Headache care in China

Detection of calcitonin gene-related peptide based on increased antigen-driven interaction with antibody variable regions

Introduction: Calcitonin gene-related peptide (CGRP) is involved in trigeminal neuralgia and migraine, and measuring the CGRP concentration in the serum is crucial for the early prediction of these conditions. Current methods for CGRP detection are primarily radioimmunoassay, which needs radioactive substances and enzyme-linked immunosorbent assays (ELISAs) which need long detection time and some have a narrow detection range. Methods: The genes of anti-CGRP antibody variable regions were cloned into pDong1 vector to obtain pDong1/Fab-CGRP, with which phage-Fab was prepared, and the concentration of CGRP was detected by competitive ELISA. The pDong1/Fab-CGRP was modified to obtain pDong1/OS-CGRP, with which the co-expression solution containing phage-displayed heavy chain variable fragments (phage-VH) and light chain was obtained. CGRP was detected by OS-ELISA based on phage-VH, antibody light chain, and anti-light chain antibody. The VL gene was cloned into the pMAL vector to obtain pMAL-VL (CGRP), with which maltose binding protein fused with VL (MBP-VL) was prepared. CGRP was detected by OS-ELISA employing MBP-VL and phage-VH. Results: OS-ELISAs that measure the CGRP concentration by quantifying the interaction between variable regions were investigated. OS-ELISA using phage-VH and secreted light chains in the same culture system exhibited a limit of detection (LOD) of 0.05 nM, offering higher sensitivity than competitive assay with an LOD of 0.75 nM, whereas using phage-VH and separately prepared MBP-VL exhibited an LOD of 0.15 nM and a broader detection range of 0.15-500 nM than competitive ELISA, whose detection range was 0.75-10 nM. Discussion: The combination of the two OS assays achieved high sensitivity and a broad detection range for CGRP, which may have significance in clinical applications.

Rimegepant orally disintegrating tablet 75 mg for acute treatment of migraine in adults from China: a subgroup analysis of a double-blind, randomized, placebo-controlled, phase 3 clinical trial

BACKGROUND

Rimegepant orally disintegrating tablet (ODT), an oral small-molecule calcitonin gene-related peptide receptor antagonist, is indicated for acute and preventive treatment of migraine in the United States and other countries. Previously, a large clinical trial assessed the efficacy and safety of rimegepant ODT 75 mg for the acute treatment of migraine in adults living in China or South Korea. A post hoc subgroup analysis of this trial was performed to evaluate the efficacy and safety of rimegepant for acute treatment of migraine in adults living in China.

METHODS

Eligible participants were ≥ 18 years of age and had a ≥ 1-year history of migraine, with 2 to 8 attacks of moderate or severe pain intensity per month and < 15 headache days per month during the 3 months before screening. Participants self-administered rimegepant ODT 75 mg or matching placebo to treat a single migraine attack of moderate or severe pain intensity. The co-primary endpoints were pain freedom and freedom from the most bothersome symptom (MBS) at 2 h post-dose. Key secondary endpoints included pain relief at 2 h post-dose, ability to function normally at 2 h post-dose, use of rescue medication within 24 h post-dose, and sustained pain freedom from 2 to 24 h and 2 to 48 h post-dose. All p values were nominal. Safety was assessed via treatment-emergent adverse events (TEAEs), electrocardiograms, vital signs, and routine laboratory tests.

RESULTS

Overall, 1075 participants (rimegepant, n = 538; placebo, n = 537) were included in the subgroup analysis. Rimegepant was more effective than placebo for the co-primary endpoints of pain freedom (18.2% vs. 10.6%, p = 0.0004) and freedom from the MBS (48.0% vs. 31.8%, p <  0.0001), as well as all key secondary endpoints. The incidence of TEAEs was comparable between the rimegepant (15.2%) and placebo (16.4%) groups. No signal of drug-induced liver injury was observed, and no study drug-related serious TEAEs were reported in the rimegepant group.

