Non-Pharmacological Approaches to Headaches: Non-Invasive Neuromodulation, Nutraceuticals, and Behavioral Approaches

Longitudinal neurofunctional changes in medication overuse headache patients after mindfulness practice in a randomized controlled trial (the MIND-CM study)

BACKGROUND

Mindfulness practice has gained interest in the management of Chronic Migraine associated with Medication Overuse Headache (CM-MOH). Mindfulness is characterized by present-moment self-awareness and relies on attention control and emotion regulation, improving headache-related pain management. Mindfulness modulates the Default Mode Network (DMN), Salience Network (SN), and Fronto-Parietal Network (FPN) functional connectivity. However, the neural mechanisms underlying headache-related pain management with mindfulness are still unclear. In this study, we tested neurofunctional changes after mindfulness practice added to pharmacological treatment as usual in CM-MOH patients.

METHODS

The present study is a longitudinal phase-III single-blind Randomized Controlled Trial (MIND-CM study; NCT03671681). Patients had a diagnosis of CM-MOH, no history of neurological and severe psychiatric comorbidities, and were attending our specialty headache centre. Patients were divided in Treatment as Usual (TaU) and mindfulness added to TaU (TaU + MIND) groups. Patients underwent a neuroimaging and clinical assessment before the treatment and after one year. Longitudinal comparisons of DMN, SN, and FPN connectivity were performed between groups and correlated with clinical changes. Vertex-wise analysis was performed to assess cortical thickness changes.

RESULTS

177 CM-MOH patients were randomized to either TaU group or TaU + MIND group. Thirty-four patients, divided in 17 TaU and 17 TaU + MIND, completed the neuroimaging follow-up. At the follow-up, both groups showed an improvement in most clinical variables, whereas only TaU + MIND patients showed a significant headache frequency reduction (p = 0.028). After one year, TaU + MIND patients showed greater SN functional connectivity with the left posterior insula (p-FWE = 0.007) and sensorimotor cortex (p-FWE = 0.026). In TaU + MIND patients only, greater SN-insular connectivity was associated with improved depression scores (r = -0.51, p = 0.038). A longitudinal increase in cortical thickness was observed in the insular cluster in these patients (p = 0.015). Increased anterior cingulate cortex thickness was also reported in TaU + MIND group (p-FWE = 0.02).

CONCLUSIONS

Increased SN-insular connectivity might modulate chronic pain perception and the management of negative emotions. Enhanced SN-sensorimotor connectivity could reflect improved body-awareness of painful sensations. Expanded cingulate cortex thickness might sustain improved cognitive processing of nociceptive information. Our findings unveil the therapeutic potential of mindfulness and the underlying neural mechanisms in CM-MOH patients.

TRIAL REGISTRATION

Name of Registry; MIND-CM study; Registration Number ClinicalTrials.gov identifier: NCT0367168; Registration Date: 14/09/2018.

Multimodal digital health treatments for Chronic Migraine associated with Medication Overuse Headache: a literature appraisal and results of a single-arm open trial (the BE-HOME program)

BACKGROUND

Mindfulness-based treatments gained popularity for migraine treatment. In this manuscript we report the results of a single-arm open pilot study that evaluated the impact of a multimodal web-based intervention combining home-based medication withdrawal, patients' education, and online mindfulness-based interventions. We aimed to address whether our program had the ability to show a change in the observed parameters and the study should therefore be intended as an early phase trial.

METHODS

Consecutive patients with chronic migraine associated with medication overuse headache were enrolled, followed-up for 12 months, in a program that included home-based medication withdrawal, education on the correct use of drugs and lifestyle issues, prescription of tailored pharmacological prophylaxis, and attendance to six online mindfulness-based sessions. We tested the effect of the program on improving headache frequency, medication intake, quality of life (QoL), headache impact, depression, self-efficacy, and pain catastrophizing.

RESULTS

A total of 37 patients completed the study (10 dropped out). We observed a large improvement in headache frequency, medication intake, headache impact, and QoL, a moderate improvement in pain catastrophizing and a mild improvement in depression symptoms; 70% to 76% of patients achieved 50% or more reduction in headache frequency from baseline to each follow-up (p < .01).

CONCLUSIONS

The results of our multimodal program showed significant improvements in headache frequency, medication intake, and patient-reported outcomes. Future studies are needed to better identify patients who might benefit most from Digital Health Interventions and to demonstrate at least an equivalence in outcome with in-person programs carried out in hospital settings.

