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Objectives: This study investigated to identify the clinical significance of allodynia compared with other sensory hypersensitivities (SH) in migraine patients., Methods: New patients with migraine were recruited from a headache clinic, and we collected data regarding their clinical characteristics and identified SH including photophobia, phonophobia, osmophobia, and allodynia. The patients completed the 12-item Allodynia Symptom Checklist, Migraine Disability Assessment Scale (MIDAS), Headache Impact Test-6 (HIT-6), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Insomnia Severity Index (ISI), Fatigue Severity Scale (FSS), and Migraine-Specific Quality of Life Questionnaire Version 2.1. We divided the patients into three groups: SH with allodynia (group 1), SH without allodynia (group 2), and no SH (group 3). Clinical characteristics, psychosomatic features, and quality of life (QOL) were compared among these groups., Results: A total of 312 migraine patients participated in the study. Among them, 58 (18.6%), 202 (64.7%), and 52 (16.7%) were allocated to groups 1, 2, and 3, respectively. Chronic migraine, family history of migraine, medication overuse headache, earlier age at onset, longer disease duration, higher headache intensity, and aggravation with physical activity were more prevalent in group 1 than in groups 2 or 3. Scores of the MIDAS, HIT-6, PHQ-9, GAD-7, ISI, and FSS were the highest in group 1, followed by groups 2 and group 3. The lowest QOL was noted in group 1, followed by groups 2 and group 3., Conclusions: This study revealed that SH in migraine, particularly combined with allodynia, may result in poor clinical outcomes.

Objective: The current study aimed to describe the impact of parental migraine on adolescent children (aged 11-17) living at home with a parent with migraine., Background: Emerging evidence suggests that migraine impacts the family members of people with migraine. However, there has been little research to evaluate the perspective of the child of a parent with migraine., Methods: This cross-sectional observational study included parents who met International Classification of Headache Disorders criteria for migraine and their 11-17-year-old children currently living with the parent with migraine recruited from neurologist offices and online. Parents completed measures of demographics, a diagnostic migraine criteria screener, parental illness impact (Parental Illness Impact Survey - Revised; subscales = Burden of Daily Help, Emotional Impact, Social Impact, Communication and Understanding, Impact on Personal Future, Friends Reactions, Parent/Child Relationship, and Global Well-Being), migraine-related disability (MIDAS), headache attack frequency, and headache attack pain intensity. Children completed measures of demographics, parental illness impact, and a migraine diagnostic screener if applicable., Results: Children (n = 40) reported the greatest impact of their parent's migraine on the Global Well-Being (M = 3.3, SD = 0.9) and Parent/Child Relationship (M = 3.5, SD = 0.6) subscales. There were no significant differences between the average child and parent rating of parental migraine impact on children. Correlations between parent and child ratings of parental migraine impact were strongest for the Social Impact subscale (ρ = 0.55, P < .001), and non-significant for the Parent/Child Relationship (ρ = 0.13, P = .416) and Friends Reactions (ρ = 0.18, P = .257) subscales. Higher attack frequency and endorsing severe disability on the MIDAS were associated with higher child-rated impact (eg, lower scores) on Global Well-Being (frequency ρ = -0.35, P = .028; MIDAS t(38) = 2.74, P = .009) and Impact on Personal Future (frequency ρ = -0.41, P = .009; MIDAS t(35.7) = 2.49, P = .017) subscales. Higher attack pain intensity was associated with higher child-rated impact (eg, lower scores) on Burden of Daily Help (r = -0.34, P = .031) and Emotional Impact (r = -0.40, P = .010). Over half of children (23/40, 57.5%) reported some kind of service or intervention to help them manage the impact of their parent's migraine on their lives would be helpful., Conclusions: Parental migraine impacts children aged 11-17 living in the home, particularly in the domains of global well-being and the parent/child relationship. Parent and child reports are not strongly correlated across all domains of parental impact., (© 2018 American Headache Society.)

Objective: This study was conducted to investigate sex differences in the prevalence and clinical presentation of migraine and probable migraine in a general population-based sample., Background: While there is research on sex differences in clinical characteristics and their impact on migraine headache, only few studies have investigated sex differences in probable migraine in population-based settings. Moreover, compared with Western countries, the prevalence of probable migraine in Asia is relatively high. This cross-sectional study was designed to investigate sex differences in the prevalence and clinical presentation of migraine and probable migraine in a general population-based sample., Methods: We used the data of the Korean Headache-Sleep Study, which is a nationwide survey on headache and sleep., Results: We interviewed 7430 people, and 3114 of them agreed to participate in our study (rejection rate, 58.1%). Among these people, 419 withdrew their participation during the interview. Ultimately, 2695 people completed our survey (cooperation rate, 36.3%). The prevalence of overall migraine and probable migraine was 350/1350 (25.9%) for women and 172/1345 (12.8%) for men (P < .001, respectively). The prevalence of migraine (107/1350 [7.9%] vs 36/1345 [2.7%], P < .001) and probable migraine (243/1350 [18.0%] vs 136/1345 [10.1%], P < .001) was significantly higher among women than among men. Headache frequency per month (median [interquartile range]) (1.0 [0.3-3.0] vs 0.8 [0.3-2.0], P = .037), the visual analog scale score for headache intensity (5.0 [4.0-7.0] vs 5.0 [3.0-6.0], P = .019), and the impact of headache {Headache Impact Test-6 score (47.0 [42.0-54.0] vs 44.0 [42.0-51.8], P = .013)} were significantly higher among women with probable migraine than men. Headache frequency per month (2.0 [0.4-4.0] vs 1.0 [0.3-2.0], P = .073), headache intensity (6.0 [5.0-8.0] vs 6.0 [4.2-7.0], P = .281), and the impact of headache (55.0 [48.0-61.0] vs 49.0 [46.3-60.8], P = .225) were not significantly different between women and men with migraine. Other comorbidities or associated symptoms, such as anxiety and depression, were not significantly different between women and men with migraine and probable migraine, except for nausea in probable migraine., Conclusion: Women experience more severe symptoms and a higher impact of headache than men among participants with probable migraine. Our findings suggest that women with PM need a more intensive evaluation and treatment than men with PM., (© 2019 American Headache Society.)

Animal models have provided a growing body of information about the pathophysiology of headaches and novel therapeutic targets. In recent years, experiments in awake animals have gained attention as more relevant headache models. Pain can be assessed in animals using behavioral alterations, which includes sensory-discriminative, affective-emotional and cognitive aspects. Spontaneous behavioral alterations such as increased grooming, freezing, eye blinking, wet dog shake and head shake and decreased locomotion, rearing, food or water consumption observed during pain episodes are oftentimes easy to translate into clinical outcomes, but are giving little information about the localization and modality of the pain. Evoked pain response such as tactile and thermal hypersensitivity measures are less translatable but gives more insight into mechanisms of action. Mechanical allodynia is usually assessed with von Frey monofilaments and dynamic aesthesiometer, and thermal allodynia can be evaluated with acetone evaporation test and Hargreaves' test in animal models. Anxiety and depression are the most frequent comorbid diseases in headache disorders. Anxiety-like behaviors are evaluated with the open-field, elevated plus-maze or light/dark box tests. Interpretation of the latter test is challenging in migraine models, as presence of photophobia or photosensitivity can also be measured in light/dark boxes. Depressive behavior is assessed with the forced-swim or tail suspension tests. The majority of headache patients complain of cognitive symptoms and migraine is associated with poor cognitive performance in clinic-based studies. Cluster headache and tension type headache patients also exhibit a reversible cognitive dysfunction during the headache attacks. However, only a limited number of animal studies have investigated cognitive aspects of headache disorders, which remains a relatively unexplored aspect of these pathologies. Thus, the headache field has an excellent and growing selection of model systems that are likely to yield exciting advances in the future.

