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Hypertension Responsible for Detrimental Effects of Leisure Screen Time on Migraine
Key clinical point: This Mendelian randomization study showed that leisure screen time (LST) worsens migraine, whereas moderate to vigorous physical activity (MVPA) alleviates it, with hypertension and diastolic blood pressure (DBP) being responsible for the effects of MVPA or LST on migraine.
Major findings: Genetically predicted LST was associated with a significantly increased risk for migraine (odds ratio [OR] 1.28; P < .001), whereas MVPA was linked to a significantly reduced risk (OR 0.73; P = .000006). Hypertension mediated 4.86% and 24.81% of the effects of MVPA and LST on migraine risk, respectively, and DBP accounted for 4.66% of the effects of MVPA on migraine risk.
Study details: This study included 18,477 patients with migraine and 287,837 control individuals without migraine from the FinnGen consortium and 26,052 patients with migraine and 487,214 control individuals without migraine from the large-scale genome-wide association studies.
Disclosures: This study was supported by grants from the National Natural Science Foundation of China and others. The authors declared no conflicts of interest.
Source: Gan Q, Song E, Zhang L, et al. The role of hypertension in the relationship between leisure screen time, physical activity and migraine: A 2-sample Mendelian randomization study. J Headache Pain. 2024;25:122 (Jul 24). Doi: 10.1186/s10194-024-01820-4 Source
Key clinical point: This Mendelian randomization study showed that leisure screen time (LST) worsens migraine, whereas moderate to vigorous physical activity (MVPA) alleviates it, with hypertension and diastolic blood pressure (DBP) being responsible for the effects of MVPA or LST on migraine.
Major findings: Genetically predicted LST was associated with a significantly increased risk for migraine (odds ratio [OR] 1.28; P < .001), whereas MVPA was linked to a significantly reduced risk (OR 0.73; P = .000006). Hypertension mediated 4.86% and 24.81% of the effects of MVPA and LST on migraine risk, respectively, and DBP accounted for 4.66% of the effects of MVPA on migraine risk.
Study details: This study included 18,477 patients with migraine and 287,837 control individuals without migraine from the FinnGen consortium and 26,052 patients with migraine and 487,214 control individuals without migraine from the large-scale genome-wide association studies.
Disclosures: This study was supported by grants from the National Natural Science Foundation of China and others. The authors declared no conflicts of interest.
Source: Gan Q, Song E, Zhang L, et al. The role of hypertension in the relationship between leisure screen time, physical activity and migraine: A 2-sample Mendelian randomization study. J Headache Pain. 2024;25:122 (Jul 24). Doi: 10.1186/s10194-024-01820-4 Source
Key clinical point: This Mendelian randomization study showed that leisure screen time (LST) worsens migraine, whereas moderate to vigorous physical activity (MVPA) alleviates it, with hypertension and diastolic blood pressure (DBP) being responsible for the effects of MVPA or LST on migraine.
Major findings: Genetically predicted LST was associated with a significantly increased risk for migraine (odds ratio [OR] 1.28; P < .001), whereas MVPA was linked to a significantly reduced risk (OR 0.73; P = .000006). Hypertension mediated 4.86% and 24.81% of the effects of MVPA and LST on migraine risk, respectively, and DBP accounted for 4.66% of the effects of MVPA on migraine risk.
Study details: This study included 18,477 patients with migraine and 287,837 control individuals without migraine from the FinnGen consortium and 26,052 patients with migraine and 487,214 control individuals without migraine from the large-scale genome-wide association studies.
Disclosures: This study was supported by grants from the National Natural Science Foundation of China and others. The authors declared no conflicts of interest.
Source: Gan Q, Song E, Zhang L, et al. The role of hypertension in the relationship between leisure screen time, physical activity and migraine: A 2-sample Mendelian randomization study. J Headache Pain. 2024;25:122 (Jul 24). Doi: 10.1186/s10194-024-01820-4 Source
Atogepant Is Effective and Well Tolerated for Migraine Prevention, Irrespective of Dose
Key clinical point: The meta-analysis showed that atogepant was effective and well tolerated in patients with migraine in a non–dose-dependent manner, with rare incidences of serious treatment-emergent adverse events (TEAE) reported.
Major findings: Atogepant vs placebo led to a significant reduction in monthly migraine days (standardized mean difference [SMD] −0.40; P = .00001) and headache days (SMD −0.39; P = .00001), with consistent results observed across all dosage groups. The risk for TEAE (relative risk [RR] 1.11; P = .02) was significantly higher in the atogepant vs placebo group, with constipation (RR 2.55; P < .00001), nausea (RR 2.19; P < .00001), and urinary tract infection (RR 1.49; P = .03) being the most common.
Study details: This meta-analysis of four randomized controlled trials included 2813 patients with migraine who were treated with atogepant (10 mg, 30 mg, or 60 mg).
Disclosures: This study was supported by the Chongqing Clinical Pharmacy Key Specialties Construction Project, China. The authors declared no conflicts of interest.
Source: Hou M, Luo X, He S, et al. Efficacy and safety of atogepant, a small molecule CGRP receptor antagonist, for the preventive treatment of migraine: A systematic review and meta-analysis. J Headache Pain. 2024;25:116 (Jul 19). Doi: 10.1186/s10194-024-01822-2 Source
Key clinical point: The meta-analysis showed that atogepant was effective and well tolerated in patients with migraine in a non–dose-dependent manner, with rare incidences of serious treatment-emergent adverse events (TEAE) reported.
Major findings: Atogepant vs placebo led to a significant reduction in monthly migraine days (standardized mean difference [SMD] −0.40; P = .00001) and headache days (SMD −0.39; P = .00001), with consistent results observed across all dosage groups. The risk for TEAE (relative risk [RR] 1.11; P = .02) was significantly higher in the atogepant vs placebo group, with constipation (RR 2.55; P < .00001), nausea (RR 2.19; P < .00001), and urinary tract infection (RR 1.49; P = .03) being the most common.
Study details: This meta-analysis of four randomized controlled trials included 2813 patients with migraine who were treated with atogepant (10 mg, 30 mg, or 60 mg).
Disclosures: This study was supported by the Chongqing Clinical Pharmacy Key Specialties Construction Project, China. The authors declared no conflicts of interest.
Source: Hou M, Luo X, He S, et al. Efficacy and safety of atogepant, a small molecule CGRP receptor antagonist, for the preventive treatment of migraine: A systematic review and meta-analysis. J Headache Pain. 2024;25:116 (Jul 19). Doi: 10.1186/s10194-024-01822-2 Source
Key clinical point: The meta-analysis showed that atogepant was effective and well tolerated in patients with migraine in a non–dose-dependent manner, with rare incidences of serious treatment-emergent adverse events (TEAE) reported.