CONCLUSIONS

A single dose of rimegepant 75 mg rimegepant was effective for the acute treatment of migraine in adults living in China, with safety and tolerability similar to placebo.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04574362 Date registered: 2020-10-05.

Association between migraine and cardiovascular disease mortality: A prospective population-based cohort study

OBJECTIVE

The study assessed the association between migraine and cardiovascular disease (CVD) mortality in the US population.

BACKGROUND

Previous studies have drawn different conclusions about the association between migraine and CVD mortality based on different populations; therefore, it is important to explore the relationship between migraine and CVD mortality in the US population.

METHODS

This prospective cohort study included 10,644 participants from the National Health and Nutrition Examination Survey (NHANES) 1999-2004. Participants who reported having severe headache or migraine were classified as having migraine. Mortality data were obtained by linkage of the cohort database to the National Death Index as of December 31, 2019. Based on the International Classification of Diseases, Tenth Revision, CVD mortality includes the following disease codes: I00-I09 (acute rheumatic fever and chronic rheumatic heart diseases), I11 (hypertensive heart disease), I13 (hypertensive heart and renal disease), I20-I25 (ischemic heart diseases), I26-I28 (pulmonary embolism and other acute pulmonary heart diseases), I29 (various cardiovascular diseases caused by different reasons), I30-I51 (other forms of heart disease), and I60-I69 (cerebrovascular diseases). Data were analyzed from October to November 2022.

RESULTS

Among 10,644 adults included in the study (mean age, 46.4 [0.3] years, 5430 men [47.4%]), 2106 (20.4%) had migraine. During a median follow-up period of 201 months, there were 3078 all-cause deaths and 997 CVD deaths. Compared to individuals without migraine, those with migraine had an adjusted hazard ratio (HR) of 1.30 (95% confidence interval [CI], 1.04-1.62; p = 0.019) for CVD mortality and 1.23 (95% CI, 1.13-1.35; p < 0.001) for all-cause mortality. In subgroup analyses, migraine was associated with CVD mortality in participants who were women (HR, 1.43; 95% CI, 1.06-1.93), aged < 45 years (HR, 1.69; 95% CI, 1.04-2.76), non-Hispanic White (HR, 1.42; 95% CI, 1.09-1.86), those with a body mass index < 30 kg/m2 (HR, 1.36; 95% CI, 1.03-1.78), former or current smokers (HR, 1.36; 95% CI, 1.00-1.85), former or current alcohol drinkers (HR, 1.33; 95% CI, 1.03-1.72), and those without metabolic syndrome (HR, 1.31; 95% CI, 1.01-1.71). The association between migraine and CVD mortality was robust in sensitivity analyses, after excluding participants who died within 2 years of follow-up (HR, 1.31; 95% CI, 1.05-1.65) or those with a history of cancer at baseline (HR, 1.28; 95% CI, 1.01-1.62).

CONCLUSIONS

Migraine was associated with a higher CVD mortality rate in the US population.

Status of diagnosis and preventative treatment for primary headache disorders: real-world data of unmet needs in China

BACKGROUND

Headache disorders are widely prevalent and pose a considerable economic burden on individuals and society. Globally, misdiagnosis and inadequate treatment of primary headache disorders remain significant challenges, impeding the effective management of such conditions. Despite advancements in headache management over the last decade, a need for comprehensive evaluations of the status of primary headache disorders in China regarding diagnosis and preventative treatments persists.

METHODS

In the present study, we analyzed the established queries in the Survey of Fibromyalgia Comorbidity with Headache (SEARCH), focusing on previous diagnoses and preventative treatment regimens for primary headache disorders. This cross-sectional study encompassed adults diagnosed with primary headache disorders who sought treatment at 23 hospitals across China between September 2020 to May 2021.

