Stigma and Migraine: Developing Effective Interventions

Debunking myths in headache diagnosis for the pain practitioner

With headache being one of the most common chief complaints, it is essential for pain practitioners to interpret and differentiate a variety of headache characteristics to accurately diagnose and treat specific headache disorders. Certain misconceptions often lead to misdiagnosis. This article presents and discusses six myths about several common headache disorders (migraine, tension-type headache, cluster headache, cervicogenic headache, sinus headache, and occipital neuralgia) often encountered in clinical practice. The discussion is based primarily on the International Classification of Headache Disorders, 3rd edition and the latest studies. Recognizing and understanding the intricacies behind key headache diagnoses will help providers devise appropriate plans to better care for their patients.

Understanding public perceptions and discussions on diseases involving chronic pain through social media: cross-sectional infodemiology study

BACKGROUND

Chronic pain is a highly prevalent medical condition that negatively impacts quality of life and is associated with considerable functional disability. Certain diseases, such as fibromyalgia, headache, paraplegia, neuropathy, and multiple sclerosis, manifest with chronic pain.

OBJECTIVE

The aim of this study is to examine the number and type of tweets (original or retweet) related to chronic pain, as well as to analyze the emotions and compare the societal impact of the diseases under study.

METHODS

We investigated tweets posted between January 1, 2018, and December 31, 2022, by Twitter users in English and Spanish, as well as the generated retweets. Additionally, emotions were extracted from these tweets and their diffusion was analyzed. Furthermore, the topics most frequently discussed by users were collected.

RESULTS

A total of 72,874 tweets were analyzed, including 44,467 in English and 28,407 in Spanish. Paraplegia represented 23.3% with 16,461 of the classified tweets, followed by headache and fibromyalgia with 15,337 (21.7%) and 15,179 (21.5%) tweets, respectively. Multiple sclerosis generated 14,781 tweets (21%), and the fewest tweets were related to neuropathy with 8,830 tweets (12.5%). The results showed that the primary emotions extracted were "fear" and "sadness." Additionally, the reach and impact of these tweets were investigated through the generated retweets, with those related to headaches showing the highest interest and interaction among users.

CONCLUSION

Our results underscore the potential of leveraging social media for a better understanding of patients suffering from chronic pain and its impact on society. Among the most frequently encountered topics are those related to treatment, symptoms, or causes of the disease. Therefore, it is relevant to inform the patient to prevent misconceptions regarding their illness.

Quality of life and work productivity and activity impairment among online survey respondents with migraine across a range of headache frequency

Objective

This study aimed to describe the migraine burden and healthcare utilization in the context of headache frequency using nationwide claims data linked to online survey data previously collected in Japan.

Background

It has been shown that increase in headache frequency can impose greater impact on individuals' daily and social functioning, but migraine burden in those with low-frequency headaches remains largely unknown in Japan.

Methods

This post-hoc, observational study reported on 674 respondents who were working individuals and their family members aged 19-74 years, responded to an online questionnaire (response rate: 14.1% [21,704 responded/153,545 kencomⓇ registrants]), and were previously classified as having migraine. Disease burden in terms of Migraine-Specific Quality of Life (MSQ) and Work Productivity and Activity Impairment (WPAI) was compared across 0-3, 4-7, 8-14, and ≥ 15 monthly headache days (MHD).

Results

Among 674 respondents, 419 (62.2%), 148 (22.0%), 61 (9.1%), and 46 (6.8%) had 0-3, 4-7, 8-14, and ≥ 15 MHD, respectively. Of those, 55 (13.1%), 31 (20.9%), 19 (31.1%), and 20 (43.5%) respondents consulted physicians for headaches. Moderate-to-severe impairments in daily activities were reported by 298 (71.1%), 110 (74.3%), 46 (75.4%), and 38 (82.6%) respondents. The proportion of the respondents with WPAI >0% generally increased with increasing headache frequency (presenteeism: 41.7 and 67.5% in respondents with 0-3 and ≥ 15 MHD, respectively; overall work impairment: 44.8 and 72.5%, respectively; and activity impairment: 44.9 and 73.9%, respectively), except for absenteeism (12.4 and 22.5%, respectively). The mean MSQ score declined with increasing MHD (Role function-restrictive: 75.1 and 59.5 in those with 0-3 and ≥ 15 MHD, respectively; Role function-preventive: 85.8 and 75.0, respectively; and Emotional function: 81.9 and 63.6, respectively).

Conclusion

Based on the Japanese nationwide claims data, quality of life and work productivity decreased with increasing numbers of headache days. Substantial disease burden paired with low levels of healthcare utilization highlights the need for medical or non-medical intervention.

Headache/migraine-related stigma, quality of life, disability, and most bothersome symptom in adults with current versus previous high-frequency headache/migraine and medication overuse: results of the Migraine Report Card survey

BACKGROUND

High-frequency headache/migraine (HFM) and overuse of acute medication (medication overuse [MO]) are associated with increased disability and impact. Experiencing both HFM and MO can potentially compound impacts, including stigma; however, evidence of this is limited. The objective of this report was to evaluate self-reported stigma, health-related quality of life (HRQoL), disability, and migraine symptomology in US adults with HFM + MO from the Harris Poll Migraine Report Card survey.

