Diagnosis and management of headache in adults: summary of SIGN guideline

Neck treatment compared to aerobic exercise in migraine: A preference-based clinical trial

Objectives:

The main objective of this study was to compare the effectiveness of aerobic exercise with physiotherapy. A second objective was to evaluate whether patients with pain referred to the head during manual palpation will benefit more from physiotherapy than patients with local or no pain.

Methods:

A total of 103 patients with migraine received physiotherapy ( n = 79) or supervised aerobic exercise ( n = 24) according to their preference as an add-on treatment. Both groups had the same contact time with a specialized physiotherapist. The primary outcome measure was headache frequency during the 4 weeks after the intervention. Eighty-seven patients were analyzed at the primary end point ( n = 69 in the physiotherapy group; n = 18 in the aerobic exercise group). A follow-up assessment was conducted 3 months after the final intervention.

Results:

During the initial assessment of the upper cervical spine, 17 patients reported no pain, 45 local pain, and 25 referred pain to the head. Patients in the physiotherapy group had a mean reduction of 1.8 days (standard deviation (SD) 6.07), while patients in the aerobic exercise group had a mean reduction of 1.2 days (SD 4.27) at the primary end point. This difference was not statistically significant ( p = 0.8). The largest improvement was noted in the group that showed referred pain to the head and received physiotherapy (2.13 days (SD 7.82)). Only patients in the physiotherapy group reported a subjectively perceived general improvement.

Conclusions:

Patients had a strong preference for physiotherapy. Both groups showed small reductions in headache frequency. Effects were superior after physiotherapy but not statistically significant. Patients with pain referred to the head responded best to a physiotherapy intervention.

Report of guidelines for diagnosis and treatment of common internal diseases in Chinese medicine: Headache

Headache is one of the most common clinical complaints and is listed as one of the top 10 disability disorders by the World Health Organization (WHO). For standardizing the diagnosis and treatment of headache and improve the level of clinical diagnosis and treatment of traditional Chinese medicine (TCM), on 30 January 2019, China Association of Chinese Medicine officially issued the Guidelines for Diagnosis and Treatment of Common Internal Diseases in Chinese Medicine-Headache (T/CACM 1271-2019). The Guidelines were developed following the method process recommended by Technical Requirements for the Revision of TCM Clinical Diagnosis and Treatment Guidelines (pilot edition), and also referring to WHO Handbook for Guideline Development. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework was also followed. The protocol was formulated by the guideline project team, which comprised of specialists of TCM encephalopathy, guideline methodologist, patient representative, etc. Question regarding the treatment of headaches in TCM were formulated and 18 most important ones were chosen as PICOs (population, intervention, comparison, outcomes). Comprehensive search and review of the literature were performed and the quality of the evidence was assessed and rated based on certain criteria. Twenty-five recommendations were put forward in the Guidelines through three rounds of expert consensus based on their quality of evidence, in addition to the balance of pros and cons of these interventions, patient preferences and values, and economic factors. It is the first and the only clinical practice guide for Chinese medicine accepted by National Guidelines Clearinghouse in the world.

Which Examination Tests Detect Differences in Cervical Musculoskeletal Impairments in People With Migraine? A Systematic Review and Meta-Analysis

BACKGROUND

Most patients with migraine report associated neck pain. Whether neck pain is a symptom of migraine or an indicator for associated cervical musculoskeletal impairment has not yet been determined. Physical examination tests to detect cervical impairments in people with headache have been suggested, but results have not been evaluated systematically and combined in meta-analyses.

PURPOSE

The purpose of this study was to identify musculoskeletal impairments in people with migraine and people who were healthy (healthy controls) by reviewing published data on physical examination results.

DATA SOURCES

PubMed, CINAHL, Web of Science, and the Cochrane Register of Clinical Trials were searched for studies published prior to December 2017.

STUDY SELECTION

Publications investigating physical examination procedures that are feasible for use in a physical therapy setting for patients with migraine and healthy controls were independently selected by 2 researchers.

DATA EXTRACTION

One researcher extracted the data into predesigned data extraction tables. Entries were checked for correctness by a second researcher. The Downs and Black Scale was used for risk-of-bias assessment by 2 reviewers independently.