Major findings: Atogepant vs placebo led to a significant reduction in monthly migraine days (standardized mean difference [SMD] −0.40; P = .00001) and headache days (SMD −0.39; P = .00001), with consistent results observed across all dosage groups. The risk for TEAE (relative risk [RR] 1.11; P = .02) was significantly higher in the atogepant vs placebo group, with constipation (RR 2.55; P < .00001), nausea (RR 2.19; P < .00001), and urinary tract infection (RR 1.49; P = .03) being the most common.
Study details: This meta-analysis of four randomized controlled trials included 2813 patients with migraine who were treated with atogepant (10 mg, 30 mg, or 60 mg).
Disclosures: This study was supported by the Chongqing Clinical Pharmacy Key Specialties Construction Project, China. The authors declared no conflicts of interest.
Source: Hou M, Luo X, He S, et al. Efficacy and safety of atogepant, a small molecule CGRP receptor antagonist, for the preventive treatment of migraine: A systematic review and meta-analysis. J Headache Pain. 2024;25:116 (Jul 19). Doi: 10.1186/s10194-024-01822-2 Source
Aura Increases Disability in Migraine
Key clinical point: The presence of migraine aura exacerbated migraine-related disability, mainly due to concurrent non-pain symptoms of migraine rather than the aura itself.
Major findings: The presence of aura on the first day of the migraine episode was significantly associated with increased odds of disability across all migraine days (odds ratio [OR] 1.40; P < .001); and non-pain symptoms, such as allodynia, photophobia, phonophobia, and nausea or vomiting (P < .001 for all). No association was observed between aura and headache-related migraine symptoms.
Study details: This observational prospective cohort study included 554 adults with episodic migraine, with complete data on migraine symptoms and psychological variables collected daily for 90 days using the N-1 Headache™ digital app (N = 11,156 total migraine days).
Disclosures: This study did not receive funding from any sources. The authors declared no conflicts of interest.
Source: Denney DE, Lee AA, Landy SH, Smitherman TA. Headache-related disability as a function of migraine aura: A daily diary study. Headache. 2024 (Aug 1). Doi: 10.1111/head.14796 Source
Key clinical point: The presence of migraine aura exacerbated migraine-related disability, mainly due to concurrent non-pain symptoms of migraine rather than the aura itself.
Major findings: The presence of aura on the first day of the migraine episode was significantly associated with increased odds of disability across all migraine days (odds ratio [OR] 1.40; P < .001); and non-pain symptoms, such as allodynia, photophobia, phonophobia, and nausea or vomiting (P < .001 for all). No association was observed between aura and headache-related migraine symptoms.
Study details: This observational prospective cohort study included 554 adults with episodic migraine, with complete data on migraine symptoms and psychological variables collected daily for 90 days using the N-1 Headache™ digital app (N = 11,156 total migraine days).
Disclosures: This study did not receive funding from any sources. The authors declared no conflicts of interest.
Source: Denney DE, Lee AA, Landy SH, Smitherman TA. Headache-related disability as a function of migraine aura: A daily diary study. Headache. 2024 (Aug 1). Doi: 10.1111/head.14796 Source
Key clinical point: The presence of migraine aura exacerbated migraine-related disability, mainly due to concurrent non-pain symptoms of migraine rather than the aura itself.
Major findings: The presence of aura on the first day of the migraine episode was significantly associated with increased odds of disability across all migraine days (odds ratio [OR] 1.40; P < .001); and non-pain symptoms, such as allodynia, photophobia, phonophobia, and nausea or vomiting (P < .001 for all). No association was observed between aura and headache-related migraine symptoms.
Study details: This observational prospective cohort study included 554 adults with episodic migraine, with complete data on migraine symptoms and psychological variables collected daily for 90 days using the N-1 Headache™ digital app (N = 11,156 total migraine days).
Disclosures: This study did not receive funding from any sources. The authors declared no conflicts of interest.
Source: Denney DE, Lee AA, Landy SH, Smitherman TA. Headache-related disability as a function of migraine aura: A daily diary study. Headache. 2024 (Aug 1). Doi: 10.1111/head.14796 Source
History of Abuse May Worsen Disease Burden in Migraine
Key clinical point: Patients with migraine and a history of abuse had a greater migraine burden than those without a history of abuse, with this association being mediated by depression and anxiety.
Major findings: Patients with migraine who did vs did not have a history of abuse had significantly higher migraine-specific disability (68 vs 49), subjective cognitive impairment (10 vs 7), and pain interference (65 vs 62.5) scores, as well as greater overall work impairment (47.6% vs 38.6%) and activity impairment (49.3% vs 39.3%; all P < .001). Depression and anxiety mediated the association between history of abuse and migraine burden.
Study details: This cross-sectional study included 866 patients with migraine from the American Registry for Migraine Research, of whom 316 (36.5 %) had a history of abuse.
Disclosures: This study was supported by the American Migraine Foundation and American Academy of Neurology. Some authors declared receiving research funding from or having other ties with various sources.
Source: Trivedi M, Dumkrieger G, Chong CD, et al. A history of abuse is associated with more severe migraine- and pain-related disability: Results from the American Registry for Migraine Research. Headache. 2024 (Jul 25). Doi: 10.1111/head.14787 Source
Key clinical point: Patients with migraine and a history of abuse had a greater migraine burden than those without a history of abuse, with this association being mediated by depression and anxiety.
Major findings: Patients with migraine who did vs did not have a history of abuse had significantly higher migraine-specific disability (68 vs 49), subjective cognitive impairment (10 vs 7), and pain interference (65 vs 62.5) scores, as well as greater overall work impairment (47.6% vs 38.6%) and activity impairment (49.3% vs 39.3%; all P < .001). Depression and anxiety mediated the association between history of abuse and migraine burden.
Study details: This cross-sectional study included 866 patients with migraine from the American Registry for Migraine Research, of whom 316 (36.5 %) had a history of abuse.
Disclosures: This study was supported by the American Migraine Foundation and American Academy of Neurology. Some authors declared receiving research funding from or having other ties with various sources.
Source: Trivedi M, Dumkrieger G, Chong CD, et al. A history of abuse is associated with more severe migraine- and pain-related disability: Results from the American Registry for Migraine Research. Headache. 2024 (Jul 25). Doi: 10.1111/head.14787 Source
Key clinical point: Patients with migraine and a history of abuse had a greater migraine burden than those without a history of abuse, with this association being mediated by depression and anxiety.
Major findings: Patients with migraine who did vs did not have a history of abuse had significantly higher migraine-specific disability (68 vs 49), subjective cognitive impairment (10 vs 7), and pain interference (65 vs 62.5) scores, as well as greater overall work impairment (47.6% vs 38.6%) and activity impairment (49.3% vs 39.3%; all P < .001). Depression and anxiety mediated the association between history of abuse and migraine burden.
