The global prevalence of headache: an update, with analysis of the influences of methodological factors on prevalence estimates

Efficacy and Tolerability of Anti-CGRP Monoclonal Antibodies in Patients Aged ≥ 65 Years With Daily or Nondaily Migraine

Background and Objectives

Despite decreasing prevalence of migraine with advancing age, there remains a significant proportion of individuals aged ≥65 years with migraine. Treatment of this population is difficult and they are often excluded from clinical trials, limiting evidence regarding migraine treatment outcomes. Our objective is to assess the efficacy and tolerability of anti-calcitonin gene-related peptide (CGRP) monoclonal antibody (mAb) therapies (erenumab, fremanezumab, and galcanezumab) in patients ≥65 years (O65) compared with patients <65 (U65) with daily or nondaily migraine.

Methods

This observational study uses retrospective data from the electronic medical records of patients who were treated with an anti-CGRP mAb between June 2018 and November 2021. Efficacy was determined through a reduction in monthly migraine days (MMDs) and Headache Impact Test (HIT-6) scores from baseline to posttreatment. Tolerability was examined through the number of adverse events reported per group. Mann-Whitney tests were used to compare the efficacy and tolerability of U65 and O65 patients overall and separated into daily and nondaily migraine groups.

Results

The dataset consisted of U65 (n = 2,707; median [interquartile range]; 45.4 [35.8-53.8] years) or O65 (n = 304; 69.5 [67.3-73.3] years) and further separated into daily (n = 1,303) and nondaily (n = 1,708) migraine. There was no difference (p = 0.57) in the median MMD reduction between U65 (10 days [0.0-17.0]) and O65 (10 days [0.0-16.5]). Similarly, no difference was found among patients with nondaily migraine (p = 0.82) and patients with daily migraine (p = 0.59). HIT-6 scores decreased from severe to moderate/substantial impact for all groups. The daily and nondaily groups showed differences in meeting the 50% improvement threshold (nondaily U65, 67% vs daily U65, 54%, p < 0.0001; nondaily O65, 65% vs daily O65, 49%, p = 0.008). Side effects were reported (829/3,011), with a higher incidence in the U65 (22% O65, 28% U65). The most common side effects for both groups were injection site reaction/rash (40%) and constipation (25%).

Discussion

This retrospective analysis provides real-world evidence that there is no difference in the efficacy and tolerability of treatment with erenumab, fremanezumab, and galcanezumab in patients O65 when compared with patients U65 both with daily or nondaily migraine. These data may help guide the choice of migraine treatment in older populations.

Dry needling techniques as a treatment for improving disability and pain in patients with different types of headache: A systematic review and meta-analysis

BACKGROUND

Headaches, a widespread neuromuscular ailment, pose a significant burden on individuals and society, necessitating both pharmacological and non-pharmacological interventions. Dry needling (DN) has surfaced as a notable non-pharmacological alternative for addressing headaches. We aim to compare DN intervention with the control group in the management of different types of headaches.

METHODS

A comprehensive meta-analysis was conducted, encompassing a systematic exploration of five electronic databases up to May 2023, with studies assessed for validity using the Cochrane risk of bias tool. Eligible studies included those with a control group, which could consist of sham interventions, physiotherapy, or pharmacological treatments. Outcomes related to disability, headache intensity, and frequency were extracted and analyzed.

RESULTS

Out of 4304 studies screened, 13 randomized controlled trials (RCTs) were included in this systematic review, of them 10 RCTs were included in the meta-analysis. A significant decline in the disability score and headache intensity was evident in the DN group compared to the control group, one and three-month follow-ups. Specifically, substantial reductions in headache frequency were prominent after one and three months post-intervention.

CONCLUSION

Dry needling manifests as a potent intervention, diminishing headache intensity and frequency, albeit with lower impact on disability scores. The observed benefits were especially pronounced after one and three months, though the heterogeneous nature of some data analyses mandates further detailed studies to gain a clearer understanding of DN's efficacy on the assessed outcomes.

Rimegepant and atogepant: novel drugs providing innovative opportunities in the management of migraine

INTRODUCTION

Rimegepant and atogepant, two innovative oral medications for the treatment of migraine, are gaining prominence in the treatment of migraine. However, outside of specialist headache centers, these novel medications remain subjectively underutilized. While multiple rationales exist describing their underutilization, a leading factor is the complexity and clinical flexibility attributed to the individual members of the gepant medication class.

AREAS COVERED

This review provides a brief review of the current uses, common adverse events, and potential areas of future clinical innovation attributed to rimegepant and atogepant. A database search for the term 'Rimegepant OR Atogepant' was completed, yielding 240 individual results. Following multiple rounds of assessment that aimed to determine relevance of each individual result, 42 studies were included in the synthesis of this review.

EXPERT OPINION

Rimegepant and atogepant are exciting medications that demonstrate significant clinical innovation within the field of migraine therapy. While current indications are clear, data is lacking regarding the future expanded roles of these medications. Current areas of potential therapeutic innovation for rimegepant and atogepant include the pediatric population, in pregnancy and breastfeeding, in cluster headache and post-traumatic headache, and in patients that previously discontinued calcitonin gene-related peptide (CGRP) monoclonal antibody (mAb) therapy.

Primary headache content on online community platforms: a scoping review protocol

INTRODUCTION

As the usage of online platforms becomes increasingly prevalent to share information, it is essential to garner a better understanding of the content disseminated across the internet. Studies have found that patients are relying on online resources to gather medical information, potentially encountering misinformation. The sharing of information concerning primary headaches, despite affecting a large portion of the world's population, has not been comprehensively analysed through the lens of online content. This scoping review seeks to explore the extent of available information, uncover existing gaps in knowledge, and to serve as a resource for healthcare providers to educate themselves to provide informed care to patients.

METHODS AND ANALYSIS

Studies considered for inclusion are those focused on primary headache (including migraines, tension headaches and cluster headaches) content posted on a community platform. Any online community forum will be eligible, including but not limited to TikTok, Twitter, Facebook, YouTube, Instagram, online forums and blogs. Studies will be limited to those published in English, with no geographic restriction. Five electronic databases, namely PubMed, Cochrane Library, Scopus, EMBASE, PsycInfo, will be searched for published reports. Two reviewers will independently screen titles and abstracts. The reviewers will then assess the full texts selected. In both cases, disagreements will be discussed with a third reviewer and consensus will be achieved. Data analysis will be descriptive with a narrative summary.

ETHICS AND DISSEMINATION

Since this is a scoping review of previously published summary data, ethical approval for this study is not needed. Findings will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

This protocol is registered on the Open Science Framework Repository (https://doi.org/10.17605/OSF.IO/2MAFN).

Epidemiology of headache presentations to United States emergency departments from 2016 to 2023

INTRODUCTION

Headaches are a common condition seen in the Emergency Department (ED), with numerous trials focused on improving care for these patients. However, there is limited recent large-scale, robust data available on the incidence, admission rates, evaluation, and treatment in the ED setting.

METHODS

This was a cross-sectional study of ED presentations for headache from 1/1/2016 to 12/31/2023 using the Epic Cosmos national database. All ED visits with headache-relevant ICD-10 coding were included. Outcomes included percentage of total ED visits, admission rates, computed tomography (CT) brain imaging, lumbar puncture (LP) performance, and medication administration. Medications were analyzed by class (NSAIDs, acetaminophen, dopamine antagonists, diphenhydramine, opioids, intravenous fluids, caffeine, and magnesium sulfate). Subgroup analyses were performed by specific types of dopamine antagonists.

RESULTS

Of 188,482,644 ED encounters, 6,007,090 (3.2%) were due to headache. Of these, 246,082 (4.1%) were admitted. Nearly half (46.6%) of patients received at least one CT. Rates of CT head without contrast increased from 38.2% to 47.9% over time, while rates of CT angiography rose from 2.8% to 10.2%. 1.4% of all patients received an LP, with rates decreasing from 1.8% to 1.1% over time. The most common medication was NSAIDs (45.3%), followed by dopamine antagonists (44.8%), diphenhydramine (38.1%), acetaminophen (24.8%), opioids (16.3%), magnesium sulfate (0.2%), and caffeine (0.1%). 50.8% of patients received intravenous fluids. Rates of opioids declined over time, while dopamine antagonists, acetaminophen, and intravenous fluid administration increased.

CONCLUSION

Headaches represent a common reason for ED presentation, with approximately 4% of patients being admitted. Imaging is frequently performed, with rises in CT without contrast and CT angiography rates over time, while LP rates have been declining. NSAIDs remain the most common medication given, with opioids declining over time while non-opioid agents such as dopamine antagonists have increased. These findings can help inform health policy initiatives, such as those focused on radiologic imaging and evidence-based medication administration.