METHODS

US adults (≥ 18 yrs., no upper age limit) who screened positive for migraine per the ID Migraine™ screener completed an online survey. Participants were classified into "current HFM + MO" (≥ 8 days/month with headache/migraine and ≥ 10 days/month of acute medication use over last few months) or "previous HFM + MO" (previously experienced HFM + MO, headaches now occur ≤ 7 days/month with ≤ 9 days/month of acute medication use). Stigma, HRQoL, disability, and most bothersome symptom (MBS) were captured. The validated 8-item Stigma Scale for Chronic Illnesses (SSCI-8) assessed internal and external stigma (scores ≥ 60 are clinically significant). Raw data were weighted to the US adult population. Statistically significant differences were determined by a standard t-test of column proportions and means at the 90% (p < 0.1) and 95% (p < 0.05) confidence levels.

RESULTS

Participants (N = 550) were categorized as having current (n = 440; mean age 41.1 years; 54% female; 57% White, not Hispanic; 24% Hispanic; 11% Black, not Hispanic) or previous (n = 110; mean age 47.2 years; 49% female; 75% White, not Hispanic; 13% Hispanic; 4% Black, not Hispanic) HFM + MO. Compared to those with previous HFM + MO (21%), adults with current HFM + MO were more likely to experience clinically significant levels of stigma (47%). Men with current HFM + MO (52% compared to men with previous HFM + MO [25%] and women with current [41%] or previous [18%] HFM + MO), non-Hispanic Black (51% compared to White, not Hispanic [45%] and Hispanic [48%] current HFM + MO groups and White, not Hispanic previous HFM + MO [12%]), current HFM + MO aged 18-49 years (50% compared to those with current HFM + MO aged ≥ 50 years [33%] and those with previous HFM + MO aged 18-49 [34%] and ≥ 50 years [4%]), and employed respondents (53% current and 29% previous compared to those not employed [32% current and 12% previous]) reported higher rates of clinically significant stigma. Those with current HFM + MO were more likely to have worse HRQoL and disability due to headache/migraine. Respondents aged ≥ 50 years with current HFM + MO were more likely than respondents aged 18-49 years with current HFM + MO to indicate that their overall quality of life (66% vs. 52%) and their ability to participate in hobbies/activities they enjoy were negatively impacted by headache/migraine (61% vs. 49%). Pain-related symptoms were identified as the MBS.

CONCLUSIONS

Together these data suggest that current and previous HFM + MO can be associated with undesirable outcomes, including stigma and reduced HRQoL, which were greatest among people with current HFM + MO, but still considerable for people with previous HFM + MO.

Global, regional, and national burden and trends of migraine among women of childbearing age from 1990 to 2021: insights from the Global Burden of Disease Study 2021

BACKGROUND

Migraine, a neurological disorder with a significant female predilection, is the leading cause of disability-adjusted life years (DALYs) in women of childbearing age (WCBA). There is currently a lack of comprehensive literature analysis on the overall global burden and changing trends of migraines in WCBA.

METHODS

This study extracted three main indicators, including prevalence, incidence, and DALYs, related to migraine in WCBA from the Global Burden of Disease(GBD) database from 1990 to 2021. Our study presented point estimates with 95% uncertainty intervals (UIs). It evaluated the changing trends in the burden of migraine in WCBA using the estimated annual percentage change (EAPC) and percentage change.

RESULTS

In 2021, the global prevalence, incidence, and DALYs cases of migraine among WCBA were 493.94 million, 33.33 million, and 18.25 million, respectively, with percentage changes of 48%, 43%, and 47% compared to 1990. Over the past 32 years, global prevalence rates and DALYs rates globally have increased, with an EAPC of 0.03 (95% UI: 0.02 to 0.05) and 0.04 (95% UI: 0.03 to 0.05), while incidence rates have decreased with an EAPC of -0.07 (95% UI: -0.08 to -0.05). Among the 5 Socio-Demographic Index (SDI) regions, in 2021, the middle SDI region recorded the highest cases of prevalence, incidence, and DALYs of migraine among WCBA, estimated at 157.1 million, 10.56 million, and 5.81 million, respectively, approximately one-third of the global total. In terms of age, in 2021, the global incidence cases for the age group 15-19 years were 5942.5 thousand, with an incidence rate per 100,000 population of 1957.02, the highest among all age groups. The total number of migraine cases and incidence rate among WCBA show an increasing trend with age, particularly in the 45-49 age group.

CONCLUSIONS

Overall, the burden of migraine among WCBA has significantly increased globally over the past 32 years, particularly within the middle SDI and the 45-49 age group. Research findings emphasize the importance of customized interventions aimed at addressing the issue of migraines in WCBA, thus contributing to the attainment of Sustainable Development Goal 3 set by the World Health Organization.

A mixed-method systematic review of the perspectives of young people, carers and professionals on psychiatric diagnosis in childhood and adolescence

PROBLEM

The significance and complexities of a psychiatric diagnosis have been well-documented in existing literature. Despite the reliability and accuracy of such diagnoses, the impact and use of diagnostic labelling on young people remains unclear.

