Improvement In Headache Frequency Research Articles

Multimodal digital health treatments for Chronic Migraine associated with Medication Overuse Headache: a literature appraisal and results of a single-arm open trial (the BE-HOME program).

Mindfulness-based treatments gained popularity for migraine treatment. In this manuscript we report the results of a single-arm open pilot study that evaluated the impact of a multimodal web-based intervention combining home-based medication withdrawal, patients' education, and online mindfulness-based interventions. We aimed to address whether our program had the ability to show a change in the observed parameters and the study should therefore be intended as an early phase trial. Consecutive patients with chronic migraine associated with medication overuse headache were enrolled, followed-up for 12months, in a program that included home-based medication withdrawal, education on the correct use of drugs and lifestyle issues, prescription of tailored pharmacological prophylaxis, and attendance to six online mindfulness-based sessions. We tested the effect of the program on improving headache frequency, medication intake, quality of life (QoL), headache impact, depression, self-efficacy, and pain catastrophizing. A total of 37 patients completed the study (10 dropped out). We observed a large improvement in headache frequency, medication intake, headache impact, and QoL, a moderate improvement in pain catastrophizing and a mild improvement in depression symptoms; 70% to 76% of patients achieved 50% or more reduction in headache frequency from baseline to each follow-up (p < .01). The results of our multimodal program showed significant improvements in headache frequency, medication intake, and patient-reported outcomes. Future studies are needed to better identify patients who might benefit most from Digital Health Interventions and to demonstrate at least an equivalence in outcome with in-person programs carried out in hospital settings.

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.

Migraine Outcome Should Not Be Used to Determine Diagnosis, Severity, and Therapy: Moving Towards a Multiparametric Definition of Chronicity

Chronic migraine (CM) diagnosis is nowadays based on the threshold of 15 headache days/month for three consecutive months, of which at least eight have migraine headache features. In recent years, proposals for reducing the threshold to 8 days/month have been proposed. The sole frequency parameter, however, is partial considering the variability in frequency, pain severity, associated symptoms, such as nausea, osmophobia, and photophobia, and presence of aura, but also the variable response to treatment and the association with several comorbidities. Therefore, in our opinion, a multiparameter perspective has to be taken into account that considers the underlying pathophysiology, in particular the presence of tension-type-like pain, cutaneous allodynia, and reduced pain threshold. A paradigm change in the definition of chronic migraine moves far beyond the mere 8 vs. 15 days/month, but has ethical and practical implications for treatment: should patients be treated with the most effective prophylactic drugs, i.e., monoclonal antibodies (MABs), if they enter into a new definition of CM? How should clinicians deal with treatment escalation towards MABs? What is the role of associated conditions, response to treatments, lifestyle issues, and psychological factors? And, finally, which endpoint should we use to define effectiveness? Is improvement in headache frequency enough, or should we move towards disability, quality of life, or workplace productivity?

433 Efficacy and Safety of Surgical Decompression for Migraine: A Systematic Review

INTRODUCTION: Migraine is a common disabling disease with high socioeconomic and personal impacts. Despite various medical options, many patients suffer refractory and chronic migraines. New surgical approaches are gaining traction as viable options to treat migraines. METHODS: The study was conducted in accordance with PRISMA guidelines. An inclusive search of several databases from January 1990 to December 2nd, 2020, was performed. Studies reporting various decompression approaches of peripheral nerves for chronic or refractory migraines were included and analyzed. The risk of bias of individual studies was assessed in accordance with the modified Newcastle-Ottawa Quality Assessment Scale. Only those studies representing their data of migraine with mean frequency and intensity of headache, as well as their complication event rate, were reported. RESULTS: Total, 22 studies comprising 1377 patients with migraines were included. Mean age of patients undergoing surgery was 44.22 (95% CI 42.96 - 45.48) years. Patients underwent surgery for migraine comprising decompression of supraorbital, supratrochlear, zygomaticotemporal, or occipital nerve. Most studies reported recovery from headache with improvement in mean headache frequency (range 4.4 to 16.6 days per month) and mean headache intensity (range 2.80 to 7.30 in visual analog scale). The risk of bias was high, with the bias being high in 10 studies and moderate in 11 studies. Total complication rate was 8.0% (95% CI 4.0%-13.0%) which included paresthesia, wound infection, and hypertrophic scarring in a follow-up duration of 2 to 66 months. Heterogeneity in outcome measures and moderate-to-high risk of bias in the majority of studies precluded for meta-analysis. CONCLUSION: Despite improvement in headache frequency and intensity reported on surgical decompression for migraine, available studies reported used variable outcome measures and had moderate-to-high risk of bias.

