An international study to assess reliability of the Migraine Disability Assessment (MIDAS) score

[Retrospective evaluation of electronically recorded patient questionnaires of a university outpatient pain clinic with the painDETECT® questionnaire]

BACKGROUND AND OBJECTIVE

Psychometric tests can provide important information for diagnostics and progression in chronic pain patients. Between 2008 and 2018, the electronic system painDETECT® was used in the outpatient pain clinic of the Hannover Medical School (MHH). The aim of this retrospective study was to evaluate the pain symptomatology data recorded using painDETECT® and the treatment procedures used in the patient cohort examined over a period of 15 months.

MATERIAL AND METHODS

A statistical analysis of baseline and follow-up data was performed. The analysis comprised pain-related parameters recorded by use of the painDETECT® system as well as outpatient records.

RESULTS

Baseline data of 459 patients (66% women) could be evaluated. The most common clinical pictures were spinal pain, headache, facial pain, and somatoform disorders, mostly with many years of previous treatment. Approximately 40% showed evidence of neuropathic pain components or central sensitization. With a mean pain intensity of VAS 6 (0-10), a predominantly high degree of chronicity was present. Approximately one third showed a high degree of pain-related functional impairment. Slightly more than half showed evidence of clinically relevant depression. Approximately 80% showed clinically relevant sleep disturbances. Follow-up data were available for 145 patients (31.6%). The proportion of patients receiving a nonpharmacological form of treatment increased by 44.1% (physical therapy) and by 24.1% (psychotherapeutic procedures) during the observation period. The use of co-analgesics increased by approximately 30% over the course.

CONCLUSION

In the outpatient setting, an extension of treatment can be successful for high-grade chronic pain patients. Close structural networking with the clinics for rehabilitation medicine and for psychosomatics and psychotherapy at the MHH can be a favorable prerequisite for this.

Migraine headache in patients with spontaneous coronary artery dissection: A report of the iSCAD Registry

INTRODUCTION

Spontaneous coronary artery dissection (SCAD) is a nonatherosclerotic cause of myocardial infarction. Migraine headache has been reported to be common among patients with SCAD, but the degree of migraine-related disability has not been quantified.

METHODS

Clinical data and headache variables were obtained from the baseline assessment of the prospective, multicenter iSCAD Registry. Migraine-related disability was quantified using the self-reported Migraine Disability Assessment (MIDAS). Demographic, clinical, psychosocial, and medical characteristics from data entry forms were compared between patients with and without migraine.

RESULTS

Of the 773 patients with available data, 46% reported previous or current migraines. Those with migraines were more likely to be women (96.9% vs 90.3%, p = 0.0003). The presence of underlying carotid fibromuscular dysplasia was associated with migraine (35% vs 27%, p = 0.0175). There was not a significant association with carotid artery dissection and migraine. Current migraine frequency was less than monthly (58%), monthly (24%), weekly (16%), and daily (3%). Triptan use was reported in 32.5% of patients, and 17.5% used daily migraine prophylactic medications. Using the MIDAS to quantify disability related to migraine, 60.2% reported little or no disability, 14.4% mild, 12.7% moderate, and 12.7% severe. The mean MIDAS score was 9.9 (mild to moderate disability). Patients with SCAD had higher rates of depression and anxiety (28.2% vs 17.7% [p = 0.0004] and 35.3% vs 26.7% [p = 0.0099], respectively).

CONCLUSIONS

Migraines are common, frequent, and a source of disability in patients with SCAD. The association between female sex, anxiety, and depression may provide some insight for potential treatment modalities.

A new neuromodulation method in chronic migraine; non-ınvasive pulsed radiofrequency, a single-blinded, randomised, controlled trial

OBJECTIVE

Non-invasive pulsed radiofrequency (NipRF) therapy, a neuromodulation method for peripheral nerves, is a new treatment modality for pain. We aimed to show the changes in pain severity and frequency per month in chronic migraine with NipRF treatment.

METHODS

We treated patients diagnosed with chronic migraine according to the International Classification of Headache Disorders III beta diagnostic criteria. In half of the patients, we applied pulsed radiofrequency (pRF) treatment with transcutaneous electrodes to the greater occipital nerve (GON) trace. In the other half, we applied the GON block under ultrasound guidance. The Migraine Disability Assessment Scale (MIDAS) was administered to the participants, and those with scores > 2 were included in the study. Pain intensity and frequency were evaluated using the visual analog scale (VAS) and a headache diary completed before and 4 weeks after treatment.

RESULTS

When both groups were compared, the pre- and post-treatment VAS scores and headache frequencies were similar. Comparing the pre-treatment and post-treatment values within the groups, VAS scores and headache frequency decreased significantly after treatment in both groups (p < 0.001).

CONCLUSION

In this study, we observed that NipRF treatment is safe and effective for treating chronic migraine. Pain intensity and frequency decreased with NipRF treatment, similar to that in the GON block group.

CLINICAL TRIALS REGISTRATION NUMBER

NCT05499689, Date: 08/11/2022.

Long-term impact of transcatheter closure interatrial shunts on disabling migraine

BACKGROUNDS

Effectiveness of patent foramen ovale (PFO) closure on relief of migraine, is still unclear. We sought to analyse the long-term (>10 years) effects of interatrial septal shunt repair on disabling migraine performing a retrospective non-randomised study.

METHODS

Clinical records of patients with disabling, medication-refractory migraine and PFO or significant ASD referred to our centre for closure from 2006 to 2018, were analysed.

RESULTS

Forty -six patients (38 female, mean age 40.0 ± 3.7 years) with PFO and 32 patients with significant ASD (28 female, mean age 38.0 ± 4.1 years) submitted to transcatheter closure had a pre-existing disabling migraine with mean Migraine Disability Assessment Score (MIDAS) of 35.8 ± 4.7. After a mean follow-up of 118.2 ± 19.1 months (range 96 to 144), 72 out of 78 patients were still followed-up: in all subjects, aura was abolished, and migraine improved also in patients without aura. The mean MIDAS significantly decreased from baseline value (p < 0.01). Complete migraine resolution was associated in PFO patients with a shorter history of migraine, a more severe thrombophilic profile, a more severe Right-to-Left Shunt (RLS) and larger left atrial diameter and volume, and in ASD patients with bidirectional shunt.

CONCLUSIONS

Device-based repair of PFO/ASD in patients with migraine was associated with abolition of aura and symptoms reduction in the long-term period.

A real-world prospective observational study of eptinezumab in Asian patients with migraine

OBJECTIVE

To evaluate the real-world effectiveness of eptinezumab for migraine prevention in Asian patients.

BACKGROUND

Eptinezumab is a monoclonal antibody that targets calcitonin gene-related peptide (CGRP), a potent vasodilator with an important role in migraine pathophysiology. Although there is robust clinical evidence from pivotal Phase 3 placebo-controlled trials of the efficacy of eptinezumab for migraine prevention, there are limited data on the real-world effectiveness of eptinezumab in Asian patient cohorts.

METHODS

This was a non-interventional, prospective, multisite cohort study of adults with migraine (International Classification of Headache Disorders, 3rd edition criteria) in Singapore who were prescribed eptinezumab (100 mg at baseline and Month 3, administered intravenously) and were followed until Month 6. The primary endpoint was change from baseline in monthly migraine days (MMDs) at Month 3 and Month 6. Secondary endpoints were ≥30% and ≥50% responder rates, and change from baseline in the Headache Impact Test-6 (HIT-6), Migraine Disability Assessment (MIDAS), Migraine-Specific Quality of Life (MSQ), patient-identified most bothersome symptom (PI-MBS), acute medication use at Month 3 and Month 6, and safety.

RESULTS

Enrolled patients (completed = 29/30) had on average 3.4 (SD 2.9) previous preventive treatments; 29/30 of the patients had trialed at least one previous preventive treatment without benefit. Most had previously trialed oral preventives (87%, 26/30) and anti-CGRP (70%, 21/30). Relative to baseline, mean MMDs decreased by 4.3 days (95% CI 2.1-6.4; p < 0.001) at Month 3 and 4.9 days (95% CI 2.1-7.7; p < 0.001) at Month 6. At Month 3 and Month 6, 14/30 (47%) and 15/29 (52%) of the patients were ≥30% responders, and 6/30 (20%) and 8/29 (28%) patients were ≥50% responders, respectively. The number of patients with severe life impairment based on the HIT-6 score (total score 60-78) decreased from 24/30 (80%) at baseline to 19/30 (63%) at Month 3 and 19/29 (66%) at Month 6. The mean MIDAS score decreased by 24.6 points (95% CI 2.82-46.38; p = 0.028) at Month 6, and the mean MSQ score increased by 12.2 points (95% CI 5.18-19.20; p = 0.001) at Month 3 and 13.6 points (95% CI 4.58-22.66; p = 0.004) at Month 6. Most patients reported improvement in the PI-MBS at Month 3 (73%, 22/30) and Month 6 (55%, 16/29). Acute medication use for headache relief decreased by 3.3 days/month (95% CI 1.0-5.6; p = 0.007) at Month 3 and 4.7 days/month (95% CI 1.7-7.7; p = 0.003) at Month 6. Treatment-emergent adverse events (TEAEs) were reported in 16/30 (54%) patients, mostly mild/moderate in severity. No serious TEAEs led to treatment discontinuation.

CONCLUSION

Quarterly eptinezumab administration was effective and well-tolerated in Asian patients with chronic migraine.

