Headache Center Research Articles

Evaluating Headache and Facial Pain in a Headache Diagnostic Laboratory: Experiences from the Danish Headache Center.

Diagnostic tests are not routinely used for the diagnosis of primary headaches. It is possible that laboratory tests could be developed and implemented at tertiary headache centers to be an integrated part of the diagnosis and management of headache patients, and laboratory tests that can be used on-site at headache centers could help in evaluating patients with secondary headache disorders. In this narrative review, we present some of the studies that have been made so far at the Headache Diagnostic Laboratory at the Danish Headache Center that aim to investigate and phenotype primary headaches and investigate secondary headaches as well as improve management. Semi-structured interviews and deep phenotyping, quantitative sensory testing, and provocation studies have been shown to be valuable in categorizing primary and secondary headache subtypes, possible pathophysiology, and defining needs for further research. In patients suspected of increased intracranial pressure, transorbital ultrasound with measurement of the optic sheath diameter may be useful in monitoring patients. The management of headache patients needs to be critically evaluated to optimize treatment continuously. A Headache Diagnostic Laboratory is very useful and should be an integrated part of headache care and management at tertiary headache centers.

Near-death experiences are associated with rapid eye movement (REM) sleep intrusions in migraine patients, independent of migraine aura.

Migraine aura, near-death experiences (NDEs), and rapid eye movement (REM) sleep intrusions might share common mechanisms. Here, we investigated the prevalence of NDEs and REM sleep intrusions in people with migraine. We hypothesized that NDEs and REM sleep intrusions are more prevalent in migraine patients with aura than in those without. We conducted a prospective cross-sectional cohort study at a tertiary headache center, based on a prespecified sample size (n = 808). Migraine patients completed a series of questionnaires, including questions about demographic and headache characteristics, the 16-item Greyson NDE scale, four questions about REM sleep intrusions, and the Depression, Anxiety, and Stress Scale 21 (DASS-21). Of 808 migraine patients (mean age 44.4 ± 13.3 years, 87.0% women), 353 (43.7%) had a current or previous history of migraine aura. Prevalence of NDE was 2.7% and not different in patients with and without aura (2.8% vs. 2.6%; p > 0.999). REM sleep intrusions were reported by 5.4% of participants and in a similar proportion of patients with and without aura (6.3% vs. 4.9%; p = 0.43). However, participants with REM sleep intrusions had had an NDE more often than participants without REM sleep intrusions (n = 5/44, 11.4% vs. n = 17/754, 2.2%; p = 0.005). Higher DASS-21 scores were associated with REM sleep intrusions (p < 0.001). In this tertiary center cohort study, the prevalence of NDE and REM sleep intrusions was not influenced by migraine aura status. However, we identified an association between NDE and REM sleep intrusions, which corroborates the notion that they might share pathophysiological mechanisms.

Efficacy of mindfulness added to treatment as usual in patients with chronic migraine and medication overuse headache: a phase-III single-blind randomized-controlled trial (the MIND-CM study)

BackgroundMindfulness gained considerable attention for migraine management, but RCTs are lacking. We aimed to assess the efficacy of a six-sessions mindfulness-based treatment added to treatment as usual (TaU) in patients with Chronic Migraine (CM) and Medication Overuse Headache (MOH) on headache frequency, medication intake, quality of life, disability, depression and anxiety, cutaneous allodynia, awareness of inner states, work-related difficulties, and disease cost.MethodsIn this Phase-III single-blind RCT carried out in a specialty Italian headache center, 177 patients with CM and MOH were randomized 1:1 to either TaU (withdrawal from overused drugs, education on proper medication use and lifestyle issues, and tailored prophylaxis) or mindfulness-based intervention added to TaU (TaU + MIND). The mindfulness-based intervention consisted of six group session of mindfulness practice and 7–10 min daily self-practice. The primary endpoint was the achievement of ≥ 50% headache frequency reduction at 12 months compared to baseline, and was analyzed on an intention-to-treat principle using Pearson’s Chi-Squared test. Secondary endpoints included medication intake, quality of life (QoL), disability, depression and anxiety, cutaneous allodynia, awareness of inner states, work-related difficulties, and disease cost. The secondary endpoints were analyzed using per-protocol linear mixed models.ResultsOut of the 177 participants 89 were randomized to TaU and 88 to TaU + MIND. Patients in the TaU + MIND group outperformed those in TaU for the primary endpoint (78.4% vs. 48.3%; p < 0.0001), and showed superior improvement in headache frequency, QoL and disability, headache impact, loss of productive time, medication intake, and in total, indirect and direct healthcare costs.ConclusionsA mindfulness-based treatment composed of six-week session and 7–10 min daily self-practice added on to TaU is superior to TaU alone for the treatment of patients with CM and MOH.Trial registrationMIND-CM was registered on clinicaltrials.gov (NCT03671681) on14/09/2018.

