Erik Greb

PHILADELPHIA – Posttraumatic headache may be associated with quantitative changes in photosensitivity and allodynia, according to results of a pilot study presented at the annual meeting of the American Headache Society. The findings suggest that patients with posttraumatic headache have abnormal, multimodal sensory processing, said Amaal J. Starling, MD, a neurologist at Mayo Clinic in Phoenix.

Mild traumatic brain injury (TBI) is a growing public health problem. Headache is the most common symptom after mild TBI, and often the most debilitating symptom for these patients. No Food and Drug Administration–approved treatments are available for patients with posttraumatic headache, and about three-quarters of these patients report that current treatments bring them no relief.

Identifying novel targets and developing new treatment options will require a deeper understanding of the pathophysiology of posttraumatic headache, said Dr. Starling. She and her colleagues conducted a pilot study to characterize allodynia, cutaneous heat pain thresholds, photophobia, and light-induced pain thresholds objectively in patients with posttraumatic headache, compared with healthy controls.
 

Participants were exposed to a bright-light stressor

The researchers enrolled 20 patients between ages 18 years and 65 years with posttraumatic headache attributed to mild TBI in their study. They matched these patients by age with 20 healthy controls. Dr. Starling and colleagues evaluated all participants prospectively using the Allodynia Symptom Checklist (ASC-12), Photosensitivity Assessment Questionnaire (PAQ), State-Trait Anxiety Inventory (STAI), and Beck Depression Inventory (BDI).

The investigators performed quantitative sensory testing to measure each participant’s cutaneous forearm heat pain threshold. Using a progressive light stimulation device, they quantified each participant’s light-induced pain threshold. Finally, Dr. Starling and colleagues obtained participants’ cutaneous heat pain thresholds immediately after, 10 minutes after, and 40 minutes after exposing them to a bright-light stressor.

The researchers found no significant differences between groups in age, gender, or race. The population’s average age was 41 years. Approximately 70% of the sample was female. Among participants with posttraumatic headache, the average time since the onset of posttraumatic headache was 46 months. The average number of headache days per month in that group was 17.2, which represented “a significantly high headache burden,” said Dr. Starling. Approximately 80% of patients with posttraumatic headache had headaches with a migraine phenotype.
 

Patients’ pain thresholds were lower

STAI and BDI scores were significantly higher among patients with posttraumatic headache, compared with controls. Mean PAQ score was 0.62 among patients and 0.24 among controls, representing significantly greater photophobia symptom severity among patients, said Dr. Starling.

Light-induced pain thresholds were significantly lower in patients with posttraumatic headache (median, 90.5 lux), compared with healthy controls (median, 863.5 lux), independent of depression and anxiety. Allodynia symptom severity was significantly higher in patients with posttraumatic headache (mean ASC-12 score, 5.7), compared with controls (mean ASC-12 score, 0.98).

In addition, the mean baseline cutaneous heat pain threshold was 40.8° C in patients with posttraumatic headache and 44.4° C in healthy controls. When participants were subjected to the bright-light stressor, the immediate change in heat pain threshold was significant in patients with posttraumatic headache (−1.9° C), compared with healthy controls. The difference between groups was not significant at 10 and 40 minutes after exposure to the stressor, however. The light intensity inducing moderate pain was 688 lux in patients with posttraumatic headache, compared with 6,000 lux in healthy controls.

“Our next steps are going to be replicating this [study] in a larger population, as well as determining whether any type of intervention would change these different types of sensory sensitivities and thresholds,” said Dr. Starling. She and her colleagues will use this human research model to examine whether posttraumatic headache differs from other headache disorders such as migraine and to examine potential differences between acute and persistent posttraumatic headache.

The study was funded through an intramural Mayo Clinic early career research award.

[email protected]

SOURCE: Starling AJ et al. AHS 2019. Abstract OR14.

PHILADELPHIA – Posttraumatic headache may be associated with quantitative changes in photosensitivity and allodynia, according to results of a pilot study presented at the annual meeting of the American Headache Society. The findings suggest that patients with posttraumatic headache have abnormal, multimodal sensory processing, said Amaal J. Starling, MD, a neurologist at Mayo Clinic in Phoenix.

Mild traumatic brain injury (TBI) is a growing public health problem. Headache is the most common symptom after mild TBI, and often the most debilitating symptom for these patients. No Food and Drug Administration–approved treatments are available for patients with posttraumatic headache, and about three-quarters of these patients report that current treatments bring them no relief.

Identifying novel targets and developing new treatment options will require a deeper understanding of the pathophysiology of posttraumatic headache, said Dr. Starling. She and her colleagues conducted a pilot study to characterize allodynia, cutaneous heat pain thresholds, photophobia, and light-induced pain thresholds objectively in patients with posttraumatic headache, compared with healthy controls.
 

Participants were exposed to a bright-light stressor

The researchers enrolled 20 patients between ages 18 years and 65 years with posttraumatic headache attributed to mild TBI in their study. They matched these patients by age with 20 healthy controls. Dr. Starling and colleagues evaluated all participants prospectively using the Allodynia Symptom Checklist (ASC-12), Photosensitivity Assessment Questionnaire (PAQ), State-Trait Anxiety Inventory (STAI), and Beck Depression Inventory (BDI).

The investigators performed quantitative sensory testing to measure each participant’s cutaneous forearm heat pain threshold. Using a progressive light stimulation device, they quantified each participant’s light-induced pain threshold. Finally, Dr. Starling and colleagues obtained participants’ cutaneous heat pain thresholds immediately after, 10 minutes after, and 40 minutes after exposing them to a bright-light stressor.

The researchers found no significant differences between groups in age, gender, or race. The population’s average age was 41 years. Approximately 70% of the sample was female. Among participants with posttraumatic headache, the average time since the onset of posttraumatic headache was 46 months. The average number of headache days per month in that group was 17.2, which represented “a significantly high headache burden,” said Dr. Starling. Approximately 80% of patients with posttraumatic headache had headaches with a migraine phenotype.
 

Patients’ pain thresholds were lower

STAI and BDI scores were significantly higher among patients with posttraumatic headache, compared with controls. Mean PAQ score was 0.62 among patients and 0.24 among controls, representing significantly greater photophobia symptom severity among patients, said Dr. Starling.

Light-induced pain thresholds were significantly lower in patients with posttraumatic headache (median, 90.5 lux), compared with healthy controls (median, 863.5 lux), independent of depression and anxiety. Allodynia symptom severity was significantly higher in patients with posttraumatic headache (mean ASC-12 score, 5.7), compared with controls (mean ASC-12 score, 0.98).

In addition, the mean baseline cutaneous heat pain threshold was 40.8° C in patients with posttraumatic headache and 44.4° C in healthy controls. When participants were subjected to the bright-light stressor, the immediate change in heat pain threshold was significant in patients with posttraumatic headache (−1.9° C), compared with healthy controls. The difference between groups was not significant at 10 and 40 minutes after exposure to the stressor, however. The light intensity inducing moderate pain was 688 lux in patients with posttraumatic headache, compared with 6,000 lux in healthy controls.

“Our next steps are going to be replicating this [study] in a larger population, as well as determining whether any type of intervention would change these different types of sensory sensitivities and thresholds,” said Dr. Starling. She and her colleagues will use this human research model to examine whether posttraumatic headache differs from other headache disorders such as migraine and to examine potential differences between acute and persistent posttraumatic headache.

The study was funded through an intramural Mayo Clinic early career research award.

[email protected]

SOURCE: Starling AJ et al. AHS 2019. Abstract OR14.

PHILADELPHIA – Posttraumatic headache may be associated with quantitative changes in photosensitivity and allodynia, according to results of a pilot study presented at the annual meeting of the American Headache Society. The findings suggest that patients with posttraumatic headache have abnormal, multimodal sensory processing, said Amaal J. Starling, MD, a neurologist at Mayo Clinic in Phoenix.

Mild traumatic brain injury (TBI) is a growing public health problem. Headache is the most common symptom after mild TBI, and often the most debilitating symptom for these patients. No Food and Drug Administration–approved treatments are available for patients with posttraumatic headache, and about three-quarters of these patients report that current treatments bring them no relief.

Identifying novel targets and developing new treatment options will require a deeper understanding of the pathophysiology of posttraumatic headache, said Dr. Starling. She and her colleagues conducted a pilot study to characterize allodynia, cutaneous heat pain thresholds, photophobia, and light-induced pain thresholds objectively in patients with posttraumatic headache, compared with healthy controls.
 

Participants were exposed to a bright-light stressor

The researchers enrolled 20 patients between ages 18 years and 65 years with posttraumatic headache attributed to mild TBI in their study. They matched these patients by age with 20 healthy controls. Dr. Starling and colleagues evaluated all participants prospectively using the Allodynia Symptom Checklist (ASC-12), Photosensitivity Assessment Questionnaire (PAQ), State-Trait Anxiety Inventory (STAI), and Beck Depression Inventory (BDI).

The investigators performed quantitative sensory testing to measure each participant’s cutaneous forearm heat pain threshold. Using a progressive light stimulation device, they quantified each participant’s light-induced pain threshold. Finally, Dr. Starling and colleagues obtained participants’ cutaneous heat pain thresholds immediately after, 10 minutes after, and 40 minutes after exposing them to a bright-light stressor.

The researchers found no significant differences between groups in age, gender, or race. The population’s average age was 41 years. Approximately 70% of the sample was female. Among participants with posttraumatic headache, the average time since the onset of posttraumatic headache was 46 months. The average number of headache days per month in that group was 17.2, which represented “a significantly high headache burden,” said Dr. Starling. Approximately 80% of patients with posttraumatic headache had headaches with a migraine phenotype.
 

Patients’ pain thresholds were lower

STAI and BDI scores were significantly higher among patients with posttraumatic headache, compared with controls. Mean PAQ score was 0.62 among patients and 0.24 among controls, representing significantly greater photophobia symptom severity among patients, said Dr. Starling.

Light-induced pain thresholds were significantly lower in patients with posttraumatic headache (median, 90.5 lux), compared with healthy controls (median, 863.5 lux), independent of depression and anxiety. Allodynia symptom severity was significantly higher in patients with posttraumatic headache (mean ASC-12 score, 5.7), compared with controls (mean ASC-12 score, 0.98).

In addition, the mean baseline cutaneous heat pain threshold was 40.8° C in patients with posttraumatic headache and 44.4° C in healthy controls. When participants were subjected to the bright-light stressor, the immediate change in heat pain threshold was significant in patients with posttraumatic headache (−1.9° C), compared with healthy controls. The difference between groups was not significant at 10 and 40 minutes after exposure to the stressor, however. The light intensity inducing moderate pain was 688 lux in patients with posttraumatic headache, compared with 6,000 lux in healthy controls.

