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

Mechanistic approach and therapeutic strategies in menstrual and non-menstrual migraine

Migraine is a common condition that can cause intense headaches, often on one side of the head, along with symptoms like nausea and sensitivity to light and sound. These headaches can be triggered by various factors, including stress, changes in hormones, sleep disturbances, diet, and even gut health. Migraines are more frequent in women, particularly those under 45, and this may be linked to hormones. After age 45, this difference between men and women becomes less noticeable. Women tend to experience migraines that are more severe and last longer than men, with menstrual migraines affecting about 22% of women during nearly half of their menstrual cycles, and 7.6% of women with migraines. Treatments for migraines include medications, lifestyle changes, and alternative therapies, all of which aim to address the different ways migraines can affect people. This review explores these aspects in detail.

Neuropsychiatric manifestations of sarcoidosis

BACKGROUND

There has been significant progress in understanding neurosarcoidosis (NS) as a distinct disorder, which encompasses a heterogeneous group of clinical and radiological alterations which can affect patients with systemic sarcoidosis or manifest isolated.

RATIONALE AND AIM OF THE STUDY

The healthcare challenges posed by NS and sarcoidosis in general extend beyond their physical symptoms and can include a variety of psychosocial factors, therefore the recognition of main neuropsychiatric symptoms can be useful to approach patients with NS. Methods: For this purpose, databases such as Pubmed, Medline and Pubmed Central (PMC) have been searched.

RESULTS

A correct diagnosis of NS is established by the combination of clinical picture, imaging features and the histopathological finding of non-caseating and non-necrotizing granulomas. After analyzing the current literature, there is a need for specific, case-control, cohort and clinical trials on the psychiatric manifestations of sarcoidosis, because the evaluation of psychological distress (in terms of emotional suffering e.g. anxiety or depression) is often underestimated.

DISCUSSION AND CONCLUSION

Exploring the neuropsychiatric manifestations of sarcoidosis is useful to raise awareness of this condition among clinicians and to establish a holistic management, which includes both physical and psychological aspects.

Guidelines to minimize risk when dry needling the rectus capitus posterior major muscle

BACKGROUND

Headache disorders are prevalent often leading to disability. The rectus capitus posterior major muscle (RCPMaj) may contribute to headache symptoms via nociceptive convergence and myodural bridging.

OBJECTIVES

To establish guidelines for needle length and needle angle to mitigate risks during dry needling RCPMaj.

DESIGN

Cadaveric investigation.

METHODS

Twenty-five cadavers (mean age: 80.1 ± 13.2 years) were placed in prone. Depth measurements from the skin to the C2 spinous process were taken following midline incision. Dissection continued exposing the RCPMaj for three measures including: 1) posterior angle from the frontal plane, 2) lateral angle from midline, and 3) distance from the external occipital protuberance to the lateral most RCPMaj.

RESULTS

Mean values for tissue thickness overlying C2 spinous process (37 ± 7.3 mm), RCPMaj posterior angle from the frontal plane (65.2° ±10°), RCPMaj lateral angle from midline (34.7° ±12.9°), and distance from the external occipital protuberance to the lateral most RCPMaj (30.6 mm ± 9.3 mm) were used to calculate a needle inclination of ≤45° and a needle length <40 mm to reach the occipital portion of RCPMaj with an a priori insertion point of midway between the C2 spinous process and the C1 transverse process.

CONCLUSION

Inserting a dry needle <40 mm in length midway between the C2 spinous process and the C1 transverse process with a cranial angle of ≤45° relative to the frontal plane would increase the likelihood of reaching the RCPMaj and mitigate penetrating deeper structures.

Low health literacy impact on headache diagnosis

Health literacy has a broad range of impacts, including whether and where a person seeks treatment and how well that patient interprets and applies clinical recommendations. Patients with headache may not seek treatment, may fail to disclose even severe pain to their physician, and may not understand or adhere to treatment. Universal precautions can be a helpful initial approach, and information styles can be modified as needed over time. Patients should be asked about headache and explanations about headache causes and treatment should be given in everyday language. The teach-back method can confirm if patients understand instructions. Health literacy can impact how patients perceive their headaches and how well they adhere to treatments. Health literacy is a two-way street; it depends on the patient's ability to understand and act on clinical information and the clinician's ability to give clear information. Language and cultural barriers can adversely impact health literacy, even in patients who otherwise have good understanding of medical advice. While health literacy can impact outcomes, those with low or very high health literacy are most likely to be non-adherent, albeit for different reasons. Clinical action plans can be valuable for those with severe headache.

The Chronic Headache Self-Efficacy Scale: Development and assessment of measurement properties

OBJECTIVE

To develop and assess the psychometrics of the Chronic Headache Self-Efficacy Scale (CHASE).

BACKGROUND

Existing scales assess self-efficacy in coping strategies and management of symptoms and triggers but do not measure other important self-efficacy domains, such as performing daily activities and socializing in patients with chronic daily headache (CDH).

METHODS

The study had two phases: (i) Development of the 14-item CHASE, with items derived from patients with CDH and a multidisciplinary healthcare team; (ii) longitudinal observational study for psychometric evaluation. Participants with CDH (N = 79) completed the CHASE, Headache Management Self-Efficacy Scale (HMSE), six-item Headache Impact Test-6 (HIT-6), and 12-item Short Form Health Survey (SF-12) at baseline, 24-72 h after baseline, and 12 weeks after baseline. The Global Rating of Change (GROC) assessed perceived change in symptoms. We assessed internal consistency, day-to-day reliability, convergent and known group discriminant validity, dimensionality, and responsiveness via minimal clinical important difference (MCID).

RESULTS

For day-to-day reliability, the CHASE intraclass correlation coefficient was 0.68 (95% confidence interval 0.49-0.81), with standard error of measurement and minimal detectable change of 10.3% and 24%, respectively. The CHASE had two independent factors (total R2 = 54.5%) that can be combined into a single score (Cronbach's alpha internal consistency 0.88). For convergent validity, the CHASE score was related to the HIT-6, HMSE, and SF-12 (R2: 0.17-0.29, all p < 0.001). For known group discriminant validity, individuals with an active headache had a lower CHASE score than those without (mean [standard deviation] 47.7 [17.3]% vs. 57.2 [19.8]%, p < 0.001). Classification and regression tree analysis showed the MCID for meaningful positive symptom change on the GROC was a CHASE change of >8% or CHASE change of 8% with baseline CHASE >67%.

CONCLUSION

The CHASE is a reliable and valid questionnaire for assessing self-efficacy in performing daily activities, socializing, managing headache symptoms and triggers, and guiding treatment plans for patients with CDH.

Sex difference in TRPM3 channel functioning in nociceptive and vascular systems: an emerging target for migraine therapy in females?

Transient Receptor Potential Melastatin 3 (TRPM3) channels are Ca2+ permeable ion channels that act as polymodal sensors of mechanical, thermal, and various chemical stimuli. TRPM3 channels are highly expressed in the trigeminovascular system, including trigeminal neurons and the vasculature. Their presence in dural afferents suggests that they are potential triggers of migraine pain, which is originating from the meningeal area. This area is densely innervated by autonomous and trigeminal nerves that contain the major migraine mediator calcitonin gene-related peptide (CGRP) in peptidergic nerve fibers. Co-expression of TRPM3 channels and CGRP receptors in meningeal nerves suggests a potential interplay between both signalling systems. Compared to other members of the TRP family, TRPM3 channels have a high sensitivity to sex hormones and to the endogenous neurosteroid pregnenolone sulfate (PregS). The predominantly female sex hormones estrogen and progesterone, of which the levels drop during menses, act as natural inhibitors of TRPM3 channels, while PregS is a known endogenous agonist of these channels. A decrease in sex hormone levels has also been suggested as trigger for attacks of menstrually-related migraine. Notably, there is a remarkable sex difference in TRPM3-mediated effects in trigeminal nociceptive signalling and the vasculature. In line with this, the relaxation of human isolated meningeal arteries induced by the activation of TRPM3 channels is greater in females. Additionally, the sex-dependent vasodilatory responses to CGRP in meningeal arteries seem to be influenced by age-related hormonal changes, which could contribute to sex differences in migraine pathology. Consistent with these observations, activation of TRPM3 channels triggers nociceptive sensory firing much more prominently in female than male mouse meninges, suggesting that pain processing in female patients with migraine may differ. Overall, the combined TRPM3-related neuronal and vascular mechanisms could provide a possible explanation for the higher prevalence and even the more severe quality of migraine attacks in females. This narrative review summarizes recent data on the sex-dependent roles of TRPM3 channels in migraine pathophysiology, the potential interplay between TRPM3 and CGRP signalling, and highlights the prospects for translational therapies targeting TRPM3 channels, which may be of particular relevance for women with migraine.

