, and costs were sourced from national databases. Results were reported as incremental fiscal consequences (2023 US dollars) and were discounted at 3% annually. Results: The fiscal burden of migraine in Argentina was estimated to be 6505 p e r i n d i v i d u a l a n d 1237 million across the entire migraine population. Annually, 29% of government costs were due to public sector absenteeism, 39% related to healthcare costs, 19% to foregone direct and indirect tax revenue, and 12% to foregone corporation taxes. Additional government transfers represented a minor contribution to the overall fiscal impact of migraine in Argentina. Discussion: The high rate of informal employment is likely to undermine disease burden estimates. Gender disparities were notable, with women bearing 76% of the burden, highlighting the need for gender-specific interventions. Conclusions: This study reveals a significant economic burden of migraine to the Argentinian government, primarily driven by absenteeism, healthcare costs, and foregone tax contributions. Targeted, gender-responsive healthcare and labor policies, especially for sectors with high informal employment, could help reduce these fiscal impacts.

Impact of Headache and Over-the-Counter Treatment on Pain and Functional and Cognitive Parameters: A Real-World Study across Three Geographies

INTRODUCTION

Individuals with headache choose over-the-counter (OTC) medications to relieve pain and associated symptoms. This real-world evidence study investigated the effect of three OTC headache treatments on headache intensity and the associated impairment of cognitive and functional parameters in headache sufferers in Germany, Brazil, and Japan.

METHODS

This prospective, multinational, observational eDiary-based study included adults experiencing headache for ≥ 6 months, with ≥ 2 headache episodes per month requiring treatment and using one of the three OTC headache treatments (Germany: ibuprofen 400 mg + caffeine 100 mg; Brazil: dipyrone 1 g; Japan: ibuprofen 100 mg + caffeine 40 mg). The primary endpoint was change in headache intensity (11-point numeric rating scale [NRS]) from baseline (headache onset) to 2 h post-treatment. Secondary endpoints were association between NRS scores for headache intensity and for cognitive and functional parameters and change in these parameters from baseline to 2 h post-treatment.

RESULTS

Of the 32,623 individuals screened, 1239 were enrolled in the study, with 607 having their first headache episode treated using one of the OTC treatments. Baseline demographics and characteristics were similar across the cohorts. At 2 h post-treatment, headache intensity significantly improved, with the mean change from baseline being 3.4 (3.1, 3.7, 95% confidence interval), 4.2 (3.9, 4.5), and 3.0 (2.7, 3.3) for German, Brazilian, and Japanese cohorts, respectively. Improvement was observed in all cognitive and functional parameters. The NRS score for headache intensity significantly predicted NRS scores of all cognitive and functional parameters (P < 0.0001).

CONCLUSIONS

The study shows that headache intensity significantly affects cognitive and functional aspects, as well as overall quality of life, for sufferers globally. It confirms the effectiveness of OTC medications and suggests using headache intensity as a self-assessment tool for symptom severity, highlighting the need for new parameters in the OTC domain to improve public health benefits.

Multidisciplinary headache treatment with work-focus in Norway: An observational study

BackgroundHeadache-related sick leave is increasing in Norway. In cooperation with the Norwegian Labour and Welfare Administration we established the first Norwegian multidisciplinary headache clinic for patients with current or recurrent sick leave due to headaches. The primary objective of this study was to evaluate treatment effects on headache frequency and sick leave, and secondly to identify predictors for improvement and return-to-work.MethodsA team comprising neurologists, nurses, physiotherapists, psychologists, and job specialists treated patients aged 18-67 years with headache-related sick leave. Validated questionnaires and semi-structured interviews were conducted at baseline, 3, 6, and 12 months. Mixed effects linear and logistic regression was performed with headache days and sick leave as outcomes.ResultsOne hundred and one patients completed the 12-month follow-up. The median monthly headache days decreased from 24 (Interquartile range [IQR], 15.5-30) at baseline to 10 (IQR, 4-20) at 12 months (p < 0.001). Headache-related sick leave declined from 53.5% to 33.7% (p < 0.001). Migraine diagnosis and long-term sick leave at baseline negatively predicted for return-to-work, while female sex and low baseline headache frequency predicted favorable clinical outcomes.ConclusionMultidisciplinary treatment reduced headache frequency and increased work attendance. Our findings have potential implications for healthcare policy and resource allocation.

Pharmacologic Treatment of Acute Attacks of Episodic Migraine: A Systematic Review and Network Meta-analysis for the American College of Physicians

BACKGROUND

Migraine is common, affecting 15% of Americans.

PURPOSE

To compare benefits and harms of pharmacologic treatments for acute attacks of episodic migraine in adults and assess cost-effectiveness.

DATA SOURCES

Three electronic databases searched to October 2024, gray literature, and reference lists.

STUDY SELECTION

Two investigators independently selected English-language randomized trials.

DATA EXTRACTION

Single reviewer data extraction with second review. Dual independent risk of bias and certainty of evidence (COE) assessment.

DATA SYNTHESIS

Twenty-one head-to-head and 165 placebo-controlled trials were included in meta-analyses and network meta-analyses. Triptans were more effective than acetaminophen (low COE) and nonsteroidal anti-inflammatory drugs (NSAIDs) (high COE) for pain outcomes at 2 hours and pain freedom up to 48 hours. Triptan and acetaminophen combinations were more effective than acetaminophen alone (moderate COE) for pain outcomes at 2 hours and pain freedom up to 48 hours but not more than triptans alone (low COE). Triptan and NSAID combinations were more effective for pain outcomes at 2 hours and pain freedom up to 48 hours compared with acetaminophen (low COE), gepants (low COE), NSAIDs (high COE), and triptan monotherapy (moderate COE). Triptan regimens, however, often had a higher risk for adverse events. One study found triptans more cost-effective than ditans and gepants.

LIMITATIONS

Harms assessment was limited to randomized trials. Many comparisons lacked sufficient evidence to draw conclusions.

CONCLUSION

Triptans and combinations of triptans were more effective than NSAID and acetaminophen alone.

PRIMARY FUNDING SOURCE

American College of Physicians. (PROSPERO: CRD42023441146).

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.

Epidemiology of clinically significant migraine in Israel: a retrospective database study

BACKGROUND

Epidemiological studies on migraine are valuable for tracking disease trends, identifying risk factors, and informing treatment strategies. This study assessed the prevalence and annual incidence of clinically significant migraine in Israel from 2017 to 2022, with analyses stratified by age, sex, socioeconomic status, and district. Additionally, we compared relevant characteristics between adult migraine and non-migraine members of Leumit Healthcare Services (LHS), a national health provider in Israel.

METHODS

This retrospective study used LHS electronic health records to evaluate migraine prevalence and annual incidence from 2017 to 2022 among adult LHS members. Clinically significant migraine patients were identified using stringent criteria, including repeated diagnostic codes for migraine, confirmation by a neurologist, or the use of migraine-specific therapies. Each migraine patient was matched 1:1 with a control individual of similar age, sex, socioeconomic status, and ethnic background.

RESULTS

The prevalence of clinically significant migraine increased from 4.5% in 2017 to 5.2% in 2022, with significantly higher rates in women compared to men (8% vs. 2.4% in 2022). The mean age of migraine patients was 46.8 years in 2022. The annual incidence of migraine in 2022 was 43 per 10,000 individuals over 18, with approximately 75% of new cases occurring in women, with a mean age of 36.5 years. The annual incidence of migraine slightly decreased over the period. Approximately two-thirds of new patients were diagnosed by neurologists, with only 19% diagnosed by family physicians. Compared to a matched control population, migraine patients showed a higher prevalence of low body mass index (BMI) and higher diastolic blood pressure (BP). Additionally, distinct differences in laboratory findings were observed among migraine patients, notably lower glucose and hemoglobin A1c levels, lower rate of microalbuminuria, with higher hemoglobin, which may be associated with migraine pathophysiology.

CONCLUSION

This study provides a detailed epidemiological and clinical profile of patients with clinically significant migraine in LHS from 2017 to 2022. Notable trends include higher rates of migraine among patients with lower BMI, higher diastolic BP, lower glucose, and higher hemoglobin, suggesting potential modifiable risk factors.

Healthcare Utilization, Costs, and Treatment Discontinuation in Adults with Episodic Migraine Initiating Galcanezumab Versus Rimegepant: A US Retrospective Claims Analysis

INTRODUCTION

To date, no study has compared the healthcare resource utilization (HCRU), costs, and discontinuation of the two calcitonin gene-related peptide antagonists, galcanezumab (monoclonal antibody subcutaneously injected monthly) and rimegepant (oral gepant taken every other day), for migraine prevention. This study aimed to assess all-cause and migraine-related HCRU, costs, and treatment discontinuation at 12 months following treatment initiation in commercial/Medicare beneficiaries with episodic migraine who received galcanezumab versus rimegepant as preventive migraine treatment.

METHODS

This retrospective study used the Merative™ MarketScan® Research Databases (June 2020-June 2023). Adults with episodic migraine were grouped into the galcanezumab (≥ 1 claim) or rimegepant cohort (≥ 1 claim with quantity ≥ 15 during the index period). Changes from baseline in all-cause and migraine-related HCRU and cost between the propensity score-matched cohorts were determined using Wilcoxon signed rank test and chi-square test. Treatment discontinuation was assessed using Kaplan-Meier analysis and Cox proportional hazards model.