Effects of Dry Needling on Active Myofascial Trigger Points and Pain Intensity in Tension-Type Headache: A Randomized Controlled Study

Tension-type headache is the most prevalent type of headache and is commonly associated with myofascial pain syndrome and the presence of active myofascial trigger points. This randomized controlled trial aimed to assess the impact of dry needling on the total number of active trigger points, pain intensity, and perceived clinical change in tension-type headache subjects. Thirty-two subjects were randomly assigned to the control and dry needling groups. The presence of active trigger points in 15 head and neck muscles, the headache intensity, and the perceived clinical change were evaluated. A single dry needling technique was administered at each active trigger point across three sessions. Significant differences were observed in the post-treatment measures favouring the dry needling group, including reductions in the headache intensity scores (p = 0.034) and the total number of active trigger points (p = 0.039). Moreover, significant differences in the perception of clinical change were found between the control and treatment groups (p = 0.000). Dry needling demonstrated positive effects in reducing the number of active trigger points and improving the short-term headache intensity in tension-type headache patients. A single dry needling session applied in the cranio-cervical area resulted in a self-perceived improvement compared to the control subjects.

The World Health Organization Intersectoral Global Action Plan on Epilepsy and Other Neurological Disorders and the headache revolution: from headache burden to a global action plan for headache disorders

The World Health Organization (WHO) Intersectoral Global Action Plan on Epilepsy and Other Neurological Disorders was developed by WHO to address the worldwide challenges and gaps in provision of care and services for people with epilepsy and other neurological disorders and to ensure a comprehensive, coordinated response across sectors to the burden of neurologic diseases and to promote brain health across life-course. Headache disorders constitute the second most burdensome of all neurological diseases after stroke, but the first if young and midlife adults are taken into account. Despite the availability of a range of treatments, disability associated with headache disorders, and with migraine, remains very high. In addition, there are inequalities between high-income and low and middle income countries in access to medical care. In line with several brain health initiatives following the WHOiGAP resolution, herein we tailor the main pillars of the action plan to headache disorders: (1) raising policy prioritization and strengthen governance; (2) providing effective, timely and responsive diagnosis, treatment and care; (3) implementing strategies for promotion and prevention; (4) fostering research and innovation and strengthen information systems. Specific targets for future policy actions are proposed. The Global Action Plan triggered a revolution in neurology, not only by increasing public awareness of brain disorders and brain health but also by boosting the number of neurologists in training, raising research funding and making neurology a public health priority for policy makers. Reducing the burden of headache disorders will not only improve the quality of life and wellbeing of people with headache but also reduce the burden of neurological disorders increasing global brain health and, thus, global population health.

Do Electrical Stimulation Devices Reduce Pain and Improve Function?-A Comparative Review

BACKGROUND

Multiple forms of electrical stimulation (ES) potentially offer widely varying clinical benefits. Diminished function commonly associated with acute and chronic pain lessens productivity and increases medical costs. This review aims to compare the relative effects of various forms of ES on functional and pain outcomes.

METHODS

A comprehensive literature search focused on studies of commonly marketed forms of ES used for treatment of pain and improvement of function. Peer-reviewed manuscripts were categorized as "Important" (systematic review or meta-analysis, randomized controlled trial, observational cohort study) and "Minor" (retrospective case series, case report, opinion review) for each identified form of ES.

RESULTS AND DISCUSSION

Varying forms of ES have markedly different technical parameters, applications, and indications, based on clinically meaningful impact on pain perception, function improvement, and medication reduction. Despite being around for decades, there is limited quality evidence for most forms of ES, although there are several notable exceptions for treatment of specific indications. Neuromuscular electrical stimulation (NMES) has well-demonstrated beneficial effects for rehabilitation of selective spinal cord injured (SCI), post-stroke, and debilitated inpatients. Functional electrical stimulation (FES) has similarly shown effectiveness in rehabilitation of some stroke, SCI, and foot drop outpatients. H-Wave® device stimulation (HWDS) has moderate supportive evidence for treatment of acute and refractory chronic pain, consistently demonstrating improvements in function and pain measures across diverse populations. Interestingly, transcutaneous electrical nerve stimulation (TENS), the most widely used form of ES, demonstrated insignificant or very low levels of pain and functional improvement.

CONCLUSION

Ten of 13 reviewed forms of ES have only limited quality evidence for clinically significant reduction of pain or improvement of function across different patient populations. NMES and FES have reasonably demonstrated effectiveness, albeit for specific clinical rehabilitation indications. HWDS was associated with the most clinically significant outcomes, in terms of functional improvement combined with reduction of pain and medication use. More rigorous long-term clinical trials are needed to further validate appropriate use and specific indications for most forms of ES.

LEVEL OF EVIDENCE

II.