The occurrence of cervicogenic headache: A mapping review

BACKGROUND

Occurrence of cervicogenic headache (CeH), mostly expressed by estimates of the prevalence, ranges between 0.4% and 42%. However, transparency on such estimates is lacking, which hinders generalizing results.

OBJECTIVE

Mapping the occurrence (expressed by incidence/prevalence) of CeH.

DESIGN

Mapping review.

METHOD

A systematic literature search of PubMed, EMBASE, Web of Science, Scopus databases (last search update January 28th, 2025). The search query comprised terminology relating to "CeH", "prevalence", "incidence".

RESULTS

Thirty-four publications were included (prevalence n = 32, incidence n = 2). The prevalence of CeH varied depending on the geographical location (Norway: 0.17% - USA: 69%), population (age: 0.17%-56.7%, chronic headache: 0.17% - computer users: 64.5%), setting (inpatient: 13.8%-69%, outpatient: 0.38%-10%), diagnostic criteria (International Headache Society: 0.38%-40%, Cervicogenic Headache International Study Group: 0.17%-64.5%), and diagnostic process (questionnaires: 5.3%-64.5%, clinical examination: 0.17%-56.7%, diagnostic block: 0.17%-16.1%).

CONCLUSION

Most publications were retrieved from Europe, Asia, and the United States. One multicentre study provided results for the African continent. No conclusion could be drawn on the incidence of CeH. The populations studied (e.g., general, age-stratified, specific), settings (e.g., hospital, private practice, clinics, emergency services), diagnostic criteria (e.g., International Headache Society or Cervicogenic Headache International Study Group) and processes (e.g., questionnaires, clinical examination) were heterogeneous. Four publications required a diagnostic block in the diagnostic process. A standardized methodology, especially regarding the diagnostic criteria and process, is needed to compare studies, guarantee quality, and provide estimates to inform policy makers.

German translation, transcultural adaptation and test-retest reliability of the headache screening questionnaire

INTRODUCTION

Tension-type headache (TTH) and migraines are frequent headache types. For appropriate treatment, physiotherapists need to be able to recognize these two headache types. The Dutch Headache Screening Questionnaire (HSQ-DV) is the only screening questionnaire designed specifically for migraines and TTH, based on the latest International Classification of Headache Disorders and supporting evidence. The aim of this study is to translate the HSQ-DV into German and evaluate its test-retest reliability.

METHODS

A cross-sectional and prospective cohort study was conducted to answer the research questions. The HSQ-DV was translated according to the COMSIN checklist for patient-reported outcome measurement instruments. Test-retest reliability was assessed with a retest after two weeks. Weighted kappa values, intraclass-correlation coefficients (ICCs) and standard error of the measurements (SEMs) were calculated separately for migraines and THH, based on point scale ranging from 0 to 8.

RESULTS

The HSQ-DV was translated and culturally adapted into German. An introductory clarification was added to guide participants with multiple headaches, which headache type to consider. Sixty-one subjects were included in the reliability study. For migraine, the weighted kappa was 0.70 (95% Confidence Interval (CI) 0.52 to 0.87), the ICC was 0.84 (95% CI: 0.71 to 0.91), and the SEM was 0.39 points. For TTH, the weighted kappa was 0.73 (95% CI: 0.57 to 0.90), the ICC was 0.85 (95% CI: 0.74 to 0.92), and the SEM was 0.29 points.

CONCLUSION

The HSQ-GV is a reliable screening questionnaire for migraines and TTH in physiotherapy settings, demonstrating substantial to nearly perfect reliability.

Herpes simplex-2 meningitis presenting with headache in pregnancy

Herpes simplex virus (HSV) is a double-stranded DNA virus, whose primary target is epithelial cells. It is disseminated by hematogenous spread. HSV type 2 (HSV-2) usually causes genital infection with mucocutaneous lesions or it may be asymptomatic. HSV-2 is also an important cause of meningitis either during primary infection or by (recurrent) reactivation of dormant virus within the central nervous system. The authors present the case of a nulliparous woman in her mid-20s presenting to the emergency department at 22 weeks' gestation with acute onset of headache. CT of the head and magnetic resonance angiography (MRA) were unremarkable. She received broad-spectrum antimicrobial therapy for suspected meningitis. Her cerebrospinal fluid culture detected HSV-2. She denied a history of oral or genital herpes. She commenced treatment with intravenous acyclovir 10 mg/kg 8 hourly for 7 days. She responded clinically and her headache resolved. There remains a relative dearth of cases of HSV-2 meningitis reported in the literature hence making pregnancy management and delivery planning challenging for obstetricians. This case demonstrates the importance of the multidisciplinary team involvement of genitourinary medicine and sexual health physicians, obstetricians and neonatologists with formal documentation of a birth and postnatal care plan.

Chronic Stress and Headaches: The Role of the HPA Axis and Autonomic Nervous System

Chronic stress significantly influences the pathogenesis of headache disorders, affecting millions worldwide. This review explores the intricate relationship between stress and headaches, focusing on the dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis and autonomic nervous system (ANS). Persistent stress could lead to neuroinflammation, increased pain sensitivity, and vascular changes that could contribute to headache development and progression. The bidirectional nature of this relationship creates a vicious cycle, with recurrent headaches becoming a source of additional stress. Dysregulation of the HPA axis and ANS imbalance could amplify susceptibility to headaches, intensifying their frequency and severity. While pharmacological interventions remain common, non-pharmacological approaches targeting stress reduction, such as cognitive-behavioral therapy, biofeedback, and relaxation techniques, offer promising avenues for comprehensive headache management. By addressing the underlying stress-related mechanisms, these approaches provide a sustainable strategy to reduce headache frequency and improve patients' quality of life.

Acupuncture for the prevention of episodic migraine

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To investigate whether acupuncture is more effective than 'sham' (placebo) acupuncture, no preventative treatment or routine care only, or other interventions, in reducing headache frequency in people with episodic migraine.

Risk of Attempted and Completed Suicide in Persons Diagnosed With Headache

Importance

Although past research suggests an association between migraine and attempted suicide, there is limited research regarding risk of attempted and completed suicide across headache disorders.

Objective

To examine the risk of attempted and completed suicide associated with diagnosis of migraine, tension-type headache, posttraumatic headache, and trigeminal autonomic cephalalgia (TAC).

Design, Setting, and Participants

This was a population-based cohort study of Danish citizens from 1995 to 2020. The setting was in Denmark, with a population of 5.6 million people. Persons 15 years and older who were diagnosed with headache were matched by sex and birth year to persons without headache diagnosis with a ratio of 5:1. Data analysis was conducted from May 2023 to May 2024.

Exposures

First-time headache diagnoses identified from inpatient hospitalizations, emergency department visits, and outpatient specialty clinic visits using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes.

Main Outcomes and Measures

Diagnostic codes from the ICD-10 were used to identify attempted suicide from the Danish National Patient Registry and the Danish Psychiatric Central Research Register and completed suicides from the Danish Register of Causes of Death. Absolute risks (ARs) and risk differences (RDs) for attempted and completed suicide were calculated using the cumulative incidence function. Hazard ratios (HRs) for attempted and completed suicide associated with headache diagnosis were computed adjusting for age, sex, year, education, income, baseline comorbidities, and accounting for competing risk of death.

Results

In total, 119 486 persons (83 046 female [69.5%]) diagnosed with headache were identified and matched with 597 430 persons (415 230 female [69.5%]) drawn from the general population. Participants' median (IQR) age was 40.1 (29.1-51.6) years. The 15-year AR of attempted suicide among persons diagnosed with headache was 0.78% (95% CI, 0.72%-0.85%) vs 0.33% (95% CI, 0.31%-0.35%) in the comparison cohort (RD, 0.45%; 95% CI, 0.39%-0.53%). The 15-year AR of completed suicide among persons diagnosed with headache was 0.21% (95% CI, 0.17%-0.24%) vs 0.15% (95% CI, 0.13%-0.16%) in the comparison cohort (RD, 0.06%; 95% CI, 0.02%-0.10%). The hazards of attempted suicide (HR, 2.04; 95% CI, 1.84-2.27) and completed suicide (HR, 1.40; 95% CI, 1.17-1.68) were elevated among persons with headache vs comparison cohort members. Findings were consistent across headache types, with stronger associations for TACs and posttraumatic headache.

Conclusions and Relevance

Results of this cohort study revealing the robust and persistent association of headache diagnoses with attempted and completed suicide suggest that behavioral health evaluation and treatment may be important for these patients.

