Headache & Migraine

Inpatient headache admissions are often considered a last-case scenario option for patients with chronic refractory migraine. Initially described by Raskin,¹ the admission typically consists of repetitive infusions of dihydroergotamine (DHE) with a pretreatment of antihistamine, neuroleptic, and other antinausea medications in addition to anti-inflammatory or steroid medications, IV fluids, and magnesium. Often this is superimposed on a continuous infusion of lidocaine or ketamine. One common concern is whether the use of DHE is safe for patients at a higher risk for vascular disease. Wang and colleagues reported on the incidence of cardiovascular adverse events in this population receiving repetitive intravenous DHE.

They present findings based on the Jefferson Headache Center (Philadelphia, Pennsylvania) Inpatient Headache Protocol, looking at patients admitted from January through October 2019. Of the 347 patients admitted during this period, 64 were identified as having either an elevated or low risk for atherosclerotic vascular disease. The degree of vascular risk was determined on the basis of an atherosclerotic cardiovascular disease calculation, using body mass index values, cholesterol level, and mean arterial blood pressure readings, as well as smoking and diabetes history. A score < 5.0% was designated low risk, while elevated risk included scores up to 20%. DHE was not offered to patients with a history of moderate to severe ischemic heart disease, coronary vasospasm, peripheral artery disease, Raynaud phenomenon, or ischemic stroke.

The primary outcome was treatment effectiveness, determined by an 11-point pain scale; secondary outcomes included tolerability, as defined by change in the patient's QTc (corrected QT interval) based on their daily ECG monitoring, the incidence of chest pain or shortness of breath, and whether DHE needed to be tapered or discontinued. The researchers noted that the elevated-vascular-risk group had fewer patients receiving the maximum dose of DHE and receiving less DHE over the course of their admission as compared with the low-risk group. They also reported lower response rates and less freedom from pain after admission. No clinically significant adverse events were noted in either group, and only three patients had sustained ECG changes from baseline.

DHE remains an effective treatment for the most chronic and refractory migraine cases, and it can be provided safely and effectively in an appropriately monitored setting. Although there still are contraindications for receiving DHE, those who can receive it may benefit significantly. Ideally, this should be done with cardiac clearance if there is any doubt regarding the vascular risk for any individual patient.

The frequency and severity of migraine can fluctuate due to a myriad of factors. When faced with worsening migraine, most healthcare providers ask their patients about specific triggers or other potential causes that may have led to the recent subacute worsening. Many healthcare providers will also investigate further, and when appropriate, order serum lab testing to determine whether any potential metabolic derangement, vitamin deficiency, or other abnormality could be contributing. Subclinical hypothyroidism is a common finding when investigating for these potential causes of worsening migraine, and often our internal medicine or endocrinology colleagues will discount these findings as "borderline" or still within normal limits. Dev and colleagues sought to determine whether low-dose thyroid replacement was beneficial for migraine prevention in this situation.

This study defined subclinical hypothyroidism as a thyroid-stimulating hormone (TSH) level of 4.5-10.0 mIU/L with a normal free thyroxine (T4), measured twice within 6 weeks for confirmation. Patients with prior thyroid disease were excluded from the study. Participants were randomly assigned to take 25 μg levothyroxine supplementation or placebo and were allowed to continue their migraine treatments. The primary outcomes were reduction in headache duration, frequency, severity, and Migraine Disability Assessment (MIDAS) score after 3 months.

A total of 87 patients with migraine and subclinical hypothyroidism were recruited, and the investigators noted a statistically significant improvement in all parameters (migraine frequency, severity, duration, MIDAS score) after 3 months of low-dose thyroid supplementation. This was maintained at a 3-month follow-up visit as well. TSH levels normalized in 87% of participants after repeat testing 3 months after the intervention.

When evaluating patients with worsening migraine who had been stable, it is wise to consider subclinical hypothyroidism as a potential etiology. Low-dose thyroid hormone supplementation appears to be well tolerated and effective for normalizing both TSH levels and, importantly, the migrainous exacerbation. Clinicians often will start or add preventive medications, ignoring the reason that there was an exacerbation in the first place, even though many of our colleagues choose not to treat this degree of hypothyroidism.

Many variants of migraine are better recognized and understood now; chief among these is vestibular migraine (VM). VM is a migraine subtype characterized by frequent or near-constant vestibular symptoms (vertigo, lightheadedness, disequilibrium, or rocking) with superimposed headache symptoms with some migrainous features. VM is generally considered to be more difficult to treat and more treatment-refractory than episodic or chronic migraine without vestibular symptoms. There are few treatments that are specific for this variant of migraine. Chen and colleagues sought to better understand the evidence of specific treatments for VM via meta-analysis.

Only randomized controlled trials were included in this meta-analysis; seven studies that specifically recruited patients with vestibular migraine using International Classification of Headache Disorders (ICHD) criteria were included. The outcomes of the studies were changes in frequency or severity of vestibular migraine attacks. The studies that were included were published from 2014 to 2022 and comprised multiple treatment comparisons, including metoprolol, venlafaxine, valproic acid, propranolol, flunarizine, a probiotic, and relaxation techniques.

Three interventions were noted to be significantly beneficial for VM prevention, specifically a decrease in migraine frequency: valproic acid, propranolol, and venlafaxine. Valproic acid yielded the greatest decrease in VM frequency among all interventions. None of the interventions were associated with improvement in VM severity, and none of the treatments were associated with significantly different adverse-event and dropout rates.

VM is widely thought to be underdiagnosed and should be considered more frequently. This includes situations in which the headache component of the patient's complaints is relatively mild but still associated with features of migraines, such as sensitivities to light and sound, nausea, or unilateral presentations of pain. There remain very few high-quality VM studies, but this meta-analysis should highlight potential treatment options and raise the profile for this diagnosis in order for further trials to be performed.

