Headache & Migraine

Migraine is well known as a vascular phenomenon, but research over time has shown that vasodilation is a secondary feature of headache rather than the cause of headache pain. Calcitonin gene-related peptide (CGRP) and other vasoactive inflammatory proteins transmit nociceptive signals through the trigeminal system, and although vasodilation occurs, it is not essential for migraine attacks to occur. White matter changes on MRI are a common finding in people with migraine, and the burden of migraine often correlates with the amount of white matter changes seen. This connection highlights the indirect connection between migraine and vascular risks factors, and this study attempts to better quantify this, specifically with respect to stroke and myocardial infarction (MI).

The study by Fuglsang and colleagues was a registry-based nationwide population-based cohort study that included over 200,000 individuals with migraine, using data collected from 1996 to 2018. Participants were differentiated as having or not having migraine on the basis of prescriptions of preventive or acute migraine medications. Male and female participants were further subdivided, and these groups were compared to healthy controls. The primary endpoints were hazard ratio and absolute risk differences for developing hemorrhagic or ischemic stroke or MI among all groups.

The researchers found an increased risk for ischemic stroke that was equal among male and female participants. Hemorrhagic stroke and MI were seen to be increased in migraine, but primarily among women with migraine. This study specifically investigated what the researchers termed "premature" stroke and MI, and there remains a likelihood that estrogen could be the differentiating factor between the difference in risk between male and female participants with migraine. I have recently highlighted a number of studies investigating vascular risk factors associated with migraine; this study will help clinicians appropriately educate their patients with migraine regarding vascular risk.

The first medications reported as helpful preventively for migraine were antihypertensives, specifically beta-blockers (BB). A number of other medications in other antihypertensive subclasses have also subsequently been shown to be helpful for migraine prevention. These include angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARB), calcium channel blockers (CCB), and alpha-blockers (AB). Carcel and colleagues conducted a meta-analysis that investigated a wide variety of antihypertensive medications in multiple classes and compared the reduction in headache frequency as defined as headache days per month.

This analysis reviewed 50 studies involving over 4000 participants. The majority of the studies (35 out 50 [70%]) had a cross-over design. The medications evaluated included clonidine (an alpha agonist), candesartan (an ARB), telmisartan (an ARB), propranolol (a BB), timolol (a BB), pindolol (a BB), metoprolol (a BB), bisoprolol (a BB), atenolol (a BB), alprenolol (a BB), nimodipine (a CCB), nifedipine (a CCB), verapamil (a CCB), nicardipine (a CCB), enalapril (an ACE inhibitor), and lisinopril (an ACE inhibitor). For each class of antihypertensive, there was a lower number of monthly headache days with treatment compared with placebo; the greatest reduction was for the CCB with a mean difference of about 2 days per month. BB on average decreased headache days per month by 0.7 days. For BB, there was no clear trend to increased efficacy with increased dose. Only six trials reported the difference in blood pressure: On average, there was a 9.3 mm Hg drop in systolic and 3.0 mm Hg drop in diastolic pressure.

The authors showed that there is statistical significance for the use of antihypertensive medications for decreasing migraine days per month, and this was statistically significant separately for numerous specific drugs within the classes: clonidine, candesartan, atenolol, bisoprolol, propranolol, timolol, nicardipine, and verapamil. Antihypertensive medications remain some of the most popular first-line preventive options for migraine, and although the benefit of this class as a whole is mild (slightly more than 1 day per month), it can be an excellent option for many patients

The relationship between migraine and caffeine is necessarily controversial. Caffeine is included as a component of many over-the-counter migraine treatments, and the beneficial effect of caffeine as an acute treatment for migraine has been documented for decades. Reduction in caffeine, however, has also been established as a helpful lifestyle modification for prevention of migraine attacks. Zhang and colleagues used data from the National Health and Nutrition Examination Survey database, a program conducted by the Centers for Disease Control and Prevention to assess the health and nutritional status of adults and children in the United States.

This study sought to quantify the relationship between dietary caffeine and "severe headache." For this study, "severe headache" was defined as answering yes to the question: During the past 3 months, did you have severe headaches or migraines? Dietary caffeine intake was collected through two 24-hour dietary recall interviews, one in person and one 3-10 days later via telephone. The amount of caffeine consumed was estimated in mg/day from all caffeine-containing foods and beverages, including coffee, tea, soda, and chocolate, using the US Department of Agriculture's Food and Nutrient Database. Each participant's mean caffeine intake was defined as the difference between the first and second dietary recalls.

A large number of covariates were assessed as well, including age, race/ethnicity, body mass index, poverty-income ratio, educational level, marital status, hypertension, cancer, energy intake, protein intake, calcium intake, magnesium intake, iron intake, sodium intake, alcohol status, smoking status, and triglyceride level. A total of 8993 participants were included. Caffeine intake was divided into four groups: ≥ 0 to < 40 mg/day, ≥ 40 to < 200 mg/day, ≥ 200 to < 400 mg/day, and ≥ 400 mg/day. After adjusting for confounders, a significant association between dietary caffeine intake and severe headaches or migraines was detected.

Curiously, in this study, only male participants were included. The authors found a clear correlation between the amount of caffeine consumed over a 24-hour period and severe migraine attacks. Further evaluation should investigate the frequency of attacks rather than just individual experience over a 3-month period. Although caffeine is helpful acutely, higher dose consumption is a risk factor for worsening migraine.

Migraine is well known as a vascular phenomenon, but research over time has shown that vasodilation is a secondary feature of headache rather than the cause of headache pain. Calcitonin gene-related peptide (CGRP) and other vasoactive inflammatory proteins transmit nociceptive signals through the trigeminal system, and although vasodilation occurs, it is not essential for migraine attacks to occur. White matter changes on MRI are a common finding in people with migraine, and the burden of migraine often correlates with the amount of white matter changes seen. This connection highlights the indirect connection between migraine and vascular risks factors, and this study attempts to better quantify this, specifically with respect to stroke and myocardial infarction (MI).

The study by Fuglsang and colleagues was a registry-based nationwide population-based cohort study that included over 200,000 individuals with migraine, using data collected from 1996 to 2018. Participants were differentiated as having or not having migraine on the basis of prescriptions of preventive or acute migraine medications. Male and female participants were further subdivided, and these groups were compared to healthy controls. The primary endpoints were hazard ratio and absolute risk differences for developing hemorrhagic or ischemic stroke or MI among all groups.

The researchers found an increased risk for ischemic stroke that was equal among male and female participants. Hemorrhagic stroke and MI were seen to be increased in migraine, but primarily among women with migraine. This study specifically investigated what the researchers termed "premature" stroke and MI, and there remains a likelihood that estrogen could be the differentiating factor between the difference in risk between male and female participants with migraine. I have recently highlighted a number of studies investigating vascular risk factors associated with migraine; this study will help clinicians appropriately educate their patients with migraine regarding vascular risk.

The first medications reported as helpful preventively for migraine were antihypertensives, specifically beta-blockers (BB). A number of other medications in other antihypertensive subclasses have also subsequently been shown to be helpful for migraine prevention. These include angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARB), calcium channel blockers (CCB), and alpha-blockers (AB). Carcel and colleagues conducted a meta-analysis that investigated a wide variety of antihypertensive medications in multiple classes and compared the reduction in headache frequency as defined as headache days per month.

