Headache & Migraine

Key clinical point: Women of reproductive age experiencing migraines should be screened for endometriosis.

Major finding: Migraine headache was more frequent in women with endometriosis than in those without endometriosis (35.2% vs. 17.4%; P = .003).

Study details: The data were obtained from a French case-control study of 314 nonpregnant women younger than 42 years.

Disclosures: The authors declared no conflicts of interest.

Citation: Maitrot-Mantelet L et al. Cephalalgia. 2019 Dec 6. doi: 10.1177/0333102419893965.

Key clinical point: Women of reproductive age experiencing migraines should be screened for endometriosis.

Major finding: Migraine headache was more frequent in women with endometriosis than in those without endometriosis (35.2% vs. 17.4%; P = .003).

Study details: The data were obtained from a French case-control study of 314 nonpregnant women younger than 42 years.

Disclosures: The authors declared no conflicts of interest.

Citation: Maitrot-Mantelet L et al. Cephalalgia. 2019 Dec 6. doi: 10.1177/0333102419893965.

Key clinical point: Women of reproductive age experiencing migraines should be screened for endometriosis.

Major finding: Migraine headache was more frequent in women with endometriosis than in those without endometriosis (35.2% vs. 17.4%; P = .003).

Study details: The data were obtained from a French case-control study of 314 nonpregnant women younger than 42 years.

Disclosures: The authors declared no conflicts of interest.

Citation: Maitrot-Mantelet L et al. Cephalalgia. 2019 Dec 6. doi: 10.1177/0333102419893965.

Key clinical point: Shift workers are more likely to develop migraines and headaches than day workers.

Major finding: Shift workers had a 72% and 25% higher risk of developing migraine and unspecified headache, respectively, compared with day workers.

Study details: A longitudinal study included 2,952 individuals for the analyses of shift work and headache and 2,272 individuals for the analyses of shift work and migraine from the Danish PRISME cohort.

Disclosures: The study was funded by NordForsk, Nordic Program on Health and Welfare. The original PRISME study was supported by the Danish Working Environment Research Fund. The authors declared no conflicts of interest.

Citation: Appel AM et al. Int Arch Occup Environ Health. 2020 Jan 11. doi: 10.1007/s00420-019-01512-6.

Key clinical point: Shift workers are more likely to develop migraines and headaches than day workers.

Major finding: Shift workers had a 72% and 25% higher risk of developing migraine and unspecified headache, respectively, compared with day workers.

Study details: A longitudinal study included 2,952 individuals for the analyses of shift work and headache and 2,272 individuals for the analyses of shift work and migraine from the Danish PRISME cohort.

Disclosures: The study was funded by NordForsk, Nordic Program on Health and Welfare. The original PRISME study was supported by the Danish Working Environment Research Fund. The authors declared no conflicts of interest.

Citation: Appel AM et al. Int Arch Occup Environ Health. 2020 Jan 11. doi: 10.1007/s00420-019-01512-6.

Key clinical point: Shift workers are more likely to develop migraines and headaches than day workers.

Major finding: Shift workers had a 72% and 25% higher risk of developing migraine and unspecified headache, respectively, compared with day workers.

Study details: A longitudinal study included 2,952 individuals for the analyses of shift work and headache and 2,272 individuals for the analyses of shift work and migraine from the Danish PRISME cohort.

Disclosures: The study was funded by NordForsk, Nordic Program on Health and Welfare. The original PRISME study was supported by the Danish Working Environment Research Fund. The authors declared no conflicts of interest.

Citation: Appel AM et al. Int Arch Occup Environ Health. 2020 Jan 11. doi: 10.1007/s00420-019-01512-6.

A network meta-analysis of migraine treatments in children found little evidence that prophylactic medicines work in this population.

Marta Ortiz/iStock/Getty Images Plus

Clinicians hoped that medications used in adults – such as antidepressants, antiepileptics, antihypertensive agents, calcium channel blockers, and food supplements – would find similar success in children. Unfortunately, researchers found only short-term signs of efficacy over placebo, with no benefit lasting more than 6 months.

The study, conducted by a team led by Cosima Locher, PhD, of Boston Children’s Hospital, included 23 double-blind, randomized, controlled trials with a total of 2,217 patients; the mean age was 11 years. They compared 12 pharmacologic agents with each other or with placebo in the study, published online in JAMA Pediatrics.

In a main efficacy analysis that included 19 studies, only two treatments outperformed placebo: propranolol (standardized mean difference, 0.60; 95% confidence interval, 0.03-1.17) and topiramate (SMD, 0.59; 95% CI, 0.03-1.15). There were no statistically significant between-treatment differences.

The results had an overall low to moderate certainty.

When propranolol was compared to placebo, the 95% prediction interval (–0.62 to 1.82) was wider than the significant confidence interval (0.03-1.17), and comprised both beneficial and detrimental effects. A similar result was found with topiramate, with a prediction interval of –0.62 to 1.80 extending into nonsignificant effects (95% CI, 0.03-1.15). In both cases, significant effects were found only when the prediction interval was 70%.

In a long-term analysis (greater than 6 months), no treatment outperformed placebo.

The treatments generally were acceptable. The researchers found no significant difference in tolerability between any of the treatments and each other or placebo. Safety data analyzed from 13 trials revealed no significant differences between treatments and placebo.

“Because specific effects of drugs are associated with the size of the placebo effect, the lack of drug efficacy in our NMA [network meta-analysis] could be owing to a comparatively high placebo effect in children. In fact, there is indirect evidence [from other studies] that the placebo effect is more pronounced in children and adolescents than in adults,” Dr. Locher and associates said. They suggested that studies were needed to quantify the placebo effect in pediatric migraine, and if it was large, to develop innovative therapies making use of this.

The findings should lead to some changes in practice, Boris Zernikow, MD, PhD, of Children’s and Adolescents’ Hospital Datteln (Germany) wrote in an accompanying editorial.

Pharmacological prophylactic treatment of childhood migraine should be an exception rather than the rule, and nonpharmacologic approaches should be emphasized, particularly because the placebo effect is magnified in children, he said.

Many who suffer migraines in childhood will continue to be affected in adulthood, so pediatric intervention is a good opportunity to instill effective strategies. These include: using abortive medication early in an attack and using antimigraine medications for only that specific type of headache; engaging in physical activity to reduce migraine attacks; getting sufficient sleep; and learning relaxation and other psychological approaches to counter migraines.

Dr. Zernikow had no relevant financial disclosures. One study author received grants from Amgen and other support from Grunenthal and Akelos. The study received funding from the Sara Page Mayo Endowment for Pediatric Pain Research, Education, and Treatment; the Swiss National Science Foundation; the Schweizer-Arau-Foundation; and the Theophrastus Foundation.

