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Objective: To evaluate the association of routine exercise with headache frequency, intensity, and duration among adults with episodic migraine (EM). Background: A comprehensive management plan for EM must aim at reducing disability and cost of care; to do so requires optimizing acute and preventive medications, and behavior changes. Prophylactic medication use is associated with adverse events and contraindications with comorbidities. Aerobic exercise is reported to decrease migraine frequency. However, no study has evaluated a potential synergistic relation between regular exercise and preventive medication use among patients with EM. Design and Methods: This was a secondary analysis of data from a prospective cohort study of adults with EMs. In that study, adults with EM (using International Classification of Headache Disorders‐3 criteria confirmed by study physicians) were recruited from three academic medical centers in Boston, MA. At baseline, participants provided information on exercise, clinical and demographic characteristics, and lifestyle behaviors. We prospectively collected daily information on headaches and health behavior over at least 6 weeks using electronic questionnaires from 94 participants. We assessed the association between baseline self‐reported moderate‐vigorous exercise at least three times per week, at baseline, and prospectively recorded headache frequency, intensity, and duration. We further assessed whether these associations differed by the prevalent use of prophylactic migraine medication. Results: Data from 94 of 98 eligible participants were used in the analysis as 4 participants had missing data on routine exercise frequency or intensity at baseline. On average, patients who reported moderate‐vigorous exercise at least three times per week at enrollment had 1.5 fewer headache days per month (−1.5 headache days/month; 95% confidence interval [CI] −3.1 to 0.1) compared to less exercise; this was not statistically significant (p = 0.066). The association between exercise and headache days per month varied by baseline use of migraine prophylaxis (p‐value of interaction = 0.009). Among those who reported regular use of migraine prophylaxis, a report of moderate‐vigorous exercise at least three times per week was associated with 5.1 fewer headache days (−5.1: 95% CI −8.2 to −2.0; p = 0.001) compared to those who reported lower levels of exercise. However, among those not using migraine prophylaxis, we observed only 0.4 fewer headache days per month (−0.4: 95% CI −2.2 to 1.3; p = 0.636) associated with moderate‐vigorous exercise at least three times/week, a result that was not statistically significant. There was no association of self‐reported moderate‐vigorous exercise at least three times a week with headache intensity or duration. Conclusion: In patients with EM, those who reported moderate‐vigorous exercise at least three times per week had fewer headache days per month, though not statistically significant. This association was significantly stronger in those who used prophylactic medication for migraines. Exercise appeared not to be associated with the severity or duration of headaches. Routine moderate‐vigorous exercise may be an important adjunctive strategy for improving headache burden in patients eligible for migraine prophylaxis. [ABSTRACT FROM AUTHOR]

Background: Status migrainosus (SM) is defined as a debilitating migraine attack lasting more than 72 hours in patients previously known to suffer from migraine headache. Typically, these attacks fail to respond to over the counter and abortive medications. The sphenopalatine ganglion (SPG) plays a critical role in propagating both pain and the autonomic symptoms commonly associated with migraines. SPG block via transnasal lidocaine is moderately effective in reducing migraine symptoms, but this approach is often poorly tolerated and the results are inconsistent. We proposed that an SPG block using a suprazygomatic injection approach would be a safe and effective option to abort or alleviate pain and autonomic symptoms of SM. Methods: Through a retrospective records review, we identified patients with a well‐established diagnosis of migraine, based on the International Headache Society criteria. Patients selected for study inclusion were diagnosed with SM, had failed to respond to 2 or more abortive medications, and had received a suprazygomatic SPG block. Patients had also been asked to rate their pain on a 1–10 Likert scale, both before and 30 minutes after the injection. Results: Eighty‐eight consecutive patients (20 men and 68 women) received a total of 252 suprazygomatic SPG block procedures in the outpatient headache clinic after traditional medications failed to abort their SM. At 30 minutes following the injections, there was a 67.2% (±26.6%) reduction in pain severity with a median reduction of 5 points (IQR= −6 to −3) on the Likert scale (ranging from 1 to 10). Overall, patients experienced a statistically significant reduction in pain severity (P < .0001). Conclusion: The SPG is known to play an integral role in the pathophysiology of facial pain and the trigeminal autonomic cephalalgias, although its exact role in the generation and maintenance of migraine headache remains unclear. Regional anesthetic suprazygomatic SPG block is potentially effective for immediate relief of SM. We believe the procedure is simple to perform and has minimal risk. [ABSTRACT FROM AUTHOR]