Additional Reference

1. Raskin NH. Repetitive intravenous dihydroergotamine as therapy for intractable migraine. Neurology. 1986;36(7):995-997. doi: 10.1212/WNL.36.7.995

Inpatient headache admissions are often considered a last-case scenario option for patients with chronic refractory migraine. Initially described by Raskin,¹ the admission typically consists of repetitive infusions of dihydroergotamine (DHE) with a pretreatment of antihistamine, neuroleptic, and other antinausea medications in addition to anti-inflammatory or steroid medications, IV fluids, and magnesium. Often this is superimposed on a continuous infusion of lidocaine or ketamine. One common concern is whether the use of DHE is safe for patients at a higher risk for vascular disease. Wang and colleagues reported on the incidence of cardiovascular adverse events in this population receiving repetitive intravenous DHE.

They present findings based on the Jefferson Headache Center (Philadelphia, Pennsylvania) Inpatient Headache Protocol, looking at patients admitted from January through October 2019. Of the 347 patients admitted during this period, 64 were identified as having either an elevated or low risk for atherosclerotic vascular disease. The degree of vascular risk was determined on the basis of an atherosclerotic cardiovascular disease calculation, using body mass index values, cholesterol level, and mean arterial blood pressure readings, as well as smoking and diabetes history. A score < 5.0% was designated low risk, while elevated risk included scores up to 20%. DHE was not offered to patients with a history of moderate to severe ischemic heart disease, coronary vasospasm, peripheral artery disease, Raynaud phenomenon, or ischemic stroke.

The primary outcome was treatment effectiveness, determined by an 11-point pain scale; secondary outcomes included tolerability, as defined by change in the patient's QTc (corrected QT interval) based on their daily ECG monitoring, the incidence of chest pain or shortness of breath, and whether DHE needed to be tapered or discontinued. The researchers noted that the elevated-vascular-risk group had fewer patients receiving the maximum dose of DHE and receiving less DHE over the course of their admission as compared with the low-risk group. They also reported lower response rates and less freedom from pain after admission. No clinically significant adverse events were noted in either group, and only three patients had sustained ECG changes from baseline.

DHE remains an effective treatment for the most chronic and refractory migraine cases, and it can be provided safely and effectively in an appropriately monitored setting. Although there still are contraindications for receiving DHE, those who can receive it may benefit significantly. Ideally, this should be done with cardiac clearance if there is any doubt regarding the vascular risk for any individual patient.

The frequency and severity of migraine can fluctuate due to a myriad of factors. When faced with worsening migraine, most healthcare providers ask their patients about specific triggers or other potential causes that may have led to the recent subacute worsening. Many healthcare providers will also investigate further, and when appropriate, order serum lab testing to determine whether any potential metabolic derangement, vitamin deficiency, or other abnormality could be contributing. Subclinical hypothyroidism is a common finding when investigating for these potential causes of worsening migraine, and often our internal medicine or endocrinology colleagues will discount these findings as "borderline" or still within normal limits. Dev and colleagues sought to determine whether low-dose thyroid replacement was beneficial for migraine prevention in this situation.

This study defined subclinical hypothyroidism as a thyroid-stimulating hormone (TSH) level of 4.5-10.0 mIU/L with a normal free thyroxine (T4), measured twice within 6 weeks for confirmation. Patients with prior thyroid disease were excluded from the study. Participants were randomly assigned to take 25 μg levothyroxine supplementation or placebo and were allowed to continue their migraine treatments. The primary outcomes were reduction in headache duration, frequency, severity, and Migraine Disability Assessment (MIDAS) score after 3 months.

A total of 87 patients with migraine and subclinical hypothyroidism were recruited, and the investigators noted a statistically significant improvement in all parameters (migraine frequency, severity, duration, MIDAS score) after 3 months of low-dose thyroid supplementation. This was maintained at a 3-month follow-up visit as well. TSH levels normalized in 87% of participants after repeat testing 3 months after the intervention.

When evaluating patients with worsening migraine who had been stable, it is wise to consider subclinical hypothyroidism as a potential etiology. Low-dose thyroid hormone supplementation appears to be well tolerated and effective for normalizing both TSH levels and, importantly, the migrainous exacerbation. Clinicians often will start or add preventive medications, ignoring the reason that there was an exacerbation in the first place, even though many of our colleagues choose not to treat this degree of hypothyroidism.

Many variants of migraine are better recognized and understood now; chief among these is vestibular migraine (VM). VM is a migraine subtype characterized by frequent or near-constant vestibular symptoms (vertigo, lightheadedness, disequilibrium, or rocking) with superimposed headache symptoms with some migrainous features. VM is generally considered to be more difficult to treat and more treatment-refractory than episodic or chronic migraine without vestibular symptoms. There are few treatments that are specific for this variant of migraine. Chen and colleagues sought to better understand the evidence of specific treatments for VM via meta-analysis.

Only randomized controlled trials were included in this meta-analysis; seven studies that specifically recruited patients with vestibular migraine using International Classification of Headache Disorders (ICHD) criteria were included. The outcomes of the studies were changes in frequency or severity of vestibular migraine attacks. The studies that were included were published from 2014 to 2022 and comprised multiple treatment comparisons, including metoprolol, venlafaxine, valproic acid, propranolol, flunarizine, a probiotic, and relaxation techniques.

Three interventions were noted to be significantly beneficial for VM prevention, specifically a decrease in migraine frequency: valproic acid, propranolol, and venlafaxine. Valproic acid yielded the greatest decrease in VM frequency among all interventions. None of the interventions were associated with improvement in VM severity, and none of the treatments were associated with significantly different adverse-event and dropout rates.

VM is widely thought to be underdiagnosed and should be considered more frequently. This includes situations in which the headache component of the patient's complaints is relatively mild but still associated with features of migraines, such as sensitivities to light and sound, nausea, or unilateral presentations of pain. There remain very few high-quality VM studies, but this meta-analysis should highlight potential treatment options and raise the profile for this diagnosis in order for further trials to be performed.