This analysis reviewed 50 studies involving over 4000 participants. The majority of the studies (35 out 50 [70%]) had a cross-over design. The medications evaluated included clonidine (an alpha agonist), candesartan (an ARB), telmisartan (an ARB), propranolol (a BB), timolol (a BB), pindolol (a BB), metoprolol (a BB), bisoprolol (a BB), atenolol (a BB), alprenolol (a BB), nimodipine (a CCB), nifedipine (a CCB), verapamil (a CCB), nicardipine (a CCB), enalapril (an ACE inhibitor), and lisinopril (an ACE inhibitor). For each class of antihypertensive, there was a lower number of monthly headache days with treatment compared with placebo; the greatest reduction was for the CCB with a mean difference of about 2 days per month. BB on average decreased headache days per month by 0.7 days. For BB, there was no clear trend to increased efficacy with increased dose. Only six trials reported the difference in blood pressure: On average, there was a 9.3 mm Hg drop in systolic and 3.0 mm Hg drop in diastolic pressure.

The authors showed that there is statistical significance for the use of antihypertensive medications for decreasing migraine days per month, and this was statistically significant separately for numerous specific drugs within the classes: clonidine, candesartan, atenolol, bisoprolol, propranolol, timolol, nicardipine, and verapamil. Antihypertensive medications remain some of the most popular first-line preventive options for migraine, and although the benefit of this class as a whole is mild (slightly more than 1 day per month), it can be an excellent option for many patients

The relationship between migraine and caffeine is necessarily controversial. Caffeine is included as a component of many over-the-counter migraine treatments, and the beneficial effect of caffeine as an acute treatment for migraine has been documented for decades. Reduction in caffeine, however, has also been established as a helpful lifestyle modification for prevention of migraine attacks. Zhang and colleagues used data from the National Health and Nutrition Examination Survey database, a program conducted by the Centers for Disease Control and Prevention to assess the health and nutritional status of adults and children in the United States.

This study sought to quantify the relationship between dietary caffeine and "severe headache." For this study, "severe headache" was defined as answering yes to the question: During the past 3 months, did you have severe headaches or migraines? Dietary caffeine intake was collected through two 24-hour dietary recall interviews, one in person and one 3-10 days later via telephone. The amount of caffeine consumed was estimated in mg/day from all caffeine-containing foods and beverages, including coffee, tea, soda, and chocolate, using the US Department of Agriculture's Food and Nutrient Database. Each participant's mean caffeine intake was defined as the difference between the first and second dietary recalls.

A large number of covariates were assessed as well, including age, race/ethnicity, body mass index, poverty-income ratio, educational level, marital status, hypertension, cancer, energy intake, protein intake, calcium intake, magnesium intake, iron intake, sodium intake, alcohol status, smoking status, and triglyceride level. A total of 8993 participants were included. Caffeine intake was divided into four groups: ≥ 0 to < 40 mg/day, ≥ 40 to < 200 mg/day, ≥ 200 to < 400 mg/day, and ≥ 400 mg/day. After adjusting for confounders, a significant association between dietary caffeine intake and severe headaches or migraines was detected.

Curiously, in this study, only male participants were included. The authors found a clear correlation between the amount of caffeine consumed over a 24-hour period and severe migraine attacks. Further evaluation should investigate the frequency of attacks rather than just individual experience over a 3-month period. Although caffeine is helpful acutely, higher dose consumption is a risk factor for worsening migraine.

Migraine is well known as a vascular phenomenon, but research over time has shown that vasodilation is a secondary feature of headache rather than the cause of headache pain. Calcitonin gene-related peptide (CGRP) and other vasoactive inflammatory proteins transmit nociceptive signals through the trigeminal system, and although vasodilation occurs, it is not essential for migraine attacks to occur. White matter changes on MRI are a common finding in people with migraine, and the burden of migraine often correlates with the amount of white matter changes seen. This connection highlights the indirect connection between migraine and vascular risks factors, and this study attempts to better quantify this, specifically with respect to stroke and myocardial infarction (MI).

The study by Fuglsang and colleagues was a registry-based nationwide population-based cohort study that included over 200,000 individuals with migraine, using data collected from 1996 to 2018. Participants were differentiated as having or not having migraine on the basis of prescriptions of preventive or acute migraine medications. Male and female participants were further subdivided, and these groups were compared to healthy controls. The primary endpoints were hazard ratio and absolute risk differences for developing hemorrhagic or ischemic stroke or MI among all groups.

The researchers found an increased risk for ischemic stroke that was equal among male and female participants. Hemorrhagic stroke and MI were seen to be increased in migraine, but primarily among women with migraine. This study specifically investigated what the researchers termed "premature" stroke and MI, and there remains a likelihood that estrogen could be the differentiating factor between the difference in risk between male and female participants with migraine. I have recently highlighted a number of studies investigating vascular risk factors associated with migraine; this study will help clinicians appropriately educate their patients with migraine regarding vascular risk.

The first medications reported as helpful preventively for migraine were antihypertensives, specifically beta-blockers (BB). A number of other medications in other antihypertensive subclasses have also subsequently been shown to be helpful for migraine prevention. These include angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARB), calcium channel blockers (CCB), and alpha-blockers (AB). Carcel and colleagues conducted a meta-analysis that investigated a wide variety of antihypertensive medications in multiple classes and compared the reduction in headache frequency as defined as headache days per month.

This analysis reviewed 50 studies involving over 4000 participants. The majority of the studies (35 out 50 [70%]) had a cross-over design. The medications evaluated included clonidine (an alpha agonist), candesartan (an ARB), telmisartan (an ARB), propranolol (a BB), timolol (a BB), pindolol (a BB), metoprolol (a BB), bisoprolol (a BB), atenolol (a BB), alprenolol (a BB), nimodipine (a CCB), nifedipine (a CCB), verapamil (a CCB), nicardipine (a CCB), enalapril (an ACE inhibitor), and lisinopril (an ACE inhibitor). For each class of antihypertensive, there was a lower number of monthly headache days with treatment compared with placebo; the greatest reduction was for the CCB with a mean difference of about 2 days per month. BB on average decreased headache days per month by 0.7 days. For BB, there was no clear trend to increased efficacy with increased dose. Only six trials reported the difference in blood pressure: On average, there was a 9.3 mm Hg drop in systolic and 3.0 mm Hg drop in diastolic pressure.

The authors showed that there is statistical significance for the use of antihypertensive medications for decreasing migraine days per month, and this was statistically significant separately for numerous specific drugs within the classes: clonidine, candesartan, atenolol, bisoprolol, propranolol, timolol, nicardipine, and verapamil. Antihypertensive medications remain some of the most popular first-line preventive options for migraine, and although the benefit of this class as a whole is mild (slightly more than 1 day per month), it can be an excellent option for many patients

The relationship between migraine and caffeine is necessarily controversial. Caffeine is included as a component of many over-the-counter migraine treatments, and the beneficial effect of caffeine as an acute treatment for migraine has been documented for decades. Reduction in caffeine, however, has also been established as a helpful lifestyle modification for prevention of migraine attacks. Zhang and colleagues used data from the National Health and Nutrition Examination Survey database, a program conducted by the Centers for Disease Control and Prevention to assess the health and nutritional status of adults and children in the United States.