Effect of a High-Fat Meal on the Pharmacokinetics of an Immediate Release Atogepant Tablet

Atogepant, an oral calcitonin gene-related peptide receptor antagonist, is approved for the preventive treatment of migraine. A phase 1, open-label, single-dose, 2-period crossover study evaluated the effect of a high-fat meal on the pharmacokinetics and safety of atogepant in 20 healthy adults. Administration of atogepant 60 mg immediate-release (IR) tablets under fed conditions reduced the area under the plasma concentration-time curve (AUC) from 0 to time t and from 0 to time infinity by approximately 18% and reduced the maximum plasma concentration (Cmax) by 22%. The 90% confidence intervals for the geometric mean ratios of Cmax and AUC were not contained within the bioequivalence limits of 80%-125%. There was no change in the median time to maximum plasma concentration in the fed versus fasted state. The incidence of treatment-emergent adverse events (TEAEs) was similar between fed and fasted conditions. Four TEAEs were considered related to study intervention and were reported after participants received atogepant under fasted conditions (3 participants). A single-dose atogepant 60 mg IR tablet was safe and tolerated under both fed and fasted states. Due to the wide effective dose range of 10-60 mg/day for atogepant for the preventive treatment of migraine, the food effect on its pharmacokinetics is not considered clinically relevant.

Hallmarks of primary headache: part 1 - migraine

BACKGROUND AND AIM

Migraine is a common disabling conditions which, globally, affects 15.2% of the population. It is the second cause of health loss in terms of years lived with disability, the first among women. Despite being so common, it is poorly recognised and too often undertreated. Specialty centres and neurologists with specific expertise on headache disorders have the knowledge to provide specific care: however, those who do not regularly treat patients with migraine will benefit from a synopsis on the most relevant and updated information about this condition. This paper presents a comprehensive view on the hallmarks of migraine, from genetics and diagnostic markers, up to treatments and societal impact, and reports the elements that identify migraine specific features.

MAIN RESULTS

The most relevant hallmark of migraine is that it has common and individual features together. Besides the known clinical manifestations, migraine presentation is heterogeneous with regard to frequency of attacks, presence of aura, response to therapy, associated comorbidities or other symptoms, which likely reflect migraine heterogeneous genetic and molecular basis. The amount of therapies for acute and for prophylactic treatment is really wide, and one of the difficulties is with finding the best treatment for the single patient. In addition to this, patients carry out different daily life activities, and might show lifestyle habits which are not entirely adequate to manage migraine day by day. Education will be more and more important as a strategy of brain health promotion, because this will enable reducing the amount of subjects needing specialty care, thus leaving it to those who require it in reason of refractory condition or presence of comorbidities.

CONCLUSIONS

Recognizing the hallmarks of migraine and the features of single patients enables prescribing specific pharmacological and non-pharmacological treatments. Medical research on headaches today particularly suffers from the syndrome of single-disease approach, but it is important to have a cross-sectional and joint vision with other close specialties, in order to treat our patients with a comprehensive approach that a heterogeneous condition like migraine requires.

Painful Call About the Under-Reporting of Children's Pain During Humanitarian Crises

Humanitarian crises often require urgent medical care to people of concern. Such medical aid includes assessing and treating acute medical needs and ongoing chronic health conditions. Among the people of concern there are children, who are often the most vulnerable population in humanitarian contexts because they often lack the experience, independence, and cognitive and verbal skills to deal with the ordeals they are facing. These limitations might prevent identification and diagnosis of pain. The under-diagnosis and under-treated pain by health care providers might be also due to the perceived urgency of more acute or life-threatening medical needs with limited medical equipment and personnel, lack of awareness, or assessment tools in such contexts. Additionally, due to issues of anonymity and lack of formal guidelines, there is a severe lack of standardized registration of children's pain conditions in humanitarian crises. Finally, acute pain is also a predictor of post-traumatic stress disorder, a common outcome in such disasters. We call on health care providers to use standardized scales to assess children's pain intensity, frequency, and duration, and to treat it appropriately. These will not only reduce children's physical suffering but may also prevent subsequent risk of PTSD.

2023 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline for the Management of Headache

DESCRIPTION

Headache medicine and therapeutics evidence have been rapidly expanding and evolving since the 2020 U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) clinical practice guideline (CPG) for the management of headache. Therefore, the CPG was revised in 2023, earlier than the standard 5-year cycle. This article reviews the 2023 CPG recommendations relevant to primary care clinicians for treatment and prevention of migraine and tension-type headache (TTH).

METHODS

Subject experts from the VA and the DoD developed 12 key questions, which guided a systematic search using predefined inclusion and exclusion criteria. After reviewing evidence from 5 databases published between 6 March 2019 and 16 August 2022, the work group considered the strength and quality of the evidence, patient preferences, and benefits versus harms on critical outcomes before making consensus recommendations.

RECOMMENDATIONS

The revised CPG includes 52 recommendations on evaluation, pharmacotherapy, invasive interventions, and nonpharmacologic interventions for selected primary and secondary headache disorders. In addition to triptans and aspirin-acetaminophen-caffeine, newer calcitonin gene-related peptide (CGRP) inhibitors (gepants) are options for treatment of acute migraine. Medications to prevent episodic migraine (EM) include angiotensin-receptor blockers, lisinopril, magnesium, topiramate, valproate, memantine, the newer CGRP monoclonal antibodies, and atogepant. AbobotulinumtoxinA can be used for prevention of chronic migraine but not EM. Gabapentin is not recommended for prevention of EM. Ibuprofen (400 mg) and acetaminophen (1000 mg) can be used for treatment of TTH, and amitriptyline for prevention of chronic TTH. Physical therapy or aerobic exercise can be used in management of TTH and migraines.

Patient self rated pain: headache versus migraine a retrospective chart review

BACKGROUND

The International Classification of Headache Disorders (ICHD-3) uses moderate or severe pain intensity in the diagnostic criterion for migraine. However, few studies have analyzed pain rating on a visual analog scale to identify the numerical intensity that correlates with migraine.

OBJECTIVE

To evaluate the impact of daily self-rated headache pain among patients with either episodic or chronic migraine. This study specifically aims to evaluate the probability of patients labeling their head pain as a headache vs. migraine based on the pain level reported.

METHODS

A retrospective chart review was conducted on patients with a clinical diagnosis of migraine from July 1, 2014, to July 1, 2019.

RESULTS

Data of 114 subjects (57 episodic migraine and 57 chronic migraine) were used for analysis. Patients with episodic migraine on average rated a migraine more severe than a headache (4.1 vs. 6.4; p < 0.001). Patients with chronic migraine on average also rated migraine more severe than a headache (4.3 vs. 6.8; p = 0.0054). Chronic migraine patients transitioned from calling head pain a headache to a migraine significantly later than episodic migraine patients (4.5 vs. 6.8; p < 0.05).

CONCLUSION

A migraine is perceived as having higher pain intensity than a headache in patients with both episodic and chronic migraine. On average, patients with chronic migraine had a higher pain rating at which they report head pain to be considered a migraine.

Associations between the waist-to-height ratio index and migraine: A cross-section study of the NHANES 1999-2004

BACKGROUND

The importance of obesity as a factor that increases the probability of migraine episodes is increasingly acknowledged. Thus, this study aimed to explore the potential correlation between central obesity and migraine, emphasizing the waist-to-height ratio (WHtR) as a key measure in assessing this relationship.

METHODS

This cross-sectional analysis included 13,344 individuals who participated in the National Health and Nutrition Examination Survey (NHANES) from 1999-2004. To investigate the association associations between WHtR and migraine, we utilized refined multivariate logistic regression models, smoothing curve fitting methods, subpopulation analysis, and interactive testing.

RESULTS

Of the 13,344 participants, 2,764 (20.72%) had migraines. A significant positive correlation was observed between the WHtR and migraine incidence in both the partially adjusted model (3.08 [95% CI: 1.92-4.94]) and the crude model (1.95 [95% CI: 1.23-3.08]). The participants in the highest quartile of the WHtR had a 13% greater incidence of migraine than those in the lowest quartile [1.13(0.99,1.28)]. The interaction analysis revealed a statistically significant difference (p<0.01) in this relationship among the subgroups. Notably, the correlation between WHtR and migraine risk was not significant and negative in patients ≥60 years, indicating that obesity has a mitigating role in preventing migraine in this elderly population.

CONCLUSIONS

The incidence of migraine increased concomitantly with increased WHtR. However, central obesity has a protective effect against migraine occurrence in individuals ≥60 years. Thus, our findings underscore the importance of WHtR in migraine prevention and management strategies and highlight its potential as a critical biomarker for mitigating migraine incidence.

Understanding the efficacy and tolerability of migraine treatment: a deep dive into CGRP antagonists

INTRODUCTION

The discovery of the role of the calcitonin gene-related peptide (CGPR) in migraine pathogenesis ushered in a new era in headache medicine. This evidence led to the development of small-molecule CGRP receptor antagonists and monoclonal antibodies targeting either CGRP or its receptor.

AREAS COVERED

We will present selected aspects of the role of CGRP in the pathogenesis of migraine, the efficacy of CGRP-targeted treatment, and the still-open questions regarding the practical application of CGRP antagonists in headache medicine.

EXPERT OPINION

CGRP-targeting drugs represent a transformative approach to migraine treatment, offering superior efficacy and tolerability compared to traditional therapies, they are a helpful addition to the treatment arsenal but also have their flaws and require further observation. Their availability provides new hope for migraine patients, particularly those who have not responded adequately to conventional treatments. Future directions for migraine care planning, especially for chronic migraine and medication-overuse headache, should include universal access to these specific and effective forms of therapy to prevent complications from the disease and its negative effects in many aspects of a patient's life.

[Temporal trend of the global prevalence rate of tension-type headache in children and adolescents in 1990-2021]

OBJECTIVES

To investigate the prevalence of tension-type headache (TTH) in children and adolescents aged 0-19 years globally in 1990-2021, and to provide a basis for the prevention and treatment of TTH.

