Non-Pharmacological Treatment for Primary Headaches Prevention and Lifestyle Changes in a Low-Income Community of Brazil: A Randomized Clinical Trial

Efficacy of different acupuncture-related therapies for tension-type headache: a systematic review and network meta-analysis

Background

Tension-type headache (TTH) is among the most common primary headache disorders, characterized by recurrent episodes that are difficult to manage, thus posing a significant public health challenge. Acupuncture, a well-recognized non-pharmacological treatment, is frequently employed for pain management, including TTH. However, the variety of acupuncture techniques and inconsistent treatment outcomes underscore the need for a thorough evaluation. This study aims to update the current evidence on acupuncture and related therapies for TTH, evaluate the efficacy and safety of various acupuncture therapies, and identify the most effective therapeutic strategies, providing valuable guidance for clinical practice.

Methods

We systematically searched randomized controlled trials (RCTs) from four English databases (PubMed, Embase, Cochrane Library, and Web of Science) and four Chinese databases (Wanfang, VIP, CNKI, and SinoMed), including gray literature, up to April 19, 2024. The outcome measures included headache frequency, duration, pain intensity, and responder rate. A Bayesian network meta-analysis was conducted using Stata 17.0 to assess the relative effectiveness and safety of the different acupuncture therapies. This study was registered with the Prospective Register of Systematic Reviews (CRD42024537187).

Results

A total of 42 RCTs, encompassing 4,103 participants and 21 distinct treatment therapies, were included in the analysis. The network meta-analysis yielded the following findings: (1) regarding responder rate, several acupuncture or combined acupuncture and medication approaches, such as electro-acupuncture (EA) + cupping therapy (CT) [odds ratio (OR) = 28.66, 95% CI: 1.68 to 487.35], manual acupuncture (MA) + bloodletting therapy (BT) (OR = 6.07, 95% CI: 1.81 to 20.29), plum blossom needle tapping (PBNT) (OR = 3.76, 95% CI: 1.04 to 13.65), and scalp acupuncture (SPA) (OR = 3.65, 95% CI: 2.29 to 5.83), were significantly more effective than western medicine (WM) alone, with EA + CT (92.1%) being the most effective. (2) In terms of reducing headache frequency, EA (85.9%) was the most effective, followed by MA + PBNT (80.9%) and MA + WM (78.4%). Compared to WM, both MA + PBNT (SMD = -1.76, 95% CI: -3.31 to -0.22) and EA (SMD = -1.75, 95% CI: -3.30 to -0.20) significantly reduced headache frequency. (3) For shortening headache duration, EA (83.9%) emerged as the most effective treatment, followed by MA + WM (73.5%) and laser acupuncture (LA) (68.5%). (4) In terms of pain intensity reduction, the MA + WM combination (89.4%) was superior to other treatments, with SPA + WM (77.7%) being the next most effective. Compared to herbal medicine (HM), both MA + WM (SMD = -2.37, 95% CI: -4.20 to -0.55) and MA alone (SMD = -1.00, 95% CI: -1.75 to -0.24) significantly alleviated pain intensity.

Conclusion

This comprehensive analysis of 21 acupuncture and related therapies demonstrates that EA is the most effective in reducing headache frequency and shortening headache duration, while EA + CT and MA + WM are the optimal therapies for enhancing responder rate and reducing pain intensity, respectively. However, clinical decisions should be individualized based on the specific needs of each patient.

Systematic review registration

The study protocol was registered on the PROSPERO database under registration number CRD42024537187 (https://www.crd.york.ac.uk/prospero/#recordDetails).

Behavioral therapy in migraine: Expanding the therapeutic arsenal

BACKGROUND AND PURPOSE

The US Headache Consortium developed evidence-based guidelines for the treatment of migraine and found grade A evidence in support of behavior therapy (BT). Understanding the mechanisms of BT may improve the management of migraine and reduce its burden.

METHODS

We performed a narrative review to define the current evidence of BT and determine its usefulness in migraine management.

RESULTS

The information was obtained from 116 publications, with 56 of them retrieved through direct searches in PubMed (2011-2020) and the remainder selected by the authors to complete the content. BT might reduce migraine impact by decreasing the sympathetic nervous system's response to stress and increasing pain tolerance. Acting in headache-related surroundings can be improved, together with headache duration and self-efficacy. Applications such as mobile health and electronic health applications can help to carry out healthier lifestyle patterns. Regarding medication overuse, BT seems to be a good choice, with similar results to pharmacological prophylaxis. Advantages of using BT are the lack of adverse effects and the unrestricted use in children, where BT is postulated to be even more effective than the standardized pharmacopeia.