This study sought to quantify the relationship between dietary caffeine and "severe headache." For this study, "severe headache" was defined as answering yes to the question: During the past 3 months, did you have severe headaches or migraines? Dietary caffeine intake was collected through two 24-hour dietary recall interviews, one in person and one 3-10 days later via telephone. The amount of caffeine consumed was estimated in mg/day from all caffeine-containing foods and beverages, including coffee, tea, soda, and chocolate, using the US Department of Agriculture's Food and Nutrient Database. Each participant's mean caffeine intake was defined as the difference between the first and second dietary recalls.

A large number of covariates were assessed as well, including age, race/ethnicity, body mass index, poverty-income ratio, educational level, marital status, hypertension, cancer, energy intake, protein intake, calcium intake, magnesium intake, iron intake, sodium intake, alcohol status, smoking status, and triglyceride level. A total of 8993 participants were included. Caffeine intake was divided into four groups: ≥ 0 to < 40 mg/day, ≥ 40 to < 200 mg/day, ≥ 200 to < 400 mg/day, and ≥ 400 mg/day. After adjusting for confounders, a significant association between dietary caffeine intake and severe headaches or migraines was detected.

Curiously, in this study, only male participants were included. The authors found a clear correlation between the amount of caffeine consumed over a 24-hour period and severe migraine attacks. Further evaluation should investigate the frequency of attacks rather than just individual experience over a 3-month period. Although caffeine is helpful acutely, higher dose consumption is a risk factor for worsening migraine.

What types of headache and other illnesses respond to biofeedback training?

Migraine affects about 12% of the US and most Western populations, and is 3 times more common in women than men. Migraine can be treated with a variety of strategies that include medications and nonpharmacologic therapies such as biofeedback, as well as other behavioral therapies and devices. Biofeedback refers to the use of instrumentation to monitor and display physiologic responses that the patient may not be aware of so that they can be “modified” in a more adaptive direction. Feedback gives immediate objective information and is usually combined with a relaxation-based therapy. The most common biofeedback treatments for migraine include feeding back muscle activity in the face and neck to help people relax contracted muscles and teach them a “low-arousal” response; they learn to increase finger temperature, which coincides with modifying the “stress” nervous system. Biofeedback has been shown to be helpful for migraine and tension-type headache. It is also helpful to decrease anxiety and stress levels and lower blood pressure.

Can patients use biofeedback treatments in conjunction with migraine medication?

Research has shown that migraine, in particular higher-frequency migraine, is best treated by a combination of medications and behavioral strategies. Biofeedback is a good option for use in conjunction with medication for migraine.

Who is trained to provide biofeedback treatments?

Biofeedback for migraine is something usually performed by psychologists and other professionals with specialized training. Many practitioners are certified by the Biofeedback Certification Institute of America (BCIA). It is important to find an experienced biofeedback practitioner who also has some expertise in treating headache disorders. 

How are biofeedback treatments performed?

Biofeedback is a therapy that follows a learning model whereby the patient gradually learns a self-regulation skill that impacts their headaches. 

Patients come to an office, typically once per week, where they are attached to instruments that measure physical responses associated with migraine. The patient typically sits in a comfortable chair or recliner, and numerous physiologic responses are monitored with surface electrodes. 

When treating headache, sensors are typically placed on the head and neck to monitor muscle responses and a thermistor is placed on a finger to measure temperature. Feedback is given via visual cues (computer graphics) or a change in auditory tone as the patient is taught various relaxation techniques.  

Patients use the feedback to learn a physiologic relaxation response that may be beneficial for their headache management. Most of the research on biofeedback is related to treatment to prevent migraine; however, these techniques can be helpful to use during an acute attack, ideally paired with an acute care migraine medication. 

Can children with migraine have biofeedback treatments as well?

 Most children typically have a lower frequency of migraine than adults, although some have frequent migraines with associated disability and are candidates for preventive medication (although no medications are yet approved for children by the US Food and Drug Association). Most children are good candidates for behavioral therapies such as biofeedback. There are many computer games utilized in biofeedback training that children easily learn to modify physical responses. There are some fairly recent data suggesting that behavioral treatments, some of which include biofeedback, are effective strategies for children and may be more effective than preventive medication.  

What other types of illnesses could benefit from biofeedback training?    

There are data showing that biofeedback therapy can be helpful for anxiety disorders, insomnia, and functional bowel disorders and may help in modifying high blood pressure. It can also be a very effective stress-management strategy.  

Do you refer some of your patients with migraine to a psychologist for biofeedback treatments?      

 Yes, but it is always good for the referring physician to check on the credentials of the person performing the biofeedback treatment. Some headache specialists might do it themselves, but we do not. It takes a while—at least several sessions—and psychologists are better at it. Patients’ perspectives are also important. We communicate with the referred biofeedback treatment specialist to get more insight on the patient. For example, some patients are anxious and depressed, and they are not sleeping at night. The doctor we referred the patient to may recommend an antidepressant for the patient to help address those issues. It is a team effort.

What is the average cost per treatment?      
The costs vary throughout the country and range from $75 to $400 per session. Insurance coverage varies.  

How many times should a patient go in for treatment?    

Most protocols are about 10 to 12 sessions, depending on patient response. 

Have there been clinical trials on biofeedback treatments/devices?  

There have been many clinical trials that have been positive, so there is good evidence that biofeedback can be an effective treatment for migraine and tension-type headache. There are many types of biofeedback devices that measure different modalities. The most common one used in migraine is measuring scalp muscle contraction with surface electromyography or measuring peripheral blood flow with a temperature gauge. The goals are to relax muscles and learn to increase finger temperature, which is related to decreased arousal of the sympathetic nervous system or stress system. Other modalities include learning to modulate brain waves (electroencephalography or neurofeedback) and certain cardiovascular measures that reduce the stress response by a different mechanism. The goal is for patients to learn a low arousal response that they can utilize in their natural environment. Certain breathing techniques and visualization exercises are also helpful, but biofeedback refers to using physiologic recording equipment to help learn to change physical responses related to headache disorder. 

Over our years of experience, we have found that biofeedback can help a large percentage of our patients with migraine and tension-type headache, and it is associated with almost no adverse events.

What types of headache and other illnesses respond to biofeedback training?

Migraine affects about 12% of the US and most Western populations, and is 3 times more common in women than men. Migraine can be treated with a variety of strategies that include medications and nonpharmacologic therapies such as biofeedback, as well as other behavioral therapies and devices. Biofeedback refers to the use of instrumentation to monitor and display physiologic responses that the patient may not be aware of so that they can be “modified” in a more adaptive direction. Feedback gives immediate objective information and is usually combined with a relaxation-based therapy. The most common biofeedback treatments for migraine include feeding back muscle activity in the face and neck to help people relax contracted muscles and teach them a “low-arousal” response; they learn to increase finger temperature, which coincides with modifying the “stress” nervous system. Biofeedback has been shown to be helpful for migraine and tension-type headache. It is also helpful to decrease anxiety and stress levels and lower blood pressure.

Can patients use biofeedback treatments in conjunction with migraine medication?

Research has shown that migraine, in particular higher-frequency migraine, is best treated by a combination of medications and behavioral strategies. Biofeedback is a good option for use in conjunction with medication for migraine.

