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Ketogenic diets improve symptoms and fatigue in chronic and high-frequency episodic migraine
Key clinical point: Three different ketogenic diets (KD)—very-low-calorie ketogenic diet (VLCKD), low-glycemic-index diet (LGID), and 2:1 KD—improved migraine frequency, migraine intensity, and fatigue in patients with chronic and high-frequency episodic migraine.
Major finding: At 3 months, all three KD led to a significant reduction in the fatigue severity scale (FSS) scores, along with reductions in the frequency and intensity of migraine attacks, Migraine Disability Assessment Test (MIDAS) scores, and Headache Impact Test 6 (HIT-6) scores (all P < .001). The mean reduction in FSS had positive correlation with the mean reduction in MIDAS (r = 0.361; P = .002) and HIT-6 (r = 0.344; P = .001) scores.
Study details: This retrospective single-center pilot study included 76 patients with chronic or high-frequency episodic migraine who followed three different KD (VLCKD, LGID, or 2:1 KD) for ≥3 months.
Disclosures: This study did not receive any funding. The authors declared no conflicts of interest.
Source: Tereshko Y, Dal Bello S, et al. The effect of three different ketogenic diet protocols on migraine and fatigue in chronic and high-frequency episodic migraine: A pilot study. Nutrients. 2023;15(20):4334 (Oct 11). doi: 10.3390/nu15204334
Key clinical point: Three different ketogenic diets (KD)—very-low-calorie ketogenic diet (VLCKD), low-glycemic-index diet (LGID), and 2:1 KD—improved migraine frequency, migraine intensity, and fatigue in patients with chronic and high-frequency episodic migraine.
Major finding: At 3 months, all three KD led to a significant reduction in the fatigue severity scale (FSS) scores, along with reductions in the frequency and intensity of migraine attacks, Migraine Disability Assessment Test (MIDAS) scores, and Headache Impact Test 6 (HIT-6) scores (all P < .001). The mean reduction in FSS had positive correlation with the mean reduction in MIDAS (r = 0.361; P = .002) and HIT-6 (r = 0.344; P = .001) scores.
Study details: This retrospective single-center pilot study included 76 patients with chronic or high-frequency episodic migraine who followed three different KD (VLCKD, LGID, or 2:1 KD) for ≥3 months.
Disclosures: This study did not receive any funding. The authors declared no conflicts of interest.
Source: Tereshko Y, Dal Bello S, et al. The effect of three different ketogenic diet protocols on migraine and fatigue in chronic and high-frequency episodic migraine: A pilot study. Nutrients. 2023;15(20):4334 (Oct 11). doi: 10.3390/nu15204334
Key clinical point: Three different ketogenic diets (KD)—very-low-calorie ketogenic diet (VLCKD), low-glycemic-index diet (LGID), and 2:1 KD—improved migraine frequency, migraine intensity, and fatigue in patients with chronic and high-frequency episodic migraine.
Major finding: At 3 months, all three KD led to a significant reduction in the fatigue severity scale (FSS) scores, along with reductions in the frequency and intensity of migraine attacks, Migraine Disability Assessment Test (MIDAS) scores, and Headache Impact Test 6 (HIT-6) scores (all P < .001). The mean reduction in FSS had positive correlation with the mean reduction in MIDAS (r = 0.361; P = .002) and HIT-6 (r = 0.344; P = .001) scores.
Study details: This retrospective single-center pilot study included 76 patients with chronic or high-frequency episodic migraine who followed three different KD (VLCKD, LGID, or 2:1 KD) for ≥3 months.
Disclosures: This study did not receive any funding. The authors declared no conflicts of interest.
Source: Tereshko Y, Dal Bello S, et al. The effect of three different ketogenic diet protocols on migraine and fatigue in chronic and high-frequency episodic migraine: A pilot study. Nutrients. 2023;15(20):4334 (Oct 11). doi: 10.3390/nu15204334
Adolescents with migraine need smooth handoff to adult care
, according to a headache specialist who treats adults and children and spoke at the 2023 Scottsdale Headache Symposium.
“I would start at about the age of 15 or 16,” said Hope L. O’Brien, MD, Headache Center of Hope, University of Cincinnati.
Describing the steps that she thinks should be included in an effective transition, Dr. O’Brien maintained, “you will have a greater chance of successful transition and lessen the likelihood of the chronicity and the poor outcomes that we see in adults.”
Dr. O’Brien, who developed a headache clinic that serves individuals between the ages of 15 and 27, has substantial experience with headache patients in this age range. She acknowledged that there are no guideline recommendations for how best to guide the transition from pediatric to adult care, but she has developed some strategies at her own institution, including a tool for determining when the transition should be considered.
“Transition readiness is something that you need to think about,” she said. “You don’t just do it [automatically] at the age of 18.”
TRAQ questionnaire is helpful
The Transition Readiness Assessment Questionnaire (TRAQ) is one tool that can be helpful, according to Dr. O’Brien, This tool, which can be used to evaluate whether young patients feel prepared to describe their own health status and needs and advocate on their own behalf, is not specific to headache, but the principle is particularly important in headache because of the importance of the patient’s history. Dr. O’Brien said that a fellow in her program, Allyson Bazarsky, MD, who is now affiliated with the University of Vermont Medical Center, Burlington, validated TRAQ for headache about 6 years ago.
“TRAQ is available online. It’s free. You can download it as a PDF,” Dr. O’Brien said. In fact, several age-specific versions can now be found readily on a web search for TRAQ questionnaire.
Ultimately, TRAQ helps the clinician to gauge what patients know about their disease, the medications they are taking, and the relevance of any comorbidities, such as mood disorders. It also provides insight about the ability to understand their health issues and to communicate well with caregivers.
Dr. O’Brien sees this as a process over time, rather than something to be implemented a few months before the transition.
“It is important to start making the shift during childhood and talking directly to the child,” Dr. O’Brien said. If education about the disease and its triggers are started relatively early in adolescence, the transition will not only be easier, but patients might have a chance to understand and control their disease at an earlier age.
With this kind of approach, most children are at least in the preparation stage by age 18 years. However, the age at which patients are suitable for transition varies substantially. Many patients 18 years of age or older are in the “action phase,” meaning it is time to take steps to transition.
Again, based on the interrelationship between headache and comorbidities, particularly mood disorders, such as depression and anxiety, the goal should not be limited to headache. Young adults should be educated about taking responsibility for their overall health.
In addition to educating the patient, Dr. O’Brien recommended preparing a transfer packet, such as the one described in an article published in Headache. Geared for communicating with the clinician who will take over care, the contents should include a detailed medical history along with the current treatment plan and list of medications that have been effective and those that have failed, according to Dr. O’Brien.
“An emergency plan in the form of an emergency department letter in case the patient needs to seek emergent care at an outside facility” is also appropriate, Dr. O’Brien said.
The patient should be aware of what is in the transfer pack in order to participate in an informed discussion of health care with the adult neurologist.
Poor transition linked to poor outcomes
A substantial proportion of adolescents with migraine continue to experience episodes as an adult, particularly those with a delayed diagnosis of migraine, those with a first degree relative who has migraine, and those with poor health habits, but this is not inevitable. Dr. O’Brien noted that “unsuccessful transition of care” into adulthood is a factor associated with poorer outcomes, making it an appropriate target for optimizing outcomes.
“Have that discussion on transfer of care with an action plan and do that early, especially in those with chronic or persistent disability headaches,” Dr. O’Brien emphasized.
This is pertinent advice, according to Amy A. Gelfand, MD, director of the child and adolescent headache program at Benioff Children’s Hospitals, University of California, San Francisco. Senior author of a comprehensive review article on pediatric migraine in Neurologic Clinics, Dr. Gelfand said the practical value of young adults learning what medications they are taking, and why, can place them in a better position to monitor their disease and to understand when a clinical visit is appropriate.
“I agree that it is important to help young adults (i.e., 18- or 19-year-olds) to prepare for the transition from the pediatric health care environment to the adult one,” said Dr. Gelfand, who has written frequently on this and related topics, such as the impact of comorbidities on outcome.
Dr. O’Brien reports financial relationships with AbbVie, Eli Lilly, Guidepoint, Pfizer, and Vector Psychometric Group. Dr. Gelfand reports financial relationships with Allergan, Eli Lilly, EMKinetics, eNeura, Teva and Zosano.
, according to a headache specialist who treats adults and children and spoke at the 2023 Scottsdale Headache Symposium.
“I would start at about the age of 15 or 16,” said Hope L. O’Brien, MD, Headache Center of Hope, University of Cincinnati.
Describing the steps that she thinks should be included in an effective transition, Dr. O’Brien maintained, “you will have a greater chance of successful transition and lessen the likelihood of the chronicity and the poor outcomes that we see in adults.”
Dr. O’Brien, who developed a headache clinic that serves individuals between the ages of 15 and 27, has substantial experience with headache patients in this age range. She acknowledged that there are no guideline recommendations for how best to guide the transition from pediatric to adult care, but she has developed some strategies at her own institution, including a tool for determining when the transition should be considered.
“Transition readiness is something that you need to think about,” she said. “You don’t just do it [automatically] at the age of 18.”
TRAQ questionnaire is helpful
The Transition Readiness Assessment Questionnaire (TRAQ) is one tool that can be helpful, according to Dr. O’Brien, This tool, which can be used to evaluate whether young patients feel prepared to describe their own health status and needs and advocate on their own behalf, is not specific to headache, but the principle is particularly important in headache because of the importance of the patient’s history. Dr. O’Brien said that a fellow in her program, Allyson Bazarsky, MD, who is now affiliated with the University of Vermont Medical Center, Burlington, validated TRAQ for headache about 6 years ago.
“TRAQ is available online. It’s free. You can download it as a PDF,” Dr. O’Brien said. In fact, several age-specific versions can now be found readily on a web search for TRAQ questionnaire.
Ultimately, TRAQ helps the clinician to gauge what patients know about their disease, the medications they are taking, and the relevance of any comorbidities, such as mood disorders. It also provides insight about the ability to understand their health issues and to communicate well with caregivers.
Dr. O’Brien sees this as a process over time, rather than something to be implemented a few months before the transition.
“It is important to start making the shift during childhood and talking directly to the child,” Dr. O’Brien said. If education about the disease and its triggers are started relatively early in adolescence, the transition will not only be easier, but patients might have a chance to understand and control their disease at an earlier age.
With this kind of approach, most children are at least in the preparation stage by age 18 years. However, the age at which patients are suitable for transition varies substantially. Many patients 18 years of age or older are in the “action phase,” meaning it is time to take steps to transition.
Again, based on the interrelationship between headache and comorbidities, particularly mood disorders, such as depression and anxiety, the goal should not be limited to headache. Young adults should be educated about taking responsibility for their overall health.
In addition to educating the patient, Dr. O’Brien recommended preparing a transfer packet, such as the one described in an article published in Headache. Geared for communicating with the clinician who will take over care, the contents should include a detailed medical history along with the current treatment plan and list of medications that have been effective and those that have failed, according to Dr. O’Brien.
“An emergency plan in the form of an emergency department letter in case the patient needs to seek emergent care at an outside facility” is also appropriate, Dr. O’Brien said.
The patient should be aware of what is in the transfer pack in order to participate in an informed discussion of health care with the adult neurologist.