METHODS

A systematic review was conducted using six databases, identifying 13 studies that explored psychiatric diagnosis experiences in professionals, caregivers, and young people.

FINDINGS

This review focuses on three main themes related to psychiatric diagnosis in young people. The first theme is diagnostic subjectivity, which explores the accuracy, usefulness, potential harm and alternatives (e.g. psychological formulation) to psychiatric diagnosis in this population. The second theme is the utility of psychiatric diagnosis, which considers whether it helps young people access appropriate support and gain a better understanding of themselves and their presenting issues. The third theme is stigma, which examines the negative experiences and discrimination that young people may face due to their psychiatric diagnosis.

CONCLUSIONS

There is relatively limited literature which discusses the experience of psychiatric diagnosis in young people, caregivers and professionals. The available literature is difficult to compare due to discrepancies between methodologies and services, and there are several gaps i.e. a limited focus on the experience of young people themselves. Different views and experiences of psychiatric diagnosis among professionals, caregivers, and young people could impact young people's quality of life, access to healthcare, and identity development. The current literature needs to be more comprehensive to draw firm conclusions about young people's experiences with psychiatric diagnosis.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Internal stigmatization in patients with chronic migraine and medication overuse headache

OBJECTIVES

Internalized stigma can have profound effects on how individuals with migraines and other primary headache disorders see themselves and their quality of life. We aimed to investigate internalized stigma in patients with chronic migraines and medication overuse headaches.

METHODS

A total of 57 patients (52 women, 5 men) were included in the study, 26 of these patients were affected by chronic migraine, 31 of them were affected by medication overuse headache and chronic migraine. The Internalized Stigma Scale in Mental Illness (Ristsher's stigmatization scale) and General Health Questionnaire were applied to all patients.

RESULTS

In Ristsher's stigmatization scale, which measures internalization of stigma, internalized stigmatization was more significant in patients with medication overuse headache than in patients with chronic migraine compared to groups (p:0.05). The subtitle of alienation was statistically significant when the groups were compared to all subscales in the form of alienation, confirmation of stereotypes, perceived discrimination, social withdrawal and resistance to stigma (p:0.05).

DISCUSSION

Although internal stigmatize has been observed in chronic migraine patients, medication overuse headache is also a type of headache with intense stigma. In addition, this internal stigma perhaps plays an active role in the transformation of chronic migraine patients to medication overuse headaches patient.

Self-management Experience of Nurses Living with Migraine: A Qualitative Study

BACKGROUND

Migraine is a neurobiological condition characterized by a constellation of unpredictable symptoms and is the second cause of disability worldwide. Migraine is prevalent among nurses. However, literature exploring nurses' experience of living with migraine is scarce which has important individual and systems implications for health and wellness and patient safety. Self-management is essential in chronic disease management as the patient engages in various strategies to be able to live with their condition.

PURPOSE

This study explored the experiences of living and working with migraine among female nurses in Ontario, with particular attention to their priorities and strategies for self-management.

METHODS

Interpretive description methodology was employed to guide this study and informed a thematic analysis approach to examine the self-management experiences of nurses living with migraine.

RESULTS

Nurses engaged in various self-management strategies including pharmacological and non-pharmacological strategies and highlighted the role of technology in migraine self-management. Participants described experiences of living with migraine as an invisible condition including feelings of not being understood, stigmatization, and the absence of formal support at the workplace.

CONCLUSION

The implications of these findings support the incorporation of a critical approach to relational engagement that is person-centred including nonjudgemental, strength-based care as a practice approach when caring for persons living with migraines and the need to include experiential learning in educational curriculums as a strategy to reduce stigma against migraines.

Harris Poll Migraine Report Card: population-based examination of high-frequency headache/migraine and acute medication overuse

BACKGROUND

Migraine is a disabling neurologic disease that can fluctuate over time in severity, frequency, and acute medication use. Harris Poll Migraine Report Card was a US population-based survey to ascertain quantifiable distinctions amongst individuals with current versus previous high-frequency headache/migraine and acute medication overuse (HFM+AMO). The objective of this report is to compare self-reported experiences in the migraine journey of adults with HFM+AMO to those who previously experienced HFM+AMO but currently have a sustained reduction in headache/migraine frequency and acute medication use.

METHODS

An online survey was available to a general population panel of adults (≥18 years) with migraine per the ID Migraine™ screener. Respondents were classified into "current HFM+AMO" (within the last few months had ≥8 headache days/month and ≥10 days/month of acute medication use; n=440) or "previous HFM+AMO" (previously had HFM+AMO, but within the last few months had ≤7 headache days/month and ≤9 days/month of acute medication use; n=110). Survey questions pertained to demographics, diagnosis, living with migraine, healthcare provider (HCP) communication, and treatment.