Rethinking headache as a global public health case model for reaching the SDG 3 HEALTH by 2030

The 2030 Agenda for Sustainable Development sets out, through 17 Sustainable Development Goals (SDGs), a path for the prosperity of people and the planet. SDG 3 in particular aims to ensure healthy lives and promote well-being for all at all ages and includes several targets to enhance health. This review presents a "headache-tailored" perspective on how to achieve SDG 3 by focusing on six specific actions: targeting chronic headaches; reducing the overuse of acute pain-relieving medications; promoting the education of healthcare professionals; granting access to medication in low- and middle-income countries (LMIC); implementing training and educational opportunities for healthcare professionals in low and middle income countries; building a global alliance against headache disorders. Addressing the burden of headache disorders directly impacts on populations' health, as well as on the possibility to improve the productivity of people aged below 50, women in particular. Our analysis pointed out several elements, and included: moving forward from frequency-based parameters to define headache severity; recognizing and managing comorbid diseases and risk factors; implementing a disease management multi-modal management model that incorporates pharmacological and non-pharmacological treatments; early recognizing and managing the overuse of acute pain-relieving medications; promoting undergraduate, postgraduate, and continuing medical education of healthcare professionals with specific training on headache; and promoting a culture that favors the recognition of headaches as diseases with a neurobiological basis, where this is not yet recognized. Making headache care more sustainable is an achievable objective, which will require multi-stakeholder collaborations across all sectors of society, both health-related and not health-related. Robust investments will be needed; however, considering the high prevalence of headache disorders and the associated disability, these investments will surely improve multiple health outcomes and lift development and well-being globally.

Multimodal Migraine Management and the Pursuit of Migraine Freedom: A Narrative Review

Migraine is a neurologic disease with a complex pathophysiology that can be controlled with current treatment options but not cured. Therefore, treatment expectations are highly variable. The concept of migraine freedom was recently introduced and can mean different things, with some, for example, expecting complete freedom from headache and associated symptoms and others accepting the occasional migraine attack if it does not impact functioning. Therefore, migraine management should be optimized so that patients can have the best opportunity to achieve their optimal treatment goals. With migraine freedom as a goal and, given the complex pathophysiology of migraine and the high incidence of comorbidities among individuals with migraine, treatment with a single modality may be insufficient, as it may not achieve migraine freedom in those with more frequent or disabling attacks. In this clinical perspective article, we have identified four key, partially overlapping principles of multimodal migraine treatment: (1) manage common comorbidities; (2) control modifiable risk factors for progression by addressing medication and caffeine overuse; (3) diagnose and treat secondary causes of headache, if present; and (4) individualize acute and preventive treatments to minimize pain, functional disability, and allodynia. There are many barriers to pursuing migraine freedom, and strategies to overcome them should be optimized. Migraine freedom should be an aspirational goal both at the individual attack level and for the disease overall. We believe that a comprehensive and multimodal approach that addresses all barriers people with migraine face could move patients closer to migraine freedom.

Efficacy of mindfulness added to treatment as usual in patients with chronic migraine and medication overuse headache: a phase-III single-blind randomized-controlled trial (the MIND-CM study)

BACKGROUND

Mindfulness gained considerable attention for migraine management, but RCTs are lacking. We aimed to assess the efficacy of a six-sessions mindfulness-based treatment added to treatment as usual (TaU) in patients with Chronic Migraine (CM) and Medication Overuse Headache (MOH) on headache frequency, medication intake, quality of life, disability, depression and anxiety, cutaneous allodynia, awareness of inner states, work-related difficulties, and disease cost.

METHODS

In this Phase-III single-blind RCT carried out in a specialty Italian headache center, 177 patients with CM and MOH were randomized 1:1 to either TaU (withdrawal from overused drugs, education on proper medication use and lifestyle issues, and tailored prophylaxis) or mindfulness-based intervention added to TaU (TaU + MIND). The mindfulness-based intervention consisted of six group session of mindfulness practice and 7-10 min daily self-practice. The primary endpoint was the achievement of ≥ 50% headache frequency reduction at 12 months compared to baseline, and was analyzed on an intention-to-treat principle using Pearson's Chi-Squared test. Secondary endpoints included medication intake, quality of life (QoL), disability, depression and anxiety, cutaneous allodynia, awareness of inner states, work-related difficulties, and disease cost. The secondary endpoints were analyzed using per-protocol linear mixed models.

RESULTS

Out of the 177 participants 89 were randomized to TaU and 88 to TaU + MIND. Patients in the TaU + MIND group outperformed those in TaU for the primary endpoint (78.4% vs. 48.3%; p < 0.0001), and showed superior improvement in headache frequency, QoL and disability, headache impact, loss of productive time, medication intake, and in total, indirect and direct healthcare costs.

CONCLUSIONS

A mindfulness-based treatment composed of six-week session and 7-10 min daily self-practice added on to TaU is superior to TaU alone for the treatment of patients with CM and MOH.

TRIAL REGISTRATION

MIND-CM was registered on clinicaltrials.gov (NCT03671681) on14/09/2018.

