User login
Higher dietary caffeine intake tied to severe headaches or migraines
Key clinical point: Higher intake of dietary caffeine was positively associated with a higher prevalence of severe headaches or migraines in US adults.
Major finding: Overall, the incidence of severe headaches or migraines increased by 5% with each 100 mg/day increase in dietary caffeine intake (odds ratio [OR] 1.05; P < .001), with the risk increasing by 42% with caffeine intake ≥ 400 mg/day vs ≥0 to <40 mg/day (OR 1.42; P < .001).
Study details: This cross-sectional study evaluated the association between dietary caffeine intake and severe headaches or migraines in 8993 U.S. adults age ≥ 20 years.
Disclosures: This study was funded by the Shandong Traditional Chinese Medicine Science and Technology Development Project, China. The authors declared no conflicts of interest.
Source: Zhang L et al. Association between dietary caffeine intake and severe headache or migraine in US adults. Sci Rep. 2023;13:10220 (Jun 23). Doi: 10.1038/s41598-023-36325-8
Key clinical point: Higher intake of dietary caffeine was positively associated with a higher prevalence of severe headaches or migraines in US adults.
Major finding: Overall, the incidence of severe headaches or migraines increased by 5% with each 100 mg/day increase in dietary caffeine intake (odds ratio [OR] 1.05; P < .001), with the risk increasing by 42% with caffeine intake ≥ 400 mg/day vs ≥0 to <40 mg/day (OR 1.42; P < .001).
Study details: This cross-sectional study evaluated the association between dietary caffeine intake and severe headaches or migraines in 8993 U.S. adults age ≥ 20 years.
Disclosures: This study was funded by the Shandong Traditional Chinese Medicine Science and Technology Development Project, China. The authors declared no conflicts of interest.
Source: Zhang L et al. Association between dietary caffeine intake and severe headache or migraine in US adults. Sci Rep. 2023;13:10220 (Jun 23). Doi: 10.1038/s41598-023-36325-8
Key clinical point: Higher intake of dietary caffeine was positively associated with a higher prevalence of severe headaches or migraines in US adults.
Major finding: Overall, the incidence of severe headaches or migraines increased by 5% with each 100 mg/day increase in dietary caffeine intake (odds ratio [OR] 1.05; P < .001), with the risk increasing by 42% with caffeine intake ≥ 400 mg/day vs ≥0 to <40 mg/day (OR 1.42; P < .001).
Study details: This cross-sectional study evaluated the association between dietary caffeine intake and severe headaches or migraines in 8993 U.S. adults age ≥ 20 years.
Disclosures: This study was funded by the Shandong Traditional Chinese Medicine Science and Technology Development Project, China. The authors declared no conflicts of interest.
Source: Zhang L et al. Association between dietary caffeine intake and severe headache or migraine in US adults. Sci Rep. 2023;13:10220 (Jun 23). Doi: 10.1038/s41598-023-36325-8
Long-term erenumab shows sustained efficacy and safety in chronic migraine
Key clinical point: Long-term erenumab treatment demonstrated sustained efficacy and safety in patients with chronic migraine (CM) with and without acute medication overuse (AMO), with erenumab reducing acute medication consumption and many patients moving to non-AMO status.
Major finding: Among baseline acute migraine-specific medication users at 52 weeks, the mean monthly migraine-specific medication days reduced by 7.4 (95% CI 6.4-8.3) days and 5.4 (95% CI 4.7-6.1) days in the AMO and non-AMO groups, respectively, with 66.1% of patients in the AMO group moving to the non-AMO group.
Study details: This post hoc subgroup analysis of a 52-week open-label extension study following a 12-week double-blind study included 469 patients with CM stratified by AMO status who were randomly assigned to receive placebo or erenumab (70 or 140 mg) throughout or switch from 70 to 140 mg erenumab.
Disclosures: This study was funded by Amgen Inc. Some authors declared being employees or stockholders of Amgen. The other authors declared ties with various sources, including Amgen.
Source: Tepper SJ et al. Long-term efficacy and safety of erenumab in patients with chronic migraine and acute medication overuse: A subgroup analysis. Headache. 2023;63(6):730-742 (Jun 14). Doi: 10.1111/head.14536
Key clinical point: Long-term erenumab treatment demonstrated sustained efficacy and safety in patients with chronic migraine (CM) with and without acute medication overuse (AMO), with erenumab reducing acute medication consumption and many patients moving to non-AMO status.
Major finding: Among baseline acute migraine-specific medication users at 52 weeks, the mean monthly migraine-specific medication days reduced by 7.4 (95% CI 6.4-8.3) days and 5.4 (95% CI 4.7-6.1) days in the AMO and non-AMO groups, respectively, with 66.1% of patients in the AMO group moving to the non-AMO group.
Study details: This post hoc subgroup analysis of a 52-week open-label extension study following a 12-week double-blind study included 469 patients with CM stratified by AMO status who were randomly assigned to receive placebo or erenumab (70 or 140 mg) throughout or switch from 70 to 140 mg erenumab.
Disclosures: This study was funded by Amgen Inc. Some authors declared being employees or stockholders of Amgen. The other authors declared ties with various sources, including Amgen.
Source: Tepper SJ et al. Long-term efficacy and safety of erenumab in patients with chronic migraine and acute medication overuse: A subgroup analysis. Headache. 2023;63(6):730-742 (Jun 14). Doi: 10.1111/head.14536
Key clinical point: Long-term erenumab treatment demonstrated sustained efficacy and safety in patients with chronic migraine (CM) with and without acute medication overuse (AMO), with erenumab reducing acute medication consumption and many patients moving to non-AMO status.
Major finding: Among baseline acute migraine-specific medication users at 52 weeks, the mean monthly migraine-specific medication days reduced by 7.4 (95% CI 6.4-8.3) days and 5.4 (95% CI 4.7-6.1) days in the AMO and non-AMO groups, respectively, with 66.1% of patients in the AMO group moving to the non-AMO group.
Study details: This post hoc subgroup analysis of a 52-week open-label extension study following a 12-week double-blind study included 469 patients with CM stratified by AMO status who were randomly assigned to receive placebo or erenumab (70 or 140 mg) throughout or switch from 70 to 140 mg erenumab.
Disclosures: This study was funded by Amgen Inc. Some authors declared being employees or stockholders of Amgen. The other authors declared ties with various sources, including Amgen.
Source: Tepper SJ et al. Long-term efficacy and safety of erenumab in patients with chronic migraine and acute medication overuse: A subgroup analysis. Headache. 2023;63(6):730-742 (Jun 14). Doi: 10.1111/head.14536
Ultrasound-guided stellate ganglion block: A safe and effective option for treating migraine in elderly
Key clinical point: Ultrasound-guided stellate ganglion block (SGB) appeared to be safe and effective in reducing pain intensity, headache frequency and duration, and the need for adjunctive anti-migraine medications in elderly patients with migraine.
Major finding: At 3 months after ultrasound-guided SGB treatment, the mean Numerical Rating Scale score reduced from 7.3 at baseline to 3.6 (P < .001), the mean headache frequency per month reduced from 23.1 days at baseline to 14.0 days (P = .001), and the mean headache duration decreased from 22.7 hours at baseline to 14.3 hours (P = .001), with 64% of patients experiencing ≥50% reduction in anti-migraine medication consumption. No procedure-related serious adverse events were reported.
Study details: Findings are from a retrospective observational case series study including 52 elderly patients (age ≥ 65 years) with migraine who received ultrasound-guided SGB treatment for headache management.
Disclosures: This study did not disclose the funding source. The authors declared no conflicts of interest.
Source: Yu B et al. Ultrasound-guided stellate ganglion block for the treatment of migraine in elderly patients: A retrospective and observational study. Headache. 2023;63(6):763-770 (Jun 14). Doi: 10.1111/head.14537
Key clinical point: Ultrasound-guided stellate ganglion block (SGB) appeared to be safe and effective in reducing pain intensity, headache frequency and duration, and the need for adjunctive anti-migraine medications in elderly patients with migraine.
