Headache & Migraine

People with higher dietary zinc intake have a nearly one-third lower risk of migraine than those who get little zinc in their diets, according to results from a cross-sectional study of more than 11,000 American adults.

For their research, published online in Headache, Huanxian Liu, MD, and colleagues at Chinese PLA General Hospital in Beijing, analyzed publicly available data from the U.S. National Health and Nutrition Examination Survey to determine whether people self-reporting migraine or severe headache saw lower zinc intake, compared with people without migraine. The data used in the analysis was collected between 1999 and 2004, and contained information on foods and drinks consumed by participants in a 24-hour period, along with additional health information.
 

An inverse relationship

The investigators divided their study’s 11,088 participants (mean age, 46.5 years; 50% female) into quintiles based on dietary zinc consumption as inferred from foods eaten. They also considered zinc supplementation, for which data was available for 4,324 participants, of whom 2,607 reported use of supplements containing zinc.

Some 20% of the cohort (n = 2,236) reported migraine or severe headache within the previous 3 months. Pregnant women were excluded from analysis, and the investigators adjusted for a range of covariates, including age, sex, ethnicity, education level, body mass, smoking, diabetes, cardiovascular disease, and nutritional factors.

Dr. Liu and colleagues reported an inverse association between dietary zinc consumption and migraine, with the highest-consuming quintile of the cohort (15.8 mg or more zinc per day) seeing lowest risk of migraine (odds ratio, 0.70; 95% confidence interval, 0.52-0.94; P = .029), compared with the low-consuming quintile (5.9 mg or less daily). Among people getting high levels of zinc (19.3-32.5 mg daily) through supplements, risk of migraine was lower still, to between an OR of 0.62 (95% CI: 0.46–0.83, P = 0.019) and an OR of 0.67 (95% CI, 0.49–0.91; P = .045).

While the investigators acknowledged limitations of the study, including its cross-sectional design and use of a broad question to discern prevalence of migraine, the findings suggest that “zinc is an important nutrient that influences migraine,” they wrote, citing evidence for its antioxidant and anti-inflammatory properties.
 

The importance of nutritional factors

Commenting on the research findings, Deborah I. Friedman, MD, MPH, a headache specialist in Dallas, said that Dr. Liu and colleagues’ findings added to a growing information base about nutritional factors and migraine. For example, “low magnesium levels are common in people with migraine, and magnesium supplementation is a recommended preventive treatment for migraine.”

Dr. Friedman cited a recent study showing that vitamin B₁₂ and magnesium supplementation in women (, combined with high-intensity interval training, “silenced” the inflammation signaling pathway, helped migraine pain and decreased levels of calcitonin gene-related peptide. A 2022 randomized trial found that alpha lipoic acid supplementation reduced migraine severity, frequency and disability in women with episodic migraine.

Vitamin D levels are also lower in people with migraine, compared with controls, Dr. Friedman noted, and a randomized trial of 2,000 IU of vitamin D₃ daily saw reduced monthly headache days, attack duration, severe headaches, and analgesic use, compared with placebo. Other nutrients implicated in migraine include coenzyme Q10, calcium, folic acid, vitamin B₆, and vitamin B₁.

“What should a patient with migraine do with all of this information? First, eat a healthy and balanced diet,” Dr. Friedman said. “Sources of dietary zinc include red meat, nuts, legumes, poultry, shellfish (especially oysters), whole grains, some cereals, and even dark chocolate. The recommended daily dosage of zinc is 9.5 mg in men and 7 mg in women. Most people get enough zinc in their diet; vegetarians, vegans, pregnant or breastfeeding women, and adults over age 65 may need to take supplemental zinc.”

Dr. Liu and colleagues’ work was supported by China’s National Natural Science Foundation. The investigators reported no financial conflicts of interest. Dr. Friedman has received financial support from Alder, Allergan, Amgen, Biohaven, Eli Lilly, Merck, Teva, and other pharmaceutical manufacturers.

People with higher dietary zinc intake have a nearly one-third lower risk of migraine than those who get little zinc in their diets, according to results from a cross-sectional study of more than 11,000 American adults.

For their research, published online in Headache, Huanxian Liu, MD, and colleagues at Chinese PLA General Hospital in Beijing, analyzed publicly available data from the U.S. National Health and Nutrition Examination Survey to determine whether people self-reporting migraine or severe headache saw lower zinc intake, compared with people without migraine. The data used in the analysis was collected between 1999 and 2004, and contained information on foods and drinks consumed by participants in a 24-hour period, along with additional health information.
 

An inverse relationship

The investigators divided their study’s 11,088 participants (mean age, 46.5 years; 50% female) into quintiles based on dietary zinc consumption as inferred from foods eaten. They also considered zinc supplementation, for which data was available for 4,324 participants, of whom 2,607 reported use of supplements containing zinc.

Some 20% of the cohort (n = 2,236) reported migraine or severe headache within the previous 3 months. Pregnant women were excluded from analysis, and the investigators adjusted for a range of covariates, including age, sex, ethnicity, education level, body mass, smoking, diabetes, cardiovascular disease, and nutritional factors.

Dr. Liu and colleagues reported an inverse association between dietary zinc consumption and migraine, with the highest-consuming quintile of the cohort (15.8 mg or more zinc per day) seeing lowest risk of migraine (odds ratio, 0.70; 95% confidence interval, 0.52-0.94; P = .029), compared with the low-consuming quintile (5.9 mg or less daily). Among people getting high levels of zinc (19.3-32.5 mg daily) through supplements, risk of migraine was lower still, to between an OR of 0.62 (95% CI: 0.46–0.83, P = 0.019) and an OR of 0.67 (95% CI, 0.49–0.91; P = .045).

While the investigators acknowledged limitations of the study, including its cross-sectional design and use of a broad question to discern prevalence of migraine, the findings suggest that “zinc is an important nutrient that influences migraine,” they wrote, citing evidence for its antioxidant and anti-inflammatory properties.
 

The importance of nutritional factors

Commenting on the research findings, Deborah I. Friedman, MD, MPH, a headache specialist in Dallas, said that Dr. Liu and colleagues’ findings added to a growing information base about nutritional factors and migraine. For example, “low magnesium levels are common in people with migraine, and magnesium supplementation is a recommended preventive treatment for migraine.”

Dr. Friedman cited a recent study showing that vitamin B₁₂ and magnesium supplementation in women (, combined with high-intensity interval training, “silenced” the inflammation signaling pathway, helped migraine pain and decreased levels of calcitonin gene-related peptide. A 2022 randomized trial found that alpha lipoic acid supplementation reduced migraine severity, frequency and disability in women with episodic migraine.

Vitamin D levels are also lower in people with migraine, compared with controls, Dr. Friedman noted, and a randomized trial of 2,000 IU of vitamin D₃ daily saw reduced monthly headache days, attack duration, severe headaches, and analgesic use, compared with placebo. Other nutrients implicated in migraine include coenzyme Q10, calcium, folic acid, vitamin B₆, and vitamin B₁.

“What should a patient with migraine do with all of this information? First, eat a healthy and balanced diet,” Dr. Friedman said. “Sources of dietary zinc include red meat, nuts, legumes, poultry, shellfish (especially oysters), whole grains, some cereals, and even dark chocolate. The recommended daily dosage of zinc is 9.5 mg in men and 7 mg in women. Most people get enough zinc in their diet; vegetarians, vegans, pregnant or breastfeeding women, and adults over age 65 may need to take supplemental zinc.”

Dr. Liu and colleagues’ work was supported by China’s National Natural Science Foundation. The investigators reported no financial conflicts of interest. Dr. Friedman has received financial support from Alder, Allergan, Amgen, Biohaven, Eli Lilly, Merck, Teva, and other pharmaceutical manufacturers.

People with higher dietary zinc intake have a nearly one-third lower risk of migraine than those who get little zinc in their diets, according to results from a cross-sectional study of more than 11,000 American adults.

For their research, published online in Headache, Huanxian Liu, MD, and colleagues at Chinese PLA General Hospital in Beijing, analyzed publicly available data from the U.S. National Health and Nutrition Examination Survey to determine whether people self-reporting migraine or severe headache saw lower zinc intake, compared with people without migraine. The data used in the analysis was collected between 1999 and 2004, and contained information on foods and drinks consumed by participants in a 24-hour period, along with additional health information.
 

