Headache & Migraine

PHILADELPHIA – Mindfulness-based cognitive therapy tailored for migraine may reduce migraine-related disability, even as the number of headache days and pain intensity remain unchanged, according to randomized clinical trial results.

“The fact that people can improve how they live their daily life even with the same amount of headache days and the same pain intensity is remarkable,” said study investigator Elizabeth K. Seng, PhD, associate professor of psychology at Yeshiva University and research associate professor of neurology at Albert Einstein College of Medicine, both in New York. “I think this gives us a little bit of a clue about when to use these kinds of treatments.”

Dr. Seng presented findings from the phase 2b pilot trial at the annual meeting of the American Headache Society.

To study the efficacy of mindfulness-based cognitive therapy for migraine, Dr. Seng and her research colleagues recruited participants with migraine in the New York City area between 2015 and 2018. In all, 60 patients were randomized to receive 8 weekly individual 75-minute mindfulness-based cognitive therapy for migraine sessions or 8 weeks on a wait list with treatment as usual.

Primary outcomes were Month 0 to Month 4 changes in perceived disability, measured using the Henry Ford Disability Inventory (HDI) and functional disability measured using the Migraine Disability Assessment Scale (MIDAS). Secondary outcomes included changes in headache days per 30 days and headache pain intensity.

Participants had a mean age of about 40 years, about 92% were women, and approximately half of the patients had chronic migraine. Participants had an average baseline HDI of 51.4, and 83.3% had MIDAS scores indicating severe disability. Patients averaged 10.4 headache attack days per month, and mean headache attack severity on a 0-10 scale was 6.2. Attrition did not significantly differ between the mindfulness-based cognitive therapy and control groups.

Patients who received mindfulness-based cognitive therapy for migraine experienced an approximately 15-point reduction on the HDI scale at 4 months, whereas wait-listed patients did not experience much of a change, Dr. Seng said. The difference between groups was statistically significant.

At 4 months, a smaller proportion of patients in the mindfulness-based cognitive therapy group had a MIDAS score of 21 or greater, but the difference between groups was not statistically significant. The data indicate a large effect that the study was underpowered to detect, Dr. Seng said.

A planned subgroup analysis found that mindfulness-based cognitive therapy produced changes in disability that were greater in patients with episodic migraine, compared with patients with chronic migraine. A reduction in MIDAS scores was statistically significant among patients with episodic migraine.

During the trial, one patient experienced increased headache frequency and intensity and changed their preventive treatment regimen, which investigators considered unrelated to mindfulness-based cognitive therapy. In addition, one patient experienced flooding – a vivid recollection of a traumatic event – which is an expected effect of meditation and relaxation therapy, Dr. Seng said. The patient completed the study and was satisfied with the mindfulness-based cognitive therapy training, she said.

“Preliminary evidence suggests that mindfulness-based cognitive therapy could be recommended to reduce headache-related disability in people with episodic migraine or people who have some kind of effective prevention on board, but they are still experiencing high levels of disability,” Dr. Seng said.

Although flooding may occur in patients with a trauma history who use meditation and relaxation, the techniques still may be useful, Dr. Seng said. “In the VA setting, we use meditation and relaxation all the time. But it helps to forewarn patients that they might experience distressful flooding and [to provide] techniques that they can use to reduce the impact of that.”

[email protected]

PHILADELPHIA – Mindfulness-based cognitive therapy tailored for migraine may reduce migraine-related disability, even as the number of headache days and pain intensity remain unchanged, according to randomized clinical trial results.

“The fact that people can improve how they live their daily life even with the same amount of headache days and the same pain intensity is remarkable,” said study investigator Elizabeth K. Seng, PhD, associate professor of psychology at Yeshiva University and research associate professor of neurology at Albert Einstein College of Medicine, both in New York. “I think this gives us a little bit of a clue about when to use these kinds of treatments.”

Dr. Seng presented findings from the phase 2b pilot trial at the annual meeting of the American Headache Society.

To study the efficacy of mindfulness-based cognitive therapy for migraine, Dr. Seng and her research colleagues recruited participants with migraine in the New York City area between 2015 and 2018. In all, 60 patients were randomized to receive 8 weekly individual 75-minute mindfulness-based cognitive therapy for migraine sessions or 8 weeks on a wait list with treatment as usual.

Primary outcomes were Month 0 to Month 4 changes in perceived disability, measured using the Henry Ford Disability Inventory (HDI) and functional disability measured using the Migraine Disability Assessment Scale (MIDAS). Secondary outcomes included changes in headache days per 30 days and headache pain intensity.

Participants had a mean age of about 40 years, about 92% were women, and approximately half of the patients had chronic migraine. Participants had an average baseline HDI of 51.4, and 83.3% had MIDAS scores indicating severe disability. Patients averaged 10.4 headache attack days per month, and mean headache attack severity on a 0-10 scale was 6.2. Attrition did not significantly differ between the mindfulness-based cognitive therapy and control groups.

Patients who received mindfulness-based cognitive therapy for migraine experienced an approximately 15-point reduction on the HDI scale at 4 months, whereas wait-listed patients did not experience much of a change, Dr. Seng said. The difference between groups was statistically significant.

At 4 months, a smaller proportion of patients in the mindfulness-based cognitive therapy group had a MIDAS score of 21 or greater, but the difference between groups was not statistically significant. The data indicate a large effect that the study was underpowered to detect, Dr. Seng said.

A planned subgroup analysis found that mindfulness-based cognitive therapy produced changes in disability that were greater in patients with episodic migraine, compared with patients with chronic migraine. A reduction in MIDAS scores was statistically significant among patients with episodic migraine.

During the trial, one patient experienced increased headache frequency and intensity and changed their preventive treatment regimen, which investigators considered unrelated to mindfulness-based cognitive therapy. In addition, one patient experienced flooding – a vivid recollection of a traumatic event – which is an expected effect of meditation and relaxation therapy, Dr. Seng said. The patient completed the study and was satisfied with the mindfulness-based cognitive therapy training, she said.

“Preliminary evidence suggests that mindfulness-based cognitive therapy could be recommended to reduce headache-related disability in people with episodic migraine or people who have some kind of effective prevention on board, but they are still experiencing high levels of disability,” Dr. Seng said.