METHODS

Based on the Global Burden of Disease Study data, the age-standardized prevalence distribution of TTH and its changing trend were analyzed among the children and adolescents aged 0-19 years, with different sexes, age groups, sociodemographic index (SDI) regions and countries/territories.

RESULTS

The age-standardized prevalence rate (ASPR) of TTH in children and adolescents aged 0-19 globally in 2021 was 17 339.89/100 000, which was increased by 1.73% since 1990. The ASPR in females was slightly higher than that in males (1990: 17 707.65/100 000 vs 16 403.78/100 000; 2021: 17 946.29/100 000 vs 16 763.09/100 000). The ASPR in adolescence was significantly higher than that in school-aged and preschool periods (1990: 27 672.04/100 000 vs 10 134.16/100 000; 2021: 28 239.04/100 000 vs 10 059.39/100 000). Regions with high SDI exhibited a higher ASPR than the other regions, with significant differences in prevalence rates across different countries. From 1990 to 2021, there was a slight increase in global ASPR, with an average annual percentage change (AAPC) of 0.06%. Females experienced a smaller increase than males based on AAPC (0.04% vs 0.07%). There was reduction in ASPR in preschool and school-aged groups, with an AAPC of -0.02%, while there was a significant increase in ASPR in adolescence, with an AAPC of 0.07%. ASPR decreased in regions with low-middle and low levels of SDI, with an AAPC of -0.02% and -0.04%, respectively, while it increased in regions with middle SDI, with an AAPC of 0.24%.

CONCLUSIONS

There is a consistent increase in the ASPR of TTH in children and adolescents aged 0-19 years globally, with significant differences across sexes, age groups, SDI regions and countries/territories.

Efficacy and Tolerability of Erenumab and Topiramate for Prevention of Chronic Migraine: A Retrospective Cohort Study

Background and Objectives: Migraine is a chronic neurological disorder affecting approximately 14% of the global population. Beyond physical pain, migraines significantly impact individuals' quality of life, influencing education, employment, and income levels. Topiramate, a second-generation antiepileptic medication, has demonstrated notable efficacy in reducing the occurrence of chronic migraine. Over the past three decades, extensive research has implicated the neuropeptide calcitonin gene-related peptide (CGRP) in migraine pathogenesis. Erenumab, the first FDA-approved CGRP inhibitor, received approval in 2018. This study aims to compare the clinical efficacy of Erenumab and Topiramate for migraine prevention. Materials and Methods: We conducted a retrospective cohort study of adults with episodic or chronic migraine over a 12-month period, comparing Erenumab (n = 52) and Topiramate (n = 56). Outcomes assessed included changes in the Migraine Disability Assessment (MIDAS) scores from baseline over the last three months of treatment and the proportion of patients achieving a ≥50% reduction in MIDAS scores by the end of the study. Results: The Erenumab group showed significant improvement, with nearly 79% of patients achieving a 50% reduction in their MIDAS score, with a mean reduction of 3.76. Notably, only two patients (3.8.5) discontinued treatment due to adverse events. In contrast, the Topiramate group had over 15% of patients achieve a 50% reduction in MIDAS scores, with a mean reduction of 5.89, and a had discontinuation rate of 14.2% due to adverse events. Conclusions: Both Topiramate and Erenumab are effective for migraine prevention. However, Topiramate has lower tolerability and more side effects, while Erenumab offers better tolerability and safety at a higher cost. Treatment decisions should be individualized based on patient needs, efficacy, safety, and cost considerations.

Non-Migraine Head Pain and Botulinum Toxin

Botulinum toxin A (BT-A), a potential neurotoxin produced by the bacterium Clostridium botulinum, is known for its ability to prevent the release of acetylcholine at the neuromuscular synapse, leading to temporary muscle paralysis. BT-A is used for a wide range of therapeutic applications. Several studies have shown mechanisms beyond the inhibition of acetylcholine release for pain control. BT-A inhibits the release of neurotransmitters associated with pain and inflammation, such as glutamate, CGRP, and substance P. Additionally, it would be effective in nerve entrapment leading to neuronal hypersensitivity, which is known as a new pathogenesis of painful conditions. BT-A has been applied to the treatment of a wide variety of neurological disorders. Since 2010, BT-A application has been approved and widely used as a chronic migraine prophylaxis. Moreover, due to its effects on pain through sensory modulation, it may also be effective for other headaches. Several studies using BT-A, at different doses and administration sites for headaches, have shown beneficial effects on frequency and severity. In this review, we provide an overview of using BT-A to treat primary and secondary headache disorders.

Association between human herpes simplex virus and severe headache or migraine among aged 20-49 years: a cross-sectional study

Background and purpose

Previous studies have shown that human herpes simplex virus (HSV) infection may be associated with the onset of headache or migraine. We aimed to investigate the association between HSV infection and severe headache or migraine.

Materials and methods

The cross-sectional data on 5,730 participants aged 20-49 years were obtained from the 1999-2004 National Health and Nutrition Examination Survey (NHANES). We used weighted logistic regression analysis to assess the association between HSV infection (HSV-1 gG-1 and HSV-2 gG-2) and severe headache or migraine, and performed subgroup analyses.

Results

Our study found that women, higher education, higher body mass index, better family conditions, smoking and alcohol consumption were all associated with severe headaches or migraines. After adjusting for confounding factors such as sex, age, race, and education, HSV-2 (+) was still significantly associated with severe headache or migraine (OR = 1.22, 95%CI:1.03-1.46, p = 0.0443). In subgroup analyses, we found that participants with HSV-1 (-) and HSV-2 (+) were also significantly associated with severe headache or migraine (OR = 1.41, 95%CI:1.04-1.91, p = 0.0281).

Conclusion

HSV-2 gG-2(+) was significantly associated with severe headache or migraine.

The role of environmental sensitivity, traumatic experiences, defense mechanisms and mental pain on central sensitivity: testing a path analysis model in chronic headache on quality of life

Central pain sensitivity (CS) is defined as an increased responsiveness of nociceptive neurons in the central nervous system to normal or subthreshold inputs. The main aim of this paper is to investigate if and how specific psychological constructs are related with CS burden in patients with chronic headache (CH). Specifically, research question 1 explores the association of temperament, personality, childhood adversities, defense mechanisms and mental pain with CS burden. Research question 2 aims to test the role of the best predictors of CS burden in affecting the quality of life (QoL) using path analysis. A total of 508 women with CH completed a psycho-diagnostic survey. Results showed that higher levels of low sensory threshold (β = 0.200), bodily threat traumatic experiences (β = 0.156), neurotic defenses (β = 0.109) and mental pain (β = 0.343) emerged as the best predictors of higher CS burden. The model presented demonstrated a satisfactory fit (GFI = 0.984; NFI = 0.966; CFI = 0.979; RMSEA = 0.056 [95% CI 0.028-0.085]) with large and medium effect sizes on physical (-0.654) and psychological QoL (-0.246). The study showed a key role of psychological dimensions in CS burden levels and their relationships with QoL in CH patients. From a clinical perspective, these results suggest the importance of evaluating the level of CS burden during the clinical assessment for chronic pain conditions such as CH, since it may contribute to guide patients to tailored psychological and medical treatments, thereby saving time and costs on diagnostic procedures for chronic pain.

Characterization of rimegepant drug-drug interactions using the cytochrome P450 probe drugs, itraconazole, rifampin, fluconazole, and midazolam

OBJECTIVE

Reported here are the results of four rimegepant phase I studies, in healthy participants, aimed at determining the in vivo potential of rimegepant (75 mg) for cytochrome P450 (CYP) 3A4-related drug-drug interactions (DDIs).

BACKGROUND

Rimegepant orally disintegrating tablet (Pfizer Inc., New York, NY, USA) is a calcitonin gene-related peptide receptor antagonist approved for acute treatment of migraine and preventive treatment of episodic migraine. People with migraine commonly use multiple drug treatments, with the potential for DDIs.

METHODS

Each study was an open-label, single-arm, single-sequence, crossover study. Rimegepant was tested as a victim drug by separate co-administration of itraconazole (a strong CYP3A4 inhibitor and P-glycoprotein inhibitor) in Study 1, rifampin (a strong CYP3A4 inducer and moderate CYP2C9 inducer) in Study 2, and fluconazole (a strong CYP2C9 inhibitor and moderate CYP3A4 inhibitor) in Study 3, and as a perpetrator drug by co-administration with midazolam (a CYP3A4 substrate) in Study 4.

RESULTS

Mean values of single-dose rimegepant maximum concentration (Cmax) and area under the curve from time 0 to infinity (AUC0-inf) increased with itraconazole co-administration (n = 22) by 1.42-fold (90% confidence interval [CI] 1.25-1.61) and by 4.14-fold (90% CI 3.87-4.44), respectively, and decreased with rifampin co-administration (n = 21) to 36% (90% CI 31.2-41.4%) and to 19% (90% CI 16.3-21.4%), respectively. Co-administration with fluconazole (n = 23) increased rimegepant mean AUC0-inf by 1.80-fold (90% CI 1.68-1.93), with no impact on Cmax (1.04-fold; 90% CI 0.94-1.15). Co-administration of rimegepant single dose (300 mg; n = 14) or multiple doses (150 mg/day; n = 14) increased the mean Cmax of midazolam by 1.38-fold (90% CI 1.13-1.67) and 1.53-fold (90% CI 1.32-1.78), respectively, and the AUC0-inf of midazolam by 1.86-fold (90% CI 1.58-2.19) and 1.91-fold (90% CI 1.63-2.25), respectively.