An inverse relationship

The investigators divided their study’s 11,088 participants (mean age, 46.5 years; 50% female) into quintiles based on dietary zinc consumption as inferred from foods eaten. They also considered zinc supplementation, for which data was available for 4,324 participants, of whom 2,607 reported use of supplements containing zinc.

Some 20% of the cohort (n = 2,236) reported migraine or severe headache within the previous 3 months. Pregnant women were excluded from analysis, and the investigators adjusted for a range of covariates, including age, sex, ethnicity, education level, body mass, smoking, diabetes, cardiovascular disease, and nutritional factors.

Dr. Liu and colleagues reported an inverse association between dietary zinc consumption and migraine, with the highest-consuming quintile of the cohort (15.8 mg or more zinc per day) seeing lowest risk of migraine (odds ratio, 0.70; 95% confidence interval, 0.52-0.94; P = .029), compared with the low-consuming quintile (5.9 mg or less daily). Among people getting high levels of zinc (19.3-32.5 mg daily) through supplements, risk of migraine was lower still, to between an OR of 0.62 (95% CI: 0.46–0.83, P = 0.019) and an OR of 0.67 (95% CI, 0.49–0.91; P = .045).

While the investigators acknowledged limitations of the study, including its cross-sectional design and use of a broad question to discern prevalence of migraine, the findings suggest that “zinc is an important nutrient that influences migraine,” they wrote, citing evidence for its antioxidant and anti-inflammatory properties.
 

The importance of nutritional factors

Commenting on the research findings, Deborah I. Friedman, MD, MPH, a headache specialist in Dallas, said that Dr. Liu and colleagues’ findings added to a growing information base about nutritional factors and migraine. For example, “low magnesium levels are common in people with migraine, and magnesium supplementation is a recommended preventive treatment for migraine.”

Dr. Friedman cited a recent study showing that vitamin B₁₂ and magnesium supplementation in women (, combined with high-intensity interval training, “silenced” the inflammation signaling pathway, helped migraine pain and decreased levels of calcitonin gene-related peptide. A 2022 randomized trial found that alpha lipoic acid supplementation reduced migraine severity, frequency and disability in women with episodic migraine.

Vitamin D levels are also lower in people with migraine, compared with controls, Dr. Friedman noted, and a randomized trial of 2,000 IU of vitamin D₃ daily saw reduced monthly headache days, attack duration, severe headaches, and analgesic use, compared with placebo. Other nutrients implicated in migraine include coenzyme Q10, calcium, folic acid, vitamin B₆, and vitamin B₁.

“What should a patient with migraine do with all of this information? First, eat a healthy and balanced diet,” Dr. Friedman said. “Sources of dietary zinc include red meat, nuts, legumes, poultry, shellfish (especially oysters), whole grains, some cereals, and even dark chocolate. The recommended daily dosage of zinc is 9.5 mg in men and 7 mg in women. Most people get enough zinc in their diet; vegetarians, vegans, pregnant or breastfeeding women, and adults over age 65 may need to take supplemental zinc.”

Dr. Liu and colleagues’ work was supported by China’s National Natural Science Foundation. The investigators reported no financial conflicts of interest. Dr. Friedman has received financial support from Alder, Allergan, Amgen, Biohaven, Eli Lilly, Merck, Teva, and other pharmaceutical manufacturers.

Persistent postconcussion symptoms (PPCS) are tied to a significantly increased risk of developing subsequent depressive symptoms, new research shows.

Results of a large meta-analysis that included 18 studies and more than 9,000 patients showed a fourfold higher risk of developing depressive symptoms in those with PPCS versus those without PPCS.

“In this meta-analysis, experiencing PPCS was associated with a higher risk of experiencing depressive symptoms,” write the investigators, led by Maude Lambert, PhD, of the School of Psychology, University of Ottawa, and Bloorview Research Institute, Toronto.

“There are several important clinical and health policy implications of the findings. Most notably, the development of strategies for effective prevention and earlier intervention to optimize mental health recovery following a concussion should be supported,” they add.

The study was published online  in JAMA Network Open.
 

‘Important minority’

An “important minority” of 15%-30% of those with concussions continue to experience symptoms for months, or even years, following the injury, the investigators note.

Symptoms vary but can include headaches, fatigue, dizziness, cognitive difficulties, and emotional changes, which can “significantly impact an individual’s everyday functioning.”

The association between PPCS and mental health outcomes “has emerged as an area of interest” over the past decade, with multiple studies pointing to bidirectional associations between depressive symptoms and PPCS, the researchers note. Individuals with PPCS are at significantly higher risk of experiencing depressive symptoms, and depressive symptoms, in turn, predict more prolonged postconcussion recovery, they add.

The authors conducted a previous scoping review that showed individuals with PPCS had “greater mental health difficulties than individuals who recovered from concussion or healthy controls.”

But “quantitative summaries evaluating the magnitude and nature of the association between PPCS and mental health outcomes were not conducted,” so they decided to conduct a follow-up meta-analysis to corroborate the hypothesis that PPCS may be associated with depressive symptoms.

The researchers also wanted to “investigate potential moderators of that association and determine whether the association between depressive symptoms and PPCS differed based on age, sex, mental illness, history of concussion, and time since the injury.”

This could have “significant public health implications” as it represents an “important step” toward understanding the association between PPCS and mental health, paving the way for the “development of optimal postconcussion intervention strategies, targeting effective prevention and earlier intervention to enhance recovery trajectories, improve mental health, and promote well-being following concussion.”

To be included in the meta-analysis, a study had to focus on participants who had experienced a concussion, diagnosed by a health care professional, or as classified by diagnostic measures, and who experienced greater than or equal to 1 concussion symptom lasting greater than 4 weeks.

There was no explicit upper limit on duration, and individuals of all ages were eligible.

Depressive symptoms were defined as “an outcome that must be measured by a validated and standardized measure of depression.”
 

Biopsychosocial model

Of 580 reports assessed for eligibility, 18 were included in the meta-analysis, incorporating a total of 9,101 participants, with a median (range) sample size of 154 (48-4,462) participants and a mean (SD) participant age of 33.7 (14.4) years.

The mean length of time since the concussion was 21.3 (18.7) weeks. Of the participants, a mean of 36.1% (11.1%) had a history of greater than or equal to 2 concussions.

Close to three-quarters of the studies (72%) used a cross-sectional design, with most studies conducted in North America, and the remaining conducted in Europe, China, and New Zealand.

The researchers found a “significant positive association” between PPCS and postinjury depressive symptoms (odds ratio, 4.87; 95% confidence interval, 3.01-7.90; P < .001), “representing a large effect size.”

Funnel plot and Egger test analyses “suggested the presence of a publication bias.” However, even after accounting for publication bias, the effect size “of large magnitude” remained, the authors report (OR, 4.56; 95% CI, 2.82-7.37; P < .001).

No significant moderators were identified, “likely due to the small number of studies included,” they speculate.

They note that the current study “does not allow inference about the causal directionality of the association” between PPCS and postinjury depressive symptoms, so the question remains: Do PPCS induce depressive symptoms, or do depressive symptoms induce PPCS?”

Despite this unanswered question, the findings still have important clinical and public health implications, highlighting “the need for a greater understanding of the mechanisms of development and etiology of depressive symptoms postconcussion” and emphasizing “the necessary emergence for timely and effective treatment interventions for depressive symptoms to optimize the long-term prognosis of concussion,” the authors note.

They add that several research teams “have aimed to gain more insight into the etiology and underlying mechanisms of development and course of mental health difficulties in individuals who experience a concussion” and have arrived at a biopsychosocial framework, in light of “the myriad of contributing physiological, biological, and psychosocial factors.”

They recommend the establishment of “specialized multidisciplinary or interdisciplinary concussion care programs should include health care professionals with strong clinical foundations and training in mental health conditions.”
 

Speedy multidisciplinary care

Commenting on the research, Charles Tator, MD, PhD, professor of neurosurgery, University of Toronto, Division of Neurosurgery, Toronto Western Hospital, said the researchers “performed a thorough systematic review” showing “emphatically that depression occurs in this population.”

Dr. Tator, the director of the Canadian Concussion Centre, who was not involved with the current study, continued: “Nowadays clinical discoveries are validated through a progression of case reports, single-center retrospective cohort studies like ours, referenced by [Dr.] Lambert et al., and then confirmatory systematic reviews, each adding important layers of evidence.”