Purpose of Review: In other disease states, adherence to behavioral therapies has gained attention, with a greater amount of studies discussing, defining, and optimizing adherence. For example, a meta-analysis formally discussed adherence in 25 studies of CBT for 11 different disorders, with only 6 of the 25 omitting addressing or defining adherence. Many studies have discussed the use of text messages, graph-based adherence rates, and email/telephone reminders to improve adherence. This paper examined the available literature regarding adherence to behavioral therapy for migraine as well as adherence to similar therapies in other disease states. The goal of this research is to apply lessons learned from adherence to behavioral therapy for other diseases in better understanding how we can improve adherence to behavioral therapy for migraine., Recent Findings: Treatment for migraine typically includes both pharmacologic and non-pharmacologic therapies, including progressive muscle relaxation (PMR), cognitive behavioral therapy (CBT), and biofeedback. Behavioral therapies have been shown to significantly reduce headache frequency and intensity, but high attrition rates and suboptimal adherence can undermine their efficacy. Traditionally, adherence to behavioral therapy has been defined by self-report, including paper headache diaries and assignments. In person attendance has also been employed as a method of defining and monitoring adherence. With the advent of personal electronics, measurements of adherence have shifted to include electronic-based methods such as computer-based programs and mobile-based therapies. Furthermore, some studies have taken advantage of electronic methods such as email reminders, push notifications, and other mobile-based reminders to optimize adherence. The JITA-I, a novel method of engaging individual patient adherence, has also been suggested as a possible method to improve adherence by tailoring engagement with a mobile health app-based on patient input. These novel methods may be utilized in behavioral therapy for migraine for further optimizing adherence. Few intervention studies to date have addressed the optimal ways to impact adherence to migraine behavioral therapy. Further research is required regarding adherence with behavioral therapies, specifically via mobile health interventions to better understand how to define and improve adherence via this novel forum. Once we are able to understand optimal methods of tracking adherence, we will be better equipped to understand the role of adherence in shaping outcomes for behavioral therapy in migraine.

Background: The role of avoidance and endurance behaviour is well established in chronic musculoskeletal pain, but less is known about its significance in migraine., Methods: The Avoidance-Endurance Questionnaire behavioural subscales, the Pain Disability Index (PDI), the Migraine Disability Assessment Scale (MIDAS) and the Hospital Anxiety and Depression Scale (HADS) were obtained from 128 migraine patients (90 episodic, 38 chronic). Sixty nine of them were re-evaluated after 3-6 months., Results: At baseline, there were positive relations between avoidance (especially social avoidance behaviour) and pain-related disability as assessed by the PDI (Wald χ 2 [1] = 32.301, p < 0.001) and the MIDAS (Wald χ 2 [1] = 14.387, p < 0.001). A negative relation of endurance behaviour with PDI scores did not survive multiple regression analysis. In addition, there was a positive relation of social avoidance with the HADS depression score (Wald χ 2 [1] = 3.938, p = 0.047) and a negative relation of endurance (especially the humour-distraction subscale) with the HADS anxiety score (Wald χ 2 [1] = 6.163, p = 0.013). Neither avoidance nor endurance were related to headache intensity or frequency, or to a diagnosis of episodic vs. chronic migraine. 3-6 months after treatment at our headache centre, headache frequency, intensity and pain-related disability were significantly improved (all p < 0.01) while avoidance and endurance were unchanged., Conclusions: This indicates that improvement in headache frequency and disability can be achieved in the absence of changes in avoidance or endurance behaviour. However, because of its significant link to headache-related disability, avoidance behaviour (especially social avoidance) should be investigated as a potential additional target of migraine therapy.

This article gives an overview of migraine in children. It outlines the epidemiology of the condition and describes presentation with headache and other symptoms and linked conditions. It aims to raise awareness of the diagnosis of migraine and its impact on children and young people, their families and school life. The author also describes methods of diagnosis and management, and the importance of recognising and of avoiding medication overuse., Competing Interests: None declared, (©2019 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

Objective: High affective reactivity to pain (i.e., increased negative affect in response to pain) can have an adverse impact on the well-being of individuals with chronic pain. The present study examined the role of momentary and average positive affect and trait mindfulness in protecting against affective reactivity to chronic migraine-related pain., Methods: The sample included 61 adults with chronic migraine. Following the experience sampling method, participants completed smartphone-based assessments of momentary pain intensity (PI), positive affect (PA), and negative affect (NA) at nine random moments a day for 7 consecutive days. The Five-Facet Mindfulness Questionnaire was used to assess two dimensions of mindfulness: nonjudging and nonreactivity., Results: Momentary PA inversely predicted the strength of the concurrent but not the time-lagged associations between PI and NA. Average PA predicted neither the strength of the concurrent nor the time-lagged associations between PI and NA. Furthermore, the concurrent associations between PI and NA were weaker in individuals who reported higher "nonjudging" while "nonreactivity" did not significantly moderate these associations., Conclusions: Results provide partial support for the dynamic model of affect in the context of chronic migraine. State PA seems to play a larger role in momentary affective reactivity to chronic migraine-related pain than trait PA. Results also suggest that the ability to take a nonjudgmental stance toward negative experiences may lower momentary affective reactivity to pain. These factors seem promising targets for interventions aimed at improving the well-being of individuals with chronic migraine. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Background and Objectives: Migraine headache is the seventh leading cause of disability worldwide causing adverse outcomes in many aspects of an individual's life. Many psychological aspects affect chronic migraine (CM): illness perception, anxiety, depressive symptoms, and job satisfaction. This observational study aimed to examine the association among illness perception, anxiety, depressive symptoms, and job satisfaction, connected to migraine and its features., Methods: Ninety-eight individuals with CM treated with OnabotulinumtoxinA were recruited from the Regional Referral Headache Centre of Sant'Andrea Hospital in Rome. They completed 4 questionnaires (Brief Illness Perception Quality of Life, Enjoyment and Satisfaction Questionnaire, State-Trait Anxiety Inventory, Beck Depression Inventory-II) and a socio-anamnestic form., Results: This cross-sectional study examined 2 mediational models. The first one demonstrated an indirect mediating effect of trait anxiety on the association between illness perception and job satisfaction (ab = -0.217, 95% CI [-0.37, -0.09]). In the second model, depressive symptoms mediated the association between illness perception and job satisfaction (ab = -0.186, 95% CI [-0.33, -0.04])., Conclusions: In our study, levels of anxiety and depressive symptoms showed a mediational effect on the association between illness perception and job fulfillment. It is important to develop interventions aimed at improving the quality of life of individuals with CM and to increase knowledge about headache and psychological consequences., (© 2018 American Headache Society.)

Objective:: To evaluate the change in quality of life (QOL) of patients with Meniere's disease (MD) after treatment with migraine prophylaxis therapy., Methods:: Patients with definite MD were given the Meniere's Disease Outcomes Questionnaire-Retrospective (MDOQ-R) after migraine prophylactic therapy to assess QOL. Changes in physical, emotional, and social parameters affected by MD were calculated, along with a global pre- and posttreatment QOL scores., Results:: The MDOQ-R was given to 27 consecutive patients with definite MD. Patients who had at least an 18-month follow-up were included, resulting in 25 questionnaires. The mean change in QOL score was 25 ± 16 (range, -3 to 55), P = .02. Quality of life was improved in 23 (92%) of the respondents in every metric measured, unchanged in 1 (4%), and poorer in 1 (4%) of patients after migraine prophylaxis treatment., Conclusions:: Majority of MD patients who had all failed diuretic therapy responded positively to medications used for migraine prophylaxis, as indicated by a significant improvement in QOL. This study may further suggest a correlation between the pathophysiologic basis of disease in MD and vestibular migraine. Patients with MD may be successfully managed with medications intended to treat migraine.

