Frequency Of Migraine Attacks Research Articles

Study of Serum Magnesium Levels in Migraine Patients During the Ictal and Interictal Phases

Background and objectives: Migraine is among the most common headaches, with a 15% worldwide incidence. It is distinguished by neurovascular dysfunction and recurring headaches. Magnesium (Mg), as a controller of synaptic activity, is hypothesised to play a role in migraine pathogenesis. The cerebral cortex's hyperexcitability has been identified as a key feature in the pathophysiology of migraine, and magnesium (Mg) is a known neuronal excitability regulator. To evaluate the serum magnesium levels of migraine patients during and between attacks to those of healthy controls. Methods: Sixty migraine patients who met the inclusion criteria and the equal number of healthy controls were enrolled in the study. For the diagnosis of migraine, the International Classification of Headache Disorders, 3rd Edition, 2013 (ICHD-III) criteria were applied. Result: The mean serum magnesium levels of migraine patients throughout the interictal phase were significantly lower than those of healthy controls (1.849 0.135 vs 2.090 0.205, P 0.001, statistically significant). During attacks, the mean serum magnesium concentration was substantially lower than between attacks (P = 0.003, 1.822 0.149 vs 1.849 0.135, respectively). In migraine patients, serum magnesium levels exhibited an inverse linear relationship with attack frequency. Conclusion: The relatively low serum magnesium levels in migraine patients compared to healthy controls and the inverse relationship between serum magnesium levels and the frequency of migraine attacks suggest that magnesium plays a significant role in the pathogenesis of migraine and may be a viable therapeutic option.

The volume of the thalamus and hippocampus in a right-handed female episodic migraine group

Background/aimMigraine is a disabling headache with clinical and radiological complications. The aim of this study was to investigate the volume of the thalamus and hippocampus in migraineurs, the role of white matter lesions (WMLs), and the migraine characteristics in volume changes.MethodsBrain MRIs of 161 right-handed female episodic migraine patients and 40 right-handed, age-related, healthy women were performed. Left and right thalamus segmentation was performed on the 3D MPRAGE images using the Freesurfer 5.3 image analysis suite. Hippocampal subfield segmentation was based on a novel statistical atlas built primarily upon ultra-high-resolution ex vivo MRI data.ResultsThe left hippocampus had a smaller and the left thalamus had a larger total volume than the right one in both the control (p < 0.001) and migraine groups (p <0.001). Patients with white matter lesions (L+) showed smaller right thalamus and right hippocampal tail volumes than patients without lesions (L–) (p = 0.002 and p = 0.015, respectively) and controls (p = 0.039 and p = 0.025, respectively). For the right hippocampal body, we found significantly smaller volume in L+ patients when compared to L– patients (p = 0.018) and a similar trend when compared to the control group (p = 0.064). Patients without aura (A–) showed a larger right hippocampus (p = 0.029), right hippocampal body (p = 0.012), and tail volumes (p = 0.011) than patients with aura (A+). Inverse correlations were found between attack frequency and the volumes of the left and right hippocampal tails (p = 0.018 and p = 0.008, respectively).ConclusionThese findings indicate that WMLs may influence the volume of the right thalamus and hippocampus, while migraine aura and attack frequency may lead to volume changes in different parts of the hippocampi in migraine patients. These data support the necessity of effective migraine management to limit subcortical volume loss in migraineurs.

Tai Chi for the prophylaxis of episodic migraine: protocol of a non-inferiority randomized controlled trial with mechanism exploration