SOURCES: Locher C et al. JAMA Pediatrics. 2020 Feb 10. doi: 10.1001/jamapediatrics.2019.5856; Zernikow B. JAMA Pediatrics. 2020 Feb 10. doi: 10.1001/jamapediatrics.2019.5907.

A network meta-analysis of migraine treatments in children found little evidence that prophylactic medicines work in this population.

Marta Ortiz/iStock/Getty Images Plus

Clinicians hoped that medications used in adults – such as antidepressants, antiepileptics, antihypertensive agents, calcium channel blockers, and food supplements – would find similar success in children. Unfortunately, researchers found only short-term signs of efficacy over placebo, with no benefit lasting more than 6 months.

The study, conducted by a team led by Cosima Locher, PhD, of Boston Children’s Hospital, included 23 double-blind, randomized, controlled trials with a total of 2,217 patients; the mean age was 11 years. They compared 12 pharmacologic agents with each other or with placebo in the study, published online in JAMA Pediatrics.

In a main efficacy analysis that included 19 studies, only two treatments outperformed placebo: propranolol (standardized mean difference, 0.60; 95% confidence interval, 0.03-1.17) and topiramate (SMD, 0.59; 95% CI, 0.03-1.15). There were no statistically significant between-treatment differences.

The results had an overall low to moderate certainty.

When propranolol was compared to placebo, the 95% prediction interval (–0.62 to 1.82) was wider than the significant confidence interval (0.03-1.17), and comprised both beneficial and detrimental effects. A similar result was found with topiramate, with a prediction interval of –0.62 to 1.80 extending into nonsignificant effects (95% CI, 0.03-1.15). In both cases, significant effects were found only when the prediction interval was 70%.

In a long-term analysis (greater than 6 months), no treatment outperformed placebo.

The treatments generally were acceptable. The researchers found no significant difference in tolerability between any of the treatments and each other or placebo. Safety data analyzed from 13 trials revealed no significant differences between treatments and placebo.

“Because specific effects of drugs are associated with the size of the placebo effect, the lack of drug efficacy in our NMA [network meta-analysis] could be owing to a comparatively high placebo effect in children. In fact, there is indirect evidence [from other studies] that the placebo effect is more pronounced in children and adolescents than in adults,” Dr. Locher and associates said. They suggested that studies were needed to quantify the placebo effect in pediatric migraine, and if it was large, to develop innovative therapies making use of this.

The findings should lead to some changes in practice, Boris Zernikow, MD, PhD, of Children’s and Adolescents’ Hospital Datteln (Germany) wrote in an accompanying editorial.

Pharmacological prophylactic treatment of childhood migraine should be an exception rather than the rule, and nonpharmacologic approaches should be emphasized, particularly because the placebo effect is magnified in children, he said.

Many who suffer migraines in childhood will continue to be affected in adulthood, so pediatric intervention is a good opportunity to instill effective strategies. These include: using abortive medication early in an attack and using antimigraine medications for only that specific type of headache; engaging in physical activity to reduce migraine attacks; getting sufficient sleep; and learning relaxation and other psychological approaches to counter migraines.

Dr. Zernikow had no relevant financial disclosures. One study author received grants from Amgen and other support from Grunenthal and Akelos. The study received funding from the Sara Page Mayo Endowment for Pediatric Pain Research, Education, and Treatment; the Swiss National Science Foundation; the Schweizer-Arau-Foundation; and the Theophrastus Foundation.

SOURCES: Locher C et al. JAMA Pediatrics. 2020 Feb 10. doi: 10.1001/jamapediatrics.2019.5856; Zernikow B. JAMA Pediatrics. 2020 Feb 10. doi: 10.1001/jamapediatrics.2019.5907.

A network meta-analysis of migraine treatments in children found little evidence that prophylactic medicines work in this population.

Marta Ortiz/iStock/Getty Images Plus

Clinicians hoped that medications used in adults – such as antidepressants, antiepileptics, antihypertensive agents, calcium channel blockers, and food supplements – would find similar success in children. Unfortunately, researchers found only short-term signs of efficacy over placebo, with no benefit lasting more than 6 months.

The study, conducted by a team led by Cosima Locher, PhD, of Boston Children’s Hospital, included 23 double-blind, randomized, controlled trials with a total of 2,217 patients; the mean age was 11 years. They compared 12 pharmacologic agents with each other or with placebo in the study, published online in JAMA Pediatrics.

In a main efficacy analysis that included 19 studies, only two treatments outperformed placebo: propranolol (standardized mean difference, 0.60; 95% confidence interval, 0.03-1.17) and topiramate (SMD, 0.59; 95% CI, 0.03-1.15). There were no statistically significant between-treatment differences.

The results had an overall low to moderate certainty.

When propranolol was compared to placebo, the 95% prediction interval (–0.62 to 1.82) was wider than the significant confidence interval (0.03-1.17), and comprised both beneficial and detrimental effects. A similar result was found with topiramate, with a prediction interval of –0.62 to 1.80 extending into nonsignificant effects (95% CI, 0.03-1.15). In both cases, significant effects were found only when the prediction interval was 70%.

In a long-term analysis (greater than 6 months), no treatment outperformed placebo.

The treatments generally were acceptable. The researchers found no significant difference in tolerability between any of the treatments and each other or placebo. Safety data analyzed from 13 trials revealed no significant differences between treatments and placebo.

“Because specific effects of drugs are associated with the size of the placebo effect, the lack of drug efficacy in our NMA [network meta-analysis] could be owing to a comparatively high placebo effect in children. In fact, there is indirect evidence [from other studies] that the placebo effect is more pronounced in children and adolescents than in adults,” Dr. Locher and associates said. They suggested that studies were needed to quantify the placebo effect in pediatric migraine, and if it was large, to develop innovative therapies making use of this.

The findings should lead to some changes in practice, Boris Zernikow, MD, PhD, of Children’s and Adolescents’ Hospital Datteln (Germany) wrote in an accompanying editorial.

Pharmacological prophylactic treatment of childhood migraine should be an exception rather than the rule, and nonpharmacologic approaches should be emphasized, particularly because the placebo effect is magnified in children, he said.

Many who suffer migraines in childhood will continue to be affected in adulthood, so pediatric intervention is a good opportunity to instill effective strategies. These include: using abortive medication early in an attack and using antimigraine medications for only that specific type of headache; engaging in physical activity to reduce migraine attacks; getting sufficient sleep; and learning relaxation and other psychological approaches to counter migraines.