Evaluation of ultrasound-guided PFO occlusion in the treatment of vestibular migraine

BACKGROUND

Currently, surgery is the mainstay of the clinical treatment of vestibular migraine.

OBJECTIVE

To investigate the clinical efficacy and safety of using transesophageal echocardiography-guided interventional closure of the patent foramen ovale (PFO) in the treatment of vestibular migraine.

METHODS

The study included 52 patients with vestibular migraine who were admitted to our hospital between June 2019 and June 2021. All selected patients underwent a transesophageal echocardiography-guided interventional closure of the PFO and were followed up for one year after surgery. We observed the clinical efficacy and surgical success rate one year after surgery and compared the improvement in clinical symptoms and perioperative safety at different time points.

RESULTS

The overall remission rate and the surgical success rate for the 52 patients with vestibular migraine one year after surgery were 86.54% and 96.15%, respectively. Compared to the pre-surgery levels, there was a significant progressively decreasing trend in the scores on the Headache Impact Test-6 (HIT-6), Visual Analogue Scale (VAS), Migraine Disability Assessment (MIDAS) questionnaire, frequency of headaches, and duration of headaches in patients with vestibular migraine at 1, 3, and 6 months after surgery (P< 0.05). Among the 52 patients, one developed atrial fibrillation three hours after surgery, which then spontaneously converted to sinus rhythm, and none of the other patients had adverse outcomes such as hematoma at the puncture site during the perioperative period.

CONCLUSION

Transesophageal echocardiography-guided interventional closure of the PFO for treating vestibular migraine significantly improved the symptoms of migraine in patients, with a high surgical success rate, significant clinical efficacy, and favorable safety.

Optic Nerve Sheath MR Imaging Measurements in Patients with Orthostatic Headaches and Normal Findings on Conventional Imaging Predict the Presence of an Underlying CSF-Venous Fistula

BACKGROUND AND PURPOSE

Spontaneous spinal CSF leaks typically cause orthostatic headache, but their detection may require specialized and invasive spinal imaging. We undertook a study to determine the value of simple optic nerve sheath MR imaging measurements in predicting the likelihood of finding a CSF-venous fistula, a type of leak that cannot be detected with routine spine MR imaging or CT myelography, among patients with orthostatic headache and normal conventional brain and spine imaging findings.

MATERIALS AND METHODS

This cohort study included a consecutive group of patients with orthostatic headache and normal conventional brain and spine imaging findings who underwent digital subtraction myelography under general anesthesia to look for spinal CSF-venous fistulas.

RESULTS

The study group consisted of 93 patients (71 women and 22 men; mean age, 47.5 years; range, 17-84 years). Digital subtraction myelography demonstrated a CSF-venous fistula in 15 patients. The mean age of these 8 women and 7 men was 56 years (range, 23-83 years). The mean optic nerve sheath diameter was 4.0 mm, and the mean perioptic subarachnoid space was 0.5 mm in patients with a CSF-venous fistula compared with 4.9 and 1.2 mm, respectively, in patients without a fistula (P < .001). Optimal cutoff values were found at 4.4 mm for optic nerve sheath diameter and 1.0 mm for the perioptic subarachnoid space. Fistulas were detected in about 50% of patients with optic nerve sheath diameter or perioptic subarachnoid space measurements below these cutoff values compared with <2% of patients with optic nerve sheath diameter or perioptic subarachnoid space measurements above these cutoff values. Following surgical ligation of the fistula, optic nerve sheath diameter increased from 4.0 to 5.3 mm and the perioptic subarachnoid space increased from 0.5 to 1.2 mm (P < .001).

CONCLUSIONS

Concerns about a spinal CSF leak should not be dismissed in patients with orthostatic headache when conventional imaging findings are normal, and simple optic nerve sheath MR imaging measurements can help decide if more imaging needs to be performed in this patient population.

Consensus recommendations on the role of nurses in headache care: A European e-Delphi study

BACKGROUND

Nurses work at headache centres throughout Europe, and their care for migraine patients is acknowledged. However, the specific roles and tasks of nursing vary, and a unified understanding is lacking, posing challenges to knowledge sharing and research.

OBJECTIVES

Using an e-Delphi study method, the objective is to obtain healthcare professional headache experts' opinions on nursing-specific roles and tasks and combine this into consensus statements for nurse recommendations for migraine treatment.

METHODS

A three-round questionnaire study was conducted with nurses and neurologists from 18 specialised headache centres in 10 countries. In round 1, statements were compiled from a systematic examination of existing literature and expert opinions. In rounds 2 and 3, the experts rated the importance of statements (from round 1) on a 5-point Likert scale. Statements were analysed using a content analysis method, and the consensus of pre-defined statements was evaluated with gradually increased predetermined criteria using descriptive statistics.

RESULTS

Twenty-one experts, representing all 10 countries, participated. The predetermined consensus of ≥70% agreement was reached for 42 out of the initial 63 statements. These statements formed the final recommendations within two themes: "The nurses' roles and tasks in the clinical setting" and "The nurses' roles and tasks in educating patients and colleagues." The consensus level of statements was strong, with 40% receiving unanimous agreement (100%) and 97% achieving relatively high agreement (>80%).

CONCLUSION

Nursing plays a vital role with diverse tasks in migraine care. This study offers practical recommendations and a framework for nurses, equipping them with a clinical tool to enhance care and promote a coordinated approach to migraine treatment.

Prevalence and burden of migraine in the United States: A systematic review

BACKGROUND

This study reviewed migraine prevalence and disability gathered through epidemiologic survey studies in the United States conducted over the past three decades. We summarized these studies and evaluated changing patterns of disease prevalence and disability.

METHODS

We conducted a systematic review of US studies addressing the prevalence, disability, and/or burden of migraine, including both episodic migraine (EM) and chronic migraine (CM). A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol was used in conjunction with the PubMed search engine. Eligible studies were published before February 2022, were conducted in the United States, included representative samples, and used a case definition of migraine based on the International Classification of Headache Disorders (ICHD). The primary measure of disease burden was the Migraine Disability Assessment Scale (MIDAS). The MIDAS measures days lost due to migraine over 3 months in three domains and defines groups with moderate (Grade III) or severe disability (Grade IV) using cut-scores.

RESULTS

Of the 1609 identified records, 26 publications from 11 US population-based studies met eligibility criteria. The prevalence of migraine in the population has remained relatively consistent for the past 30 years: ranging from 11.7% to 14.7% overall, 17.1% to 19.2% in women, and 5.6% to 7.2% in men in the studies reviewed. CM prevalence is 0.91% (1.3% among women and 0.5% of men) in adults and 0.8% in adolescents. The proportion of people with migraine and moderate-to-severe MIDAS disability (Grades III-IV), has trended upward across studies from 22.0% in 2005 to 39.0% in 2012, to 43.2% in 2016, and 42.4% in 2018. A consistently higher proportion of women were assigned MIDAS Grades III/IV relative to men.

CONCLUSION

The prevalence of migraine in the United States has remained stable over the past three decades while migraine-related disability has increased. The disability trend could reflect changes in reporting, study methodology, social and societal changes, or changes in exacerbating or remediating factors that make migraine more disabling, among other hypotheses. These issues merit further investigation.

Pain medication beliefs in individuals with headache

OBJECTIVE

To evaluate pain medication beliefs in a community sample of individuals with headache.

BACKGROUND

Previous studies of medication adherence for individuals with headache have identified a high rate of prescription nonfulfillment, frequent medication discontinuation, and widely varying levels of medication-related satisfaction. Still, there is a limited understanding of how these individuals view their medications and their relationships with health-care providers. Insight into these perceptions could prove useful in explaining medication adherence behaviors.

METHODS

In this secondary analysis of a cross-sectional study, data from N = 215 adults with headache were analyzed. Participants completed the Pain Medication Attitudes Questionnaire (PMAQ), Center for Epidemiologic Studies Depression Scale (CES-D), State-Trait Anxiety Inventory Form Y-2, Weekly Stress Inventory Short Form, and Migraine Disability Scale. These participants also provided a list of their current pain medications.

RESULTS

Using the PMAQ, participants could be characterized as having medication beliefs that were "trusting and unconcerned" (n = 83/215 [38.6%]), "skeptical and somewhat worried" (n = 99/215 [46.0%]), or "skeptical and concerned" (n = 33/215 [15.3%]). Individuals with skeptical and concerned beliefs expressed elevated concerns (z > 1.15) about side effects, scrutiny, perceived need, tolerance, withdrawal, and addiction. Individuals who were trusting and unconcerned expressed low levels (z < -0.40) of these beliefs. Increasing levels of mistrust and medication concerns were correlated with higher depression scores on the CES-D, with values ranging from r = 0.23 to r = 0.38.

CONCLUSIONS

Subgroups of pain medication beliefs were identified, including two groups of patients with at least some concerns about their medical providers. Beliefs ranged from a lack of concern about using pain medications to worries about scrutiny and harm. It is unclear if poor experiences with pain medications cause these beliefs or if they prevent individuals from effectively utilizing medications. Additionally, more negative beliefs about pain medications were associated with more depressive symptoms.