Background and Aim: Factors implicated in the evolution of episodic migraine into chronic migraine are largely elusive. Medication overuse is considered to be one of the main determinants, but other possible clinical and psychological factors can play a role. The aim of this study is to identify factors that are associated with chronic migraine with medication overuse., Method: We enrolled consecutive migraine patients, subdividing them in two groups: Subjects with a long history of episodic migraine and subjects with chronic migraine and medication overuse. We then compared their clinical and psychological variables in a cross-sectional study., Results: Three hundred and eighteen patients were enrolled, of which 156 were episodic migraine and 162 were chronic migraine and medication overuse patients. The mean age was 42.1 ± 10.3, 80.8% were female. The duration of migraine was 24.6 years in episodic migraine and 24.0 years in chronic migraine and medication overuse ( p = 0.57). After the multivariate analysis, the factors associated to chronic migraine and medication overuse were: Marital status (married vs. unmarried, OR 3.65, 95% CI 1.63-8.19, p = 0.002; separated/divorced/widowed vs. unmarried, OR 4.19, 95% CI 1.13-15.47, p = 0.031), physical activity (OR 0.42, 95% CI 0.19-0.91, p = 0.029), age at onset of migraine (OR 0.94, 95% CI 0.89-0.98, p = 0.016), use of at least one migraine preventive medication (OR 2.36, 95% CI 1.18-4.71, p = 0.014), history of depression (OR 2.91, 95% CI 1.25-6.73, p = 0.012), insomnia associated with the use of hypnotics (OR 5.59, 95% CI 1.65-18.93, p = 0.006), traumatic head injuries (OR 3.54, 95% CI 1.57-7.99, p = 0.002), snoring (OR 2.24, 95% CI 1.05-4.79, p = 0.036), previous and/or actual use of combined oral contraceptives (OR 3.38, 95% CI 1.10-10.3, p = 0.031) and higher scores in the Childhood Trauma questionnaire (OR 1.48, 95% CI 1.09-2.02, p = 0.012)., Conclusion: We considered several aspects that may be involved in the development of chronic migraine and medication overuse. A multivariate analysis identified 10 factors belonging to five different areas, to suggest that chronic migraine and medication overuse onset is likely influenced by a complex mixture of factors. This information is useful when planning strategies to prevent and manage chronic migraine and medication overuse.

Objective: To assess the prevalence of falls and fear of falling in patients with migraine compared with controls., Design: Cross-sectional., Setting: Tertiary headache clinic., Participants: This study consisted of 105 controls and 105 consecutive patients diagnosed with migraine with aura (MA, n=35), migraine without aura (MO, n=35) and chronic migraine (CM, n=35)., Main Outcome Measures: Patients were interviewed using a questionnaire containing questions about the history of falls and impairment in balance, and completed the International Falls Efficacy Scale (FES-I). Groups were contrasted using Student's t-test and analysis of variance, and prevalence ratios were estimated., Results: Falls and self-reported impairment in balance are more prevalent in patients with migraine (54% and 69%, respectively) than in controls (2% and 2%, respectively). In particular, patients with CM and MA reported a greater mean number of falls during the previous year {CM 1.4 [standard deviation (SD) 2.2]; MA 2.2 (SD 2.3)} compared with patients with MO [0.5 (SD 1.0); P <0.04] and controls [0.05 (SD 0.2); P <0.002]. The prevalence ratio of falls was greater in patients with MA (7.2; P <0.002) and CM (4.5; P <0.002) compared with controls. Patients with migraine experienced a high level of concern about falls during their daily activities compared with controls (29.8 vs 20.1 points in the FES-I questionnaire; P<0.0001)., Conclusions: The balance impairment of patients with migraine may have a functional impact. Migraine is associated with risk of falling, and patients exhibit a higher prevalence of impairment in balance, falls and fear of falling., (Copyright © 2018 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.)

Studies in interictal migraine show either normal or impaired pain modulation, at the psychophysical level. To date, pain modulation in migraineurs has yet to be explored concurrent with imaging methods. We aimed to investigate brain activity associated with endogenous analgesia by functional magnetic resonance imaging in attack-free migraineurs. Thirty-nine episodic migraineurs and 35 controls participated. Endogenous analgesia efficiency was assessed by the conditioned pain modulation (CPM) paradigm during functional magnetic resonance imaging. Conditioned pain modulation included 4 stimulation sequences of either test stimulus (noxious contact heat at forearm) given stand alone (Ts&#95;alone) or concomitant to contralateral foot immersion in cold water (Ts&#95;conditioned). The psychophysical CPM (Ts&#95;conditioned minus Ts&#95;alone; 0-10 numerical rating scale) and related brain activity were examined. No group differences were found in the psychophysical CPM (controls: -0.52 ± 0.80; migraineurs: -0.20 ± 0.88; repeated-measures analysis of variance: P = 0.110) or related brain activity (family wise error [P < 0.05] correction at the voxel level). Within groups, controls showed a significant CPM effect (Ts&#95;alone: 6.15 ± 2.03 vs Ts&#95;conditioned: 5.63 ± 1.97; P < 0.001), whereas migraineurs did not (Ts&#95;alone: 5.60 ± 1.92 vs Ts&#95;conditioned: 5.39 ± 2.30; P = 0.153); yet, both groups showed significant CPM-related decreased deactivation in prefrontal areas including the superior frontal gyrus and parietal regions including precuneus. The change in brain activity seems related to task demands rather than to pain reduction. The lack of group difference between migraineurs and controls in CPM and its related brain activity may result from (1) the specific CPM methodology used in this study, since migraineurs are reported to show various pain modulation efficiency for different test paradigms and/or (2) pathophysiological diversity of patients with migraine.

Cognitive dysfunction has recently gained attention as a significant problem among migraine sufferers. All of the clinical studies show poor cognitive performance during migraine attacks, though, the interictal data are conflicting. Migraineurs show impaired cognitive function interictally in most of the clinic-based studies. Population-based studies did not reveal a difference in cognitive functions between migraineurs and controls. The specific cognitive domains involved are information processing speed, basic attention, executive functions, verbal and non-verbal memory and verbal skills. Neurophysiological, imaging and pharmacological studies support clinical symptoms of cognitive impairment in migraine. Longitudinal studies do not suggest progressive cognitive decline over time in migraine patients. Preventive medications and comorbid disorders such as depression and anxiety can impact cognitive function, but cannot fully explain the cognitive impairment in migraine. In contrast to migraine, tension type or cluster headache are not associated with cognitive impairment, at least during headache-free periods.

Objective: To determine if migraine patients with high achievement motivation have an increased use of acute headache medication., Background: It has been hypothesized that high achievement-motivated migraine patients have an increased use of acute headache medication to be able to perform at work and during daily life, putting them at risk for medication overuse headache (MOH)., Methods: The Achievement Motivation Inventory and use of acute headache medication were assessed in 117 migraine patients (60 episodic, 57 chronic) at their first appointment at our tertiary headache center., Results: Patients with low vs high achievement motivation were not significantly different in acute headache medication days per month (10.8 ± 6.9 vs 10.9 ± 7.8, P = .98), in acute headache medication use in the absence of headache (to prevent occurrence of headache later that day: 51.8% vs 48.2%, P = .38), in having a diagnosis of MOH (37.9 vs 23.7%, P = .12), or in reduction of acute headache medication days at 3 and 6 months follow-up (both P > .20)., Conclusions: High achievement motivation in migraine patients was not associated with increased acute headache medication use or more frequent diagnosis of MOH., (© 2018 American Headache Society.)

