Efficacy of various exercise interventions for migraine treatment: A systematic review and network meta-analysis

OBJECTIVE

To compare various exercise modalities' efficacy on migraine frequency, intensity, duration, and disability.

BACKGROUND

Exercise has been shown to be an effective intervention to reduce migraine symptoms and disability; however, no clear evidence exists regarding the most effective exercise modalities for migraine treatment.

METHODS

A systematic review was performed in PubMed, PEDro, Web of Science, and Google Scholar. Clinical trials that analyzed the efficacy of various exercise modalities in addressing the frequency, intensity, duration, and disability of patients with migraine were included. Eight network meta-analyses based on frequentist (F) and Bayesian (B) models were developed to estimate the direct and indirect evidence of various exercise modalities. Standardized mean difference (SMD) and 95% confidence (CI) and credible intervals (CrI) were calculated for each treatment effect based on Hedge's g and p scores to rank the modalities.

RESULTS

We included 28 studies with 1501 migraine participants. Yoga (F: SMD -1.30; 95% CI -2.09, -0.51; B: SMD -1.33; 95% CrI -2.21, -0.45), high-intensity aerobic exercise (F: SMD -1.30; 95% CI -2.21, -0.39; B: SMD -1.17; 95% CrI -2.20, -0.20) and moderate-intensity continuous aerobic exercise (F: SMD -1.01; 95% CI -1.63, -0.39; B: SMD -1.06; 95% CrI -1.74, -0.38) were significantly superior to pharmacological treatment alone for decreasing migraine frequency based on both models. Only yoga (F: SMD -1.40; 95% CI -2.41, -0.39; B: SMD -1.41; 95% CrI -2.54, -0.27) was significantly superior to pharmacological treatment alone for reducing migraine intensity. For diminishing migraine duration, high-intensity aerobic exercise (F: SMD -1.64; 95% CI -2.43, -0.85; B: SMD -1.56; 95% CrI -2.59, -0.63) and moderate-intensity continuous aerobic exercise (SMD -0.96; 95% CI -1.50, -0.41; B: SMD -1.00; 95% CrI -1.71, -0.31) were superior to pharmacological treatment alone.

CONCLUSION

Very low-quality evidence showed that yoga, high- and moderate-intensity aerobic exercises were the best interventions for reducing migraine frequency and intensity; high- and moderate-intensity aerobic exercises were best for decreasing migraine duration; and moderate-intensity aerobic exercise was best for diminishing disability.

Individualized spectral filters alleviate persistent photophobia, headaches and migraines in active duty military and Veterans following brain trauma

PURPOSE

Consistent with association between photophobia and headache, growing evidence suggests an underlying causal relationship between light sensitivity and central pain. We investigated whether an intervention to regulate light sensitivity by filtering only wavelengths causing difficulties for the specific individual could alleviate headaches/migraines resulting from traumatic brain injury (TBI).

METHODS

Secondary data analysis of a clinical database including N = 392 military personnel (97% men, 3% women), ranging in age from 20 to 51 years, diagnosed with TBI, persistent headaches/migraines, and light sensitivity. The average elapsed time from TBI diagnosis to intervention was 3 years. Headache/migraine severity, frequency, medication use, and difficulties related to daily functioning were assessed pre and 4-12 weeks post-intervention with individualized spectral filters.

RESULTS

Monthly migraine frequency decreased significantly from an average of 14.8 to 1.9, with 74% reporting no migraines post-intervention. Prescription and over-the-counter medication use decreased by more than 70%. Individuals also reported significant improvement in light sensitivity, headaches/migraine severity, and physical and perceptual symptoms.

CONCLUSIONS

Wearing individualized spectral filters was associated with symptom relief, increased subjective quality of reported health and well-being, and decreased objective medication use for TBI-related persistent headaches/migraines. These results support a suggested relationship between dysregulated light sensitivity and central regulation of pain.

Age as a predictive factor for reduced intracranial compliance in patients with headache

BACKGROUND

 Increased intracranial pressure (ICP) consists of a set of signs and symptoms related to changes in intracranial compliance (ICC) and ICP.

OBJECTIVE

 This study presents a retrospective analysis of patients who underwent non-invasive monitoring of ICC based on complaints of headache, correlating decreased brain compliance and increased intracranial pressure.

METHODS

 Noninvasive ICC monitoring was performed using a Brain4care device, which contains a strain gauge and a recorder connected to a mechanical device that touches the scalp surface in the frontoparietal area lateral to the sagittal suture. This tool monitors the ICP by identifying small changes in skull measurements that are caused by pressure variations, i.e., skull deformation is associated with the detection of changes in mean ICP. A clinical evaluation of 32 patients with complaints of headache occurred from the analysis of their medical records.

RESULTS

 Of the 32 patients initially chosen, it was possible to complete the analysis of 18 due to the availability of data in the medical records. From the non-invasive monitoring of the ICC, the following data were collected: time-to-peak, P2/P1 ratio, age, and gender. From the statistical analysis of age and P2/P1 ratio, it was noted that as age increases, ICC tends to decrease regardless of sex (p < 0.05).

CONCLUSION

 This study concluded that there is a correlation between changes in intracranial compliance and headache complaints in outpatients. There was also a relationship between age and decreased intracranial compliance but without a specific pain pattern.

Indian Consensus on the Role of Amitriptyline in Migraine Prophylaxis

Migraine is a globally prevalent neurological disorder. Amitriptyline, a tricyclic antidepressant, has shown potential as a prophylactic treatment for migraine; however, its role as a first-line medication has been debated. A modified Delphi method was used to develop consensus statements on migraine and its management. The literature review identified knowledge gaps, and two survey rounds were conducted among a panel of experts. Consensus was reached for 12 out of 23 initial survey questions, whereas no consensus was reached for four questions after the deliberation in the second round. The results showed that migraine is highly prevalent among women aged 15-35 years in India. Amitriptyline is an effective monotherapy for prophylactic migraine management, with a recommended initial dose of 5-10 mg. A gradual titration over six months achieves optimal results. Amitriptyline is also safe for managing catamenial migraine and can be used at lower doses during pregnancy to alleviate symptoms. The outcomes of this study emphasize that amitriptyline should be considered as a primary prophylactic treatment for migraine because of its efficacy and safety. The evidence-based consensus achieved is intended to serve as guidance for healthcare practitioners in India, and it is anticipated that such adoption will lead to improvement in patient outcomes and an enhancement in the quality of life for those affected by migraines.

Persistent headache attributed to past ischemic stroke: A prospective cohort study

OBJECTIVE

To assess the incidence, characteristics, and risk factors for developing persistent headache attributed to past ischemic stroke.

BACKGROUND

Although the most recent International Classification of Headache Disorders has recognized the existence of persistent headache attributed to past ischemic stroke, there has been limited research in this area.

METHODS

This was a prospective cohort study. We initially assessed patients hospitalized with ischemic stroke admitted within 72 h of symptom onset. All patients underwent diffusion-weighted magnetic resonance imaging. These patients were re-interviewed by telephone 1 year after the stroke. Semi-structured questionnaires, the National Institutes of Health Stroke Scale (NIHSS), and six-item Headache Impact Test were used.

RESULTS

A total of 119 participants answered the interview conducted 1 year after the stroke. The mean (standard deviation) age was 64 (13.1) years, 82/119 (68.9%) were female, and the median (interquartile range) NIHSS score was 2 (1.0-4.0). The incidence rate of persistent headache attributed to past ischemic stroke was 12/119 (10.1%; 95% confidence interval [CI] 5.3-17.0%). The most frequent pattern presented was a migraine-like pattern in seven of the 12 (58.3%) patients, which had a substantial/severe impact on five of the 12 (41.7%). For most patients this headache continued, although it began to improve. Previous migraine (odds ratio 7.1, 95% CI 1.06-50.0; p = 0.043) and headache intensity in the acute phase of stroke (odds ratio 1.75, 95% CI 1.13-2.7; p = 0.012) were associated with the occurrence of persistent headache attributed to past ischemic stroke.

CONCLUSION

Persistent headache attributed to past ischemic stroke is a frequent complication after stroke. It often has a significant impact on patients' lives and presents a migraine-like pattern as its most frequent phenotype.

The history and rationale of the development of new drugs for migraine treatment

Migraine is one of the most prevalent and disabling diseases in the world. Migraine attack treatments and prophylactic treatments of this disease are essential to lessen its individual, social, and economic impact. This is a narrative review of the main drugs used for treating migraine, as well as the experimental models and the theoretical frameworks that led to their development. Ergot derivatives, triptans, non-steroid anti-inflammatory drugs, tricyclic antidepressants, beta-blockers,: flunarizine,: valproic acid,: topiramate, onabotulinumtoxin A, ditans, monoclonal antibodies against CGRP and its receptor, and gepants are discussed. Possible therapeutic targets for the development of new drugs that are under development are also addressed. Many of the drugs currently in use for treating migraine were developed for the treatment of other diseases, but have proven effective for the treatment of migraine, expanding knowledge about the disease. With a better understanding of the pathophysiology of migraine, new drugs have been and continue to be developed specifically for the treatment of this disease.

Effectiveness of intraoral splints in the treatment of migraine and tension-type headache: A systematic review

OBJECTIVES

The main objective of this systematic review was to assess the effectiveness of intraoral splints in treating migraine and tension-type headaches.

