Management Of Migraine Research Articles

Hyperacusis in migraine: pilot project

The stress caused by headache may be related to the development of hearing disorders, such as hyperacusis and phonophobia. Hyperacusis is an unpleasant sensation caused by exposure to a due reduction in your tolerance. Characterized by an increase in sound sensitivity via the auditory pathway and by the ability to hear. However, some few problems can occur, while others can even be from the intensity in case of elevation. Phonophobia is a common symptom and with migration criteria, without a diagnosis of hyperacusis was still little in this context. For this reason, a better understanding of hyperacusis corresponds to a new means for the management and diagnosis of migraine. Keywords: migraine, hyperacusis, phonophobia.

Lifestyle Modifications for Migraine Management.

Migraine is a disabling disease that inflicts a heavy burden on individuals who suffer from it. Significant advances are being made in understanding the pathophysiology and treatment of the disease. The role of lifestyle modifications has become increasingly predominant. We reviewed the current and available data on the role of a healthy lifestyle in the management of migraine. Physical activity, management of obesity, a healthy diet, and a better lifestyle, such as adequate sleep and avoidance of drug abuse, significantly contribute to reducing the frequency and severity of attacks. It is important to consider these factors in the overall management strategies for migraine sufferers.

A Markov Analysis of Surgical versus Medical Management of Chronic Migraines.

Refractory chronic migraine is a common and debilitating neurologic condition, affecting over 8 million people in the United States. It is associated with billions of dollars in lost productivity annually. Novel medical (anti-calcitonin gene-related peptide antibodies) and surgical treatment modalities have emerged for chronic migraine in recent years. The current study investigated the cost-utility of surgical versus medical management of refractory chronic migraine. A Markov cohort analysis using hybrid Monte Carlo patient simulation was performed to compare surgical decompression versus erenumab for the treatment of refractory chronic migraine in adults. Both societal and payer perspectives were considered. Primary model outcomes included incremental cost-effectiveness ratio, or cost per quality-adjusted life-year gained. Over a 5-year period, migraine surgery was associated with an increase of 0.2 quality-adjusted life-year per patient when compared to erenumab. In terms of costs, the results demonstrated a $19,337 decrease in direct medical costs and a $491 decrease in indirect costs (productivity lost) for the surgery cohort compared to erenumab. Because surgery improved quality of life and decreased costs compared to erenumab, even when considering revision surgery needs, surgery was the overall dominant treatment in terms of cost-effectiveness. Sensitivity analyses demonstrated that surgery was cost-effective compared to erenumab when patients required therapy for at least 1 year. Surgical deactivation of migraine trigger sites may pose a cost-effective approach to treating refractory chronic migraine in adults. This is especially the case when patients are anticipated to require therapy for more than 1 year.

Machine prescription for chronic migraine.

Responsive to treatment individually, chronic migraine remains strikingly resistant collectively, incurring the second-highest population burden of disability worldwide. A heterogeneity of responsiveness, requiring prolonged—currently heuristic—individual evaluation of available treatments, may reflect a diversity of causal mechanisms, or the failure to identify the most important, single causal factor. Distinguishing between these possibilities, now possible through the application of complex modelling to large-scale data, is critical to determine the optimal approach to identify new interventions in migraine and making the best use of existing ones. Examining a richly phenotyped cohort of 1446 consecutive unselected patients with chronic migraine, here we use causal multitask Gaussian process models to estimate individual treatment effects across 10 classes of preventatives. Such modelling enables us to quantify the accessibility of heterogeneous responsiveness to high-dimensional modelling, to infer the likely scale of the underlying causal diversity. We calculate the treatment effects in the overall population, and the conditional treatment effects among those modelled to respond and compare the true response rates between these two groups. Identifying a difference in response rates between the groups supports a diversity of causal mechanisms. Moreover, we propose a data-driven machine prescription policy, estimating the time-to-response when sequentially trialling preventatives by individualized treatment effects and comparing it to expert guideline sequences. All model performances are quantified out-of-sample. We identify significantly higher true response rates among individuals modelled to respond, compared with the overall population (mean difference of 0.034; 95% confidence interval 0.003–0.065; P = 0.033), supporting significant heterogeneity of responsiveness and diverse causal mechanisms. The machine prescription policy yields an estimated 35% reduction in time-to-response (3.750 months; 95% confidence interval 3.507–3.993; P < 0.0001) compared with expert guidelines, with no substantive increase in expense per patient. We conclude that the highly distributed mode of causation in chronic migraine necessitates high-dimensional modelling for optimal management. Machine prescription should be considered an essential clinical decision-support tool in the future management of chronic migraine.