Additional Reference

1. Raskin NH. Repetitive intravenous dihydroergotamine as therapy for intractable migraine. Neurology. 1986;36(7):995-997. doi: 10.1212/WNL.36.7.995

Inpatient headache admissions are often considered a last-case scenario option for patients with chronic refractory migraine. Initially described by Raskin,¹ the admission typically consists of repetitive infusions of dihydroergotamine (DHE) with a pretreatment of antihistamine, neuroleptic, and other antinausea medications in addition to anti-inflammatory or steroid medications, IV fluids, and magnesium. Often this is superimposed on a continuous infusion of lidocaine or ketamine. One common concern is whether the use of DHE is safe for patients at a higher risk for vascular disease. Wang and colleagues reported on the incidence of cardiovascular adverse events in this population receiving repetitive intravenous DHE.

They present findings based on the Jefferson Headache Center (Philadelphia, Pennsylvania) Inpatient Headache Protocol, looking at patients admitted from January through October 2019. Of the 347 patients admitted during this period, 64 were identified as having either an elevated or low risk for atherosclerotic vascular disease. The degree of vascular risk was determined on the basis of an atherosclerotic cardiovascular disease calculation, using body mass index values, cholesterol level, and mean arterial blood pressure readings, as well as smoking and diabetes history. A score < 5.0% was designated low risk, while elevated risk included scores up to 20%. DHE was not offered to patients with a history of moderate to severe ischemic heart disease, coronary vasospasm, peripheral artery disease, Raynaud phenomenon, or ischemic stroke.

The primary outcome was treatment effectiveness, determined by an 11-point pain scale; secondary outcomes included tolerability, as defined by change in the patient's QTc (corrected QT interval) based on their daily ECG monitoring, the incidence of chest pain or shortness of breath, and whether DHE needed to be tapered or discontinued. The researchers noted that the elevated-vascular-risk group had fewer patients receiving the maximum dose of DHE and receiving less DHE over the course of their admission as compared with the low-risk group. They also reported lower response rates and less freedom from pain after admission. No clinically significant adverse events were noted in either group, and only three patients had sustained ECG changes from baseline.

DHE remains an effective treatment for the most chronic and refractory migraine cases, and it can be provided safely and effectively in an appropriately monitored setting. Although there still are contraindications for receiving DHE, those who can receive it may benefit significantly. Ideally, this should be done with cardiac clearance if there is any doubt regarding the vascular risk for any individual patient.

The frequency and severity of migraine can fluctuate due to a myriad of factors. When faced with worsening migraine, most healthcare providers ask their patients about specific triggers or other potential causes that may have led to the recent subacute worsening. Many healthcare providers will also investigate further, and when appropriate, order serum lab testing to determine whether any potential metabolic derangement, vitamin deficiency, or other abnormality could be contributing. Subclinical hypothyroidism is a common finding when investigating for these potential causes of worsening migraine, and often our internal medicine or endocrinology colleagues will discount these findings as "borderline" or still within normal limits. Dev and colleagues sought to determine whether low-dose thyroid replacement was beneficial for migraine prevention in this situation.

This study defined subclinical hypothyroidism as a thyroid-stimulating hormone (TSH) level of 4.5-10.0 mIU/L with a normal free thyroxine (T4), measured twice within 6 weeks for confirmation. Patients with prior thyroid disease were excluded from the study. Participants were randomly assigned to take 25 μg levothyroxine supplementation or placebo and were allowed to continue their migraine treatments. The primary outcomes were reduction in headache duration, frequency, severity, and Migraine Disability Assessment (MIDAS) score after 3 months.

A total of 87 patients with migraine and subclinical hypothyroidism were recruited, and the investigators noted a statistically significant improvement in all parameters (migraine frequency, severity, duration, MIDAS score) after 3 months of low-dose thyroid supplementation. This was maintained at a 3-month follow-up visit as well. TSH levels normalized in 87% of participants after repeat testing 3 months after the intervention.

When evaluating patients with worsening migraine who had been stable, it is wise to consider subclinical hypothyroidism as a potential etiology. Low-dose thyroid hormone supplementation appears to be well tolerated and effective for normalizing both TSH levels and, importantly, the migrainous exacerbation. Clinicians often will start or add preventive medications, ignoring the reason that there was an exacerbation in the first place, even though many of our colleagues choose not to treat this degree of hypothyroidism.

Many variants of migraine are better recognized and understood now; chief among these is vestibular migraine (VM). VM is a migraine subtype characterized by frequent or near-constant vestibular symptoms (vertigo, lightheadedness, disequilibrium, or rocking) with superimposed headache symptoms with some migrainous features. VM is generally considered to be more difficult to treat and more treatment-refractory than episodic or chronic migraine without vestibular symptoms. There are few treatments that are specific for this variant of migraine. Chen and colleagues sought to better understand the evidence of specific treatments for VM via meta-analysis.

Only randomized controlled trials were included in this meta-analysis; seven studies that specifically recruited patients with vestibular migraine using International Classification of Headache Disorders (ICHD) criteria were included. The outcomes of the studies were changes in frequency or severity of vestibular migraine attacks. The studies that were included were published from 2014 to 2022 and comprised multiple treatment comparisons, including metoprolol, venlafaxine, valproic acid, propranolol, flunarizine, a probiotic, and relaxation techniques.

Three interventions were noted to be significantly beneficial for VM prevention, specifically a decrease in migraine frequency: valproic acid, propranolol, and venlafaxine. Valproic acid yielded the greatest decrease in VM frequency among all interventions. None of the interventions were associated with improvement in VM severity, and none of the treatments were associated with significantly different adverse-event and dropout rates.

VM is widely thought to be underdiagnosed and should be considered more frequently. This includes situations in which the headache component of the patient's complaints is relatively mild but still associated with features of migraines, such as sensitivities to light and sound, nausea, or unilateral presentations of pain. There remain very few high-quality VM studies, but this meta-analysis should highlight potential treatment options and raise the profile for this diagnosis in order for further trials to be performed.