Who is trained to provide biofeedback treatments?

Biofeedback for migraine is something usually performed by psychologists and other professionals with specialized training. Many practitioners are certified by the Biofeedback Certification Institute of America (BCIA). It is important to find an experienced biofeedback practitioner who also has some expertise in treating headache disorders. 

How are biofeedback treatments performed?

Biofeedback is a therapy that follows a learning model whereby the patient gradually learns a self-regulation skill that impacts their headaches. 

Patients come to an office, typically once per week, where they are attached to instruments that measure physical responses associated with migraine. The patient typically sits in a comfortable chair or recliner, and numerous physiologic responses are monitored with surface electrodes. 

When treating headache, sensors are typically placed on the head and neck to monitor muscle responses and a thermistor is placed on a finger to measure temperature. Feedback is given via visual cues (computer graphics) or a change in auditory tone as the patient is taught various relaxation techniques.  

Patients use the feedback to learn a physiologic relaxation response that may be beneficial for their headache management. Most of the research on biofeedback is related to treatment to prevent migraine; however, these techniques can be helpful to use during an acute attack, ideally paired with an acute care migraine medication. 

Can children with migraine have biofeedback treatments as well?

 Most children typically have a lower frequency of migraine than adults, although some have frequent migraines with associated disability and are candidates for preventive medication (although no medications are yet approved for children by the US Food and Drug Association). Most children are good candidates for behavioral therapies such as biofeedback. There are many computer games utilized in biofeedback training that children easily learn to modify physical responses. There are some fairly recent data suggesting that behavioral treatments, some of which include biofeedback, are effective strategies for children and may be more effective than preventive medication.  

What other types of illnesses could benefit from biofeedback training?    

There are data showing that biofeedback therapy can be helpful for anxiety disorders, insomnia, and functional bowel disorders and may help in modifying high blood pressure. It can also be a very effective stress-management strategy.  

Do you refer some of your patients with migraine to a psychologist for biofeedback treatments?      

 Yes, but it is always good for the referring physician to check on the credentials of the person performing the biofeedback treatment. Some headache specialists might do it themselves, but we do not. It takes a while—at least several sessions—and psychologists are better at it. Patients’ perspectives are also important. We communicate with the referred biofeedback treatment specialist to get more insight on the patient. For example, some patients are anxious and depressed, and they are not sleeping at night. The doctor we referred the patient to may recommend an antidepressant for the patient to help address those issues. It is a team effort.

What is the average cost per treatment?      
The costs vary throughout the country and range from $75 to $400 per session. Insurance coverage varies.  

How many times should a patient go in for treatment?    

Most protocols are about 10 to 12 sessions, depending on patient response. 

Have there been clinical trials on biofeedback treatments/devices?  

There have been many clinical trials that have been positive, so there is good evidence that biofeedback can be an effective treatment for migraine and tension-type headache. There are many types of biofeedback devices that measure different modalities. The most common one used in migraine is measuring scalp muscle contraction with surface electromyography or measuring peripheral blood flow with a temperature gauge. The goals are to relax muscles and learn to increase finger temperature, which is related to decreased arousal of the sympathetic nervous system or stress system. Other modalities include learning to modulate brain waves (electroencephalography or neurofeedback) and certain cardiovascular measures that reduce the stress response by a different mechanism. The goal is for patients to learn a low arousal response that they can utilize in their natural environment. Certain breathing techniques and visualization exercises are also helpful, but biofeedback refers to using physiologic recording equipment to help learn to change physical responses related to headache disorder. 

Over our years of experience, we have found that biofeedback can help a large percentage of our patients with migraine and tension-type headache, and it is associated with almost no adverse events.

What types of headache and other illnesses respond to biofeedback training?

Migraine affects about 12% of the US and most Western populations, and is 3 times more common in women than men. Migraine can be treated with a variety of strategies that include medications and nonpharmacologic therapies such as biofeedback, as well as other behavioral therapies and devices. Biofeedback refers to the use of instrumentation to monitor and display physiologic responses that the patient may not be aware of so that they can be “modified” in a more adaptive direction. Feedback gives immediate objective information and is usually combined with a relaxation-based therapy. The most common biofeedback treatments for migraine include feeding back muscle activity in the face and neck to help people relax contracted muscles and teach them a “low-arousal” response; they learn to increase finger temperature, which coincides with modifying the “stress” nervous system. Biofeedback has been shown to be helpful for migraine and tension-type headache. It is also helpful to decrease anxiety and stress levels and lower blood pressure.

Can patients use biofeedback treatments in conjunction with migraine medication?

Research has shown that migraine, in particular higher-frequency migraine, is best treated by a combination of medications and behavioral strategies. Biofeedback is a good option for use in conjunction with medication for migraine.

Who is trained to provide biofeedback treatments?

Biofeedback for migraine is something usually performed by psychologists and other professionals with specialized training. Many practitioners are certified by the Biofeedback Certification Institute of America (BCIA). It is important to find an experienced biofeedback practitioner who also has some expertise in treating headache disorders. 

How are biofeedback treatments performed?

Biofeedback is a therapy that follows a learning model whereby the patient gradually learns a self-regulation skill that impacts their headaches. 

Patients come to an office, typically once per week, where they are attached to instruments that measure physical responses associated with migraine. The patient typically sits in a comfortable chair or recliner, and numerous physiologic responses are monitored with surface electrodes. 

When treating headache, sensors are typically placed on the head and neck to monitor muscle responses and a thermistor is placed on a finger to measure temperature. Feedback is given via visual cues (computer graphics) or a change in auditory tone as the patient is taught various relaxation techniques.  

Patients use the feedback to learn a physiologic relaxation response that may be beneficial for their headache management. Most of the research on biofeedback is related to treatment to prevent migraine; however, these techniques can be helpful to use during an acute attack, ideally paired with an acute care migraine medication. 

Can children with migraine have biofeedback treatments as well?

 Most children typically have a lower frequency of migraine than adults, although some have frequent migraines with associated disability and are candidates for preventive medication (although no medications are yet approved for children by the US Food and Drug Association). Most children are good candidates for behavioral therapies such as biofeedback. There are many computer games utilized in biofeedback training that children easily learn to modify physical responses. There are some fairly recent data suggesting that behavioral treatments, some of which include biofeedback, are effective strategies for children and may be more effective than preventive medication.  

What other types of illnesses could benefit from biofeedback training?    

There are data showing that biofeedback therapy can be helpful for anxiety disorders, insomnia, and functional bowel disorders and may help in modifying high blood pressure. It can also be a very effective stress-management strategy.  

Do you refer some of your patients with migraine to a psychologist for biofeedback treatments?      

 Yes, but it is always good for the referring physician to check on the credentials of the person performing the biofeedback treatment. Some headache specialists might do it themselves, but we do not. It takes a while—at least several sessions—and psychologists are better at it. Patients’ perspectives are also important. We communicate with the referred biofeedback treatment specialist to get more insight on the patient. For example, some patients are anxious and depressed, and they are not sleeping at night. The doctor we referred the patient to may recommend an antidepressant for the patient to help address those issues. It is a team effort.

What is the average cost per treatment?      
The costs vary throughout the country and range from $75 to $400 per session. Insurance coverage varies.  