CONCLUSIONS

BT is an interesting tool that can be used as an add-on therapy in migraine. Through BT, the autonomy and empowerment of migraine patients is enhanced. BT may not cure migraine, but it could help to reduce pain severity perception, disability, and migraine impact, adding an emotive and cognitive approach to the perceptive role of pharmacopeia. Thus, a better approach in migraine, implementing specific therapeutic management, can improve migraine control.

Headache Specialists' Perceptions of the Role of Health Psychologists in Headache Management: A Qualitative Study

Background Since headache specialists cannot treat all the patients with headache disorders, multidisciplinary teams that include health psychologists are becoming more prevalent. Health psychologists mainly use a form of cognitive-behavioral therapy (CBT), along with biofeedback on occasion, to effectively address patients' pain and headache disorders. The Veterans Health Administration (VHA) is one setting that routinely includes a health psychologist with advanced training in pain disorders in their pain care to its veterans. The VHA has established Headache Centers of Excellence (HCoE) around the country to provide multidisciplinary treatment for patients with headache disorders, which enables headache specialists to regularly interact with health psychologists. Objective The study's objective is to evaluate headache specialists' views of health psychologists in the treatment of patients with headache disorders. Method Semi-structured interviews were conducted with headache specialists in academic-based healthcare settings, the community, and VHA HCoE sites. The interviews were audio-recorded and de-identified so they could be transcribed and analyzed using content matrix analysis. Results Four themes emerged: headache specialists desired to work with health psychologists and included them as members of multidisciplinary teams; valued health psychologists because they provided non-pharmacological treatments, such as CBT and biofeedback; preferred in-person communication with health psychologists; and used multiple titles when referring to health psychologists. Conclusion Headache specialists valued health psychologists as providers of behavioral and non-pharmacological treatments and considered them essential members of multidisciplinary teams. Headache specialists should strive to work with a headache psychologist, not just a general health psychologist. By committing to this, headache specialists can foster changes in the quality of care, resource allocation, and training experiences related to health psychologists.

Efficacy of acupuncture for tension-type headache prophylaxis: systematic review and meta-analysis with trial sequential analysis

BACKGROUND

Acupuncture has been shown to reduce tension-type headache (TTH) frequency in previous studies. Nevertheless, repeated significance testing might inflate type I error. We aimed to verify the effectiveness and safety of acupuncture in reducing TTH frequency by meta-analysis and trial sequential analysis (TSA).

METHODS

Ovid Medline, Embase, and Cochrane Library were searched until September 29, 2022. Randomized controlled trials comparing acupuncture with sham acupuncture, no acupuncture, or other active therapies in adults with TTH were included. The primary outcome was TTH frequency. The secondary outcomes were responder rate and adverse event.

RESULTS

Fourteen studies involving 2795 participants were included. Acupuncture had more reduction than sham acupuncture in TTH frequency, both after treatment (standardized mean difference [SMD] - 0.80, 95% CI - 1.36 to - 0.24, P = 0.005) and at the follow-up period (SMD - 1.33, 95% CI - 2.18 to - 0.49, P = 0.002), while TSA showed the included sample size did not exceed required information size (RIS). Acupuncture was superior over no acupuncture after treatment (SMD - 0.52, 95% CI - 0.63 to - 0.41, P < 0.001), and cumulative sample size reached RIS. In terms of responder rate, acupuncture had a higher responder rate compared with sham acupuncture both after treatment (relative ratio [RR] 1.28, 95% CI 1.12 to 1.46, P = 0.0003) and the follow-up period (RR 1.37, 95% CI 1.19 to 1.58, P < 0.0001), but the sample size is inadequate.

CONCLUSION

Acupuncture is an efficacious and safe treatment for TTH prevention, but this conclusion might be limited by the generally very low to low quality evidence. TSA suggested that high-quality trials are needed to verify the efficacy and safety of acupuncture compared to sham acupuncture.