Long-Term Effect of Switching From an Anti-CGRP Receptor to an Anti-CGRP Ligand Antibody in Treatment-Refractory Chronic Migraine: A Prospective Real-World Analysis

In migraine patients with a poor response to a calcitonin gene-related peptide monoclonal antibody against the receptor, switching to a calcitonin gene-related peptide monoclonal antibodies against the ligand may be beneficial. This was a long-term real-world prospective analysis conducted in treatment-refractory chronic migraine patients coming from two large tertiary referral headache centres, who did not achieve a meaningful response to erenumab and were switched to fremanezumab. Responders to fremanezumab were considered those who achieved at least 30% reduction in monthly migraine days by month 3, compared to the post-erenumab baseline. Secondary efficacy and disability outcomes were analysed. Thirty-nine patients (female n = 32, 82.1%; median age: 49 years old, IQR = 29.0–56.0) were included. After three months of treatment with fremanezumab, ten out of 39 patients (25.6%) were considered responders. Four of the 11 patients who continued fremanezumab became responders at month 6, increasing the number of responders to 14 patients (35.9%). Responders received a median of 12 injections (IQR = 9.0–18.0) at the time of the analysis. After the last treatment, 13 patients (33.3%) remained responders. The number of mean monthly migraine days significantly decreased from 21.4 at baseline (IQR = 10.7–30.0) to 8.6 (IQR = 3.8–13.9) at the last follow-up. Painkillers intake and HIT-6 score were significantly reduced at the last follow-up. About 1/3 of patients with treatment refractory chronic migraine who have a disappointing response to erenumab and switch to fremanezumab, obtained a meaningful and sustained improvement of their migraine load over time, supporting the appropriateness of this therapeutic approach in clinical practice.

Treatment of hemiplegic migraine with anti-calcitonin gene-related peptide monoclonal antibodies: A case series in a tertiary-care headache center.

Hemiplegic migraine (HM) is a subtype of migraine with aura that includes motor weakness; such headaches can be excruciating. The presence of not only headache but also aura symptoms of HM increase the burden on patients, and the treatment of HM is sometimes challenging. Monoclonal antibodies (mAbs) targeting the calcitonin gene-related peptide (CGRP) pathway are novel migraine preventive treatments that have shown promising efficacy in patients with migraine; however, there have been no reports regarding their efficacy in HM to date. Six patients with HM were treated with galcanezumab in a tertiary-care headache center. After 3 months of treatment, the number of monthly days with headache of at least moderate severity was reduced in three patients. The number of days each month with weakness was also reduced in four patients. Furthermore, the Patient's Global Impression of Change and change in Migraine Disability Assessment total score, were improved in five of the six patients after the treatment; however, the change from baseline in days with bothersome symptoms did not show any specific trends in our patients. Notably, no adverse events were reported during the treatments. The mechanism underlying the improvement in aura symptoms in our patients is not clear; however, we speculate that a small amount of CGRP mAbs have a direct mode of action in the central nervous system; alternatively, blocking the CGRP pathway in the periphery may secondarily inhibit cortical spreading depression. While prudence must be practiced, galcanezumab was still generally effective in HM and well tolerated. Further prospective clinical studies will more clearly elucidate the effects of CGRP mAbs in patients with HM.

Visual hypersensitivity in patients treated with anti-calcitonin gene-related peptide (receptor) monoclonal antibodies.

To evaluate the effect of treatment with anti-calcitonin gene-related peptide (CGRP; receptor) antibodies on visual hypersensitivity in patients with migraine. Increased visual sensitivity can be present both during and outside migraine attacks. CGRP has been demonstrated to play a key role in light-aversive behavior. In this prospective follow-up study, patients treated for migraine with erenumab (n = 105) or fremanezumab (n = 100) in the Leiden Headache Center were invited to complete a questionnaire on visual sensitivity (the Leiden Visual Sensitivity Scale [L-VISS]), pertaining to both their ictal and interictal state, before starting treatment (T0) and 3 months after treatment initiation (T1). Using a daily e-diary, treatment effectiveness was assessed in weeks 9-12 compared to a 4-week pre-treatment baseline period. L-VISS scores were compared between T0 and T1. Subsequently, the association between the reduction in L-VISS scores and the reduction in monthly migraine days (MMD) was investigated. At 3 months, the visual hypersensitivity decreased, with a decrease in mean ± standard deviation (SD) ictal L-VISS (from 20.1 ± 7.7 to 19.2 ± 8.1, p = 0.042) and a decrease in mean ± SD interictal L-VISS (from 11.8 ± 6.6 to 11.1 ± 7.0, p = 0.050). We found a positive association between the reduction in MMD and the decrease in interictal L-VISS (β = 0.2, p = 0.010) and the reduction in ictal L-VISS (β = 0.3, p = 0.001). A decrease in visual hypersensitivity in patients with migraine after treatment with anti-CGRP (receptor) antibodies is positively associated with clinical response on migraine.