Objective Low-cost evidence-based tools are needed to facilitate the early identification of patients with possible psychogenic nonepileptic seizures ( PNES). Prior to accurate diagnosis, patients with PNES do not receive interventions that address the cause of their seizures and therefore incur high medical costs and disability due to an uncontrolled seizure disorder. Both seizures and comorbidities may contribute to this high cost. Methods Based on data from 1,365 adult patients with video-electroencephalography-confirmed diagnoses from a single center, we used logistic and Poisson regression to compare the total number of comorbidities, number of medications, and presence of specific comorbidities in five mutually exclusive groups of diagnoses: epileptic seizures ( ES) only, PNES only, mixed PNES and ES, physiologic nonepileptic seizurelike events, and inconclusive monitoring. To determine the diagnostic utility of comorbid diagnoses and medication history to differentiate PNES only from ES only, we used multivariate logistic regression, controlling for sex and age, trained using a retrospective database and validated using a prospective database. Results Our model differentiated PNES only from ES only with a prospective accuracy of 78% (95% confidence interval =72-84%) and area under the curve of 79%. With a few exceptions, the number of comorbidities and medications was more predictive than a specific comorbidity. Comorbidities associated with PNES were asthma, chronic pain, and migraines (p < 0.01). Comorbidities associated with ES were diabetes mellitus and nonmetastatic neoplasm (p < 0.01). The population-level analysis suggested that patients with mixed PNES and ES may be a population distinct from patients with either condition alone. Significance An accurate patient-reported medical history and medication history can be useful when screening for possible PNES. Our prospectively validated and objective score may assist in the interpretation of the medication and medical history in the context of the seizure description and history. [ABSTRACT FROM AUTHOR]

Chronic headaches are common and can have a significant effect on quality of life. Approved treatment options are vast and include the use botulinum toxin injections. The objective of this study is to evaluate the effects of purely cosmetic onabotulinumtoxinA (BOTOX®) injections on the frequency and severity of chronic headaches. Patients seeking treatment of hyperfunctional facial lines were enrolled to complete pre- and posttreatment questionnaires assessing headache symptoms. Quantitative data was compared using paired two-tailed student t-tests between groups of patients who received onabotulinumtoxinA injections, both onabotulinumtoxinA and hyaluronic acid (Restylane®) injections, and hyaluronic acid injections. One hundred and ten patients were enrolled; 73 completed the study. Of the 45 patients with pretreatment headaches, 76% (22/29) that received cosmetic onabotulinumtoxinA injections alone and 69% (27/39) that received onabotulinumtoxinA with or without hyaluronic acid injections reported overall improvement in headaches. Patients who received only onabotulinumtoxinA reported a significant decrease in the frequency (P = 0.0016) and severity (P = 0.0002) of headaches, and the number of days over-the-counter medications were taken (P = 0.0238). It took an average 9.5 days for headache improvement vs. 4.4 days for an appearance change. In patients who received only hyaluronic acid injections (n = 6), no significant improvement in headaches was reported. Overall satisfaction was high and unaffected by whether patients experienced headache relief. The majority of patients (93%) reported that they would "definitely" or "likely" receive onabotulinumtoxinA injections again in the future. Purely cosmetic onabotulinumtoxinA injections of doses between 15–50 units can significantly decrease the severity and frequency of headaches. [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis To identify whether relationships exist between epistaxis and migraines in hereditary hemorrhagic telangiectasia (HHT), to potentially provide further preventative and therapeutic options for the debilitating nosebleeds that are often very difficult to manage in clinical practice. Study Design Study participants were recruited from a UK specialist service, and online following advertisement by the HHT Foundation International. They completed a nonbiased questionnaire in which paired questions on nosebleeds and migraines were separated by at least 17 other questions. Methods Migraines were defined as headaches with associated autonomic and/or neurological features. The reported frequencies and precipitants of epistaxis and migraines were compared using numerical scales applied equally for each condition. Results The 220 HHT-affected respondents reported frequent nosebleeds, 153 (69.5%) used iron tablets, and 39 (17.7%) had received at least 10 blood transfusions. Migraines displaying typical features were reported by 51 (23.2%), and were more common with pulmonary or cerebral arteriovenous malformations. Thirty of 51 (58.8%) migraine sufferers reported that nosebleeds occurred at the same time as their migraines. More frequent migraines were reported by patients with more frequent nosebleeds ( r2 = 15%, P = .007), or transfusions ( r2 = 16.9%, P = .004). In menstrual, lifestyle, and dietary analyses, consistency was observed between factors having no effect, and those provoking both nosebleeds and migraines in multiple patients (premenses; activity; lack of sleep; stress; caffeine, cheese, alcohol, and chocolate). Conclusions We demonstrate an unexpected and provocative association between nosebleeds and migraines in HHT patients. Evaluation of whether antimigraine approaches limit HHT nosebleeds may be appropriate. Level of Evidence 4 Laryngoscope, 124:1521-1528, 2014 [ABSTRACT FROM AUTHOR]