RESULTS

The study comprised 2,868 participants who were systematically examined. Migraine and tension-type headaches (TTH) constituted a majority of the primary headache disorders, accounting for 74.1% (2,124/2,868) and 23.3% (668/2,868) of the participants, respectively. Medication overuse headache (MOH) affected 8.1% (231/2,868) of individuals with primary headache disorders. Over half of the individuals with primary headache disorders (56.6%, 1,624/2,868) remained undiagnosed. The previously correct diagnosis rates for migraine, TTH, TACs, and MOH were 27.3% (580/2,124), 8.1% (54/668), 23.2% (13/56), and 3.5% (8/231), respectively. The misdiagnosis of "Nervous headache" was found to be the most prevalent among individuals with migraine (9.9%, 211/2,124), TTH (10.0%, 67/668), trigeminal autonomic cephalalgias (TACs) (17.9%, 10/56), and other primary headache disorders (10.0%, 2/20) respectively. Only a minor proportion of individuals with migraine (16.5%, 77/468) and TTH (4.7%, 2/43) had received preventive medication before participating in the study.

CONCLUSIONS

While there has been progress made in the rate of correct diagnosis of primary headache disorders in China compared to a decade ago, the prevalence of misdiagnosis and inadequate treatment of primary headaches remains a veritable issue. As such, focused efforts are essential to augment the diagnosis and preventive treatment measures related to primary headache disorders in the future.

Telemedicine efficacy and satisfaction of patients and headache specialists in migraine management

Background

Migraine follow-up is difficult for outpatients, especially after the COVID-19 pandemic, we tried to identify the most appropriate telemedicine methods for migraine in terms of efficacy, safety, patient compliance, and patient and physician satisfaction.

Methods

Migraine patients were screened from the Headache Center of the First Affiliated Hospital of Chongqing Medical University from September 2019 to December 2021 and randomly classified into an outpatient group and four telemedicine groups: social software, telephone, E-mail, and short message. Headache specialists followed up with the patients 3 and 6 months after their visit and asked about their satisfaction with the follow-up in each instance, as were the headache specialists.

Results

A total of 147 migraine patients were included, of whom 65 completed the follow-up. After 3 and 6 months of follow-up, the proportion of patients whose monthly headache frequency decreased by over 50% in the social-software, telephone, and E-mail groups was no different from that in the outpatient group. A similar result was obtained from evaluations with the Visual Analog Scale, the Headache Impact Test and the Migraine Disability Assessment compared with baseline in social software and telephone groups. The compliance in social-software group was not worse than that in the outpatient group. The proportion of patients in the E-mail group who completed the follow-up and the proportion of patients in the telephone group who consistently took preventive medication were significantly lower than those in the outpatient group. After 6 months, the majority of patients in the outpatient, social-software, and telephone groups and headache specialists in the outpatient, social-software groups were satisfied with the follow-up, while fewer patients in the E-mail group and fewer specialists in the telephone and E-mail group showed their satisfaction.

Conclusion

Compared with outpatient visits, it is safe and effective to use social software and telephone to follow up on migraine patients, and E-mail and short-message follow-up have lower feasibility. Migraine patients prefer social-software and telephone follow-up, while specialists prefer social-software follow-up.

The prevalence and clinical features of fibromyalgia in Chinese hospital patients with primary headache: The survey of fibromyalgia comorbid with headache

OBJECTIVE

The aims were to explore the prevalence and clinical features of fibromyalgia in Chinese hospital patients with primary headache.

BACKGROUND

Studies done in non-Chinese populations suggest that around one-third of patients with primary headache have fibromyalgia, but data from mainland China are limited. Investigations into the prevalence and clinical features of fibromyalgia in Chinese patients with primary headache would improve our understanding of these two complex disease areas and help guide future clinical practice.