Propofol + Granisetron vs. Propofol + Metoclopramide in Symptom Management of Acute Migraine Headache; a Double-Blind Randomized Clinical Trial.

Introduction:Acute headache is one of the most common reasons for emergency department (ED) visits. This study aimed to compare the combination of propofol and granisetron with propofol and metoclopramide in symptom management of acute migraine headache.Methods:In this double-blind randomized clinical trial, 60 adult patients with acute migraine headache who referred to ED were randomly divided into two groups of propofol + metoclopramide and propofol + granisetron. Pain and nausea/vomiting severity as well as blood pressure were compared between groups 30, 45, and 60 minutes after treatment. Results:The two groups had similar situation regarding mean age (p = 0.606), sex distribution (p = 0.793), baseline severity of pain (p = 0.642), frequency of nausea/vomiting (p = 0.488), and vital signs (p > 0.05). The severity of pain was similar in the two groups 30 (p = 0.731), 45 (p = 0.460), and 60 (p = 0.712) minutes after treatment. The number of patients with resistant nausea and vomiting 60 minutes after treatment was significantly higher in metoclopramide group (30.0% versus 10.0%; p = 0.033). Diastolic pressure 60 minutes after treatment (81.43 ±8.94 vs. 74.97 ± 4.8; p = 0.001) and heart rate 30 minutes after treatment (68.87 ±6.52 vs. 73.57± 7.62; p = 0.013) had statistically significant differences between the groups. Conclusion:The combination of propofol and granisetron was superior to propofol and metoclopramide in case of controlling nausea and vomiting of cases with acute migraine headache; meanwhile, no differences were observed in case of pain relief and hemodynamic status between the two groups.

Migraine Attacks and Relevant Trigger Factors in Undergraduate Nursing Students in Hong Kong: A Cross-Sectional Study.

ObjectiveThis study aimed to examine the prevalence and features of migraine and explore the possible migraine triggers in a sample of university nursing students in Hong Kong.MethodsA cross-sectional study using self-administered questionnaires was conducted in the Hong Kong Polytechnic University in 2016. The questionnaire included ID Migraine™ for migraine screening and items measuring the frequency, duration, severity, associated symptoms, and trigger factors of migraine. Years 2–5 undergraduate nursing students from the university completed the questionnaires. Binary logistic regression was conducted to examine the migraine-associated factors.ResultsA total of 702 nursing students, including 168 males and 534 females, were successfully screened. Their mean age was 20.8 ± 1.4 years. The overall prevalence of migraine reached 11.8%. Over half (67.5%) of the students with migraine experienced attacks at least once per month. Each attack had a median duration of 3 h (interquartile range: 1–4 h) and the mean pain intensity score of 6.4 ± 1.6. Students with a family history of migraine (adjusted odds ratio [OR]: 1.89; 95% confidence interval [CI]: 1.10, 3.25; p < 0.05) and poor general health status (Adjusted OR: 3.41, 95% CI: 1.05, 11.09; p < 0.05) were more likely to suffer from migraine than those without. The three most common migraine triggers were the lack of sleep (94.0%), change in sleep schedule (83.1%), and noise (81.9%). Female students were more likely to experience fatigue-triggered migraine than male students (85.9% vs 63.2%, p < 0.05).ConclusionMigraine prevalence was relatively high among undergraduate nursing students in Hong Kong. Sleep problem was the most frequent trigger factor. The students’ awareness of migraine attacks should be increased, and migraine management must be improved by avoiding common trigger factors in this population.