BackgroundMigraine is a complex neurovascular disorder with considerable clinical, social and economic issues. Tai chi has the potential to be an alternative prophylactic treatment for migraine with high safety since the adverse effects and limited efficacy of available medications.AimsThe proposed study aims to compare the prophylaxis efficacy of 24-week Tai Chi training on migraine attacks with the standard prophylactic medication; and to explore the mechanism of Tai Chi in preventing migraine attacks by analyzing the associations between changes of migraine attacks and changes of neurovascular functions and inflammatory makers.MethodThis is a two-arm parallel non-inferiority randomized controlled trial. In total 220 Hong Kong Chinese women aged 18–65 years with diagnosis of episodic migraine will be recruited and randomized to either the Tai Chi training group or the standard prophylactic medication group with 1:1 ratio, and receive the 24 weeks of modified 33-short form Yang-style Tai Chi training and the standard prophylactic medications, respectively. A 24-week follow-up will be implemented for both groups. For efficacy examination, the primary outcome was the frequency of migraine attacks measured by the migraine diary; and for the mechanism exploration, the primary outcome was the volume and number of white matter hyperintensity (WMH) measured by magnetic resonance imaging (MRI). The measurements will be conducted at the baseline, 24th weeks, and 48th weeks. Linear mixed model will be adopted to comprehensively analyze the changes of variables within and between groups.DiscussionGiven the importance of reducing disease burden and financial cost of migraine attacks, the findings of this study will provide new insights regarding the role of Tai Chi in alleviating migraine burden and further shed light on the mechanism action of Tai Chi on preventing headache attacks.Trial registrationClinicalTrials.gov NCT05690737. Registered on January 28, 2023.

Prolotherapy in the treatment of chronic migraine — Case report

IntroductionChronic migraine is a socioeconomic and individual burden since it is the largest cause of disability in people under 50 years of age. Although there are several prophylactic drug alternatives, some patients are vulnerable to refractoriness with significant damage to their quality of life. Prolotherapy, a subcutaneous injection of dextrose in peripheral nerves, advocates as a promising tool in the management of this pathology.Case reportA patient with refractory chronic migraine to drug therapy who was submitted to neurofascial prolotherapy. Weekly administration of a 2 ml solution of 1% ropivacaine and 10% glucose in the head peripheral nerves for 6 weeks. Reduced disability and frequency of migraine attacks for a period of 8 weeks after interventions.ConclusionProlotherapy proved itself to be a notable technique for reducing the number of days in a month that a patient with refractory chronic migraine to standardized therapy has had headaches. However, placebo group studies are needed to determine the efficacy of the procedure.

All Roads Lead to the Gut: The Importance of the Microbiota and Diet in Migraine.

Migraine, a prevalent neurological condition and the third most common disease globally, places a significant economic burden on society. Despite extensive research efforts, the precise underlying mechanism of the disease remains incompletely comprehended. Nevertheless, it is established that the activation and sensitization of the trigeminal system are crucial during migraine attacks, and specific substances have been recognized for their distinct involvement in the pathomechanism of migraine. Recently, an expanding body of data indicates that migraine attacks can be prevented and treated through dietary means. It is important to highlight that the various diets available pose risks for patients without professional guidance. This comprehensive overview explores the connection between migraine, the gut microbiome, and gastrointestinal disorders. It provides insight into migraine-triggering foods, and discusses potential diets to help reduce the frequency and severity of migraine attacks. Additionally, it delves into the benefits of using pre- and probiotics as adjunctive therapy in migraine treatment.

Targeting Glutamate Neurotoxicity through Dietary Manipulation: Potential Treatment for Migraine.

Glutamate, the main excitatory neurotransmitter in the central nervous system, is implicated in both the initiation of migraine as well as central sensitization, which increases the frequency of migraine attacks. Excessive levels of glutamate can lead to excitotoxicity in the nervous system which can disrupt normal neurotransmission and contribute to neuronal injury or death. Glutamate-mediated excitotoxicity also leads to neuroinflammation, oxidative stress, blood-brain barrier permeability, and cerebral vasodilation, all of which are associated with migraine pathophysiology. Experimental evidence has shown the protective effects of several nutrients against excitotoxicity. The current review focuses on the mechanisms behind glutamate's involvement in migraines as well as a discussion on how specific nutrients are able to work towards restoring glutamate homeostasis. Understanding glutamate's role in migraine is of vital importance for understanding why migraine is commonly comorbid with widespread pain conditions and for informing future research directions.

A Case Report of Migraine With Aura Worsened After Starting Apixaban and Literature Review.