The Utility of a Novel, Combined Biofeedback-Virtual Reality Device as Add-on Treatment for Chronic Migraine: A Randomized Pilot Study

OBJECTIVES

To determine if the frequent use of a combined biofeedback-virtual reality device improves headache-related outcomes in chronic migraine.

MATERIALS AND METHODS

In this randomized, controlled pilot study, 50 adults with chronic migraine were randomized to the experimental group (frequent use of a heart rate variability biofeedback-virtual reality device plus standard medical care; n=25) or wait-list control group (standard medical care alone; n=25). The primary outcome was a reduction in mean monthly headache days between groups at 12 weeks. Secondary outcomes included mean change in acute analgesic use frequency, depression, migraine-related disability, stress, insomnia, and catastrophizing between groups at 12 weeks. Tertiary outcomes included change in heart rate variability and device-related user experience measures.

RESULTS

A statistically significant reduction in mean monthly headache days between groups was not demonstrated at 12 weeks. However, statistically significant decreases in the mean frequency of total acute analgesic use per month (65% decrease in the experimental group versus 35% decrease in the control group, P <0.01) and depression score (35% decrease in the experimental group versus 0.5% increase in the control group; P <0.05) were shown at 12 weeks. At study completion, more than 50% of participants reported device satisfaction on a 5-level Likert scale.

DISCUSSION

Frequent use of a portable biofeedback-virtual reality device was associated with decreases in the frequency of acute analgesic use and in depression in individuals with chronic migraine. This platform holds promise as an add-on treatment for chronic migraine, especially for individuals aiming to decrease acute analgesic use or interested in nonmedication approaches.

Relationship of sleep quality, chronotype, and obstructive sleep apnea with migraine in the elderly population

PURPOSE

Disturbances of sleep have frequently been reported in individuals with migraine. On top of this, an elderly patient with migraine also suffers from sleep disturbances due to changes in physiologic and mental health associated with aging. This study aimed to compare several sleep factors, namely sleep quality, chronotype, and obstructive sleep apnea (OSA) risk, between elderly people with and without migraine.

METHODS

This was a multicenter cross-sectional study conducted in 10 neurologic clinics located in Tehran, Iran, over 2 years. The sample size was calculated as 189, including 63 migraine and 126 non-migraine patients.

RESULTS

A significant difference was observed in the mean score of the global Pittsburgh Sleep Quality Index (PSQI) between migraine and non-migraine groups (p-value = 0.002), and in the individual components of the PSQI. However, there were no significant differences in the frequency of different types of chronotype (p-value = 0.125, T = 1.541) or OSA risk between the two groups (p-value = 0.568, T = -0.573). The binary logistic regression model showed that the relationship between global PSQI and migraine was significant (p = 0.002).

CONCLUSION

Sleep quality is a problem for elderly migraine sufferers. Meanwhile, certain factors such as chronotype and OSA have no significant relationship with migraine among community-dwelling seniors. Further studies are required to enhance our understanding of this observation.

The Be-Home Kids Program: An Integrated Approach for Delivering Behavioral Therapies to Adolescents with Episodic and Chronic Migraine

Migraine disorders are common in populations of children and adolescents. There are different pharmacological treatments for migraine in young patients, but none have specific indications, and doubts about their efficacy exist. The feasibility and effectiveness of behavioral approaches have already been documented in clinical experiences, and they are generally associated with fewer or no unpleasant effects. Among them, mindfulness practice offers a suitable alternative to other adolescent treatments. We present the results of a pilot study, the Be-Home Kids program, performed during the COVID-19 emergency. It was delivered by web and included education on drug use, lifestyle issues, and six sessions of mindfulness-based behavioral practice. We assessed headache frequency, medication intake, and other psychological variables and followed twenty-one adolescents with chronic or high-frequency episodic migraine without aura for 12 months. Results indicated an overall clinical improvement, particularly a 64% reduction in headache frequency over 12 months. In conclusion, our results indicate that a combined treatment which includes patients' education and six sessions of mindfulness-based practice delivered over the web, can be of great support in reducing headache frequency, medication intake, and the associated psychological burden disability in adolescent migraine patients.

The effectiveness of botulinum toxin for chronic tension-type headache prophylaxis: A systematic review and meta-analysis

BACKGROUND

A systematic and meta-analysis was conducted to examine the evidence of the effects of botulinum toxin A on chronic tension-type headache.

METHODS

Cochrane, Embase, Ovid, ProQuest, PubMed, Scopus, Web-of-Science databases, and ClinicallTrials.gov registry were systematically searched for studies examining the effects of botulinum toxin A on tension-type headaches. The records were screened by two independent reviewers using pre-determined eligibility criteria. DerSimonian Liard random-effects meta-analyses were performed using the 'meta' package (5.2-0) in R (4.2.0). Risk of bias and quality of evidence were assessed using the Cochrane Collaboration's Tool RoB 2 and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Clinical significance was determined using pre-defined minimal clinically important differences.

