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Objectives: To assess real-world effectiveness, safety, and usage of erenumab in Canadian patients with episodic and chronic migraine with prior ineffective prophylactic treatments., Background: In randomized controlled trials, erenumab demonstrated efficacy for migraine prevention in patients with ≤4 prior ineffective prophylactic migraine therapies. The "Migraine prevention with AimoviG: Informative Canadian real-world study" (MAGIC) assessed real-world effectiveness of erenumab in Canadian patients with migraine., Methods: MAGIC was a prospective open-label, observational study conducted in Canadian patients with chronic migraine (CM) and episodic migraine (EM) with two to six categories of prior ineffective prophylactic therapies. Participants were administered 70 mg or 140 mg erenumab monthly based on physician's assessment. Migraine attacks were self-assessed using an electronic diary and patient-reported outcome questionnaires. The primary outcome was the proportion of subjects achieving ≥50% reduction in monthly migraine days (MMD) after the 3-month treatment period., Results: Among the 95 participants who mostly experienced two (54.7%) or three (32.6%) prior categories of ineffective prophylactic therapies and who initiated erenumab, treatment was generally safe and well tolerated; 89/95 (93.7%) participants initiated treatment with 140 mg erenumab. At week 12, 32/95 (33.7%) participants including 17/64 (26.6%) CM and 15/32 (48.4%) EM achieved ≥50% reduction in MMD while 30/86 (34.9%) participants including 19/55 (34.5%) CM and 11/31 (35.5%) EM achieved ≥50% reduction in MMD at week 24. Through patient-reported outcome questionnaires, 62/95 (65.3%) and 45/86 (52.3%) participants reported improvement of their condition at weeks 12 and 24, respectively. Physicians observed improvement in the condition of 78/95 (82.1%) and 67/86 (77.9%) participants at weeks 12 and 24, respectively., Conclusion: One-third of patients with EM and CM achieved ≥50% MMD reduction after 3 months of erenumab treatment. This study provides real-world evidence of erenumab effectiveness, safety, and usage for migraine prevention in adult Canadian patients with multiple prior ineffective prophylactic treatments., (© 2022 Novartis Pharmaceuticals Canada Inc. Headache: The Journal of Head and Face Pain published by Wiley Periodicals LLC on behalf of American Headache Society.)

Background: There is a considerable amount of practice variation in managing migraines in emergency settings, and evidence-based therapies are often not used first line., Methods: A peer-reviewed search of databases (MEDLINE, Embase, CENTRAL) was carried out to identify randomized and quasi-randomized controlled trials of interventions for acute pain relief in adults presenting with migraine to emergency settings. Where possible, data were pooled into meta-analyses., Results: Two independent reviewers screened 831 titles and abstracts for eligibility. Three independent reviewers subsequently evaluated 120 full text articles for inclusion, of which 44 were included. Individual studies were then assigned a US Preventive Services Task Force quality rating. The GRADE scheme was used to assign a level of evidence and recommendation strength for each intervention., Interpretation: We strongly recommend the use of prochlorperazine based on a high level of evidence, lysine acetylsalicylic acid, metoclopramide and sumatriptan, based on a moderate level of evidence, and ketorolac, based on a low level of evidence. We weakly recommend the use of chlorpromazine based on a moderate level of evidence, and ergotamine, dihydroergotamine, lidocaine intranasal and meperidine, based on a low level of evidence. We found evidence to recommend strongly against the use of dexamethasone, based on a moderate level of evidence, and granisetron, haloperidol and trimethobenzamide based on a low level of evidence. Based on moderate-quality evidence, we recommend weakly against the use of acetaminophen and magnesium sulfate. Based on low-quality evidence, we recommend weakly against the use of diclofenac, droperidol, lidocaine intravenous, lysine clonixinate, morphine, propofol, sodium valproate and tramadol., (© International Headache Society 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Background: Patients with chronic migraine and medication overuse are significant consumers of health care resources., Objective: To determine whether botulinum toxin type A prophylaxis reduces the cost of acute migraine medications in patients with chronic migraine and triptan overuse., Methods: In this multicenter, open-label study, patients with chronic migraine (≥ 15 headache days/month) who were triptan overusers (triptan intake ≥ 10 days/month for ≥ 3 months) received botulinum toxin type A (95-130 U) at baseline and month three. Headache (HA) frequency and medication use were assessed with patient diaries, and headache-related disability by means of the MIDAS and Headache Impact Test-6 questionnaires., Results: Of 53 patients enrolled (mean age ± standard deviation, 46.5 years ± 8.4; 47 [88.7%] females), 48 (90.6%) completed the study at month six. Based on headache diaries, significant (P ≤ 0.0002) decreases from baseline were observed for days per month with headache/migraine, days with any acute headache medication use, days with triptan use, and triptan doses taken per month. A significant (P < 0.0001) increase from baseline in headache-free days per month was also observed. Prescription medication costs for acute headache medications decreased significantly, including significant reductions in triptan costs (mean reduction of -C$106.32 ± 122.87/month during botulinum toxin type A prophylaxis; P < 0.0001). At baseline, 78% of patients had severe disability (MIDAS score) and 86.8% had severe impact due to headache (HIT-6 scores); at month six, this decreased to 60% and 68%, respectively., Conclusions: Botulinum toxin type A prophylactic therapy markedly decreased costs related to acute headache medication use in patients with chronic migraine and triptan overuse.