Epilepsy, bipolar disorder, and migraines are common disorders that are often associated with disturbances in menstrual function in adolescent girls. Women with untreated epilepsy are more likely to have irregular menstrual cycles than are nonepileptic controls, indicating that the disease itself plays a role in the etiology of these reproductive abnormalities. In addition, many girls with these disorders require chronic maintenance treatment with agents that may perturb the hypothalamic-pituitary-ovarian axis. Valproate is a highly effective antiepileptic drug used widely to treat epilepsy, bipolar disorder, and migraines. Valproate induces features of the polycystic ovary syndrome (PCOS) in approximately 7% of women. Girls with epilepsy, and possibly bipolar disorder, appear particularly susceptible to developing PCOS features on valproate, perhaps on account of the relative immaturity of their hypothalamic-pituitary-ovarian axes. Antipsychotics are highly effective drugs used widely to treat adolescents with bipolar disorder, psychotic disorders, and behavioral disturbances. Some, but not all of the antipsychotic, induce hyperprolactinemia, which may result in oligo- or amenorrhea. Prolonged amenorrhea in association with hyperprolactinemia incurs significant risks for bone health in adolescent girls. Because of the potential reproductive health risks associated with use of specific antiepileptic drugs and selective antipsychotics, these agents are vital treatments for adolescents with severe illnesses. Use of these agents should be considered and weighed against the risk of using alternative agents, which have their own side effects, or not treating these serious neurologic and psychiatric disorders. [ABSTRACT FROM AUTHOR]

Purpose: To describe the experiences of midlife women with migraines. Design and Methods: Qualitative data were collected in two consecutive studies, using open-ended interviews, focus groups, and online discussion boards. Interpretive methods were used for analysis. Findings: Three patterns were identified: Changing Headache Patterns; Predicting, Preventing, and Controlling Headaches; and Keeping on the Move. These patterns indicated how women's headaches changed over time, how headaches were envisioned within the context of their lives, what strategies were used to meet work and home responsibilities, and how women controlled their headaches while maintaining a sense of perspective. Conclusions: Many midlife women with migraines receive inadequate or inappropriate treatment, and better dissemination of current diagnostic and treatment guidelines is necessary. Ongoing research is needed to increase understanding of how this problem affects midlife women's lives and of what interventions might prevent or alleviate migraine discomfort. [ABSTRACT FROM AUTHOR]

Thomas Jefferson had severe headaches on a number of occasions during his adult life, as noted by most of his biographers. Some occurred during important historical events, including the period just before the writing of the Declaration of Independence. Historians generally have considered these headaches to be migraines, while some physician authors have considered the alternative diagnoses of tension-type headaches and cluster headaches. A review of the literature, including Jefferson's many letters, suggests that they probably were migraines, although not all of the current diagnostic criteria can be met. [ABSTRACT FROM AUTHOR]