Repetitive transcranial magnetic stimulation for prophylactive treatment of chronic migraine: A randomised, single-blind, parallel-group, sham-controlled trial

Background: Pilot studies suggest that repetitive transcranial magnetic stimulation could be effective in migraine. We studied its efficacy for prophylaxis of chronic migraine. Methods: We undertook a randomised, single-blind, sham-controlled study in patients with chronic migraine. Subjects were randomly allocated to sham, high-frequency repetitive transcranial magnetic stimulation (HF-rTMS) or low-frequency repetitive transcranial magnetic stimulation (LF-rTMS). The primary outcome was the reduction of attacks at four weeks. In addition, reduction of severity of headache based on the Visual Analogue Scale score at two &amp; four weeks and a functional disability score at four weeks was recorded. Results: One hundred and eight patients were allocated to sham stimulation (n=36), HF-rTMS (n=36) and LF-rTMS (n=36) groups. The number of attacks per month decreased to 7.05+/-1.45 at four weeks post-rTMS in the HF-rTMS (p&lt;0.001) as compared to the LF-rTMS (10.61+/-1.69) and sham (10.83+/-3.37) groups. The VAS score in the HF-rTMS group was significantly lowered (p &lt; 0.001) from 8.61+/-1.15 at baseline to 6.63+/-0.96, and 7.19+/-0.98 at two and four weeks respectively. The duration of headache in hours over 4 weeks reduced from 32.4+/-14.9 to 11.6+/-6.14 in the HF-rTMS group (p&lt;0.001), but did not change significantly in the LF-rTMS (30.4+/-11.9 to 27.8+/-14, p&gt;0.05) and sham (26.8+/-11.06 to 37+/-15, p&gt;0.05) in sham groups. There was no significant difference in functional disability between all the study groups at four weeks. Conclusion: High-frequency, but not low-frequency, repetitive transcranial magnetic stimulation may be useful in management of chronic migraine.

Vestibular migraine (VM) management for an ENT surgeon - an update on diagnostic criteria and current management strategies

Overview: Vestibular migraine is a very common problem needing attention as it’s a diagnosis frequently missed. This article discusses key diagnostic indicators including ID-migraine, motion sickness, phono/photophobia. Key management options including prophylactic and abortive medications are also discussed. Findings: Using of the 3 item ID-Migraine questionnaire increases sensitivity. There is no RCT evidence that Nutraceuticals usage, restriction of MSG Caffeine Chocolates, artificial sweeteners, processed meats, alcohol and aged cheese are useful in management VM. Although beta blockers are used as prophylaxis, metoprolol may not be effective.The mainstay of abortive management is 5HT receptor agonists. Recommendations: It is necessary to raise the awareness of the diagnostic entity and necessary training and education should be given to care givers. Future research is necessary to identify therapeutic agents and lifestyle changes specifically to be effective in this condition.

Migraine in Adult Primary Care

Migraine is a prevalent primary headache disorder characterized by episodic attacks. It affects more than 1 billion people worldwide. Because of its episodic nature and varying symptomology, migraine is often underdiagnosed and undertreated in the primary care setting. Migraine is often disabling, and the negative burden of migraine impacts financial, socioeconomic, and personal aspects of the client’s life. Several treatments are available for acute migraine attacks, including a few novel medications. The management of migraine is complex and involves both acute treatment and prevention. Ultimately, accurate assessment, diagnosis, and collaboration lead to a more optimal course of treatment and management.