Although flooding may occur in patients with a trauma history who use meditation and relaxation, the techniques still may be useful, Dr. Seng said. “In the VA setting, we use meditation and relaxation all the time. But it helps to forewarn patients that they might experience distressful flooding and [to provide] techniques that they can use to reduce the impact of that.”

[email protected]

PHILADELPHIA – Mindfulness-based cognitive therapy tailored for migraine may reduce migraine-related disability, even as the number of headache days and pain intensity remain unchanged, according to randomized clinical trial results.

“The fact that people can improve how they live their daily life even with the same amount of headache days and the same pain intensity is remarkable,” said study investigator Elizabeth K. Seng, PhD, associate professor of psychology at Yeshiva University and research associate professor of neurology at Albert Einstein College of Medicine, both in New York. “I think this gives us a little bit of a clue about when to use these kinds of treatments.”

Dr. Seng presented findings from the phase 2b pilot trial at the annual meeting of the American Headache Society.

To study the efficacy of mindfulness-based cognitive therapy for migraine, Dr. Seng and her research colleagues recruited participants with migraine in the New York City area between 2015 and 2018. In all, 60 patients were randomized to receive 8 weekly individual 75-minute mindfulness-based cognitive therapy for migraine sessions or 8 weeks on a wait list with treatment as usual.

Primary outcomes were Month 0 to Month 4 changes in perceived disability, measured using the Henry Ford Disability Inventory (HDI) and functional disability measured using the Migraine Disability Assessment Scale (MIDAS). Secondary outcomes included changes in headache days per 30 days and headache pain intensity.

Participants had a mean age of about 40 years, about 92% were women, and approximately half of the patients had chronic migraine. Participants had an average baseline HDI of 51.4, and 83.3% had MIDAS scores indicating severe disability. Patients averaged 10.4 headache attack days per month, and mean headache attack severity on a 0-10 scale was 6.2. Attrition did not significantly differ between the mindfulness-based cognitive therapy and control groups.

Patients who received mindfulness-based cognitive therapy for migraine experienced an approximately 15-point reduction on the HDI scale at 4 months, whereas wait-listed patients did not experience much of a change, Dr. Seng said. The difference between groups was statistically significant.

At 4 months, a smaller proportion of patients in the mindfulness-based cognitive therapy group had a MIDAS score of 21 or greater, but the difference between groups was not statistically significant. The data indicate a large effect that the study was underpowered to detect, Dr. Seng said.

A planned subgroup analysis found that mindfulness-based cognitive therapy produced changes in disability that were greater in patients with episodic migraine, compared with patients with chronic migraine. A reduction in MIDAS scores was statistically significant among patients with episodic migraine.

During the trial, one patient experienced increased headache frequency and intensity and changed their preventive treatment regimen, which investigators considered unrelated to mindfulness-based cognitive therapy. In addition, one patient experienced flooding – a vivid recollection of a traumatic event – which is an expected effect of meditation and relaxation therapy, Dr. Seng said. The patient completed the study and was satisfied with the mindfulness-based cognitive therapy training, she said.

“Preliminary evidence suggests that mindfulness-based cognitive therapy could be recommended to reduce headache-related disability in people with episodic migraine or people who have some kind of effective prevention on board, but they are still experiencing high levels of disability,” Dr. Seng said.

Although flooding may occur in patients with a trauma history who use meditation and relaxation, the techniques still may be useful, Dr. Seng said. “In the VA setting, we use meditation and relaxation all the time. But it helps to forewarn patients that they might experience distressful flooding and [to provide] techniques that they can use to reduce the impact of that.”

[email protected]

PHILADELPHIA – Patients with a history of migraine who underwent any type of surgery and then received a perioperative prescription for a headache abortive agent such as a triptan had 37% fewer readmissions for pain during the 30 days following surgery compared with patients who did not receive a migraine abortive prescription, according to an observational review of nearly 22,000 migraine patients from the Boston area.

Mitchel L. Zoler/MDedge News

While this statistically significant observational association must be viewed with caution, it provides compelling evidence for clinicians to prescribe a migraine abortive agent to migraineurs soon after surgery so that patients have these drugs handy if a migraine strikes, a possibility made likely by the stress and disruption of surgery, Katharina Platzbecker, MD, said at the annual meeting of the American Headache Society.

Postoperative migraine patients who received an abortive prescription specifically for a triptan or ergotamine showed an even stronger protective association, with an adjusted, statistically-significant 67% reduced rate of 30-day readmission for pain compared with the 50% of migraine patients who did not receive an abortive agent prescription after their surgery, said Dr. Platzbecker, a research fellow in the department of anesthesia, critical care, and pain medicine at Beth Israel Deaconess Medical Center in Boston. Only 8% of patients in the study received a triptan or ergotamine, with the vast majority of these patients getting a triptan.

The other types of abortive drugs prescribed perioperatively to migraine patients were NSAIDs or acetaminophen, received by 47% of the patients studied. The adjusted analysis showed that patients who received a prescription for one of these drugs had a statistically significant 35% reduced rate of 30-day readmission for pain. Patients who did not receive a prescription for a migraine abortive drug often got an opioid prescription, which went to 87% of the entire study population. Some patients received perioperative prescriptions for more than one drug. The analysis also showed that periopertive opioid prescriptions had no significant association with the 30-day rate of pain readmissions. In addition, prescription of any pain-reducing medication immediately prior to surgery as prophylaxis, which occurred in 17% of patients, had no significant association with the rate of 30-day postoperative pain readmission.


Despite the lack of clear causal evidence, clinicians should “definitely” be more aggressive in prescribing abortive treatments, especially triptans, to patients with a history of migraine who undergo surgery, Dr. Platzbecker said in an interview. These patients “are likely at risk for migraine [episodes] after surgery,”

Her study used data collected from nearly 25,000 patients with a history of a migraine billing diagnosis who underwent surgery and was a patient in either the Beth Israel or Partners (Massachusetts General Hospital and Brigham and Women’s Hospital) health systems during 2005-2017. Complete data that fulfilled the requirements of the study were available for 21,932 of these patients, of whom 11,011 (50%) received a perioperative prescription for an abortive drug and 10,921 (50%) did not. The prescribing occurred totally at the discretion of each patient’s physicians and surgeons. The researchers defined perioperative prescription as a billing entry for a drug anytime after surgery and within 30 days of hospital discharge or until readmission. The entire group studied averaged about 50 years old, more than 80% were women, and those who received an abortive treatment prescription generally had longer surgeries, more inpatient surgeries, and higher rates of various comorbidities. The adjusted statistical analysis took into account baseline differences like these.

