International Headache Society (IHS): International Headache Congress

BERLIN – Women with endometriosis have nearly twice the odds of experiencing migraine headaches within a year of diagnosis than do those without the condition, according to a large, population-based, case-control study.

The findings of that study join conflicting data in the literature regarding comorbidity between migraines and endometriosis. For example, a genetic study of twins supports the relationship with an odds ratio of 1.57 (Genet. Epidemiol. 2009;33:105-13). Other researchers found a higher incidence of endometriosis among 22% of 171 women with migraine and 10% of 104 controls without migraine (Headache 2007;47:1069-78). In contrast, other investigators found that migraine was associated with chronic pelvic pain in a study of 108 women, but that endometriosis was not a significant factor (Fertil. Steril. 2011;95;895-9).

First author of the current study, Dr. Jong-Ling Fuh, a neurologist at the Neurological Institute of Taipei (Taiwan) Veterans General Hospital, said at the International Headache Congress that "there are many similarities between migraine and endometriosis."

For example, early menarche is a well-known risk factor for endometriosis, Dr. Fuh said. Menarche before age 12 years is also associated with increased prevalence of both migraine and nonmigraine headache (Eur. J. Neurol. 2011;18:321-8).

In addition, menorrhagia is a frequent complaint among women with endometriosis, Dr. Fuh said. In one study, for example, 63% of migraine patients reported recent history of menorrhagia, compared with 37% of controls (Headache 2006;46:422-8).

In the current study, migraines occurred in 1% of 20,220 women with endometriosis, which was significantly different from the rate of 0.5% seen in 101,100 women in a control group (odds ratio, 1.91).

Women with both conditions had similarly higher odds of first developing migraine (OR, 2.00) or endometriosis (OR, 1.85). However, after controlling for other clinical factors, researchers found that the association remained significant only when migraine preceded endometriosis (OR, 2.40), which suggests these headaches could predict endometriosis in some patients, Dr. Fuh said.

"Migraine was still an independent risk factor for endometriosis" after researchers controlled for patient age, medical history of infertility or pelvic pain, and previous laparoscopic surgery, Dr. Fuh added at the congress, which was sponsored by the International Headache Society and the American Headache Society. The data came from inpatient and outpatient ICD-9 codes in 2000-2007 in Taiwan’s National Health Insurance Research Database.

The study population included women aged 18-51 years (mean age, 38). Dr. Fuh reported that when the researchers examined only the 707 women who had migraine from either group, they found that endometriosis was more common among these migraineurs (28%) than in 19% of 120,613 of women without migraine.

A meeting attendee asked if the current endometriosis findings would remain statistically significant if pelvic pain was removed. "We did control for pelvic pain in our regression model, and pelvic pain and endometriosis were both independent risk factors [for migraine]," Dr. Fuh responded.

Although the physiological link between migraine and endometriosis remains unclear, Dr. Fuh proposed that the underlying mechanism for the comorbid association could be the "activation of sensory fibers within ectopic endometrial tissue, [leading] to hyperactivity of neurons throughout the central nervous system."

Use of a large database is a strength of the study, Dr. Fuh said. Potential limitations include a reliance on administrative coding and possible underdiagnosis of migraine. A meeting attendee commented that underdiagnosis of migraine could be a "big factor" with only 1% prevalence in the study. "I agree with you," Dr. Fuh said. "We need more education of primary care physicians about migraine ... to diagnose more."

Dr. Fuh had no relevant financial disclosures.

BERLIN – Women with endometriosis have nearly twice the odds of experiencing migraine headaches within a year of diagnosis than do those without the condition, according to a large, population-based, case-control study.

The findings of that study join conflicting data in the literature regarding comorbidity between migraines and endometriosis. For example, a genetic study of twins supports the relationship with an odds ratio of 1.57 (Genet. Epidemiol. 2009;33:105-13). Other researchers found a higher incidence of endometriosis among 22% of 171 women with migraine and 10% of 104 controls without migraine (Headache 2007;47:1069-78). In contrast, other investigators found that migraine was associated with chronic pelvic pain in a study of 108 women, but that endometriosis was not a significant factor (Fertil. Steril. 2011;95;895-9).

First author of the current study, Dr. Jong-Ling Fuh, a neurologist at the Neurological Institute of Taipei (Taiwan) Veterans General Hospital, said at the International Headache Congress that "there are many similarities between migraine and endometriosis."

For example, early menarche is a well-known risk factor for endometriosis, Dr. Fuh said. Menarche before age 12 years is also associated with increased prevalence of both migraine and nonmigraine headache (Eur. J. Neurol. 2011;18:321-8).

In addition, menorrhagia is a frequent complaint among women with endometriosis, Dr. Fuh said. In one study, for example, 63% of migraine patients reported recent history of menorrhagia, compared with 37% of controls (Headache 2006;46:422-8).

In the current study, migraines occurred in 1% of 20,220 women with endometriosis, which was significantly different from the rate of 0.5% seen in 101,100 women in a control group (odds ratio, 1.91).

Women with both conditions had similarly higher odds of first developing migraine (OR, 2.00) or endometriosis (OR, 1.85). However, after controlling for other clinical factors, researchers found that the association remained significant only when migraine preceded endometriosis (OR, 2.40), which suggests these headaches could predict endometriosis in some patients, Dr. Fuh said.

"Migraine was still an independent risk factor for endometriosis" after researchers controlled for patient age, medical history of infertility or pelvic pain, and previous laparoscopic surgery, Dr. Fuh added at the congress, which was sponsored by the International Headache Society and the American Headache Society. The data came from inpatient and outpatient ICD-9 codes in 2000-2007 in Taiwan’s National Health Insurance Research Database.

The study population included women aged 18-51 years (mean age, 38). Dr. Fuh reported that when the researchers examined only the 707 women who had migraine from either group, they found that endometriosis was more common among these migraineurs (28%) than in 19% of 120,613 of women without migraine.

A meeting attendee asked if the current endometriosis findings would remain statistically significant if pelvic pain was removed. "We did control for pelvic pain in our regression model, and pelvic pain and endometriosis were both independent risk factors [for migraine]," Dr. Fuh responded.

Although the physiological link between migraine and endometriosis remains unclear, Dr. Fuh proposed that the underlying mechanism for the comorbid association could be the "activation of sensory fibers within ectopic endometrial tissue, [leading] to hyperactivity of neurons throughout the central nervous system."

Use of a large database is a strength of the study, Dr. Fuh said. Potential limitations include a reliance on administrative coding and possible underdiagnosis of migraine. A meeting attendee commented that underdiagnosis of migraine could be a "big factor" with only 1% prevalence in the study. "I agree with you," Dr. Fuh said. "We need more education of primary care physicians about migraine ... to diagnose more."

Dr. Fuh had no relevant financial disclosures.

BERLIN – Women with endometriosis have nearly twice the odds of experiencing migraine headaches within a year of diagnosis than do those without the condition, according to a large, population-based, case-control study.

The findings of that study join conflicting data in the literature regarding comorbidity between migraines and endometriosis. For example, a genetic study of twins supports the relationship with an odds ratio of 1.57 (Genet. Epidemiol. 2009;33:105-13). Other researchers found a higher incidence of endometriosis among 22% of 171 women with migraine and 10% of 104 controls without migraine (Headache 2007;47:1069-78). In contrast, other investigators found that migraine was associated with chronic pelvic pain in a study of 108 women, but that endometriosis was not a significant factor (Fertil. Steril. 2011;95;895-9).

First author of the current study, Dr. Jong-Ling Fuh, a neurologist at the Neurological Institute of Taipei (Taiwan) Veterans General Hospital, said at the International Headache Congress that "there are many similarities between migraine and endometriosis."

For example, early menarche is a well-known risk factor for endometriosis, Dr. Fuh said. Menarche before age 12 years is also associated with increased prevalence of both migraine and nonmigraine headache (Eur. J. Neurol. 2011;18:321-8).

In addition, menorrhagia is a frequent complaint among women with endometriosis, Dr. Fuh said. In one study, for example, 63% of migraine patients reported recent history of menorrhagia, compared with 37% of controls (Headache 2006;46:422-8).

In the current study, migraines occurred in 1% of 20,220 women with endometriosis, which was significantly different from the rate of 0.5% seen in 101,100 women in a control group (odds ratio, 1.91).

Women with both conditions had similarly higher odds of first developing migraine (OR, 2.00) or endometriosis (OR, 1.85). However, after controlling for other clinical factors, researchers found that the association remained significant only when migraine preceded endometriosis (OR, 2.40), which suggests these headaches could predict endometriosis in some patients, Dr. Fuh said.

"Migraine was still an independent risk factor for endometriosis" after researchers controlled for patient age, medical history of infertility or pelvic pain, and previous laparoscopic surgery, Dr. Fuh added at the congress, which was sponsored by the International Headache Society and the American Headache Society. The data came from inpatient and outpatient ICD-9 codes in 2000-2007 in Taiwan’s National Health Insurance Research Database.

The study population included women aged 18-51 years (mean age, 38). Dr. Fuh reported that when the researchers examined only the 707 women who had migraine from either group, they found that endometriosis was more common among these migraineurs (28%) than in 19% of 120,613 of women without migraine.

A meeting attendee asked if the current endometriosis findings would remain statistically significant if pelvic pain was removed. "We did control for pelvic pain in our regression model, and pelvic pain and endometriosis were both independent risk factors [for migraine]," Dr. Fuh responded.

Although the physiological link between migraine and endometriosis remains unclear, Dr. Fuh proposed that the underlying mechanism for the comorbid association could be the "activation of sensory fibers within ectopic endometrial tissue, [leading] to hyperactivity of neurons throughout the central nervous system."

Use of a large database is a strength of the study, Dr. Fuh said. Potential limitations include a reliance on administrative coding and possible underdiagnosis of migraine. A meeting attendee commented that underdiagnosis of migraine could be a "big factor" with only 1% prevalence in the study. "I agree with you," Dr. Fuh said. "We need more education of primary care physicians about migraine ... to diagnose more."

Dr. Fuh had no relevant financial disclosures.

BERLIN – Patients with migraine and depression have more than twice the odds of experiencing cutaneous allodynia during a headache attack than do patients with migraine but no depression, according to a survey of 2,597 patients.

Current depression or history of depression was associated with 2.4 times greater odds of cutaneous allodynia (the perception of pain caused by non-noxious stimuli to normal skin), Dr. Mark Louter said at the International Headache Congress.

Allodynia also was clearly predicted by gender, age at onset of headaches, and increased frequency of migraine, Dr. Louter said.