Readability analysis and concept mapping of PROMs used for headache disorders

OBJECTIVE

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The impact of primary headaches on disability outcomes: a literature review and meta-analysis to inform future iterations of the Global Burden of Disease study

BACKGROUND

The burden and disability associated with headaches are conceptualized and measured differently at patients' and populations' levels. At the patients' level, through patient-reported outcome measures (PROMs); at population level, through disability weights (DW) and years lived with a disability (YLDs) developed by the Global Burden of Disease Study (GBD). DW are 0-1 coefficients that address health loss and have been defined through lay descriptions. With this literature review, we aimed to provide a comprehensive analysis of disability in headache disorders, and to present a coefficient referring to patients' disability which might inform future GBD definitions of DW for headache disorders.

METHODS

We searched SCOPUS and PubMed for papers published between 2015 and 2023 addressing disability in headache disorders. The selected manuscript included a reference to headache frequency and at least one PROM. A meta-analytic approach was carried out to address relevant differences for the most commonly used PROMs (by headache type, tertiles of medication intake, tertiles of females' percentage in the sample, and age). We developed a 0-1 coefficient based on the MIDAS, on the HIT-6, and on MIDAS + HIT-6 which was intended to promote future DW iterations by the GBD consortium.

RESULTS

A total of 366 studies, 596 sub-samples, and more than 133,000 single patients were available, mostly referred to cases with migraine. Almost all PROMs showed the ability to differentiate disability severity across conditions and tertiles of medication intake. The indexes we developed can be used to inform future iterations of DW, in particular considering their ability to differentiate across age and tertiles of medication intake.

CONCLUSIONS

Our review provides reference values for the most commonly used PROMS and a data-driven coefficient whose main added value is its ability to differentiate across tertiles of age and medication intake which underlie on one side the increased burden due to aging (it is likely connected to the increased impact of common comorbidities), and by the other side the increased burden due to medication consumption, which can be considered as a proxy for headache severity. Both elements should be considered when describing disability of headache disorders at population levels.

Associations between the burdens of comorbid sleep problems, central sensitization, and headache-related disability in patients with migraine

Objective

Sleep disturbances are common in migraine patients and affect quality of life. Central sensitization (CS) is likely to play a role in the increased severity and chronicity of migraine. We hypothesized that the number of comorbid sleep problems would affect headache-related disability through the effects of central sensitization (CS).

Methods

We performed a cross-sectional study including 215 consecutive patients with migraine. Insomnia was defined as a Pittsburgh Sleep Quality Index (PSQI) global score greater than 5. Probable REM sleep behavior disorder (pRBD) was defined as an RBD screening score of 5 or greater. Excessive daytime sleepiness (EDS) was defined as an Epworth Sleepiness Scale score of 10 or higher. Suspected sleep apnea (SA) was defined as patients with snoring or sleep apnea witnessed 3 or more nights a week. CS was assessed by the Central Sensitization Inventory (CSI).

Results

Restless legs syndrome, insomnia, EDS, SA and pRBD were observed in 25.6%, 71.6%, 34.4%, 10.2%, and 21.4%, respectively, of the patients. At least one sleep problem was present in 87.0% of the patients. According to the results of the multinomial logistic regression analysis with no sleep problems as a reference, after we corrected for adjustment factors, the Migraine Disability Assessment (MIDAS) score significantly increased when three or more comorbid sleep problems were present. According to our mediation analysis, an increased number of sleep problems had a direct effect on the MIDAS score after we adjusted for other variables, and the CSI score was indirectly involved in this association.

Conclusion

The present study showed an association between migraine-related disability and the burden of multiple sleep problems, which was partially mediated by CS.

Postdromal symptoms in migraine: a REFORM study

BACKGROUND

Migraine is a multiphasic neurovascular disorder, where headache can be succeeded by postdromal symptoms. However, there are limited research on postdromal symptoms. This study aimed to investigate the proportion of individuals with migraine from a tertiary care unit reporting postdromal symptoms in adherence with the ICHD-3 definition. We also aimed to examine how the means of enquiry might influence the estimated proportions. Additionally, we explored whether any clinical features might affect the likelihood of reporting postdromal symptoms. Finally, we assessed to what extend the postdromal symptoms might impact the disease burden.

METHODS

In a cross-sectional study, we enrolled adult participants diagnosed with migraine who were asked to report their postdromal symptoms (i.e., unprompted reporting). Subsequently, a 16-item list was used to further ascertain the occurrence of postdromal symptoms (i.e., prompted reporting). Clinical characteristics were obtained through a semi-structured interview. Moreover, electronic questionnaires were used to assess the disease burden, i.e., the Six-Item Headache Impact Test (HIT-6), Migraine Disability Assessment (MIDAS), and the World Health Organization Disability Assessment 2.0 (WHODAS 2.0).

RESULTS

Among 631 participants with migraine, a higher proportion experienced at least one postdromal symptom when prompted (n = 509 [80.7%]) compared with unprompted reporting (n = 421 [66.7%], P < 0.001). Furthermore, the total number of postdromal symptoms experienced was greater with prompted than unprompted reporting (medians 3 [IQR 1 - 6] versus 1 [IQR 0 - 2]; P < 0.001). Furthermore, the likelihood of reporting postdromal symptoms increased with the presence of premonitory symptoms and decreased with higher number of monthly migraine days. Weak correlations were identified between the number of postdromal symptoms reported and both HIT-6 (ρ = 0.14; P < 0.001) and WHODAS scores (ρ = 0.15; P < 0.001), whilst no correlation was observed with MIDAS score (ρ = 0.08; P = 0.054).

CONCLUSIONS

Postdromal symptoms are prevalent in individuals with migraine from a tertiary care unit. However, reported estimates warrant cautious interpretation as they depend on the means of enquiry, presence of premonitory symptoms, and frequency of monthly migraine days. Moreover, a weak correlation was identified between the number of postdromal symptoms and both HIT-6 and WHODAS scores, indicating only a marginal influence on the disease burden.

Premonitory symptoms in migraine: A REFORM Study

BACKGROUND

Estimates of proportions of people with migraine who report premonitory symptoms vary greatly among previous studies. Our aims were to establish the proportion of patients reporting premonitory symptoms and its dependency on the enquiry method. Additionally, we investigated the impact of premonitory symptoms on disease burden using Headache Impact Test (HIT-6), Migraine Disability Assessment (MIDAS) and World Health Organization Disability Assessment 2.0 (WHODAS 2.0), whilst investigating how various clinical factors influenced the likelihood of reporting premonitory symptoms.

METHODS

In a cross-sectional study, premonitory symptoms were assessed among 632 patients with migraine. Unprompted enquiry was used first, followed by a list of 17 items (prompted). Additionally, we obtained clinical characteristics through a semi-structured interview.

RESULTS

Prompted enquiry resulted in a greater proportion reporting premonitory symptoms than unprompted (69.9% vs. 43.0%; p < 0.001) and with higher symptom counts (medians 2, interquartile range = 0-6 vs. 1, interquartile range = 0-1; p < 0.001). The number of symptoms correlated weakly with HIT-6 (ρ = 0.14; p < 0.001) and WHODAS scores (ρ = 0.09; p = 0.041). Reporting postdromal symptoms or triggers increased the probability of reporting premonitory symptoms, whereas monthly migraine days decreased it.

CONCLUSIONS

The use of a standardized and optimized method for assessing premonitory symptoms is necessary to estimate their prevalence and to understand whether and how they contribute to disease burden.

Altered neurovascular coupling in migraine without aura

Neurovascular coupling (NVC) provides new insights into migraine, a neurological disorder impacting over one billion people worldwide. This study compared NVC and cerebral blood flow (CBF) in patients with migraine without aura (MwoA) and healthy controls. About 55 MwoA patients in the interictal phase and 40 age- and sex-matched healthy controls underwent resting-state functional magnetic resonance imaging and arterial spin-labeling perfusion imaging scans. The CBF and resting-state neuronal activity indicators, including the amplitudes of low-frequency fluctuation (ALFF), regional homogeneity (ReHo), and degree centrality (DC), were calculated for each participant. The global and regional NVCs were assessed using cross-voxel CBF-neuronal activity correlations and CBF/neuronal activity ratios. Patients with MwoA showed increased CBF/ALFF ratios in the left media, superior and inferior frontal gyri, and anterior cingulate gyrus, increased CBF/DC ratios in the left middle and inferior frontal gyri, and increased CBF/ReHo ratios in the right corpus callosum and right posterior cingulate gyrus. Lower CBF/ALFF ratios in the right rectal gyrus, the left orbital gyrus, the right inferior frontal gyrus, and the right superior temporal gyrus were also found in the MwoA patients. Furthermore, the CBF/ALFF ratios in the inferior frontal and superior temporal gyri were positively correlated with the Headache Impact Test scores and Hamilton anxiety scale scores in the MwoA patients. These findings provide evidence for the theory that abnormal NVC contributes to MwoA.

The Effect of OnabotulinumtoxinA on Headache Intensity and Number of Monthly Headache Days in Individuals with Chronic Migraine with Different Levels of Neck Disability

One of the treatment methods used in chronic migraine is OnabotulinumtoxinA. The effects of OnabotulinumtoxinA on headache intensity (HI) and number of monthly headache days (NMHD) in chronic migraine (CM) patients classified according to neck disability levels are unknown. Our aim was to investigate the effect of OnabotulinumtoxinA on the HI and the NMHD in individuals with CM with different levels of neck disability. One hundred sixteen patients were enrolled in the study. The OnabotulinumtoxinA protocol was administered as per Follow-the-Pain PREEMPT. The Neck Disability Index was used to evaluate neck disability. Primary outcome measures were headache intensity, assessed with the Visual Analogue Scale, and the number of monthly headache days recorded from patients' diaries. Secondary outcome measures were migraine disability, assessed with the Migraine Disability Assessment Test, and quality-of-life, assessed with the Headache Impact Test-6. All assessments were made at baseline and end of the treatment. The OnabotulinumtoxinA treatment showed a greater improvement effect in the number of monthly headache days (p = 0.000) and migraine disability (p = 0.000) parameters in the severe and complete disability groups. CM patients with complete and severe neck disability received the most benefit in reducing the NMHD at 3 months after OnabotulinumtoxinA treatment, but the HI decreased at a similar level in all neck disability groups.