Multiple medications have been related to triggering headache attacks or worsening headache frequency or severity in patients with migraine disease. However, the impact of direct oral anticoagulants on headache frequency and severity in patients with migraine disease is unclear. Current literature is scarce and controversial. A 45-year-old male with a history of migraine with aura for the last 20 years underwent percutaneous transcatheter closure of an atrial septal defect due to right ventricular enlargement and systolic dysfunction. The intervention was complicated by postprocedural atrial fibrillation, for which he was started on apixaban. Shortly after starting the apixaban, the patient experienced an increase in the frequency and severity of his migraine with aura episodes that were persistent until he discontinued this medication 7 months later. Following the discontinuation of apixaban, the patient's frequency and severity of migraine episodes returned to baseline almost immediately. Novel oral anticoagulants, including apixaban, may be associated with an increase in the frequency and severity of migraine attacks in patients with migraine disease. Larger observational studies are required to investigate further the impact of direct oral anticoagulants on migraine disease.

A meta-analytic review of acceptance-based interventions for migraine.

To determine the efficacy of acceptance and mindfulness-based interventions on migraine disability, medication use, and attack frequency. Acceptance-based approaches to headache management are those in which individuals learn to mitigate the influence of pain-related experiences on their general functioning without controlling pain itself. Treatment approaches include acceptance and commitment therapy (ACT) and mindfulness-based practices. Both have shown promise in improving broad functioning and disability among individuals with headache. Despite a growing body of research examining acceptance-based interventions for headache broadly and migraine specifically, no meta-analytic review of ACT interventions for headache exists, and two meta-analytic reviews of mindfulness-based practices yielded conflicting results. The present study aimed to systematically and quantitatively review the literature related to the efficacy of acceptance-based interventions among adults with migraine. A multi-database search (PubMed/MEDLINE, Scopus, PsycINFO, and the Cochrane Central Register of Controlled Trials) identified clinical trials among individuals with migraine that compared structured ACT or mindfulness-based interventions to control treatment. Random-effects meta-analyses were performed using RevMan 5.4 meta-analytic software, and standardized mean differences (SMD) with 95% confidence intervals (CIs) quantified effect sizes on outcomes of disability, medication use, and headache frequency. Heterogeneity was quantified via I2 index and explored via subgroup analyses. Acceptance-based interventions yielded significant improvements in disability (SMD = -0.38, 95% CI = -0.56 to -0.20; I2 = 25%, p = 0.20) but not in medication use (SMD = -0.25, 95% CI: -0.57 to 0.06; I2 = 0%, p = 0.82) or headache frequency (SMD = -0.16, 95% CI = -0.37 to 0.05; I2 = 0%, p = 0.73). Results suggest that acceptance-based interventions are effective in improving disability among adults with migraine and are a viable non-pharmacological treatment option, in addition to well-established behavioral migraine management approaches, for patients seeking functional improvement.

Manual cervical therapy and vestibular migraine: A case series.

Vestibular migraine (VM) is a relatively new diagnostic entity with incomplete knowledge regarding pathophysiological mechanisms and therapeutic guidelines. By reporting the effect of manual cervical therapy (MCT) on people with VM, we suggest a possible role for upper cervical afferents in VM treatment and/or pathogenesis. The objective was to describe the change in clinical presentation and self-reported symptoms of VM corresponding to MCT and followed up to six months. A nonrandomised *ABA design was utilised to consecutively and prospectively evaluate selected patients with diagnosed VM. Symptom characteristics (frequency and intensity) were recorded along with standardised patient-reported outcomes (PROs) to document the response to MCT. Three patients were recruited who met the diagnostic criteria for VM. All three patients demonstrated improvement in both migraine attack and interictal symptom frequency. These improvements mirrored changes in PROs and were sustained over a six-month follow-up period. The improvement that coincided with the intervention including MCT was rapid, observable and sustained. This suggests that the upper cervical spine could be a therapeutic target in VM and may have implications for future research into the pathogenesis of VM.