Objective: The objective of this study was to compare the headache impact test (HIT-6) and the migraine disability assessment scale (MIDAS) as clinical measures of headache-related disability., Background: The degree of headache-related disability is an important factor in treatment planning. Many quality of life and headache disability measures exist but it is unclear which of the available disability measures is the most helpful in planning and measuring headache management., Methods: We compared HIT-6 and MIDAS scores from 798 patients from the Canadian Headache Outpatient Registry and Database (CHORD). Correlation and regression analyses were used to examine the relationships between the HIT-6 and MIDAS total scores, headache frequency and intensity, and Beck Depression Inventory (BDI-II) scores., Results: A positive correlation was found between HIT-6 and MIDAS scores (r = 0.52). The BDI-II scores correlated equally with the HIT-6 and the MIDAS (r = 0.42). There was a non-monotonic relationship between headache frequency and the MIDAS, and a non-linear monotonic relationship between headache frequency and the HIT-6 (r = 0.24). The correlation was higher between the intensity and the HIT-6 scores (r = 0.46), than MIDAS (r = 0.26) scores. Seventy-nine percent of patients fell into the most severe HIT-6 disability category, compared with the 57% of patients that fell into the most severe MIDAS disability category. Significantly more patients were placed in a more severe category with the HIT-6 than with the MIDAS (McNemar chi-square = 191 on 6 d.f., P < .0001)., Conclusions: The HIT-6 and MIDAS appear to measure headache-related disability in a similar fashion. However, some important differences may exist. Headache intensity appears to influence HIT-6 score more than the MIDAS, whereas the MIDAS was influenced more by headache frequency. Using the HIT-6 and MIDAS together may give a more accurate assessment of a patient's headache-related disability.

The goal of the Canadian Migraine Forum was to work towards improving the lives of Canadians with migraine by reducing their migraine-related disability. Migraine has been ranked 19th by the World Health Organization among causes of years of life lived with disability. To improve management of migraine in Canada, the participants in the forum identified several important needs and strategies. There is a need for more leaders in the field of migraine to work with other stakeholders to obtain funding and develop treatment programs across Canada. Leadership is also required to address the under use of both migraine specific symptomatic medications and prophylactic medications in Canada. More non-physician health professionals are required to work with physicians in migraine treatment teams. This could assist with a shortage of physician resources, and could also help to better meet the needs of the migraine patient. Individuals with migraine need to be identified who could work with health care professionals to help meet the needs of the migraine patients in our communities. Application of the chronic disease management model for migraine treatment was also seen as an important factor for the management of migraine. Programs are needed to promote earlier diagnosis, long-term follow-up, comprehensive patient education, and the use of multidisciplinary treatment teams where appropriate. Also considered important was the need to increase knowledge about migraine through public awareness campaigns, websites, medical education, and appropriate reading material for patients. The public needs to be aware that migraine is a biological disorder that can cause significant disability and suffering. Lastly, there is a pressing need to promote more migraine research, including careful outcome assessments for treatment programs that involve non-pharmacological treatments and a team based approach to migraine management. There are many challenges that must be overcome if we are to be successful in reducing migraine related disability in Canada. Success will depend upon the joint efforts of physicians, other healthcare professionals, individuals with migraine, and the public at large.