Major finding: At 3 months after ultrasound-guided SGB treatment, the mean Numerical Rating Scale score reduced from 7.3 at baseline to 3.6 (P < .001), the mean headache frequency per month reduced from 23.1 days at baseline to 14.0 days (P = .001), and the mean headache duration decreased from 22.7 hours at baseline to 14.3 hours (P = .001), with 64% of patients experiencing ≥50% reduction in anti-migraine medication consumption. No procedure-related serious adverse events were reported.
Study details: Findings are from a retrospective observational case series study including 52 elderly patients (age ≥ 65 years) with migraine who received ultrasound-guided SGB treatment for headache management.
Disclosures: This study did not disclose the funding source. The authors declared no conflicts of interest.
Source: Yu B et al. Ultrasound-guided stellate ganglion block for the treatment of migraine in elderly patients: A retrospective and observational study. Headache. 2023;63(6):763-770 (Jun 14). Doi: 10.1111/head.14537
Key clinical point: Ultrasound-guided stellate ganglion block (SGB) appeared to be safe and effective in reducing pain intensity, headache frequency and duration, and the need for adjunctive anti-migraine medications in elderly patients with migraine.
Major finding: At 3 months after ultrasound-guided SGB treatment, the mean Numerical Rating Scale score reduced from 7.3 at baseline to 3.6 (P < .001), the mean headache frequency per month reduced from 23.1 days at baseline to 14.0 days (P = .001), and the mean headache duration decreased from 22.7 hours at baseline to 14.3 hours (P = .001), with 64% of patients experiencing ≥50% reduction in anti-migraine medication consumption. No procedure-related serious adverse events were reported.
Study details: Findings are from a retrospective observational case series study including 52 elderly patients (age ≥ 65 years) with migraine who received ultrasound-guided SGB treatment for headache management.
Disclosures: This study did not disclose the funding source. The authors declared no conflicts of interest.
Source: Yu B et al. Ultrasound-guided stellate ganglion block for the treatment of migraine in elderly patients: A retrospective and observational study. Headache. 2023;63(6):763-770 (Jun 14). Doi: 10.1111/head.14537
Decrease in visual hypersensitivity predicts clinical response to anti-CGRP mAbs in migraine
Key clinical point: In patients with migraine, treatment with anti-calcitonin gene-related peptide (anti-CGRP) monoclonal antibodies (mAb) reduced visual hypersensitivity, and this reduction was positively associated with a decrease in monthly migraine days (MMD).
Major finding: After 3 months of treatment with anti-CGRP mAb, the mean ictal Leiden Visual Sensitivity Scale (L-VISS) score decreased from 20.1 to 19.2 (P = .042) and the mean interictal L-VISS score decreased from 11.8 to 11.1 (P = .050), and a positive correlation was observed between the reduction in MMD and the decrease in ictal L-VISS (β 0.3; P = .001) and interictal L-VISS (β 0.2; P = .010) scores.
Study details: This prospective follow-up study included 205 patients with migraine who were treated with either erenumab (n = 105) or fremanezumab (n = 100).
Disclosures: This study did not disclose the funding source. Three authors declared receiving consultancy or industry and independent support from various sources. The other authors declared no conflicts of interest.
Source: de Vries Lentsch S et al. Visual hypersensitivity in patients treated with anti-calcitonin gene-related peptide (receptor) monoclonal antibodies. Headache. 2023;63(7):926-933 (Jun 26). Doi: 10.1111/head.14531
Key clinical point: In patients with migraine, treatment with anti-calcitonin gene-related peptide (anti-CGRP) monoclonal antibodies (mAb) reduced visual hypersensitivity, and this reduction was positively associated with a decrease in monthly migraine days (MMD).
Major finding: After 3 months of treatment with anti-CGRP mAb, the mean ictal Leiden Visual Sensitivity Scale (L-VISS) score decreased from 20.1 to 19.2 (P = .042) and the mean interictal L-VISS score decreased from 11.8 to 11.1 (P = .050), and a positive correlation was observed between the reduction in MMD and the decrease in ictal L-VISS (β 0.3; P = .001) and interictal L-VISS (β 0.2; P = .010) scores.
Study details: This prospective follow-up study included 205 patients with migraine who were treated with either erenumab (n = 105) or fremanezumab (n = 100).
Disclosures: This study did not disclose the funding source. Three authors declared receiving consultancy or industry and independent support from various sources. The other authors declared no conflicts of interest.
Source: de Vries Lentsch S et al. Visual hypersensitivity in patients treated with anti-calcitonin gene-related peptide (receptor) monoclonal antibodies. Headache. 2023;63(7):926-933 (Jun 26). Doi: 10.1111/head.14531
Key clinical point: In patients with migraine, treatment with anti-calcitonin gene-related peptide (anti-CGRP) monoclonal antibodies (mAb) reduced visual hypersensitivity, and this reduction was positively associated with a decrease in monthly migraine days (MMD).
Major finding: After 3 months of treatment with anti-CGRP mAb, the mean ictal Leiden Visual Sensitivity Scale (L-VISS) score decreased from 20.1 to 19.2 (P = .042) and the mean interictal L-VISS score decreased from 11.8 to 11.1 (P = .050), and a positive correlation was observed between the reduction in MMD and the decrease in ictal L-VISS (β 0.3; P = .001) and interictal L-VISS (β 0.2; P = .010) scores.
Study details: This prospective follow-up study included 205 patients with migraine who were treated with either erenumab (n = 105) or fremanezumab (n = 100).
Disclosures: This study did not disclose the funding source. Three authors declared receiving consultancy or industry and independent support from various sources. The other authors declared no conflicts of interest.
Source: de Vries Lentsch S et al. Visual hypersensitivity in patients treated with anti-calcitonin gene-related peptide (receptor) monoclonal antibodies. Headache. 2023;63(7):926-933 (Jun 26). Doi: 10.1111/head.14531
Meta-analysis confirms benefits of rimegepant in episodic migraine
Key clinical point: Meta-analysis confirmed better therapeutic efficacy of rimegepant compared with placebo in patients with episodic migraine (EM), along with no significant difference in adverse events.
Major finding: Rimegepant was more effective than placebo in terms of achieving pain freedom and pain relief at 2 hours (odds ratio [OR] 1.84 and 1.80, respectively), 2-24 hours (OR 2.44 and 2.10, respectively), and 2-48 hours (OR 2.27 and 1.92, respectively; all P < .00001) post-dose. The occurrence of adverse events was not significantly different between the rimegepant and control arms (P = .06).
Study details: The data come from a systematic review and meta-analysis of 4 randomized controlled trials including 4230 patients with EM.
Disclosures: This study did not declare the source of funding. The authors declared no conflicts of interest.
Source: Wang Q et al. Clinical efficacy and safety of rimegepant in the treatment of migraine: A meta-analysis of randomized controlled trials. Front Neurol. 2023;14:1205778 (Jun 20). Doi: 10.3389/fneur.2023.1205778
Key clinical point: Meta-analysis confirmed better therapeutic efficacy of rimegepant compared with placebo in patients with episodic migraine (EM), along with no significant difference in adverse events.
Major finding: Rimegepant was more effective than placebo in terms of achieving pain freedom and pain relief at 2 hours (odds ratio [OR] 1.84 and 1.80, respectively), 2-24 hours (OR 2.44 and 2.10, respectively), and 2-48 hours (OR 2.27 and 1.92, respectively; all P < .00001) post-dose. The occurrence of adverse events was not significantly different between the rimegepant and control arms (P = .06).
Study details: The data come from a systematic review and meta-analysis of 4 randomized controlled trials including 4230 patients with EM.
Disclosures: This study did not declare the source of funding. The authors declared no conflicts of interest.
Source: Wang Q et al. Clinical efficacy and safety of rimegepant in the treatment of migraine: A meta-analysis of randomized controlled trials. Front Neurol. 2023;14:1205778 (Jun 20). Doi: 10.3389/fneur.2023.1205778
Key clinical point: Meta-analysis confirmed better therapeutic efficacy of rimegepant compared with placebo in patients with episodic migraine (EM), along with no significant difference in adverse events.