DATA SYNTHESIS

Thirty-five studies (involving 1033 participants who were healthy [healthy controls] and 1371 participants with migraine) were included in the qualitative synthesis, and 18 were included in the meta-analyses (544 healthy controls and 603 participants with migraine). Overall, studies were rated as having a low to moderate risk of bias. Included studies reported 20 different test procedures. Combined mean effects indicated that 4 of the tests included in the meta-analyses distinguished between patients and controls: range of cervical motion, flexion-rotation, pressure pain thresholds, and forward head posture in a standing position.

LIMITATIONS

Manual joint testing and evaluation of trigger points were the 2 most frequently investigated tests not included in the meta-analyses because of heterogeneity of reporting and procedures.

CONCLUSIONS

Three tests confirmed the presence of musculoskeletal impairments in participants with migraine when combined in meta-analyses. Pressure pain thresholds added information on sensory processing. Additional tests might be useful but require standardized protocols and reporting.

Non-pharmacological management of persistent headaches associated with neck pain: A clinical practice guideline from the Ontario protocol for traffic injury management (OPTIMa) collaboration

OBJECTIVES

To develop an evidence-based guideline for the non-pharmacological management of persistent headaches associated with neck pain (i.e., tension-type or cervicogenic).

METHODS

This guideline is based on systematic reviews of high-quality studies. A multidisciplinary expert panel considered the evidence of clinical benefits, cost-effectiveness, societal and ethical values, and patient experiences when formulating recommendations. Target audience includes clinicians; target population is adults with persistent headaches associated with neck pain.

RESULTS

When managing patients with headaches associated with neck pain, clinicians should (a) rule out major structural or other pathologies, or migraine as the cause of headaches; (b) classify headaches associated with neck pain as tension-type headache or cervicogenic headache once other sources of headache pathology has been ruled out; (c) provide care in partnership with the patient and involve the patient in care planning and decision making; (d) provide care in addition to structured patient education; (e) consider low-load endurance craniocervical and cervicoscapular exercises for tension-type headaches (episodic or chronic) or cervicogenic headaches >3 months duration; (f) consider general exercise, multimodal care (spinal mobilization, craniocervical exercise and postural correction) or clinical massage for chronic tension-type headaches; (g) do not offer manipulation of the cervical spine as the sole form of treatment for episodic or chronic tension-type headaches; (h) consider manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine for cervicogenic headaches >3 months duration. However, there is no added benefit in combining spinal manipulation, spinal mobilization and exercises; and (i) reassess the patient at every visit to assess outcomes and determine whether a referral is indicated.

CONCLUSIONS

Our evidence-based guideline provides recommendations for the conservative management of persistent headaches associated with neck pain. The impact of the guideline in clinical practice requires validation.

SIGNIFICANCE

Neck pain and headaches are very common comorbidities in the population. Tension-type and cervicogenic headaches can be treated effectively with specific exercises. Manual therapy can be considered as an adjunct therapy to exercise to treat patients with cervicogenic headaches. The management of tension-type and cervicogenic headaches should be patient-centred.

Altered muscle activity during rest and during mental or physical activity is not a trait symptom of migraine - a neck muscle EMG study

BACKGROUND

Migraineurs have a high prevalence of neck pain prior to or during headache attacks. Whether neck pain is a symptom of migraine or an indicator for a constant neck muscle dysfunction potentially triggering migraine attacks is a topic of scientific debate. The presence of myofascial trigger points in neck muscles including the trapezius muscle, points towards muscle alterations associated with migraine. We measured electromyography (EMG) of the neck muscles in a large cohort to identify whether neck pain and neckmuscle tension reported by migraine patients can be attributed to increased neck muscle activation during rest, mental stress or physical activity.

METHODS

Surface EMG responses of the trapezius muscle were recorded during a paradigm including rest periods, mental stress and physical activity of 102 participants (31 chronic migraine, 43 episodic migraine, 28 healthy participants).

RESULTS

All groups showed increased trapezius activity during mental stress and physical activity compared to rest. There was no statistically significant difference between migraine patients and healthy controls for any of the 3 conditions except for the initial mental stress situation (F (2,56.022) = 8.302, p = 0.001), where controls increased tension by only 4.75%, episodic migraineurs by 17.39% and chronic migraineurs by 28.61%. Both migraine groups returned to resting EMG levels within the same timeframe as healthy controls.

CONCLUSIONS

Neck pain associated with migraine can therefore not be attributed to increased trapezius activity during rest, mental stress and physical activity or prolonged muscle activity and should not be seen as a constantly underlying trigger but rather as an accompanying symptom of migraine.

