Non-pharmacological approach to migraine prophylaxis: part II

Bibliometric Analysis of 100 Most Highly Cited Publications on Acupuncture for Migraine

Background

Migraine is a serious global health concern that imposed a huge economic burden on social health care. Over the past few decades, the analgesic effects of acupuncture have been widely recognized, and there is a growing body of research on acupuncture for migraine. Citation analysis is a branch of bibliometrics that helps researchers analyze and identify historical or landmark studies within the scientific literature. Currently, there is no analysis of the 100 most highly cited publications on acupuncture for migraine.

Methods

The 100 most highly cited publications on acupuncture for migraine were screened using the Science Citation Index Expanded of the Web of Science Core Collection database. CiteSpace and VOSviewer programs were used for bibliometric analysis.

Results

A total of 493 publications on acupuncture for migraine were identified. 100 of the most highly cited publications on acupuncture for migraine were published from 1984-2020. These publications were cited 6142 times with an h-index of 44 and 84% were original articles. The highest frequency of citations was 416. A total of 335 authors were involved in the study with 37 lead authors. 212 institutions from 20 countries contributed to the 100 most highly cited publications. The most published studies came from the United States (n=36), followed by China (n=27) and Germany (n=26). The Technical University of Munich published the largest number of papers (n = 15). Top-cited publications mainly came from the Headache (n=13, citations=582). Neuroimaging is gradually emerging as a hot topic of research.

Conclusion

This is the first bibliometric analysis to offer a thorough list of the 100 most highly cited papers on acupuncture for migraine, demonstrating significant progress and emerging trends in this field to assist researchers in determining the direction for further research.

The Effect of Ginger (Zingiber officinale Rosc.) Consumption in Headache Prophylaxis in Patients with Migraine: A Randomized Placebo-Controlled Clinical Trial

Background: Migraine sufferers seek a range of treatments according to the frequency and severity of their symptoms. Just a few research studies have shown the effectiveness of ginger derivatives for migraine treatment. Ginger has analgesic properties and is effective for the acute treatment of migraines, and there is anecdotal evidence of its effectiveness in migraine prevention. Objectives: The goal of this research was to see whether ginger may help prophylaxis of migraine episodes. Methods: This randomized, double-blind, placebo-controlled clinical study was done in the Neurology Clinic of Golestan Hospital (Ahvaz, Iran). This research enrolled 103 individuals with episodic migraine aged 18 to 50 years. Randomization was used to divide the participants into two groups: control and intervention. For three months, patients were given 500 mg dry extract of ginger (5% active component) or placebo (starch) tablets twice a day. At the baseline and end of the study, MIDAS score, the number and duration of migraine attacks, headache severity, demographic data, dietary intakes, and anthropometric indices were collected. The data were statistically analyzed using the SPSS (version 26). In all tests, a P < 0.05 was deemed statistically significant. Results: At the end of the study, MIDAS score, duration of migraine attacks, and headache severity decreased significantly in the ginger group compared to the placebo group (P < 0.05). Furthermore, there was no statistically significant difference in the number of migraine episodes between the two groups. Conclusions: Compared to the placebo, ginger has a stronger efficacy in the prevention of migraine.

Post-traumatic cephalalgia

After traumatic brain injury (TBI), a host of symptoms of varying severity and associated functional impairment may occur. One of the most commonly encountered and challenging to treat are the post-traumatic cephalalgias. Post-traumatic cephalalgia (PTC) or headache is often conceptualized as a single entity as currently classified using the ICHD-3. Yet, the terminology applicable to the major primary, non-traumatic, headache disorders such as migraine, tension headache, and cervicogenic headache are often used to specify the specific type of headache the patients experiences seemingly disparate from the unitary definition of post-traumatic headache adopted by ICHD-3. More complex post-traumatic presentations attributable to brain injury as well as other headache conditions are important to consider as well as other causes such as medication overuse headache and medication induced headache. Treatment of any post-traumatic cephalalgia must be optimized by understanding that there may be more than one headache pain generator, that comorbid traumatic problems may contribute to the pain presentation and that pre-existing conditions could impact both symptom complaint, clinical presentation and recovery. Any treatment for PTC must harmonize with ongoing medical and psychosocial aspects of recovery.