“This evaluative process has now endorsed the importance of early treatment of mental health symptoms in patients with persisting symptoms, which can include depression, anxiety, and PTSD,” he said.

He recommended that treatment should start with family physicians and nurse practitioners “but may require escalation to psychologists and social workers and then to psychiatrists who are often more skilled in medication selection.”

He encouraged “speedy multidisciplinary care,” noting that the possibility of suicide is worrisome.

No source of study funding was listed. A study coauthor, Shannon Scratch, PhD, has reported receiving funds from the Holland Bloorview Kids Rehabilitation Hospital Foundation (via the Holland Family Professorship in Acquired Brain Injury) during the conduct of this study. No other disclosures were reported. Dr. Tator has reported no relevant financial relationships.

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

Persistent postconcussion symptoms (PPCS) are tied to a significantly increased risk of developing subsequent depressive symptoms, new research shows.

Results of a large meta-analysis that included 18 studies and more than 9,000 patients showed a fourfold higher risk of developing depressive symptoms in those with PPCS versus those without PPCS.

“In this meta-analysis, experiencing PPCS was associated with a higher risk of experiencing depressive symptoms,” write the investigators, led by Maude Lambert, PhD, of the School of Psychology, University of Ottawa, and Bloorview Research Institute, Toronto.

“There are several important clinical and health policy implications of the findings. Most notably, the development of strategies for effective prevention and earlier intervention to optimize mental health recovery following a concussion should be supported,” they add.

The study was published online  in JAMA Network Open.
 

‘Important minority’

An “important minority” of 15%-30% of those with concussions continue to experience symptoms for months, or even years, following the injury, the investigators note.

Symptoms vary but can include headaches, fatigue, dizziness, cognitive difficulties, and emotional changes, which can “significantly impact an individual’s everyday functioning.”

The association between PPCS and mental health outcomes “has emerged as an area of interest” over the past decade, with multiple studies pointing to bidirectional associations between depressive symptoms and PPCS, the researchers note. Individuals with PPCS are at significantly higher risk of experiencing depressive symptoms, and depressive symptoms, in turn, predict more prolonged postconcussion recovery, they add.

The authors conducted a previous scoping review that showed individuals with PPCS had “greater mental health difficulties than individuals who recovered from concussion or healthy controls.”

But “quantitative summaries evaluating the magnitude and nature of the association between PPCS and mental health outcomes were not conducted,” so they decided to conduct a follow-up meta-analysis to corroborate the hypothesis that PPCS may be associated with depressive symptoms.

The researchers also wanted to “investigate potential moderators of that association and determine whether the association between depressive symptoms and PPCS differed based on age, sex, mental illness, history of concussion, and time since the injury.”

This could have “significant public health implications” as it represents an “important step” toward understanding the association between PPCS and mental health, paving the way for the “development of optimal postconcussion intervention strategies, targeting effective prevention and earlier intervention to enhance recovery trajectories, improve mental health, and promote well-being following concussion.”

To be included in the meta-analysis, a study had to focus on participants who had experienced a concussion, diagnosed by a health care professional, or as classified by diagnostic measures, and who experienced greater than or equal to 1 concussion symptom lasting greater than 4 weeks.

There was no explicit upper limit on duration, and individuals of all ages were eligible.

Depressive symptoms were defined as “an outcome that must be measured by a validated and standardized measure of depression.”
 

Biopsychosocial model

Of 580 reports assessed for eligibility, 18 were included in the meta-analysis, incorporating a total of 9,101 participants, with a median (range) sample size of 154 (48-4,462) participants and a mean (SD) participant age of 33.7 (14.4) years.

The mean length of time since the concussion was 21.3 (18.7) weeks. Of the participants, a mean of 36.1% (11.1%) had a history of greater than or equal to 2 concussions.

Close to three-quarters of the studies (72%) used a cross-sectional design, with most studies conducted in North America, and the remaining conducted in Europe, China, and New Zealand.

The researchers found a “significant positive association” between PPCS and postinjury depressive symptoms (odds ratio, 4.87; 95% confidence interval, 3.01-7.90; P < .001), “representing a large effect size.”

Funnel plot and Egger test analyses “suggested the presence of a publication bias.” However, even after accounting for publication bias, the effect size “of large magnitude” remained, the authors report (OR, 4.56; 95% CI, 2.82-7.37; P < .001).

No significant moderators were identified, “likely due to the small number of studies included,” they speculate.

They note that the current study “does not allow inference about the causal directionality of the association” between PPCS and postinjury depressive symptoms, so the question remains: Do PPCS induce depressive symptoms, or do depressive symptoms induce PPCS?”

Despite this unanswered question, the findings still have important clinical and public health implications, highlighting “the need for a greater understanding of the mechanisms of development and etiology of depressive symptoms postconcussion” and emphasizing “the necessary emergence for timely and effective treatment interventions for depressive symptoms to optimize the long-term prognosis of concussion,” the authors note.

They add that several research teams “have aimed to gain more insight into the etiology and underlying mechanisms of development and course of mental health difficulties in individuals who experience a concussion” and have arrived at a biopsychosocial framework, in light of “the myriad of contributing physiological, biological, and psychosocial factors.”

They recommend the establishment of “specialized multidisciplinary or interdisciplinary concussion care programs should include health care professionals with strong clinical foundations and training in mental health conditions.”
 

Speedy multidisciplinary care

Commenting on the research, Charles Tator, MD, PhD, professor of neurosurgery, University of Toronto, Division of Neurosurgery, Toronto Western Hospital, said the researchers “performed a thorough systematic review” showing “emphatically that depression occurs in this population.”

Dr. Tator, the director of the Canadian Concussion Centre, who was not involved with the current study, continued: “Nowadays clinical discoveries are validated through a progression of case reports, single-center retrospective cohort studies like ours, referenced by [Dr.] Lambert et al., and then confirmatory systematic reviews, each adding important layers of evidence.”

“This evaluative process has now endorsed the importance of early treatment of mental health symptoms in patients with persisting symptoms, which can include depression, anxiety, and PTSD,” he said.

He recommended that treatment should start with family physicians and nurse practitioners “but may require escalation to psychologists and social workers and then to psychiatrists who are often more skilled in medication selection.”

He encouraged “speedy multidisciplinary care,” noting that the possibility of suicide is worrisome.

No source of study funding was listed. A study coauthor, Shannon Scratch, PhD, has reported receiving funds from the Holland Bloorview Kids Rehabilitation Hospital Foundation (via the Holland Family Professorship in Acquired Brain Injury) during the conduct of this study. No other disclosures were reported. Dr. Tator has reported no relevant financial relationships.

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

Persistent postconcussion symptoms (PPCS) are tied to a significantly increased risk of developing subsequent depressive symptoms, new research shows.

Results of a large meta-analysis that included 18 studies and more than 9,000 patients showed a fourfold higher risk of developing depressive symptoms in those with PPCS versus those without PPCS.

“In this meta-analysis, experiencing PPCS was associated with a higher risk of experiencing depressive symptoms,” write the investigators, led by Maude Lambert, PhD, of the School of Psychology, University of Ottawa, and Bloorview Research Institute, Toronto.

“There are several important clinical and health policy implications of the findings. Most notably, the development of strategies for effective prevention and earlier intervention to optimize mental health recovery following a concussion should be supported,” they add.

The study was published online  in JAMA Network Open.
 

‘Important minority’

An “important minority” of 15%-30% of those with concussions continue to experience symptoms for months, or even years, following the injury, the investigators note.

Symptoms vary but can include headaches, fatigue, dizziness, cognitive difficulties, and emotional changes, which can “significantly impact an individual’s everyday functioning.”

The association between PPCS and mental health outcomes “has emerged as an area of interest” over the past decade, with multiple studies pointing to bidirectional associations between depressive symptoms and PPCS, the researchers note. Individuals with PPCS are at significantly higher risk of experiencing depressive symptoms, and depressive symptoms, in turn, predict more prolonged postconcussion recovery, they add.

The authors conducted a previous scoping review that showed individuals with PPCS had “greater mental health difficulties than individuals who recovered from concussion or healthy controls.”