CONCLUSIONS

Based on the magnitude of DDIs, these studies indicate the following: co-administration of rimegepant with a strong CYP3A4 inhibitor should be avoided; during co-administration with a moderate CYP3A4 inhibitor, another dose of rimegepant within 48 h should be avoided; co-administration of rimegepant with a strong or moderate CYP3A4 inducer should be avoided; CYP2C9 does not play a meaningful role in rimegepant metabolism; and there is no clinically meaningful CYP3A4 inhibition by rimegepant.

"I am now on 'speaking terms' with my migraine monster" - patient experiences in acceptance-based cognitive behavioral therapy delivered via the internet for migraine: a randomized controlled pilot study using a mixed-method approach

Migraine is a common neurological disorder globally. Migraines, with or without aura, are episodic and recurring with symptom-free periods. Frequent and prolonged attacks can lead to chronic migraine. This pilot randomized controlled trial (RCT) aimed to evaluate feasibility of therapist-guided, acceptance-based internet cognitive behavioral therapy (iCBT) as an adjunct to standard medical care for migraine patients in Swedish primary healthcare settings using a mixed methods approach. Participants (treatment n = 15, control n = 14) underwent qualitative and quantitative assessments to evaluate feasibility, acceptance, and initial treatment effects. Interviews with participants (n = 7) indicate that most participants had struggled with migraines for decades and expressed dissatisfaction with the limited medical care. They found the flexible, digital format particularly helpful, praising its accessibility and structured learning. While they appreciated the comprehensive content, some faced challenges with the psychological language and the program pace. Post-treatment, participants reported emotional and behavioral changes, and better migraine management. Seventy-two percent of the 29 participants completed both baseline and 3-month follow-up measures. On average, participants completed 7.7 modules, with 60% completing all 10 modules. Promising effect size indicated a reduction in migraine days during the three-month follow-up. Both qualitative and quantitative data support the feasibility and acceptability of the intervention in primary care settings.

Principles of Pain Management

OBJECTIVE

This article introduces the general principles of assessing, diagnosing, and managing pain relevant to neurologic practice.

LATEST DEVELOPMENTS

Scientific understanding of and clinical practices related to pain and pain management are advancing. The field is remarkable for the diversity of health professions engaged in this effort, including physicians, scientists, psychologists, pharmacists, and many others. Pain classification is transforming with pending changes to the International Classification of Diseases diagnostic coding system, and pain assessment has moved toward consistent application of the biopsychosocial model. The diagnosis of pain has continued to become more sophisticated with the development of additional testing modalities, clearer classification systems, and diagnostic criteria. Pain management requires both pharmacologic and nonpharmacologic elements; systematic review evidence for both of these and interventional and surgical management are increasingly available. The context of treatment remains important given the impact of social determinants of health and limitations of access to diagnostic and treatment resources. Due to global and interprofessional collaborations as well as new research funding, the outlook is positive.

ESSENTIAL POINTS

Pain is a protean experience for humans; functional MRI (fMRI) and other research modalities show that pain perception is highly multifocal, and modulation occurs at many nervous system levels. Neurologists bring special skills to pain evaluation and management, are well equipped to appreciate both the focal and diffuse nature of pain, and can envision how pain attenuates sleep, cognitive function, mobility, motivation, and social connection. By operationalizing expert knowledge of the nervous system, implementing relevant therapies, and collaborating with diverse health professions to manage pain, neurologists can succeed at and find meaning in optimizing patient outcomes.

Bioinformatic Analysis from a Descriptive Profile of miRNAs in Chronic Migraine

Chronic migraines have been described chiefly only from a clinical perspective. However, searching for reliable molecular markers has allowed for the discovery of the expression of different genes mainly associated with inflammation, neuro-vascularization, and pain-related pathways. The interest in microRNAs (miRs) that can regulate the expression of these genes has gained significant relevance since multiple miRs could play a key role in regulating these events. In this study, miRs were searched in samples from patients with chronic migraine, and the inclusion criteria were carefully reviewed. Different bioinformatic tools, such as miRbase, targetscan, miRPath, tissue atlas, and miR2Disease, were used to analyze the samples. Our findings revealed that some of the miRs were expressed more (miR-197, miR-101, miR-92a, miR-375, and miR-146b) and less (miR-133a/b, miR-134, miR-195, and miR-340) than others. We concluded that, during chronic migraine, common pathways, such as inflammation, vascularization, neurodevelopment, nociceptive pain, and pharmacological resistance, were associated with this disease.

Atogepant for migraine prevention: a meta-analysis of safety and efficacy in adults

Background

Migraine is a neurological condition marked by frequent headaches, which tends to be accompanied by nausea and vomiting in severe instances. Injectable therapies for migraine, such as monoclonal antibodies that target calcitonin gene-related peptide (CGRP), have proven to be effective and safe. While various oral drugs are available, none have been developed for migraines. Patients prefer oral therapies because they are easier to use, making atogepant, an orally accessible small-molecule CGRP receptor antagonist, a possible alternative.

Objectives

This systematic review and meta-analysis compared the safety and effectiveness of atogepant with placebo in treating migraine.

Methods

Adhering to the PRISMA guidelines, we meticulously gathered randomized controlled trials (RCTs) from databases including the Cochrane Library, PubMed, Science Direct, and ClinicalTrials.gov. Studies comparing atogepant with placebo and reporting monthly migraine days (MMDs) as the primary outcome along with secondary outcomes such as monthly headache days and acute medication use days were included. Two independent reviewers conducted the data extraction and quality assessment. Statistical analyses were carried out using RevMan, utilizing risk ratios for dichotomous outcomes and mean differences for continuous outcomes, and a random-effects model.

Results

Our primary outcome was the change in MMDs over 12 weeks, which showed a significant reduction with atogepant at dosages of 10, 30, and 60 mg. Secondary outcomes, such as monthly headache days, proportion of patients achieving a ≥ 50% reduction in MMDs, acute medication use days, and patient-reported outcomes, consistently showed that atogepant outperformed placebo, highlighting its effectiveness in reducing the migraine burden.

Conclusion

Higher doses of atogepant are more effective in lowering migraine and headache-related days and increasing quality of life metrics. However, this is accompanied by an increased incidence of adverse events, suggesting the need for careful dose optimization to balance the benefits and risks.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=563395. Unique Identifier: CRD42024563395.

Disparities in the Representation of Sex, Race and Ethnicity in Tension-Type Headache Clinical Trials

While tension-type headache (TTH) is the most common primary headache disorder, its effect according to sex, race and ethnicity remains unclear. We investigated disparities in sex, racial and ethnic representation in TTH clinical trials with comparison to global disease burdens. In this cross-sectional analysis, TTH clinical trials had female overrepresentation and racial and ethnic minority underrepresentation, which may affect understanding of the impact of TTH on different populations and personalized treatment development. Trial enrollment that is diverse and reflective of global disease burdens is crucial for improving study generalizability, understanding of diverse clinical presentations, and ensuring healthcare equity.

Prevalence and Awareness of Medication Overuse Headache among Undergraduate Students at the University of Belgrade

BACKGROUND

Medication overuse headache (MOH) is a prevalent and potentially preventable secondary headache disorder linked to the excessive use of medications intended for primary headache management, particularly migraine.

AIM

The aim of our study was to assess the prevalence of MOH among undergraduate students and explore their awareness.

METHODOLOGY

This observational cross-sectional study included 401 active undergraduate students from the University of Belgrade. Data were collected through an anonymous online questionnaire which was distributed among student groups and via social media. The questionnaire specially designed for this study was developed in accordance with established guidelines for headache epidemiological research.

RESULTS

Among the surveyed students, 10 of them (2.5%) met the criteria for the diagnosis of MOH. Awareness of MOH was noted in 149 (37.2%) students, with higher awareness among medical students and those aged 22-25 years. Despite this awareness, there was no significant difference in MOH occurrence between those aware and unaware of the condition (aware 2.7% vs. unaware 2.4%, p = 1.000). Additionally, significant gaps in education and communication about MOH were evident.

LIMITATIONS

Participants were recruited through convenience sampling from a single university at one time point. The questionnaire was not specifically validated in the student population, and the data relied on self-reporting.

CONCLUSIONS

Our study highlighted a notable prevalence of MOH among undergraduate students, with a substantial portion exhibiting awareness of its risks. Despite this awareness, our findings suggest ongoing gaps in education and communication regarding MOH, emphasizing the need for targeted interventions.

Involvement of the cerebellum in structural connectivity enhancement in episodic migraine

BACKGROUND

The pathophysiology of migraine remains poorly understood, yet a growing number of studies have shown structural connectivity disruptions across large-scale brain networks. Although both structural and functional changes have been found in the cerebellum of migraine patients, the cerebellum has barely been assessed in previous structural connectivity studies of migraine. Our objective is to investigate the structural connectivity of the entire brain, including the cerebellum, in individuals diagnosed with episodic migraine without aura during the interictal phase, compared with healthy controls.

