Headache最新文献

Objective: To assess the prevalence, frequency, and characteristics of headache disorders in transgender individuals receiving gender-affirming hormone therapy (GAHT), and to explore the relationship between GAHT and headache pathophysiology. We hypothesized that estrogen-based GAHT would be associated with increased risk of headache, particularly migraine, whereas testosterone-based GAHT would be associated with reduced headache burden.

Background: Migraine is a highly disabling headache disorder that disproportionately affects cisgender women, with hormonal fluctuations playing a key role in its pathophysiology. Despite extensive research in cisgender populations, there is a gap in our understanding about the prevalence and characteristics of headache disorders, including migraine, in transgender and nonbinary individuals undergoing GAHT, and there is true urgency to fill this knowledge gap.

Methods: We conducted a cross-sectional, observational study using an anonymous online survey targeting transgender and nonbinary individuals in Argentina from October 2023 to February 2024. Eligible participants were aged ≥18 years and receiving GAHT. The validated Migraine Screen Questionnaire (MS-Q) was used to identify migraine-like headaches. Additional items assessed changes in headache characteristics associated with GAHT.

Results: Of 160 participants, 102 (63.7%; 95% confidence interval [CI] 56.1%-70.8%) reported experiencing headaches. Of these, 86.3% (number [n] = 88) were receiving testosterone, 11.8% (n = 12) estrogens, and 2.0% (n = 2) were receiving other GAHT. Only 24.5% (n = 24) reported a prior headache diagnosis, including 18 participants (17.6%; 95% CI 11.3%-26.2%) with migraine. Based on the MS-Q, 46.1% (n = 47) screened positive for migraine-like headaches. New headache or worsening of headache was more frequently reported by estrogen users (66.6%) compared to those using testosterone (27.2%). Improvement or resolution of headaches was reported by 26.1% of testosterone users compared to 8.3% of estrogen users.

Conclusion: Estrogen-based GAHT was associated with a higher proportion of individuals reporting new or worsening headaches, whereas testosterone-based GAHT was more often associated with headache improvement. These associations underscore the need for further research into how GAHT modulates headache patterns, as well as the high rate of underdiagnosed headache disorders in this population.

Objectives/background: This study was undertaken to review the published literature and provide a position statement from the American Headache Society regarding the safety, efficacy, and impact on access to care of telemedicine for the clinical management of patients with headache disorders. Access to specialized care in headache medicine is severely limited in the United States and worldwide. Telemedicine has been used as an approach to care delivery in headache medicine for more than a decade, with accelerated adoption during the COVID-19 pandemic. There is now uncertainty regarding the extent to which telemedicine will be accepted by health systems and reimbursed by payers moving forward. The purpose of this position statement is to summarize evidence and clinical experience supporting the utility of telemedicine in headache medicine.

Methods: Evidence regarding the safety and efficacy of telemedicine, and patient and clinician satisfaction with the use of telemedicine for headache specialty care, was gathered from a variety of sources, including PubMed, Google Scholar, and ClinicalTrials.gov. The results and conclusions based upon these results were reviewed and discussed by the authors and the Board of Directors of the American Headache Society to confirm consistency with clinical experience and to achieve consensus.

Results: Several randomized clinical trials and observational studies have been performed to compare telemedicine with in-person visits in the management of patients with headache disorders. These studies showed consistently that telemedicine is noninferior to in-person care based upon multiple outcome measures, including disability measures, patient satisfaction, and clinician satisfaction. In addition, these studies found that telemedicine rarely leads to a missed diagnosis of secondary headache or mismanagement of primary headache. Telemedicine has substantial advantages for patients, including improved access to care and reduced costs associated with obtaining care. Studies evaluating health care utilization indicate no significant differences between patients evaluated and treated virtually versus in person. Obvious limitations of telemedicine include the inability to perform an in-person physical exam or to perform injections. For a substantial number of patients, however, these limitations are outweighed by its advantages. The experience with telemedicine reported in the literature is consistent with the experience of the Board of Directors of the American Headache Society, who endorse its use for patients when feasible and appropriate.