But “quantitative summaries evaluating the magnitude and nature of the association between PPCS and mental health outcomes were not conducted,” so they decided to conduct a follow-up meta-analysis to corroborate the hypothesis that PPCS may be associated with depressive symptoms.

The researchers also wanted to “investigate potential moderators of that association and determine whether the association between depressive symptoms and PPCS differed based on age, sex, mental illness, history of concussion, and time since the injury.”

This could have “significant public health implications” as it represents an “important step” toward understanding the association between PPCS and mental health, paving the way for the “development of optimal postconcussion intervention strategies, targeting effective prevention and earlier intervention to enhance recovery trajectories, improve mental health, and promote well-being following concussion.”

To be included in the meta-analysis, a study had to focus on participants who had experienced a concussion, diagnosed by a health care professional, or as classified by diagnostic measures, and who experienced greater than or equal to 1 concussion symptom lasting greater than 4 weeks.

There was no explicit upper limit on duration, and individuals of all ages were eligible.

Depressive symptoms were defined as “an outcome that must be measured by a validated and standardized measure of depression.”
 

Biopsychosocial model

Of 580 reports assessed for eligibility, 18 were included in the meta-analysis, incorporating a total of 9,101 participants, with a median (range) sample size of 154 (48-4,462) participants and a mean (SD) participant age of 33.7 (14.4) years.

The mean length of time since the concussion was 21.3 (18.7) weeks. Of the participants, a mean of 36.1% (11.1%) had a history of greater than or equal to 2 concussions.

Close to three-quarters of the studies (72%) used a cross-sectional design, with most studies conducted in North America, and the remaining conducted in Europe, China, and New Zealand.

The researchers found a “significant positive association” between PPCS and postinjury depressive symptoms (odds ratio, 4.87; 95% confidence interval, 3.01-7.90; P < .001), “representing a large effect size.”

Funnel plot and Egger test analyses “suggested the presence of a publication bias.” However, even after accounting for publication bias, the effect size “of large magnitude” remained, the authors report (OR, 4.56; 95% CI, 2.82-7.37; P < .001).

No significant moderators were identified, “likely due to the small number of studies included,” they speculate.

They note that the current study “does not allow inference about the causal directionality of the association” between PPCS and postinjury depressive symptoms, so the question remains: Do PPCS induce depressive symptoms, or do depressive symptoms induce PPCS?”

Despite this unanswered question, the findings still have important clinical and public health implications, highlighting “the need for a greater understanding of the mechanisms of development and etiology of depressive symptoms postconcussion” and emphasizing “the necessary emergence for timely and effective treatment interventions for depressive symptoms to optimize the long-term prognosis of concussion,” the authors note.

They add that several research teams “have aimed to gain more insight into the etiology and underlying mechanisms of development and course of mental health difficulties in individuals who experience a concussion” and have arrived at a biopsychosocial framework, in light of “the myriad of contributing physiological, biological, and psychosocial factors.”

They recommend the establishment of “specialized multidisciplinary or interdisciplinary concussion care programs should include health care professionals with strong clinical foundations and training in mental health conditions.”
 

Speedy multidisciplinary care

Commenting on the research, Charles Tator, MD, PhD, professor of neurosurgery, University of Toronto, Division of Neurosurgery, Toronto Western Hospital, said the researchers “performed a thorough systematic review” showing “emphatically that depression occurs in this population.”

Dr. Tator, the director of the Canadian Concussion Centre, who was not involved with the current study, continued: “Nowadays clinical discoveries are validated through a progression of case reports, single-center retrospective cohort studies like ours, referenced by [Dr.] Lambert et al., and then confirmatory systematic reviews, each adding important layers of evidence.”

“This evaluative process has now endorsed the importance of early treatment of mental health symptoms in patients with persisting symptoms, which can include depression, anxiety, and PTSD,” he said.

He recommended that treatment should start with family physicians and nurse practitioners “but may require escalation to psychologists and social workers and then to psychiatrists who are often more skilled in medication selection.”

He encouraged “speedy multidisciplinary care,” noting that the possibility of suicide is worrisome.

No source of study funding was listed. A study coauthor, Shannon Scratch, PhD, has reported receiving funds from the Holland Bloorview Kids Rehabilitation Hospital Foundation (via the Holland Family Professorship in Acquired Brain Injury) during the conduct of this study. No other disclosures were reported. Dr. Tator has reported no relevant financial relationships.

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

January's theme is migraine triggers. We'll take a look at three recent studies that have tried to better determine the nature of specific triggers for headache.

One of the most common and reportedly consistent migraine triggers is exposure to alcohol, and the International Classification of Headache Disorders (ICHD-3) includes alcohol-induced headache as a secondary headache. Little is known regarding the association between migraine and alcohol. Vives-Mestres and colleagues investigated the alcohol intake of people using a digital health diary for headache. They specifically looked at the 48 hours preceding a migraine attack and whether alcohol was consumed, and also the number of beverages consumed. This was further adjusted for sex, age, and average weekly alcohol intake.

The N1-Headache Tracker is a digital headache diary that patients use to track their daily headache symptoms and inform them of potential migraine risk factors. Over a 90-day period, this study followed patients that did not meet the criteria for a diagnosis of chronic migraine. They also reported on their intake to the platform that they regularly consume alcohol. Of note, persons who never tracked alcohol consumption were excluded from this study. On intake to the platform, alcohol exposure was characterized both as whether daily consumption of alcohol was occurring and as the total daily number of alcoholic beverages.

The primary outcome of this study was migraine attack 1 day after alcohol consumption. Participants were specifically asked if their headaches were diagnosed as migraine by a physician. Migraine attack onset was considered binary, and a logistic model was used to estimate the probability of having a migraine attack on any given day with the association of alcohol intake for up to 48 hours prior to that day.

A total of 487 people with migraine were included in this trial and they collectively contributed over 43,000 diary days; almost 6000 were first days of a migraine attack. Overall alcohol consumption was not considered high and was noted to vary between groups; people with lower frequency migraine tended to have higher rates of alcohol intake. No significant correlation was observed between the presence of migraine attacks within 48 hours after alcohol consumption. This did not vary among different probability models; a population-level model showed that the probability of a migraine attack 2 days after alcohol intake was 25% lower than the probability of an attack with no alcohol consumption. This was also true after adjustment for age, sex, and average number of alcoholic beverages per week.

The association between migraine and alcohol is complicated, and the concept of migraine triggers in general is very complex. Although over 70% of people with migraine say that they have a consistent trigger, and alcohol is consistently at the top of the list of those reported triggers, there does not appear to be a direct correlation between migraine and alcohol exposure. The greatest caveat of this study is the fact that people with chronic migraine were excluded. Further research should specifically investigate triggers such as alcohol in this population.

The use of proton pump inhibitors (PPI) has been shown in previous studies over the past few years to be associated with a number of neurologic events and risks, including impaired hearing, vision, and memory, as well as migraine occurrence. The specifics of this association are not well known — specifically, whether the duration of use is the main factor, or whether it is acute exposure to a PPI medication that is a trigger. Kang and colleagues reviewed data in the Korean national database and developed a case-control model to study this association specifically.

The migraine and control groups were equally matched: They had the same demographics, smoking status, alcohol consumption, blood pressure range, fasting glucose, and total cholesterol. Past and current PPI use and comparisons of migraine occurrence were further differentiated among patients who were exposed to PPI medications for < 30 days, 30-365 days, and > 365 days.

The use of PPI treatments was noted to be linked to increased migraine regardless of duration, and regardless of the acute presence of the PPI. Even a history of prior PPI use was noted to increase the odds ratio of migraine development. This was significant among all subgroups, independent of age, sex, and other comorbidities. There was no difference in the presence of aura associated with migraine.

As we noted above, the concept of migraine triggers is overall poorly understood. This is even more the case when it comes to historical exposures. Although the use of PPI medications appears to be associated with the occurrence of migraine in this population, these medications are necessary in many instances, including in patients with severe gastritis and gastroesophageal reflux refractory to diet changes. It remains to be seen precisely how PPI medications would potentially lead to a higher incidence of migraine.

Among many of the triggers discussed, specific foods are commonly thought to be associated with migraine. Although there is scant evidence for a specific diet to improve migraine frequency, many patients are very interested in potential dietary changes that may help them. Prior studies and reviews have looked at gluten-free, dairy-free, low-carbohydrate, low-tyramine, and elimination diets — all of which were not associated with a significant improvement in migraine frequency or severity. Bakıran and colleagues sought to investigate an antioxidant-rich diet that included polyphenols and carotenoids — substances that may improve systemic inflammation, glucose metabolism, and oxidative stress.