A Validation Study for the German Versions of the Feeling Scale and the Felt Arousal Scale for a Progressive Muscle Relaxation Exercise

The aim of the present study is to prove the construct validity of the German versions of the Feeling Scale (FS) and the Felt Arousal Scale (FAS) for a progressive muscle relaxation (PMR) exercise. A total of 228 sport science students conducted the PMR exercise for 45 min and completed the FS, the FAS, and the Self-Assessment Manikin (SAM) in a pre-test-post-test design. A significant decrease in arousal (t(227) = 8.296, p < 0.001) and a significant increase in pleasure (t(227) = 4.748, p < 0.001) were observed. For convergent validity, the correlations between the FS and the subscale SAM-P for the valence dimension (r = 0.67, p < 0.001) and between the FAS and the subscale SAM-A for the arousal dimension (r = 0.31, p < 0.001) were significant. For discriminant validity, the correlations between different constructs (FS and SAM-A, FAS and SAM-P) were not significant, whereas the discriminant analysis between the FS and the FAS revealed a negative significant correlation (r = -0.15, p < 0.001). Together, the pattern of results confirms the use of the German versions of the FS and the FAS to measure the affective response for a PMR exercise.

Socioeconomic and geographic inequalities in headache disability in Brazil: The 2019 National Health Survey

OBJECTIVE

To map the socioeconomic and geographic inequalities in headache disability in Brazil.

BACKGROUND

Headache disability and its social determinants are poorly investigated in Brazil.

METHODS

This is a secondary, cross-sectional analysis of the 2019 National Health Survey database, a representative sample of the Brazilian population. Working-aged Brazilians (aged ≥14 years) were included in the analyses (n = 225,563). Headache disability was inquired through questions on the number of days the respondent was unable to perform customary daily activities in the past 2 weeks. Proportion estimates and the mean days lost were compared between socioeconomic categories. Sample weights were used.

RESULTS

Among 14 disease-related disability groups, headache disability (n = 1228) was the second most prevalent disability in adolescents and fifth among adults aged <50 years. In the headache disability sample, there was a higher proportion of females at 72.4% (95% confidence interval [CI] 68.5%-75.9%), with a mean (95% CI) age of 41.1 (40.1-42.0) years and days lost due to disability of 3.4 (3.2-3.6) days. The sociodemographic distribution across income strata (quartiles) of the headache disability sample showed the highest proportions at the lowest income quartile in the Northeast region (15.4%, 95% CI 12.8%-18.4%), for people of Brown color (17.5%, 95% CI 14.7%-20.7%), and with the lowest education level (l3.6%, 95% CI 11.3%-16.2%). Black people, those from the North region, and those with the lowest education level had more days lost than White people (mean [95% CI] 4.1 [3.5-4.6] vs. 3.1 [2.8-3.4] days, p = 0.008), those from the Southeast region (mean [95% CI] 3.8 [3.4-4.2] vs. 2.8 [2.4-3.3] days, p = 0.022), and people with the highest education level (mean [95% CI] 3.9 [3.6-4.2] vs. 2.8 [2.3-3.3] days, p = 0.005), respectively.

CONCLUSION

In Brazil, headache disability is one of the leading causes of disability and it is characterized by socioeconomic inequalities.

Effects on neuromodulation, acupuncture, and aerobic exercises on migraine and tension-type headache outcomes: A systematic review and meta-analysis

BACKGROUND

Headache disorders are common diseases that cause a social burden. This systematic review and meta-analysis aimed to evaluate the effects of various non-pharmacological treatments to address or prevent acute headaches, including neuromodulation, acupuncture, and aerobic exercises in patients with episodic migraine and tension-type headache (TTH).

METHODS

We performed a systematic search of the electronic databases PubMed, Cochrane Library, Embase, China National Knowledge Infrastructure, WANFANG MEDICINE ONLINE, and Chinese Medical Journal database using Stata/SE 14.0 to obtain weighted mean differences (WMDs). The outcomes included monthly headache days, headache intensity, headache duration, days per month of acute medication use, and the Medical Outcomes Study 36-Item Short-Form Health Survey.

