Headache & Migraine

A new tool can help streamline diagnosis and treatment of migraine in the primary care setting, research suggests.

Early results from a small pilot study showed that the tool, essentially a medical record “best-practice alert,” reduces specialist referrals and MRI studies.

The idea behind the tool is to give primary care physicians “fingertip access” to prompts on patients’ electronic health record, leading to best migraine management and treatment, said coinvestigator, Scott M. Friedenberg, MD, vice chair of clinical practice, Geisinger Medical Center, Danville, Pa.

When clinicians enter a headache diagnosis into a patient’s EHR, a pop-up asks a handful of questions and “prompts them with the right medications so if they just click a button, they can order the medications straight away,” Dr. Friedenberg said.

The findings were presented at the annual meeting of the American Headache Society.
 

Fewer referrals, MRI testing

Researchers reviewed charts for 693 general neurology referrals. About 20% of the patients were referred for headache. In about 80% of these cases, the final diagnosis was migraine and/or chronic daily headache.

The physicians had documented criteria for identifying migraine, such as sensitivity to light, nausea, and missed social activity or work, in fewer than 1% of cases. There’s roughly an 80% chance that if a headache meets two of these three criteria, it is a migraine, Dr. Friedenberg noted.

About 60% of the participants with headache were referred with no treatment trial. About 20% were referred after having tried two medicines, and 30% were referred after trying one medicine.

“In many cases, we’re being asked to evaluate people with primary headache or uncomplicated headache that has not been treated,” said Dr. Friedenberg.

The investigators developed the tool, and its most recent iteration was tested by 10 physicians at two sites for 3 months. These doctors did not receive education on headache, they were just taught how to use the tool.

Results showed that referrals for neurology consults dropped 77% and MRI ordering dropped 35% after use of the tool. This translated into a savings of $192,000.

However, using the tool didn’t significantly affect prescribing habits of the physicians.
 

Migraine frequently undertreated

“When you drill it down, the only thing that changed were medications they were comfortable with, so they increased steroids and nonsteroidal prescribing, but preventives didn’t change, narcotics didn’t change, and CGRP [calcitonin gene-related peptide] inhibitors didn’t change,” Dr. Friedenberg said.

Although believing patients are “not bad enough to treat” might help explain why clinicians did not change prescribing habits, the reality is that many patients have migraine and should be treated, he added.

Dr. Friedenberg pointed out that previous research suggests that 60% or more of patients with a primary headache or migraine are undertreated.

The tool should increase awareness about, and comfort level with, diagnosing and treating migraine among primary care doctors, he noted. “We hope it will make it easier for them to do the right thing and have neurology as a readily available partner,” said Dr. Friedenberg.

“Primary care doctors are incredibly busy and incredibly pressured, and anything you can do to help facilitate that is a positive,” he added.

The researchers now plan to train pharmacists to comanage headache along with primary care doctors, as is done, for example, for patients with diabetes. This should result in a reduction in physician burden, said Dr. Friedenberg.

The next step is to conduct a larger study at the 38 sites in the Geisinger health complex. Half the sites will use the new tool, and the other half will continue to use their current headache management process.

“The study will compare everything from MRI ordering to neurology referrals and prescribing, how often patients go to the emergency department, how often they have a clinic visit, whether the provider is satisfied with the tool, and if the patient’s headaches are getting better,” Dr. Friedenberg said.
 

Lessons for clinical practice

Jessica Ailani, MD, director at MedStar Georgetown Headache Center and associate professor in the department of neurology at Georgetown University, cochaired the session in which the research was presented and called the project “really fantastic.”

The study offers “many lessons” for clinical practice and showed that the tool was effective in improving diagnosis of migraine, said Dr. Ailani, who is also secretary of the American Headache Society.

“There’s a long wait time to see specialists, and most migraine can be diagnosed and basic management can be done by primary care physicians,” she said.

“The next step would be to work on a way to improve prescriptions of migraine-specific treatments,” she added.

Dr. Ailani noted that the AHS would be keen to find ways to engage in “collaborative work” with the investigators.

The investigators and Dr. Ailani reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A new tool can help streamline diagnosis and treatment of migraine in the primary care setting, research suggests.

Early results from a small pilot study showed that the tool, essentially a medical record “best-practice alert,” reduces specialist referrals and MRI studies.

The idea behind the tool is to give primary care physicians “fingertip access” to prompts on patients’ electronic health record, leading to best migraine management and treatment, said coinvestigator, Scott M. Friedenberg, MD, vice chair of clinical practice, Geisinger Medical Center, Danville, Pa.

When clinicians enter a headache diagnosis into a patient’s EHR, a pop-up asks a handful of questions and “prompts them with the right medications so if they just click a button, they can order the medications straight away,” Dr. Friedenberg said.

The findings were presented at the annual meeting of the American Headache Society.
 

Fewer referrals, MRI testing

Researchers reviewed charts for 693 general neurology referrals. About 20% of the patients were referred for headache. In about 80% of these cases, the final diagnosis was migraine and/or chronic daily headache.

The physicians had documented criteria for identifying migraine, such as sensitivity to light, nausea, and missed social activity or work, in fewer than 1% of cases. There’s roughly an 80% chance that if a headache meets two of these three criteria, it is a migraine, Dr. Friedenberg noted.