Nearly 70%, or 1,810 of the 2,597 migraineurs who completed the digital depression questionnaire, reported cutaneous allodynia during their migraine attacks.

Women had significantly greater odds of reporting cutaneous allodynia, compared with men (odds ratio, 3.3).

Looked at another way, the odds for migraineurs who reported cutaneous allodynia to also report depression in their lifetime was significantly greater than for those who did not report allodynia (OR, 2.2). This multivariate logistic regression analysis was adjusted for age, gender, frequency of attack, type of migraine, and use of prophylactic medication.

A meeting attendee asked about depression severity. "That is a good question, but for this analysis, we dichotomized the patients into depression versus no depression," Dr. Louter responded.

"Cutaneous allodynia was associated with higher headache frequency, symptoms of anxiety and depression, and a younger onset of headache," said Dr. Louter, a physician-researcher in neurology and psychiatry at Leiden (Netherlands) University Medical Center.

The study was cross-sectional, so causality cannot be demonstrated, Dr. Louter said at the congress, which was sponsored by the International Headache Society and the American Headache Society. Respondents were adults with migraine aged 18-74 years who had been identified from the Leiden University Medical Centre Migraine Neuro-Analysis Program (LUMINA) database.

Migraine type and body mass index were not significantly associated with presence of cutaneous allodynia.

A total 3,029 self-reported migraineurs completed a headache questionnaire based on ICHD-II migraine criteria; 2,597 completed a depression questionnaire that included the Hospital Anxiety and Depression Scale-Depression subscale (HADS-D), the Center for Epidemiologic Studies Depression (CES-D) scale, and additional questions about lifetime depression. Another 2,269 answered a follow-up questionnaire on headache frequency. Cutaneous allodynia was assessed with a validated 12-item scale, similar to the Allodynia Symptom Checklist.

This study demonstrates that two-thirds of migraineurs have cutaneous allodynia during their attacks, Dr. Louter said. Important findings include a preponderance of cutaneous allodynia among women with migraine, but most importantly, in migraineurs with lifetime depression, he added.

"We think more research is needed to evaluate this further," Dr. Louter said.

Dr. Louter said that he had no relevant disclosures.

BERLIN – Patients with migraine and depression have more than twice the odds of experiencing cutaneous allodynia during a headache attack than do patients with migraine but no depression, according to a survey of 2,597 patients.

Current depression or history of depression was associated with 2.4 times greater odds of cutaneous allodynia (the perception of pain caused by non-noxious stimuli to normal skin), Dr. Mark Louter said at the International Headache Congress.

Allodynia also was clearly predicted by gender, age at onset of headaches, and increased frequency of migraine, Dr. Louter said.

Nearly 70%, or 1,810 of the 2,597 migraineurs who completed the digital depression questionnaire, reported cutaneous allodynia during their migraine attacks.

Women had significantly greater odds of reporting cutaneous allodynia, compared with men (odds ratio, 3.3).

Looked at another way, the odds for migraineurs who reported cutaneous allodynia to also report depression in their lifetime was significantly greater than for those who did not report allodynia (OR, 2.2). This multivariate logistic regression analysis was adjusted for age, gender, frequency of attack, type of migraine, and use of prophylactic medication.

A meeting attendee asked about depression severity. "That is a good question, but for this analysis, we dichotomized the patients into depression versus no depression," Dr. Louter responded.

"Cutaneous allodynia was associated with higher headache frequency, symptoms of anxiety and depression, and a younger onset of headache," said Dr. Louter, a physician-researcher in neurology and psychiatry at Leiden (Netherlands) University Medical Center.

The study was cross-sectional, so causality cannot be demonstrated, Dr. Louter said at the congress, which was sponsored by the International Headache Society and the American Headache Society. Respondents were adults with migraine aged 18-74 years who had been identified from the Leiden University Medical Centre Migraine Neuro-Analysis Program (LUMINA) database.

Migraine type and body mass index were not significantly associated with presence of cutaneous allodynia.

A total 3,029 self-reported migraineurs completed a headache questionnaire based on ICHD-II migraine criteria; 2,597 completed a depression questionnaire that included the Hospital Anxiety and Depression Scale-Depression subscale (HADS-D), the Center for Epidemiologic Studies Depression (CES-D) scale, and additional questions about lifetime depression. Another 2,269 answered a follow-up questionnaire on headache frequency. Cutaneous allodynia was assessed with a validated 12-item scale, similar to the Allodynia Symptom Checklist.

This study demonstrates that two-thirds of migraineurs have cutaneous allodynia during their attacks, Dr. Louter said. Important findings include a preponderance of cutaneous allodynia among women with migraine, but most importantly, in migraineurs with lifetime depression, he added.

"We think more research is needed to evaluate this further," Dr. Louter said.

Dr. Louter said that he had no relevant disclosures.

BERLIN – Patients with migraine and depression have more than twice the odds of experiencing cutaneous allodynia during a headache attack than do patients with migraine but no depression, according to a survey of 2,597 patients.

Current depression or history of depression was associated with 2.4 times greater odds of cutaneous allodynia (the perception of pain caused by non-noxious stimuli to normal skin), Dr. Mark Louter said at the International Headache Congress.

Allodynia also was clearly predicted by gender, age at onset of headaches, and increased frequency of migraine, Dr. Louter said.

Nearly 70%, or 1,810 of the 2,597 migraineurs who completed the digital depression questionnaire, reported cutaneous allodynia during their migraine attacks.

Women had significantly greater odds of reporting cutaneous allodynia, compared with men (odds ratio, 3.3).

Looked at another way, the odds for migraineurs who reported cutaneous allodynia to also report depression in their lifetime was significantly greater than for those who did not report allodynia (OR, 2.2). This multivariate logistic regression analysis was adjusted for age, gender, frequency of attack, type of migraine, and use of prophylactic medication.

A meeting attendee asked about depression severity. "That is a good question, but for this analysis, we dichotomized the patients into depression versus no depression," Dr. Louter responded.

"Cutaneous allodynia was associated with higher headache frequency, symptoms of anxiety and depression, and a younger onset of headache," said Dr. Louter, a physician-researcher in neurology and psychiatry at Leiden (Netherlands) University Medical Center.

The study was cross-sectional, so causality cannot be demonstrated, Dr. Louter said at the congress, which was sponsored by the International Headache Society and the American Headache Society. Respondents were adults with migraine aged 18-74 years who had been identified from the Leiden University Medical Centre Migraine Neuro-Analysis Program (LUMINA) database.

Migraine type and body mass index were not significantly associated with presence of cutaneous allodynia.

A total 3,029 self-reported migraineurs completed a headache questionnaire based on ICHD-II migraine criteria; 2,597 completed a depression questionnaire that included the Hospital Anxiety and Depression Scale-Depression subscale (HADS-D), the Center for Epidemiologic Studies Depression (CES-D) scale, and additional questions about lifetime depression. Another 2,269 answered a follow-up questionnaire on headache frequency. Cutaneous allodynia was assessed with a validated 12-item scale, similar to the Allodynia Symptom Checklist.

This study demonstrates that two-thirds of migraineurs have cutaneous allodynia during their attacks, Dr. Louter said. Important findings include a preponderance of cutaneous allodynia among women with migraine, but most importantly, in migraineurs with lifetime depression, he added.

"We think more research is needed to evaluate this further," Dr. Louter said.

Dr. Louter said that he had no relevant disclosures.

BERLIN – Asking patients to fill out a daily diary 1 month before their initial evaluation improves the accuracy of their headache diagnosis compared with clinical evaluation alone, according to a prospective, multicenter study.

"The basic daily headache diary was well accepted by patients and was well accepted by physicians," Dr. Rigmor Jensen said at the International Headache Congress.

An earlier pilot study with 76 patients demonstrated the paper-based diary improved diagnostic sensitivity from 75% to 92% and specificity from 58% to 87% when combined with a clinical interview and examination (Cephalalgia 2008;28:1023-30). In addition, the diary provided useful data on the frequency of different types of headaches within the same patient, and patients reported that it was easy to use, said Dr. Jensen, an investigator on both studies.

Following this initial success, Dr. Jensen and her associates expanded their research to multiple clinical sites in Europe and South America. They randomized newly referred patients on a waiting list to two groups. They then compared 321 patients given a daily diary to complete 1 month prior to first consultation with 305 patients who received usual care (clinical evaluation and examination only).

Participants in the diary group recorded headache symptoms, medications taken, and whether their pain was unilateral or bilateral. This group provided their physicians with more complete diagnostic information. "The adequacy of the diary and clinical interview for headache diagnosis was 98% compared to 87% for the interview alone," Dr. Jensen said at the congress, which was sponsored by the International Headache Society and the American Headache Society.

The mean number of diagnoses per patient was significantly higher in patients who kept a diary than among those who received usual care (1.22 vs. 1.14). Only tension-type headache (episodic or chronic) was diagnosed more often in the usual care group than in the diary group (39% vs. 25%). Otherwise, there were no significant differences by headache type, said Dr. Jensen, director of the Danish headache center at Glostrup (Denmark) Hospital.

A meeting attendee asked how much additional time it takes physicians to read the diaries. "We did not record the timing," Dr. Jensen said. "But we asked the doctors, and for some it was time saving and for others it was time consuming." She added, "In my experience, the patients are prepared for questions, so it’s time saving for most of us used to using the diary. In the long run, we find it is time saving."

A total 97% of physicians reported they were satisfied with the diary. Incompleteness of some diaries and a lack of specificity for migraines with aura were among the reported problems. Dr. Jensen said a separate diary for patients who experience headache with aura is in development.

The same percentage of patients in the diary group reported satisfaction. Two patients each reported problems with understanding the questions; describing their headache intensity; the small size of the text; and the time it took to complete the daily entries. "These were not the same two patients complaining on each one," said Dr. Jensen, who also is professor of headache and neurologic pain at the University of Copenhagen.

The diary works in multiple cultures and languages. The study sites were in Italy, Denmark, Russia, Serbia, Portugal, Georgia, Germany, Chile, and Argentina.

An electronic version of the diary is in development.

Dr. Jensen said that she had no relevant financial disclosures.

BERLIN – Asking patients to fill out a daily diary 1 month before their initial evaluation improves the accuracy of their headache diagnosis compared with clinical evaluation alone, according to a prospective, multicenter study.

"The basic daily headache diary was well accepted by patients and was well accepted by physicians," Dr. Rigmor Jensen said at the International Headache Congress.