An ultra-sensitive electrochemical sensor for the detection of acetaminophen in the presence of etilefrine using bimetallic Pd–Ag/reduced graphene oxide nanocomposites

In this study we report a one-step procedure for the fabrication of Pd–Ag bimetallic nanoparticles on the surface of a graphene oxide (rGO) support.

Interventions for migraine prophylaxis: protocol of an umbrella systematic review and network meta-analysis

INTRODUCTION

Multiple interventions are effective for migraine prophylaxis. However, the comparative effectiveness of these interventions is still not clear. Therefore, the aim of this study is to summarise the direct and indirect evidence for pharmacological and non-pharmacological interventions to prevent migraine attack.

METHODS AND ANALYSIS

We will perform an umbrella systematic review to identify eligible randomised controlled trials (RCTs) for the recommended interventions for migraine prophylaxis according to the guidelines. A comprehensive literature search will be conducted in MEDLINE, EMBASE and the Cochrane library for systematic reviews, which will be screened for RCTs. We will describe the general information of the RCTs for participants, interventions, outcome measurements, comparisons and the primary findings. Additionally, a network meta-analysis will be conducted to determine the comparative effectiveness of the treatments with a random-effects model. The absolute and relative effectiveness of the treatments will be provided. The heterogeneity and inconsistency between trials will be assessed by the I(2) statistical test and Cochrane's Q test. Risk of bias will be assessed and the overall strength of the evidence will be summarised.

DISCUSSION

The result of this network meta-analysis will provide direct and indirect evidence of treatments for migraine prophylaxis, and it may provide a ranking of the treatments for patients and clinicians to help them select the best option.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42015015297.

Impact of clinical performance examination on incoming interns' clinical competency in differential diagnosis of headache

BACKGROUND

In Korea, clinical performance examination (CPX) has been included in license examination for medical doctors since 2009 in order to improve clinical performance of medical students. This study aimed to evaluate the contribution of CPX to medical education.

METHODS

Clinical competency in the differential diagnosis of secondary headache was compared between the incoming interns in 2009 unexposed to CPX and the incoming interns in 2010 exposed to CPX, using the data of patients who visited the emergency department due to headache (181 patients seen by 60 CPX non-exposed interns and 150 patients seen by 50 CPX-exposed interns). We obtained the data by reviewing electronic medical records and nominal lists of doctors. Clinical competency was assessed by sensitivity and specificity between the diagnostic impression by interns and the final diagnosis. The association between CPX exposure and clinical competency in secondary headache diagnosis was evaluated using multiple logistic regression analysis.

RESULTS

When we assessed clinical competency on the basis of all listed diagnostic impressions, sensitivity and specificity were 67.9% and 80.0%, respectively, for headaches seen by CPX-exposed interns, and 51.7%, and 71.7%, respectively, for headaches seen by CPX non-exposed interns. Multivariable adjusted logistic regression analysis showed exposure to CPX was not associated with increased competency for identifying secondary headache.

CONCLUSION

Exposure to CPX as a part of the medical license examination was not effective for the improvement of clinical competency of interns in identifying secondary headache.

Triptans and serious adverse vascular events: data mining of the FDA Adverse Event Reporting System database

AIM

The aim of this article is to investigate the vascular safety profile of triptans through an analysis of the United States Food and Drug Administration Adverse Event Reporting System (FDA_AERS) database with a special focus on serious and unexpected adverse events.

METHODS

A CASE/NON-CASE analysis was performed on the reports entered in the FDA_AERS from 2004 to 2010: CASES were reports with at least one event included in the MedDRA system organ classes 'Cardiac disorder' or 'Vascular disorders', whereas NON-CASES were all the remaining reports. Co-reported cardiovascular drugs were used as a proxy of cardiovascular risk and the adjusted reporting odds ratio (adj.ROR) with 95% confidence intervals (95% CI) was calculated. Disproportionality signals were defined as adj.ROR value >1. Adverse events were considered unexpected if not mentioned on the relevant label.

RESULTS

Among 2,131,688 reports, 7808 concerned triptans. CASES were 2593 among triptans and 665,940 for all other drugs. Unexpected disproportionality signals were found in the following high-level terms of the MedDRA hierarchy: 'Cerebrovascular and spinal necrosis and vascular insufficiency' (103 triptan cases), 'Aneurysms and dissections non-site specific' (15), 'Pregnancy-associated hypertension' (10), 'Reproductive system necrosis and vascular insufficiency' (3).