Additional Reference

1. Raskin NH. Repetitive intravenous dihydroergotamine as therapy for intractable migraine. Neurology. 1986;36(7):995-997. doi: 10.1212/WNL.36.7.995

Key clinical point: Attention-deficit hyperactivity disorder (ADHD) symptoms and impulsive personality traits appeared to be more prevalent in patients with episodic migraine than in control individuals.

Major finding: Patients with episodic migraine vs control individuals had higher mean scores for inattention (5.0 vs 2.7; P < .00001), hyperactivity (4.0 vs 2.5; P = .000621), and impulsivity (2.0 vs 1.1; P = .000407) on the ADHD scale. A higher percentage of patients vs control participants (35.5% vs 8.6%) scored ‘often’ or ‘very often’ in ≥1 items of the impulsivity subscale (P < .05).

Study details: This observational cohort study included 100 patients with episodic migraine and 150 control participants without migraine.

Disclosures: This study did not receive any specific funding. The authors declared no conflicts of interest.

Source: Gonzalez-Hernandez A et al. Attention deficit hyperactivity disorder in adults with migraine. J Atten Disord. 2023 (Sep 27). doi: 10.1177/10870547231199256

Key clinical point: Attention-deficit hyperactivity disorder (ADHD) symptoms and impulsive personality traits appeared to be more prevalent in patients with episodic migraine than in control individuals.

Major finding: Patients with episodic migraine vs control individuals had higher mean scores for inattention (5.0 vs 2.7; P < .00001), hyperactivity (4.0 vs 2.5; P = .000621), and impulsivity (2.0 vs 1.1; P = .000407) on the ADHD scale. A higher percentage of patients vs control participants (35.5% vs 8.6%) scored ‘often’ or ‘very often’ in ≥1 items of the impulsivity subscale (P < .05).

Study details: This observational cohort study included 100 patients with episodic migraine and 150 control participants without migraine.

Disclosures: This study did not receive any specific funding. The authors declared no conflicts of interest.

Source: Gonzalez-Hernandez A et al. Attention deficit hyperactivity disorder in adults with migraine. J Atten Disord. 2023 (Sep 27). doi: 10.1177/10870547231199256

Key clinical point: Attention-deficit hyperactivity disorder (ADHD) symptoms and impulsive personality traits appeared to be more prevalent in patients with episodic migraine than in control individuals.

Major finding: Patients with episodic migraine vs control individuals had higher mean scores for inattention (5.0 vs 2.7; P < .00001), hyperactivity (4.0 vs 2.5; P = .000621), and impulsivity (2.0 vs 1.1; P = .000407) on the ADHD scale. A higher percentage of patients vs control participants (35.5% vs 8.6%) scored ‘often’ or ‘very often’ in ≥1 items of the impulsivity subscale (P < .05).

Study details: This observational cohort study included 100 patients with episodic migraine and 150 control participants without migraine.

Disclosures: This study did not receive any specific funding. The authors declared no conflicts of interest.

Source: Gonzalez-Hernandez A et al. Attention deficit hyperactivity disorder in adults with migraine. J Atten Disord. 2023 (Sep 27). doi: 10.1177/10870547231199256

Key clinical point: In patients with migraine, an increase in monthly headache days (MHD) adversely impacts health-related quality of life (HRQoL) measured by the Migraine-Specific Quality-of-Life Questionnaire (MSQ), with the impact being partially mediated by depression, allodynia, and anxiety.

Major finding: For every 1-day increase in the MHD, the scores for MSQ’s Role Function-Restrictive, Role Function-Preventive, and Emotional Function parameters worsened by 0.92, 0.60, and 1.23 points, respectively (all P < .001). Depression, allodynia, and anxiety mediated 15.2%-24.3%, 9.6%-16.1%, and 2.3%-6.0%, respectively, of the total observed effects of MHD on the HRQoL.

Study details: Findings are from a post hoc analysis of the CaMEO study including 12,715 patients with migraine who completed the Core and Comorbidities/Endophenotypes modules.

Disclosures: This study was funded by Allergan (prior to its acquisition by AbbVie). B Dabruzzo declared being an employee of AbbVie and may own its stocks. The other authors declared ties with various sources, including AbbVie.

Source: Lipton RB et al. Impact of monthly headache days on migraine-related quality of life: Results from the Chronic Migraine Epidemiology and Outcomes (CaMEO) study. Headache. 2023 (Oct 5). doi: 10.1111/head.14629

Key clinical point: In patients with migraine, an increase in monthly headache days (MHD) adversely impacts health-related quality of life (HRQoL) measured by the Migraine-Specific Quality-of-Life Questionnaire (MSQ), with the impact being partially mediated by depression, allodynia, and anxiety.

Major finding: For every 1-day increase in the MHD, the scores for MSQ’s Role Function-Restrictive, Role Function-Preventive, and Emotional Function parameters worsened by 0.92, 0.60, and 1.23 points, respectively (all P < .001). Depression, allodynia, and anxiety mediated 15.2%-24.3%, 9.6%-16.1%, and 2.3%-6.0%, respectively, of the total observed effects of MHD on the HRQoL.

Study details: Findings are from a post hoc analysis of the CaMEO study including 12,715 patients with migraine who completed the Core and Comorbidities/Endophenotypes modules.

Disclosures: This study was funded by Allergan (prior to its acquisition by AbbVie). B Dabruzzo declared being an employee of AbbVie and may own its stocks. The other authors declared ties with various sources, including AbbVie.

Source: Lipton RB et al. Impact of monthly headache days on migraine-related quality of life: Results from the Chronic Migraine Epidemiology and Outcomes (CaMEO) study. Headache. 2023 (Oct 5). doi: 10.1111/head.14629

Key clinical point: In patients with migraine, an increase in monthly headache days (MHD) adversely impacts health-related quality of life (HRQoL) measured by the Migraine-Specific Quality-of-Life Questionnaire (MSQ), with the impact being partially mediated by depression, allodynia, and anxiety.