Study details: This cross-sectional study included 866 patients with migraine from the American Registry for Migraine Research, of whom 316 (36.5 %) had a history of abuse.
Disclosures: This study was supported by the American Migraine Foundation and American Academy of Neurology. Some authors declared receiving research funding from or having other ties with various sources.
Source: Trivedi M, Dumkrieger G, Chong CD, et al. A history of abuse is associated with more severe migraine- and pain-related disability: Results from the American Registry for Migraine Research. Headache. 2024 (Jul 25). Doi: 10.1111/head.14787 Source
Anti-CGRP Antibody Efficacy Unaffected by Chronic Migraine Duration
Key clinical point: Anti-calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAb) were effective and showed a similar time to onset in patients with chronic migraine (CM), irrespective of disease duration.
Major findings: At 10-12 months of follow-up, anti-CGRP mAb reduced monthly migraine days by an average of 12 days across all tertiles of CM duration (P = .946). Additionally, monthly headache days and acute medication use significantly decreased from baseline to 10-12 months (P < .001) across all tertiles of CM duration, indicating no difference in the time to onset of anti-CGRP mAb across tertiles.
Study details: This cohort study included 335 patients with CM treated with anti-CGRP mAb for at least 12 months. Patients were categorized into different tertiles of CM duration: 0-7 years, 8-18 years, and 18-60 years.
Disclosures: This study did not disclose any funding sources. Four authors declared receiving personal fees from or having other ties with various sources.
Source: Ornello R, Baldini F, Onofri A, et al. Impact of duration of chronic migraine on long-term effectiveness of monoclonal antibodies targeting the calcitonin gene-related peptide pathway-A real-world study. Headache. 2024 (Jul 16). Doi: 10.1111/head.14788 Source
Key clinical point: Anti-calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAb) were effective and showed a similar time to onset in patients with chronic migraine (CM), irrespective of disease duration.
Major findings: At 10-12 months of follow-up, anti-CGRP mAb reduced monthly migraine days by an average of 12 days across all tertiles of CM duration (P = .946). Additionally, monthly headache days and acute medication use significantly decreased from baseline to 10-12 months (P < .001) across all tertiles of CM duration, indicating no difference in the time to onset of anti-CGRP mAb across tertiles.
Study details: This cohort study included 335 patients with CM treated with anti-CGRP mAb for at least 12 months. Patients were categorized into different tertiles of CM duration: 0-7 years, 8-18 years, and 18-60 years.
Disclosures: This study did not disclose any funding sources. Four authors declared receiving personal fees from or having other ties with various sources.
Source: Ornello R, Baldini F, Onofri A, et al. Impact of duration of chronic migraine on long-term effectiveness of monoclonal antibodies targeting the calcitonin gene-related peptide pathway-A real-world study. Headache. 2024 (Jul 16). Doi: 10.1111/head.14788 Source
Key clinical point: Anti-calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAb) were effective and showed a similar time to onset in patients with chronic migraine (CM), irrespective of disease duration.
Major findings: At 10-12 months of follow-up, anti-CGRP mAb reduced monthly migraine days by an average of 12 days across all tertiles of CM duration (P = .946). Additionally, monthly headache days and acute medication use significantly decreased from baseline to 10-12 months (P < .001) across all tertiles of CM duration, indicating no difference in the time to onset of anti-CGRP mAb across tertiles.
Study details: This cohort study included 335 patients with CM treated with anti-CGRP mAb for at least 12 months. Patients were categorized into different tertiles of CM duration: 0-7 years, 8-18 years, and 18-60 years.
Disclosures: This study did not disclose any funding sources. Four authors declared receiving personal fees from or having other ties with various sources.
Source: Ornello R, Baldini F, Onofri A, et al. Impact of duration of chronic migraine on long-term effectiveness of monoclonal antibodies targeting the calcitonin gene-related peptide pathway-A real-world study. Headache. 2024 (Jul 16). Doi: 10.1111/head.14788 Source
Childhood Abuse Linked to Migraine Risk, Meta-analysis Shows
Key clinical point: Childhood abuse was significantly associated with an increased risk for migraine, with specific types such as physical, sexual, and emotional abuse showing a positive association with migraine onset.
Major findings: Individuals who experienced childhood abuse had a higher risk for migraine than those who did not (odd ratio [OR] 1.60; 95% CI 1.49-1.71). This risk was increased in those who were exposed to sexual abuse (OR 1.71; 95% CI 1.43-2.04), physical abuse (OR 1.47; 95% CI 1.38-1.56), and emotional abuse (OR 1.71; 95% CI 1.52-1.93).
Study details: This meta-analysis of 12 studies evaluated the association between childhood abuse and migraine in 110,776 patients with migraine.
Disclosures: No funding source was disclosed for this study. The authors declared no conflicts of interest.
Source: Liu J, Guo Y, Huang Z, et al. Childhood abuse and risk of migraine: A systematic review and meta-analysis. Child Abuse Negl. 2024;155:106961 (Aug 2). Doi: 10.1016/j.chiabu.2024.106961 Source
Key clinical point: Childhood abuse was significantly associated with an increased risk for migraine, with specific types such as physical, sexual, and emotional abuse showing a positive association with migraine onset.
Major findings: Individuals who experienced childhood abuse had a higher risk for migraine than those who did not (odd ratio [OR] 1.60; 95% CI 1.49-1.71). This risk was increased in those who were exposed to sexual abuse (OR 1.71; 95% CI 1.43-2.04), physical abuse (OR 1.47; 95% CI 1.38-1.56), and emotional abuse (OR 1.71; 95% CI 1.52-1.93).
Study details: This meta-analysis of 12 studies evaluated the association between childhood abuse and migraine in 110,776 patients with migraine.
Disclosures: No funding source was disclosed for this study. The authors declared no conflicts of interest.
Source: Liu J, Guo Y, Huang Z, et al. Childhood abuse and risk of migraine: A systematic review and meta-analysis. Child Abuse Negl. 2024;155:106961 (Aug 2). Doi: 10.1016/j.chiabu.2024.106961 Source
Key clinical point: Childhood abuse was significantly associated with an increased risk for migraine, with specific types such as physical, sexual, and emotional abuse showing a positive association with migraine onset.
Major findings: Individuals who experienced childhood abuse had a higher risk for migraine than those who did not (odd ratio [OR] 1.60; 95% CI 1.49-1.71). This risk was increased in those who were exposed to sexual abuse (OR 1.71; 95% CI 1.43-2.04), physical abuse (OR 1.47; 95% CI 1.38-1.56), and emotional abuse (OR 1.71; 95% CI 1.52-1.93).
Study details: This meta-analysis of 12 studies evaluated the association between childhood abuse and migraine in 110,776 patients with migraine.