About 60% of the participants with headache were referred with no treatment trial. About 20% were referred after having tried two medicines, and 30% were referred after trying one medicine.

“In many cases, we’re being asked to evaluate people with primary headache or uncomplicated headache that has not been treated,” said Dr. Friedenberg.

The investigators developed the tool, and its most recent iteration was tested by 10 physicians at two sites for 3 months. These doctors did not receive education on headache, they were just taught how to use the tool.

Results showed that referrals for neurology consults dropped 77% and MRI ordering dropped 35% after use of the tool. This translated into a savings of $192,000.

However, using the tool didn’t significantly affect prescribing habits of the physicians.
 

Migraine frequently undertreated

“When you drill it down, the only thing that changed were medications they were comfortable with, so they increased steroids and nonsteroidal prescribing, but preventives didn’t change, narcotics didn’t change, and CGRP [calcitonin gene-related peptide] inhibitors didn’t change,” Dr. Friedenberg said.

Although believing patients are “not bad enough to treat” might help explain why clinicians did not change prescribing habits, the reality is that many patients have migraine and should be treated, he added.

Dr. Friedenberg pointed out that previous research suggests that 60% or more of patients with a primary headache or migraine are undertreated.

The tool should increase awareness about, and comfort level with, diagnosing and treating migraine among primary care doctors, he noted. “We hope it will make it easier for them to do the right thing and have neurology as a readily available partner,” said Dr. Friedenberg.

“Primary care doctors are incredibly busy and incredibly pressured, and anything you can do to help facilitate that is a positive,” he added.

The researchers now plan to train pharmacists to comanage headache along with primary care doctors, as is done, for example, for patients with diabetes. This should result in a reduction in physician burden, said Dr. Friedenberg.

The next step is to conduct a larger study at the 38 sites in the Geisinger health complex. Half the sites will use the new tool, and the other half will continue to use their current headache management process.

“The study will compare everything from MRI ordering to neurology referrals and prescribing, how often patients go to the emergency department, how often they have a clinic visit, whether the provider is satisfied with the tool, and if the patient’s headaches are getting better,” Dr. Friedenberg said.
 

Lessons for clinical practice

Jessica Ailani, MD, director at MedStar Georgetown Headache Center and associate professor in the department of neurology at Georgetown University, cochaired the session in which the research was presented and called the project “really fantastic.”

The study offers “many lessons” for clinical practice and showed that the tool was effective in improving diagnosis of migraine, said Dr. Ailani, who is also secretary of the American Headache Society.

“There’s a long wait time to see specialists, and most migraine can be diagnosed and basic management can be done by primary care physicians,” she said.

“The next step would be to work on a way to improve prescriptions of migraine-specific treatments,” she added.

Dr. Ailani noted that the AHS would be keen to find ways to engage in “collaborative work” with the investigators.

The investigators and Dr. Ailani reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A new tool can help streamline diagnosis and treatment of migraine in the primary care setting, research suggests.

Early results from a small pilot study showed that the tool, essentially a medical record “best-practice alert,” reduces specialist referrals and MRI studies.

The idea behind the tool is to give primary care physicians “fingertip access” to prompts on patients’ electronic health record, leading to best migraine management and treatment, said coinvestigator, Scott M. Friedenberg, MD, vice chair of clinical practice, Geisinger Medical Center, Danville, Pa.

When clinicians enter a headache diagnosis into a patient’s EHR, a pop-up asks a handful of questions and “prompts them with the right medications so if they just click a button, they can order the medications straight away,” Dr. Friedenberg said.

The findings were presented at the annual meeting of the American Headache Society.
 

Fewer referrals, MRI testing

Researchers reviewed charts for 693 general neurology referrals. About 20% of the patients were referred for headache. In about 80% of these cases, the final diagnosis was migraine and/or chronic daily headache.

The physicians had documented criteria for identifying migraine, such as sensitivity to light, nausea, and missed social activity or work, in fewer than 1% of cases. There’s roughly an 80% chance that if a headache meets two of these three criteria, it is a migraine, Dr. Friedenberg noted.

About 60% of the participants with headache were referred with no treatment trial. About 20% were referred after having tried two medicines, and 30% were referred after trying one medicine.

“In many cases, we’re being asked to evaluate people with primary headache or uncomplicated headache that has not been treated,” said Dr. Friedenberg.

The investigators developed the tool, and its most recent iteration was tested by 10 physicians at two sites for 3 months. These doctors did not receive education on headache, they were just taught how to use the tool.

Results showed that referrals for neurology consults dropped 77% and MRI ordering dropped 35% after use of the tool. This translated into a savings of $192,000.

However, using the tool didn’t significantly affect prescribing habits of the physicians.
 

Migraine frequently undertreated

“When you drill it down, the only thing that changed were medications they were comfortable with, so they increased steroids and nonsteroidal prescribing, but preventives didn’t change, narcotics didn’t change, and CGRP [calcitonin gene-related peptide] inhibitors didn’t change,” Dr. Friedenberg said.

Although believing patients are “not bad enough to treat” might help explain why clinicians did not change prescribing habits, the reality is that many patients have migraine and should be treated, he added.

Dr. Friedenberg pointed out that previous research suggests that 60% or more of patients with a primary headache or migraine are undertreated.