Major finding: Rimegepant was more effective than placebo in terms of achieving pain freedom and pain relief at 2 hours (odds ratio [OR] 1.84 and 1.80, respectively), 2-24 hours (OR 2.44 and 2.10, respectively), and 2-48 hours (OR 2.27 and 1.92, respectively; all P < .00001) post-dose. The occurrence of adverse events was not significantly different between the rimegepant and control arms (P = .06).
Study details: The data come from a systematic review and meta-analysis of 4 randomized controlled trials including 4230 patients with EM.
Disclosures: This study did not declare the source of funding. The authors declared no conflicts of interest.
Source: Wang Q et al. Clinical efficacy and safety of rimegepant in the treatment of migraine: A meta-analysis of randomized controlled trials. Front Neurol. 2023;14:1205778 (Jun 20). Doi: 10.3389/fneur.2023.1205778
Potential moderators of response to behavioral treatment for migraine prophylaxis
Key clinical point: Disability, anxiety, and comorbid mental disorders moderated the long-term effect of migraine-specific cognitive behavioral therapy (miCBT) or relaxation training (RLX) on headache days in patients with migraine, with those having higher and lower burden benefitting more from miCBT and RLX, respectively.
Major finding: Patients with higher headache-related disability (B −0.41; P = .047), anxiety (B −0.66; P = .056), and comorbid mental disorders (B −4.98; P = .053) benefited more from miCBT, whereas those with relatively lower headache-related disability and anxiety and without any comorbid mental disorder benefited more from RLX at 12 months of follow-up.
Study details: This secondary analysis of an open-label randomized controlled trial included 121 patients with migraine who were randomly assigned to the miCBT (n = 40), RLX (n = 41), or waiting-list control (n = 40) group.
Disclosures: This study received no specific funding. C Gaul and E Liesering-Latta declared receiving consulting and lecture honoraria from various sources. C Gaul declared serving as an honorary secretary of the German Migraine and Headache Society. The other authors declared no conflicts of interest.
Source: Klan T et al. Behavioral treatment for migraine prophylaxis in adults: Moderator analysis of a randomized controlled trial. Cephalalgia. 2023;43(6) (Jun 8). Doi: 10.1177/03331024231178237
Key clinical point: Disability, anxiety, and comorbid mental disorders moderated the long-term effect of migraine-specific cognitive behavioral therapy (miCBT) or relaxation training (RLX) on headache days in patients with migraine, with those having higher and lower burden benefitting more from miCBT and RLX, respectively.
Major finding: Patients with higher headache-related disability (B −0.41; P = .047), anxiety (B −0.66; P = .056), and comorbid mental disorders (B −4.98; P = .053) benefited more from miCBT, whereas those with relatively lower headache-related disability and anxiety and without any comorbid mental disorder benefited more from RLX at 12 months of follow-up.
Study details: This secondary analysis of an open-label randomized controlled trial included 121 patients with migraine who were randomly assigned to the miCBT (n = 40), RLX (n = 41), or waiting-list control (n = 40) group.
Disclosures: This study received no specific funding. C Gaul and E Liesering-Latta declared receiving consulting and lecture honoraria from various sources. C Gaul declared serving as an honorary secretary of the German Migraine and Headache Society. The other authors declared no conflicts of interest.
Source: Klan T et al. Behavioral treatment for migraine prophylaxis in adults: Moderator analysis of a randomized controlled trial. Cephalalgia. 2023;43(6) (Jun 8). Doi: 10.1177/03331024231178237
Key clinical point: Disability, anxiety, and comorbid mental disorders moderated the long-term effect of migraine-specific cognitive behavioral therapy (miCBT) or relaxation training (RLX) on headache days in patients with migraine, with those having higher and lower burden benefitting more from miCBT and RLX, respectively.
Major finding: Patients with higher headache-related disability (B −0.41; P = .047), anxiety (B −0.66; P = .056), and comorbid mental disorders (B −4.98; P = .053) benefited more from miCBT, whereas those with relatively lower headache-related disability and anxiety and without any comorbid mental disorder benefited more from RLX at 12 months of follow-up.
Study details: This secondary analysis of an open-label randomized controlled trial included 121 patients with migraine who were randomly assigned to the miCBT (n = 40), RLX (n = 41), or waiting-list control (n = 40) group.
Disclosures: This study received no specific funding. C Gaul and E Liesering-Latta declared receiving consulting and lecture honoraria from various sources. C Gaul declared serving as an honorary secretary of the German Migraine and Headache Society. The other authors declared no conflicts of interest.
Source: Klan T et al. Behavioral treatment for migraine prophylaxis in adults: Moderator analysis of a randomized controlled trial. Cephalalgia. 2023;43(6) (Jun 8). Doi: 10.1177/03331024231178237
Study supports use of BP-lowering medications for prevention of episodic migraine
Key clinical point: A broad category of blood pressure (BP)-lowering medication classes and drugs effectively reduced headache frequency in patients with episodic migraine.
Major finding: Compared with placebo, headache days per month reduced significantly with alpha-blockers (P = .023), angiotensin II receptor blockers (P = .024), beta-blockers (P = .035), and calcium channel blockers (P = .025). Specific BP-lowering drugs, such as clonidine (P = .026), candesartan (P = .001), atenolol (P = .010), bisoprolol (P = .000), propranolol (P = .000), timolol (P = .000), nicardipine (P = .001), and verapamil (P = .016), also effectively reduced the number of headache days per month.
Study details: Findings are from a systematic review and meta-analysis of 50 studies including 4310 participants.
Disclosures: This study received no specific funding. LR Griffiths reported receiving migraine research funding from the Australian National Health and Medical Research Council. AS Zagami declared being an associate editor for Cephalalgia. A Rodgers declared being an inventor for George Health Enterprises. The other authors declared no conflicts of interest.
Source: Carcel C, Haghdoost F, et al. The effect of blood pressure lowering medications on the prevention of episodic migraine: A systematic review and meta-analysis. Cephalalgia. 2023 (Jun 23). Doi: 10.1177/03331024231183166
Key clinical point: A broad category of blood pressure (BP)-lowering medication classes and drugs effectively reduced headache frequency in patients with episodic migraine.
Major finding: Compared with placebo, headache days per month reduced significantly with alpha-blockers (P = .023), angiotensin II receptor blockers (P = .024), beta-blockers (P = .035), and calcium channel blockers (P = .025). Specific BP-lowering drugs, such as clonidine (P = .026), candesartan (P = .001), atenolol (P = .010), bisoprolol (P = .000), propranolol (P = .000), timolol (P = .000), nicardipine (P = .001), and verapamil (P = .016), also effectively reduced the number of headache days per month.
Study details: Findings are from a systematic review and meta-analysis of 50 studies including 4310 participants.
Disclosures: This study received no specific funding. LR Griffiths reported receiving migraine research funding from the Australian National Health and Medical Research Council. AS Zagami declared being an associate editor for Cephalalgia. A Rodgers declared being an inventor for George Health Enterprises. The other authors declared no conflicts of interest.
Source: Carcel C, Haghdoost F, et al. The effect of blood pressure lowering medications on the prevention of episodic migraine: A systematic review and meta-analysis. Cephalalgia. 2023 (Jun 23). Doi: 10.1177/03331024231183166
Key clinical point: A broad category of blood pressure (BP)-lowering medication classes and drugs effectively reduced headache frequency in patients with episodic migraine.
Major finding: Compared with placebo, headache days per month reduced significantly with alpha-blockers (P = .023), angiotensin II receptor blockers (P = .024), beta-blockers (P = .035), and calcium channel blockers (P = .025). Specific BP-lowering drugs, such as clonidine (P = .026), candesartan (P = .001), atenolol (P = .010), bisoprolol (P = .000), propranolol (P = .000), timolol (P = .000), nicardipine (P = .001), and verapamil (P = .016), also effectively reduced the number of headache days per month.
Study details: Findings are from a systematic review and meta-analysis of 50 studies including 4310 participants.
Disclosures: This study received no specific funding. LR Griffiths reported receiving migraine research funding from the Australian National Health and Medical Research Council. AS Zagami declared being an associate editor for Cephalalgia. A Rodgers declared being an inventor for George Health Enterprises. The other authors declared no conflicts of interest.