Disclosures: No funding source was disclosed for this study. The authors declared no conflicts of interest.
Source: Liu J, Guo Y, Huang Z, et al. Childhood abuse and risk of migraine: A systematic review and meta-analysis. Child Abuse Negl. 2024;155:106961 (Aug 2). Doi: 10.1016/j.chiabu.2024.106961 Source
Increasing Daily Steps Predicts Treatment Response to Anti-CGRP Antibodies in Chronic Migraine
Key clinical point: The daily step count increased noticeably after initiating treatment with anti-calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAb) in adults with chronic migraine, with a positive association seen between the increase in daily steps and the treatment response to CGRP mAbs.
Major findings: The average number of steps per day increased from 4421 before initiation of anti-CGRP mAb treatment to 5241 at 3 months after initiation of treatment (P = .039), reflecting a mean percentage increase of 21.3% (95% CI 0.5-42.1). There was a positive association between an increase in daily steps and a reduction in monthly migraine days (correlation coefficient 0.521; P = .013).
Study details: This single-center, cross-sectional, retrospective study included 22 patients with chronic migraine who were treated with anti-CGRP mAbs (erenumab or fremanezumab).
Disclosures: The study was supported by the Lundbeck Foundation. Several authors declared receiving grants, honoraria, or personal fees from or having other ties with various sources.
Source: Jantzen FT, Chaudhry BA, Younis S, et al. Average steps per day as marker of treatment response with anti-CGRP mAbs in adults with chronic migraine: A pilot study. Sci Rep. 2024;14:18068 (Aug 5). Doi: 10.1038/s41598-024-68915-5 Source
Key clinical point: The daily step count increased noticeably after initiating treatment with anti-calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAb) in adults with chronic migraine, with a positive association seen between the increase in daily steps and the treatment response to CGRP mAbs.
Major findings: The average number of steps per day increased from 4421 before initiation of anti-CGRP mAb treatment to 5241 at 3 months after initiation of treatment (P = .039), reflecting a mean percentage increase of 21.3% (95% CI 0.5-42.1). There was a positive association between an increase in daily steps and a reduction in monthly migraine days (correlation coefficient 0.521; P = .013).
Study details: This single-center, cross-sectional, retrospective study included 22 patients with chronic migraine who were treated with anti-CGRP mAbs (erenumab or fremanezumab).
Disclosures: The study was supported by the Lundbeck Foundation. Several authors declared receiving grants, honoraria, or personal fees from or having other ties with various sources.
Source: Jantzen FT, Chaudhry BA, Younis S, et al. Average steps per day as marker of treatment response with anti-CGRP mAbs in adults with chronic migraine: A pilot study. Sci Rep. 2024;14:18068 (Aug 5). Doi: 10.1038/s41598-024-68915-5 Source
Key clinical point: The daily step count increased noticeably after initiating treatment with anti-calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAb) in adults with chronic migraine, with a positive association seen between the increase in daily steps and the treatment response to CGRP mAbs.
Major findings: The average number of steps per day increased from 4421 before initiation of anti-CGRP mAb treatment to 5241 at 3 months after initiation of treatment (P = .039), reflecting a mean percentage increase of 21.3% (95% CI 0.5-42.1). There was a positive association between an increase in daily steps and a reduction in monthly migraine days (correlation coefficient 0.521; P = .013).
Study details: This single-center, cross-sectional, retrospective study included 22 patients with chronic migraine who were treated with anti-CGRP mAbs (erenumab or fremanezumab).
Disclosures: The study was supported by the Lundbeck Foundation. Several authors declared receiving grants, honoraria, or personal fees from or having other ties with various sources.
Source: Jantzen FT, Chaudhry BA, Younis S, et al. Average steps per day as marker of treatment response with anti-CGRP mAbs in adults with chronic migraine: A pilot study. Sci Rep. 2024;14:18068 (Aug 5). Doi: 10.1038/s41598-024-68915-5 Source
Proinflammatory Diet Linked to Chronic Migraine Risk in Women
Key clinical point: Women with an increased adherence to a pro-inflammatory diet, as measured using a dietary inflammation score (DIS), had an increased risk for chronic migraine (CM).
Major findings: Women with CM had a significantly higher DIS than those with episodic migraine (EM) (0.08 vs 0.62; P = .002). The risk for CM was two times higher in women with a high DIS than in those with a low DIS (adjusted odd ratio 2.02; Ptrend = .03).
Study details: This cross-sectional study included 285 women with migraine, of whom 169 (59.3%) had EM and 116 (40.7%) had CM.
Disclosures: This study was supported by the Student Research Committee of Ahvaz Jundishapur University of Medical Sciences. The authors declared no conflicts of interest.
Source: Bakhshimoghaddam F, Shalilahmadi D, Mahdavi R, et al. Association of dietary and lifestyle inflammation score (DLIS) with chronic migraine in women: A cross-sectional study. Sci Rep. 2024;14:16406 (Jul 16). Doi: 10.1038/s41598-024-66776-6 Source
Key clinical point: Women with an increased adherence to a pro-inflammatory diet, as measured using a dietary inflammation score (DIS), had an increased risk for chronic migraine (CM).
Major findings: Women with CM had a significantly higher DIS than those with episodic migraine (EM) (0.08 vs 0.62; P = .002). The risk for CM was two times higher in women with a high DIS than in those with a low DIS (adjusted odd ratio 2.02; Ptrend = .03).
Study details: This cross-sectional study included 285 women with migraine, of whom 169 (59.3%) had EM and 116 (40.7%) had CM.
Disclosures: This study was supported by the Student Research Committee of Ahvaz Jundishapur University of Medical Sciences. The authors declared no conflicts of interest.
Source: Bakhshimoghaddam F, Shalilahmadi D, Mahdavi R, et al. Association of dietary and lifestyle inflammation score (DLIS) with chronic migraine in women: A cross-sectional study. Sci Rep. 2024;14:16406 (Jul 16). Doi: 10.1038/s41598-024-66776-6 Source
Key clinical point: Women with an increased adherence to a pro-inflammatory diet, as measured using a dietary inflammation score (DIS), had an increased risk for chronic migraine (CM).
Major findings: Women with CM had a significantly higher DIS than those with episodic migraine (EM) (0.08 vs 0.62; P = .002). The risk for CM was two times higher in women with a high DIS than in those with a low DIS (adjusted odd ratio 2.02; Ptrend = .03).
Study details: This cross-sectional study included 285 women with migraine, of whom 169 (59.3%) had EM and 116 (40.7%) had CM.
Disclosures: This study was supported by the Student Research Committee of Ahvaz Jundishapur University of Medical Sciences. The authors declared no conflicts of interest.