We set out to examine selected clinical characteristics of migraine patients referred to neurologists specializing in headache in Canada, and to document their pharmacological therapy both before and after consultation with the neurologist. Demographic, clinical and pharmacotherapy data were collected at the time of consultation for 606 patients referred to five headache clinics and who were given a migraine diagnosis by the neurologist. Data were analysed as part of the Canadian Headache Outpatient Registry and Database (CHORD) Project. The mean age of the migraine patients was 39.7 years; and 82.5% were female. The majority of patients suffered severe impact from their headaches. Prior to consultation, 48.7% were taking a triptan; after consultation, 97.2% were on a triptan. Before consultation, 30.9% were on a prophylactic drug; after consultation, 70.4% were. 20.8% of patients were medication overusers. Of these medication overusers, 42.4% were overusing an opiate, usually in combination with other analgesics; 21.6% were overusing a triptan. Medication changes made by the neurologists at consultation included a large increase in the use of both triptans and prophylactic medications. Medication overuse, particularly opiate overuse, remains a significant problem in patients with migraine in Canada.

Objective: To determine which medications UK migraineurs have access to and assess the usage of these products in a 'real-life' setting., Research Design and Methods: Data were collected using an online questionnaire, which subjects were directed to by advertisements in pharmacies, a UK national newspaper, on the internet and information on the Migraine Action Association website and newsletters. Respondents were eligible for inclusion if attacks fulfilled International Headache Society criteria for migraine and/or if previously diagnosed by a physician as having migraine., Main Outcome Measures: Respondents were asked to specify which products had been prescribed or purchased for migraine treatment. The pattern of use of these products was determined, including the reasons why respondents chose particular products to treat attacks., Results: Of 3072 eligible respondents, the majority had purchased a variety of over-the-counter (OTC) medicines for treatment of attacks. Eighty-seven per cent had been diagnosed by a physician and were prescribed multiple products (average 1.68); 45% received triptans, but 26% were still prescribed products that were also available OTC. Over half (52%) of respondents initially used an OTC medicine to treat the last migraine attack. However, 73% required a second dose/product, mainly as a result of lack of efficacy of the first dose/product. Respondents using triptans were less likely to require a second dose/product than those not using triptans (52% vs. 78%, respectively). The two main reasons for choosing a triptan to treat an attack were the need for quick control and the severity of the attack. Satisfaction with regard to migraine medication was higher among triptan-users than nontriptan users., Conclusions: Medicines that are available OTC are often used as first-line therapy for migraine despite many migraineurs having access to prescription therapies such as triptans. Many migraineurs require a second dose/product, possibly indicating sub-optimal treatment efficacy. Physicians should consider the range of migraine-specific treatments available, including triptans, in order to develop a treatment plan that is based on the patient's needs and preferences.

Objective: To investigate the impact of migraine on migraineurs and their families and evaluate migraineurs' preference for different treatment formulations. This study also assessed the prevalence and impact of migraine with menstruation., Methods: Participants (n = 1028) from around the world (USA [39%], Canada [20%], Europe [37%] and other countries [4%]) completed an online questionnaire. Of these, 866 were migraineurs and 162 were non-migraineurs living with/related to migraineurs. Migraineurs were identified based on responses to a modified Kiel questionnaire and/or diagnosis of migraine by a doctor. Disability was quantified using the Migraine Disability Assessment Scale (MIDAS)., Results: Migraineurs missed more days from family/leisure activities than from work/school (mean 4.2 vs 2.4 days) in the previous 3 months. On an additional 6.2 days within the 3-month period, productivity at work/school was reduced by at least half. Inability and reduced ability (by at least half) to perform household work were reported on 6.0 and 6.5 days, respectively. Of the women surveyed, 51% identified menstruation as a trigger for attacks and 6% reported attacks solely with menstruation (i. e. attacks occurred during menstruation on at least 9 out of 10 occasions), the latter associated with a higher pain score than other attacks. Living with or being related to a migraineur decreased nonmigraineurs' ability to participate in home/family life (moderate/great impact 49%) and social/leisure activities (moderate/great impact 47%). In a tradeoff analysis, 60% of treatment choice was driven by formulation type and 40% was driven by speed of onset. As migraine disability increased, speed of onset became more important., Conclusions: This study confirms the significant burden of migraine on patients and families/cohabitants, highlighting not only reduced productivity and absences from work/school, but also time missed from family/social occasions. Many women identify menstruation to be associated with more painful attacks. Overall, in terms of treatment choice, formulation type was a more important driver than speed of onset; however, as migrainerelated disability escalates, speed of onset becomes more important. To optimise migraine management, treatment choice should be based on individual patients' needs and preferences.