“Our next steps are going to be replicating this [study] in a larger population, as well as determining whether any type of intervention would change these different types of sensory sensitivities and thresholds,” said Dr. Starling. She and her colleagues will use this human research model to examine whether posttraumatic headache differs from other headache disorders such as migraine and to examine potential differences between acute and persistent posttraumatic headache.

The study was funded through an intramural Mayo Clinic early career research award.

[email protected]

SOURCE: Starling AJ et al. AHS 2019. Abstract OR14.

Philadelphia – The more exposure that a person without migraine has to people with the disorder, the more likely he or she is to have potentially stigmatizing attitudes toward migraine, according to an analysis presented at the annual meeting of the American Headache Society.

“We need to understand why this is true,” said Robert Shapiro, MD, PhD, professor of neurological sciences at the University of Vermont in Burlington. The finding also raises questions about which measures could successfully mitigate these stigmatizing attitudes.
 

An examination of data from OVERCOME

Stigma is a social process by which people are excluded from society because of particular traits that they have. The process encompasses stereotypes, prejudice, and discrimination. Data suggest that the level of stigma that people with migraine experience is similar to that experienced by people with epilepsy. Other data indicate that people without migraine are equally likely to hold stigmatizing attitudes toward people with migraine and people with epilepsy.

Dr. Shapiro and colleagues examined data from the Observational Survey of the Epidemiology, Treatment, and Care of Migraine (OVERCOME) study to better understand the attitudes that people without migraine have toward those who have the disorder. The data were gathered in fall 2018 through a web-based survey of a representative U.S. sample population. The researchers focused on a random sample of 2,000 people without migraine who responded to 11 questions about their attitudes toward patients with migraine. Responses described the frequency of holding attitudes and were scored on a 5-point Likert scale. The researchers categorized the responses “don’t know,” “never,” and “rarely” as “no” answers, and “sometimes,” “often,” and “very often” as “yes” answers. In addition, Dr. Shapiro and colleagues characterized each responder’s proximity to migraine according to the number of people with migraine that he or she knew (0, 1, or 2 or more) and the type of relationship (none, coworker, friend, or family member).
 

Sample was demographically representative

The demographic and socioeconomic characteristics of the study sample were similar to those of the most recent U.S. census data. The population’s mean age was 48, and 51% were female. Approximately 65% of respondents were non-Hispanic white, 14% were Hispanic, 11% were non-Hispanic black, 5% were Asian, and 5% were “other.” Approximately 45% of respondents reported that they had never known anyone with migraine. “Given the prevalence of migraine, it’s extraordinary that only 13% acknowledged that they had known two or more people with migraine,” said Dr. Shapiro. The finding raises questions about whether people with migraine have received adequate diagnoses and are aware of their disorder, he added. About 5% of the sample reported knowing only a coworker with migraine, and 37% reported knowing only one person with migraine.

About 31% of respondents thought that people with migraine use the disorder to avoid school or work commitments, and 33% thought that patients used migraine to avoid family or social commitments. Approximately 27% of respondents thought that people with migraine used it to get attention. About 45% of respondents thought that migraine should be treated easily, and 36% thought that people have migraine because of their own unhealthy behavior.

Individuals who knew people with migraine consistently held more negative attitudes toward those people, compared with those who did not know anyone with migraine. “These data are a little alarming,” said Dr. Shapiro. “They point to the difficulties that people with disabling migraine often encounter in having their experiences with the disease receive validation and understanding.”

Among the study’s strengths is the fact that it examined a large, population-based sample. The survey was conducted before many of the newer medications for migraine were available, and respondents were not likely to have been influenced by commercials that raised awareness of migraine, said Dr. Shapiro. The sample was not random, however, and the survey questions were based on the investigators’ interests, rather than on objective data. The generalizability of the results is in question, he added.

Dr. Shapiro consults for Eli Lilly, which sponsored the OVERCOME study.

[email protected]

SOURCE: Shapiro R et al. AHS 2019. Abstract OR15.

Philadelphia – The more exposure that a person without migraine has to people with the disorder, the more likely he or she is to have potentially stigmatizing attitudes toward migraine, according to an analysis presented at the annual meeting of the American Headache Society.

“We need to understand why this is true,” said Robert Shapiro, MD, PhD, professor of neurological sciences at the University of Vermont in Burlington. The finding also raises questions about which measures could successfully mitigate these stigmatizing attitudes.
 

An examination of data from OVERCOME

Stigma is a social process by which people are excluded from society because of particular traits that they have. The process encompasses stereotypes, prejudice, and discrimination. Data suggest that the level of stigma that people with migraine experience is similar to that experienced by people with epilepsy. Other data indicate that people without migraine are equally likely to hold stigmatizing attitudes toward people with migraine and people with epilepsy.

Dr. Shapiro and colleagues examined data from the Observational Survey of the Epidemiology, Treatment, and Care of Migraine (OVERCOME) study to better understand the attitudes that people without migraine have toward those who have the disorder. The data were gathered in fall 2018 through a web-based survey of a representative U.S. sample population. The researchers focused on a random sample of 2,000 people without migraine who responded to 11 questions about their attitudes toward patients with migraine. Responses described the frequency of holding attitudes and were scored on a 5-point Likert scale. The researchers categorized the responses “don’t know,” “never,” and “rarely” as “no” answers, and “sometimes,” “often,” and “very often” as “yes” answers. In addition, Dr. Shapiro and colleagues characterized each responder’s proximity to migraine according to the number of people with migraine that he or she knew (0, 1, or 2 or more) and the type of relationship (none, coworker, friend, or family member).
 

Sample was demographically representative

The demographic and socioeconomic characteristics of the study sample were similar to those of the most recent U.S. census data. The population’s mean age was 48, and 51% were female. Approximately 65% of respondents were non-Hispanic white, 14% were Hispanic, 11% were non-Hispanic black, 5% were Asian, and 5% were “other.” Approximately 45% of respondents reported that they had never known anyone with migraine. “Given the prevalence of migraine, it’s extraordinary that only 13% acknowledged that they had known two or more people with migraine,” said Dr. Shapiro. The finding raises questions about whether people with migraine have received adequate diagnoses and are aware of their disorder, he added. About 5% of the sample reported knowing only a coworker with migraine, and 37% reported knowing only one person with migraine.

About 31% of respondents thought that people with migraine use the disorder to avoid school or work commitments, and 33% thought that patients used migraine to avoid family or social commitments. Approximately 27% of respondents thought that people with migraine used it to get attention. About 45% of respondents thought that migraine should be treated easily, and 36% thought that people have migraine because of their own unhealthy behavior.

Individuals who knew people with migraine consistently held more negative attitudes toward those people, compared with those who did not know anyone with migraine. “These data are a little alarming,” said Dr. Shapiro. “They point to the difficulties that people with disabling migraine often encounter in having their experiences with the disease receive validation and understanding.”

Among the study’s strengths is the fact that it examined a large, population-based sample. The survey was conducted before many of the newer medications for migraine were available, and respondents were not likely to have been influenced by commercials that raised awareness of migraine, said Dr. Shapiro. The sample was not random, however, and the survey questions were based on the investigators’ interests, rather than on objective data. The generalizability of the results is in question, he added.

Dr. Shapiro consults for Eli Lilly, which sponsored the OVERCOME study.

[email protected]

SOURCE: Shapiro R et al. AHS 2019. Abstract OR15.

Philadelphia – The more exposure that a person without migraine has to people with the disorder, the more likely he or she is to have potentially stigmatizing attitudes toward migraine, according to an analysis presented at the annual meeting of the American Headache Society.

“We need to understand why this is true,” said Robert Shapiro, MD, PhD, professor of neurological sciences at the University of Vermont in Burlington. The finding also raises questions about which measures could successfully mitigate these stigmatizing attitudes.
 

An examination of data from OVERCOME

Stigma is a social process by which people are excluded from society because of particular traits that they have. The process encompasses stereotypes, prejudice, and discrimination. Data suggest that the level of stigma that people with migraine experience is similar to that experienced by people with epilepsy. Other data indicate that people without migraine are equally likely to hold stigmatizing attitudes toward people with migraine and people with epilepsy.

Dr. Shapiro and colleagues examined data from the Observational Survey of the Epidemiology, Treatment, and Care of Migraine (OVERCOME) study to better understand the attitudes that people without migraine have toward those who have the disorder. The data were gathered in fall 2018 through a web-based survey of a representative U.S. sample population. The researchers focused on a random sample of 2,000 people without migraine who responded to 11 questions about their attitudes toward patients with migraine. Responses described the frequency of holding attitudes and were scored on a 5-point Likert scale. The researchers categorized the responses “don’t know,” “never,” and “rarely” as “no” answers, and “sometimes,” “often,” and “very often” as “yes” answers. In addition, Dr. Shapiro and colleagues characterized each responder’s proximity to migraine according to the number of people with migraine that he or she knew (0, 1, or 2 or more) and the type of relationship (none, coworker, friend, or family member).
 

Sample was demographically representative

The demographic and socioeconomic characteristics of the study sample were similar to those of the most recent U.S. census data. The population’s mean age was 48, and 51% were female. Approximately 65% of respondents were non-Hispanic white, 14% were Hispanic, 11% were non-Hispanic black, 5% were Asian, and 5% were “other.” Approximately 45% of respondents reported that they had never known anyone with migraine. “Given the prevalence of migraine, it’s extraordinary that only 13% acknowledged that they had known two or more people with migraine,” said Dr. Shapiro. The finding raises questions about whether people with migraine have received adequate diagnoses and are aware of their disorder, he added. About 5% of the sample reported knowing only a coworker with migraine, and 37% reported knowing only one person with migraine.

About 31% of respondents thought that people with migraine use the disorder to avoid school or work commitments, and 33% thought that patients used migraine to avoid family or social commitments. Approximately 27% of respondents thought that people with migraine used it to get attention. About 45% of respondents thought that migraine should be treated easily, and 36% thought that people have migraine because of their own unhealthy behavior.

Individuals who knew people with migraine consistently held more negative attitudes toward those people, compared with those who did not know anyone with migraine. “These data are a little alarming,” said Dr. Shapiro. “They point to the difficulties that people with disabling migraine often encounter in having their experiences with the disease receive validation and understanding.”

Among the study’s strengths is the fact that it examined a large, population-based sample. The survey was conducted before many of the newer medications for migraine were available, and respondents were not likely to have been influenced by commercials that raised awareness of migraine, said Dr. Shapiro. The sample was not random, however, and the survey questions were based on the investigators’ interests, rather than on objective data. The generalizability of the results is in question, he added.

Dr. Shapiro consults for Eli Lilly, which sponsored the OVERCOME study.

[email protected]

SOURCE: Shapiro R et al. AHS 2019. Abstract OR15.