An earlier pilot study with 76 patients demonstrated the paper-based diary improved diagnostic sensitivity from 75% to 92% and specificity from 58% to 87% when combined with a clinical interview and examination (Cephalalgia 2008;28:1023-30). In addition, the diary provided useful data on the frequency of different types of headaches within the same patient, and patients reported that it was easy to use, said Dr. Jensen, an investigator on both studies.

Following this initial success, Dr. Jensen and her associates expanded their research to multiple clinical sites in Europe and South America. They randomized newly referred patients on a waiting list to two groups. They then compared 321 patients given a daily diary to complete 1 month prior to first consultation with 305 patients who received usual care (clinical evaluation and examination only).

Participants in the diary group recorded headache symptoms, medications taken, and whether their pain was unilateral or bilateral. This group provided their physicians with more complete diagnostic information. "The adequacy of the diary and clinical interview for headache diagnosis was 98% compared to 87% for the interview alone," Dr. Jensen said at the congress, which was sponsored by the International Headache Society and the American Headache Society.

The mean number of diagnoses per patient was significantly higher in patients who kept a diary than among those who received usual care (1.22 vs. 1.14). Only tension-type headache (episodic or chronic) was diagnosed more often in the usual care group than in the diary group (39% vs. 25%). Otherwise, there were no significant differences by headache type, said Dr. Jensen, director of the Danish headache center at Glostrup (Denmark) Hospital.

A meeting attendee asked how much additional time it takes physicians to read the diaries. "We did not record the timing," Dr. Jensen said. "But we asked the doctors, and for some it was time saving and for others it was time consuming." She added, "In my experience, the patients are prepared for questions, so it’s time saving for most of us used to using the diary. In the long run, we find it is time saving."

A total 97% of physicians reported they were satisfied with the diary. Incompleteness of some diaries and a lack of specificity for migraines with aura were among the reported problems. Dr. Jensen said a separate diary for patients who experience headache with aura is in development.

The same percentage of patients in the diary group reported satisfaction. Two patients each reported problems with understanding the questions; describing their headache intensity; the small size of the text; and the time it took to complete the daily entries. "These were not the same two patients complaining on each one," said Dr. Jensen, who also is professor of headache and neurologic pain at the University of Copenhagen.

The diary works in multiple cultures and languages. The study sites were in Italy, Denmark, Russia, Serbia, Portugal, Georgia, Germany, Chile, and Argentina.

An electronic version of the diary is in development.

Dr. Jensen said that she had no relevant financial disclosures.

BERLIN – Asking patients to fill out a daily diary 1 month before their initial evaluation improves the accuracy of their headache diagnosis compared with clinical evaluation alone, according to a prospective, multicenter study.

"The basic daily headache diary was well accepted by patients and was well accepted by physicians," Dr. Rigmor Jensen said at the International Headache Congress.

An earlier pilot study with 76 patients demonstrated the paper-based diary improved diagnostic sensitivity from 75% to 92% and specificity from 58% to 87% when combined with a clinical interview and examination (Cephalalgia 2008;28:1023-30). In addition, the diary provided useful data on the frequency of different types of headaches within the same patient, and patients reported that it was easy to use, said Dr. Jensen, an investigator on both studies.

Following this initial success, Dr. Jensen and her associates expanded their research to multiple clinical sites in Europe and South America. They randomized newly referred patients on a waiting list to two groups. They then compared 321 patients given a daily diary to complete 1 month prior to first consultation with 305 patients who received usual care (clinical evaluation and examination only).

Participants in the diary group recorded headache symptoms, medications taken, and whether their pain was unilateral or bilateral. This group provided their physicians with more complete diagnostic information. "The adequacy of the diary and clinical interview for headache diagnosis was 98% compared to 87% for the interview alone," Dr. Jensen said at the congress, which was sponsored by the International Headache Society and the American Headache Society.

The mean number of diagnoses per patient was significantly higher in patients who kept a diary than among those who received usual care (1.22 vs. 1.14). Only tension-type headache (episodic or chronic) was diagnosed more often in the usual care group than in the diary group (39% vs. 25%). Otherwise, there were no significant differences by headache type, said Dr. Jensen, director of the Danish headache center at Glostrup (Denmark) Hospital.

A meeting attendee asked how much additional time it takes physicians to read the diaries. "We did not record the timing," Dr. Jensen said. "But we asked the doctors, and for some it was time saving and for others it was time consuming." She added, "In my experience, the patients are prepared for questions, so it’s time saving for most of us used to using the diary. In the long run, we find it is time saving."

A total 97% of physicians reported they were satisfied with the diary. Incompleteness of some diaries and a lack of specificity for migraines with aura were among the reported problems. Dr. Jensen said a separate diary for patients who experience headache with aura is in development.

The same percentage of patients in the diary group reported satisfaction. Two patients each reported problems with understanding the questions; describing their headache intensity; the small size of the text; and the time it took to complete the daily entries. "These were not the same two patients complaining on each one," said Dr. Jensen, who also is professor of headache and neurologic pain at the University of Copenhagen.

The diary works in multiple cultures and languages. The study sites were in Italy, Denmark, Russia, Serbia, Portugal, Georgia, Germany, Chile, and Argentina.

An electronic version of the diary is in development.

Dr. Jensen said that she had no relevant financial disclosures.

BERLIN – Do you have older patients who experience migraines with aura? You might want to check their lipid levels.

Older patients who experience migraines with aura may be at increased risk for elevated lipids, particularly total cholesterol and triglycerides, according to the EVA (Epidemiology of Vascular Aging) study.

Migraine with aura has been linked to increased risk of ischemic vascular events, Dr. Tobias Kurth said at the International Headache Congress, which was sponsored by the International Headache Society and the American Headache Society. "Migraine with aura is also associated with increased prevalence of cardiovascular risk factors, including elevated levels of some vascular biomarkers" (Eur. J. Neurol. 2011;18:504-11; Neurology. 2005;64:614-20).

However, "there is a lack of data in the elderly, a group with increased lipids," Dr. Kurth said.

The researchers conducted a cross-sectional study of 1,155 EVA participants with complete lipid and headache information. The patients were classified into groups of three (called tertiles), based on their levels of different blood biomarkers. Their average age was 69 years.

A total of 166 participants had a history of migraine, including 23 who reported migraine with aura. Another 64 had nonmigraine headaches, and the vast majority (925 people) reported no severe headaches. Researchers determined the presence and type of headache through telephone interviews in this longitudinal study.

"There was a strong association with migraine with aura and increasing levels of cholesterol, with nearly a sixfold risk of being in third tertile" of total cholesterol, compared with patients without headache, said Dr. Kurth, director of research in the neuroepidemiology unit at Inserm (Institut National de la Santé et de la Recherche Médicale) in Paris.

Those with migraine with aura had greater adjusted odds (odds ratio, 5.97) of being in the third tertile for total cholesterol. Their risk for being in the second tertile also was greater (OR, 4.67), compared with those without headache.

Researchers also found a strong association between migraine with aura and elevated triglycerides (OR, 4.42 for the third tertile).

The findings confirm previous reports in the literature, Dr. Kurth said. "We observed a pattern consistent with other studies."

Interestingly, the associations held only for migraine with aura. No other headache forms in this elderly population were associated with increased lipid levels, Dr. Kurth said. "Migraine with aura is associated with an unfavorable lipid profile. Migraine with aura could be a marker for increased lipid levels."

A meeting attendee asked if the findings would warrant prescription of statin medication for patients with migraine with aura. "Enough is now published from population-based science that we can try, but I wouldn’t say statins are medications to treat migraine at this point," Dr. Kurth replied.

The large, population-based nature of the study was a strength, Dr. Kurth said. Headache assessment by neurologists via a telephone interview is a possible weakness, he added.

Further targeted research is needed, said Dr. Kurth, who reported that he had no relevant disclosures.

BERLIN – Do you have older patients who experience migraines with aura? You might want to check their lipid levels.

Older patients who experience migraines with aura may be at increased risk for elevated lipids, particularly total cholesterol and triglycerides, according to the EVA (Epidemiology of Vascular Aging) study.

Migraine with aura has been linked to increased risk of ischemic vascular events, Dr. Tobias Kurth said at the International Headache Congress, which was sponsored by the International Headache Society and the American Headache Society. "Migraine with aura is also associated with increased prevalence of cardiovascular risk factors, including elevated levels of some vascular biomarkers" (Eur. J. Neurol. 2011;18:504-11; Neurology. 2005;64:614-20).

However, "there is a lack of data in the elderly, a group with increased lipids," Dr. Kurth said.

The researchers conducted a cross-sectional study of 1,155 EVA participants with complete lipid and headache information. The patients were classified into groups of three (called tertiles), based on their levels of different blood biomarkers. Their average age was 69 years.

A total of 166 participants had a history of migraine, including 23 who reported migraine with aura. Another 64 had nonmigraine headaches, and the vast majority (925 people) reported no severe headaches. Researchers determined the presence and type of headache through telephone interviews in this longitudinal study.

"There was a strong association with migraine with aura and increasing levels of cholesterol, with nearly a sixfold risk of being in third tertile" of total cholesterol, compared with patients without headache, said Dr. Kurth, director of research in the neuroepidemiology unit at Inserm (Institut National de la Santé et de la Recherche Médicale) in Paris.

Those with migraine with aura had greater adjusted odds (odds ratio, 5.97) of being in the third tertile for total cholesterol. Their risk for being in the second tertile also was greater (OR, 4.67), compared with those without headache.

Researchers also found a strong association between migraine with aura and elevated triglycerides (OR, 4.42 for the third tertile).

The findings confirm previous reports in the literature, Dr. Kurth said. "We observed a pattern consistent with other studies."

Interestingly, the associations held only for migraine with aura. No other headache forms in this elderly population were associated with increased lipid levels, Dr. Kurth said. "Migraine with aura is associated with an unfavorable lipid profile. Migraine with aura could be a marker for increased lipid levels."

A meeting attendee asked if the findings would warrant prescription of statin medication for patients with migraine with aura. "Enough is now published from population-based science that we can try, but I wouldn’t say statins are medications to treat migraine at this point," Dr. Kurth replied.

The large, population-based nature of the study was a strength, Dr. Kurth said. Headache assessment by neurologists via a telephone interview is a possible weakness, he added.

Further targeted research is needed, said Dr. Kurth, who reported that he had no relevant disclosures.

BERLIN – Do you have older patients who experience migraines with aura? You might want to check their lipid levels.