Activation, or the altered perception of activation, of trigeminal nerves that innervate the cranial vasculature is considered to be a pivotal component of the pathophysiology of acute migraine.Calcitonin gene-related peptide (CGRP) levels are increased during migraine and after trigeminal nerve stimulation in the cat. Both CGRP and nitric oxide (NO) infusion causes headache and delayed migraine in migraineurs. Neurogenic stimulation of a cranial window, CGRP and NO injection all cause meningeal artery dilation in the rat when viewed using intravital microscopy.Topiramate is an antiepileptic drug with established efficacy as a migraine preventive, and has recently been shown to inhibit neurons of the trigeminocervical complex after superior sagittal sinus stimulation.In this study, we used intravital microscopy with neurogenic dural vasodilation, and CGRP- and NO-induced dilation to examine whether intravenous topiramate has effects on the trigeminovascular system.Topiramate was able to attentuate neurogenic dural vasodilation maximally after 15 min by 52% at 30 mg kg−1 (t5=6.78, n=6); there was no significant inhibition at 10 mg kg−1.There was also significant attenuation of the NO-induced dilation maximally after 15 min, at both 10 and 30 mg kg−1 by 21% (t6=6.09, n=7) and 41% (t6=5.3, n=7), respectively.CGRP-induced dilation was not inhibited at either dose of topiramate.The study demonstrates that topiramate is likely to inhibit neurogenic dural vasodilation by inhibiting the release of CGRP from prejunctional trigeminal neurons, thus attenuating the dural vasodilation. Topiramate is not able to act postsynaptically at the blood vessels themselves as the CGRP-induced dilation was not attenuated.The data are consistent with an effect of topiramate on trigeminovascular activation which may form part of its preventive antimigraine mechanisms of action.British Journal of Pharmacology (2005) 146, 7–14. doi:10.1038/sj.bjp.0706290; published online 27 June 2005 [ABSTRACT FROM AUTHOR]

Background.—Migraine is a significant problem for many children. Topiramate has been suggested to be effective for the prophylaxis of migraine in adults, but has not yet been examined in children. The drug has been demonstrated to be safe and effective for childhood seizure disorders. The objective of this study was to demonstrate the safety and efficacy of topiramate for the prevention of pediatric migraine. Methods.—Children with frequent migraine were prescribed topiramate for headache prevention. Dosages, serum levels, and Serum Glutamic Oxalacetic Transaminase (SGOT) levels were monitored. Changes in frequency, severity, and duration of headaches were recorded and changes in headache-related disability using PedMIDAS also were measured. Results.—Ninety-seven children were treated with topiramate, and 75 were reevaluated 88.7 ± 35.7 days later, 41 were seen at a second follow-up, and 17 were seen at a third follow-up evaluation. The daily dose reached at second evaluation was 84.0 ± 38.6 mg/day or 1.42 ± 0.74 mg/kg/day. This corresponded to a mean serum level of 2.8 ± 1.6 μg/mL. The mean headache frequency was reduced from 16.5 ± 10.0 to 11.6 ± 10.2 days per month (P <0.001) with a further reduction to 9.4 ± 8.4 days by the second follow-up (P <0.001). Severity and duration of headache also were reduced. Headache disability improved, with a reduction of Pediatric Migraine Disability Assessment score from 36.0 ± 42.3 to 20.8 ± 34.0 at the first follow-up (P <0.05), 19.1 ± 22.0 at the second follow-up (P <0.005), and 10.9 ± 16.9 at the third follow-up (P <0.001). Most patients tolerated topiramate well. The most common side effects reported were cognitive (12.5%), weight loss (5.6%), and sensory (2.8%). Conclusions.—Topiramate is potentially an effective prophylactic medication for children with frequent migraine. [ABSTRACT FROM AUTHOR]

Objective .—The purpose of this study was to describe the overall prevalence of migraines within National Collegiate Athletic Association Division I men's and women's basketball players. In addition, the prevalence of migraines was determined across gender and ethnic groups for the same sample. Background .—Although numerous studies have assessed the prevalence of migraines within the general population, college students, professional groups, industrial/work place settings, and overseas populations, little has been done with athletes. To the best of our knowledge, no study of the incidence of migraines in athletes has been previously conducted. It has also been reported that migraines cause depression, insomnia, fatigue, anorexia, nausea, and vomiting, all of which might hinder athletic performance. Sports medicine clinicians and researchers also agree that migraines in athletes are probably underreported and often misdiagnosed. Methods .—Seven hundred ninety-one Division I men and women basketball players representing 51 colleges and universities were mailed a previously validated survey asking questions about headaches. All surveys were analyzed with a validated diagnostic algorithm consistent with the International Headaches Society's (IHS) criteria for headache diagnosis. Descriptive statistics were used to report the prevalence rate for gender and ethnic groups, as well as the entire sample. Chi-square tests were performed (P = 0.05) to determine if there were any differences in the prevalence of migraines among gender and ethnic groups. Results .—Results showed that 2.9% (n = 23 of 791) of the total sample was classified as having migraines meeting IHS guidelines. In addition, 0.9% (n = 3 of 332) of men and 4.4% (n = 20 of 459) of women were classified as having migraines meeting IHS guidelines. Additionally, results showed that women reported migraines (χ2 = 8.140, P = 0.004) more often than men. When comparing... [ABSTRACT FROM AUTHOR]