Neck Pain Disability on Headache Impact and the Association between Sleep Disturbance and Neck Pain in Migraine.

Neck pain (NP) is a prevalent symptom among migraine patients, but its disability on headache impact and the contributing factors for comorbid NP are poorly understood. This study aimed to investigate NP disability on the impact of headaches among migraineurs and factors linked to comorbid NP, including sleep-related variables. This cross-sectional study was conducted at a university hospital headache center, for headache patients at their first visits. Included in the study were 295 patients with migraines (217 females; 39.0 ± 10.8 years; 101 chronic migraine). Information on NP, history of physician-diagnosed cervical spine or disc disorders, detailed parameters of headache, and sleep and mood variables were collected. Logistic analysis of the severe impact of headache and contributing factors for NP were performed. NP was present in 153 participants (51.9%) with migraine, with high NP disability observed in 28 patients, and 125 patients had low NP disability. In multivariable analysis, NP disability, medication days per month, severe disability of migraine, and excessive daytime sleepiness were significant predictors for severe impact of headache. Thirty-seven patients with physician-diagnosed cervical spine or disc disorders were excluded from the NP analysis. Higher monthly headache days, female gender, and a high likelihood of obstructive sleep apnea were positively correlated with the presence of NP among migraineurs in multivariable analysis. Overall, the study highlights the potential impact of sleep-related variables and monthly headache days on NP in these patients. The high disability of NP was also associated with severe impact of headache.

Real-world study of intranasal ketamine for use in patients with refractory chronic migraine: a retrospective analysis

IntroductionSubanesthetic ketamine infusion has been used for managing refractory headache in inpatient or outpatient infusion settings. Intranasal ketamine may be an alternative option for outpatient care.MethodsA retrospective study was conducted...

The effect of Lu AG09222 on PACAP38- and VIP-induced vasodilation, heart rate increase, and headache in healthy subjects: an interventional, randomized, double-blind, parallel-group, placebo-controlled study

BackgroundPituitary adenylate cyclase-activating polypeptide (PACAP), structurally related to vasoactive intestinal peptide (VIP), is one of the important mediators in the pathogenesis of migraine and is known to dilate cranial arteries and induce headache and migraine. Our objective was to determine whether Lu AG09222—an investigational humanized monoclonal antibody directed against PACAP ligand—would inhibit the PACAP-signaling cascade by abolishing its vasodilatory and headache-inducing abilities.MethodsIn a randomized, double-blind, parallel-group, single-dose, placebo-controlled study of Lu AG09222, healthy volunteers aged 18–45 years without history of headache disorders were randomly allocated to three treatment sequences (1:2:2) on two experimental infusion visits with 9 ± 3 days’ interval: placebo + saline + saline (n = 5), placebo + PACAP38 + VIP (n = 10), and Lu AG09222 + PACAP38 + VIP (n = 10). The primary outcome measure was area under the curve (AUC) of the change in superficial temporal artery (STA) diameter from 0 to 120 min after start of infusion of PACAP38. The study was conducted at the Danish Headache Center in Copenhagen, Denmark.ResultsIn participants who received Lu AG09222 + PACAP38 infusion, there was a significantly lower STA diameter (mean (SE) [95% CI] AUC ‒35.4 (4.32) [‒44.6, ‒26.3] mm × min; P < 0.0001) compared to participants who received placebo + PACAP38 infusion. Secondary and explorative analysis revealed that PACAP38 infusion induced an increase in facial blood flow, heart rate and mild headache, and indicated that these PACAP38-induced responses were inhibited by Lu AG09222.ConclusionsThis proof-of-mechanism study demonstrated that Lu AG09222 inhibited PACAP38-induced cephalic vasodilation and increases in heart rate, and reduced concomitant headache. Lu AG09222 may be a potential therapy against migraine and other PACAP-mediated diseases.Trial registrationClinicalTrials.gov: NCT04976309. Registration date: July 19, 2021.Graphical

Burden of migraine in patients attending Belgian headache specialists: real-world evidence from the BECOME study.