Most bothersome symptom in migraine and probable migraine: A population-based study

Recently, the most bothersome symptom has been recommended as a co-primary endpoint in clinical trials on the acute treatment of migraine. Probable migraine is a subtype of migraine that fulfills all but one criterion for migraine diagnosis. We aimed to compare the most bothersome symptom between probable migraine and migraine. This study analyzed data from a nationwide study conducted in Korea, and the most bothersome symptom was assessed by requesting the participants to select one of the four typical accompanying symptoms of migraine. Responses to acute treatment were evaluated using the migraine Treatment Optimization Questionnaire-6. Nausea was the most bothersome symptom, followed by phonophobia and vomiting in the migraine group (nausea, 61.8%; phonophobia, 25.3%; vomiting, 10.0%; and photophobia, 2.9%) and the probable migraine group (nausea, 82.2%; phonophobia, 9.5%; vomiting, 5.6%; and photophobia, 2.7%). In participants with migraine, vomiting (adjusted odds ratio = 6.513; 95% confidence interval, 1.763-24.057) and phonophobia (adjusted odds ratio = 0.437; 95% confidence interval, 0.206-0.929) were significantly associated with severe headache intensity and nausea was significantly associated with >3 headache days per 30 days (adjusted odds ratio = 0.441; 95% confidence, 0.210-0.927). Different patterns of associations were observed in probable migraine.

Stress and headaches in university students during the COVID-19 pandemic

With regards to the relationship between mental and physical health conditions, some studies predict increased headache frequency as a result of exposure to stressful situations. Thus, the purpose of our study was to investigate whether headache characteristics among a sample of university students (N = 234) correlated with fear of COVID-19, stress and quality of life vis-à-vis the pandemic. We found statistically significant positive correlations between headache frequency and both general stress and quality of life. Further, results from a multiple regression analysis suggested that fear of COVID-19 did not account for incremental variance in headache intensity. Explanations for our key findings, limitations of our study, and future directions for post pandemic studies on headache experience are outlined.

Patient headache questionnaires can improve headache diagnosis and treatment in children

OBJECTIVE

To examine trends in diagnosis of headache and migraine in a large pediatric neurology cohort, and test whether an electronic health record (EHR)-integrated headache questionnaire can increase specificity of diagnosis and likelihood of prescribing migraine treatment.

BACKGROUND

Under-diagnosis of migraine contributes to the burden of disease. As we founded our Pediatric Headache Program in 2013, we recognized that the proportion of patients with headache who were given a diagnosis of migraine was much lower than expected.

METHODS

We developed a patient headache questionnaire, initially on paper (2013-2014), then in an electronic database (2014-2016), and finally integrated into our electronic health record (pilot: 2016, full: May 2017). We compared diagnoses and prescribed treatments for new patients who were given a headache diagnosis, looking at trends in the proportion of patients given specific diagnoses (migraine, etc.) versus the non-specific diagnosis, "headache." Next, we conducted a prospective cohort study to test for association between provider use of the form and the presence of a specific diagnosis, then for an association between specific diagnosis and prescription of migraine treatment.

RESULTS

Between July 2011 and December 2022 the proportion of new headache patients who were given a diagnosis of migraine increased 9.7% and non-specific headache diagnoses decreased 21.0%. In the EHR cohort (June 2017-December 2022, n = 15,122), use of the provider form increased the rate of specific diagnosis to 87.2% (1839/2109) compared to 75.5% (5708/7560) without a patient questionnaire, nearly doubling the odds of making a specific diagnosis (odds ratio [OR] 1.90, 95% confidence interval [CI]: 1.65-2.19). Compared to those given only a non-specific headache diagnosis who were prescribed a migraine therapy 53.7% (1766/3286) of the time, 75.3% (8914/11836) of those given a specific diagnosis received a migraine therapy, more than doubling the odds of prescription (OR 2.39, 95% CI: 2.20-2.60).

CONCLUSIONS

Interventions to improve specificity of diagnosis were effective and led to increased rates of prescription of migraine treatments. These results have been sustained over several years. This headache questionnaire was adapted into the Foundation system of EpicCare, so it is broadly available as a clinical and research tool for institutions that use this EHR software.

Study of severe migraine in general medicine

OBJECTIVE

To evaluate the criteria of severe migraine in a general population consulting a general practitioner (GP) and to evaluate assessment of migraine severity in the migraine patient as well as treating physicians' knowledge of their patient's migraine and its severity.

METHODS

We questioned voluntary headache patients who had an appointment with a GP about the severity of their migraine using recognized scores - HIT-6 and MIDAS - as well as with a specific questionnaire created for the study. We compared the criteria for severe migraine with the patient's description of their symptoms, their HIT-6 score, their MIDAS score, and the GP's opinion, analyzing collected data using means and standard deviations.

RESULTS

We found that 152 out of 942 headache patients questioned in the general medicine setting met the criteria of "strict migraine", corresponding to 10.3% prevalence. Seventy-one out of 100 patients (71%) with migraine who filled out in the questionnaire completely had what is characterized as "severe migraine". Forty-one (57%) of the 71 severe migraine patients presented the strict criteria. Additionally, 21 of the 29 (72%) patients with a non-severe diagnosis agreed that their headache was non-severe. When the HIT-6 score was stratified above 65, correspondence between the questionnaire-derived diagnosis and patient perception of severity was observed in 36 of the 58 (62%) with severe migraine. Finally, participating GPs were aware of their patient's migraine for 60% of patients with migraine. GPs correctly classified the severity of their patient's migraine for 55 (36%) patients.

CONCLUSION

GP education and training about migraine remain a public health issue. The diagnosis of severe migraine is necessary for proper patient management. Current criteria for severe migraine are not robust enough; we propose a modification of the criteria.

Changes in cognitive appraisal in a randomized controlled trial of mindfulness-based cognitive therapy for patients with migraine

OBJECTIVE

This study is a secondary analysis evaluating changes in cognitive fusion and pain catastrophizing over 8 weeks of mindfulness-based cognitive therapy for migraine (MBCT-M) intervention versus waitlist/treatment as usual.

BACKGROUND

Migraine is a common disabling neurological condition. MBCT-M combines elements of cognitive behavioral therapy with mindfulness-based approaches and has demonstrated efficacy in reducing migraine-related disability.

METHODS

A total of 60 adults with migraine completed a 30-day run-in before randomization into a parallel design of either eight weekly individual MBCT-M sessions (n = 31) or waitlist/treatment as usual (n = 29): participants were followed for 1 month after. Participants completed the Pain Catastrophizing Scale (PCS) and the Cognitive Fusion Questionnaire (CFQ) at Months 0, 1, 2, and 4.

RESULTS

The PCS scores decreased more in the MBCT-M group (mean [SD] at baseline = 22.5 [9.6]; at Month 4 = 15.1 [8.8]) than in the waitlist/treatment as usual group (mean [SD] at baseline = 24.9 [9.0]; at Month 4 = 22.5 [10.4]) from Month 0 to 4 (β = -7.24, p = 0.001, 95% confidence interval [CI] -11.39 to -3.09). The CFQ (mean [SD] baseline = 27.6 [8.0]; at Month 4 = 25.0 [8.0]) did not change significantly from Month 0 to 4 (β = -1.2, p = 0.482, 95% CI -4.5 to 2.1). Parallel mediation analyses indicated that decreases in the PCS and CFQ together (β = -6.1, SE = 2.5, 95% CI -11.6 to -1.8), and the PCS alone (β = -4.8, SE = 2.04, 95% CI -9.1 to -1.1), mediated changes in headache disability in the MBCT-M treatment completer group (n = 19).

CONCLUSION

In this study, pain catastrophizing showed strong promise as a potential mechanism of MBCT-M. Future research should continue to explore cognitive appraisal changes in mindfulness-based interventions.

Triptan non-response in specialized headache care: cross-sectional data from the DMKG Headache Registry

BACKGROUND

Triptans are effective for many migraine patients, but some do not experience adequate efficacy and tolerability. The European Headache Federation (EHF) has proposed that patients with lack of efficacy and/or tolerability of ≥ 2 triptans ('triptan resistance') could be considered eligible for treatment with the novel medications from the ditan and gepant groups. There is little data on the frequency of 'triptan resistance'.

METHODS

We used patient self-report data from the German Migraine and Headache Society (DMKG) Headache Registry to assess triptan response and triptan efficacy and/or tolerability failure.

RESULTS

A total of 2284 adult migraine patients (females: 85.4%, age: 39.4 ± 12.8 years) were included. 42.5% (n = 970) had failed ≥ 1 triptan, 13.1% (n = 300) had failed ≥ 2 triptans (meeting the EHF definition of 'triptan resistance'), and 3.9% (n = 88) had failed ≥ 3 triptans. Compared to triptan responders (current use, no failure, n = 597), triptan non-responders had significantly more severe migraine (higher frequency (p < 0.001), intensity (p < 0.05), and disability (p < 0.001)), that further increased with the level of triptan failure. Responders rates were highest for nasal and oral zolmitriptan, oral eletriptan and subcutaneous sumatriptan.