Poor transition linked to poor outcomes
A substantial proportion of adolescents with migraine continue to experience episodes as an adult, particularly those with a delayed diagnosis of migraine, those with a first degree relative who has migraine, and those with poor health habits, but this is not inevitable. Dr. O’Brien noted that “unsuccessful transition of care” into adulthood is a factor associated with poorer outcomes, making it an appropriate target for optimizing outcomes.
“Have that discussion on transfer of care with an action plan and do that early, especially in those with chronic or persistent disability headaches,” Dr. O’Brien emphasized.
This is pertinent advice, according to Amy A. Gelfand, MD, director of the child and adolescent headache program at Benioff Children’s Hospitals, University of California, San Francisco. Senior author of a comprehensive review article on pediatric migraine in Neurologic Clinics, Dr. Gelfand said the practical value of young adults learning what medications they are taking, and why, can place them in a better position to monitor their disease and to understand when a clinical visit is appropriate.
“I agree that it is important to help young adults (i.e., 18- or 19-year-olds) to prepare for the transition from the pediatric health care environment to the adult one,” said Dr. Gelfand, who has written frequently on this and related topics, such as the impact of comorbidities on outcome.
Dr. O’Brien reports financial relationships with AbbVie, Eli Lilly, Guidepoint, Pfizer, and Vector Psychometric Group. Dr. Gelfand reports financial relationships with Allergan, Eli Lilly, EMKinetics, eNeura, Teva and Zosano.
, according to a headache specialist who treats adults and children and spoke at the 2023 Scottsdale Headache Symposium.
“I would start at about the age of 15 or 16,” said Hope L. O’Brien, MD, Headache Center of Hope, University of Cincinnati.
Describing the steps that she thinks should be included in an effective transition, Dr. O’Brien maintained, “you will have a greater chance of successful transition and lessen the likelihood of the chronicity and the poor outcomes that we see in adults.”
Dr. O’Brien, who developed a headache clinic that serves individuals between the ages of 15 and 27, has substantial experience with headache patients in this age range. She acknowledged that there are no guideline recommendations for how best to guide the transition from pediatric to adult care, but she has developed some strategies at her own institution, including a tool for determining when the transition should be considered.
“Transition readiness is something that you need to think about,” she said. “You don’t just do it [automatically] at the age of 18.”
TRAQ questionnaire is helpful
The Transition Readiness Assessment Questionnaire (TRAQ) is one tool that can be helpful, according to Dr. O’Brien, This tool, which can be used to evaluate whether young patients feel prepared to describe their own health status and needs and advocate on their own behalf, is not specific to headache, but the principle is particularly important in headache because of the importance of the patient’s history. Dr. O’Brien said that a fellow in her program, Allyson Bazarsky, MD, who is now affiliated with the University of Vermont Medical Center, Burlington, validated TRAQ for headache about 6 years ago.
“TRAQ is available online. It’s free. You can download it as a PDF,” Dr. O’Brien said. In fact, several age-specific versions can now be found readily on a web search for TRAQ questionnaire.
Ultimately, TRAQ helps the clinician to gauge what patients know about their disease, the medications they are taking, and the relevance of any comorbidities, such as mood disorders. It also provides insight about the ability to understand their health issues and to communicate well with caregivers.
Dr. O’Brien sees this as a process over time, rather than something to be implemented a few months before the transition.
“It is important to start making the shift during childhood and talking directly to the child,” Dr. O’Brien said. If education about the disease and its triggers are started relatively early in adolescence, the transition will not only be easier, but patients might have a chance to understand and control their disease at an earlier age.
With this kind of approach, most children are at least in the preparation stage by age 18 years. However, the age at which patients are suitable for transition varies substantially. Many patients 18 years of age or older are in the “action phase,” meaning it is time to take steps to transition.
Again, based on the interrelationship between headache and comorbidities, particularly mood disorders, such as depression and anxiety, the goal should not be limited to headache. Young adults should be educated about taking responsibility for their overall health.
In addition to educating the patient, Dr. O’Brien recommended preparing a transfer packet, such as the one described in an article published in Headache. Geared for communicating with the clinician who will take over care, the contents should include a detailed medical history along with the current treatment plan and list of medications that have been effective and those that have failed, according to Dr. O’Brien.
“An emergency plan in the form of an emergency department letter in case the patient needs to seek emergent care at an outside facility” is also appropriate, Dr. O’Brien said.
The patient should be aware of what is in the transfer pack in order to participate in an informed discussion of health care with the adult neurologist.
Poor transition linked to poor outcomes
A substantial proportion of adolescents with migraine continue to experience episodes as an adult, particularly those with a delayed diagnosis of migraine, those with a first degree relative who has migraine, and those with poor health habits, but this is not inevitable. Dr. O’Brien noted that “unsuccessful transition of care” into adulthood is a factor associated with poorer outcomes, making it an appropriate target for optimizing outcomes.
“Have that discussion on transfer of care with an action plan and do that early, especially in those with chronic or persistent disability headaches,” Dr. O’Brien emphasized.
This is pertinent advice, according to Amy A. Gelfand, MD, director of the child and adolescent headache program at Benioff Children’s Hospitals, University of California, San Francisco. Senior author of a comprehensive review article on pediatric migraine in Neurologic Clinics, Dr. Gelfand said the practical value of young adults learning what medications they are taking, and why, can place them in a better position to monitor their disease and to understand when a clinical visit is appropriate.
“I agree that it is important to help young adults (i.e., 18- or 19-year-olds) to prepare for the transition from the pediatric health care environment to the adult one,” said Dr. Gelfand, who has written frequently on this and related topics, such as the impact of comorbidities on outcome.
Dr. O’Brien reports financial relationships with AbbVie, Eli Lilly, Guidepoint, Pfizer, and Vector Psychometric Group. Dr. Gelfand reports financial relationships with Allergan, Eli Lilly, EMKinetics, eNeura, Teva and Zosano.
FROM THE 2023 SCOTTSDALE HEADACHE SYMPOSIUM
Switching Patients From a Triptan to a Gepant for Acute Migraine Care and Effective Preventives
Dr. Rapoport: Most patients who come into my office today, even those whom I have
treated for the last 30 years for acute care of migraine attacks, are taking 1 of the 7
triptan medications available. They might be taking triptans as a tablet—the most
common form—as a nasal spray, or by injection; however, not all patients are suited for
triptans, and sometimes, the need arises to switch to a different class of medication for
treating migraine acutely.
What are the reasons patients switch from a triptan to a gepant?
For some patients, triptans are not working well enough or are causing adverse events.
Other patients have developed cardiac risk factors such as elevated blood pressure,
obesity, smoking, and/or lack of exercise. I am always concerned about constriction of
the coronary blood vessels. Patients who already have some cardiac risk factors and
those who have some actual cardiac disease or have had a previous heart attack
already have constriction of their blood vessels and are not candidates for triptans, as
they are contraindicated.
How do you switch a patient from a triptan to a gepant?
It is important to have some discussion with the patient before the switch. For example,
if a patient with no cardiac risk factors comes into the office asking about this new
medicine, I will ask them several questions about their triptan to ensure it works well
enough (ie, to ascertain if the patient’s migraines improve within 30 to 60 minutes and
are much better within 2 hours of taking the medication). I want to be sure that they do
not have any adverse events related to the triptan, such as chest pain, drowsiness, or
dizziness. I like to ensure that whatever they are taking works long enough—at least 24
hours, preferably 48 hours—so they no longer have a headache, especially the next
day. If the headache comes back the next day, they must re-treat. If I determine the
triptan is not working well for them or they have significant adverse events, I will move
on.
Gepants are small-molecule calcitonin gene-related peptide (CGRP) receptor
antagonists, which are pills that only last for 2 to 3 days in the body. There are 2
gepants for acute care and 2 for the prevention of migraine. The first gepant approved
by the US Food and Drug Administration (FDA) for acute care was ubrogepant
(Ubrelvy), which comes in 2 sizes, 50 mg or 100 mg tablets. I sometimes start with 50
mg, but for the more difficult migraine patient, I will start with 100 mg. If the medicine is
not doing a complete job within 2 hours, the patient may take a second dose, up to 200
mg. Some adverse events may include nausea or slight drowsiness. The patient should
avoid certain medicines such as antifungal medicines (eg, ketoconazole, itraconazole)
and certain antibiotics like clarithromycin.
Another gepant, rimegepant (Nurtec), comes in only 1 size, a 75-mg oral disintegrating
tablet, which can be used both for acute care of migraine and for prevention. Patients
can take a tablet as soon as their migraine attack begins, and they are not to repeat it
that day. If the headache does not go away in 2 hours, I want them to then take a triptan
and an anti-inflammatory drug (there is no contraindication to mix these drugs). I want
them to try it at least 1 more time, encouraging patients to take it early, right at the start
of the headache. If the medicine is still not working by the second or third time, they
should stop using it. Preventively, patients take 75 mg every other day, which can be
quite effective. Side effects are slight nausea and some abdominal pain or dyspepsia.
A third gepant is atogepant (Qulipta), which is only for migraine prevention. It comes in
10 mg, 30 mg, and 60 mg and is taken once every day as a preventive. It can cause
some drowsiness, constipation, and nausea.
Are there any other acute care drugs you recommend if triptans are not working?
Yes, there is another drug class called the ditans. These medications work very well but
have more adverse events associated with them than I like. A higher percentage of
patients seem to be pain-free in 2 hours when using a ditan; however, the only one
available, lasmiditan (Reyvow), has never been studied against a gepant, so I cannot
say if one is better than the other. Lasmitidan works similarly to a triptan by stimulating
serotonin 1F receptors but does not constrict blood vessels. Up to 15% of patients have
dizziness and up to 7% have drowsiness, so patients should not drive within 8 hours
after taking lasmiditan. This medication is available in 2 sizes, 100 mg and 200 mg. I
usually give patients a 200-mg dose, which is good enough for 24 hours. Ditans are a
Schedule V drug, meaning some patients might take more than they should because it
makes them feel good. It can be a challenging drug to get, but it is an excellent acute
care drug when none of the mentioned adverse events occur.
Which preventive drugs do you tend to prescribe your patients for migraine since
triptans are not preventive?
For many years, we have used some of the older preventives. Antidepressants can be
an option for preventive treatment of migraine. Amitriptyline, a tricyclic antidepressant, is
a pretty good medicine. However, it has a lot of adverse events associated with it,
including dry mouth, weight gain, and drowsiness, so patients who take this at night
often sleep better. The dose is 10 mg to 50 mg taken before bed. This drug is often
used, but I would not say I like to prescribe it as much as other medications, even
though amitriptyline is effective and likely to work by affecting the level of serotonin and
other chemicals in the brain. There is little evidence that other classes of
antidepressants, such as selective serotonin reuptake inhibitors and serotonin and
norepinephrine reuptake inhibitors, are effective for migraine prevention. Adverse
effects may include weight gain, fatigue, constipation, and dry mouth, making it difficult
for a patient to stick with treatment.
Beta blockers are another preventive medication option for migraine. Beta blockers are
best known as a medical treatment for cardiovascular conditions, such as hypertension,
stable or unstable angina, and congestive heart failure. Beta blockers prevent the stress
hormone adrenaline (epinephrine) from binding to beta receptors, slowing heart rate
and lowering blood pressure. A commonly used beta blocker is propranolol (Inderal),
which also comes in a long-acting preparation. Doses range from 60 mg to 180
mg. Other beta blockers effective for migraine prevention include metoprolol, nadolol,
and atenolol.