Among adolescents examined in the emergency department, exposure to synthetic cannabinoids is strongly associated with neuropsychiatric morbidity, according to data published online July 8 ahead of print in Pediatrics. The results support a distinct neuropsychiatric profile of acute synthetic cannabinoid toxicity in adolescents, wrote the investigators.

Synthetic cannabinoids have become popular and accessible and primarily are used for recreation. The adverse effects of synthetic cannabinoid toxicity reported in the literature include tachycardia, cardiac ischemia, acute kidney injury, agitation, first episode of psychosis, seizures, and death. Adolescents are the largest age group presenting to the emergency department with acute synthetic cannabinoid toxicity, and this population requires more intensive care than adults with the same presentation.
 

A multicenter registry analysis

To describe the neuropsychiatric presentation of adolescents to the emergency department after synthetic cannabinoid exposure, compared with that of cannabis exposure, Sarah Ann R. Anderson, MD, PhD, an adolescent medicine fellow at Columbia University Irving Medical Center in New York, and colleagues performed a multicenter registry analysis. They examined data collected from January 2010 through September 2018 from adolescent patients who presented to sites that participate in the Toxicology Investigators Consortium. For each patient, clinicians requested a consultation by a medical toxicologist to aid care. The exposures recorded in the case registry are reported by the patients or witnesses.

Eligible patients were between ages 13 and 19 years and presented to an emergency department with synthetic cannabinoid or cannabis exposure. Dr. Anderson and colleagues collected variables such as age, sex, reported exposures, death in hospital, location of toxicology encounter, and neuropsychiatric signs or symptoms. Patients whose exposure report came from a service outside of an emergency department and those with concomitant use of cannabis and synthetic cannabinoids were excluded. For the purpose of analysis, the investigators classified patients into the following four categories: exposure to synthetic cannabinoids alone, exposure to synthetic cannabinoids and other drugs, exposure to cannabis alone, and exposure to cannabis and other drugs.

Dr. Anderson and colleagues included 348 patients in their study. The sample included 107 patients in the synthetic cannabinoid–only group, 38 in the synthetic cannabinoid/polydrug group, 86 in the cannabis-only group, and 117 in the cannabis/polydrug group. Males predominated in all groups. The one death in the study occurred in the synthetic cannabinoid–only group.
 

Synthetic cannabinoid exposure increased risk for seizures

Compared with the cannabis-only group, the synthetic cannabinoid–only group had an increased risk of coma or CNS depression (odds ratio, 3.42) and seizures (OR, 3.89). The risk of agitation was significantly lower in the synthetic cannabinoid–only group, compared with the cannabis-only group (OR, 0.18). The two single-drug exposure groups did not differ in their associated risks of delirium or toxic psychosis, extrapyramidal signs, dystonia or rigidity, or hallucinations.

Exposure to synthetic cannabinoids plus other drugs was associated with increased risk of agitation (OR, 3.11) and seizures (OR, 4.8), compared with exposure to cannabis plus other drugs. Among patients exposed to synthetic cannabinoids plus other drugs, the most common class of other drug was sympathomimetics (such as synthetic cathinones, cocaine, and amphetamines). Sympathomimetics and ethanol were the two most common classes of drugs among patients exposed to cannabis plus other drugs.
 

Synthetic cannabinoids may have distinctive neuropsychiatric outcomes

“Findings from our study further confirm the previously described association between synthetic cannabinoid–specific overdose and severe neuropsychiatric outcomes,” wrote Dr. Anderson and colleagues. They underscore “the need for targeted public health messaging to adolescents about the dangers of using synthetic cannabinoids alone or combined with other substances.”

The investigators’ finding that patients exposed to synthetic cannabinoids alone had a lower risk of agitation than those exposed to cannabis alone is not consistent with contemporary literature on synthetic cannabinoid–associated agitation. This discordance may reflect differences in the populations studied, “with more severe toxicity prompting the emergency department presentations reported in this study,” wrote Dr. Anderson and colleagues. The current study also may be affected by selection bias, they added.

The researchers acknowledged several limitations of their study. For example, the registry lacked data for variables such as race or ethnicity, concurrent illness, previous drug use, and comorbid conditions. Another limitation was that substance exposure was patient- or witness-reported, and no testing to confirm exposure to synthetic cannabinoids was performed. Finally, the study had a relatively small sample size and lacked information about patients’ long-term outcomes.

Dr. Anderson and colleagues described future research that could address open questions. Analyzing urine to identify the synthetic cannabinoid used and correlating it with the presentation in the emergency department could illuminate specific toxidromes associated with particular compounds, they wrote. Longitudinal data on the long-term effects of adolescent exposure to synthetic cannabinoids would be valuable for understanding potential long-term neurocognitive impairments. “Lastly, additional investigations into the management of adolescent synthetic cannabinoid toxicity in the emergency department is warranted, given the health care cost burden of synthetic cannabinoid–related emergency department visits,” they concluded.

The study was not supported by external funding, and the authors had no relevant disclosures.

[email protected]

SOURCE: Anderson SAR et al. Pediatrics. 2019 Jul 8. doi: 10.1542/peds.2018-2690.

Among adolescents examined in the emergency department, exposure to synthetic cannabinoids is strongly associated with neuropsychiatric morbidity, according to data published online July 8 ahead of print in Pediatrics. The results support a distinct neuropsychiatric profile of acute synthetic cannabinoid toxicity in adolescents, wrote the investigators.

Synthetic cannabinoids have become popular and accessible and primarily are used for recreation. The adverse effects of synthetic cannabinoid toxicity reported in the literature include tachycardia, cardiac ischemia, acute kidney injury, agitation, first episode of psychosis, seizures, and death. Adolescents are the largest age group presenting to the emergency department with acute synthetic cannabinoid toxicity, and this population requires more intensive care than adults with the same presentation.
 

A multicenter registry analysis

To describe the neuropsychiatric presentation of adolescents to the emergency department after synthetic cannabinoid exposure, compared with that of cannabis exposure, Sarah Ann R. Anderson, MD, PhD, an adolescent medicine fellow at Columbia University Irving Medical Center in New York, and colleagues performed a multicenter registry analysis. They examined data collected from January 2010 through September 2018 from adolescent patients who presented to sites that participate in the Toxicology Investigators Consortium. For each patient, clinicians requested a consultation by a medical toxicologist to aid care. The exposures recorded in the case registry are reported by the patients or witnesses.

Eligible patients were between ages 13 and 19 years and presented to an emergency department with synthetic cannabinoid or cannabis exposure. Dr. Anderson and colleagues collected variables such as age, sex, reported exposures, death in hospital, location of toxicology encounter, and neuropsychiatric signs or symptoms. Patients whose exposure report came from a service outside of an emergency department and those with concomitant use of cannabis and synthetic cannabinoids were excluded. For the purpose of analysis, the investigators classified patients into the following four categories: exposure to synthetic cannabinoids alone, exposure to synthetic cannabinoids and other drugs, exposure to cannabis alone, and exposure to cannabis and other drugs.

Dr. Anderson and colleagues included 348 patients in their study. The sample included 107 patients in the synthetic cannabinoid–only group, 38 in the synthetic cannabinoid/polydrug group, 86 in the cannabis-only group, and 117 in the cannabis/polydrug group. Males predominated in all groups. The one death in the study occurred in the synthetic cannabinoid–only group.
 

Synthetic cannabinoid exposure increased risk for seizures

Compared with the cannabis-only group, the synthetic cannabinoid–only group had an increased risk of coma or CNS depression (odds ratio, 3.42) and seizures (OR, 3.89). The risk of agitation was significantly lower in the synthetic cannabinoid–only group, compared with the cannabis-only group (OR, 0.18). The two single-drug exposure groups did not differ in their associated risks of delirium or toxic psychosis, extrapyramidal signs, dystonia or rigidity, or hallucinations.

Exposure to synthetic cannabinoids plus other drugs was associated with increased risk of agitation (OR, 3.11) and seizures (OR, 4.8), compared with exposure to cannabis plus other drugs. Among patients exposed to synthetic cannabinoids plus other drugs, the most common class of other drug was sympathomimetics (such as synthetic cathinones, cocaine, and amphetamines). Sympathomimetics and ethanol were the two most common classes of drugs among patients exposed to cannabis plus other drugs.
 

Synthetic cannabinoids may have distinctive neuropsychiatric outcomes

“Findings from our study further confirm the previously described association between synthetic cannabinoid–specific overdose and severe neuropsychiatric outcomes,” wrote Dr. Anderson and colleagues. They underscore “the need for targeted public health messaging to adolescents about the dangers of using synthetic cannabinoids alone or combined with other substances.”

The investigators’ finding that patients exposed to synthetic cannabinoids alone had a lower risk of agitation than those exposed to cannabis alone is not consistent with contemporary literature on synthetic cannabinoid–associated agitation. This discordance may reflect differences in the populations studied, “with more severe toxicity prompting the emergency department presentations reported in this study,” wrote Dr. Anderson and colleagues. The current study also may be affected by selection bias, they added.

The researchers acknowledged several limitations of their study. For example, the registry lacked data for variables such as race or ethnicity, concurrent illness, previous drug use, and comorbid conditions. Another limitation was that substance exposure was patient- or witness-reported, and no testing to confirm exposure to synthetic cannabinoids was performed. Finally, the study had a relatively small sample size and lacked information about patients’ long-term outcomes.

Dr. Anderson and colleagues described future research that could address open questions. Analyzing urine to identify the synthetic cannabinoid used and correlating it with the presentation in the emergency department could illuminate specific toxidromes associated with particular compounds, they wrote. Longitudinal data on the long-term effects of adolescent exposure to synthetic cannabinoids would be valuable for understanding potential long-term neurocognitive impairments. “Lastly, additional investigations into the management of adolescent synthetic cannabinoid toxicity in the emergency department is warranted, given the health care cost burden of synthetic cannabinoid–related emergency department visits,” they concluded.

The study was not supported by external funding, and the authors had no relevant disclosures.

[email protected]

SOURCE: Anderson SAR et al. Pediatrics. 2019 Jul 8. doi: 10.1542/peds.2018-2690.

Among adolescents examined in the emergency department, exposure to synthetic cannabinoids is strongly associated with neuropsychiatric morbidity, according to data published online July 8 ahead of print in Pediatrics. The results support a distinct neuropsychiatric profile of acute synthetic cannabinoid toxicity in adolescents, wrote the investigators.

Synthetic cannabinoids have become popular and accessible and primarily are used for recreation. The adverse effects of synthetic cannabinoid toxicity reported in the literature include tachycardia, cardiac ischemia, acute kidney injury, agitation, first episode of psychosis, seizures, and death. Adolescents are the largest age group presenting to the emergency department with acute synthetic cannabinoid toxicity, and this population requires more intensive care than adults with the same presentation.
 