RESULTS

Of 872 identified articles, 27 were included in the meta-analysis. Neuromodulation was associated with reduced headache days (WMD: -1.274, 95% CI [-1.914, -0.634], P < .001), duration (WMD: -2.2, 95% CI [-3.32, -0.107], P < .001) and medication consumption (WMD: -1.808, 95% CI [-2.546, -1.071], P < .001) in cases of migraine. Acupuncture was associated with the alleviation of headache days (WMD: -0.677, 95% CI [-0.932, -0.422], P < .001) and intensity (WMD: -0.893, 95% CI [-1.573, -0.212], P = .01) in cases of migraine and acute medication use (WMD: -3.29, 95% CI [-4.86, -1.72], P < .001) in cases of TTH. Aerobic exercise was associated with reduced headache duration (WMD: -5.1, 95% CI [-8.97, -1.22], P = .01) in cases of TTH. The risk of bias for included articles was moderate.

CONCLUSIONS

There is low- and moderate-quality evidence that neuromodulation, acupuncture, and aerobic exercises are associated with attenuated headache symptoms in patients with episodic migraine or TTH. However, high-quality studies are needed to draw more detailed conclusions.

What is the efficacy of aerobic exercise versus strength training in the treatment of migraine? A systematic review and network meta-analysis of clinical trials

Background

Multiple clinical trials with different exercise protocols have demonstrated efficacy in the management of migraine. However, there is no head-to-head comparison of efficacy between the different exercise interventions.

Methods

A systematic review and network meta-analysis was performed involving all clinical trials which determined the efficacy of exercise interventions in reducing the frequency of monthly migraine. Medical journal search engines included Web of Science, PubMed, and Scopus spanning all previous years up to July 30, 2022. Both aerobic and strength/resistance training protocols were included. The mean difference (MD, 95% confidence interval) in monthly migraine frequency from baseline to end-of-intervention between the active and control arms was used as an outcome measure. Efficacy evidence from direct and indirect comparisons was combined by conducting a random effects model network meta-analysis. The efficacy of the three exercise protocols was compared, i.e., moderate-intensity aerobic exercise, high-intensity aerobic exercise, and strength/resistance training. Studies that compared the efficacy of migraine medications (topiramate, amitriptyline) to exercise were included. Additionally, the risk of bias in all included studies was assessed by using the Cochrane Risk of Bias version 2 (RoB2).

Results

There were 21 published clinical trials that involved a total of 1195 migraine patients with a mean age of 35 years and a female-to-male ratio of 6.7. There were 27 pairwise comparisons and 8 indirect comparisons. The rank of the interventions was as follows: strength training (MD = -3.55 [− 6.15, − 0.95]), high-intensity aerobic exercise (-3.13 [-5.28, -0.97]), moderate-intensity aerobic exercise (-2.18 [-3.25, -1.11]), topiramate (-0.98 [-4.16, 2.20]), placebo, amitriptyline (3.82 [− 1.03, 8.68]). The RoB2 assessment showed that 85% of the included studies demonstrated low risk of bias, while 15% indicated high risk of bias for intention-to-treat analysis. Sources of high risk of bias include randomization process and handling of missing outcome data.

Conclusion

Strength training exercise regimens demonstrated the highest efficacy in reducing migraine burden, followed by high-intensity aerobic exercise.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10194-022-01503-y.

Effects of Different Therapeutic Exercise Modalities on Migraine or Tension-Type Headache: A Systematic Review and Meta-Analysis with a Replicability Analysis

The primary aim of this study was to review the effect of exercise in comparison with a non-active treatment on pain intensity, frequency of headache episodes, headache duration, quality of life, medication use, and psychological symptoms, in patients with migraine or tension-type headache (TTH). A systematic search was conducted in various electronic databases to identify all relevant studies: Medline (PubMed), PEDro, EBSCO and Google Scholar. Clinical trials assessing the effects of exercise interventions in patients with primary headaches were selected. Methodological quality was evaluated using the Cochrane Risk of Bias Tool and PEDro scale and qualitative analysis was based on classifying the results into levels of evidence according to the GRADE. 19 studies (2776 participants; 85% female) were included. The meta-analysis showed statistically significant differences in pain intensity for aerobic training in patients with migraine (SMD = -0.65; 95% CI = -1.07 to -0.22, very low certainty evidence) and for strength training in patients with TTH (SMD = -0.84; 95% CI = -1.68 to- -0.01, very low certainty evidence). Statistically significant differences were also found in the medication use (SMD = -0.51; 95% CI = -0.85 to -0.17, low certainty evidence). Low transparency, replicability and high risk of bias were found. Aerobic training has a small to moderate clinical effect on pain intensity and medication use on migraine patients, with very low to low certainty of evidence. Strength training showed a moderate clinical effect with very low quality of evidence in patients with TTH. Exercise could be considered as clinically relevant for the management of patients with primary headaches, but the presence of low certainty of evidence and low transparency and replicability limited its clinical application. PERSPECTIVE: This article presents current evidence about exercise interventions in patients with primary headaches, including migraine and tension-type headache. Existing findings are reviewed, and relevant data are provided on the effectiveness of each exercise modality, as well as its certainty of evidence and clinical applicability.