Many of my patients are young, healthy females who like to exercise. Most report that
their heart rate is slow, they get short of breath, and they cannot exercise as effectively
while on a beta blocker. It also takes about 2 months until this medication starts
working. Patients may feel as if they are having too many adverse events, so I start
them on a very low dose and build it up gradually for a month and see how they are
feeling.
Epilepsy medicines can also be used to prevent migraine. There are 2 common
epilepsy medications. Topiramate (Topamax) doses can range from 75 mg to 100 mg
and are sometimes higher. Topiramate is a good medicine, but there are many potential
adverse events: tingling in the extremities, difficulty finding words when speaking,
confusion, raised eye pressure, and others. Divalproex sodium (Depakote) is another
popular medication, available in 500 mg to 1000 mg doses. This medicine can cause
some endocrine problems in women and can also damage the spinal cords of a fetus,
so this drug should not be taken during early pregnancy.
Monoclonal antibodies against CGRP are a strong preventive medication and a new
class of drugs that were first approved by the FDA in 2018. They are designed to
prevent episodic migraine (up to 14 headache days per month), chronic migraine (15 or
more headache days per month) and seem to work when a patient has medication
overuse headaches. CGRP is a neuropeptide involved in many body processes,
including blood pressure regulation, tissue repair, wound healing, and inflammation, and
is a potent vasodilator. When CGRP is released in the brain, it affects the trigeminal
nerve, increasing pain transmission and sensitivities to touch and temperature. CGRP
also causes inflammation and pain that happen during a migraine; it makes headache
pain worse and causes headaches to last longer.
Some CGRP inhibitors block CGRP from binding to CGRP receptors, a key contributor
to the trigeminal nerve pain and inflammation of migraine, while some grab the CGRP
and prevent it from activating the receptor.
The 2 classes of these drugs are monoclonal antibodies against CGRP and small
molecule CGRP antagonists. Fortunately, CGRPs have long half-lives and work for 1 to
3 months. The CGRP monoclonal antibodies are large molecule drugs. There are 4
different types, and 2 of them are injected by the patient at home once a month. One
can be injected at home once a month or every 3 months. For the latter option, patients
need to triple up with 3 injections in one day, so they do not have to inject for 3 months.
The fourth CGRP is an intravenous infusion that can be administered in an infusion
center or at home. This one is more inconvenient, but it is a strong drug. The small
molecule CGRP antagonists are taken by mouth in pill form. All CGRPs have been
shown to decrease the number of headaches per month.
The main goal of preventive therapy is to lessen the impact of migraines on patients’
lives by reducing how often they occur, how severe they are, and how long they last.
Preventive therapy also decreases disability and improves patients’ functioning over
time. Preventive therapy can help keep the costs for migraine care down by reducing
the need for acute treatments and allowing the patient to keep working or taking care of
their kids. Furthermore, preventive medications can make acute migraine treatments
more effective and help avoid the overuse of acute medications.
Dr. Rapoport: Most patients who come into my office today, even those whom I have
treated for the last 30 years for acute care of migraine attacks, are taking 1 of the 7
triptan medications available. They might be taking triptans as a tablet—the most
common form—as a nasal spray, or by injection; however, not all patients are suited for
triptans, and sometimes, the need arises to switch to a different class of medication for
treating migraine acutely.
What are the reasons patients switch from a triptan to a gepant?
For some patients, triptans are not working well enough or are causing adverse events.
Other patients have developed cardiac risk factors such as elevated blood pressure,
obesity, smoking, and/or lack of exercise. I am always concerned about constriction of
the coronary blood vessels. Patients who already have some cardiac risk factors and
those who have some actual cardiac disease or have had a previous heart attack
already have constriction of their blood vessels and are not candidates for triptans, as
they are contraindicated.
How do you switch a patient from a triptan to a gepant?
It is important to have some discussion with the patient before the switch. For example,
if a patient with no cardiac risk factors comes into the office asking about this new
medicine, I will ask them several questions about their triptan to ensure it works well
enough (ie, to ascertain if the patient’s migraines improve within 30 to 60 minutes and
are much better within 2 hours of taking the medication). I want to be sure that they do
not have any adverse events related to the triptan, such as chest pain, drowsiness, or
dizziness. I like to ensure that whatever they are taking works long enough—at least 24
hours, preferably 48 hours—so they no longer have a headache, especially the next
day. If the headache comes back the next day, they must re-treat. If I determine the
triptan is not working well for them or they have significant adverse events, I will move
on.
Gepants are small-molecule calcitonin gene-related peptide (CGRP) receptor
antagonists, which are pills that only last for 2 to 3 days in the body. There are 2
gepants for acute care and 2 for the prevention of migraine. The first gepant approved
by the US Food and Drug Administration (FDA) for acute care was ubrogepant
(Ubrelvy), which comes in 2 sizes, 50 mg or 100 mg tablets. I sometimes start with 50
mg, but for the more difficult migraine patient, I will start with 100 mg. If the medicine is
not doing a complete job within 2 hours, the patient may take a second dose, up to 200
mg. Some adverse events may include nausea or slight drowsiness. The patient should
avoid certain medicines such as antifungal medicines (eg, ketoconazole, itraconazole)
and certain antibiotics like clarithromycin.
Another gepant, rimegepant (Nurtec), comes in only 1 size, a 75-mg oral disintegrating
tablet, which can be used both for acute care of migraine and for prevention. Patients
can take a tablet as soon as their migraine attack begins, and they are not to repeat it
that day. If the headache does not go away in 2 hours, I want them to then take a triptan
and an anti-inflammatory drug (there is no contraindication to mix these drugs). I want
them to try it at least 1 more time, encouraging patients to take it early, right at the start
of the headache. If the medicine is still not working by the second or third time, they
should stop using it. Preventively, patients take 75 mg every other day, which can be
quite effective. Side effects are slight nausea and some abdominal pain or dyspepsia.
A third gepant is atogepant (Qulipta), which is only for migraine prevention. It comes in
10 mg, 30 mg, and 60 mg and is taken once every day as a preventive. It can cause
some drowsiness, constipation, and nausea.
Are there any other acute care drugs you recommend if triptans are not working?
Yes, there is another drug class called the ditans. These medications work very well but
have more adverse events associated with them than I like. A higher percentage of
patients seem to be pain-free in 2 hours when using a ditan; however, the only one
available, lasmiditan (Reyvow), has never been studied against a gepant, so I cannot
say if one is better than the other. Lasmitidan works similarly to a triptan by stimulating
serotonin 1F receptors but does not constrict blood vessels. Up to 15% of patients have
dizziness and up to 7% have drowsiness, so patients should not drive within 8 hours
after taking lasmiditan. This medication is available in 2 sizes, 100 mg and 200 mg. I
usually give patients a 200-mg dose, which is good enough for 24 hours. Ditans are a
Schedule V drug, meaning some patients might take more than they should because it
makes them feel good. It can be a challenging drug to get, but it is an excellent acute
care drug when none of the mentioned adverse events occur.
Which preventive drugs do you tend to prescribe your patients for migraine since
triptans are not preventive?
For many years, we have used some of the older preventives. Antidepressants can be
an option for preventive treatment of migraine. Amitriptyline, a tricyclic antidepressant, is
a pretty good medicine. However, it has a lot of adverse events associated with it,
including dry mouth, weight gain, and drowsiness, so patients who take this at night
often sleep better. The dose is 10 mg to 50 mg taken before bed. This drug is often
used, but I would not say I like to prescribe it as much as other medications, even
though amitriptyline is effective and likely to work by affecting the level of serotonin and
other chemicals in the brain. There is little evidence that other classes of
antidepressants, such as selective serotonin reuptake inhibitors and serotonin and
norepinephrine reuptake inhibitors, are effective for migraine prevention. Adverse
effects may include weight gain, fatigue, constipation, and dry mouth, making it difficult
for a patient to stick with treatment.
Beta blockers are another preventive medication option for migraine. Beta blockers are
best known as a medical treatment for cardiovascular conditions, such as hypertension,
stable or unstable angina, and congestive heart failure. Beta blockers prevent the stress
hormone adrenaline (epinephrine) from binding to beta receptors, slowing heart rate
and lowering blood pressure. A commonly used beta blocker is propranolol (Inderal),
which also comes in a long-acting preparation. Doses range from 60 mg to 180
mg. Other beta blockers effective for migraine prevention include metoprolol, nadolol,
and atenolol.
Many of my patients are young, healthy females who like to exercise. Most report that
their heart rate is slow, they get short of breath, and they cannot exercise as effectively
while on a beta blocker. It also takes about 2 months until this medication starts
working. Patients may feel as if they are having too many adverse events, so I start
them on a very low dose and build it up gradually for a month and see how they are
feeling.
Epilepsy medicines can also be used to prevent migraine. There are 2 common
epilepsy medications. Topiramate (Topamax) doses can range from 75 mg to 100 mg
and are sometimes higher. Topiramate is a good medicine, but there are many potential
adverse events: tingling in the extremities, difficulty finding words when speaking,
confusion, raised eye pressure, and others. Divalproex sodium (Depakote) is another
popular medication, available in 500 mg to 1000 mg doses. This medicine can cause
some endocrine problems in women and can also damage the spinal cords of a fetus,
so this drug should not be taken during early pregnancy.
Monoclonal antibodies against CGRP are a strong preventive medication and a new
class of drugs that were first approved by the FDA in 2018. They are designed to
prevent episodic migraine (up to 14 headache days per month), chronic migraine (15 or
more headache days per month) and seem to work when a patient has medication
overuse headaches. CGRP is a neuropeptide involved in many body processes,
including blood pressure regulation, tissue repair, wound healing, and inflammation, and
is a potent vasodilator. When CGRP is released in the brain, it affects the trigeminal
nerve, increasing pain transmission and sensitivities to touch and temperature. CGRP
also causes inflammation and pain that happen during a migraine; it makes headache
pain worse and causes headaches to last longer.
Some CGRP inhibitors block CGRP from binding to CGRP receptors, a key contributor
to the trigeminal nerve pain and inflammation of migraine, while some grab the CGRP
and prevent it from activating the receptor.
The 2 classes of these drugs are monoclonal antibodies against CGRP and small
molecule CGRP antagonists. Fortunately, CGRPs have long half-lives and work for 1 to
3 months. The CGRP monoclonal antibodies are large molecule drugs. There are 4
different types, and 2 of them are injected by the patient at home once a month. One
can be injected at home once a month or every 3 months. For the latter option, patients
need to triple up with 3 injections in one day, so they do not have to inject for 3 months.
The fourth CGRP is an intravenous infusion that can be administered in an infusion
center or at home. This one is more inconvenient, but it is a strong drug. The small
molecule CGRP antagonists are taken by mouth in pill form. All CGRPs have been
shown to decrease the number of headaches per month.
The main goal of preventive therapy is to lessen the impact of migraines on patients’
lives by reducing how often they occur, how severe they are, and how long they last.
Preventive therapy also decreases disability and improves patients’ functioning over
time. Preventive therapy can help keep the costs for migraine care down by reducing
the need for acute treatments and allowing the patient to keep working or taking care of
their kids. Furthermore, preventive medications can make acute migraine treatments
more effective and help avoid the overuse of acute medications.