A multicenter registry analysis

To describe the neuropsychiatric presentation of adolescents to the emergency department after synthetic cannabinoid exposure, compared with that of cannabis exposure, Sarah Ann R. Anderson, MD, PhD, an adolescent medicine fellow at Columbia University Irving Medical Center in New York, and colleagues performed a multicenter registry analysis. They examined data collected from January 2010 through September 2018 from adolescent patients who presented to sites that participate in the Toxicology Investigators Consortium. For each patient, clinicians requested a consultation by a medical toxicologist to aid care. The exposures recorded in the case registry are reported by the patients or witnesses.

Eligible patients were between ages 13 and 19 years and presented to an emergency department with synthetic cannabinoid or cannabis exposure. Dr. Anderson and colleagues collected variables such as age, sex, reported exposures, death in hospital, location of toxicology encounter, and neuropsychiatric signs or symptoms. Patients whose exposure report came from a service outside of an emergency department and those with concomitant use of cannabis and synthetic cannabinoids were excluded. For the purpose of analysis, the investigators classified patients into the following four categories: exposure to synthetic cannabinoids alone, exposure to synthetic cannabinoids and other drugs, exposure to cannabis alone, and exposure to cannabis and other drugs.

Dr. Anderson and colleagues included 348 patients in their study. The sample included 107 patients in the synthetic cannabinoid–only group, 38 in the synthetic cannabinoid/polydrug group, 86 in the cannabis-only group, and 117 in the cannabis/polydrug group. Males predominated in all groups. The one death in the study occurred in the synthetic cannabinoid–only group.
 

Synthetic cannabinoid exposure increased risk for seizures

Compared with the cannabis-only group, the synthetic cannabinoid–only group had an increased risk of coma or CNS depression (odds ratio, 3.42) and seizures (OR, 3.89). The risk of agitation was significantly lower in the synthetic cannabinoid–only group, compared with the cannabis-only group (OR, 0.18). The two single-drug exposure groups did not differ in their associated risks of delirium or toxic psychosis, extrapyramidal signs, dystonia or rigidity, or hallucinations.

Exposure to synthetic cannabinoids plus other drugs was associated with increased risk of agitation (OR, 3.11) and seizures (OR, 4.8), compared with exposure to cannabis plus other drugs. Among patients exposed to synthetic cannabinoids plus other drugs, the most common class of other drug was sympathomimetics (such as synthetic cathinones, cocaine, and amphetamines). Sympathomimetics and ethanol were the two most common classes of drugs among patients exposed to cannabis plus other drugs.
 

Synthetic cannabinoids may have distinctive neuropsychiatric outcomes

“Findings from our study further confirm the previously described association between synthetic cannabinoid–specific overdose and severe neuropsychiatric outcomes,” wrote Dr. Anderson and colleagues. They underscore “the need for targeted public health messaging to adolescents about the dangers of using synthetic cannabinoids alone or combined with other substances.”

The investigators’ finding that patients exposed to synthetic cannabinoids alone had a lower risk of agitation than those exposed to cannabis alone is not consistent with contemporary literature on synthetic cannabinoid–associated agitation. This discordance may reflect differences in the populations studied, “with more severe toxicity prompting the emergency department presentations reported in this study,” wrote Dr. Anderson and colleagues. The current study also may be affected by selection bias, they added.

The researchers acknowledged several limitations of their study. For example, the registry lacked data for variables such as race or ethnicity, concurrent illness, previous drug use, and comorbid conditions. Another limitation was that substance exposure was patient- or witness-reported, and no testing to confirm exposure to synthetic cannabinoids was performed. Finally, the study had a relatively small sample size and lacked information about patients’ long-term outcomes.

Dr. Anderson and colleagues described future research that could address open questions. Analyzing urine to identify the synthetic cannabinoid used and correlating it with the presentation in the emergency department could illuminate specific toxidromes associated with particular compounds, they wrote. Longitudinal data on the long-term effects of adolescent exposure to synthetic cannabinoids would be valuable for understanding potential long-term neurocognitive impairments. “Lastly, additional investigations into the management of adolescent synthetic cannabinoid toxicity in the emergency department is warranted, given the health care cost burden of synthetic cannabinoid–related emergency department visits,” they concluded.

The study was not supported by external funding, and the authors had no relevant disclosures.

[email protected]

SOURCE: Anderson SAR et al. Pediatrics. 2019 Jul 8. doi: 10.1542/peds.2018-2690.

PHILADELPHIA – A majority of migraineurs with 4 or more headache days per month have seen a health care professional for headache in the preceding 12 months, according to an investigation presented at the annual meeting of the American Headache Society.

The largest group of these patients consults primary care physicians. The acute and preventive migraine treatment that these patients receive vary according to the type of provider that they see. Nevertheless, treatment is generally suboptimal, compared with the standards of current guidelines, said the investigators.

Bruce Jancin/MDedge News

Migraine is underdiagnosed and undertreated, said Dawn C. Buse, PhD, clinical professor of neurology at Albert Einstein College of Medicine, New York, and colleagues. Recent changes in health care policy and the expanded array of treatments for migraine warrant an investigation of the current state of migraine care, they added. They examined survey data to understand where patients with migraine in the United States seek care, which characteristics are associated with seeking care in the previous 12 months, and which treatments are prescribed.

Dr. Buse and colleagues analyzed data from the OVERCOME (Observational Survey of the Epidemiology, Treatment, and Care of Migraine) study. These data were obtained in 2018 using a Web-based survey of a representative U.S. sample of 21,143 patients with migraine. The investigators focused on care seeking and medication use in a subsample of 8,844 patients with 4 or more migraine headache days per month to better understand those with the greatest care needs.

The mean age of this subsample was 42.0 years. Approximately 78% of participants were female, and 74.8% were white. In the preceding 12 months, 61.1% of the patients sought care for migraine; 38.3% sought care from more than two types of provider. Provider types included primary care physicians (45.5%), neurologists (20.2%), emergency medicine clinicians (19.2%), urgent care providers (14.4%), pain specialists (12.8%), headache specialists (12.0%), and retail (nonurgent) clinics (10.4%).

Dr. Buse and colleagues found that sociodemographic factors such as age, sex, education, income, and health insurance type influenced participants’ likelihood of seeking care. Seeking care was positively associated with the number of headache days, pain severity, allodynia, aura, and prodrome. When the researchers examined migraine characteristics, they found that nausea and vomiting (68.8%) was more likely to prompt a patient to seek care, compared with phonophobia and photophobia (64.3%). Participants who sought care from a headache specialist (55.0%) or a neurologist (50.1%) were most likely to be using migraine preventive medication. More than 20% of migraineurs seeking care from primary care, urgent care, or retail clinic professionals were undiagnosed.

Primary care doctors were most likely to prescribe triptans, followed by opioids and preventive medications. Neurologists and headache specialists were most likely to prescribe preventive medications and unlikely to prescribe opioids.

Eli Lilly funds the OVERCOME study. Dr. Buse consults for Lilly on this study, but she and her coauthors who do not work in the industry did not receive any funding for any work related to writing, publishing, or presenting any abstracts, posters, platforms, or manuscripts.

[email protected]

PHILADELPHIA – A majority of migraineurs with 4 or more headache days per month have seen a health care professional for headache in the preceding 12 months, according to an investigation presented at the annual meeting of the American Headache Society.

The largest group of these patients consults primary care physicians. The acute and preventive migraine treatment that these patients receive vary according to the type of provider that they see. Nevertheless, treatment is generally suboptimal, compared with the standards of current guidelines, said the investigators.

Bruce Jancin/MDedge News

Migraine is underdiagnosed and undertreated, said Dawn C. Buse, PhD, clinical professor of neurology at Albert Einstein College of Medicine, New York, and colleagues. Recent changes in health care policy and the expanded array of treatments for migraine warrant an investigation of the current state of migraine care, they added. They examined survey data to understand where patients with migraine in the United States seek care, which characteristics are associated with seeking care in the previous 12 months, and which treatments are prescribed.

Dr. Buse and colleagues analyzed data from the OVERCOME (Observational Survey of the Epidemiology, Treatment, and Care of Migraine) study. These data were obtained in 2018 using a Web-based survey of a representative U.S. sample of 21,143 patients with migraine. The investigators focused on care seeking and medication use in a subsample of 8,844 patients with 4 or more migraine headache days per month to better understand those with the greatest care needs.

The mean age of this subsample was 42.0 years. Approximately 78% of participants were female, and 74.8% were white. In the preceding 12 months, 61.1% of the patients sought care for migraine; 38.3% sought care from more than two types of provider. Provider types included primary care physicians (45.5%), neurologists (20.2%), emergency medicine clinicians (19.2%), urgent care providers (14.4%), pain specialists (12.8%), headache specialists (12.0%), and retail (nonurgent) clinics (10.4%).

Dr. Buse and colleagues found that sociodemographic factors such as age, sex, education, income, and health insurance type influenced participants’ likelihood of seeking care. Seeking care was positively associated with the number of headache days, pain severity, allodynia, aura, and prodrome. When the researchers examined migraine characteristics, they found that nausea and vomiting (68.8%) was more likely to prompt a patient to seek care, compared with phonophobia and photophobia (64.3%). Participants who sought care from a headache specialist (55.0%) or a neurologist (50.1%) were most likely to be using migraine preventive medication. More than 20% of migraineurs seeking care from primary care, urgent care, or retail clinic professionals were undiagnosed.

Primary care doctors were most likely to prescribe triptans, followed by opioids and preventive medications. Neurologists and headache specialists were most likely to prescribe preventive medications and unlikely to prescribe opioids.

Eli Lilly funds the OVERCOME study. Dr. Buse consults for Lilly on this study, but she and her coauthors who do not work in the industry did not receive any funding for any work related to writing, publishing, or presenting any abstracts, posters, platforms, or manuscripts.

[email protected]

PHILADELPHIA – A majority of migraineurs with 4 or more headache days per month have seen a health care professional for headache in the preceding 12 months, according to an investigation presented at the annual meeting of the American Headache Society.

The largest group of these patients consults primary care physicians. The acute and preventive migraine treatment that these patients receive vary according to the type of provider that they see. Nevertheless, treatment is generally suboptimal, compared with the standards of current guidelines, said the investigators.

Bruce Jancin/MDedge News

Migraine is underdiagnosed and undertreated, said Dawn C. Buse, PhD, clinical professor of neurology at Albert Einstein College of Medicine, New York, and colleagues. Recent changes in health care policy and the expanded array of treatments for migraine warrant an investigation of the current state of migraine care, they added. They examined survey data to understand where patients with migraine in the United States seek care, which characteristics are associated with seeking care in the previous 12 months, and which treatments are prescribed.