The tool should increase awareness about, and comfort level with, diagnosing and treating migraine among primary care doctors, he noted. “We hope it will make it easier for them to do the right thing and have neurology as a readily available partner,” said Dr. Friedenberg.

“Primary care doctors are incredibly busy and incredibly pressured, and anything you can do to help facilitate that is a positive,” he added.

The researchers now plan to train pharmacists to comanage headache along with primary care doctors, as is done, for example, for patients with diabetes. This should result in a reduction in physician burden, said Dr. Friedenberg.

The next step is to conduct a larger study at the 38 sites in the Geisinger health complex. Half the sites will use the new tool, and the other half will continue to use their current headache management process.

“The study will compare everything from MRI ordering to neurology referrals and prescribing, how often patients go to the emergency department, how often they have a clinic visit, whether the provider is satisfied with the tool, and if the patient’s headaches are getting better,” Dr. Friedenberg said.
 

Lessons for clinical practice

Jessica Ailani, MD, director at MedStar Georgetown Headache Center and associate professor in the department of neurology at Georgetown University, cochaired the session in which the research was presented and called the project “really fantastic.”

The study offers “many lessons” for clinical practice and showed that the tool was effective in improving diagnosis of migraine, said Dr. Ailani, who is also secretary of the American Headache Society.

“There’s a long wait time to see specialists, and most migraine can be diagnosed and basic management can be done by primary care physicians,” she said.

“The next step would be to work on a way to improve prescriptions of migraine-specific treatments,” she added.

Dr. Ailani noted that the AHS would be keen to find ways to engage in “collaborative work” with the investigators.

The investigators and Dr. Ailani reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Key clinical point: Severe migraine without aura increased the long-term risk for atrial fibrillation (AF) by 16%-21% in both men and women. The risk for future AF was highest in women with severe migraine with aura but not significant in male counterparts.

Major finding: Men (adjusted hazard ratio [aHR] 1.21; 95% CI 1.12-1.31) and women (aHR 1.16; 95% CI 1.09-1.22) with severe migraine without aura had a modest but significantly higher risk for AF. The risk was most prominent in women with severe migraine with aura (aHR 1.48; 95% CI 1.18-1.85), but was not significant in men.

Study details: Findings are from a large-scale population-based study including 4,020,488 participants without AF, of which 4986 and 105,029 had migraine with and without aura, respectively.

Disclosures: This study was supported by a Korea Medical Device Development Fund grant funded by the Korea Government. E-K Choi and GYH Lip reported receiving research grants or speaking fees or serving as consultants or speakers for various sources.

Source: Rhee T-M et al. Type and severity of migraine determines risk of atrial fibrillation in women. Front Cardiovasc Med. 2022;9:910225 (May 31). Doi: 10.3389/fcvm.2022.910225

Key clinical point: Severe migraine without aura increased the long-term risk for atrial fibrillation (AF) by 16%-21% in both men and women. The risk for future AF was highest in women with severe migraine with aura but not significant in male counterparts.

Major finding: Men (adjusted hazard ratio [aHR] 1.21; 95% CI 1.12-1.31) and women (aHR 1.16; 95% CI 1.09-1.22) with severe migraine without aura had a modest but significantly higher risk for AF. The risk was most prominent in women with severe migraine with aura (aHR 1.48; 95% CI 1.18-1.85), but was not significant in men.

Study details: Findings are from a large-scale population-based study including 4,020,488 participants without AF, of which 4986 and 105,029 had migraine with and without aura, respectively.

Disclosures: This study was supported by a Korea Medical Device Development Fund grant funded by the Korea Government. E-K Choi and GYH Lip reported receiving research grants or speaking fees or serving as consultants or speakers for various sources.

Source: Rhee T-M et al. Type and severity of migraine determines risk of atrial fibrillation in women. Front Cardiovasc Med. 2022;9:910225 (May 31). Doi: 10.3389/fcvm.2022.910225

Key clinical point: Severe migraine without aura increased the long-term risk for atrial fibrillation (AF) by 16%-21% in both men and women. The risk for future AF was highest in women with severe migraine with aura but not significant in male counterparts.

Major finding: Men (adjusted hazard ratio [aHR] 1.21; 95% CI 1.12-1.31) and women (aHR 1.16; 95% CI 1.09-1.22) with severe migraine without aura had a modest but significantly higher risk for AF. The risk was most prominent in women with severe migraine with aura (aHR 1.48; 95% CI 1.18-1.85), but was not significant in men.

Study details: Findings are from a large-scale population-based study including 4,020,488 participants without AF, of which 4986 and 105,029 had migraine with and without aura, respectively.

Disclosures: This study was supported by a Korea Medical Device Development Fund grant funded by the Korea Government. E-K Choi and GYH Lip reported receiving research grants or speaking fees or serving as consultants or speakers for various sources.

Source: Rhee T-M et al. Type and severity of migraine determines risk of atrial fibrillation in women. Front Cardiovasc Med. 2022;9:910225 (May 31). Doi: 10.3389/fcvm.2022.910225

Key clinical point: A higher proportion of patients with migraine treated with atogepant vs. placebo showed a significant reduction in the monthly migraine days (MMD) during the 12 weeks of treatment.