Source: Bakhshimoghaddam F, Shalilahmadi D, Mahdavi R, et al. Association of dietary and lifestyle inflammation score (DLIS) with chronic migraine in women: A cross-sectional study. Sci Rep. 2024;14:16406 (Jul 16). Doi: 10.1038/s41598-024-66776-6 Source
Cardiovascular Risk Factors Affect Migraine Risk in Women
Key clinical point: Cardiovascular risk factors (CVRF), such as current smoking status and diabetes mellitus, were associated with a decreased prevalence of migraine in middle-aged and older-aged women, whereas elevated diastolic blood pressure (BP) was associated with an increased prevalence.
Major findings: Among women, current smokers (odds ratio [OR] 0.72; 95% CI 0.58-0.90) and those with diabetes mellitus (OR 0.74; 95% CI 0.56-0.98) had a decreased prevalence of migraine. Conversely, women with elevated diastolic BP had an increased prevalence of migraine (OR per standard deviation increase 1.16; 95% CI 1.04-1.29). No significant association was observed between CVRF and migraine in men.
Study details: This cross-sectional analysis assessed sex-specific associations of CVRF with migraine in 7266 middle-aged and older participants (4181 women and 3085 men) from the Rotterdam Study.
Disclosures: The Rotterdam Study was funded by the Erasmus Medical Center, Erasmus University Rotterdam, and others. Antoinette MaassenVanDenBrink declared receiving research grants or consultation fees from various sources.
Source: Al-Hassany L, Acarsoy C, Ikram MK, et al. Sex-specific association of cardiovascular risk factors with migraine: The Population-Based Rotterdam Study. Neurology. 2024;103:e209700 (Aug 27). Doi: 10.1212/WNL.0000000000209700 Source
Key clinical point: Cardiovascular risk factors (CVRF), such as current smoking status and diabetes mellitus, were associated with a decreased prevalence of migraine in middle-aged and older-aged women, whereas elevated diastolic blood pressure (BP) was associated with an increased prevalence.
Major findings: Among women, current smokers (odds ratio [OR] 0.72; 95% CI 0.58-0.90) and those with diabetes mellitus (OR 0.74; 95% CI 0.56-0.98) had a decreased prevalence of migraine. Conversely, women with elevated diastolic BP had an increased prevalence of migraine (OR per standard deviation increase 1.16; 95% CI 1.04-1.29). No significant association was observed between CVRF and migraine in men.
Study details: This cross-sectional analysis assessed sex-specific associations of CVRF with migraine in 7266 middle-aged and older participants (4181 women and 3085 men) from the Rotterdam Study.
Disclosures: The Rotterdam Study was funded by the Erasmus Medical Center, Erasmus University Rotterdam, and others. Antoinette MaassenVanDenBrink declared receiving research grants or consultation fees from various sources.
Source: Al-Hassany L, Acarsoy C, Ikram MK, et al. Sex-specific association of cardiovascular risk factors with migraine: The Population-Based Rotterdam Study. Neurology. 2024;103:e209700 (Aug 27). Doi: 10.1212/WNL.0000000000209700 Source
Key clinical point: Cardiovascular risk factors (CVRF), such as current smoking status and diabetes mellitus, were associated with a decreased prevalence of migraine in middle-aged and older-aged women, whereas elevated diastolic blood pressure (BP) was associated with an increased prevalence.
Major findings: Among women, current smokers (odds ratio [OR] 0.72; 95% CI 0.58-0.90) and those with diabetes mellitus (OR 0.74; 95% CI 0.56-0.98) had a decreased prevalence of migraine. Conversely, women with elevated diastolic BP had an increased prevalence of migraine (OR per standard deviation increase 1.16; 95% CI 1.04-1.29). No significant association was observed between CVRF and migraine in men.
Study details: This cross-sectional analysis assessed sex-specific associations of CVRF with migraine in 7266 middle-aged and older participants (4181 women and 3085 men) from the Rotterdam Study.
Disclosures: The Rotterdam Study was funded by the Erasmus Medical Center, Erasmus University Rotterdam, and others. Antoinette MaassenVanDenBrink declared receiving research grants or consultation fees from various sources.
Source: Al-Hassany L, Acarsoy C, Ikram MK, et al. Sex-specific association of cardiovascular risk factors with migraine: The Population-Based Rotterdam Study. Neurology. 2024;103:e209700 (Aug 27). Doi: 10.1212/WNL.0000000000209700 Source
AHS White Paper Guides Treatment of Posttraumatic Headache in Youth
The guidance document, the first of its kind, covers risk factors for prolonged recovery, along with pharmacologic and nonpharmacologic management strategies, and supports an emphasis on multidisciplinary care, lead author Carlyn Patterson Gentile, MD, PhD, attending physician in the Division of Neurology at Children’s Hospital of Philadelphia in Pennsylvania, and colleagues reported.
“There are no guidelines to inform the management of posttraumatic headache in youth, but multiple studies have been conducted over the past 2 decades,” the authors wrote in Headache. “This white paper aims to provide a thorough review of the current literature, identify gaps in knowledge, and provide a road map for [posttraumatic headache] management in youth based on available evidence and expert opinion.”
Clarity for an Underrecognized Issue
According to Russell Lonser, MD, professor and chair of neurological surgery at Ohio State University, Columbus, the white paper is important because it offers concrete guidance for health care providers who may be less familiar with posttraumatic headache in youth.
“It brings together all of the previous literature ... in a very well-written way,” Dr. Lonser said in an interview. “More than anything, it could reassure [providers] that they shouldn’t be hunting down potentially magical cures, and reassure them in symptomatic management.”
Meeryo C. Choe, MD, associate clinical professor of pediatric neurology at UCLA Health in Calabasas, California, said the paper also helps shine a light on what may be a more common condition than the public suspects.
“While the media focuses on the effects of concussion in professional sports athletes, the biggest population of athletes is in our youth population,” Dr. Choe said in a written comment. “Almost 25 million children participate in sports throughout the country, and yet we lack guidelines on how to treat posttraumatic headache which can often develop into persistent postconcussive symptoms.”
This white paper, she noted, builds on Dr. Gentile’s 2021 systematic review, introduces new management recommendations, and aligns with the latest consensus statement from the Concussion in Sport Group.
Risk Factors
The white paper first emphasizes the importance of early identification of youth at high risk for prolonged recovery from posttraumatic headache. Risk factors include female sex, adolescent age, a high number of acute symptoms following the initial injury, and social determinants of health.
“I agree that it is important to identify these patients early to improve the recovery trajectory,” Dr. Choe said.
Identifying these individuals quickly allows for timely intervention with both pharmacologic and nonpharmacologic therapies, Dr. Gentile and colleagues noted, potentially mitigating persistent symptoms. Clinicians are encouraged to perform thorough initial assessments to identify these risk factors and initiate early, personalized management plans.