Additional sensitivity analyses showed that perioperative prescriptions for abortive treatments also linked with significant reductions in all 30-day hospital readmissions, and with 30-day pain readmissions in patients who received surgery as inpatients as well as in those who were outpatients, and the association was specific to migraine patients. When Dr. Platzbecker expanded the group of patients she examined to more than 62,000 with any headache diagnosis the association between receiving a prescription for an abortive treatment and reduced 30-day pain readmissions became statistically insignificant.

Dr. Platzbecker and her associates previously reported results from an adjusted analysis showing that patients from the same database with a history of migraine who underwent surgery had an overall 42% increased rate of 30-day readmissions for pain compared with surgery patients who had no migraine history (Cephalagia. 2019 Feb;39[2]:286-95).

Dr. Platzbecker had no commercial disclosures.

[email protected]

On Twitter @mitchelzoler

This article was updated 7/16/19.

PHILADELPHIA – Patients with a history of migraine who underwent any type of surgery and then received a perioperative prescription for a headache abortive agent such as a triptan had 37% fewer readmissions for pain during the 30 days following surgery compared with patients who did not receive a migraine abortive prescription, according to an observational review of nearly 22,000 migraine patients from the Boston area.

Mitchel L. Zoler/MDedge News

While this statistically significant observational association must be viewed with caution, it provides compelling evidence for clinicians to prescribe a migraine abortive agent to migraineurs soon after surgery so that patients have these drugs handy if a migraine strikes, a possibility made likely by the stress and disruption of surgery, Katharina Platzbecker, MD, said at the annual meeting of the American Headache Society.

Postoperative migraine patients who received an abortive prescription specifically for a triptan or ergotamine showed an even stronger protective association, with an adjusted, statistically-significant 67% reduced rate of 30-day readmission for pain compared with the 50% of migraine patients who did not receive an abortive agent prescription after their surgery, said Dr. Platzbecker, a research fellow in the department of anesthesia, critical care, and pain medicine at Beth Israel Deaconess Medical Center in Boston. Only 8% of patients in the study received a triptan or ergotamine, with the vast majority of these patients getting a triptan.

The other types of abortive drugs prescribed perioperatively to migraine patients were NSAIDs or acetaminophen, received by 47% of the patients studied. The adjusted analysis showed that patients who received a prescription for one of these drugs had a statistically significant 35% reduced rate of 30-day readmission for pain. Patients who did not receive a prescription for a migraine abortive drug often got an opioid prescription, which went to 87% of the entire study population. Some patients received perioperative prescriptions for more than one drug. The analysis also showed that periopertive opioid prescriptions had no significant association with the 30-day rate of pain readmissions. In addition, prescription of any pain-reducing medication immediately prior to surgery as prophylaxis, which occurred in 17% of patients, had no significant association with the rate of 30-day postoperative pain readmission.


Despite the lack of clear causal evidence, clinicians should “definitely” be more aggressive in prescribing abortive treatments, especially triptans, to patients with a history of migraine who undergo surgery, Dr. Platzbecker said in an interview. These patients “are likely at risk for migraine [episodes] after surgery,”

Her study used data collected from nearly 25,000 patients with a history of a migraine billing diagnosis who underwent surgery and was a patient in either the Beth Israel or Partners (Massachusetts General Hospital and Brigham and Women’s Hospital) health systems during 2005-2017. Complete data that fulfilled the requirements of the study were available for 21,932 of these patients, of whom 11,011 (50%) received a perioperative prescription for an abortive drug and 10,921 (50%) did not. The prescribing occurred totally at the discretion of each patient’s physicians and surgeons. The researchers defined perioperative prescription as a billing entry for a drug anytime after surgery and within 30 days of hospital discharge or until readmission. The entire group studied averaged about 50 years old, more than 80% were women, and those who received an abortive treatment prescription generally had longer surgeries, more inpatient surgeries, and higher rates of various comorbidities. The adjusted statistical analysis took into account baseline differences like these.

Additional sensitivity analyses showed that perioperative prescriptions for abortive treatments also linked with significant reductions in all 30-day hospital readmissions, and with 30-day pain readmissions in patients who received surgery as inpatients as well as in those who were outpatients, and the association was specific to migraine patients. When Dr. Platzbecker expanded the group of patients she examined to more than 62,000 with any headache diagnosis the association between receiving a prescription for an abortive treatment and reduced 30-day pain readmissions became statistically insignificant.

Dr. Platzbecker and her associates previously reported results from an adjusted analysis showing that patients from the same database with a history of migraine who underwent surgery had an overall 42% increased rate of 30-day readmissions for pain compared with surgery patients who had no migraine history (Cephalagia. 2019 Feb;39[2]:286-95).

Dr. Platzbecker had no commercial disclosures.

[email protected]

On Twitter @mitchelzoler

This article was updated 7/16/19.

PHILADELPHIA – Patients with a history of migraine who underwent any type of surgery and then received a perioperative prescription for a headache abortive agent such as a triptan had 37% fewer readmissions for pain during the 30 days following surgery compared with patients who did not receive a migraine abortive prescription, according to an observational review of nearly 22,000 migraine patients from the Boston area.

Mitchel L. Zoler/MDedge News

While this statistically significant observational association must be viewed with caution, it provides compelling evidence for clinicians to prescribe a migraine abortive agent to migraineurs soon after surgery so that patients have these drugs handy if a migraine strikes, a possibility made likely by the stress and disruption of surgery, Katharina Platzbecker, MD, said at the annual meeting of the American Headache Society.

Postoperative migraine patients who received an abortive prescription specifically for a triptan or ergotamine showed an even stronger protective association, with an adjusted, statistically-significant 67% reduced rate of 30-day readmission for pain compared with the 50% of migraine patients who did not receive an abortive agent prescription after their surgery, said Dr. Platzbecker, a research fellow in the department of anesthesia, critical care, and pain medicine at Beth Israel Deaconess Medical Center in Boston. Only 8% of patients in the study received a triptan or ergotamine, with the vast majority of these patients getting a triptan.