Major finding: At 12 weeks, ≥50% reduction in the mean MMD was achieved by a significantly higher proportion of patients receiving 10 mg (55.6%), 30 mg (58.7%), or 60 mg (60.8%) atogepant compared with placebo (29.0%; all P < .001), with findings being similar for ≥25%, ≥75%, and 100% reduction in mean MMD. The incidence of treatment-emergent adverse events was similar among the treatment groups.

Study details: This was a secondary analysis of the ADVANCE trial including 873 patients with a ≥1-year history of migraine with or without aura who were randomly assigned to receive atogepant (10, 30, or 60 mg; n = 659) or placebo (n = 214).

Disclosures: This study was sponsored by Allergan. Some authors declared receiving speaking fees, consulting fees, personal fees, research grants, or royalties or owing stocks or stock options in various sources, including Allergan/AbbVie.

Source: Lipton RB et al. Rates of response to atogepant for migraine prophylaxis among adults:

A secondary analysis of a randomized clinical trial. JAMA Netw Open. 2022;5(6):e2215499 Jun 8). Doi:  10.1001/jamanetworkopen.2022.15499

Key clinical point: A higher proportion of patients with migraine treated with atogepant vs. placebo showed a significant reduction in the monthly migraine days (MMD) during the 12 weeks of treatment.

Major finding: At 12 weeks, ≥50% reduction in the mean MMD was achieved by a significantly higher proportion of patients receiving 10 mg (55.6%), 30 mg (58.7%), or 60 mg (60.8%) atogepant compared with placebo (29.0%; all P < .001), with findings being similar for ≥25%, ≥75%, and 100% reduction in mean MMD. The incidence of treatment-emergent adverse events was similar among the treatment groups.

Study details: This was a secondary analysis of the ADVANCE trial including 873 patients with a ≥1-year history of migraine with or without aura who were randomly assigned to receive atogepant (10, 30, or 60 mg; n = 659) or placebo (n = 214).

Disclosures: This study was sponsored by Allergan. Some authors declared receiving speaking fees, consulting fees, personal fees, research grants, or royalties or owing stocks or stock options in various sources, including Allergan/AbbVie.

Source: Lipton RB et al. Rates of response to atogepant for migraine prophylaxis among adults:

A secondary analysis of a randomized clinical trial. JAMA Netw Open. 2022;5(6):e2215499 Jun 8). Doi:  10.1001/jamanetworkopen.2022.15499

Key clinical point: A higher proportion of patients with migraine treated with atogepant vs. placebo showed a significant reduction in the monthly migraine days (MMD) during the 12 weeks of treatment.

Major finding: At 12 weeks, ≥50% reduction in the mean MMD was achieved by a significantly higher proportion of patients receiving 10 mg (55.6%), 30 mg (58.7%), or 60 mg (60.8%) atogepant compared with placebo (29.0%; all P < .001), with findings being similar for ≥25%, ≥75%, and 100% reduction in mean MMD. The incidence of treatment-emergent adverse events was similar among the treatment groups.

Study details: This was a secondary analysis of the ADVANCE trial including 873 patients with a ≥1-year history of migraine with or without aura who were randomly assigned to receive atogepant (10, 30, or 60 mg; n = 659) or placebo (n = 214).

Disclosures: This study was sponsored by Allergan. Some authors declared receiving speaking fees, consulting fees, personal fees, research grants, or royalties or owing stocks or stock options in various sources, including Allergan/AbbVie.

Source: Lipton RB et al. Rates of response to atogepant for migraine prophylaxis among adults:

A secondary analysis of a randomized clinical trial. JAMA Netw Open. 2022;5(6):e2215499 Jun 8). Doi:  10.1001/jamanetworkopen.2022.15499

Key clinical point: Migraine was significantly associated with fetal-type posterior cerebral artery (PCA) status in patients with ischemic stroke.

Major finding: Fetal-type PCA status was independently associated with migraine (adjusted odds ratio [aOR] 2.06; P = .005). The other factors independently associated with migraine were hypertension (aOR 1.97; P = .011), female gender (aOR 2.03; P = .017) and National Institutes of Health Stroke Scale score at admission (aOR 1.08; P = .018).

Study details: This cross-sectional study included 750 patients aged ≥18 years with ischemic stroke, of which 11.3% had migraine history.

Disclosures: This study received no specific funding. The authors declared no conflicts of interest.

Source: Zhang Y et al. The association between migraine and fetal-type posterior cerebral artery in patients with ischemic stroke. Cerebrovasc Dis. 2022 (May 13). Doi: 10.1159/000524616

Key clinical point: Migraine was significantly associated with fetal-type posterior cerebral artery (PCA) status in patients with ischemic stroke.

Major finding: Fetal-type PCA status was independently associated with migraine (adjusted odds ratio [aOR] 2.06; P = .005). The other factors independently associated with migraine were hypertension (aOR 1.97; P = .011), female gender (aOR 2.03; P = .017) and National Institutes of Health Stroke Scale score at admission (aOR 1.08; P = .018).

Study details: This cross-sectional study included 750 patients aged ≥18 years with ischemic stroke, of which 11.3% had migraine history.

Disclosures: This study received no specific funding. The authors declared no conflicts of interest.