CONCLUSION

In the present setting (specialized headache care in Germany), 13.1% of the patients had failed ≥ 2 triptans. Triptan failure was associated with increased migraine severity and disability, emphasizing the importance of establishing an effective and tolerable acute migraine medication. Acute treatment optimization might include switching to one of the triptans with the highest responder rates and/or to a different acute medication class.

TRIAL REGISTRATION

The DMKG Headache Registry is registered with the German Clinical Trials Register (DRKS 00021081).

Altered resting-state effective connectivity of trigeminal vascular system in migraine without aura: A spectral dynamic causal modeling study

BACKGROUND

The trigeminal vascular system is an important part of the anatomical and physiological basis of migraine. The effective connectivity (EC) among the regions of interest (ROIs) in the trigeminal vascular system involved in migraine without aura (MWoA) remains unclear.

METHODS

In this cross-sectional study, 48 patients (mean [SD] age 38.06 [10.35] years; male, 14/48 [29%]) with MWoA during the interictal phase and 48 healthy controls of similar age and sex (mean [SD] age 38.96 [10.96] years; male, 14/48 [29%]) underwent resting-state functional magnetic resonance imaging (fMRI). Dynamic causal modeling analysis was conducted to investigate directional EC among ROIs in the trigeminal vascular system including the bilateral brainstem, the primary somatosensory cortex (S1), the thalamus, and the insula.

RESULTS

Compared with the healthy control group, MWoA represented significantly reduced EC from the left brainstem (Brainstem.L) to the left insula (MWoA: mean [SD] -0.16 [0.36]; healthy controls: mean [SD] 0.11 [0.41]; Pcorrected  = 0.021), reduced EC from the Brainstem.L to the right insula (MWoA: mean [SD] -0.15 [0.39]; healthy controls: mean [SD] 0.03 [0.35]; Pcorrected  = 0.021), and decreased EC from the left thalamus (Thalamus.L) to the Brainstem.L (MWoA: mean [SD] -0.13 [0.56]; healthy controls: mean [SD] 0.10 [0.45]; Pcorrected  = 0.021). Altered EC parameters were not significantly correlated with MWoA clinical data.

CONCLUSION

These results further provide increasing evidence that disturbed homeostasis of the trigeminovascular nociceptive pathway is involved in the pathophysiological mechanisms of migraine. Patients with MWoA exhibited a regional interaction distinct from healthy controls in the neural pathway of the Bilateral Insula-Brainstem.L-Thalamus.L, which may shed light on the future understanding of brain mechanisms for MWoA. Future brain-based interventions are suggested to consider the dysregulation in the Bilateral Insula-Brainstem.L-Thalamus.L circuits.

Perception of typical migraine images on the internet: Comparison between a metropolis and a smaller rural city in Germany

The medial portrayal of migraine is often stereotypical and inaccurate but reflects how society perceives migraine. The discrepancy between others' views and the reality of affected individuals may negatively affect access to treatment and the disease course of patients with migraine. This study aimed to investigate whether images presented in the media as typical migraine attacks are perceived as realistic and representative by migraine patients in Rostock, a smaller town in rural Germany, and compare the results to those from Berlin, a large metropolis. We performed an online survey in Rostock. Migraine patients were shown ten images of migraine attacks, which were among the most downloaded stock pictures on the internet under the search term "migraine". They rated on a scale of 0-100 to what extent the pictures were realistic for migraine attacks (realism score), representative of their own migraine (representation score), or the society's view of migraine (society score). In addition, we compared our results with a recently published study from the metropolitan region of Berlin. A total of 174 migraine patients completed our survey. Mean (SD) realism, representation, and society scores were 59.9 (17.5), 56.7 (18.3), and 58.4 (17.1) respectively. Images of older patients were perceived as significantly more realistic and representative than those of younger patients (P < .001). Patients in Rostock (rural region) rated the images as significantly more realistic and representative than survey participants in Berlin (metropolis). Migraine patients in a rural region found typical migraine images only moderately realistic and representative but to a higher degree than their counterparts from a metropolis.

Visual Aura in Non-Migraine Headaches: A Population Study

BACKGROUND

Visual aura (VA) occurs mostly in migraine with aura (MA), but some case studies have reported aura in non-migraine headaches. Thus, information of VA in non-migraine headaches is scarce. Aim of this study was to investigate the prevalence and impact of VA in non-migraine headache and compare it with that of migraine headache.

METHODS

This study was a nationwide population-based study. We used an internet-based headache diagnosis questionnaire to diagnose headache, and various modules to evaluate clinical features and comorbidities of participants with headache. We defined migraine headache as migraine and probable migraine (PM), whereas non-migraine headache was defined as a headache but not migraine or PM. VA was defined as a self-reporting VA rating scale score ≥ 3.

RESULTS

Of the 3,030 participants, 1,431 (47.2%) and 507 (16.7%) had non-migraine headache and migraine headache, respectively. VA prevalence was much lower in the non-migraine headache group than in the migraine headache group (14.5% [207/1,431] vs. 26.0% [132/507], P < 0.001). In subjects with non-migraine headache, those with VA had a markedly higher number of headache days per 30 days (median [25th-75th percentiles]: 2.0 [1.0-5.0] vs. 2.0 [1.0-3.0], P < 0.001), and headache-related disability (6.0 [3.0-16.0] vs. 2.0 [0.0-7.0], P < 0.001) than those without VA. VA prevalence did not differ significantly according to age and sex.

CONCLUSION

Non-migraine headache with VA patients had more severe symptoms than those without VA. These findings may improve the understanding of VA and the management of individuals with non-migraine headache.

Sex-related differences in migraine clinical features by frequency of occurrence: a cross-sectional study

OBJECTIVES

The sex-related differences of migraine hold clinical relevance to achieve a better diagnosis and treatment. The purpose of this cross-sectional study was to evaluate sex-related differences in migraine features, the impact, and health care resources for people who suffer from episodic migraine (EM) and chronic migraine (CM).

METHODS

184 patients (72 % women; 61.4 % with EM; mean (SD) age of 38.7 (10.4) years) were assessed through the Migraine Disability Assessment, the Short Form 36 Health Survey, the Beck Depression Inventory II and the State-Trait Anxiety Inventory. Additionally, medication intake and medical assistance were recorded. Multivariate analyses were performed, stratifying by frequency of occurrence (EM and CM) and sex (men and women).

RESULTS

The results showed that women presented a greater number of symptoms (p=0.03), pain intensity (p<0.01), pain duration (p=0.03), disability (p=0.01), amount of symptomatic medication (p=0.04) and medical visits (p=0.001), as well as a worse physical role (p=0.004) than men with EM. However, no significant differences between them were found for CM (p>0.05). Moreover, it was identified that there was a significant increase in medication intake among people with CM compared to EM (p<0.001). It is worth noting that there were no significant differences by diagnosis and sex in emotional status (p>0.05).

CONCLUSIONS

Migraine features, impact and health care resources were greater in women than men with EM; yet no significant differences between them were found for CM. The findings of the present study may contribute to a better diagnosis and treatment response in people with migraines.

Preventive treatment patterns and treatment satisfaction in migraine: results of the OVERCOME (EU) study

BACKGROUND

Insights into the burden, needs and treatment of migraine from internet-based surveys in diverse real-world migraine populations are needed, especially at a time when novel preventive migraine medications are becoming part of the therapeutic armamentarium. The objectives of this analysis are to describe traditional preventive (orals and onabotulinum toxin A) treatment patterns in the OVERCOME (EU) study migraine cohort, as well as treatment patterns and patient satisfaction with current treatment in a subgroup of respondents eligible for migraine preventive medication.

METHODS

The cross-sectional non-interventional OVERCOME (EU) study was conducted (October 2020-February 2021) via an online survey among adults (aged ≥ 18 years) resident in Germany or Spain. Participants, registered in existing online panels, who were willing to provide consent were considered. The migraine cohort included participants reporting headache/migraine in the past year, identified based on a validated migraine diagnostic questionnaire and/or self-reported physician diagnosis. A subgroup of survey respondents defined as eligible for migraine preventive medication at the point in time the cross-sectional survey was taken was also analysed. Variables assessed included sociodemographic and migraine-related clinical characteristics, preventive (traditional and calcitonin gene-related peptide monoclonal antibodies) treatment patterns and patient satisfaction with current treatment. Results are descriptive only.

RESULTS

Of the 20,756 participants in the migraine cohort, 78.5% sought professional medical care, 50.8% received a migraine diagnosis and only 17.7% had ever used preventive medication. Half (53.3%) of participants currently using preventives took their most recent medication for six months or less. Most patients (73.9%) classified as eligible for preventive medication (based on headache frequency and/or at least moderate disability due to migraine) reported not using traditional preventives and many of those who did (66.8%) were not satisfied with their current standard of care.

CONCLUSIONS

Our findings highlight the low proportion of people diagnosed with migraine despite a higher rate of consultation and suggest the need for better access to treatment for people with migraine and new preventive therapies with improved efficacy and safety profiles to improve adherence and patient satisfaction.