Older patients who experience migraines with aura may be at increased risk for elevated lipids, particularly total cholesterol and triglycerides, according to the EVA (Epidemiology of Vascular Aging) study.

Migraine with aura has been linked to increased risk of ischemic vascular events, Dr. Tobias Kurth said at the International Headache Congress, which was sponsored by the International Headache Society and the American Headache Society. "Migraine with aura is also associated with increased prevalence of cardiovascular risk factors, including elevated levels of some vascular biomarkers" (Eur. J. Neurol. 2011;18:504-11; Neurology. 2005;64:614-20).

However, "there is a lack of data in the elderly, a group with increased lipids," Dr. Kurth said.

The researchers conducted a cross-sectional study of 1,155 EVA participants with complete lipid and headache information. The patients were classified into groups of three (called tertiles), based on their levels of different blood biomarkers. Their average age was 69 years.

A total of 166 participants had a history of migraine, including 23 who reported migraine with aura. Another 64 had nonmigraine headaches, and the vast majority (925 people) reported no severe headaches. Researchers determined the presence and type of headache through telephone interviews in this longitudinal study.

"There was a strong association with migraine with aura and increasing levels of cholesterol, with nearly a sixfold risk of being in third tertile" of total cholesterol, compared with patients without headache, said Dr. Kurth, director of research in the neuroepidemiology unit at Inserm (Institut National de la Santé et de la Recherche Médicale) in Paris.

Those with migraine with aura had greater adjusted odds (odds ratio, 5.97) of being in the third tertile for total cholesterol. Their risk for being in the second tertile also was greater (OR, 4.67), compared with those without headache.

Researchers also found a strong association between migraine with aura and elevated triglycerides (OR, 4.42 for the third tertile).

The findings confirm previous reports in the literature, Dr. Kurth said. "We observed a pattern consistent with other studies."

Interestingly, the associations held only for migraine with aura. No other headache forms in this elderly population were associated with increased lipid levels, Dr. Kurth said. "Migraine with aura is associated with an unfavorable lipid profile. Migraine with aura could be a marker for increased lipid levels."

A meeting attendee asked if the findings would warrant prescription of statin medication for patients with migraine with aura. "Enough is now published from population-based science that we can try, but I wouldn’t say statins are medications to treat migraine at this point," Dr. Kurth replied.

The large, population-based nature of the study was a strength, Dr. Kurth said. Headache assessment by neurologists via a telephone interview is a possible weakness, he added.

Further targeted research is needed, said Dr. Kurth, who reported that he had no relevant disclosures.

BERLIN – Rizatriptan fought migraine more effectively in children and adolescents when it was dosed according to body weight in a randomized, double-blind parallel group trial.

Previous industry-sponsored rizatriptan studies in children revealed no significant treatment effects, Dr. Tony W. Ho said. For example, in one study of 291 adolescents, the 2-hour response rate was 66% with treatment versus 56% with placebo. The lack of significant efficacy could be due to all patients receiving the same 5-mg tablets, a dose that can be insufficient given the increase in body mass index among 12- to 17-year-olds, he added.

"If you think about it, many adolescents are as heavy as some adults nowadays but may receive a lower dose," said Dr. Ho, a researcher at Merck Sharp & Dohme Corp., Whitehouse Station, N.J., a subsidiary of Merck & Co., which markets rizatriptan as Maxalt.

In the current study, Dr. Ho and his associates tried weight-based dosing in children aged 12-17 years with a history of moderate to severe attacks. Those who weighed less than 40 kg received 5-mg of rizatriptan orally disintegrating tablets (ODT; Maxalt-MLT), and those 40 kg or heavier received 10 mg within 30 minutes of a moderate to severe attack.

"These teenagers were heavier than we expected, with a mean BMI of 22.6 [kg/m²]. The majority of patients were from the U.S.," Dr. Ho said at the International Headache Congress, which was sponsored by the International Headache Society and the American Headache Society.

A total 570 of the 702 participants were evaluable for efficacy analyses and were studied further. The researchers found 31% of the treatment group (87 of 284 participants) reported freedom from pain at 2 hours (the primary outcome), compared with 22% (63 of 286) of the placebo group. The odds ratio favoring rizatriptan was 1.55. Patients rated their pain from 1 (a happy face meaning no head pain) up to 5 (a frowning face reflecting very bad head pain).

"Weight-based rizatriptan ODT treatment demonstrated a statistically significant difference versus placebo in eliminating pain," Dr. Ho said.

The study featured a double-blind, run-in phase design. "Even with a design to reduce the placebo effect, we still had a 22% rate," Dr. Ho said.

Patients randomized to rizatriptan also experienced significantly less nausea, vomiting, and impairment of activities of daily living, compared with those who received placebo, Dr. Ho said. "This supports a weight-based approach to treating pediatric migraine."

A meeting attendee questioned the incidence of vomiting reported in the study, stating that "usually the rate of severe vomiting is 60%-70%, but you had lower than 15%."

The children rated severity of associated symptoms, including vomiting, using a five-face scale, Dr. Ho replied. "I don’t know how that is related to other definitions of severity."

There was no statistically significant difference in 2-hour pain relief, a secondary outcome experienced by 59% of the treated group and 51% of the placebo group.

Rizatriptan use is off label in pediatric patients. The Food and Drug Administration cleared this selective 5-hydroxytryptamine_1B/1D receptor agonist for acute treatment of migraine attacks with or without aura in adults 18 years and older.

Rizatriptan was generally well tolerated, Dr. Ho said. The overall adverse event rate within 14 days was 24% in the treatment group and 23% in the placebo group.

Of the 702 patients enrolled, 91% were female. All participants had a history of migraine (with or without aura) for at least 6 months. They also reported one to eight moderate to severe migraine attacks per month and a lack of satisfactory relief with the use of nonsteroidal anti-inflammatory drugs.

Dr. Ho said additional data on children 6 years and older are forthcoming.

BERLIN – Rizatriptan fought migraine more effectively in children and adolescents when it was dosed according to body weight in a randomized, double-blind parallel group trial.

Previous industry-sponsored rizatriptan studies in children revealed no significant treatment effects, Dr. Tony W. Ho said. For example, in one study of 291 adolescents, the 2-hour response rate was 66% with treatment versus 56% with placebo. The lack of significant efficacy could be due to all patients receiving the same 5-mg tablets, a dose that can be insufficient given the increase in body mass index among 12- to 17-year-olds, he added.

"If you think about it, many adolescents are as heavy as some adults nowadays but may receive a lower dose," said Dr. Ho, a researcher at Merck Sharp & Dohme Corp., Whitehouse Station, N.J., a subsidiary of Merck & Co., which markets rizatriptan as Maxalt.

In the current study, Dr. Ho and his associates tried weight-based dosing in children aged 12-17 years with a history of moderate to severe attacks. Those who weighed less than 40 kg received 5-mg of rizatriptan orally disintegrating tablets (ODT; Maxalt-MLT), and those 40 kg or heavier received 10 mg within 30 minutes of a moderate to severe attack.

"These teenagers were heavier than we expected, with a mean BMI of 22.6 [kg/m²]. The majority of patients were from the U.S.," Dr. Ho said at the International Headache Congress, which was sponsored by the International Headache Society and the American Headache Society.

A total 570 of the 702 participants were evaluable for efficacy analyses and were studied further. The researchers found 31% of the treatment group (87 of 284 participants) reported freedom from pain at 2 hours (the primary outcome), compared with 22% (63 of 286) of the placebo group. The odds ratio favoring rizatriptan was 1.55. Patients rated their pain from 1 (a happy face meaning no head pain) up to 5 (a frowning face reflecting very bad head pain).

"Weight-based rizatriptan ODT treatment demonstrated a statistically significant difference versus placebo in eliminating pain," Dr. Ho said.

The study featured a double-blind, run-in phase design. "Even with a design to reduce the placebo effect, we still had a 22% rate," Dr. Ho said.

Patients randomized to rizatriptan also experienced significantly less nausea, vomiting, and impairment of activities of daily living, compared with those who received placebo, Dr. Ho said. "This supports a weight-based approach to treating pediatric migraine."

A meeting attendee questioned the incidence of vomiting reported in the study, stating that "usually the rate of severe vomiting is 60%-70%, but you had lower than 15%."

The children rated severity of associated symptoms, including vomiting, using a five-face scale, Dr. Ho replied. "I don’t know how that is related to other definitions of severity."

There was no statistically significant difference in 2-hour pain relief, a secondary outcome experienced by 59% of the treated group and 51% of the placebo group.

Rizatriptan use is off label in pediatric patients. The Food and Drug Administration cleared this selective 5-hydroxytryptamine_1B/1D receptor agonist for acute treatment of migraine attacks with or without aura in adults 18 years and older.

Rizatriptan was generally well tolerated, Dr. Ho said. The overall adverse event rate within 14 days was 24% in the treatment group and 23% in the placebo group.

Of the 702 patients enrolled, 91% were female. All participants had a history of migraine (with or without aura) for at least 6 months. They also reported one to eight moderate to severe migraine attacks per month and a lack of satisfactory relief with the use of nonsteroidal anti-inflammatory drugs.

Dr. Ho said additional data on children 6 years and older are forthcoming.

BERLIN – Rizatriptan fought migraine more effectively in children and adolescents when it was dosed according to body weight in a randomized, double-blind parallel group trial.

Previous industry-sponsored rizatriptan studies in children revealed no significant treatment effects, Dr. Tony W. Ho said. For example, in one study of 291 adolescents, the 2-hour response rate was 66% with treatment versus 56% with placebo. The lack of significant efficacy could be due to all patients receiving the same 5-mg tablets, a dose that can be insufficient given the increase in body mass index among 12- to 17-year-olds, he added.

"If you think about it, many adolescents are as heavy as some adults nowadays but may receive a lower dose," said Dr. Ho, a researcher at Merck Sharp & Dohme Corp., Whitehouse Station, N.J., a subsidiary of Merck & Co., which markets rizatriptan as Maxalt.

In the current study, Dr. Ho and his associates tried weight-based dosing in children aged 12-17 years with a history of moderate to severe attacks. Those who weighed less than 40 kg received 5-mg of rizatriptan orally disintegrating tablets (ODT; Maxalt-MLT), and those 40 kg or heavier received 10 mg within 30 minutes of a moderate to severe attack.

"These teenagers were heavier than we expected, with a mean BMI of 22.6 [kg/m²]. The majority of patients were from the U.S.," Dr. Ho said at the International Headache Congress, which was sponsored by the International Headache Society and the American Headache Society.