The other types of abortive drugs prescribed perioperatively to migraine patients were NSAIDs or acetaminophen, received by 47% of the patients studied. The adjusted analysis showed that patients who received a prescription for one of these drugs had a statistically significant 35% reduced rate of 30-day readmission for pain. Patients who did not receive a prescription for a migraine abortive drug often got an opioid prescription, which went to 87% of the entire study population. Some patients received perioperative prescriptions for more than one drug. The analysis also showed that periopertive opioid prescriptions had no significant association with the 30-day rate of pain readmissions. In addition, prescription of any pain-reducing medication immediately prior to surgery as prophylaxis, which occurred in 17% of patients, had no significant association with the rate of 30-day postoperative pain readmission.


Despite the lack of clear causal evidence, clinicians should “definitely” be more aggressive in prescribing abortive treatments, especially triptans, to patients with a history of migraine who undergo surgery, Dr. Platzbecker said in an interview. These patients “are likely at risk for migraine [episodes] after surgery,”

Her study used data collected from nearly 25,000 patients with a history of a migraine billing diagnosis who underwent surgery and was a patient in either the Beth Israel or Partners (Massachusetts General Hospital and Brigham and Women’s Hospital) health systems during 2005-2017. Complete data that fulfilled the requirements of the study were available for 21,932 of these patients, of whom 11,011 (50%) received a perioperative prescription for an abortive drug and 10,921 (50%) did not. The prescribing occurred totally at the discretion of each patient’s physicians and surgeons. The researchers defined perioperative prescription as a billing entry for a drug anytime after surgery and within 30 days of hospital discharge or until readmission. The entire group studied averaged about 50 years old, more than 80% were women, and those who received an abortive treatment prescription generally had longer surgeries, more inpatient surgeries, and higher rates of various comorbidities. The adjusted statistical analysis took into account baseline differences like these.

Additional sensitivity analyses showed that perioperative prescriptions for abortive treatments also linked with significant reductions in all 30-day hospital readmissions, and with 30-day pain readmissions in patients who received surgery as inpatients as well as in those who were outpatients, and the association was specific to migraine patients. When Dr. Platzbecker expanded the group of patients she examined to more than 62,000 with any headache diagnosis the association between receiving a prescription for an abortive treatment and reduced 30-day pain readmissions became statistically insignificant.

Dr. Platzbecker and her associates previously reported results from an adjusted analysis showing that patients from the same database with a history of migraine who underwent surgery had an overall 42% increased rate of 30-day readmissions for pain compared with surgery patients who had no migraine history (Cephalagia. 2019 Feb;39[2]:286-95).

Dr. Platzbecker had no commercial disclosures.

[email protected]

On Twitter @mitchelzoler

This article was updated 7/16/19.

PHILADELPHIA – Migraine patients fared as well when managed for a year by telemedicine as when managed by a 12-month series of routine office visits in a single-center, randomized trial with 40 patients, the first reported randomized study of the impact of true telemedicine on mid-term migraine management.

“Telemedicine was viable and produced similar outcomes at 1 year in a highly disabled cohort,” Deborah I. Friedman, MD, said at the annual meeting of the American Headache Society. Many patients expressed high satisfaction with the approach. In addition to resulting in predictably shorter travel times for patients, it also linked with a cut in the consultation length by about a quarter, reported Dr. Friedman, a professor of neurology and chief of the division of headache medicine at UT Southwestern Medical Center in Dallas.

“There is a lot of opportunity for telemedicine, particularly in headache medicine because usually after the first visit we mostly just talk with patients with no further examinations, so it lends itself to telemedicine. It extends your reach.” Dr. Friedman said in a video interview. It is particularly attractive to patients who live a substantial distance from the clinic or find it hard to fit an office visit into their schedule, but some participants said they preferred the direct interaction of an office visit, she noted.

In addition to showing the efficacy of telemedicine in this setting, Dr. Friedman said that she hoped the findings may help pave the way for easier insurance payment for telemedicine consultations with migraineurs.

“One of the main reasons I did this study was to provide evidence to use for compensation for telemedicine visits. It will be good to have evidence in the medical literature that the outcomes are similar and that nothing is lost in patient care with telemedicine,” she said.

The study randomized 40 patients scheduled to see Dr. Friedman for the first time for a migraine consultation and to start treatment. After all patients had their initial office visit and examination, 22 of the patients entered the telemedicine arm and had follow-up consultations after 4-6 weeks, and after 3, 6, 9, and 12 months. The remaining 18 patients were randomized to receive these consultations in the office. Eighteen of the telemedicine patients and 12 of the in-office patients returned for a 12-month assessment. Patients averaged about 40 years old, they had actual or potential travel distances for in-office visits that in some cases exceeded 300 miles one way, and their Migraine Disability Assessment score averaged just above 40.

The telmedicine patients completed 93% of their visits compared with 88% of the in-office patients, a difference that was not statistically different. Migraine Disability Assessment scores improved by an average of 24 points in the telemedicine patients and by an average 19 points among the in-office controls, a difference that was not significant. The two groups also showed similar levels of treatment response for reductions in number of headache days and headache severity improvement. Average session length was 25 minutes with telemedicine and 34 minutes in office, a statistically significant difference that Dr. Friedman attributed to the interest by patients who have traveled long distances to see her to “get their money’s worth” from their visit.


Dr. Friedman highlighted the importance of having the visual aspect of a telemedicine consultation in addition to the conversation. For the trial the audio-visual link was via a standard laptop connection. Some patients assigned to telemedicine voiced regret over not being able to be examined, immediately start a new treatment, or receive drug samples. Dr. Friedman said that she couldn’t think of any migraine patients to whom she wouldn’t offer the option of telemedicine visits following an initial, in-person visit. But her use of telemedicine in routine practice is on hold right now as her institution, UT Southwestern, is still working out its consent and billing system, she said.

The study received partial funding from Merck. Dr. Friedman had no relevant disclosures.

[email protected]

On Twitter @mitchelzoler

SOURCE: Friedman DI. Headache. 2019 June;59[S1]:1-208, LBOR01.

PHILADELPHIA – Migraine patients fared as well when managed for a year by telemedicine as when managed by a 12-month series of routine office visits in a single-center, randomized trial with 40 patients, the first reported randomized study of the impact of true telemedicine on mid-term migraine management.