DISCUSSION

Our analysis revealed three main groups of unexpected associations between triptans and serious vascular events: ischaemic cerebrovascular events, aneurysms and artery dissections, and pregnancy-related vascular events. A case-by-case assessment is needed to confirm or disprove their plausibility and large-scale analytical studies should be planned for risk rate estimation. In the meantime, clinicians should pay special attention to migraine diagnosis and vascular risk assessment before prescribing a triptan, also promptly reporting any unexpected event to pharmacovigilance systems.

Primary care direct access MRI for the investigation of chronic headache

AIM

To assess the efficacy of a primary-care imaging pathway for neurology outpatients, from inception to deployment, compared with traditional outpatient referral.

MATERIALS AND METHODS

After local agreement, guidelines were generated providing pathways for diagnosis and treatment of common causes of headache, highlighting "red-flag" features requiring urgent neurology referral, and selecting patients for direct magnetic resonance imaging (MRI) referral. In addition, reports were clarified and standardized. To evaluate the efficacy of the access pathway, a retrospective sequential review of 100 MRI investigations was performed comparing general practitioner (GP) referral, with traditional neurology referral plus imaging, acquired before the pathway started.

RESULTS

No statistically significant difference in rates of major abnormalities, incidental findings or ischaemic lesions were identified between the two cohorts. Reported patient satisfaction was high, with a cost reduction for groups using the pathway.

CONCLUSION

The findings of the present study suggest that a defined access pathway for imaging to investigate chronic headache can be deployed appropriately in a primary-care setting.

Costs associated with outpatient, emergency room and inpatient care for migraine in the USA

Background: Data on the average US costs of an outpatient visit, emergency room (ER) visit or hospitalization for migraine are scant, with the most recent available values based on healthcare charges reported from 1994 data.

Methods: We estimated healthcare costs associated with outpatient and ER visits and inpatient hospitalizations related to migraine retrospectively obtained from the 2007 Medstat MarketScan Commercial Claims & Encounters database. Tabulated costs reflected payments from insurers, patients and other sources. All costs were adjusted to 2010 US dollars.

Results: The estimated mean cost (95% CI) for migraine-related care per outpatient visit ( N = 680,946) was $139.88 ($139.35–140.41); per ER visit ( N = 88,128) was $775.09 ($768.10–782.09); and per inpatient hospitalization ( N = 5516) was $7317.07 ($7134.96–7499.17). The most frequently coded procedures at outpatient and ER visits were subcutaneous or intra-muscular injection, and for hospitalizations was computed tomography. Estimated annual US healthcare costs in 2010 for migraine associated with: outpatient visits were $3.2 billion, ER visits were $700 million, and inpatient hospitalizations were $375 million.

Conclusions: Direct healthcare costs associated with patient visits and hospitalizations for migraine headaches have increased since previously published estimates. Further research is needed to understand the current overall healthcare cost burden per patient and within the US population.

Migraine prevalence, treatment and impact: the canadian women and migraine study

BACKGROUND

The prevalence of migraine headache varies somewhat across geographic regions. The last Canadian population-based study of migraine was in 1994. We report the findings of the Canadian Women and Migraine Survey. In addition to reporting migraine prevalence in Canadian women, the survey identified current consultation and treatment practices of women with migraine, and the psychological burden of migraine.

METHODS

The survey was conducted with a population-based sample of 1210 women using standard telephone research methods. Headache diagnoses were based on the International Headache Society (IHS) Classification.

RESULTS

Calculated prevalence of migraine headache was 26%. Only 51% of women with migraine had consulted a physician about their headaches. Women with migraines rely on over-the-counter medications and non-specific prescription medications. Less than 10% of women with migraine use triptans/dihydroergotamine for primary treatment. Ninety seven percent of women with migraine reported at least one psychosocial impact resulting from migraines.

CONCLUSIONS

The prevalence of migraine in Canadian women appears static, and is again shown to be slightly higher than that reported in the United States. As in other epidemiologic studies, many women with migraine do not seek medical help for their headaches and perhaps as a result, few are using migraine-specific medications to treat their headaches. The impact of migraine on Canadian women is substantial with almost all women with migraine reporting adverse psychosocial effects of migraines on their lives.