Objective: To evaluate factors associated naturalistically with adherence to a mobile headache diary., Background: Self-monitoring (keeping a headache diary) is commonly used in headache to enhance diagnostic accuracy and evaluate the effectiveness of headache therapies. Mobile applications are increasingly used to facilitate keeping a headache diary. Little is known about the factors associated with adherence to mobile headache diaries., Methods: In this naturalistic longitudinal cohort study, people with headache (n = 1561) registered to use Curelator Headache® (now called N1-Headache®), an application that includes a mobile headache diary, through their physician (coupon), or directly through the website or app store using either a paid or free version of the application. Participants completed baseline questionnaires and were asked to complete daily recordings of headache symptoms and other factors for at least 90 days. Baseline questionnaires included headache characteristics and migraine disability. Daily recordings included headache symptoms and anxiety ratings. Adherence to keeping the headache diary was conceptualized as completion (kept the headache diary for 90 days), adherence rate (proportion of diary days completed 90 days after registration), and completion delay (the number of days past 90 days after registration required to complete 90 days of headache diary)., Results: The majority of participants reported migraine as the most common headache type (90.0%), and reported an average of 30.8 headache days/90 days (SD = 24.2). One-third of participants completed 90 days of headache diary (32.4%). Endorsing higher daily anxiety scores (8/10 OR = 0.97 [95% CI = 0.96, 0.99]; 10/10 OR = 0.96 [95% CI = 0.91, 0.99]) was associated with lower odds of completion, whereas higher age (OR = 1.04 [95% CI = 1.03, 1.05]), and downloading the app paid vs free (OR = 4.27 [95% CI = 2.62, 7.06]), paid vs coupon (OR = 2.43, 95% CI = 1.41, 4.26]), or through a physician coupon vs free (OR = 1.75 [95% CI = 1.27, 2.42]) were associated with higher odds of completion. The median adherence rate at 90 days was 0.34 (IQR = 0.10-0.88), indicating that half of participants kept 34 or fewer days 90 diary days after registration. Endorsing high daily anxiety scores (5/10 OR = 0.98 [95% CI = 0.97, 1.00]; 8/10 OR = 0.96 [95% CI = 0.94, 0.98]; 10/10 OR = 0.96 [9% CI = 0.92, 0.98]) and higher age (OR = 1.05 [95% CI = 1.04, 1.07]) were associated with lower odds of adhering at 90 days, whereas downloading the app paid vs free (OR = 9.63 [95% CI = 4.61, 25.51]), paid vs coupon (OR = 2.39, 95% CI = 1.27, 5.10]), or through a physician coupon vs free (OR = 4.01 [95% CI = 2.54, 7.26]) were associated with higher odds of adhering at 90 days. Among completers, the median completion delay was 6.0 days (IQR = 2.0-15.0). Among completers, endorsing high daily anxiety scores (9/10 OR = 1/06 [95% CI = 1.01, 1.12]) and younger age (OR = 0.98 [95% CI = 0.97, 1.00]) was associated with completion delay; downloading the app through physician coupon vs free (OR = 0.40 [95% CI = 0.22, 0.71]) or paid vs free (OR = 0.38 [95% CI = 0.20, 0.72]) was associated with lower odds of completing 90 diary days in 90 calendar days., Conclusion: This naturalistic observational study confirmed evidence from clinical observation and research: adherence to mobile headache diaries is a challenge for a significant proportion of people with headache. Endorsing higher levels of daily anxiety, younger age, and downloading the app for free (vs either paying for the self-monitoring app or receiving a physician referral coupon) were associated with poorer adherence to keeping a mobile headache diary., (© 2018 American Headache Society.)

Background and Purpose: Migraine headache is an enormous health care burden resulting in billions of dollars in workforce revenue lost and millions of lost workdays per year. Migraine headaches and depression are common comorbidities and require expertise in treatment and prevention., Methods: The aim of this article is to update the nurse practitioner (NP) on best clinical practices for managing the patient with migraine and previously diagnosed depression. This will include an overview of the pathophysiology of migraine, as well as criteria for diagnosis, treatment, prevention, and patient teaching., Conclusions: Migraine and depression are commonly linked and require expertise in treatment to achieve the best patient outcomes., Implications for Practice: Patients with migraine are more likely to have depression than the general population. Both conditions require optimal treatment and patient education to reduce overall disease burden. A better understanding of the relationship between depression and migraine will enable the NP to better manage patients with migraine and comorbid depression.

Objective: The objective of this study was to develop a method for evaluating patient-relevant outcomes of interventions for preventing migraine attacks, followed by an assessment of the content validity of a new patient-reported outcome (PRO) instrument: the Migraine Functional Impact Questionnaire (MFIQ)., Background: The aim of preventive treatments for migraine is not only to reduce migraine frequency, but also to restore patients' ability to function and improve quality of life., Methods: A multi-stage process based on best practice methods and regulatory guidelines for ensuring content validity of PRO instruments for evaluating treatment benefit was followed. Qualitative concept elicitation interviews conducted to understand the experiences of adults with migraine underpinned the development of the instrument. The initial stage included the development of a conceptual disease model (CDM) based on information from these interviews. This CDM was used to identify the concepts of interests (COI) to evaluate outcomes of preventive treatments. The results of the interviews were also used in stage 2, to develop a measurement framework for collecting data about these COI. In the third stage, existing instruments were reviewed for coverage of the concepts in the framework and evidence of concept elicitation to the point of saturation, to support content validity. In the fourth stage, an instrument was drafted to evaluate concepts in the framework, based on the qualitative data collected from the interviews. Following a review by clinical and translation experts, the new instrument was tested in adults with migraine in the fifth stage using 2 rounds of cognitive interviews, and was modified based on interview feedback. In the last stage, the instrument was linguistically adapted, using methods recommended for PRO instruments, to ensure conceptual equivalence of language versions for use in international studies. Each language version was tested in at least 5 native speakers using cognitive interviews., Results: Results from the concept elicitation interviews suggested that migraine had an impact on various aspects of functioning. A conceptual framework for evaluating functional outcomes was developed for the concept selected based on a review of the CDM - physical and emotional functioning, every day activities, and social/leisure activities. Existing PROs lacked coverage of some concepts in the conceptual framework, had recall periods that were inappropriate for capturing the experience of COI or did not have evidence of content validity. A novel PRO instrument, the MFIQ, was developed to address these gaps. Cognitive interviews with 9 adults with migraine resulted in minor changes to the items of the MFIQ, and a final round of 8 interviews confirmed the changes were acceptable and supported its validity. The interviews conducted to test linguistic adaptations confirmed conceptual equivalence in the 25 countries evaluated., Conclusions: Development of the MFIQ followed best measurement practices to ensure content validity and followed regulatory guidelines for PRO instruments to evaluate benefits of treatments. The MFIQ was developed for use in clinical trials or clinical practice settings to track outcomes of preventive treatments that are most relevant to adults with migraine., (© 2018 The Authors Headache: The Journal of Head and Face Pain published by Wiley Periodicals, Inc. on behalf of American Headache Society.)

Background: Many children suffering from chronic headache and migraine present with comorbid functional disability, including physical, social, emotional, and academic activities. For children severely impaired by headache, intensive interdisciplinary pain rehabilitation treatment (IIPT) can improve functioning. However, there are limited data evaluating children's response to rehabilitation across several time points., Objective: This study aims to evaluate the trajectory of recovery for children undergoing IIPT for chronic headache, as well as to examine the proposed assumption that physical and psychosocial functioning improves prior to a reported reduction in pain., Methods: A retrospective analysis of patient-reported outcomes in a clinical database of 135 children admitted to an IIPT program between the years 2008 and 2014 was analyzed. Available data across 5 separate time points (up to 1-year post-discharge) were reviewed., Results: One hundred and thirty-five children of mean age 15.2 (SD = 2.2) and 74% female provided data for review. Linear mixed model demonstrated a statistically significant improvement in pain-specific measures of functioning, including daily functioning (change estimate = -14.53) emotional functioning (change estimate = -14.63), family functioning (change estimate = -5.78), and school absences (change estimate = -11.47) over a 12-month period (all P's ≤ .01). A more general measure of quality of life improved during the program, based upon child (change estimate = +10.07) and parent report (change estimate = +15.31); although these gains did not continue to improve post-discharge. As expected, although children did not report a reduction in pain during rehabilitation (change estimate = +0.07), they did report a significant drop in perceived pain in the 12 months following discharge from the program (change estimate = -2.12, P ≤ .01)., Conclusions: Children with chronic headache and migraine who are severely functionally impaired demonstrated linear improvement in pain-specific patient-reported outcomes over time; however, there remains a need for improved methodology in analyzing response to IIPT programs., (© 2018 American Headache Society.)