CGRP, Migraine, and Brain MRI in CADASIL: A Pilot Study

BACKGROUND

Migraine is associated with neuroimaging differences in cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). However, it is unknown if migraine-related disability (MRD) or if calcitonin gene-related peptide (CGRP), a vasoactive peptide important in migraine pathology, have radiographic implications. The aims of this study were to identify whether MRD or interictal serum CGRP levels impacted neuroimaging findings for those with CADASIL.

MATERIALS AND METHODS

A cross-sectional analysis was performed. The primary outcomes were neuroimaging differences associated with MRD among those with migraine or interictal serum CGRP levels of those with and without migraine. MRD was defined by 2 migraine disability scales (Migraine Disability Assessment, Headache Impact Test-6). Retrospective brain magnetic resonance imaging was reviewed (average 1.7 ± 2.0 y before enrollment). Rank-sum and χ 2 tests were used.

RESULTS

Those with migraine (n=25, vs. n=14 without) were younger [median 49 (25 to 82) y vs. 60 (31 to 82) y, P <0.007], had fewer cerebral microbleeds (0 to 31 vs. 0 to 50, P =0.02) and less frequently had anterior temporal lobe T2 hyperintensities [68% (17/25) vs 100% (14/14), P =0.02]. MRD scale outcomes had no significant radiographic associations. Interictal serum CGRP did not differ (migraine: n=18, 27.0±9.6 pg/mL vs. no migraine: n=10, 26.8±15.7 pg/mL, P =0.965).

CONCLUSIONS

Migraine may forestall microangiopathy in CADASIL, though possibly independent of severity as measured by MRD. Interictal serum CGRP did not differ in our cohort suggesting CGRP may not be vital to migraine pathophysiology in CADASIL. Larger studies are needed to account for age differences.

Development and initial validation of the Kiswahili version of the Migraine Disability Assessment (MIDAS-K) questionnaire

BACKGROUND

The Migraine Disability Assessment Scale (MIDAS) is one of the tools for measuring and understanding disability caused by migraine. The purpose of this study was to validate a Kiswahili translation of the MIDAS (MIDAS-K) among patients suffering from migraines in Dar es Salaam, Tanzania.

METHODS

A psychometric validation study of MIDAS was conducted after translation to Kiswahili. A total of 70 people with migraine were recruited by systematic random sampling and they completed the MIDAS-K questionnaire twice, 10-14 days apart. Internal consistency, split-half reliability, and test-retest reliability, convergent and divergent validity were examined.

RESULTS

70 patients (F:M; 59:11) with median (25th, 75th) headache days of 4.0 (2.0, 7.0) were recruited. Twenty-eight out of 70 (40%) of the population had severe disability on MIDAS-K. The overall test-retest reliability of MIDAS-K was high (ICC = 0.86; 95% CI = 0.78-0.92 p < 0.001). Factor analysis showed a two-factor structure; the number of days missed and reduced efficiency. MIDAS-K had a good internal consistency of 0.78, good split-half reliability of 0.80 and acceptable test-retest reliability for all items as well as total MIDAS-K scores.

CONCLUSION

The Kiswahili version of the MIDAS questionnaire (MIDAS-K) is a valid, responsive, and reliable tool to measure migraine-related disability among Tanzanians and other Swahili-speaking populations. Quantification of migraine disability in the region will guide policies directed at care allotment, improvement in the provision of interventions for migraine, as well as enhancement of health-related quality of life for patients with migraine in our region.

The Utility of a Novel, Combined Biofeedback-Virtual Reality Device as Add-on Treatment for Chronic Migraine: A Randomized Pilot Study

OBJECTIVES

To determine if the frequent use of a combined biofeedback-virtual reality device improves headache-related outcomes in chronic migraine.

MATERIALS AND METHODS

In this randomized, controlled pilot study, 50 adults with chronic migraine were randomized to the experimental group (frequent use of a heart rate variability biofeedback-virtual reality device plus standard medical care; n=25) or wait-list control group (standard medical care alone; n=25). The primary outcome was a reduction in mean monthly headache days between groups at 12 weeks. Secondary outcomes included mean change in acute analgesic use frequency, depression, migraine-related disability, stress, insomnia, and catastrophizing between groups at 12 weeks. Tertiary outcomes included change in heart rate variability and device-related user experience measures.

RESULTS

A statistically significant reduction in mean monthly headache days between groups was not demonstrated at 12 weeks. However, statistically significant decreases in the mean frequency of total acute analgesic use per month (65% decrease in the experimental group versus 35% decrease in the control group, P <0.01) and depression score (35% decrease in the experimental group versus 0.5% increase in the control group; P <0.05) were shown at 12 weeks. At study completion, more than 50% of participants reported device satisfaction on a 5-level Likert scale.

DISCUSSION

Frequent use of a portable biofeedback-virtual reality device was associated with decreases in the frequency of acute analgesic use and in depression in individuals with chronic migraine. This platform holds promise as an add-on treatment for chronic migraine, especially for individuals aiming to decrease acute analgesic use or interested in nonmedication approaches.

Burden of migraine in patients attending Belgian headache specialists: real-world evidence from the BECOME study

INTRODUCTION

Migraine is a primary headache disorder, which imposes a major burden on the sufferers. The BECOME study (Burden of migrainE in specialist headache Centers treating patients with prOphylactic treatMent failurE) attempted to characterize and assess the prevalence, burden and healthcare resource utilization of migraine patients presenting in specialized headache centers in Europe and Israel. In this paper, we will describe the patient characteristics of the Belgian headache centers.

METHODS

The BECOME study was a prospective, non-interventional, cross-sectional study consisting of two parts. In the first part of the study, data were collected from subjects with a diagnosis of migraine. Subsequently, patients with ≥ 4 monthly migraine days (MMD) and ≥ 1 prior preventive treatment failure (PPTF) filled out validated questionnaires to assess the burden of disease.

RESULTS

In part 1 of the Belgian study population (N = 806), 45% of patients reported ≥ 8 MMD and 25% had failed ≥ 4 preventive treatments. In part 2 (N = 90), more than 90% of patients reported having severe impact of headache on daily life and having severe migraine-related disability. The impact was the highest for patients with ≥ 15 MMD, however, even within the patient population with < 8 MMD, the burden was significant. Almost 40% of the study population suffered from anxiety.

CONCLUSIONS

These findings in the Belgian sample of the BECOME study demonstrate the substantial burden and unmet need for the management of difficult-to-treat migraine.

Associations between anxiety, depression with migraine, and migraine-related burdens

Background

Anxiety and depression are the most common psychiatric comorbidities in migraine, but their impact on the risk of developing migraine and their gender and age differences are unclear, and research on their associations with migraine-related burdens are limited.

Objective

To systematically explore the association between anxiety and depression with migraine and migraine-related burdens, including the risk of developing migraine, as well as migraine frequency, severity, disability, headache impact, quality of life and sleep quality.

Methods

A total of 170 migraineurs and 85 sex-and age-matched healthy control subjects were recruited consecutively for this study. Anxiety and depression were assessed using Zung's Self-rating Anxiety Scale (SAS) and Self-rating Depression Scale (SDS), respectively. Logistic regression and linear regression analyses were used to explore the associations between anxiety and depression with migraine and its burdens. The receiver operating characteristic (ROC) curve was used to evaluate the predictive value of SAS score and SDS score on migraine and its severe burdens.

Results

After adjusting for confounders, anxiety and depression remained significantly associated with an increased risk of developing migraine, with odds ratios of 5.186 (95% CI:1.755-15.322) and 3.147 (95% CI:1.387-7.141), respectively. Meanwhile, there were significant additive interactions between the association of anxiety and depression with the risk of developing migraine in gender and age (P for interaction <0.05), and the stronger correlations were found in participants with an age ≤ 36 years old and females. In addition, anxiety and depression were significantly independently associated with the migraine frequency, severity, disability, headache impact, quality of life, and sleep quality in migraine patients (P trend <0.05). The area under the ROC curve (AUC) of SAS score in predicting developing migraine was significantly higher than that of SDS score [0.749 (95% CI: 0.691-0.801) vs. 0.633 (95% CI: 0.571-0.692), p < 0.0001].

Conclusion

Anxiety and depression were significantly independently associated with the increased risk of migraine and migraine-related burdens. Enhanced assessment of SAS score and SDS score is of great clinical value for the early prevention and treatment of migraine and its burdens.

Migraine Patient Care Model Preferences in a Community Practice

Background and Objectives

Developing high-value care models with limited resources for large populations of individuals with migraine requires advanced understanding of patient preferences for care delivery methods. In this study, we aimed to inform the development of migraine care models by assessing patient preferences for types of care delivery and determining differences based on migraine frequency and disability.

Methods

We analyzed unpublished data from a cross-sectional survey of 516 randomly selected individuals with migraine within a community practice associated with Mayo Clinic, Rochester, MN.

Results

Individuals with chronic migraine, compared with those with episodic migraine, were more likely to prefer a visit with a neurologist (p = 0.0005), synchronous telephone conference with primary care provider (PCP) and neurologist (p = 0.0102), and a written migraine action plan in the medical record (p = 0.0343). Compared with those with mild/no disability, individuals with moderate-to-severe disability were more likely to prefer a visit with a neurologist (p < 0.0001), synchronous video or telephone conference with PCP and neurologist (p < 0.0001), PCP communication with neurologist (p = 0.0099), electronic message to primary care team with access to neurologist (p = 0.0216), and written action plan in the medical record (p = 0.0011). Collectively, individuals most preferred telephone follow-up and least preferred communications with a nurse or pharmacist or generalized education (all p < 0.001).