RESULTS

All-cause and migraine-related HCRU and costs increased over the 12-month follow-up in both cohorts. The galcanezumab cohort had a significantly lower increase in mean all-cause total medical + pharmacy costs (21% lower) and migraine-related total medical + pharmacy costs (76% lower) than the rimegepant cohort at the 12-month follow-up (p < 0.0001 for both assessments). Mean (standard deviation) number of days from initiation to discontinuation (> 60-day gap) was 244.6 (135.3) for galcanezumab cohort and 178.1 (141.1) for rimegepant cohort (p < 0.0001). Treatment discontinuation rate was 1.8 times less likely in the galcanezumab cohort than the rimegepant cohort (hazard ratio = 1.81, 95% confidence interval = 1.56-2.10). Similar trends were observed using a 30-day gap.

CONCLUSION

Among matched patients, both cohorts of patients with episodic migraine showed all-cause and migraine-related total cost increases over 12 months. However, the magnitude of the increases was significantly lower for the galcanezumab cohort than for the rimegepant cohort. Treatment discontinuation rate was significantly lower in the galcanezumab versus the rimegepant cohort.

The Dual Burden of Post-Traumatic Headache: Health Consequences and Economic Impact

PURPOSE OF REVIEW

To review the history and impact and burden of post-traumatic headache (PTH).

RECENT FINDINGS

PTH is a prevalent headache disorder that many healthcare providers encounter. Unlike more extensively researched primary headache disorders like migraines, PTH has not been as thoroughly studied, and there are fewer treatments specifically tested for it. A significant obstacle to conducting detailed population studies on PTH is the need for the headache to occur shortly after a traumatic event. Despite these challenges, PTH is recognized as a disabling condition with considerable effects on quality of life and economic impact. PTH is a distressing and debilitating condition. Although there have been efforts to evaluate its personal and economic effects, these studies are limited compared to the more extensive research conducted on other primary headache disorders. More comprehensive epidemiological studies are needed.

Healthcare resource use and costs associated with the misdiagnosis of migraine

OBJECTIVE

To compare healthcare resource utilization and healthcare costs in patients with migraine with or without a history of misdiagnosis.

BACKGROUND

Despite the high prevalence of migraine, migraine is commonly misdiagnosed. The healthcare resource use and cost burden of a misdiagnosis is unknown.

METHODS

This retrospective cohort study identified adults with an incident migraine diagnosis from the Merative™ Marketscan® Commercial and Medicare Supplemental Databases between June 2018 and 2019. Patients with a diagnosis of commonly considered misdiagnoses (headache, sinusitis, or cervical pain) before their migraine diagnosis were classified as the "misdiagnosed cohort." Patients in the misdiagnosed cohort were potentially misdiagnosed, then eventually received a correct diagnosis. Patients without a history of commonly considered misdiagnoses prior to their migraine diagnosis were classified as the "correctly diagnosed cohort." Healthcare resource utilization and healthcare costs were assessed in the period before migraine diagnosis and compared between the cohorts. Outcomes were reported as per patient per month and compared with incidence rate ratios.

RESULTS

A total of 29,147 patients comprised the correctly diagnosed cohort and 3841 patients comprised the misdiagnosed cohort and met the inclusion criteria. Patients in the misdiagnosed cohort had statistically significantly higher rates of inpatient admissions (0.02 vs. 0.01, incidence rate ratio [IRR] 1.61, 95% confidence interval [CI] 1.47-1.74), emergency department visits (0.10 vs. 0.05; IRR 1.89, 95% CI 1.79-1.99), neurologist visits (0.12 vs. 0.02; IRR 5.95, 95% CI 5.40-6.57), non-neurologist outpatient visits (2.64 vs. 1.58; IRR 1.67, 95% CI 1.62-1.72) and prescription fills (2.82 vs. 1.84; IRR 1.53, 95% CI 1.48-1.58) compared to correctly diagnosed patients. Misdiagnosed patients had statistically significantly higher rates of healthcare cost accrual for inpatient admissions ($1362 vs. $518; IRR 2.62, 95% CI 2.50-2.75), emergency department visits ($222 vs. $98; IRR 2.27, 95% CI 2.18-2.36), neurologist visits ($42 vs. $9; IRR 4.39, 95% CI 4.00-4.79), non-neurologist outpatient visits ($1327 vs. $641; IRR 2.07, 95% CI 1.91-2.24), and prescription fills ($305 vs. $215; IRR 1.41, 95% CI 1.18-1.70) compared to correctly diagnosed patients.

CONCLUSION

Patients with migraine who have a history of misdiagnoses have higher rates of healthcare resource utilization and cost accrual versus those without such history.

Middle meningeal artery embolization in migraine: From concept to reality

Migraine is a common neurological disorder that primarily affects young adults. Despite the availability of multiple therapeutic options for patients with intractable migraine, a significant proportion of these patients remain refractory to treatment, highlighting the importance for novel therapies. In this study, we comprehensively assessed the role of the middle meningeal artery (MMA) in the management of intractable migraine. Although the exact pathophysiology of migraine remains a subject of debate, the neurovascular theory of migraine has gained attention recently following multiple studies assessing the role of the MMA in migraine pathophysiology. In addition, the successful utilization of lidocaine both through intravenous injection and directly into the MMA, as well as favorable results observed in the form of headache relief following MMA embolization (MMAE) in patients with chronic subdural hematoma, has further substantiated the neurovascular theory hypothesis. In this study, we evaluated the current evidence, potential trends, role of other injection medications, as well as risks and limitations of MMAE in the management of patients with refractory migraine. Intractable migraine is a complex condition that often requires multimodal management. MMAE has emerged as a promising, novel therapeutic technique that may help reduce pain and minimize the need for additional treatments. However, further prospective and randomized trials are still necessary for further validation.

Scoping Review: The Effects of Interrupted Onabotulinumtoxin A Treatment for Chronic Migraine Prevention During the COVID-19 Pandemic

Objective

To systematically examine the literature on the clinical consequences of inadvertent delays in scheduled onabotulinumtoxin A (OTA) therapy for chronic migraine during the COVID-19 pandemic and assess recommendations when access to OTA is limited.

Background

The coronavirus (COVID-19) pandemic was unprecedented in its impact on the global medical community. Most healthcare institutions in the United States (US) and the world had begun significantly limiting elective procedures, undermining management of many debilitating chronic conditions. OTA injections, were similarly involuntarily postponed, leading to significant setbacks in symptom control.

Methods

A comprehensive literature search was conducted on databases of Medline and Embase with search timeframe defined as the point of database inception to March 1st, 2024, and the search was performed on March 2nd, 2024. The search strategy was independently formulated by two authors (QR and CR) and was reviewed and approved by all authors of the article after appropriate amendments.

Results

A total of nine articles met the defined inclusion criteria. They collectively demonstrated marked delays in OTA treatment with decline in migraine symptom control measured in the form of migraine intensity, frequency, as well as patient satisfaction in disease management. Quality of care in the form of follow-ups also appeared compromised. Alternative strategies of telemedicine and the administration of calcitonin gene-related peptide monoclonal antibodies (CGRP mAb) were adopted in place of conventional treatment.

Conclusion

The COVID-19 pandemic had caused marked clinical deterioration in the migraine patient populations across US, Europe, and the Middle East. Strategies employed to circumvent this limitation included the adoption of remote consultation via telemedicine as well as the use of pharmacological agents such as CGRP antagonists. In the event of a reoccurrence of a worldwide pandemic, strategies should be implemented to prevent the cessation of needed treatment for those suffering from chronic migraine.

2023 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline for the Management of Headache

DESCRIPTION

Headache medicine and therapeutics evidence have been rapidly expanding and evolving since the 2020 U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) clinical practice guideline (CPG) for the management of headache. Therefore, the CPG was revised in 2023, earlier than the standard 5-year cycle. This article reviews the 2023 CPG recommendations relevant to primary care clinicians for treatment and prevention of migraine and tension-type headache (TTH).

METHODS

Subject experts from the VA and the DoD developed 12 key questions, which guided a systematic search using predefined inclusion and exclusion criteria. After reviewing evidence from 5 databases published between 6 March 2019 and 16 August 2022, the work group considered the strength and quality of the evidence, patient preferences, and benefits versus harms on critical outcomes before making consensus recommendations.

RECOMMENDATIONS

The revised CPG includes 52 recommendations on evaluation, pharmacotherapy, invasive interventions, and nonpharmacologic interventions for selected primary and secondary headache disorders. In addition to triptans and aspirin-acetaminophen-caffeine, newer calcitonin gene-related peptide (CGRP) inhibitors (gepants) are options for treatment of acute migraine. Medications to prevent episodic migraine (EM) include angiotensin-receptor blockers, lisinopril, magnesium, topiramate, valproate, memantine, the newer CGRP monoclonal antibodies, and atogepant. AbobotulinumtoxinA can be used for prevention of chronic migraine but not EM. Gabapentin is not recommended for prevention of EM. Ibuprofen (400 mg) and acetaminophen (1000 mg) can be used for treatment of TTH, and amitriptyline for prevention of chronic TTH. Physical therapy or aerobic exercise can be used in management of TTH and migraines.

Headache Disorders in VHA Primary Care: Prevalence, Psychiatric Comorbidity, and Health Care Utilization

Military veterans are at increased risk for headache disorders compared to the general population, yet the prevalence and burden associated with headache disorders among veterans is not yet well understood. In this electronic medical record study, we examined the prevalence of headache disorders among veterans seen in a northeastern network of Veterans Health Administration (VHA) primary care during 2017-2018. We also examined rates of psychiatric comorbidity and health care utilization of veterans with headache disorders for the year following the date of the first headache code in the medical record. Of the total population of veterans in the network, 1.3% had a headache disorder and another 3.5% had a possible headache disorder. Migraine and chronic migraine represented the majority of cases. Posttraumatic stress disorder was the most frequent psychiatric comorbidity. Having a headache disorder was associated with higher rates of primary care, neurology, pain clinic, and mental health service use but not higher rates of emergency department or Whole Health (e.g., patient-centered, holistic health services) use. Prevalence findings are comparable to those previously found among veterans, but a substantial proportion of veterans may have been misdiagnosed. Veterans with headache disorders have high rates of psychiatric comorbidity and use several types of health services at higher rates. Findings highlight the need for interdisciplinary care and further education and support for primary care providers. Primary care settings that integrate evidence-based behavioral and Whole Health services may be an optimal way of providing more holistic care for headache disorders.