Source: Carcel C, Haghdoost F, et al. The effect of blood pressure lowering medications on the prevention of episodic migraine: A systematic review and meta-analysis. Cephalalgia. 2023 (Jun 23). Doi: 10.1177/03331024231183166
Migraine elevates risk for ischemic stroke in men and women with migraine
Key clinical point: Migraine increased the risk for premature ischemic stroke similarly among women and men aged ≤60 years; however, the effect of migraine on the risk for premature myocardial infarction (MI) and hemorrhagic stroke was greater only in women but not in men with migraine.
Major finding: Compared with those without migraine, women (adjusted HR [aHR] 1.21) and men (aHR 1.23; both P < .001) with migraine showed a similar increase in the risk for premature ischemic stroke. However, the risk for premature MI (aHR 1.22; 95% CI 1.14-1.31; P < .001) and hemorrhagic stroke (aHR 1.13; 95% CI 1.02-1.24; P = .014) was significantly higher in women with vs without migraine but not in men.
Study details: This nationwide population-based cohort study included 179,680 women and 40,757 men with migraine.
Disclosures: This study did not receive any specific funding. CH Fuglsang declared owning stock in Novo Nordisk, and M Schmidt declared being supported by the Novo Nordisk Foundation.
Source: Fuglsang CH et al. Migraine and risk of premature myocardial infarction and stroke among men and women: A Danish population-based cohort study. PLoS Med. 2023;20(6):e1004238 (Jun 13). Doi: 10.1371/journal.pmed.1004238
Key clinical point: Migraine increased the risk for premature ischemic stroke similarly among women and men aged ≤60 years; however, the effect of migraine on the risk for premature myocardial infarction (MI) and hemorrhagic stroke was greater only in women but not in men with migraine.
Major finding: Compared with those without migraine, women (adjusted HR [aHR] 1.21) and men (aHR 1.23; both P < .001) with migraine showed a similar increase in the risk for premature ischemic stroke. However, the risk for premature MI (aHR 1.22; 95% CI 1.14-1.31; P < .001) and hemorrhagic stroke (aHR 1.13; 95% CI 1.02-1.24; P = .014) was significantly higher in women with vs without migraine but not in men.
Study details: This nationwide population-based cohort study included 179,680 women and 40,757 men with migraine.
Disclosures: This study did not receive any specific funding. CH Fuglsang declared owning stock in Novo Nordisk, and M Schmidt declared being supported by the Novo Nordisk Foundation.
Source: Fuglsang CH et al. Migraine and risk of premature myocardial infarction and stroke among men and women: A Danish population-based cohort study. PLoS Med. 2023;20(6):e1004238 (Jun 13). Doi: 10.1371/journal.pmed.1004238
Key clinical point: Migraine increased the risk for premature ischemic stroke similarly among women and men aged ≤60 years; however, the effect of migraine on the risk for premature myocardial infarction (MI) and hemorrhagic stroke was greater only in women but not in men with migraine.
Major finding: Compared with those without migraine, women (adjusted HR [aHR] 1.21) and men (aHR 1.23; both P < .001) with migraine showed a similar increase in the risk for premature ischemic stroke. However, the risk for premature MI (aHR 1.22; 95% CI 1.14-1.31; P < .001) and hemorrhagic stroke (aHR 1.13; 95% CI 1.02-1.24; P = .014) was significantly higher in women with vs without migraine but not in men.
Study details: This nationwide population-based cohort study included 179,680 women and 40,757 men with migraine.
Disclosures: This study did not receive any specific funding. CH Fuglsang declared owning stock in Novo Nordisk, and M Schmidt declared being supported by the Novo Nordisk Foundation.
Source: Fuglsang CH et al. Migraine and risk of premature myocardial infarction and stroke among men and women: A Danish population-based cohort study. PLoS Med. 2023;20(6):e1004238 (Jun 13). Doi: 10.1371/journal.pmed.1004238
Commentary: Refractory chronic migraine treatment, July 2023
Calcitonin gene-related peptide (CGRP) antagonist medications have revolutionized migraine therapy since being introduced in 2018. The initial preventive trials for monoclonal antibodies (mAb) excluded older adults, with a cutoff in all studies at age 65 years. Long-term safety studies have not revealed signals for concern related to vascular or other adverse events. The study by Muñoz-Vendrell and colleagues investigated the efficacy of CGRP mAb in treatment-refractory older adults.
This was an observational retrospective study in participants older than 65 years that had previously used three or more prior migraine preventives unsuccessfully. The primary endpoints were reduction in monthly migraine days after 6 months of treatment and the presence of adverse effects. Secondary endpoints were reductions in headache and acute medication frequency as well as improvement in patient reported outcomes.
A total of 162 participants were followed at 18 different headache centers throughout Spain. All patients had at least 8 headache days per month and had been treated unsuccessfully with three prior medications for migraine prevention, one of which was botulinum toxin. The median age was 68 years, and over 80% had chronic migraine. The reduction in mean headache days was 10 days per month; 72% continued to use their CGRP mAb after using it for 6 months. Participants were compared relative to medication overuse but no significant differences were found between those who overused medication and others.
This study highlights the efficacy of CGRP medications in those outside of the initially studied population. Other preventive medications may be contraindicated in this population, but CGRP antagonists do appear to be safe and effective options for older adults.
Opiate medications are typically considered inappropriate as an acute treatment for migraine. Even infrequent use of opiate medications has been shown to be associated with worse migraine outcomes, specifically higher frequency and a higher likelihood to convert from episodic to chronic migraine. Van Welie and colleagues performed a cross-sectional questionnaire-based study assessing levels of opioid use in patients with migraine.
Participants were selected from the Leiden Headache Center and fit the diagnostic criteria of migraine. They were given an e-questionnaire to determine their use of these opiates: buprenorphine, fentanyl, hydromorphone, morphine, oxycodone, tapentadol, and tramadol (codeine was not included in this list). Patients were separately divided between chronic and episodic migraine groups. The primary outcome was assessing for current acute treatment of migraine with an opiate; secondary outcomes were association of chronicity of migraine and likelihood of medication overuse with opiate use.
Only approximately 1.8% of participants reported that they currently use an opiate for acute migraine treatment; 12.5% reported that they previously have used an opiate and 25.7% reported using an opiate for another pain condition. Tramadol was the most commonly used opiate medication, followed by oxycodone and morphine; 2.4% of patients reported that their opiate use was not prescribed by their doctor. Primary care doctors were the most common prescribers of the opiate medications; 16% of the time, patients were told that it was a preventive treatment for migraine. Opiate use was more frequent in patients with a diagnosis of chronic migraine, and the duration of use was greater.
Opiate medications remain a poor acute choice of treatment for migraine, and this study shows a correlation between higher opiate use and chronic migraine. There are many other acute medications now available for migraine, many of them migraine-specific treatments, such as triptans, gepants, and ditans. This research again shows that opiates should be avoided if at all possible for migraine.
Patients with medication overuse headache are more likely to be treatment-refractory, and the addition of acute medications often can be less effective if they remain on the overused medication. There has been a long-standing debate whether it is best to wean medications first or start a preventive initially when faced with medication overuse. The CGRP antagonists may be one of the better preventive options in this situation, and one mAb (fremenezumab) reported positive data in a small medication overuse trial. The study by Guerzoni and colleagues investigated the effectiveness of galcanezumab in chronic migraine with medication overuse.
This was a prospective trial conducted at the University Hospital of Modena. A total of 78 patients with a diagnosis of chronic migraine and medication overuse were enrolled for 15 months, with follow-up every 3 months. At each follow-up appointment, they completed a questionnaire asking them details about: mean migraine days per month, mean number of painkillers taken per month, mean days per month taking a painkiller, average migraine severity, and the Headache Impact Test (HIT-6) and Migraine Disability Assessment (MIDAS) questions. Patients were given the standard-dosing regimen of glacanezumab for migraine and were not blinded; this was an open-label study.
The mean migraine days per month were significantly reduced after 3, 6, 9, and 12 months. The amount of painkillers used per month and days of painkillers per month both reduced significantly as well. Migraine-related disability on HIT-6 and MIDAS were all reduced significantly as well. The most significant improvement long-term was noted in patients who improved the most during the initial 3 months of treatment.