How many times should a patient go in for treatment?    

Most protocols are about 10 to 12 sessions, depending on patient response. 

Have there been clinical trials on biofeedback treatments/devices?  

There have been many clinical trials that have been positive, so there is good evidence that biofeedback can be an effective treatment for migraine and tension-type headache. There are many types of biofeedback devices that measure different modalities. The most common one used in migraine is measuring scalp muscle contraction with surface electromyography or measuring peripheral blood flow with a temperature gauge. The goals are to relax muscles and learn to increase finger temperature, which is related to decreased arousal of the sympathetic nervous system or stress system. Other modalities include learning to modulate brain waves (electroencephalography or neurofeedback) and certain cardiovascular measures that reduce the stress response by a different mechanism. The goal is for patients to learn a low arousal response that they can utilize in their natural environment. Certain breathing techniques and visualization exercises are also helpful, but biofeedback refers to using physiologic recording equipment to help learn to change physical responses related to headache disorder. 

Over our years of experience, we have found that biofeedback can help a large percentage of our patients with migraine and tension-type headache, and it is associated with almost no adverse events.

Key clinical point: Nearly one third of patients with treatment-refractory chronic migraine (CM) who did not respond to anti-calcitonin gene-related peptide (CGRP) receptor monoclonal antibodies (mAb) showed a meaningful response to anti-CGRP ligand mAb.

Major finding: Overall, 25.6% of patients achieved ≥30% reduction in monthly migraine days (MMD) after 3 months of initiating fremanezumab and were considered responders, with the mean MMD significantly reducing from 21.4 days at baseline to 15.0 days at 3 months (P = .007), 8.6 days at 6 months (P = .007), and 8.6 days at the last follow-up (P = .001). Treatment-related side effects were generally mild.

Study details: This long-term prospective real-world analysis included 39 patients with treatment-refractory CM who did not achieve a meaningful response to erenumab and switched to fremanezumab.

Disclosures: This study did not disclose the funding source. Some authors declared receiving research grants, funding for travel, personal fees as speakers or advisors, or honoraria for participation in advisory boards from various sources.

Source: Lambru G et al. Long-term effect of switching from an anti-CGRP receptor to an anti-CGRP ligand antibody in treatment-refractory chronic migraine: A prospective real-world analysis. Neurotherapeutics. 2023 (Jul 10). Doi: 10.1007/s13311-023-01394-0

Key clinical point: Nearly one third of patients with treatment-refractory chronic migraine (CM) who did not respond to anti-calcitonin gene-related peptide (CGRP) receptor monoclonal antibodies (mAb) showed a meaningful response to anti-CGRP ligand mAb.

Major finding: Overall, 25.6% of patients achieved ≥30% reduction in monthly migraine days (MMD) after 3 months of initiating fremanezumab and were considered responders, with the mean MMD significantly reducing from 21.4 days at baseline to 15.0 days at 3 months (P = .007), 8.6 days at 6 months (P = .007), and 8.6 days at the last follow-up (P = .001). Treatment-related side effects were generally mild.

Study details: This long-term prospective real-world analysis included 39 patients with treatment-refractory CM who did not achieve a meaningful response to erenumab and switched to fremanezumab.

Disclosures: This study did not disclose the funding source. Some authors declared receiving research grants, funding for travel, personal fees as speakers or advisors, or honoraria for participation in advisory boards from various sources.

Source: Lambru G et al. Long-term effect of switching from an anti-CGRP receptor to an anti-CGRP ligand antibody in treatment-refractory chronic migraine: A prospective real-world analysis. Neurotherapeutics. 2023 (Jul 10). Doi: 10.1007/s13311-023-01394-0

Key clinical point: Nearly one third of patients with treatment-refractory chronic migraine (CM) who did not respond to anti-calcitonin gene-related peptide (CGRP) receptor monoclonal antibodies (mAb) showed a meaningful response to anti-CGRP ligand mAb.

Major finding: Overall, 25.6% of patients achieved ≥30% reduction in monthly migraine days (MMD) after 3 months of initiating fremanezumab and were considered responders, with the mean MMD significantly reducing from 21.4 days at baseline to 15.0 days at 3 months (P = .007), 8.6 days at 6 months (P = .007), and 8.6 days at the last follow-up (P = .001). Treatment-related side effects were generally mild.

Study details: This long-term prospective real-world analysis included 39 patients with treatment-refractory CM who did not achieve a meaningful response to erenumab and switched to fremanezumab.

Disclosures: This study did not disclose the funding source. Some authors declared receiving research grants, funding for travel, personal fees as speakers or advisors, or honoraria for participation in advisory boards from various sources.

Source: Lambru G et al. Long-term effect of switching from an anti-CGRP receptor to an anti-CGRP ligand antibody in treatment-refractory chronic migraine: A prospective real-world analysis. Neurotherapeutics. 2023 (Jul 10). Doi: 10.1007/s13311-023-01394-0

Key clinical point: Prophylactic treatment with monthly or quarterly fremanezumab demonstrated favorable efficacy and tolerability in a real-world cohort of patients with episodic migraine (EM) or chronic migraine (CM).

Major finding: After initiating fremanezumab, the monthly migraine days reduced by 6.1, 7.7, and 8.5 days at 1, 3, and 6 months, respectively, with similar reductions observed when categorized by EM or CM (all P < .001). At 6 months, ≥50%, ≥75%, and 100% response rates were achieved by 67.6%, 22.5%, and 5.4% of patients in the overall cohort, respectively, with 48.0% of patients with CM experiencing remission to EM after 1-month fremanezumab treatment. Overall, 9.5% of the patients experienced adverse reactions, which were mostly mild.

Study details: Findings are from a retrospective study that included 127 patients with migraine (EM n = 54; CM n = 73) who received monthly or quarterly fremanezumab doses over 6 months.

Disclosures: This study received no specific funding from any source. Four authors declared receiving lecture fees from various sources.

Source: Suzuki S et al. Real-world experience with monthly and quarterly dosing of fremanezumab for the treatment of patients with migraine in Japan. Front Neurol. 2023;14:1220285 (Jul 6). Doi: 10.3389/fneur.2023.1220285

Key clinical point: Prophylactic treatment with monthly or quarterly fremanezumab demonstrated favorable efficacy and tolerability in a real-world cohort of patients with episodic migraine (EM) or chronic migraine (CM).

Major finding: After initiating fremanezumab, the monthly migraine days reduced by 6.1, 7.7, and 8.5 days at 1, 3, and 6 months, respectively, with similar reductions observed when categorized by EM or CM (all P < .001). At 6 months, ≥50%, ≥75%, and 100% response rates were achieved by 67.6%, 22.5%, and 5.4% of patients in the overall cohort, respectively, with 48.0% of patients with CM experiencing remission to EM after 1-month fremanezumab treatment. Overall, 9.5% of the patients experienced adverse reactions, which were mostly mild.

Study details: Findings are from a retrospective study that included 127 patients with migraine (EM n = 54; CM n = 73) who received monthly or quarterly fremanezumab doses over 6 months.

Disclosures: This study received no specific funding from any source. Four authors declared receiving lecture fees from various sources.