Discussion

We observed differences in migraine care delivery preferences between migraine frequency and level of migraine disability. Observations support development of care pathways that include a written migraine action plan, primary care-neurology collaboration including nontraditional interactions, and prioritization of traditional neurology consultation for the most disabled patients.

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.

Emotion dysregulation in migraine patients: can it be a hallmark the probability of the transformation from episodİc to chronic?

OBJECTIVE

The main aim of this study was to examine patients with migraine in terms of emotional dysregulation and to evaluate whether the emotion dysregulation is effective on chronicity in migraine.

MATERIALS AND METHODS

A total of 85 migraine patients and 61 healthy participants were included in this study. All participants were evaluated using Migraine Disability Scale (MIDAS), Visual Analog Scale (VAS), Depression, Anxiety, and Stress Scale (DASS-21), Difficulties in Emotion Regulation Scale (DERS), Pain Catastrophizing Scale (PCS), and the Discomfort Intolerance Scale (DIS). Then, all results were compared between the migraine patients and healthy individuals. In addition, the migraine patients were separated into three groups as patients without an aura, patients with an aura and patients with chronic migraine and then their results were compared among them. Finally, the predictive markers of chronic migraine were explored using regression analyses.

RESULTS

Among 85 migraine patients, the mean age was 31.5 (SD = 7.98); 83.5% were women. The total and subscale scores of DERS, PCS, DIS, and DASS-21 were significantly higher in patients than in healthy individuals (p < 0.01). Subscale scores of DERS, DIS, and DASS-21 in the chronic migraine patients were found to be higher than in the other two patient groups (p < 0.01). Logistic regression analysis showed that chronic migraine could be associated with 'lack of emotional clarity' (OR = 1.229; p = 0.042), 'lack of awareness' (OR = 1.187; p = 0.032), 'migraine associated disability' (OR = 1.128; p = 0.033), and 'stress' (OR = 1.292; p = 0.027).

CONCLUSION

This study results showed that chronic migraine could be associated with the emotional dysregulation. To our knowledge, this study is the preliminary study in the literature and, therefore, new studies with large samples are needed.

Time of Day and Chronotype-Dependent Synchrony Effects Exercise-Induced Reduction in Migraine Load: A Pilot Cross-Over Randomized Trial

Migraines are the most common cause of chronic pain. Effective, non-pharmacological strategies to reduce migraine load, like exercise, are needed, but it is unclear how exercise timing and chronotype modulate the effects. We sought to determine the effects of time-of-day of exercise, and synchrony with one's chronotype, on migraine load. We performed a pilot cross-over randomized trial where participants with chronic migraine completed two one-month exercise interventions, consisting of either morning exercise (before 09:00 a.m.) or evening exercise (after 7:00 p.m.) in a randomized repeated measures cross-over design (Clinical Trial #NCT04553445). Synchrony was determined by exercise time and chronotype (i.e., a morning type participant exercising in the morning is 'in-sync,' while an evening type participant exercising in the morning is 'out-of-sync'). Migraine burden, and anthropometric assessment occurred before and after each month of exercise. Data was analyzed using repeated measures ANOVA with significance accepted at p < 0.05. When comparing morning and evening exercise, there was no significant improvements in any migraine-related parameters. However, when comparing in-sync and out-of-sync exercise, we found that migraine burden was only improved following in-sync exercise, while no benefits were seen in out-of-sync exercise. Our data suggests that exercise timing has limited impact, but synchrony with chronotype may be essential to decrease migraine load in chronic migraineurs.

Management of Episodic Migraine with Neuromodulation: A Case Report

Migraine is a highly prevalent neurovascular disorder that affects approximately 15% of the global population. Migraine attacks are a complex cascade of neurologic events that lead to debilitating symptoms and are often associated with inhibitory behavior. The constellation of severe signs and symptoms during the ictal phase (headache attack) makes migraine the third most common cause of disability globally in both sexes under the age of 50. Misuse of pharmaceuticals, such as opiates, can lead to devastating outcomes and exacerbation of pain and headache attacks. A safe and well-tolerated non-pharmacological research approach is high-definition transcranial direct current stimulation over the M1.

Annual indirect costs savings in patients with episodic or chronic migraine: a post-hoc analysis of phase 3 galcanezumab clinical trials in the United States

BACKGROUND

Galcanezumab (GMB) improved quality-of-life and reduced disability of patients with episodic (EM) and chronic migraine (CM) in Phase 3 trials.

AIM

To estimate indirect cost savings associated with GMB treatment in patients with migraine in the United States (US).

METHODS

We analyzed data of patients from the US from three randomized, Phase 3, double-blind, placebo (PBO)-controlled GMB studies: EVOLVE-1 and EVOLVE-2 (EM patients), REGAIN (CM patients). Annual indirect costs were calculated using items of the Migraine Disability Assessment (MIDAS) questionnaire: lost time/productivity at work/school, household work, and leisure time. All costs were annualized and expressed in 2019 US dollars. While the main analysis considered lost time/productivity at work/school and household work as a full day, a sensitivity analysis was performed by discounting them by half. For EM, annual indirect costs savings were estimated using mixed model repeated measures analysis. For CM, ANCOVA models were used to estimate annual indirect costs savings as change from baseline.

RESULTS

The analysis included 805 patients with EM (mean age = 41.4 years; PBO = 534; GMB = 271) and 423 patients with CM (mean age = 38.9 years; PBO = 279; GMB = 144). Compared to PBO, GMB significantly reduced annual indirect costs among patients with EM at 3 months (least square mean [95% confidence interval] work/school = $1,883.6 [603.64-3,163.65], p = .0040, household work = $628.9 [352.95-904.88], p <.0001, and leisure activity = $499.17 [42.36-955.98], p = .0323) and 6 months (work/school = $2,382.29 [1,065.48-3,699.10], p = .0004, household work = $559.45 [268.99-849.90], p = .0002, and leisure activity = $753.81 [334.35-1,173.27], p = .0004), whereas a significant difference was not observed among patients with CM. Sensitivity analysis results were similar to primary analysis results.

CONCLUSIONS

GMB treatment versus PBO resulted in significantly greater indirect cost savings in patients with EM through improved productivity at work/school, household work, and leisure days. Patients with CM receiving GMB versus PBO attained greater cost savings, although not statistically significant, through reduced lost productivity at work/school.

OnabotulinumtoxinA Treatment in Chronic Migraine: Investigation of Its Effects on Disability, Headache and Neck Pain Intensity

Neck disability and pain are frequently encountered problems in patients with chronic migraine (CM). The long-term stimuli of neurons in the trigeminocervical junction may explain this situation. OnabotulinumtoxinA (ONA) treatment is one of the proven treatments for CM; however, there is no study data on the efficacy of ONA treatment on neck disability and pain in CM patients. Therefore, we aimed to investigate the effect of ONA treatment on disability, neck pain and headache intensity in CM patients. One hundred thirty-four patients who met the inclusion criteria were included in the study. ONA treatment was administered at a dose of 195 U to 39 sites in total as per Follow-the-Pain PREEMPT protocol. The disability was evaluated with the Neck Disability Index and the Migraine Disability Assessment; pain intensity was evaluated with the Visual Analogue Scale; the monthly number of headache days were recorded; quality of life was evaluated with the Headache Impact Test. All assessments were recorded at baseline and 3 months after treatment. After the treatment, neck−migraine disabilities decreased from severe to mild for neck and moderate for migraine (p < 0.001). Neck pain and headache intensities decreased by almost half (p < 0.001). The median number of monthly headache days decreased from 20 days to 6 days (p < 0.000). The quality-of-life level decreased significantly from severe to substantial level (p < 0.001). According to our results, ONA treatment was effective in reducing neck-related problems in CM patients. Long-term follow-up results may provide researchers with more comprehensive results in terms of the treatment of chronic migraine−neck-related problems.

Decrease Retinal Thickness in Patients with Chronic Migraine Evaluated by Optical Coherence Tomography

The purpose of this study is to determine the possible alterations that may occur in the thickness of the retinal nerve fibre layer (RNFL), ganglion cell layer (GCL), and macular thickness in patients with chronic migraines compared with healthy controls. Hence, we examined some of the possibilities that are offered by optical coherence tomography (OCT) in order to study different neurological diseases and to study its application, in this case, how it may be applied to patients with chronic migraines. This was an observational cross-sectional study in adults aged 18-65 years. The study group consisted of 90 patients (90 eyes) with chronic migraines who met the inclusion criteria, and 90 healthy controls (90 eyes) matched for age and sex. Retinal thickness was measured by spectral domain OCT (SD-OCT). The thickness of the superior quadrant of the peripapillary RNFL, as well as the mean thickness in the macula, RNFL macular, and GCL was significantly thinner in chronic migraine patients than in healthy controls (p ≤ 0.05). Chronic migraines are associated with a decrease in retinal thickness which is detectable by an OCT diagnostic technique. The quantification of the axonal damage could be used as a biomarker to help in the diagnosis and monitoring of this pathology. Further studies will be needed to confirm these findings.