RESULTS

Eleven controlled trials were included (390 botulinum toxin A, 297 controls). Botulinum toxin A was associated with significant improvements in standardized headache intensity (-0.502 standard deviations [-0.945, -0.058]), headache frequency (-2.830 days/month [-4.082, -1.578]), daily headache duration (-0.965 [-1.860, -0.069]) and the frequency of acute pain medication use (-2.200 days/month [-3.485, -0.915]) vs controls. Botulinum toxin A-associated improvements exceeded minimal clinically important differences for headache intensity, frequency, and acute pain medication use. A 79% (28%, 150%) greater response rate was observed for botulinum toxin A vs controls in improving chronic tension-type headache. Treatment of eight chronic tension-type headache patients was sufficient to elicit a therapeutic response in one patient.

CONCLUSIONS

Corroborating the current mechanistic evidence, our meta-analysis supports the utility of botulinum toxin A for managing chronic tension-type headaches. However, due to limitations in the quality of evidence, adequately-powered high-quality controlled trials examining the effects of Botulinum toxin A on chronic tension-type headache are warranted.

REGISTRATION

Protocol preregistered in PROSPERO International Prospective Register of Systematic Reviews (CRD42020178616).

A Single-Group Study on the Effect of OnabotulinumtoxinA in Patients with Chronic Migraine Associated with Medication Overuse Headache: Pain Catastrophizing Plays a Role

Pain catastrophizing and cutaneous allodynia are commonly altered in patients with chronic migraine associated with medication overuse headache (CM-MOH) and tend to improve in parallel with clinical improvement. The relation between pain catastrophizing and cutaneous allodynia is poorly understood in patients with CM-MOH receiving OnabotulinumtoxinA therapy. In this single-arm open-label longitudinal observational study, patients with CM-MOH were assigned to structured withdrawal and then administered OnabotulinumtoxinA (5 sessions on a three-month basis, 195 UI per 31 sites). Headache frequency, medication intake, disability, impact, cutaneous allodynia and pain catastrophizing were evaluated with specific questionnaires. In total, 96 patients were enrolled and 79 completed the 12-month follow-up. With the exclusion of cutaneous allodynia and the magnification subscale of the pain catastrophizing questionnaire, all variables showed significant improvement by the sixth month, which was maintained at 12 months. Reduction of pain catastrophizing, and particularly of its helplessness subscale, was a significant predictor of reduction in headache frequency and medication intake. Pain catastrophizing is often implicated in the clinical improvement in patients with CM-MOH receiving behavioral treatments, but, in this study, also showed a role in patients receiving OnabotulinumtoxinA; combining OnabotulinumtoxinA and behavioral treatments specifically addressing pain catastrophizing might further enhance patients' clinical outcome.

A Preliminary Analysis on the Feasibility and Short-Term Efficacy of a Phase-III RCT on Mindfulness Added to Treatment as Usual for Patients with Chronic Migraine and Medication Overuse Headache

This preliminary analysis of a single-blind phase-III RCT aims to compare the feasibility and short-term efficacy of mindfulness as an add-on to treatment as usual (TaU) in the management of patients with chronic migraine (CM) and medication overuse headache (MOH). Patients were randomized to either TaU (structured withdrawal of overused drugs, patient education and pharmacological prophylaxis) or TaU + MIND, wherein patients additionally received six 90 min weekly group sessions of mindfulness-based therapy. Repeated measures analyses were used to test whether patients in the two arms showed different course with regard to headache frequency and medication intake over a three-month period. Drop-out rates were not different between the two groups: 6/89 (6.7%) and 9/88 (10.2%) among those in TaU and TaU + MIND, respectively. A significant effect of time for all variables was shown, together with a significant effect of time by group, favoring TaU + MIND condition for headache frequency (p = 0.025) and NSAID intake (p = 0.007), controlling for age and CM duration. In total, 45/83 (54.2%) and 69/79 (75.9%) of the patients allocated to TaU and TaU + MIND, respectively, achieved 50% or more headache-day reduction (chi-squared 8.38, p = 0.004). Our preliminary analysis indicates that adding six mindfulness-based sessions to TaU was feasible and showed short-term efficacy in the treatment of patients with CM and MOH.

Acceptance and commitment therapy for episodic migraine: Rationale and design of a pilot randomized controlled trial

Migraine is a debilitating disorder with limited pharmacological options. Many migraine medications can have intolerable side effects leading patients to seek complementary and integrative health (CIM) approaches for treatment. One option that is growing in popularity and evidence is Acceptance and Commitment Therapy (ACT), a mindfulness-based therapy. The purpose of this paper is to describe how ACT may be an effective modality integrated into the treatment of migraine and to describe the design of a pilot study of ACT for migraine. First, we review the research and the promise of mindfulness therapies for the treatment of migraine. Then, we describe how ACT differs from other mindfulness therapies for migraine and why it can be a promising option for these patients. Finally, we summarize the design of a pilot study designed to determine the feasibility of performing a future fully powered study to determine the effectiveness of ACT on migraine frequency and disability. This pilot study includes unique features, including a remotely-delivered ACT intervention and the measurement of cortisol levels before and after the intervention.