Dr. Buse and colleagues analyzed data from the OVERCOME (Observational Survey of the Epidemiology, Treatment, and Care of Migraine) study. These data were obtained in 2018 using a Web-based survey of a representative U.S. sample of 21,143 patients with migraine. The investigators focused on care seeking and medication use in a subsample of 8,844 patients with 4 or more migraine headache days per month to better understand those with the greatest care needs.

The mean age of this subsample was 42.0 years. Approximately 78% of participants were female, and 74.8% were white. In the preceding 12 months, 61.1% of the patients sought care for migraine; 38.3% sought care from more than two types of provider. Provider types included primary care physicians (45.5%), neurologists (20.2%), emergency medicine clinicians (19.2%), urgent care providers (14.4%), pain specialists (12.8%), headache specialists (12.0%), and retail (nonurgent) clinics (10.4%).

Dr. Buse and colleagues found that sociodemographic factors such as age, sex, education, income, and health insurance type influenced participants’ likelihood of seeking care. Seeking care was positively associated with the number of headache days, pain severity, allodynia, aura, and prodrome. When the researchers examined migraine characteristics, they found that nausea and vomiting (68.8%) was more likely to prompt a patient to seek care, compared with phonophobia and photophobia (64.3%). Participants who sought care from a headache specialist (55.0%) or a neurologist (50.1%) were most likely to be using migraine preventive medication. More than 20% of migraineurs seeking care from primary care, urgent care, or retail clinic professionals were undiagnosed.

Primary care doctors were most likely to prescribe triptans, followed by opioids and preventive medications. Neurologists and headache specialists were most likely to prescribe preventive medications and unlikely to prescribe opioids.

Eli Lilly funds the OVERCOME study. Dr. Buse consults for Lilly on this study, but she and her coauthors who do not work in the industry did not receive any funding for any work related to writing, publishing, or presenting any abstracts, posters, platforms, or manuscripts.

[email protected]

PHILADELPHIA – The level of exposure to white light is associated with acute risk of headache onset in patients with episodic migraine, according to research presented at the annual meeting of the American Headache Society. The data raise the question of whether modifying light exposure could reduce headache frequency in this population, said Suzanne M. Bertisch, MD, MPH, a physician and clinical investigator in the division of sleep and circadian disorders at Brigham and Women’s Hospital in Boston.

About 40% of patients with migraine identify light as a trigger. Most studies that have examined the association between light and migraine onset have been retrospective and have relied on subjective measures of light exposure.

From March 2016 to August 2017, Dr. Bertisch and colleagues enrolled 101 adults with episodic migraine into a prospective cohort study. For 79 of these participants, light exposure was measured continuously for 6 weeks by actigraph. In the morning and evening, participants recorded data such as headache onset, duration, and intensity in electronic headache diaries. They also recorded data about covariates such as caffeine intake, alcohol intake, sleep, and stress.

Dr. Bertisch and colleagues divided the day into four 6-hour periods and calculated mean light exposure within each period. After researchers adjusted for covariates, they found that higher mean photopic illuminance was associated with a 12% higher risk of headache during the same period. Mean photopic illuminance was not associated with headache onset in the next period, however.

Dr. Bertisch had no disclosures relevant to this study.

[email protected]

PHILADELPHIA – The level of exposure to white light is associated with acute risk of headache onset in patients with episodic migraine, according to research presented at the annual meeting of the American Headache Society. The data raise the question of whether modifying light exposure could reduce headache frequency in this population, said Suzanne M. Bertisch, MD, MPH, a physician and clinical investigator in the division of sleep and circadian disorders at Brigham and Women’s Hospital in Boston.

About 40% of patients with migraine identify light as a trigger. Most studies that have examined the association between light and migraine onset have been retrospective and have relied on subjective measures of light exposure.

From March 2016 to August 2017, Dr. Bertisch and colleagues enrolled 101 adults with episodic migraine into a prospective cohort study. For 79 of these participants, light exposure was measured continuously for 6 weeks by actigraph. In the morning and evening, participants recorded data such as headache onset, duration, and intensity in electronic headache diaries. They also recorded data about covariates such as caffeine intake, alcohol intake, sleep, and stress.

Dr. Bertisch and colleagues divided the day into four 6-hour periods and calculated mean light exposure within each period. After researchers adjusted for covariates, they found that higher mean photopic illuminance was associated with a 12% higher risk of headache during the same period. Mean photopic illuminance was not associated with headache onset in the next period, however.

Dr. Bertisch had no disclosures relevant to this study.

[email protected]

PHILADELPHIA – The level of exposure to white light is associated with acute risk of headache onset in patients with episodic migraine, according to research presented at the annual meeting of the American Headache Society. The data raise the question of whether modifying light exposure could reduce headache frequency in this population, said Suzanne M. Bertisch, MD, MPH, a physician and clinical investigator in the division of sleep and circadian disorders at Brigham and Women’s Hospital in Boston.

About 40% of patients with migraine identify light as a trigger. Most studies that have examined the association between light and migraine onset have been retrospective and have relied on subjective measures of light exposure.

From March 2016 to August 2017, Dr. Bertisch and colleagues enrolled 101 adults with episodic migraine into a prospective cohort study. For 79 of these participants, light exposure was measured continuously for 6 weeks by actigraph. In the morning and evening, participants recorded data such as headache onset, duration, and intensity in electronic headache diaries. They also recorded data about covariates such as caffeine intake, alcohol intake, sleep, and stress.

Dr. Bertisch and colleagues divided the day into four 6-hour periods and calculated mean light exposure within each period. After researchers adjusted for covariates, they found that higher mean photopic illuminance was associated with a 12% higher risk of headache during the same period. Mean photopic illuminance was not associated with headache onset in the next period, however.

Dr. Bertisch had no disclosures relevant to this study.

[email protected]

PHILADELPHIA – The headache field is not free of the gender bias that affects medicine in general, said Elizabeth W. Loder, MD, chief of the Division of Headache and Pain at Brigham and Women’s Hospital in Boston, at the annual meeting of the American Headache Society. Women accrue credentials and are accorded respect as headache experts more slowly than men, she said. They are underrepresented among the speakers at headache conferences and are less likely than men to be invited to write editorials for peer-reviewed publications. Furthermore, a significant proportion of female headache specialists experiences sexual harassment in their professional environments.

Bias also affects interactions between patients and headache specialists, said Dr. Loder. Regardless of their gender, patients expect female care providers to be sympathetic and understanding. If they perceive that a female physician does not sufficiently display these attributes, they often write critical reviews of them on the Internet. In contrast, male physicians are not expected to be particularly caring, and patients praise them highly when they are.

Recognition of these biases is increasing, however. Representation of women in professional societies and on conference programs will improve, and emerging codes of conduct will reduce sexual harassment, said Dr. Loder. Headache specialists can take various steps, such as offering recognition and encouragement, to make the field more welcoming to women and to other disadvantaged groups.

[email protected]

PHILADELPHIA – The headache field is not free of the gender bias that affects medicine in general, said Elizabeth W. Loder, MD, chief of the Division of Headache and Pain at Brigham and Women’s Hospital in Boston, at the annual meeting of the American Headache Society. Women accrue credentials and are accorded respect as headache experts more slowly than men, she said. They are underrepresented among the speakers at headache conferences and are less likely than men to be invited to write editorials for peer-reviewed publications. Furthermore, a significant proportion of female headache specialists experiences sexual harassment in their professional environments.

Bias also affects interactions between patients and headache specialists, said Dr. Loder. Regardless of their gender, patients expect female care providers to be sympathetic and understanding. If they perceive that a female physician does not sufficiently display these attributes, they often write critical reviews of them on the Internet. In contrast, male physicians are not expected to be particularly caring, and patients praise them highly when they are.

Recognition of these biases is increasing, however. Representation of women in professional societies and on conference programs will improve, and emerging codes of conduct will reduce sexual harassment, said Dr. Loder. Headache specialists can take various steps, such as offering recognition and encouragement, to make the field more welcoming to women and to other disadvantaged groups.

[email protected]

PHILADELPHIA – The headache field is not free of the gender bias that affects medicine in general, said Elizabeth W. Loder, MD, chief of the Division of Headache and Pain at Brigham and Women’s Hospital in Boston, at the annual meeting of the American Headache Society. Women accrue credentials and are accorded respect as headache experts more slowly than men, she said. They are underrepresented among the speakers at headache conferences and are less likely than men to be invited to write editorials for peer-reviewed publications. Furthermore, a significant proportion of female headache specialists experiences sexual harassment in their professional environments.

Bias also affects interactions between patients and headache specialists, said Dr. Loder. Regardless of their gender, patients expect female care providers to be sympathetic and understanding. If they perceive that a female physician does not sufficiently display these attributes, they often write critical reviews of them on the Internet. In contrast, male physicians are not expected to be particularly caring, and patients praise them highly when they are.

Recognition of these biases is increasing, however. Representation of women in professional societies and on conference programs will improve, and emerging codes of conduct will reduce sexual harassment, said Dr. Loder. Headache specialists can take various steps, such as offering recognition and encouragement, to make the field more welcoming to women and to other disadvantaged groups.

[email protected]

PHILADELPHIA – More than one-third of patients with migraine who take prescription medications use opioids, although guidelines recommend against it, according to a study presented at the annual meeting of the American Headache Society. Opioid use among migraineurs is associated with indicators of poor health, such as high body mass index (BMI), high pain scores, and cardiovascular comorbidities. Some variables associated with opioid use are modifiable.

Mitchel L. Zoler/MDedge News

Medical associations do not recommend opioid use for migraine because it may increase the risks of dependence, suboptimal outcomes, and new-onset chronic migraine. Richard B. Lipton, MD, Edwin S. Lowe Chair in neurology at Albert Einstein College of Medicine in Bronx, New York, and colleagues analyzed data from the Chronic Migraine Epidemiology and Outcomes (CaMEO) study to identify variables associated with opioid use among patients who treat their headaches with acute prescription medications.

Using a web panel that was demographically similar to the U.S. population, CaMEO identified people with migraine, based on the criteria of the International Classification of Headache Disorders, 3rd Edition. Dr. Lipton and colleagues examined participants who reported currently using or having on hand acute prescription pain medication to treat headaches. The researchers compared the features (e.g., demographics, attack frequency, treatment choices, headache-related disability, and comorbidity) of self-reported opioid users with those of nonusers. They created nested, multivariable, binary logistic regression models to evaluate opioid use or nonuse as the outcome. Dr. Lipton and colleagues entered covariates in blocks (i.e., sociodemographics, headache and respondent characteristics, psychiatric comorbidities, emergency facility use for headache in the preceding 6 months, and one or more cardiovascular [CV] comorbidity) and removed nonsignificant sociodemographic variables from the model.