Migraine is a primary headache disorder, which imposes a major burden on the sufferers. The BECOME study (Burden of migrainE in specialist headache Centers treating patients with prOphylactic treatMent failurE) attempted to characterize and assess the prevalence, burden and healthcare resource utilization of migraine patients presenting in specialized headache centers in Europe and Israel. In this paper, we will describe the patient characteristics of the Belgian headache centers. The BECOME study was a prospective, non-interventional, cross-sectional study consisting of two parts. In the first part of the study, data were collected from subjects with a diagnosis of migraine. Subsequently, patients with ≥ 4 monthly migraine days (MMD) and ≥ 1 prior preventive treatment failure (PPTF) filled out validated questionnaires to assess the burden of disease. In part 1 of the Belgian study population (N = 806), 45% of patients reported ≥ 8 MMD and 25% had failed ≥ 4 preventive treatments. In part 2 (N = 90), more than 90% of patients reported having severe impact of headache on daily life and having severe migraine-related disability. The impact was the highest for patients with ≥ 15 MMD, however, even within the patient population with < 8 MMD, the burden was significant. Almost 40% of the study population suffered from anxiety. These findings in the Belgian sample of the BECOME study demonstrate the substantial burden and unmet need for the management of difficult-to-treat migraine.

Galcanezumab for the treatment of chronic migraine and medication overuse headache: Real-world clinical evidence in a severely impaired patient population.

Galcanezumab is a monoclonal antibody acting against the calcitonin gene-related peptide approved for the preventive treatment of migraine. The aim of this article is to explore its effectiveness and safety of galcanezumab in chronic migraine (CM) with medication overuse-headache (MOH). Seventy-eight patients were consecutively enrolled at the Modena headache center and followed up for 15 months. Visits were scheduled every 3 months, and the following variables were collected: the number of migraine days per month (MDM); the painkillers taken per month (PM); the number of days per month in which the patient took, at least, one painkiller; the six-item headache impact test; and the migraine disability assessment questionnaire (MIDAS) score. Demographic features of the analyzed sample were collected at the baseline and adverse events (AEs) were collected at every visit. After 12 months, galcanezumab significantly reduced the MDM, the PM, the number of days on medication, the HIT-6 as well as the MIDAS scores (all p < .0001). The greatest amelioration was obtained in the first trimester of treatment. A higher MDM, a higher NRS score at the baseline, and a higher number of failed preventive treatments negatively predict the CM relief at the year of treatment. No serious AEs were registered and only one drop-out was due to AE. Galcanezumab is effective and safe for the treatment of patients affected by CM and MOH. Patients with a higher impairment at the baseline may found less benefits with galcanezumab.

Normal glymphatic system function in patients with new daily persistent headache using diffusion tensor image analysis along the perivascular space.

To investigate the glymphatic function in patients with new daily persistent headache (NDPH) using the diffusion tensor image analysis along the perivascular space (DTI-ALPS) method. NDPH, a rare and treatment-refractory primary headache disorder, is poorly understood. There is limited evidence to suggest that headaches are associated with glymphatic dysfunction. Thus far, no studies have evaluated glymphatic function in patients with NDPH. In this cross-sectional study conducted in the Headache Center of Beijing Tiantan Hospital, patients with NDPH and healthy controls were enrolled. All participants underwent brain magnetic resonance imaging examinations. Clinical characteristics and neuropsychological evaluation were examined in patients with NDPH. ALPS indexes for both hemispheres were measured to determine the glymphatic system function in patients with NDPH and healthy controls. In total, 27 patients with NDPH (14 males, 13 females; age [mean ± standard deviation (SD)]: 36.6 ± 20.6) and 33 healthy controls (15 males, 18 females; age [mean ± SD]: 36.0 ± 10.8) were included in the analysis. No significant differences between groups were observed in the left ALPS index (1.583 ± 0.182 vs. 1.586 ± 0.175, mean difference = 0.003, 95% confidence interval [CI] of difference = -0.089 to 0.096, p = 0.942), or right ALPS index (1.578 ± 0.230 vs. 1.559 ± 0.206, mean difference = -0.027, 95% CI of difference = -0.132 to 0.094, p = 0.738). Additionally, ALPS indexes were not correlated with clinical characteristics or neuropsychiatric scores. No glymphatic dysfunction was detected in patients with NDPH by means of the ALPS method. Additional studies with larger samples are needed to confirm these preliminary findings and improve the understanding of glymphatic function in NDPH.