A total 570 of the 702 participants were evaluable for efficacy analyses and were studied further. The researchers found 31% of the treatment group (87 of 284 participants) reported freedom from pain at 2 hours (the primary outcome), compared with 22% (63 of 286) of the placebo group. The odds ratio favoring rizatriptan was 1.55. Patients rated their pain from 1 (a happy face meaning no head pain) up to 5 (a frowning face reflecting very bad head pain).

"Weight-based rizatriptan ODT treatment demonstrated a statistically significant difference versus placebo in eliminating pain," Dr. Ho said.

The study featured a double-blind, run-in phase design. "Even with a design to reduce the placebo effect, we still had a 22% rate," Dr. Ho said.

Patients randomized to rizatriptan also experienced significantly less nausea, vomiting, and impairment of activities of daily living, compared with those who received placebo, Dr. Ho said. "This supports a weight-based approach to treating pediatric migraine."

A meeting attendee questioned the incidence of vomiting reported in the study, stating that "usually the rate of severe vomiting is 60%-70%, but you had lower than 15%."

The children rated severity of associated symptoms, including vomiting, using a five-face scale, Dr. Ho replied. "I don’t know how that is related to other definitions of severity."

There was no statistically significant difference in 2-hour pain relief, a secondary outcome experienced by 59% of the treated group and 51% of the placebo group.

Rizatriptan use is off label in pediatric patients. The Food and Drug Administration cleared this selective 5-hydroxytryptamine_1B/1D receptor agonist for acute treatment of migraine attacks with or without aura in adults 18 years and older.

Rizatriptan was generally well tolerated, Dr. Ho said. The overall adverse event rate within 14 days was 24% in the treatment group and 23% in the placebo group.

Of the 702 patients enrolled, 91% were female. All participants had a history of migraine (with or without aura) for at least 6 months. They also reported one to eight moderate to severe migraine attacks per month and a lack of satisfactory relief with the use of nonsteroidal anti-inflammatory drugs.

Dr. Ho said additional data on children 6 years and older are forthcoming.

BERLIN – People never treated for their chronic migraines and those who failed a previous first-line medication reported similar reductions in frequency of headache days after treatment with onabotulinumtoxinA in a post hoc comparison study of the two phase III studies that Allergan used to gain approval for the new indication.

Some migraine medications work better in treatment-naïve patients, compared with those with a past marred by partial responses or one or more failures to first-line prophylactic therapies.

For this reason, Dr. Sheena K. Aurora and her associates assessed data from the two Phase 3 Research Evaluating Migraine Prophylaxis Therapy (PREEMPT) studies (Headache 2010;50:921-36) determine if onabotulinumtoxinA treatment works the same way. They compared 575 participants with a history of migraine prophylaxis use to another 809 participants who never tried such a first-line medication, as defined by the British Association for the Study of Headache (BASH). Amitriptyline and propranolol were the most common previous medications.

There was no significant difference in the reduction of frequency of headache days with onabotulinumtoxinA between previously-treated and untreated patients, Dr. Aurora said at the International Headache Congress, which was sponsored by the International Headache Society and the American Headache Society. A total 45% of patients with a history of first-line medication use versus 50% of those with no such history had a significant reduction in frequency of headache days.

"OnabotulinumtoxinA is an effective treatment of chronic migraine patients who previously failed BASH first-line migraine prophylactic meds and those naïve to BASH first-line migraine prophylactic treatment," said Dr. Aurora, a neurologist specializing in headache, migraine, and movement disorders at the Swedish Pain and Headache Center in Seattle.

Patients also experienced significant improvements in several secondary outcome measures that did not differ significantly between groups. These outcomes included frequency of migraine days, number of moderate to severe headache days, total cumulative hours of headache on headache days, and percentage of participants who reported severe migraines with a 60 or higher on the Headache Impact Test (HIT-6).

patient reports of improvements in health-related quality of life and disability did not differ significantly between groups, Dr. Aurora said.

The BASH guidelines assign medications to first-, second-, and third-line categories for prophylaxis against episodic migraines. However, many physicians use the same medicines to help chronic migraine sufferers, Dr. Aurora said, so the study answers a clinically relevant question.

Chronic migraine affects approximately 2% of the global population. Chronic migraine sufferers also report greater disability than patients with episodic migraine, according to Dr. Andrew Blumenfeld, who spoke during a separate session at the congress. "Chronic migraineurs experience a higher percentage of severe disability on more headache days than episodic migraineurs."

The burden of illness could be an additional criterion to define chronic migraine beyond the traditional cutoff of 15 or more affected days per month, said Dr. Blumenfeld, who was the lead author on a study comparing disability status and migraine frequency (Cephalalgia 2011;31:301-15). He is a neurologist in private practice in Encinitas, Calif.

The PREEMPT studies included 1,384 highly disabled migraine patients who reported 15 or more days per month with a headache lasting at least 4 hours per day. The 24-week, multicenter, double-blind study researchers randomized 688 of these men and women ages 18 to 65 years old to onabotulinumtoxinA and another 696 to placebo. A 32-week, open-label phase followed the acute treatment study. "There was a cumulative benefit over time – most patients continued to receive treatment benefit after five treatment cycles," Dr. David Dodick, one of the PREEMPT investigators, said in a separate presentation at the congress. "In clinical practice, patients should be administered at least two treatment cycles. If they have absolutely no response, do not proceed."

"You can tell patients that almost 70% of patients treated with [onabotulinumtoxinA] had 50% or more reduction in headache days at 56 weeks," said Dr. Dodick, professor of neurology at the Mayo Clinic in Phoenix, Ariz.

The mechanism of action of onabotulinumtoxinA in chronic migraine remains to be elucidated, Dr. Dodick said. "I don’t think any of us know how the prophylactic medications work in practice." In animal models, peripheral injections of the toxin reduced pain and c-fos protein expression in the spinal dorsal horn and inhibited central sensitization of spinal and medullary dorsal horn neurons, he said. "Clearly, injecting botulinum toxin peripherally has an effect on neurons centrally. Is it trans-synaptic spread or reduction in afferent drive or a combination of the two?"

A recommended injection method for chronic migraine based on the PREEMPT studies is explained, including a diagram of onabotulinumtoxinA injection sites, was published last year (Headache 2010;50:1406-18).

Allergan funded the post hoc analysis. Dr. Aurora said she is a member of the Allergan medical advisory board. Dr. Blumenfeld and Dr. Dodick have received funding from Allergan.

BERLIN – People never treated for their chronic migraines and those who failed a previous first-line medication reported similar reductions in frequency of headache days after treatment with onabotulinumtoxinA in a post hoc comparison study of the two phase III studies that Allergan used to gain approval for the new indication.

Some migraine medications work better in treatment-naïve patients, compared with those with a past marred by partial responses or one or more failures to first-line prophylactic therapies.

For this reason, Dr. Sheena K. Aurora and her associates assessed data from the two Phase 3 Research Evaluating Migraine Prophylaxis Therapy (PREEMPT) studies (Headache 2010;50:921-36) determine if onabotulinumtoxinA treatment works the same way. They compared 575 participants with a history of migraine prophylaxis use to another 809 participants who never tried such a first-line medication, as defined by the British Association for the Study of Headache (BASH). Amitriptyline and propranolol were the most common previous medications.

There was no significant difference in the reduction of frequency of headache days with onabotulinumtoxinA between previously-treated and untreated patients, Dr. Aurora said at the International Headache Congress, which was sponsored by the International Headache Society and the American Headache Society. A total 45% of patients with a history of first-line medication use versus 50% of those with no such history had a significant reduction in frequency of headache days.

"OnabotulinumtoxinA is an effective treatment of chronic migraine patients who previously failed BASH first-line migraine prophylactic meds and those naïve to BASH first-line migraine prophylactic treatment," said Dr. Aurora, a neurologist specializing in headache, migraine, and movement disorders at the Swedish Pain and Headache Center in Seattle.

Patients also experienced significant improvements in several secondary outcome measures that did not differ significantly between groups. These outcomes included frequency of migraine days, number of moderate to severe headache days, total cumulative hours of headache on headache days, and percentage of participants who reported severe migraines with a 60 or higher on the Headache Impact Test (HIT-6).

patient reports of improvements in health-related quality of life and disability did not differ significantly between groups, Dr. Aurora said.

The BASH guidelines assign medications to first-, second-, and third-line categories for prophylaxis against episodic migraines. However, many physicians use the same medicines to help chronic migraine sufferers, Dr. Aurora said, so the study answers a clinically relevant question.

Chronic migraine affects approximately 2% of the global population. Chronic migraine sufferers also report greater disability than patients with episodic migraine, according to Dr. Andrew Blumenfeld, who spoke during a separate session at the congress. "Chronic migraineurs experience a higher percentage of severe disability on more headache days than episodic migraineurs."

The burden of illness could be an additional criterion to define chronic migraine beyond the traditional cutoff of 15 or more affected days per month, said Dr. Blumenfeld, who was the lead author on a study comparing disability status and migraine frequency (Cephalalgia 2011;31:301-15). He is a neurologist in private practice in Encinitas, Calif.

The PREEMPT studies included 1,384 highly disabled migraine patients who reported 15 or more days per month with a headache lasting at least 4 hours per day. The 24-week, multicenter, double-blind study researchers randomized 688 of these men and women ages 18 to 65 years old to onabotulinumtoxinA and another 696 to placebo. A 32-week, open-label phase followed the acute treatment study. "There was a cumulative benefit over time – most patients continued to receive treatment benefit after five treatment cycles," Dr. David Dodick, one of the PREEMPT investigators, said in a separate presentation at the congress. "In clinical practice, patients should be administered at least two treatment cycles. If they have absolutely no response, do not proceed."

"You can tell patients that almost 70% of patients treated with [onabotulinumtoxinA] had 50% or more reduction in headache days at 56 weeks," said Dr. Dodick, professor of neurology at the Mayo Clinic in Phoenix, Ariz.

The mechanism of action of onabotulinumtoxinA in chronic migraine remains to be elucidated, Dr. Dodick said. "I don’t think any of us know how the prophylactic medications work in practice." In animal models, peripheral injections of the toxin reduced pain and c-fos protein expression in the spinal dorsal horn and inhibited central sensitization of spinal and medullary dorsal horn neurons, he said. "Clearly, injecting botulinum toxin peripherally has an effect on neurons centrally. Is it trans-synaptic spread or reduction in afferent drive or a combination of the two?"

A recommended injection method for chronic migraine based on the PREEMPT studies is explained, including a diagram of onabotulinumtoxinA injection sites, was published last year (Headache 2010;50:1406-18).