Marginal health care expenditures and health-related quality of life burden in patients with migraine

BACKGROUND

Migraine, characterized by recurrent, severe headaches, presents a considerable challenge for patients, health care systems, and employers in the United States. However, there is a lack of recent estimates of the economic and humanistic burden in this population.

OBJECTIVE

To assess the incremental burden of migraine on the total all-cause health care costs and health-related quality of life (HRQoL) in the United States, using data from the Medical Expenditure Panel Survey (MEPS).

METHOD

This retrospective cross-sectional study included adults (≥18 years) with and without migraine on the 2019-2021 full-year consolidated MEPS Household Component and Medical Provider Component data files. Descriptive analyses were conducted to compare health care expenditures and HRQoL among patients with and without migraine. To estimate the marginal effect of migraine on total health care spending, a two-part model generalized linear models was employed. HRQoL was evaluated using physical component summary (PCS) and mental component summary (MCS) scores based on the items in the Veterans Rand 12 Health Survey. A multivariate linear regression with log-link was conducted to understanding the factors associated with PCS and MCS scores. All analyses accounted for complex survey design of MEPS.

RESULTS

The study included approximately 1.14 million patients with migraine and approximately 184 million patients without migraine. The patients with migraine were majorly female (82.81%), aged 18-45 years (50.24%), and residing in the southern region of the United States (41.45%). A two-part model revealed that marginal total health care expenditures among patients with migraine were $6,078.56 (95% CI = $4,618.45-$8,141.34) higher compared with those without migraine. In terms of HRQoL, average PCS scores in migraine and nonmigraine groups were 39.79 and 42.15, respectively. The average MCS scores were 46.63 and 49.95 for migraine and nonmigraine groups, respectively. After adjusting for sociodemographic characteristics, multivariable linear regression models revealed that the PCS score was 2.14 (95% CI = 1.17-4.55) units lower, and the MCS score was 3.19 (95% CI = 2.51-6.07) units lower among patients with migraine compared with those without.

CONCLUSIONS

Migraine imposes a substantial economic burden on both health care payers and patients in the United States. Notably, prescription drugs make up nearly half of the overall cost. Additionally, patients with migraine experience lower levels of physical and mental HRQoL compared with those without migraine.

A Retrospective Analysis of Disease Epidemiology, Comorbidity Burden, Treatment Patterns, and Healthcare Resource Utilization of Migraine in the United Arab Emirates

INTRODUCTION

Migraine is a recurrent, disabling neurological disorder with a substantial global disease burden. However, limited real-world data are available on the patient characteristics, treatment patterns, comorbidities, and economic burden of migraine in the United Arab Emirates (UAE). In this study, we evaluated the disease burden, comorbidities, treatment patterns, specialties involved in migraine diagnosis, and healthcare resource utilization (HCRU) and associated costs in patients with migraine in Dubai, UAE.

METHODS

A retrospective, secondary database cohort study was conducted from 01 January 2014 to 31 March 2022 using the Dubai Real-World Database. Patients aged ≥ 18 years with at least one diagnosis claim for migraine with continuous enrollment during the study period were included. Patients were stratified into treatment sub-cohorts. Outcomes were evaluated in terms of clinical characteristics, comorbidities, specialists visited, treatment patterns, and HCRU.

RESULTS

The study included 203,222 patients (mean age: 40 years), with male predominance (55.4%). About 13.4% of patients had specific cardiovascular comorbidities. Frequently prescribed drug classes were nonsteroidal anti-inflammatory drugs (84.4%), triptans (29.8%), and beta-blockers (12.8%), while only 1.0% of patients with migraine were prescribed newer medications like calcitonin gene-related peptide antagonists. General medicine was the most frequently visited specialty on the index date (51.5%). The all-cause and migraine-specific median gross costs during the 12-month post-index period were US $1252.6 (2.4-564,740.7) and US $198.1 (0-168,903.3) respectively, with maximum contribution from inpatients. The contribution of migraine-specific median costs to all-cause median costs was highest for the diagnosis-related group (64.9%), followed by consumables (35.2%), medications (32.0%), procedures (24.5%), and services (24.5%).

CONCLUSION

Migraine significantly impacts healthcare costs in the UAE. The role of newer therapies in migraine management should be explored to reduce the associated socioeconomic burden and improve patients' quality of life.

Changes in Use of Migraine Medications, Healthcare Resource Utilization, and Associated Direct Costs Over 12 Months Following Initiation of Erenumab: A US Retrospective Real-World Analysis

INTRODUCTION

Erenumab-aooe is approved for the preventive treatment of migraine in adults. Recent publications have evaluated migraine medication use during the 6 months after starting erenumab, but longer-term follow-up data are limited. The objective of this study was to describe 12-month medication use and changes in healthcare resource utilization (HRU) and associated direct costs among patients initiating erenumab.

METHODS

We identified adult patients with an erenumab claim in the Merative MarketScan Commercial and Medicare Databases from May 2018 through September 2019. Eligible patients had ≥ 12 months of continuous medical and pharmacy coverage before (pre-index period) and after (post-index period) the index date (first erenumab claim) in addition to pre-index evidence of migraine. Patients were stratified by post-index-period adherence to erenumab, defined as ≥ 80% of days covered (adherent) or < 80% of days covered (non-adherent). Outcomes were measured pre- and post-index, and differences between these periods were described.

RESULTS

Among 7528 eligible patients, the mean (standard deviation) age was 45.1 (11.4) years and 85.4% were female; 38.5% of patients were adherent to erenumab. Most patients used acute or traditional migraine-preventive medications pre-index, with reductions in use observed post-index (acute medication was used by 95.6% of patients pre-index, compared to 92.3% post-index; traditional preventive medication was used by 89.6% of patients pre-index, compared to 81.9% post-index). Reductions were observed for HRU of emergency room visits (- 3.8%) and brain- and other head-imaging studies (- 7.5%). Overall costs associated with acute and traditional preventive medications were reduced (- $764), but costs for HRU increased slightly ($76). When stratifying by adherence and combining costs for acute and traditional preventive medications and HRU, adherent patients had cost decreases (- $1947), while non-adherent patients had cost increases ($101).

CONCLUSION

Most patients initiating erenumab had prior use of acute and traditional migraine-preventive therapies. The reduction in acute and traditional migraine-preventive medication use and HRU over the 12-month follow-up supports the long-term clinical benefits of erenumab in the real-world setting.

Association between composite dietary antioxidant index and migraine in American young women: insights from NHANES 1999-2004 cross-sectional data

Background

Excessive oxidative stress is one of the key pathophysiological mechanisms underlying migraine, and increasing antioxidant intake has proven to be an effective strategy for the prevention and improvement of migraine symptoms. To explore the relationship between the composite dietary antioxidant index (CDAI) and the occurrence of migraine attacks.

Methods

Cross-sectional data from the National Health and Nutrition Examination Survey (NHANES) spanning 1999-2004 were utilized. Logistic regression, stratified analysis, and restricted cubic spline (RCS) models were employed to investigate the association between CDAI and migraine attacks.

Results

A total of 8,137 adults aged ≥20 were enrolled, comprising 1,610 patients with migraine and 6,527 non-migraine individuals. After adjusting for all covariates, CDAI was negatively correlated with migraine. In the overall participants, compared with the CDAI Q1 (-5.83 to -2.14) group, the adjusted odds ratio (OR) for migraine in Q3 (-0.59 to 1.53) and Q4 (1.53-44.63) groups were 0.71 [95% confidence interval (95% CI): 0.54-0.92, p = 0.011] and 0.64 (95% CI: 0.47-0.87, p = 0.005), respectively. After stratifying by age and gender, the protective effect was more pronounced in females aged 20-50, with adjusted OR for Q3 (-0.59 to 1.53) and Q4 (1.53-44.63) groups of 0.60 (95% CI: 0.40-0.90, p = 0.013) and 0.48 (95% CI: 0.30-0.78, p = 0.003), respectively. The RCS curve indicated a nonlinear relationship between CDAI and migraine in females aged 20-50, with a threshold of 0.006.

Conclusion

CDAI is negatively correlated with migraine attacks, and a higher CDAI may be an effective protective factor in preventing migraine attacks, especially in women aged 20-50.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Calcitonin Gene-Related Peptide Inhibitors in the Treatment of Migraine in the Pediatric and Adolescent Populations: A Review

There are limited well-studied treatments for migraine in the pediatric population. Calcitonin gene-related peptide (CGRP) inhibitors are an established safe and effective treatment in adults, and use may be appropriate for pediatric patients in certain clinical situations. We describe migraine pathophysiology as it relates to CGRP, provide an overview of available medications, and discuss clinical usage in this population.

Molecular nociceptive mechanisms in migraine: The migraine cascade

OBJECTIVE

This review will explore the categorization of migraine-provoking molecules, their cellular actions, site of action and potential drug targets based on the migraine cascade model.

METHODS

Personal experience and literature.