MATERIAL AND METHODS

The article search was conducted within seven electronic databases (Medline, PubMed, Embase, CINAHL PLUS with full text, Cochrane Library Trials, Web of Science, and Scopus) with no date limits or language restrictions up to June 12, 2022. Strict inclusion and exclusion criteria were set for article selection. At the same time as data extraction, each study's risk of bias (RoB) was evaluated using the Cochrane tool to assess their RoB. Subsequently, the Cochrane Grading of Recommendations Assessment Development and Evaluation was used to evaluate the certainty of the evidence.

RESULTS

Four controlled clinical trials were included. These trials were heterogeneous in terms of (1) diagnosis, (2) design of the intraoral splints, and (3) tools for reporting the results, which made it difficult to compile the data as well as evaluate its quality. Trials reported a reduction in the frequency of headache and pain intensity when using intraoral splints; however, this therapy was not superior to medications.

CONCLUSIONS

The evidence is very low for the use of oral splints as a therapeutic alternative to medication in the treatment of migraine and/or tension-type headache.

Headaches treatment with EMG biofeedback: a focused systematic review and meta-analysis

INTRODUCTION

The aim of this paper was to present an up-to-date evaluation of the efficacy of EMG-biofeedback (EMG-BFB) for primary headaches and to address possible mediators of outcome.

EVIDENCE ACQUISITION

PubMed, Scopus, Embase and Pedro databases were searched from inception to May 1, 2023. All randomized controlled trials (RCT) studies using an EMG-BFB to treat headache have been included in this systematic review. The current systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations and was registered in the PROSPERO database (CRD42022312827). Methodological quality was assessed through the Risk of Bias tool 2 (RoB 2). The effect sizes and 95% confidence interval (CI) were calculated by random-effect models on frequency, intensity, and duration variables. Egger regression and the Begg-Mazumdar rank correlation test were used for publication bias.

EVIDENCE SYNTHESIS

A total of 3059 articles were identified through the database searches. 29 articles, involving 1342 participants, met the inclusion criteria for the systematic review; of them, 4 were included in the meta-analysis. Ten studies reported a significant improvement in the EMG-BFB group with respect to the control group. Meta-analyses show a reduction in the intensity of attacks in patients subjected to EMG-BFB (ES 0.21 [(95% CI=-0.02; 0.44), P value=0.07] based on 293 patients).

CONCLUSIONS

EMG-BFB represents a non-pharmacological approach to headache treatment as shown via qualitative synthesis, despite not impressive results, this technique can be particularly useful in paediatric or in adult patients who cannot undergo drug therapies. Quantitative synthesis revealed a promising effect in the intensity of headaches attacks. Moreover, no significant effect was found about the effectiveness of EMG-BFB in the reduction of frequency and durations of headache attacks. Future studies with new multimodal technologic assessment and following RCT guidelines can unmask the potentiality of EMG-BFB in the treatment of headache.

Prevalence and Associated Factors of Depression among Adults Suffering from Migraine in Spain

Considering the significance of migraine and the limited amount of research conducted on its association with depression in population-based studies in Spain, this study aimed to determine the prevalence and change of depression from 2017 to 2020 among adults with migraine in Spain and to analyze the sociodemographic and health-related variables linked to depression in migraine sufferers. A cross-sectional study on 5329 adults with migraine from the Spanish National Health Survey 2017 and the European Health Survey in Spain 2020 was performed. Binary logistic regression was used to examine the factors related to depression. A total of 26.32% of people with migraine suffered from depression. No significant changes in that prevalence between 2017 and 2020 were observed. The risk factors associated with depression included being between the ages of 25 and 44 (p = 0.018), being separated or divorced (p = 0.033), being unemployed (p < 0.001), not engaging in recreational physical activity (p = 0.016), perceiving one's health as average, poor, or very poor (p < 0.001), experiencing moderate to severe pain in daily activities (p = 0.011, p = 0.004, p < 0.001, respectively), and having 1-2 or ≥3 chronic conditions (p = 0.003, p < 0.001, respectively). Conversely, being married (p = 0.001) and alcohol consumption (p = 0.007) were identified as protective factors.

From CGRP to PACAP, VIP, and Beyond: Unraveling the Next Chapters in Migraine Treatment

Migraine is a neurovascular disorder that can be debilitating for individuals and society. Current research focuses on finding effective analgesics and management strategies for migraines by targeting specific receptors and neuropeptides. Nonetheless, newly approved calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAbs) have a 50% responder rate ranging from 27 to 71.0%, whereas CGRP receptor inhibitors have a 50% responder rate ranging from 56 to 71%. To address the need for novel therapeutic targets, researchers are exploring the potential of another secretin family peptide, pituitary adenylate cyclase-activating polypeptide (PACAP), as a ground-breaking treatment avenue for migraine. Preclinical models have revealed how PACAP affects the trigeminal system, which is implicated in headache disorders. Clinical studies have demonstrated the significance of PACAP in migraine pathophysiology; however, a few clinical trials remain inconclusive: the pituitary adenylate cyclase-activating peptide 1 receptor mAb, AMG 301 showed no benefit for migraine prevention, while the PACAP ligand mAb, Lu AG09222 significantly reduced the number of monthly migraine days over placebo in a phase 2 clinical trial. Meanwhile, another secretin family peptide vasoactive intestinal peptide (VIP) is gaining interest as a potential new target. In light of recent advances in PACAP research, we emphasize the potential of PACAP as a promising target for migraine treatment, highlighting the significance of exploring PACAP as a member of the antimigraine armamentarium, especially for patients who do not respond to or contraindicated to anti-CGRP therapies. By updating our knowledge of PACAP and its unique contribution to migraine pathophysiology, we can pave the way for reinforcing PACAP and other secretin peptides, including VIP, as a novel treatment option for migraines.

Association between weight status and migraine in the paediatric population: a systematic review and meta-analysis

Introduction

An association between weight status and migraine has been previously reported; however, this relationship has only been studied in adults, not in the paediatric population.

Objective

To evaluate the association between weight status and migraine in the paediatric population.

Methods

We searched PubMed/Medline, Scopus, Web of Science, Ovid Medline, and Embase using a cut-off date of May 2023. We included observational studies that evaluated the association between weight status (underweight, overweight, obese, and excess weight) and migraine in the paediatric population (children and adolescents). Normal weight was the comparator. The outcome was migraine (all types, episodic and chronic). We performed meta-analyses using a random-effects model to estimate the pooled effects for each outcome. Sensitivity analysis was performed based on study design and risk of bias (using the Newcastle-Ottawa Scale). Certainty of evidence was assessed using the GRADE approach.

Results

Eight studies (6 cross-sectional, 1 case-control and 1 cohort) covering 16,556 patients were included. The overall certainty of evidence was very low for the association between overweight, obesity, and excess weight with migraine. In the sensitivity analysis, meta-analyses of studies with a low risk of bias found that the overweight population probably had an increased odds of migraine (OR: 1.70; 95% CI: 1.14 to 2.53; I2 = 32.3%, p = 0.224) and that excess weight may increase the odds of migraine (OR: 1.58; 95% CI: 1.06 to 2.35; I2 = 83.7%, p = 0.002). Additionally, cohort and case-control studies found that obesity probably increases the odds of migraine. No studies analysed the association between underweight and migraine.

Conclusion

The associations between overweight, obesity, excess weight and migraine were uncertain, but studies with better methodological quality reported increased odds. Future longitudinal studies with proper confounding control are needed to disentangle their causal relationship.

Systematic review registration

PROSPERO, identifier CRD42021271533.

Predicting Sumatriptan Responsiveness Based on Structural Connectivity in Patients Newly Diagnosed With Migraine

BACKGROUND AND PURPOSE

We aimed to determine whether structural brain connectivity is significantly associated with the response to sumatriptan in patients with migraine.

METHODS

We retrospectively enrolled patients with newly diagnosed migraine who underwent brain diffusion-tensor imaging (DTI) at the time of diagnosis, with regular follow-up for at least 6 months after the initial diagnosis. Patients were classified into good- and poor-responder groups according to their response to sumatriptan. We analyzed the structural connectivity using DTI by applying graph theory using DSI Studio software.

RESULTS

We enrolled 59 patients (35 good responders and 24 poor responders) and 30 healthy controls. Global structural connectivity differed significantly between patients with migraine and healthy controls, while local structural connectivity differed significantly between good and poor responders. The betweenness centrality was lower in good responders than in poor responders in the left lateral geniculate thalamic nucleus (26.078 vs. 41.371, p=0.039) and right medial mediodorsal magnocellular thalamic nucleus (60.856 vs. 90.378, p=0.021), whereas was higher in good responders in the left lateral pulvinar thalamic nucleus (98.365 vs. 50.347, p=0.003) and right medial pulvinar thalamic nucleus (216.047 vs. 156.651, p=0.036).

CONCLUSIONS

We found that structural connectivity in patients with migraine differed from that in healthy controls. Moreover, the local structural connectivity varied with the response to sumatriptan, which suggests that structural connectivity is a useful factor for predicting how a patient will respond to sumatriptan.

Clinical characteristics of headaches in an urban Mennonite group in South Brazil

BACKGROUND

Genetic variants play a pathophysiological role in headaches, especially in migraine. The Mennonite group (MG) has been geographically and genetically isolated throughout its history, harboring a distinctive distribution of diseases.