Major finding: For every 1-day increase in the MHD, the scores for MSQ’s Role Function-Restrictive, Role Function-Preventive, and Emotional Function parameters worsened by 0.92, 0.60, and 1.23 points, respectively (all P < .001). Depression, allodynia, and anxiety mediated 15.2%-24.3%, 9.6%-16.1%, and 2.3%-6.0%, respectively, of the total observed effects of MHD on the HRQoL.

Study details: Findings are from a post hoc analysis of the CaMEO study including 12,715 patients with migraine who completed the Core and Comorbidities/Endophenotypes modules.

Disclosures: This study was funded by Allergan (prior to its acquisition by AbbVie). B Dabruzzo declared being an employee of AbbVie and may own its stocks. The other authors declared ties with various sources, including AbbVie.

Source: Lipton RB et al. Impact of monthly headache days on migraine-related quality of life: Results from the Chronic Migraine Epidemiology and Outcomes (CaMEO) study. Headache. 2023 (Oct 5). doi: 10.1111/head.14629

Key clinical point: Valproic acid, propranolol, and venlafaxine significantly improved vestibular migraine frequency but had no significant differences in terms of vestibular migraine severity, dropout rates, and safety profiles compared with placebo.

Major finding: Compared with placebo, valproic acid (standardized mean difference [SMD] −1.61; 95% CI −2.69 to −0.54), propranolol (SMD −1.36; 95% CI −2.55 to −0.17), and venlafaxine (SMD −1.25; 95% CI −2.32 to −0.18) led to better improvement in vestibular migraine frequency. However, vestibular migraine severity, dropout rates, and safety profiles did not differ significantly between the treatment groups.

Study details: This network meta-analysis of seven randomized controlled trials included 828 patients with vestibular migraine.

Disclosures: This study did not receive any specific funding. The authors declared no conflicts of interest.

Source: Chen J-J et al. Network meta-analysis of different treatments for vestibular migraine. CNS Drugs. 2023;37(9):837-847 (Sep 7). doi: 10.1007/s40263-023-01037-0

Key clinical point: Valproic acid, propranolol, and venlafaxine significantly improved vestibular migraine frequency but had no significant differences in terms of vestibular migraine severity, dropout rates, and safety profiles compared with placebo.

Major finding: Compared with placebo, valproic acid (standardized mean difference [SMD] −1.61; 95% CI −2.69 to −0.54), propranolol (SMD −1.36; 95% CI −2.55 to −0.17), and venlafaxine (SMD −1.25; 95% CI −2.32 to −0.18) led to better improvement in vestibular migraine frequency. However, vestibular migraine severity, dropout rates, and safety profiles did not differ significantly between the treatment groups.

Study details: This network meta-analysis of seven randomized controlled trials included 828 patients with vestibular migraine.

Disclosures: This study did not receive any specific funding. The authors declared no conflicts of interest.

Source: Chen J-J et al. Network meta-analysis of different treatments for vestibular migraine. CNS Drugs. 2023;37(9):837-847 (Sep 7). doi: 10.1007/s40263-023-01037-0

Key clinical point: Valproic acid, propranolol, and venlafaxine significantly improved vestibular migraine frequency but had no significant differences in terms of vestibular migraine severity, dropout rates, and safety profiles compared with placebo.

Major finding: Compared with placebo, valproic acid (standardized mean difference [SMD] −1.61; 95% CI −2.69 to −0.54), propranolol (SMD −1.36; 95% CI −2.55 to −0.17), and venlafaxine (SMD −1.25; 95% CI −2.32 to −0.18) led to better improvement in vestibular migraine frequency. However, vestibular migraine severity, dropout rates, and safety profiles did not differ significantly between the treatment groups.

Study details: This network meta-analysis of seven randomized controlled trials included 828 patients with vestibular migraine.

Disclosures: This study did not receive any specific funding. The authors declared no conflicts of interest.

Source: Chen J-J et al. Network meta-analysis of different treatments for vestibular migraine. CNS Drugs. 2023;37(9):837-847 (Sep 7). doi: 10.1007/s40263-023-01037-0

Key clinical point: High dietary potassium intake is associated with a decreased risk for migraine, with an L-shaped correlation between dietary potassium intake and migraine highlighting an inflection at ~1,439.3 mg/day.

Major finding: Participants in the second quartile (potassium intake 1771-2476 mg/day) vs first quartile (potassium intake ≤ 1771 mg/day) showed a lower risk for migraine (adjusted odds ratio 0.84; P = .021), which suggested an L-shaped (non-linear) association between dietary potassium intake and migraine (P = .016), with an inflection at ~1439.3 mg/day.

Study details: This cross-sectional study included 10,254 participants age ≥ 20 years, of whom 2065 (20.1%) had migraine.

Disclosures: This study did not receive any funding. The authors declared no conflicts of interest.

Source: Xu L et al. Association between dietary potassium intake and severe headache or migraine in US adults: A population-based analysis. Front Nutr. 2023;10:1255468 (Sep 15). doi:  10.3389/fnut.2023.1255468

Key clinical point: High dietary potassium intake is associated with a decreased risk for migraine, with an L-shaped correlation between dietary potassium intake and migraine highlighting an inflection at ~1,439.3 mg/day.

Major finding: Participants in the second quartile (potassium intake 1771-2476 mg/day) vs first quartile (potassium intake ≤ 1771 mg/day) showed a lower risk for migraine (adjusted odds ratio 0.84; P = .021), which suggested an L-shaped (non-linear) association between dietary potassium intake and migraine (P = .016), with an inflection at ~1439.3 mg/day.

Study details: This cross-sectional study included 10,254 participants age ≥ 20 years, of whom 2065 (20.1%) had migraine.