“Telemedicine was viable and produced similar outcomes at 1 year in a highly disabled cohort,” Deborah I. Friedman, MD, said at the annual meeting of the American Headache Society. Many patients expressed high satisfaction with the approach. In addition to resulting in predictably shorter travel times for patients, it also linked with a cut in the consultation length by about a quarter, reported Dr. Friedman, a professor of neurology and chief of the division of headache medicine at UT Southwestern Medical Center in Dallas.

“There is a lot of opportunity for telemedicine, particularly in headache medicine because usually after the first visit we mostly just talk with patients with no further examinations, so it lends itself to telemedicine. It extends your reach.” Dr. Friedman said in a video interview. It is particularly attractive to patients who live a substantial distance from the clinic or find it hard to fit an office visit into their schedule, but some participants said they preferred the direct interaction of an office visit, she noted.

In addition to showing the efficacy of telemedicine in this setting, Dr. Friedman said that she hoped the findings may help pave the way for easier insurance payment for telemedicine consultations with migraineurs.

“One of the main reasons I did this study was to provide evidence to use for compensation for telemedicine visits. It will be good to have evidence in the medical literature that the outcomes are similar and that nothing is lost in patient care with telemedicine,” she said.

The study randomized 40 patients scheduled to see Dr. Friedman for the first time for a migraine consultation and to start treatment. After all patients had their initial office visit and examination, 22 of the patients entered the telemedicine arm and had follow-up consultations after 4-6 weeks, and after 3, 6, 9, and 12 months. The remaining 18 patients were randomized to receive these consultations in the office. Eighteen of the telemedicine patients and 12 of the in-office patients returned for a 12-month assessment. Patients averaged about 40 years old, they had actual or potential travel distances for in-office visits that in some cases exceeded 300 miles one way, and their Migraine Disability Assessment score averaged just above 40.

The telmedicine patients completed 93% of their visits compared with 88% of the in-office patients, a difference that was not statistically different. Migraine Disability Assessment scores improved by an average of 24 points in the telemedicine patients and by an average 19 points among the in-office controls, a difference that was not significant. The two groups also showed similar levels of treatment response for reductions in number of headache days and headache severity improvement. Average session length was 25 minutes with telemedicine and 34 minutes in office, a statistically significant difference that Dr. Friedman attributed to the interest by patients who have traveled long distances to see her to “get their money’s worth” from their visit.


Dr. Friedman highlighted the importance of having the visual aspect of a telemedicine consultation in addition to the conversation. For the trial the audio-visual link was via a standard laptop connection. Some patients assigned to telemedicine voiced regret over not being able to be examined, immediately start a new treatment, or receive drug samples. Dr. Friedman said that she couldn’t think of any migraine patients to whom she wouldn’t offer the option of telemedicine visits following an initial, in-person visit. But her use of telemedicine in routine practice is on hold right now as her institution, UT Southwestern, is still working out its consent and billing system, she said.

The study received partial funding from Merck. Dr. Friedman had no relevant disclosures.

[email protected]

On Twitter @mitchelzoler

SOURCE: Friedman DI. Headache. 2019 June;59[S1]:1-208, LBOR01.

PHILADELPHIA – Migraine patients fared as well when managed for a year by telemedicine as when managed by a 12-month series of routine office visits in a single-center, randomized trial with 40 patients, the first reported randomized study of the impact of true telemedicine on mid-term migraine management.

“Telemedicine was viable and produced similar outcomes at 1 year in a highly disabled cohort,” Deborah I. Friedman, MD, said at the annual meeting of the American Headache Society. Many patients expressed high satisfaction with the approach. In addition to resulting in predictably shorter travel times for patients, it also linked with a cut in the consultation length by about a quarter, reported Dr. Friedman, a professor of neurology and chief of the division of headache medicine at UT Southwestern Medical Center in Dallas.

“There is a lot of opportunity for telemedicine, particularly in headache medicine because usually after the first visit we mostly just talk with patients with no further examinations, so it lends itself to telemedicine. It extends your reach.” Dr. Friedman said in a video interview. It is particularly attractive to patients who live a substantial distance from the clinic or find it hard to fit an office visit into their schedule, but some participants said they preferred the direct interaction of an office visit, she noted.

In addition to showing the efficacy of telemedicine in this setting, Dr. Friedman said that she hoped the findings may help pave the way for easier insurance payment for telemedicine consultations with migraineurs.

“One of the main reasons I did this study was to provide evidence to use for compensation for telemedicine visits. It will be good to have evidence in the medical literature that the outcomes are similar and that nothing is lost in patient care with telemedicine,” she said.

The study randomized 40 patients scheduled to see Dr. Friedman for the first time for a migraine consultation and to start treatment. After all patients had their initial office visit and examination, 22 of the patients entered the telemedicine arm and had follow-up consultations after 4-6 weeks, and after 3, 6, 9, and 12 months. The remaining 18 patients were randomized to receive these consultations in the office. Eighteen of the telemedicine patients and 12 of the in-office patients returned for a 12-month assessment. Patients averaged about 40 years old, they had actual or potential travel distances for in-office visits that in some cases exceeded 300 miles one way, and their Migraine Disability Assessment score averaged just above 40.

The telmedicine patients completed 93% of their visits compared with 88% of the in-office patients, a difference that was not statistically different. Migraine Disability Assessment scores improved by an average of 24 points in the telemedicine patients and by an average 19 points among the in-office controls, a difference that was not significant. The two groups also showed similar levels of treatment response for reductions in number of headache days and headache severity improvement. Average session length was 25 minutes with telemedicine and 34 minutes in office, a statistically significant difference that Dr. Friedman attributed to the interest by patients who have traveled long distances to see her to “get their money’s worth” from their visit.


Dr. Friedman highlighted the importance of having the visual aspect of a telemedicine consultation in addition to the conversation. For the trial the audio-visual link was via a standard laptop connection. Some patients assigned to telemedicine voiced regret over not being able to be examined, immediately start a new treatment, or receive drug samples. Dr. Friedman said that she couldn’t think of any migraine patients to whom she wouldn’t offer the option of telemedicine visits following an initial, in-person visit. But her use of telemedicine in routine practice is on hold right now as her institution, UT Southwestern, is still working out its consent and billing system, she said.

The study received partial funding from Merck. Dr. Friedman had no relevant disclosures.

[email protected]

On Twitter @mitchelzoler

SOURCE: Friedman DI. Headache. 2019 June;59[S1]:1-208, LBOR01.