Multidisciplinary headache clinic-impact of a new model for headache care in Dubai

INTRODUCTION

Primary headache disorders pose a huge burden to health systems around the world. A new model for headache care was introduced at two primary health centers (PHCs) in Dubai, UAE. Our objective is to describe the model, and the impact it had on increasing the number of patients receiving specialist care as well as on patient's response and satisfaction level.

METHODS

The model consisted of a weekly multi-disciplinary headache clinic with a neurologist, a general physician, a psychologist and a nurse, at each of the two PHCs. Patients were referred from all PHCs in Dubai. Follow up visits were either with the general physician or through tele-headache with the neurologist. We used the HURT questionnaire to evaluate the headache for each patient at baseline and then again at follow up. Information on patient satisfaction was also collected. Data were analyzed using SPSS version 21.

RESULTS

The model proved to be effective in terms of increase in the number of headache patients receiving specialist care. Using HURT questionnaire, improvement was seen in good control and in the sense of control over headache, and in risk of medication overuse between baseline and follow up visits. Patient satisfaction with various aspects of headache care was 80-90% after the first visit and improved further at follow up.

CONCLUSION

Our multi-disciplinary headache model improved the access of patients to neurologists, and resulted in improved headache control and patient satisfaction levels. Other countries can adopt such models to improve headache care for their patients.

Applications of Ketogenic Diets in Patients with Headache: Clinical Recommendations

Headaches are among the most prevalent and disabling neurologic disorders and there are several unmet needs as current pharmacological options are inadequate in treating patients with chronic headache, and a growing interest focuses on nutritional approaches as non-pharmacological treatments. Among these, the largest body of evidence supports the use of the ketogenic diet (KD). Exactly 100 years ago, KD was first used to treat drug-resistant epilepsy, but subsequent applications of this diet also involved other neurological disorders. Evidence of KD effectiveness in migraine emerged in 1928, but in the last several year's different groups of researchers and clinicians began utilizing this therapeutic option to treat patients with drug-resistant migraine, cluster headache, and/or headache comorbid with metabolic syndrome. Here we describe the existing evidence supporting the potential benefits of KDs in the management of headaches, explore the potential mechanisms of action involved in the efficacy in-depth, and synthesize results of working meetings of an Italian panel of experts on this topic. The aim of the working group was to create a clinical recommendation on indications and optimal clinical practice to treat patients with headaches using KDs. The results we present here are designed to advance the knowledge and application of KDs in the treatment of headaches.

Effects of combining manual therapy, neck muscle exercises, and therapeutic pain neuroscience education in patients with migraine: a study protocol for a randomized clinical trial

BACKGROUND

Non-pharmacological approaches for the management of migraine exhibit low to moderate effectiveness due to a lack of high-quality randomized clinical trials. In fact, previous studies applied isolated techniques, which were not representative of common clinical practice. A multimodal approach for migraine may benefit these patients more than isolated approaches. This randomized clinical trial aims to determine the effectiveness of a multimodal protocol combining manual therapy, exercise, and therapeutic pain neuroscience education versus the application of manual therapy or pain neuroscience education alone in patients with migraine.

METHODS

This clinical trial will include 75 individuals of both sexes, aged between 18 and 55 years, with migraine. Participants will be randomized into three groups: the therapeutic pain neuroscience education (TPNE; n = 25) group, the manual therapy (MT; n = 25) group, and the multimodal (MM; n = 25) group. The TPNE group will receive one orientation session on migraine and pain self-management, and recommendations for daily active stretching and walking, with subsequent therapist monitoring. The MT group will receive manual therapies targeting musculoskeletal disorders of the cervical spine. The MM group will receive manual therapies targeting musculoskeletal disorders of the cervical spine, active neck exercises, and therapeutic pain neuroscience education. The treatment period will last 12 weeks. The primary outcome will be the headache impact, measured using the Headache Impact Test (HIT-6). Secondary outcomes will include migraine frequency and intensity, cervical mobility and strength parameters, neck pain-related disability, kinesiophobia, cutaneous allodynia, pain-related catastrophizing, quality of life, and self-perception of change. All outcomes will be evaluated at the fourth, eighth, and twelfth weeks of the treatment period. Primary and secondary clinical outcomes, such as headache impact, frequency, and intensity, will also be evaluated at the 1-, 2-, and 4-month follow-ups.