Initial Management of Acute Posttraumatic Headache
For the initial management of acute posttraumatic headache, the white paper recommends a scheduled dosing regimen of simple analgesics. Ibuprofen at a dosage of 10 mg/kg every 6-8 hours (up to a maximum of 600 mg per dose) combined with acetaminophen has shown the best evidence for efficacy. Provided the patient is clinically stable, this regimen should be initiated within 48 hours of the injury and maintained with scheduled dosing for 3-10 days.
If effective, these medications can subsequently be used on an as-needed basis. Careful usage of analgesics is crucial, the white paper cautions, as overadministration can lead to medication-overuse headaches, complicating the recovery process.
Secondary Treatment Options
In cases where first-line oral medications are ineffective, the AHS white paper outlines several secondary treatment options. These include acute intravenous therapies such as ketorolac, dopamine receptor antagonists, and intravenous fluids. Nerve blocks and oral corticosteroid bridges may also be considered.
The white paper stresses the importance of individualized treatment plans that consider the specific needs and responses of each patient, noting that the evidence supporting these approaches is primarily derived from retrospective studies and case reports.
“Patient preferences should be factored in,” said Sean Rose, MD, pediatric neurologist and codirector of the Complex Concussion Clinic at Nationwide Children’s Hospital, Columbus, Ohio.
Supplements and Preventive Measures
For adolescents and young adults at high risk of prolonged posttraumatic headache, the white paper suggests the use of riboflavin and magnesium supplements. Small randomized clinical trials suggest that these supplements may aid in speeding recovery when administered for 1-2 weeks within 48 hours of injury.
If significant headache persists after 2 weeks, a regimen of riboflavin 400 mg daily and magnesium 400-500 mg nightly can be trialed for 6-8 weeks, in line with recommendations for migraine prevention. Additionally, melatonin at a dose of 3-5 mg nightly for an 8-week course may be considered for patients experiencing comorbid sleep disturbances.
Targeted Preventative Therapy
The white paper emphasizes the importance of targeting preventative therapy to the primary headache phenotype.
For instance, patients presenting with a migraine phenotype, or those with a personal or family history of migraines, may be most likely to respond to medications proven effective in migraine prevention, such as amitriptyline, topiramate, and propranolol.
“Most research evidence [for treating posttraumatic headache in youth] is still based on the treatment of migraine,” Dr. Rose pointed out in a written comment.
Dr. Gentile and colleagues recommend initiating preventive therapies 4-6 weeks post injury if headaches are not improving, occur more than 1-2 days per week, or significantly impact daily functioning.
Specialist Referrals and Physical Activity
Referral to a headache specialist is advised for patients who do not respond to first-line acute and preventive therapies. Specialists can offer advanced diagnostic and therapeutic options, the authors noted, ensuring a comprehensive approach to managing posttraumatic headache.
The white paper also recommends noncontact, sub–symptom threshold aerobic physical activity and activities of daily living after an initial 24-48 hour period of symptom-limited cognitive and physical rest. Engaging in these activities may promote faster recovery and help patients gradually return to their normal routines.
“This has been a shift in the concussion treatment approach over the last decade, and is one of the most important interventions we can recommend as physicians,” Dr. Choe noted. “This is where pediatricians and emergency department physicians seeing children acutely can really make a difference in the recovery trajectory for a child after a concussion. ‘Cocoon therapy’ has been proven not only to not work, but be detrimental to recovery.”
Nonpharmacologic Interventions
Based on clinical assessment, nonpharmacologic interventions may also be considered, according to the white paper. These interventions include cervico-vestibular therapy, which addresses neck and balance issues, and cognitive-behavioral therapy, which helps manage the psychological aspects of chronic headache. Dr. Gentile and colleagues highlighted the potential benefits of a collaborative care model that incorporates these nonpharmacologic interventions alongside pharmacologic treatments, providing a holistic approach to posttraumatic headache management.
“Persisting headaches after concussion are often driven by multiple factors,” Dr. Rose said. “Multidisciplinary concussion clinics can offer multiple treatment approaches such as behavioral, physical therapy, exercise, and medication options.”
Unmet Needs
The white paper concludes by calling for high-quality prospective cohort studies and placebo-controlled, randomized, controlled trials to further advance the understanding and treatment of posttraumatic headache in children.
Dr. Lonser, Dr. Choe, and Dr. Rose all agreed.
“More focused treatment trials are needed to gauge efficacy in children with headache after concussion,” Dr. Rose said.
Specifically, Dr. Gentile and colleagues underscored the need to standardize data collection via common elements, which could improve the ability to compare results across studies and develop more effective treatments. In addition, research into the underlying pathophysiology of posttraumatic headache is crucial for identifying new therapeutic targets and clinical and biological markers that can personalize patient care.
They also stressed the importance of exploring the impact of health disparities and social determinants on posttraumatic headache outcomes, aiming to develop interventions that are equitable and accessible to all patient populations.The white paper was approved by the AHS, and supported by the National Institutes of Health/National Institute of Neurological Disorders and Stroke K23 NS124986. The authors disclosed relationships with Eli Lilly, Pfizer, Amgen, and others. The interviewees disclosed no conflicts of interest.
The guidance document, the first of its kind, covers risk factors for prolonged recovery, along with pharmacologic and nonpharmacologic management strategies, and supports an emphasis on multidisciplinary care, lead author Carlyn Patterson Gentile, MD, PhD, attending physician in the Division of Neurology at Children’s Hospital of Philadelphia in Pennsylvania, and colleagues reported.
“There are no guidelines to inform the management of posttraumatic headache in youth, but multiple studies have been conducted over the past 2 decades,” the authors wrote in Headache. “This white paper aims to provide a thorough review of the current literature, identify gaps in knowledge, and provide a road map for [posttraumatic headache] management in youth based on available evidence and expert opinion.”
Clarity for an Underrecognized Issue
According to Russell Lonser, MD, professor and chair of neurological surgery at Ohio State University, Columbus, the white paper is important because it offers concrete guidance for health care providers who may be less familiar with posttraumatic headache in youth.
“It brings together all of the previous literature ... in a very well-written way,” Dr. Lonser said in an interview. “More than anything, it could reassure [providers] that they shouldn’t be hunting down potentially magical cures, and reassure them in symptomatic management.”
Meeryo C. Choe, MD, associate clinical professor of pediatric neurology at UCLA Health in Calabasas, California, said the paper also helps shine a light on what may be a more common condition than the public suspects.
“While the media focuses on the effects of concussion in professional sports athletes, the biggest population of athletes is in our youth population,” Dr. Choe said in a written comment. “Almost 25 million children participate in sports throughout the country, and yet we lack guidelines on how to treat posttraumatic headache which can often develop into persistent postconcussive symptoms.”