Real-world impact of fremanezumab on migraine symptoms and resource utilization in the United States

BackgroundFremanezumab, a fully humanized monoclonal antibody (IgG2Δa) that selectively targets calcitonin gene-related peptide (CGRP), is approved for migraine prevention in adults. Real-world data on the effectiveness of fremanezumab are limited. This retrospective, observational cohort study assessed patient-reported migraine symptoms, health care resource utilization (HCRU), and direct medical costs before and after fremanezumab treatment initiation.MethodsData were extracted from September 2018 through June 2020 from the Midwest component of EMRClaims+®, an integrated health services database containing > 20 million medical records from national commercial insurance claims, Medicare claims, and regional electronic medical records. Patients included in the cohort analysis were aged ≥ 18 years and were administered fremanezumab, with enrollment or treatment history for ≥ 6 months prior (pre-index) to initiating fremanezumab (index date) and ≥ 1 month after the index date (post-index), and without pregnancy or pregnancy-related encounters during the study period. Patient-reported headache frequency, migraine pain intensity (MPI), composite migraine symptoms, and HCRU were assessed pre-index and ≥ 1 month after fremanezumab initiation. Wilcoxon signed-rank tests were used to compare means of migraine symptoms and outcomes and HCRU before and after fremanezumab initiation.ResultsOverall, 172 patients were eligible for analysis. Of patients who self-reported (n = 129), 83.7% reported improvement in headache frequency or symptoms after fremanezumab treatment. Specifically, headache frequency decreased by 63% after fremanezumab initiation: mean (standard deviation) headache frequency was 22.24 (9.29) days per month pre-index versus 8.24 (7.42) days per month post-index (P < 0.0001). Mean MPI also decreased by 18% after fremanezumab initiation: MPI was 5.47 (3.19) pre-index versus 4.51 (3.34) post-index (P = 0.014). Mean emergency room (ER) visits per month decreased from 0.72 to 0.54 (P = 0.003), and mean outpatient visits per month decreased from 1.04 to 0.81 (P < 0.001). Mean hospitalizations per month decreased, but the results did not reach statistical significance (P = 0.095). Hospitalization and ER costs decreased, while outpatient costs increased, from pre-index to post-index, but differences were not statistically significant (P ≥ 0.232).ConclusionsSignificant reductions in headache frequency, MPI, and HCRU were observed after fremanezumab initiation in patients with migraine in a US real-world setting.

Efficacy of Erenumab in the Treatment of Trigeminal Neuralgia: A Retrospective Case Series.

Trigeminal neuralgia (TN) is a chronic, often refractory, pain condition, which adversely affects the lives of patients. Current treatments are only mildly effective. Anti-calcitonin gene-related peptide (CGRP) monoclonal antibodies have been successfully studied in the treatment of migraines. CGRP plays a role in both TN and migraine. It is prudent to attempt CGRP monoclonal antibody therapy in TN. Erenumab, a human anti-CGRP monoclonal antibody medication, modulates CGRP, which is elevated in patients with TN. The primary objective of this study was to evaluate the efficacy of erenumab for patients with TN. Retrospective analysis was performed on data collected from 10 patients diagnosed with TN and treated with erenumab for 6 months. Pain was tracked using a numeric pain rating scale (NPRS) from 0 to 10. The effect of erenumab on NPRS after 6 months' time was the primary end point. Secondary end points included side effects to therapy, improvement in headache frequency in those with comorbid migraine, evaluating mood following therapy, and global mood improvement using scale (worse, no change, improved). Nine of 10 patients (90.0%) reported improvement in pain severity and in global mood improvement. Three patients reported resolution of anxiety and/or depression. Side effects were minimal, with 3 patients reporting constipation, injection site reactions, or both. Based on these results, erenumab appears to be an efficacious treatment option for patients with refractory TN. Patients experienced improvement in pain, reduced frequency of headache, and improvement in mood. Treatment was well tolerated with only mild side effects reported. This study provides Class IV evidence that erenumab increases the probability of improved pain control in patients with medication-resistant TN.