Dr. Zernikow had no relevant financial disclosures. One study author received grants from Amgen and other support from Grunenthal and Akelos. The study received funding from the Sara Page Mayo Endowment for Pediatric Pain Research, Education, and Treatment; the Swiss National Science Foundation; the Schweizer-Arau-Foundation; and the Theophrastus Foundation.

SOURCES: Locher C et al. JAMA Pediatrics. 2020 Feb 10. doi: 10.1001/jamapediatrics.2019.5856; Zernikow B. JAMA Pediatrics. 2020 Feb 10. doi: 10.1001/jamapediatrics.2019.5907.

Among patients with chronic migraine, dependent personality trait is associated with failure to respond to onabotulinumtoxin A, according to research published in the January issue of Headache. The research may be the first to show that personality traits predict response to onabotulinumtoxin A in this population.

“These findings point out that conducting an evaluation of personality traits in patients with chronic migraine might be helpful in the prediction of the course and election of the treatment, as well as identifying patients who might benefit from a multidisciplinary approach,” wrote Alicia Gonzalez-Martinez, MD, of the Hospital Universitario de La Princesa and Instituto de Investigación Sanitaria de La Princesa in Madrid and colleagues. “Categorical questionnaires such as the Salamanca screening test seem to be useful for this purpose.”
 

Researchers used ICD-10 personality criteria

Personality patterns in patients with migraine and other primary headaches have been the subject of decades of research. Munoz et al. found that certain personality traits are associated with migraine and chronic migraine, and this association may influence clinical management and treatment. The effect of personality traits on response to treatment, however, had not been studied previously.

Dr. Gonzalez-Martinez and colleagues hypothesized that cluster C traits (e.g., obsessive-compulsive, dependent, and anxious), as defined by ICD-10, are associated with nonresponse to onabotulinumtoxin A. To test this hypothesis, they conducted a case-control observational study in a cohort of patients with chronic migraine. Eligible patients presented to one of two headache units of a tertiary hospital between January and May 2018. The investigators obtained a complete headache history and demographic information from each patient. Patients had at least two treatment cycles of onabotulinumtoxin A. Dr. Gonzalez-Martinez and colleagues defined treatment response as a reduction in the number of monthly migraine days of at least 50% after at least two treatment cycles.

The investigators assessed participants’ personality traits by administering the Salamanca test, a brief categorical inventory that examines 11 personality traits using 22 questions. Patients completed the test at the beginning of the study period and before they were classified as responders or nonresponders.
 

Medication overuse was a potential confounder

The study population included 112 patients with chronic migraine. One hundred patients (89%) were women. Participants’ mean age at initiation of onabotulinumtoxin A treatment was 43 years. The population’s mean duration of chronic migraine was 29 months. Eighty-three patients (74.1%) had medication overuse, and 96 (85.7%) responded to onabotulinumtoxin A.

Cluster A traits in the population included paranoid (prevalence, 10.7%), schizoid (38.4%), and schizotypal (7.1%). Cluster B traits included histrionic (50%), antisocial (1.8%), narcissistic (9.8%), emotional instability subtype impulsive (27.7%), and emotional instability subtype limit (EISL, 24.1%). Cluster C traits were anxious (58.9%) anancastic (i.e., obsessive-compulsive, 54.5%), and dependent (32.1%).

The investigators found no differences in demographics between responders and nonresponders. In a univariate analysis, dependent traits (e.g., passivity and emotional overdependence on others) and EISL traits (e.g., impulsivity and disturbed self-image) were significantly more common among nonresponders. In a multivariate analysis, dependent traits remained significantly associated with nonresponse to onabotulinumtoxin A.

Medication overuse was a potential confounder in the study, according to Dr. Gonzalez-Martinez and colleagues. One of the study’s limitations was its absence of a healthy control group. Another was the fact that the psychometrics of the Salamanca screening test have not been published in a peer-reviewed journal and may need further examination.

Dependent personality “may also be part of the proposed chronic pain sufferer personality,” wrote the investigators. “Early detection of personality traits could improve management and outcome of chronic migraine patients. Additionally, the possibility to predict the effectiveness of onabotulinumtoxin A therapy may reduce costs and latency time of effect in patients with improbable effectiveness.”

The study had no outside funding, and the authors reported no conflicts of interest.

[email protected]

SOURCE: Gonzalez-Martinez A et al. Headache. 2020;60(1):153-61.

Among patients with chronic migraine, dependent personality trait is associated with failure to respond to onabotulinumtoxin A, according to research published in the January issue of Headache. The research may be the first to show that personality traits predict response to onabotulinumtoxin A in this population.

“These findings point out that conducting an evaluation of personality traits in patients with chronic migraine might be helpful in the prediction of the course and election of the treatment, as well as identifying patients who might benefit from a multidisciplinary approach,” wrote Alicia Gonzalez-Martinez, MD, of the Hospital Universitario de La Princesa and Instituto de Investigación Sanitaria de La Princesa in Madrid and colleagues. “Categorical questionnaires such as the Salamanca screening test seem to be useful for this purpose.”
 

Researchers used ICD-10 personality criteria

Personality patterns in patients with migraine and other primary headaches have been the subject of decades of research. Munoz et al. found that certain personality traits are associated with migraine and chronic migraine, and this association may influence clinical management and treatment. The effect of personality traits on response to treatment, however, had not been studied previously.

Dr. Gonzalez-Martinez and colleagues hypothesized that cluster C traits (e.g., obsessive-compulsive, dependent, and anxious), as defined by ICD-10, are associated with nonresponse to onabotulinumtoxin A. To test this hypothesis, they conducted a case-control observational study in a cohort of patients with chronic migraine. Eligible patients presented to one of two headache units of a tertiary hospital between January and May 2018. The investigators obtained a complete headache history and demographic information from each patient. Patients had at least two treatment cycles of onabotulinumtoxin A. Dr. Gonzalez-Martinez and colleagues defined treatment response as a reduction in the number of monthly migraine days of at least 50% after at least two treatment cycles.

The investigators assessed participants’ personality traits by administering the Salamanca test, a brief categorical inventory that examines 11 personality traits using 22 questions. Patients completed the test at the beginning of the study period and before they were classified as responders or nonresponders.
 

Medication overuse was a potential confounder

The study population included 112 patients with chronic migraine. One hundred patients (89%) were women. Participants’ mean age at initiation of onabotulinumtoxin A treatment was 43 years. The population’s mean duration of chronic migraine was 29 months. Eighty-three patients (74.1%) had medication overuse, and 96 (85.7%) responded to onabotulinumtoxin A.