Phytochemical-rich foods include fruits and vegetables (excluding potatoes) as well as nuts, whole grains, pulses, and olive oil. The phytochemical index is a tool used by dietitians and nutritionists to assess the phytochemical content in a diet.

A total of 90 patients who had a diagnosis of episodic migraine by a neurologist were enrolled. Individuals were excluded if they had a body mass index > 40 or < 18 or had other significant chronic comorbidities, such as hypertension, diabetes, hepatic or renal disease, or other neurologic conditions. Participants filled out a headache diary over 3 months; the Migraine Disability Assessment (MIDAS) questionnaire was also followed in order to assess migraine-related disability. Diet quality was cataloged as per patient records; patients also filled out a 3-day nonconsecutive food diary. This information was added to a food software program that calculated specific nutrients, including the phytochemical index.

Participants were divided into groups with good diet quality and poor diet quality based on their phytochemical index. No differences were seen in migraine frequency or disability between these groups, although mean attack duration was lower in those with poor diet quality. Severity was noted to be higher in those with poor diet quality; 75% of participants with poor diet quality experienced severe attacks.

Overall, the results of this study are very mixed. Participants on the recommended high phytochemical diet were seen to have lower severity of migraine but a prolonged duration of attack. There also was no correlation between this diet and either frequency or disability. This was a small study, and further research should focus on this among other diet changes that have the possibility to improve the quality of life of people with migraine.

January's theme is migraine triggers. We'll take a look at three recent studies that have tried to better determine the nature of specific triggers for headache.

One of the most common and reportedly consistent migraine triggers is exposure to alcohol, and the International Classification of Headache Disorders (ICHD-3) includes alcohol-induced headache as a secondary headache. Little is known regarding the association between migraine and alcohol. Vives-Mestres and colleagues investigated the alcohol intake of people using a digital health diary for headache. They specifically looked at the 48 hours preceding a migraine attack and whether alcohol was consumed, and also the number of beverages consumed. This was further adjusted for sex, age, and average weekly alcohol intake.

The N1-Headache Tracker is a digital headache diary that patients use to track their daily headache symptoms and inform them of potential migraine risk factors. Over a 90-day period, this study followed patients that did not meet the criteria for a diagnosis of chronic migraine. They also reported on their intake to the platform that they regularly consume alcohol. Of note, persons who never tracked alcohol consumption were excluded from this study. On intake to the platform, alcohol exposure was characterized both as whether daily consumption of alcohol was occurring and as the total daily number of alcoholic beverages.

The primary outcome of this study was migraine attack 1 day after alcohol consumption. Participants were specifically asked if their headaches were diagnosed as migraine by a physician. Migraine attack onset was considered binary, and a logistic model was used to estimate the probability of having a migraine attack on any given day with the association of alcohol intake for up to 48 hours prior to that day.

A total of 487 people with migraine were included in this trial and they collectively contributed over 43,000 diary days; almost 6000 were first days of a migraine attack. Overall alcohol consumption was not considered high and was noted to vary between groups; people with lower frequency migraine tended to have higher rates of alcohol intake. No significant correlation was observed between the presence of migraine attacks within 48 hours after alcohol consumption. This did not vary among different probability models; a population-level model showed that the probability of a migraine attack 2 days after alcohol intake was 25% lower than the probability of an attack with no alcohol consumption. This was also true after adjustment for age, sex, and average number of alcoholic beverages per week.

The association between migraine and alcohol is complicated, and the concept of migraine triggers in general is very complex. Although over 70% of people with migraine say that they have a consistent trigger, and alcohol is consistently at the top of the list of those reported triggers, there does not appear to be a direct correlation between migraine and alcohol exposure. The greatest caveat of this study is the fact that people with chronic migraine were excluded. Further research should specifically investigate triggers such as alcohol in this population.

The use of proton pump inhibitors (PPI) has been shown in previous studies over the past few years to be associated with a number of neurologic events and risks, including impaired hearing, vision, and memory, as well as migraine occurrence. The specifics of this association are not well known — specifically, whether the duration of use is the main factor, or whether it is acute exposure to a PPI medication that is a trigger. Kang and colleagues reviewed data in the Korean national database and developed a case-control model to study this association specifically.

The migraine and control groups were equally matched: They had the same demographics, smoking status, alcohol consumption, blood pressure range, fasting glucose, and total cholesterol. Past and current PPI use and comparisons of migraine occurrence were further differentiated among patients who were exposed to PPI medications for < 30 days, 30-365 days, and > 365 days.

The use of PPI treatments was noted to be linked to increased migraine regardless of duration, and regardless of the acute presence of the PPI. Even a history of prior PPI use was noted to increase the odds ratio of migraine development. This was significant among all subgroups, independent of age, sex, and other comorbidities. There was no difference in the presence of aura associated with migraine.

As we noted above, the concept of migraine triggers is overall poorly understood. This is even more the case when it comes to historical exposures. Although the use of PPI medications appears to be associated with the occurrence of migraine in this population, these medications are necessary in many instances, including in patients with severe gastritis and gastroesophageal reflux refractory to diet changes. It remains to be seen precisely how PPI medications would potentially lead to a higher incidence of migraine.

Among many of the triggers discussed, specific foods are commonly thought to be associated with migraine. Although there is scant evidence for a specific diet to improve migraine frequency, many patients are very interested in potential dietary changes that may help them. Prior studies and reviews have looked at gluten-free, dairy-free, low-carbohydrate, low-tyramine, and elimination diets — all of which were not associated with a significant improvement in migraine frequency or severity. Bakıran and colleagues sought to investigate an antioxidant-rich diet that included polyphenols and carotenoids — substances that may improve systemic inflammation, glucose metabolism, and oxidative stress.

Phytochemical-rich foods include fruits and vegetables (excluding potatoes) as well as nuts, whole grains, pulses, and olive oil. The phytochemical index is a tool used by dietitians and nutritionists to assess the phytochemical content in a diet.

A total of 90 patients who had a diagnosis of episodic migraine by a neurologist were enrolled. Individuals were excluded if they had a body mass index > 40 or < 18 or had other significant chronic comorbidities, such as hypertension, diabetes, hepatic or renal disease, or other neurologic conditions. Participants filled out a headache diary over 3 months; the Migraine Disability Assessment (MIDAS) questionnaire was also followed in order to assess migraine-related disability. Diet quality was cataloged as per patient records; patients also filled out a 3-day nonconsecutive food diary. This information was added to a food software program that calculated specific nutrients, including the phytochemical index.

Participants were divided into groups with good diet quality and poor diet quality based on their phytochemical index. No differences were seen in migraine frequency or disability between these groups, although mean attack duration was lower in those with poor diet quality. Severity was noted to be higher in those with poor diet quality; 75% of participants with poor diet quality experienced severe attacks.

Overall, the results of this study are very mixed. Participants on the recommended high phytochemical diet were seen to have lower severity of migraine but a prolonged duration of attack. There also was no correlation between this diet and either frequency or disability. This was a small study, and further research should focus on this among other diet changes that have the possibility to improve the quality of life of people with migraine.

January's theme is migraine triggers. We'll take a look at three recent studies that have tried to better determine the nature of specific triggers for headache.

One of the most common and reportedly consistent migraine triggers is exposure to alcohol, and the International Classification of Headache Disorders (ICHD-3) includes alcohol-induced headache as a secondary headache. Little is known regarding the association between migraine and alcohol. Vives-Mestres and colleagues investigated the alcohol intake of people using a digital health diary for headache. They specifically looked at the 48 hours preceding a migraine attack and whether alcohol was consumed, and also the number of beverages consumed. This was further adjusted for sex, age, and average weekly alcohol intake.

The N1-Headache Tracker is a digital headache diary that patients use to track their daily headache symptoms and inform them of potential migraine risk factors. Over a 90-day period, this study followed patients that did not meet the criteria for a diagnosis of chronic migraine. They also reported on their intake to the platform that they regularly consume alcohol. Of note, persons who never tracked alcohol consumption were excluded from this study. On intake to the platform, alcohol exposure was characterized both as whether daily consumption of alcohol was occurring and as the total daily number of alcoholic beverages.