Source: Suzuki S et al. Real-world experience with monthly and quarterly dosing of fremanezumab for the treatment of patients with migraine in Japan. Front Neurol. 2023;14:1220285 (Jul 6). Doi: 10.3389/fneur.2023.1220285

Key clinical point: Prophylactic treatment with monthly or quarterly fremanezumab demonstrated favorable efficacy and tolerability in a real-world cohort of patients with episodic migraine (EM) or chronic migraine (CM).

Major finding: After initiating fremanezumab, the monthly migraine days reduced by 6.1, 7.7, and 8.5 days at 1, 3, and 6 months, respectively, with similar reductions observed when categorized by EM or CM (all P < .001). At 6 months, ≥50%, ≥75%, and 100% response rates were achieved by 67.6%, 22.5%, and 5.4% of patients in the overall cohort, respectively, with 48.0% of patients with CM experiencing remission to EM after 1-month fremanezumab treatment. Overall, 9.5% of the patients experienced adverse reactions, which were mostly mild.

Study details: Findings are from a retrospective study that included 127 patients with migraine (EM n = 54; CM n = 73) who received monthly or quarterly fremanezumab doses over 6 months.

Disclosures: This study received no specific funding from any source. Four authors declared receiving lecture fees from various sources.

Source: Suzuki S et al. Real-world experience with monthly and quarterly dosing of fremanezumab for the treatment of patients with migraine in Japan. Front Neurol. 2023;14:1220285 (Jul 6). Doi: 10.3389/fneur.2023.1220285

Key clinical point: Higher intake of dietary caffeine was positively associated with a higher prevalence of severe headaches or migraines in US adults.

Major finding: Overall, the incidence of severe headaches or migraines increased by 5% with each 100 mg/day increase in dietary caffeine intake (odds ratio [OR] 1.05; P < .001), with the risk increasing by 42% with caffeine intake ≥ 400 mg/day vs ≥0 to <40 mg/day (OR 1.42; P < .001).

Study details: This cross-sectional study evaluated the association between dietary caffeine intake and severe headaches or migraines in 8993 U.S. adults age ≥ 20 years.

Disclosures: This study was funded by the Shandong Traditional Chinese Medicine Science and Technology Development Project, China. The authors declared no conflicts of interest.

Source: Zhang L et al. Association between dietary caffeine intake and severe headache or migraine in US adults. Sci Rep. 2023;13:10220 (Jun 23). Doi: 10.1038/s41598-023-36325-8

Key clinical point: Higher intake of dietary caffeine was positively associated with a higher prevalence of severe headaches or migraines in US adults.

Major finding: Overall, the incidence of severe headaches or migraines increased by 5% with each 100 mg/day increase in dietary caffeine intake (odds ratio [OR] 1.05; P < .001), with the risk increasing by 42% with caffeine intake ≥ 400 mg/day vs ≥0 to <40 mg/day (OR 1.42; P < .001).

Study details: This cross-sectional study evaluated the association between dietary caffeine intake and severe headaches or migraines in 8993 U.S. adults age ≥ 20 years.

Disclosures: This study was funded by the Shandong Traditional Chinese Medicine Science and Technology Development Project, China. The authors declared no conflicts of interest.

Source: Zhang L et al. Association between dietary caffeine intake and severe headache or migraine in US adults. Sci Rep. 2023;13:10220 (Jun 23). Doi: 10.1038/s41598-023-36325-8

Key clinical point: Higher intake of dietary caffeine was positively associated with a higher prevalence of severe headaches or migraines in US adults.

Major finding: Overall, the incidence of severe headaches or migraines increased by 5% with each 100 mg/day increase in dietary caffeine intake (odds ratio [OR] 1.05; P < .001), with the risk increasing by 42% with caffeine intake ≥ 400 mg/day vs ≥0 to <40 mg/day (OR 1.42; P < .001).

Study details: This cross-sectional study evaluated the association between dietary caffeine intake and severe headaches or migraines in 8993 U.S. adults age ≥ 20 years.

Disclosures: This study was funded by the Shandong Traditional Chinese Medicine Science and Technology Development Project, China. The authors declared no conflicts of interest.

Source: Zhang L et al. Association between dietary caffeine intake and severe headache or migraine in US adults. Sci Rep. 2023;13:10220 (Jun 23). Doi: 10.1038/s41598-023-36325-8

Key clinical point: Long-term erenumab treatment demonstrated sustained efficacy and safety in patients with chronic migraine (CM) with and without acute medication overuse (AMO), with erenumab reducing acute medication consumption and many patients moving to non-AMO status.

Major finding: Among baseline acute migraine-specific medication users at 52 weeks, the mean monthly migraine-specific medication days reduced by 7.4 (95% CI 6.4-8.3) days and 5.4 (95% CI 4.7-6.1) days in the AMO and non-AMO groups, respectively, with 66.1% of patients in the AMO group moving to the non-AMO group.

Study details: This post hoc subgroup analysis of a 52-week open-label extension study following a 12-week double-blind study included 469 patients with CM stratified by AMO status who were randomly assigned to receive placebo or erenumab (70 or 140 mg) throughout or switch from 70 to 140 mg erenumab.

Disclosures: This study was funded by Amgen Inc. Some authors declared being employees or stockholders of Amgen. The other authors declared ties with various sources, including Amgen.

Source: Tepper SJ et al. Long-term efficacy and safety of erenumab in patients with chronic migraine and acute medication overuse: A subgroup analysis. Headache. 2023;63(6):730-742 (Jun 14). Doi: 10.1111/head.14536

Key clinical point: Long-term erenumab treatment demonstrated sustained efficacy and safety in patients with chronic migraine (CM) with and without acute medication overuse (AMO), with erenumab reducing acute medication consumption and many patients moving to non-AMO status.

Major finding: Among baseline acute migraine-specific medication users at 52 weeks, the mean monthly migraine-specific medication days reduced by 7.4 (95% CI 6.4-8.3) days and 5.4 (95% CI 4.7-6.1) days in the AMO and non-AMO groups, respectively, with 66.1% of patients in the AMO group moving to the non-AMO group.

Study details: This post hoc subgroup analysis of a 52-week open-label extension study following a 12-week double-blind study included 469 patients with CM stratified by AMO status who were randomly assigned to receive placebo or erenumab (70 or 140 mg) throughout or switch from 70 to 140 mg erenumab.

Disclosures: This study was funded by Amgen Inc. Some authors declared being employees or stockholders of Amgen. The other authors declared ties with various sources, including Amgen.

Source: Tepper SJ et al. Long-term efficacy and safety of erenumab in patients with chronic migraine and acute medication overuse: A subgroup analysis. Headache. 2023;63(6):730-742 (Jun 14). Doi: 10.1111/head.14536

Key clinical point: Long-term erenumab treatment demonstrated sustained efficacy and safety in patients with chronic migraine (CM) with and without acute medication overuse (AMO), with erenumab reducing acute medication consumption and many patients moving to non-AMO status.

Major finding: Among baseline acute migraine-specific medication users at 52 weeks, the mean monthly migraine-specific medication days reduced by 7.4 (95% CI 6.4-8.3) days and 5.4 (95% CI 4.7-6.1) days in the AMO and non-AMO groups, respectively, with 66.1% of patients in the AMO group moving to the non-AMO group.