RESULTS

Participants in the current HFM+AMO group had 15.2 monthly headache days and 17.4 days of monthly acute medication use in last few months compared to 4.2 and 4.1 days for the previous HFM+AMO group, respectively. Overall, current preventive pharmacologic treatment use was low (15-16%; P>0.1 for current vs previous) in both groups. Previous HFM+AMO respondents reported better current acute treatment optimization. More respondents with current (80%) than previous HFM+AMO (66%) expressed concern with their current health (P<0.05). More than one-third of both groups wished their HCP better understood their mental/emotional health (current 37%, previous 35%; P>0.1 for current vs previous) and 47% (current) to 54% (previous) of respondents worried about asking their HCP too many questions (P>0.1 for current vs previous).

CONCLUSION

Apart from optimization of acute medication, medical interventions did not significantly differentiate between the current and previous HFM+AMO groups. Use of preventive pharmacological medication was low in both groups. Adults with current HFM+AMO more often had health concerns, yet both groups expressed concerns of disease burden. Optimization of acute and preventive medication and addressing mental/emotional health concerns of patients are areas where migraine care may impact outcomes regardless of their disease burden.

Migraine-Related Stigma and Its Relationship to Disability, Interictal Burden, and Quality of Life: Results of the OVERCOME (US) Study

BACKGROUND AND OBJECTIVES

This population-based analysis characterizes the relative frequency of migraine-related stigma and its cross-sectional relationship to migraine outcomes. We hypothesized that migraine-related stigma would be inversely associated with favorable migraine outcomes across headache day categories.

METHODS

OVERCOME (US) is a web-based observational study that annually recruited a demographically representative US sample and then identified people with active migraine using a validated migraine diagnostic questionnaire. It also assessed how frequently respondents experienced migraine-related stigma using a novel 12-item questionnaire (Migraine-Related Stigma, MiRS) that contained 2 factors; feeling that others viewed migraine as being used for Secondary Gain (8 items, α = 0.92) and feeling that others were Minimizing disease Burden (4 items, α = 0.86). We defined 5 groups: (1) MiRS-Both (Secondary Gain and Minimizing Burden often/very often; (2) MiRS-SG (Secondary Gain often/very often); (3) MiRS-MB (Minimizing Burden often/very often); (4) MiRS-Rarely/Sometimes; (5) MiRS-Never. Using MiRS group as the independent variable, we modeled its cross-sectional relationship to disability (Migraine Disability Assessment, MIDAS), interictal burden (Migraine Interictal Burden Scale-4), and migraine-specific quality of life (Migraine Specific Quality of Life v2.1 Role Function-Restrictive) while controlling for sociodemographics, clinical features, and monthly headache day categories.

RESULTS

Among this population-based sample with active migraine (n = 59,001), mean age was 41.3 years and respondents predominantly identified as female (74.9%) and as White (70.1%). Among respondents, 41.1% reported experiencing, on average, ≥4 monthly headache days and 31.7% experienced migraine-related stigma often/very often; the proportion experiencing migraine-related stigma often/very often increased from 25.5% among those with <4 monthly headache days to 47.5% among those with ≥15 monthly headache days. The risk for increased disability (MIDAS score) was significant for each MiRS group compared with the MiRS-Never group; the risk more than doubled for the MiRS-Both group (rate ratio 2.68, 95% CI 2.56-2.80). For disability, interictal burden, and migraine-specific quality of life, increased migraine-related stigma was associated with increased disease burden across all monthly headache day categories.

DISCUSSION

OVERCOME (US) found that 31.7% of people with migraine experienced migraine-related stigma often/very often and was associated with more disability, greater interictal burden, and reduced quality of life.

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

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

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.

Headache disorders and relevant sex and socioeconomic patterns in adolescents and young adults across 204 countries and territories: an updated global analysis

BACKGROUND

Primary headache disorders are a group of highly prevalent and disabling neurological diseases that mainly consist of migraine and tension-type headache (TTH). A previous study showed that the burden of headaches peaked at a working age that ranged from 15 to 49, particularly among females, affecting their productivity and severely damaging their social interactions.

METHODS

The latest dataset was retrieved from the Global Burden of Disease (GBD) Study 2019. Three indicators, including prevalence, incidence, and years lived with disability (YLDs), were adopted for evaluation. The overall and specific headache burdens were fully compared and analysed at global, regional, and national levels. The ratio of female YLD rates to male YLD rates due to headaches was calculated to estimate the sex pattern. Finally, we utilized the two-tailed Spearman test to explore the potential association between socioeconomic background and headaches among young people.

RESULTS

Globally, for overall headache disorders, a total of 2,049,979,883 prevalent cases (95% uncertainty interval (UI): 1,864,148,110 to 2,239,388,034), 601,229,802 incident cases (95% UI: 530,329,914 to 681,007,934), and 38,355,993 YLDs (95% UI: 7,259,286 to 83,634,503) were observed for those aged 10 to 54 in 2019. Sex differences were widely found for all headache types among adolescents and young adults, especially migraine. However, the most interesting finding was that the associations we tested between the socioeconomic environment and young headache patients were positive, regardless of region or specific country or territory.

CONCLUSIONS

Overall, the global burden of headaches in adolescents and young adults largely increased from 1990 to 2019. Although slight declines were observed in sex differences, they remained significant and challenging. The positive correlations between headache and socioeconomic background among young people were relatively inconsistent with previous investigations, and several related hypotheses were proposed for explanation. Interdisciplinary actions involving education, policy- and law-making, and basic medical practice are desperately needed to further fight against the headache burden, promote gender equality in headache care, and eliminate the stigmatization of headache patients in student and working groups.