Reduction of headache intensity and frequency with maxillary stabilization splint therapy in patients with temporomandibular disorders-headache comorbidity: a systematic review and meta-analysis.

This systematic review and meta-analysis aimed to analyze the effectiveness of maxillary stabilization splint (SS) therapy to reduce headache (HA) intensity and HA frequency in patients with temporomandibular disorders (TMD)-HA comorbidity. Randomized controlled trials (RCTs) using full-arch coverage, hard resin, and maxillary SS therapy were included. Electronic databases, including Cochrane Library, MEDLINE through PubMed, Web of Science, and EMBASE, were searched. The risk of bias was analyzed based on Cochrane's handbook. The search yielded 247 references up to January 28, 2020. Nine RCTs were included at a high risk of bias. The comparison groups included other splints, counseling, jaw exercises, medications, neurologic treatment, and occlusal equilibration. Four studies reported a statistically significant reduction in HA intensity, and five studies reported significant improvement in HA frequency from baseline at 2-12 months in patients with TMD-HA comorbidity treated with a full-arch hard maxillary SS. HA frequency in tension-type HA (TTH) comorbid with TMD diagnoses of myofascial pain (MFP) or capsulitis/synovitis improved significantly with SS than that with full-arch maxillary non-occluding splint (NOS) in two studies. Comparison groups receiving hard partial-arch maxillary splint nociceptive trigeminal inhibition (NTI) showed statistically significant improvements in HA intensity in patients with mixed TMD phenotypes of MFP and disc displacement comorbid with “general HA.” Comparison groups receiving partial-arch maxillary resilient/soft splint (Relax) showed significant improvements in both HA intensity and frequency in patients with HA concomitant with MFP. The meta-analysis showed no statistically significant difference in the improvement of pain intensity at 2-3 months with comparison of the splints (partial-arch soft [Relax], hard [NTI], and full-arch NOS) or splint use compliance at 6-12 months with comparison of the splints (partial-arch Relax and full-arch NOS) versus the SS groups in patients with various TMD-HA comorbidities. In conclusion, although SS therapy showed a statistically significant decrease in HA intensity and HA frequency when reported, the evidence quality was low due to the high bias risk and small sample size. Therefore, further studies are required.

(293) Calcitonin Gene-Related Peptide Inhibitor: Role in Treatment of Hemicrania Continua, with Potential Benefit in Controlling Diarrhea

Erenumab is a calcitonin gene-related peptide (CGRP) monoclonal antibody, approved recently for prevention of episodic and chronic migraine. CGRP is involved in the pathogenesis of migraine, and erenumab works by blocking the CGRP receptors. Common side effects include injection site reactions and constipation. Here we present a patient with hemicrania continua (HC) who responded well to erenumab, while the medication additionally treated her debilitating diarrhea. A 61-year-old female with history of intractable, refractory, chronic, daily, left hemicranial headaches with migrainous features associated with restlessness, but without cranial autonomic symptoms, was diagnosed to have HC with 100 % response to high dose indomethacin trial. She was maintained on low dose indomethacin due to severe acid reflux, along with topiramate, and greater occipital nerve cryoanalgesia, with partial relief. The patient had additionally been complaining of chronic daily watery diarrhea of unknown etiology with intolerance to solids and liquids for 1 year prior to staring the indomethacin. She complained of about 6 loose stools per day. The patient was started on erenumab 70 mg subcutaneously and re-evaluated after 4 weeks. She reported 50% improvement in headache frequency and intensity one week after starting the medication, with no side effects. Additionally, four days after erenumab was started she noted that her stools appeared more formed and her bowel movements reduced in frequency to once daily. She denied constipation. We plan to take her off indomethacin if the favorable response continues. CGRP inhibitors are a new class of drugs that appear to show great promise in migraine prophylaxis with minimal side effects. We believe that this case demonstrates potential benefit of erenumab in other headache syndromes such as HC, as well as highlighting its effectiveness in treating diarrhea. Further studies need to be done to ascertain the full potential of these drugs.