Disclosures: This study did not receive any funding. The authors declared no conflicts of interest.

Source: Xu L et al. Association between dietary potassium intake and severe headache or migraine in US adults: A population-based analysis. Front Nutr. 2023;10:1255468 (Sep 15). doi:  10.3389/fnut.2023.1255468

Key clinical point: High dietary potassium intake is associated with a decreased risk for migraine, with an L-shaped correlation between dietary potassium intake and migraine highlighting an inflection at ~1,439.3 mg/day.

Major finding: Participants in the second quartile (potassium intake 1771-2476 mg/day) vs first quartile (potassium intake ≤ 1771 mg/day) showed a lower risk for migraine (adjusted odds ratio 0.84; P = .021), which suggested an L-shaped (non-linear) association between dietary potassium intake and migraine (P = .016), with an inflection at ~1439.3 mg/day.

Study details: This cross-sectional study included 10,254 participants age ≥ 20 years, of whom 2065 (20.1%) had migraine.

Disclosures: This study did not receive any funding. The authors declared no conflicts of interest.

Source: Xu L et al. Association between dietary potassium intake and severe headache or migraine in US adults: A population-based analysis. Front Nutr. 2023;10:1255468 (Sep 15). doi:  10.3389/fnut.2023.1255468

Key clinical point: Poor sleep could be a significant risk factor for an ensuing migraine attack, and an intensely painful migraine attack may lead to a subsequent increase in sleep duration, thus highlighting that sleep hygiene is an inherent part of migraine management.

Major finding: The odds of having a migraine attack increased by 6.1% and 17.4% with every deviation from mean sleep and every sleep interruption, respectively, during the previous day, whereas the overall sleep duration had no effect on attack occurrences. An intensely painful attack (M = 0.13; 95% high density interval 0.06-0.20) positively predicted increased sleep duration during the same evening.

Study details: This retrospective cross-sectional study included 724 patients (ages, 18-81 years) with a mean monthly migraine attack frequency of 9.94.

Disclosures: This study was supported by a UK Medical Research Council PhD studentship. Two authors declared being employees of Healint Pte. Ltd, and some authors declared ties with various sources.

Source: Stanyer EC et al. Investigating the relationship between sleep and migraine in a global sample: A Bayesian cross-sectional approach. J Headache Pain. 2023;24:123 (Sep 8). doi: 10.1186/s10194-023-01638-6

Key clinical point: Poor sleep could be a significant risk factor for an ensuing migraine attack, and an intensely painful migraine attack may lead to a subsequent increase in sleep duration, thus highlighting that sleep hygiene is an inherent part of migraine management.

Major finding: The odds of having a migraine attack increased by 6.1% and 17.4% with every deviation from mean sleep and every sleep interruption, respectively, during the previous day, whereas the overall sleep duration had no effect on attack occurrences. An intensely painful attack (M = 0.13; 95% high density interval 0.06-0.20) positively predicted increased sleep duration during the same evening.

Study details: This retrospective cross-sectional study included 724 patients (ages, 18-81 years) with a mean monthly migraine attack frequency of 9.94.

Disclosures: This study was supported by a UK Medical Research Council PhD studentship. Two authors declared being employees of Healint Pte. Ltd, and some authors declared ties with various sources.

Source: Stanyer EC et al. Investigating the relationship between sleep and migraine in a global sample: A Bayesian cross-sectional approach. J Headache Pain. 2023;24:123 (Sep 8). doi: 10.1186/s10194-023-01638-6

Key clinical point: Poor sleep could be a significant risk factor for an ensuing migraine attack, and an intensely painful migraine attack may lead to a subsequent increase in sleep duration, thus highlighting that sleep hygiene is an inherent part of migraine management.

Major finding: The odds of having a migraine attack increased by 6.1% and 17.4% with every deviation from mean sleep and every sleep interruption, respectively, during the previous day, whereas the overall sleep duration had no effect on attack occurrences. An intensely painful attack (M = 0.13; 95% high density interval 0.06-0.20) positively predicted increased sleep duration during the same evening.

Study details: This retrospective cross-sectional study included 724 patients (ages, 18-81 years) with a mean monthly migraine attack frequency of 9.94.

Disclosures: This study was supported by a UK Medical Research Council PhD studentship. Two authors declared being employees of Healint Pte. Ltd, and some authors declared ties with various sources.

Source: Stanyer EC et al. Investigating the relationship between sleep and migraine in a global sample: A Bayesian cross-sectional approach. J Headache Pain. 2023;24:123 (Sep 8). doi: 10.1186/s10194-023-01638-6

Key clinical point: In this real-world study of patients with migraine, galcanezumab showed higher response rates than those reported in clinical trials, with chronic migraine (CM) and multiple failures to previous preventive medication being significant predictors of a poor response to galcanezumab.

Major finding: At 3 months of galcanezumab treatment, 55.7% of patients showed a 50% response to galcanezumab. CM (odds ratio [OR] 0.09; P = .047) and the number of previous nonresponse to preventive medication classes (OR 0.55; P = .022) were significantly associated with a poor response to galcanezumab.

Study details: This real-world study involved a prospective follow-up of 104 patients with migraine who received monthly galcanezumab.

Disclosures: This study was supported by the New Faculty Startup Fund from Seoul National University and a National Research Foundation of Korea grant. The authors declared no conflicts of interest.

Source: Kim SA et al. Predictors of galcanezumab response in a real-world study of Korean patients with migraine. Sci Rep. 2023;13:14825 (Sep 8). doi: 10.1038/s41598-023-42110-4

Key clinical point: In this real-world study of patients with migraine, galcanezumab showed higher response rates than those reported in clinical trials, with chronic migraine (CM) and multiple failures to previous preventive medication being significant predictors of a poor response to galcanezumab.