Current state of headache training within Canadian Neurology Residency program: a national survey

BACKGROUND

Headache disorders are the most common neurological disorders worldwide. Despite their widespread prevalence and importance, the topic of headache is inconsistently taught at both the undergraduate and postgraduate levels. The goal of this study is to establish a better picture of the current state of Headache Medicine (HM) training in Neurology postgraduate programs in Canada and describe the impact of the current pandemic on training in this domain.

METHODS

Online surveys were sent to senior residents of adult Neurology programs in Canada. We also conducted telephone interviews with Neurology Program Directors. Descriptive statistics were analyzed, and thematic analysis was used to review free text.

RESULTS

A total of 36 residents, and 3 Program Directors participated in the study. Most of the teaching in HM is done by headache specialists and general neurology faculty. Formal teaching is mainly given during academic half day. Most of the programs expose their residents to Onabotulinum toxin A injections and peripheral nerve blocks, but they don't offer much formal teaching regarding these procedures. Residents consider HM teaching important and they would like to have more. They don't feel comfortable performing interventional headache treatments, despite feeling this should be part of the skillset of a general neurologist.

CONCLUSION

Our study is the first to establish the current state of headache teaching in post-graduate neurology programs as perceived by trainees and program directors in Canada. The current educational offerings leave residents feeling poorly prepared to manage headaches, including procedural interventions. There is a need to diversify the source of teaching, so the educational burden doesn't lie mostly upon Headache specialists who are already in short supply. Neurology Residency programs need to adapt their curriculum to face the current need in HM.

Advocacy for patients with headache disorders

Primary headache disorders are worldwide highly prevalent and burdensome and should be therefore considered as a global public health priority. However, too many patients with primary headache disorders still do not receive satisfying care. The most likely identified reasons for such a scenario - lack of public awareness, stigma, lack of trained professionals with inadequate healthcare systems and policies - are remediable. Despite the progresses that were made in headache advocacy, these efforts have not yielded substantial improvements in research funding or access to specialty care and even standards of care. The situation is more complex in Low and Middle Income Countries (LMICs) where headache advocacy is urgently needed given the magnitude of the difficulties that patients with primary headache disorders face in accessing care. The growing emergence of coordinated, collaborative, patient-centered advocacy efforts with improved patient-clinician partnership is an opportunity to enhance progress in advocacy for a satisfying life and optimal and equitable care for people with primary headache disorders. LMICs can benefit greatly from coordinating these efforts on a global scale. The recent organization of a training program on headache diagnosis and management for healthcare professionals in Africa is a concrete example.

Psychological Approaches for Migraine Management

Migraine headaches are among the most prevalent and disabling pain conditions worldwide. Best-practice migraine management is multidisciplinary and includes the psychological approaches to address cognitive, behavioral, and affective factors that worsen pain, distress, and disability. The psychological interventions with the strongest research support are relaxation strategies, cognitive-behavioral therapy, and biofeedback, though the quality of clinical trials for all psychological interventions needs continued improvement. The efficacy of psychological interventions may be improved by validating technology-based delivery systems, developing interventions for trauma and life stress, and precision medicine approaches matching treatments to patients based on specific clinical characteristics.

Migraine and the Gender Divide

Migraine is a global neurologic disease that is highly prevalent, especially in women. Studies have observed a predisposition for the development of migraine in women, although the mechanisms involved have yet to be fully elucidated. This review aimed to summarize the recent evidence regarding the epidemiology, pathophysiology, and treatment of migraine and highlight key sex differences. We also identify gaps in care for both women and men living with migraine and discuss the presence of migraine-related stigma and how this may impact the efficacy of clinical care.

The Migraine Stigma Kaleidoscope View

The stigma of migraine, despite an impressive body of data on the epidemiological of migraine and the associated disability, burden and cost of migraine to patients, has not been fully evaluated as an important factor in the chronicization of the disease and social isolation of the patient. In this commentary, we present three points of view. From the point of view of a European advocacy body active in the field of migraine medicine, actions to improve the perception of migraine within the community regarding the stigma for people with migraine are presented at the personal, relational and occupational levels. From the point of view of a clinician who is an expert on migraine, proposals are made for treatment and rehabilitation paths specifically dedicated to the reintegration of these individuals into social contexts.

Safety, tolerability, and efficacy of zavegepant 10 mg nasal spray for the acute treatment of migraine in the USA: a phase 3, double-blind, randomised, placebo-controlled multicentre trial

BACKGROUND

Intranasal formulations can provide treatment options for people with migraine in whom oral drugs are ineffective, slow-acting, or intolerable because of nausea and vomiting. Zavegepant, an intranasally administered small molecule calcitonin gene-related peptide (CGRP) receptor antagonist, was previously assessed in a phase 2/3 trial. This phase 3 trial aimed to compare the efficacy, tolerability, safety, and timecourse of response for zavegepant nasal spray with placebo in the acute treatment of migraine.