Dr. Rapoport: Most patients who come into my office today, even those whom I have
treated for the last 30 years for acute care of migraine attacks, are taking 1 of the 7
triptan medications available. They might be taking triptans as a tablet—the most
common form—as a nasal spray, or by injection; however, not all patients are suited for
triptans, and sometimes, the need arises to switch to a different class of medication for
treating migraine acutely.
What are the reasons patients switch from a triptan to a gepant?
For some patients, triptans are not working well enough or are causing adverse events.
Other patients have developed cardiac risk factors such as elevated blood pressure,
obesity, smoking, and/or lack of exercise. I am always concerned about constriction of
the coronary blood vessels. Patients who already have some cardiac risk factors and
those who have some actual cardiac disease or have had a previous heart attack
already have constriction of their blood vessels and are not candidates for triptans, as
they are contraindicated.
How do you switch a patient from a triptan to a gepant?
It is important to have some discussion with the patient before the switch. For example,
if a patient with no cardiac risk factors comes into the office asking about this new
medicine, I will ask them several questions about their triptan to ensure it works well
enough (ie, to ascertain if the patient’s migraines improve within 30 to 60 minutes and
are much better within 2 hours of taking the medication). I want to be sure that they do
not have any adverse events related to the triptan, such as chest pain, drowsiness, or
dizziness. I like to ensure that whatever they are taking works long enough—at least 24
hours, preferably 48 hours—so they no longer have a headache, especially the next
day. If the headache comes back the next day, they must re-treat. If I determine the
triptan is not working well for them or they have significant adverse events, I will move
on.
Gepants are small-molecule calcitonin gene-related peptide (CGRP) receptor
antagonists, which are pills that only last for 2 to 3 days in the body. There are 2
gepants for acute care and 2 for the prevention of migraine. The first gepant approved
by the US Food and Drug Administration (FDA) for acute care was ubrogepant
(Ubrelvy), which comes in 2 sizes, 50 mg or 100 mg tablets. I sometimes start with 50
mg, but for the more difficult migraine patient, I will start with 100 mg. If the medicine is
not doing a complete job within 2 hours, the patient may take a second dose, up to 200
mg. Some adverse events may include nausea or slight drowsiness. The patient should
avoid certain medicines such as antifungal medicines (eg, ketoconazole, itraconazole)
and certain antibiotics like clarithromycin.
Another gepant, rimegepant (Nurtec), comes in only 1 size, a 75-mg oral disintegrating
tablet, which can be used both for acute care of migraine and for prevention. Patients
can take a tablet as soon as their migraine attack begins, and they are not to repeat it
that day. If the headache does not go away in 2 hours, I want them to then take a triptan
and an anti-inflammatory drug (there is no contraindication to mix these drugs). I want
them to try it at least 1 more time, encouraging patients to take it early, right at the start
of the headache. If the medicine is still not working by the second or third time, they
should stop using it. Preventively, patients take 75 mg every other day, which can be
quite effective. Side effects are slight nausea and some abdominal pain or dyspepsia.
A third gepant is atogepant (Qulipta), which is only for migraine prevention. It comes in
10 mg, 30 mg, and 60 mg and is taken once every day as a preventive. It can cause
some drowsiness, constipation, and nausea.
Are there any other acute care drugs you recommend if triptans are not working?
Yes, there is another drug class called the ditans. These medications work very well but
have more adverse events associated with them than I like. A higher percentage of
patients seem to be pain-free in 2 hours when using a ditan; however, the only one
available, lasmiditan (Reyvow), has never been studied against a gepant, so I cannot
say if one is better than the other. Lasmitidan works similarly to a triptan by stimulating
serotonin 1F receptors but does not constrict blood vessels. Up to 15% of patients have
dizziness and up to 7% have drowsiness, so patients should not drive within 8 hours
after taking lasmiditan. This medication is available in 2 sizes, 100 mg and 200 mg. I
usually give patients a 200-mg dose, which is good enough for 24 hours. Ditans are a
Schedule V drug, meaning some patients might take more than they should because it
makes them feel good. It can be a challenging drug to get, but it is an excellent acute
care drug when none of the mentioned adverse events occur.
Which preventive drugs do you tend to prescribe your patients for migraine since
triptans are not preventive?
For many years, we have used some of the older preventives. Antidepressants can be
an option for preventive treatment of migraine. Amitriptyline, a tricyclic antidepressant, is
a pretty good medicine. However, it has a lot of adverse events associated with it,
including dry mouth, weight gain, and drowsiness, so patients who take this at night
often sleep better. The dose is 10 mg to 50 mg taken before bed. This drug is often
used, but I would not say I like to prescribe it as much as other medications, even
though amitriptyline is effective and likely to work by affecting the level of serotonin and
other chemicals in the brain. There is little evidence that other classes of
antidepressants, such as selective serotonin reuptake inhibitors and serotonin and
norepinephrine reuptake inhibitors, are effective for migraine prevention. Adverse
effects may include weight gain, fatigue, constipation, and dry mouth, making it difficult
for a patient to stick with treatment.
Beta blockers are another preventive medication option for migraine. Beta blockers are
best known as a medical treatment for cardiovascular conditions, such as hypertension,
stable or unstable angina, and congestive heart failure. Beta blockers prevent the stress
hormone adrenaline (epinephrine) from binding to beta receptors, slowing heart rate
and lowering blood pressure. A commonly used beta blocker is propranolol (Inderal),
which also comes in a long-acting preparation. Doses range from 60 mg to 180
mg. Other beta blockers effective for migraine prevention include metoprolol, nadolol,
and atenolol.
Many of my patients are young, healthy females who like to exercise. Most report that
their heart rate is slow, they get short of breath, and they cannot exercise as effectively
while on a beta blocker. It also takes about 2 months until this medication starts
working. Patients may feel as if they are having too many adverse events, so I start
them on a very low dose and build it up gradually for a month and see how they are
feeling.
Epilepsy medicines can also be used to prevent migraine. There are 2 common
epilepsy medications. Topiramate (Topamax) doses can range from 75 mg to 100 mg
and are sometimes higher. Topiramate is a good medicine, but there are many potential
adverse events: tingling in the extremities, difficulty finding words when speaking,
confusion, raised eye pressure, and others. Divalproex sodium (Depakote) is another
popular medication, available in 500 mg to 1000 mg doses. This medicine can cause
some endocrine problems in women and can also damage the spinal cords of a fetus,
so this drug should not be taken during early pregnancy.
Monoclonal antibodies against CGRP are a strong preventive medication and a new
class of drugs that were first approved by the FDA in 2018. They are designed to
prevent episodic migraine (up to 14 headache days per month), chronic migraine (15 or
more headache days per month) and seem to work when a patient has medication
overuse headaches. CGRP is a neuropeptide involved in many body processes,
including blood pressure regulation, tissue repair, wound healing, and inflammation, and
is a potent vasodilator. When CGRP is released in the brain, it affects the trigeminal
nerve, increasing pain transmission and sensitivities to touch and temperature. CGRP
also causes inflammation and pain that happen during a migraine; it makes headache
pain worse and causes headaches to last longer.
Some CGRP inhibitors block CGRP from binding to CGRP receptors, a key contributor
to the trigeminal nerve pain and inflammation of migraine, while some grab the CGRP
and prevent it from activating the receptor.
The 2 classes of these drugs are monoclonal antibodies against CGRP and small
molecule CGRP antagonists. Fortunately, CGRPs have long half-lives and work for 1 to
3 months. The CGRP monoclonal antibodies are large molecule drugs. There are 4
different types, and 2 of them are injected by the patient at home once a month. One
can be injected at home once a month or every 3 months. For the latter option, patients
need to triple up with 3 injections in one day, so they do not have to inject for 3 months.
The fourth CGRP is an intravenous infusion that can be administered in an infusion
center or at home. This one is more inconvenient, but it is a strong drug. The small
molecule CGRP antagonists are taken by mouth in pill form. All CGRPs have been
shown to decrease the number of headaches per month.
The main goal of preventive therapy is to lessen the impact of migraines on patients’
lives by reducing how often they occur, how severe they are, and how long they last.
Preventive therapy also decreases disability and improves patients’ functioning over
time. Preventive therapy can help keep the costs for migraine care down by reducing
the need for acute treatments and allowing the patient to keep working or taking care of
their kids. Furthermore, preventive medications can make acute migraine treatments
more effective and help avoid the overuse of acute medications.
Avoid adding to minority stress when treating headache in LGBTQIA+ patients
It is “important not to assume that just because someone is a member of the LGBTQ+ community they will need psychiatric or behavioral health support,” said Maya A. Marzouk, PhD, division of behavioral medicine and clinical psychology, Cincinnati Children’s Hospital Medical Center.
Instead, it is useful not to make any assumptions. There is a potential association between minority status and headache susceptibility, but it is more reasonable initially to address the diagnosis and treatment of headache in LGBTQIA+ patients the same way it is addressed in any other patient, Dr. Marzouk said at the 2023 Scottsdale Headache Symposium.
The acronym to describe individuals with gender identities different from male and female and sexual orientations not limited to heterosexuality has been in almost constant evolution over several decades. An addition sign that accompanies LGBTQIA refers to those who do not identify with any letters in the acronym (lesbian, gay, bisexual, transsexual, queer/questioning, intersex, and asexual).
Take steps to normalize the interaction
Although many clinicians have been acclimated to these diverse identifies, not all have risen above preconceptions that become obstacles to effective care, according to Dr. Marzouk. In the context of headache management, Dr. Marzouk emphasized the need to be respectful of the range of gender identities and sexual orientations and to take steps to normalize the interaction.
For example, Dr. Marzouk advised using gender-neutral language at the start of each patient encounter and ask open-ended questions about gender, sexual identify, and pronouns to avoid patient discomfort from misidentification. In turn, the clinicians can establish their own gender identification and preferred pronouns to reinforce the idea that doing so is normal behavior.
This change in approach should be made “for all patients. Do not try to guess who needs them,” she said.
Intake forms and office atmosphere, such as signs and images, should also be welcoming to all patients, she added. Rather than trying to make adjustments for a LGBTQIA+ visit, Dr. Marzouk said a uniform approach helps normalize the experience of LGBTQIA+ patients without singling them out.
Despite the effort to provide an open and welcoming environment, Dr. Marzouk acknowledged that mistakes are difficult to avoid for those with limited experience serving the LGBTQIA+ community. When mistakes are made, she advised clinicians to immediately acknowledge the mistake and ask for guidance from the patient.
The potential offense is making the patient feel “other” or abnormal.
A higher rate of migraine
The interactions that LBGTQIA+ patients have with others outside their community is a possible explanation for the substantial rate of headache as well as headache with comorbid psychiatric disorders in this population.
In a survey published in 2020, the rate of migraine was 19.7% in heterosexual women, 26.7% in lesbians, and 36.8% in bisexual women. Among men, it rose from 9.8% in heterosexuals to 14.8% in gays and then to 22.8% in bisexuals.
Migraine relative to headache is also associated with more mood disorders among LGBTQIA+ individuals. In a study published in 2022, LGBTQIA+ patients with migraine relative to those with headache were more likely to have depression (46.4% vs. 22.3%; P < .001), anxiety (72.1% vs. 51.6%; P < .001), and posttraumatic stress disorder (37.5% vs. 21.4%; P < .001).