METHODS

This cross-sectional study included adults with primary headache treated at 23 Chinese hospitals from September 2020 to May 2021. Fibromyalgia was diagnosed using the modified 2010 American College of Rheumatology criteria. Mood and insomnia were evaluated employing the Hospital Anxiety and Depression Scale and the Insomnia Severity Index.

RESULTS

A total of 2782 participants were analyzed. The fibromyalgia prevalence was 6.0% (166/2782; 95% confidence interval: 5.1%, 6.8%). Compared to primary headache patients without combined fibromyalgia, patients with primary headache combined with fibromyalgia were more likely to be older (47.8 vs. 41.7 years), women (83.7% [139/166] vs. 72.8% [1904/2616]), less educated (65.1% [108/166] vs. 45.2% [1183/2616]), and with longer-duration headache (10.0 vs. 8.0 years). Such patients were more likely to exhibit comorbid depression (34.3% [57/166] vs. 9.9% [260/2616]), anxiety (16.3% [27/166] vs. 2.7% [70/2612]), and insomnia (58.4% [97/166] vs. 17.1% [447/2616]). Fibromyalgia was more prevalent in those with chronic (rather than episodic) migraine (11.1% [46/414] vs. 4.4% [72/1653], p < 0.001) and chronic (rather than episodic) tension-type headache (11.5% [27/235] vs. 4.6% [19/409], p = 0.001). Most fibromyalgia pain was in the shoulders, neck, and upper back.

CONCLUSIONS

The prevalence of fibromyalgia in mainland Chinese patients with primary headache was 6.0%. Fibromyalgia was more common in those with chronic rather than episodic headache. The most common sites of fibromyalgia pain were the neck, shoulders, and back.

San Pian decoction can treat nitroglycerin-induced migraine in rats by inhibiting the PI3K/AKT and MAPK signaling pathways

ETHNOPHARMACOLOGICAL RELEVANCE

San Pian decoction (SPD), a traditional Chinese medicine preparation composed of eight herbs, has been reported to alleviate migraine. However, its active ingredients and the potential mechanism of action remains unclear. The purpose of this study was to comprehensively analyze SPD for the treatment of chronic migraine based on pharmacological direction and to identify the active ingredients and pharmacological mechanism of SPD in the treatment of migraine.

MATERIALS AND METHODS

The active components in SPD were identified by AB SCIEX quadrupole time-of-flight mass spectrometer, and the prediction targets and pharmacological networks related to migraine were constructed. The mechanism of SPD in treating migraine was studied through network pharmacology, which was further verified using pharmacological experiments.

RESULTS

A total of 489 targets of 26 compounds were identified. Based on Venn analysis, we found 117 intersection targets between SPD and migraine, that is, these targets were related to the treatment of migraine. Gene ontology and Kyoto Encyclopedia of Genes and Genomes enrichment analysis revealed that the treatment of migraine using SPD was related to the PI3K/AKT and MAPK signaling pathways. The effect of SPD on migraine was verified by measuring the levels of the inflammatory factors, nitric oxide (NO), interleukin (IL-6), endothelin (ET),5-hydroxytryptamine(5-HT), indoleamine 2,3-dioxygenas (IDO), tumor necrosis factor (TNF-α) and calcitonin gene-related peptide (CGRP). Lastly, real-time polymerase chain reaction and western blotting were used to verify gene and protein expression in the PI3K/AKT and MAPK signaling pathways. Expression of the genes P38, JNK, ERK, PI3K and AKT, and the protein expression of p-P38, p-JNK, p-ERK, p-AKT and p-PI3K were significantly downregulated. Our findings indicated that SPD could prevent inflammation by regulating the inflammatory cytokines and key genes and proteins in the PI3K/AKT and MAPK signaling pathways to treat migraine.

CONCLUSION

Our findings reveal that SPD could treat nitroglycerin-induced migraine by regulating p-AKT, p-pI3k, p-p38, p-ERK, p-JNK, IL-6, and TNF-α inflammatory factors in the PI3K/AKT and MAPK signaling pathways.