Background: Chronic migraine is a chronic medical condition associated with resistance to pharmacological treatment and poor benefits from the psychological interventions studied to date, including acceptance and commitment therapy or mindfulness. This manuscript describes the rationale and methods for a pilot feasibility study designed to (1) establish and (2) evaluate the feasibility and acceptability of research procedures and interventions to investigate whether well-being therapy improves outcomes relative to a control condition., Methods: The current intervention will use a randomized controlled trial design, wherein 30 outpatients with chronic migraine will be randomized (1:1) to well-being therapy (n = 15) or to a control condition (n = 15). Primary outcomes include the level of disability caused by migraine and the frequency, duration, and intensity of migraine attacks; the secondary outcomes focus on anxiety, depression, psychological well-being, euthymia, and distress. Primary and secondary outcomes will be assessed at baseline, after sessions 4 and 8, and at 3-month follow-up. The Ethical Review Boards at the University-Hospital Careggi has approved the study (5th December 2017)., Discussion: Identifying medium-term interventions able to improve chronic migraine is relevant to manage this illness. The present randomized trial might represent a step forward for managing chronic migraine by means of psychological interventions., Trial Registration: ClinicalTrial.gov Identifier: NCT03404336 . Registered on 19 January 2018.

Background: Systemic autonomic changes are well known in migraineurs. Also, masticatory disorders are reported to be associated with migraine. However, if those phenomena are interrelated, and how, is unclear. Moreover, the knowledge on the autonomic responses to masticatory stimuli in migraineurs is limited., Objective: To investigate tooth clenching-related cardiac autonomic regulation in migraineurs., Methods: We compared maximal tooth clenching-induced systemic autonomic responses, indicated by heart rate variability and blood pressure changes, in headache-free migraineurs (n = 17) and control subjects (n = 22)., Results: Levels of high-frequency power, reflecting vagal activity, were lower in migraineurs at baseline but increased after tooth clenching whereas in controls they returned to baseline (P < 0.05, mixed model analysis). In multivariate regression model, the presence of migraine predicted the baseline levels of low- and high-frequency power and sympathovagal balance, and the post-test increase in high-frequency power, with the attack frequency and side of headache as the modifiers of the measured changes in migraineurs. The painful signs of temporomandibular disorders, found in clinical oral examination, enhanced both maximal changes in RR intervals and post-test vagal responses to tooth clenching only in migraineurs., Conclusion: The enhanced post-clenching vagal activation may represent a marker of the augmented trigeminocardiac reflex to stimulation of trigeminal area, sensitised in migraineurs. Our results support an involvement of autonomic mechanisms in migraine pathophysiology and are interesting in terms of interactions between migraine and masticatory disorders, elucidating one potential way how masticatory disorders may aggravate migraine., (© 2018 John Wiley & Sons Ltd.)

Background: It is common clinical experience that, after structured withdrawal, some patients with chronic migraine and medication overuse headache (CM with MOH) are more prone than others to relapse and to be in need of further structured treatments. Our aim was to explore similarities and differences between frequent relapsers (FRs) and non-frequent relapsers (NFRs) by considering their point of view, perceptions, and perspective of their subjective experience with relapse into CM with MOH., Methods: Patients were consecutively recruited on occasion of a structured withdrawal treatment and were interviewed individually about their headache experience and their perspectives on relapse into CM with MOH. We considered FR those patients requiring 2 or more structured withdrawals for MOH within 3 years. A narrative approach with no preconceived coding schemes was employed. To facilitate coding, categorization and organization of data the software QRS NVivo 11.0 was used: themes were defined as common to FR and NFR, or peculiar (by frequency or content) to one of the 2 groups., Results: Sixteen patients (13 women; mean age of 53) were interviewed: 7 were classified as FRs. A total of 22 themes emerged from 552 single quotations (the 10 most relevant covered 82% of the entire body of quotations). Four themes were commonly reported by both FR and NFR patients, and 6 were peculiar to one group only. Common aspects included issues connected to the dilemma between disclosing, concealing and the feelings of isolation around MOH, the idea of being addicted to medication, presence of anxiety, and the attempt to use non-pharmacological therapies as an alternative to medication. Peculiar aspects included causal attribution (FRs attributed headache to uncontrollable factors); future expectations at the time point of withdrawal (FRs were generally resigned); high-performance functioning (FRs believed they are "forced" to reach high levels of performance as a consequence of others' inability); coping strategies (FRs tended to "passively accept" problems and showed avoidance-related behaviors). Moreover, FRs were less frequently aware of their problems and described more frequently depressive symptoms., Conclusions: Our results highlight that some differences between FR and NFR patients with CM and MOH exist. Frequent relapsers among patients with CM and MOH reported some important peculiarities of the lived experience of having chronic migraine; clinicians should recognize these psychosocial aspects such as social relationships, future expectations, the experience of illness, medication management, and how the withdrawal experience is regarded, as they may be associated with frequent relapse into MOH., (© 2018 American Headache Society.)

Background: The degree to which work-related difficulties are recognized in headache research is poor and often carried out with inadequate information such as "reduced ability to work as usual", which do not capture at all the variety of difficulties and the factors that impact over them. The aim of this paper is to present the validation of the HEADWORK questionnaire, which addresses the amount and severity of difficulties in work-related tasks and the factors that impact over them., Methods: We developed a set of items based on a previous literature review and patients' focus groups and tested it on a wide set of patients with episodic and chronic migraine attending eight different Italian headache centers. HEADWORK factor structure was assessed with exploratory and confirmatory factor analysis; internal consistency and construct validity were addressed as well., Results: The validation sample (N = 373) was mostly composed of patients with episodic migraine without aura (64.3%) and of females (81%). Factor analysis retrieved two different scales: "Work-related difficulties", composed of eleven items which explain 67.1% of the total variance, and "Factors contributing to work difficulties", composed of six items which explain 52.1% of the total variance. Both HEADWORK subscales have good measurement properties, with higher scores being associated to higher disability, lower quality of life, lower productivity, higher headache frequency and pain intensity., Conclusions: HEADWORK is a 17-item, two-scale questionnaire addressing the impact of migraine on work-related difficulties in terms of difficulties in general or specific skills, and the factors contributing to these difficulties, defined as negative impact on work tasks. It can be used to address disability weights for the purpose of calculating the burden of migraine, and to assess the balance between therapeutic and side effects of medication on productivity.

Background: Migraine is a distinct neurological disease that imposes a significant burden on patients, society, and the healthcare system. This study aimed to characterize the incremental burden of migraine in individuals who suffer from ≥4 monthly headache days (MHDs) by examining health-related quality of life (HRQoL), impairments to work productivity and daily activities, and healthcare resource utilization (HRU) in the EU5 (France, Germany, Italy, Spain, United Kingdom)., Methods: This retrospective cross-sectional study used data from the 2016 National Health and Wellness Survey (NHWS; N = 80,600). Short-Form 36-Item Health Survey, version 2 (SF-36v2) physical and mental component summary scores (PCS and MCS), Short-form-6D (SF-6D), and EuroQoL (EQ-5D), impairments to work productivity and daily activities (Work Productivity and Activity Impairment Questionnaire (WPAI), and HRU were compared between migraine respondents suffering from ≥4 MHDs (n = 218) and non-migraine controls (n = 218) by propensity score matching using sociodemographic characteristics. Chi-square, T-tests, and Mann-Whitney tests were performed to determine significant differences between the groups after propensity score matching., Results: HRQoL was lower in migraine individuals suffering from ≥4 MHDs compared with non-migraine controls, with reduced SF-36v2 PCS (46.00 vs 50.51) and MCS (37.69 vs 44.82), SF-6D health state utility score (0.62 vs 0.71), and EQ-5D score (0.68 vs 0.81) (for all, p < 0.001). Respondents with migraine suffering from ≥4 MHDs also reported higher levels of absenteeism from work (14.43% vs 9.46%; p = 0.001), presenteeism (35.52% vs 20.97%), overall work impairment (38.70% vs 23.27%), and activity impairment (44.17% vs 27.75%) than non-migraine controls (for all, p < 0.001). Additionally, HRU was significantly higher for individuals with ≥4 MHDs compared to their matched controls. Consistently, migraine subgroups (4-7 MHDs, 8-14 MHDs and CM) had lower HRQoL, greater overall work and activity impairment, and higher HRU compared to non-migraine controls., Conclusions: Migraine of ≥4 MHDs was associated with poorer HRQoL, greater work productivity loss, and higher HRU compared with non-migraine controls. The findings of the study suggest that an unmet need exists among individuals suffering from ≥4 MHDs in the EU5 suggesting the need for effective prophylactic treatments to lessen the humanistic and economic burden of migraine.