A vicious cycle of underdiagnosis and undertreatment
These associations are consistent with minority stress theory, according to Dr. Marzouk. This theory postulates that the associated stress of discrimination, rejection, and microaggressions, such as explicit efforts to make LGBTQIA+ individuals to feel “other,” produces epigenetic changes and dysregulation of the hypothalamic-pituitary-adrenal axis. In turn, this plays a role in the pathogenesis of migraine.
The inconsistency with which minority stress affects LGBTQIA+ patients might be due to relative differences in social support, coping skills, an innate resilience to these effects, Dr. Marzouk explained.
Dr. Marzouk characterized the LGBTQIA+ community as “underserved” for treatment of headache. She suggested that medical mistrust and self-blame among LGBTQIA+ individuals might be factors contributing to a vicious cycle of underdiagnosis and undertreatment. Efforts by the medical community to reach out to the LGBTQIA+ community are appropriate to address an unmet need.
“Individuals with psychiatric comorbidities may experience even more benefit from migraine care,” she said.
Clinical studies should be more inclusive
While agreeing in principle with these remarks, Eric A. Kaiser, MD, PhD, department of neurology, University of Pennsylvania, Philadelphia, said that this area would be better advanced if studies routinely included patients with diverse-gender identities and sexual orientations. Speaking about how to organize these studies, Dr. Kaiser suggested that enrollment criteria should explicitly seek these individuals and that these differences should be captured in the baseline characteristics.
“For example, gender options could include man, woman, non-binary, gender diverse, gender nonconforming, or gender nonspecified,” he said.
To close “the significant knowledge gap that exists in managing headache disorders in sexually- and gender- diverse people,” Dr. Kaiser said that clinical research studies, like patient treatment of diverse populations, “should be conducted with welcoming and affirming practices.”
Dr. Marzouk reported no potential conflicts of interest. Dr. Kaiser reported financial relationships with Amgen and Lundbeck.
It is “important not to assume that just because someone is a member of the LGBTQ+ community they will need psychiatric or behavioral health support,” said Maya A. Marzouk, PhD, division of behavioral medicine and clinical psychology, Cincinnati Children’s Hospital Medical Center.
Instead, it is useful not to make any assumptions. There is a potential association between minority status and headache susceptibility, but it is more reasonable initially to address the diagnosis and treatment of headache in LGBTQIA+ patients the same way it is addressed in any other patient, Dr. Marzouk said at the 2023 Scottsdale Headache Symposium.
The acronym to describe individuals with gender identities different from male and female and sexual orientations not limited to heterosexuality has been in almost constant evolution over several decades. An addition sign that accompanies LGBTQIA refers to those who do not identify with any letters in the acronym (lesbian, gay, bisexual, transsexual, queer/questioning, intersex, and asexual).
Take steps to normalize the interaction
Although many clinicians have been acclimated to these diverse identifies, not all have risen above preconceptions that become obstacles to effective care, according to Dr. Marzouk. In the context of headache management, Dr. Marzouk emphasized the need to be respectful of the range of gender identities and sexual orientations and to take steps to normalize the interaction.
For example, Dr. Marzouk advised using gender-neutral language at the start of each patient encounter and ask open-ended questions about gender, sexual identify, and pronouns to avoid patient discomfort from misidentification. In turn, the clinicians can establish their own gender identification and preferred pronouns to reinforce the idea that doing so is normal behavior.
This change in approach should be made “for all patients. Do not try to guess who needs them,” she said.
Intake forms and office atmosphere, such as signs and images, should also be welcoming to all patients, she added. Rather than trying to make adjustments for a LGBTQIA+ visit, Dr. Marzouk said a uniform approach helps normalize the experience of LGBTQIA+ patients without singling them out.
Despite the effort to provide an open and welcoming environment, Dr. Marzouk acknowledged that mistakes are difficult to avoid for those with limited experience serving the LGBTQIA+ community. When mistakes are made, she advised clinicians to immediately acknowledge the mistake and ask for guidance from the patient.
The potential offense is making the patient feel “other” or abnormal.
A higher rate of migraine
The interactions that LBGTQIA+ patients have with others outside their community is a possible explanation for the substantial rate of headache as well as headache with comorbid psychiatric disorders in this population.
In a survey published in 2020, the rate of migraine was 19.7% in heterosexual women, 26.7% in lesbians, and 36.8% in bisexual women. Among men, it rose from 9.8% in heterosexuals to 14.8% in gays and then to 22.8% in bisexuals.
Migraine relative to headache is also associated with more mood disorders among LGBTQIA+ individuals. In a study published in 2022, LGBTQIA+ patients with migraine relative to those with headache were more likely to have depression (46.4% vs. 22.3%; P < .001), anxiety (72.1% vs. 51.6%; P < .001), and posttraumatic stress disorder (37.5% vs. 21.4%; P < .001).
A vicious cycle of underdiagnosis and undertreatment
These associations are consistent with minority stress theory, according to Dr. Marzouk. This theory postulates that the associated stress of discrimination, rejection, and microaggressions, such as explicit efforts to make LGBTQIA+ individuals to feel “other,” produces epigenetic changes and dysregulation of the hypothalamic-pituitary-adrenal axis. In turn, this plays a role in the pathogenesis of migraine.
The inconsistency with which minority stress affects LGBTQIA+ patients might be due to relative differences in social support, coping skills, an innate resilience to these effects, Dr. Marzouk explained.
Dr. Marzouk characterized the LGBTQIA+ community as “underserved” for treatment of headache. She suggested that medical mistrust and self-blame among LGBTQIA+ individuals might be factors contributing to a vicious cycle of underdiagnosis and undertreatment. Efforts by the medical community to reach out to the LGBTQIA+ community are appropriate to address an unmet need.
“Individuals with psychiatric comorbidities may experience even more benefit from migraine care,” she said.
Clinical studies should be more inclusive
While agreeing in principle with these remarks, Eric A. Kaiser, MD, PhD, department of neurology, University of Pennsylvania, Philadelphia, said that this area would be better advanced if studies routinely included patients with diverse-gender identities and sexual orientations. Speaking about how to organize these studies, Dr. Kaiser suggested that enrollment criteria should explicitly seek these individuals and that these differences should be captured in the baseline characteristics.
“For example, gender options could include man, woman, non-binary, gender diverse, gender nonconforming, or gender nonspecified,” he said.
To close “the significant knowledge gap that exists in managing headache disorders in sexually- and gender- diverse people,” Dr. Kaiser said that clinical research studies, like patient treatment of diverse populations, “should be conducted with welcoming and affirming practices.”
Dr. Marzouk reported no potential conflicts of interest. Dr. Kaiser reported financial relationships with Amgen and Lundbeck.
It is “important not to assume that just because someone is a member of the LGBTQ+ community they will need psychiatric or behavioral health support,” said Maya A. Marzouk, PhD, division of behavioral medicine and clinical psychology, Cincinnati Children’s Hospital Medical Center.
Instead, it is useful not to make any assumptions. There is a potential association between minority status and headache susceptibility, but it is more reasonable initially to address the diagnosis and treatment of headache in LGBTQIA+ patients the same way it is addressed in any other patient, Dr. Marzouk said at the 2023 Scottsdale Headache Symposium.
The acronym to describe individuals with gender identities different from male and female and sexual orientations not limited to heterosexuality has been in almost constant evolution over several decades. An addition sign that accompanies LGBTQIA refers to those who do not identify with any letters in the acronym (lesbian, gay, bisexual, transsexual, queer/questioning, intersex, and asexual).
Take steps to normalize the interaction
Although many clinicians have been acclimated to these diverse identifies, not all have risen above preconceptions that become obstacles to effective care, according to Dr. Marzouk. In the context of headache management, Dr. Marzouk emphasized the need to be respectful of the range of gender identities and sexual orientations and to take steps to normalize the interaction.
For example, Dr. Marzouk advised using gender-neutral language at the start of each patient encounter and ask open-ended questions about gender, sexual identify, and pronouns to avoid patient discomfort from misidentification. In turn, the clinicians can establish their own gender identification and preferred pronouns to reinforce the idea that doing so is normal behavior.
This change in approach should be made “for all patients. Do not try to guess who needs them,” she said.
Intake forms and office atmosphere, such as signs and images, should also be welcoming to all patients, she added. Rather than trying to make adjustments for a LGBTQIA+ visit, Dr. Marzouk said a uniform approach helps normalize the experience of LGBTQIA+ patients without singling them out.
Despite the effort to provide an open and welcoming environment, Dr. Marzouk acknowledged that mistakes are difficult to avoid for those with limited experience serving the LGBTQIA+ community. When mistakes are made, she advised clinicians to immediately acknowledge the mistake and ask for guidance from the patient.
The potential offense is making the patient feel “other” or abnormal.
A higher rate of migraine
The interactions that LBGTQIA+ patients have with others outside their community is a possible explanation for the substantial rate of headache as well as headache with comorbid psychiatric disorders in this population.
In a survey published in 2020, the rate of migraine was 19.7% in heterosexual women, 26.7% in lesbians, and 36.8% in bisexual women. Among men, it rose from 9.8% in heterosexuals to 14.8% in gays and then to 22.8% in bisexuals.
Migraine relative to headache is also associated with more mood disorders among LGBTQIA+ individuals. In a study published in 2022, LGBTQIA+ patients with migraine relative to those with headache were more likely to have depression (46.4% vs. 22.3%; P < .001), anxiety (72.1% vs. 51.6%; P < .001), and posttraumatic stress disorder (37.5% vs. 21.4%; P < .001).
A vicious cycle of underdiagnosis and undertreatment
These associations are consistent with minority stress theory, according to Dr. Marzouk. This theory postulates that the associated stress of discrimination, rejection, and microaggressions, such as explicit efforts to make LGBTQIA+ individuals to feel “other,” produces epigenetic changes and dysregulation of the hypothalamic-pituitary-adrenal axis. In turn, this plays a role in the pathogenesis of migraine.
The inconsistency with which minority stress affects LGBTQIA+ patients might be due to relative differences in social support, coping skills, an innate resilience to these effects, Dr. Marzouk explained.
Dr. Marzouk characterized the LGBTQIA+ community as “underserved” for treatment of headache. She suggested that medical mistrust and self-blame among LGBTQIA+ individuals might be factors contributing to a vicious cycle of underdiagnosis and undertreatment. Efforts by the medical community to reach out to the LGBTQIA+ community are appropriate to address an unmet need.
“Individuals with psychiatric comorbidities may experience even more benefit from migraine care,” she said.
Clinical studies should be more inclusive
While agreeing in principle with these remarks, Eric A. Kaiser, MD, PhD, department of neurology, University of Pennsylvania, Philadelphia, said that this area would be better advanced if studies routinely included patients with diverse-gender identities and sexual orientations. Speaking about how to organize these studies, Dr. Kaiser suggested that enrollment criteria should explicitly seek these individuals and that these differences should be captured in the baseline characteristics.
“For example, gender options could include man, woman, non-binary, gender diverse, gender nonconforming, or gender nonspecified,” he said.
To close “the significant knowledge gap that exists in managing headache disorders in sexually- and gender- diverse people,” Dr. Kaiser said that clinical research studies, like patient treatment of diverse populations, “should be conducted with welcoming and affirming practices.”
Dr. Marzouk reported no potential conflicts of interest. Dr. Kaiser reported financial relationships with Amgen and Lundbeck.