Allergan funded the post hoc analysis. Dr. Aurora said she is a member of the Allergan medical advisory board. Dr. Blumenfeld and Dr. Dodick have received funding from Allergan.

BERLIN – People never treated for their chronic migraines and those who failed a previous first-line medication reported similar reductions in frequency of headache days after treatment with onabotulinumtoxinA in a post hoc comparison study of the two phase III studies that Allergan used to gain approval for the new indication.

Some migraine medications work better in treatment-naïve patients, compared with those with a past marred by partial responses or one or more failures to first-line prophylactic therapies.

For this reason, Dr. Sheena K. Aurora and her associates assessed data from the two Phase 3 Research Evaluating Migraine Prophylaxis Therapy (PREEMPT) studies (Headache 2010;50:921-36) determine if onabotulinumtoxinA treatment works the same way. They compared 575 participants with a history of migraine prophylaxis use to another 809 participants who never tried such a first-line medication, as defined by the British Association for the Study of Headache (BASH). Amitriptyline and propranolol were the most common previous medications.

There was no significant difference in the reduction of frequency of headache days with onabotulinumtoxinA between previously-treated and untreated patients, Dr. Aurora said at the International Headache Congress, which was sponsored by the International Headache Society and the American Headache Society. A total 45% of patients with a history of first-line medication use versus 50% of those with no such history had a significant reduction in frequency of headache days.

"OnabotulinumtoxinA is an effective treatment of chronic migraine patients who previously failed BASH first-line migraine prophylactic meds and those naïve to BASH first-line migraine prophylactic treatment," said Dr. Aurora, a neurologist specializing in headache, migraine, and movement disorders at the Swedish Pain and Headache Center in Seattle.

Patients also experienced significant improvements in several secondary outcome measures that did not differ significantly between groups. These outcomes included frequency of migraine days, number of moderate to severe headache days, total cumulative hours of headache on headache days, and percentage of participants who reported severe migraines with a 60 or higher on the Headache Impact Test (HIT-6).

patient reports of improvements in health-related quality of life and disability did not differ significantly between groups, Dr. Aurora said.

The BASH guidelines assign medications to first-, second-, and third-line categories for prophylaxis against episodic migraines. However, many physicians use the same medicines to help chronic migraine sufferers, Dr. Aurora said, so the study answers a clinically relevant question.

Chronic migraine affects approximately 2% of the global population. Chronic migraine sufferers also report greater disability than patients with episodic migraine, according to Dr. Andrew Blumenfeld, who spoke during a separate session at the congress. "Chronic migraineurs experience a higher percentage of severe disability on more headache days than episodic migraineurs."

The burden of illness could be an additional criterion to define chronic migraine beyond the traditional cutoff of 15 or more affected days per month, said Dr. Blumenfeld, who was the lead author on a study comparing disability status and migraine frequency (Cephalalgia 2011;31:301-15). He is a neurologist in private practice in Encinitas, Calif.

The PREEMPT studies included 1,384 highly disabled migraine patients who reported 15 or more days per month with a headache lasting at least 4 hours per day. The 24-week, multicenter, double-blind study researchers randomized 688 of these men and women ages 18 to 65 years old to onabotulinumtoxinA and another 696 to placebo. A 32-week, open-label phase followed the acute treatment study. "There was a cumulative benefit over time – most patients continued to receive treatment benefit after five treatment cycles," Dr. David Dodick, one of the PREEMPT investigators, said in a separate presentation at the congress. "In clinical practice, patients should be administered at least two treatment cycles. If they have absolutely no response, do not proceed."

"You can tell patients that almost 70% of patients treated with [onabotulinumtoxinA] had 50% or more reduction in headache days at 56 weeks," said Dr. Dodick, professor of neurology at the Mayo Clinic in Phoenix, Ariz.

The mechanism of action of onabotulinumtoxinA in chronic migraine remains to be elucidated, Dr. Dodick said. "I don’t think any of us know how the prophylactic medications work in practice." In animal models, peripheral injections of the toxin reduced pain and c-fos protein expression in the spinal dorsal horn and inhibited central sensitization of spinal and medullary dorsal horn neurons, he said. "Clearly, injecting botulinum toxin peripherally has an effect on neurons centrally. Is it trans-synaptic spread or reduction in afferent drive or a combination of the two?"

A recommended injection method for chronic migraine based on the PREEMPT studies is explained, including a diagram of onabotulinumtoxinA injection sites, was published last year (Headache 2010;50:1406-18).

Allergan funded the post hoc analysis. Dr. Aurora said she is a member of the Allergan medical advisory board. Dr. Blumenfeld and Dr. Dodick have received funding from Allergan.

BERLIN – Reports from airline passengers who experience sudden onset, severe, and short duration headaches – primarily during landing – contain enough common and unique features to support a new, distinct form of headache, according to a study.

"There are some peculiar, common characteristics," Dr. Federico Mainardi said at the International Headache Congress, which was sponsored by the International Headache Society and the American Headache Society. A total of 63 people who responded to a questionnaire cited the common factors of strict unilateral presentation, absence of companion symptoms, and spontaneous resolution once they were on the ground and at the airport.

Sinus conditions sometimes cause severe headaches in migraine patients, Dr. Mainardi said, but only two participants reported concurrent sinusitis. This and other physiologic explanations were ruled out for the remainder, including a subset who underwent MRI and sinus CT scanning, said Dr. Mainardi, a neurologist at the Headache Centre at S.S. Giovanni e Paolo Hospital, Venice, Italy.

Because 60 of the 63 participants had at least one attack occur during the landing phase, Dr. Mainardi suggested that patients with a history of these attacks should take nonsteroidal anti-inflammatory drug prophylaxis either before takeoff on a short flight or during a longer flight. Some respondents reported that this strategy prevented subsequent attacks. He reminded clinicians to rule out organic pathology when a patient reports one of these in-flight headache attacks.

A majority of the participants (46) did not experience a "headache attributed to airplane travel" during their first experience flying. Many people experienced repeat attacks, including 15 patients who reported attacks on more than half their flights and 9 who suffered an attack each time they flew.

Dr. Mainardi described his first case and, together with seven other cases published in the literature, he and his colleagues devised specific criteria for these headaches (J. Headache Pain. 2007;8:196-9). The criteria include repeated attacks, occurrence during airplane travel, duration up to 20 minutes, and fronto-periorbital location.

Dr. Mainardi said that after the publication of the criteria he and his associates received e-mails from people worldwide experiencing the same kind of headache. "This is not an infrequent condition."

Of these 69 contacts, 63 returned a completed questionnaire in which they described and rated their experience. Their mean age was 37 years, and 41 (65%) of the respondents were men. Using International Classification of Headache Disorders (ICHD-II) criteria on the questionnaire, 35 (56%) had a concomitant primary headache, including 15 who reported tension type headaches, 11 who reported migraine with aura, and 3 who met criteria for probable tension type headache. Six reported more than one primary headache type. No participant suffered from cluster headache.

All patients rated their attacks as "severe" or "very severe." These headaches negatively influenced the decision to fly in the future for 44 respondents (70%). This reflects the severity of the pain, Dr. Mainardi said.

All patients denied alcohol consumption prior to the attacks and none gained relief from measures such as chewing, swallowing, or performing a Valsalva maneuver. The duration of flight was not a factor associated with the headache attacks, Dr. Mainardi said.

New cases continue to come forward, and he and his colleagues had identified 74 cases at the time of the congress. Based on more recent experience, he suggested two modifications to the criteria proposed in 2007: an increase in duration up to 30 minutes and expansion of the anatomic location of these attacks to include the parietal region.

Headache attributed to airplane travel is not included in the ICHD-II. Therefore, Dr. Mainardi said, "This should be proposed as a new entity in the forthcoming edition of the ICHD-III."

He said that he had no relevant financial disclosures.

BERLIN – Reports from airline passengers who experience sudden onset, severe, and short duration headaches – primarily during landing – contain enough common and unique features to support a new, distinct form of headache, according to a study.

"There are some peculiar, common characteristics," Dr. Federico Mainardi said at the International Headache Congress, which was sponsored by the International Headache Society and the American Headache Society. A total of 63 people who responded to a questionnaire cited the common factors of strict unilateral presentation, absence of companion symptoms, and spontaneous resolution once they were on the ground and at the airport.

Sinus conditions sometimes cause severe headaches in migraine patients, Dr. Mainardi said, but only two participants reported concurrent sinusitis. This and other physiologic explanations were ruled out for the remainder, including a subset who underwent MRI and sinus CT scanning, said Dr. Mainardi, a neurologist at the Headache Centre at S.S. Giovanni e Paolo Hospital, Venice, Italy.

Because 60 of the 63 participants had at least one attack occur during the landing phase, Dr. Mainardi suggested that patients with a history of these attacks should take nonsteroidal anti-inflammatory drug prophylaxis either before takeoff on a short flight or during a longer flight. Some respondents reported that this strategy prevented subsequent attacks. He reminded clinicians to rule out organic pathology when a patient reports one of these in-flight headache attacks.

A majority of the participants (46) did not experience a "headache attributed to airplane travel" during their first experience flying. Many people experienced repeat attacks, including 15 patients who reported attacks on more than half their flights and 9 who suffered an attack each time they flew.

Dr. Mainardi described his first case and, together with seven other cases published in the literature, he and his colleagues devised specific criteria for these headaches (J. Headache Pain. 2007;8:196-9). The criteria include repeated attacks, occurrence during airplane travel, duration up to 20 minutes, and fronto-periorbital location.

Dr. Mainardi said that after the publication of the criteria he and his associates received e-mails from people worldwide experiencing the same kind of headache. "This is not an infrequent condition."

Of these 69 contacts, 63 returned a completed questionnaire in which they described and rated their experience. Their mean age was 37 years, and 41 (65%) of the respondents were men. Using International Classification of Headache Disorders (ICHD-II) criteria on the questionnaire, 35 (56%) had a concomitant primary headache, including 15 who reported tension type headaches, 11 who reported migraine with aura, and 3 who met criteria for probable tension type headache. Six reported more than one primary headache type. No participant suffered from cluster headache.

All patients rated their attacks as "severe" or "very severe." These headaches negatively influenced the decision to fly in the future for 44 respondents (70%). This reflects the severity of the pain, Dr. Mainardi said.

All patients denied alcohol consumption prior to the attacks and none gained relief from measures such as chewing, swallowing, or performing a Valsalva maneuver. The duration of flight was not a factor associated with the headache attacks, Dr. Mainardi said.