RESULTS

Migraine impacts over 1 billion people worldwide but is underfunded in research. Recent progress, particularly through the human and animal provocation model, has deepened our understanding of its mechanisms. This model have identified endogenous neuropeptides such as calcitonin gene-related peptide (CGRP) and pituitary adenylate cyclase-activating peptide (PACAP) that induces controlled migraine-like attacks leading to significant discoveries of their role in migraine. This knowledge led to the development of CGRP-inhibiting drugs; a groundbreaking migraine treatment now accessible globally. Also a PACAP-inhibiting drug was effective in a recent phase II trial. Notably, rodent studies have shed light on pain pathways and the mechanisms of various migraine-inducing substances identifying novel drug targets. This is primarily done by using selective inhibitors that target specific signaling pathways of the known migraine triggers leading to the hypothesized cellular cascade model of migraine.

CONCLUSION

The model of migraine presents numerous opportunities for innovative drug development. The future of new migraine treatments is limited only by the investment from pharmaceutical companies.

Migraine Treatment and Healthcare Resource Utilization in Alberta, Canada

BACKGROUND

Migraine poses a significant burden worldwide; however, there is limited evidence as to the burden in Canada. This study examined the treatment patterns, healthcare resource use (HRU), and costs among newly diagnosed or recurrent patients with migraine in Alberta, Canada, from the time of diagnosis or recurrence.

METHODS

This retrospective observational study utilized administrative health data from Alberta, Canada. Patients were included in the Total Migraine Cohort if they had: (1) ≥1 International Classification of Diseases diagnostic code for migraine; or (2) ≥1 prescription dispense(s) for triptans from April 1, 2012, to March 31, 2018, with no previous diagnosis or dispensation code from April 1, 2010, to April 1, 2012.

RESULTS

The mean age of the cohort (n = 199,931) was 40.0 years and 72.3% were women. The most common comorbidity was depression (19.7%). In each medication class examined, less than one-third of the cohort was prescribed triptans and fewer than one-fifth was prescribed a preventive. Among patients with ≥1 dispense, the mean rate of opioid prescriptions was 4.61 per patient-year, compared to 2.28 triptan prescriptions per patient-year. Migraine-related HRU accounted for 3%-10% of all use.

CONCLUSION

Comorbidities and high all-cause HRU were observed among newly diagnosed or recurrent patients with migraine. There is an underutilization of acute and preventive medications in the management of migraine. The high rate of opioid use reinforces the suboptimal management of migraine in Alberta. Migraine management may improve by educating healthcare professionals to optimize treatment strategies.

A 3-year follow-up study of outcomes associated with patterns of traditional acute and preventive migraine treatment: An administrative claims-based cohort study in the United States

OBJECTIVE

To describe treatment patterns and direct healthcare costs over 3 years following initiation of standard of care acute and preventive migraine medications in patients with migraine in the United States.

BACKGROUND

There are limited data on long-term (>1 year) migraine treatments patterns and associated outcomes.

METHODS

This was a retrospective, observational cohort study using US claims data from the IBM® MarketScan® Research Database (January 2010-December 2017). Adults were included if they had a prescription claim for acute migraine treatments (AMT) or preventive migraine treatments (PMT) in the index period (January 2011-December 2014). The AMT cohort was categorized as persistent, cycled, or added-on subgroups; the PMT cohort was categorized PMT-persistent, switched without gaps, or cycled with gaps. Migraine-specific annual direct costs (2017 US$) across AMT and PMT cohort subgroups were summarized at baseline through 3 years from index (follow-up).

RESULTS

During the index period, 20,778 and 42,259 patients initiated an AMT and a PMT, respectively. At the 3-year follow-up, migraine-specific direct costs were lower in the persistent subgroup relative to the non-persistent subgroups in both AMT (mean [SD]: $789 [$1741] vs. $2847 [$8149] in the added-on subgroup and $862 [$5426] for the cycled subgroup) and PMT cohorts (mean [SD]: $1817 [$5892] in the persistent subgroup vs. $4257 [$11,392] in the switched without gaps subgroup and $3269 [$18,540] in the cycled with gaps subgroup). Acute medication overuse was lower in the persistent subgroup (1025/6504 [27.2%]) vs. non-persistent subgroups (11,236/58,863 [32.2%] in cycled with gaps subgroup and 1431/6504 [39.4%] in the switched without gaps subgroup). Most patients used multiple acute (19,717/20,778 [94.9%]) or preventive (38,494/42,259 [91.1%]) pharmacological therapies over 3 years following treatment initiation. Gaps in preventive therapy were common; an average gap ranged from 85 to 211 days (~3-7 months).

CONCLUSION

Migraine-specific annual healthcare costs and acute migraine medication overuse remained lowest among patients with persistent AMT and PMT versus non-persistent treatment. Study findings are limited to the US population. Future studies should compare costs and associated outcomes between newer preventive migraine medications in patients with migraine.

Rare GPR37L1 Variants Reveal Potential Association between GPR37L1 and Disorders of Anxiety and Migraine

GPR37L1 is an orphan receptor that couples through heterotrimeric G-proteins to regulate physiological functions. Since its role in humans is not fully defined, we used an unbiased computational approach to assess the clinical significance of rare G-protein-coupled receptor 37-like 1 (GPR37L1) genetic variants found among 51,289 whole-exome sequences from the DiscovEHR cohort. Rare GPR37L1 coding variants were binned according to predicted pathogenicity and analyzed by sequence kernel association testing to reveal significant associations with disease diagnostic codes for epilepsy and migraine, among others. Since associations do not prove causality, rare GPR37L1 variants were functionally analyzed in SK-N-MC cells to evaluate potential signaling differences and pathogenicity. Notably, receptor variants exhibited varying abilities to reduce cAMP levels, activate mitogen-activated protein kinase (MAPK) signaling, and/or upregulate receptor expression in response to the agonist prosaptide (TX14(A)), as compared with the wild-type receptor. In addition to signaling changes, knock-out (KO) of GPR37L1 or expression of certain rare variants altered cellular cholesterol levels, which were also acutely regulated by administration of the agonist TX14(A) via activation of the MAPK pathway. Finally, to simulate the impact of rare nonsense variants found in the large patient cohort, a KO mouse line lacking Gpr37l1 was generated. Although KO animals did not recapitulate an acute migraine phenotype, the loss of this receptor produced sex-specific changes in anxiety-related disorders often seen in chronic migraineurs. Collectively, these observations define the existence of rare GPR37L1 variants associated with neuropsychiatric conditions in the human population and identify the signaling changes contributing to pathological processes.

Treatment delay from onset of occipital neuralgia symptoms to treatment with nerve decompression surgery: a prospective cohort study

BACKGROUND

The aims of this study were to (1) evaluate the time between onset of occipital neuralgia symptoms and nerve decompression surgery, (2) perform a cost comparison analysis between surgical and nonsurgical treatment of occipital neuralgia, and (3) report postoperative results of nerve decompression for occipital neuralgia.

METHODS

Subjects (n = 1112) who underwent screening for nerve decompression surgery were evaluated for occipital neuralgia. Of those, 367 patients (33%) met the inclusion criteria. Timing of occipital neuralgia symptom onset and pain characteristics were prospectively collected. Cost associated with the nonsurgical treatment of occipital neuralgia was calculated for the period between onset of symptoms and surgery.

RESULTS

A total of 226 patients (73%) underwent occipital nerve decompression. The average time between onset of occipital neuralgia and surgery was 19 years (7.1-32). Postoperatively, the median number of pain days per month decreased by 17 (0-26, 57%) (P < .001), the median pain intensity decreased by 4 (2-8, 44%) (P < .001), and median pain duration in hours was reduced by 12 (2-23, 50%) (P < .001). The annual mean cost of nonsurgical occipital neuralgia treatment was $28 728.82 ($16 419.42-$41 198.41) per patient. The mean cost during the 19-year time frame before surgery was $545 847.75($311 968.90-$782 769.82).

CONCLUSION

This study demonstrates that patients suffer from occipital neuralgia for an average of 19 years before undergoing surgery. Nerve decompression reduces symptom severity significantly and should be considered earlier in the treatment course of occipital neuralgia that is refractory to conservative treatment to prevent patient morbidity and decrease direct and indirect health care costs.

Healthcare utilisation and economic burden of migraines among bank employees in China: a probabilistic modelling study

BACKGROUND

Despite the recognised high prevalence of migraines among bank employees, yet their healthcare utilisation patterns and the economic burden of migraines remain underexplored.

AIM

To examine migraine-related healthcare utilisation among bank employees in China, and to estimate the economic burden of migraines.

METHODS

A cross-sectional survey was conducted in Guizhou province, China between May and October 2022. The HARDSHIP questionnaire was used to identify migraine-positive individuals and enquire about their healthcare utilisation and productivity losses. A probabilistic decision-analytic model with a micro-costing approach was used to estimate the economic burden from the perspectives of the healthcare system, employers, and society. All costs were expressed in 2022 United States dollars. One-way and probabilistic sensitivity analyses were performed.

RESULTS

Nearly half of individuals with migraines reported not seeking medical care. Only 21.8% reported seeking outpatient consultations, 52.5% reported taking medicines, and 27.1% reported using complementary therapies. Chronic migraine patients had significantly higher healthcare utilisation than episodic migraine patients. Among individuals with a monthly migraine frequency of 15 days or more, 63.6% took inappropriate treatments by excessively using acute medications. Migraines in the banking sector in Guizhou cost the healthcare system a median of $7,578.0 thousand (25th to 75th percentile $4,509.2-$16,434.9 thousand) per year, employers $89,750.3 thousand (25th to 75th percentile $53,211.6-$151,162.2 thousand), and society $108,850.3 thousand (25th to 75th percentile $67,370.1-$181,048.6 thousand). The median societal cost per patient-year is $3,078.1. Migraine prevalence and productivity losses were identified as key cost drivers.

CONCLUSIONS

The study points to the need to raise awareness of migraines across all stakeholders and to improve the organisation of the migraine care system. A substantial economic burden of migraines on the healthcare system, employers, and society at large was highlighted. These cost estimates offer evidence-based benchmarks for assessing economic savings from improved migraine management, and can also draw the attention of Chinese policymakers to prioritise migraine policies within the banking and other office-based occupations.