Cluster A traits in the population included paranoid (prevalence, 10.7%), schizoid (38.4%), and schizotypal (7.1%). Cluster B traits included histrionic (50%), antisocial (1.8%), narcissistic (9.8%), emotional instability subtype impulsive (27.7%), and emotional instability subtype limit (EISL, 24.1%). Cluster C traits were anxious (58.9%) anancastic (i.e., obsessive-compulsive, 54.5%), and dependent (32.1%).

The investigators found no differences in demographics between responders and nonresponders. In a univariate analysis, dependent traits (e.g., passivity and emotional overdependence on others) and EISL traits (e.g., impulsivity and disturbed self-image) were significantly more common among nonresponders. In a multivariate analysis, dependent traits remained significantly associated with nonresponse to onabotulinumtoxin A.

Medication overuse was a potential confounder in the study, according to Dr. Gonzalez-Martinez and colleagues. One of the study’s limitations was its absence of a healthy control group. Another was the fact that the psychometrics of the Salamanca screening test have not been published in a peer-reviewed journal and may need further examination.

Dependent personality “may also be part of the proposed chronic pain sufferer personality,” wrote the investigators. “Early detection of personality traits could improve management and outcome of chronic migraine patients. Additionally, the possibility to predict the effectiveness of onabotulinumtoxin A therapy may reduce costs and latency time of effect in patients with improbable effectiveness.”

The study had no outside funding, and the authors reported no conflicts of interest.

[email protected]

SOURCE: Gonzalez-Martinez A et al. Headache. 2020;60(1):153-61.

Among patients with chronic migraine, dependent personality trait is associated with failure to respond to onabotulinumtoxin A, according to research published in the January issue of Headache. The research may be the first to show that personality traits predict response to onabotulinumtoxin A in this population.

“These findings point out that conducting an evaluation of personality traits in patients with chronic migraine might be helpful in the prediction of the course and election of the treatment, as well as identifying patients who might benefit from a multidisciplinary approach,” wrote Alicia Gonzalez-Martinez, MD, of the Hospital Universitario de La Princesa and Instituto de Investigación Sanitaria de La Princesa in Madrid and colleagues. “Categorical questionnaires such as the Salamanca screening test seem to be useful for this purpose.”
 

Researchers used ICD-10 personality criteria

Personality patterns in patients with migraine and other primary headaches have been the subject of decades of research. Munoz et al. found that certain personality traits are associated with migraine and chronic migraine, and this association may influence clinical management and treatment. The effect of personality traits on response to treatment, however, had not been studied previously.

Dr. Gonzalez-Martinez and colleagues hypothesized that cluster C traits (e.g., obsessive-compulsive, dependent, and anxious), as defined by ICD-10, are associated with nonresponse to onabotulinumtoxin A. To test this hypothesis, they conducted a case-control observational study in a cohort of patients with chronic migraine. Eligible patients presented to one of two headache units of a tertiary hospital between January and May 2018. The investigators obtained a complete headache history and demographic information from each patient. Patients had at least two treatment cycles of onabotulinumtoxin A. Dr. Gonzalez-Martinez and colleagues defined treatment response as a reduction in the number of monthly migraine days of at least 50% after at least two treatment cycles.

The investigators assessed participants’ personality traits by administering the Salamanca test, a brief categorical inventory that examines 11 personality traits using 22 questions. Patients completed the test at the beginning of the study period and before they were classified as responders or nonresponders.
 

Medication overuse was a potential confounder

The study population included 112 patients with chronic migraine. One hundred patients (89%) were women. Participants’ mean age at initiation of onabotulinumtoxin A treatment was 43 years. The population’s mean duration of chronic migraine was 29 months. Eighty-three patients (74.1%) had medication overuse, and 96 (85.7%) responded to onabotulinumtoxin A.

Cluster A traits in the population included paranoid (prevalence, 10.7%), schizoid (38.4%), and schizotypal (7.1%). Cluster B traits included histrionic (50%), antisocial (1.8%), narcissistic (9.8%), emotional instability subtype impulsive (27.7%), and emotional instability subtype limit (EISL, 24.1%). Cluster C traits were anxious (58.9%) anancastic (i.e., obsessive-compulsive, 54.5%), and dependent (32.1%).

The investigators found no differences in demographics between responders and nonresponders. In a univariate analysis, dependent traits (e.g., passivity and emotional overdependence on others) and EISL traits (e.g., impulsivity and disturbed self-image) were significantly more common among nonresponders. In a multivariate analysis, dependent traits remained significantly associated with nonresponse to onabotulinumtoxin A.

Medication overuse was a potential confounder in the study, according to Dr. Gonzalez-Martinez and colleagues. One of the study’s limitations was its absence of a healthy control group. Another was the fact that the psychometrics of the Salamanca screening test have not been published in a peer-reviewed journal and may need further examination.

Dependent personality “may also be part of the proposed chronic pain sufferer personality,” wrote the investigators. “Early detection of personality traits could improve management and outcome of chronic migraine patients. Additionally, the possibility to predict the effectiveness of onabotulinumtoxin A therapy may reduce costs and latency time of effect in patients with improbable effectiveness.”

The study had no outside funding, and the authors reported no conflicts of interest.

[email protected]

SOURCE: Gonzalez-Martinez A et al. Headache. 2020;60(1):153-61.

An oral solution of celecoxib is more effective than placebo for the acute treatment of migraine, according to trial results published in the January issue of Headache.

Two hours after treatment, a significantly greater proportion of patients who received the liquid solution, known as DFN-15, had freedom from pain and freedom from their most bothersome accompanying symptom – nausea, photophobia, or phonophobia – compared with patients who received placebo. The pain freedom rates were 35.6% with celecoxib oral solution and 21.7% with placebo. The rates of freedom from the most bothersome symptom were 57.8% with celecoxib oral solution and 44.8% with placebo.

About 9% of patients who received celecoxib oral solution had treatment-emergent adverse events related to the study drug, the most common of which were dysgeusia (4.2%) and nausea (3.2%). In comparison, about 6% of patients who received placebo had treatment-emergent adverse events. There were no serious treatment-emergent adverse events.

“DFN‐15 has the potential to become a reliable and convenient acute therapeutic option for patients with migraine,” said lead author Richard B. Lipton, MD, and colleagues. Dr. Lipton is affiliated with the Albert Einstein College of Medicine in New York.
 