METHODS

To that end, 14 migraine patients and 15 healthy controls were recruited (all female), and diffusion-weighted and T1-weighted MRI data were acquired. The structural connectome was estimated for each participant based on two different whole-brain parcellations, including cortical and subcortical regions as well as the cerebellum. The structural connectivity patterns, as well as global and local graph theory metrics, were compared between patients and controls, for each of the two parcellations, using network-based statistics and a generalized linear model (GLM), respectively. We also compared the number of connectome streamlines within specific white matter tracts using a GLM.

RESULTS

We found increased structural connectivity in migraine patients relative to healthy controls with a distinct involvement of cerebellar regions, using both parcellations. Specifically, the node degree of the posterior lobe of the cerebellum was greater in patients than in controls and patients presented a higher number of streamlines within the anterior limb of the internal capsule. Moreover, the connectomes of patients exhibited greater global efficiency and shorter characteristic path length, which correlated with the age onset of migraine.

CONCLUSIONS

A distinctive pattern of heightened structural connectivity and enhanced global efficiency in migraine patients compared to controls was identified, which distinctively involves the cerebellum. These findings provide evidence for increased integration within structural brain networks in migraine and underscore the significance of the cerebellum in migraine pathophysiology.

Trends in the prevalence and pharmacological management of migraine during pregnancy in the UK, 2000-2018

BACKGROUND

Migraine is common in women of reproductive age. This study aimed to (1) describe the prevalence of migraine in pregnant women in the UK, (2) identify drugs commonly prescribed for migraine during pregnancy and (3) identify characteristics associated with being prescribed medication for migraine during pregnancy.

METHODS

The Clinical Practice Research Datalink pregnancy register, a database of pregnancy episodes identified in anonymised primary care health records, was used.Crude and age-standardised prevalence of migraine during pregnancy and the proportion of women with migraine prescribed drugs used for migraine management were calculated for each year between 2000 and 2018.Logistic regression was used to describe the relationship between patient characteristics and being prescribed migraine medication during pregnancy.

RESULTS

1 377 053 pregnancies were included, of which 187 328 were in women with a history of migraine. The age-adjusted prevalence increased from 11.4% in 2000 to 17.2% in 2018. There was an increase in the rates of prescription for numerous medications for the management of migraine.Older women (adjusted OR (aOR) 1.41 (1.20 to 1.66)), women of black (aOR 1.40 (1.32 to 1.48)) and South Asian ethnicity (aOR 1.48 (1.38 to 1.59)), those living in the most deprived areas (aOR 1.60 (1.54 to 1.66)), women who were obese (aOR 1.39 (1.35 to 1.43)), smokers (aOR 1.15 (1.12 to 1.18)) and those with comorbid conditions were more likely to receive a prescription during pregnancy.

CONCLUSIONS

Rates of recorded migraine have increased over the past two decades as well as rates of prescribing in women with migraine. Higher prescribing rates are seen in certain groups, which has the potential to exacerbate health inequalities.

The association between dietary antioxidant quality score and intensity and frequency of migraine headaches among women: a cross-sectional study

BACKGROUND

Migraine is an episodic disorder and a frequent form of headache. An impaired balance between free radical production and an impaired antioxidant defense system leading to oxidative damage may play a major role in migraine etiology. We sought to investigate whether dietary antioxidant quality score (DAQS) is associated with migraine intensity and frequency among women suffering from migraine.

METHODS

This cross-sectional study was conducted on 265 women. The data related to anthropometric measures and dietary intake were collected. DAQS score was calculated based on FFQ (food frequency questionnaire) vs. the reference daily intake (RDI) quantity. To measure migraine intensity, the migraine disability assessment questionnaire (MIDAS) and visual analog scale (VAS) were used. The frequency of headaches was defined as the days the participants had headaches in the last month and a 30-day headache diary was used.

RESULTS

The results of the study demonstrated that VAS, MIDAS, and frequency of headaches were reduced significantly from the low DAQS (poor quality of antioxidants) to high DAQS (high quality of antioxidants) after adjusting covariates. Also, multinomial regression showed there was an inverse association between higher DAQS and the frequency of headaches. In the adjusted model, subjects with the higher DAQS were 69% less likely to have moderate migraine disability, compared with those with the lower DAQS. Linear regression showed, there was an inverse association between vitamin C intake and the grades of pain severity.َAlso in a crude model, a negative association was found between vitamin E and the frequency of headaches.

CONCLUSION

In conclusion, Participants with higher DAQS had lower migraine intensity and headache frequency. In addition, the consumption of vitamin C may potentially associate with decreasing the severity of headaches. Dietary antioxidants should be monitored closely in individuals suffering from migraine.

Artificial Intelligence and Virtual Reality in Headache Disorder Diagnosis, Classification, and Management

PURPOSE OF REVIEW

This review provides an overview of the current and future role of artificial intelligence (AI) and virtual reality (VR) in addressing the complexities inherent to the diagnosis, classification, and management of headache disorders.

RECENT FINDINGS

Through machine learning and natural language processing approaches, AI offers unprecedented opportunities to identify patterns within complex and voluminous datasets, including brain imaging data. This technology has demonstrated promise in optimizing diagnostic approaches to headache disorders and automating their classification, an attribute particularly beneficial for non-specialist providers. Furthermore, AI can enhance headache disorder management by enabling the forecasting of acute events of interest, such as migraine headaches or medication overuse, and by guiding treatment selection based on insights from predictive modeling. Additionally, AI may facilitate the streamlining of treatment efficacy monitoring and enable the automation of real-time treatment parameter adjustments. VR technology, on the other hand, offers controllable and immersive experiences, thus providing a unique avenue for the investigation of the sensory-perceptual symptomatology associated with certain headache disorders. Moreover, recent studies suggest that VR, combined with biofeedback, may serve as a viable adjunct to conventional treatment. Addressing challenges to the widespread adoption of AI and VR in headache medicine, including reimbursement policies and data privacy concerns, mandates collaborative efforts from stakeholders to enable the equitable, safe, and effective utilization of these technologies in advancing headache disorder care. This review highlights the potential of AI and VR to support precise diagnostics, automate classification, and enhance management strategies for headache disorders.

Childhood abuse and risk of migraine: A systematic review and meta-analysis

BACKGROUND

Childhood abuse is associated with an increased risk of migraines. However, the literature on this association is limited.

OBJECTIVE

To determine the pooled effect size of the association between childhood abuse and migraines.

PARTICIPANTS AND SETTING

System review and meta-analysis.

METHODS

A systematic literature search for studies published until September 20, 2023, was performed using the Embase, PubMed, and Web of Science databases. Specifically, original articles reporting the statistical effect size (odds ratio) of the association between childhood abuse and migraines were selected. Pooled odds ratios (ORs) and 95 % confidence intervals (CIs) were calculated using random- or fixed-effects models. Publication bias was examined using funnel plots, and sensitivity analysis was used to explore the stability of the pooled results.

RESULTS

Twelve studies involving 110,776 participants were included. Individuals with childhood abuse (OR = 1.60, 95 % CI: 1.49, 1.71) were at increased risk of migraine when compared with individuals with no childhood abuse. Of the different types of childhood abuse examined, sexual abuse (OR = 1.71, 95 % CI: 1.43, 2.04), physical abuse (OR = 1.47, 95 % CI: 1.38, 1.56), and emotional abuse (OR = 1.71, 95 % CI: 1.52, 1.93) were associated with an increased risk of migraine.

CONCLUSIONS

Childhood abuse increases migraine risk. Multifaceted interventions to curb abuse and related behaviors can effectively reduce migraine risk. However, considering that multiple factors, such as obesity and anxiety, are causatively associated with both childhood abuse and migraines, our findings should be interpreted with caution.

Relationship between pain activity patterns, and physical and psychological aspects and sleep quality in women with migraine

Migraine can cause different pain activity patterns. This cross-sectional study examines the relationship between pain activity patterns and physical and psychological aspects and sleep quality in women with migraine. Women diagnosed with migraine (n = 129) were reached through social media and announcements. Outcome measures were Pattern of Activity Measure-Pain (POAM-P) (avoidance, overdoing, pacing), Migraine Disability Assessment Scale (MIDAS), International Physical Activity Questionnaire-Short Form (IPAQ-SF), Depression Anxiety Stress Scale-21 (DASS-21), the Pittsburgh Sleep Quality Index (PSQI). While there was a negative correlation between the POAMP-avoidance and the IPAQ-SF rho = -0.178), there were positive correlations between the POAMP-avoidance and the MIDAS (rho = 0.454), the DASS-21-depression (rho = 0.413), the DASS-21-anxiety (rho = 0.321), and the DASS-21-stress (rho = 0.446). There were positive correlations between the POAMP-overdoing, and the DASS-21-depression (rho = 0.229), the DASS-21-stress (rho = 0.207), and the PSQI (rho = 0.217). There were also positive correlations between the POAMP-pacing and the MIDAS (rho = 0.283), the DASS-21-depression (rho = 0.250), and the DASS-21-anxiety (rho = 0.213) (p < .05). Pain activity patterns in women with migraines were associated with their disability, physical activity, psychological state, and sleep quality. Determining treatment based on pain activity patterns can improve migraine treatment outcomes.