Headache in Patients with Celiac Disease and Its Response to the Gluten-Free Diet.

To describe headache characteristics among celiac disease (CD) patients and to analyze the relationship between CD and headache. An online survey analyzing the characteristics of headache and its response to the gluten-free diet (GFD) in celiac patients was published on Argentinean Celiac social networks, open to the public to complete. The results were analyzed using chi-square test or Mann-Whitney test accordingly. A total of 1,517 subjects completed the survey, and 866 (55.2%) met the inclusion criteria (headache and CD confirmed with positive biopsy). The subjects were predominantly female (94.5%) and had a median age of 39 ± 11.27 years. Tension-type headache was the most prevalent headache type (52%), followed by migraine without (32.5%) and with aura (15.4%), respectively. Of the included participants, 24% reported headache as the main symptom that resulted in the diagnosis of CD. Following initiation of GFD, headache frequency and intensity improved significantly more in participants with migraine than tension-type headache (P = .02 and P = .013, respectively). Compliance to GFD was higher among subjects with severe manifestations (77% vs 66%, P = .05), and compliant individuals showed a 48% improvement in headache frequency (P = .049). An association between food transgressions and headache was better recognized by migraineurs (P = .02). These results suggest that strict compliance to the GFD could improve headache in celiac patients with headache, even in those without gastrointestinal symptoms. This observation could provide an additional factor when convincing patients to follow a GFD, thus reducing the morbidity related to CD.

Pain-related avoidance and endurance behaviour in migraine: an observational study

BackgroundThe role of avoidance and endurance behaviour is well established in chronic musculoskeletal pain, but less is known about its significance in migraine.MethodsThe 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.ResultsAt baseline, there were positive relations between avoidance (especially social avoidance behaviour) and pain-related disability as assessed by the PDI (Wald χ2 [1] = 32.301, p < 0.001) and the MIDAS (Wald χ2 [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 χ2 [1] = 3.938, p = 0.047) and a negative relation of endurance (especially the humour-distraction subscale) with the HADS anxiety score (Wald χ2 [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.ConclusionsThis 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.

Role of glutamate and its receptors in migraine with reference to amitriptyline and transcranial magnetic stimulation therapy

Glutamate plays an important role in migraine pathogenesis but there is paucity of studies on glutamate in migraine subtypes, effect of treatment on glutamate levels and the changes in glutamate receptors. In this study we report the glutamate levels and changes in glutamate receptors following amitriptyline (AMT) or repetitive Transcranial Magnetic Stimulation (rTMS) therapy.One hundred and fifty migraine patients having more than 4 migraine attacks per month were included. Thirty patients were treated with AMT and 120 with rTMS; 24 patients received 3 sessions, 36 received single session of rTMS and 60 patients received sham stimulation. The severity of headache was assessed by VAS score, Migraine Index (MI) and frequency of headache. Good outcome was defined by 50% improvement in headache frequency; severity and MI. Plasma glutamate level were measured by enzyme linked immunosorbant assay and relative expression of NR2B and mGluR3 receptors by real time polymerase chain reaction. The changes in these parameters before and after treatment were measured and correlated with the clinical parameters.Glutamate levels (P = 0.006) and NR2B receptor expressions (P < 0.001) were significantly higher in migraine patients compared to the controls. Chronic migraine patients had higher glutamate level (P = 0.05). Glutamate and NR2B receptor declined after treatment (P < 0.001). There was a decline in glutamate levels following rTMS (P = 0.03), sham stimulation (P = 0.05) and AMT treatment (P = 0.003). NR2B receptors also declined after rTMS (P = 0.005) and AMT treatment (P = 0.01). It can be concluded that migraine is associated with high plasma glutamate and NR2B receptor which decline following AMT or rTMS therapy.