OBJECTIVE

To determine the characteristics of headaches in a group with direct Mennonite ancestry contrasting with other urban community members (control group [CG]).

METHODS

Subjects with headaches were asked to complete a questionnaire covering: the type of headache, presence of aura, frequency and duration of attacks, pain location and severity, analgesic consumption, premonitory and postdromic manifestations, Depressive Thoughts Scale, Epworth Sleepiness Scale (ESS), General Anxiety Disorder-7, Patient Health Questionnaire-9 (PHQ-9), Migraine Disability Assessment, and Composite Autonomic System Score.

RESULTS

We included 103 participants (CG: 45, Mennonite group [MG]: 58). Migraine was the most common headache (CG: 91.1%; MG: 81.0%; p = 0.172), followed by tension-type headache (CG: 8.9%; MG: 15.5%; p = 0.381). Aura was identified by 44.4% and 39.7% in the CG and MG, respectively (p = 0.689). The groups differed only concerning the frequency of retro-orbital pain (CG: 55.6%; MG: 32.8%; p = 0.027), PHQ-9 (CG: median 7, range 0 to 22; MG: median 5, range 0 to 19; p = 0.031) and ESS (CG: median 0, range 0 to 270; MG: median 0, range 0 to 108; p = 0.048) scores.

CONCLUSION

There were no major differences in the prevalence and clinical characterization of headaches between the MG and the CG. However, the latter showed more diffuse pain, sleepiness, and depressive symptoms. Specific genetic or epigenetic variants in Mennonite descendants might account for these differences.

Evaluation of the efficacy of peripheral nerve block alone in episodic and chronic migraine patients

BACKGROUND

Peripheral nerve block (PNB) is usually performed in patients with migraine who are resistant to treatment with medications.

OBJECTIVE

To compare the efficacy of PNB alone and PNB combined with prophylactic medications in migraine patients.

METHOD

The data on migraine patients who underwent PNB in our clinic between November 2019 and January 2022 were retrospectively reviewed. Blocks of the greater occipital nerve (GON), lesser occipital nerve (LON) and supraorbital nerve (SON) were performed upon admission and in the second week.

RESULTS

The study included 116 patients. While 21 out of 39 episodic migraine (EM) patients continued to use prophylactic medications, 18 were followed up with PNB alone. While 49 out of 77 chronic migraine (CM) patients continued to use prophylactic medications, 28 were followed up with PNB alone. Comparison of the admission and second-month data of the patients who only underwent PNB and those who continued the drug treatment together with PNB in both the EM and the CM group showed that the number of days with pain, number of analgesics taken and scores on the Visual Analog Scale (VAS) and the Migraine Disability Assessment (MIDAS) were significantly reduced in both groups (p < 0.01). Comparison of the second-month data of the patients followed up with PNB alone and those followed up with PNB together with prophylactic medications showed that there was no significant difference between the EM and CM patients (p > 0.05).

CONCLUSION

Bilateral GON, LON and SON block with lidocaine injection seems to be an effective treatment on its own, without the need for prophylactic medications, in both EM and CM patients during a two-month follow-up.

Brazilian headache registry: methods and preliminary data of the pilot study

BACKGROUND

Evaluation and treatment of primary and secondary headaches is a global public health challenge. Recognizing the epidemiological impact of headaches, a group of researchers linked to the Brazilian Headache Society proposed the Brazilian Headache Registry and drew up its initial protocol.

OBJECTIVE

Here we describe the methods and preliminary data obtained from the pilot study.

METHODS

This was a multicenter longitudinal observational study conducted between September 2020 and August 2021. Prospective data were collected in three specialist centers for headache care in states in southern and southeastern Brazil. Patients aged 18 years or older who sought care for headache in tertiary centers and who agreed to participate in the study, were considered eligible.

RESULTS

Sixty-six patients were included in the pilot study: 43 (65%) from Rio Grande do Sul state and 23 (35%) from Minas Gerais state. Overall, 90% were female, and the subjects' mean age was 38.2 ± 11.2 years. Primary headaches accounted for 85.3% of the diagnoses made. Among secondary headaches, medication overuse headache was the most frequent type (7.1%).

CONCLUSIONS

The pilot study showed the feasibility of the research protocol developed for tertiary centers. The Brazilian Headache Registry will form a source of longitudinal data with the aim of contributing to better characterization of the various phenotypes of patients with primary and secondary headaches, and to detailing the use of health resources and identifying predictors of better clinical outcomes.

A Scoping Review and Meta-Analysis of Anti-CGRP Monoclonal Antibodies: Predicting Response

Calcitonin gene-related peptide-targeted monoclonal antibodies (CGRP mAbs) are increasingly being used as preventive treatments for migraine. Their effectiveness and safety were established through numerous randomized placebo-controlled trials and real-world studies, yet a significant proportion of patients do not respond to this treatment, and currently, there is a lack of accepted predictors of response to guide expectations, as data from studies so far are lacking and inconsistent. We searched Embase and MEDLINE databases for studies reporting on predictors of response to CGRP and/or CGRP-receptor (CGRP-R) mAbs, defined as a 30% or 50% reduction in monthly headache or migraine days at varying durations of follow-up. Quantitative synthesis was performed where applicable. We found 38 real-world studies that investigated the association between various predictors and response rates. Based on these studies, good response to triptans and unilateral pain with or without unilateral autonomic symptoms are predictors of a good response to CGRP(-R) mAbs. Conversely, obesity, interictal allodynia, the presence of daily headaches, a higher number of non-successful previous prophylactic medications, and psychiatric comorbidities including depression are predictive of a poor response to CGRP(-R) mAbs. Future studies should confirm these results and help to generate more tailored treatment strategies in patients with migraine.

Ketosis and migraine: a systematic review of the literature and meta-analysis

Introduction

Headaches are a prevalent disorder worldwide, and there is compelling evidence that certain dietary interventions could provide relief from attacks. One promising approach is ketogenic therapy, which replaces the brain's glucose fuel source with ketone bodies, potentially reducing the frequency or severity of headaches.

Aim

This study aims to conduct a systematic review of the scientific literature on the impact of ketosis on migraine, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method.

Results

After a careful selection process and bias evaluation, 10 articles were included in the review, primarily from Italy. The bias assessment indicated that 50% of the selected articles had a low risk of bias in all domains, with the randomization process being the most problematic domain. Unfortunately, the evaluation of ketosis was inconsistent between articles, with some assessing ketonuria, some assessing ketonemia, and some not assessing ketosis levels at all. Therefore, no association could be made between the level of ketosis and the prevention or reduction of migraine attacks. The ketogenic therapies tested in migraine treatments included the very low-calorie ketogenic diet (VLCKD, n = 4), modified Atkins diet (MAD, n = 3), classic ketogenic diet (cKDT, n = 2), and the administration of an exogenous source of beta-hydroxybutyrate (BHB). The meta-analysis, despite reporting high heterogeneity, found that all interventions had an overall significant effect (Z = 9.07, p < 0.00001; subgroup differences, Chi2 = 9.19, dif = 3, p = 0.03; I², 67.4%), regardless of the type of endogenous or exogenous induction of ketosis.

Conclusion

The initial findings of this study suggest that metabolic ketogenic therapy may provide some benefit in treating migraines and encourage further studies, especially randomized clinical trials with appropriate and standardized methodologies. The review strongly recommends the use of the adequate measurement of ketone levels during ketogenic therapy to monitor adherence to the treatment and improve knowledge of the relationship between ketone bodies and efficacy.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42022330626.

The Prevalence of Migraine in Inflammatory Bowel Disease, a Systematic Review and Meta-Analysis

Background

Patients with inflammatory bowel disease (IBD) suffer from a wide range of comorbidities such as migraine. In studies, the prevalence of migraine in cases with IBD was reported differently. The goal of this systematic review and meta-analysis was to estimate the pooled prevalence of migraine in IBD cases.

Methods

Two researchers independently and systematically searched PubMed, Scopus, EMBASE, Web of Science, and google scholar. They also searched the gray literature including references of the included studies and conference abstracts which were published up to May 2021. Cross-sectional studies were included.

Results

The literature search revealed 840 articles, and after deleting duplicates, 650 remained. For the meta-analysis, 10 studies were included. Totally, 62,554 patients were evaluated. The pooled prevalence of migraine in patients with IBD was 19% (95% CI: 15-22%). The pooled prevalence of migraine in ulcerative colitis (UC) was 10% (95% CI: 4-15%) (I² = 99.8%, P < 0.001). The pooled prevalence of migraine in the Crohn's disease (CD) group was 24% (95% CI: 17-30%) (I² = 98.8%, P < 0.001). The pooled odds of developing migraine in IBD cases was 1.51 (95% CI: 1-2.27) (I² = 90.8%, P < 0.001).

Conclusions

The result of this systematic review and meta-analysis showed that the pooled prevalence of migraine in patients with IBD was 19% (95% CI: 15-22%).

Lasmiditan in Japanese Patients with Common Migraine Comorbidities or Concomitant Medications: A Post Hoc Safety and Efficacy Analysis from the MONONOFU Study

Background

Migraine is often comorbid with other disorders. People with migraine may be prescribed one or more concomitant medications. This post hoc analysis assessed the safety and efficacy of lasmiditan in Japanese people with migraine comorbidities or using concomitant medications.