Assessing celecoxib in migraineurs

Evidence-based guidelines recommend nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, diclofenac, ibuprofen, and naproxen, as effective acute migraine treatments, but these medications may increase the risk of adverse gastrointestinal events, the authors said. Celecoxib, a selective cyclooxygenase (COX)-2 inhibitor, is indicated for the treatment of acute pain in patients with ankylosing spondylitis, osteoarthritis, primary dysmenorrhea, and rheumatoid arthritis. Although it produces analgesia similar to other NSAIDs, among patients with osteoarthritis and rheumatoid arthritis, celecoxib is associated with significantly lower risk of gastrointestinal events, compared with naproxen and ibuprofen, and significantly lower risk of renal events, compared with ibuprofen.

Researchers have studied an oral capsule form of celecoxib (Celebrex, Pfizer) as an acute treatment for migraine in an open-label study that compared celecoxib with naproxen sodium. “While preliminary results suggest comparable efficacy but better tolerability than widely used and guideline-recommended NSAIDs, celecoxib is not currently approved for migraine,” the authors said.

Compared with the oral capsule formulation, the oral liquid solution DFN-15 has a faster median time to peak concentration under fasting conditions (within 1 hour vs. 2.5 hours), which “could translate into more rapid onset of pain relief,” the authors said. In addition, DFN-15 may have greater bioavailability, which could lower dose requirements and improve safety and tolerability. To compare the efficacy, tolerability, and safety of 120-mg DFN-15 with placebo for the acute treatment of migraine, researchers conducted a randomized, double-blind, placebo-controlled study.
 

Participants used single-dose bottles

Researchers randomized 622 patients 1:1 to DFN-15 or placebo, and 567 treated a migraine during the trial. Patients had a mean age of 40 years, and 87% were female. Patients had episodic migraine with or without aura, no signs of medication overuse, and two-eight migraine attacks per month. For the trial, patients treated a single migraine attack of moderate to severe intensity within 1 hour of onset. “Each subject was given a single‐dose bottle of DFN‐15 120 mg or matching placebo containing 4.8 mL liquid,” Dr. Lipton and colleagues said. “They were instructed to drink the entire contents of the bottle to ensure complete consumption of study medication.”

Freedom from pain and freedom from the most bothersome symptom at 2 hours were the coprimary endpoints. “DFN‐15 was also significantly superior to placebo on multiple secondary 2‐hour endpoints, including freedom from photophobia, pain relief, change in functional disability from baseline, overall and 24‐hour satisfaction with treatment, and use of rescue medication,” they reported.

“A new COX‐2 inhibitor that is effective and rapidly absorbed could provide an important new option for a wide range of patients,” the authors said. “Though cross‐study comparisons are problematic, the current results for DFN‐15 indicate that its efficacy is similar to that of NSAIDs and small‐molecule calcitonin gene‐related peptide receptor antagonists (gepants), based on placebo‐subtracted rates pain freedom in acute treatment trials (14%‐21%). DFN‐15 may also be useful among triptan users, who are at elevated risk of medication‐overuse headache and for whom TEAEs within 24 hours postdose are common. ... The form and delivery system of DFN‐15 – a ready‐to‐use solution in a 4.8‐mL single‐use bottle – may support patient adherence.”

The trial had robust placebo response rates, which may have been influenced by “the novelty of a ready‐made oral solution, which has not been previously tested for the acute treatment of migraine,” the authors noted. In addition, the trial does not address the treatment of mild pain or treatment across multiple attacks.

The trial was supported by Dr. Reddy’s Laboratories, manufacturer of DFN-15. Two authors are employed by and own stock in Dr. Reddy’s. Dr. Lipton and a coauthor disclosed research support from and consulting for Dr. Reddy’s.
 

[email protected]

SOURCE: Lipton RB et al. Headache. 2020;60(1):58-70. doi: 10.1111/head.13663.

An oral solution of celecoxib is more effective than placebo for the acute treatment of migraine, according to trial results published in the January issue of Headache.

Two hours after treatment, a significantly greater proportion of patients who received the liquid solution, known as DFN-15, had freedom from pain and freedom from their most bothersome accompanying symptom – nausea, photophobia, or phonophobia – compared with patients who received placebo. The pain freedom rates were 35.6% with celecoxib oral solution and 21.7% with placebo. The rates of freedom from the most bothersome symptom were 57.8% with celecoxib oral solution and 44.8% with placebo.

About 9% of patients who received celecoxib oral solution had treatment-emergent adverse events related to the study drug, the most common of which were dysgeusia (4.2%) and nausea (3.2%). In comparison, about 6% of patients who received placebo had treatment-emergent adverse events. There were no serious treatment-emergent adverse events.

“DFN‐15 has the potential to become a reliable and convenient acute therapeutic option for patients with migraine,” said lead author Richard B. Lipton, MD, and colleagues. Dr. Lipton is affiliated with the Albert Einstein College of Medicine in New York.
 

Assessing celecoxib in migraineurs

Evidence-based guidelines recommend nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, diclofenac, ibuprofen, and naproxen, as effective acute migraine treatments, but these medications may increase the risk of adverse gastrointestinal events, the authors said. Celecoxib, a selective cyclooxygenase (COX)-2 inhibitor, is indicated for the treatment of acute pain in patients with ankylosing spondylitis, osteoarthritis, primary dysmenorrhea, and rheumatoid arthritis. Although it produces analgesia similar to other NSAIDs, among patients with osteoarthritis and rheumatoid arthritis, celecoxib is associated with significantly lower risk of gastrointestinal events, compared with naproxen and ibuprofen, and significantly lower risk of renal events, compared with ibuprofen.

Researchers have studied an oral capsule form of celecoxib (Celebrex, Pfizer) as an acute treatment for migraine in an open-label study that compared celecoxib with naproxen sodium. “While preliminary results suggest comparable efficacy but better tolerability than widely used and guideline-recommended NSAIDs, celecoxib is not currently approved for migraine,” the authors said.

Compared with the oral capsule formulation, the oral liquid solution DFN-15 has a faster median time to peak concentration under fasting conditions (within 1 hour vs. 2.5 hours), which “could translate into more rapid onset of pain relief,” the authors said. In addition, DFN-15 may have greater bioavailability, which could lower dose requirements and improve safety and tolerability. To compare the efficacy, tolerability, and safety of 120-mg DFN-15 with placebo for the acute treatment of migraine, researchers conducted a randomized, double-blind, placebo-controlled study.
 

Participants used single-dose bottles

Researchers randomized 622 patients 1:1 to DFN-15 or placebo, and 567 treated a migraine during the trial. Patients had a mean age of 40 years, and 87% were female. Patients had episodic migraine with or without aura, no signs of medication overuse, and two-eight migraine attacks per month. For the trial, patients treated a single migraine attack of moderate to severe intensity within 1 hour of onset. “Each subject was given a single‐dose bottle of DFN‐15 120 mg or matching placebo containing 4.8 mL liquid,” Dr. Lipton and colleagues said. “They were instructed to drink the entire contents of the bottle to ensure complete consumption of study medication.”