An analysis of the burden of migraine and tension-type headache across the global, China, the United States, India and Japan

Background

Recurrent headaches in headache disorders adversely impact quality of life and job. Migraines and tension-type headache TTH) are the most common primary headaches and a prominent cause of disability globally. However, few research compare headache illness burden in China, India, the United States (US), and Japan.

Methods

Global and Chinese, the US, Indian, and Japanese migraine and TTH incidence, prevalence, and disability-adjusted life years were taken from the GBD database for 1990-2021. The data is studied utilizing decomposition analysis, health inequality research, joinpoint regression model, and Bayesian Average Annual Percentage Change (BAPC) model.

Results

The study found that migraine mostly affects women aged 15-49, while TTH are evenly distributed across gender and age. The worldwide average annual percentage change (AAPC) in disease-adjusted life years (DALYs) for migraine and TTH from 1990 to 2021 was 0.0357, a statistically significant trend (p < 0.001), as determined using joinpoint analysis. China exhibited the quickest rise in migraine and TTH incidence and prevalence, as well as the age-standardized rate (ASR) of DALYs, of the four nations analyzed. The US had the highest value of these indicators. Forecasting models reveal that without policy action, migraine prevalence will grow but TTH prevalence would stay unchanged. Decomposition research showed that population expansion is the major cause of migraines and TTH, which will be slightly alleviated by population aging. Health disparities across economic growth areas lessened between 1990 and 2021, according to the report.

Conclusion

Globally and in China, migraine and TTH incidence and burden have increased since 1990. Migraines are becoming more common in young and middle-aged women, so headache treatment professionals should invest more in patient education to raise awareness and improve self-management to reduce disease burden and medical costs.

Epidemiology of clinically significant migraine in Israel: a retrospective database study

BACKGROUND

Epidemiological studies on migraine are valuable for tracking disease trends, identifying risk factors, and informing treatment strategies. This study assessed the prevalence and annual incidence of clinically significant migraine in Israel from 2017 to 2022, with analyses stratified by age, sex, socioeconomic status, and district. Additionally, we compared relevant characteristics between adult migraine and non-migraine members of Leumit Healthcare Services (LHS), a national health provider in Israel.

METHODS

This retrospective study used LHS electronic health records to evaluate migraine prevalence and annual incidence from 2017 to 2022 among adult LHS members. Clinically significant migraine patients were identified using stringent criteria, including repeated diagnostic codes for migraine, confirmation by a neurologist, or the use of migraine-specific therapies. Each migraine patient was matched 1:1 with a control individual of similar age, sex, socioeconomic status, and ethnic background.

RESULTS

The prevalence of clinically significant migraine increased from 4.5% in 2017 to 5.2% in 2022, with significantly higher rates in women compared to men (8% vs. 2.4% in 2022). The mean age of migraine patients was 46.8 years in 2022. The annual incidence of migraine in 2022 was 43 per 10,000 individuals over 18, with approximately 75% of new cases occurring in women, with a mean age of 36.5 years. The annual incidence of migraine slightly decreased over the period. Approximately two-thirds of new patients were diagnosed by neurologists, with only 19% diagnosed by family physicians. Compared to a matched control population, migraine patients showed a higher prevalence of low body mass index (BMI) and higher diastolic blood pressure (BP). Additionally, distinct differences in laboratory findings were observed among migraine patients, notably lower glucose and hemoglobin A1c levels, lower rate of microalbuminuria, with higher hemoglobin, which may be associated with migraine pathophysiology.

CONCLUSION

This study provides a detailed epidemiological and clinical profile of patients with clinically significant migraine in LHS from 2017 to 2022. Notable trends include higher rates of migraine among patients with lower BMI, higher diastolic BP, lower glucose, and higher hemoglobin, suggesting potential modifiable risk factors.

Prevalence, Treatment, and Unmet Needs of Migraine in the Middle East: A Systematic Review

INTRODUCTION

Migraine is a debilitating neurological disorder characterized by recurrent throbbing, moderate-to-severe headaches that disrupt daily chores, leisure, and social activities of patients, impacting their overall quality of life (QoL). Despite the high disease burden, there is a scarcity of data on migraines within the Middle East (ME) region. Thus, a systematic literature review (SLR) was conducted to examine epidemiological data, treatment patterns, QoL, and unmet needs regarding migraines in the ME region.

METHODS

Electronic searches were carried out using the MEDLINE® and Embase® databases via the OvidSP® platform for articles published prior to April 2024. The inclusion and exclusion criteria for the selection of studies were based on the Patients, Intervention, Comparator, Outcomes, and Study design framework, which identified 42 studies.

RESULTS

The prevalence of migraines reported from the region ranged between 2.6 and 32%, and the average age of patients with migraines reported in these studies ranged from 27 to 37.5 years. The data indicated a gender disparity in migraine prevalence, with women exhibiting a 2- to 2.5-fold higher prevalence. Common comorbidities reported were depression, anxiety, and irritable bowel disease. Migraines significantly impact patients' physical and emotional well-being, leading to disabilities and loss of productivity. The most common triggers of migraines were sleep disorders, dietary habits, and stress. The current treatment landscape for acute migraines encompasses anti-inflammatory agents, analgesics, triptans, ditans, calcitonin-gene-related peptides, and antiemetics. However, migraines in the region are often underestimated, underreported, and undertreated. Several unmet needs persist in the region, including delayed referral along with delayed diagnosis, misdiagnosis, poor treatment adherence, limited accessibility to treatments, and a lack of awareness among health care providers and patients.

CONCLUSIONS

The SLR highlights knowledge gaps in clinical aspects and the treatment of migraines and enables clinicians to make informed decisions to ensure optimal patient outcomes in diverse clinical settings.

Cardiovascular Safety of Anti-CGRP Monoclonal Antibodies in Older Adults or Adults With Disability With Migraine

Importance

Monoclonal antibodies (mAbs) targeting calcitonin gene-related peptide (CGRP) or its receptor (anti-CGRP mAbs) offer effective migraine-specific preventive treatment. However, concerns exist about their potential cardiovascular risks due to CGRP blockade.

Objective

To compare the incidence of cardiovascular disease (CVD) between Medicare beneficiaries with migraine who initiated anti-CGRP-mAbs vs onabotulinumtoxinA in the US.

Design, Setting, and Participants

This retrospective, sequential cohort study was conducted among a nationally representative population-based sample of Medicare claims from May 2018 through December 2020. Data analysis was performed from August to December 2023. This study included fee-for-service Medicare beneficiaries aged 18 years or older with migraine who initiated either anti-CGRP mAbs or onabotulinumtoxinA. Beneficiaries who had a history of myocardial infarction (MI), stroke, cluster headache, malignant cancer, or hospice service within a 1-year baseline period prior to treatment initiation were excluded. To minimize channeling bias from new drug introductions and time-related bias due to the COVID-19 pandemic, 5 cohorts were established, representing sequential 6-month calendar intervals based on the initial prescription or date of index anti-CGRP mAbs or onabotulinumtoxinA use.

Exposure

Anti-CGRP mAbs vs onabotulinumtoxinA.

Main Outcomes and Measures

The primary outcome was time to first MI or stroke. Secondary outcomes included hypertensive crisis, peripheral revascularization, and Raynaud phenomenon. The inverse probability of treatment-weighted Cox proportional hazards models were used to compare outcomes between the 2 treatment groups.

Results

Among 266 848 eligible patients with migraine, 5153 patients initiated anti-CGRP mAbs (mean [SD] age, 57.8 [14.0] years; 4308 female patients [83.6%]) and 4000 patients initiated onabotulinumtoxinA (mean [SD] age, 61.9 [13.7] years; 3353 female patients [83.8%]). Use of anti-CGRP mAbs was not associated with an increased risk of composite CVD events (adjusted hazard ratio [aHR], 0.88; 95% CI, 0.44-1.77), hypertensive crisis (aHR, 0.46; 95% CI, 0.14-1.55), peripheral revascularization (aHR, 1.50; 95% CI, 0.48-4.73), or Raynaud phenomenon (aHR, 0.75; 95% CI, 0.45-1.24) compared with onabotulinumtoxinA. Subgroup analyses by age group and presence of established non-MI or stroke CVD showed similar findings.

Conclusions and Relevance

In this cohort study, despite initial concerns regarding the cardiovascular effects of CGRP blockade, anti-CGRP mAbs were not associated with an increased risk of CVD compared with onabotulinumtoxinA among adult Medicare beneficiaries with migraine, who were predominantly older adults or individuals with disability. Future studies with longer follow-up periods and in other populations are needed to confirm these findings.

The Global Burden of Migraine: A 30-Year Trend Review and Future Projections by Age, Sex, Country, and Region

INTRODUCTION

Migraine is a prevalent neurological disorder causing significant disability worldwide. Despite extensive research on specific populations, comprehensive analyses of global trends are remains limited.