This white paper, she noted, builds on Dr. Gentile’s 2021 systematic review, introduces new management recommendations, and aligns with the latest consensus statement from the Concussion in Sport Group.
Risk Factors
The white paper first emphasizes the importance of early identification of youth at high risk for prolonged recovery from posttraumatic headache. Risk factors include female sex, adolescent age, a high number of acute symptoms following the initial injury, and social determinants of health.
“I agree that it is important to identify these patients early to improve the recovery trajectory,” Dr. Choe said.
Identifying these individuals quickly allows for timely intervention with both pharmacologic and nonpharmacologic therapies, Dr. Gentile and colleagues noted, potentially mitigating persistent symptoms. Clinicians are encouraged to perform thorough initial assessments to identify these risk factors and initiate early, personalized management plans.
Initial Management of Acute Posttraumatic Headache
For the initial management of acute posttraumatic headache, the white paper recommends a scheduled dosing regimen of simple analgesics. Ibuprofen at a dosage of 10 mg/kg every 6-8 hours (up to a maximum of 600 mg per dose) combined with acetaminophen has shown the best evidence for efficacy. Provided the patient is clinically stable, this regimen should be initiated within 48 hours of the injury and maintained with scheduled dosing for 3-10 days.
If effective, these medications can subsequently be used on an as-needed basis. Careful usage of analgesics is crucial, the white paper cautions, as overadministration can lead to medication-overuse headaches, complicating the recovery process.
Secondary Treatment Options
In cases where first-line oral medications are ineffective, the AHS white paper outlines several secondary treatment options. These include acute intravenous therapies such as ketorolac, dopamine receptor antagonists, and intravenous fluids. Nerve blocks and oral corticosteroid bridges may also be considered.
The white paper stresses the importance of individualized treatment plans that consider the specific needs and responses of each patient, noting that the evidence supporting these approaches is primarily derived from retrospective studies and case reports.
“Patient preferences should be factored in,” said Sean Rose, MD, pediatric neurologist and codirector of the Complex Concussion Clinic at Nationwide Children’s Hospital, Columbus, Ohio.
Supplements and Preventive Measures
For adolescents and young adults at high risk of prolonged posttraumatic headache, the white paper suggests the use of riboflavin and magnesium supplements. Small randomized clinical trials suggest that these supplements may aid in speeding recovery when administered for 1-2 weeks within 48 hours of injury.
If significant headache persists after 2 weeks, a regimen of riboflavin 400 mg daily and magnesium 400-500 mg nightly can be trialed for 6-8 weeks, in line with recommendations for migraine prevention. Additionally, melatonin at a dose of 3-5 mg nightly for an 8-week course may be considered for patients experiencing comorbid sleep disturbances.
Targeted Preventative Therapy
The white paper emphasizes the importance of targeting preventative therapy to the primary headache phenotype.
For instance, patients presenting with a migraine phenotype, or those with a personal or family history of migraines, may be most likely to respond to medications proven effective in migraine prevention, such as amitriptyline, topiramate, and propranolol.
“Most research evidence [for treating posttraumatic headache in youth] is still based on the treatment of migraine,” Dr. Rose pointed out in a written comment.
Dr. Gentile and colleagues recommend initiating preventive therapies 4-6 weeks post injury if headaches are not improving, occur more than 1-2 days per week, or significantly impact daily functioning.
Specialist Referrals and Physical Activity
Referral to a headache specialist is advised for patients who do not respond to first-line acute and preventive therapies. Specialists can offer advanced diagnostic and therapeutic options, the authors noted, ensuring a comprehensive approach to managing posttraumatic headache.
The white paper also recommends noncontact, sub–symptom threshold aerobic physical activity and activities of daily living after an initial 24-48 hour period of symptom-limited cognitive and physical rest. Engaging in these activities may promote faster recovery and help patients gradually return to their normal routines.
“This has been a shift in the concussion treatment approach over the last decade, and is one of the most important interventions we can recommend as physicians,” Dr. Choe noted. “This is where pediatricians and emergency department physicians seeing children acutely can really make a difference in the recovery trajectory for a child after a concussion. ‘Cocoon therapy’ has been proven not only to not work, but be detrimental to recovery.”
Nonpharmacologic Interventions
Based on clinical assessment, nonpharmacologic interventions may also be considered, according to the white paper. These interventions include cervico-vestibular therapy, which addresses neck and balance issues, and cognitive-behavioral therapy, which helps manage the psychological aspects of chronic headache. Dr. Gentile and colleagues highlighted the potential benefits of a collaborative care model that incorporates these nonpharmacologic interventions alongside pharmacologic treatments, providing a holistic approach to posttraumatic headache management.
“Persisting headaches after concussion are often driven by multiple factors,” Dr. Rose said. “Multidisciplinary concussion clinics can offer multiple treatment approaches such as behavioral, physical therapy, exercise, and medication options.”
Unmet Needs
The white paper concludes by calling for high-quality prospective cohort studies and placebo-controlled, randomized, controlled trials to further advance the understanding and treatment of posttraumatic headache in children.
Dr. Lonser, Dr. Choe, and Dr. Rose all agreed.
“More focused treatment trials are needed to gauge efficacy in children with headache after concussion,” Dr. Rose said.
Specifically, Dr. Gentile and colleagues underscored the need to standardize data collection via common elements, which could improve the ability to compare results across studies and develop more effective treatments. In addition, research into the underlying pathophysiology of posttraumatic headache is crucial for identifying new therapeutic targets and clinical and biological markers that can personalize patient care.
They also stressed the importance of exploring the impact of health disparities and social determinants on posttraumatic headache outcomes, aiming to develop interventions that are equitable and accessible to all patient populations.The white paper was approved by the AHS, and supported by the National Institutes of Health/National Institute of Neurological Disorders and Stroke K23 NS124986. The authors disclosed relationships with Eli Lilly, Pfizer, Amgen, and others. The interviewees disclosed no conflicts of interest.
The guidance document, the first of its kind, covers risk factors for prolonged recovery, along with pharmacologic and nonpharmacologic management strategies, and supports an emphasis on multidisciplinary care, lead author Carlyn Patterson Gentile, MD, PhD, attending physician in the Division of Neurology at Children’s Hospital of Philadelphia in Pennsylvania, and colleagues reported.
“There are no guidelines to inform the management of posttraumatic headache in youth, but multiple studies have been conducted over the past 2 decades,” the authors wrote in Headache. “This white paper aims to provide a thorough review of the current literature, identify gaps in knowledge, and provide a road map for [posttraumatic headache] management in youth based on available evidence and expert opinion.”
Clarity for an Underrecognized Issue
According to Russell Lonser, MD, professor and chair of neurological surgery at Ohio State University, Columbus, the white paper is important because it offers concrete guidance for health care providers who may be less familiar with posttraumatic headache in youth.