Insights from 25 years of onabotulinumtoxinA in migraine - mechanisms and management

OnabotulinumtoxinA (BTX-A) was first linked to beneficial effects in migraine 25 years ago and was approved by the FDA for preventive treatment of chronic migraine in 2010. The treatment has since had a major impact on the well-being of people with chronic migraine. The clinical development programme for BTX-A and research since its approval have provided insights into the neuromodulatory sensory effect of BTX-A, how it can control chronic migraine despite its peripheral action, and the underlying biology of migraine as a disease. In this Review, we consider the impact that BTX-A has had on the management of chronic migraine and on the research field. We discuss the insights provided by clinical research, encompassing the clinical trials and subsequent real-world evidence, and the mechanistic insights provided by preclinical and translational research. We also provide an overview of future directions of research in the field BTX-A in migraine and the clinical translation of this research.

Brain structural network modular and connectivity alterations in subtypes of patients with migraine and medication overuse headache

Migraine, one of the most prevalent and debilitating neurological disorders, can be classified based on attack frequency into episodic migraine (EM) and chronic migraine (CM). Medication overuse headache (MOH), a type of chronic headache, arises when painkillers are overused by individuals with untreated or inadequately treated headaches. This study compares regional cortical morphological alterations and brain structural network changes among these headache subgroups. Sixty participants, including 20 in each of the following patient groups (EM, CM, MOH), and healthy controls (HC) completed the study. Our results show that the EM group exhibited cortical thickness (CTs) thinning predominantly in the left limbic, whereas CM patients exhibited CTs thinning across both left and right hemispheres. The MOH group demonstrated the most widespread CTs thinning. Both CM and MOH exhibited comparable patterns of CTs thinning within lobes, leading to reduced intra-lobe connectivity. While there were no significant differences in total inter-lobe connectivity between migraine groups and HC, both CM and MOH groups exhibited significantly decreased inter-limbic connectivity compared to HC and EM groups. In addition, they showed increased inter-frontal and inter-parietal connectivity, suggesting possible compensatory mechanisms to offset the loss of inter-lobe connectivity between the limbic and other lobes. Both CM and MOH groups exhibited a significant loss of global efficiency and a decrease in betweenness centrality in their brain networks, with MOH showing the most pronounced decrease and CM showing the second largest decrease. Our results suggest that aberrant structural brain networks in CM and MOH are less efficient, less centralization, and abnormally segregated.

Impact of an Electronic Health Record-Based Interruptive Alert Among Patients With Headaches Seen in Primary Care: Cluster Randomized Controlled Trial

Background

Headaches, including migraines, are one of the most common causes of disability and account for nearly 20%-30% of referrals from primary care to neurology. In primary care, electronic health record-based alerts offer a mechanism to influence health care provider behaviors, manage neurology referrals, and optimize headache care.

Objective

This project aimed to evaluate the impact of an electronic alert implemented in primary care on patients' overall headache management.

Methods

We conducted a stratified cluster-randomized study across 38 primary care clinic sites between December 2021 to December 2022 at a large integrated health care delivery system in the United States. Clinics were stratified into 6 blocks based on region and patient-to-health care provider ratios and then 1:1 randomized within each block into either the control or intervention. Health care providers practicing at intervention clinics received an interruptive alert in the electronic health record. The primary end point was a change in headache burden, measured using the Headache Impact Test 6 scale, from baseline to 6 months. Secondary outcomes included changes in headache frequency and intensity, access to care, and resource use. We analyzed the difference-in-differences between the arms at follow-up at the individual patient level.

Results

We enrolled 203 adult patients with a confirmed headache diagnosis. At baseline, the average Headache Impact Test 6 scores in each arm were not significantly different (intervention: mean 63, SD 6.9; control: mean 61.8, SD 6.6; P=.21). We observed a significant reduction in the headache burden only in the intervention arm at follow-up (3.5 points; P=.009). The reduction in the headache burden was not statistically different between groups (difference-in-differences estimate -1.89, 95% CI -5 to 1.31; P=.25). Similarly, secondary outcomes were not significantly different between groups. Only 11.32% (303/2677) of alerts were acted upon.

Conclusions

The use of an interruptive electronic alert did not significantly improve headache outcomes. Low use of alerts by health care providers prompts future alterations of the alert and exploration of alternative approaches.

A qualitative exploration of migraine in students attending Irish Universities

INTRODUCTION

The complex neurological disorder of migraine is prevalent (19%) and burdensome in university students. Qualitative research exploring the lived experience of migraine in students has yet to be conducted.

METHODS

Students clinically diagnosed with migraine were recruited (purposive sampling) from a sample of Irish third-level institutions for a one-time anonymized Zoom focus group or individual interview. Focus group questions were sent to participants in advance. Interviews were iterative. Participants were also invited to submit a drawing. The interviews were audio-recorded, transcribed, and sent to participants for triangulation. Reflexive thematic content analysis was undertaken, data was imported to Microsoft Excel, initial codes were generated, and themes and sub-themes were derived from the codes. The Standards for Reporting Qualitative Studies Checklist (S1 File) ensured study rigour.

RESULTS

Twenty students from three Irish universities participated (mean age 23.8 years). The four key themes identified were (i) Migraine Characteristics, (ii) Migraine Self-Management, (iii) Migraine Clinical Management, and (iii) Migraine Impacts. Migraine was described as not just a headache but a debilitating sensory experience. A notable high level of self-management satisfaction indicated hopeful coping strategies. However, many participants said medications were ineffective and had side effects, and clinical management could be improved. Additionally, there was a marked academic and social impact of migraine, psychological issues abounded, and several participants worried about finances.

CONCLUSIONS

Migraine is impactful in a cohort of students attending Irish third-level institutions, with students carrying a wide range of debilitating migraine burdens. Students demonstrate an attitude of resilience and determination despite these challenges. Migraine awareness and education campaigns on university campuses are warranted.

Cost-effectiveness analysis of rimegepant for on-demand acute treatment of migraine in China

Purpose

This study assesses the cost-effectiveness of rimegepant for the on-demand acute treatment of migraine in the Chinese population, focusing on headache relief within a 2 h timeframe. Utilizing data from Phase III clinical trials on rimegepant involving Asian populations, this analysis aims to provide essential insights for healthcare decision-making in the context of migraine management in China.

Patients and methods

Employing a decision tree model, this research evaluates the cost-effectiveness of rimegepant over a concise 2 h period, exclusively considering its direct market price of 219.00 CNY per dose for on-demand, single-use treatment upon approval in China. This model is based on pain relief outcomes from a clinical trial, categorizing health outcomes by the achievement of pain freedom and alleviation from the most bothersome symptom within two hours post-administration.

Results

The study unveils that rimegepant adds 0.0018 quality-adjusted life days (QALD) with an incremental cost-effectiveness ratio (ICER) of 122,166.07 CNY/QALD. Against a daily cost-effectiveness threshold derived from the 2023 per capita GDP of China (734.45 CNY/day), rimegepant falls short of proving its cost-effectiveness. A significant price reduction to approximately 1.32 CNY per dose is required for rimegepant to be considered cost-effective within this framework. Furthermore, a series of sensitivity analyses were conducted to validate the robustness of these results.

Conclusion

While rimegepant shows clinical efficacy in providing rapid relief from migraine symptoms, its current pricing exceeds the threshold for cost-effectiveness in the Chinese healthcare setting. This study underscores the need for price adjustments to enhance the accessibility and economic viability of new migraine treatments.

The prevalence of headache disorders in children and adolescents in Benin: a schools-based study

BACKGROUND

A global schools-based programme within the Global Campaign against Headache is estimating the burden of headache in children (6-11 years) and adolescents (12-17 years), cluster-sampling the world by conducting national studies in all world regions. Its purpose is to complement population-based studies in adults, adding to knowledge of the burden of headache and informing educational and health policies. This study in Benin was the third in the programme from sub-Saharan Africa (SSA).

METHODS

We followed the generic protocol for the global study. In a cross-sectional survey, the child and adolescent versions of the Headache-Attributed Restriction, Disability, Social Handicap and Impaired Participation (HARDSHIP) structured questionnaire were administered to pupils within their classes in 16 schools selected from across the country to be representative of its diversities. Headache diagnostic questions were based on ICHD-3 criteria but for the inclusion of undifferentiated headache (UdH).

RESULTS

Very large proportions of pupils were absent on the survey days. The sampled population defined by class registers totalled 11,802 pupils, of whom only 2,488 were present. A further 193 pupils (or their parents) declined the survey. The surveyed sampled (N = 2,295; males 1,156 [50.4%], females 1,139 [49.6%]) included 1,081 children (47.1%) and 1,214 adolescents (52.9%), with a non-participating proportion (193/2,488) of 7.8%. Headache ever was reported by 97.3% of the sample. Age- and gender-adjusted 1-year prevalences, according to responses given, were 53.4% for migraine (almost three quarters of this being probable migraine), 21.3% for tension-type headache, 8.2% for UdH, 1.0% for probable medication-overuse headache (pMOH) and 2.6% for other headache on ≥ 15 days/month (H15+). Both pMOH and other H15 + were substantially more prevalent among adolescents.

CONCLUSION

The finding for migraine is anomalous, but, within this series of studies, the same was found in Zambia and similar in Ethiopia, both in SSA. While many cases identified as probable migraine, especially among children, might better have been diagnosed as UdH, the true prevalence of migraine almost certainly exceeds 21%. Regardless of diagnosis, headache is very common among children and adolescents in Benin. The study sounds an alarm with regard to pMOH as a developing problem pre-adulthood.