Prevention of Migraine

Migraine, a primary headache disorder is a chronic and complex neurological disease that affects millions of people worldwide, impacting their quality of life. It is one of the most common reasons why individuals seek the advice of their physician, and is one of the most common referrals seen in the offices of general neurologists and headache specialists. In the past decade, there has been robust research on not only the pathophysiology of migraine but in the efforts to treat and, importantly, prevent. The introduction of calcitonin gene related peptide antagonists (CGRP-A) have opened new doors for preventive treatment options. OnabotulinumtoxinA (BoNTA) has remained a staple in the treatment of chronic migraine with data emerging with combination therapy. Neurostimulation has offered additional nonpharmacologic approaches to migraine treatment. In addition to lifestyle and behavioral modifications, these have changed the landscape of migraine prevention.

Applying a biopsychosocial model to migraine: rationale and clinical implications

Migraine is a complex condition in which genetic predisposition interacts with other biological and environmental factors determining its course. A hyperresponsive brain cortex, peripheral and central alterations in pain processing, and comorbidities play a role from an individual biological standpoint. Besides, dysfunctional psychological mechanisms, social and lifestyle factors may intervene and impact on the clinical phenotype of the disease, promote its transformation from episodic into chronic migraine and may increase migraine-related disability.Thus, given the multifactorial origin of the condition, the application of a biopsychosocial approach in the management of migraine could favor therapeutic success. While in chronic pain conditions the biopsychosocial approach is already a mainstay of treatment, in migraine the biomedical approach is still dominant. It is instead advisable to carefully consider the individual with migraine as a whole, in order to plan a tailored treatment. In this review, we first reported an analytical and critical discussion of the biological, psychological, and social factors involved in migraine. Then, we addressed the management implications of the application of a biopsychosocial model discussing how the integration between non-pharmacological management and conventional biomedical treatment may provide advantages to migraine care.

From the New Diagnostic Criteria to COVID-19 Pandemic Passing Through the Placebo Effect. What Have We Learned in the Management of Pediatric Migrane Over the Past 5 Years?

In 2018, the Food and Drug Administration (FDA) approval of anti-calcitonin gene-related peptide (CGRP) therapies for the treatment of migraine represented a milestone for the management of the disease in adults. On the contrary, the novelties in the field of pediatric migraine are inserted in a different scenario and still concern: (1) diagnostic criteria of the international classification of headache disorders-3 (ICHD-3) that show numerous limits of applicability in the developmental age; (2) the release of the results of the Childhood and Adolescent Migraine Prevention (CHAMP) study that raised doubts about the usefulness of traditional drugs for the treatment of pediatric migraine; (3) the Coronavirus disease 2019 (COVID-19) pandemic has put the spotlight on the importance of managing the psychological factors associated with the disease. In this mini review we discuss the most relevant news in pediatric migraine over the last 5 years.

Headaches in Pregnancy and Postpartum: ACOG Clinical Practice Guideline No. 3

PURPOSE

To provide updated evidence-based recommendations for the evaluation and treatment of primary and secondary headaches in pregnancy and postpartum.

TARGET POPULATION

Pregnant and postpartum patients with a history of or experiencing primary or new secondary headaches.

METHODS

This guideline was developed using an a priori protocol in conjunction with a writing team consisting of two specialists in obstetrics and gynecology appointed by the ACOG Committee on Clinical Practice Guidelines-Obstetrics and one external subject matter expert. ACOG medical librarians completed a comprehensive literature search for primary literature within Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. Studies that moved forward to the full-text screening stage were assessed by two authors from the writing team based on standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations Assessment, Development, and Evaluation) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements.

RECOMMENDATIONS

This Clinical Practice Guideline includes recommendations on interventions to prevent primary headache in individuals who are pregnant or attempting to become pregnant, postpartum, or breastfeeding; evaluation for symptomatic patients presenting with primary and secondary headaches during pregnancy; and treatment options for primary and secondary headaches during pregnancy and lactation. Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence.