Migraine among students of a medical college in western China: a cross-sectional study

Objective

As one of the most common primary headaches in clinical practice, migraine affects the learning ability and life quality of college students worldwide, posing a heavy burden on individuals and society. This study aims to investigate the incidence of migraine among Chinese medical college students and to explore its characteristics and typical triggers.

Method

From July 2019 to July 2020, North Sichuan Medical College in Sichuan province, China preliminarily screened migraine cases using ID-Migraine through cluster sampling. College students with positive ID-Migraine results would be included in this study if they were further diagnosed with migraine by neurologists based on ICHD-3. After the ethical review, patients’ personal and headache information would be collected, and the frequency, severity, onset time, and related triggers of migraine would be measured.

Results

The preliminary screening covered 8783 college students. The overall prevalence rate of migraine is 6.57%, 5.90% in men and 6.77% in women. The prevalence rate of migraine is higher for students in the first and second grades (8.01%, 8.05%), and students with a family history of migraine are more likely to suffer from migraine (OR = 1.509, 95% CI 1.060–2.148, P = 0.022 < 0.005). Staying up late (n = 329, 57.01%), stress (n = 319, 55.29%), catch a cold (n = 313, 54.25%) and sleep disorders (n = 302, 52.34%) are the common triggers.

Conclusion

Migraine is common among college students in North Sichuan Medical College. The incidence is higher among lower grade students, female students, and students with a family history of migraine. Improving sleep quality and reducing stress may be effective in relieving migraines.

Structured headache services as the solution to the ill-health burden of headache: 1. Rationale and description

In countries where headache services exist at all, their focus is usually on specialist (tertiary) care. This is clinically and economically inappropriate: most headache disorders can effectively and more efficiently (and at lower cost) be treated in educationally supported primary care. At the same time, compartmentalizing divisions between primary, secondary and tertiary care in many health-care systems create multiple inefficiencies, confronting patients attempting to navigate these levels (the "patient journey") with perplexing obstacles.High demand for headache care, estimated here in a needs-assessment exercise, is the biggest of the challenges to reform. It is also the principal reason why reform is necessary.The structured headache services model presented here by experts from all world regions on behalf of the Global Campaign against Headache is the suggested health-care solution to headache. It develops and refines previous proposals, responding to the challenge of high demand by basing headache services in primary care, with two supporting arguments. First, only primary care can deliver headache services equitably to the large numbers of people needing it. Second, with educational supports, they can do so effectively to most of these people. The model calls for vertical integration between care levels (primary, secondary and tertiary), and protection of the more advanced levels for the minority of patients who need them. At the same time, it is amenable to horizontal integration with other care services. It is adaptable according to the broader national or regional health services in which headache services should be embedded.It is, according to evidence and argument presented, an efficient and cost-effective model, but these are claims to be tested in formal economic analyses.

Common variants in KCNK5 and FHL5 genes contributed to the susceptibility of migraine without aura in Han Chinese population

A recent genome-wide meta study suggested that rs67338227 in the FHL5 gene and rs10456100 in the KCNK5 gene are associated with migraine from 27 population-based cohorts excluding Chinese population. Given that migraine without aura (MO) is the most common subtype of migraine, our aim was to systematically investigate the relationship of common variants in FHL5 and KCNK5 genes with the susceptibility to MO and provide clues as to the nature of the mechanisms involved in the etiology of migraine. A total of 3306 subjects including 1042 patients with MO and 2264 controls were recruited for the discovery stage, and 2530 individuals including 842 patients with MO and 1688 controls for the replication stage. Twenty-two tag SNPs (7 from FHL5 and 15 from KCNK5) were selected for genotyping. Genetic associations were analyzed at both single-marker and haplotype levels. Potential functional consequences of the significant SNPs were analyzed using gene expression data obtained from the GTEx database. Two SNPs, rs10456100 (KCNK5, P = 9.01 × 10-9) and rs7775721 (FHL5, P = 6.86 × 10-13), were determined to be significantly associated with MO in the discovery sample and were then replicated in another sample. In the combined sample set, the T allele of both SNPs was significantly associated with the increased risk of MO. Significant eQTL signals were identified for both SNP rs10456100 and rs7775721. Our findings suggest that the T allele carriers of SNP rs10456100 and rs7775721 are at increased risk of migraine.