Source: Zhang Y et al. The association between migraine and fetal-type posterior cerebral artery in patients with ischemic stroke. Cerebrovasc Dis. 2022 (May 13). Doi: 10.1159/000524616

Key clinical point: Migraine was significantly associated with fetal-type posterior cerebral artery (PCA) status in patients with ischemic stroke.

Major finding: Fetal-type PCA status was independently associated with migraine (adjusted odds ratio [aOR] 2.06; P = .005). The other factors independently associated with migraine were hypertension (aOR 1.97; P = .011), female gender (aOR 2.03; P = .017) and National Institutes of Health Stroke Scale score at admission (aOR 1.08; P = .018).

Study details: This cross-sectional study included 750 patients aged ≥18 years with ischemic stroke, of which 11.3% had migraine history.

Disclosures: This study received no specific funding. The authors declared no conflicts of interest.

Source: Zhang Y et al. The association between migraine and fetal-type posterior cerebral artery in patients with ischemic stroke. Cerebrovasc Dis. 2022 (May 13). Doi: 10.1159/000524616

Key clinical point: Erenumab is effective and well tolerated in patients with chronic migraine who did not respond to previous migraine treatments.

Major finding: Overall, 71.4% of patients treated with erenumab achieved ≥30% reduction in monthly migraine days from baseline to 9-12 weeks and 34.0% of patients at all assessment periods through 52 weeks. Constipation was the most common adverse event and 13.7% of patients discontinued treatment because of a lack of tolerability.

Study details: The data come from a 52-week, prospective, observational study including 300 patients with chronic migraine who received ≥1 dose of erenumab, of which 273 and 119 patients completed 12 and 52 weeks of treatment, respectively.

Disclosures: This study was funded by and conducted in collaboration with Novartis Pharma AG, Basel, Switzerland. Some authors reported being consultants, speakers, or scientific advisors for or receiving personal fees from various sources, including Novartis. Two authors declared being employees of and holding stocks in Novartis.

Source: Cullum CK et al. Real-world long-term efficacy and safety of erenumab in adults with chronic migraine: A 52-week, single-center, prospective, observational study. J Headache Pain. 2022;23(1):61 Jun 2). Doi: 10.1186/s10194-022-01433-9

Key clinical point: Erenumab is effective and well tolerated in patients with chronic migraine who did not respond to previous migraine treatments.

Major finding: Overall, 71.4% of patients treated with erenumab achieved ≥30% reduction in monthly migraine days from baseline to 9-12 weeks and 34.0% of patients at all assessment periods through 52 weeks. Constipation was the most common adverse event and 13.7% of patients discontinued treatment because of a lack of tolerability.

Study details: The data come from a 52-week, prospective, observational study including 300 patients with chronic migraine who received ≥1 dose of erenumab, of which 273 and 119 patients completed 12 and 52 weeks of treatment, respectively.

Disclosures: This study was funded by and conducted in collaboration with Novartis Pharma AG, Basel, Switzerland. Some authors reported being consultants, speakers, or scientific advisors for or receiving personal fees from various sources, including Novartis. Two authors declared being employees of and holding stocks in Novartis.

Source: Cullum CK et al. Real-world long-term efficacy and safety of erenumab in adults with chronic migraine: A 52-week, single-center, prospective, observational study. J Headache Pain. 2022;23(1):61 Jun 2). Doi: 10.1186/s10194-022-01433-9

Key clinical point: Erenumab is effective and well tolerated in patients with chronic migraine who did not respond to previous migraine treatments.

Major finding: Overall, 71.4% of patients treated with erenumab achieved ≥30% reduction in monthly migraine days from baseline to 9-12 weeks and 34.0% of patients at all assessment periods through 52 weeks. Constipation was the most common adverse event and 13.7% of patients discontinued treatment because of a lack of tolerability.

Study details: The data come from a 52-week, prospective, observational study including 300 patients with chronic migraine who received ≥1 dose of erenumab, of which 273 and 119 patients completed 12 and 52 weeks of treatment, respectively.

Disclosures: This study was funded by and conducted in collaboration with Novartis Pharma AG, Basel, Switzerland. Some authors reported being consultants, speakers, or scientific advisors for or receiving personal fees from various sources, including Novartis. Two authors declared being employees of and holding stocks in Novartis.

Source: Cullum CK et al. Real-world long-term efficacy and safety of erenumab in adults with chronic migraine: A 52-week, single-center, prospective, observational study. J Headache Pain. 2022;23(1):61 Jun 2). Doi: 10.1186/s10194-022-01433-9

Key clinical point: Intravenous (IV) ketorolac plus metoclopramide failed to improve pain intensity in children presenting to the emergency department (ED) for the acute treatment of migraine compared with metoclopramide monotherapy.

Major finding: The mean change in pain intensity as assessed by a 100 mm Visual Analog Scale at 120 minutes was −44 mm (95% CI 32-57 mm) in the monotherapy group and −36 mm (95% CI 23-49 mm) in the ketorolac group, corresponding to a mean difference of 8 mm between the groups (P = .355), with no significant between-group difference in headache recurrence and adverse events.

Study details: Findings are from a double-blind, randomized placebo-controlled trial including 53 children aged 6-17 years presenting to the ED for the acute treatment of migraine. They were randomly assigned to receive IV ketorolac plus metoclopramide (n = 26) or IV metoclopramide plus placebo (n = 27).