Effect of a Mindfulness-Based Intervention for Chronic Migraine and High Frequency Episodic Migraine in Adolescents: A Pilot Single-Arm Open-Label Study

In this single-arm pilot open-label study we examined the effect of a mindfulness-based intervention on reduction of headache frequency after 12 months in adolescents aged 12-18 with chronic or high-frequency migraine without aura. Adolescents were recruited at the headache center of the C. Besta Neurological Institute and followed-up for 12 months. The mindfulness-based intervention was delivered in small groups and consisted of six weekly group sessions of guided meditation, and one booster session 15 days after. Patients filled in questionnaires assessing headache frequency (primary endpoint), medication intake, disability, anxiety, depression, catastrophizing, and caregivers' burden. Within-person ANOVA was used to address variation of endpoints over time. Thirty-five out of 37 patients completed the study for primary endpoints, and 33 for secondary endpoints. Headache frequency dropped from 21.3 (95% CI 18.5; 24.1) to 9.6 (95% CI 6.1; 13.1) days per month at 12 months (F = 30.5, p < 0.001); 23 patients out of 35 (65.7%) achieved a headache frequency reduction greater than or equal to 50%. Significant improvements were also reported for medication intake (F = 18.7, p < 0.001), disability (F = 3.8, p = 0.027), trait anxiety (F = 5.1, p = 0.009), symptoms of depression (F = 9.5, p < 0.001), and catastrophizing (F = 23.6, p < 0.001). In conclusions, our study shows a reduction of headache attacks in adolescents who follow a mindfulness-based program, suggesting benefit of this nonpharmacological approach.

The Use of Behavioral Modalities for Headache During Pregnancy and Breastfeeding

Purpose of Review

Migraine is primary headache which commonly affects women of childbearing age. Migraine and other primary headache disorders are also common during pregnancy. Understanding which treatments are effective and can be safely given to patients with primary headache during pregnancy and lactation is essential in supporting these patients before, during, and after childbirth. Behavioral modalities have the potential to improve the health of both mother and baby, while empowering patients to make informed decisions in family planning and creating future treatment plans.

Recent Findings

Research shows that behavioral therapies can be powerful tools to treat pain conditions with minimal side effects. Recent literature prioritizes behavioral therapies in preparation for pregnancy, during pregnancy, and during lactation due to the superior safety profile of such therapies. Digital resources for behavioral therapy are another well-received recent direction supported by growing evidence of both efficacy and safety. Popular with patients and headache specialists, digital behavioral therapy has taken various forms during the pandemic, such as telemedicine, online psychology support groups, and smartphone applications that patients can interact with on their own time.

Summary

In summary, the purpose of this review is to equip providers with important information and updates on the use of behavioral modalities for the treatment of primary headache during pregnancy and lactation.

Understanding the diagnoses and medical care experience of patients with new daily persistent headache: a qualitative study in Spain

OBJECTIVE

To explore the experiences of patients suffering from new daily persistent headache (NDPH) regarding the diagnostic process, treatment and medical care.

DESIGN

A qualitative phenomenological study was conducted.

SETTING

A specialised headache unit at two university hospitals in Spain between February 2017 and December 2018.

PARTICIPANTS

Patients diagnosed with NDPH according to the International Classification of Headache disorders (third beta edition).

METHODS

Purposeful sampling was performed. Data were collected using unstructured and semistructured interviews, researchers' field notes and patients' drawings. An inductive thematic analysis was used to identify significant emerging themes from interviews, field notes and descriptions of patients' drawings. Also, Guillemin's proposal was used to analyse the contents of drawings.

RESULTS

Nineteen patients with a mean age of 45.3 were recruited. Four main themes emerged: (1) Seeking a diagnosis, patients visit many doctors without receiving a clear answer and their diagnosis is delayed; (2) Self-medication-minimising pill intake, medication is ineffective, and therefore, some patients discontinue treatment, or are flexible with how they take medication; (3) Trying other non-pharmacological options, many patients turn to other therapies and complementary and/or alternative therapies as a second option, however these are ineffective and (4) Medical care, with two subthemes, referrals and lacking continuity of care, and building the doctor-patient relationship. Patients describe how the referral breaks the continuity of care, and how they identify the traits of a doctor who is approachable and which behaviours the doctor should avoid when caring for patients.

CONCLUSIONS

An in-depth knowledge of the beliefs and expectations of patients with NDPH will allow the professional to establish a relationship of trust, which will improve the patients' knowledge of which therapies are the most appropriate, and to establish expectations based on the relationship with the doctor, and not only on patients' beliefs.