Background: Chronic migraine (CM) is associated with severe psychological symptoms and disabilities. Information on the relationship between stress and the outcomes of acute CM treatment is limited., Methods: We evaluated the clinical presentation and stress levels of patients with CM who visited the neurology departments of 14 hospitals between September and December 2015. The patients were divided into stress and reference groups on the basis of the Korean version of the Brief Encounter Psychosocial Instrument (BEPSI-K). Quality of life was evaluated using EuroQol Five Dimension Questionnaire Three-Level. The Migraine Assessment of Current Therapy questionnaire was used to assess the outcomes of acute treatment., Results: This study included 186 CM patients. On the basis of the BEPSI-K score, 79 and 107 patients were assigned to the stress and reference groups, respectively. The stress group had more patients with poor outcomes of acute treatment than the reference group (67.1% vs 40.2%, P < 0.001). In a multivariate analysis, female gender (odds ratio [OR] = 3.266, 95% confidence interval [CI] = 1.172-9.103, P = 0.024), the number of headache-free days per month (OR = 0.932, 95% CI = 0.883-0.985, P = 0.012), and BEPSI-K score (OR = 1.667, 95% CI = 1.051-2.643, P = 0.030) predicted poor outcomes of acute treatment., Conclusions: High levels of stress were reported by 42.5% of patients with CM. The association between stress and the outcomes of acute treatment suggests that stress is an important clinical variable for improving the management of CM.

Objectives: The objective of the present study was to assess the presence of cognitive deficits in patients with chronic migraine, and to assess the main factors that trigger cognitive disorders, such as comorbidities or the use of medications., Methods: Chronic migraine and control groups were interviewed in a case-control study. The frequency and intensity of the headache, medication used and associated comorbidities were determined. All patients were submitted to an extended neuropsychological assessment., Results: The chronic migraine group (n = 30) had a worse performance in the Montreal Cognitive Assessment Test (p = 0.00), Verbal Fluency (p = 0.00), Stroop (p = 0.00), Clock Drawing Test (p = 0.00), Digit Span (p = 0.00) and Matrix Reasoning (p = 0.01). After statistical adjustment by linear regression, migraine continued to be the only relevant factor in the poorer performance in the Montreal Cognitive Assessment, Verbal Fluency, Clock Drawing and Stroop tests., Conclusions: Patients with chronic migraine have cognitive deficits in multiple tasks, regardless of the presence of comorbidities or the use of medications.

Background: A dearth of effective and affordable treatment options has rendered nonpharmacological self-management a crucial part of living with migraine-a debilitating neurobiological condition without cure that disproportionately disables vulnerable women., Objective: The aim of the study was to describe the development and use of a systems thinking, problem-structuring data collection approach that was applied to the study of migraine self-management with women in diverse social locations., Methods: Two systems mapping activities were developed for use in focus groups: one to unpack a migraine episode (system support map) and the other (connection circle [CC]) to construct a mental model of self-management. Later in the process, a strengths-based problem-solving tool was developed to replace the CC., Results: The CCs-often enlightening for affluent participants-left marginalized women feeling overwhelmed and defeated, as a solution to one challenge became the cause of another. Through constant comparison analysis, we recalibrated the approach using a theory, clinical experience, and participant feedback and replaced the CC with a strengths-based problem-solving activity highlighting relationships and trade-offs in a more agential, actionable way., Discussion: Bringing a critical lens and strengths-based approaches to work with vulnerable populations can replace traditional deficit thinking in healthcare, developing options for leveraging resources and understanding complex health behaviors without losing sight of systemic, distributional justice issues. These systems thinking tools can provide a way to extrapolate the complexities of actual self-management behaviors and challenges faced by vulnerable women with migraine versus what they may be instructed to do by a medical model that does not always account for the social and structural determinants of equity and health.

Background: To identify aggression and its association with suicidality in migraine patients., Methods: We enrolled 144 migraine patients who made their first visit to our headache clinic. We collected data regarding their clinical characteristics and the patients completes the Aggression Questionnaire (AQ) and other questionnaires. We also interviewed patients with the Mini International Neuropsychiatric Interview-Plus Version 5.0.0 (MINI) to identify their suicidality. The degree of aggression in migraine patients was compared to the degree of aggression in healthy controls. Major determinants for aggression and its association with suicidality were also examined., Results: The overall AQ score and anger and hostility subscale scores were higher in migraine patients than controls. For migraine chronicity, patients with chronic migraine (CM) had a higher overall AQ score and physical aggression, anger, and hostility subscale scores than controls. On the other hand, all AQ scores in patients with episodic migraine were not different from the scores of the controls. Although several factors were associated with the overall AQ score, major determinants were anxiety (ß = 0.395, p < 0.001), headache intensity (ß = 0.180, p = 0.016), and CM (ß = - 0.165, p = 0.037). Patients who had suicidality based on the MINI showed a higher overall AQ score than patients without suicidality (p < 0.001)., Conclusions: Aggression is likely to be a common feature in CM. Comorbid aggression may help to identify suicidality in migraine patients.

Background: Primary headaches are associated with psychological distress, neuroticism and disability. However, little is known about headache-related disability and psychological distress among people with secondary chronic headaches., Methods: 30,000 persons aged 30-44 from the general population was screened for headache by a questionnaire. The responder rate was 71%. The International Classification of Headache Disorders with supplementary definitions for chronic rhinosinusitis and cervicogenic headache were used. The Hopkins Symptom Checklist-25 assessed high psychological distress, the Migraine Disability Assessment questionnaire assessed disability, and Eysenck Personality Questionnaire assessed neuroticism., Results: Ninety-five of the 113 eligible participants (84%) completed the self-reported questionnaire. A total of 38 people had chronic post-traumatic headache, 21 had cervicogenic headache, and 39 had headache attributed to chronic rhinosinusitis, while 9 had co-occurrence of chronic post-traumatic and cervicogenic headache. Six persons had miscellaneous secondary chronic headaches. Overall, 49% of those with secondary chronic headache reported high psychological distress, which is significantly higher than in the general population. A high level of neuroticism was significantly more common in those with secondary chronic headache than in the general population. Severe headache-related disability was reported by 69%. 92 persons were followed up after 3 years. A low headache frequency was the only significant predictor of improvement of ≥ 25% in headache days. Having post-traumatic or cervicogenic headache and not headache attributed to chronic rhinosinusitis predicted an increased risk &gt; 25% worsening of headache days or having a severe disability at 3 years follow-up., Conclusion: Psychological distress and neuroticism were more common among people with secondary chronic headache than in the general population. Only a high headache frequency was significantly associated with increased headache disability at baseline and a poor prognosis in the long term.

Migraine is a common chronic neurological disease that disproportionately affects women. Migraine has significant negative effects on physical, emotional, and social aspects of health, and can be costly for patients, employers, and society as a whole. Growing evidence supports the roles of sex and gender in migraine risk, pathophysiology, presentation, diagnosis, treatment, and management. However, sex and gender differences in migraine have received limited attention, which can impede advancements in migraine detection, treatment, care, and education. The Society for Women's Health Research convened an interdisciplinary expert panel of researchers, clinicians, and advocates for a roundtable meeting to review the current research on sex and gender differences in migraine. This review summarizes discussions from the roundtable and prioritizes areas of need that warrant further attention in migraine research, care, and education. Examining sex and gender differences in migraine and addressing knowledge gaps will decrease the health and economic burden of migraine for both women and men.