Conclusion: Telemedicine has significantly advanced the care of patients with headache disorders. Its further development and deployment should be supported and reimbursed.

Objective: This review was conducted to analyze the current knowledge on the topic of the relation between migraine and patent foramen ovale (PFO) and indicate the most crucial clinical implications.

Background: Migraine is a primary headache disorder that affects a significant part of the global population. Importantly, it has been considered a risk factor for ischemic stroke, especially in women with migraine with aura. The foramen ovale is a physiological opening in the atrial septum formed during fetal life, which closes in most people in the first year after birth. However, in some people, it can be present in adulthood and is called the patent foramen ovale. PFO is more likely to occur in patients with migraine compared to the population not experiencing migraine headaches.

Methods: Two review teams, comprising migraine experts and stroke experts, were engaged in the screening process, resulting in the inclusion of 204 relevant publications. To be considered for inclusion, an article had to directly cover the topic of PFO or migraine.

Results: In the following work, we have focused on several aspects regarding the direct and indirect relationship between migraine and PFO. Although analyzing migraine pathogenesis, apart from the straight link between PFO and migraine, others are also considered, such as a prominent Eustachian valve or Chiari valve, causing a high-risk PFO or a paradoxical embolism. Regarding the clinical practice, the prevalence of PFO and migraine, indications for exact therapies, and subsequently, neuroimaging in the view of PFO and migraine, have been scrutinized. Another crucial aspect of this review is the risk of stroke in patients with migraine, considering the PFO presence. It is suggested that patients with migraine have more vascular lesions on magnetic resonance imaging and more often experience strokes. Thus, the question arises whether PFO should be closed as stroke prophylaxis in every migraine patient.

Conclusions: Several aspects have been explored; however, more research is needed to draw clear conclusions with further indications for clinical practice. Nevertheless, it seems that not in all patients with migraine with PFO should the closure procedure be performed, but when the PFO is of a high-risk form or there are other indications, it should at least be considered.

Objective: The objective of this study was to summarize the available evidence regarding the clinical value and trend over time of lumbar cerebrospinal fluid (CSF) opening pressure utilization to diagnose spontaneous intracranial hypotension (SIH).

Background: CSF opening pressure obtained via lumbar puncture is one of the diagnostic criteria for SIH based on the International Criteria for Headache Disorders, 3rd Edition (ICHD-3), but it has questionable utility as an initial investigation for diagnosing SIH.

Methods: The authors performed a systematic literature review and meta-analysis. PubMed/MEDLINE, Scopus, and Cochrane Library were searched from inception to October 2022. Original studies and case series in English reporting three or more patients with suspected or known SIH and CSF pressure measurement were included. Meta-analyses and meta-regression were used to calculate pooled estimates and examine the impact of age, sex, and publication year on outcomes, including CSF pressure < 60 mm CSF, orthostatic headache, and positive findings on brain magnetic resonance imaging (MRI), spinal imaging, and radionuclide studies.

Results: For every 1-year increase in the year of publication, the odds of reporting low CSF pressure decreased by 6.20% (adjusted odds ratio [aOR] = 0.94, aOR 95% confidence interval [CI] = [0.90, 0.97], p = 0.001), the odds of reporting a positive brain MRI increased by 4.67% (aOR = 1.05, aOR 95% CI = [1.01, 1.09], p = 0.026), and the odds of reporting orthostatic headache increased by 9.13% (aOR = 1.09, aOR 95% CI = [1.03, 1.15], p = 0.002). Each 1% increase in the percentage of patients with orthostatic headache was associated with a 3.13% increase in the odds of low CSF pressure (aOR = 1.03, aOR 95% CI = [1.01, 1.05], p = 0.003). Similarly, as the percentage of patients with low CSF pressure increased by 1%, there was a 2.53% increase in the odds of orthostatic headache (aOR = 1.03, aOR 95% CI = [1.01, 1.04], p = 0.005). It was estimated that 31.9% of patients with SIH had normal opening pressure (95% CI = [24.0%, 40.8%], prediction interval = [5.0%, 80.5%]). Every 1% increase in the percentage of patients with positive brain MRI was associated with a 5.25% increase in the odds of positive spinal imaging (aOR = 1.05, aOR 95% CI = [1.00, 1.11], p = 0.047). Age and positive radionuclide study did not significantly impact the outcomes measured. The corresponding I² for each outcome was reduced by controlling for study-wide covariates believed to impact the prevalence of each outcome. Sensitivity analyses did not reveal discrepancies in results when studies requiring outcomes of interest were removed.