METHODS

We extracted incidence, prevalence, and disability-adjusted life years (DALYs) data for migraine from the Global Burden of Disease 2021 database. Trends were analyzed across regions, age groups, sexes, and sociodemographic index (SDI) using estimated annual percentage changes (EAPC). Predictive models (ARIMA) were used to forecast trends to 2050.

RESULTS

From 1990 to 2021, the global burden of migraine significantly increased: prevalence increased by 58.15%, from 732.56 million to 1.16 billion cases, and incidence increased by 42.06%. The DALYs also increased by 58.27%. There were differences between the sexes: female individuals had higher absolute rates of migraine incidence and prevalence, but male individuals exhibited a four- to five-fold more rapid increase than female individuals in these parameters. Adolescents (< 20 years old) have the fastest growth in prevalence and DALYs. Regionally, high SDI regions having the highest age-standardized rate (ASR) and low SDI regions having the lowest ASR in DALYs. East Asia and Latin America exhibited the most significant increases in migraine burden, whereas Southeast Asia exhibited the most pronounced decrease. Predictive analysis suggests prevalence will continue to rise until 2050, particularly among male individuals and adolescents.

CONCLUSIONS

The global burden of migraine has significantly escalated from 1990 to 2021, with female individuals bearing a greater burden but male individuals showing a faster growth rate. Adolescents also face a rapidly rising prevalence. Disparities across SDI regions, countries, age groups, and sexes emphasize the need for targeted public health strategies. Focused interventions are required to mitigate the growing impact of migraines on global health, particularly among male individuals and adolescents.

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.

Efficacy of ubrogepant and atogepant in males and females with migraine: A secondary analysis of randomized clinical trials

BACKGROUND

Published evidence supporting efficacy of calcitonin gene-related peptide receptor antagonists as acute migraine treatments in males is limited.

METHODS

To fill the gap, we present male and female data from four ubrogepant and four atogepant randomized, double-blind, placebo-controlled trials for acute and preventive treatment of migraine, respectively. Acute outcomes included 2-h pain freedom and absence of most bothersome symptom (co-primary; headache-phase randomized, double-blind, placebo-controlled trials); absence of moderate-to-severe headache within 24 h (primary; prodrome randomized, double-blind, placebo-controlled trial). Preventive outcome included change from baseline in mean monthly migraine days across 12 weeks (primary).

RESULTS

Pooled data from phase 3 headache-phase ubrogepant randomized, double-blind, placebo-controlled trials showed similar rates of pain freedom (19.4% vs 21.1%) and absence of most bothersome symptom (35.1% vs 39.0%) 2 h post-dose between males and females, respectively. Time course of pain freedom and absence of most bothersome symptom over 48 h was similar between male and female subgroups. Comparable reductions in mean monthly migraine days across 12-week treatment periods were found between males and females treated with atogepant 60 mg once-daily in pooled episodic migraine and chronic migraine randomized, double-blind, placebo-controlled trials.

CONCLUSION/INTERPRETATION

In ubrogepant and atogepant randomized, double-blind, placebo-controlled trials, although analysis power for males is limited due to small sample sizes, evidence supports similar treatment effects in males and females with migraine.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02828020; NCT02867709; NCT04492020; NCT01613248; NCT02848326; NCT03777059; NCT04740827; NCT03855137.

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.

Effects of selected dietary supplements on migraine prophylaxis: A systematic review and dose-response meta-analysis of randomized controlled trials

BACKGROUND

The existing evidence on the effect of dietary supplements for preventing migraines has generated conflicting results.

METHODS

We assessed alterations in migraine clinical features corresponding to the intake of dietary supplements. Our main outcomes included the frequency (number of attacks), duration (in hours), the severity (intensity) and the monthly migraine days. Using a dose-response meta-analysis, we estimated the dose-dependent impact. The certainty of evidence was evaluated using the GRADE tool.

RESULTS

Finally, twenty-two trials were included in the systematic review and meta-analysis. Magnesium supplementation reduced migraine attacks (mean difference (MD) = -2.51), severity (MD = -0.88), and the monthly migraine days (MD = -1.66) compared with the control group. CoQ10 decreased the frequency (MD = -1.73), severity (MD = -1.35), and duration of migraine (MD = -1.72). Riboflavin decreased attack frequency (MD = -1.34). Alpha-lipoic acid decreased attack frequency (MD = -1.24) and severity (MD = -0.38). Probiotics decreased the frequency (MD = -1.16), severity (MD = -1.07) and the monthly migraine days (MD = -3.02). Vitamin D reduced migraine frequency (MD = -1.69) and the monthly migraine days (MD = -2.41). In adults, compared with placebo, these supplements did not significantly affect other outcomes, and omega-3 supplementation did not yield a statistically significant reduction in any of these outcomes.

CONCLUSION

The use of certain dietary supplements has resulted in a significant decrease in migraine prophylaxis. Further clinical trials of high quality appear to be beneficial.

Exploring the associations of sleep bruxism and obstructive sleep apnea with migraine among patients with temporomandibular disorder: A polysomnographic study

BACKGROUND

Migraine is the most common disabling headache disorder in the world. Temporomandibular disorders (TMDs) are a group of conditions characterized by pain/dysfunction of masticatory muscles or their associated structures. There is a lack of studies concerning the association between sleep disorders such as sleep bruxism (SB), obstructive sleep apnea (OSA), migraine, and TMD, despite the increased prevalence of these conditions in TMD patients.

OBJECTIVE

Our case-control study assesses the potential relationship among SB, OSA, and migraine using polysomnography (PSG) among the group with TMD.

METHODS

One hundred nineteen patients with TMD were recruited and hospitalized in the Department and Clinic of Internal Medicine, Occupational Diseases, Hypertension, and Clinical Oncology at Wroclaw Medical University. Their sleep parameters were assessed by PSG according to American Academy of Sleep Medicine guidelines. Migraine diagnosis was based on the third edition of the International Classification of Headache Disorders. The group of 30 patients with median age 35.0 years (interquartile range [IQR]: 26.0, 41.0) were diagnosed with migraine and this group consisted of 17 without aura (MwoA) and 13 with aura (MwA). Thirty patients with migraine were compared to 89 patients with TMD without migraine (controls) with median age 37.0 years (IQR: 26.0, 44.0).

RESULTS

Sleep bruxism was detected in 86% of the migraine group and 71.9% of control participants. The median bruxism episode index (BEI) among patients with migraine was 3.8 n/h (IQR: 2.7, 5.8) and 3.5 n/h (IQR: 1.8, 6.0) in the control group. SB and severe SB (respectively, BEI > 2 and BEI > 4) were not associated with migraine (odds ratio [OR] = 2.68, 95% confidence interval [CI]: 0.84-8.55, p = 0.095; OR = 0.98, 95% CI: 0.42-2.32, p = 0.966). However, mixed bruxism episodes were more frequent in the migraine group compared to study participants not experiencing migraine (median 0.7 n/h [IQR: 0.4, 1.6] vs. median 0.5 n/h [IQR: 0.2, 0.9], p = 0.044; OR = 1.96 with 95% CI: 1.16-3.32, p = 0.013). The median average duration of SB episodes in the migraine group was longer than in the controls (7.0 s [IQR: 5.5, 8.4] vs. 5.9 s [IQR: 5.1, 6.6], p = 0.005). The apnea-hypopnea index (AHI) value was not associated with migraine compared to controls (OR = 1.01, 95% CI: 0.96-1.06, p = 0.605), but MwoA had significantly increased AHI values compared to MwA (mean AHI = -0.1, standard deviation [SD] = 1.5 for MwA vs. mean AHI = 0.9 with SD = 1.3 for MwoA, p = 0.049).

CONCLUSION

Sleep bruxism may not be associated with migraine among patients with TMD; however, mixed bruxism episodes were more frequent in the migraine group. The increased duration of SB episodes in patients with migraine may suggest the common background of these conditions. OSA is also not associated with migraine; however, MwoA might increase the odds of OSA. There is a need to further explore sleep disturbances and migraine, especially in groups with their increased prevalence, such as patients with TMD.

Fitness-to-work considerations in the paradigmatic pain condition of headache disorder

Headache disorders are common, including in the working population. Clinicians caring for patients with headache need to be aware of work-related factors as potential causes or triggers of headache disorders, and consider the impact of headache on fitness-to-work, especially in safety-sensitive and decision-critical roles. Such fitness-to-work determination should include individualized consideration of the nature of the headache disorder itself, the pattern of the headache, the impact of sleep deprivation on the headache as it relates to fitness to do shiftwork, medication and substance side effects, fitness-to-work implications of associated medical or psychiatric conditions, and the potential of symptom feigning or malingering for secondary gain. As clinicians often struggle with fitness-to-work determinations, a structured approach to fitness-to-work assessments in headache conditions and other pain conditions would improve clarity for clinicians and increase the quality of care provided to patients, with potential benefits for workplace safety and policy in this arena as well.