The primary outcome of this study was migraine attack 1 day after alcohol consumption. Participants were specifically asked if their headaches were diagnosed as migraine by a physician. Migraine attack onset was considered binary, and a logistic model was used to estimate the probability of having a migraine attack on any given day with the association of alcohol intake for up to 48 hours prior to that day.

A total of 487 people with migraine were included in this trial and they collectively contributed over 43,000 diary days; almost 6000 were first days of a migraine attack. Overall alcohol consumption was not considered high and was noted to vary between groups; people with lower frequency migraine tended to have higher rates of alcohol intake. No significant correlation was observed between the presence of migraine attacks within 48 hours after alcohol consumption. This did not vary among different probability models; a population-level model showed that the probability of a migraine attack 2 days after alcohol intake was 25% lower than the probability of an attack with no alcohol consumption. This was also true after adjustment for age, sex, and average number of alcoholic beverages per week.

The association between migraine and alcohol is complicated, and the concept of migraine triggers in general is very complex. Although over 70% of people with migraine say that they have a consistent trigger, and alcohol is consistently at the top of the list of those reported triggers, there does not appear to be a direct correlation between migraine and alcohol exposure. The greatest caveat of this study is the fact that people with chronic migraine were excluded. Further research should specifically investigate triggers such as alcohol in this population.

The use of proton pump inhibitors (PPI) has been shown in previous studies over the past few years to be associated with a number of neurologic events and risks, including impaired hearing, vision, and memory, as well as migraine occurrence. The specifics of this association are not well known — specifically, whether the duration of use is the main factor, or whether it is acute exposure to a PPI medication that is a trigger. Kang and colleagues reviewed data in the Korean national database and developed a case-control model to study this association specifically.

The migraine and control groups were equally matched: They had the same demographics, smoking status, alcohol consumption, blood pressure range, fasting glucose, and total cholesterol. Past and current PPI use and comparisons of migraine occurrence were further differentiated among patients who were exposed to PPI medications for < 30 days, 30-365 days, and > 365 days.

The use of PPI treatments was noted to be linked to increased migraine regardless of duration, and regardless of the acute presence of the PPI. Even a history of prior PPI use was noted to increase the odds ratio of migraine development. This was significant among all subgroups, independent of age, sex, and other comorbidities. There was no difference in the presence of aura associated with migraine.

As we noted above, the concept of migraine triggers is overall poorly understood. This is even more the case when it comes to historical exposures. Although the use of PPI medications appears to be associated with the occurrence of migraine in this population, these medications are necessary in many instances, including in patients with severe gastritis and gastroesophageal reflux refractory to diet changes. It remains to be seen precisely how PPI medications would potentially lead to a higher incidence of migraine.

Among many of the triggers discussed, specific foods are commonly thought to be associated with migraine. Although there is scant evidence for a specific diet to improve migraine frequency, many patients are very interested in potential dietary changes that may help them. Prior studies and reviews have looked at gluten-free, dairy-free, low-carbohydrate, low-tyramine, and elimination diets — all of which were not associated with a significant improvement in migraine frequency or severity. Bakıran and colleagues sought to investigate an antioxidant-rich diet that included polyphenols and carotenoids — substances that may improve systemic inflammation, glucose metabolism, and oxidative stress.

Phytochemical-rich foods include fruits and vegetables (excluding potatoes) as well as nuts, whole grains, pulses, and olive oil. The phytochemical index is a tool used by dietitians and nutritionists to assess the phytochemical content in a diet.

A total of 90 patients who had a diagnosis of episodic migraine by a neurologist were enrolled. Individuals were excluded if they had a body mass index > 40 or < 18 or had other significant chronic comorbidities, such as hypertension, diabetes, hepatic or renal disease, or other neurologic conditions. Participants filled out a headache diary over 3 months; the Migraine Disability Assessment (MIDAS) questionnaire was also followed in order to assess migraine-related disability. Diet quality was cataloged as per patient records; patients also filled out a 3-day nonconsecutive food diary. This information was added to a food software program that calculated specific nutrients, including the phytochemical index.

Participants were divided into groups with good diet quality and poor diet quality based on their phytochemical index. No differences were seen in migraine frequency or disability between these groups, although mean attack duration was lower in those with poor diet quality. Severity was noted to be higher in those with poor diet quality; 75% of participants with poor diet quality experienced severe attacks.

Overall, the results of this study are very mixed. Participants on the recommended high phytochemical diet were seen to have lower severity of migraine but a prolonged duration of attack. There also was no correlation between this diet and either frequency or disability. This was a small study, and further research should focus on this among other diet changes that have the possibility to improve the quality of life of people with migraine.

Cluster headache is associated with a significantly increased risk for comorbid conditions, including mental disorders and other neurologic disease, leading to significant disability and absenteeism, new research shows.

Results from a Swedish register-based study also showed that patients with cluster headache had a sixfold increased risk for central nervous system disorders and a twofold increased risk for musculoskeletal disorders.

Although cluster headaches are often more prevalent in men, researchers found that multimorbidity rates were significantly higher in women. In addition, rates of external injuries were significantly higher among individuals with cluster headache than among persons without cluster headache.

“The findings very clearly indicate that cluster headache patients suffer from other health issues as well and that they are at risk of having longer periods of times when they cannot work,” said lead investigator Caroline Ran, PhD, a research specialist in the department of neuroscience at the Karolinska Institutet, Stockholm.

“It’s really important for clinicians to look at cluster headache from a broader perspective and make sure that patients are followed up so that they don’t risk ending up in a situation where they have several comorbidities,” Dr. Ran added.

The findings were published online in Neurology.
 

‘Striking’ finding

Cluster headache is one of the most severe and debilitating types of headache. It causes intense pain behind the eyes, which has been described as being worse than pain associated with childbirth or kidney stones.

Attacks can occur multiple times in a single day and can last up to 3 hours. Cluster headache is rare, occurring in about 1 in 1,000 individuals, and is more common in men. Underdiagnosis is common – especially in women.

The study drew on two Swedish population-based registries and included 3,240 patients with cluster headache aged 16-64 years and 16,200 matched control persons. The analysis covered medical visits from 2001 to 2010.

Results showed that 91.9% of participants with cluster headache had some type of multimorbidity. By comparison, 77.6% of the control group had some type of multimorbidity (odds ratio, 3.26; P < .0001).

Prior studies have shown a higher incidence of mental health and behavioral disorders among patients with cluster headache. However, when the researchers removed those conditions along with external injuries from the dataset, patients with headache were still significantly more likely to have multiple co-occurring illnesses (86.7% vs. 68.8%; OR, 2.95; P < .0001).

The most common comorbid conditions in the overall cluster headache group were diseases of the nervous system (OR, 5.9; 95% CI, 5.46 -6.42); 51.8% of the cluster headache group reported these disorders, compared with just 15.4% of the control group.

Diseases of the eye, the respiratory, gastrointestinal, and musculoskeletal systems, and connective tissue were also significantly more common among patients with cluster headache.

“For each diagnosis that we investigated, we found a higher incidence in the cluster headache group, and we thought this was a very striking finding and worth discussing in the clinical setting that these patients are at risk of general ill health,” Dr. Ran said.
 

Risky behavior?

Another novel finding was the higher rate of external injuries among the cluster headache group, compared with the control group. The finding seems to back up the theory that patients with cluster headache are more likely to engage in risky behaviors, the researchers noted.

In the cluster headache group, external injuries were reported by 47.1% of men and 41% of women, versus 34.9% and 26.0%, respectively, in the control group.

“Now we can also show that cluster headache patients have more injuries and that is totally unrelated to the biological health of the individuals, so that could also indicate higher risk taking,” Dr. Ran said.

Overall multimorbidity rates and diagnoses in each medical category except external injury were higher among women with cluster headache than men with headaches. In addition, the mean number of days on sick leave and disability pension was higher among women with cluster headache than among men with cluster headache (83.71 days vs. 52.56 days).

Overall, the mean number of sickness absence and disability pension net days in 2010 was nearly twice as high in the cluster headache group as in the control group (63.15 days vs. 34.08 days).

Removing mental and behavioral health disorders from the mix did not lower those numbers.

“Our numbers indicate that the mental health issues that are related to cluster headache might not impact their work situation as much as the other comorbidities,” Dr. Ran said.
 