Persistent post-traumatic headache: a migrainous loop or not? The clinical evidence

BACKGROUND

Headache is a common complication of traumatic brain injury. The International Headache Society defines post-traumatic headache as a secondary headache attributed to trauma or injury to the head that develops within seven days following trauma. Acute post-traumatic headache resolves after 3 months, but persistent post-traumatic headache usually lasts much longer and accounts for 4% of all secondary headache disorders.

MAIN BODY

The clinical features of post-traumatic headache after traumatic brain injury resemble various types of primary headaches and the most frequent are migraine-like or tension-type-like phenotypes. The neuroimaging studies that have compared persistent post-traumatic headache and migraine found different structural and functional brain changes, although migraine and post-traumatic headache may be clinically similar. Therapy of various clinical phenotypes of post-traumatic headache almost entirely mirrors the therapy of the corresponding primary headache and are currently based on expert opinion rather than scientific evidence. Pharmacologic therapies include both abortive and prophylactic agents with prophylaxis targeting comorbidities, especially impaired sleep and post-traumatic disorder. There are also effective options for non-pharmacologic therapy of post-traumatic headache, including cognitive-behavioral approaches, onabotulinum toxin injections, life-style considerations, etc. CONCLUSION: Notwithstanding some phenotypic similarities, persistent post-traumatic headache after traumatic brain injury, is considered a separate phenomenon from migraine but available data is inconclusive. High-quality studies are further required to investigate the pathophysiological mechanisms of this secondary headache, in order to identify new targets for treatment and to prevent disability.

Psychological therapies for the prevention of migraine in adults

BACKGROUND

Migraine is a common neurological problem associated with the highest burden amongst neurological conditions in terms of years lived with disability. Medications can be used as prophylaxis or rescue medicines, but are costly and not always effective. A range of psychological interventions have been developed to manage migraine.

OBJECTIVES

The objective was to evaluate the efficacy and adverse events of psychological therapies for the prevention of migraine in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL from their inception until July 2018, and trials registries in the UK, USA, Australia and New Zealand for randomised controlled trials of any psychological intervention for adults with migraine.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of a psychological therapy for people with chronic or episodic migraine, with or without aura. Interventions could be compared to another active treatment (psychological or medical), an attention-placebo (e.g. supportive counselling) or other placebo, routine care, or waiting-list control. We excluded studies where fewer than 15 participants completed each arm.

DATA COLLECTION AND ANALYSIS

We extracted study characteristics and outcome data at post-treatment and the longest available follow-up. We analysed intervention versus control comparisons for the primary outcome of migraine frequency. We measured migraine frequency using days with migraines or number of migraine attacks measured in the four weeks after treatment. In addition, we analysed the following secondary outcomes: responder rate (the proportion of participants with a 50% reduction in migraine frequency between the four weeks prior to and the four weeks after treatment); migraine intensity; migraine duration; migraine medication usage; mood; quality of life; migraine-related disability; and proportion of participants reporting adverse events during the treatment. We included these variables, where available, at follow-up, the timing of which varied between the studies. We used the GRADE approach to judge the quality of the evidence.