Study details: This post hoc subgroup analysis of a 52-week open-label extension study following a 12-week double-blind study included 469 patients with CM stratified by AMO status who were randomly assigned to receive placebo or erenumab (70 or 140 mg) throughout or switch from 70 to 140 mg erenumab.

Disclosures: This study was funded by Amgen Inc. Some authors declared being employees or stockholders of Amgen. The other authors declared ties with various sources, including Amgen.

Source: Tepper SJ et al. Long-term efficacy and safety of erenumab in patients with chronic migraine and acute medication overuse: A subgroup analysis. Headache. 2023;63(6):730-742 (Jun 14). Doi: 10.1111/head.14536

Key clinical point: Ultrasound-guided stellate ganglion block (SGB) appeared to be safe and effective in reducing pain intensity, headache frequency and duration, and the need for adjunctive anti-migraine medications in elderly patients with migraine.

Major finding: At 3 months after ultrasound-guided SGB treatment, the mean Numerical Rating Scale score reduced from 7.3 at baseline to 3.6 (P < .001), the mean headache frequency per month reduced from 23.1 days at baseline to 14.0 days (P = .001), and the mean headache duration decreased from 22.7 hours at baseline to 14.3 hours (P = .001), with 64% of patients experiencing ≥50% reduction in anti-migraine medication consumption. No procedure-related serious adverse events were reported.

Study details: Findings are from a retrospective observational case series study including 52 elderly patients (age ≥ 65 years) with migraine who received ultrasound-guided SGB treatment for headache management.

Disclosures: This study did not disclose the funding source. The authors declared no conflicts of interest.

Source: Yu B et al. Ultrasound-guided stellate ganglion block for the treatment of migraine in elderly patients: A retrospective and observational study. Headache. 2023;63(6):763-770 (Jun 14). Doi: 10.1111/head.14537

Key clinical point: Ultrasound-guided stellate ganglion block (SGB) appeared to be safe and effective in reducing pain intensity, headache frequency and duration, and the need for adjunctive anti-migraine medications in elderly patients with migraine.

Major finding: At 3 months after ultrasound-guided SGB treatment, the mean Numerical Rating Scale score reduced from 7.3 at baseline to 3.6 (P < .001), the mean headache frequency per month reduced from 23.1 days at baseline to 14.0 days (P = .001), and the mean headache duration decreased from 22.7 hours at baseline to 14.3 hours (P = .001), with 64% of patients experiencing ≥50% reduction in anti-migraine medication consumption. No procedure-related serious adverse events were reported.

Study details: Findings are from a retrospective observational case series study including 52 elderly patients (age ≥ 65 years) with migraine who received ultrasound-guided SGB treatment for headache management.

Disclosures: This study did not disclose the funding source. The authors declared no conflicts of interest.

Source: Yu B et al. Ultrasound-guided stellate ganglion block for the treatment of migraine in elderly patients: A retrospective and observational study. Headache. 2023;63(6):763-770 (Jun 14). Doi: 10.1111/head.14537

Key clinical point: Ultrasound-guided stellate ganglion block (SGB) appeared to be safe and effective in reducing pain intensity, headache frequency and duration, and the need for adjunctive anti-migraine medications in elderly patients with migraine.

Major finding: At 3 months after ultrasound-guided SGB treatment, the mean Numerical Rating Scale score reduced from 7.3 at baseline to 3.6 (P < .001), the mean headache frequency per month reduced from 23.1 days at baseline to 14.0 days (P = .001), and the mean headache duration decreased from 22.7 hours at baseline to 14.3 hours (P = .001), with 64% of patients experiencing ≥50% reduction in anti-migraine medication consumption. No procedure-related serious adverse events were reported.

Study details: Findings are from a retrospective observational case series study including 52 elderly patients (age ≥ 65 years) with migraine who received ultrasound-guided SGB treatment for headache management.

Disclosures: This study did not disclose the funding source. The authors declared no conflicts of interest.

Source: Yu B et al. Ultrasound-guided stellate ganglion block for the treatment of migraine in elderly patients: A retrospective and observational study. Headache. 2023;63(6):763-770 (Jun 14). Doi: 10.1111/head.14537

Key clinical point: In patients with migraine, treatment with anti-calcitonin gene-related peptide (anti-CGRP) monoclonal antibodies (mAb) reduced visual hypersensitivity, and this reduction was positively associated with a decrease in monthly migraine days (MMD).

Major finding: After 3 months of treatment with anti-CGRP mAb, the mean ictal Leiden Visual Sensitivity Scale (L-VISS) score decreased from 20.1 to 19.2 (P = .042) and the mean interictal L-VISS score decreased from 11.8 to 11.1 (P = .050), and a positive correlation was observed between the reduction in MMD and the decrease in ictal L-VISS (β 0.3; P = .001) and interictal L-VISS (β 0.2; P = .010) scores.

Study details: This prospective follow-up study included 205 patients with migraine who were treated with either erenumab (n = 105) or fremanezumab (n = 100).

Disclosures: This study did not disclose the funding source. Three authors declared receiving consultancy or industry and independent support from various sources. The other authors declared no conflicts of interest.

Source: de Vries Lentsch S et al. Visual hypersensitivity in patients treated with anti-calcitonin gene-related peptide (receptor) monoclonal antibodies. Headache. 2023;63(7):926-933 (Jun 26). Doi: 10.1111/head.14531

Key clinical point: In patients with migraine, treatment with anti-calcitonin gene-related peptide (anti-CGRP) monoclonal antibodies (mAb) reduced visual hypersensitivity, and this reduction was positively associated with a decrease in monthly migraine days (MMD).

Major finding: After 3 months of treatment with anti-CGRP mAb, the mean ictal Leiden Visual Sensitivity Scale (L-VISS) score decreased from 20.1 to 19.2 (P = .042) and the mean interictal L-VISS score decreased from 11.8 to 11.1 (P = .050), and a positive correlation was observed between the reduction in MMD and the decrease in ictal L-VISS (β 0.3; P = .001) and interictal L-VISS (β 0.2; P = .010) scores.

Study details: This prospective follow-up study included 205 patients with migraine who were treated with either erenumab (n = 105) or fremanezumab (n = 100).

Disclosures: This study did not disclose the funding source. Three authors declared receiving consultancy or industry and independent support from various sources. The other authors declared no conflicts of interest.

Source: de Vries Lentsch S et al. Visual hypersensitivity in patients treated with anti-calcitonin gene-related peptide (receptor) monoclonal antibodies. Headache. 2023;63(7):926-933 (Jun 26). Doi: 10.1111/head.14531

Key clinical point: In patients with migraine, treatment with anti-calcitonin gene-related peptide (anti-CGRP) monoclonal antibodies (mAb) reduced visual hypersensitivity, and this reduction was positively associated with a decrease in monthly migraine days (MMD).

Major finding: After 3 months of treatment with anti-CGRP mAb, the mean ictal Leiden Visual Sensitivity Scale (L-VISS) score decreased from 20.1 to 19.2 (P = .042) and the mean interictal L-VISS score decreased from 11.8 to 11.1 (P = .050), and a positive correlation was observed between the reduction in MMD and the decrease in ictal L-VISS (β 0.3; P = .001) and interictal L-VISS (β 0.2; P = .010) scores.

Study details: This prospective follow-up study included 205 patients with migraine who were treated with either erenumab (n = 105) or fremanezumab (n = 100).