Freedom from pain and freedom from the most bothersome symptom at 2 hours were the coprimary endpoints. “DFN‐15 was also significantly superior to placebo on multiple secondary 2‐hour endpoints, including freedom from photophobia, pain relief, change in functional disability from baseline, overall and 24‐hour satisfaction with treatment, and use of rescue medication,” they reported.

“A new COX‐2 inhibitor that is effective and rapidly absorbed could provide an important new option for a wide range of patients,” the authors said. “Though cross‐study comparisons are problematic, the current results for DFN‐15 indicate that its efficacy is similar to that of NSAIDs and small‐molecule calcitonin gene‐related peptide receptor antagonists (gepants), based on placebo‐subtracted rates pain freedom in acute treatment trials (14%‐21%). DFN‐15 may also be useful among triptan users, who are at elevated risk of medication‐overuse headache and for whom TEAEs within 24 hours postdose are common. ... The form and delivery system of DFN‐15 – a ready‐to‐use solution in a 4.8‐mL single‐use bottle – may support patient adherence.”

The trial had robust placebo response rates, which may have been influenced by “the novelty of a ready‐made oral solution, which has not been previously tested for the acute treatment of migraine,” the authors noted. In addition, the trial does not address the treatment of mild pain or treatment across multiple attacks.

The trial was supported by Dr. Reddy’s Laboratories, manufacturer of DFN-15. Two authors are employed by and own stock in Dr. Reddy’s. Dr. Lipton and a coauthor disclosed research support from and consulting for Dr. Reddy’s.
 

[email protected]

SOURCE: Lipton RB et al. Headache. 2020;60(1):58-70. doi: 10.1111/head.13663.

An oral solution of celecoxib is more effective than placebo for the acute treatment of migraine, according to trial results published in the January issue of Headache.

Two hours after treatment, a significantly greater proportion of patients who received the liquid solution, known as DFN-15, had freedom from pain and freedom from their most bothersome accompanying symptom – nausea, photophobia, or phonophobia – compared with patients who received placebo. The pain freedom rates were 35.6% with celecoxib oral solution and 21.7% with placebo. The rates of freedom from the most bothersome symptom were 57.8% with celecoxib oral solution and 44.8% with placebo.

About 9% of patients who received celecoxib oral solution had treatment-emergent adverse events related to the study drug, the most common of which were dysgeusia (4.2%) and nausea (3.2%). In comparison, about 6% of patients who received placebo had treatment-emergent adverse events. There were no serious treatment-emergent adverse events.

“DFN‐15 has the potential to become a reliable and convenient acute therapeutic option for patients with migraine,” said lead author Richard B. Lipton, MD, and colleagues. Dr. Lipton is affiliated with the Albert Einstein College of Medicine in New York.
 

Assessing celecoxib in migraineurs

Evidence-based guidelines recommend nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, diclofenac, ibuprofen, and naproxen, as effective acute migraine treatments, but these medications may increase the risk of adverse gastrointestinal events, the authors said. Celecoxib, a selective cyclooxygenase (COX)-2 inhibitor, is indicated for the treatment of acute pain in patients with ankylosing spondylitis, osteoarthritis, primary dysmenorrhea, and rheumatoid arthritis. Although it produces analgesia similar to other NSAIDs, among patients with osteoarthritis and rheumatoid arthritis, celecoxib is associated with significantly lower risk of gastrointestinal events, compared with naproxen and ibuprofen, and significantly lower risk of renal events, compared with ibuprofen.

Researchers have studied an oral capsule form of celecoxib (Celebrex, Pfizer) as an acute treatment for migraine in an open-label study that compared celecoxib with naproxen sodium. “While preliminary results suggest comparable efficacy but better tolerability than widely used and guideline-recommended NSAIDs, celecoxib is not currently approved for migraine,” the authors said.

Compared with the oral capsule formulation, the oral liquid solution DFN-15 has a faster median time to peak concentration under fasting conditions (within 1 hour vs. 2.5 hours), which “could translate into more rapid onset of pain relief,” the authors said. In addition, DFN-15 may have greater bioavailability, which could lower dose requirements and improve safety and tolerability. To compare the efficacy, tolerability, and safety of 120-mg DFN-15 with placebo for the acute treatment of migraine, researchers conducted a randomized, double-blind, placebo-controlled study.
 

Participants used single-dose bottles

Researchers randomized 622 patients 1:1 to DFN-15 or placebo, and 567 treated a migraine during the trial. Patients had a mean age of 40 years, and 87% were female. Patients had episodic migraine with or without aura, no signs of medication overuse, and two-eight migraine attacks per month. For the trial, patients treated a single migraine attack of moderate to severe intensity within 1 hour of onset. “Each subject was given a single‐dose bottle of DFN‐15 120 mg or matching placebo containing 4.8 mL liquid,” Dr. Lipton and colleagues said. “They were instructed to drink the entire contents of the bottle to ensure complete consumption of study medication.”

Freedom from pain and freedom from the most bothersome symptom at 2 hours were the coprimary endpoints. “DFN‐15 was also significantly superior to placebo on multiple secondary 2‐hour endpoints, including freedom from photophobia, pain relief, change in functional disability from baseline, overall and 24‐hour satisfaction with treatment, and use of rescue medication,” they reported.

“A new COX‐2 inhibitor that is effective and rapidly absorbed could provide an important new option for a wide range of patients,” the authors said. “Though cross‐study comparisons are problematic, the current results for DFN‐15 indicate that its efficacy is similar to that of NSAIDs and small‐molecule calcitonin gene‐related peptide receptor antagonists (gepants), based on placebo‐subtracted rates pain freedom in acute treatment trials (14%‐21%). DFN‐15 may also be useful among triptan users, who are at elevated risk of medication‐overuse headache and for whom TEAEs within 24 hours postdose are common. ... The form and delivery system of DFN‐15 – a ready‐to‐use solution in a 4.8‐mL single‐use bottle – may support patient adherence.”

The trial had robust placebo response rates, which may have been influenced by “the novelty of a ready‐made oral solution, which has not been previously tested for the acute treatment of migraine,” the authors noted. In addition, the trial does not address the treatment of mild pain or treatment across multiple attacks.

The trial was supported by Dr. Reddy’s Laboratories, manufacturer of DFN-15. Two authors are employed by and own stock in Dr. Reddy’s. Dr. Lipton and a coauthor disclosed research support from and consulting for Dr. Reddy’s.
 