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

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

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

[email protected]

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

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

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

[email protected]

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

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

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

[email protected]

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

Mitchel L. Zoler/MDedge News

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

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

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

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

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

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

[email protected]

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

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

Mitchel L. Zoler/MDedge News

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

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

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

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

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

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

[email protected]

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

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

Mitchel L. Zoler/MDedge News

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

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

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

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

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

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

[email protected]

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

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

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

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

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

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

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

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

[email protected]

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

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

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

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

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

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

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

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

[email protected]

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

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

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

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

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

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

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

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

[email protected]

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

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

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

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

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

Dr. Martin had no relevant disclosures.

[email protected]

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

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

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

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

Dr. Martin had no relevant disclosures.

[email protected]

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

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

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

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

Dr. Martin had no relevant disclosures.

[email protected]

PHILADELPHIA – Mothers with migraine are more likely to have babies with colic, according to research presented at the annual meeting of the American Headache Society. Fathers with migraine are not more likely to have children with colic, however. These findings may have implications for the care of mothers with migraine and their children, said Amy Gelfand, MD, associate professor of neurology at the University of California, San Francisco.

Smaller studies have suggested associations between migraine and colic. To examine this relationship in a large, national sample, Dr. Gelfand and her research colleagues conducted a cross-sectional survey of biological parents of 4- to 8-week-olds in the United States. The researchers analyzed data from 1,419 participants – 827 mothers and 592 fathers – who completed online surveys in 2017 and 2018.

Parents provided information about their and their infants’ health. The investigators identified migraineurs using modified International Classification of Headache Disorders 3rd edition criteria and determined infant colic by response to the question, “Has your baby cried for at least 3 hours on at least 3 days in the last week?”

In all, 33.5% of the mothers had migraine or probable migraine, and 20.8% of the fathers had migraine or probable migraine. Maternal migraine was associated with increased odds of infant colic (odds ratio, 1.7). Among mothers with migraine and headache frequency of 15 or more days per month, the likelihood of having an infant with colic was even greater (OR, 2.5).

“The cause of colic is unknown, yet colic is common, and these frequent bouts of intense crying or fussiness can be particularly frustrating for parents, creating family stress and anxiety,” Dr. Gelfand said in a news release. “New moms who are armed with knowledge of the connection between their own history of migraine and infant colic can be better prepared for these often difficult first months of a baby and new mother’s journey.”

[email protected]

PHILADELPHIA – Mothers with migraine are more likely to have babies with colic, according to research presented at the annual meeting of the American Headache Society. Fathers with migraine are not more likely to have children with colic, however. These findings may have implications for the care of mothers with migraine and their children, said Amy Gelfand, MD, associate professor of neurology at the University of California, San Francisco.

Smaller studies have suggested associations between migraine and colic. To examine this relationship in a large, national sample, Dr. Gelfand and her research colleagues conducted a cross-sectional survey of biological parents of 4- to 8-week-olds in the United States. The researchers analyzed data from 1,419 participants – 827 mothers and 592 fathers – who completed online surveys in 2017 and 2018.

Parents provided information about their and their infants’ health. The investigators identified migraineurs using modified International Classification of Headache Disorders 3rd edition criteria and determined infant colic by response to the question, “Has your baby cried for at least 3 hours on at least 3 days in the last week?”

In all, 33.5% of the mothers had migraine or probable migraine, and 20.8% of the fathers had migraine or probable migraine. Maternal migraine was associated with increased odds of infant colic (odds ratio, 1.7). Among mothers with migraine and headache frequency of 15 or more days per month, the likelihood of having an infant with colic was even greater (OR, 2.5).

“The cause of colic is unknown, yet colic is common, and these frequent bouts of intense crying or fussiness can be particularly frustrating for parents, creating family stress and anxiety,” Dr. Gelfand said in a news release. “New moms who are armed with knowledge of the connection between their own history of migraine and infant colic can be better prepared for these often difficult first months of a baby and new mother’s journey.”

[email protected]

PHILADELPHIA – Mothers with migraine are more likely to have babies with colic, according to research presented at the annual meeting of the American Headache Society. Fathers with migraine are not more likely to have children with colic, however. These findings may have implications for the care of mothers with migraine and their children, said Amy Gelfand, MD, associate professor of neurology at the University of California, San Francisco.

Smaller studies have suggested associations between migraine and colic. To examine this relationship in a large, national sample, Dr. Gelfand and her research colleagues conducted a cross-sectional survey of biological parents of 4- to 8-week-olds in the United States. The researchers analyzed data from 1,419 participants – 827 mothers and 592 fathers – who completed online surveys in 2017 and 2018.

Parents provided information about their and their infants’ health. The investigators identified migraineurs using modified International Classification of Headache Disorders 3rd edition criteria and determined infant colic by response to the question, “Has your baby cried for at least 3 hours on at least 3 days in the last week?”

In all, 33.5% of the mothers had migraine or probable migraine, and 20.8% of the fathers had migraine or probable migraine. Maternal migraine was associated with increased odds of infant colic (odds ratio, 1.7). Among mothers with migraine and headache frequency of 15 or more days per month, the likelihood of having an infant with colic was even greater (OR, 2.5).

“The cause of colic is unknown, yet colic is common, and these frequent bouts of intense crying or fussiness can be particularly frustrating for parents, creating family stress and anxiety,” Dr. Gelfand said in a news release. “New moms who are armed with knowledge of the connection between their own history of migraine and infant colic can be better prepared for these often difficult first months of a baby and new mother’s journey.”

[email protected]

PHILADELPHIA – The more days per month a person reported experiencing migraine headaches the greater their prevalence of various comorbidities associated with migraine headaches, including insomnia, depression, anxiety, and gastric ulcer disease, according to results from a survey of more than 92,000 U.S. residents.

Mitchel L. Zoler/MDedge News

“Increasing monthly headache day [MHD] frequency was associated with an increased risk of other health conditions in people with migraine,” Richard B. Lipton, MD, and his associates reported in a poster at the annual meeting of the American Headache Society. “The findings may be due to direct causality, reverse causality, shared risk factors, or detection bias.”

Additional analysis of the association with gastric ulcer disease (GUD) showed that it also linked with the number of days per month when a person with migraine used an NSAID. Migraineurs who self-reported having GUD averaged 10.5 days a month using an NSAID, compared with an average NSAID usage of just over 6 days a month among migraineurs without GUD, Dr. Lipton, a professor and vice-chair of neurology at Albert Einstein College of Medicine, New York, reported in a separate poster at the meeting.