Patients and Methods

The MONONOFU study was a Phase 2, randomized, placebo-controlled, multicenter study of lasmiditan for acute migraine treatment in Japanese adults. Patients reported comorbidities (pre-existing or coexisting conditions) during screening. Concomitant medications (any drugs taken ±48 hours of the study drug) and treatment-emergent adverse events (TEAEs) were recorded in a paper diary. Study drug efficacy (pain freedom 2 hours after administration of study drug) was reported in an eDiary. Logistic regression models were used for subgroup analyses of safety (incidence of TEAEs) and efficacy (pain freedom at 2 hours post dose) of lasmiditan in relation to presence/absence of comorbidities, and safety in relation to concomitant medications.

Results

Common comorbidities (occurring in ≥10% of any lasmiditan dose group) were seasonal allergies, allergic rhinitis, tension-type headache, cervicobrachial syndrome, dysmenorrhea, nasopharyngitis, musculoskeletal stiffness, chronic gastritis, constipation, and insomnia. There was no significant interaction of treatment with comorbidity for safety or efficacy. There was also no significant interaction between treatment and concomitant medication groups of special interest (acetaminophen/nonsteroidal anti-inflammatory drugs, triptans, antiemetics, central nervous system depressant medications, serotonergic medications, antiepileptics, antihypertensive medications, Chinese herbal medicines, and contraceptives) for incidence of TEAEs.

Conclusion

In Japanese people with migraine, the safety of lasmiditan appeared to be independent of common comorbidities and concomitant medications; efficacy appeared to be independent of comorbid conditions.

Clinical Trials Registration

NCT03962738 (ClinicalTrials.gov).

Neutralizing Antibody Formation with OnabotulinumtoxinA (BOTOX®) Treatment from Global Registration Studies across Multiple Indications: A Meta-Analysis

Though the formation of neutralizing antibodies (NAbs) during treatment with botulinum neurotoxin is rare, their presence may nonetheless affect the biological activity of botulinum toxin and negatively impact clinical response. The goal of this updated meta-analysis was to evaluate and characterize the rate of NAb formation using an expanded dataset composed of 33 prospective placebo-controlled and open-label clinical trials with nearly 30,000 longitudinal subject records prior to and following onabotulinumtoxinA treatment in 10 therapeutic and aesthetic indications. Total onabotulinumtoxinA doses per treatment ranged from 10 U to 600 U administered in ≤15 treatment cycles. The NAb formation at baseline and post-treatment was tested and examined for impact on clinical safety and efficacy. Overall, 27 of the 5876 evaluable subjects (0.5%) developed NAbs after onabotulinumtoxinA treatment. At study exit, 16 of the 5876 subjects (0.3%) remained NAb positive. Due to the low incidence of NAb formation, no clear relationship was discernable between positive NAb results and gender, indication, dose level, dosing interval, treatment cycles, or the site of injection. Only five subjects who developed NAbs post-treatment were considered secondary nonresponders. Subjects who developed NAbs revealed no other evidence of immunological reactions or clinical disorders. This comprehensive meta-analysis confirms the low NAb formation rate following onabotulinumtoxinA treatment across multiple indications, and its limited clinical impact on treatment safety and efficacy.

Outcomes of Surgical Treatment of Migraines: A Systematic Review & Meta-Analysis

Background: Migraine surgery at 1 of 6 identified "trigger sites" of a target cranial sensory nerve has rapidly grown in popularity since 2000. This study summarizes the effect of migraine surgery on headache severity, headache frequency, and the migraine headache index score which is derived by multiplying migraine severity, frequency, and duration. Materials and Methods: This is a PRISMA-compliant systematic review of 5 databases searched from inception through May 2020 and is registered under the PROSPERO ID: CRD42020197085. Clinical trials treating headaches with surgery were included. Risk of bias was assessed in randomized controlled trials. Meta-analyses were performed on outcomes using a random effects model to determine the pooled mean change from baseline and when possible, to compare treatment to control. Results: 18 studies met criteria including 6 randomized controlled trials, 1 controlled clinical trial, and 11 uncontrolled clinical trials treated 1143 patients with pathologies including migraine, occipital migraine, frontal migraine, occipital nerve triggered headache, frontal headache, occipital neuralgia, and cervicogenic headache. Migraine surgery reduced headache frequency at 1 year postoperative by 13.0 days per month as compared to baseline (I2 = 0%), reduced headache severity at 8 weeks to 5 years postoperative by 4.16 points on a 0 to 10 scale as compared to baseline (I2 = 53%), and reduced migraine headache index at 1 to 5 years postoperative by 83.1 points as compared to baseline (I2 = 2%). These meta-analyses are limited by a small number of studies that could be analyzed, including studies with high risk of bias. Conclusion: Migraine surgery provided a clinically and statistically significant reduction in headache frequency, severity, and migraine headache index scores. Additional studies, including randomized controlled trials with low risk-of-bias should be performed to improve the precision of the outcome improvements.

Clinical Potential of Adrenomedullin Signaling in the Cardiovascular System

Numerous clinical studies have revealed the utility of circulating AM (adrenomedullin) or MR-proAM (mid-regional proAM 45-92) as an effective prognostic and diagnostic biomarker for a variety of cardiovascular-related pathophysiologies. Thus, there is strong supporting evidence encouraging the exploration of the AM-CLR (calcitonin receptor-like receptor) signaling pathway as a therapeutic target. This is further bolstered because several drugs targeting the shared CGRP (calcitonin gene-related peptide)-CLR pathway are already Food and Drug Administration-approved and on the market for the treatment of migraine. In this review, we summarize the AM-CLR signaling pathway and its modulatory mechanisms and provide an overview of the current understanding of the physiological and pathological roles of AM-CLR signaling and the yet untapped potentials of AM as a biomarker or therapeutic target in cardiac and vascular diseases and provide an outlook on the recently emerged strategies that may provide further boost to the possible clinical applications of AM signaling.

Pharmacological interventions for prophylaxis of vestibular migraine

BACKGROUND

Vestibular migraine is a form of migraine where one of the main features is recurrent attacks of vertigo. These episodes are often associated with other features of migraine, including headache and sensitivity to light or sound. These unpredictable and severe attacks of vertigo can lead to a considerable reduction in quality of life. The condition is estimated to affect just under 1% of the population, although many people remain undiagnosed. A number of pharmacological interventions have been used or proposed to be used as prophylaxis for this condition, to help reduce the frequency of the attacks. These are predominantly based on treatments that are in use for headache migraine, with the belief that the underlying pathophysiology of these conditions is similar.

OBJECTIVES

To assess the benefits and harms of pharmacological treatments used for prophylaxis of vestibular migraine.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 23 September 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs in adults with definite or probable vestibular migraine comparing beta-blockers, calcium channel blockers, antiepileptics, antidepressants, diuretics, monoclonal antibodies against calcitonin gene-related peptide (or its receptor), botulinum toxin or hormonal modification with either placebo or no treatment. We excluded studies with a cross-over design, unless data from the first phase of the study could be identified.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were: 1) improvement in vertigo (assessed as a dichotomous outcome - improved or not improved), 2) change in vertigo (assessed as a continuous outcome, with a score on a numerical scale) and 3) serious adverse events. Our secondary outcomes were: 4) disease-specific health-related quality of life, 5) improvement in headache, 6) improvement in other migrainous symptoms and 7) other adverse effects. We considered outcomes reported at three time points: < 3 months, 3 to < 6 months, > 6 to 12 months. We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

We included three studies with a total of 209 participants. One evaluated beta-blockers and the other two evaluated calcium channel blockers. We did not identify any evidence for the remaining interventions of interest. Beta-blockers versus placebo One study (including 130 participants, 61% female) evaluated the use of 95 mg metoprolol once daily for six months, compared to placebo. The proportion of people who reported improvement in vertigo was not assessed in this study. Some data were reported on the frequency of vertigo attacks at six months and the occurrence of serious adverse effects. However, this is a single, small study and for all outcomes the certainty of evidence was low or very low. We are unable to draw meaningful conclusions from the numerical results. Calcium channel blockers versus no treatment Two studies, which included a total of 79 participants (72% female), assessed the use of 10 mg flunarizine once daily for three months, compared to no intervention. All of the evidence for this comparison was of very low certainty. Most of our outcomes were only reported by a single study, therefore we were unable to conduct any meta-analysis. Some data were reported on improvement in vertigo and change in vertigo, but no information was available regarding serious adverse events. We are unable to draw meaningful conclusions from the numerical results, as these data come from single, small studies and the certainty of the evidence was very low.

AUTHORS CONCLUSIONS

There is very limited evidence from placebo-controlled randomised trials regarding the efficacy and potential harms of pharmacological interventions for prophylaxis of vestibular migraine. We only identified evidence for two of our interventions of interest (beta-blockers and calcium channel blockers) and all evidence was of low or very low certainty. Further research is necessary to identify whether these treatments are effective at improving symptoms and whether there are any harms associated with their use.

Headache and systemic lupus erythematosus: A narrative review

OBJECTIVE

To review the epidemiology, the differential diagnosis, and the clinical and laboratory factors associated with the care management of headaches in patients with systemic lupus erythematosus (SLE).