Conclusion: Our analysis found that recent studies indicate a reduced reliance on opening pressure for diagnosing SIH. Rather, results suggest an increasing reliance on contrast-enhanced brain MRI, spine

Background: Evidence suggests that exercise has clinically relevant benefits for migraine, but an optimal prescription standard remains undefined. We aimed to assess the effectiveness of aerobic exercise on migraine intensity and frequency through a dose-response meta-analysis.

Methods: A data search was performed in PubMed, PEDro, Google Scholar, and EBSCO from inception to September 1, 2024. Randomized controlled trials and quasi-experimental studies of aerobic exercise in patients with a clinical diagnosis of migraine were included. The outcome measures were pain intensity and migraine frequency. The dose-response relationship was evaluated using a dose-response meta-analysis.

Results: Fifteen studies (253 participants) were included. Meta-analysis showed a statistically significant decrease in pain intensity between pre and post intervention (standardized mean differences [SMD], -1.1; 95% confidence interval [CI], -1.72 to -0.47). The spline model showed a U-shape statistically significant association (χ² = 112.03, df = 2, p < 0.001) between total minutes of aerobic exercise and reduction in pain intensity. A minimum dose of 200 min was required for moderate effects, with a maximum effect at 900 min (SMD, -2.4; 95% CI, -2.85 to -1.95). Meta-analysis showed a statistically significant decrease in migraine frequency between pre and post intervention (SMD, -0.79; 95% CI, -1.1 to -0.47). The spline model showed a U-shape statistically significant association (χ² = 86.41, dl = 2, p < 0.001) between total minutes of aerobic exercise and reduction in migraine frequency. A minimum dose of 300 total minutes of aerobic exercise program duration was required to obtain a moderate effect in reducing migraine frequency, with a maximum effect at 950 min (SMD, -1.55; 95% CI, -1.87 to -1.22).

Conclusions: This meta-analysis suggests that aerobic exercise may be effective in reducing both pain intensity and migraine frequency in people with migraine. The greatest observed effect on both variables was observed at a cumulative dose of approximately 900-950 total minutes of aerobic exercise during the program, and higher doses may not present additional benefits. These findings support a preliminary recommendation of 3 weekly 30-min sessions over 10-11 weeks, to be confirmed in future high-quality trials.

Objective: To evaluate the effect of erenumab treatment beyond monthly migraine days in patients with high-frequency episodic migraine who did not respond to at least one previous migraine preventive treatment.

Background: Reduction in monthly migraine days has been the efficacy standard for migraine preventive treatments; however, it does not fully capture the holistic benefit of the therapy. Erenumab, a monoclonal antibody targeting the calcitonin gene-related peptide pathway, has demonstrated reduction in monthly migraine days and improvement in function in patients with episodic and chronic migraine.

Methods: In this phase 4, interventional, double-blind, randomized, placebo-controlled, multicenter, global study, treatment with erenumab was assessed over 4 months in adults with high-frequency episodic migraine. The study was conducted at 61 sites located across North America and Europe between September 2020 and October 2023. Patients with ≥1 qualifying oral triptan-treated migraine attack at baseline were randomized to receive erenumab 140 mg or placebo subcutaneously once monthly. The primary endpoint was change from baseline in mean monthly hours of at least moderate headache pain intensity over months 1, 2, and 3; secondary endpoints included change from baseline in mean monthly function, mean monthly duration of at least moderate pain intensity in migraine attacks, and mean monthly peak migraine pain intensity. Safety outcomes were also assessed.