The Migraine in America Symptoms and Treatment (MAST) study enrolled more than 90,000 U.S. residents starting in 2016. Using a validated diagnostic screening tool, the MAST researchers identified 15,133 of these people as having at least one day with a migraine headache during the 3 months prior to the survey and 77,453 who reported no migraine history (Headache. 2018 Oct;58[9]: 1408-26). The people with migraine averaged 43 years old, compared with an average of 52 years for those without migraine; 73% of the migraineurs were women.

Analysis of the prevalence of various self-reported, physician-diagnosed comorbidities showed a strong correlation between the relative odds of having a comorbidity and the self-reported number of MHDs. For example, the odds ratio for having insomnia, compared with the people without migraine, was nearly 200% among people reporting 1-4 MHDs, more than 300% higher among those reporting 5-9 MHDs, 500% higher with MHDs of 10-14, and nearly 700% higher among people reporting 20 or more MHDs. The researchers saw roughly similar patterns of rising comorbidity prevalence with higher numbers of MHDs for depression, anxiety, and GUD. The prevalence of a history of stroke or transient ischemic attack also increased with increasing numbers of MHDs but less steeply than for the other comorbidities. And while the prevalence of peripheral artery disease and epilepsy was consistently more than 100% greater among the migraineurs, compared with those with no recent migraine history, the prevalence of each of these two comorbidities showed no clear pattern of increasing prevalence as MHDs increased.

The analysis looked specifically at the relationship between GUD and NSAID use among people reporting migraine. Overall, the migraineurs had a greater than 200% increased prevalence of GUD than those without migraine. The odds ratio for GUD among migraineurs with 1-4 MHDs was 2.6, compared with those without migraine, and the odds ratio steadily rose with increasing MHDs to a peak of 490% higher among those who averaged 21 or more MHDs.

This link between the number of MHDs and prevalence of GUD may have some relationship to oral NSAID use, as overall NSAID use was higher among people with recent migraines than in those without migraines. However, the number of days per month of oral NSAID use appeared to plateau at an average of about 19 days once people reported having at least 10 MHDs, the researchers said. Even when people reported having more than twice as many MHDs their NSAID use remained at an average of about 19 days per month.

MAST was sponsored by Dr. Reddy’s Laboratories. Dr. Lipton had been a consultant to Dr. Reddy’s and to several other companies.

[email protected]

SOURCE: Lipton RB et al. Headache. 2019 June;59[S1]:1-208, P54.

PHILADELPHIA – The more days per month a person reported experiencing migraine headaches the greater their prevalence of various comorbidities associated with migraine headaches, including insomnia, depression, anxiety, and gastric ulcer disease, according to results from a survey of more than 92,000 U.S. residents.

Mitchel L. Zoler/MDedge News

“Increasing monthly headache day [MHD] frequency was associated with an increased risk of other health conditions in people with migraine,” Richard B. Lipton, MD, and his associates reported in a poster at the annual meeting of the American Headache Society. “The findings may be due to direct causality, reverse causality, shared risk factors, or detection bias.”

Additional analysis of the association with gastric ulcer disease (GUD) showed that it also linked with the number of days per month when a person with migraine used an NSAID. Migraineurs who self-reported having GUD averaged 10.5 days a month using an NSAID, compared with an average NSAID usage of just over 6 days a month among migraineurs without GUD, Dr. Lipton, a professor and vice-chair of neurology at Albert Einstein College of Medicine, New York, reported in a separate poster at the meeting.

The Migraine in America Symptoms and Treatment (MAST) study enrolled more than 90,000 U.S. residents starting in 2016. Using a validated diagnostic screening tool, the MAST researchers identified 15,133 of these people as having at least one day with a migraine headache during the 3 months prior to the survey and 77,453 who reported no migraine history (Headache. 2018 Oct;58[9]: 1408-26). The people with migraine averaged 43 years old, compared with an average of 52 years for those without migraine; 73% of the migraineurs were women.

Analysis of the prevalence of various self-reported, physician-diagnosed comorbidities showed a strong correlation between the relative odds of having a comorbidity and the self-reported number of MHDs. For example, the odds ratio for having insomnia, compared with the people without migraine, was nearly 200% among people reporting 1-4 MHDs, more than 300% higher among those reporting 5-9 MHDs, 500% higher with MHDs of 10-14, and nearly 700% higher among people reporting 20 or more MHDs. The researchers saw roughly similar patterns of rising comorbidity prevalence with higher numbers of MHDs for depression, anxiety, and GUD. The prevalence of a history of stroke or transient ischemic attack also increased with increasing numbers of MHDs but less steeply than for the other comorbidities. And while the prevalence of peripheral artery disease and epilepsy was consistently more than 100% greater among the migraineurs, compared with those with no recent migraine history, the prevalence of each of these two comorbidities showed no clear pattern of increasing prevalence as MHDs increased.

The analysis looked specifically at the relationship between GUD and NSAID use among people reporting migraine. Overall, the migraineurs had a greater than 200% increased prevalence of GUD than those without migraine. The odds ratio for GUD among migraineurs with 1-4 MHDs was 2.6, compared with those without migraine, and the odds ratio steadily rose with increasing MHDs to a peak of 490% higher among those who averaged 21 or more MHDs.

This link between the number of MHDs and prevalence of GUD may have some relationship to oral NSAID use, as overall NSAID use was higher among people with recent migraines than in those without migraines. However, the number of days per month of oral NSAID use appeared to plateau at an average of about 19 days once people reported having at least 10 MHDs, the researchers said. Even when people reported having more than twice as many MHDs their NSAID use remained at an average of about 19 days per month.

MAST was sponsored by Dr. Reddy’s Laboratories. Dr. Lipton had been a consultant to Dr. Reddy’s and to several other companies.

[email protected]

SOURCE: Lipton RB et al. Headache. 2019 June;59[S1]:1-208, P54.

PHILADELPHIA – The more days per month a person reported experiencing migraine headaches the greater their prevalence of various comorbidities associated with migraine headaches, including insomnia, depression, anxiety, and gastric ulcer disease, according to results from a survey of more than 92,000 U.S. residents.