DISCUSSION

The results of this randomized clinical trial may provide high-quality clinical evidence of the effects of non-pharmacological treatment options for the management of migraine.

TRIAL REGISTRATION

This study was registered under the access code RBR-7s22c75 in the Registro Brasileiro de Ensaios Clínicos (ReBEC) in December 2020.

Novel Therapies in Acute Migraine Management: Small-Molecule Calcitonin Gene-Receptor Antagonists and Serotonin 1F Receptor Agonist

OBJECTIVE

To review the efficacy, safety, and cost of 3 newly approved agents-ubrogepant, lasmiditan, and rimegepant-representing 2 therapeutic classes, calcitonin gene-related peptide (CGRP) receptor antagonist and serotonin 1F (5-HT1F) agonists, for the acute treatment of migraine with or without aura.

DATA SOURCES

The Institute of Health US National Library of Medicine Clinical Trials, PubMed, and Cochrane databases were queried. Abstracts, journal articles, and other relevant sources published or present were reviewed. Search terms included the following: ubrogepant, MK-1602, Ubrelvy®, rimegepant, Nurtec®, BHV-3000, BMS-927711, lasmiditan, Reyvow®, LY573144.

STUDY SELECTION AND DATA EXTRACTION

Relevant English-language articles from June 30, 2010, to August 31, 2020, were evaluated and included in the narrative.

DATA SYNTHESIS

CGRP receptor antagonists, ubrogepant and rimegepant, achieved 2-hour pain freedom and freedom from the most bothersome migraine symptom (MBS) at 2 hours. Both agents were well tolerated, with adverse effects similar to placebo. Lasmiditan, a 5-HT1F receptor antagonist, also improved 2-hour pain freedom and freedom from the MBS at 2 hours. Lasmiditan is associated with dizziness, paresthesia, somnolence, nausea, fatigue, and lethargy.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

Ubrogepant, rimegepant, and lasmiditan represent a new and exciting chapter in acute migraine therapy. To date, no head-to-head studies have compared these agents with the triptans. Ubrogepant and lasmiditan are effective in triptan nonresponders. None of the 3 agents is contraindicated in cardiovascular disease, unlike the triptans.

CONCLUSIONS

Based on available data, ubrogepant, rimegepant, and lasmiditan should be reserved as second-line therapy and may be safe in patients with cardiovascular risk. Lasmiditan's adverse effect profile may limit its use.

21st century headache: mapping new territory

Background

With headache experienced by up to 75% of adults worldwide in the last year, primary headache disorders constitute a major public health problem, yet they remain under-diagnosed and under-treated.

Headache prevalence and burden is changing as society evolves, with headache now occurring earlier in life. Contributing factors, mostly associated with changing life style, such as stress, bad posture, physical inactivity, sleep disturbance, poor diet and excess use of digital technology may be associated with the phenomenon that could be labelled as ‘21st century headache’. This is especially notable in workplace and learning environments where headache impacts mental clarity and therefore cognitive performance. The headache-related impact on productivity and absenteeism negatively influences an individual’s behaviour and quality of life, and is also associated with a high economic cost. Since the majority of sufferers opt to self-treat rather than seek medical advice, substantial knowledge on headache prevalence, causation and burden is unknown globally. Mapping the entire population of headache sufferers can close this knowledge gap, leading to better headache management. The broad use of digital technology to gather real world data on headache triggers, burden and management strategies, in self-treated population will allow these sufferers to access appropriate support and medication, and therefore improve quality of life.

Conclusion

These data can yield important insights into a substantial global healthcare issue and form the basis for improved patient awareness, professional education, clinical study design and drug development.