FROM THE 2023 SCOTTSDALE HEADACHE SYMPOSIUM
Commentary: Examining Inpatient Admission, Hypothyroidism, and Vestibular Migraine, November 2023
Inpatient headache admissions are often considered a last-case scenario option for patients with chronic refractory migraine. Initially described by Raskin,1 the admission typically consists of repetitive infusions of dihydroergotamine (DHE) with a pretreatment of antihistamine, neuroleptic, and other antinausea medications in addition to anti-inflammatory or steroid medications, IV fluids, and magnesium. Often this is superimposed on a continuous infusion of lidocaine or ketamine. One common concern is whether the use of DHE is safe for patients at a higher risk for vascular disease. Wang and colleagues reported on the incidence of cardiovascular adverse events in this population receiving repetitive intravenous DHE.
They present findings based on the Jefferson Headache Center (Philadelphia, Pennsylvania) Inpatient Headache Protocol, looking at patients admitted from January through October 2019. Of the 347 patients admitted during this period, 64 were identified as having either an elevated or low risk for atherosclerotic vascular disease. The degree of vascular risk was determined on the basis of an atherosclerotic cardiovascular disease calculation, using body mass index values, cholesterol level, and mean arterial blood pressure readings, as well as smoking and diabetes history. A score < 5.0% was designated low risk, while elevated risk included scores up to 20%. DHE was not offered to patients with a history of moderate to severe ischemic heart disease, coronary vasospasm, peripheral artery disease, Raynaud phenomenon, or ischemic stroke.
The primary outcome was treatment effectiveness, determined by an 11-point pain scale; secondary outcomes included tolerability, as defined by change in the patient's QTc (corrected QT interval) based on their daily ECG monitoring, the incidence of chest pain or shortness of breath, and whether DHE needed to be tapered or discontinued. The researchers noted that the elevated-vascular-risk group had fewer patients receiving the maximum dose of DHE and receiving less DHE over the course of their admission as compared with the low-risk group. They also reported lower response rates and less freedom from pain after admission. No clinically significant adverse events were noted in either group, and only three patients had sustained ECG changes from baseline.
DHE remains an effective treatment for the most chronic and refractory migraine cases, and it can be provided safely and effectively in an appropriately monitored setting. Although there still are contraindications for receiving DHE, those who can receive it may benefit significantly. Ideally, this should be done with cardiac clearance if there is any doubt regarding the vascular risk for any individual patient.
The frequency and severity of migraine can fluctuate due to a myriad of factors. When faced with worsening migraine, most healthcare providers ask their patients about specific triggers or other potential causes that may have led to the recent subacute worsening. Many healthcare providers will also investigate further, and when appropriate, order serum lab testing to determine whether any potential metabolic derangement, vitamin deficiency, or other abnormality could be contributing. Subclinical hypothyroidism is a common finding when investigating for these potential causes of worsening migraine, and often our internal medicine or endocrinology colleagues will discount these findings as "borderline" or still within normal limits. Dev and colleagues sought to determine whether low-dose thyroid replacement was beneficial for migraine prevention in this situation.
This study defined subclinical hypothyroidism as a thyroid-stimulating hormone (TSH) level of 4.5-10.0 mIU/L with a normal free thyroxine (T4), measured twice within 6 weeks for confirmation. Patients with prior thyroid disease were excluded from the study. Participants were randomly assigned to take 25 μg levothyroxine supplementation or placebo and were allowed to continue their migraine treatments. The primary outcomes were reduction in headache duration, frequency, severity, and Migraine Disability Assessment (MIDAS) score after 3 months.
A total of 87 patients with migraine and subclinical hypothyroidism were recruited, and the investigators noted a statistically significant improvement in all parameters (migraine frequency, severity, duration, MIDAS score) after 3 months of low-dose thyroid supplementation. This was maintained at a 3-month follow-up visit as well. TSH levels normalized in 87% of participants after repeat testing 3 months after the intervention.
When evaluating patients with worsening migraine who had been stable, it is wise to consider subclinical hypothyroidism as a potential etiology. Low-dose thyroid hormone supplementation appears to be well tolerated and effective for normalizing both TSH levels and, importantly, the migrainous exacerbation. Clinicians often will start or add preventive medications, ignoring the reason that there was an exacerbation in the first place, even though many of our colleagues choose not to treat this degree of hypothyroidism.
Many variants of migraine are better recognized and understood now; chief among these is vestibular migraine (VM). VM is a migraine subtype characterized by frequent or near-constant vestibular symptoms (vertigo, lightheadedness, disequilibrium, or rocking) with superimposed headache symptoms with some migrainous features. VM is generally considered to be more difficult to treat and more treatment-refractory than episodic or chronic migraine without vestibular symptoms. There are few treatments that are specific for this variant of migraine. Chen and colleagues sought to better understand the evidence of specific treatments for VM via meta-analysis.
Only randomized controlled trials were included in this meta-analysis; seven studies that specifically recruited patients with vestibular migraine using International Classification of Headache Disorders (ICHD) criteria were included. The outcomes of the studies were changes in frequency or severity of vestibular migraine attacks. The studies that were included were published from 2014 to 2022 and comprised multiple treatment comparisons, including metoprolol, venlafaxine, valproic acid, propranolol, flunarizine, a probiotic, and relaxation techniques.
Three interventions were noted to be significantly beneficial for VM prevention, specifically a decrease in migraine frequency: valproic acid, propranolol, and venlafaxine. Valproic acid yielded the greatest decrease in VM frequency among all interventions. None of the interventions were associated with improvement in VM severity, and none of the treatments were associated with significantly different adverse-event and dropout rates.
VM is widely thought to be underdiagnosed and should be considered more frequently. This includes situations in which the headache component of the patient's complaints is relatively mild but still associated with features of migraines, such as sensitivities to light and sound, nausea, or unilateral presentations of pain. There remain very few high-quality VM studies, but this meta-analysis should highlight potential treatment options and raise the profile for this diagnosis in order for further trials to be performed.
Additional Reference
1. Raskin NH. Repetitive intravenous dihydroergotamine as therapy for intractable migraine. Neurology. 1986;36(7):995-997. doi: 10.1212/WNL.36.7.995
Inpatient headache admissions are often considered a last-case scenario option for patients with chronic refractory migraine. Initially described by Raskin,1 the admission typically consists of repetitive infusions of dihydroergotamine (DHE) with a pretreatment of antihistamine, neuroleptic, and other antinausea medications in addition to anti-inflammatory or steroid medications, IV fluids, and magnesium. Often this is superimposed on a continuous infusion of lidocaine or ketamine. One common concern is whether the use of DHE is safe for patients at a higher risk for vascular disease. Wang and colleagues reported on the incidence of cardiovascular adverse events in this population receiving repetitive intravenous DHE.
They present findings based on the Jefferson Headache Center (Philadelphia, Pennsylvania) Inpatient Headache Protocol, looking at patients admitted from January through October 2019. Of the 347 patients admitted during this period, 64 were identified as having either an elevated or low risk for atherosclerotic vascular disease. The degree of vascular risk was determined on the basis of an atherosclerotic cardiovascular disease calculation, using body mass index values, cholesterol level, and mean arterial blood pressure readings, as well as smoking and diabetes history. A score < 5.0% was designated low risk, while elevated risk included scores up to 20%. DHE was not offered to patients with a history of moderate to severe ischemic heart disease, coronary vasospasm, peripheral artery disease, Raynaud phenomenon, or ischemic stroke.
The primary outcome was treatment effectiveness, determined by an 11-point pain scale; secondary outcomes included tolerability, as defined by change in the patient's QTc (corrected QT interval) based on their daily ECG monitoring, the incidence of chest pain or shortness of breath, and whether DHE needed to be tapered or discontinued. The researchers noted that the elevated-vascular-risk group had fewer patients receiving the maximum dose of DHE and receiving less DHE over the course of their admission as compared with the low-risk group. They also reported lower response rates and less freedom from pain after admission. No clinically significant adverse events were noted in either group, and only three patients had sustained ECG changes from baseline.
DHE remains an effective treatment for the most chronic and refractory migraine cases, and it can be provided safely and effectively in an appropriately monitored setting. Although there still are contraindications for receiving DHE, those who can receive it may benefit significantly. Ideally, this should be done with cardiac clearance if there is any doubt regarding the vascular risk for any individual patient.
The frequency and severity of migraine can fluctuate due to a myriad of factors. When faced with worsening migraine, most healthcare providers ask their patients about specific triggers or other potential causes that may have led to the recent subacute worsening. Many healthcare providers will also investigate further, and when appropriate, order serum lab testing to determine whether any potential metabolic derangement, vitamin deficiency, or other abnormality could be contributing. Subclinical hypothyroidism is a common finding when investigating for these potential causes of worsening migraine, and often our internal medicine or endocrinology colleagues will discount these findings as "borderline" or still within normal limits. Dev and colleagues sought to determine whether low-dose thyroid replacement was beneficial for migraine prevention in this situation.
This study defined subclinical hypothyroidism as a thyroid-stimulating hormone (TSH) level of 4.5-10.0 mIU/L with a normal free thyroxine (T4), measured twice within 6 weeks for confirmation. Patients with prior thyroid disease were excluded from the study. Participants were randomly assigned to take 25 μg levothyroxine supplementation or placebo and were allowed to continue their migraine treatments. The primary outcomes were reduction in headache duration, frequency, severity, and Migraine Disability Assessment (MIDAS) score after 3 months.
A total of 87 patients with migraine and subclinical hypothyroidism were recruited, and the investigators noted a statistically significant improvement in all parameters (migraine frequency, severity, duration, MIDAS score) after 3 months of low-dose thyroid supplementation. This was maintained at a 3-month follow-up visit as well. TSH levels normalized in 87% of participants after repeat testing 3 months after the intervention.
When evaluating patients with worsening migraine who had been stable, it is wise to consider subclinical hypothyroidism as a potential etiology. Low-dose thyroid hormone supplementation appears to be well tolerated and effective for normalizing both TSH levels and, importantly, the migrainous exacerbation. Clinicians often will start or add preventive medications, ignoring the reason that there was an exacerbation in the first place, even though many of our colleagues choose not to treat this degree of hypothyroidism.
Many variants of migraine are better recognized and understood now; chief among these is vestibular migraine (VM). VM is a migraine subtype characterized by frequent or near-constant vestibular symptoms (vertigo, lightheadedness, disequilibrium, or rocking) with superimposed headache symptoms with some migrainous features. VM is generally considered to be more difficult to treat and more treatment-refractory than episodic or chronic migraine without vestibular symptoms. There are few treatments that are specific for this variant of migraine. Chen and colleagues sought to better understand the evidence of specific treatments for VM via meta-analysis.
Only randomized controlled trials were included in this meta-analysis; seven studies that specifically recruited patients with vestibular migraine using International Classification of Headache Disorders (ICHD) criteria were included. The outcomes of the studies were changes in frequency or severity of vestibular migraine attacks. The studies that were included were published from 2014 to 2022 and comprised multiple treatment comparisons, including metoprolol, venlafaxine, valproic acid, propranolol, flunarizine, a probiotic, and relaxation techniques.
Three interventions were noted to be significantly beneficial for VM prevention, specifically a decrease in migraine frequency: valproic acid, propranolol, and venlafaxine. Valproic acid yielded the greatest decrease in VM frequency among all interventions. None of the interventions were associated with improvement in VM severity, and none of the treatments were associated with significantly different adverse-event and dropout rates.