The debate regarding the best treatment for patients with medication overuse will continue, but this study highlights the effectiveness of CGRP mAb use in this population. Patients were able to decrease the use of acute medications without a strict wean off of their previous medication. Ideally, a similar study should also be done for additional mAb and oral CGRP antagonists.
Calcitonin gene-related peptide (CGRP) antagonist medications have revolutionized migraine therapy since being introduced in 2018. The initial preventive trials for monoclonal antibodies (mAb) excluded older adults, with a cutoff in all studies at age 65 years. Long-term safety studies have not revealed signals for concern related to vascular or other adverse events. The study by Muñoz-Vendrell and colleagues investigated the efficacy of CGRP mAb in treatment-refractory older adults.
This was an observational retrospective study in participants older than 65 years that had previously used three or more prior migraine preventives unsuccessfully. The primary endpoints were reduction in monthly migraine days after 6 months of treatment and the presence of adverse effects. Secondary endpoints were reductions in headache and acute medication frequency as well as improvement in patient reported outcomes.
A total of 162 participants were followed at 18 different headache centers throughout Spain. All patients had at least 8 headache days per month and had been treated unsuccessfully with three prior medications for migraine prevention, one of which was botulinum toxin. The median age was 68 years, and over 80% had chronic migraine. The reduction in mean headache days was 10 days per month; 72% continued to use their CGRP mAb after using it for 6 months. Participants were compared relative to medication overuse but no significant differences were found between those who overused medication and others.
This study highlights the efficacy of CGRP medications in those outside of the initially studied population. Other preventive medications may be contraindicated in this population, but CGRP antagonists do appear to be safe and effective options for older adults.
Opiate medications are typically considered inappropriate as an acute treatment for migraine. Even infrequent use of opiate medications has been shown to be associated with worse migraine outcomes, specifically higher frequency and a higher likelihood to convert from episodic to chronic migraine. Van Welie and colleagues performed a cross-sectional questionnaire-based study assessing levels of opioid use in patients with migraine.
Participants were selected from the Leiden Headache Center and fit the diagnostic criteria of migraine. They were given an e-questionnaire to determine their use of these opiates: buprenorphine, fentanyl, hydromorphone, morphine, oxycodone, tapentadol, and tramadol (codeine was not included in this list). Patients were separately divided between chronic and episodic migraine groups. The primary outcome was assessing for current acute treatment of migraine with an opiate; secondary outcomes were association of chronicity of migraine and likelihood of medication overuse with opiate use.
Only approximately 1.8% of participants reported that they currently use an opiate for acute migraine treatment; 12.5% reported that they previously have used an opiate and 25.7% reported using an opiate for another pain condition. Tramadol was the most commonly used opiate medication, followed by oxycodone and morphine; 2.4% of patients reported that their opiate use was not prescribed by their doctor. Primary care doctors were the most common prescribers of the opiate medications; 16% of the time, patients were told that it was a preventive treatment for migraine. Opiate use was more frequent in patients with a diagnosis of chronic migraine, and the duration of use was greater.
Opiate medications remain a poor acute choice of treatment for migraine, and this study shows a correlation between higher opiate use and chronic migraine. There are many other acute medications now available for migraine, many of them migraine-specific treatments, such as triptans, gepants, and ditans. This research again shows that opiates should be avoided if at all possible for migraine.
Patients with medication overuse headache are more likely to be treatment-refractory, and the addition of acute medications often can be less effective if they remain on the overused medication. There has been a long-standing debate whether it is best to wean medications first or start a preventive initially when faced with medication overuse. The CGRP antagonists may be one of the better preventive options in this situation, and one mAb (fremenezumab) reported positive data in a small medication overuse trial. The study by Guerzoni and colleagues investigated the effectiveness of galcanezumab in chronic migraine with medication overuse.
This was a prospective trial conducted at the University Hospital of Modena. A total of 78 patients with a diagnosis of chronic migraine and medication overuse were enrolled for 15 months, with follow-up every 3 months. At each follow-up appointment, they completed a questionnaire asking them details about: mean migraine days per month, mean number of painkillers taken per month, mean days per month taking a painkiller, average migraine severity, and the Headache Impact Test (HIT-6) and Migraine Disability Assessment (MIDAS) questions. Patients were given the standard-dosing regimen of glacanezumab for migraine and were not blinded; this was an open-label study.
The mean migraine days per month were significantly reduced after 3, 6, 9, and 12 months. The amount of painkillers used per month and days of painkillers per month both reduced significantly as well. Migraine-related disability on HIT-6 and MIDAS were all reduced significantly as well. The most significant improvement long-term was noted in patients who improved the most during the initial 3 months of treatment.
The debate regarding the best treatment for patients with medication overuse will continue, but this study highlights the effectiveness of CGRP mAb use in this population. Patients were able to decrease the use of acute medications without a strict wean off of their previous medication. Ideally, a similar study should also be done for additional mAb and oral CGRP antagonists.
Calcitonin gene-related peptide (CGRP) antagonist medications have revolutionized migraine therapy since being introduced in 2018. The initial preventive trials for monoclonal antibodies (mAb) excluded older adults, with a cutoff in all studies at age 65 years. Long-term safety studies have not revealed signals for concern related to vascular or other adverse events. The study by Muñoz-Vendrell and colleagues investigated the efficacy of CGRP mAb in treatment-refractory older adults.
This was an observational retrospective study in participants older than 65 years that had previously used three or more prior migraine preventives unsuccessfully. The primary endpoints were reduction in monthly migraine days after 6 months of treatment and the presence of adverse effects. Secondary endpoints were reductions in headache and acute medication frequency as well as improvement in patient reported outcomes.
A total of 162 participants were followed at 18 different headache centers throughout Spain. All patients had at least 8 headache days per month and had been treated unsuccessfully with three prior medications for migraine prevention, one of which was botulinum toxin. The median age was 68 years, and over 80% had chronic migraine. The reduction in mean headache days was 10 days per month; 72% continued to use their CGRP mAb after using it for 6 months. Participants were compared relative to medication overuse but no significant differences were found between those who overused medication and others.
This study highlights the efficacy of CGRP medications in those outside of the initially studied population. Other preventive medications may be contraindicated in this population, but CGRP antagonists do appear to be safe and effective options for older adults.
Opiate medications are typically considered inappropriate as an acute treatment for migraine. Even infrequent use of opiate medications has been shown to be associated with worse migraine outcomes, specifically higher frequency and a higher likelihood to convert from episodic to chronic migraine. Van Welie and colleagues performed a cross-sectional questionnaire-based study assessing levels of opioid use in patients with migraine.
Participants were selected from the Leiden Headache Center and fit the diagnostic criteria of migraine. They were given an e-questionnaire to determine their use of these opiates: buprenorphine, fentanyl, hydromorphone, morphine, oxycodone, tapentadol, and tramadol (codeine was not included in this list). Patients were separately divided between chronic and episodic migraine groups. The primary outcome was assessing for current acute treatment of migraine with an opiate; secondary outcomes were association of chronicity of migraine and likelihood of medication overuse with opiate use.
Only approximately 1.8% of participants reported that they currently use an opiate for acute migraine treatment; 12.5% reported that they previously have used an opiate and 25.7% reported using an opiate for another pain condition. Tramadol was the most commonly used opiate medication, followed by oxycodone and morphine; 2.4% of patients reported that their opiate use was not prescribed by their doctor. Primary care doctors were the most common prescribers of the opiate medications; 16% of the time, patients were told that it was a preventive treatment for migraine. Opiate use was more frequent in patients with a diagnosis of chronic migraine, and the duration of use was greater.
Opiate medications remain a poor acute choice of treatment for migraine, and this study shows a correlation between higher opiate use and chronic migraine. There are many other acute medications now available for migraine, many of them migraine-specific treatments, such as triptans, gepants, and ditans. This research again shows that opiates should be avoided if at all possible for migraine.