BACKGROUND

SLE is a chronic autoimmune disease and in 12%-95% of patients, the nervous system is involved. Headache is a frequently reported, although nonspecific, symptom that may potentially represent serious underlying diagnoses. Primary headaches may also occur in these patients, thereby causing a negative and significant impact on their quality of life.

METHODS

This is a narrative review. A literature review was conducted on the PubMed platform using the following terms: (1) headache and (2) lupus. All articles considered relevant were included. No limitations were imposed for the publication date.

RESULTS

Headache is a frequent symptom in patients with SLE. Although its prevalence is similar to the general population, headaches nonetheless tend to have a greater negative impact on these patients. Patients with SLE are more likely to experience headache due to vascular diseases such as cerebral venous sinus thrombosis, stroke, reversible cerebral vasoconstriction syndrome, posterior reversible encephalopathy syndrome, and vasculitis. Aseptic meningitis, neuroinfections, intracranial neoplasms, and intracranial hypertension or hypotension may also be a cause of headache in these patients. Although used in disease activity scores, the concept of lupus headache is controversial.

CONCLUSIONS

Headache is a frequent symptom in patients with SLE. An appropriate approach enables the potentially serious conditions, which are the causes of secondary headaches, to be recognized and treated, together with an appropriate diagnosis and treatment of primary headaches.

Assessing the influence of migraine on ischemic penumbra and on the prognosis of ischemic stroke: A prospective cohort study

INTRODUCTION

There is controversy as to whether migraine affects the behavior of ischemic penumbra during the acute phase of an ischemic stroke, thereby accelerating the formation of cerebral infarction.

OBJECTIVES

To assess whether migraine modifies the existence and volume of the divergence between the areas of diffusion and perfusion in the stroke (the penumbra) and whether migraine implies a poorer prognosis after the stroke.

METHODS

This was a prospective cohort study. We included hospitalized patients with ischemic stroke within 72 h of symptom onset (convenience sampling). A semi-structured questionnaire, the National Institute of Health Stroke Scale, and the modified Rankin Scale (mRS) were used. Patients underwent magnetic resonance imaging (MRI) of the brain with diffusion and with perfusion. Patients were assessed by telephone 3 months after the stroke to determine the prognosis. Scores of > 2 on the mRS were considered to have a poor prognosis.

RESULTS

A total of 221 patients were included, 131/221 (59%) of whom were male, and with a mean (SD) age of 68.2 (13.8) years. Ischemic penumbra analysis was performed in 118 patients. There was no association between migraine and the absence of ischemic penumbra (16/63 [25%] vs. 12/55 [22%]; odds ratio 1.22, 95% confidence interval 0.52-2.87; p = 0.64). There was no difference in stroke volume between those with and without migraine (median [interquartile range] 1.0 [0.4-7.9] vs. 1.8 [0.3-9.4] cm³ ; p = 0.99). Migraine was not associated with the stroke prognosis after multivariable analysis.

CONCLUSION

Migraine is not associated with the absence of ischemic penumbra, the volume of the ischemic penumbra, or the stroke prognosis.

Frequency and Size of In Situ Thrombus Within Patent Foramen Ovale

BACKGROUND

High-resolution optical coherence tomography can detect in situ thrombi within patent foramen ovale (PFO), which can become a dangerous embolic source. This study aimed to investigate the frequency and size of in situ thrombus within PFO using optical coherence tomography.

METHODS

The cross-sectional study was conducted at Fuwai Hospital (Beijing, China) between 2020 and 2021. From 528 consecutive patients with PFO, 117 (age, 34.33 [SD, 11.30] years) without known vascular risk factors were included; according to PFO-related symptoms, they were divided into the stroke (n=43, including 5 patients with transient ischemic attack), migraine (n=49) and asymptomatic (n=25) groups. Optical coherence tomography was used to evaluate in situ thrombi and abnormal endocardium within PFO. Univariable analysis and a logistic model were used to evaluate the association between stroke and in situ thrombus; age, sex, body mass index, and antithrombotic therapy were included as covariates.

RESULTS

Antithrombotic therapy was used more frequently in the stroke group than in the migraine group (76.7% versus 12.2%; P<0.001). In situ PFO thrombi were detected in 36 (83.7%), 28 (57.1%), and 0 (0.0%) patients from the stroke, migraine, and asymptomatic groups, respectively (P<0.001). Between the stroke and migraine groups, there was no significant difference in the median (interquartile range) thrombus number per patient (7 [3-12] versus 2 [0-10]; P=0.199), maximum thrombus diameter (0.35 [0.20-0.46] versus 0.21 [0-0.68] mm; P=0.597), or total thrombus volume (0.02 [0.01-0.05] versus 0.01 [0-0.05] mm³; P=0.386). Additionally, in situ thrombus was significantly associated with stroke risk (odds ratio, 4.59 [95% CI, 1.26-16.69]). Abnormal endocardium within PFO occurred in patients with in situ thrombi (71.9%) but not in those without. During optical coherence tomography examination, migraine occurred in 2 patients with in situ thrombi.

CONCLUSIONS

The frequency of in situ thrombus was extremely high in stroke and migraine groups, while none of the asymptomatic individuals presented with an in situ thrombus. In situ thrombus formation may play a role in patients with PFO-associated stroke or migraines and have therapeutic implications.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT04686253.

Safety profile of lasmiditan in patients with migraine in an Asian population

BACKGROUND

MONONOFU, a multicenter, randomized, double-blind, placebo-controlled phase 2 study of Japanese patients with migraine, was pivotal for lasmiditan approval in Japan. However, treatment-emergent adverse events (TEAEs) were more common than in global studies. A detailed safety profile would assist patient management.

RESEARCH DESIGN AND METHODS

Safety assessments in MONONOFU included specific terms reported, frequency, severity, time to onset, duration, TEAE management, common TEAE risk factors, and TEAE-efficacy associations.

RESULTS

Of 846 participants, 691 were assessed for safety. The proportion of participants reporting ≥1 TEAE was 23.4% with placebo and 70.9% with lasmiditan; 87.3% of TEAEs with lasmiditan were mild. The most frequent TEAEs with lasmiditan, dizziness (39.4%) and somnolence (19.3%), started ≤1 hour postdose (median durations: 2.5 and 3.3 hours, respectively). Higher lasmiditan dose, but not patient factors including body size, was identified as a clinically meaningful predictor of dizziness and somnolence. There were no adverse consequences of neurological TEAEs, which did not appear to adversely affect lasmiditan efficacy.

CONCLUSIONS

In the MONONOFU study, TEAEs appeared typically mild, transient, and self-limiting. Lasmiditan may represent a useful and well-tolerated acute treatment option for smaller (body mass index <30 kg/m²) patients and Asian patients with migraine.

Prevalence of vestibular migraine in an otolaryngologic clinic: Preliminary clinical diagnosis versus diagnosis according to the strictly applied Bárány criteria

BACKGROUND

Diagnostic criteria of vestibular migraine (VM) by the Bárány classification consists of complex combinations of characteristics of dizziness: episodes, intensity, duration, migraine according to International Classification of Headache Disorders (ICHD), and migraine features accompanying vertigo. The prevalence according to strictly applied Bárány criteria may be much lower than preliminary clincal diagnosis.

OBJECTIVE

The purpose of this study is to investigate the prevalence of VM according to strictly applied Bárány criteria among dizzy patients who visited the otolaryngology department.

METHODS

The medical records of patients with dizziness from December 2018 to November 2020 were retrospectively searched using a clinical big data system. The patients completed a questionnaire designed to identify VM according to Bárány classification. Microsoft Excel function formulas were used to identify cases that met the criteria.

RESULTS

During the study period, 955 new patients visited the otolaryngology department complaining of dizziness, of which 11.6% were assessed as preliminary clinical diagnosis of VM in outpatient clinic. However, VM according to strictly applied Bárány criteria accounted for only 2.9% of dizzy patients.

CONCLUSION

The prevalence of VM according to strictly applied Bárány criteria could be significantly lower than that of preliminary clinical diagnosis in outpatient clinic.

Real-world experience of OnabotulinumtoxinA treatment in female patients with chronic migraine: a qualitative study using in-depth interviews

BACKGROUND

Chronic migraine (CM) causes great disability and affects an individual's quality of life. OnabotulinumtoxinA (OBT-A, Botox®) was the first prophylactic treatment specifically indicated for CM. The aim of this study was to describe the experiences of women with CM treated with OBT-A.

MATERIALS AND METHODS

The study design is a qualitative descriptive study. A purposeful sampling of 30 women (mean age, 42.7; standard deviation, 10.6) who had received at least two administrations of OBT-A for CM (PREEMPT protocol) was performed. Data collection included in-depth interviews and researchers' field notes. A thematic analysis was carried out according to qualitative research guidelines.

RESULTS

Five themes were identified: (a) A long way to go before Botox®, (b) First time hearing about the treatment and its expectations, (c) The administration of Botox®, (d) Treatment effects, and (e) Follow-up. Patients described a long history of treatment failures prior to the start of OBT-A treatment. Information about this migraine treatment came from the neurologist; following the information, patients had high expectations, including unrealistic expectations regarding the onset and duration of effect. They acknowledged fear of the injections and some discomfort due to the procedure. With treatment, participants reported better migraine control and an improvement in their quality of life. Follow-up had some barriers, such as delayed appointments for subsequent doses, but also strengths, such as effectiveness and few side effects.