Racial and Ethnic Disparities in Emergency Department Wait Times for Headache

Headache is a common complaint of individuals seeking treatment in the emergency department (ED). Because pain is subjective, medical evaluation is susceptible to implicit bias that can lead to disparities in wait times. The aim of this study was to determine whether there are racial and ethnic disparities in ED wait times for headache. Our study used the 2015-2018 National Hospital Ambulatory Care Surveys (NHAMCS), a nationally representative sample of ambulatory care visits to EDs. Our sample consisted of visits made by adults for headaches, which were identified using ICD-10 diagnosis codes and NHAMCS reason for visit codes. There were 12,301,655 ED visits for headache represented by our sample. The mean wait time for headache visits was 38.1 min (95%CI: 31.1, 45.0). The mean wait time for Non-Hispanic White patients, non-Hispanic Black patients, Hispanic patients, and the other race and ethnicity groups were 34.7 min (95%CI: 27.5, 42.0), 46.4 min (95%CI: 26.5, 66.4), 37.9 min (95%CI: 19.4, 56.3), and 21.0 min (95%CI: 6.3, 35.7) respectively. After controlling for patient- and hospital-level covariates, visits by non-Hispanic Black patients had 40% (95%CI: -0.01, 0.81, p = 0.056) longer wait times and visits by Hispanic patients had 39% (95%CI: -0.03, 0.80, p = 0.068) longer wait times than visits by non-Hispanic White patients. While our findings suggest that there may be longer wait times for visits by non-Hispanic Black and Hispanic patients compared to visits by non-Hispanic White patients, further research is needed to confirm these findings and determine causes of wait times disparities in the ED.

Genomics of Brain Disorders 4.0

Several historic, scientific events have occurred in the decade 2013-2023, in particular the COVID-19 pandemic. This massive pathogenic threat, which has affected the world's population, has had a devastating effect on scientific production worldwide. [...].

Treating the Uninsured and Underinsured with Migraine in the USA

PURPOSE OF REVIEW

To define, describe, and identify potential solutions for health disparities in the uninsured and underinsured with migraine in the USA.

RECENT FINDINGS

Uninsured and underinsured patients with migraine experience health disparities in diagnosis and treatment of migraine. Migraine patients have higher healthcare costs and higher employment disability, which contribute to a higher likelihood of uninsured or underinsured status. Uninsured or underinsured status, combined with factors such as race, socioeconomic status, geographic location, and care location, are correlated with delays in or decreased migraine diagnosis and treatment. Migraine prevalence is increased in the uninsured and underinsured. Potential solutions include advocacy for policy changes that improve access to care, increasing awareness and representation of underrepresented groups, providing resources to patients to reduce costs, and active patient engagement in migraine care. Continued efforts from all stakeholders have the potential to reduce health disparities in uninsured and underinsured patients with migraine, reducing disability and improving quality of life.

Early and annual projected savings from anti-CGRP monoclonal antibodies in migraine prevention: a cost-benefit analysis in the working-age population

BACKGROUND

Migraine is one of the main causes of disability worldwide. Anti-CGRP monoclonal antibodies (MAbs) have proven to be safe and efficacious as preventive migraine treatments. However, their use is restricted in many countries due to their apparently high cost. Cost-benefit studies are needed.

OBJECTIVE

To study the cost-benefit of anti-CGRP MAbs in working-age patients with migraine.

METHODS

This is a prospective cohort study of consecutive migraine patients treated with anti-CGRP MAbs (erenumab, fremanezumab and galcanezumab) following National reimbursement policy in a specialized headache clinic. Migraine characteristics and the work impact scale (WPAI) were compared between baseline (M0) and after 3 (M3) and 6 months (M6) of treatment. Using WPAI and the municipal average hourly wage, we calculated indirect costs (absenteeism and presenteeism) at each time point. Direct costs (emergency visits, acute medication use) were also analysed. A cost-benefit study was performed considering the different costs and savings of treating with MAbs. Based on these data an annual projection was conducted.

RESULTS

From 256 treated working-age patients, 148 were employed (89.2% women; mean age 48.0 ± 8.5 years), of which 41.2% (61/148) were responders (> 50% reduction in monthly headache days (MHD)). Statistically significant reductions between M0 and M3/M6 were found in absenteeism (p < 0.001) and presenteeism (p < 0.001). Average savings in indirect costs per patient at M3 were absenteeism 105.4 euros/month and presenteeism 394.3 euros/month, similar for M6. Considering the monthly cost of anti-CGRP MAbs, the cost-benefit analysis showed savings of 159.8 euros per patient at M3, with an annual projected savings of 639.2 euros/patient. Both responders and partial responders (30-50% reduction in MHD) presented a positive cost-benefit balance. The overall savings of the cohort at M3/M6 compensated the negative cost-benefit balance for non-responders (< 30% reduction in MHD).

CONCLUSION

Anti-CGRP MAbs have a positive impact in the workforce significantly reducing absenteeism and presenteeism. In Spain, this benefit overcomes the expenses derived from their use already at 3 months and is potentially sustainable at longer term; also in patients who are only partial responders, prompting reconsideration of current reimbursement criteria and motivating the extension of similar cost-benefit studies in other countries.

Health care resource utilization and costs associated with diagnosed medication overuse headache and potential acute medication overuse in individuals with migraine

OBJECTIVE

Estimate health care resource utilization and costs associated with medication overuse headache and potential acute medication overuse.

METHODS

A retrospective analysis was conducted with Clinformatics Data Mart data (1 January 2019-31 December 2019) that included continuously enrolled commercially insured adults with migraine (International Classification of Diseases, Tenth Revision, Clinical Modification [ICD-10-CM] code G43.xxx). Medication overuse headache was defined as ≥1 inpatient or ≥2 outpatient claims with an ICD-10-CM code G44.41/40 (drug-induced headache). Potential acute medication overuse was defined as possessing sufficient medication for >10 mean treatment days/month for ergots, triptans, opioids, or combination analgesics or >15 mean cumulative days/month for simple prescription analgesics (e.g., acetaminophen, aspirin, other non-opioid analgesics) for >6 consecutive months. All-cause and migraine-related health care resource utilization and costs were compared after adjusting for demographic and clinical characteristics.

RESULTS

Among 90,017 individuals with migraine, the frequency of medication overuse headache/potential acute medication overuse was 12.6% (diagnosed medication overuse headache: 0.6%; potential acute medication overuse: 12.1%). Adjusted all-cause total costs ($31,235 vs $21,486; difference: $9,749 [P < 0.001]) and adjusted migraine-related total costs ($9,770 vs $6,207; difference: $3,563 [P < 0.001]) were higher in the medication overuse headache/potential acute medication overuse group versus those without medication overuse headache/potential acute medication overuse.

CONCLUSIONS

Individuals with diagnosed medication overuse headache/potential acute medication overuse had higher all-cause and migraine-related health care resource utilization and costs versus individuals without medication overuse headache/potential acute medication overuse, suggesting that improved migraine management is needed to reduce associated costs.

Health equity, care access and quality in headache - part 1

Current definitions of migraine that are based mainly on clinical characteristics do not account for other patient's features such as those related to an impaired quality of life, due to loss of social life and productivity, and the differences related to the geographical distribution of the disease and cultural misconceptions which tend to underestimate migraine as a psychosocial rather than neurobiological disorder.Global differences definition, care access, and health equity for headache disorders, especially migraine are reported in this paper from a collaborative group of the editorial board members of the Journal of Headache and Pain. Other components that affect patients with migraine, in addition to the impact promoted by the migraine symptoms such as stigma and social determinants, are also reported.

An Online Psychological Program for Adolescents and Young Adults With Headaches: Iterative Design and Rapid Usability Testing

BACKGROUND

Headache disorders are common, debilitating health problems. Cognitive-behavioral therapy (CBT) is recommended but rarely easily available. With the use of the internet and communication technologies among youth and young adults, these individuals could be self-trained in CBT skills. There is an increasing number of internet-based interventions for headaches, but there has been little research into the usability of these interventions because evaluating usability across the intervention development life cycle is costly. We developed an internet-based CBT program, the Specialized Program for Headache Reduction (SPHERE). While developing it, we aimed to improve SPHERE through rapid usability testing cycles.

OBJECTIVE

This study aims to presents a rapid and affordable usability testing approach that can be performed throughout the intervention development life cycle. This paper also provides evidence of the usability of SPHERE.

METHODS

We used the "think aloud" usability testing method based on Krug's approach to test user interaction within a lab setting. This was followed by a short posttest interview. We planned to test SPHERE with 3-5 participants testing the same part of the program each cycle. Both the design and development team and the research team actively participated in the usability testing process. Observers independently identified the top 3 usability issues, rated their severity, and conducted debriefing sessions to come to consensus on major issues and generate potential solutions.

RESULTS

The testing process allowed major usability issues to be identified and rectified rapidly before piloting SPHERE in a real-world context. A total of 2 cycles of testing were conducted. Of the usability issues encountered in cycles 1 and 2, a total of 68% (17/25) and 32% (12/38), respectively, were rated as major, discussed, and fixed.

CONCLUSIONS

This study shows that rapid usability testing is an essential part of the design process that improves program functionality and can be easy and inexpensive to undertake.

Clinical effectiveness of pharmacological interventions for managing chronic migraine in adults: a systematic review and network meta-analysis

BACKGROUND

Chronic migraine can be a profoundly disabling disorder that may be treated with preventive medications. However, uncertainty remains as to which preventive medication is the most effective. We present a network meta-analysis to determine the effectiveness and rank of preventive drugs for chronic migraine in adults.