Patients with medication overuse headache are more likely to be treatment-refractory, and the addition of acute medications often can be less effective if they remain on the overused medication. There has been a long-standing debate whether it is best to wean medications first or start a preventive initially when faced with medication overuse. The CGRP antagonists may be one of the better preventive options in this situation, and one mAb (fremenezumab) reported positive data in a small medication overuse trial. The study by Guerzoni and colleagues investigated the effectiveness of galcanezumab in chronic migraine with medication overuse.
This was a prospective trial conducted at the University Hospital of Modena. A total of 78 patients with a diagnosis of chronic migraine and medication overuse were enrolled for 15 months, with follow-up every 3 months. At each follow-up appointment, they completed a questionnaire asking them details about: mean migraine days per month, mean number of painkillers taken per month, mean days per month taking a painkiller, average migraine severity, and the Headache Impact Test (HIT-6) and Migraine Disability Assessment (MIDAS) questions. Patients were given the standard-dosing regimen of glacanezumab for migraine and were not blinded; this was an open-label study.
The mean migraine days per month were significantly reduced after 3, 6, 9, and 12 months. The amount of painkillers used per month and days of painkillers per month both reduced significantly as well. Migraine-related disability on HIT-6 and MIDAS were all reduced significantly as well. The most significant improvement long-term was noted in patients who improved the most during the initial 3 months of treatment.
The debate regarding the best treatment for patients with medication overuse will continue, but this study highlights the effectiveness of CGRP mAb use in this population. Patients were able to decrease the use of acute medications without a strict wean off of their previous medication. Ideally, a similar study should also be done for additional mAb and oral CGRP antagonists.
What is the proper treatment for posttraumatic headache? Expert debate
AUSTIN, TEX – There are no guidelines available, nor is there much quality evidence to support one decision or another, according to two experts who debated the question at the annual meeting of the American Headache Society.
Early treatment
Frank Conidi, DO, spoke first, and pointed out the need to define both early treatment and the condition being treated. Is it early-treatment abortive, is it preventative, and if the patient has a concussion, is it a mild traumatic brain injury (TBI), or severe TBI?
The majority of patients with posttraumatic headache will meet criteria for migraine or probable migraine. “It can be anywhere from 58% to upwards of 90%. And if you see these patients, it makes sense, because posttraumatic headache patients are disabled by their headaches,” said Dr. Conidi, director of the Florida Center for Headache and Sports Neurology.
He argued for early treatment to reduce chronification. “We know that if headaches are left untreated, they’re going to start to spiral up and become daily. This leads to the development of peripheral and central sensitization and lowers the threshold for further migraine attacks,” said Dr. Conidi.
He noted that patients with posttraumatic headache often have comorbidities such as sleep issues, neck pain, or posttraumatic stress disorder, all of which are risk factors for chronification. Treatment does not necessarily mean medication, however. “The mainstay of posttraumatic headache treatment is actually physical and cognitive activity to tolerance. And what I call the 20/5 rule: 20 minutes of physical activity with 5-minute chill breaks. In addition, we use light sub-aerobic exercise 3 to 5 days out in concussion, [which] has been shown to improve concussion recovery time,” he said.
Dr. Conidi suggested treatment of triggers, such as neck issues and whiplash symptoms. “Probably the best treatment I’ve ever seen, and I published on this, are pericranial nerve blocks. Pericranial nerve blocks work wonderfully. If you’re going to block the pericranial nerves, block them all, not just the occipital. Block the trigeminal branches. I’ve actually been able to locate a little two-and-a-half-inch plastic Luer-lock catheter that I can hook on a 1-cc syringe with viscous lidocaine, and I can do sphenopalatine ganglion blocks on all my patients now for under 25 cents. So we’ve been combining the nerve blocks, and we’ve been using them early. Oftentimes the patients won’t have any further headaches, especially if it’s [after] a concussion,” he said.
With respect to concussion-related posttraumatic headache, he summed up: “We’re aggressive early. We’re using intervention. We’re layering our treatment. We’re using medications: prednisone, NSAIDS, and now we have gepants. We’ve been having good success with using gepants,” he said.
Treatment of TBI patients is broadly similar, with the main difference being that neurologists typically won’t see such patients early on as they may be in rehab facilities or hospitals for extended periods. “You may not be getting [to see] them for 1 or 2 months. In that case, you want to educate your neurosurgery and your [physical medicine and rehabilitation] colleagues on the treatment.
Finally, he described work that his group has done in using stimulants for posttraumatic headache. “Stimulants not only treat the cognitive symptoms, but they give the patient cognitive reserve and we find that it gets the patient through the day so they actually have less headaches. It’s a form of prevention. I know there are shortages nationally of both Adderall and Ritalin, but we have had excellent results in our posttraumatic patients using these types of medications,” said Dr. Conidi.
Delayed treatment
Amaal J. Starling, MD, offered a counterargument, but she narrowed the question down to whether preventive treatment should be used within one and a half months of the injury, which she defined as early treatment. Her argument against early preventive treatment centered around the core value of beneficence – to act for the benefit of the patient, and avoid harm.
She discussed the natural history of posttraumatic headache, which is largely self-limited. For example, an NCAA study that found 88% of concussions had symptom resolution within 1 week, and 86% of posttraumatic headache resolved within 1 week. “If individuals routinely are having a self-limited course, there is no need for early treatment with a preventive treatment option because the majority of posttraumatic headache is resolving within that one-and-a-half-month postinjury threshold. The better recommendation, as provided in evidence from Dr. Conidi’s presentation, is to provide supportive care, including acute medications or acute treatment options like nerve blocks for acute pain relief and symptom relief,” said Dr. Starling, associate professor of neurology at Mayo Clinic in Scottsdale, Ariz.
Dr. Starling expressed concern that preventive medications could lead to worsening of comorbidities. For example, posttraumatic headache is often associated with autonomic dysfunction and visual vestibular dysfunction. The former commonly occurs with concussion and is similar to postural orthostatic tachycardia syndrome (POTS), and the second most common symptom of POTS is headache, according to Dr. Starling. Posttraumatic POTS is treated similarly to idiopathic POTS, with a nonpharmacologic approach. One element of POTS management is to withdraw exacerbating medications such as beta-blockers, tricyclic antidepressants, and SNRIs. “These look strikingly similar to some of the headache preventive medications that we might consider for somebody, and so the concern is early preventive treatment with these medications to treat the posttraumatic headache may actually worsen some of these comorbidities that are present in our posttraumatic headache patients. We have to be careful about potentially exacerbating comorbidities with early preventive treatment,” she said.
Prevention medications for headache can also worsen visual vestibular dysfunction, such as dizziness. There are some data suggesting that vestibular rehabilitation and vision therapy can improve dizziness, but also headache. “We all know that many of our preventive medications for headache could potentially exacerbate visual vestibular symptoms, so we have to be careful about that. So again, first do no harm. Posttraumatic POTS is common and causes headache. Posttraumatic vestibular dysfunction is common and causes headache. Instead of initiating a headache preventive medication early, we recommend to identify these comorbidities and provide targeted treatment. Treatment of these comorbidities may, in and of itself, improve the headache. We also we have to be careful because some preventive medications may worsen the comorbidities,” said Dr. Starling.
Areas of agreement
Dr. Conidi agreed that preventative treatment is less likely to be needed for concussion patients, but said that TBI patients are more likely to require it to prevent chronification. Dr. Starling agreed that chronification is an important concern, but she noted that many posttraumatic headache patients are athletes, and preventative medications can also lead to issues that might interfere with return to play, such as decreased sweating, or weight gain or loss. This is complicated by the fact that titration and weaning periods can be long. “We have to be very careful about these medications’ side effects, especially when we don’t have the evidence to demonstrate that it is worth the potential risk of being put on these medications,” she said.
The debate led Catherin Chong, PhD, to ask about the state of the field. “There’s a posttraumatic headache special interest section here [at AHS 2023], and the question that really is coming up at every meeting is, is there some coherence in the field? Is it too early or is it time for a position statement?” asked Dr. Chong, a career scientist at Mayo Clinic (Phoenix). Dr. Chong comoderated the debate and ensuing discussion.