METHODS

This double-blind, randomised, placebo-controlled, multicentre phase 3 trial, conducted at 90 academic medical centres, headache clinics, and independent research facilities in the USA, recruited adults (aged ≥18 years) with a history of two to eight moderate or severe migraine attacks per month. Participants were randomly assigned (1:1) to zavegepant 10 mg nasal spray or matching placebo and self-treated a single migraine attack of moderate or severe pain intensity. Randomisation was stratified by the use or non-use of preventive medication. Study centre personnel entered eligible participants into the study using an interactive web response system that was operated and managed by an independent contract research organisation. All participants, investigators, and the funder were masked to group assignment. The coprimary endpoints, freedom from pain and freedom from the most bothersome symptom at 2 h after the treatment dose, were assessed in all randomly assigned participants who took the study medication, had a migraine attack of moderate or severe pain intensity at baseline, and provided at least one evaluable post-baseline efficacy datapoint. Safety was analysed in all randomly assigned participants who received at least one dose. The study is registered with ClinicalTrials.gov, number NCT04571060, and is closed to accrual.

FINDINGS

Between Oct 27, 2020, and Aug 20, 2021, 1978 participants were recruited and assessed for eligibility. 1405 participants were eligible (703 were assigned to zavegepant and 702 to placebo), and 1269 were included in the efficacy analysis set (623 in the zavegepant group and 646 in the placebo group). 2 h after the treatment dose, more participants in the zavegepant group than in the placebo group had pain freedom (147 [24%] of 623 participants vs 96 [15%] of 646 participants, risk difference 8·8 percentage points, 95% CI 4·5-13·1; p<0·0001) and freedom from their most bothersome symptom (247 [40%] vs 201 [31%], risk difference 8·7 percentage points, 3·4-13·9; p=0·0012). The most common adverse events in either treatment group (≥2%) were dysgeusia (129 [21%] of 629 in the zavegepant group vs 31 [5%] of 653 in the placebo group), nasal discomfort (23 [4%] vs five [1%]), and nausea (20 [3%] vs seven [1%]). No signal of hepatotoxicity due to zavegepant was identified.

INTERPRETATION

Zavegepant 10 mg nasal spray was efficacious in the acute treatment of migraine, with favourable tolerability and safety profiles. Additional trials are needed to establish the long-term safety and consistency of effect across attacks.

FUNDING

Biohaven Pharmaceuticals.

Characterizing healthcare utilization patterns in a Danish population with headache: results from the nationwide headache in Denmark (HINDER) panel

INTRODUCTION

Worldwide, far from all of those who would benefit make use of headache services, largely because of clinical, social, and political barriers to access. Identifying the factors contributing to low healthcare utilization can generate evidence to guide health policy. Our purpose here is better to characterize healthcare utilization patterns in Denmark.

METHODS

The Headache in Denmark (HINDER) study is a nationwide cross-sectional survey of people with headache, conducted using SurveyXact (Rambøll Group A/S, Copenhagen). Healthcare utilization was assessed in a study sample generated by population screening and recruitment. Data collection occurred over two weeks, from September 23^rd until October 4^th, 2021. The questions enquired into disease characteristics, management, burden, medication intake and healthcare utilization.

RESULTS

The number of participants included in the HINDER panel was 4,431, with 2,990 (67.5%: 2,522 [84.3%] female, 468 [15.7%] male; mean age 40.9 ± 11.6 years) completing the survey. One quarter of participants (27.7%) disagreed or strongly disagreed that they were able to manage their headache attacks. Most participants (81.7%) agreed or strongly agreed that their headache was a burden in their everyday lives. The most reported acute medications, by 87.2% of participants, were simple analgesics; of note, 8.6% reported using opioids for their headache. One quarter of participants (24.4%) had never consulted a medical doctor for their headache; one in six (16.5%: more than two thirds of the 24.4%) had never done so despite agreeing or strongly agreeing that their headache was a burden in their everyday lives. Two thirds (65.3%) of participants overall, and almost three quarters (72.4%) of those with weekly headache, had tried one or more complementary or alternative therapies outside conventional medical care.

CONCLUSIONS

Our findings are indicative of inadequate delivery of headache care in a country that provides free and universal coverage for all its residents. The implications are twofold. First, it is not sufficient merely to make services available: public education and increased awareness are necessary to encourage uptake by those who would benefit. Second, educational interventions in both pre- and postgraduate settings are necessary, but a prerequisite for these is a resetting of policy priorities, properly to reflect the very high population ill-health burden of headache.

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

OBJECTIVE

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Societal and personal impact of migraine

Migraine is one of the main causes of years lived with disability (YLDs) worldwide, as showed in the Global Burden of Diseases Study. Its influence on patients' life is relevant and pervasive, with a specific impact on social, family, and work functioning, considering that migraine mainly affects adults under the age of 50. Several studies demonstrated that relations inside the family as well as in every social context are negatively influenced by migraine. According to the results of studies and surveys from different countries, patients' daily activities are often limited during migraine attacks, particularly in terms of performance in social and domestic activities and in terms of reduced productivity in work and school duties. Also an interictal burden is present. Migraineurs are conditioned by the fear of the next attack, often suffer from comorbid conditions such as anxiety and depression, and are subject to different forms of stigma. Consequently, migraine implies relevant costs for the individuals and for society, with higher figures for indirect costs (related to reduced participation and to limited productivity) than indirect costs (related to drugs, medical visits, examinations, and hospitalization).