Background: Illness perception is significantly related to several outcome measures in different medical conditions. However, little is known about headache-related causal attributions and cognitive and emotional representations in patients with migraine., Objective: To examine perceived causes of headache and demographic, clinical, and psychological correlates and predictors of illness perception in patients with migraine attending a tertiary care headache centre., Methods: A sample of 143 patients with migraine (85.3% women, mean age 44.0 ± 12.1 years) completed the Brief Illness Perception Questionnaire (Brief IPQ), the Symptom Questionnaire (SQ), and the Migraine Disability Assessment (MIDAS) Questionnaire. A set of demographic and clinical characteristics was also collected., Results: Stress, heredity, and nervousness were the most frequent perceived causes of headache. Female gender was significantly related to higher Brief IPQ "consequences" and "emotional response" scores. Increased psychological distress and a poorer clinical course were significantly associated with more negative illness representations. In multiple regression analysis, a longer illness duration, increased depressive symptoms, and higher levels of headache-related disability and painfulness of headache attacks independently predicted a worse illness perception., Conclusions: In patients with migraine, depressive symptoms and a worse disease status, characterized by a longer history of suffering, higher disability and more painful headache attacks, may negatively affect illness perception. It could also be that dysfunctional illness representations lead to depressive symptoms and decrease patients' motivation to adhere to treatments, resulting in a worse outcome. Future studies should examine whether the improvement of illness perception through specific psychological interventions may promote a better adaptation to migraine., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Migraine headache is a neurologic disorder which mainly affects younger and productive segment of population. Migraine not only causes pain; but also affects quality of life in terms of low productivity and economic loss. The main aim of this study was to examine migraine-related disability, co-morbid depression, and relationship between the two., Methods: A cross-sectional study was conducted among migraineurs who visited two neurology referral clinics. The study was conducted between June 1st 2016 to December 30 th 2016. Migraine disability assessment score [MIDAS] and patient health questionnaire [PHQ-9] were used to assess disability and depression, respectively., Results: A total of 70 patients participated in the study. Fifty-three (74.3%) of our study participants were women. Fifty one (72.9%) study participants were between age group 20-40 years. Migraine without aura was the most common subtype (70%); migraine with aura accounted for the other 28.6%. The mean (± SD) headache frequency and intensity was 23.4 ± 14.9 days and 7.4 ± 1.2 respectively. Major depressive disorder was common in this group (41.4%). The mean MIDAS and PHQ-9 scores were 46.7 ± 30 and 9.2 ± 4.4 respectively. More than two-thirds (74.3%) of our participants had severe disability. We found a statistically significant correlation between migraine-related disability and co morbid depression among our participants(r = 0.318, p-value = 0.007)., Conclusion: The positive correlation observed between migraine-related disability and co-morbid depression warrant routine screening and treatment of disability and depression in migraineurs; In addition, the observed high degree of disability among our participants may indicate sub optimal treatment of these patients.

Introduction: Migraine, a chronic neurological disorder characterized by episodic severe headache pain and functional impairment, affects approximately 12% of the general US population. Veterans returning from Iraq or Afghanistan have two to four times the incidence of migraine of the general population. Veterans with migraines are more than twice as likely to have comorbid psychiatric conditions as veterans without migraines, with depression and post-traumatic stress disorder being most prevalent. This psychiatric-migraine comorbidity is of major public health significance, as it leads to decreased quality of life, poorer response to migraine and mental health treatment, and overall worse prognosis. Unfortunately, acceptable and effective treatments for these comorbid problems have rarely been investigated. The aims of this study are to examine the acceptability, feasibility, and preliminary efficacy of a 1-d acceptance and commitment therapy (ACT) plus Migraine Education workshop., Method: Twenty-five veterans with migraines and co-occurring depression and/or anxiety completed the 1-d ACT plus Migraine Education workshop. Veterans completed assessments of depressive and anxiety symptoms, general functioning, headache-related disability, and ACT-specific skills at baseline and 3 mo after the workshop. Changes from baseline to 3-mo follow-up on the self-report and clinician-rated measures were assessed using the paired t-test and Wilcoxon signed-rank test. Veterans also completed semistructured qualitative interviews documenting their experiences with the workshop 2 wk and 3 mo following the intervention. Qualitative data were analyzed via directed content analysis. Individual codes were aggregated into larger themes agreed upon by consensus., Results: At 3-mo follow-up, veterans significantly improved in depressive and anxiety symptoms, general functioning, and headache-related disability compared with baseline. Additionally, veterans significantly improved in pain acceptance and engagement in valued life areas. In interviews, veterans indicated that the migraine education helped them feel more knowledgeable about their condition, and this empowered them to better manage their headaches, including talking to their physician about medication adjustments. The ACT component led to greater awareness of the role stress plays in exacerbating pain and ways to manage this stress, including greater acceptance and greater engagement in valued life activities. For some, however, the role of stress in exacerbating migraines needed to be highlighted more. Veterans appreciated being in a group with other veterans with similar health difficulties and wanted this to be incorporated into ongoing care at the Veterans Affairs medical center. The patient education manuals were useful to the veterans, with some referring to them during the months following the workshop., Conclusion: Findings of this small trial have important implications pending replication in a more rigorously designed large-scale study. A 1-d ACT plus Migraine Education workshop is an acceptable and feasible treatment approach for veterans with migraines and significant distress. Significantly reduced distress and disability, as well as improved coping skills, suggest that veterans were activated to engage more fully in their lives and clinical care. The availability of an effective transdiagnostic intervention that can be completed in 1 d is particularly valuable for veterans who have multiple comorbid conditions and who encounter practical barriers to engaging in the usual prescribed weekly therapy treatments.

Objectives: To replicate a study by Schutze and colleagues on a headache sample, rather than a heterogenous chronic pain sample, investigating whether level of mindfulness predicts key components in the Fear-Avoidance Model of chronic pain (pain intensity, negative affect, pain catastrophizing, pain-related fear, pain hypervigilance, and functional disability); to investigate the relationships between level of mindfulness and headache/migraine pain intensity, frequency, and duration., Materials and Methods: Participants were 217 individuals who self-reported chronic headache/migraine (51 male, 166 female), aged between 18 and 65 years. Participants completed an online survey measuring demographics, mindfulness, the key components of the Fear-Avoidance Model, and headache pain intensity, duration, and frequency., Results: Mindfulness had significant negative correlations (P<0.05) with all variables except headache pain intensity and headache frequency. Mindfulness significantly predicted negative affect, pain catastrophizing, fear of pain, pain hypervigilance, and headache duration (P<0.05). Mindfulness remained a significant predictor of negative affect and pain hypervigilance after controlling for other key components and background characteristics (P<0.05). Mindfulness did not moderate the relationship between pain intensity and pain catastrophizing (P=0.204)., Discussion: Findings suggest that mindfulness may be integrated into the Fear-Avoidance Model of chronic pain for individuals with chronic headache/migraine. Directions for future research are discussed.

Background: Major depressive disorder is a common comorbidity in migraineurs. Depression may affect the progression and prognosis of migraine. Few studies have examined the brain function in migraineurs that may cause this comorbidity. Here, we aimed to explore depression-related abnormalities in the intrinsic brain activity of interictal migraineurs with comorbid depression using resting-state functional magnetic resonance imaging., Results: Significant main effects of migraine and depression provided evidence that migraine and depression jointly affected the left medial prefrontal cortex, which was thought to be the neural basis of self-referential mental activity in previous studies. Abnormalities in this region may contribute to determining the common symptoms of migraine and depression and even result in comorbidity. Additionally, migraineurs with comorbid depression had different developmental trajectories in the right thalamus and fusiform, which were associated with recognizing, transmitting, controlling and remembering pain and emotion., Conclusions: Based on our findings, the abnormal mPFC which may contribute to determining the common symptoms in migraine and depression and may be a therapeutic target for migraineurs comorbid depression. The different developmental trajectory in thalamus and fusiform indicates that the comorbidity may arise through a specific mechanism rather than simple superposition of migraine and depression.