MAIN RESULTS

We found 21 RCTs including 2482 participants with migraine, and we extracted meta-analytic data from 14 of these studies. The majority of studies recruited participants through advertisements, included participants with migraine according to the International Classification of Headache Disorders (ICHD) criteria and those with and without aura. Most intervention arms were a form of behavioural or cognitive-behavioural therapy. The majority of comparator arms were no treatment, routine care or waiting list. Interventions varied from one 20-minute session to 14 hours of intervention. No study had unequivocally low risk of bias; all had at least one domain at high risk of bias, and 20 had two to five domains at high risk. Reporting of randomisation procedures and allocation concealment were at high or unclear risk of bias. We downgraded the quality of evidence for outcomes to very low, due to very serious limitations in study quality and imprecision. Reporting in trials was poor; we found no preregistrations stipulating the outcomes, or demonstrating equivalent expectations between groups. Few studies reported our outcomes of interest, most only reported outcomes post treatment; follow-up data were sparse.Post-treatment effectsWe found no evidence of an effect of psychological interventions for migraine frequency in number of migraines or days with migraine (standardised mean difference (SMD) -0.02, 95% confidence interval (CI) -0.17 to 0.13; 4 studies, 681 participants; very low-quality evidence).The responder rate (proportion of participants with migraine frequency reduction of more than 50%) was greater for those who received a psychological intervention compared to control: 101/186 participants (54%) with psychological therapy; 37/152 participants (24%) with control (risk ratio (RR) 2.21, 95% CI 1.63 to 2.98; 4 studies, 338 participants; very low-quality evidence). We found no effect of psychological therapies on migraine intensity (SMD -0.13, 95% CI -0.28 to 0.02; 4 studies, 685 participants). There were no data for migraine duration (hours of migraine per day). There was no effect on migraine medication usage (SMD -0.06, 95% CI -0.35 to 0.24; 2 studies, 483 participants), mood (mean difference (MD) 0.08, 95% CI -0.33 to 0.49; 4 studies, 432 participants), quality of life (SMD -0.02, 95% CI -0.30 to 0.26; 4 studies, 565 participants), or migraine-related disability (SMD -0.67, 95% CI -1.34 to 0.00; 6 studies, 952 participants). The proportion of participants reporting adverse events did not differ between those receiving psychological treatment (9/107; 8%) and control (30/101; 30%) (RR 0.16, 95% CI 0.00 to 7.85; 2 studies, 208 participants). Only two studies reported adverse events and so we were unable to draw any conclusions.We rated evidence from all studies as very low quality.Follow-upOnly four studies reported any follow-up data. Follow-ups ranged from four months following intervention to 11 months following intervention. There was no evidence of an effect on any outcomes at follow-up (very low-quality evidence).

AUTHORS' CONCLUSIONS

This review identified 21 studies of psychological interventions for the management of migraine. We did not find evidence that psychological interventions affected migraine frequency, a result based on four studies of primarily brief treatments. Those who received psychological interventions were twice as likely to be classified as responders in the short term, but this was based on very low-quality evidence and there was no evidence of an effect of psychological intervention compared to control at follow-up. There was no evidence of an effect of psychological interventions on medication usage, mood, migraine-related disability or quality of life. There was no evidence of an effect of psychological interventions on migraine frequency in the short-term or long-term. In terms of adverse events, we were unable to draw conclusions as there was insufficient evidence. High and unclear risk of bias in study design and reporting, small numbers of participants, performance and detection bias meant that we rated all evidence as very low quality. Therefore, we conclude that there is an absence of high-quality evidence to determine whether psychological interventions are effective in managing migraine in adults and we are uncertain whether there is any difference between psychological therapies and controls.

Acupuncture therapy in treating migraine: results of a magnetic resonance spectroscopy imaging study

Background

Acupuncture has been proven to be effective as an alternative therapy in treating migraine, but the pathophysiological mechanisms of the treatment remain unclear. This study investigated possible neurochemical responses to acupuncture treatment.

Patients and methods

Proton magnetic resonance spectroscopy imaging was used to investigate biochemical levels pre- and post-acupuncture treatment. Participants (N=45) included subjects diagnosed with: 1) migraine without aura; 2) cervicogenic headache; and 3) healthy controls. Participants in the two patient groups received verum acupuncture using acupoints that target migraine without aura but not cervicogenic headache, while the healthy controls received a sham treatment. All participants had magnetic resonance spectroscopy scans before and after the acupuncture therapy. Levels of brain metabolites were examined in relation to clinical headache assessment scores.

Results

A significant increase in N-acetylaspartate/creatine was observed in bilateral thalamus in migraine without aura after the acupuncture treatment, which was significantly correlated with the headache intensity score.

Conclusion

The data demonstrate brain biochemical changes underlying the effect of acupuncture treatment of migraine.

Acupuncture in migraine prophylaxis in Czech patients: an open-label randomized controlled trial

BACKGROUND

Adjuvant acupuncture for the symptomatic treatment of migraine reduces the frequency of headaches and may be at least similarly effective to treatment with prophylactic drugs.

METHODS

This article describes an open-label randomized controlled clinical trial with two groups: the intervention group (n=42) and the waiting-list control group (n=44). This study occurred at the Czech-Chinese Center for Traditional Chinese Medicine at the University Hospital Hradec Kralove between October 2015 and April 2017.