Eptinezumab treatment initiated during a migraine attack is associated with meaningful improvement in patient-reported outcome measures: secondary results from the randomized controlled RELIEF study

BackgroundDemonstrating therapeutic value from the patient perspective is important in patient-centered migraine management. The objective of this study was to investigate the impact of eptinezumab, a preventive migraine treatment, on patient-reported headache impact, acute medication optimization, and perception of disease change when initiated during a migraine attack.MethodsRELIEF was a randomized, double-blind, placebo-controlled trial conducted between 2019 and 2020 in adults with ≥1-year history of migraine and 4–15 migraine days per month in the 3 months prior to screening. Patients were randomized (1:1) to a 30-min infusion of eptinezumab 100 mg or placebo within 1–6 h of a qualifying migraine attack onset. The 6-item Headache Impact Test (HIT-6) and 6-item Migraine Treatment Optimization Questionnaire (mTOQ-6) were administered at baseline and week 4, and the Patient Global Impression of Change (PGIC) at week 4. A post hoc analysis of these measures was conducted in patients who reported headache pain freedom at 2 h after infusion start.ResultsOf 480 patients enrolled and treated, 476 completed the study and are included in this analysis. Mean baseline HIT-6 total scores indicated severe headache impact (eptinezumab, 65.1; placebo, 64.8). At week 4, the eptinezumab-treated group demonstrated clinically meaningful improvement in HIT-6 total score compared with placebo (mean change from baseline: eptinezumab, − 8.7; placebo, − 4.5; mean [95% CI] difference from placebo: − 4.2 [− 5.75, − 2.63], P < .0001), with greater reductions in each item score vs placebo (P < .001 all comparisons). Change in HIT-6 total score in the subgroup with 2-h headache pain freedom was − 13.8 for the eptinezumab group compared with − 4.9 for the placebo group. mTOQ-6 total score mean change from baseline favored eptinezumab (change, 2.1) compared with placebo (1.2; mean [95% CI] difference: 0.9 [0.3, 1.5], P < .01). More eptinezumab-treated patients rated PGIC as much or very much improved than placebo patients (59.3% vs 25.9%).ConclusionsWhen administered during a migraine attack, eptinezumab significantly improved patient-reported outcomes after 4 weeks compared with placebo, with particularly pronounced effects in patients reporting headache pain freedom at 2 h after infusion start.Trial registrationClinicalTrials.gov Identifier: NCT04152083. November 5, 2019.

Nose-to-brain lipid nanocarriers: An active transportation across BBB in migraine management

The present study focused on the development and evaluation of nanotechnology-based carrier systems of solid lipid nanoparticles (SLNs) to enhance the permeation and bioavailability of zolmitriptan across blood-brain-barrier (BBB). SLNs are the emerging field of nanotechnology with numerous applications like cosmetics and pharmaceutical research. Zolmitriptan-loaded SLNs were prepared by high-pressure homogenization method for targeted drug delivery to the brain. The SLNs were found to be round in shape with particle size ranging from 110 to 200 nm and zeta potential upto − 24.83 ± 3.03 mV which indicates good colloidal stability. The maximum entrapment efficiency of zolmitriptan in SLNs was found to be 84.17 ± 12.24%. The in-vitro drug release and ex-vivo release studies exhibited 95.85 ± 2.44% and 82.06 ± 2.94% drug release, respectively for 24 h. In-vivo studies was performed on male Wistar rats wherein the concentration of zolmitriptan was estimated in cerebrospinal fluid by LC-MS method. The selected formulation incorporated with SLNs showed significant enhancement in pharmacokinetic parameters like AUC (37.05 ± 2.45 ng/mL), Cmax (42.08 ± 1.32 ng/mL), Tmax (30 min), and t1/2 (1.28 h). Zolmitriptan-loaded SLNs via intranasal administration offers a novel approach to effectively circumvent first-pass hepatic metabolism than conventional oral route with 4-fold alleviation in permeation and 2-fold improvement in bioavailability.