Major finding: At 3 months of galcanezumab treatment, 55.7% of patients showed a 50% response to galcanezumab. CM (odds ratio [OR] 0.09; P = .047) and the number of previous nonresponse to preventive medication classes (OR 0.55; P = .022) were significantly associated with a poor response to galcanezumab.

Study details: This real-world study involved a prospective follow-up of 104 patients with migraine who received monthly galcanezumab.

Disclosures: This study was supported by the New Faculty Startup Fund from Seoul National University and a National Research Foundation of Korea grant. The authors declared no conflicts of interest.

Source: Kim SA et al. Predictors of galcanezumab response in a real-world study of Korean patients with migraine. Sci Rep. 2023;13:14825 (Sep 8). doi: 10.1038/s41598-023-42110-4

Key clinical point: In this real-world study of patients with migraine, galcanezumab showed higher response rates than those reported in clinical trials, with chronic migraine (CM) and multiple failures to previous preventive medication being significant predictors of a poor response to galcanezumab.

Major finding: At 3 months of galcanezumab treatment, 55.7% of patients showed a 50% response to galcanezumab. CM (odds ratio [OR] 0.09; P = .047) and the number of previous nonresponse to preventive medication classes (OR 0.55; P = .022) were significantly associated with a poor response to galcanezumab.

Study details: This real-world study involved a prospective follow-up of 104 patients with migraine who received monthly galcanezumab.

Disclosures: This study was supported by the New Faculty Startup Fund from Seoul National University and a National Research Foundation of Korea grant. The authors declared no conflicts of interest.

Source: Kim SA et al. Predictors of galcanezumab response in a real-world study of Korean patients with migraine. Sci Rep. 2023;13:14825 (Sep 8). doi: 10.1038/s41598-023-42110-4

Key clinical point: A significant proportion of patients with migraine do not respond to ≥1 triptans, and this lack of response is associated with increased migraine severity and disability.

Major finding: Overall, 42.5%, 13.1%, 3.9%, and 0.6% of patients did not respond to ≥1, ≥2 triptans, ≥3 triptans, and ≥3 triptans including a subcutaneous formulation, respectively, with triptan non-responders vs responders having a significantly higher migraine frequency (P < .001), intensity (P < .05), and disability (P < .001).

Study details: This study evaluated 2284 patients with migraine using cross-sectional data from the German Migraine and Headache Society Headache Registry.

Disclosures: This study was supported by Projekt DEAL. Several authors declared serving as advisory boards members or consultants for or receiving travel or research grants or honoraria for consulting, lectures, advisory boards, adboards, and educational talks from various sources.

Source: Ruscheweyh R et al. Triptan non-response in specialized headache care: Cross-sectional data from the DMKG Headache Registry. J Headache Pain. 2023;24:135 (Oct 10). doi: 10.1186/s10194-023-01676-0

Key clinical point: A significant proportion of patients with migraine do not respond to ≥1 triptans, and this lack of response is associated with increased migraine severity and disability.

Major finding: Overall, 42.5%, 13.1%, 3.9%, and 0.6% of patients did not respond to ≥1, ≥2 triptans, ≥3 triptans, and ≥3 triptans including a subcutaneous formulation, respectively, with triptan non-responders vs responders having a significantly higher migraine frequency (P < .001), intensity (P < .05), and disability (P < .001).

Study details: This study evaluated 2284 patients with migraine using cross-sectional data from the German Migraine and Headache Society Headache Registry.

Disclosures: This study was supported by Projekt DEAL. Several authors declared serving as advisory boards members or consultants for or receiving travel or research grants or honoraria for consulting, lectures, advisory boards, adboards, and educational talks from various sources.

Source: Ruscheweyh R et al. Triptan non-response in specialized headache care: Cross-sectional data from the DMKG Headache Registry. J Headache Pain. 2023;24:135 (Oct 10). doi: 10.1186/s10194-023-01676-0

Key clinical point: A significant proportion of patients with migraine do not respond to ≥1 triptans, and this lack of response is associated with increased migraine severity and disability.

Major finding: Overall, 42.5%, 13.1%, 3.9%, and 0.6% of patients did not respond to ≥1, ≥2 triptans, ≥3 triptans, and ≥3 triptans including a subcutaneous formulation, respectively, with triptan non-responders vs responders having a significantly higher migraine frequency (P < .001), intensity (P < .05), and disability (P < .001).

Study details: This study evaluated 2284 patients with migraine using cross-sectional data from the German Migraine and Headache Society Headache Registry.

Disclosures: This study was supported by Projekt DEAL. Several authors declared serving as advisory boards members or consultants for or receiving travel or research grants or honoraria for consulting, lectures, advisory boards, adboards, and educational talks from various sources.

Source: Ruscheweyh R et al. Triptan non-response in specialized headache care: Cross-sectional data from the DMKG Headache Registry. J Headache Pain. 2023;24:135 (Oct 10). doi: 10.1186/s10194-023-01676-0

Key clinical point: Cutaneous allodynia and aura contribute significantly to the risk for calcitonin gene-related peptide (CGRP)-induced migraine attacks in patients having migraine with or without aura.

Major finding: Overall, 79% of patients had CGRP-induced migraine attacks during a 12-hour observation period following CGRP infusion. The presence of cutaneous allodynia and aura, respectively, led to significant increase (odds ratio [OR] 3.26; P = .013) and decrease (OR 0.32; P = .02) in the risk for CGRP-induced migraine attacks.

Study details: The data come from a non-randomized, open-label trial including 139 patients having migraine with or without aura who received a continuous 20-min intravenous infusion of CGRP (dosage, 1.5 mg/minute).

Disclosures: This study was funded by a professor grant from the Lundbeck Foundation, Denmark. Five authors declared receiving personal fees and institutional grants from various sources. M Ashina declared serving as an associate editor of Cephalalgia, The Journal of Headache and Pain, and Brain.