The Effect of Bariatric Surgery on Migraine Headache in Morbid Obese Patients

Background: Migraine is a common and chronic neuro-inflammatory disease with progressive and episodic headache manifestation that leads to considerable disability. Many studies recognized that obesity is a risk factor for progression of migraine. Furthermore, both migraine and obesity is highly prevalent and important risk factors of chronic cardiovascular disease, stroke, and other inflammatory disease. Thus, it is very important if weight loss could alleviate the migraine headache and its related comorbidities. Aim: The present review article was conducted to assess the potential effect of Bariatric surgery on improvement of migraine headaches in morbid obese patients. Search Strategy: Scopus, PubMed and web of science electronic database were systematically searched with key words of “Bariatric surgery”, “gastric Bypass”; “Morbid Obesity” and “Migraine headache” for interventional studies investigated the impact of Bariatric surgery on migraine headache. Results: The findings suggest significant improvement in headache frequency, duration, migraine-induced discomfort and migraine derived symptoms (nausea, phono and photophobia and) occurs as early as 3 months after bariatric surgery. Moreover, patients who had higher weight loss were more likely to experience a 50% or higher reduction in headache frequency, duration and severity. Conclusions: The entire evidences suggest patients with indications of bariatric surgery will benefit from the improvements in the Migraine headache after surgery. However, it remains unclear whether Bariatric-induced endocrine, gut-brain axis alterations, or reduction in adipokine contribute to migraine improvement, so further studies are needed to confirm and clarify these findings.

Role of β endorphin in pain relief following high rate repetitive transcranial magnetic stimulation in migraine

BackgroundIn migraine, high rate repetitive transcranial magnetic stimulation (rTMS) has been reported to be effective, and β endorphin (BE) may have a role in headache relief. ObjectiveTo report the role of BE and its μ (MOR) and δ opioid receptors (DOR) in headache relief following high rate rTMS in migraine. MethodsNinety-three migraine patients having more than 4 attacks per month were included. 10 Hz rTMS (600 pulses in 10 trains) was delivered to left motor cortex; 3 sessions to 24 (group 1), 1 session to 22 (group II) and sham stimulation to 47 patients (group III). Plasma BE, and MOR and DOR RNA expressions were measured before and third session of rTMS. The improvement in headache frequency and severity was assessed at 1month. ResultsPlasma BE level was lower in the migraine patients compared to controls (P = 0.01). Post-stimulation BE level was higher in group I compared to group III (P = 0.02). The responders had higher BE level than non-responders (P = 0.004). Post-stimulation BE level above 4 ng/ml was associated with improvement in headache frequency in 43 (81.1%) patients, whereas only 23 (57.5%) improved if BE was below 4 ng/ml (P = 0.02) irrespective of type of rTMS. Conclusion10 Hz rTMS relieves headache by increasing BE level. BE level above 4 ng/ml is critical in headache relief irrespective of type of rTMS.

Headache and Treatment of Unruptured Intracranial Aneurysms

The relationship between unruptured intracranial aneurysms (UIAs) and chronic headache and the impact of aneurysm treatment on headache outcome are controversial. The aim of this study was to determine clinical features of a supposedly primary headache in patients with UIA. We also assessed changes in headache characteristics after UIA treatment. We examined clinical and imaging data of patients in whom a UIA was diagnosed during diagnostic workup of a suspected primary headache. Medical records were reviewed and personal telephone follow-ups were performed after UIA treatment to assess changes in the frequency and intensity of the headache. Forty-two patients (76%) reported a substantial improvement in headache frequency and intensity after UIA treatment. Forty-five patients (81%) reported a decrease in headache frequency from a median of 8 days/month before treatment to 1 day/month after treatment (95% confidence interval [CI] 81-83, P < .001). The average intensity in an analog pain scale was 7.7 ± 1.6 before treatment and 5.6 ± 2.4 after treatment (P < .001). Higher headache frequency was associated with a greater odd of improvement after treatment (odds ratio 1.12, 95% CI 1.0-1.26, P = .03). No associations were found between the type of headache, type of treatment (endovascular versus surgical), number, size, or localization of the aneurysms and the response to treatment. The treatment of UIA had a robust beneficial effect on previous headache. Although a "placebo" effect of aneurysm treatment cannot be ruled out, these results suggest a potential association between UIA and certain chronic headaches usually considered to be primary.

Efficacy of single versus three sessions of high rate repetitive transcranial magnetic stimulation in chronic migraine and tension-type headache.