Efficacy of the Digital Therapeutic sinCephalea in the prophylaxis of migraine in patients with episodic migraine: study protocol for a digital, randomized, open-label, standard treatment controlled trial

BACKGROUND

The German government implemented the Digital Healthcare Act in order to bring Digital Therapeutics into standard medical care. This is one of the first regulatory pathways to reimbursement for Digital Therapeutics (DTx). The Digital Therapeutic sinCephalea is intended to act as a prophylactic treatment of migraine by reducing the migraine days. For this, sinCephalea determines personalized nutritional recommendations using continuous glucose monitoring (CGM) data and enables the patients to follow a personalized low-glycemic nutrition. Migraine is a headache disorder with the highest socioeconomic burden. Emerging evidence shows that CGM-based personalized nutritional recommendations are of prophylactic use in episodic migraine. However, prospective data are yet missing to demonstrate clinical effectiveness. This study is designed to fill this gap.

METHODS

Patients between 18 and 65 years of age with proven migraine and a minimal disease severity of 3 migraine days per month are included. After a 4-week baseline phase as a pre-study, patients are randomized to the DTx intervention or a waiting-list control. The objective of the study is to show differences between the intervention and control groups regarding the change of migraine symptoms and of effects of migraine on daily life.

DISCUSSION

To our knowledge, this is the first systematic clinical trial with a fully digital program to enable patients with migraine to follow a personalized low-glycemic nutrition in order to reduce their number of migraine days and the migraine-induced impact on daily life. Designing a clinical study using a digital intervention includes some obstacles, which are addressed in this study approach.

TRIAL REGISTRATION

German Registry of Clinical Studies (Deutsches Register Klinischer Studien) DRKS-ID DRKS00024657. Registered on March 8, 2021.

Evaluation of retinal vessel and perfusion density in migraine patients by optical coherence tomography angiography

BACKGROUND

Migraine is a neurovascular disease and has been reported as a risk factor for ocular vascular complications. Our study aimed to compare the retinal vessel density and perfusion density between migraine patients and healthy subjects by optical coherence tomography angiography (OCTA).

METHODS

In this prospective study, 23 patients with migraine with aura (MWA) and 31 patients with migraine without aura (MWOA), and 32 age- and gender-matched healthy controls (HC) were enrolled. The vessel density (VD) and perfusion density (PD) were evaluated in a 6 × 6 mm scan of the macula and optic nerve head (ONH) with the Cirrus HD-OCT 5000 device. The measurement area is divided into three areas: center (c), inner ring (ir), outer ring (or) (with diameters of 1, 3, and 6 mm respectively), and nine subfields, according to the Early Treatment Retinopathy Study grid.

RESULTS

The macular cVD, cPD, and temporal orVD in MWA and MWOA groups were significantly reduced than those of HC. On optic nerve head OCTA, patients with MWA had decreased cVD, average irVD, inferior irVD, and temporal orVD compared with HCs while MWOA had reduced cVD than HC group. In addition, PD was not significantly different among MWA, MWOA, and HC groups in any measure in the optic nerve head. The Migraine Disability Assessment Score (MIDAS) and attack frequency were significantly inversely correlated with cVD, cPD, irVD, and irPD of macula and ONH.

CONCLUSIONS

Vessel and perfusion density of macula were reduced in both MWA and MWOA. Vessel density, but not perfusion density of ONH was decreased in MWA. The migraine severity and attack frequency were significantly inversely correlated with vessel and perfusion density of macula and ONH.

Acceptance and commitment therapy for episodic migraine: Rationale and design of a pilot randomized controlled trial

Migraine is a debilitating disorder with limited pharmacological options. Many migraine medications can have intolerable side effects leading patients to seek complementary and integrative health (CIM) approaches for treatment. One option that is growing in popularity and evidence is Acceptance and Commitment Therapy (ACT), a mindfulness-based therapy. The purpose of this paper is to describe how ACT may be an effective modality integrated into the treatment of migraine and to describe the design of a pilot study of ACT for migraine. First, we review the research and the promise of mindfulness therapies for the treatment of migraine. Then, we describe how ACT differs from other mindfulness therapies for migraine and why it can be a promising option for these patients. Finally, we summarize the design of a pilot study designed to determine the feasibility of performing a future fully powered study to determine the effectiveness of ACT on migraine frequency and disability. This pilot study includes unique features, including a remotely-delivered ACT intervention and the measurement of cortisol levels before and after the intervention.

Non-aura visual disturbance with high visual aura rating scale scores has stronger association with migraine chronification than typical aura

OBJECTIVES

To investigate the clinical correlates of visual symptoms in patients with migraine.

METHOD

Patients with migraine that attended our headache clinics were enrolled. Headache profiles, disability, and comorbidities were acquired with structured questionnaires. A semi-structured visual phenomenon questionnaire was also used to assess the characteristics of visual symptoms, including visual aura in patients with migraine with aura and transient visual disturbance in patients with migraine without aura. Headache specialists interviewed with the participants for the ascertainment of diagnosis and verification of the questionnaires.

RESULT

Migraine with aura patients with visual aura (n = 743, female/male = 2.3, mean age: 34.7 ± 12.2 years) and migraine without aura patients with non-aura transient visual disturbance (n = 1,808, female/male = 4.4, mean age: 39.4 ± 12.6 years) were enrolled. Patients with transient visual disturbance had higher headache-related disability and more psychiatric comorbidities. Chronic migraine was more common in migraine without aura than migraine with aura patients (41.9% vs. 11.8%, OR = 5.48 [95% CI: 4.33-7.02], p < 0.001). The associations remained after adjusting confounding factors.

CONCLUSION

Presence of non-aura transient visual disturbance may suggest a higher migraine-related disability and is linked to higher risk of chronic migraine than typical migraine aura in migraine patients. Further studies are needed to elucidate the potential mechanism.

Headache: What to ask, how to examine, and which scales to use. Recommendations of the Spanish Society of Neurology's Headache Study Group

INTRODUCTION

Headache is the most common neurological complaint at the different levels of the healthcare system, and clinical history and physical examination are essential in the diagnosis and treatment of these patients. With the objective of unifying the care given to patients with headache, the Spanish Society of Neurology's Headache Study Group (GECSEN) has decided to establish a series of consensus recommendations to improve and guarantee adequate care in primary care, emergency services, and neurology departments.

METHODS

With the aim of creating a practical document, the recommendations follow the dynamics of a medical consultation: clinical history, physical examination, and scales quantifying headache impact and disability. In addition, we provide recommendations for follow-up and managing patients' expectations of the treatment.

CONCLUSIONS

With this tool, we aim to improve the care given to patients with headache in order to guarantee adequate, homogeneous care across Spain.

Association between sleep quality, migraine and migraine burden

Background

The relationship between sleep and migraine is well known to be bidirectional. However, few studies have systematically assessed the association between sleep quality and the risk of developing migraine, and its gender and age differences are unclear. And there is currently limited evidence on the associations between sleep quality and migraine-related burdens.

Objective

The objectives of this study were to: (1) explore the association between sleep quality and the risk of developing migraine, and its gender and age differences; (2) investigate the associations between sleep quality and the total pain burden, severity, disability, headache impact, quality of life, anxiety, and depression of migraine patients.

Methods

This study consecutively enrolled 134 migraine patients and 70 sex- and age-matched healthy control subjects. Sleep quality was assessed through the Pittsburgh Sleep Quality Index (PSQI). Logistic regression and linear regression analyses were used to explore the associations between sleep quality with the risk of developing migraine and the migraine-related burdens.

Results

The prevalence of poor sleep quality in migraine patients was significantly higher than that in subjects without migraine (P &lt; 0.001). After adjusting for various confounding factors, the risk of migraine with poor sleep quality remained 3.981 times that of those with good sleep quality. The subgroup analysis showed that there were significant additive interactions between poor sleep quality and the risk of migraine in gender, age, and education level (P for interaction &lt; 0.05), and the stronger correlations were found in females, populations with ages more than 35 years old, and with lower education levels. In addition, multivariate linear regression analysis showed that poor sleep quality was significantly and independently associated with the total pain burden, severity, headache impact, quality of life, anxiety, and depression in migraine patients (P trend &lt; 0.05).

Conclusion

Poor sleep quality was significantly independently associated with an increased risk of developing migraine and the migraine-related burdens. Strengthening PSQI assessment is valuable for the early prevention and treatment of migraine patients.

Potential Add-On Effects of Manual Therapy Techniques in Migraine Patients: A Randomised Controlled Trial

Objective: To ascertain whether the combination of soft tissue and articulatory manual techniques is more effective than either one of these techniques alone for reducing migraine impact; Methods: Seventy-five participants with migraine were randomly divided into three groups (n = 25 per group): (i) soft tissue (STG), (ii) articulatory (AG), and (iii) combined treatment (STAG). Pain, frequency of occurrence, duration, disability and impact, depression and anxiety levels, and perception of change were analysed at baseline, post intervention (T2) and at four-week follow-up (T3); Results: STAG showed a significantly greater reduction in pain versus STG and AG at T2 (p < 0.001; p = 0.014) and at T3 (p < 0.001; p = 0.01). Furthermore, STAG achieved a significantly greater reduction in pain duration versus STG at T2 (p = 0.020) and T3 (p = 0.026) and a greater impression of change versus STG (p = 0.004) and AG (p = 0.037) at T3. Similar effects were observed in all groups for frequency of occurrence, migraine disability, impact, and depression and anxiety levels; Conclusions: A combined manual therapy protocol including soft tissue and articulatory techniques yields larger improvements on pain and perception of change than either technique alone, yet the three therapeutic approaches show similar benefits for reducing pain, disability and impact caused by the migraine, depression or anxiety levels.