The researchers identified 2,388 respondents with migraine who currently used acute prescription medications for headache. Of this group, 867 (36.3%) used opioids. Compared with opioid nonusers, opioid users had significant increases in monthly headache days; frequency of emergency care use for headache within the past 6 months; medication overuse frequency; presence of allodynia, depression, anxiety, and CV comorbidity; Total Pain Index (TPI) scores; and diabetes diagnoses.

Factors significantly associated with opioid use included male sex (odds ratio [OR], 1.74); increasing body mass index BMI (OR, 1.02); allodynia (OR, 1.39); increasing monthly headache day frequency; increasing TPI scores excluding the head, face, and neck (1.32); anxiety (OR, 1.37); depression (OR, 1.50); one or more CV comorbidity (OR, 1.56); and emergency facility use for headache in the past 6 months (OR, 1.73). The OR of opioid use was 1.37 in patients with a monthly headache frequency of 10-14 days and 1.62 in patients with a frequency of 15 or more days, compared with patients with a monthly headache frequency of 0-4 days.

Receiving a diagnosis of migraine or chronic migraine was associated with a significantly lower likelihood of opioid use (OR, 0.38).

Allergan funded the CaMEO study and paid Dr. Lipton for consulting services.

[email protected]

SOURCE: Lipton R et al. AHS 2019. Abstract 629332.

PHILADELPHIA – More than one-third of patients with migraine who take prescription medications use opioids, although guidelines recommend against it, according to a study presented at the annual meeting of the American Headache Society. Opioid use among migraineurs is associated with indicators of poor health, such as high body mass index (BMI), high pain scores, and cardiovascular comorbidities. Some variables associated with opioid use are modifiable.

Mitchel L. Zoler/MDedge News

Medical associations do not recommend opioid use for migraine because it may increase the risks of dependence, suboptimal outcomes, and new-onset chronic migraine. Richard B. Lipton, MD, Edwin S. Lowe Chair in neurology at Albert Einstein College of Medicine in Bronx, New York, and colleagues analyzed data from the Chronic Migraine Epidemiology and Outcomes (CaMEO) study to identify variables associated with opioid use among patients who treat their headaches with acute prescription medications.

Using a web panel that was demographically similar to the U.S. population, CaMEO identified people with migraine, based on the criteria of the International Classification of Headache Disorders, 3rd Edition. Dr. Lipton and colleagues examined participants who reported currently using or having on hand acute prescription pain medication to treat headaches. The researchers compared the features (e.g., demographics, attack frequency, treatment choices, headache-related disability, and comorbidity) of self-reported opioid users with those of nonusers. They created nested, multivariable, binary logistic regression models to evaluate opioid use or nonuse as the outcome. Dr. Lipton and colleagues entered covariates in blocks (i.e., sociodemographics, headache and respondent characteristics, psychiatric comorbidities, emergency facility use for headache in the preceding 6 months, and one or more cardiovascular [CV] comorbidity) and removed nonsignificant sociodemographic variables from the model.

The researchers identified 2,388 respondents with migraine who currently used acute prescription medications for headache. Of this group, 867 (36.3%) used opioids. Compared with opioid nonusers, opioid users had significant increases in monthly headache days; frequency of emergency care use for headache within the past 6 months; medication overuse frequency; presence of allodynia, depression, anxiety, and CV comorbidity; Total Pain Index (TPI) scores; and diabetes diagnoses.

Factors significantly associated with opioid use included male sex (odds ratio [OR], 1.74); increasing body mass index BMI (OR, 1.02); allodynia (OR, 1.39); increasing monthly headache day frequency; increasing TPI scores excluding the head, face, and neck (1.32); anxiety (OR, 1.37); depression (OR, 1.50); one or more CV comorbidity (OR, 1.56); and emergency facility use for headache in the past 6 months (OR, 1.73). The OR of opioid use was 1.37 in patients with a monthly headache frequency of 10-14 days and 1.62 in patients with a frequency of 15 or more days, compared with patients with a monthly headache frequency of 0-4 days.

Receiving a diagnosis of migraine or chronic migraine was associated with a significantly lower likelihood of opioid use (OR, 0.38).

Allergan funded the CaMEO study and paid Dr. Lipton for consulting services.

[email protected]

SOURCE: Lipton R et al. AHS 2019. Abstract 629332.

PHILADELPHIA – More than one-third of patients with migraine who take prescription medications use opioids, although guidelines recommend against it, according to a study presented at the annual meeting of the American Headache Society. Opioid use among migraineurs is associated with indicators of poor health, such as high body mass index (BMI), high pain scores, and cardiovascular comorbidities. Some variables associated with opioid use are modifiable.

Mitchel L. Zoler/MDedge News

Medical associations do not recommend opioid use for migraine because it may increase the risks of dependence, suboptimal outcomes, and new-onset chronic migraine. Richard B. Lipton, MD, Edwin S. Lowe Chair in neurology at Albert Einstein College of Medicine in Bronx, New York, and colleagues analyzed data from the Chronic Migraine Epidemiology and Outcomes (CaMEO) study to identify variables associated with opioid use among patients who treat their headaches with acute prescription medications.

Using a web panel that was demographically similar to the U.S. population, CaMEO identified people with migraine, based on the criteria of the International Classification of Headache Disorders, 3rd Edition. Dr. Lipton and colleagues examined participants who reported currently using or having on hand acute prescription pain medication to treat headaches. The researchers compared the features (e.g., demographics, attack frequency, treatment choices, headache-related disability, and comorbidity) of self-reported opioid users with those of nonusers. They created nested, multivariable, binary logistic regression models to evaluate opioid use or nonuse as the outcome. Dr. Lipton and colleagues entered covariates in blocks (i.e., sociodemographics, headache and respondent characteristics, psychiatric comorbidities, emergency facility use for headache in the preceding 6 months, and one or more cardiovascular [CV] comorbidity) and removed nonsignificant sociodemographic variables from the model.

The researchers identified 2,388 respondents with migraine who currently used acute prescription medications for headache. Of this group, 867 (36.3%) used opioids. Compared with opioid nonusers, opioid users had significant increases in monthly headache days; frequency of emergency care use for headache within the past 6 months; medication overuse frequency; presence of allodynia, depression, anxiety, and CV comorbidity; Total Pain Index (TPI) scores; and diabetes diagnoses.

Factors significantly associated with opioid use included male sex (odds ratio [OR], 1.74); increasing body mass index BMI (OR, 1.02); allodynia (OR, 1.39); increasing monthly headache day frequency; increasing TPI scores excluding the head, face, and neck (1.32); anxiety (OR, 1.37); depression (OR, 1.50); one or more CV comorbidity (OR, 1.56); and emergency facility use for headache in the past 6 months (OR, 1.73). The OR of opioid use was 1.37 in patients with a monthly headache frequency of 10-14 days and 1.62 in patients with a frequency of 15 or more days, compared with patients with a monthly headache frequency of 0-4 days.

Receiving a diagnosis of migraine or chronic migraine was associated with a significantly lower likelihood of opioid use (OR, 0.38).

Allergan funded the CaMEO study and paid Dr. Lipton for consulting services.

[email protected]

SOURCE: Lipton R et al. AHS 2019. Abstract 629332.

PHILADELPHIA – Monthly or quarterly treatment with fremanezumab provides significant and clinically meaningful reductions in migraine days at 4 weeks, compared with placebo, in patients with inadequate responses to as many as four classes of preventive medications for migraine, according to research presented at the annual meeting of the American Headache Society. Fremanezumab may be an effective treatment for a population that otherwise is difficult to treat, said the researchers.

Fremanezumab is a fully humanized monoclonal antibody that selectively targets calcitonin gene-related peptide (CGRP). Previous trials have supported the treatment’s efficacy for the preventive treatment of episodic and chronic migraine in adults. Egilius L. H. Spierings, MD, PhD, a clinical professor of neurology at Tufts Medical Center in Boston and the founder, medical director, and principal investigator at MedVadis Research in Watertown, Massachusetts, and colleagues conducted the phase 3 FOCUS study to examine fremanezumab’s efficacy at preventing migraine in adults with chronic or episodic migraine and inadequate response to two to four classes of migraine preventive medications.

The investigators randomized patients in this multinational, double-blind study to one of three treatment arms. In the first arm, participants received monthly subcutaneous doses of fremanezumab. Patients with chronic migraine in this arm received 675 mg during month 1 and 225 mg during months 2 and 3. Patients with episodic migraine received 225 mg each month. In the second arm, participants received quarterly treatment with fremanezumab (i.e., 675 mg during month 1, followed by placebo during months 2 and 3). In the third arm, participants received matched monthly placebo. The treatment period lasted for 12 weeks.

Dr. Spierings and colleagues created logistic regression models to compare the proportions of responders, defined as patients who achieved 50% or greater and 75% or greater reduction in mean monthly migraine days, during the 4- and 12-week periods after the first dose of study drug. They used a logistic regression model to analyze the proportions of patients who achieved 50% or greater reduction in mean monthly migraine days during the first 4 weeks and sustained this level of response throughout the 12-week period. The study’s secondary endpoints were 50% or greater reductions in migraine days at weeks 4 and 12.

The investigators randomized 837 patients. In all, 278 participants received placebo, 283 received monthly fremanezumab, and 276 received quarterly fremanezumab. At baseline, the mean number of migraine days was 14.3 in the placebo arm, 14.1 in the monthly fremanezumab arm, and 14.1 in the quarterly fremanezumab arm. The proportions of patients who failed to respond to 2, 3, and 4 classes of preventive medications, respectively, were 51%, 29%, and 19% in the placebo group; 47%, 35%, and 18% in the monthly fremanezumab group; and 51%, 31%, and 18% in the quarterly fremanezumab group.

Overall, approximately 37% of patients receiving fremanezumab achieved 50% or greater reductions in migraine days within 4 weeks of the first dose, compared with 10% of patients who received placebo. Approximately 20% of patients receiving fremanezumab had sustained 50% or greater reductions in migraine days from 4 weeks throughout the 12-week treatment period, compared with 3% of controls. Higher proportions of patients also achieved 75% or greater reductions at 4 weeks and during 12 weeks after the first dose with fremanezumab, compared with placebo.

Dr. Spierings is a member of the Teva Pharmaceuticals speakers bureau and has received research grants from the company. His coinvestigators are all employees of Teva, which manufactures fremanezumab.

[email protected]

SOURCE: Spierings ELH et al. AHS 2019. Abstract 631663.

PHILADELPHIA – Monthly or quarterly treatment with fremanezumab provides significant and clinically meaningful reductions in migraine days at 4 weeks, compared with placebo, in patients with inadequate responses to as many as four classes of preventive medications for migraine, according to research presented at the annual meeting of the American Headache Society. Fremanezumab may be an effective treatment for a population that otherwise is difficult to treat, said the researchers.

