Headache最新文献

Background: Despite optimized therapy, up to 30% of patients with trigeminal neuralgia (TN) experience treatment failure. To date, there is limited and low-quality data available on rescue strategies for this subset of patients. This study describes clinical outcomes associated with intravenous (IV) magnesium sulfate and methocarbamol, with or without adjunctive antiseizure medications (ASMs), in the management of acute, refractory TN pain crises.

Methods: This was a single-center, retrospective cohort study conducted at the Cleveland Clinic Headache and Facial Pain Section from January 2015 to 2024. We analyzed adults (≥18 years) with treatment-refractory TN who received a standardized 3-day infusion regimen of magnesium sulfate and methocarbamol, with or without IV ASMs (levetiracetam, lacosamide, or valproic acid). Each encounter represented a distinct TN pain crisis treated with 3 consecutive days of infusion therapy. Infusions were administered specifically during acute exacerbations of pain that occurred despite ongoing or previously attempted maintenance treatment. Pain intensity was assessed using the 11-point numerical rating scale before and after each infusion day. The primary outcome was the proportion of encounters achieving a ≥50% reduction in NRS score from day 1 preinfusion to day 3 postinfusion.

Results: A total of 170 patients were included. The patient encounters analyzed in this study had an overall mean age of 57.0 years and consisted mostly of females (n = 130, 76.5%). A ≥50% reduction in pain score was achieved in 86.9% of encounters. The largest reduction occurred on day 1, with diminishing but continued improvements on days 2 and 3. Adjunctive IV ASMs were not associated with improved response compared to the magnesium and methocarbamol alone (72.4% vs. 75.8%, respectively; p = 0.740). Pain Disability Index scores also improved among patients with follow-up data.

Conclusion: A 3-day IV infusion protocol combining magnesium sulfate and methocarbamol, with or without adjunctive ASMs, was associated with rapid, meaningful pain relief in most patients with acute TN pain crises. Larger, prospective studies are warranted to further investigate and confirm the effectiveness of this IV treatment strategy for managing this challenging neurological condition.

Objective: This study evaluated cranial magnetic resonance imaging (MRI) signs in patients with post-dural puncture headache (PDPH) using an established assessment score developed for spontaneous intracranial hypotension (Bern score). We hypothesize that patients with chronic PDPH do not have typical imaging features of intracranial hypotension.

Background: PDPH is a well-known complication following an intentional or unintentional lumbar dural puncture with positional headache, neck stiffness, and hearing disturbances usually resolving within 14 days. However, the chronic course of PDPH is poorly represented in the third version of the International Classification of Headache Disorders (ICHD-3). Moreover, data on the role of cranial MRI in this cohort are lacking, but could facilitate care and management of chronic PDPH.

Methods: In this post hoc retrospective case series based on a chart review, we identified 86 consecutive patients from a tertiary medical care center in Freiburg, Germany between 01/2018 and 10/2024 with chronic PDPH, defined as persisting symptoms for >14 days post puncture and/or persisting after one or more epidural blood patches (EBP). Inclusion criteria were history of lumbar puncture (LP) or unintended dural puncture (UDP) and contrast enhanced cranial MRI for assessment of Bern score in all patients. Presence of epidural lumbar fluid was evaluated using heavily T2-weighted MRI or computed tomography (CT) myelography, whenever available (83/86 patients). Data were reviewed independently and blinded by two radiologists.

Results: Eighty-six patients with chronic PDPH (66 females; mean age of 38.8 ± 11.2 SD years) were included with LP as primary cause in 72% (n=62) and UDP while peridural (synonymous epidural) anesthesia (PDA) in 28% (n = 24). Median symptom duration was 220.0 (interquartile range [IQR] 94.0-474.0) days. Overall median Bern score was 2.0 (IQR 1.0-3.0) with no significant differences between LP versus PDA (p = 0.379). Local epidural fluid was present in 9/83 (11%) cases with adequate imaging and accompanied by higher median Bern scores (5.0 vs. 2.0; p = 0.026). Prior EBP was linked to lower median Bern scores (1.0 vs. 3.5; p < 0.001).