Source: Al-Khazali HM et al. An exploratory analysis of clinical and sociodemographic factors in CGRP-induced migraine attacks: A REFORM study. Cephalalgia. 2023 (Oct 10). doi: 10.1177/03331024231206375

Key clinical point: Cutaneous allodynia and aura contribute significantly to the risk for calcitonin gene-related peptide (CGRP)-induced migraine attacks in patients having migraine with or without aura.

Major finding: Overall, 79% of patients had CGRP-induced migraine attacks during a 12-hour observation period following CGRP infusion. The presence of cutaneous allodynia and aura, respectively, led to significant increase (odds ratio [OR] 3.26; P = .013) and decrease (OR 0.32; P = .02) in the risk for CGRP-induced migraine attacks.

Study details: The data come from a non-randomized, open-label trial including 139 patients having migraine with or without aura who received a continuous 20-min intravenous infusion of CGRP (dosage, 1.5 mg/minute).

Disclosures: This study was funded by a professor grant from the Lundbeck Foundation, Denmark. Five authors declared receiving personal fees and institutional grants from various sources. M Ashina declared serving as an associate editor of Cephalalgia, The Journal of Headache and Pain, and Brain.

Source: Al-Khazali HM et al. An exploratory analysis of clinical and sociodemographic factors in CGRP-induced migraine attacks: A REFORM study. Cephalalgia. 2023 (Oct 10). doi: 10.1177/03331024231206375

Key clinical point: Cutaneous allodynia and aura contribute significantly to the risk for calcitonin gene-related peptide (CGRP)-induced migraine attacks in patients having migraine with or without aura.

Major finding: Overall, 79% of patients had CGRP-induced migraine attacks during a 12-hour observation period following CGRP infusion. The presence of cutaneous allodynia and aura, respectively, led to significant increase (odds ratio [OR] 3.26; P = .013) and decrease (OR 0.32; P = .02) in the risk for CGRP-induced migraine attacks.

Study details: The data come from a non-randomized, open-label trial including 139 patients having migraine with or without aura who received a continuous 20-min intravenous infusion of CGRP (dosage, 1.5 mg/minute).

Disclosures: This study was funded by a professor grant from the Lundbeck Foundation, Denmark. Five authors declared receiving personal fees and institutional grants from various sources. M Ashina declared serving as an associate editor of Cephalalgia, The Journal of Headache and Pain, and Brain.

Source: Al-Khazali HM et al. An exploratory analysis of clinical and sociodemographic factors in CGRP-induced migraine attacks: A REFORM study. Cephalalgia. 2023 (Oct 10). doi: 10.1177/03331024231206375

Key clinical point: Add-on therapy with a low fixed dose of levothyroxine significantly reduced the headache frequency and severity in patients with episodic migraine and subclinical hypothyroidism.

Major finding: At a 3-month follow-up, patients receiving levothyroxine supplementation vs placebo showed a significant reduction in the mean headache frequency (1.67 vs 3.28) and severity (2.05 vs 3.20; both P = .001), mean Migraine Disability Assessment Score (MIDAS; 6.30 vs 8.45; P = .026), and mean MIDAS grade (1.49 vs 1.84; P = .029).

Study details: The data come from a prospective, quasi-randomized interventional study including 87 patients with episodic migraine and subclinical hypothyroidism who were quasi-randomized to the levothyroxine supplementation (n = 43) or placebo (n = 44) arm.

Disclosures: This study was supported by an Institution of Eminence, India, grant. The authors declared no conflicts of interest.

Source: Dev P et al. The effect of low dose thyroid replacement therapy in patients with episodic migraine and subclinical hypothyroidism: A randomised placebo-controlled trial. Cephalalgia. 2023 (Oct 6). doi: 10.1177/03331024231182684

Key clinical point: Add-on therapy with a low fixed dose of levothyroxine significantly reduced the headache frequency and severity in patients with episodic migraine and subclinical hypothyroidism.

Major finding: At a 3-month follow-up, patients receiving levothyroxine supplementation vs placebo showed a significant reduction in the mean headache frequency (1.67 vs 3.28) and severity (2.05 vs 3.20; both P = .001), mean Migraine Disability Assessment Score (MIDAS; 6.30 vs 8.45; P = .026), and mean MIDAS grade (1.49 vs 1.84; P = .029).

Study details: The data come from a prospective, quasi-randomized interventional study including 87 patients with episodic migraine and subclinical hypothyroidism who were quasi-randomized to the levothyroxine supplementation (n = 43) or placebo (n = 44) arm.

Disclosures: This study was supported by an Institution of Eminence, India, grant. The authors declared no conflicts of interest.

Source: Dev P et al. The effect of low dose thyroid replacement therapy in patients with episodic migraine and subclinical hypothyroidism: A randomised placebo-controlled trial. Cephalalgia. 2023 (Oct 6). doi: 10.1177/03331024231182684

Key clinical point: Add-on therapy with a low fixed dose of levothyroxine significantly reduced the headache frequency and severity in patients with episodic migraine and subclinical hypothyroidism.

Major finding: At a 3-month follow-up, patients receiving levothyroxine supplementation vs placebo showed a significant reduction in the mean headache frequency (1.67 vs 3.28) and severity (2.05 vs 3.20; both P = .001), mean Migraine Disability Assessment Score (MIDAS; 6.30 vs 8.45; P = .026), and mean MIDAS grade (1.49 vs 1.84; P = .029).

Study details: The data come from a prospective, quasi-randomized interventional study including 87 patients with episodic migraine and subclinical hypothyroidism who were quasi-randomized to the levothyroxine supplementation (n = 43) or placebo (n = 44) arm.

Disclosures: This study was supported by an Institution of Eminence, India, grant. The authors declared no conflicts of interest.

Source: Dev P et al. The effect of low dose thyroid replacement therapy in patients with episodic migraine and subclinical hypothyroidism: A randomised placebo-controlled trial. Cephalalgia. 2023 (Oct 6). doi: 10.1177/03331024231182684