Studies on the Mechanism of Glutamate Metabolism in NTG-Induced Migraine Rats Treated with DCXF

Objective

To explore the mechanism of the antimigraine effect by active components extracted from the Dachuanxiong prescription (DCXF), nitroglycerin- (NTG-) induced migraine rats were used to detect the change of glutamate metabolism and the overall metabolic profile at different time points in the serum and Trigeminocervical complex(TCC) samples.

Method

The biological samples that were obtained at 30 minutes, 60 minutes, and 90 minutes after model establishment or drug administration were tested by GC-TOF-MS. Then, real-time PCR and western blot were applied to detect changes in the expression of some substances involved in glutamate metabolism.

Result

DCXF could improve the metabolic profile of serum and TCC in migraine rats and showed the time trend of treatment, mainly involved by amino acid metabolism (glutamate, aspartic acid, and alanine metabolism). In addition, DCXF could increase the expressions of GS at 60 min and 90 min and EAAT1 at 90 min. The results of GS protein were similar to that of mRNA.

Conclusion

The antimigraine effect of DCXF could be achieved by improving the metabolic profile and increasing the expressions of GS and EAAT1 to promote the glutamate cycle of TCC and serum samples in NTG-induced migraine rats to a certain extent.

Chinese herbal medicine for headache: A systematic review and meta-analysis of high-quality randomized controlled trials

BACKGROUND

Chinese herbal medicines (CHMs) are widely used to relieve headache in Asia. However, it is uncertain whether there is robust evidence on the effects of CHMs for headache.

PURPOSE

To assess the effectiveness and safety of CHMs for headache using systematic review of high-quality randomized controlled trials (RCTs).

METHODS

Electronic search was conducted on six databases from inception to January 2018. We included the RCTs that met the requirement of at least 4 out of the 7 domains according to the Cochrane risk of bias tool.

RESULTS

Thirty RCTs with 3447 subjects were ultimately included for analysis and all trials were conducted in Asia. Meta-analysis showed that CHMs monotherapy were superior to placebo in reducing headache frequency [SMD -0.48 (95% CI -0.76, -0.20); p < 0.01], headache days [SMD -0.29 (95% CI -0.45, -0.13); p < 0.01], headache duration[SMD -0.58 (95% CI -0.81, -0.36); p < 0.01], headache intensity [SMD -0.42 (95% CI -0.62, -0.23); p < 0.01] and analgesic consumption [SMD -0.36 (95% CI -0.52, -0.21); p < 0.01] and improving clinical efficacy rate (p < 0.01). Similarly, CHMs monotherapy were superior to western conventional medicines (WCMs) in headache frequency [SMD -0.57 (95% CI -0.84, -0.29); p < 0.01], headache days (p < 0.01), analgesic consumption [SMD -1.63 (95% CI -1.98, -1.28); p < 0.01], headache intensity [SMD -0.81 (95% CI -1.06, -0.57); p < 0.01], and clinical efficacy rate [RR 1.24 (95% CI 1.18, 1.31); p < 0.01], except reducing headache duration (p > 0.05). CHMs adjunct therapy can improve clinical efficacy rate compared with WCMs alone [RR 1.15 (95% CI 1.09, 1.22); p < 0.01]. Meanwhile, CHMs had fewer adverse events than that of controls.

CONCLUSION

The findings supported, at least to an extent, the use of CHM for headache patients; however, we should treat the results cautiously because the clinical heterogeneity.