Global, regional and national epidemiological trends of multiple myeloma from 1990 to 2021: a systematic analysis of the Global Burden of Disease study 2021

Background

Multiple myeloma (MM) is a growing global public health challenge. Known epidemiological data suggest that MM accounts for approximately 10% of all hematologic malignancies and remains the second most common hematologic cancer worldwide. This study utilized data from the 2021 Global Burden of Diseases (GBD) study to evaluate the prevalence, incidence, mortality, disability-adjusted life years (DALYs), and attributable risk factors of MM from 1990 to 2021, and to project future trends for the next 15 years.

Methods

GBD 2021 data were analyzed to assess MM's global burden using four key epidemiological measures: prevalence, incidence, mortality, and DALYs. Estimates are reported per 100,000 population with uncertainty intervals (UI). Temporal trends were assessed through estimated annual percentage change (EAPC) and 95% confidence intervals (CI). All analyses were conducted using R version 4.2.1.

Results

From 1990 to 2021, global MM prevalence, incidence, mortality, and DALYs more than doubled, particularly among males. All Social-Demographic Index (SDI) regions showed increases in ASPR, ASIR, ASMR, and ASDR (all EAPCs >0), with the middle SDI regions exhibiting the most rapid growth. ARIMA model predictions suggest that the MM burden will continue rising over the next 15 years. The proportion of MM cases attributable to high BMI also increased globally, from 6.40% in 1990 to 7.96% in 2021. MM primarily affects older adults, with the highest incidence observed in the 70-74 age group and the highest mortality rate recorded in the same age range.

Conclusion

MM presents an escalating global health challenge. Targeted preventive interventions and improvements in diagnosis, treatment, and care are critical, especially in underdeveloped regions, to address the growing global burden of MM.

Global trends in migraine and anxiety over the past 10 years: a bibliometric analysis

Background

Recent studies have shown that migraine significantly increases the incidence of anxiety and is positively correlated with the severity and frequency of migraine. The relationship between migraine and anxiety has attracted extensive attention. This study focused on the association between migraine and anxiety, aiming to predict potential future research trends.

Methods

A bibliometric analysis was conducted using publications from the Core Collection of Web of Science. We utilized CiteSpace.5.8.R3 and VOSviewer 1.6.17 to evaluate the value of articles over the past 10 years.

Results

The number of publications has increased significantly over the past 10 years. The cooperative network analysis shows that the United States is the most collaborative country. Additionally, Harvard University is the institution and Richard B. Lipton the individual with the highest number of studies on migraine. The analysis of keyword outbreaks indicates that the strong citation burst words are closely related to sex differences, activation, allodynia, and preventive treatment, which represent emerging new research areas and potential hotspots for future research.

Conclusion

An overall upward trend in the research of migraine and anxiety was observed. Sex differences, functional magnetic resonance imaging (fMRI), activation, allodynia, and preventive treatment are predicted to be hotspots in the future.

Functional Disability and Psychological Impact in Headache Patients: A Comparative Study Using Conventional Statistics and Machine Learning Analysis

Background and Objectives: Recent research has focused on exploring the relationships between various factors associated with headaches and understanding their impact on individuals' psychological states. Utilizing statistical methods and machine learning models, these studies aim to analyze and predict these relationships to develop effective approaches for headache management and prevention. Materials and Methods: Analyzing data from 398 patients (train set = 318 and test set = 80), we investigated the influence of various features on outcomes such as depression, anxiety, and headache intensity using machine learning and linear regression. The study employed a mixed-methods approach, combining medical records, interviews, and surveys to gather comprehensive data on participants' experiences with headaches and their associated psychological effects. Results: Machine learning models, including Random Forest (utilized for Headache Impact Test-6, Patient Health Questionnaire-9, and Generalized Anxiety Disorder-7) and Support Vector Regression (applied to Migraine Disability Assessment), revealed key features contributing to each outcome through Shapley values, while linear regression provided additional insights. Frequent analgesic medication emerged as a significant predictor of poorer life quality (Headache Impact Test-6, root mean squared error = 7.656) and increased depression (Patient Health Questionnaire-9, root mean squared error = 5.07) and anxiety (Generalized Anxiety Disorder-7, root mean squared error = 4.899) in the Random Forest model. However, interpreting the importance of features in complex models like supportive vector regression poses challenges, and determining causality between factors such as medication usage and pain severity was not feasible. Conclusions: Our study underscores the importance of considering individual characteristics in optimizing treatment strategies for headache patients.

Quality of Headache Management in Inpatients

PURPOSE

Headache is a prevalent and highly disabling neurological disorder. There are no data on its prevalence in and impact on hospitalized patients. The objective of this study was to describe the prevalence of headache in hospitalized patients, triggers associated with headaches in this population, and compliance with documentation in the electronic medical record system (EMRS).

DESIGN

This was a prospective, descriptive, observational, cross-sectional study. Inpatients who agreed were included.

METHODS

Demographic data, admission-related data, and headache data were collected. Data were obtained from the EMRS and direct interviews with patients. Data were collected at three time points in 2021 and 2022. Statistical analysis, comprising primary and secondary data analysis, was performed with R.

RESULTS

Of the 403 admitted patients, 65.5% (264 of 403) participated. A total of 39% (103 of 264) had presented with headache during their hospitalization, of whom 48.5% (50 of 103) had experienced headache in the preceding 24 hours. Of these, 35.9% (37 of 103) identified stress and 26.2% (27 of 103) identified noise as the most frequent triggers and 24.3% (25 of 103) identified headache as a secondary symptom derived from the cause of admission. During the daily follow-up by the nurse, 95.5% (252 of 264) of patients indicated that they had been asked about pain in general and 11.4% (30 of 264) indicated that they had been asked specifically about headache. No records were obtained from the computer program because although some patients were asked about headache, answers were not recorded in the prespecified "headache" item in the EMRS.

CONCLUSIONS

Headache is a prevalent symptom in hospitalized patients. Health care professionals should ask, register, and care about headache routinely to improve patients' well-being.

Chronic overlapping pain conditions and nociplastic pain

Chronic overlapping pain conditions (COPCs) are a subset of chronic pain conditions commonly comorbid with one another and more prevalent in women and individuals assigned female at birth (AFAB). Pain experience in these conditions may better fit with a new mechanistic pain descriptor, nociplastic pain, and nociplastic pain may represent a shared underlying factor among COPCs. We applied GenomicSEM common-factor genome-wide association study (GWAS) and multivariate transcriptome-wide association (TWAS) analyses to existing GWAS output for six COPCs in order to find genetic variation associated with nociplastic pain, followed by genetic correlation (linkage disequilibrium score regression), gene set, and tissue enrichment analyses. We found 24 independent single nucleotide polymorphisms (SNPs), and 127 unique genes significantly associated with nociplastic pain, and showed nociplastic pain to be a polygenic trait with significant SNP heritability. We found significant genetic overlap between multisite chronic pain and nociplastic pain, and to a smaller extent with rheumatoid arthritis and a neuropathic pain phenotype. Tissue enrichment analyses highlighted cardiac and thyroid tissue, and gene set enrichment analyses emphasized potential shared mechanisms in cognitive, personality, and metabolic traits and nociplastic pain along with distinct pathology in migraine and headache. We used a well-powered network approach to investigate nociplastic pain using existing COPC GWAS output, and show nociplastic pain to be a complex, heritable trait, in addition to contributing to understanding of potential mechanisms in development of nociplastic pain.

Consistency between headache diagnoses and ICHD-3 criteria across different levels of care

BACKGROUND

Diagnosing headache disorders poses significant challenges, particularly in primary and secondary levels of care (PSLC), potentially leading to misdiagnosis and underdiagnosis. This study evaluates diagnostic agreement for migraine, tension-type headache (TTH), and cluster headache (CH) between PSLC and tertiary care (TLC) and assesses adherence to the International Classification of Headache Disorders 3rd edition (ICHD-3) guidelines.

METHODS

A retrospective, cross-sectional analysis was conducted at Charité - Universitätsmedizin Berlin's tertiary headache center. The patients' self-reported diagnoses from the PSLC were compared with those in TLC and with ICHD-3 criteria. Cohen's kappa (κ) and R² were used to assess diagnostic agreement.

RESULTS

Among 1,468 patients (43.4 ± 14.4 years; 74.5% women), 69.5% reported a diagnosis in PSLC, and 99.5% were diagnosed at their first TLC visit. Overall agreement between PSLC and TLC was 80% (κ = 0.55; R²=30%). Agreement between the PSLC and ICHD-3 was 77% for migraine, 82% for TTH, and 96% for CH (κ = 0.65; R²=41%). TLC diagnoses aligned with ICHD-3 in over 90%.