[email protected]

SOURCE: Lipton RB et al. Headache. 2020;60(1):58-70. doi: 10.1111/head.13663.

Key clinical point: About one-quarter of pediatric patients with headache have joint hypermobility.

Major finding: Among children with headache and joint hypermobility, 80% had severe headache disability.

Study details: A prospective, single-center study of 76 children with headache.

Disclosures: The study was not supported by funding, and the investigators had no disclosures.

Citation: Sahjwani D et al. CNS 2019, Abstract 101.

Key clinical point: About one-quarter of pediatric patients with headache have joint hypermobility.

Major finding: Among children with headache and joint hypermobility, 80% had severe headache disability.

Study details: A prospective, single-center study of 76 children with headache.

Disclosures: The study was not supported by funding, and the investigators had no disclosures.

Citation: Sahjwani D et al. CNS 2019, Abstract 101.

Key clinical point: About one-quarter of pediatric patients with headache have joint hypermobility.

Major finding: Among children with headache and joint hypermobility, 80% had severe headache disability.

Study details: A prospective, single-center study of 76 children with headache.

Disclosures: The study was not supported by funding, and the investigators had no disclosures.

Citation: Sahjwani D et al. CNS 2019, Abstract 101.

Key clinical point: New daily persistent headache may be relatively common among children presenting to headache clinics.

Major finding: Girls with new daily persistent headache report symptoms such as photophobia, phonophobia, and nausea significantly more frequently than boys do.

Study details: An observational study of 454 pediatric patients with new daily persistent headache.

Disclosures: The study was not supported by funding, and the investigators had no disclosures.

Citation: Pierce E et al. CNS 2019, Abstract 100.

Key clinical point: New daily persistent headache may be relatively common among children presenting to headache clinics.

Major finding: Girls with new daily persistent headache report symptoms such as photophobia, phonophobia, and nausea significantly more frequently than boys do.

Study details: An observational study of 454 pediatric patients with new daily persistent headache.

Disclosures: The study was not supported by funding, and the investigators had no disclosures.

Citation: Pierce E et al. CNS 2019, Abstract 100.

Key clinical point: New daily persistent headache may be relatively common among children presenting to headache clinics.

Major finding: Girls with new daily persistent headache report symptoms such as photophobia, phonophobia, and nausea significantly more frequently than boys do.

Study details: An observational study of 454 pediatric patients with new daily persistent headache.

Disclosures: The study was not supported by funding, and the investigators had no disclosures.

Citation: Pierce E et al. CNS 2019, Abstract 100.

Key clinical point: Ubrogepant, an oral calcitonin gene–related peptide (CGRP)–receptor antagonist, may relieve patients’ migraine pain and their most bothersome associated symptom, such as photophobia, phonophobia, or nausea, at 2 hours after acute treatment.

Major finding: At 2 hours, pain freedom was reported by 101 of 464 participants in the ubrogepant 50-mg group (21.8%), 90 of 435 in the ubrogepant 25-mg group (20.7%), and 65 of 456 in the placebo group (14.3%).

Study details: ACHIEVE II was a randomized, double-blind, placebo-controlled, single-attack clinical trial that included more than 1,300 adults with migraine.

Disclosures: The trial was sponsored by Allergan, the company developing the drug. Several authors are Allergan employees. Dr. Lipton is a consultant, advisory board member, or has received honoraria from Allergan and other companies.

Citation: Lipton RB et al. JAMA. 2019;322(19):1887-98. doi: 10.1001/jama.2019.16711.

Key clinical point: Ubrogepant, an oral calcitonin gene–related peptide (CGRP)–receptor antagonist, may relieve patients’ migraine pain and their most bothersome associated symptom, such as photophobia, phonophobia, or nausea, at 2 hours after acute treatment.

Major finding: At 2 hours, pain freedom was reported by 101 of 464 participants in the ubrogepant 50-mg group (21.8%), 90 of 435 in the ubrogepant 25-mg group (20.7%), and 65 of 456 in the placebo group (14.3%).

Study details: ACHIEVE II was a randomized, double-blind, placebo-controlled, single-attack clinical trial that included more than 1,300 adults with migraine.

Disclosures: The trial was sponsored by Allergan, the company developing the drug. Several authors are Allergan employees. Dr. Lipton is a consultant, advisory board member, or has received honoraria from Allergan and other companies.

Citation: Lipton RB et al. JAMA. 2019;322(19):1887-98. doi: 10.1001/jama.2019.16711.

Key clinical point: Ubrogepant, an oral calcitonin gene–related peptide (CGRP)–receptor antagonist, may relieve patients’ migraine pain and their most bothersome associated symptom, such as photophobia, phonophobia, or nausea, at 2 hours after acute treatment.

Major finding: At 2 hours, pain freedom was reported by 101 of 464 participants in the ubrogepant 50-mg group (21.8%), 90 of 435 in the ubrogepant 25-mg group (20.7%), and 65 of 456 in the placebo group (14.3%).

Study details: ACHIEVE II was a randomized, double-blind, placebo-controlled, single-attack clinical trial that included more than 1,300 adults with migraine.

Disclosures: The trial was sponsored by Allergan, the company developing the drug. Several authors are Allergan employees. Dr. Lipton is a consultant, advisory board member, or has received honoraria from Allergan and other companies.

Citation: Lipton RB et al. JAMA. 2019;322(19):1887-98. doi: 10.1001/jama.2019.16711.

Key clinical point: Headache is a significant concern after pediatric hemispherectomy.

Major finding: Of 22 children who underwent hemispherectomy, 19 (86.4%) had headaches after the surgery.

Study details: A retrospective chart review and follow-up questionnaires that were administered to 22 children with hemispherectomy.

Citation: Pandit I et al. CNS 2019. Abstract 99.

Key clinical point: Headache is a significant concern after pediatric hemispherectomy.

Major finding: Of 22 children who underwent hemispherectomy, 19 (86.4%) had headaches after the surgery.

Study details: A retrospective chart review and follow-up questionnaires that were administered to 22 children with hemispherectomy.

Citation: Pandit I et al. CNS 2019. Abstract 99.

Key clinical point: Headache is a significant concern after pediatric hemispherectomy.

Major finding: Of 22 children who underwent hemispherectomy, 19 (86.4%) had headaches after the surgery.

Study details: A retrospective chart review and follow-up questionnaires that were administered to 22 children with hemispherectomy.

Citation: Pandit I et al. CNS 2019. Abstract 99.