Case Series to evaluate role of Nutool Therapy on Headache frequency, MIDAS (Migraine Disability Assessment Score) headache intensity by VAS in diagnosed cases of Shaqiqa (Migraine) in Delhi

Almost all Unani physicians have advocated Nutool therapy in the management of migraine (Shaqiqa), particularly with or without medicated oil or liquid, but unfortunately these have not evaluated on scientific parameters. Despite the fact that, this therapy is in the practice of Unani physician and a large number of patients have been treated successfully; this regimen still requires scientific validation to generalize their popularity and acceptability. Present paper is the case series of diagnosed migraine patients to assess the effect of Nutool therapy on headache intensity, MIDAS scale and Pain intensity. The present study entitled “Case Series to evaluate role of Nutool Therapy on Headache frequency (from the daily headache diary),MIDAS (migraine disability assessment score) headache intensity by VAS in diagnosed cases of Shaqiqa (Migraine) in patients attending HAHU and SUMER ,Jamia Hamdard Delhi was conducted in the Department of Tahaffuzi-wa-samaji Tib, SUMER, Jamia Hamdard, New Delhi during the period of September 2020 to Nov 2020 in Psychiatric OPD of HAHC Hospital, Jamia Hamdard, New Delhi on diagnosed Patients of Migraine as per ICHD3rd (International classification of headache disorders) Criteria. Nutool with Rogan Gul was done for 30 minutes for 12 sittings. The analysis of Nutool therapy on intensity of pain was done and it was found that Nutool therapy reduced the intensity of pain, and it was found statistically significant P&lt;.005 (ANOVA of repeated measures) Freidman statistic Fr =17.76. Nutool therapy also reduced the MIDAS (migraine disability assessment score) and was statistically significant (P&lt;.0047).and was effective on intensity of headache and found statistically significantly P&lt;.0001. Further studies need to be carried out so that it can be advocated on large scale in management of migraine effectively.&#x0D; Keywords: Migraine, Nutool, Rogan-e-Gul, MIDAS, VAS, Pain.

Calcitonin gene-related peptide and pituitary adenylate cyclase-activating polypeptide in migraine treatment.

To review the latest advances in migraine management with a focus on medications specifically developed for the treatment of migraine. Randomized clinical trials demonstrated the efficacy of calcitonin gene-related peptide (CGRP) mAbs for the preventive treatment of migraine and the small molecule CGRP receptor antagonist gepants for acute abortion and prevention of migraine attacks. Pituitary adenylate cyclase-activating polypeptide (PACAP) is another signaling molecule of interest and represents a potential new drug class of mechanism-based migraine medications. Drugs targeting PACAP are currently undergoing clinical trials, and the coming years will reveal whether this class of drugs will expand our therapeutic armamentarium. Here, we summarize the role of CGRP and PACAP in migraine pathophysiology and discuss novel therapies targeting the CGRP and PACAP signaling pathways.

Caracterización del manejo del paciente con migraña en Atención Primaria en España. Análisis de los resultados del proyecto europeo My-LIFE anamnesis

IntroductionMigraine affects more than 4.5 million people in Spain, resulting in a considerable socioeconomic impact. Although national and international guidelines have been published, the management of patients with migraine, especially those with chronic migraine, is inadequate. Subjects and methodsWe conducted a survey among 40 primary care (PC) physicians in Spain as part of a European project involving 201 physicians from 5 countries. ResultsMost participants issued diagnoses of episodic migraine and chronic migraine (93% vs 65%); 82.5% indicated that they did not refer these patients to specialists, and 100% of PC physicians stated that they were responsible for patient follow-up. The main tools used in PC for diagnosis and follow-up were clinical interviews, medical histories, and the patient diaries. Our data revealed that the treatments prescribed were not in accordance with the national and international guidelines. Participants who did not refer patients estimated that only 48% of patients received preventive treatment, and that the assessment of efficacy was based on patient perception. Seventy percent of respondents indicated a need for migraine training. Finally, 100% of participants considered that a guide for medical history taking and referral would be essential or useful for the management of migraine in PC. ConclusionsThe survey results revealed a need for training and guidance in PC to improve the diagnosis and management of patients with migraine, particularly chronic migraine.

Migraine.