Struggle is real

Commenting on the findings, Heidi Schwarz, MD, professor of clinical neurology at the University of Rochester (N.Y.) Medical Center, called the study a “valuable contribution” to the field and to the treatment of cluster headache.

“It’s a good study that addresses factors that really need to be considered as you take care of these patients,” said Dr. Schwarz, who was not involved with the research.

“The most salient features of this is that cluster headache is quite disabling, and if you add a comorbidity to it, it’s even more disabling,” she said.

Dr. Schwarz noted that cluster headache is often misdiagnosed as migraine or is overlooked altogether, especially in women. These data underscore that, although cluster headache is more common in men, it affects women too and could lead to even greater disability.

“This has a direct impact on patient quality of life, and in the end, that really should be what we’re looking to enhance,” Dr. Schwarz said. “When a patient with cluster comes in and they tell you they’re really struggling, believe them because it’s quite real.”

The findings also fill a gap in the literature and offer the kind of data that could not be collected in the United States, she noted. Sweden provides paid sick time for all workers aged 16 and older and offers a disability pension to all workers whose ability to work is temporarily or permanently inhibited because of illness or injury.

“You will never get this kind of data in the United States because this kind of data comes from two datasets that are extremely inclusive and detailed in a society, Sweden, where they have a social support system,” Dr. Schwarz said.

The study was funded by the Swedish Research Council, the Swedish Brain Foundation, and Mellby Gård, Region Stockholm, Märta Lundkvist stiftelse and Karolinska Institutet research funds. Dr. Ran and Dr. Schwarz report no relevant financial relationships.

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

Cluster headache is associated with a significantly increased risk for comorbid conditions, including mental disorders and other neurologic disease, leading to significant disability and absenteeism, new research shows.

Results from a Swedish register-based study also showed that patients with cluster headache had a sixfold increased risk for central nervous system disorders and a twofold increased risk for musculoskeletal disorders.

Although cluster headaches are often more prevalent in men, researchers found that multimorbidity rates were significantly higher in women. In addition, rates of external injuries were significantly higher among individuals with cluster headache than among persons without cluster headache.

“The findings very clearly indicate that cluster headache patients suffer from other health issues as well and that they are at risk of having longer periods of times when they cannot work,” said lead investigator Caroline Ran, PhD, a research specialist in the department of neuroscience at the Karolinska Institutet, Stockholm.

“It’s really important for clinicians to look at cluster headache from a broader perspective and make sure that patients are followed up so that they don’t risk ending up in a situation where they have several comorbidities,” Dr. Ran added.

The findings were published online in Neurology.
 

‘Striking’ finding

Cluster headache is one of the most severe and debilitating types of headache. It causes intense pain behind the eyes, which has been described as being worse than pain associated with childbirth or kidney stones.

Attacks can occur multiple times in a single day and can last up to 3 hours. Cluster headache is rare, occurring in about 1 in 1,000 individuals, and is more common in men. Underdiagnosis is common – especially in women.

The study drew on two Swedish population-based registries and included 3,240 patients with cluster headache aged 16-64 years and 16,200 matched control persons. The analysis covered medical visits from 2001 to 2010.

Results showed that 91.9% of participants with cluster headache had some type of multimorbidity. By comparison, 77.6% of the control group had some type of multimorbidity (odds ratio, 3.26; P < .0001).

Prior studies have shown a higher incidence of mental health and behavioral disorders among patients with cluster headache. However, when the researchers removed those conditions along with external injuries from the dataset, patients with headache were still significantly more likely to have multiple co-occurring illnesses (86.7% vs. 68.8%; OR, 2.95; P < .0001).

The most common comorbid conditions in the overall cluster headache group were diseases of the nervous system (OR, 5.9; 95% CI, 5.46 -6.42); 51.8% of the cluster headache group reported these disorders, compared with just 15.4% of the control group.

Diseases of the eye, the respiratory, gastrointestinal, and musculoskeletal systems, and connective tissue were also significantly more common among patients with cluster headache.

“For each diagnosis that we investigated, we found a higher incidence in the cluster headache group, and we thought this was a very striking finding and worth discussing in the clinical setting that these patients are at risk of general ill health,” Dr. Ran said.
 

Risky behavior?

Another novel finding was the higher rate of external injuries among the cluster headache group, compared with the control group. The finding seems to back up the theory that patients with cluster headache are more likely to engage in risky behaviors, the researchers noted.

In the cluster headache group, external injuries were reported by 47.1% of men and 41% of women, versus 34.9% and 26.0%, respectively, in the control group.

“Now we can also show that cluster headache patients have more injuries and that is totally unrelated to the biological health of the individuals, so that could also indicate higher risk taking,” Dr. Ran said.

Overall multimorbidity rates and diagnoses in each medical category except external injury were higher among women with cluster headache than men with headaches. In addition, the mean number of days on sick leave and disability pension was higher among women with cluster headache than among men with cluster headache (83.71 days vs. 52.56 days).

Overall, the mean number of sickness absence and disability pension net days in 2010 was nearly twice as high in the cluster headache group as in the control group (63.15 days vs. 34.08 days).

Removing mental and behavioral health disorders from the mix did not lower those numbers.

“Our numbers indicate that the mental health issues that are related to cluster headache might not impact their work situation as much as the other comorbidities,” Dr. Ran said.
 

Struggle is real

Commenting on the findings, Heidi Schwarz, MD, professor of clinical neurology at the University of Rochester (N.Y.) Medical Center, called the study a “valuable contribution” to the field and to the treatment of cluster headache.

“It’s a good study that addresses factors that really need to be considered as you take care of these patients,” said Dr. Schwarz, who was not involved with the research.

“The most salient features of this is that cluster headache is quite disabling, and if you add a comorbidity to it, it’s even more disabling,” she said.

Dr. Schwarz noted that cluster headache is often misdiagnosed as migraine or is overlooked altogether, especially in women. These data underscore that, although cluster headache is more common in men, it affects women too and could lead to even greater disability.

“This has a direct impact on patient quality of life, and in the end, that really should be what we’re looking to enhance,” Dr. Schwarz said. “When a patient with cluster comes in and they tell you they’re really struggling, believe them because it’s quite real.”

The findings also fill a gap in the literature and offer the kind of data that could not be collected in the United States, she noted. Sweden provides paid sick time for all workers aged 16 and older and offers a disability pension to all workers whose ability to work is temporarily or permanently inhibited because of illness or injury.

“You will never get this kind of data in the United States because this kind of data comes from two datasets that are extremely inclusive and detailed in a society, Sweden, where they have a social support system,” Dr. Schwarz said.

The study was funded by the Swedish Research Council, the Swedish Brain Foundation, and Mellby Gård, Region Stockholm, Märta Lundkvist stiftelse and Karolinska Institutet research funds. Dr. Ran and Dr. Schwarz report no relevant financial relationships.

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

Cluster headache is associated with a significantly increased risk for comorbid conditions, including mental disorders and other neurologic disease, leading to significant disability and absenteeism, new research shows.

Results from a Swedish register-based study also showed that patients with cluster headache had a sixfold increased risk for central nervous system disorders and a twofold increased risk for musculoskeletal disorders.

Although cluster headaches are often more prevalent in men, researchers found that multimorbidity rates were significantly higher in women. In addition, rates of external injuries were significantly higher among individuals with cluster headache than among persons without cluster headache.

“The findings very clearly indicate that cluster headache patients suffer from other health issues as well and that they are at risk of having longer periods of times when they cannot work,” said lead investigator Caroline Ran, PhD, a research specialist in the department of neuroscience at the Karolinska Institutet, Stockholm.

“It’s really important for clinicians to look at cluster headache from a broader perspective and make sure that patients are followed up so that they don’t risk ending up in a situation where they have several comorbidities,” Dr. Ran added.

The findings were published online in Neurology.
 

‘Striking’ finding

Cluster headache is one of the most severe and debilitating types of headache. It causes intense pain behind the eyes, which has been described as being worse than pain associated with childbirth or kidney stones.

Attacks can occur multiple times in a single day and can last up to 3 hours. Cluster headache is rare, occurring in about 1 in 1,000 individuals, and is more common in men. Underdiagnosis is common – especially in women.