Different Experiences in Chronic Migraine Etiology, Treatment and Comorbidities of Hawaii’s Ethnic Groups (P14-12.006)

<h3>Objective:</h3> To determine racial disparities in CM treatment and comorbidities of patients in Hawaii, a state characterized by its a majority-minority patient population. We hypothesize that minority populations are under-treated. <h3>Background:</h3> Chronic migraine (CM) is a debilitating condition with negative repercussions on the socioeconomic status of patients; compounded by under-diagnosis and treatment in minority populations. Identifying treatment and comorbidity characteristics of CM patients in Hawaii will guide treatment of migraines. <h3>Design/Methods:</h3> We performed a retrospective chart review on patients diagnosed with CM at a headache and facial pain center in Honolulu, Hawaii. 743 patients with a clinic visit from January 27, 2022 to April 27, 2022 were retrieved from <i>eClinicalWorks</i>. Patients without sufficient data were excluded, yielding 298 patients fulfilling inclusion criteria of a) ICD-10 code diagnosis of CM b) lack of secondary migraine etiology and c) fulfilling IHCD-3 standards of CM. Socioeconomic demographic variables were collected including self-reported race, age, obesity, number of medications and public/private health insurance. Patient treatment modalities were recorded: botulinum toxin (BoNT), pharmacologic treatment, monoclonal antibodies, and physical therapy. <h3>Results:</h3> Native Hawaiian/Pacific Islander (NHPI) patients reported the highest prevalence of obesity (60.9%) at &gt;30% compared to other race groups (p&lt;0.001). History of diabetes was low across all race groups (7.7%). However, NHPI patients had a higher history of diabetes (14.5%) (p= 0.004), hypertension (37.7%), &gt;13% higher than other race groups (p= 0.01). Significantly more white patients received BoNT as therapy (73.9%), &gt;25% compared to other race groups (p= 0.02). Public insurance was significantly more common in NHPI patients (59.4%) followed by other minorities (57.1%), with a 9–11% difference compared to other race groups. (p=0.02) <h3>Conclusions:</h3> Our findings suggest barriers to BoNT treatment in minority patients. Comorbidities in NHPI patients, such as obesity, diabetes and hypertension, differ from other ethnic groups. <b>Disclosure:</b> Miss Lu has nothing to disclose. Ms. Yamane has nothing to disclose. Mr. Keahi has nothing to disclose. Mr. Tong has nothing to disclose. Mr. Goo has nothing to disclose. The institution of an immediate family member of Ms. Prabhudesai has received research support from National Eye Institute. An immediate family member of Ms. Prabhudesai has received intellectual property interests from a discovery or technology relating to health care. The institution of Dr. Chen has received research support from NIH. Dr. Vajjala has nothing to disclose. Enrique Carrazana has received personal compensation for serving as an employee of Neurelis. Enrique Carrazana has received personal compensation in the range of $100,000-$499,999 for serving as a Consultant for Neurelis, Alexza, Zogenix. Enrique Carrazana has received personal compensation in the range of $10,000-$49,999 for serving as an officer or member of the Board of Directors for Hawaii-Biotech, CND Life Sciences. Enrique Carrazana has stock in Neurelis, Marinus, . Dr. Viereck has nothing to disclose. The institution of Dr. Liow has received research support from UCB. The institution of Dr. Liow has received research support from Livanova. The institution of Dr. Liow has received research support from Biogen. The institution of Dr. Liow has received research support from Novartis. The institution of Dr. Liow has received research support from Eisai. The institution of Dr. Liow has received research support from Engage Therapeutics. The institution of Dr. Liow has received research support from SK Lifescience. The institution of Dr. Liow has received research support from Cerevel. The institution of Dr. Liow has received research support from Xenon. The institution of Dr. Liow has received research support from NeuroDerm. The institution of Dr. Liow has received research support from Avanir. The institution of Dr. Liow has received research support from Annovis. The institution of Dr. Liow has received research support from Acadia.

A History of Headache Medicine Training in the United States (P4-3.007)