Conclusion: Patients with chronic PDPH predominantly present a low Bern score and rarely exhibit spinal epidural fluid. If present, spinal epidural fluid is accompanied by higher Bern score. Our findings highlight the unreliability of current MRI diagnostics to detect patients with chronic PDPH, which must not lead to a mitigation of the diagnosis or a refusal of treatment. Further research on MRI markers is needed here.

Objective: The aim of this study was to synthesize a unifying disease model for idiopathic intracranial hypertension (IIH) based on the current literature.

Background: IIH is a complex neurological condition defined by abnormally elevated intracranial pressure in the absence of an identifiable etiology. Although various causal mechanisms are thought to contribute to the development of IIH pathophysiology, how they interrelate remains poorly understood.

Methods: Here, we synthesize emerging evidence indicating that cerebrospinal fluid (CSF) and interstitial fluid (ISF) dyshomeostasis drive IIH pathology and how alterations in neurofluid regulation are associated with transverse sinus stenosis, brain volume, and the cerebral glymphatic system.

Results: We propose a unified disease model where obesity-mediated metabolic dysfunction results in impaired glymphatic clearance with consequential accumulation of brain ISF with resultant increased brain volume. This subsequently results in extramural compression of the dural venous sinuses. Dural venous stenosis causes venous hypertension with further veno-glymphatic congestion and a positive feedback loop on impaired glymphatic drainage, which further perpetuates interstitial fluid stasis and increased brain volume with increased intracranial pressure.

Conclusions: The presented unifying disease model integrates various observations and suspected drivers of the condition into a cohesive framework of IIH pathogenesis that may be used for future investigations and clinical conceptualization.

Background: OnabotulinumtoxinA (BoNT-A) is an established preventive treatment for chronic migraine but involves 31 to 40 injections per session, often causing discomfort and post-procedural headaches. Remote electrical neuromodulation (REN) is a noninvasive therapy with efficacy in migraine treatment via conditioned pain modulation but has not been evaluated for procedural pain. This study evaluated REN's effectiveness in reducing acute procedural pain and postprocedural headache associated with BoNT-A injections.

Methods: This was an investigator-initiated single-center, randomized, single-blind, sham-controlled crossover study enrolled 80 adults (aged 22 to 74 years) with chronic migraine undergoing routine BoNT-A treatment. Each participant received one injection session without a device, followed by sessions using active REN and sham in randomized order. REN was applied to the upper arm 10 min prior to injections and removed after injection completion. Pain intensity was measured using a visual analog scale (0 to 100) at pre-procedure, intra-procedure, and post-procedure time points. The primary outcome was procedural pain intensity, and secondary outcomes included post-procedural headache incidence and adverse events. Due to clear benefit, the study was terminated early based on predefined stopping criteria.

Results: Final analysis of 60 participants (mean age 48.0 years; 49/60, 82% female) demonstrated that pre-procedural pain levels were not significantly different between baseline and the active REN or sham (p > 0.999 and p = 0.485, respectively). However, during and after BoNT-A administration, the active REN group reported significantly lower pain scores compared to both the sham and baseline conditions. At intra-procedure, the REN group experienced a mean pain reduction of 15.0 points (p < 0.001), and at post-procedure experienced a 19.1-point reduction (p < 0.001). Sham treatment did not result in significant pain reduction compared to baseline (p > 0.999 for both intra-procedure and post-procedure). Additionally, REN lowered the incidence of headache as an adverse event, with only 15% (8/52) of participants experiencing post-procedural headache compared to 55% (29/53) in the sham group and 39% (23/59) at baseline (odds ratio = 0.28, 95% confidence interval: 0.10 to 0.69, p = 0.008). No additional adverse events were reported.

Conclusions: REN significantly reduces procedural pain and post-procedural headache associated with BoNT-A injections for chronic migraine and may serve as a noninvasive, easily implemented pain management strategy for acute procedural pain. REN represents a promising approach to improving patient comfort during routine migraine treatment as well as reducing post-procedural headache.

Objective: To assess the efficacy of cannabis for the treatment of acute migraine.

Background: Preclinical and retrospective studies suggest cannabinoids may be effective in migraine treatment. However, there have been no randomized clinical trials examining the efficacy of cannabinoids for acute migraine.