Dr. Starling felt it’s too early for a position statement, but a scoping review could identify research questions that could lead to a position statement. “I’m really excited about the work that’s being done to identify the cohort of individuals with acute posttraumatic headache that may chronify to persistent posttraumatic headache so that we can minimize the risk of exposing the large cohort that’s going to be likely self-limited to a treatment option. Then we can identify those individuals where that risk is worth it because they’re the ones that could lead to chronification. Figuring out if that’s looking at levels of allodynia or other factors that can [help identify those at most risk] would be important,” she said.
Dr. Conidi agreed with the need for more information on the parameters to be studied, but he expressed the belief that any position statement would be a consensus statement. “It’s not going to have any hard evidence behind it, but I do think we need [a position statement]. Even in the general neurology world, there’s a huge lack of understanding of how to treat these patients,” he said.
Dr. Conidi did not make any disclosures. Dr. Starling has consulted for AbbVie, Allergan, Amgen, Axsome Therapeutics, Everyday Health, Lundbeck, Med-IQ, Medscape, Neurolief, Satsuma, and WebMD. Dr. Chong has no relevant financial disclosures.
AUSTIN, TEX – There are no guidelines available, nor is there much quality evidence to support one decision or another, according to two experts who debated the question at the annual meeting of the American Headache Society.
Early treatment
Frank Conidi, DO, spoke first, and pointed out the need to define both early treatment and the condition being treated. Is it early-treatment abortive, is it preventative, and if the patient has a concussion, is it a mild traumatic brain injury (TBI), or severe TBI?
The majority of patients with posttraumatic headache will meet criteria for migraine or probable migraine. “It can be anywhere from 58% to upwards of 90%. And if you see these patients, it makes sense, because posttraumatic headache patients are disabled by their headaches,” said Dr. Conidi, director of the Florida Center for Headache and Sports Neurology.
He argued for early treatment to reduce chronification. “We know that if headaches are left untreated, they’re going to start to spiral up and become daily. This leads to the development of peripheral and central sensitization and lowers the threshold for further migraine attacks,” said Dr. Conidi.
He noted that patients with posttraumatic headache often have comorbidities such as sleep issues, neck pain, or posttraumatic stress disorder, all of which are risk factors for chronification. Treatment does not necessarily mean medication, however. “The mainstay of posttraumatic headache treatment is actually physical and cognitive activity to tolerance. And what I call the 20/5 rule: 20 minutes of physical activity with 5-minute chill breaks. In addition, we use light sub-aerobic exercise 3 to 5 days out in concussion, [which] has been shown to improve concussion recovery time,” he said.
Dr. Conidi suggested treatment of triggers, such as neck issues and whiplash symptoms. “Probably the best treatment I’ve ever seen, and I published on this, are pericranial nerve blocks. Pericranial nerve blocks work wonderfully. If you’re going to block the pericranial nerves, block them all, not just the occipital. Block the trigeminal branches. I’ve actually been able to locate a little two-and-a-half-inch plastic Luer-lock catheter that I can hook on a 1-cc syringe with viscous lidocaine, and I can do sphenopalatine ganglion blocks on all my patients now for under 25 cents. So we’ve been combining the nerve blocks, and we’ve been using them early. Oftentimes the patients won’t have any further headaches, especially if it’s [after] a concussion,” he said.
With respect to concussion-related posttraumatic headache, he summed up: “We’re aggressive early. We’re using intervention. We’re layering our treatment. We’re using medications: prednisone, NSAIDS, and now we have gepants. We’ve been having good success with using gepants,” he said.
Treatment of TBI patients is broadly similar, with the main difference being that neurologists typically won’t see such patients early on as they may be in rehab facilities or hospitals for extended periods. “You may not be getting [to see] them for 1 or 2 months. In that case, you want to educate your neurosurgery and your [physical medicine and rehabilitation] colleagues on the treatment.
Finally, he described work that his group has done in using stimulants for posttraumatic headache. “Stimulants not only treat the cognitive symptoms, but they give the patient cognitive reserve and we find that it gets the patient through the day so they actually have less headaches. It’s a form of prevention. I know there are shortages nationally of both Adderall and Ritalin, but we have had excellent results in our posttraumatic patients using these types of medications,” said Dr. Conidi.
Delayed treatment
Amaal J. Starling, MD, offered a counterargument, but she narrowed the question down to whether preventive treatment should be used within one and a half months of the injury, which she defined as early treatment. Her argument against early preventive treatment centered around the core value of beneficence – to act for the benefit of the patient, and avoid harm.
She discussed the natural history of posttraumatic headache, which is largely self-limited. For example, an NCAA study that found 88% of concussions had symptom resolution within 1 week, and 86% of posttraumatic headache resolved within 1 week. “If individuals routinely are having a self-limited course, there is no need for early treatment with a preventive treatment option because the majority of posttraumatic headache is resolving within that one-and-a-half-month postinjury threshold. The better recommendation, as provided in evidence from Dr. Conidi’s presentation, is to provide supportive care, including acute medications or acute treatment options like nerve blocks for acute pain relief and symptom relief,” said Dr. Starling, associate professor of neurology at Mayo Clinic in Scottsdale, Ariz.
Dr. Starling expressed concern that preventive medications could lead to worsening of comorbidities. For example, posttraumatic headache is often associated with autonomic dysfunction and visual vestibular dysfunction. The former commonly occurs with concussion and is similar to postural orthostatic tachycardia syndrome (POTS), and the second most common symptom of POTS is headache, according to Dr. Starling. Posttraumatic POTS is treated similarly to idiopathic POTS, with a nonpharmacologic approach. One element of POTS management is to withdraw exacerbating medications such as beta-blockers, tricyclic antidepressants, and SNRIs. “These look strikingly similar to some of the headache preventive medications that we might consider for somebody, and so the concern is early preventive treatment with these medications to treat the posttraumatic headache may actually worsen some of these comorbidities that are present in our posttraumatic headache patients. We have to be careful about potentially exacerbating comorbidities with early preventive treatment,” she said.
Prevention medications for headache can also worsen visual vestibular dysfunction, such as dizziness. There are some data suggesting that vestibular rehabilitation and vision therapy can improve dizziness, but also headache. “We all know that many of our preventive medications for headache could potentially exacerbate visual vestibular symptoms, so we have to be careful about that. So again, first do no harm. Posttraumatic POTS is common and causes headache. Posttraumatic vestibular dysfunction is common and causes headache. Instead of initiating a headache preventive medication early, we recommend to identify these comorbidities and provide targeted treatment. Treatment of these comorbidities may, in and of itself, improve the headache. We also we have to be careful because some preventive medications may worsen the comorbidities,” said Dr. Starling.
Areas of agreement
Dr. Conidi agreed that preventative treatment is less likely to be needed for concussion patients, but said that TBI patients are more likely to require it to prevent chronification. Dr. Starling agreed that chronification is an important concern, but she noted that many posttraumatic headache patients are athletes, and preventative medications can also lead to issues that might interfere with return to play, such as decreased sweating, or weight gain or loss. This is complicated by the fact that titration and weaning periods can be long. “We have to be very careful about these medications’ side effects, especially when we don’t have the evidence to demonstrate that it is worth the potential risk of being put on these medications,” she said.
The debate led Catherin Chong, PhD, to ask about the state of the field. “There’s a posttraumatic headache special interest section here [at AHS 2023], and the question that really is coming up at every meeting is, is there some coherence in the field? Is it too early or is it time for a position statement?” asked Dr. Chong, a career scientist at Mayo Clinic (Phoenix). Dr. Chong comoderated the debate and ensuing discussion.
Dr. Starling felt it’s too early for a position statement, but a scoping review could identify research questions that could lead to a position statement. “I’m really excited about the work that’s being done to identify the cohort of individuals with acute posttraumatic headache that may chronify to persistent posttraumatic headache so that we can minimize the risk of exposing the large cohort that’s going to be likely self-limited to a treatment option. Then we can identify those individuals where that risk is worth it because they’re the ones that could lead to chronification. Figuring out if that’s looking at levels of allodynia or other factors that can [help identify those at most risk] would be important,” she said.