<h3>Objective:</h3> To review the history of training in Headache Medicine in the 20th and 21st Century in America and provide insights into key dates and events that shape current practice. <h3>Background:</h3> Headache is a burgeoning field within Neurology with 49 fellowships now UCNS accredited. These accredited centers represent signficant growth over short period. Unofficial apprenticeships date to the 1940s with Montefiore Hospital. The last 14 years accreditation has been under UCNS with subsequent exponential growth of programs. 700+ candidates hold certificates with invagination of training programs into academic centers around the country making higher level care available to more. <h3>Design/Methods:</h3> The timeline of UCNS was reviewed and information gathered about which programs became certified with the data graphed out and compared to yearly certification numbers of specialists. Individuals at centers including the Diamond Institute, the Graham Institute, the Jefferson H Center and Montefiore Center were interviewed and primary sources were contacted to discuss the history. Finally, a literature search was performed to look into what headache centers existed prior to inception of the UCNS and to understand what model of education was performed and how successful those centers were at developing new headache specialists in practice. <h3>Results:</h3> The last 15 years led to more formalized structure for accreditation of programs and certification of specialists under the UCNS. Historically training centers were limited, idiosynchratic and followed an apprenticeship model. The current growth in training programs has led to 49 current acc credited programs and dozens of yearly graduates. Several named centers have trained a large volume of providers and have fostered practitioners who have created other centers. <h3>Conclusions:</h3> Schools of thought in Headache Medicine have grown around several centers with roots in an apprenticeship form of education. Over 15 years fellowship training has become more formalized, clearer in objectives and in expectations for trainees with dramatic growth. <b>Disclosure:</b> Dr. Rosen has received personal compensation for serving as an employee of Northwell Health. An immediate family member of Dr. Rosen has received personal compensation for serving as an employee of New York University. Dr. Rosen has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Allergan/ Abbvie. Dr. Rosen has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Amgen/ Novartis. Dr. Rosen has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Eli Lilly. Dr. Rosen has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Lundbeck. Dr. Rosen has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Biohaven. Dr. Rosen has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Theranica. Dr. Rosen has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Allergan/ Abbvie. Dr. Rosen has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Springer. Dr. Rosen has received personal compensation in the range of $500-$4,999 for serving as a Speaker with American Headache Society.

Headwork as innovative tool for monitoring MABs efficacy in migraine and their influence on work activity (P12-12.010)

<h3>Objective:</h3> HEADWORK (HW) is a new evaluation tool, developed specifically to assess the impact on work tasks and reduced productivity of migraineurs. The aim of this study was to test the performance of HW on migraine patients treated with MABs. <h3>Background:</h3> Monoclonal antibodies (MABs) have been a game changer in the treatment of migraine since their approval. Their efficacy is generally assessed with disease related metrics, but there is an increasing need to evaluate the impact of disease treatment. <h3>Design/Methods:</h3> We enrolled 69 patients receiving treatment with MABs at the Headache Centres of IRCCS “C. Besta” (Milan) and IRCCS “C. Mondino” (Pavia). They were assessed with the HEADWORK questionnaire at baseline and at the 3rd (M3) and 6th month (M6) of treatment. HW questionnaire consists of two sections: “Work-related difficulties” (HW1) rates difficulty in general skills, problems solving or starting new task; “Factors contributing to work-related difficulties” (HW2) to asses the negatively impact of some factors, such as noise and brightness of the workplace. <h3>Results:</h3> Population: 15 M and 54 F, mean age (49.5y±8.6), mean age at onset of disease (18y±7), mean duration of disease (34y±11.6). We observed a marked and consistent and significant reduction in ‘classical’ indicators: monthly migraine days (15±5.7 at baseline, 5±5.8 at M3, 6±6.2 at M6), medications per month (15±8.7 at baseline, 5±12.1 at M3, 6±6.6 at M6), MIDAS (41±43.2 at baseline, 6.5±11.3 at M3, 5±13 at M6), HIT-6 (66±2.8 at baseline, 59±8.7 at M3, 59±8.2 at M6). HW scores paralleled the above parameters: HW1 (20±8.1 at baseline, 11±9 at M3, 7±8.2 at M6), HW2 (9±6 at baseline, 5±4.8 at M3, 3±3.8 at M6). <h3>Conclusions:</h3> Our findings confirm the effectiveness of MABs, on clinical markers. HW1 and HW2 also show an extremely positive impact on work related activities. HW appears a suitable tool to assess migraine-related work disability in these patients. <b>Disclosure:</b> Dr. Montisano has nothing to disclose. Ms. Vaghi has nothing to disclose. Alberto Raggi has nothing to disclose. Grazia Sances has nothing to disclose. Cristina Tassorelli has nothing to disclose. Dr. Grazzi has received personal compensation in the range of $0-$499 for serving as a Consultant for EliLilly. Dr. Grazzi has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for allergan-abbvie.

Real-World Effectiveness of Eptinezumab after Treatment with Subcutaneous CGRP Monoclonal Antibodies in Patients with Migraine (P12-12.009)