QuEChERS-assisted ion pair chromatography/fluorescence detection method for determination of antimigraine combination therapy in rabbit plasma samples: Application to a pharmacokinetic study

Antimigraine combination therapy has shown significant effectiveness in relieving pain, as well as reducing the frequency, duration, and severity of migraine attacks if compared to a single migraine medication. This work represents the first analytical investigation for emphasizing the synergistic effect of combining ophthalmic beta blockers with triptans in migraine treatment. The presented study was conducted to investigate the pharmacokinetic profile of almotriptan (ALM), a serotonin (5-HT1B/1D) receptor agonist used to treat migraine, when coadministered with timolol (TIM) or verapamil (VER) which are considered as an adjuvant therapy in migraine prevention. Ion pair chromatography (IPC) with online fluorescence detection was applied to simultaneously detect and quantify the binary mixtures of ALM/TIM and ALM/VER in rabbit plasma samples. The separation was achieved using a Platinum C18 analytical column with a mobile phase composed of methanol: 35 mmol L-1 phosphate buffer solution containing 10 mmol L-1 SDS at pH = 6.8 (60:40 v/v). Several parameters were evaluated during the optimization of separation conditions including mobile phase composition, buffer concentration, buffer pH and concentration of ion pair reagent. A thorough investigation of the retention mechanism was performed, and the results showed that Coulomb forces were the main contributors to the overall retention mechanism, which may be hydrophobically assisted. QuEChERS extraction technique was utilized to extract the investigated drugs from plasma samples and a detailed study was carried out to optimize partition/extraction solvents, pH, extraction salts, sample volume and clean-up step. The method had a limit of detection and quantitation of 5.6 and 16.9 ng mL-1 for ALM in ALM/TIM mixture and 2.5 and 7.6 ng mL-1 for ALM in ALM/VER mixture, with an overall recovery not less than 95.22%. This newly proposed method offers a faster alternative to existing chromatographic methods for extraction and determination of ALM in binary mixtures with TIM or VER in rabbit plasma and provides a platform for studying pharmacokinetic parameters. The coadministration of either TIM or VER with ALM resulted in a notable rise in Cmax (maximum plasma concentration) and AUC (area under the plasma concentration-time curve) of ALM, implying possible alterations in the absorption and overall exposure of ALM.

Determination of the Frequency of Migraine Attacks in Pregnant Women and the Ways They Cope with Headaches: A Cross-Sectional Study.

One out of every five women of reproductive age suffers from migraine. Although headaches subside in most women during pregnancy, attacks continue and even worsen in some women. Pregnant women try to relieve pain with medication or non-pharmacological treatment methods. This descriptive and cross-sectional study was conducted to determine the incidence of migraine attacks in pregnant women diagnosed with migraine and the ways they cope with headaches. The study included 191 pregnant women who were diagnosed with migraine in the pre-pregnancy period. McNemar analysis was performed to test the relationship between descriptive statistical methods and categorical variables when the data were analyzed. The mean gestational age of the participants was 28.31 ± 8.64 weeks, and their mean age at the onset of migraine was 20.74 ± 5.63 years. The comparison of the duration, frequency, and severity of headaches suffered before and during pregnancy demonstrated that there were statistical differences between them (p < 0.05). The frequency of using methods such as taking painkillers, resting in a dark room, and having cold application and massage to relieve headaches before pregnancy decreased statistically significantly during pregnancy (p < 0.05). As a result, the frequency and severity of migraines decrease during pregnancy. The tendency to resort to pharmacological or non-pharmacological methods used to relieve headaches decreases during pregnancy. Although migraine has many adverse effects on pregnancy, pregnant women do not demand satisfactory information from health professionals about migraine headaches during pregnancy.