The not so hidden impact of interictal burden in migraine: A narrative review

Migraine is a highly prevalent neurological disease of varying attack frequency. Headache attacks that are accompanied by a combination of impact on daily activities, photophobia and/or nausea are most commonly migraine. The headache phase of a migraine attack has attracted more research, assessment tools and treatment goals than any other feature, characteristic, or phase of migraine. However, the migraine attack may encompass up to 4 phases: the prodrome, aura, headache phase and postdrome. There is growing recognition that the burden of migraine, including symptoms associated with the headache phase of the attack, may persist between migraine attacks, sometimes referred to as the "interictal phase." These include allodynia, hypersensitivity, photophobia, phonophobia, osmophobia, visual/vestibular disturbances and motion sickness. Subtle interictal clinical manifestations and a patient's trepidation to make plans or commitments due to the unpredictability of migraine attacks may contribute to poorer quality of life. However, there are only a few tools available to assess the interictal burden. Herein, we examine the recent advances in the recognition, description, and assessment of the interictal burden of migraine. We also highlight the value in patients feeling comfortable discussing the symptoms and overall burden of migraine when discussing migraine treatment needs with their provider.

The unique role of stigma in migraine-related disability and quality of life

BACKGROUND

Stigma is increasingly recognized as an important social feature of living with migraine.

METHODS

Adults with migraine recruited from neurology offices completed the validated Stigma Scale for Chronic Illnesses 8-item version (SSCI-8); two outcome measures (the Migraine Disability Assessment [MIDAS] and the Migraine-Specific Quality of Life Questionnaire v 2.1 [MSQ]); and measures of allodynia (Allodynia Symptom Checklist [ASC-12]), pain cognition (Pain Catastrophizing Scale [PCS]), and psychiatric symptoms (Patient Reported Measurement Information System Anxiety [PROMIS-A] and Depression [PROMIS-D]). Pearson and Spearman correlations evaluated bivariate relationships, and linear (MSQ) and logistic (MIDAS Severe Disability, scores ≥21) regressions evaluated the unique variance associated with SSCI-8 beyond other study variables. Conditional process analysis evaluated mediation hypotheses between study variables.

RESULTS

Participants (n = 121) reported levels of stigma on par with other chronic illnesses (SSCI-8 M = 53.0, standard deviation [SD] = 7.8), with 25/127 (19.6%) reporting clinically significant levels of stigma (SSCI-8 T-score ≥ 60). Higher SSCI-8 scores were associated with higher monthly headache day frequency (r = 0.35), MIDAS (ρ = 0.41), ASC-12 (r = 0.24, p < 0.01), PCS (r = 0.46), both PROMIS-A (r = 0.43) and D (r = 0.42), and lower MSQ subscale scores (Role Restriction r = -0.50; Role Prevention r = -0.48; Emotion Function r = -0.50), all ps <0.001 unless otherwise noted. The SSCI-8 contributed significantly beyond migraine symptoms and other psychological factors for MSQ Emotion Function (5% unique variance) and MIDAS Severe Disability (6% of unique variance). The SSCI-8 mediated relationships between headache frequency and the MSQ subscales and MIDAS Severe Disability. The PCS mediated relationships between the SSCI-8 and MSQ subscales. The PROMIS-D mediated relationships between the SSCI-8 and MSQ Role Restriction and MSQ Role Prevention.

CONCLUSIONS

Migraine stigma has medium to large associations with migraine outcomes and psychiatric symptoms and is independently associated with migraine disability and emotion-related quality of life. Migraine stigma is an important contributor to the relationship between headache frequency and migraine outcomes.

Impact of Asymptomatic Neurosyphilis on Patients Quality of Life and Social Stigma

Background/Objectives

Neurosyphilis is a disease caused by Treponema pallidum when it invades the central nervous system. Asymptomatic neurosyphilis (ANS) is one of the most common types of neurosyphilis, however it is often misdiagnosed. This study aimed to explore the impact of ANS on patient's quality of life and social stigma.

Methods

A total of 159 ANS patients were diagnosed by their serology and cerebrospinal fluid. These patients' stigma and quality of life were assessed separately through the Social Impact Scale (SIS) and the Easy Response Questionnaire.

Results

The average age was 36.25±8.36 years old, and 114 patients were males (71.69%). The serum syphilis test of 159 selected patients was positive, and the indicators of nucleus cells, protein quantification, and syphilis antibodies in the cerebrospinal fluid met the criteria for ANS. The total stigma score was (40.23 ±10.12), with the scores of the different entries being clearly differentiated, with the highest being the 15th entry (I feel I need to keep my illness a secret), with an average score of 3.15/4.

Conclusion

Patients with asymptomatic neurosyphilis may feel social stigma and are more negative when facing their disease. Health-care workers should be aware of the particular aspects of their condition and pay special attention to the need for patient privacy.