New cases continue to come forward, and he and his colleagues had identified 74 cases at the time of the congress. Based on more recent experience, he suggested two modifications to the criteria proposed in 2007: an increase in duration up to 30 minutes and expansion of the anatomic location of these attacks to include the parietal region.

Headache attributed to airplane travel is not included in the ICHD-II. Therefore, Dr. Mainardi said, "This should be proposed as a new entity in the forthcoming edition of the ICHD-III."

He said that he had no relevant financial disclosures.

BERLIN – Reports from airline passengers who experience sudden onset, severe, and short duration headaches – primarily during landing – contain enough common and unique features to support a new, distinct form of headache, according to a study.

"There are some peculiar, common characteristics," Dr. Federico Mainardi said at the International Headache Congress, which was sponsored by the International Headache Society and the American Headache Society. A total of 63 people who responded to a questionnaire cited the common factors of strict unilateral presentation, absence of companion symptoms, and spontaneous resolution once they were on the ground and at the airport.

Sinus conditions sometimes cause severe headaches in migraine patients, Dr. Mainardi said, but only two participants reported concurrent sinusitis. This and other physiologic explanations were ruled out for the remainder, including a subset who underwent MRI and sinus CT scanning, said Dr. Mainardi, a neurologist at the Headache Centre at S.S. Giovanni e Paolo Hospital, Venice, Italy.

Because 60 of the 63 participants had at least one attack occur during the landing phase, Dr. Mainardi suggested that patients with a history of these attacks should take nonsteroidal anti-inflammatory drug prophylaxis either before takeoff on a short flight or during a longer flight. Some respondents reported that this strategy prevented subsequent attacks. He reminded clinicians to rule out organic pathology when a patient reports one of these in-flight headache attacks.

A majority of the participants (46) did not experience a "headache attributed to airplane travel" during their first experience flying. Many people experienced repeat attacks, including 15 patients who reported attacks on more than half their flights and 9 who suffered an attack each time they flew.

Dr. Mainardi described his first case and, together with seven other cases published in the literature, he and his colleagues devised specific criteria for these headaches (J. Headache Pain. 2007;8:196-9). The criteria include repeated attacks, occurrence during airplane travel, duration up to 20 minutes, and fronto-periorbital location.

Dr. Mainardi said that after the publication of the criteria he and his associates received e-mails from people worldwide experiencing the same kind of headache. "This is not an infrequent condition."

Of these 69 contacts, 63 returned a completed questionnaire in which they described and rated their experience. Their mean age was 37 years, and 41 (65%) of the respondents were men. Using International Classification of Headache Disorders (ICHD-II) criteria on the questionnaire, 35 (56%) had a concomitant primary headache, including 15 who reported tension type headaches, 11 who reported migraine with aura, and 3 who met criteria for probable tension type headache. Six reported more than one primary headache type. No participant suffered from cluster headache.

All patients rated their attacks as "severe" or "very severe." These headaches negatively influenced the decision to fly in the future for 44 respondents (70%). This reflects the severity of the pain, Dr. Mainardi said.

All patients denied alcohol consumption prior to the attacks and none gained relief from measures such as chewing, swallowing, or performing a Valsalva maneuver. The duration of flight was not a factor associated with the headache attacks, Dr. Mainardi said.

New cases continue to come forward, and he and his colleagues had identified 74 cases at the time of the congress. Based on more recent experience, he suggested two modifications to the criteria proposed in 2007: an increase in duration up to 30 minutes and expansion of the anatomic location of these attacks to include the parietal region.

Headache attributed to airplane travel is not included in the ICHD-II. Therefore, Dr. Mainardi said, "This should be proposed as a new entity in the forthcoming edition of the ICHD-III."

He said that he had no relevant financial disclosures.

BERLIN – "Do you take an attack treatment more than 10 days per month?" "Is this intake on a regular basis?"

With these two questions, clinicians at a headache treatment center in France quickly screened and identified patients with medication overuse headache, according to a validation study of the screening questions.

The traditional approach to diagnosis of medication overuse headache involving the revised International Classification of Headache Disorders (ICHD-II) criteria requires a face-to-face interview that takes considerable clinician time and expertise, Dr. Virginie Dousset said at the International Headache Congress, which is sponsored by the International Headache Society and the American Headache Society.

"In this context, it would be useful to have a tool to screen for medication overuse headache sufferers for clinical studies and for general practitioners," Dr. Dousset said.

Dr. Dousset and her colleagues transformed the second edition ICHD-II criteria into four simplified questions for a patient self-administered screening tool. To determine its sensitivity and specificity, they recruited 79 consecutive patients between September 2009 and February 2010. All participants presented for their first evaluation at the Bordeaux Headache Centre at the University of Bordeaux, where Dr. Dousset is director.

After 2 participants withdrew, 42 patients with medication overuse headache and 35 migraine sufferers without medication overuse were assessed further. Investigators compared their responses to the questions with diagnoses made by headache specialists using the formal ICHD-II criteria.

The initial screen featured four questions. But when the two questions regarding attack treatment frequency and regular use of medications were combined, they had the best sensitivity (95%) and specificity (80%) for identification of medication overuse headache.

"This self questionnaire is simple, rapid, and easily administered in headache clinics to screen medication overuse headache patients," Dr. Dousset said.

The question, "Do you have headache on 15 days or more per month?" had 81% sensitivity and 85% specificity. A fourth question that asked about headache duration exceeding 3 months had 98% sensitivity but a specificity of only 18%. Therefore, this item was dropped for insufficient discrimination between medication overuse and other types of headache, Dr. Dousset said.

Participants included both men and women aged 18 years or older with a normal clinical examination. They had no primary headache type other than migraine. Mean age was significantly higher in the medication overuse headache cohort at 47 years, compared with a mean of 37 years in the migraine cohort. Both groups consisted mostly of women: 81% with medication overuse headache and 63% with migraine.

The self-questionnaire and neurologic diagnosis were performed independently on the same day. A nurse unaware of the neurologic diagnosis supervised patients but offered no help on the questionnaire. The neurologist was blinded to the results of the patient questionnaire.

The results concur with a previous study by other researchers that showed a sensitivity of 75% and specificity of 100% for medication overuse headache diagnosis when patients reported a headache more than 15 days/month and intake of medication 4 or more days/week (J. Headache Pain 2008;9:289-94).

It is important to screen for medication overuse headaches because they impair quality of life for patients and lead to increased disability and decreased productivity, Dr. Dousset said. These headaches also are common, affecting an estimated 0.9%-1.8% of the general population and up to 80% of patients referred to a headache center for specialty care.

"We have to ask the question about applicability [of the screening questionnaire] outside headache centers," Dr. Dousset said. Although that is the focus of future research, she believes asking these two questions will prove an effective screening method for patients seen in a primary care setting as well.

Dr. Dousset said that she had no relevant financial disclosures.

BERLIN – "Do you take an attack treatment more than 10 days per month?" "Is this intake on a regular basis?"

With these two questions, clinicians at a headache treatment center in France quickly screened and identified patients with medication overuse headache, according to a validation study of the screening questions.

The traditional approach to diagnosis of medication overuse headache involving the revised International Classification of Headache Disorders (ICHD-II) criteria requires a face-to-face interview that takes considerable clinician time and expertise, Dr. Virginie Dousset said at the International Headache Congress, which is sponsored by the International Headache Society and the American Headache Society.

"In this context, it would be useful to have a tool to screen for medication overuse headache sufferers for clinical studies and for general practitioners," Dr. Dousset said.

Dr. Dousset and her colleagues transformed the second edition ICHD-II criteria into four simplified questions for a patient self-administered screening tool. To determine its sensitivity and specificity, they recruited 79 consecutive patients between September 2009 and February 2010. All participants presented for their first evaluation at the Bordeaux Headache Centre at the University of Bordeaux, where Dr. Dousset is director.

After 2 participants withdrew, 42 patients with medication overuse headache and 35 migraine sufferers without medication overuse were assessed further. Investigators compared their responses to the questions with diagnoses made by headache specialists using the formal ICHD-II criteria.

The initial screen featured four questions. But when the two questions regarding attack treatment frequency and regular use of medications were combined, they had the best sensitivity (95%) and specificity (80%) for identification of medication overuse headache.

"This self questionnaire is simple, rapid, and easily administered in headache clinics to screen medication overuse headache patients," Dr. Dousset said.

The question, "Do you have headache on 15 days or more per month?" had 81% sensitivity and 85% specificity. A fourth question that asked about headache duration exceeding 3 months had 98% sensitivity but a specificity of only 18%. Therefore, this item was dropped for insufficient discrimination between medication overuse and other types of headache, Dr. Dousset said.

Participants included both men and women aged 18 years or older with a normal clinical examination. They had no primary headache type other than migraine. Mean age was significantly higher in the medication overuse headache cohort at 47 years, compared with a mean of 37 years in the migraine cohort. Both groups consisted mostly of women: 81% with medication overuse headache and 63% with migraine.

The self-questionnaire and neurologic diagnosis were performed independently on the same day. A nurse unaware of the neurologic diagnosis supervised patients but offered no help on the questionnaire. The neurologist was blinded to the results of the patient questionnaire.

The results concur with a previous study by other researchers that showed a sensitivity of 75% and specificity of 100% for medication overuse headache diagnosis when patients reported a headache more than 15 days/month and intake of medication 4 or more days/week (J. Headache Pain 2008;9:289-94).

It is important to screen for medication overuse headaches because they impair quality of life for patients and lead to increased disability and decreased productivity, Dr. Dousset said. These headaches also are common, affecting an estimated 0.9%-1.8% of the general population and up to 80% of patients referred to a headache center for specialty care.

"We have to ask the question about applicability [of the screening questionnaire] outside headache centers," Dr. Dousset said. Although that is the focus of future research, she believes asking these two questions will prove an effective screening method for patients seen in a primary care setting as well.

Dr. Dousset said that she had no relevant financial disclosures.

BERLIN – "Do you take an attack treatment more than 10 days per month?" "Is this intake on a regular basis?"

With these two questions, clinicians at a headache treatment center in France quickly screened and identified patients with medication overuse headache, according to a validation study of the screening questions.

The traditional approach to diagnosis of medication overuse headache involving the revised International Classification of Headache Disorders (ICHD-II) criteria requires a face-to-face interview that takes considerable clinician time and expertise, Dr. Virginie Dousset said at the International Headache Congress, which is sponsored by the International Headache Society and the American Headache Society.