Disclosures: This study was funded by the Canadian Institutes of Health Research through a Drug Safety and Effectiveness Network grant. The authors declared no conflicts of interest.

Source: Richer LP et al. A randomized trial of ketorolac and metoclopramide for migraine in the emergency department. Headache. 2022 ; 62: 681-689 (Jun 7). Doi: 10.1111/head.14307

Key clinical point: Intravenous (IV) ketorolac plus metoclopramide failed to improve pain intensity in children presenting to the emergency department (ED) for the acute treatment of migraine compared with metoclopramide monotherapy.

Major finding: The mean change in pain intensity as assessed by a 100 mm Visual Analog Scale at 120 minutes was −44 mm (95% CI 32-57 mm) in the monotherapy group and −36 mm (95% CI 23-49 mm) in the ketorolac group, corresponding to a mean difference of 8 mm between the groups (P = .355), with no significant between-group difference in headache recurrence and adverse events.

Study details: Findings are from a double-blind, randomized placebo-controlled trial including 53 children aged 6-17 years presenting to the ED for the acute treatment of migraine. They were randomly assigned to receive IV ketorolac plus metoclopramide (n = 26) or IV metoclopramide plus placebo (n = 27).

Disclosures: This study was funded by the Canadian Institutes of Health Research through a Drug Safety and Effectiveness Network grant. The authors declared no conflicts of interest.

Source: Richer LP et al. A randomized trial of ketorolac and metoclopramide for migraine in the emergency department. Headache. 2022 ; 62: 681-689 (Jun 7). Doi: 10.1111/head.14307

Key clinical point: Intravenous (IV) ketorolac plus metoclopramide failed to improve pain intensity in children presenting to the emergency department (ED) for the acute treatment of migraine compared with metoclopramide monotherapy.

Major finding: The mean change in pain intensity as assessed by a 100 mm Visual Analog Scale at 120 minutes was −44 mm (95% CI 32-57 mm) in the monotherapy group and −36 mm (95% CI 23-49 mm) in the ketorolac group, corresponding to a mean difference of 8 mm between the groups (P = .355), with no significant between-group difference in headache recurrence and adverse events.

Study details: Findings are from a double-blind, randomized placebo-controlled trial including 53 children aged 6-17 years presenting to the ED for the acute treatment of migraine. They were randomly assigned to receive IV ketorolac plus metoclopramide (n = 26) or IV metoclopramide plus placebo (n = 27).

Disclosures: This study was funded by the Canadian Institutes of Health Research through a Drug Safety and Effectiveness Network grant. The authors declared no conflicts of interest.

Source: Richer LP et al. A randomized trial of ketorolac and metoclopramide for migraine in the emergency department. Headache. 2022 ; 62: 681-689 (Jun 7). Doi: 10.1111/head.14307

Key clinical point: Patients hospitalized with refractory chronic migraine treated with continuous multiday lidocaine infusions showed a significant improvement in pain immediately after the infusion, with some patients maintaining this improvement at 1 month.

Major finding: Median pain ratings decreased from 7.0 on admission to 1.0 at discharge (P < .001), with 87.8% of admissions being cases of acute response. Among acute responders with data on average pain, 43.2% demonstrated sustained response at 1 month.

Study details: The data come from a retrospective cohort study of 609 hospital admissions involving 537 patients with refractory chronic migraine who received continuous multiday lidocaine infusions.

Disclosures: This study did not receive any specific funding. SD Silberstein declared serving as a consultant and advisory panel member for and receiving honoraria from various sources.

Source: Schwenk ES et al. Lidocaine infusions for refractory chronic migraine: A retrospective analysis. Reg Anesth Pain Med. 2022;47:408-413 (May 23). Doi: 10.1136/rapm-2021-103180

Key clinical point: Patients hospitalized with refractory chronic migraine treated with continuous multiday lidocaine infusions showed a significant improvement in pain immediately after the infusion, with some patients maintaining this improvement at 1 month.

Major finding: Median pain ratings decreased from 7.0 on admission to 1.0 at discharge (P < .001), with 87.8% of admissions being cases of acute response. Among acute responders with data on average pain, 43.2% demonstrated sustained response at 1 month.

Study details: The data come from a retrospective cohort study of 609 hospital admissions involving 537 patients with refractory chronic migraine who received continuous multiday lidocaine infusions.

Disclosures: This study did not receive any specific funding. SD Silberstein declared serving as a consultant and advisory panel member for and receiving honoraria from various sources.

Source: Schwenk ES et al. Lidocaine infusions for refractory chronic migraine: A retrospective analysis. Reg Anesth Pain Med. 2022;47:408-413 (May 23). Doi: 10.1136/rapm-2021-103180

Key clinical point: Patients hospitalized with refractory chronic migraine treated with continuous multiday lidocaine infusions showed a significant improvement in pain immediately after the infusion, with some patients maintaining this improvement at 1 month.

Major finding: Median pain ratings decreased from 7.0 on admission to 1.0 at discharge (P < .001), with 87.8% of admissions being cases of acute response. Among acute responders with data on average pain, 43.2% demonstrated sustained response at 1 month.

Study details: The data come from a retrospective cohort study of 609 hospital admissions involving 537 patients with refractory chronic migraine who received continuous multiday lidocaine infusions.