VM is widely thought to be underdiagnosed and should be considered more frequently. This includes situations in which the headache component of the patient's complaints is relatively mild but still associated with features of migraines, such as sensitivities to light and sound, nausea, or unilateral presentations of pain. There remain very few high-quality VM studies, but this meta-analysis should highlight potential treatment options and raise the profile for this diagnosis in order for further trials to be performed.
Additional Reference
1. Raskin NH. Repetitive intravenous dihydroergotamine as therapy for intractable migraine. Neurology. 1986;36(7):995-997. doi: 10.1212/WNL.36.7.995
Inpatient headache admissions are often considered a last-case scenario option for patients with chronic refractory migraine. Initially described by Raskin,1 the admission typically consists of repetitive infusions of dihydroergotamine (DHE) with a pretreatment of antihistamine, neuroleptic, and other antinausea medications in addition to anti-inflammatory or steroid medications, IV fluids, and magnesium. Often this is superimposed on a continuous infusion of lidocaine or ketamine. One common concern is whether the use of DHE is safe for patients at a higher risk for vascular disease. Wang and colleagues reported on the incidence of cardiovascular adverse events in this population receiving repetitive intravenous DHE.
They present findings based on the Jefferson Headache Center (Philadelphia, Pennsylvania) Inpatient Headache Protocol, looking at patients admitted from January through October 2019. Of the 347 patients admitted during this period, 64 were identified as having either an elevated or low risk for atherosclerotic vascular disease. The degree of vascular risk was determined on the basis of an atherosclerotic cardiovascular disease calculation, using body mass index values, cholesterol level, and mean arterial blood pressure readings, as well as smoking and diabetes history. A score < 5.0% was designated low risk, while elevated risk included scores up to 20%. DHE was not offered to patients with a history of moderate to severe ischemic heart disease, coronary vasospasm, peripheral artery disease, Raynaud phenomenon, or ischemic stroke.
The primary outcome was treatment effectiveness, determined by an 11-point pain scale; secondary outcomes included tolerability, as defined by change in the patient's QTc (corrected QT interval) based on their daily ECG monitoring, the incidence of chest pain or shortness of breath, and whether DHE needed to be tapered or discontinued. The researchers noted that the elevated-vascular-risk group had fewer patients receiving the maximum dose of DHE and receiving less DHE over the course of their admission as compared with the low-risk group. They also reported lower response rates and less freedom from pain after admission. No clinically significant adverse events were noted in either group, and only three patients had sustained ECG changes from baseline.
DHE remains an effective treatment for the most chronic and refractory migraine cases, and it can be provided safely and effectively in an appropriately monitored setting. Although there still are contraindications for receiving DHE, those who can receive it may benefit significantly. Ideally, this should be done with cardiac clearance if there is any doubt regarding the vascular risk for any individual patient.
The frequency and severity of migraine can fluctuate due to a myriad of factors. When faced with worsening migraine, most healthcare providers ask their patients about specific triggers or other potential causes that may have led to the recent subacute worsening. Many healthcare providers will also investigate further, and when appropriate, order serum lab testing to determine whether any potential metabolic derangement, vitamin deficiency, or other abnormality could be contributing. Subclinical hypothyroidism is a common finding when investigating for these potential causes of worsening migraine, and often our internal medicine or endocrinology colleagues will discount these findings as "borderline" or still within normal limits. Dev and colleagues sought to determine whether low-dose thyroid replacement was beneficial for migraine prevention in this situation.
This study defined subclinical hypothyroidism as a thyroid-stimulating hormone (TSH) level of 4.5-10.0 mIU/L with a normal free thyroxine (T4), measured twice within 6 weeks for confirmation. Patients with prior thyroid disease were excluded from the study. Participants were randomly assigned to take 25 μg levothyroxine supplementation or placebo and were allowed to continue their migraine treatments. The primary outcomes were reduction in headache duration, frequency, severity, and Migraine Disability Assessment (MIDAS) score after 3 months.
A total of 87 patients with migraine and subclinical hypothyroidism were recruited, and the investigators noted a statistically significant improvement in all parameters (migraine frequency, severity, duration, MIDAS score) after 3 months of low-dose thyroid supplementation. This was maintained at a 3-month follow-up visit as well. TSH levels normalized in 87% of participants after repeat testing 3 months after the intervention.
When evaluating patients with worsening migraine who had been stable, it is wise to consider subclinical hypothyroidism as a potential etiology. Low-dose thyroid hormone supplementation appears to be well tolerated and effective for normalizing both TSH levels and, importantly, the migrainous exacerbation. Clinicians often will start or add preventive medications, ignoring the reason that there was an exacerbation in the first place, even though many of our colleagues choose not to treat this degree of hypothyroidism.
Many variants of migraine are better recognized and understood now; chief among these is vestibular migraine (VM). VM is a migraine subtype characterized by frequent or near-constant vestibular symptoms (vertigo, lightheadedness, disequilibrium, or rocking) with superimposed headache symptoms with some migrainous features. VM is generally considered to be more difficult to treat and more treatment-refractory than episodic or chronic migraine without vestibular symptoms. There are few treatments that are specific for this variant of migraine. Chen and colleagues sought to better understand the evidence of specific treatments for VM via meta-analysis.
Only randomized controlled trials were included in this meta-analysis; seven studies that specifically recruited patients with vestibular migraine using International Classification of Headache Disorders (ICHD) criteria were included. The outcomes of the studies were changes in frequency or severity of vestibular migraine attacks. The studies that were included were published from 2014 to 2022 and comprised multiple treatment comparisons, including metoprolol, venlafaxine, valproic acid, propranolol, flunarizine, a probiotic, and relaxation techniques.
Three interventions were noted to be significantly beneficial for VM prevention, specifically a decrease in migraine frequency: valproic acid, propranolol, and venlafaxine. Valproic acid yielded the greatest decrease in VM frequency among all interventions. None of the interventions were associated with improvement in VM severity, and none of the treatments were associated with significantly different adverse-event and dropout rates.
VM is widely thought to be underdiagnosed and should be considered more frequently. This includes situations in which the headache component of the patient's complaints is relatively mild but still associated with features of migraines, such as sensitivities to light and sound, nausea, or unilateral presentations of pain. There remain very few high-quality VM studies, but this meta-analysis should highlight potential treatment options and raise the profile for this diagnosis in order for further trials to be performed.
Additional Reference
1. Raskin NH. Repetitive intravenous dihydroergotamine as therapy for intractable migraine. Neurology. 1986;36(7):995-997. doi: 10.1212/WNL.36.7.995
Higher prevalence of ADHD in episodic migraine
Key clinical point: Attention-deficit hyperactivity disorder (ADHD) symptoms and impulsive personality traits appeared to be more prevalent in patients with episodic migraine than in control individuals.
Major finding: Patients with episodic migraine vs control individuals had higher mean scores for inattention (5.0 vs 2.7; P < .00001), hyperactivity (4.0 vs 2.5; P = .000621), and impulsivity (2.0 vs 1.1; P = .000407) on the ADHD scale. A higher percentage of patients vs control participants (35.5% vs 8.6%) scored ‘often’ or ‘very often’ in ≥1 items of the impulsivity subscale (P < .05).
Study details: This observational cohort study included 100 patients with episodic migraine and 150 control participants without migraine.
Disclosures: This study did not receive any specific funding. The authors declared no conflicts of interest.
Source: Gonzalez-Hernandez A et al. Attention deficit hyperactivity disorder in adults with migraine. J Atten Disord. 2023 (Sep 27). doi: 10.1177/10870547231199256
Key clinical point: Attention-deficit hyperactivity disorder (ADHD) symptoms and impulsive personality traits appeared to be more prevalent in patients with episodic migraine than in control individuals.
Major finding: Patients with episodic migraine vs control individuals had higher mean scores for inattention (5.0 vs 2.7; P < .00001), hyperactivity (4.0 vs 2.5; P = .000621), and impulsivity (2.0 vs 1.1; P = .000407) on the ADHD scale. A higher percentage of patients vs control participants (35.5% vs 8.6%) scored ‘often’ or ‘very often’ in ≥1 items of the impulsivity subscale (P < .05).
Study details: This observational cohort study included 100 patients with episodic migraine and 150 control participants without migraine.
Disclosures: This study did not receive any specific funding. The authors declared no conflicts of interest.
Source: Gonzalez-Hernandez A et al. Attention deficit hyperactivity disorder in adults with migraine. J Atten Disord. 2023 (Sep 27). doi: 10.1177/10870547231199256
Key clinical point: Attention-deficit hyperactivity disorder (ADHD) symptoms and impulsive personality traits appeared to be more prevalent in patients with episodic migraine than in control individuals.
Major finding: Patients with episodic migraine vs control individuals had higher mean scores for inattention (5.0 vs 2.7; P < .00001), hyperactivity (4.0 vs 2.5; P = .000621), and impulsivity (2.0 vs 1.1; P = .000407) on the ADHD scale. A higher percentage of patients vs control participants (35.5% vs 8.6%) scored ‘often’ or ‘very often’ in ≥1 items of the impulsivity subscale (P < .05).
Study details: This observational cohort study included 100 patients with episodic migraine and 150 control participants without migraine.
Disclosures: This study did not receive any specific funding. The authors declared no conflicts of interest.
Source: Gonzalez-Hernandez A et al. Attention deficit hyperactivity disorder in adults with migraine. J Atten Disord. 2023 (Sep 27). doi: 10.1177/10870547231199256
Increase in monthly headache days adversely affects quality of life in migraine
Key clinical point: In patients with migraine, an increase in monthly headache days (MHD) adversely impacts health-related quality of life (HRQoL) measured by the Migraine-Specific Quality-of-Life Questionnaire (MSQ), with the impact being partially mediated by depression, allodynia, and anxiety.
Major finding: For every 1-day increase in the MHD, the scores for MSQ’s Role Function-Restrictive, Role Function-Preventive, and Emotional Function parameters worsened by 0.92, 0.60, and 1.23 points, respectively (all P < .001). Depression, allodynia, and anxiety mediated 15.2%-24.3%, 9.6%-16.1%, and 2.3%-6.0%, respectively, of the total observed effects of MHD on the HRQoL.
Study details: Findings are from a post hoc analysis of the CaMEO study including 12,715 patients with migraine who completed the Core and Comorbidities/Endophenotypes modules.
Disclosures: This study was funded by Allergan (prior to its acquisition by AbbVie). B Dabruzzo declared being an employee of AbbVie and may own its stocks. The other authors declared ties with various sources, including AbbVie.
Source: Lipton RB et al. Impact of monthly headache days on migraine-related quality of life: Results from the Chronic Migraine Epidemiology and Outcomes (CaMEO) study. Headache. 2023 (Oct 5). doi: 10.1111/head.14629
Key clinical point: In patients with migraine, an increase in monthly headache days (MHD) adversely impacts health-related quality of life (HRQoL) measured by the Migraine-Specific Quality-of-Life Questionnaire (MSQ), with the impact being partially mediated by depression, allodynia, and anxiety.