Results: Of 512 randomized patients, 510 received erenumab 140 mg (n = 254) or placebo (n = 256) once monthly. Demographics and baseline characteristics were balanced between the two treatment arms. Erenumab 140 mg was superior to placebo in reducing duration of moderate or severe headache pain intensity over months 1, 2, and 3 (least squares mean [95% confidence interval {CI}] difference, -7.95 [-11.45, -4.46]; p < 0.001). Compared with placebo, erenumab significantly reduced migraine functional impact as assessed by the four domains of the Migraine Functional Impact Questionnaire, with a least squares mean (95% CI) difference of -7.36 (-10.80, -3.92) for physical functioning, -7.10 (-10.34, -3.87) for usual activities, -6.82 (-10.37, -3.27) for social functioning, and - 7.05 (-10.76, -3.34) for emotional functioning (p < 0.001 for all domains). Significant reductions with erenumab compared with placebo were also observed in duration of at least moderate pain intensity in residual or break-through migraine attacks (least squares mean [95% CI] difference, -1.07 [-1.92, -0.22]; p = 0.013) and peak migraine pain intensity (-0.48 [-0.85, -0.11]; p = 0.011). Incidence of grade 3 adverse events was 1.6% with erenumab and 1.2% with placebo; no grade 4 or fatal adverse events were reported in either treatment arm.

Conclusion: Findings from the EMBRACE study demonstrated that treatment with er

Background: Patients with migraine aged ≥65 years old are underrepresented in clinical trials. This study compares effectiveness, excellent response, and tolerability of galcanezumab in patients ≥65 years and those younger than 65 years, specifically assessing age as a predictor of response.

Methods: This real-life, multicenter cohort study included patients with chronic or high-frequency episodic migraine who did not respond to more than or equal to three preventive drugs, treated with galcanezumab, and followed for 12 months from 12 Spanish hospitals, between November 2019 and January 2022. Effectiveness was defined as ≥50% reduction in monthly headache days (MHD), and excellent response as ≥75% reduction at 6 months. Tolerability was based on the percentage of patients discontinuing due to adverse events.

Results: We included 1055 patients (934 patients <65 years, 121 patients ≥65 years). Older patients had higher baseline MHD [25 (interquartile range [IQR] 15-30) vs. 20 (14-30), p = 0.045], but lower HIT-6 scores [67 (IQR 63-72) vs. 69 (66-73), p < 0.001]. Effectiveness was similar across age groups at 3 (57.0% vs. 48.8%, p = 0.090), 6 (57.0% vs. 51.8%, p = 0.281), and 12 months (52.1% vs. 51.4%, p = 0.889). However, excellent response was more frequent in the ≥65 years group at 3 months (32.2% vs. 23.1%, p = 0.028) and 6 months (33.9% vs. 23.5%, p = 0.012), with a non-significant difference at 12 months (33.1% vs. 25.4%, p = 0.071). Tolerability was comparable within age groups (5.8% discontinuation due to adverse effects in patients ≥65 years vs. 6.7% in patients <65 years; p = 0.837). Age was independently associated with effectiveness (adjusted odds ratio [aOR]: 1.02; 95% confidence interval [CI]: 1.004-1.03) and excellent response (aOR: 1.02; 95% CI: 1.01-1.04). A statistically significant association was found in the logistic regression model for excellent response when age was dichotomized at 65 years, with increasing age linked to a higher likelihood of an excellent treatment response (aOR: 1.79; 95% CI: 1.13-2.82, p = 0.012).

Conclusions: Galcanezumab is as effective and well-tolerated in patients aged ≥65 years as in younger patients but older patients showed a higher rate of excellent response. Age is associated with a better response to galcanezumab.