Disclosures: This study did not receive any specific funding. SD Silberstein declared serving as a consultant and advisory panel member for and receiving honoraria from various sources.

Source: Schwenk ES et al. Lidocaine infusions for refractory chronic migraine: A retrospective analysis. Reg Anesth Pain Med. 2022;47:408-413 (May 23). Doi: 10.1136/rapm-2021-103180

Key clinical point: Cold interventions, including cold-gel headband, cold-gel cap, and intraoral cooling, provide instant relief from pain in patients with migraine; however, their long-term effects on pain are not significant.

Major finding: The cold intervention group vs. control group led to a significant reduction in pain on a visual analog scale score at 30 minutes (standard mean difference [SMD] −3.21; P = .02) but a nonsignificant reduction in the score at 24 hours (SMD −0.44; P = .07) after the intervention.

Study details: This was a meta-analysis of 6 studies (4 randomized controlled trials and 2 quasi-experimental studies) that included adult patients with migraine who underwent a cold intervention.

Disclosures: The study was partially sponsored by the Ministry of Science and Technology, Israel. The authors declared no conflicts of interest.

Source: Hsu Y-Y et al. Cold intervention for relieving migraine symptoms: A systematic review and meta-analysis. J Clin Nurs. 2022 (May 20). Doi: 10.1111/jocn.16368

Key clinical point: Cold interventions, including cold-gel headband, cold-gel cap, and intraoral cooling, provide instant relief from pain in patients with migraine; however, their long-term effects on pain are not significant.

Major finding: The cold intervention group vs. control group led to a significant reduction in pain on a visual analog scale score at 30 minutes (standard mean difference [SMD] −3.21; P = .02) but a nonsignificant reduction in the score at 24 hours (SMD −0.44; P = .07) after the intervention.

Study details: This was a meta-analysis of 6 studies (4 randomized controlled trials and 2 quasi-experimental studies) that included adult patients with migraine who underwent a cold intervention.

Disclosures: The study was partially sponsored by the Ministry of Science and Technology, Israel. The authors declared no conflicts of interest.

Source: Hsu Y-Y et al. Cold intervention for relieving migraine symptoms: A systematic review and meta-analysis. J Clin Nurs. 2022 (May 20). Doi: 10.1111/jocn.16368

Key clinical point: Cold interventions, including cold-gel headband, cold-gel cap, and intraoral cooling, provide instant relief from pain in patients with migraine; however, their long-term effects on pain are not significant.

Major finding: The cold intervention group vs. control group led to a significant reduction in pain on a visual analog scale score at 30 minutes (standard mean difference [SMD] −3.21; P = .02) but a nonsignificant reduction in the score at 24 hours (SMD −0.44; P = .07) after the intervention.

Study details: This was a meta-analysis of 6 studies (4 randomized controlled trials and 2 quasi-experimental studies) that included adult patients with migraine who underwent a cold intervention.

Disclosures: The study was partially sponsored by the Ministry of Science and Technology, Israel. The authors declared no conflicts of interest.

Source: Hsu Y-Y et al. Cold intervention for relieving migraine symptoms: A systematic review and meta-analysis. J Clin Nurs. 2022 (May 20). Doi: 10.1111/jocn.16368

Key clinical point: As a migraine preventive agent, fremanezumab is effective across the full patient spectrum, including those with episodic migraine (EM), chronic migraine (CM), and difficult-to-treat (DTT) migraine (patients with medication overuse [MO], major depressive disorder [MDD], generalized anxiety disorder [GAD], or exposure to a different calcitonin gene-related peptide monoclonal antibody [CGRP mAb]).

Major finding: At month 6, the mean monthly migraine days reduced in patients with EM (−7.7 days), CM (−10.1 days), MO (−10.8 days), MDD (−9.9 days), GAD (−9.5 days), and prior CGRP mAb exposure (−9.0 days).

Study details: Findings are from a retrospective, online chart review study that collected data from 1003 patients with EM/CM aged ≥18 years at fremanezumab initiation, including those with DTT migraine, and 421 clinicians treating patients with EM/CM in a US-based practice.

Disclosures: This study was funded by Teva Pharmaceuticals. All authors declared being current or former employees of Teva Pharmaceuticals or Analysis Group, which performed these analyses funded by Teva.

Source: Driessen MT et al. Real-world effectiveness after initiating fremanezumab treatment in US patients with episodic and chronic migraine or difficult-to-treat migraine. J Headache Pain. 2022;23:56 (May 16). Doi: 10.1186/s10194-022-01415-x

Key clinical point: As a migraine preventive agent, fremanezumab is effective across the full patient spectrum, including those with episodic migraine (EM), chronic migraine (CM), and difficult-to-treat (DTT) migraine (patients with medication overuse [MO], major depressive disorder [MDD], generalized anxiety disorder [GAD], or exposure to a different calcitonin gene-related peptide monoclonal antibody [CGRP mAb]).

Major finding: At month 6, the mean monthly migraine days reduced in patients with EM (−7.7 days), CM (−10.1 days), MO (−10.8 days), MDD (−9.9 days), GAD (−9.5 days), and prior CGRP mAb exposure (−9.0 days).