CONCLUSION

Our findings indicate a significant degree of diagnostic agreement across different levels of care according to the ICHD-3 guidelines. However, there remains insufficient reliability in clinical diagnostics, highlighting the need for continued efforts to improve the early recognition and diagnostic accuracy and consistency of primary headaches to optimize patient care and treatment outcomes in Germany.

Exploring infodemiology: unraveling the intricate relationships among stress, headaches, migraines, and suicide through Google Trends analysis

Introduction

Google Trends has emerged as a vital resource for understanding public information-seeking behavior. This study investigates the interconnected search trends of stress, headaches, migraines, and suicide, highlighting their relevance to public health and mental well-being. By employing infodemiology, the study explores temporal and geographical patterns in search behavior and examines the impact of global events like the COVID-19 pandemic.

Methods

Data mining was conducted using Google Trends for the search terms "stress," "headache," "migraine," and "suicide." Relative Search Volume (RSV) data from October 2013 to October 2023 was collected and adjusted for time and location. Statistical analyses, including Pearson correlation tests, linear regression, and seasonal Mann-Kendall tests, were applied to identify correlations, trends, and seasonal variations. Geographical differences were also analyzed to understand regional disparities.

Results

Significant correlations were observed among the search terms, with "migraine" and "suicide" showing the strongest association. Seasonal variations revealed a peak in search volumes during winter months. Geographical analysis highlighted consistently high RSV in the Philippines for all terms. During the COVID-19 pandemic, searches for stress, headaches, and migraines showed notable increases, reflecting heightened public interest in mental health-related topics during this period.

Discussion

The study underscores the interconnected nature of stress, headaches, migraines, and suicide in public search behavior. Seasonal patterns and regional variations emphasize the need for targeted interventions. The observed surge in search volume during the COVID-19 pandemic highlights the profound impact of global crises on mental health and the importance of timely public health responses.

Conclusion

Google Trends provides valuable insights into the public's interest in health-related topics, demonstrating the intricate relationship between stress, headaches, migraines, and suicide. The findings highlight the need for increased mental health awareness and interventions, particularly during times of heightened stress. Further research is essential to develop strategies that mitigate the impact of these stressors on public health.

Life after benign paroxysmal positional vertigo: one-year analysis of recurrence, headaches, neck pain, falls, and functional vestibular symptoms

PURPOSE

Benign paroxysmal positional vertigo (BPPV) is a vestibular disorder causing recurrent episodes of vertigo. Despite symptom resolution at discharge, events such as relapses, migraines, neck pain, falls, and persistent postural-perceptual dizziness (PPPD) may occur. This study aims to estimate the incidence, timing, and risk factors for these symptoms.

METHODS

This multicenter, prospective, observational study recruited patients with a first episode of BPPV. Patients were treated with canalith repositioning maneuvers and discharged when no nystagmus was observed. Follow-up included in-person and telephone assessments over one year. The incidence and timing of symptoms were calculated, and risk factors were identified through regression models.

RESULTS

201 patients were recruited, and 124 met the inclusion criteria. 70.97% experienced events after discharge, though symptoms were not always severe enough to seek medical care. No useful risk factors were found for predicting BPPV recurrence. Low vitamin D levels increased recurrence risk but did not effectively discriminate patients. Women were more likely to develop headaches. Prior headaches, migraines, or neck pain were the strongest predictors of future occurrences of these conditions. Headaches or neck pain themselves triggered vestibular symptoms, often indistinguishable from BPPV. BPPV was associated with new-onset neck pain. The risk of falls increased with age. Anxiety triggered by BPPV predicted PPPD. Developing symptoms after discharge increased the likelihood of other events.

CONCLUSION

Although BPPV is considered resolved when no nystagmus is observed during provocation tests, it should be understood as a condition accompanied by other symptoms that often persist after discharge in most patients.

Depression and anxiety in Chinese patients hospitalized with primary headache: A cross-sectional multicenter study

BACKGROUND

Primary headache and psychiatric diseases are bidirectional correlated. The real-world data of depression and anxiety in Chinese patients hospitalized for primary headache, considering all subtypes, remain unclear.

METHODS

This study enrolled patients attending eight Chinese headache centers from October 2022 to September 2023. A WeChat mini-program was designed to collect data. Headache was diagnosed and confirmed by two headache specialists. The Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7 were used to assess depression and anxiety.

RESULTS

Overall, 1963 patients with primary headache were analyzed; the prevalence of depression and anxiety was 20.1% (396/1963) and 14.8% (290/1963), respectively. Of the 1963 patients, 217 (11.1%) had history of anxiety or depression and 184 (9.4%) had undergone assessments. Patients with both primary headache and depression were more likely to be women (77.8% vs 71.9%), experience more severe headache (numerical rating scale; 6.2 ± 1.9 vs 5.7 ± 1.9) and greater impacts on quality of life (Headache Impact Test-6; 65.3± 8.5 vs 58.1 ± 11.5). Those with both primary headache and anxiety exhibited similar results and were less educated. Depression and anxiety were more prevalent in chronic migraineurs (CM) than in episodic migraineurs (36.8% vs 16.9% and 28.9% vs 12.3%, respectively) and in those with chronic (CTTH) than in those with episodic tension-type headache (30.6% vs 15.1% and 20.1% vs 12.8%, respectively).

CONCLUSION

Depression and anxiety are inadequately diagnosed and strongly associated with sex, severe headache, chronification and disability in patients with primary headache in China. To improve the health of patients with primary headaches, early screening for depression and anxiety is important.

Relative frequency, characteristics, and disease burden of patients with migraine unsuitable for triptan treatment: A systematic literature review

OBJECTIVE

This review was conducted to systematically identify evidence characterizing patients with migraine who are unsuitable for triptans.

BACKGROUND

Triptans are not suitable as first-line treatment for all patients with migraine due to contraindications, lack of efficacy, and/or poor tolerability. However, there is debate about the frequency and characteristics of these patients and the burden they experience.

METHODS

MEDLINE, Embase, and conference abstracts (2011-2022) were reviewed for evidence on patients with migraine unsuitable for triptans for any reason. Data from publications describing the frequency and characteristics of this group, as well as the clinical, humanistic, or economic burden of disease in this population, were extracted.

RESULTS

Of 1460 records screened, 29 publications met inclusion criteria. Persistence with triptans was low; 51%-66% of patients starting a new triptan did not refill it, and 43%-100% discontinued their initial triptan over 2 years. In one study, 14% of patients with migraine reported prior discontinuation/failure of ≥ 2 triptans due to inadequate efficacy or poor tolerability. Up to 15% of patients with migraine had triptan contraindications, and ≥ 20% of patients receiving triptans had contraindications. In four studies, 10%-44% of patients who tried triptans had insufficient response, although definitions varied. Patients who achieved a sufficient response typically did so with their first triptan; few became responders with additional triptans. Of patients who did not respond to one to two triptans and received another, 45% were dissatisfied with the final triptan. Approximately half of patients who tried two to three triptans had an insufficient response. Greater disability, impact of disease, and depression were reported in triptan discontinuers compared to those with sustained use. Worse quality of life scores and utility values were reported in triptan insufficient versus sufficient responders, as were greater migraine-related costs, work impairment, and health-care resource utilization.

CONCLUSION

The total population of patients unsuitable for triptans is uncertain, but the literature highlights a large group who cannot or do not persist with triptans, and current evidence suggests a high burden in this population and an unmet need for new therapeutic options. Further research is needed to determine the frequency of unsuitability for triptans more precisely and to assess the associated burden.

Exploring the association between familial hemiplegic migraine genes (CACNA1A, ATP1A2 and SCN1A) with migraine and epilepsy: A UK Biobank exome-wide association study

BACKGROUND

Familial hemiplegic migraine (FHM) types 1-3 are associated with protein-altering genetic variants in CACNA1A, ATP1A2 and SCN1A, respectively. These genes have also been linked to epilepsy. Previous studies primarily focused on phenotypes, examining genetic variants in individuals with characteristic FHM symptoms. This study aimed to investigate the association of FHM genetic variation with migraine and epilepsy, utilizing a genotype-first approach.

METHODS

Whole-exome sequence data from 454,706 individuals from the UK Biobank were examined for self-reported and inpatient-diagnosed migraine and epilepsy. Carriers were compared with non-carriers in a burden analysis using logistic regression while accounting for age, biological sex and UK Biobank assessment center. A machine learning-based approach was employed to predict whether variants resulted in gain-of-function (GoF), loss-of-function (LoF) or neutral effects.