Fremanezumab is a fully humanized monoclonal antibody that selectively targets calcitonin gene-related peptide (CGRP). Previous trials have supported the treatment’s efficacy for the preventive treatment of episodic and chronic migraine in adults. Egilius L. H. Spierings, MD, PhD, a clinical professor of neurology at Tufts Medical Center in Boston and the founder, medical director, and principal investigator at MedVadis Research in Watertown, Massachusetts, and colleagues conducted the phase 3 FOCUS study to examine fremanezumab’s efficacy at preventing migraine in adults with chronic or episodic migraine and inadequate response to two to four classes of migraine preventive medications.

The investigators randomized patients in this multinational, double-blind study to one of three treatment arms. In the first arm, participants received monthly subcutaneous doses of fremanezumab. Patients with chronic migraine in this arm received 675 mg during month 1 and 225 mg during months 2 and 3. Patients with episodic migraine received 225 mg each month. In the second arm, participants received quarterly treatment with fremanezumab (i.e., 675 mg during month 1, followed by placebo during months 2 and 3). In the third arm, participants received matched monthly placebo. The treatment period lasted for 12 weeks.

Dr. Spierings and colleagues created logistic regression models to compare the proportions of responders, defined as patients who achieved 50% or greater and 75% or greater reduction in mean monthly migraine days, during the 4- and 12-week periods after the first dose of study drug. They used a logistic regression model to analyze the proportions of patients who achieved 50% or greater reduction in mean monthly migraine days during the first 4 weeks and sustained this level of response throughout the 12-week period. The study’s secondary endpoints were 50% or greater reductions in migraine days at weeks 4 and 12.

The investigators randomized 837 patients. In all, 278 participants received placebo, 283 received monthly fremanezumab, and 276 received quarterly fremanezumab. At baseline, the mean number of migraine days was 14.3 in the placebo arm, 14.1 in the monthly fremanezumab arm, and 14.1 in the quarterly fremanezumab arm. The proportions of patients who failed to respond to 2, 3, and 4 classes of preventive medications, respectively, were 51%, 29%, and 19% in the placebo group; 47%, 35%, and 18% in the monthly fremanezumab group; and 51%, 31%, and 18% in the quarterly fremanezumab group.

Overall, approximately 37% of patients receiving fremanezumab achieved 50% or greater reductions in migraine days within 4 weeks of the first dose, compared with 10% of patients who received placebo. Approximately 20% of patients receiving fremanezumab had sustained 50% or greater reductions in migraine days from 4 weeks throughout the 12-week treatment period, compared with 3% of controls. Higher proportions of patients also achieved 75% or greater reductions at 4 weeks and during 12 weeks after the first dose with fremanezumab, compared with placebo.

Dr. Spierings is a member of the Teva Pharmaceuticals speakers bureau and has received research grants from the company. His coinvestigators are all employees of Teva, which manufactures fremanezumab.

[email protected]

SOURCE: Spierings ELH et al. AHS 2019. Abstract 631663.

PHILADELPHIA – Monthly or quarterly treatment with fremanezumab provides significant and clinically meaningful reductions in migraine days at 4 weeks, compared with placebo, in patients with inadequate responses to as many as four classes of preventive medications for migraine, according to research presented at the annual meeting of the American Headache Society. Fremanezumab may be an effective treatment for a population that otherwise is difficult to treat, said the researchers.

Fremanezumab is a fully humanized monoclonal antibody that selectively targets calcitonin gene-related peptide (CGRP). Previous trials have supported the treatment’s efficacy for the preventive treatment of episodic and chronic migraine in adults. Egilius L. H. Spierings, MD, PhD, a clinical professor of neurology at Tufts Medical Center in Boston and the founder, medical director, and principal investigator at MedVadis Research in Watertown, Massachusetts, and colleagues conducted the phase 3 FOCUS study to examine fremanezumab’s efficacy at preventing migraine in adults with chronic or episodic migraine and inadequate response to two to four classes of migraine preventive medications.

The investigators randomized patients in this multinational, double-blind study to one of three treatment arms. In the first arm, participants received monthly subcutaneous doses of fremanezumab. Patients with chronic migraine in this arm received 675 mg during month 1 and 225 mg during months 2 and 3. Patients with episodic migraine received 225 mg each month. In the second arm, participants received quarterly treatment with fremanezumab (i.e., 675 mg during month 1, followed by placebo during months 2 and 3). In the third arm, participants received matched monthly placebo. The treatment period lasted for 12 weeks.

Dr. Spierings and colleagues created logistic regression models to compare the proportions of responders, defined as patients who achieved 50% or greater and 75% or greater reduction in mean monthly migraine days, during the 4- and 12-week periods after the first dose of study drug. They used a logistic regression model to analyze the proportions of patients who achieved 50% or greater reduction in mean monthly migraine days during the first 4 weeks and sustained this level of response throughout the 12-week period. The study’s secondary endpoints were 50% or greater reductions in migraine days at weeks 4 and 12.

The investigators randomized 837 patients. In all, 278 participants received placebo, 283 received monthly fremanezumab, and 276 received quarterly fremanezumab. At baseline, the mean number of migraine days was 14.3 in the placebo arm, 14.1 in the monthly fremanezumab arm, and 14.1 in the quarterly fremanezumab arm. The proportions of patients who failed to respond to 2, 3, and 4 classes of preventive medications, respectively, were 51%, 29%, and 19% in the placebo group; 47%, 35%, and 18% in the monthly fremanezumab group; and 51%, 31%, and 18% in the quarterly fremanezumab group.

Overall, approximately 37% of patients receiving fremanezumab achieved 50% or greater reductions in migraine days within 4 weeks of the first dose, compared with 10% of patients who received placebo. Approximately 20% of patients receiving fremanezumab had sustained 50% or greater reductions in migraine days from 4 weeks throughout the 12-week treatment period, compared with 3% of controls. Higher proportions of patients also achieved 75% or greater reductions at 4 weeks and during 12 weeks after the first dose with fremanezumab, compared with placebo.

Dr. Spierings is a member of the Teva Pharmaceuticals speakers bureau and has received research grants from the company. His coinvestigators are all employees of Teva, which manufactures fremanezumab.

[email protected]

SOURCE: Spierings ELH et al. AHS 2019. Abstract 631663.

PHILADELPHIA – The age at which adolescent girls experience thelarche and menarche is associated with the prevalence of migraine during later adolescence, according to research presented at the annual meeting of the American Headache Society. The results suggest that earlier exposure to estrogen increases the risk for migraine in adolescent girls, said Vincent Martin, MD, director of the Headache and Facial Pain Center at the University of Cincinnati Gardner Neuroscience Institute.

Previous studies observed an association between earlier onset of menarche and greater prevalence of migraine in adolescent girls, but no investigators had examined the relationship between earlier stages of pubertal development, such as thelarche and pubarche, and migraine.

Dr. Martin and colleagues included participants in the Breast Cancer and Environment Research Program puberty cohort in their study. Physicians examined the girls every 6 to 12 months from the time that they were aged 6-8 years to the time of late adolescence. During the last examination, participants responded to a validated questionnaire to determine whether they met International Classification of Headache Disorders–3 criteria for a diagnosis of migraine. Dr. Martin and colleagues performed logistic regression to examine whether age at thelarche, pubarche, or menarche predicted migraine.

Of 761 girls included in this study, 85 (11.2%) received a diagnosis of migraine. The mean age at which the questionnaire was administered was 15.6 years. After adjusting the data for potential confounders, the researchers found that an earlier age of onset of thelarche and menarche was associated with a higher prevalence of migraine. A 1-year decrease in the age of onset of thelarche or menarche was associated with a 32.8% or 33.8% increase in the odds of migraine headache, respectively. Pubarche was not associated with migraine.

Dr. Martin had no relevant disclosures.

[email protected]

PHILADELPHIA – The age at which adolescent girls experience thelarche and menarche is associated with the prevalence of migraine during later adolescence, according to research presented at the annual meeting of the American Headache Society. The results suggest that earlier exposure to estrogen increases the risk for migraine in adolescent girls, said Vincent Martin, MD, director of the Headache and Facial Pain Center at the University of Cincinnati Gardner Neuroscience Institute.

Previous studies observed an association between earlier onset of menarche and greater prevalence of migraine in adolescent girls, but no investigators had examined the relationship between earlier stages of pubertal development, such as thelarche and pubarche, and migraine.

Dr. Martin and colleagues included participants in the Breast Cancer and Environment Research Program puberty cohort in their study. Physicians examined the girls every 6 to 12 months from the time that they were aged 6-8 years to the time of late adolescence. During the last examination, participants responded to a validated questionnaire to determine whether they met International Classification of Headache Disorders–3 criteria for a diagnosis of migraine. Dr. Martin and colleagues performed logistic regression to examine whether age at thelarche, pubarche, or menarche predicted migraine.

Of 761 girls included in this study, 85 (11.2%) received a diagnosis of migraine. The mean age at which the questionnaire was administered was 15.6 years. After adjusting the data for potential confounders, the researchers found that an earlier age of onset of thelarche and menarche was associated with a higher prevalence of migraine. A 1-year decrease in the age of onset of thelarche or menarche was associated with a 32.8% or 33.8% increase in the odds of migraine headache, respectively. Pubarche was not associated with migraine.

Dr. Martin had no relevant disclosures.

[email protected]

PHILADELPHIA – The age at which adolescent girls experience thelarche and menarche is associated with the prevalence of migraine during later adolescence, according to research presented at the annual meeting of the American Headache Society. The results suggest that earlier exposure to estrogen increases the risk for migraine in adolescent girls, said Vincent Martin, MD, director of the Headache and Facial Pain Center at the University of Cincinnati Gardner Neuroscience Institute.

Previous studies observed an association between earlier onset of menarche and greater prevalence of migraine in adolescent girls, but no investigators had examined the relationship between earlier stages of pubertal development, such as thelarche and pubarche, and migraine.

Dr. Martin and colleagues included participants in the Breast Cancer and Environment Research Program puberty cohort in their study. Physicians examined the girls every 6 to 12 months from the time that they were aged 6-8 years to the time of late adolescence. During the last examination, participants responded to a validated questionnaire to determine whether they met International Classification of Headache Disorders–3 criteria for a diagnosis of migraine. Dr. Martin and colleagues performed logistic regression to examine whether age at thelarche, pubarche, or menarche predicted migraine.

Of 761 girls included in this study, 85 (11.2%) received a diagnosis of migraine. The mean age at which the questionnaire was administered was 15.6 years. After adjusting the data for potential confounders, the researchers found that an earlier age of onset of thelarche and menarche was associated with a higher prevalence of migraine. A 1-year decrease in the age of onset of thelarche or menarche was associated with a 32.8% or 33.8% increase in the odds of migraine headache, respectively. Pubarche was not associated with migraine.