Study details: Findings are from a retrospective, online chart review study that collected data from 1003 patients with EM/CM aged ≥18 years at fremanezumab initiation, including those with DTT migraine, and 421 clinicians treating patients with EM/CM in a US-based practice.

Disclosures: This study was funded by Teva Pharmaceuticals. All authors declared being current or former employees of Teva Pharmaceuticals or Analysis Group, which performed these analyses funded by Teva.

Source: Driessen MT et al. Real-world effectiveness after initiating fremanezumab treatment in US patients with episodic and chronic migraine or difficult-to-treat migraine. J Headache Pain. 2022;23:56 (May 16). Doi: 10.1186/s10194-022-01415-x

Key clinical point: As a migraine preventive agent, fremanezumab is effective across the full patient spectrum, including those with episodic migraine (EM), chronic migraine (CM), and difficult-to-treat (DTT) migraine (patients with medication overuse [MO], major depressive disorder [MDD], generalized anxiety disorder [GAD], or exposure to a different calcitonin gene-related peptide monoclonal antibody [CGRP mAb]).

Major finding: At month 6, the mean monthly migraine days reduced in patients with EM (−7.7 days), CM (−10.1 days), MO (−10.8 days), MDD (−9.9 days), GAD (−9.5 days), and prior CGRP mAb exposure (−9.0 days).

Study details: Findings are from a retrospective, online chart review study that collected data from 1003 patients with EM/CM aged ≥18 years at fremanezumab initiation, including those with DTT migraine, and 421 clinicians treating patients with EM/CM in a US-based practice.

Disclosures: This study was funded by Teva Pharmaceuticals. All authors declared being current or former employees of Teva Pharmaceuticals or Analysis Group, which performed these analyses funded by Teva.

Source: Driessen MT et al. Real-world effectiveness after initiating fremanezumab treatment in US patients with episodic and chronic migraine or difficult-to-treat migraine. J Headache Pain. 2022;23:56 (May 16). Doi: 10.1186/s10194-022-01415-x

Key clinical point: A dose of 120 mg  galcanezumab  subcutaneously safely and effectively reduces headache frequency, intensity, and duration in patients with episodic and chronic migraine and previous unsuccessful preventive treatments.

Major finding: The 6-month galcanezumab treatment led to a significant decrease in the headache attack frequency (−14.19 headache days/month; P < .001), headache attack pain intensity (numerical rating scale score −2.74; P < .001), and headache attack duration (−6.65 hours; P < .001).

Study details: The data come from an observational, prospective study including 43 patients with episodic high frequency and chronic migraine and unsuccessful treatment with ≥3 preventive medication classes who received monthly 120 mg galcanezumab subcutaneously.

Disclosures: This study received no specific funding. Some authors declared receiving speaker honoraria and travel funding from various sources and serving as associate editors of neurology journals such as European Journal of Neurology.

Source: Silvestro M et al. Galcanezumab effect on “whole pain burden” and multidimensional outcomes in migraine patients with previous unsuccessful treatments: A real-world experience. J Headache Pain. 2022;23:69 (Jun 13. Doi:  10.1186/s10194-022-01436-6

Key clinical point: A dose of 120 mg  galcanezumab  subcutaneously safely and effectively reduces headache frequency, intensity, and duration in patients with episodic and chronic migraine and previous unsuccessful preventive treatments.

Major finding: The 6-month galcanezumab treatment led to a significant decrease in the headache attack frequency (−14.19 headache days/month; P < .001), headache attack pain intensity (numerical rating scale score −2.74; P < .001), and headache attack duration (−6.65 hours; P < .001).

Study details: The data come from an observational, prospective study including 43 patients with episodic high frequency and chronic migraine and unsuccessful treatment with ≥3 preventive medication classes who received monthly 120 mg galcanezumab subcutaneously.

Disclosures: This study received no specific funding. Some authors declared receiving speaker honoraria and travel funding from various sources and serving as associate editors of neurology journals such as European Journal of Neurology.

Source: Silvestro M et al. Galcanezumab effect on “whole pain burden” and multidimensional outcomes in migraine patients with previous unsuccessful treatments: A real-world experience. J Headache Pain. 2022;23:69 (Jun 13. Doi:  10.1186/s10194-022-01436-6

Key clinical point: A dose of 120 mg  galcanezumab  subcutaneously safely and effectively reduces headache frequency, intensity, and duration in patients with episodic and chronic migraine and previous unsuccessful preventive treatments.

Major finding: The 6-month galcanezumab treatment led to a significant decrease in the headache attack frequency (−14.19 headache days/month; P < .001), headache attack pain intensity (numerical rating scale score −2.74; P < .001), and headache attack duration (−6.65 hours; P < .001).

Study details: The data come from an observational, prospective study including 43 patients with episodic high frequency and chronic migraine and unsuccessful treatment with ≥3 preventive medication classes who received monthly 120 mg galcanezumab subcutaneously.

Disclosures: This study received no specific funding. Some authors declared receiving speaker honoraria and travel funding from various sources and serving as associate editors of neurology journals such as European Journal of Neurology.

Source: Silvestro M et al. Galcanezumab effect on “whole pain burden” and multidimensional outcomes in migraine patients with previous unsuccessful treatments: A real-world experience. J Headache Pain. 2022;23:69 (Jun 13. Doi:  10.1186/s10194-022-01436-6