<h3>Objective:</h3> To evaluate the effectiveness of eptinezumab in patients with migraine after 6 and 12 months. <h3>Background:</h3> Patients who switched from subcutaneous CGRP mAbs to intravenous CGRP mAb (i.e., eptinezumab) are refractory to most preventive medications. While several real-world studies reported positive outcomes within 6 months of eptinezumab use, the eptinezumab usage pattern and treatment response after 1-year remain unknown. <h3>Design/Methods:</h3> This single-center retrospective study examined the first 30 subjects who received eptinezumab at the Jefferson Headache Center. We collected demographics, reasons for the switch, and usage pattern/response to eptinezumab after 6 and 12 months. The generalized estimating equation (GEE) test adjusted for age, sex, and BMI was used for repeated measure analysis. Missing data were not included. <h3>Results:</h3> We reviewed 30 patients (25 female, age 52.3±12.6, BMI 28.3±6.1) who experienced headaches for 26.8±17.8 years and switched to eptinezumab. At the index date, all subjects received a 100mg regimen and reported a mean monthly headache (MHD) of 24.6±8.6 and average pain intensity (API) of 6.2±1.8. After 6 months, 23 subjects continued, and 14 (61%) received a 300mg regimen. They had an MHD of 24.5±9.4 (n=16) and API of 5.7±1.4 (n=14). After 12 months, 15 subjects continued, and 10 (71.4%) were on a 300mg regimen. These subjects had an MHD of 22.5±10.5 (n=12) and API of 5.5±1.3 (n=12). The main reasons for eptinezumab discontinuation were inadequate response (n=6/15; 40%), intolerance (n=3/15; 20%), and insurance (n=5/15, 33%). There were insignificant reductions at 6 and 12 months of MHD (−0.71, 95%CI −3.42 to 2.00, p=0.61; −1.36, 95%CI −4.52 to 1.81, p=0.40) and API (−0.46, 95%CI −1.17 to 0.24, p=0.20; −0.63, 95%CI −1.38 to 0.13, p=0.11). <h3>Conclusions:</h3> In our study, patients may sustain no apparent benefit upon switching to eptinezumab after 6 or 12 months, reflecting the refractory nature of this study population. More prospective studies are needed. <b>Disclosure:</b> Miss Casaletto has nothing to disclose. Dr. Yang has nothing to disclose. Mr. Waters has nothing to disclose. Mr. Curran has nothing to disclose. Mr. Lowe has nothing to disclose. An immediate family member of Dr. Yuan has received personal compensation for serving as an employee of Merck. Dr. Yuan has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Trillen Medical. The institution of Dr. Yuan has received research support from NIH. Dr. Yuan has received publishing royalties from a publication relating to health care. Dr. Yuan has received personal compensation in the range of $0-$499 for serving as a Grant reviewer with NIH.

A Cross-Sectional Survey of Prevailing Opinions from Headache Specialists Regarding Status Migrainosus Management (P11-12.001)

<h3>Objective:</h3> To gather the prevailing opinions of headache specialists regarding status migrainosus (SM) management based on clinical experience and exposure to scientific data. <h3>Background:</h3> SM is a debilitating migraine complication with intense symptoms lasting &gt;72 hours. Although SM epidemiologic data are unclear, a recent population-based study in Minnesota reported that 15% of individuals experienced a recurrent SM attack during the following year. Although no evidence-based treatment guidelines for SM exist, treatment can include steroids, nerve blocks, nonsteroidal anti-inflammatory drugs, triptans, ergotamine, neuroleptics, and dihydroergotamine mesylate (DHE). Consensus on defining clinical trial endpoints for SM to improve future research and outcomes is an unmet need. <h3>Design/Methods:</h3> A cross-sectional phone survey was conducted with 33 headache specialists from tertiary headache centers across the United States. Verbal responses to 8 questions asked at random about SM patterns observed and treatment protocols used for SM management were given. <h3>Results:</h3> Most headache specialists reported treating SM patients every week, sometimes several patients per day. Cases were frequently observed at the clinic, but some required hospital admission when clinics were considered inadequate for SM treatment. Most headache specialists used drug infusions, the Raskin or modified DHE protocol, or steroids to treat SM. While DHE is considered the gold standard to completely break recurrence, drug inaccessibility and hesitation to send patients to hospitals limit its use. Most headache specialists reported refractory patients being more prone to recurrent SM attacks. Treatment goals included avoiding emergency room (ER) visits and providing patients with autonomy and at-home treatments (eg, self-injections, oral steroids). <h3>Conclusions:</h3> Headache specialists treat multiple SM patients per week and value treatments that break the headache and offer sustained pain relief while avoiding ER visits. Although DHE was viewed favorably for SM, it was underutilized and often only as a last resort due to accessibility issues. <b>Disclosure:</b> Dr. Robblee has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Impel. Dr. Robblee has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Abbvie. An immediate family member of Dr. Robblee has received personal compensation in the range of $0-$499 for serving as an officer or member of the Board of Directors for Scottsdale Providence. The institution of Dr. Robblee has received research support from Eli Lilly. The institution of Dr. Robblee has received research support from AbbVie. The institution of Dr. Robblee has received research support from Barrow Neurological Institute. Dr. Robblee has received publishing royalties from a publication relating to health care. Dr. Robblee has received publishing royalties from a publication relating to health care. Dr. Vann has received personal compensation for serving as an employee of Impel Neuropharma. Dr. Vann has received personal compensation for serving as an employee of Biogen. Dr. Fitzpatrick has received personal compensation for serving as an employee of Impel Pharmaceuticals. Dr. Murphy has nothing to disclose. Dr. Ray has received personal compensation for serving as an employee of Impel Pharmaceuticals. Dr. Ray has stock in Impel Pharmaceuticals. Dr. Shrewsbury has received personal compensation for serving as an employee of Impel NeuroPharma. Dr. Shrewsbury has received stock or an ownership interest from Impel NeuroPharma. Dr. Aurora has received personal compensation for serving as an employee of Impel Neuropharma. Dr. Aurora has stock in Impel Neurpharma.