Migraine attacks among medical students in Soochow University, Southeast China: a cross-sectional study

Purpose

Migraine is one of the most common primary headache disorders and is burdensome to both the individual and society, influencing the academic performance and quality of daily lives of medical students worldwide. This study aimed to investigate the migraine prevalence in a sample of university medical students in China and to examine the features and typical trigger factors of migraine among these students.

Patients and methods

From May 2016 to August 2016, a total of 1,060 medical students who were enrolled in Soochow University in Jiangsu Province in China were chosen through stratified random sampling. A self-administered questionnaire that included the ID Migraine™ for screening of migraine cases was used to collect data. The frequency, severity, duration of migraine attacks, and relevant trigger factors were measured for migraine cases. In total, 986 students completed the questionnaire.

Results

The overall migraine prevalence among students was 7.91%, with 4.64% in male and 9.84% in female students. Junior-grade students had a higher migraine prevalence than senior students (prevalence of migraine of year 1 to year 5 undergraduates: 10.83%, 8.9% vs. 6.25%, 4.42%, 5.33%, P<0.05; prevalence of migraine of year 1 to year 3 graduates: 9.68%, 9.71% vs. 6.38%, P<0.05). Students with a positive family history were more likely to suffer migraine than those without (OR=8.48, 95% CI: 4.33–16.59). Stress (n=73, 93.59%), lack of sleep (n=72, 92.31%), and change of sleeping time (n=68, 87.18%) were the top three trigger factors among the students.

Conclusion

Migraine was common among medical students from a university in China, and especially higher in female and junior-grade students, and those with a family history of migraine. Reducing stress and improving sleep quality might be effective to reduce migraine attacks in this population.

Lifting the burden of headache in China: managing migraine in a SMART way

With support from Lifting The Burden , a UK-registered charitable organization, a nationwide survey of headache disorders in the Chinese adult population was conducted in 2008-2009. This project, which was within the Global Campaign against Headache, showed that headache disorders have a major adverse impact on public health in China. Subsequently, as essential support for implementing headache services around the country, an enactment of stage 3 (intervention) of the Global Campaign against Headache - the continuing medical education (CME) program Headache Schools - was established. 'SMART' (Screen, Migraine, Aura, Red flag and Treatment), a systematic and operational disease management model, was introduced with the aims of enhancing neurologists' knowledge of migraine, standardizing their diagnostic and treatment approaches, and improving their practices and outcomes. To date, 615 neurologists have been trained and 135 headache clinics have been established. In future, as we promote SMART in CME, we can use the database of our computerized clinical decision support systems to evaluate the impact on treatment outcomes.

New evidence for involvement of ESR1 gene in susceptibility to Chinese migraine

Migraine is a common and disabling nervous system disease with a significant genetic predisposition. The sex hormones play an important role in the pathogenesis of migraine. However, the conclusions of the previous genetic relation studies are conflicting. The aim of this study is to determine whether variants in genes involved in estrogen receptor and estrogen hormone metabolism are related to Chinese migraine. By employing a case-control approach, 8 SNPs in the ESR1, ESR2, and CYP19A1 genes are studied in a cohort of 494 migraine cases and 533 controls. In addition, genotyping is performed using Sequenom MALDI-TOF mass spectrometry iPLEX platform. Univariate and multivariate analyses are carried out by logistic regression. The corresponding haplotypes are studied with the Haploview software and gene-gene interaction is assessed using the Generalized Multifactor Dimensionality Reduction (GMDR) analysis. There are significant differences in allelic distributions for rs2234693 and rs9340799 in ESR1 gene between patients with migraine and control subjects. Univariate logistic analysis shows that rs2234693 and rs9340799 are risk factors for migraine, but multivariate analysis reveals that only rs2234693 is significant associated with migraine. In the subgroup analysis, rs2234693 in ESR1 gene is found associated with menstrually related migraine. Further haplotypic analysis shows that rs2234693-rs9340799 TA haplotype serves as risk haplotype for migraine. The GMDR analysis identifies rs2234693 in ESR1 alone to be a crucial candidate in migraine susceptibility. This study is in agreement with the previous studies that variants in the ESR1 gene are associated with migraine suggesting that it plays a role in the migraine process.