Key Points:

• The “Migraine and Neck Pain Study” analyzed data from nearly 500 adult participants in an effort to uncover an association between migraine-related episodic vertigo and the phases of migraine.
• The study participants included men and women aged 18 to 65, who had episodic migraine with aura and/or without aura.
• Migraines were divided into 3 time segments for evaluation: (1) Onset of headache, (2) less than 2 hours before the onset of headache, and (3) 2 to 48 hours before the onset of headache.
• 30% of participants reported episodic vertigo at any point during their migraine attack, while 16% reported it at the start of headache, 10% reported it within 2 hours before their headache, and just 3% reported symptoms between 2 and 24 hours beforehand.
• The study concluded that episodic vertigo could be considered more of a “headache phase phenomenon” rather than a prodromal symptom.

Alan M. Rapoport, MD:

Vertigo in a migraineur has long created confusion as to diagnosis and treatment. I myself always wondered how much I had to work up vertigo or even dizziness if a patient had migraine. I also did not know what to do when a patient with migraine had attacks of vertigo without headache. Were they manifestations of migraine and should they be treated that way?

This study examined a 500 adult patient population who had migraine with or without aura. Christian Lampl was interested in seeing how many had headache, and the timing of when vertigo occurred. It was carefully measured to determine if it usually occurred during or before the headache phase. Migraines were divided into 3 time segments for evaluation: (1) Onset of headache, (2) less than 2 hours before the onset of headache, and (3) 2 to 48 hours before the onset of headache, when prodrome occurs.

• The study determined that 30 % of the patients reported vertigo at some point during their migraine attack; 16% reported it at the start of headache, 10% reported it within 2 hours before their headache, and just 3% reported symptoms between 2 and 24 hours beforehand., which would have been in the prodromal phase.  
• The study concluded that episodic vertigo could be considered more of a “headache phase phenomenon” rather than a prodromal symptom. This was interesting but it left unanswered one of my questions which is, how many had vertigo unrelated to headache and what is that and how do we treat it.
• Although not addressed in this study, there is consensus that if there is enough vertigo in a migraineur, they should be placed on a migraine preventive therapy. It will be interesting to see what the new monoclonal antibodies to CGRP do to vertigo in a treated migraineur. Some headache specialists will even treat an attack of vertigo without headache with a triptan.

Key Points:

• The “Migraine and Neck Pain Study” analyzed data from nearly 500 adult participants in an effort to uncover an association between migraine-related episodic vertigo and the phases of migraine.
• The study participants included men and women aged 18 to 65, who had episodic migraine with aura and/or without aura.
• Migraines were divided into 3 time segments for evaluation: (1) Onset of headache, (2) less than 2 hours before the onset of headache, and (3) 2 to 48 hours before the onset of headache.
• 30% of participants reported episodic vertigo at any point during their migraine attack, while 16% reported it at the start of headache, 10% reported it within 2 hours before their headache, and just 3% reported symptoms between 2 and 24 hours beforehand.
• The study concluded that episodic vertigo could be considered more of a “headache phase phenomenon” rather than a prodromal symptom.

Alan M. Rapoport, MD:

Vertigo in a migraineur has long created confusion as to diagnosis and treatment. I myself always wondered how much I had to work up vertigo or even dizziness if a patient had migraine. I also did not know what to do when a patient with migraine had attacks of vertigo without headache. Were they manifestations of migraine and should they be treated that way?

This study examined a 500 adult patient population who had migraine with or without aura. Christian Lampl was interested in seeing how many had headache, and the timing of when vertigo occurred. It was carefully measured to determine if it usually occurred during or before the headache phase. Migraines were divided into 3 time segments for evaluation: (1) Onset of headache, (2) less than 2 hours before the onset of headache, and (3) 2 to 48 hours before the onset of headache, when prodrome occurs.

• The study determined that 30 % of the patients reported vertigo at some point during their migraine attack; 16% reported it at the start of headache, 10% reported it within 2 hours before their headache, and just 3% reported symptoms between 2 and 24 hours beforehand., which would have been in the prodromal phase.  
• The study concluded that episodic vertigo could be considered more of a “headache phase phenomenon” rather than a prodromal symptom. This was interesting but it left unanswered one of my questions which is, how many had vertigo unrelated to headache and what is that and how do we treat it.
• Although not addressed in this study, there is consensus that if there is enough vertigo in a migraineur, they should be placed on a migraine preventive therapy. It will be interesting to see what the new monoclonal antibodies to CGRP do to vertigo in a treated migraineur. Some headache specialists will even treat an attack of vertigo without headache with a triptan.

Key Points:

• The “Migraine and Neck Pain Study” analyzed data from nearly 500 adult participants in an effort to uncover an association between migraine-related episodic vertigo and the phases of migraine.
• The study participants included men and women aged 18 to 65, who had episodic migraine with aura and/or without aura.
• Migraines were divided into 3 time segments for evaluation: (1) Onset of headache, (2) less than 2 hours before the onset of headache, and (3) 2 to 48 hours before the onset of headache.
• 30% of participants reported episodic vertigo at any point during their migraine attack, while 16% reported it at the start of headache, 10% reported it within 2 hours before their headache, and just 3% reported symptoms between 2 and 24 hours beforehand.
• The study concluded that episodic vertigo could be considered more of a “headache phase phenomenon” rather than a prodromal symptom.

Alan M. Rapoport, MD:

Vertigo in a migraineur has long created confusion as to diagnosis and treatment. I myself always wondered how much I had to work up vertigo or even dizziness if a patient had migraine. I also did not know what to do when a patient with migraine had attacks of vertigo without headache. Were they manifestations of migraine and should they be treated that way?

This study examined a 500 adult patient population who had migraine with or without aura. Christian Lampl was interested in seeing how many had headache, and the timing of when vertigo occurred. It was carefully measured to determine if it usually occurred during or before the headache phase. Migraines were divided into 3 time segments for evaluation: (1) Onset of headache, (2) less than 2 hours before the onset of headache, and (3) 2 to 48 hours before the onset of headache, when prodrome occurs.

• The study determined that 30 % of the patients reported vertigo at some point during their migraine attack; 16% reported it at the start of headache, 10% reported it within 2 hours before their headache, and just 3% reported symptoms between 2 and 24 hours beforehand., which would have been in the prodromal phase.  
• The study concluded that episodic vertigo could be considered more of a “headache phase phenomenon” rather than a prodromal symptom. This was interesting but it left unanswered one of my questions which is, how many had vertigo unrelated to headache and what is that and how do we treat it.
• Although not addressed in this study, there is consensus that if there is enough vertigo in a migraineur, they should be placed on a migraine preventive therapy. It will be interesting to see what the new monoclonal antibodies to CGRP do to vertigo in a treated migraineur. Some headache specialists will even treat an attack of vertigo without headache with a triptan.