CONCLUSIONS

Qualitative research offers insight into how patients with CM experience treatment with OBT-A. Our results highlight some relevant aspects that should be considered when providing OBT-A treatment.

Lasmiditan for single migraine attack in Japanese patients with cardiovascular risk factors: subgroup analysis of a phase 2 randomized placebo-controlled trial

BACKGROUND

Some migraine treatments are contraindicated for patients with cardiovascular disease (CVD) or risk factors (CVRFs). We report safety and efficacy of lasmiditan, a new oral acute migraine treatment with no cardiovascular contraindication, in Japanese patients with CVRFs.

RESEARCH DESIGN AND METHODS

MONONOFU was a multicenter, randomized, double-blind, placebo-controlled, phase 2 study of Japanese patients with migraine (met International Headache Society criteria, Migraine Disability Assessment score ≥11, disabling migraine for ≥1 year). Eligible patients were randomized (7:3:7:6) to placebo or lasmiditan 50, 100, 200 mg. This prespecified analysis described CVDs, CVRFs, and cardiovascular treatment-emergent adverse events (TEAEs). Efficacy (proportion pain-free, experienced pain relief, most bothersome symptom-free, or disability-free 2 hours post-dose) was evaluated within CVRF subgroups (≤1, ≥2).

RESULTS

Of 846 randomized patients, 691 were analyzed (CVRF≤1: 375; CVRF≥2: 316). The proportion of lasmiditan-treated patients with ≥1 TEAE was not related to CVRF numbers. Eighteen (3.8%) lasmiditan-treated and three (1.4%) placebo-treated patients reported likely cardiovascular TEAEs. Lasmiditan was more effective than placebo at relieving pain, symptoms, and disability in both CVRF subgroups. There was no consistent relationship between CVRF subgroups and efficacy.

CONCLUSIONS

Lasmiditan was well tolerated and effective in Japanese patients with migraine and CVRFs.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03962738.

Practice guidelines for the treatment of acute migraine and chronic knee osteoarthritis with paracetamol: an expert appraisal on evolution over time between scientific societies

BACKGROUND

Paracetamol is the commonest analgesic worldwide in primary care. Despite evidence-based recommendations for management of acute and chronic pain with paracetamol, practices seem to vary considerably in its modalities of use, with or without restrictions, between renowned scientific societies and over time.

OBJECTIVE

Qualitative assessment of similarities, differences, and changes over time in guidelines for paracetamol use in acute and chronic pain.

METHODS

We focused on two common pain conditions for which paracetamol is widely used: acute migraine and chronic knee osteoarthritis (OA). In 19 guidelines (10 for acute migraine, 9 for chronic knee OA) from 10 scientific societies (AAN/AHS, ACR/AF, CHS, EFNS, EHF/LTB, ESCEO, EULAR, SFEMC, SRF, OARSI) published between 1997 and 2021, methods, results and conclusions were compared, between guidelines and over time.

RESULTS

In acute migraine, there was a shift from no recommendation for paracetamol or recommendation only for mild attacks to recommendation for mild to moderate attacks in updated guidelines, without restriction for use for four of the five scientific societies. In knee OA, although updated guidelines generally used the GRADE system, recommendations remained heterogeneous between scientific societies: recommendation without or with restrictions, or not recommended. Consensus is lacking regarding long-course safety and efficacy in acute pain and pain at mobilization.

CONCLUSIONS

Most migraine guidelines now recommend paracetamol for mild to moderate pain. Knee OA guidelines vary on the use of paracetamol: a more holistic approach is needed for this condition, considering patient profile, disease stage, and pain management during physical activity to clarify its appropriate use.

Consensus of the Brazilian Headache Society (SBCe) for the Prophylactic Treatment of Episodic Migraine: part I

The Brazilian Headache Society (Sociedade Brasileira de Cefaleia, SBCe, in Portuguese) nominated a Committee of Authors with the aim of establishing a consensus with recommendations regarding prophylactic treatment for episodic migraine based on articles published in the worldwide literature, as well as personal experience. Migraine affects 1 billion people around the world and more than 30 million Brazilians. In addition, it is an underdiagnosed and undertreated disorder. It is well known within the medical community of neurologists, and especially among headache specialists, that there is a need to disseminate knowledge about prophylactic treatment for migraine. For this purpose, together with the need for drug updates and to expand knowledge of the disease itself (frequency, intensity, duration, impact and perhaps the progression of migraine), this Consensus was developed, following a full online methodology, by 12 groups who reviewed and wrote about the pharmacological categories of the drugs used and, at the end of the process, met to read and establish conclusions for this document. The drug classes studied were: anticonvulsants, tricyclic antidepressants, monoclonal anti-calcitonin gene-related peptide (anti-CGRP) antibodies, beta-blockers, antihypertensives, calcium channel inhibitors, other antidepressants (selective serotonin reuptake inhibitors, SSRIs, and dual-action antidepressants), other drugs, and polytherapy. Hormonal treatment and anti-inflammatories and triptans in minimum prophylaxis schemes (miniprophylaxis) will be covered in a specific chapter. The drug classes studied for part I of the Consensus were: anticonvulsants, tricyclic antidepressants, monoclonal anti-CGRP antibodies, and beta-blockers.

Headache at the chronic stage of cerebral venous thrombosis

BACKGROUND

Headache is the most frequent symptom of cerebral venous thrombosis (CVT) but there is limited information about the frequency and phenotype of headache, weeks to months after cerebral venous thrombosis (post-cerebral venous thrombosis headache, post cerebral venous thrombosis headache).

OBJECTIVE

To assess the frequency, characteristics and predictors of PCH.

METHODS

In this cross-sectional study, the frequency and characteristics of PCH were assessed in cerebral venous thrombosis survivors. Patients were interviewed between six months and five years after the cerebral venous thrombosis diagnosis. Clinical and imaging characteristics at the time of cerebral venous thrombosis diagnosis, as well as history of headache prior to cerebral venous thrombosis were compared in subjects with (Group_PCH) and without PCH (Group_control).

RESULTS

Subjects (n = 100; 82% women) were assessed, on average, at 1.1 ± 1.6 years of follow-up. PCH was present in 59% of the patients, phenotypes of tension-type-like headache were present in 31/59 (52.6%) and of migraine-like headache in 16/59 (27.1%). History of primary headache prior to cerebral venous thrombosis was significantly more common (OR: 6.4; 95% CI: 1.7-36.3) in Group_PCH (33.9%) than in Group_control (7.3%).

CONCLUSION

Post cerebral venous thrombosis headache was present in more than half of the patients. History of prior headache may be a risk factor for post cerebral venous thrombosis headache. Prospective studies are required to confirm these findings and determine mechanisms, as well as interventions for prevention and treatment of post cerebral venous thrombosis headache.

Greater occipital nerve block for chronic migraine patients: A meta-analysis

INTRODUCTION

Greater occipital nerve block (GONB) is a minimally invasive procedure frequently used in patients with chronic migraine (CM); however, the quality of the evidence supporting its use is still unknown. Therefore, we aimed to conduct a systematic review, meta-analysis and quality assessment of GONB local anaesthetics combined or not with corticosteroids to prevent CM.

METHODS

We searched Medline, Scopus and Web of Science up to October 2020. We included randomized control trials (RCT) and observational studies assessing GONB without language restrictions. Two researchers selected the studies, extracted the data and evaluated the risk of bias independently. The primary outcomes measured to assess efficacy were the change from baseline in the intensity and frequency of headache in the intervention group compared to placebo at a onetime point. We performed a meta-analysis with random effect models, and we evaluated random errors with trial sequential analysis (TSA). We assessed the risk of bias (ROB) with the ROB2 tool and the certainty of the evidence with GRADE.

RESULTS

We identified 2864 studies in the databases and included three RCTs for quantitative synthesis. Most ROB assessments were 'high risk' or 'some concerns'. GONB reduced the intensity of headaches at the end of the first month (MD: -1.35, 95% CI: -2.12 to -0.59) and the second month (MD: -2.10, CI 95%: -2.94 to -1.26) as well as the frequency of headaches (first month: MD: -4.45 days, 95% CI: -6.56 to -2.34 days; second month: MD: -5.49, 95% CI -8.94 to -2.03 days). Corticosteroids did not show a significant decrease in the frequency of headaches during the first month of treatment (MD: -1.1 days, 95% CI: -4.1 to 1.8, p = .45). Included trials reported similar adverse events between groups. The exploratory TSA showed inconclusive results. Overall, the quality of the evidence was very low because of the substantial risk of bias and imprecision.

CONCLUSION

The limited evidence available shows that GONB with local anaesthetics could reduce headache frequency and intensity compared to placebo, while adding corticosteroids did not show additional benefits. GONB was safe with a similar number of minor adverse events. However, our confidence in these estimates is very low since the evidence is based on a few trials, with a small sample size and a significant risk of bias. In addition, the exploratory TSA was inconclusive, so we need larger and specific trials.