Dr. Conidi agreed with the need for more information on the parameters to be studied, but he expressed the belief that any position statement would be a consensus statement. “It’s not going to have any hard evidence behind it, but I do think we need [a position statement]. Even in the general neurology world, there’s a huge lack of understanding of how to treat these patients,” he said.
Dr. Conidi did not make any disclosures. Dr. Starling has consulted for AbbVie, Allergan, Amgen, Axsome Therapeutics, Everyday Health, Lundbeck, Med-IQ, Medscape, Neurolief, Satsuma, and WebMD. Dr. Chong has no relevant financial disclosures.
AUSTIN, TEX – There are no guidelines available, nor is there much quality evidence to support one decision or another, according to two experts who debated the question at the annual meeting of the American Headache Society.
Early treatment
Frank Conidi, DO, spoke first, and pointed out the need to define both early treatment and the condition being treated. Is it early-treatment abortive, is it preventative, and if the patient has a concussion, is it a mild traumatic brain injury (TBI), or severe TBI?
The majority of patients with posttraumatic headache will meet criteria for migraine or probable migraine. “It can be anywhere from 58% to upwards of 90%. And if you see these patients, it makes sense, because posttraumatic headache patients are disabled by their headaches,” said Dr. Conidi, director of the Florida Center for Headache and Sports Neurology.
He argued for early treatment to reduce chronification. “We know that if headaches are left untreated, they’re going to start to spiral up and become daily. This leads to the development of peripheral and central sensitization and lowers the threshold for further migraine attacks,” said Dr. Conidi.
He noted that patients with posttraumatic headache often have comorbidities such as sleep issues, neck pain, or posttraumatic stress disorder, all of which are risk factors for chronification. Treatment does not necessarily mean medication, however. “The mainstay of posttraumatic headache treatment is actually physical and cognitive activity to tolerance. And what I call the 20/5 rule: 20 minutes of physical activity with 5-minute chill breaks. In addition, we use light sub-aerobic exercise 3 to 5 days out in concussion, [which] has been shown to improve concussion recovery time,” he said.
Dr. Conidi suggested treatment of triggers, such as neck issues and whiplash symptoms. “Probably the best treatment I’ve ever seen, and I published on this, are pericranial nerve blocks. Pericranial nerve blocks work wonderfully. If you’re going to block the pericranial nerves, block them all, not just the occipital. Block the trigeminal branches. I’ve actually been able to locate a little two-and-a-half-inch plastic Luer-lock catheter that I can hook on a 1-cc syringe with viscous lidocaine, and I can do sphenopalatine ganglion blocks on all my patients now for under 25 cents. So we’ve been combining the nerve blocks, and we’ve been using them early. Oftentimes the patients won’t have any further headaches, especially if it’s [after] a concussion,” he said.
With respect to concussion-related posttraumatic headache, he summed up: “We’re aggressive early. We’re using intervention. We’re layering our treatment. We’re using medications: prednisone, NSAIDS, and now we have gepants. We’ve been having good success with using gepants,” he said.
Treatment of TBI patients is broadly similar, with the main difference being that neurologists typically won’t see such patients early on as they may be in rehab facilities or hospitals for extended periods. “You may not be getting [to see] them for 1 or 2 months. In that case, you want to educate your neurosurgery and your [physical medicine and rehabilitation] colleagues on the treatment.
Finally, he described work that his group has done in using stimulants for posttraumatic headache. “Stimulants not only treat the cognitive symptoms, but they give the patient cognitive reserve and we find that it gets the patient through the day so they actually have less headaches. It’s a form of prevention. I know there are shortages nationally of both Adderall and Ritalin, but we have had excellent results in our posttraumatic patients using these types of medications,” said Dr. Conidi.
Delayed treatment
Amaal J. Starling, MD, offered a counterargument, but she narrowed the question down to whether preventive treatment should be used within one and a half months of the injury, which she defined as early treatment. Her argument against early preventive treatment centered around the core value of beneficence – to act for the benefit of the patient, and avoid harm.
She discussed the natural history of posttraumatic headache, which is largely self-limited. For example, an NCAA study that found 88% of concussions had symptom resolution within 1 week, and 86% of posttraumatic headache resolved within 1 week. “If individuals routinely are having a self-limited course, there is no need for early treatment with a preventive treatment option because the majority of posttraumatic headache is resolving within that one-and-a-half-month postinjury threshold. The better recommendation, as provided in evidence from Dr. Conidi’s presentation, is to provide supportive care, including acute medications or acute treatment options like nerve blocks for acute pain relief and symptom relief,” said Dr. Starling, associate professor of neurology at Mayo Clinic in Scottsdale, Ariz.
Dr. Starling expressed concern that preventive medications could lead to worsening of comorbidities. For example, posttraumatic headache is often associated with autonomic dysfunction and visual vestibular dysfunction. The former commonly occurs with concussion and is similar to postural orthostatic tachycardia syndrome (POTS), and the second most common symptom of POTS is headache, according to Dr. Starling. Posttraumatic POTS is treated similarly to idiopathic POTS, with a nonpharmacologic approach. One element of POTS management is to withdraw exacerbating medications such as beta-blockers, tricyclic antidepressants, and SNRIs. “These look strikingly similar to some of the headache preventive medications that we might consider for somebody, and so the concern is early preventive treatment with these medications to treat the posttraumatic headache may actually worsen some of these comorbidities that are present in our posttraumatic headache patients. We have to be careful about potentially exacerbating comorbidities with early preventive treatment,” she said.
Prevention medications for headache can also worsen visual vestibular dysfunction, such as dizziness. There are some data suggesting that vestibular rehabilitation and vision therapy can improve dizziness, but also headache. “We all know that many of our preventive medications for headache could potentially exacerbate visual vestibular symptoms, so we have to be careful about that. So again, first do no harm. Posttraumatic POTS is common and causes headache. Posttraumatic vestibular dysfunction is common and causes headache. Instead of initiating a headache preventive medication early, we recommend to identify these comorbidities and provide targeted treatment. Treatment of these comorbidities may, in and of itself, improve the headache. We also we have to be careful because some preventive medications may worsen the comorbidities,” said Dr. Starling.
Areas of agreement
Dr. Conidi agreed that preventative treatment is less likely to be needed for concussion patients, but said that TBI patients are more likely to require it to prevent chronification. Dr. Starling agreed that chronification is an important concern, but she noted that many posttraumatic headache patients are athletes, and preventative medications can also lead to issues that might interfere with return to play, such as decreased sweating, or weight gain or loss. This is complicated by the fact that titration and weaning periods can be long. “We have to be very careful about these medications’ side effects, especially when we don’t have the evidence to demonstrate that it is worth the potential risk of being put on these medications,” she said.
The debate led Catherin Chong, PhD, to ask about the state of the field. “There’s a posttraumatic headache special interest section here [at AHS 2023], and the question that really is coming up at every meeting is, is there some coherence in the field? Is it too early or is it time for a position statement?” asked Dr. Chong, a career scientist at Mayo Clinic (Phoenix). Dr. Chong comoderated the debate and ensuing discussion.
Dr. Starling felt it’s too early for a position statement, but a scoping review could identify research questions that could lead to a position statement. “I’m really excited about the work that’s being done to identify the cohort of individuals with acute posttraumatic headache that may chronify to persistent posttraumatic headache so that we can minimize the risk of exposing the large cohort that’s going to be likely self-limited to a treatment option. Then we can identify those individuals where that risk is worth it because they’re the ones that could lead to chronification. Figuring out if that’s looking at levels of allodynia or other factors that can [help identify those at most risk] would be important,” she said.
Dr. Conidi agreed with the need for more information on the parameters to be studied, but he expressed the belief that any position statement would be a consensus statement. “It’s not going to have any hard evidence behind it, but I do think we need [a position statement]. Even in the general neurology world, there’s a huge lack of understanding of how to treat these patients,” he said.
Dr. Conidi did not make any disclosures. Dr. Starling has consulted for AbbVie, Allergan, Amgen, Axsome Therapeutics, Everyday Health, Lundbeck, Med-IQ, Medscape, Neurolief, Satsuma, and WebMD. Dr. Chong has no relevant financial disclosures.
AT AHS 2023