Mitchel L. Zoler/MDedge News

“Increasing monthly headache day [MHD] frequency was associated with an increased risk of other health conditions in people with migraine,” Richard B. Lipton, MD, and his associates reported in a poster at the annual meeting of the American Headache Society. “The findings may be due to direct causality, reverse causality, shared risk factors, or detection bias.”

Additional analysis of the association with gastric ulcer disease (GUD) showed that it also linked with the number of days per month when a person with migraine used an NSAID. Migraineurs who self-reported having GUD averaged 10.5 days a month using an NSAID, compared with an average NSAID usage of just over 6 days a month among migraineurs without GUD, Dr. Lipton, a professor and vice-chair of neurology at Albert Einstein College of Medicine, New York, reported in a separate poster at the meeting.

The Migraine in America Symptoms and Treatment (MAST) study enrolled more than 90,000 U.S. residents starting in 2016. Using a validated diagnostic screening tool, the MAST researchers identified 15,133 of these people as having at least one day with a migraine headache during the 3 months prior to the survey and 77,453 who reported no migraine history (Headache. 2018 Oct;58[9]: 1408-26). The people with migraine averaged 43 years old, compared with an average of 52 years for those without migraine; 73% of the migraineurs were women.

Analysis of the prevalence of various self-reported, physician-diagnosed comorbidities showed a strong correlation between the relative odds of having a comorbidity and the self-reported number of MHDs. For example, the odds ratio for having insomnia, compared with the people without migraine, was nearly 200% among people reporting 1-4 MHDs, more than 300% higher among those reporting 5-9 MHDs, 500% higher with MHDs of 10-14, and nearly 700% higher among people reporting 20 or more MHDs. The researchers saw roughly similar patterns of rising comorbidity prevalence with higher numbers of MHDs for depression, anxiety, and GUD. The prevalence of a history of stroke or transient ischemic attack also increased with increasing numbers of MHDs but less steeply than for the other comorbidities. And while the prevalence of peripheral artery disease and epilepsy was consistently more than 100% greater among the migraineurs, compared with those with no recent migraine history, the prevalence of each of these two comorbidities showed no clear pattern of increasing prevalence as MHDs increased.

The analysis looked specifically at the relationship between GUD and NSAID use among people reporting migraine. Overall, the migraineurs had a greater than 200% increased prevalence of GUD than those without migraine. The odds ratio for GUD among migraineurs with 1-4 MHDs was 2.6, compared with those without migraine, and the odds ratio steadily rose with increasing MHDs to a peak of 490% higher among those who averaged 21 or more MHDs.

This link between the number of MHDs and prevalence of GUD may have some relationship to oral NSAID use, as overall NSAID use was higher among people with recent migraines than in those without migraines. However, the number of days per month of oral NSAID use appeared to plateau at an average of about 19 days once people reported having at least 10 MHDs, the researchers said. Even when people reported having more than twice as many MHDs their NSAID use remained at an average of about 19 days per month.

MAST was sponsored by Dr. Reddy’s Laboratories. Dr. Lipton had been a consultant to Dr. Reddy’s and to several other companies.

[email protected]

SOURCE: Lipton RB et al. Headache. 2019 June;59[S1]:1-208, P54.

Resting-state functional imaging revealed static functional connectivity and dynamic functional connectivity differences between migraine and persistent post-traumatic headache for regions involved in pain processing, a new study found. The case-control study integrated the static functional connectivity and dynamic functional connectivity patterns of 59 a priori selected regions of interest involved in pain processing. Pairwise connectivity differences between migraine (n=33) and persistent post-traumatic headache (n=44) were determined and compared to healthy controls (n=36) with ANOVA and subsequent t-tests. Researchers found:

• Significant differences in static functional connectivity between migraine and persistent post-traumatic headache were found for 17 region pairs.
• Significant differences in dynamic functional connectivity between migraine and persistent post-traumatic headache were found for 10 region pairs.
• These differences in functional connectivity may be indicative of pathophysiology associated with migraine vs persistent post-traumatic headache.

Dumkrieger G, et al. Static and dynamic functional connectivity differences between migraine and persistent post-traumatic headache: A resting-state magnetic resonance imaging study. [Published online ahead of print May 1, 2019]. Cephalalgia. doi: 10.1177/0333102419847728.

Resting-state functional imaging revealed static functional connectivity and dynamic functional connectivity differences between migraine and persistent post-traumatic headache for regions involved in pain processing, a new study found. The case-control study integrated the static functional connectivity and dynamic functional connectivity patterns of 59 a priori selected regions of interest involved in pain processing. Pairwise connectivity differences between migraine (n=33) and persistent post-traumatic headache (n=44) were determined and compared to healthy controls (n=36) with ANOVA and subsequent t-tests. Researchers found:

• Significant differences in static functional connectivity between migraine and persistent post-traumatic headache were found for 17 region pairs.
• Significant differences in dynamic functional connectivity between migraine and persistent post-traumatic headache were found for 10 region pairs.
• These differences in functional connectivity may be indicative of pathophysiology associated with migraine vs persistent post-traumatic headache.

Dumkrieger G, et al. Static and dynamic functional connectivity differences between migraine and persistent post-traumatic headache: A resting-state magnetic resonance imaging study. [Published online ahead of print May 1, 2019]. Cephalalgia. doi: 10.1177/0333102419847728.

Resting-state functional imaging revealed static functional connectivity and dynamic functional connectivity differences between migraine and persistent post-traumatic headache for regions involved in pain processing, a new study found. The case-control study integrated the static functional connectivity and dynamic functional connectivity patterns of 59 a priori selected regions of interest involved in pain processing. Pairwise connectivity differences between migraine (n=33) and persistent post-traumatic headache (n=44) were determined and compared to healthy controls (n=36) with ANOVA and subsequent t-tests. Researchers found:

• Significant differences in static functional connectivity between migraine and persistent post-traumatic headache were found for 17 region pairs.
• Significant differences in dynamic functional connectivity between migraine and persistent post-traumatic headache were found for 10 region pairs.
• These differences in functional connectivity may be indicative of pathophysiology associated with migraine vs persistent post-traumatic headache.

Dumkrieger G, et al. Static and dynamic functional connectivity differences between migraine and persistent post-traumatic headache: A resting-state magnetic resonance imaging study. [Published online ahead of print May 1, 2019]. Cephalalgia. doi: 10.1177/0333102419847728.