Closing the treatment gap for mental, neurological and substance use disorders by strengthening existing health care platforms: strategies for delivery and integration of evidence-based interventions

This paper outlines the main elements and features of a mental health care delivery platform and its delivery channels. These include evidence-based interventions that can be delivered via this platform as well as broader health system strengthening strategies for more effective and efficient delivery of services. The focus is broadly on health systems perspective rather than strictly disorder-oriented intervention analysis. A set of evidence-based interventions within the WHO pyramid framework of self-care, primary care, and specialist care have been identified; the main challenge lies in the translation of that evidence into practice. The delivery of these interventions requires an approach that puts into practice key principles of public health, adopts systems thinking, promotes whole-of-government involvement and is focused on quality improvement. Key strategies for effective translation of evidence into action include collaborative stepped care, strengthening human resources, and integrating mental health into general health care. In order to pursue these principles and strategies using a platform-wide approach, policy makers need to engage with a wide range of stakeholders and make use of the best available evidence in a transparent manner.

A Multicenter, Double-Blind, Randomized, Placebo-Controlled Trial to Evaluate the Efficacy and Safety of Duliang Soft Capsule in Patients with Chronic Daily Headache

Objective. To investigate the efficacy and safety of traditional Chinese medicine Duliang soft capsule (DSC) in prophylactic treatment for patients with chronic daily headache (CDH). Methods. A multicenter, double-blind, randomized, placebo-controlled clinical study was conducted at 18 Chinese clinical centers. The participants received either DSC or placebo for 4 weeks. The primary efficacy measure was headache-free rate (HFR) in a 4-week period between the pretreatment and posttreatment stages. The secondary efficacy measures were the decrease of headache days, the duration of headache attacks, the frequency of analgesic usage, quality of life, disability, and the headache severity (VAS scores). The accompanying symptoms and adverse events were also assessed. Results. Of 584 CDH patients assessed, 468 eligible patients were randomized. 338 patients received DSC, while 111 patients were assigned in the placebo group. Following treatment, there was a 16.56% difference in HFR favoring DSC over placebo (P < 0.01). Significant differences were also observed between DSC and placebo groups in the secondary measures. However, no statistical difference was found between the two groups in the associated symptoms. No severe adverse effects were observed in the study. Conclusions. DSC might be an effective and well-tolerated option for the prophylactic treatment of patients with CDH.

Acupuncture treatment modulates the resting-state functional connectivity of brain regions in migraine patients without aura

OBJECTIVE

To investigate the modulatory effect of acupuncture treatment on the resting-state functional connectivity of brain regions in migraine without aura (MWoA) patients.

METHODS

Twelve MWoA patients were treated with standard acupuncture treatment for 4 weeks. All MWoA patients received resting-state functional magnetic resonance imaging (fMRI) scanning before and after acupuncture treatment. Another 12 normal subjects matched in age and gender were recruited to serve as healthy controls. The changes of restingstate functional connectivity in MWoA patients before and after the acupuncture treatment and those with the healthy controls were compared.

RESULTS

Before acupuncture treatment, the MWoA patients had significantly decreased functional connectivity in certain brain regions within the frontal and temporal lobe when compared with the healthy controls. After acupuncture treatment, brain regions showing decreased functional connectivity revealed significant reduction in MWoA patients compared with before acupuncture treatment.

CONCLUSIONS

Acupuncture treatment could increase the functional connectivity of brain regions in the intrinsic decreased brain networks in MWoA patients. The results provided further insights into the interpretation of neural mechanisms of acupuncture treatment for migraine.