“It brings together all of the previous literature ... in a very well-written way,” Dr. Lonser said in an interview. “More than anything, it could reassure [providers] that they shouldn’t be hunting down potentially magical cures, and reassure them in symptomatic management.”
Meeryo C. Choe, MD, associate clinical professor of pediatric neurology at UCLA Health in Calabasas, California, said the paper also helps shine a light on what may be a more common condition than the public suspects.
“While the media focuses on the effects of concussion in professional sports athletes, the biggest population of athletes is in our youth population,” Dr. Choe said in a written comment. “Almost 25 million children participate in sports throughout the country, and yet we lack guidelines on how to treat posttraumatic headache which can often develop into persistent postconcussive symptoms.”
This white paper, she noted, builds on Dr. Gentile’s 2021 systematic review, introduces new management recommendations, and aligns with the latest consensus statement from the Concussion in Sport Group.
Risk Factors
The white paper first emphasizes the importance of early identification of youth at high risk for prolonged recovery from posttraumatic headache. Risk factors include female sex, adolescent age, a high number of acute symptoms following the initial injury, and social determinants of health.
“I agree that it is important to identify these patients early to improve the recovery trajectory,” Dr. Choe said.
Identifying these individuals quickly allows for timely intervention with both pharmacologic and nonpharmacologic therapies, Dr. Gentile and colleagues noted, potentially mitigating persistent symptoms. Clinicians are encouraged to perform thorough initial assessments to identify these risk factors and initiate early, personalized management plans.
Initial Management of Acute Posttraumatic Headache
For the initial management of acute posttraumatic headache, the white paper recommends a scheduled dosing regimen of simple analgesics. Ibuprofen at a dosage of 10 mg/kg every 6-8 hours (up to a maximum of 600 mg per dose) combined with acetaminophen has shown the best evidence for efficacy. Provided the patient is clinically stable, this regimen should be initiated within 48 hours of the injury and maintained with scheduled dosing for 3-10 days.
If effective, these medications can subsequently be used on an as-needed basis. Careful usage of analgesics is crucial, the white paper cautions, as overadministration can lead to medication-overuse headaches, complicating the recovery process.
Secondary Treatment Options
In cases where first-line oral medications are ineffective, the AHS white paper outlines several secondary treatment options. These include acute intravenous therapies such as ketorolac, dopamine receptor antagonists, and intravenous fluids. Nerve blocks and oral corticosteroid bridges may also be considered.
The white paper stresses the importance of individualized treatment plans that consider the specific needs and responses of each patient, noting that the evidence supporting these approaches is primarily derived from retrospective studies and case reports.
“Patient preferences should be factored in,” said Sean Rose, MD, pediatric neurologist and codirector of the Complex Concussion Clinic at Nationwide Children’s Hospital, Columbus, Ohio.
Supplements and Preventive Measures
For adolescents and young adults at high risk of prolonged posttraumatic headache, the white paper suggests the use of riboflavin and magnesium supplements. Small randomized clinical trials suggest that these supplements may aid in speeding recovery when administered for 1-2 weeks within 48 hours of injury.
If significant headache persists after 2 weeks, a regimen of riboflavin 400 mg daily and magnesium 400-500 mg nightly can be trialed for 6-8 weeks, in line with recommendations for migraine prevention. Additionally, melatonin at a dose of 3-5 mg nightly for an 8-week course may be considered for patients experiencing comorbid sleep disturbances.
Targeted Preventative Therapy
The white paper emphasizes the importance of targeting preventative therapy to the primary headache phenotype.
For instance, patients presenting with a migraine phenotype, or those with a personal or family history of migraines, may be most likely to respond to medications proven effective in migraine prevention, such as amitriptyline, topiramate, and propranolol.
“Most research evidence [for treating posttraumatic headache in youth] is still based on the treatment of migraine,” Dr. Rose pointed out in a written comment.
Dr. Gentile and colleagues recommend initiating preventive therapies 4-6 weeks post injury if headaches are not improving, occur more than 1-2 days per week, or significantly impact daily functioning.
Specialist Referrals and Physical Activity
Referral to a headache specialist is advised for patients who do not respond to first-line acute and preventive therapies. Specialists can offer advanced diagnostic and therapeutic options, the authors noted, ensuring a comprehensive approach to managing posttraumatic headache.
The white paper also recommends noncontact, sub–symptom threshold aerobic physical activity and activities of daily living after an initial 24-48 hour period of symptom-limited cognitive and physical rest. Engaging in these activities may promote faster recovery and help patients gradually return to their normal routines.
“This has been a shift in the concussion treatment approach over the last decade, and is one of the most important interventions we can recommend as physicians,” Dr. Choe noted. “This is where pediatricians and emergency department physicians seeing children acutely can really make a difference in the recovery trajectory for a child after a concussion. ‘Cocoon therapy’ has been proven not only to not work, but be detrimental to recovery.”
Nonpharmacologic Interventions
Based on clinical assessment, nonpharmacologic interventions may also be considered, according to the white paper. These interventions include cervico-vestibular therapy, which addresses neck and balance issues, and cognitive-behavioral therapy, which helps manage the psychological aspects of chronic headache. Dr. Gentile and colleagues highlighted the potential benefits of a collaborative care model that incorporates these nonpharmacologic interventions alongside pharmacologic treatments, providing a holistic approach to posttraumatic headache management.
“Persisting headaches after concussion are often driven by multiple factors,” Dr. Rose said. “Multidisciplinary concussion clinics can offer multiple treatment approaches such as behavioral, physical therapy, exercise, and medication options.”
Unmet Needs
The white paper concludes by calling for high-quality prospective cohort studies and placebo-controlled, randomized, controlled trials to further advance the understanding and treatment of posttraumatic headache in children.
Dr. Lonser, Dr. Choe, and Dr. Rose all agreed.
“More focused treatment trials are needed to gauge efficacy in children with headache after concussion,” Dr. Rose said.
Specifically, Dr. Gentile and colleagues underscored the need to standardize data collection via common elements, which could improve the ability to compare results across studies and develop more effective treatments. In addition, research into the underlying pathophysiology of posttraumatic headache is crucial for identifying new therapeutic targets and clinical and biological markers that can personalize patient care.
They also stressed the importance of exploring the impact of health disparities and social determinants on posttraumatic headache outcomes, aiming to develop interventions that are equitable and accessible to all patient populations.The white paper was approved by the AHS, and supported by the National Institutes of Health/National Institute of Neurological Disorders and Stroke K23 NS124986. The authors disclosed relationships with Eli Lilly, Pfizer, Amgen, and others. The interviewees disclosed no conflicts of interest.
FROM HEADACHE