Objective.—To study the effectiveness of a standardized dose of amitriptyline, 1 mg/kg, for childhood headaches. Background.—Amitriptyline has been shown to be effective for the prophylaxis of migraine in adults. Studies in children, however, have been quite limited. In adults, the suggested effective dose range is 10 to 150 mg. In children, a standardized dosage is often not used, resulting in a dosage range in clinical practice that often varies from a very low dose to a dose equivalent to that used in adults. Methods.—Children with more than three headaches per month were treated with amitriptyline, slowly increasing the dose to 1 mg/kg per day. The frequency, severity, and duration of their headaches were initially evaluated and subsequently measured at each follow-up evaluation. Two hundred seventy-nine children had headaches occurring frequently enough to indicate prophylactic treatment. Of these children, 192 (68.8%) were treated with amitriptyline. The average age at presentation was 12.0 (± 3.0) years. The ratio of boys to girls was 1:1.74. The average frequency of headaches was 17.1 (± 10.1) days per month. The average severity was 6.84 (± 1.67) on a 10-point pain scale. The average duration was 11.5 (± 15.0) hours. The most frequent diagnoses using International Headache Society criteria were migraine (60.6%), migraine with aura (7.9%), and tension-type headache (10.4%). Of these children, 146 have been seen for at least one follow-up examination, occurring on average 67.3 (± 32.3) days after beginning prophylactic treatment. Results.—A total of 84.2% of the children reported an overall perception of being better, while 11.6% reported being the same. The frequency of headaches improved to 9.2 (± 10.0) days per month. The average severity was reduced to 5.1 (± 2.1), and the average duration was reduced to 6.3 (± 11.1) hours. If daily or continuous headaches were excluded, the... [ABSTRACT FROM AUTHOR]

What is known and objectives: Migraine is a disabling disorder that affects individuals of all ages. To date, there are multiple limitations to using guidelines‐recommended treatments and preventive therapies. The goal of this review was to provide a comprehensive clinical review of the safety, efficacy and prescribing information of the emerging calcitonin gene‐related peptide (CGRP) antagonists. Agents in this new pharmacologic class were approved by the US Food and Drug Administration (FDA) for the treatment of acute migraine attack pain and the management of episodic and chronic migraine. Methods: A total of 12 randomized, placebo‐controlled clinical trials were identified and included in the review utilizing databases such as clinicaltrial.gov, PubMed and EMBASE. The trials collectively evaluated six CGRP antagonists starting from the orally administered CGRPs such as rimegepant and ubrogepant, to the quarterly IV administered CGRP such as eptinezumab, and the monthly/quarterly subcutaneously administered agents such as erenumab, fremanezumab and galcanezumab. Results and discussion: All agents displayed significant efficacy compared with placebo, measured by reduction in mean monthly migraine days (MMD). In addition, CGRP antagonists displayed a great tolerability profile with few adverse effects. These medications were neither associated with any cardiovascular‐related adverse effects, nor do they currently have specific contraindications to pre‐existing cardiovascular conditions. This can present a safe alternative to a wide range of patients who cannot be appropriately treated with first‐line treatments such as triptans. No treatment‐related death was reported in any of the clinical trials outlined and discussed. What is new and conclusion: Calcitonin gene‐related peptide antagonists are safe and efficacious medications both in treating acute migraine headache pain and the management of episodic and chronic migraine. Head‐to‐head comparative studies with current guideline‐recommended treatments are needed. However, CGRP antagonists are promising agents that present an alternative solution for patients living with migraine. [ABSTRACT FROM AUTHOR]