RESULTS

Heterozygous carriers of GoF CACNA1A variants, LoF ATP1A2 variants or neutral SCN1A variants were at increased risk of migraine. Homozygous carriers of neutral SCN1A variants were also associated with migraine but these carriers showed a reduced disease risk of epilepsy.

CONCLUSIONS

Heterozygous genotypes in all three FHM genes were associated with migraine but not epilepsy in this genotype-focused study. Homozygous SCN1A genotypes also showed increased disease risk of migraine, yet these carriers were protected against epilepsy.

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.

The Clinical Effects of C2 and C3 Medial Branch Block for Medically Intractable Headache : a Retrospective Study

OBJECTIVE

This study aimed to evaluate the clinical effects of medial branch blocks (MBBs) C2 and C3 in treating patients with medically intractable headaches.

METHODS

The medical records of 81 patients with medically intractable headaches who underwent a C2/3 MBB between January 2019 and March 2022 were retrospectively reviewed. The degrees of pain were evaluated using a Visual analogue scale (VAS) score (rating 0-10) on baseline and after procedures. To evaluate patients' satisfaction for the treatment, self-reporting measurements were examined and were categorized as excellent (>90% pain relief), good (50-90% pain relief), fair (10-50% pain relief), and none (<10% pain relief).

RESULTS

The total number of MBB procedure was 107. The average baseline VAS score was 7.4±1.5, which improved significantly to 2.6±2.3, 3.6±2.6, and 4.5±3.2 on 1-3 days, 3-7 days, and 3 months after the procedure, respectively (Wilks' lambda within group test, p<0.001). For the subjective feeling of pain relief, percentages of "excellent" response in the self-reporting measurements were significantly decreased over time (chi-square test; p=0.001).

CONCLUSION

This study demonstrates clinical effectiveness of C2/3 MBB in patients with medically intractable headaches, with both early and prolonged benefits.

Neural Interconnections of Extracranial Nerves in Headache Surgery: Anatomical Landmarks and Clinical Implications: A Review of the Literature

SUMMARY

Headache disorders (HDs) remain a nationwide challenge for the US health care system, affecting nearly 60% of the US population. Surgical deactivation of the peripheral trigger site, also referred to as headache surgery, represents an effective treatment for patients with refractory HD pain or nonresponse to pharmacologic regimens. Research stemming from other surgical specialties has underlined the clinical relevance of neural interconnections in refining diagnostic algorithms, adapting surgical techniques, and improving overall patient outcomes. Different HD trigger points have been identified, but there is a paucity of studies discussing the mostly sensory neural interconnections between these trigger points in a comprehensive fashion. The authors provide an overview of the specific nerves involved in HD and synthesize the literature on HD nerve interconnections to deduce clinical implications. Overall, this line of research may help refine the perioperative workflow and enhance HD patient care.

Exercise in early pregnancy among women with migraine: A hospital-based cross-sectional study

OBJECTIVE

Migraine is one of the most common pain disorders among women of childbearing age. While medical treatment might be necessary for some during pregnancy, non-pharmacological approaches, such as exercise, are generally recommended. We aimed to assess the association between migraine and exercise behaviours, adherence to the national recommendations for exercise, and the type of exercise undertaken during early pregnancy within a cohort of Danish women.

METHODS

We performed a cross-sectional study using patient-reported questionnaire data from The Copenhagen Pregnancy Cohort (2013-2019). Logistic regression analyses were applied to assess associations between migraine and the selected outcomes, with adjustment for relevant confounders.

RESULTS

We included 24,017 pregnancies. Women with migraine were more likely to refrain from exercise in early pregnancy compared to those without (46.4% vs 40.8%) (aOR 1.26, 95% CI 1.12-1.41). Additionally, they were more likely not to meet the national recommendations for exercise (62.9% vs 57.8%), (aOR 1.27, 95% CI 1.13-1.42). The differences were consistent among women with migraine with aura (MA) and migraine without aura (MO), respectively. Women with and without migraine participated in similar types of exercise during early pregnancy.

CONCLUSIONS

Our findings indicate that women with migraine were less likely to engage in exercise and to adhere to the national recommendations of exercise, compared to those without. Findings were similar for women with MA and MO. The types of exercise performed did not differ between groups.

Comparison of ocular posterior segment parameters in the pediatric population with migraine without aura and tension-type headache

BACKGROUND

This study aims to compare the posterior ocular structure parameters in children with migraine without aura (MWA), tension-type headache (TTH), and a healthy control group.

METHODS

The study included 31 patients with MWA, 29 patients with TTH, and 38 healthy controls between 6 and 18 years of age. For all participants, the detailed eye examination and measurements including peripapillary retinal nerve fiber layer (pRNFL) thickness, central macular thickness (CMT), subfoveal choroidal thickness (SCT), macular vessel densities and foveal avascular zone (FAZ) parameters measured by optical coherence tomography (OCT) and OCT-angiography (OCTA), were obtained from the patient files.

RESULTS

The mean age was 12.1±3.3 years in MWA patients, 12.4±2.8 years in TTH patients, and 11.9±3.8 years in the healthy controls (p=0.844). Among the groups, the mean pRNFL thickness, CMT, and SCT values were lowest in the MWA group. However, this difference was not statistically significant (p=0.621, p=0.854 and p=0.201, respectively). The mean and four-quadrant (superior, inferior, temporal, nasal) pRNFL thicknesses, the CMT, and the SCT were not statistically significant between the groups (p=0.621, p=0.500, p=0.186, p=0.565, p=0.744, p=0.854 and p=0.201, respectively). The macular vascular densities were lower in MWA patients than in the other two groups, and there was a statistically significant difference between the groups only in the nasal quadrant of the deep retinal capillary plexus (p = 0.014). There were also no statistically significant differences between the groups in the superficial and deep FAZ area parameters (p=0.652 and p=0.985).

CONCLUSION

This study suggested that differential diagnosis between MWA and TTH can be difficult in childhood, as these conditions, which can present with ocular symptoms, may also be characterized by changes in posterior segment parameters. Long-term studies incorporating OCT-A in larger patient populations may provide valuable insights into retinal changes associated with these two distinct headache spectrums.

Epidemiological, clinical characterization and treatment patterns of migraine patients in a Colombian cohort from 2018 to 2022

BACKGROUND

To describe the epidemiology and clinical characteristics of migraine and the status of treatment in Colombia. Additionally, the use of health resources by patients was measured.

METHODS

This was a non-interventional, retrospective, descriptive study conducted in one Colombian Health Management Organization (HMO) from 2018 to 2022 with a follow-up period of 5 years. Migraine patients were identified using the International Code Disease 10th version G43, and the diagnosis was confirmed by a neurologist. The first recorded migraine diagnosis was defined as the index date. Medical records, claim databases and other electronic databases from the HMO were used to determine the clinical characteristics, treatments, and health care services.

RESULTS

A total of 89,227 patients were included in the study. The mean follow-up period was 3.7 years (standard deviation 1.2). Most of them were women (84.9%). Many patients were first seen by a general practitioner (82.6%), and only 8.9% were first seen by a neurologist. The prevalence of migraine during follow-up was between 1.69 and 2.42 patients in 100 HMO affiliates in 2020, the year with the highest prevalence (2.42 [95% CI 2.41-2.44]), and the incidence ranged from 0.032 to 1.72 per 100 patient-year at risk of developing migraine. Hypertension (21.3%), arrythmia (4.1%) and structural heart disease (3.4%) were the most common cardiovascular diseases. The annual mean number of outpatient consultations in 2018 was 1.43 consultations per patient, which decreased to 0.68 in 2022. The most frequent treatments for acute events were nonsteroidal anti-inflammatory drugs (NSAIDs) (range 37-42%) in monotherapy, combinations of analgesics (range 14-35%), and corticosteroids (range 10-15%). Triptans were used in 4% of patients in the first medication record, reaching a maximum of 16% of patients. Among preventive treatments, beta-blockers (24-49%) and antiepileptics (29-41%) were the most common.

CONCLUSION

The prevalence of migraine in Colombia according to health electronic databases was lower than that reported in previous studies conducted in the country. The treatment patterns for acute and preventive treatment of migraine follow the recommendations of different guidelines. Cardiovascular disease is relevant for the management of migraine.

Migraine in the multiple sclerosis prodrome: a prospective nationwide cohort study in pregnant women

BACKGROUND

People with multiple sclerosis (MS) have an increased risk of migraine. However, little is known about migraine and other headaches during the prodromal phase (before MS symptom onset). Our objective was to study the risk of migraine in women with MS before MS onset.