Manual cervical therapy and vestibular migraine: A case series

Background: Vestibular migraine (VM) is a relatively new diagnostic entity with incomplete knowledge regarding pathophysiological mechanisms and therapeutic guidelines. By reporting the effect of manual cervical therapy (MCT) on people with VM, we suggest a possible role for upper cervical afferents in VM treatment and/or pathogenesis. The objective was to describe the change in clinical presentation and self-reported symptoms of VM corresponding to MCT and followed up to six months. Methods: A nonrandomised *ABA design was utilised to consecutively and prospectively evaluate selected patients with diagnosed VM. Symptom characteristics (frequency and intensity) were recorded along with standardised patient-reported outcomes (PROs) to document the response to MCT. Results: Three patients were recruited who met the diagnostic criteria for VM. All three patients demonstrated improvement in both migraine attack and interictal symptom frequency. These improvements mirrored changes in PROs and were sustained over a six-month follow-up period. Conclusions: The improvement that coincided with the intervention including MCT was rapid, observable and sustained. This suggests that the upper cervical spine could be a therapeutic target in VM and may have implications for future research into the pathogenesis of VM.

Effectiveness of Acupuncture for Prophylactic Treatment of Migraine: A Systematic Review and Bayesian Network Meta-Analysis.

It is aimed to evaluate the effectiveness and provide evidence-based medical support for acupuncture as a prophylactic treatment for migraines. Randomized controlled trials (RCTs) from inception to April 2022 are included in 14 databases. Pairwise meta-analysis is conducted using STATA software V14.0, while Windows Bayesian Inference Using Gibbs Sampling (WinBUGS V.1.4.3) is applied to generate Bayesian Network Meta-analysis (NMA) using Markov chain Monte Carlo algorithm. Forty RCTs are included, with 4405 participants. The effectiveness of six acupuncture techniques, three types of prophylactic drugs, and psychotherapy are compared and ranked. Acupuncture outperformed prophylactic drugs in terms of diminishing visual analog scale (VAS) score, migraine attack frequency, and days during the treatment and at the 12-week follow-up. At the 12-week follow-up, the effectiveness of various interventions is ranked as follows: manual acupuncture (MA) > electroacupuncture (EA) > calcium antagonists (CA) in reducing VAS score; MA > EA > CA in reducing migraine attack frequency; MA > EA > β-receptor blocker and CA in reducing headache attack days. Acupuncture is a promising treatment for migraine prevention. The best option of acupuncture for improving various migraine outcomes has changed over time. However, the quality of included trials and NMA inconsistency limited the credibility of the conclusion.

Cognitive Behavioral Therapy for the Management of Episodic Migraine.

This article provides an overview of the application of CBT in the management of episodic migraine while also providing context and insight into the underlying neurophysiological mechanisms of therapeutic change. It discusses the theoretical foundations of CBT and highlights key components including education, cognitive restructuring, behavioral interventions, relaxation techniques, and lifestyle changes. Cognitive behavioral therapy (CBT) is an empirically based treatment that is well suited for the management of episodic migraine. Although first-line treatments of migraine are typically pharmacological, a review of empirical literature suggests growing evidence for the use of CBT as a standard non-pharmacological treatment of headache conditions. In summary, this article explores evidence supporting the efficacy of CBT in reducing the frequency, intensity, and duration of migraine attacks as well as improving the quality of life and psychological well-being of those with episodic migraine.

Effect of High-Definition Transcranial Direct Current Stimulation on Headache Severity and Central µ-Opioid Receptor Availability in Episodic Migraine.