Burden of disease and lifestyle habits in adolescents and young adults prone to frequent episodic migraine: A secondary comparative analysis

The objective of this study was to assess the burden of disease and prevalence of lifestyle factors for adolescents and young adults with frequent episodic migraine. We conducted a secondary comparative analysis of data collected during two previous studies. Inclusion criteria for this analysis were age 15-35 years, 15 to 44 migraine episodes within 12 weeks, and completeness of Migraine Disability Assessment and lifestyle questionnaire data. Datasets of 37 adults (median age [interquartile range]: 25 [6]) and 27 adolescents (median age [interquartile range]: 15 [1]) were analyzed. 81% (n = 30) of adults reported severe disability (16% [n = 3] of adolescents; p < 0.001). Headache frequency (24 vs. 17 days; p = 0.005) and prevalence of regular analgesic use (60% [n = 22] vs. 18% [n = 5]; p = 0.002) were significantly higher in adults. In adults, sleep duration on weekdays was significantly lower (8.5 vs. 10 h; p < 0.001). Any consumption of caffeine tended to be higher in adolescents and alcohol consumption tended to be higher in adults (p > 0.05). This study underlines the importance of educating adolescents and young adults with migraine about lifestyle habits that are likely to interfere with the condition.

A study on the correlation between pain frequency and severity and vitamin B12 levels in episodic and chronic migraine

BACKGROUND

It is believed that vitamin B12 deficiency and hyperhomocysteinemia cause endothelial cell damage by increasing the levels of free oxygen radicals, which may, in turn, be related to the onset of migraine episodes.

OBJECTIVE

The objective of our study was to ascertain a correlation between vitamin B12 levels and migraine attack frequency and pain severity.

METHODS

127 patients with migraine and 45 healthy controls who presented to Okmeydanı Training and Research Hospital were included in the study. The migraine attack frequency and the duration and severity of pain in migraineurs were recorded. Pain severity was evaluated using a visual analogue scale (VAS). Vitamin B12 levels below 300 ng/L were considered low.

RESULTS

The vitamin B12 levels in migraineurs were found to be significantly lower than those in the control group (227.30 ± 104.72 ng/L vs 278.44 ± 149.83 ng/L; p = 0.047). The vitamin B12 levels of patients with chronic migraine (CM) were found to be lower than those in patients with less frequent migraine attacks (197.50 ± 69.16 ng/L vs 278.56 ± 147.91 ng/L; p = 0.019). The ratio of vitamin B12 levels of 300 ng/L and above in patients with CM was lower than that of patients with episodic migraine (p < 0.05).

CONCLUSIONS

Along with attack frequency and pain severity assessment, it is important that migraine follow-ups should include regular measurement of vitamin B12 levels. We found lower vitamin B12 values in the CM group.

Oxygen Therapy in Cluster Headache, Migraine, and Other Headache Disorders

Oxygen therapy (OT) can relieve head pain in certain primary headache disorders, including cluster headache (CH). The exact underlying mechanism is currently uncertain, but suggested mechanisms include inhibition of the trigeminoautonomic reflex, modulation of neurotransmitters, and cerebral vasoconstriction. OT is the standard for acute treatment of CH, but patients with CH often experience considerable difficulties accessing home OT due to problems with insurance coverage. Inhalation of 100% oxygen at 6–12 L/min for 15–30 min using a non-rebreather face mask is one of the most effective acute therapies for CH, but several trials have indicated the superiority of higher oxygen flow rates of up to 15 L/min and/or using a demand-valve oxygen mask that can produce very high flow rates. Two randomized controlled trials have demonstrated the efficacy of OT in migraine, but obtaining reliable evidence is considered difficult because of different inhalation protocols, varying outcome measures, and small samples. There are some reports on the efficacy of OT as an adjuvant therapy in hypnic headache, primary headache in the emergency department, and even postdural puncture headache. The goal of this review article is to expand the knowledge regarding the use of oxygen in the treatment of headache disorders.

Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage in Young Patients With a History of Migraine

BACKGROUND

Young patients with aneurysmal subarachnoid hemorrhage (aSAH) and a history of migraine may have an increased risk of delayed cerebral ischemia. We investigated this potential association in a prospective cohort of aSAH patients under 50 years of age.

METHODS

In our prospective cohort study, we included patients with aSAH under 50 years of age from 3 hospitals in the Netherlands. We assessed lifetime migraine history with a short screener. Delayed cerebral ischemia was defined as neurological deterioration lasting >1 hour not attributable to other causes by diagnostic workup. Adjustments were made for possible confounders in multivariable Cox regression analyses, and adjusted hazard ratios were calculated.

RESULTS

We included 236 young aSAH patients (mean age, 41 years; 64% women) of whom 44 (19%) had a history of migraine (16 with aura). Patients with aSAH and a history of migraine were not at increased risk of developing delayed cerebral ischemia compared with patients without migraine (25% versus 20%; adjusted hazard ratio, 1.16 [95% CI, 0.57-2.35]). Additionally, no increased risk was found in migraine patients with aura (adjusted hazard ratio, 0.85 [95% CI, 0.30-2.44]) or in women (adjusted hazard ratio, 1.24 [95% CI, 0.58-2.68]).

CONCLUSIONS

Patients with aSAH under the age of 50 years with a history of migraine are not at increased risk of delayed cerebral ischemia.

Headache and rhinitis: pattern search on Google Trends for 17 years

OBJECTIVE

Headache and rhinitis are highly prevalent and comorbid. The objective of the present study is to analyze the correlation of headache and rhinitis, in addition to the temporal pattern of these diseases in 17 years, using the Google Trends platform.

METHODS

Google Trends was searched from January 2004 to June 2021, using the entry: ["rinite" (rhinitis) + "dor de cabeça" (headache)" + "Alzheimer" + "enxaqueca" (migraine)]. Migraine, primary headache, and Alzheimer's, with no clear relation with headache, were used as controls. After the descriptive analysis by dispersion diagrams, Pearson's test and a simple regression model were performed. Subsequently, this study analyzed the seasonality of the volume of research on rhinitis and headache.

RESULTS

A strong correlation between rhinitis and headache (0.86) was found in the time interval analyzed. In addition, a seasonality was identified in the volume of searches for the term rhinitis with increased volume in the fall and peaks in the month of May, with a decrease in the spring and early summer. Moreover, an increase of searches on headache was observed, suggesting worse burden of this pathology.

CONCLUSION

Headaches and rhinitis were correlated in 17 years of research on the Google Trends platform. Circannual variation of both conditions was observed. Additional studies with digital research may be useful to better understand the epidemiology and comorbidities of headache.

Why are CGRP monoclonal antibodies not yet the first line treatment in migraine prevention?

Migraine is a prevalent disorder and a cause of high disability, influenced by modifiable and non-modifiable risk factors. Comorbid and psychiatric illnesses are prevalent in migraine patients and should be considered when choosing preventive drugs. There have been unforeseen problems with the use of preventive treatment of migraine with oral drugs, mainly due to side-effects that cannot be tolerated and lack of efficacy, leading to high discontinuation rates. Anti-CGRP monoclonal antibodies (mAbs) have shown better tolerance profiles, based on the low dropout rates in clinical trials due to adverse events. First-line therapy is a term most expressed in some medical specialties that adopt standardized protocol treatments and may not be suitable for treating migraine. Regarding efficacy, mAbs don't seem to perform much better than the current prophylactic oral drugs in reduction of monthly migraine days compared to placebo. Monoclonal antibodies against CGRP pathway have been prescribed recently, which raises some concern about their safety in the long term. Only side effects observation will confirm whether CGRP blockade causes susceptibility to severe side-effects, at least to specific subpopulations. CGRP may play a role in regulating uteroplacental blood flow and myometrial and uterine relaxation, as well as blood pressure control, raising the suspicion that its blockade could cause complications during pregnancy. Recent guidelines retain the recommendation of starting preventive treatment of migraine with oral drugs. Both the fact that it is new and costs are the reason why guidelines recommend the prescription of mAbs only after failure of at least two oral drugs.

It is time anti-CGRP monoclonal antibodies be considered first-line prophylaxis for migraine

The result of more than thirty years of research, anti-CGRP monoclonal antibodies are currently the state of the art for migraine preventive therapy. Their efficacy and safety, supported by an already large and growing body of evidence, are added by many other advantages: an early onset of action, favorable posology, negligible pharmacological interaction, and a broad-reaching efficacy in many challenging clinical contexts. When compared to standard prophylactics, these novel medications seem at least as efficacious, clearly more tolerable and, consequently, with a superior adherence profile. Furthermore, recently published analyses indicate that they are cost-effective, especially among those with chronic migraine. Yet, current guidelines endorse their use only after multiple other preventives have failed or have been deemed not tolerable. Although this recommendation may have been sensible at first, the now available data strongly point that time has come for anti-CGRP monoclonal antibodies to be acknowledged as first-line treatments for migraine patients with severe disability. For these individuals, delaying treatment until several other alternatives have failed incurs in significant losses, both economically and to many relevant aspects of their lives.

Vestibular migraine

Vestibular migraine (VM) remains an underdiagnosed condition, often mistaken with brainstem aura. VM is defined by recurrent vestibular symptoms in at least 50% of migraine attacks. Diagnosis is established by clinical criteria based on the International Classification of Headache Disorders (ICHD-3). Estimated prevalence of VM is 1 to 2.7% of the adult population. Vestibular symptoms usually appear after the headache. VM pathophysiology remains poorly understood. Vertigo may occur before, during, after the migraine attack, or even independently, and may last seconds to hours or days. Pathophysiological mechanisms for VM are still poorly understood and are usually extrapolated from migraines. Differential diagnoses include Ménière's disease, benign paroxysmal positional vertigo, brainstem aura, transient ischemic attack, persistent perceptual postural vertigo, and episodic type 2 ataxia. Specific treatment recommendations for vestibular migraine are still scarce.