RESULTS

After 12 weeks of acupuncture, the number of migraine days was reduced by 5.5 and 2.0 days in the acupuncture and the waiting-list control groups, respectively, with a statistically significant inter-group difference of 2.0 migraine days (95% CI: -4 to -1). A significantly greater reduction in the number of migraine days per 4 weeks was reached at the end of the 6-month follow-up period in the acupuncture vs. control groups (Δ -4.0; 95% CI: -6 to -2). A statistically significant difference was observed in the number of responders to treatment (response defined as at least a 50% reduction in average monthly migraine day frequency) in the acupuncture vs waiting-list control groups (50% vs 27%; p<0.05) at the end of the intervention. A significantly greater percentage of responders to treatment was noted in the intervention vs control groups at the 6-month follow-up (81% vs 36%; p<0.001).

CONCLUSION

Acupuncture can reduce symptoms and medication use, both short term and long term, as an adjuvant treatment in migraine prophylaxis in Czech patients.

Vitamin supplementation as possible prophylactic treatment against migraine with aura and menstrual migraine

Migraine is the most common form of headache disorder globally. The etiology of migraine is multifactorial, with genetic components and environmental interactions considered to be the main causal factors. Some researchers postulate that deficits in mitochondrial energy reserves can cause migraine or an increase in homocysteine levels can lead to migraine attacks; therefore, vitamins could play a vital role in migraine prevention. For instance, riboflavin influences mitochondrial dysfunction and prevents migraine. Genes such as flavoenzyme 5,10-methylenetetrahydrofolate reductase (MTHFR), especially the C677T variant, have been associated with elevated plasma levels of homocysteine and migraine with aura. Homocysteine catalyzation requires the presence of vitamins B₆, B₁₂, and folic acid, which can decrease the severity of migraine with aura, making these vitamins potentially useful prophylactic agents for treating migraine with aura. Menstrual migraine, on the other hand, is associated with increased prostaglandin (PG) levels in the endometrium, indicating a role for vitamin E, which is an anti-PG. Vitamin C can also be used as a scavenger of reactive oxygen species for treating neurogenic inflammation in migraine patients. This paper reviews possible therapies based on vitamin supplementation for migraine prophylaxis, focusing on migraine with aura and menstrual migraine.

Late-life migraine accompaniments: A narrative review

BACKGROUND

Migraine is one of the most common chronic neurological disorders. In 1980, C. Miller Fisher described late-life migraine accompaniments as transient neurological episodes in older individuals that mimic transient ischemic attacks. There has not been an update on the underlying nature and etiology of late-life migraine accompanimentsd since the original description.

PURPOSE

The purpose of this article is to provide a comprehensive and extensive review of the late-life migraine accompaniments including the epidemiology, clinical characteristics, differential diagnosis, and treatment.

METHODS

Literature searches were performed in MEDLINE®, PubMed, Cochrane Library, and EMBASE databases for publications from 1941 to July 2014. The search terms "Migraine accompaniments," "Late life migraine," "Migraine with aura," "Typical aura without headache," "Migraine equivalents," "Acephalic migraine," "Elderly migraine," and "Transient neurological episodes" were used.

CONCLUSION

Late-life onset of migraine with aura is not rare in clinical practice and can occur without headache, especially in elderly individuals. Visual symptoms are the most common presentation, followed respectively by sensory, aphasic, and motor symptoms. Gradual evolution, the march of transient neurological deficits over several minutes and serial progression from one symptom to another in succession are typical clinical features for late-life migraine accompaniments. Transient neurological disturbances in migraine aura can mimic other serious conditions and can be easily misdiagnosed. Careful clinical correlation and appropriate investigations are essential to exclude secondary causes. Treatments are limited and still inconsistent.