Sex and age-related patterns in pediatric primary headaches: observations from an outpatient headache clinic

Background

Age reportedly affects headache prevalence differently in boys and girls. However, little empirical data exists regarding pediatric headache prevalence and headache-related burden in children and adolescents according to age and sex. In the present study, we considered age and sex while evaluating the distribution, characteristics, and impairment of primary headache disorders at a pediatric headache center in Germany.

Methods

Medical records of children and adolescents attending the headache clinic of the Interdisciplinary Pain Center of the Carl Gustav Carus University Hospital in Dresden during the period 2015-2022 were retrospectively grouped and analyzed depending on age (< or ≥14 years) and sex.

Results

The study population consisted of 652 children and adolescents, aged between 3 and 18 years. Almost two-thirds of the patients (≈60%) were females, and almost two-thirds of these females (58%) were ≥14 years of age. Generally, the most prevalent headache diagnoses as defined by the International Classification of Headache Disorders 3rd edition were episodic migraine without aura and the combination of tension-type headache and episodic migraine with or without aura i.e., mixed-type headache (each ≈27%). In the younger group (<14 years), the mixed-type headache was the most prevalent in girls (28.6%), whereas, for boys, episodic migraine without aura was the most prevalent headache diagnosis (47.4%). In the older group (≥14 years), the mixed-type headache continued to be the most prevalent for girls (30%), and it became the most prevalent for boys (26.3%). Before the age of 14, about 16% of children were severely affected by their headaches. After the age of 14, this proportion increased to roughly one-third (33%) of adolescents, driven mainly by teenage girls (26%) who were severely affected by their headaches. Furthermore, the prevalence of comorbidities was significantly higher among girls (67%), particularly in the adolescent group (74%).

Conclusions

Our data shows that headache disorders in a specialized pediatric clinic impose a significant burden, especially among teenage girls indicating high therapy needs. Enhancing awareness of early diagnosis and preventive care is crucial to mitigate the development of chronic headaches, and mitigate their adverse effects on life quality and educational capability.

The burdens attributable to headache disorders in Cameroon: national estimates from a population-based door-to-door survey, including a headache-care needs assessment

BACKGROUND

We have previously shown headache to be highly prevalent in Cameroon. Here we present the attributed burden. We also perform a headache-care needs assessment.

METHODS

This was a cross-sectional survey among adults (18-65 years) in the general population. Multistage cluster-sampling in four regions (Centre, Littoral, West and Adamawa), home to almost half the country's population, generated a representative sample. We used the standardised methodology of the Global Campaign against Headache, including the HARDSHIP questionnaire, with diagnostic questions based on ICHD-3 and enquiries into symptom burden, impaired participation (lost productivity and disengagement from social activity), quality of life (QoL) using WHOQoL-8, and willingness to pay (WTP) for effective care. We defined headache care "need" in terms of likelihood of benefit, counting all those with probable medication-overuse headache (pMOH) or other headache on ≥ 15 days/month (H15 +), with migraine on ≥ 3 days/month, or with migraine or tension-type headache (TTH) and meeting either of two criteria: a) proportion of time in ictal state (pTIS) > 3.3% and intensity ≥ 2 (moderate-to-severe); or b) ≥ 3 lost days from paid and/or household work in the preceding 3 months.

RESULTS

Among 3,100 participants, mean frequency of any headache was 6.7 days/month, mean duration 13.0 h and mean intensity 2.3 (moderate). Mean pTIS was 9.8%, which (with prevalence factored in) diluted to 6.1-7.4% of all time in the population. Most time was spent with H15 + (5.3% of all time), followed by TTH (1.0%) and migraine (0.8%). For all headache, mean lost days/3 months were 3.4 from paid work, 3.0 from household work and 0.6 from social/leisure activities, diluting to 2.5, 2.2 and 0.6 days/3 months in the population. QoL (no headache: 27.9/40) was adversely impacted by pMOH (25.0) and other H15 + (26.0) but not by migraine (28.0) or TTH (28.0). WTP (maximally XAF 4,462.40 [USD 7.65] per month) was not significantly different between headache types. An estimated 37.0% of adult Cameroonians need headache care.

CONCLUSION

Headache disorders in Cameroon are not only prevalent but also associated with high attributed burden, with heavily impaired participation. Headache-care needs are very high, but so are the economic costs of not providing care.

Diagnostics and management of headache in general practice

BACKGROUND

Headache disorders are globally prevalent and insufficient treatment contribute to low quality of life, increased disability, and socioeconomic costs. However, headache can to a large extent be treated appropriately by general practitioners.

OBJECTIVE

To explore general practitioners' (GPs') management of patients with headache lasting ≥6 months.

METHODS

In this retrospective descriptive cross-sectional study based on medical audit, all GPs practicing in Vejle municipality (population 116,992), Denmark, were invited to review their latest 20 patients with headache. Outcome measures were headache diagnostics, treatment, and referrals. Factors associated with referral to neurological treatment were examined by logistic regression.

RESULTS

Of 26 invited practices, 19 participated reporting on 367 patients with lasting headache (71.4% women; mean-age 48.5 years). One hundred and sixty-one patients had migraine (44%; IQR: 28-60%), 140 (38%; IQR: 25-44%) had tension-type headache; 243 (66%; IQR: 50-79%) used simple analgesics, 147 (40%; IQR: 29-59%) triptans, 37 (10%; IQR: 0-14%) opioids, 93 (25%; IQR: 20-35%) were prescribed preventive medication; 176 (48%; IQR: 48-59%) were referred to neurologist, and 92 (25%; IQR: 10-37%) were referred to CT or MRI scan. Associated factors for referral were >1 headache diagnosis (aOR 1.75 [95% CI: 1.05-2.95]; P = 0.03), post-traumatic headache (aOR 2.53 [95% CI: 1.25-5.38]; P = 0.01), unspecific headache (aOR 2.04 [95% CI: 1.08-3.93]; P = 0.03), and using preventive treatment (aOR 2.75 [95% CI: 1.68-4.57]; P < 0.001).

CONCLUSION

This study provides insights to how GPs manage patients with long-lasting headache. Focus should be on reducing opioids, increasing preventive treatment, and keeping more patients in primary care.

Global, regional, and national burden and trends of migraine among youths and young adults aged 15-39 years from 1990 to 2021: findings from the global burden of disease study 2021

BACKGROUND

Migraine, a widespread neurological condition, substantially affects the quality of life, particularly for adolescents and young adults. While its impact is significant, there remains a paucity of comprehensive global research on the burden of migraine in younger demographics. Our study sought to elucidate the global prevalence, incidence, and disability-adjusted life-years (DALYs) associated with migraine in the 15-39 age group from 1990 to 2021, utilizing data from the Global Burden of Disease (GBD) 2021 study.

METHODS

Our comprehensive study analyzed migraine data from the GBD 2021 report, examining the prevalence, incidence, and DALYs across 204 countries and territories over a 32-year span. We stratified the information by age, sex, year, geographical region, and Socio-demographic Index (SDI). To evaluate temporal trends in these metrics, we employed the estimated annual percentage change (EAPC) calculation.

RESULTS

Between 1990 and 2021, the worldwide prevalence of migraine among 15-39 year-olds increased substantially. By 2021, an estimated 593.8 million cases were reported, representing a 39.52% rise from 425.6 million cases in 1990. Global trends showed increases in age-standardized prevalence rate, incidence rate, and DALY rate for migraine during this period. The EAPC were positive for all three metrics: 0.09 for ASPR, 0.03 for ASIR, and 0.09 for DALY rate. Regions with medium SDI reported the highest absolute numbers of prevalent cases, incident cases, and DALYs in 2021. However, high SDI regions demonstrated the most elevated rates overall. Across the globe, migraine prevalence peaked in the 35-39 age group. Notably, female rates consistently exceeded male rates across all age categories.

CONCLUSION

The global impact of migraine on youths and young adults has grown considerably from 1990 to 2021, revealing notable variations across SDI regions, countries, age groups, and sexes. This escalating burden necessitates targeted interventions and public health initiatives, especially in areas and populations disproportionately affected by migraine.

Childhood Reading Ability and Pain in Childhood Through to Midlife

Dyslexia and pain have recently been shown to correlate on a genetic level, but there has been little exploration of this association on the phenotypic level despite reports of increased pain in Attention Deficit Hyperactivity Disorder, which commonly co-occurs with dyslexia. In this study we test for an association between reading ability, which is the primary feature of dyslexia, and pain both in childhood and adulthood. Logistic regression modeling was used to test associations between reading ability in childhood and pain from childhood to midlife in a large UK birth cohort; the 1958 National Child Development Study. Associations were found between poor childhood reading ability and increased headache and abdominal pain in childhood, and between poor childhood reading ability and headache, eye pain, back pain, and rheumatism in adulthood. Mediation analyses indicated that socioeconomic status (defined by employment) fully mediated the association between poor reading ability in childhood and back pain at age 42. By contrast, the association between reading ability and eye pain acted independently of socioeconomic status. Different mechanisms were thus indicated for the association of reading with different pain types, including manual labor and a potential shared biological pathway. PERSPECTIVE: This study found a relationship between poor reading ability in childhood and pain in childhood and adulthood. Those with reading difficulties should be monitored for pain symptoms. Future research may uncover shared biological mechanisms, increasing our understanding of pain and potential treatments.