METHODS

A nationwide, prospective cohort study of women participating in the Norwegian Mother, Father, and Child cohort study 1999-2008. The women reported the occurrence of migraine and other headaches prior to or during pregnancy. We identified women who later developed MS through data linkage with national health registries in 2018. We excluded women with an established MS diagnosis (n = 125) and women who had experienced their first clinical symptom of MS, but not yet received an MS diagnosis (n = 91). The reference group comprised all other women in the cohort (n = 85,292). We used logistic regression to estimate adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs).

RESULTS

Two hundred and forty-six women developed MS during follow-up. Of these, 116 women had MS symptom onset after 1-5 years, 92 after 6-10 years, and 38 after 10 years. Migraine was more common among women who developed MS compared to the reference group, 18% vs 11%, aOR 1.6 (1.2-2.3), adjusted for age, smoking, socioeconomic status and overweight. The risk of other headaches was similar for women who developed MS compared to the reference group, 29% vs 27%, aOR 1.1 (0.8-1.4). Migraine was reported by 21 of 116 (18%) women with ≤ 5 years until MS symptom onset (aOR 1.7 [1.1-2.8]) and 19 of 92 (21%) women with 6-10 years until MS symptom onset (aOR 1.9 [1.1-2.8]. Only three of 38 (8%) women with > 10 years until MS symptom onset reported migraine, aOR 0.7 (0.2-2.2).

CONCLUSIONS

Women with MS have increased risk of migraine, but not other headaches, up to a decade before the onset of classical MS symptoms. This supports that migraine can be a symptom of the MS prodrome. Special attention in people with migraine may lead to earlier recognition of MS.

Impact of eptinezumab on work productivity beyond reductions in monthly migraine days: post hoc analysis of the DELIVER trial

BACKGROUND

Eptinezumab's impact on self-reported work productivity in adults with migraine and 2‒4 prior preventive migraine treatment failures is not fully understood.

METHODOLOGY

Electronic diaries captured monthly migraine days (MMDs) reported by patients enrolled in the randomized, double-blind, placebo-controlled DELIVER trial (NCT04418765). The migraine-specific Work Productivity and Activity Impairment questionnaire, administered at baseline and each monthly visit, was a secondary outcome of DELIVER and used to model changes from baseline in self-reported monthly hours of absenteeism (decreased work attendance) and presenteeism (reduced work efficiency while at work with a migraine) in Canada, as the base case. Path analysis illustrated eptinezumab's impact on work productivity beyond MMDs.

RESULTS

As MMDs increased, monthly hours of absenteeism increased linearly while those of presenteeism increased quadratically. Best-fit models were improved after including an eptinezumab treatment effect, showing benefit over placebo after controlling for MMD frequency. Compared to placebo, patients treated with eptinezumab (pooled) had a modeled reduction from baseline of 7.2 h/month (absenteeism) (95% CI: -9.9, -4.5; P < 0.001) and 21.4 h/month (presenteeism) (95% CI: -26.3, -16.5; P < 0.001) over weeks 1‒24. Beyond MMD reductions, improvements in patient-identified most bothersome symptom (PI-MBS) and reductions in percent of severe migraine attacks contributed to eptinezumab's effect.

CONCLUSIONS

Eptinezumab decreased absenteeism and presenteeism based on patient reports, with data highlighting the importance of considering the PI-MBS. The greater change from baseline than placebo in self-reported absenteeism and presenteeism was only partly explained by changes in MMDs, presenting a potential opportunity to decrease the cost of migraine in the workplace.

TRIAL REGISTRATION

ClinicalTrials.gov (Identifier: NCT04418765); EudraCT (Identifier: 2019-004497-25).

Can Clinical, Psychophysical or Psychological Variables Help in Discriminating Women with Migraines from a Tertiary Center? A Diagnostic Accuracy Study

Background: Migraine diagnosis is mainly clinically based on symptomatology. The objectives of this study were (1) to determine the ability of pain thresholds to differentiate between women with and without migraines and (2) to determine the ability of clinical, psychological and psychophysical variables to differentiate between women with episodic and chronic migraines. A diagnostic accuracy study was conducted. Methods: Pressure-pain thresholds (PPTs) at one trigeminal (temporalis muscle) and one extra-trigeminal (cervical spine) and two distant-pain free (second metacarpal and tibialis anterior muscle) areas, as well as dynamic pain thresholds (DPTs), were bilaterally assessed in 100 women with migraines, recruited from tertiary hospitals (50% episodic, 50% chronic), and 50 comparable women without headaches. Migraine pain features (headache diary), migraine-associated burden (HDI), anxiety and depressive levels (HADS) and state (STAI-S)-trait (STAI-T) anxiety were also evaluated. The area under the receiver operating characteristic (ROC) curve, with optimal cut-off points, as well as the sensitivity, specificity and positive/negative likelihood ratios (LR) for each variable, were calculated. The women with migraines showed lower PPTs and DPTs than those without migraines. Results: The women with chronic migraines showed lower PPTs in the temporalis muscle than the women with episodic migraines. No clinical, psychological or psychophysical variables exhibited acceptable ROC values (≥0.7) for differentiating between women with and without migraines or between women with episodic and chronic migraines. Conclusions: Although the women with migraines had widespread pressure-pain hyperalgesia, neither the clinical, psychological nor psychophysical (pain threshold) variable exhibited the proper diagnostic accuracy to distinguish between women with and without migraines or between women with episodic and chronic migraines. New studies should clarify the clinical relevance of the findings of the current study.

Internal Ophthalmoplegic Migraine During Pregnancy: A Clinical Case

BACKGROUND

Ophthalmoplegic migraine (OM) is an uncommon variant of migraine characterised by headache and cranial nerve palsy, posing significant diagnostic and therapeutic challenges.

OBJECTIVE

This study aimed to describe an extremely rare OM variant with a partial therapeutic response.

CLINICAL CASE

A 34-year-old pregnant woman in gestational week 19.1 (G6P2A3) with a history of three consecutive spontaneous abortions presented at the emergency services with insidious onset and mild-to-moderate-intensity pulsatile bifrontal headache for 15 days, and the positional changes exacerbated this. At peak intensity, she experienced nausea, vomiting, tinnitus, and photophobia without phonophobia or osmophobia, prompting multiple visits to the emergency department. Despite a broad range of treatments, including intravenous fluids, analgesia, pericranial blocks, and preventive management, there was a non-significative improvement in the symptomatology described above. However, spontaneous resolution of this clinical picture was observed during the postpartum period.

RESULTS

This case highlights the complexity of ophthalmoplegic migraine, especially in the context of pregnancy, and raises questions about the underlying pathophysiological mechanisms. The absence of structural lesions on neuroimaging and postpartum resolution suggests a potential association with the hormonal and physiological changes associated with pregnancy.

CONCLUSIONS

Despite limited scientific evidence, this report contributes to expanding the knowledge of this rare entity and emphasises the importance of a multidisciplinary approach to its management.

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).

Deconvoluting zavegepant drug-drug interactions: A phase I study to evaluate the effects of rifampin and itraconazole on zavegepant pharmacokinetics

Zavegepant is a calcitonin gene-related peptide receptor antagonist for acute migraine treatment. This Phase I, open-label, fixed-sequence study evaluated the effects of itraconazole (a strong cytochrome P450 3A4 [CYP3A4] and P-glycoprotein [P-gp] inhibitor) on the pharmacokinetics of intranasal/oral zavegepant and the effects of rifampin (a strong inducer of CYP3A4 and P-gp; and an inhibitor of organic anion transporting polypeptide 1B3 [OATP1B3]) on oral zavegepant in healthy participants. In the intranasal/oral zavegepant-itraconazole cohort, participants received a single 10-mg dose of zavegepant nasal spray on Day 1, followed by oral zavegepant (50 mg) on Day 3. Itraconazole 200 mg once daily was administered from Days 4 to 12. On Day 7 zavegepant nasal spray and on Day 11 oral zavegepant were coadministered with itraconazole. In the oral zavegepant-rifampin cohort, participants received oral zavegepant (100 mg) on Day 1, rifampin 600 mg once daily on Days 2-10, and rifampin with zavegepant on Day 11. No significant change in zavegepant exposure was observed following coadministration of itraconazole with zavegepant nasal spray. For oral zavegepant coadministered with itraconazole, the area under the curve from 0 to infinity (AUC0-inf) and the maximum observed concentration (Cmax) of oral zavegepant increased by 59% and 77%, respectively. For oral zavegepant coadministered with rifampin, the AUC0-inf and Cmax of oral zavegepant increased by approximately 2.3- and 2.2-fold, respectively. These results suggest that OATP1B3 and intestinal P-gp are the more prominent pathways, as opposed to CYP3A4, for a zavegepant drug-drug interaction. Coadministration of OATP1B3 inhibitors with zavegepant nasal spray should be avoided.