Platelet-activating factor (PAF)-antagonists of natural origin

Presently herbal medicines are being used by about 80% of the world population for primary health care as they stood the test of time for their safety, efficacy, cultural acceptability and lesser side effects. The discovery of platelet activating factor antagonists (PAF antagonists) during these decades are going on with different framework, but the researchers led their efficiency in studying in vitro test models. Since it is assumed that PAF play a central role in etiology of many diseases in humans such as asthma, neuronal damage, migraine, cardiac diseases, inflammatory, headache etc. Present days instinctively occurring PAF antagonist exists as a specific grade of therapeutic agents for the humans against these and different diseases either laid hold of immunological or non-immunological types. Ginkgolide, cedrol and many other natural PAF antagonists such as andrographolide, α-bulnesene, cinchonine, piperine, kadsurenone, different Piper species' natural products and marine origin plants extracts or even crude drugs having PAF antagonist properties are being used currently against different inflammatory pathologies. This review is an attempt to summarize the data on PAF and action of natural PAF antagonists on it, which were evaluated by in vivo and in vitro assays.

Overview of migraine treatment

SUMMARY Migraine is ranked as the 19th top cause of disability worldwide by WHO. Despite advancements in migraine-specific acute treatment, only a minority of patients utilize these medications. Specific pharmacologic treatments consist of the ergot alkaloids and triptans (serotonin 5-HT1B/1D receptor agonists). Both classes are regarded as relatively safe and effective; however, there is a greater concern for vasoconstrictive effects with the ergots, which limits their use. Triptans transformed migraine therapy, setting in motion revolutionary research that heightened our understanding of migraine mechanisms. However, one in three migraineurs may be triptan nonresponders and there is a group of migraine patients that remains ‘refractory’ to conventional pharmacologic migraine therapy. This article discusses the approach to migraine management, reviews currently available acute and preventive pharmacologic and nonpharmacologic treatment options for migraine headache, as well as briefly focuses on novel and upcoming medicines presently under investigation.

Nutraceutical preparations in childhood migraine prophylaxis: effects on headache outcomes including disability and behaviour

Migraine is common in children, but few specific drugs are available. We performed an open-label comparison of effects of two nutraceutical preparations (ginkgolide B vs. Griffonia simplicifolia extract) on outcomes in 374 school-age children (mean 10.7 years) with migraine without aura. Half of them received ginkgolide B; and half, Griffonia simplicifolia. Both preparations were given orally twice a day for 6 months. Patients kept a headache diary. Outcomes at the beginning and end of treatment were compared. Both preparations reduced all outcome measures after 6 months of treatment. However, reductions in headache frequency, duration and intensity, PedMIDAS score and behavioural reactions to headache were significantly greater in the ginkgolide B group. Both nutraceutical treatments appear promising in paediatric migraine without aura, particularly because of their lack of side effects. However, the ginkgolide B preparation was significantly more effective in the medium-term (6 months).

Can migraine prophylaxis prevent acute mountain sickness at high altitude?

Acute mountain sickness (AMS) develops in people trekking at high altitude. The underlying mechanism is vasodilation due to low pressure of oxygen. However, individual susceptibility for AMS is unknown, thus, one cannot predict when or to whom it happens. Because AMS usually begins with headache, and because migraineurs are more vulnerable to AMS, we studied by the literatures review on the mechanism and clinical features in common, and assessed the treatment modalities for both disorders. This led to us the following hypothesis that, migraine prophylaxis may prevent or delay the onset of AMS at high altitude. Clinical features of AMS include nausea or vomiting when it progresses. Hypobaric hypoxia, dehydration or increased physical exertion trigger or aggravate both disorders. In migraine, cerebral vasodilation can happen following alteration of neuronal activity, whereas the AMS is associated with peripheral vessel dilation. Medications that dilate the vessels worsen both conditions. Acute treatment strategies for migraine overlap with to those of AMS, including drugs such as vasoconstrictors, or other analgesics. To prevent AMS, adaptation to high altitude or pharmacological prophylaxis, i.e., acetazolamide has been recommended. This carbonic anhydrase inhibitor lowers serum potassium level, and thus stabilizes membrane excitability. Acetazolamide is also effective on specific forms of migraine. Taken together, these evidences implicate that migraine prophylaxis may prevent or delay the onset of AMS by elevating the threshold for high altitude.