Transverse Sinus Stenosis as an Underdiagnosed Cause of Chronic Headache: A Case Report

Transverse sinus stenosis (TSS) is an abnormality in the cerebral venous system in which the narrowing of the transverse sinus of the brain leads to obstructed cerebral venous outflow. It is an infrequent, incidental radiological finding. However, it is not uncommon among patients with chronic headaches of unclear cause, particularly those that remain unexplained after initial evaluation or those that are refractory to medical treatment. Its diagnosis frequently eludes the initial workup, and a high degree of suspicion should be maintained since its identification can lead to potentially curative treatment. This report describes the case of a 36-year-old female with a history of chronic headache who was found to have TSS. This paper discusses its etiology, pathophysiology, clinical presentation, radiological findings, and management.

Real-world experiences of migraine patients on Erenumab: a Kuwait single center cohort

BACKGROUND

Migraine is a prevalent headache disorder with a significant impact on the quality of life. This study aims to investigate the effectiveness and safety of erenumab, mAb targeting the CGRP receptor, in treating chronic (CM) and episodic (EM) migraine in clinical practice Kuwait, providing region-specific insights to treatment options.

METHOD

This was a prospective observational cohort study of patients diagnosed with EM or CM treated with erenumab. The primary outcome of the study was to assess the proportion of patients achieving ≥ 50% reduction in monthly mean migraine days, and several changes including the mean number of monthly migraine days, the frequency of analgesic use, attack severity, AEs, and QoL.

RESULTS

The study included 151 patients with a mean age of 44.0±11.4 years, and 81.9% female. The primary outcome was achieved in 74.2% of patients, with a significant (p < 0.001) reduction in headache frequency, pain severity, analgesic use, and improvement in QoL. Age and duration of migraine were significant predictors of achieving a ≥ 50% reduction in headache frequency after therapy (OR = 0.955; p = 0.009) and (OR = 0.965; p = 0.025), respectively. Treatment compliance was observed in 76.2% of patients, and 24.5% discontinued treatment. Constipation was the most commonly reported AEs (6.0%), and conservative management was the most common approach to managing AEs.

CONCLUSION

Erenumab was effective in reducing the frequency and severity of migraine attacks and improving QoL, and safe with manageable AEs in a real-world setting in Kuwait. Further research is needed to better understand erenumab's effectiveness and safety in different populations and settings, as well as to compare it with other migraine prophylactic treatments.

Pharmacokinetics and Safety of Atogepant Co-administered with Quinidine Gluconate in Healthy Participants: A Phase 1, Open-Label, Drug-Drug Interaction Study

Atogepant, an oral calcitonin gene-related peptide receptor antagonist, is approved for the preventive treatment of migraine. Atogepant is a substrate of P-glycoprotein (P-gp), breast cancer resistance protein, organic anion transporting polypeptide transporters, and cytochrome P450 (CYP)3A4 and 2D6. Quinidine is a strong P-gp and CYP2D6 inhibitor. A phase 1 open-label study evaluated the effect of P-gp and CYP2D6 inhibition by quinidine on the pharmacokinetics of atogepant, and the safety and tolerability of atogepant and quinidine gluconate (QG) when co-administered and when given alone in 33 healthy adults. There was no significant change in the atogepant maximum plasma concentration with QG co-administration. The overall systemic exposure, the area under the plasma concentration-time curve (from time 0 to time t or to infinity), of atogepant increased by 25% when co-administered with QG. However, such an increase was not considered clinically relevant. Atogepant did not alter the mean plasma concentration of quinidine at steady state. The incidence of treatment-emergent adverse events (TEAEs) was highest when QG was administered alone (42.4%), which was primarily due to QT prolongation. Most TEAEs reported were mild in severity and resolved within 1-2 days. Co-administration of atogepant with QG did not result in any unexpected tolerability findings in this phase 1 study in healthy participants. The increase in atogepant exposure during QG co-administration could be due to inhibition of CYP2D6 (a minor contributor to atogepant clearance) as well as inhibition of P-gp.

Patterns of migraine medication use in Norway: A nationwide registry-based observational study

OBJECTIVE

The objective of this study was to describe and discuss patterns of migraine medication use in the entire Norwegian population.

METHODS

In this nationwide, observational study, all individuals with a migraine-related prescription between 2010 and 2020 were identified using the Norwegian Prescription Database. The outcomes of interest were the incidence and 1-year prevalence of migraine medication users, as well as individuals with triptan overuse. Patterns of medication use were statistically compared between women and men adjusted for age, year of treatment start, comorbidities and county of residence calculating adjusted odds ratios (aOR) with 95% confidence intervals (CI).

RESULTS

We identified 327,904 migraine medication users. The incidence ranged from 0.39% to 0.46%, and the 1-year prevalence increased from 1.99% to 2.99%. Preventive use increased >50% during the study period. Preventives were significantly more often prescribed to women than to men (39.72% vs. 33.75%; aOR 1.41, 95% CI 1.38 to 1.44). Triptan overuse was significantly more common among women, but women with overuse were more often using preventives, as compared to men (56.64% vs 52.69%; aOR = 1.43, 95% CI 1.37 to 1.49).

CONCLUSION

The prevalence of medically treated migraine is low. Overuse of triptans is frequent, especially among women. Clinicians should be encouraged to try out different triptans, recognize triptan overuse, and prescribe preventives when indicated.

Localization of the greater occipital nerve through palpation of bony landmarks: A cadaveric study

OBJECTIVE

to provide anatomic confirmation that standard methods which practitioners skilled in palpation use, can reliably identify the most likely site of emergence of the greater occipital nerve in most patients. The location and frequency of subcutaneous emergence of the greater occipital nerve and occipital artery with respect to the external occipital protuberance-mastoid line are reported.

METHODS

The external occipital protuberance and the mastoid processes were identified by palpation bilaterally on 57 body donors and the medial trisection point of a line connecting these bony landmarks was identified. A 4 cm circular dissection guide divided into 4 quadrants was centered on the trisection point and used to guide the removal of a circle of skin. The in-situ location of the nerve and artery were exposed by deep dissection within the circle. The frequency of the emergence and occurrence of the nerve and artery by quadrant were analyzed.

RESULTS

In 114 total dissections the greater occipital nerve was found to emerge within the circle 96 times (84%) and the occipital artery 100 times (88%). The nerve (90%) and artery (81%) emerged from the two inferior quadrants most of the time with no difference noted between male and female donors. The greater occipital nerve and occipital artery were found to emerge together most commonly in inferior lateral quadrant. Branches of the nerve and artery traveled together most frequently through the two lateral quadrants.

CONCLUSION

This study confirmed that the medial trisection point of the external occipital protuberance-mastoid line can be located via palpation and reliably used to pinpoint the subcutaneous emergence of the greater occipital nerve and occipital artery in most individuals. When relying on palpation alone to identify the trisection point in the clinic, infusion of nerve block inferior and lateral to this point is most likely to bathe the greater occipital nerve in anesthetic.

A cross-sectional, multicenter survey of the prevalence and influencing factors for migraine in epilepsy

OBJECTIVES

Epilepsy and migraine are common chronic neurological disease. Epidemiologic studies and shared pathophysiology and treatment suggest that these two diseases overlap. However, migraine is often underestimated among patients with epilepsy. This study aimed to evaluate the prevalence of migraine and identify the related influencing factors among adult patients with epilepsy.

METHODS

Adult patients with epilepsy were recruited at the outpatient epilepsy clinic of 13 tertiary hospitals in China from February to September 2022. ID Migraine questionnaire was applied to evaluate for migraine. Both univariable and multivariable logistic regression models were used to explore the influencing factors of migraine.

RESULTS

A total of 1326 patients with epilepsy were enrolled in this study. The prevalence of migraine among patients with epilepsy was 19.2% (254/1326). In the multivariable analysis, being female (OR = 1.451, 95% CI: 1.068-1.975; p = 0.018), focal and focal to bilateral tonic-clonic seizures (OR = 1.583, 95% CI: 1.090-2.281; p = 0.015), and current seizure attack in the last 3 months (OR = 1.967, 95% CI: 1.282-3.063; p = 0.002) were the influencing factors for migraine. However, <10% of patients with epilepsy received analgesics for migraine.

SIGNIFICANCE

Approximately 20% of patients with epilepsy screened positive for migraine. Being female, focal and focal to bilateral tonic-clonic seizures, and current seizure attack in the last 3 months were the influencing factors for migraine. Neurologists should pay more attention to the screening and management of the migraine among patients with epilepsy in China.

PLAIN LANGUAGE SUMMARY

Epilepsy and migraine are common chronic neurological disease with shared pathophysiological mechanisms and therapeutic options. However, migraine is often underestimated among patients with epilepsy. This multicenter study aimed to evaluate the prevalence of migraine and current status of treatment. In this study, approximately 20% of patients with epilepsy screened positive for migraine. Female, focal and focal to bilateral tonic-clonic seizures, and current seizure attack in the last 3 months were identified as independent influencing factors for migraine. Despite the high prevalence, the treatment for migraine was not optimistic, neurologists should pay more attention to the screening and management of migraine.