The current understanding of utilizing HD-tDCS as a targeted approach to improve headache attacks and modulate endogenous opioid systems in episodic migraine is relatively limited. This study aimed to determine whether high-definition transcranial direct current stimulation (HD-tDCS) over the primary motor cortex (M1) can improve clinical outcomes and endogenous µ-opioid receptor (µOR) availability for episodic migraineurs. In a randomized, double-blind, and sham-controlled trial, 25 patients completed 10-daily 20-min M1 HD-tDCS, repeated Positron Emission Tomography (PET) scans with a selective agonist for µOR. Twelve age- and sex-matched healthy controls participated in the baseline PET/MRI scan without neuromodulation. The primary endpoints were moderate-to-severe (M/S) headache days and responder rate (≥50% reduction on M/S headache days from baseline), and secondary endpoints included the presence of M/S headache intensity and the use of rescue medication over 1-month after treatment. In a one-month follow-up, at initial analysis, both the active and sham groups exhibited no significant differences in their primary outcomes (M/S headache days and responder rates). Similarly, secondary outcomes (M/S headache intensity and the usage of rescue medication) also revealed no significant differences between the two groups. However, subsequent analyses showed that active M1 HD-tDCS, compared to sham, resulted in a more beneficial response predominantly in higher-frequency individuals (>3 attacks/month), as demonstrated by the interaction between treatment indicator and baseline frequency of migraine attacks on the primary outcomes. These favorable outcomes were also confirmed for the secondary endpoints in higher-frequency patients. Active treatment also resulted in increased µOR concentration compared to sham in the limbic and descending pain modulatory pathway. Our exploratory mediation analysis suggests that the observed clinical efficacy of HD-tDCS in patients with higher-frequency conditions might be potentially mediated through an increase in µOR availability. The 10-daily M1 HD-tDCS can improve clinical outcomes in episodic migraineurs with a higher baseline frequency of migraine attacks (>3 attacks/month). This improvement may be, in part, facilitated by the increase in the endogenous µOR availability. www.ClinicalTrials.gov, identifier -NCT02964741.

Risk profile of patients with spontaneous cervical artery dissection.

Epidemiological data to characterize the individual risk profile of patients with spontaneous cervical artery dissection (sCeAD) are rather inconsistent. In the setting of the Italian Project on Stroke in Young Adults Cervical Artery Dissection (IPSYS CeAD), we compared the characteristics of 1,468 patients with sCeAD (mean age, 47.3±11.3; males, 56.7%) prospectively recruited at 39 Italian centres with those of 2 control groups, composed of 1) patients whose ischemic stroke was caused by mechanisms other than dissection (non-CeAD IS) selected from the prospective IPSYS registry and Brescia Stroke Registry and 2) stroke-free individuals selected from the staff members of participating hospitals, matched 1:1:1 by sex, age, and race. Compared to stroke-free subjects, sCeAD patients were more likely to be hypertensive (OR,1.65; 95%CI,1.37-1.98), to have personal history of migraine with aura (OR,2.45; 95%CI,1.74-3.34), without aura (OR,2.67; 95%CI,2.15-3.32) and family history of vascular disease in first-degree relatives (OR,1.69; 95%CI,1.39-2.05), and less likely to be diabetic (OR,0.65; 95%CI,0.47-0.91), hypercholesterolemic (OR,0.75; 95%CI,0.62-0.91), and obese (OR,0.41; 95%CI,0.31-0.54). Migraine without aura was also associated with sCeAD (OR,1.81; 95%CI,1.47-2.22) in comparison with patients with non-CeAD IS. In the subgroup of patients with migraine, sCeAD patients had higher frequency of migraine attacks and were less likely to take anti-migraine preventive medications, especially beta-blockers, compared with the other groups. The risk of sCeAD is influenced by migraine, especially migraine without aura, more than by other factors, increases with increasing frequency of attacks, and seems to be reduced by migraine preventive medications, namely beta-blockers. This article is protected by copyright. All rights reserved.

Migraine in bipolar disorder and schizophrenia; The hidden pain.

This study examined the prevalence of comorbid migraine in patients with bipolar disorder and those with schizophrenia and also examined the association between migraine comorbidity and disease characteristics of both psychiatric disorders. In this cross-sectional study, 150 patients with bipolar disorder and 150 with schizophrenia were evaluated for migraine diagnosis using the International Classification of Headache Disorders (3rd ed). Patients were selected from psychiatry outpatient clinics at Kasr Al Ainy hospitals, Cairo University. The Young Mania Rating Scale (YMRS) and the Hamilton Depression Rating Scale (HDRS) were administered to the bipolar group, whereas the Positive and Negative Syndrome Scale (PANSS) was administered to the schizophrenia group. Both groups were evaluated by the Clinical Global Impression (CGI) scale. The diagnosis of migraine was made in 34 (22.7%) of the bipolar group and 24 (16.0%) of the schizophrenia group. Patients with schizophrenia showed a significantly higher frequency and intensity of migraine attacks on the Migraine Disability Assessment scale than did the bipolar group (p < 0.001). In the bipolar group, there was no significant difference between patients with and without migraine on the YMRS, HDRS, and CGI. Among patients with schizophrenia, the duration of the migraine attacks was positively correlated with CGI scores (r = 0.40, p = 0.02). Migraine is a significant comorbidity in patients with bipolar disorder and schizophrenia.However, the intensity and frequency of migraine attacks were higher in the schizophrenia than in the bipolar group.