Migraine is a common, chronic, disorder that is typically characterized by recurrent disabling attacks of headache and accompanying symptoms, including aura. The aetiology is multifactorial with rare monogenic variants. Depression, epilepsy, stroke and myocardial infarction are comorbid diseases. Spreading depolarization probably causes aura and possibly also triggers trigeminal sensory activation, the underlying mechanism for the headache. Despite earlier beliefs, vasodilation is only a secondary phenomenon and vasoconstriction is not essential for antimigraine efficacy. Management includes analgesics or NSAIDs for mild attacks, and, for moderate or severe attacks, triptans or 5HT1B/1D receptor agonists. Because of cardiovascular safety concerns, unreliable efficacy and tolerability issues, use of ergots to abort attacks has nearly vanished in most countries. CGRP receptor antagonists (gepants) and lasmiditan, a selective 5HT1F receptor agonist, have emerged as effective acute treatments. Intramuscular onabotulinumtoxinA may be helpful in chronic migraine (migraine on ≥15 days per month) and monoclonal antibodies targeting CGRP or its receptor, as well as two gepants, have proven effective and well tolerated for the preventive treatment of migraine. Several neuromodulation modalities have been approved for acute and/or preventive migraine treatment. The emergence of new treatment targets and therapies illustrates the bright future for migraine management.

Constipation Caused by Anti-calcitonin Gene-Related Peptide Migraine Therapeutics Explained by Antagonism of Calcitonin Gene-Related Peptide's Motor-Stimulating and Prosecretory Function in the Intestine.

The development of small-molecule calcitonin gene-related peptide (CGRP) receptor antagonists (gepants) and of monoclonal antibodies targeting the CGRP system has been a major advance in the management of migraine. In the randomized controlled trials before regulatory approval, the safety of these anti-CGRP migraine therapeutics was considered favorable and to stay within the expected profile. Post-approval real-world surveys reveal, however, constipation to be a major adverse event which may affect more than 50% of patients treated with erenumab (an antibody targeting the CGRP receptor), fremanezumab or galcanezumab (antibodies targeting CGRP). In this review article we address the question whether constipation caused by inhibition of CGRP signaling can be mechanistically deduced from the known pharmacological actions and pathophysiological implications of CGRP in the digestive tract. CGRP in the gut is expressed by two distinct neuronal populations: extrinsic primary afferent nerve fibers and distinct neurons of the intrinsic enteric nervous system. In particular, CGRP is a major messenger of enteric sensory neurons which in response to mucosal stimulation activate both ascending excitatory and descending inhibitory neuronal pathways that enable propulsive (peristaltic) motor activity to take place. In addition, CGRP is able to stimulate ion and water secretion into the intestinal lumen. The motor-stimulating and prosecretory actions of CGRP combine in accelerating intestinal transit, an activity profile that has been confirmed by the ability of CGRP to induce diarrhea in mice, dogs and humans. We therefore conclude that the constipation elicited by antibodies targeting CGRP or its receptor results from interference with the physiological function of CGRP in the small and large intestine in which it contributes to the maintenance of peristaltic motor activity, ion and water secretion and intestinal transit.

Yoga as an Adjuvant therapy in management of migraine- An open label randomised trial.

Drug treatment is not very satisfactory in migraine and is associated with adverse effects. The effect of yoga as an add-on therapy in migraine was evaluated in the present study. Patients between the age of 18 and 60 years suffering from migraine were recruited from Internal Medicine and Neurology OPD. Migraine was diagnosed according to the International Headache Society, International Classification of Headache Disorders-3rd edition (IHS, ICHD-3). At baseline, clinical and autonomic parameters of patients were assessed, and consenting patients were randomized into two equal groups by using a computer-based random number generator program (version 1): conventional (C group) and conventional plus yoga (C+Y group). Both groups were given conventional therapy for migraine, and the C+Y group was given yoga as an add-on therapy. Yoga therapy was given for 5 days/week for 12 weeks, and a post-intervention assessment was done at the 14th week. Subjective variables such as frequency and average duration were assessed through headache diaries or telephonic conversation, while severity was assessed using the visual analog scale (VAS) and headache impact test (HIT-6). Independent t test and Mann-Whitney U Test (Wilcoxon rank-sum test) were used for comparing normally and non-normally distributed endpoint outcomes after treatment (AT). Out of 170 patients screened, 75 were diagnosed with migraine and only 34 patients completed the study (17 in each group). All clinical and autonomic parameters showed significant improvement in pre- and post-intervention values in both groups (P < 0.0001). On comparing the conventional (C) group and conventional + yoga (C+Y) group, the change in the VAS score was more in the C+Y group (P = 0.041) and heart rate variability showed more reduction in the C+Y group (P = 0.032). We did not find any significant difference in the clinical outcome by adding yoga therapy to conventional therapy, except reduction in VAS score and reduction in heart rate variability.