METHODS

We identified, reviewed, and extracted data from randomised controlled trials (RCTs) of preventive drugs for chronic migraine with at least 200 participants. Data were analysed using network meta-analysis.

FINDINGS

We included 12 RCTs of six medications (Eptinezumab, Erenumab, Fremanezumab, Galcanezumab, Onabotulinumtoxin A, and Topiramate) compared to placebo or each other. All drugs effectively reduced monthly headache and migraine days compared with placebo. The most effective drug for monthly headache days was Eptinezumab 300mg, with a mean difference of -2.46 days, 95% Credible Interval (CrI): -3.23 to -1.69. On the Surface Under the Cumulative Ranking Area (SUCRA) analysis, the probability that Eptinezumab 300mg was ranked highest was 0.82. For monthly migraine days, the most effective medication was Fremanezumab-monthly, with a mean difference: -2.77 days, 95% CrI: -3.36 to -2.17, and 0.98 probability of being ranked the highest. All included drugs, except Topiramate, improved headache-related quality of life. No eligible studies were identified for the other common preventive oral medications such as Amitriptyline, Candesartan, and Propranolol. The main reasons were that the studies did not define chronic migraine, were undertaken before the definition of chronic migraine, or were too small.

INTERPRETATION

All six medications were more effective than the placebo on monthly headache and migraine days. The absolute differences in the number of headache/migraine days are, at best, modest. No evidence was found to determine the relative effectiveness of the six included drugs with other oral preventive medications.

REGISTRATION

PROSPERO (number CRD42021265990).

Treatment Delay in Patients Undergoing Headache Surgery (Nerve Decompression Surgery)

Background

Although headache surgery has been shown to be an effective treatment option for refractory headache disorders, it has not been included as part of the headache disorder management algorithm by non-surgical providers. This study aims to evaluate the delay in surgical management of patients with headache disorders. In addition, a cost comparison analysis between conservative and operative treatment of headache disorders was performed, and the surgical outcomes of headache surgery were reported.

Methods

Among 1112 patients who were screened, 271 (56%) patients underwent headache surgery. Data regarding the onset of headache disorder and pre- and postoperative pain characteristics were prospectively collected. To perform a cost comparison analysis, direct and indirect costs associated with the conservative treatment of headache disorders were calculated.

Results

The median duration between onset of headache disorder symptoms and headache surgery was 20 (8.2-32) years. The annual mean cost of conservative treatment of headache disorders was $49,463.78 ($30,933.87-$66,553.70) per patient. Over the 20-year time period before surgery, the mean cost was $989,275.65 ($618,677.31-$1,331,073.99). In comparison, the mean cost of headache surgery was $11,000. The median pain days per month decreased by 16 (0-25) (p<0.001), the median pain intensity reduced by 4 (2-7) (p<0.001), and the median pain duration decreased by 11 hours (0-22) (p<0.001).

Conclusion

This study shows that patients experience symptoms of headache disorders for an average of 20 years prior to undergoing headache surgery. Surgical treatment not only significantly improves headache pain but also reduces healthcare costs and should be implemented in the management algorithm of headache disorders.

Arterial Spin Labeling in Migraine: A Review of Migraine Categories and Mimics

Migraine is a complex headache characterized by changes in functional connectivity and cerebral perfusion. The perfusion changes represent a valuable domain for targeted drug therapy. Arterial spin labeling is a noncontrast imaging technique of quantifying cerebral perfusion changes in the migraine setting. In this narrative review, we will discuss the pathophysiology of the different categories of migraine, as defined by the International Classification of Headache Disorders-3 and describe a category-based approach to delineating perfusion changes in migraine on arterial spin labeling images. We will also discuss the use of arterial spin labeling to differentiate migraine from stroke and/or seizures in the adult and pediatric populations. Our systematic approach will help improve the understanding of the complicated vascular changes that occur during migraines and identify potential areas of future research.

Feasibility and Usability of a Mobile App-Based Interactive Care Plan for Migraine in a Community Neurology Practice: Development and Pilot Implementation Study

BACKGROUND

Migraine is a common and major cause of disability, poor quality of life, and high health care use. Access to evidence-based migraine care is limited and projected to worsen. Novel mobile health app-based tools may effectively deliver migraine patient education to support self-management, facilitate remote monitoring and treatment, and improve access to care. The risk that such an intervention may increase the care team workload is a potential implementation barrier.

OBJECTIVE

This study aims to describe a novel electronic health record-integrated mobile app-based Migraine Interactive Care Plan (MICP) and evaluate its feasibility, usability, and impact on care teams in a community neurology practice.

METHODS

Consecutive enrollees between September 1, 2020, and February 16, 2022, were assessed in a single-arm observational study of usability, defined by 74.3% (127/171) completing ≥1 assigned task. Task response rates, rate and type of care team escalations, and patient-reported outcomes were summarized. Patients were prospectively recruited and randomly assigned to routine care with or without the MICP from September 1, 2020, to September 1, 2021. Feasibility was defined by equal to or fewer downstream face-to-face visits, telephone contacts, and electronic messages in the MICP cohort. The Wilcoxon rank-sum test was used to compare continuous variables, and the chi-square test was used for categorical variables for those with at least 3 months of follow-up.

RESULTS

A total of 171 patients were enrolled, and of these, 127 (74.3%) patients completed ≥1 MICP-assigned task. Mean escalations per patient per month was 0.9 (SD 0.37; range 0-1.7). Patient-confirmed understanding of the educational materials ranged from 26.6% (45/169) to 56.2% (95/169). Initial mean headache days per week was 4.54 (SD 2.06) days and declined to 2.86 (SD 1.87) days at week 26. The percentage of patients reporting favorable satisfaction increased from a baseline of 35% (20/57) to 83% (15/18; response rate of 42/136, 30.9% to 28/68, 41%) over the first 6 months. A total of 121 patients with MICP were compared with 62 patients in the control group. No differences were observed in the rate of telephone contacts or electronic messages. Fewer face-to-face visits were observed in the MICP cohort (13/121, 10.7%) compared with controls (26/62, 42%; P<.001).

CONCLUSIONS

We describe the successful implementation of an electronic health record-integrated mobile app-based care plan for migraine in a community neurology practice. We observed fewer downstream face-to-face visits without increasing telephone calls, medication refills, or electronic messages. Our findings suggest that the MICP has the potential to improve patient access without increasing care team workload and the need for patient input from diverse populations to improve and sustain patient engagement. Additional studies are needed to assess its impact in primary care.

Headache and psychological variables as predictors of disability in individuals with primary headache disorders

OBJECTIVE

To examine the relative contribution of headache symptoms and psychological factors to headache-related disability.

BACKGROUND

Both headache symptoms and comorbid psychological factors (psychiatric symptoms and transdiagnostic constructs) negatively impact functioning among individuals with migraine and tension-type headache, but few studies have explored their relative contribution to headache-related disability. We hypothesized that psychiatric symptoms and transdiagnostic variables would afford incremental contribution to disability beyond headache symptoms, and we investigated the moderating role of headache diagnosis on these relationships.

METHODS

This cross-sectional study examined data from a southern U.S. university online sample of 1818 young adults (mean [SD] age 19.0 [5.1] years; 74.6% female) who met the International Classification of Headache Disorders, third edition criteria for primary headache disorders (46.6% episodic migraine, 11.6% chronic migraine, 38.3% episodic tension-type headache, 3.5% chronic tension-type headache) and completed measures assessing psychological factors and headache-related disability. Headache, psychiatric symptoms, and transdiagnostic factors were examined in relation to headache-related disability, after controlling for sex. Moderation analyses examined the conditional effect of diagnosis on disability.

RESULTS

As predicted, both psychiatric and transdiagnostic symptoms accounted for unique variance in headache-related disability beyond headache symptoms (R2 changes of 2.7% and 2.3%, respectively). Significant three-way interactions revealed the relationship between psychiatric symptoms and disability (b = -3.16, p = 0.002), and between transdiagnostic variables and disability (b = -2.37, p = 0.034). Tests of simple slopes showed greater psychiatric symptoms and transdiagnostic variables were associated with higher levels of disability. However, the associations of these variables with disability were strongest among individuals with chronic tension-type headache (B = 3.93 for psychiatric symptoms and B = 4.62 for transdiagnostic symptoms, both p < 0.001).

CONCLUSION

Psychiatric and transdiagnostic factors contribute uniquely to headache-related functional impairment, which may be important for expanding targeted assessment and behavioral interventions.

A meta-analytic review of acceptance-based interventions for migraine

OBJECTIVE

To determine the efficacy of acceptance and mindfulness-based interventions on migraine disability, medication use, and attack frequency.

BACKGROUND

Acceptance-based approaches to headache management are those in which individuals learn to mitigate the influence of pain-related experiences on their general functioning without controlling pain itself. Treatment approaches include acceptance and commitment therapy (ACT) and mindfulness-based practices. Both have shown promise in improving broad functioning and disability among individuals with headache. Despite a growing body of research examining acceptance-based interventions for headache broadly and migraine specifically, no meta-analytic review of ACT interventions for headache exists, and two meta-analytic reviews of mindfulness-based practices yielded conflicting results.

METHODS

The present study aimed to systematically and quantitatively review the literature related to the efficacy of acceptance-based interventions among adults with migraine. A multi-database search (PubMed/MEDLINE, Scopus, PsycINFO, and the Cochrane Central Register of Controlled Trials) identified clinical trials among individuals with migraine that compared structured ACT or mindfulness-based interventions to control treatment. Random-effects meta-analyses were performed using RevMan 5.4 meta-analytic software, and standardized mean differences (SMD) with 95% confidence intervals (CIs) quantified effect sizes on outcomes of disability, medication use, and headache frequency. Heterogeneity was quantified via I2 index and explored via subgroup analyses.