Effectiveness of Hands-Off Therapy in the Management of Primary Headache: A Systematic Review and Meta-Analysis

A number of hands-off therapies have been widely reported and are used in the management of headache. This systematic review and meta-analysis aimed to assess evidence supporting these therapies on selected headache outcomes. A systematic literature search for randomized clinical trials reporting on the effects of hands-off therapies for headache was performed in two electronic databases; PubMed and Web of Science (PROSPERO: CRD42018093559). Risk of bias was assessed using the Cochrane risk of bias tool. Meta-analysis was performed using Review Manager v5.4. Thirty-five studies, including 3,403 patients with migraine, tension-type or chronic headaches were included in the review. Methodological quality of the studies ranged from poor to good. Result-synthesis revealed moderate evidence for aerobic exercises, relaxation training and pain education for reducing pain intensity and disability. Other hands-off interventions were either weak or limited in evidence. Meta-analysis of 22 studies indicated that the effect of hands-off therapies significantly differed from one another for pain intensity, disability and quality of life (p < 0.05). Relaxation training, aerobic and active/stretching exercises had significant effect on pain intensity and disability (p < 0.05). To conclude, few hands-off therapies were effective on selected headache outcomes. Evidence to support other hands-off therapies is limited by paucity of studies.

Triggers of Primary Headaches: Issues and Pathways Forward

The triggers of primary headaches have considerable significance for our understanding and management of headache and migraine. Triggers explain the variance in headaches - why they occur when they do. Trigger management is generally viewed as an important component of a comprehensive treatment approach for headaches. Historically, however, triggers have not had a prominent place in the headache literature. This situation began to change 20 to 30 years ago, and the pace of change has increased exponentially in recent times. Nevertheless, the field is beset with issues that have held it back from achieving more. This review will focus on elaborating those issues with the goal of suggesting ways forward. The first issue considered will be the definition of a trigger, and how specific triggers are labeled. Consideration will then be given to a classification system for triggers. The review will discuss next the evidence relating to whether self-reported triggers can, indeed, precipitate headaches, and how the capacity to elicit headaches may be acquired or extinguished. Attention will be given to the very important clinical issue of trigger management. Finally, the pathways forward will be proposed. Perhaps the most useful thing to accomplish at this point in time would be agreement on a definition of headache triggers, a list of triggers, and a classification system for triggers. This would greatly assist in comparing research on triggers from different research groups as well as eliminating some of the issues identified in this review. An authoritative body such as the American Headache Society or the International Headache Society, could establish a multidisciplinary committee that would complete these tasks. Consideration should also be given to incorporating triggers into the International Classification of Headache Disorders as an axis or via the use of codes, as this would raise the profile of triggers in assessment and management.

Current understanding of pineal gland structure and function in headache

PURPOSE

The pineal gland plays an important role in biological rhythms, circadian and circannual variations, which are key aspects in several headache disorders.

OVERVIEW

Melatonin, the main pineal secreting hormone, has been extensively studied in primary and secondary headache disorders. Altered melatonin secretion occurs in many headache syndromes. Experimental data show pineal gland and melatonin both interfere in headache animal models, decreasing trigeminal activation. Melatonin has been shown to regulate CGRP and control its release.

DISCUSSION

Melatonin has been used successfully as a treatment for migraine, cluster headaches and other headaches. There is a rationale for including the pineal gland as a relevant brain structure in the mechanisms of headache pathophysiology, and melatonin as a treatment option in primary headache.

Migraine: a major debilitating chronic non-communicable disease in Brazil, evidence from two national surveys

BACKGROUND

Even though migraine and other primary headache disorders are common and debilitating, major health surveys in Brazil have not included them. We repair this omission by combining data on non-communicable diseases (NCDs) in the Brazilian National Health Survey (PNS) 2013 with epidemiological data on migraine prevalence and severity in Brazil. The purpose is to rank migraine and its impact on public healthh among NCDs in order to support public-health policy toward better care for migraine in Brazil.

METHODS

Data from PNS, a cross-sectional population-based study, were merged with estimates made by the Brazilian Headache Epidemiology Study (BHES) of migraine prevalence (numbers of people affected and of candidates for migraine preventative therapy) and migraine-attributed disability.

RESULTS

Migraine ranked second in prevalence among the NCDs, and as the highest cause of disability among adults in Brazil. Probable migraine accounted for substantial additional disability. An estimated total of 5.5 million people in Brazil (or 9.5 million with probable migraine included) were in need of preventative therapy.

CONCLUSION

On this evidence, migraine should be included in the next health surveys in Brazil. Public-health policy should recognize the burden of migraine expressed in public ill health, and promote health services offering better diagnosis and treatment.