Introduction: Lateralized pain is a core diagnostic feature of migraine. In previous research, left-sided spinal pain was more frequent and associated with greater emotional distress and healthcare use than right-sided pain. We hypothesized therefore that patients with left-sided head pain might experience higher levels of distress or healthcare use than those with right-sided or bilateral pain., Methods: Medical record information was extracted for 477 randomly selected patients with migraine seen in 2011 in a tertiary headache clinic. This included demographic data, pain location, handedness, comorbid psychiatric diagnoses, medical and emergency department visits, and use of selected headache medications., Results and Discussion: Two hundred twenty-eight of four hundred seventy-seven (47.8%) patients reported lateralized pain, of which 107 (47.9%) patients were right sided compared with 65 (28.5%) left-sided patients ( p =0.001), while 56 (24.5%) reported unilateral pain with no side predominance. Contrary to expectations, with the exception of self-reported posttraumatic stress disorder, there were no statistically significant differences between left and right in measures of psychiatric distress, emergency department visits, or healthcare use., Conclusion: Although unilateral pain location can be helpful in making a migraine diagnosis, it does not appear to have additional clinical implications. Additionally, its absence does not rule out a diagnosis of migraine since more than half of migraineurs have bilateral head pain.

Objective: To evaluate relationships between psychiatric symptoms, acceptance, and migraine-related disability in a sample of people with migraine presenting at a tertiary care headache center., Background: Migraine is a chronic disease that can be severely disabling. Despite a strong theoretical basis and evidence in other pain conditions, little is known about relationships between acceptance, psychiatric symptoms, and migraine-related disability., Methods: Ninety patients with physician-diagnosed migraine completed surveys assessing demographics, headache symptoms, severe migraine-related disability (Migraine Disability Assessment Scale total score dichotomized at ≥ 21), depression (Patient Health Questionnaire-9) and anxiety symptoms (Generalized Anxiety Disorder-7), and acceptance (Chronic Pain Acceptance Questionnaire; subscales: Pain Willingness and Activity Engagement)., Results: Participants (77.8% white, non-Hispanic; 85.6% women; and 50.0% with a graduate level education) reported an average headache pain intensity of 6.7/10 (SD = 2.0). One-third (36.0%) reported chronic migraine, and half (51.5%) reported severe migraine-related disability. Lower acceptance was associated with severe migraine-related disability, t(54) = 4.13, P < .001. Higher activity engagement was associated with lower average headache pain intensity (r = -.30, P = .011). Higher acceptance was associated with lower levels of depression (r = -.48, P < .001) and anxiety symptoms (r = -.37, P = .003). Pain willingness and activity engagement serially mediated relationships between depression symptoms and severe migraine-related disability (indirect effect = 0.05, 95% CI = 0.01, 0.15), and between anxiety symptoms and severe migraine-related disability (indirect effect = 0.12, 95% CI = 0.02, 0.31)., Conclusion: Results provided preliminary support for a theoretical pathway by which psychiatric symptoms may influence migraine-related disability, in part, through their relationships with pain willingness and activity engagement., (© 2018 American Headache Society.)

Most of the data in this review have been already reported by the authors in Neurological Science, but the goal of the present paper is to realize an integrated lecture of all the available data and look to the last achievements in pain cognition, with a special focus on migraine and chronic migraine. According to the proposed integrated perspective, migraine can be viewed as an adaptive behavioral response with evolutionistic advantages.

Background: Factors associated with development of medication-overuse headache (MOH) in migraine patients are not fully understood, but with respect to prevention, the ability to predict the onset of MOH is clinically important. The aims were to examine if personality characteristics, disability and physical activity level are associated with the onset of MOH in a group of migraine patients and explore to which extend these factors combined can predict the onset of MOH., Methods: The study was a single-center prospective observational study of migraine patients. At inclusion, all patients completed questionnaires evaluating 1) personality (NEO Five-Factor Inventory), 2) disability (Migraine Disability Assessment), and 3) physical activity level (Physical Activity Scale 2.1). Diagnostic codes from patients' electronic health records confirmed if they had developed MOH during the study period of 20 months. Analyses of associations were performed and to identify which of the variables predict onset MOH, a multivariable least absolute shrinkage and selection operator (LASSO) logistic regression model was fitted to predict presence or absence of MOH., Results: Out of 131 participants, 12 % (n=16) developed MOH. Migraine disability score (OR=1.02, 95 % CI: 1.00 to 1.04), intensity of headache (OR=1.49, 95 % CI: 1.03 to 2.15) and headache frequency (OR=1.02, 95 % CI: 1.00 to 1.04) were associated with the onset of MOH adjusting for age and gender. To identify which of the variables predict onset MOH, we used a LASSO regression model, and evaluating the predictive performance of the LASSO-mode (containing the predictors MIDAS score, MIDAS-intensity and -frequency, neuroticism score, time with moderate physical activity, educational level, hours of sleep daily and number of contacts to the headache clinic) in terms of area under the curve (AUC) was weak (apparent AUC=0.62, 95% CI: 0.41-0.82)., Conclusion: Disability, headache intensity and frequency were associated with the onset of MOH whereas personality and the level of physical activity were not. The multivariable LASSO model based on personality, disability and physical activity is applicable despite moderate study size, however it can be considered as a weak classifier for discriminating between absence and presence of MOH.

Background: It is unclear whether anxiety and depression impact health-related quality of life (HRQoL) equally across neurological diseases. This study examines the association between anxiety or depression and HRQoL in select neurological disorders., Methods: HRQoL was measured using the Short Form Health Survey (SF-12) in neurological patients: epilepsy (n = 279), migraine (n = 268), multiple sclerosis (MS) (n = 222), stroke (n = 204), and Parkinson's disease (PD) (n = 224). Depression and anxiety symptoms were assessed using the Patient Health Questionnaire (PHQ-9) and Hospital Anxiety and Depression Scale (HADS-A), respectively. Multiple linear regression was used to evaluate variables associated with the SF-12 mental health component (MCS) and physical health component scores (PCS). Pratt index was used to estimate the relative importance of anxiety and depression on HRQoL., Results: Anxiety and depression had the largest contribution to PCS in stroke and to MCS in epilepsy. Overall, anxiety and depression had a larger contribution to MCS as compared to PCS, except in stroke patients. Different patterns were seen across neurological diseases, with mental health variables strongly affecting MCS in all conditions, with also a sizable contribution to PCS in migraine, MS, and stroke., Conclusions: Anxiety and depression have varying impacts on HRQoL across neurological diseases. It is important for clinicians to be aware of how these patterns differ in each condition., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Migraine is one of the most common diseases worldwide and, importantly, a major cause of disability. This translates into a huge clinical and economic burden to individuals and society. Despite existing data on how migraine affects populations, the disease continues to be underdiagnosed and therefore undertreated, so the scale of the public health problem may be underestimated. The impact on the daily lives of patients and their families has also been underappreciated. Clinical and regulatory guidelines are encouraging the use of patient-reported outcome tools (PROs), as these may help in disease management and facilitate physician-patient interactions. In clinical trials in migraine, PRO data are key to evaluating the effects of new therapies on patients, such as disability assessment, productivity, quality of life, and emotional and physical functioning. Digital technologies have enabled the development of ePRO tools, which may play a growing role in the collection of PRO data in the future. Here, we will consider the current view of the burden imposed by migraine on patients and society, illustrate this with two patient case studies, and examine the initiatives underway to use our knowledge to improve our management approaches for the disease., (© 2018 American Headache Society.)