Dr. Martin had no relevant disclosures.

[email protected]

Early nerve transfer surgery is safe and can provide significant functional improvement to patients with cervical spinal cord injury and tetraplegia, according to research published online July 4 ahead of print in the Lancet. Combining nerve transfer with tendon transfer may maximize the functional benefit of surgery.

The loss of upper extremity function after cervical spinal cord injury can reduce independence and social and vocational engagement. People with tetraplegia rank improvement in hand function as their most important goal. Tendon transfers have been the traditional method of restoring function, but interest in nerve transfers has been increasing with the publication of successful results. Nerve transfers can reanimate several muscles at once and require a smaller incision and shorter immobilization, compared with tendon transfers.
 

Injury had occurred less than 18 months previously

Natasha van Zyl, MBBS, a plastic and reconstructive surgeon at Austin Health in Melbourne, and colleagues conducted a prospective case series to examine the clinical and functional outcomes of nerve transfer surgery for the reanimation of upper limb function in patients with tetraplegia. The investigators also sought to compare these outcomes with published outcomes for tendon transfer surgery.

Between April 14, 2014, and Nov. 22, 2018, Dr. van Zyl and colleagues recruited consecutive patients of any age with early cervical spinal cord injury of motor level C5 and below. Injury was required to have occurred fewer than 18 months before enrollment. Eligible participants had been referred to a single center for upper extremity reanimation and were considered candidates for nerve transfer.

Every participant underwent single or multiple nerve transfers in one or both upper limbs, and some participants also underwent tendon transfers. The goal of surgery was the restoration of elbow extension, grasp, pinch, and hand opening. An independent assessor evaluated participants at baseline and at 12 months and 24 months after surgery. The primary outcome measures were the action research arm test (ARAT), the grasp release test (GRT), and the spinal cord independence measure (SCIM).
 

Grasp function improved significantly

Dr. van Zyl and colleagues recruited 16 participants with traumatic spinal cord injury who underwent 59 nerve transfers. Ten participants also underwent tendon transfers. The population’s mean age at time of injury was 27.3 years. Three patients were female. Motor vehicle accidents were the most common cause of injury (31%). Follow-up data at 24 months were unavailable for three patients.

Participants’ median ARAT total score significantly improved from 16.5 at baseline to 34.0 at 24 months. Median GRT total score significantly improved from 35.0 at baseline to 125.2 at 24 months. The population’s mean total SCIM score and mobility in the room and toilet SCIM score improved by more than the minimal detectable change and the minimal clinically important difference. The mean self-care SCIM score improved by more than the minimal detectable change between baseline and 24 months.

The researchers observed six adverse events related to the surgery, but none had sustained functional consequences. No patients had an increase in musculoskeletal or neuropathic pain. Four of the 50 nerve transfers with 24-month follow-up failed.
 

A novel technique

“This project is the first to comprehensively examine outcomes for early, multiple nerve transfer surgery in the upper limbs of people with tetraplegia following traumatic spinal cord injury and is the largest prospective series of nerve transfers reported in this population to date,” said Dr. van Zyl and colleagues. Study limitations included the small sample size, the high variability of spinal cord injury patterns, and the potential for the multiple procedures that each participant underwent to confound data analysis.

Future research could explore whether nerve transfers are beneficial at more than 24 months after spinal cord injury, wrote the authors. In addition, it is unclear whether function and strength continue to improve beyond 24 months after surgery.

The study was funded by the Institute for Safety, Compensation, and Recovery Research in Australia. The authors had no competing interests.

[email protected]

SOURCE: van Zyl N et al. Lancet. 2019 Jul 4. doi: 10.1016/S0140-6736(19)31143-2.

Early nerve transfer surgery is safe and can provide significant functional improvement to patients with cervical spinal cord injury and tetraplegia, according to research published online July 4 ahead of print in the Lancet. Combining nerve transfer with tendon transfer may maximize the functional benefit of surgery.

The loss of upper extremity function after cervical spinal cord injury can reduce independence and social and vocational engagement. People with tetraplegia rank improvement in hand function as their most important goal. Tendon transfers have been the traditional method of restoring function, but interest in nerve transfers has been increasing with the publication of successful results. Nerve transfers can reanimate several muscles at once and require a smaller incision and shorter immobilization, compared with tendon transfers.
 

Injury had occurred less than 18 months previously

Natasha van Zyl, MBBS, a plastic and reconstructive surgeon at Austin Health in Melbourne, and colleagues conducted a prospective case series to examine the clinical and functional outcomes of nerve transfer surgery for the reanimation of upper limb function in patients with tetraplegia. The investigators also sought to compare these outcomes with published outcomes for tendon transfer surgery.

Between April 14, 2014, and Nov. 22, 2018, Dr. van Zyl and colleagues recruited consecutive patients of any age with early cervical spinal cord injury of motor level C5 and below. Injury was required to have occurred fewer than 18 months before enrollment. Eligible participants had been referred to a single center for upper extremity reanimation and were considered candidates for nerve transfer.

Every participant underwent single or multiple nerve transfers in one or both upper limbs, and some participants also underwent tendon transfers. The goal of surgery was the restoration of elbow extension, grasp, pinch, and hand opening. An independent assessor evaluated participants at baseline and at 12 months and 24 months after surgery. The primary outcome measures were the action research arm test (ARAT), the grasp release test (GRT), and the spinal cord independence measure (SCIM).
 

Grasp function improved significantly

Dr. van Zyl and colleagues recruited 16 participants with traumatic spinal cord injury who underwent 59 nerve transfers. Ten participants also underwent tendon transfers. The population’s mean age at time of injury was 27.3 years. Three patients were female. Motor vehicle accidents were the most common cause of injury (31%). Follow-up data at 24 months were unavailable for three patients.

Participants’ median ARAT total score significantly improved from 16.5 at baseline to 34.0 at 24 months. Median GRT total score significantly improved from 35.0 at baseline to 125.2 at 24 months. The population’s mean total SCIM score and mobility in the room and toilet SCIM score improved by more than the minimal detectable change and the minimal clinically important difference. The mean self-care SCIM score improved by more than the minimal detectable change between baseline and 24 months.

The researchers observed six adverse events related to the surgery, but none had sustained functional consequences. No patients had an increase in musculoskeletal or neuropathic pain. Four of the 50 nerve transfers with 24-month follow-up failed.
 

A novel technique

“This project is the first to comprehensively examine outcomes for early, multiple nerve transfer surgery in the upper limbs of people with tetraplegia following traumatic spinal cord injury and is the largest prospective series of nerve transfers reported in this population to date,” said Dr. van Zyl and colleagues. Study limitations included the small sample size, the high variability of spinal cord injury patterns, and the potential for the multiple procedures that each participant underwent to confound data analysis.

Future research could explore whether nerve transfers are beneficial at more than 24 months after spinal cord injury, wrote the authors. In addition, it is unclear whether function and strength continue to improve beyond 24 months after surgery.

The study was funded by the Institute for Safety, Compensation, and Recovery Research in Australia. The authors had no competing interests.

[email protected]

SOURCE: van Zyl N et al. Lancet. 2019 Jul 4. doi: 10.1016/S0140-6736(19)31143-2.

Early nerve transfer surgery is safe and can provide significant functional improvement to patients with cervical spinal cord injury and tetraplegia, according to research published online July 4 ahead of print in the Lancet. Combining nerve transfer with tendon transfer may maximize the functional benefit of surgery.

The loss of upper extremity function after cervical spinal cord injury can reduce independence and social and vocational engagement. People with tetraplegia rank improvement in hand function as their most important goal. Tendon transfers have been the traditional method of restoring function, but interest in nerve transfers has been increasing with the publication of successful results. Nerve transfers can reanimate several muscles at once and require a smaller incision and shorter immobilization, compared with tendon transfers.
 

Injury had occurred less than 18 months previously

Natasha van Zyl, MBBS, a plastic and reconstructive surgeon at Austin Health in Melbourne, and colleagues conducted a prospective case series to examine the clinical and functional outcomes of nerve transfer surgery for the reanimation of upper limb function in patients with tetraplegia. The investigators also sought to compare these outcomes with published outcomes for tendon transfer surgery.

Between April 14, 2014, and Nov. 22, 2018, Dr. van Zyl and colleagues recruited consecutive patients of any age with early cervical spinal cord injury of motor level C5 and below. Injury was required to have occurred fewer than 18 months before enrollment. Eligible participants had been referred to a single center for upper extremity reanimation and were considered candidates for nerve transfer.

Every participant underwent single or multiple nerve transfers in one or both upper limbs, and some participants also underwent tendon transfers. The goal of surgery was the restoration of elbow extension, grasp, pinch, and hand opening. An independent assessor evaluated participants at baseline and at 12 months and 24 months after surgery. The primary outcome measures were the action research arm test (ARAT), the grasp release test (GRT), and the spinal cord independence measure (SCIM).
 

Grasp function improved significantly

Dr. van Zyl and colleagues recruited 16 participants with traumatic spinal cord injury who underwent 59 nerve transfers. Ten participants also underwent tendon transfers. The population’s mean age at time of injury was 27.3 years. Three patients were female. Motor vehicle accidents were the most common cause of injury (31%). Follow-up data at 24 months were unavailable for three patients.

Participants’ median ARAT total score significantly improved from 16.5 at baseline to 34.0 at 24 months. Median GRT total score significantly improved from 35.0 at baseline to 125.2 at 24 months. The population’s mean total SCIM score and mobility in the room and toilet SCIM score improved by more than the minimal detectable change and the minimal clinically important difference. The mean self-care SCIM score improved by more than the minimal detectable change between baseline and 24 months.

The researchers observed six adverse events related to the surgery, but none had sustained functional consequences. No patients had an increase in musculoskeletal or neuropathic pain. Four of the 50 nerve transfers with 24-month follow-up failed.
 

A novel technique

“This project is the first to comprehensively examine outcomes for early, multiple nerve transfer surgery in the upper limbs of people with tetraplegia following traumatic spinal cord injury and is the largest prospective series of nerve transfers reported in this population to date,” said Dr. van Zyl and colleagues. Study limitations included the small sample size, the high variability of spinal cord injury patterns, and the potential for the multiple procedures that each participant underwent to confound data analysis.

Future research could explore whether nerve transfers are beneficial at more than 24 months after spinal cord injury, wrote the authors. In addition, it is unclear whether function and strength continue to improve beyond 24 months after surgery.

The study was funded by the Institute for Safety, Compensation, and Recovery Research in Australia. The authors had no competing interests.

[email protected]

SOURCE: van Zyl N et al. Lancet. 2019 Jul 4. doi: 10.1016/S0140-6736(19)31143-2.