Ayurveda for management of migraine: A narrative review of clinical evidence.

Migraine is a primary headache disorder characterized by recurrent attacks. The economic and societal burden of migraine is substantial, affecting patients' quality of life in terms of work, social activities, and family life. This article attempts to review the available literature for clinical evidence of Ayurveda in the management of migraines. We performed a literature search from January 2000 to July 2020 on popular search engines such as Pub Med, Google Scholar, and AYUSH Research Portal using the keywords "Complementary and Alternative Medicine (CAM) and Migraine", "Ayurveda and Migraine" and "Panchakarma and Migraine". The selection criteria involved published clinical trials, including pilot studies, whereas review articles, concept papers, letters to the editor, and studies published in languages other than English were excluded. Out of 77 studies that were screened, 12 articles that satisfied the selection criteria consisted of six Randomized controlled Trials (RCTs), five non-RCTs, and one pilot study. Among them, ten studies used polyherbal and Herbo mineral formulations, two studies contained no oral medications, three trials utilized external therapies, and ten studies used panchakarma procedures. Eleven studies found Ayurveda to be clinically beneficial as monotherapy, while one study demonstrated the usefulness of Ayurveda as an add-on to conventional management. This review reveals the beneficial role of Ayurveda in the management of migraines without many side effects. Yet several limitations exist, like small sample size, short follow up, and lack of better outcome measures for pre and post-assessments. Future research should overcome these limitations and follow a robust methodology so that definitive conclusions can be drawn.

Migraine in perimenopausal women

There is an unmet need for effective diagnosis and management of migraine in perimenopausal women. Menstrual cycle hormone disruption during perimenopause is associated with an increase in migraine and menstrual migraine prevalence, together with other more commonly recognised menopause symptoms. Women of perimenopause age, i.e., early 40s to mid 50s, should routinely be asked about migraine and menopause symptoms, and provided with effective tools for management as appropriate. Simple diaries can be used to identify the frequency and duration of attacks, as well as the relationship to menstruation at outset, and to monitor response to treatment. While there is no evidence to support prescription of hormone replacement therapy (HRT) solely for management of migraine, it is the most commonly used treatment for menopause symptoms. As some types and regimens of HRT can negatively affect migraine, the general recommendation is to use transdermal oestrogen and continuous progestogen regimens where possible. In contrast to contraceptive synthetic oestrogens, physiological doses of natural oestrogen can be used by women with migraine aura. Most women, particularly those with a history of menstrual migraine, can be reassured that the natural history of migraine is to improve with increasing years post menopause.

Sex and age differences in migraine treatment and management strategies.

Migraine is one of the leading causes of disability worldwide, especially in women younger than 50 years old. Migraine has three times higher prevalence in women than in men and tends to decrease after the menopausal transition. Migraine has different clinical features in people of different ages. Clinical symptoms and factors associated with migraine can be various in women and men. Women have special types of migraine, such as pure menstrual migraine and menstrually related migraine. Besides, clinical symptoms of migraine can change during pregnancy, postpartum and lactation. Women are significantly more often than men consulting a doctor because of migraine. These features of migraine lead to different treatment and management strategies in females and males of different ages. Migraine therefore is a disorder that demonstrates the necessity of a personalization of healthcare-ensuring the proper treatment for the right patient, at the right time. Considering all the available literature and guidelines, in this chapter several strategies for management of acute and prophylactic treatments of migraine, according to sex and age differences, are discussed. The purpose of this chapter is to provide a useful piece of information improving the treatment and management of migraine.