Disclosures: This study did not disclose the funding source. Three authors declared receiving consultancy or industry and independent support from various sources. The other authors declared no conflicts of interest.

Source: de Vries Lentsch S et al. Visual hypersensitivity in patients treated with anti-calcitonin gene-related peptide (receptor) monoclonal antibodies. Headache. 2023;63(7):926-933 (Jun 26). Doi: 10.1111/head.14531

Key clinical point: Meta-analysis confirmed better therapeutic efficacy of rimegepant compared with placebo in patients with episodic migraine (EM), along with no significant difference in adverse events.

Major finding: Rimegepant was more effective than placebo in terms of achieving pain freedom and pain relief at 2 hours (odds ratio [OR] 1.84 and 1.80, respectively), 2-24 hours (OR 2.44 and 2.10, respectively), and 2-48 hours (OR 2.27 and 1.92, respectively; all P < .00001) post-dose. The occurrence of adverse events was not significantly different between the rimegepant and control arms (P = .06).

Study details: The data come from a systematic review and meta-analysis of 4 randomized controlled trials including 4230 patients with EM.

Disclosures: This study did not declare the source of funding. The authors declared no conflicts of interest.

Source: Wang Q et al. Clinical efficacy and safety of rimegepant in the treatment of migraine: A meta-analysis of randomized controlled trials. Front Neurol. 2023;14:1205778 (Jun 20). Doi: 10.3389/fneur.2023.1205778

Key clinical point: Meta-analysis confirmed better therapeutic efficacy of rimegepant compared with placebo in patients with episodic migraine (EM), along with no significant difference in adverse events.

Major finding: Rimegepant was more effective than placebo in terms of achieving pain freedom and pain relief at 2 hours (odds ratio [OR] 1.84 and 1.80, respectively), 2-24 hours (OR 2.44 and 2.10, respectively), and 2-48 hours (OR 2.27 and 1.92, respectively; all P < .00001) post-dose. The occurrence of adverse events was not significantly different between the rimegepant and control arms (P = .06).

Study details: The data come from a systematic review and meta-analysis of 4 randomized controlled trials including 4230 patients with EM.

Disclosures: This study did not declare the source of funding. The authors declared no conflicts of interest.

Source: Wang Q et al. Clinical efficacy and safety of rimegepant in the treatment of migraine: A meta-analysis of randomized controlled trials. Front Neurol. 2023;14:1205778 (Jun 20). Doi: 10.3389/fneur.2023.1205778

Key clinical point: Meta-analysis confirmed better therapeutic efficacy of rimegepant compared with placebo in patients with episodic migraine (EM), along with no significant difference in adverse events.

Major finding: Rimegepant was more effective than placebo in terms of achieving pain freedom and pain relief at 2 hours (odds ratio [OR] 1.84 and 1.80, respectively), 2-24 hours (OR 2.44 and 2.10, respectively), and 2-48 hours (OR 2.27 and 1.92, respectively; all P < .00001) post-dose. The occurrence of adverse events was not significantly different between the rimegepant and control arms (P = .06).

Study details: The data come from a systematic review and meta-analysis of 4 randomized controlled trials including 4230 patients with EM.

Disclosures: This study did not declare the source of funding. The authors declared no conflicts of interest.

Source: Wang Q et al. Clinical efficacy and safety of rimegepant in the treatment of migraine: A meta-analysis of randomized controlled trials. Front Neurol. 2023;14:1205778 (Jun 20). Doi: 10.3389/fneur.2023.1205778

Key clinical point: Disability, anxiety, and comorbid mental disorders moderated the long-term effect of migraine-specific cognitive behavioral therapy (miCBT) or relaxation training (RLX) on headache days in patients with migraine, with those having higher and lower burden benefitting more from miCBT and RLX, respectively.

Major finding: Patients with higher headache-related disability (B −0.41; P = .047), anxiety (B −0.66; P = .056), and comorbid mental disorders (B −4.98; P = .053) benefited more from miCBT, whereas those with relatively lower headache-related disability and anxiety and without any comorbid mental disorder benefited more from RLX at 12 months of follow-up.

Study details: This secondary analysis of an open-label randomized controlled trial included 121 patients with migraine who were randomly assigned to the miCBT (n = 40), RLX (n = 41), or waiting-list control (n = 40) group.

Disclosures: This study received no specific funding. C Gaul and E Liesering-Latta declared receiving consulting and lecture honoraria from various sources. C Gaul declared serving as an honorary secretary of the German Migraine and Headache Society. The other authors declared no conflicts of interest.

Source: Klan T et al. Behavioral treatment for migraine prophylaxis in adults: Moderator analysis of a randomized controlled trial. Cephalalgia. 2023;43(6) (Jun 8). Doi: 10.1177/03331024231178237

Key clinical point: Disability, anxiety, and comorbid mental disorders moderated the long-term effect of migraine-specific cognitive behavioral therapy (miCBT) or relaxation training (RLX) on headache days in patients with migraine, with those having higher and lower burden benefitting more from miCBT and RLX, respectively.

Major finding: Patients with higher headache-related disability (B −0.41; P = .047), anxiety (B −0.66; P = .056), and comorbid mental disorders (B −4.98; P = .053) benefited more from miCBT, whereas those with relatively lower headache-related disability and anxiety and without any comorbid mental disorder benefited more from RLX at 12 months of follow-up.

Study details: This secondary analysis of an open-label randomized controlled trial included 121 patients with migraine who were randomly assigned to the miCBT (n = 40), RLX (n = 41), or waiting-list control (n = 40) group.

Disclosures: This study received no specific funding. C Gaul and E Liesering-Latta declared receiving consulting and lecture honoraria from various sources. C Gaul declared serving as an honorary secretary of the German Migraine and Headache Society. The other authors declared no conflicts of interest.

Source: Klan T et al. Behavioral treatment for migraine prophylaxis in adults: Moderator analysis of a randomized controlled trial. Cephalalgia. 2023;43(6) (Jun 8). Doi: 10.1177/03331024231178237

Key clinical point: Disability, anxiety, and comorbid mental disorders moderated the long-term effect of migraine-specific cognitive behavioral therapy (miCBT) or relaxation training (RLX) on headache days in patients with migraine, with those having higher and lower burden benefitting more from miCBT and RLX, respectively.

Major finding: Patients with higher headache-related disability (B −0.41; P = .047), anxiety (B −0.66; P = .056), and comorbid mental disorders (B −4.98; P = .053) benefited more from miCBT, whereas those with relatively lower headache-related disability and anxiety and without any comorbid mental disorder benefited more from RLX at 12 months of follow-up.

Study details: This secondary analysis of an open-label randomized controlled trial included 121 patients with migraine who were randomly assigned to the miCBT (n = 40), RLX (n = 41), or waiting-list control (n = 40) group.

Disclosures: This study received no specific funding. C Gaul and E Liesering-Latta declared receiving consulting and lecture honoraria from various sources. C Gaul declared serving as an honorary secretary of the German Migraine and Headache Society. The other authors declared no conflicts of interest.

Source: Klan T et al. Behavioral treatment for migraine prophylaxis in adults: Moderator analysis of a randomized controlled trial. Cephalalgia. 2023;43(6) (Jun 8). Doi: 10.1177/03331024231178237