Diet and its role in interstitial cystitis/bladder pain syndrome (IC/BPS) and comorbid conditions

What's known on the subject? and What does the study add? Nearly 90% of patients with interstitial cystitis/bladder pain syndrome (IC/BPS) report sensitivities to a wide variety of dietary comestibles. Current questionnaire-based literature suggests that citrus fruits, tomatoes, vitamin C, artificial sweeteners, coffee, tea, carbonated and alcoholic beverages, and spicy foods tend to exacerbate symptoms, while calcium glycerophosphate and sodium bicarbonate tend to improve symptoms. At present we recommend employing a controlled method to determine dietary sensitivities, such as an elimination diet, in order to identify sensitivities while at the same time maintain optimal nutritional intake. We review current literature with regard to diet's effect upon IC/BPS and common comorbidities (irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, neuropathic pain, vulvodynia, and headache) with a focus upon questionnaire-based investigations. We discuss the pathologic mechanisms that may link diet and IC/BPS related-pain, concentrating upon specific comestibles such as acidic foods, foods high in potassium, caffeine, and alcohol. Up to 90% of patients with interstitial cystitis/bladder pain syndrome (IC/BPS) report sensitivities to a wide variety of comestibles.   Pathological mechanisms suggested to be responsible for the relationship between dietary intake and symptom exacerbation include peripheral and/or central neural upregulation, bladder epithelial dysfunction, and organ 'cross-talk', amongst others.   Current questionnaire-based data suggests that citrus fruits, tomatoes, vitamin C, artificial sweeteners, coffee, tea, carbonated and alcoholic beverages, and spicy foods tend to exacerbate symptoms, while calcium glycerophosphate and sodium bicarbonate tend to improve symptoms. Specific comestible sensitivities varied between patients and may have been influenced by comorbid conditions. This suggests that a controlled method to determine dietary sensitivities, such as an elimination diet, may play an important role in patient management.

Acupuncture versus topiramate in chronic migraine prophylaxis: a randomized clinical trial

BACKGROUND

The aim of this study was to investigate the efficacy and tolerability of acupuncture compared with topiramate treatment in chronic migraine (CM) prophylaxis.

METHODS

A total of 66 consecutive and prospective CM patients were randomly divided into two treatment arms: 1) acupuncture group: acupuncture administered in 24 sessions over 12 weeks (n = 33); and 2) topiramate group: a 4-week titration, initiated at 25 mg/day and increased by 25 mg/day weekly to a maximum of 100 mg/day followed by an 8-week maintenance period (n = 33).

RESULTS

A significantly larger decrease in the mean monthly number of moderate/severe headache days (primary end point) from 20.2 ± 1.5 days to 9.8 ± 2.8 days was observed in the acupuncture group compared with 19.8 ± 1.7 days to 12.0 ± 4.1 days in the topiramate group (p < .01) Significant differences favoring acupuncture were also observed for all secondary efficacy variables. These significant differences still existed when we focused on those patients who were overusing acute medication. Adverse events occurred in 6% of acupuncture group and 66% of topiramate group.

CONCLUSION

We suggest that acupuncture could be considered a treatment option for CM patients willing to undergo this prophylactic treatment, even for those patients with medication overuse.

Drug repurposing and adverse event prediction using high-throughput literature analysis

Drug repurposing is the process of using existing drugs in indications other than the ones they were originally designed for. It is an area of significant recent activity due to the mounting costs of traditional drug development and scarcity of new chemical entities brought to the market by bio-pharmaceutical companies. By selecting drugs that already satisfy basic toxicity, ADME and related criteria, drug repurposing promises to deliver significant value at reduced cost and in dramatically shorter time frames than is normally the case for the drug development process. The same process that results in drug repurposing can also be used for the prediction of adverse events of known or novel drugs. The analytics method is based on the description of the mechanism of action of a drug, which is then compared to the molecular mechanisms underlying all known adverse events. This review will focus on those approaches to drug repurposing and adverse event prediction that are based on the biomedical literature. Such approaches typically begin with an analysis of the literature and aim to reveal indirect relationships among seemingly unconnected biomedical entities such as genes, signaling pathways, physiological processes, and diseases. Networks of associations of these entities allow the uncovering of the molecular mechanisms underlying a disease, better understanding of the biological effects of a drug and the evaluation of its benefit/risk profile. In silico results can be tested in relevant cellular and animal models and, eventually, in clinical trials.