Quantity changes in acute headache medication use among patients with chronic migraine treated with eptinezumab: subanalysis of the PROMISE-2 study

Background

Patients with chronic migraine (CM) treated with eptinezumab in the PROMISE-2 trial achieved greater reductions in migraine and headache frequency, impact, and acute headache medication (AHM) use than did patients who received placebo. This post hoc analysis examines relationships between headache frequency reductions and changes in AHM use in patients in PROMISE-2.

Methods

PROMISE-2 was a double-blind, placebo-controlled trial conducted in adults with CM. Patients were randomized to eptinezumab 100 mg, 300 mg, or placebo, administered intravenously once every 12 weeks for up to two doses. Patients recorded headache/AHM information daily and for each event in an electronic diary; data from all days with daily reports were included. Shifts in headache frequency and AHM use were assessed in the three populations: total CM population, patients with CM and medication-overuse headache (MOH), and patients with CM and MOH who were ≥ 50% responders during treatment (response over weeks 1–24).

Results

A total of 1072 adults with CM received treatment (eptinezumab, n = 706; placebo, n = 366). Mean baseline headache frequency was 20.5 days; mean baseline AHM days was 13.4; 431 patients had MOH, of which 225 (52.2%) experienced ≥50% response over weeks 1–24. Relative to baseline, the proportion of days with both headache and AHM use decreased 25.1% (eptinezumab) versus 17.0% (placebo) in the total population (N = 1072), 29.2% versus 18.4% in the MOH subpopulation (n = 431), and 38.3% versus 31.5% in the CM with MOH population with ≥50% response subgroup (n = 225) during weeks 1–24. The proportion of days with headache and triptan use decreased 9.1% (eptinezumab) versus 5.8% (placebo), 11.8% versus 7.2%, and 14.5% versus 12.6%, respectively. Reductions in other AHM types were smaller.

Conclusions

In this post hoc analysis, eptinezumab use in patients with CM was associated with greater decreases in days with headache with AHM overall and with triptans in particular. The magnitude of effect was greater in the subgroup of CM patients with MOH and ≥ 50% response.

Trial registration

ClinicalTrials.gov Identifier: NCT02974153.

Graphical abstract

Eptinezumab reduces headache frequency and acute medication use in patients with chronic migraine.

Stigma and Chronic Pain

Stigma is defined by the World Health Organization (WHO) as "a mark of shame, disgrace or disapproval that results in an individual being rejected, discriminated against and excluded from participating in a number of different areas of society". Extensive literature searches have documented stigma in the context of health. Among the physical health conditions that are associated with stigma, chronic pain deserves particular attention. Stigma experienced by individuals with chronic pain affects their entire life. Literature identifies multiple dimensions or types of stigma, including public stigma, structural stigma and internalized stigma. Recent literature supports the biopsychosocial model of pain, according to which biological, psychological and sociocultural variables interact in a dynamic manner to shape an individual's response to chronic pain. Chronic pain affects a higher proportion of women than men around the world. There is an inadequate education of health care professionals regarding pain assessment and their insecurity to manage patients with chronic pain. A first-line intervention strategy could be to promote pain education and to expand knowledge and assessment of chronic pain, as recently highlighted for headache disorders, paradigmatically for resistant or refractory migraine, whose diagnosis, without an adequate education to understand the possible fluctuations of the disease, may have profound psychological implications with the idea of insolvability and contribute to stigmatizing the patient.

One-quarter of individuals with weekly headache have never consulted a medical doctor: a Danish nationwide cross-sectional survey

INTRODUCTION

Large numbers of people with headache who would benefit are not reached by headache services. Among the causes are poor or disorganized provision of headache services, but reluctance to seek healthcare has frequently been identified as a significant barrier. We conducted a national survey of people with headache to assess the extent of this problem in Denmark, a country with well organized, highly resourced, and readily accessible services.

METHODS

We conducted a nationwide cross-sectional survey of adults ≥ 18 years old in Denmark reporting at least one headache day in the last year. We used social media (Facebook) to publicize and drive a recruitment campaign. The survey investigated five items: (1) disease burden, (2) social life, (3) presenteeism, (4) social support, and (5) healthcare utilization.

RESULTS

We included 6,567 respondents from May 2021 to June 2021; 70.2% were female, 39.8% male, and mean age was 43.2 ± 13.4 years. Of the respondents, 54.2% reported headache at least once a week, 33.4% reported headache a couple of times a month, and 12.4% reported headache a couple of times a year. Two-thirds of respondents (66.6%) reported that headache limited their social lives occasionally or frequently. Most respondents (86.8%) reported going to work or attending educational activities occasionally or more frequently even though they had headache. Half of the respondents (49.5%) experienced lack of understanding of their headaches from people occasionally or more frequently. Almost half of respondents (43.7%) had never consulted a medical doctor for their headache; even of those with weekly headache, more than a quarter (28.3%) had never done so in their lifetimes.

CONCLUSIONS

Headache disorders continue to be a problem, even in a high-income country with free and easily accessible headache services. Further studies are needed to investigate and clarify why even people with the highest burden are hesitant to seek and make use of widely available headache services.