Histomorphometry of mast cells in the convexity of human intracranial dura mater

Mast cells, known as pro-inflammatory effector cells, are immunocytes present in the meninges and may be involved in the pathophysiology of migraine. This study aims to evaluate the histomorphometric parameters of mast cells located in the convexity of the human intracranial dura mater. For this, samples of intracranial dura mater from eight human fresh cadavers were collected between 8- and 24-h post-mortem. The whole samples were fixed and, subsequently, two fragments of 1.5 cm² each were cut from four different areas of the dura mater convexity, containing a segment of the middle meningeal artery, totaling 64 fragments. After histological processing, the fragments were submitted to microtomy (5 and 10 µm), stained with toluidine blue (0.1%), or immunohistochemically labeled for tryptase, and analyzed using optical microscopy. The following histomorphometric parameters were evaluated: distance from mast cells to vessels, the density of mast cells, and percentage of mast cells with degranulation. Histomorphometric analyzes showed a higher density of mast cells in the vicinity of blood vessels (arterial and venous), with distances around 0-150 µm. A greater number of mast cells was detected near venous vessels in the periosteal layer (17.0 ± 10.1 cells/mm²) than in the meningeal layer (14.1 ± 7.0 cells/mm²) (p < 0.05). Mast cells from the region close to the superior sagittal sinus were found in greater quantity close to the venous vessels (16.7 ± 10.1 cells/mm²) than to the arterial vessels (11.2 ± 7.5 cells/mm²) (p < 0.05). In short, in the convexity of the human intracranial dura mater, mast cells are located close to blood vessels, with a greater number of cells next to the venous vessels of the periosteal layer and in the proximal region of the superior sagittal sinus.

Propofol + Granisetron vs. Propofol + Metoclopramide in Symptom Management of Acute Migraine Headache; a Double-Blind Randomized Clinical Trial

Introduction

Acute headache is one of the most common reasons for emergency department (ED) visits. This study aimed to compare the combination of propofol and granisetron with propofol and metoclopramide in symptom management of acute migraine headache.

Methods

In this double-blind randomized clinical trial, 60 adult patients with acute migraine headache who referred to ED were randomly divided into two groups of propofol + metoclopramide and propofol + granisetron. Pain and nausea/vomiting severity as well as blood pressure were compared between groups 30, 45, and 60 minutes after treatment.

Results

The two groups had similar situation regarding mean age (p = 0.606), sex distribution (p = 0.793), baseline severity of pain (p = 0.642), frequency of nausea/vomiting (p = 0.488), and vital signs (p > 0.05). The severity of pain was similar in the two groups 30 (p = 0.731), 45 (p = 0.460), and 60 (p = 0.712) minutes after treatment. The number of patients with resistant nausea and vomiting 60 minutes after treatment was significantly higher in metoclopramide group (30.0% versus 10.0%; p = 0.033). Diastolic pressure 60 minutes after treatment (81.43 ±8.94 vs. 74.97 ± 4.8; p = 0.001) and heart rate 30 minutes after treatment (68.87 ±6.52 vs. 73.57± 7.62; p = 0.013) had statistically significant differences between the groups.

Conclusion

The combination of propofol and granisetron was superior to propofol and metoclopramide in case of controlling nausea and vomiting of cases with acute migraine headache; meanwhile, no differences were observed in case of pain relief and hemodynamic status between the two groups.

Brain networks in migraine with and without aura: An exploratory arterial spin labeling MRI study

OBJECTIVES

The aim of this exploratory study was to investigate the underlying pathomechanisms of migraine with aura (MA) and migraine without aura (MO) in the interictal phase using a connectivity analysis.

METHODS

We prospectively enrolled patients who were newly diagnosed with migraine. All patients underwent brain MRI, including diffusion tensor imaging and arterial spin labeling perfusion MRI. We analyzed the differences between patients with MA and those with MO in structural connectivity based on diffusion tensor imaging and functional connectivity based on arterial spin labeling perfusion MRI using a graph theoretical analysis.

RESULTS

We enrolled 58 patients with migraine (11 patients with MA and 47 patients with MO). There were no differences between patients with MA and those with MO in the network measures of global structural connectivity. However, differences in global functional connectivity were found between the two groups. The assortative coefficient was lower in patients with MA than in those with MO (-0.050 vs. -0.012, p = .017). There were no differences in local structural and functional connectivity between patients with MA and those with MO.

CONCLUSION

We found differences in global functional connectivity between patients with MO and those with MA. The study of MA and MO using a connectivity analysis may shed light on migraine pathophysiology. We suggest it is worthwhile to investigate if changes in functional connectivity may serve as novel biomarkers in MA. In this regard, ASL MRI appears to be valuable in the context of network analysis, but further studies are needed to confirm our findings.

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

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

History Taking in Non-Acute Vestibular Symptoms: A 4-Step Approach

History taking is crucial in the diagnostic process for vestibular disorders. To facilitate the process, systems such as TiTrATE, SO STONED, and DISCOHAT have been used to describe the different paradigms; together, they address the most important aspects of history taking, viz. time course, triggers, and accompanying symptoms. However, multiple (vestibular) disorders may co-occur in the same patient. This complicates history taking, since the time course, triggers, and accompanying symptoms can vary, depending on the disorder. History taking can, therefore, be improved by addressing the important aspects of each co-occurring vestibular disorder separately. The aim of this document is to describe a 4-step approach for improving history taking in patients with non-acute vestibular symptoms, by guiding the clinician and the patient through the history taking process. It involves a systematic approach that explicitly identifies all co-occurring vestibular disorders in the same patient, and which addresses each of these vestibular disorders separately. The four steps are: (1) describing any attack(s) of vertigo and/or dizziness; (2) describing any chronic vestibular symptoms; (3) screening for functional, psychological, and psychiatric co-morbidity; (4) establishing a comprehensive diagnosis, including all possible co-occurring (vestibular) disorders. In addition, pearls and pitfalls will be discussed separately for each step.

Effects of Curcumin Supplementation on Clinical Features and Inflammation, in Migraine Patients: A Double-Blind Controlled, Placebo Randomized Clinical Trial

BACKGROUND

Migraine is a prevalent health condition associated with significant pain and disability. Neurogenic inflammation has a key role in migraine pathophysiology. Curcumin is a well-known herb compound with anti-inflammatory function. This study was aimed to evaluate the effects of curcumin supplementation on clinical features, as well as on serum levels of calcitonine gene-related peptide (CGRP) and interleukin-6 (IL-6).

METHODS

This randomized double-blind placebo-controlled clinical trial was carried out on 44 women with migraine, receiving either 500 mg curcumin twice a day or placebo supplements for 8 weeks. Serum CGRP and IL-6 concentration, and clinical symptoms including headache severity, duration and frequency were measured at the baseline and end of study.

RESULTS

After 8-week intervention, compared with placebo, curcumin supplementation led to significand reduction in CGRP (P < 0.001), IL-6 (P = 0.041), severity (P = 0.001), and duration of headache (P = 0.007). Headache frequency showed marginal improvement in curcumin group, compared to controls (P = 0.052). Within-analysis indicated significant decrease in CGRP and severity (P < 0.001), frequency (P = 0.014) and duration (P = 0.003) and no significant decrease in IL-6 (P = 0.454), compared to baseline in curcumin group. There were no significant changes in body mass index (BMI), weight, percent body fat (PBF), and percent body muscle (PBM) between the two groups.

CONCLUSIONS

Curcumin supplementation improved the pro-inflammatory markers and clinical features of migraine headaches and that could be contributed to could be to its anti-inflammatory properties.

Migraine With Aura Is Related to Delayed Motor Control Reaction and Imbalance Following External Perturbations

Background: It is evidenced that migraineurs present balance deficits. However, the balance recovery following unexpected ground perturbations, which reflect conditions of everyday activities, has not been investigated in this population. Aim: We aimed to assess the reactive postural responses among patients with migraine with and without aura, chronic migraine, and controls. We further aimed to assess the factors associated with greater self-report of falls. Methods: Ninety patients diagnosed by headache specialists were equally classified into three migraine subgroups according to the presence of aura and chronic migraine. Thirty controls were also recruited. All participants underwent the motor control test (MCT) and adaptation test (ADT) protocols of dynamic posturography tests (EquiTest®, NeuroCom, USA). Clinical and headache features and information on falls in the previous year, fear of falling, and vestibular symptoms were also assessed. Results: Patients with aura presented a greater sway area in most of the MCT conditions than the other three groups (p = 0.001). The aura group also presented delayed latency responses after perturbations compared with controls and patients without aura (p < 0.03). In the ADT, a greater sway area was observed in patients with aura than in groups without aura, chronic migraine, and controls (p < 0.0001). The MCT and ADT sway area, the frequency of aura, and the fear of falling explained 46% of the falls in the previous 12 months. Conclusion: Patients with aura exhibited greater delay and sway area after unexpected ground perturbations than controls and other migraine subgroups, which are related to the reported number of falls.