Quantitative and Qualitative Pain Evaluation in Response to OnabotulinumtoxinA for Chronic Migraine: An Observational Real-Life Study.

(1) Background: Randomized controlled trials and real-life studies demonstrated the efficacy of OnabotulinumtoxinA (OBT-A) for CM prevention. However, no studies specifically addressed its effect on pain's quantitative intensity and qualitative characteristics. (2) Methods: This is an ambispective study: a post-hoc retrospective analysis of real-life prospectively collected data from two Italian headache centers on CM patients treated with OBT-A over one year (i.e., Cy1-4). The primary endpoint was the changes in pain intensity (Numeric Rating Scale, NRS; the Present Pain Intensity (PPI) scale, the 6-point Behavioral Rating Scale (BRS-6)) and quality scale (the short-form McGill Pain Questionnaire (SF-MPQ)) scores. We also assessed the relationship between changes in intensity and quality of pain and disability scale (MIDAS; HIT-6) scores, monthly headache days (MHDs), and monthly acute medication intake (MAMI) (3) Results: We retrieved 152 cases (51.5 years SD 11.3, 80.3% females). From baseline to Cy-4, MHDs, MAMI, NRS, PPI, and BRS-6 scores decreased (consistently p < 0.001). Only the throbbing (p = 0.004), splitting (p = 0.018), and sickening (p = 0.017) qualities of pain collected in the SF-MPQ were reduced. Score variations in MIDAS related to those in PPI scales (p = 0.035), in the BRS-6 (p = 0.001), and in the NRS (p = 0.003). Similarly, HIT-6 score changes related to PPI score modifications (p = 0.027), in BRS-6 (p = 0.001) and NRS (p = 0.006). Conversely, MAMI variation was not associated with qualitative or quantitative pain score modifications except BRS-6 (p = 0.018). (4) Conclusions: Our study shows that OBT-A alleviates migraine by reducing its impact on multiple aspects, such as frequency, disability, and pain intensity. The beneficial effect on pain intensity seems specific to pain characteristics related to C-fiber transmission and is associated with a reduction in migraine-related disability.

Fundus imaging and perimetry in patients with idiopathic intracranial hypertension - an intermethod and interrater validity study.

There is a need to improve the diagnostic process of patients suspected of papilledema. In patients with known or suspected idiopathic intracranial hypertension we validated a fundus imaging and perimetric visual field assessment system (COMPASS) performed at a headache centre in comparison to an assessment (Topcon plus OCTOPUS) at a neuroophthalmological clinic. For intermethod assessment, blinded fundus images and perimetry from COMPASS versus Topcon plus OCTOPUS were assessed by a neuroophthalmologist. For interrater assessment, fundus images and perimetry obtained by the COMPASS system were assessed by an untrained medical doctor, a trained neurologist and a trained medical student and compared to the neuroophthalmologist's assessments. For the intermethod variation of presence of papilledema on fundus images, a kappa value of 0.60, sensitivity of 87% and specificity of 73% were found. The interrater variation of presence of papilledema on fundus images showed kappa values ranging from 0.43 - 0.74, sensitivity values ranging from 69.8% - 96.2% and specificity values ranging from 45.6% - 93.4% when comparing the assessments made by the headache centre staff with neuroophthalmologist's assessments. The COMPASS showed a 59% sensitivity and moderate agreement in detecting visual field defects compared with OCTOPUS. The visual field assessment showed only slight to fair agreement from 0.19 - 0.31 between assessments made by the headache center staff and the neuroophthalmologist. The COMPASS system can be used with reasonable sensitivity in the assessment of papilledema in patients suspected of IIH at a tertiary headache centre.

Tension-type headaches

Christina R. Lindemann practices in neurology at the UC San Diego Health Headache Center in San Diego, Calif. The author has disclosed no potential conflicts of interest, financial or otherwise. Dawn Colomb-Lippa, MHS, PA-C, department editor