Effectiveness of Exercise and Manual Therapy as Treatment for Patients with Migraine, Tension-Type Headache or Cervicogenic Headache: An Umbrella and Mapping Review with Meta-Meta-Analysis

The aim of the study was to perform a mapping and umbrella review with meta-meta-analysis (MMA) to synthesise and critically evaluate the effectiveness of manual therapy (MT) and aerobic exercise (AE) in relation to pain intensity, frequency, disability and quality of life in patients with migraines, tension-type headaches (TTH) and cervicogenic headaches (CGH). A systematic search was conducted in PubMed, PEDro, Scielo and Google Scholar up to December 2020. A total of 18 articles met the inclusion criteria, and only 8 were included in the quantitative analysis. The MMA showed results in favour of the interventions in terms of pain intensity and quality of life in migraine, TTH and CCH. Data were also in favour of the intervention in terms of pain frequency in migraine and in terms of disability in TTH. However, there were no significant effects on pain frequency in TTH and CGH. The results showed moderate evidence to suggest that AE reduces pain intensity in patients with migraine. In addition, the evidence in favour of MT or a mixed intervention (including therapeutic exercise) was also moderate in terms of reducing pain intensity in patients with TTH.

Comorbidities of primary headache disorders: a literature review with meta-analysis

Background

Primary headache disorders are common and burdensome conditions. They are associated to several comorbidities, such as cardiovascular or psychiatric ones, which, in turn, contribute to the global burden of headache. The aim of this study is to provide a comprehensive description of the pooled prevalence of comorbidities of primary headache disorders using a meta-analytical approach based on studies published between 2000 and 2020.

Methods

Scopus was searched for primary research (clinical and population studies) in which medical comorbidities were described in adults with primary headache disorders. Comorbidities were extracted using a taxonomy derived from the Global Burden of Disease (GBD) study. We compared prevalence of comorbidities among headache sufferers against general population using GBD-2019 estimates, and compared comorbidities’ proportions in clinical vs. population studies, and by age and gender.

Results

A total of 139 studies reporting information on 4.19 million subjects with primary headaches were included: in total 2.75 million comorbidities were reported (median per subject 0.64, interquartile range 0.32–1.07). The most frequently addressed comorbidities were: depressive disorders, addressed in 51 studies (pooled proportion 23 %, 95 % CI 20–26 %); hypertension, addressed in 48 studies (pooled proportion 24 %, 95 % CI 22–26 %); anxiety disorders addressed in 40 studies (pooled proportion 25 %, 95 % CI 22–28 %). For conditions such as anxiety, depression and back pain, prevalence among headache sufferers was higher than in GBD-2109 estimates. Associations with average age and female prevalence within studies showed that hypertension was more frequent in studies with higher age and less females, whereas fibromyalgia, restless leg syndrome, and depressive disorders were more frequent in studies with younger age and more female.

Conclusions

Some of the most relevant comorbidities of primary headache disorders – back pain, anxiety and depression, diabetes, ischemic heart disease and stroke – are among the most burdensome conditions, together with headache themselves, according to the GBD study. A joint treatment of headaches and of these comorbidities may positively impact on headache sufferers’ health status and contribute to reduce the impact of a group of highly burdensome diseases.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10194-021-01281-z.

Assessing the Knowledge of Analgesic Drugs Utilization during Pregnancy among Women in Saudi Arabia: A Cross-Sectional Study

BACKGROUND

Pain is a common compensation mechanism in pregnant women that they may face during gestation due to physiological changes. Paracetamol and non-steroidal anti-inflammatory drugs are the most administered analgesic drugs worldwide. Therefore, safety and efficacy are important measures for the use of analgesics during pregnancy.

OBJECTIVE

Assess the knowledge of analgesic drug utilization among Saudi pregnant women.

METHOD

We conducted a self-administered survey with an electronic questionnaire via Google Drive among a sample of 406 Saudi women.

RESULTS

About half of the respondents took analgesics during the first trimester, and 52.5% of women have used analgesics at least once without any medical advice during their gestation. Most participants agreed that paracetamol is the safest and effective analgesic drug during pregnancy, yet 61.8% of women are not aware that analgesics could be detrimental to the fetus if inappropriately administered in the third trimester.

CONCLUSION

Participants have a good perception of the safest and most effective analgesic drug during pregnancy, but they have poor knowledge about analgesics' side effects.

Current Insights into Treating Vertigo in Older Adults

The number of older people has been increasing over recent decades in Western populations. Dizziness, imbalance, and vertigo constitute some of the most common complaints in older patients, and risk of falling is the most frequent and worrying consequence. It has been reported that 15–20% of the adult population experiences these debilitating symptoms. Among the diseases that may be associated with vertigo, the three classes of otological, central, and functional (psychological) dizziness may be distinguished. Overall, vestibular disorders account for 48% of vertiginous complaints in the older population. The main focus of this article is to review the forms of pharmacotherapy for vertigo, especially with regard to older patients, who may be treated simultaneously with other drugs for different comorbidities. Interactions with other drugs should be considered in the choice of a particular course of treatment. Moreover, overuse of pharmacotherapy for the management of vertigo in the elderly may prevent the development of the central compensatory mechanism that sustains both static and dynamic imbalance after a vertiginous crisis. In the majority of patients, vestibular and physical rehabilitation are strongly advised and rarely contraindicated.