RESULTS

Acceptance-based interventions yielded significant improvements in disability (SMD = -0.38, 95% CI = -0.56 to -0.20; I2  = 25%, p = 0.20) but not in medication use (SMD = -0.25, 95% CI: -0.57 to 0.06; I2  = 0%, p = 0.82) or headache frequency (SMD = -0.16, 95% CI = -0.37 to 0.05; I2  = 0%, p = 0.73).

CONCLUSION

Results suggest that acceptance-based interventions are effective in improving disability among adults with migraine and are a viable non-pharmacological treatment option, in addition to well-established behavioral migraine management approaches, for patients seeking functional improvement.

Real-world persistence and costs among patients with chronic migraine treated with onabotulinumtoxinA or calcitonin gene-related peptide monoclonal antibodies

BACKGROUND: Chronic migraine (CM) is a common neurologic disorder that imposes substantial burden on payers, patients, and society. Low rates of persistence to oral migraine preventive medications have been previously documented; however, less is known about persistence and costs associated with innovative nonoral migraine preventive medications. OBJECTIVE: To evaluate real-world persistence and costs among adults with CM treated with onabotulinumtoxinA (onabotA) or calcitonin gene-related peptide monoclonal antibodies (CGRP mAbs). METHODS: This was a retrospective, longitudinal, observational study analyzing the IBM MarketScan Commercial and Medicare databases. The study sample included adults with CM initiating treatment with either onabotA or a CGRP mAb on or after January 1, 2018. Persistence and costs over 12 months after treatment initiation were evaluated using chi-square and Student's t-tests. Persistence to onabotA was compared with CGRP mAbs as a weighted average of the class and by individual CGRP mAbs. Mean pharmacy (acute and preventive), medical (inpatient, emergency department, and outpatient), and total costs are reported. Multivariate regression analyses were conducted to generate adjusted estimates of persistence and costs after controlling for potential confounders (age, sex, region, insurance type, number of baseline comorbidities, Charlson Comorbidity Index, and number of previously used oral migraine preventive medications). RESULTS: Of 66,303 individuals with onabotA or CGRP mAb claims, 2,697 with CM met the inclusion/exclusion criteria. In the total population, individuals were primarily female (85.5%), lived in the South (48.5%), and had a mean (SD) age of 44 (12) years, which was consistent across the onabotA and CGRP mAb cohorts. Common comorbid conditions included anxiety (23.9%), depression (18.2%), hypertension (16.5%), and sleep disorders (16.9%). After adjusting for potential confounding variables, persistence to onabotA during the 12-month follow-up period was 40.7% vs 27.8% for CGRP mAbs (odds ratio [OR] = 0.683; 95% CI = 0.604-0.768; P < 0.0001). Persistence to erenumab, fremanezumab, and galcanezumab was 25.5% (OR = 0.627; 95% CI = 0.541-0.722; P < 0.0001), 30.3% (OR = 0.746; 95% CI = 0.598-0.912; P = 0.0033), and 33.7% (OR = 0.828; 95% CI = 0.667-1.006; P = 0.058). All-cause ($18,292 vs $18,275; P = 0.9739) and migraine-related ($8,990 vs $9,341; P = 0.1374) costs were comparable between the onabotA and CGRP mAb groups. CONCLUSIONS: Among adults with CM receiving onabotA and CGRP mAbs, individuals initiating onabotA treatment had higher persistence compared with those receiving CGRP mAbs. Total all-cause and migraine-related costs over 12 months were comparable between those receiving onabotA and CGRP mAbs. DISCLOSURES: This study was sponsored by Allergan (prior to its acquisition by AbbVie), they contributed to the design and interpretation of data and the writing, reviewing, and approval of final version. Writing and editorial assistance was provided to the authors by Dennis Stancavish, MS, of Peloton Advantage, LLC, an OPEN Health company, Parsippany, NJ, and was funded by AbbVie. The opinions expressed in this article are those of the authors. The authors received no honorarium/fee or other form of financial support related to the development of this article. Dr Schwedt serves on the Board of Directors for the American Headache Society and the American Migraine Foundation. Within the prior 12 months he has received research support from Amgen, Henry Jackson Foundation, Mayo Clinic, National Institutes of Health, Patient-Centered Outcomes Research Institute, SPARK Neuro, and US Department of Defense. Within the past 12 months, he has received personal compensation for serving as a consultant or advisory board member for AbbVie, Allergan, Axsome, BioDelivery Science, Biohaven, Collegium, Eli Lilly, Ipsen, Linpharma, Lundbeck, and Satsuma. He holds stock options in Aural Analytics and Nocira. He has received royalties from UpToDate. Dr Lee and Ms Shah are employees of AbbVie and may hold AbbVie stock. Dr Gillard was an employee of AbbVie and may hold AbbVie stock. Dr Knievel has served as a consultant for AbbVie, Amgen, Eli Lilly, and Biohaven; conducted research for AbbVie, Amgen, and Eli Lilly; and is on speaker programs for AbbVie and Amgen. Dr McVige has served as a speaker and/or received research support from Allergan (now AbbVie Inc.), Alder, Amgen/Novartis, Avanir, Biohaven, Eli Lilly, Lundbeck, and Teva. Ms Wang and Ms Wu are employees of Genesis Research, which provides consulting services to AbbVie. Dr Blumenfeld, within the past 12 months, has served on advisory boards for Allergan, AbbVie, Aeon, Alder, Amgen, Axsome, BDSI, Biohaven, Impel, Lundbeck, Lilly, Novartis, Revance, Teva, Theranica, and Zosano; as a speaker for Allergan, AbbVie, Amgen, BDSI, Biohaven, Lundbeck, Lilly, and Teva; as a consultant for Allergan, AbbVie, Alder, Amgen, Biohaven, Lilly, Lundbeck, Novartis, Teva, and Theranica; and as a contributing author for Allergan, AbbVie, Amgen, Biohaven, Novartis, Lilly, and Teva. He has received grant support from AbbVie and Amgen. AbbVie is committed to responsible data sharing regarding the clinical trials we sponsor. This includes access to anonymized, individual, and trial-level data (analysis data sets), as well as other information (eg, protocols, clinical study reports, or analysis plans), as long as the trials are not part of an ongoing or planned regulatory submission. This includes requests for clinical trial data for unlicensed products and indications. These clinical trial data can be requested by any qualified researchers who engage in rigorous, independent scientific research, and will be provided following review and approval of a research proposal and Statistical Analysis Plan and execution of a Data Sharing Agreement. Data requests can be submitted at any time after approval in the United States and Europe and after acceptance of this manuscript for publication. The data will be accessible for 12 months, with possible extensions considered. For more information on the process, or to submit a request, visit the following link: https://www.abbvieclinicaltrials.com/hcp/data-sharing/.

Targeting Glutamate Neurotoxicity through Dietary Manipulation: Potential Treatment for Migraine

Glutamate, the main excitatory neurotransmitter in the central nervous system, is implicated in both the initiation of migraine as well as central sensitization, which increases the frequency of migraine attacks. Excessive levels of glutamate can lead to excitotoxicity in the nervous system which can disrupt normal neurotransmission and contribute to neuronal injury or death. Glutamate-mediated excitotoxicity also leads to neuroinflammation, oxidative stress, blood-brain barrier permeability, and cerebral vasodilation, all of which are associated with migraine pathophysiology. Experimental evidence has shown the protective effects of several nutrients against excitotoxicity. The current review focuses on the mechanisms behind glutamate's involvement in migraines as well as a discussion on how specific nutrients are able to work towards restoring glutamate homeostasis. Understanding glutamate's role in migraine is of vital importance for understanding why migraine is commonly comorbid with widespread pain conditions and for informing future research directions.

Characterization of head and neck pain symptoms of patients presenting to a tertiary care pain clinic

OBJECTIVE

To characterize the presentation and symptomatology of individuals presenting with pain in head and neck regions.

METHODS

A retrospective chart-review was performed on patients with pain in the HFN presenting to a tertiary pain center in Turkey between January 2016 and January 2017. Information regarding the characteristics of pain and medical and treatment history were extracted and reviewed.

RESULTS

Among 197 subjects, 135 (68.5%) were females. The average duration of pain was 60.13 ± 92.32 months. The pain was continuous in presentation and severe in intensity in 43.1% and 51.8% of the subjects, respectively. The pain was associated with at least one somatosensory symptom in 12.1% of subjects. Common diagnoses were trigeminal neuralgia, persistent idiopathic facial pain, and migraine headaches.

CONCLUSION

Painful disorders of the HFN are associated with varying and perplexing signs and symptoms. Such patients should undergo a comprehensive clinical assessment with a multidisciplinary team.

Effect of Pranayama as Adjuvant to Medical Treatment on Severity, Frequency, and Duration of Headache in Migraine Patients: An Open-Label Randomized Controlled Trial

Background

Migraine is the second leading cause of disability worldwide with high rates of dissatisfaction for allopathic treatment among patients. Pranayama is an easy, convenient, and cost-effective method that can supplement existing standard medical treatment of migraine.

Objective

To study the effect of pranayama as an adjuvant to standard medical treatment of migraine on clinical outcome variables of migraine.

Materials and Methods

This was a randomized controlled trial conducted on 80 consecutive migraine patients who were diagnosed as per International Classification of Headache Disorders-3 (ICHD-3) criteria and were randomly allocated into two groups, that is, standard medical treatment (SMT) group and standard medical treatment plus pranayama (SMT + P) group. The effect of pranayama on clinical outcome variables of migraine was evaluated by using standardized questionnaires. The data was statistically analyzed using SPSS Statistics 20 software. A P value of ≤0.05 was considered statistically significant.