Methods: In this randomized, double-blind, placebo-controlled, crossover trial, adults with migraine treated up to four separate migraine attacks, one each with vaporized (1) 6% Δ9-tetrahydrocannabinol (THC) (THC-dominant), (2) 11% cannabidiol (CBD) (CBD-dominant), (3) 6% THC + 11% CBD, and (4) placebo cannabis flower in a randomized order. Washout period between treated migraine attacks was ≥1 week. The primary endpoint was pain relief, and secondary endpoints were pain freedom and most bothersome symptom freedom, all assessed at 2-h post-vaporization.

Results: Ninety-two participants were enrolled and randomized, and 247 migraine attacks were treated. THC + CBD was superior to placebo at achieving pain relief (67.2% vs. 46.6%, odds ratio [95% confidence interval] 2.85 [1.22, 6.65], p = 0.016), pain freedom (34.5% vs. 15.5%, 3.30 [1.24, 8.80], p = 0.017), and most bothersome symptom freedom (60.3% vs. 34.5%, 3.32 [1.45, 7.64], p = 0.005) at 2 h, as well as sustained pain freedom at 24 h and sustained most bothersome symptom freedom at 24 and 48 h. THC-dominant was superior to placebo for pain relief (68.9% vs. 46.6%, 3.14 [1.35, 7.30], p = 0.008) but not pain freedom or most bothersome symptom freedom at 2 h. CBD-dominant was not superior to placebo for pain relief, pain freedom, or most bothersome symptom freedom at 2 h. There were no serious adverse events.

Conclusion: Acute migraine treatment with 6% THC + 11% CBD was superior to placebo at 2-h post-treatment with sustained benefits at 24 and 48 h.

Objective: We analyzed data from both a national survey and a single hospital system to determine the prevalence of migraine in individuals with autism as well as identify sociodemographic and clinical characteristics associated with migraine in individuals with autism.

Background: Few studies have examined the prevalence of migraine in autism and there are no studies examining the migraine phenotype and clinical features associated with migraine in autism.

Methods: This retrospective cohort study used two databases-the National Survey of Children's Health (NSCH) and the University of California Los Angeles hospital system electronic health record (UCLA EHR). NSCH survey data from 2018, 2019, 2020, and 2021 (data collection period for each year is June to January; e.g., NSCH 2021 period is June 2021 to January 2022; N = 50,892) were queried to identify cohorts based on responses to two survey questions identifying the presence of frequent/severe headache and autism. For UCLA cohorts, patients (12/01/1979-4/16/2023, N = 4,334,162) were queried for migraine and autism based on the International Classification of Diseases diagnosis codes. We tested the hypothesis: Headache/migraine occurs more frequently in individuals with autism versus without autism. Variables including social determinants of health (SDoH) and co-occurring illnesses were compared between autism with versus without headache/migraine.

Results: Headache and migraine prevalence was higher in individuals with autism versus those without (2021 NSCH-headache % [95% confidence interval {CI}], 7.1% [4.62-9.56] vs. 3.0% [2.62-3.19], p < 0.001 and UCLA-migraine: 3.1% [2.86-3.43] vs. 2.0% [1.97-1.99], p < 0.001). Among those with autism, the presence of headache/migraine was associated with increased odds of adverse childhood experiences such as bullying (NSCH-'Weekly/Almost daily' bullying aOR = 5.93 [2.01-17.50], p = 0.001, 'Never' reference) and being a victim of violence (NSCH-'Yes' aOR = 2.82, [1.19-6.66], p = 0.018), poor general health (NSCH-'Fair/Poor' health aOR = 9.68, [3.01-31.19], p < 0.001, 'Excellent' reference), mood disturbances, including anxiety (NSCH-'Yes' aOR = 4.50, [1.63-12.41], p = 0.004; UCLA aOR = 3.40, [2.78-4.17], p < 0.001), and depression (NSCH-'Yes' aOR = 5.70, [2.50-12.97], p < 0.001; UCLA aOR = 3.76, [3.08-4.60], p < 0.001), as well as increased rates of concussion (NSCH-'Yes' aOR = 9.05, [3.19-25.66], p < 0.001; UCLA aOR = 10.28, [6.91-15.30], p < 0.001).

Conclusions: Headache/migraine occurs at higher rates in individuals with autism and is associated with increased odds of negative SDoH and clinically relevant co-occurring illnesses. This study highlights the importance of migraine screening in individuals with autism. Future work is needed to understand the burden and impact of migraine in autism.