We report the efficacy of three versus single session of 10Hz repetitive transcranial magnetic stimulation (rTMS) in chronic migraine (CM) and chronic tension-type headache (CTTH). Ninety-eight patients with CM or CTTH were included and their headache frequency, severity, functional disability and number of abortive medications were noted. Fifty-two patients were randomly assigned to group I (three true sessions) and 46 to group II (one true and two sham rTMS sessions) treatment. 10Hz rTMS comprising 600 pulses was delivered in 412.4s on the left frontal cortex. Outcomes were noted at 1, 2 and 3months. The primary outcome was 50% reduction in headache frequency, and secondary outcomes were improvement in severity, functional disability, abortive drugs and side effects. The baseline headache characteristics were similar between the two groups. Follow up at different time points revealed significant improvement in headache frequency, severity, functional disability and number of abortive drugs compared to baseline in both group I and group II patients, although these parameters were not different between the two groups. In group I, 31 (79.4%) had reduction of headache frequency and 29 (74.4%) converted to episodic headache. In group II, these were 24 (64.8%) and 22 (59.2%), respectively. In chronic migraine, the severity of headache at 2months reduced in group I compared to group II (62.5 vs 35.3%; P=0.01). Both single and three sessions of 10Hz rTMS were found to be equally effective in CM and CTTH, and resulted in conversion of chronic to episodic headache in 67.1% patients.

Ventral tegmental area deep brain stimulation for refractory chronic cluster headache

To present outcomes in a cohort of medically intractable chronic cluster headache (CCH) patients treated with ventral tegmental area (VTA) deep brain stimulation (DBS). In an uncontrolled open-label prospective study, 21 patients (17 male; mean age 52 years) with medically refractory CCH were selected for ipsilateral VTA-DBS by a specialist multidisciplinary team including a headache neurologist and functional neurosurgeon. Patients had also failed or were denied access to occipital nerve stimulation within the UK National Health Service. The primary endpoint was improvement in the headache frequency. Secondary outcomes included other headache scores (severity, duration, headache load), medication use, disability and affective scores, quality of life (QoL) measures, and adverse events. Median follow-up was 18 months (range 4-60 months). At the final follow-up point, there was 60% improvement in headache frequency (p = 0.007) and 30% improvement in headache severity (p = 0.001). The headache load (a composite score encompassing frequency, severity, and duration of attacks) improved by 68% (p = 0.002). Total monthly triptan intake of the group dropped by 57% posttreatment. Significant improvement was observed in a number of QoL, disability, and mood scales. Side effects included diplopia, which resolved in 2 patients following stimulation adjustment, and persisted in 1 patient with a history of ipsilateral trochlear nerve palsy. There were no other serious adverse events. This study supports that VTA-DBS may be a safe and effective therapy for refractory CCH patients who failed conventional treatments. This study provides Class IV evidence that VTA-DBS decreases headache frequency, severity, and headache load in patients with medically intractable chronic cluster headaches.

Comparison of Levetiracetam and sodium Valproate in migraine prophylaxis: A randomized placebo-controlled study.

Background:Migraine is a chronic and disabling disorder. Treatment of migraine often comprises of symptomatic (abortive) and preventive (prophylactic) treatment. The current drugs used in migraine prophylaxis include antidepressant drugs (Serotonin Reuptake Inhibitors, Tricyclic antidepressants), and anti-epileptic drugs (valproate, gabapentin, etc).Objective:The objective of our study was to assess the efficacy and tolerability of levetiracetam in adult migraine prophylaxis, compared to valproate and placebo.Materials and Methods:We conducted a prospective, randomized, placebo-controlled study. A total of 85 patients were randomized to receive levetiracetam 500 mg/d (n = 27), valproate 500 mg/d (n = 32) or placebo (n = 26). The patients were evaluated for treatment efficacy after 6 months. Efficacy was assessed as a more than 50% decrease in headache frequency.Results:In levetiracetam group, 17 (63.0%) patients experienced a more than 50% decrease in headache frequency, while this efficacy number was 21 (65.6%) for valproate group and 4 (15.4%) for placebo group. The difference was not statistically significant between levetiracetam and valproate, while it was significant when comparing either levetiracetam or valproate to placebo.Conclusion:Compared to placebo, levetiracetam offers improvement in headache frequency in patients with migraine. The efficacy of levetiracetam in migraine prophylaxis is comparable to currently used drugs such as valproate.