Treatment with eptinezumab for migraine prevention in people with chronic migraine and medication-overuse headache: a plain language summary.

This is a summary of three articles describing preventive treatment of migraine in participants with a diagnosis of both chronic migraine and medication-overuse headache in a study called PROMISE-2 (PRevention Of Migraine via Intravenous ALD403 Safety and Efficacy-2). People living with chronic migraine and medication-overuse headache have one of the most disabling, costly, and difficult-to-treat headache disorders. After preventive migraine treatment with eptinezumab (trade name Vyepti), participants with chronic migraine and medication-overuse headache experienced fewer migraine days, a reduced severity of migraine attacks, and a reduced use of acute medication. More participants receiving eptinezumab treatment no longer met the definition of either chronic migraine or medication-overuse headache throughout the study when compared with those receiving placebo. Eptinezumab is beneficial for people who often use acute medication(s) due to frequent headache episodes or migraine attacks.

Second-generation gepants in the treatment of migraine – a review of the findings of randomised controlled trials

Pharmacological treatment of migraine may be either acute (abortive) or preventive (prophylactic), though patients with frequent migraine attacks may require both. The aim of acute treatment is to treat attacks quickly and consistently, prevent recurrences, and restore patients to normal functioning. The goal of preventive migraine therapy is to reduce the frequency, duration, and severity of attacks. Calcitonin gene-related peptide (CGRP) is a neuropeptide which plays a critical role in migraine pathophysiology. The first CGRP antagonist studied in patients with migraine was olcegepant. Despite the fact that the efficacy of CGRP antagonists in the treatment of migraine has been demonstrated in clinical trials, further research on CGRP antagonists has been suspended due to safety concerns related to their toxic effects on the liver. In recent years, newgeneration gepants have been developed. The efficacy of rimegepant and ubrogepant as acute migraine medications, as well as atogepant and rimegepant as migraine preventives, has been confirmed in randomised placebo-controlled phase three studies. The most commonly reported treatment-related emergent adverse events of gepants include nausea and constipation. No cardiovascular or hepatic adverse events have emerged so far. CGRP antagonists do not exhibit vasoconstrictive proprieties. Gepants may be used in patients with cardiovascular diseases when triptans are contraindicated. The results of studies investigating the efficacy and tolerability of CGRP antagonists are promising and it is hoped that in the future they will broaden the range of abortive and prophylactic options for the management of migraine.

Manual cervical therapy and vestibular migraine: A case series

Background: Vestibular migraine (VM) is a relatively new diagnostic entity with incomplete knowledge regarding pathophysiological mechanisms and therapeutic guidelines. By reporting the effect of manual cervical therapy (MCT) on people with VM, we suggest a possible role for upper cervical afferents in VM treatment and/or pathogenesis. The objective was to describe the change in clinical presentation and self-reported symptoms of VM corresponding to MCT and followed up to six months. Methods: A nonrandomised *ABA design was utilised to consecutively and prospectively evaluate selected patients with diagnosed VM. Symptom characteristics (frequency and intensity) were recorded along with standardised patient-reported outcomes (PROs) to document the response to MCT. Results: Three patients were recruited who met the diagnostic criteria for VM. All three patients demonstrated improvement in both migraine attack and interictal symptom frequency. These improvements mirrored changes in PROs and were sustained over a six-month follow-up period. Conclusions: The improvement that coincided with the intervention including MCT was rapid, observable and sustained. This suggests that the upper cervical spine could be a therapeutic target in VM and may have implications for future research into the pathogenesis of VM.