"In this context, it would be useful to have a tool to screen for medication overuse headache sufferers for clinical studies and for general practitioners," Dr. Dousset said.

Dr. Dousset and her colleagues transformed the second edition ICHD-II criteria into four simplified questions for a patient self-administered screening tool. To determine its sensitivity and specificity, they recruited 79 consecutive patients between September 2009 and February 2010. All participants presented for their first evaluation at the Bordeaux Headache Centre at the University of Bordeaux, where Dr. Dousset is director.

After 2 participants withdrew, 42 patients with medication overuse headache and 35 migraine sufferers without medication overuse were assessed further. Investigators compared their responses to the questions with diagnoses made by headache specialists using the formal ICHD-II criteria.

The initial screen featured four questions. But when the two questions regarding attack treatment frequency and regular use of medications were combined, they had the best sensitivity (95%) and specificity (80%) for identification of medication overuse headache.

"This self questionnaire is simple, rapid, and easily administered in headache clinics to screen medication overuse headache patients," Dr. Dousset said.

The question, "Do you have headache on 15 days or more per month?" had 81% sensitivity and 85% specificity. A fourth question that asked about headache duration exceeding 3 months had 98% sensitivity but a specificity of only 18%. Therefore, this item was dropped for insufficient discrimination between medication overuse and other types of headache, Dr. Dousset said.

Participants included both men and women aged 18 years or older with a normal clinical examination. They had no primary headache type other than migraine. Mean age was significantly higher in the medication overuse headache cohort at 47 years, compared with a mean of 37 years in the migraine cohort. Both groups consisted mostly of women: 81% with medication overuse headache and 63% with migraine.

The self-questionnaire and neurologic diagnosis were performed independently on the same day. A nurse unaware of the neurologic diagnosis supervised patients but offered no help on the questionnaire. The neurologist was blinded to the results of the patient questionnaire.

The results concur with a previous study by other researchers that showed a sensitivity of 75% and specificity of 100% for medication overuse headache diagnosis when patients reported a headache more than 15 days/month and intake of medication 4 or more days/week (J. Headache Pain 2008;9:289-94).

It is important to screen for medication overuse headaches because they impair quality of life for patients and lead to increased disability and decreased productivity, Dr. Dousset said. These headaches also are common, affecting an estimated 0.9%-1.8% of the general population and up to 80% of patients referred to a headache center for specialty care.

"We have to ask the question about applicability [of the screening questionnaire] outside headache centers," Dr. Dousset said. Although that is the focus of future research, she believes asking these two questions will prove an effective screening method for patients seen in a primary care setting as well.

Dr. Dousset said that she had no relevant financial disclosures.

BERLIN – The factors that patients report to be triggers of familial hemiplegic migraine appear to coincide in many instances with the same triggers reported by migraine patients with and without aura, according to findings from a questionnaire-based study.

Mailed questionnaires completed by 75 patients with familial hemiplegic migraine (FHM) indicated that 63% experience between 1 and 12 triggers, whereas the remaining 37% said no environmental triggers precede their attacks, Dr. Jakob Hansen said at the International Headache Congress, which was sponsored by the International Headache Society and the American Headache Society.

At least half of the respondents reported that most commonly acute stress (following a stressful event) triggered FHM, followed in frequency by sunlight and other bright lights; acute stress (during a stressful episode); intense emotional influences; and sleep disturbances (too little or too much sleep).

"If you can identify and avoid these trigger factors, that actually might be helpful in your clinical practice, so talk to your patients about this," said Dr. Hansen, a research fellow at the Danish Headache Center at the University of Copenhagen.

The pattern of trigger factors for FHM and those previously reported for migraine with aura and migraine without aura "seem to match pretty well," he said. For example, acute stress (following a stressful event) topped the list for both FHM and migraine without aura patients.

"Now we have some data that [FHM] does not seem to be so different from the more common types of migraine," Dr. Hansen said. He added that although neurologists consider FHM a distinct headache type, the alignment of triggers suggests some shared etiology or physiology.

The researchers asked the patients to rate 16 possible environmental factors that trigger headaches on the questionnaire using a scale of 0 (never) to 4 (always).

Although patients report some of these same triggers in face-to-face consultations with physicians, "what our patients tell us triggers their headaches [can differ]," Dr. Hansen said. Patients often said these factors include hormones; foods such as cheese, red wine, or chocolate; weather changes; and medication. "Some will say, ‘I get this from my mother,’ which in part could be true, especially if they suffer from familial hemiplegic migraine."

Among the patients who selected at least one trigger for FHM on the questionnaire, 36% reported at least one trigger factor that often or always (questionnaire response of 3 or 4, respectively) precipitated a FHM attack, he said.

A total 76% of patients reported at least one FHM attack within the past year. More members of this group identified at least one trigger factor than did those without a recent attack (76% vs. 11%, respectively).

Only 15 participants reported solely having FHM headaches. Other patients also reported experiencing migraines with and without aura (29), migraines with aura (25), and migraines without aura (6).

A meeting attendee questioned the accuracy of patient self-reports, suggesting that, if asked, patients tend to overreport the number of factors that trigger their migraines. "It’s interesting that one-third of our patients did not report any trigger factors. It seemed they answered truthfully," Dr. Hansen replied.

Dr. Hansen said that he had no relevant financial disclosures.

BERLIN – The factors that patients report to be triggers of familial hemiplegic migraine appear to coincide in many instances with the same triggers reported by migraine patients with and without aura, according to findings from a questionnaire-based study.

Mailed questionnaires completed by 75 patients with familial hemiplegic migraine (FHM) indicated that 63% experience between 1 and 12 triggers, whereas the remaining 37% said no environmental triggers precede their attacks, Dr. Jakob Hansen said at the International Headache Congress, which was sponsored by the International Headache Society and the American Headache Society.

At least half of the respondents reported that most commonly acute stress (following a stressful event) triggered FHM, followed in frequency by sunlight and other bright lights; acute stress (during a stressful episode); intense emotional influences; and sleep disturbances (too little or too much sleep).

"If you can identify and avoid these trigger factors, that actually might be helpful in your clinical practice, so talk to your patients about this," said Dr. Hansen, a research fellow at the Danish Headache Center at the University of Copenhagen.

The pattern of trigger factors for FHM and those previously reported for migraine with aura and migraine without aura "seem to match pretty well," he said. For example, acute stress (following a stressful event) topped the list for both FHM and migraine without aura patients.

"Now we have some data that [FHM] does not seem to be so different from the more common types of migraine," Dr. Hansen said. He added that although neurologists consider FHM a distinct headache type, the alignment of triggers suggests some shared etiology or physiology.

The researchers asked the patients to rate 16 possible environmental factors that trigger headaches on the questionnaire using a scale of 0 (never) to 4 (always).

Although patients report some of these same triggers in face-to-face consultations with physicians, "what our patients tell us triggers their headaches [can differ]," Dr. Hansen said. Patients often said these factors include hormones; foods such as cheese, red wine, or chocolate; weather changes; and medication. "Some will say, ‘I get this from my mother,’ which in part could be true, especially if they suffer from familial hemiplegic migraine."

Among the patients who selected at least one trigger for FHM on the questionnaire, 36% reported at least one trigger factor that often or always (questionnaire response of 3 or 4, respectively) precipitated a FHM attack, he said.

A total 76% of patients reported at least one FHM attack within the past year. More members of this group identified at least one trigger factor than did those without a recent attack (76% vs. 11%, respectively).

Only 15 participants reported solely having FHM headaches. Other patients also reported experiencing migraines with and without aura (29), migraines with aura (25), and migraines without aura (6).

A meeting attendee questioned the accuracy of patient self-reports, suggesting that, if asked, patients tend to overreport the number of factors that trigger their migraines. "It’s interesting that one-third of our patients did not report any trigger factors. It seemed they answered truthfully," Dr. Hansen replied.

Dr. Hansen said that he had no relevant financial disclosures.

BERLIN – The factors that patients report to be triggers of familial hemiplegic migraine appear to coincide in many instances with the same triggers reported by migraine patients with and without aura, according to findings from a questionnaire-based study.

Mailed questionnaires completed by 75 patients with familial hemiplegic migraine (FHM) indicated that 63% experience between 1 and 12 triggers, whereas the remaining 37% said no environmental triggers precede their attacks, Dr. Jakob Hansen said at the International Headache Congress, which was sponsored by the International Headache Society and the American Headache Society.

At least half of the respondents reported that most commonly acute stress (following a stressful event) triggered FHM, followed in frequency by sunlight and other bright lights; acute stress (during a stressful episode); intense emotional influences; and sleep disturbances (too little or too much sleep).

"If you can identify and avoid these trigger factors, that actually might be helpful in your clinical practice, so talk to your patients about this," said Dr. Hansen, a research fellow at the Danish Headache Center at the University of Copenhagen.

The pattern of trigger factors for FHM and those previously reported for migraine with aura and migraine without aura "seem to match pretty well," he said. For example, acute stress (following a stressful event) topped the list for both FHM and migraine without aura patients.

"Now we have some data that [FHM] does not seem to be so different from the more common types of migraine," Dr. Hansen said. He added that although neurologists consider FHM a distinct headache type, the alignment of triggers suggests some shared etiology or physiology.

The researchers asked the patients to rate 16 possible environmental factors that trigger headaches on the questionnaire using a scale of 0 (never) to 4 (always).

Although patients report some of these same triggers in face-to-face consultations with physicians, "what our patients tell us triggers their headaches [can differ]," Dr. Hansen said. Patients often said these factors include hormones; foods such as cheese, red wine, or chocolate; weather changes; and medication. "Some will say, ‘I get this from my mother,’ which in part could be true, especially if they suffer from familial hemiplegic migraine."

Among the patients who selected at least one trigger for FHM on the questionnaire, 36% reported at least one trigger factor that often or always (questionnaire response of 3 or 4, respectively) precipitated a FHM attack, he said.

A total 76% of patients reported at least one FHM attack within the past year. More members of this group identified at least one trigger factor than did those without a recent attack (76% vs. 11%, respectively).

Only 15 participants reported solely having FHM headaches. Other patients also reported experiencing migraines with and without aura (29), migraines with aura (25), and migraines without aura (6).

A meeting attendee questioned the accuracy of patient self-reports, suggesting that, if asked, patients tend to overreport the number of factors that trigger their migraines. "It’s interesting that one-third of our patients did not report any trigger factors. It seemed they answered truthfully," Dr. Hansen replied.

Dr. Hansen said that he had no relevant financial disclosures.