Major finding: For every 1-day increase in the MHD, the scores for MSQ’s Role Function-Restrictive, Role Function-Preventive, and Emotional Function parameters worsened by 0.92, 0.60, and 1.23 points, respectively (all P < .001). Depression, allodynia, and anxiety mediated 15.2%-24.3%, 9.6%-16.1%, and 2.3%-6.0%, respectively, of the total observed effects of MHD on the HRQoL.
Study details: Findings are from a post hoc analysis of the CaMEO study including 12,715 patients with migraine who completed the Core and Comorbidities/Endophenotypes modules.
Disclosures: This study was funded by Allergan (prior to its acquisition by AbbVie). B Dabruzzo declared being an employee of AbbVie and may own its stocks. The other authors declared ties with various sources, including AbbVie.
Source: Lipton RB et al. Impact of monthly headache days on migraine-related quality of life: Results from the Chronic Migraine Epidemiology and Outcomes (CaMEO) study. Headache. 2023 (Oct 5). doi: 10.1111/head.14629
Key clinical point: In patients with migraine, an increase in monthly headache days (MHD) adversely impacts health-related quality of life (HRQoL) measured by the Migraine-Specific Quality-of-Life Questionnaire (MSQ), with the impact being partially mediated by depression, allodynia, and anxiety.
Major finding: For every 1-day increase in the MHD, the scores for MSQ’s Role Function-Restrictive, Role Function-Preventive, and Emotional Function parameters worsened by 0.92, 0.60, and 1.23 points, respectively (all P < .001). Depression, allodynia, and anxiety mediated 15.2%-24.3%, 9.6%-16.1%, and 2.3%-6.0%, respectively, of the total observed effects of MHD on the HRQoL.
Study details: Findings are from a post hoc analysis of the CaMEO study including 12,715 patients with migraine who completed the Core and Comorbidities/Endophenotypes modules.
Disclosures: This study was funded by Allergan (prior to its acquisition by AbbVie). B Dabruzzo declared being an employee of AbbVie and may own its stocks. The other authors declared ties with various sources, including AbbVie.
Source: Lipton RB et al. Impact of monthly headache days on migraine-related quality of life: Results from the Chronic Migraine Epidemiology and Outcomes (CaMEO) study. Headache. 2023 (Oct 5). doi: 10.1111/head.14629
Meta-analysis compares different treatments for vestibular migraine
Key clinical point: Valproic acid, propranolol, and venlafaxine significantly improved vestibular migraine frequency but had no significant differences in terms of vestibular migraine severity, dropout rates, and safety profiles compared with placebo.
Major finding: Compared with placebo, valproic acid (standardized mean difference [SMD] −1.61; 95% CI −2.69 to −0.54), propranolol (SMD −1.36; 95% CI −2.55 to −0.17), and venlafaxine (SMD −1.25; 95% CI −2.32 to −0.18) led to better improvement in vestibular migraine frequency. However, vestibular migraine severity, dropout rates, and safety profiles did not differ significantly between the treatment groups.
Study details: This network meta-analysis of seven randomized controlled trials included 828 patients with vestibular migraine.
Disclosures: This study did not receive any specific funding. The authors declared no conflicts of interest.
Source: Chen J-J et al. Network meta-analysis of different treatments for vestibular migraine. CNS Drugs. 2023;37(9):837-847 (Sep 7). doi: 10.1007/s40263-023-01037-0
Key clinical point: Valproic acid, propranolol, and venlafaxine significantly improved vestibular migraine frequency but had no significant differences in terms of vestibular migraine severity, dropout rates, and safety profiles compared with placebo.
Major finding: Compared with placebo, valproic acid (standardized mean difference [SMD] −1.61; 95% CI −2.69 to −0.54), propranolol (SMD −1.36; 95% CI −2.55 to −0.17), and venlafaxine (SMD −1.25; 95% CI −2.32 to −0.18) led to better improvement in vestibular migraine frequency. However, vestibular migraine severity, dropout rates, and safety profiles did not differ significantly between the treatment groups.
Study details: This network meta-analysis of seven randomized controlled trials included 828 patients with vestibular migraine.
Disclosures: This study did not receive any specific funding. The authors declared no conflicts of interest.
Source: Chen J-J et al. Network meta-analysis of different treatments for vestibular migraine. CNS Drugs. 2023;37(9):837-847 (Sep 7). doi: 10.1007/s40263-023-01037-0
Key clinical point: Valproic acid, propranolol, and venlafaxine significantly improved vestibular migraine frequency but had no significant differences in terms of vestibular migraine severity, dropout rates, and safety profiles compared with placebo.
Major finding: Compared with placebo, valproic acid (standardized mean difference [SMD] −1.61; 95% CI −2.69 to −0.54), propranolol (SMD −1.36; 95% CI −2.55 to −0.17), and venlafaxine (SMD −1.25; 95% CI −2.32 to −0.18) led to better improvement in vestibular migraine frequency. However, vestibular migraine severity, dropout rates, and safety profiles did not differ significantly between the treatment groups.
Study details: This network meta-analysis of seven randomized controlled trials included 828 patients with vestibular migraine.
Disclosures: This study did not receive any specific funding. The authors declared no conflicts of interest.
Source: Chen J-J et al. Network meta-analysis of different treatments for vestibular migraine. CNS Drugs. 2023;37(9):837-847 (Sep 7). doi: 10.1007/s40263-023-01037-0
High dietary potassium intake may help prevent migraine
Key clinical point: High dietary potassium intake is associated with a decreased risk for migraine, with an L-shaped correlation between dietary potassium intake and migraine highlighting an inflection at ~1,439.3 mg/day.
Major finding: Participants in the second quartile (potassium intake 1771-2476 mg/day) vs first quartile (potassium intake ≤ 1771 mg/day) showed a lower risk for migraine (adjusted odds ratio 0.84; P = .021), which suggested an L-shaped (non-linear) association between dietary potassium intake and migraine (P = .016), with an inflection at ~1439.3 mg/day.
Study details: This cross-sectional study included 10,254 participants age ≥ 20 years, of whom 2065 (20.1%) had migraine.
Disclosures: This study did not receive any funding. The authors declared no conflicts of interest.
Source: Xu L et al. Association between dietary potassium intake and severe headache or migraine in US adults: A population-based analysis. Front Nutr. 2023;10:1255468 (Sep 15). doi: 10.3389/fnut.2023.1255468
Key clinical point: High dietary potassium intake is associated with a decreased risk for migraine, with an L-shaped correlation between dietary potassium intake and migraine highlighting an inflection at ~1,439.3 mg/day.
Major finding: Participants in the second quartile (potassium intake 1771-2476 mg/day) vs first quartile (potassium intake ≤ 1771 mg/day) showed a lower risk for migraine (adjusted odds ratio 0.84; P = .021), which suggested an L-shaped (non-linear) association between dietary potassium intake and migraine (P = .016), with an inflection at ~1439.3 mg/day.
Study details: This cross-sectional study included 10,254 participants age ≥ 20 years, of whom 2065 (20.1%) had migraine.
Disclosures: This study did not receive any funding. The authors declared no conflicts of interest.
Source: Xu L et al. Association between dietary potassium intake and severe headache or migraine in US adults: A population-based analysis. Front Nutr. 2023;10:1255468 (Sep 15). doi: 10.3389/fnut.2023.1255468
Key clinical point: High dietary potassium intake is associated with a decreased risk for migraine, with an L-shaped correlation between dietary potassium intake and migraine highlighting an inflection at ~1,439.3 mg/day.
Major finding: Participants in the second quartile (potassium intake 1771-2476 mg/day) vs first quartile (potassium intake ≤ 1771 mg/day) showed a lower risk for migraine (adjusted odds ratio 0.84; P = .021), which suggested an L-shaped (non-linear) association between dietary potassium intake and migraine (P = .016), with an inflection at ~1439.3 mg/day.
Study details: This cross-sectional study included 10,254 participants age ≥ 20 years, of whom 2065 (20.1%) had migraine.
Disclosures: This study did not receive any funding. The authors declared no conflicts of interest.
Source: Xu L et al. Association between dietary potassium intake and severe headache or migraine in US adults: A population-based analysis. Front Nutr. 2023;10:1255468 (Sep 15). doi: 10.3389/fnut.2023.1255468
Sleep and migraine: What is the link?
Key clinical point: Poor sleep could be a significant risk factor for an ensuing migraine attack, and an intensely painful migraine attack may lead to a subsequent increase in sleep duration, thus highlighting that sleep hygiene is an inherent part of migraine management.
Major finding: The odds of having a migraine attack increased by 6.1% and 17.4% with every deviation from mean sleep and every sleep interruption, respectively, during the previous day, whereas the overall sleep duration had no effect on attack occurrences. An intensely painful attack (M = 0.13; 95% high density interval 0.06-0.20) positively predicted increased sleep duration during the same evening.
Study details: This retrospective cross-sectional study included 724 patients (ages, 18-81 years) with a mean monthly migraine attack frequency of 9.94.
Disclosures: This study was supported by a UK Medical Research Council PhD studentship. Two authors declared being employees of Healint Pte. Ltd, and some authors declared ties with various sources.
Source: Stanyer EC et al. Investigating the relationship between sleep and migraine in a global sample: A Bayesian cross-sectional approach. J Headache Pain. 2023;24:123 (Sep 8). doi: 10.1186/s10194-023-01638-6
Key clinical point: Poor sleep could be a significant risk factor for an ensuing migraine attack, and an intensely painful migraine attack may lead to a subsequent increase in sleep duration, thus highlighting that sleep hygiene is an inherent part of migraine management.
Major finding: The odds of having a migraine attack increased by 6.1% and 17.4% with every deviation from mean sleep and every sleep interruption, respectively, during the previous day, whereas the overall sleep duration had no effect on attack occurrences. An intensely painful attack (M = 0.13; 95% high density interval 0.06-0.20) positively predicted increased sleep duration during the same evening.
Study details: This retrospective cross-sectional study included 724 patients (ages, 18-81 years) with a mean monthly migraine attack frequency of 9.94.
Disclosures: This study was supported by a UK Medical Research Council PhD studentship. Two authors declared being employees of Healint Pte. Ltd, and some authors declared ties with various sources.
Source: Stanyer EC et al. Investigating the relationship between sleep and migraine in a global sample: A Bayesian cross-sectional approach. J Headache Pain. 2023;24:123 (Sep 8). doi: 10.1186/s10194-023-01638-6
Key clinical point: Poor sleep could be a significant risk factor for an ensuing migraine attack, and an intensely painful migraine attack may lead to a subsequent increase in sleep duration, thus highlighting that sleep hygiene is an inherent part of migraine management.
Major finding: The odds of having a migraine attack increased by 6.1% and 17.4% with every deviation from mean sleep and every sleep interruption, respectively, during the previous day, whereas the overall sleep duration had no effect on attack occurrences. An intensely painful attack (M = 0.13; 95% high density interval 0.06-0.20) positively predicted increased sleep duration during the same evening.
Study details: This retrospective cross-sectional study included 724 patients (ages, 18-81 years) with a mean monthly migraine attack frequency of 9.94.
Disclosures: This study was supported by a UK Medical Research Council PhD studentship. Two authors declared being employees of Healint Pte. Ltd, and some authors declared ties with various sources.
Source: Stanyer EC et al. Investigating the relationship between sleep and migraine in a global sample: A Bayesian cross-sectional approach. J Headache Pain. 2023;24:123 (Sep 8). doi: 10.1186/s10194-023-01638-6