Results

Intragroup analysis showed all clinical outcome variables of migraine reduced significantly in the SMT + P group whereas all clinical outcome variables of migraine except the duration of headache episodes reduced significantly in the SMT group. Although statistically non-significant, intergroup analysis demonstrates that reduction in headache severity, duration of headache episodes, and headache impact test-6 (HIT-6) score was more in the SMT + P group whereas reduction in headache frequency and migraine disability assessment (MIDAS) score was more in the SMT group.

Conclusion

Pranayama supplements the standard medical treatment of migraine by reducing the duration of headache episodes in addition to the reduction in headache severity, headache frequency, HIT-6 scores, and MIDAS scores.

A Multimodal Conservative Approach to Treating Migraine: A Physical Therapist's Perspective

PURPOSE OF REVIEW

Migraine is common and interventions to treat or manage it vary. Physical therapists possess a varied skill set that can assess and treat limitations related to migraine and its symptoms. Conservative and non-pharmacological examination and treatment techniques for migraine and headache management are reviewed in terms of efficacy and relevance in order to describe the physical therapist's abilities and clinical reasoning process when confronting a patient with migraine symptoms.

RECENT FINDINGS

A thorough examination is necessary to detect red flags and will reveal a person with migraine's biopsychosocial limitations to manage their symptoms. Strength, endurance, cervical mobility, and visual deficits are common in those reporting headaches and examination techniques, along with patient-reported outcome measures, can elicit objective data for re-assessment during an episode of care. Exercise interventions, manual therapy, biofeedback techniques, and vestibular therapy have become viable and efficacious non-pharmacological interventions in recent years to assist the patient with managing and mitigating their migraine symptoms, along with mindfulness-based exercises. A case study, with individualized treatment approaches based on examination findings, current evidence, and accrued expertise, demonstrates the clinical applicability of a physical therapist's multimodal approach to treating migraine. Psychologically- informed physical therapy with mindfulness-based approaches and biofeedback can help a patient gain more control over their symptoms and their body's response to head pain, while exercise and vestibular therapy can assist the system with recovery and adaptation from deficits related to migraine symptoms. A thorough examination, with an individually- tailored rehabilitation plan incorporating movement and mindfulness-based therapies, is recommended.

Associations between dietary diversity score and migraine headaches: the results from a cross-sectional study

Aims

There is limited evidence on the link between diet quality and migraine headaches. The present study aimed to evaluate the association between dietary diversity score (DDS), as a good representative of overall diet quality, and clinical features of migraine headaches.

Methods

In total, 262 subjects (224 females and 34 males), aged 20 to 50  years old were included in the present cross-sectional study. The migraine headache was diagnosed according to the third edition of the International Classification of Headache Disorders (ICHD-3). Clinical features of migraine headaches including frequency, severity, and duration of migraine headaches, headache impact test-6 (HIT-6), and serum levels of nitric oxide (NO) were assessed by standard procedures. The dietary intake of participants has been assessed by a validated 168-item food frequency questionnaire (FFQ) and used to calculate DDS. The association between DDS and clinical variables of migraine headaches was investigated using multiple linear regression analysis, and the beta (β) estimates with 95% confidence intervals (CIs) were reported.

Results

A significant inverse association was found between DDS and headache frequency (β = -2.19, 95% CI: -4.25, -0.14) and serum levels of NO (β = -6.60, 95% CI: -12.58, -0.34), when comparing patients in the third tertile of DDS to those in the first tertile. The association remained significant and became stronger after adjustment for confounders for both outcomes of headache frequency (β = -3.36, 95% CI: -5.88, -0.84) and serum levels of NO (β = -9.86, 95% CI: -18.17, -1.55). However, no significant association was found between DDS with HIT-6 score, migraine headache duration, and severity.

Conclusion

The present study demonstrates that higher dietary diversity is correlated with lower migraine frequency and serum levels of NO.

Rare GPR37L1 variants reveal potential roles in anxiety and migraine disorders

GPR37L1 is an orphan receptor that couples through heterotrimeric G-proteins to regulate physiological functions. Since its role in humans is not fully defined, we used an unbiased computational approach to assess the clinical significance of rare GPR37L1 genetic variants found among 51,289 whole exome sequences from the DiscovEHR cohort. Briefly, rare GPR37L1 coding variants were binned according to predicted pathogenicity, and analyzed by Sequence Kernel Association testing to reveal significant associations with disease diagnostic codes for epilepsy and migraine, among others. Since associations do not prove causality, rare GPR37L1 variants were then functionally analyzed in SK-N-MC cells to evaluate potential signaling differences and pathogenicity. Notably, receptor variants exhibited varying abilities to reduce cAMP levels, activate MAPK signaling, and/or upregulate receptor expression in response to the agonist prosaptide (TX14(A)), as compared to the wild-type receptor. In addition to signaling changes, knockout of GPR37L1 or expression of certain rare variants altered cellular cholesterol levels, which were also acutely regulated by administration of the agonist TX14(A) via activation of the MAPK pathway. Finally, to simulate the impact of rare nonsense variants found in the large patient cohort, a knockout (KO) mouse line lacking Gpr37L1 was generated, revealing loss of this receptor produced sex-specific changes implicated in migraine-related disorders. Collectively, these observations define the existence of rare GPR37L1 variants in the human population that are associated with neuropsychiatric conditions and identify the underlying signaling changes that are implicated in the in vivo actions of this receptor in pathological processes leading to anxiety and migraine.

SIGNIFICANCE STATEMENT

G-protein coupled receptors (GPCRs) represent a diverse group of membrane receptors that contribute to a wide range of diseases and serve as effective drug targets. However, a number of these receptors have no identified ligands or functions, i.e., orphan receptors. Over the past decade, advances have been made, but there is a need for identifying new strategies to reveal their roles in health and disease. Our results highlight the utility of rare variant analyses of orphan receptors for identifying human disease associations, coupled with functional analyses in relevant cellular and animal systems, to ultimately reveal their roles as novel drug targets for treatment of neurological disorders that lack wide-spread efficacy.

Burden of migraine with acute medication overuse or psychiatric comorbidities and treatment with CGRP pathway-targeted monoclonal antibodies: A review

Migraine is a complex and often debilitating neurological disease that affects more than 1 billion people worldwide. It is characterized by moderate-to-intense, throbbing headache attacks that are worsened by activity and is associated with nausea, vomiting, and sensitivity to light and sound. Migraine, ranked the second leading cause of years lived with disability by the World Health Organization, can diminish patients' quality of life and bring significant personal and economic burden. Furthermore, migraine patients with a history of acute medication overuse (AMO) or psychiatric comorbidities, such as depression or anxiety, may experience even greater impairment and burden, and their migraine may be more difficult-to-treat. Appropriate treatment of migraine is essential to reduce this burden and improve patient outcomes, especially for those with AMO or psychiatric comorbidities. There are several available preventive treatment options for migraine, though many of these are not migraine-specific and may have limited efficacy and/or poor tolerability. The calcitonin gene-related peptide pathway plays a key role in the pathophysiology of migraine, and monoclonal antibodies that target the calcitonin gene-related peptide pathway have been developed as specific preventive treatments for migraine. Four of these monoclonal antibodies have been approved for the preventive treatment of migraine after demonstrating favorable safety and efficacy profiles. These treatments offer substantial benefits for migraine patients, including those with AMO or common psychiatric comorbidities, by reducing monthly headache days and migraine days, days of acute medication use, and disability measures, as well as improving quality of life.

Emerging drugs for the preventive treatment of migraine: a review of CGRP monoclonal antibodies and gepants trials

INTRODUCTION

Migraine is a leading cause of years lived with disability and preventive strategies represent a mainstay to reduce health-related disability and improve quality of life of migraine patients. Until a few years ago, migraine prevention was based on drugs developed for other clinical indications and relocated in the migraine therapeutic armamentarium, characterized by unfavourable tolerability profiles. The advent of monoclonal antibodies against Calcitonin Gene-Related Peptide (CGRP) and gepants, CGRP receptor antagonists, has been a turning point in migraine prevention owing to advantageous efficacy, safety and tolerability profiles.Nevertheless, while in an ideal scenario a drug characterized by significant greater efficacy and tolerability compared to existing therapeutic strategies should be adopted as a first-line treatment, cost-effectiveness analyses available for monoclonal antibodies against CGRP pathway tend to limit their administration to more severe migraine phenotypes.

AREAS COVERED

The present narrative review aim to provide a critical appraisal of phase II and III CGRP-mAbs and gepants trials to analyse their use in clinical practice.

EXPERT OPINION

Despite monoclonal antibodies against CGRP pathway and gepants can be undoubtedly considered top-of-the-range treatments, there are still issues deserving to be addressed in the coming years as the risk of off-target effects as well as their economic sustainability based on the considerable migraine burden.

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.

Optimized Acute Treatment of Migraine Is Associated With Greater Productivity in People With Migraine: Results From the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study

OBJECTIVE

This study aimed to ascertain whether level of optimization of acute treatment of migraine is related to work productivity across the spectrum of migraine.

METHODS

Data were from the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study, an internet-based longitudinal survey. Respondents with migraine who reported full-time employment and use of ≥1 acute prescription medication for migraine were included. We determined relationships among lost productive time (LPT; measured with the Migraine Disability Assessment Scale), acute treatment optimization (Migraine Treatment Optimization Questionnaire- ), and monthly headache days (MHDs).

RESULTS

There was a direct relationship between LPT and MHD category. Greater acute treatment optimization was associated with lower total LPT, less absenteeism, and less presenteeism within each MHD category.

CONCLUSIONS

Optimizing acute treatment for migraine may reduce LPT in people with migraine and reduce indirect costs.