Psychotherapy versus usual care in pediatric migraine and tension-type headache: a single-blind controlled pilot study

BackgroundDespite growing interest in psychotherapy in child and adolescent headache, efficacy studies in this research field have focused mainly on cognitive-behavioral therapies. Whereas relaxation and cognitive-behavioral techniques, in particular, have been found to reduce the intensity and frequency of headache in children and adolescents, data on psychodynamic psychotherapy in this population are lacking.Our aim was to explore the effectiveness of a brief psychodynamic psychotherapy program in the treatment of idiopathic headache in childhood and adolescence.MethodsThirty-three newly diagnosed idiopathic headache sufferers aged 6–18 years, consecutively referred to our outpatient services, were randomized to receive either a brief cycle of psychodynamic psychotherapy (eight sessions administered at two-week intervals) or usual care (clinical interview, neurological examination, counselling, symptomatic therapy).The two groups were evaluated at baseline (T0) and at six months (T1) to be assessed for headache characteristics (i.e. frequency, intensity and duration), quality of life (i.e. the EuroQoL score), patient’s global health status (i.e. the Clinical Global Impression score), and emotional-behavioral symptoms (i.e. Child Behavior Checklist scores).ResultsThe two groups were fairly similar with reference to the main demographic and clinical variables. The T0/T1 comparison showed a statistically significant improvement in headache frequency (p = 0.005), intensity (p < 0.001) and duration (p = 0.002), a statistically significant improvement in the CGI score (p = 0.018), and a borderline improvement in the EuroQoL score (p = 0.053) in the group receiving psychotherapy.ConclusionsAccording to our pilot findings, a brief psychodynamic psychotherapy program may be more effective than usual care in children and adolescents with idiopathic headache.

Levetiracetam in Migraine Prophylaxis

Migraine is often a chronic and disabling disorder. The objective of our study was to assess the efficacy and tolerability of levetiracetam (LEV) in adult migraine prophylaxis. We conducted a prospective, randomized, placebo-controlled study. A total of 65 patients were randomized in a 1:1 ratio to receive LEV (n = 32) or placebo (n = 33). Twenty-five patients completed the study in the LEV group and 27 patients in the placebo group. Thirteen subjects discontinued early during the trial. After a 1-month run in period, LEV was started at a dose of 250 mg/d (or the matching placebo) and was increased by 250 mg/wk until the final dosage of 1000 mg/d was reached. The titration phase was followed by maintained phase of 3 months. In LEV group, we found a significant reduction in the frequency (attacks per month) of migraine (from 5.17 [SD, 1.19] at baseline to 2.21 [1.47] in the last 4 weeks) and also in severity of migraine from (2.75 [0.44] to1.29 [0.75]) as compared to the placebo group. Patients treated with LEV also reported a statistically significant reduction in the quantity of symptomatic drugs needed for symptom control as compared to the placebo group (P < 0.0001). The percentage of patients on LEV who experienced greater than or equal to 50% reduction in headache frequency was 64% compared with 22% for placebo. Compared with the placebo group, LEV offers improvement in headache frequency and severity as well as it lowers the requirement for other symptomatic drugs in adult migraine patients.

Headache in children: Effectiveness of multidisciplinary treatment in a tertiary paediatric headache clinic

The aim of this article is to evaluate the effectiveness of a specific multidisciplinary treatment programme for children with headache and to describe the concept and settings of the Children's Headache Clinic in Denmark. All new patients were included and evaluations were conducted after six and 12 months. Pharmacological and non-pharmacological treatments were offered by a team of specialists (physicians, headache nurses, a physiotherapist and a psychologist). The subjects comprised 169 children (mean age 11.7 (range 4-17), 91 females, 78 males), 39% of whom suffered from chronic headache (≥15 days/month). All children were diagnosed according to the International Classification of Headache Disorders, second edition; 20% had migraine, 34% tension-type headache, 27% mixed headache, 4% medication-overuse headache, and 15% were diagnosed with other types of headaches. Fifty per cent of the children had an improvement in headache frequency above 50% at six months. By the use of repeated measurement analysis, we found a significant decrease in headache frequency in all of the six headache groups, whereas the increase in quality of life (PedsQL™ 4.0) was significant for the group as a whole. Though preliminary, the results show a good outcome for multidisciplinary treatment programmes for children who suffer from frequent or chronic headache.