The study drew on two Swedish population-based registries and included 3,240 patients with cluster headache aged 16-64 years and 16,200 matched control persons. The analysis covered medical visits from 2001 to 2010.

Results showed that 91.9% of participants with cluster headache had some type of multimorbidity. By comparison, 77.6% of the control group had some type of multimorbidity (odds ratio, 3.26; P < .0001).

Prior studies have shown a higher incidence of mental health and behavioral disorders among patients with cluster headache. However, when the researchers removed those conditions along with external injuries from the dataset, patients with headache were still significantly more likely to have multiple co-occurring illnesses (86.7% vs. 68.8%; OR, 2.95; P < .0001).

The most common comorbid conditions in the overall cluster headache group were diseases of the nervous system (OR, 5.9; 95% CI, 5.46 -6.42); 51.8% of the cluster headache group reported these disorders, compared with just 15.4% of the control group.

Diseases of the eye, the respiratory, gastrointestinal, and musculoskeletal systems, and connective tissue were also significantly more common among patients with cluster headache.

“For each diagnosis that we investigated, we found a higher incidence in the cluster headache group, and we thought this was a very striking finding and worth discussing in the clinical setting that these patients are at risk of general ill health,” Dr. Ran said.
 

Risky behavior?

Another novel finding was the higher rate of external injuries among the cluster headache group, compared with the control group. The finding seems to back up the theory that patients with cluster headache are more likely to engage in risky behaviors, the researchers noted.

In the cluster headache group, external injuries were reported by 47.1% of men and 41% of women, versus 34.9% and 26.0%, respectively, in the control group.

“Now we can also show that cluster headache patients have more injuries and that is totally unrelated to the biological health of the individuals, so that could also indicate higher risk taking,” Dr. Ran said.

Overall multimorbidity rates and diagnoses in each medical category except external injury were higher among women with cluster headache than men with headaches. In addition, the mean number of days on sick leave and disability pension was higher among women with cluster headache than among men with cluster headache (83.71 days vs. 52.56 days).

Overall, the mean number of sickness absence and disability pension net days in 2010 was nearly twice as high in the cluster headache group as in the control group (63.15 days vs. 34.08 days).

Removing mental and behavioral health disorders from the mix did not lower those numbers.

“Our numbers indicate that the mental health issues that are related to cluster headache might not impact their work situation as much as the other comorbidities,” Dr. Ran said.
 

Struggle is real

Commenting on the findings, Heidi Schwarz, MD, professor of clinical neurology at the University of Rochester (N.Y.) Medical Center, called the study a “valuable contribution” to the field and to the treatment of cluster headache.

“It’s a good study that addresses factors that really need to be considered as you take care of these patients,” said Dr. Schwarz, who was not involved with the research.

“The most salient features of this is that cluster headache is quite disabling, and if you add a comorbidity to it, it’s even more disabling,” she said.

Dr. Schwarz noted that cluster headache is often misdiagnosed as migraine or is overlooked altogether, especially in women. These data underscore that, although cluster headache is more common in men, it affects women too and could lead to even greater disability.

“This has a direct impact on patient quality of life, and in the end, that really should be what we’re looking to enhance,” Dr. Schwarz said. “When a patient with cluster comes in and they tell you they’re really struggling, believe them because it’s quite real.”

The findings also fill a gap in the literature and offer the kind of data that could not be collected in the United States, she noted. Sweden provides paid sick time for all workers aged 16 and older and offers a disability pension to all workers whose ability to work is temporarily or permanently inhibited because of illness or injury.

“You will never get this kind of data in the United States because this kind of data comes from two datasets that are extremely inclusive and detailed in a society, Sweden, where they have a social support system,” Dr. Schwarz said.

The study was funded by the Swedish Research Council, the Swedish Brain Foundation, and Mellby Gård, Region Stockholm, Märta Lundkvist stiftelse and Karolinska Institutet research funds. Dr. Ran and Dr. Schwarz report no relevant financial relationships.

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

Key clinical point: Migraine or severe headache is a significant risk factor for cardiovascular diseases and significantly increases the risk for angina and stroke.

Major finding: Migraine or severe headache increased the overall risk for cardiovascular diseases (adjusted odds ratio [aOR] 2.77; P = .001), angina (aOR 2.27; P = .046), and stroke (aOR 3.80; P = .006), with the increased risk for cardiovascular diseases being the most prominent among participants with migraine who were women (aOR 6.02; P < .001), aged >60 years (aOR 2.69; P = .049), or had hypertension (aOR 3.57; P < .001) or hyperlipidemia (aOR 2.74; P = .003).

Study details: This cross-sectional study evaluated 5692 participants from the US National Health and Nutrition Examination Survey (NHANES), of which 1090 had migraine or severe headache.

Disclosures: This study was supported by grants from the National Natural Science Foundation of China and the Natural Science Foundation of Jiangsu Province. The authors declared no conflicts of interest.

Source: Wang K et al. Association between migraine and cardiovascular disease: A cross-sectional study. Front Cardiovasc Med. 2022;9:1044465 (Nov 24). Doi: 10.3389/fcvm.2022.1044465

Key clinical point: Migraine or severe headache is a significant risk factor for cardiovascular diseases and significantly increases the risk for angina and stroke.

Major finding: Migraine or severe headache increased the overall risk for cardiovascular diseases (adjusted odds ratio [aOR] 2.77; P = .001), angina (aOR 2.27; P = .046), and stroke (aOR 3.80; P = .006), with the increased risk for cardiovascular diseases being the most prominent among participants with migraine who were women (aOR 6.02; P < .001), aged >60 years (aOR 2.69; P = .049), or had hypertension (aOR 3.57; P < .001) or hyperlipidemia (aOR 2.74; P = .003).

Study details: This cross-sectional study evaluated 5692 participants from the US National Health and Nutrition Examination Survey (NHANES), of which 1090 had migraine or severe headache.

Disclosures: This study was supported by grants from the National Natural Science Foundation of China and the Natural Science Foundation of Jiangsu Province. The authors declared no conflicts of interest.

Source: Wang K et al. Association between migraine and cardiovascular disease: A cross-sectional study. Front Cardiovasc Med. 2022;9:1044465 (Nov 24). Doi: 10.3389/fcvm.2022.1044465

Key clinical point: Migraine or severe headache is a significant risk factor for cardiovascular diseases and significantly increases the risk for angina and stroke.

Major finding: Migraine or severe headache increased the overall risk for cardiovascular diseases (adjusted odds ratio [aOR] 2.77; P = .001), angina (aOR 2.27; P = .046), and stroke (aOR 3.80; P = .006), with the increased risk for cardiovascular diseases being the most prominent among participants with migraine who were women (aOR 6.02; P < .001), aged >60 years (aOR 2.69; P = .049), or had hypertension (aOR 3.57; P < .001) or hyperlipidemia (aOR 2.74; P = .003).

Study details: This cross-sectional study evaluated 5692 participants from the US National Health and Nutrition Examination Survey (NHANES), of which 1090 had migraine or severe headache.

Disclosures: This study was supported by grants from the National Natural Science Foundation of China and the Natural Science Foundation of Jiangsu Province. The authors declared no conflicts of interest.

Source: Wang K et al. Association between migraine and cardiovascular disease: A cross-sectional study. Front Cardiovasc Med. 2022;9:1044465 (Nov 24). Doi: 10.3389/fcvm.2022.1044465

Key clinical point: The COVID-19 pandemic adversely affected psychological functioning in young US college students with migraine and increased depression and anxiety, attenuating potential improvements achieved in headache-related disability during the pandemic.

Major finding: Levels of depression, anxiety, and stress were significantly higher during vs before the COVID-19 pandemic (all P ≤ .01), whereas headache-related disability was lower (direct effect [c′] −1.6; 95% CI −3.1 to −0.1). However, anxiety (indirect effect [b] 0.3; 95% CI 0.01-0.9) and depression (b 0.7; 95% CI 0.07-1.4) mediated an increase in headache-related disability during vs before the pandemic, thereby canceling improvements achieved during the pandemic.

Study details: This cross-sectional study included 365 undergraduate students aged ≥18 years with episodic migraine with or without aura or chronic migraine who were surveyed before (n = 223) or during (n = 142) the COVID-19 pandemic.

Disclosures: This study did not receive any specific funding. TA Smitherman reported previously serving on the advisory board for Teva Pharmaceuticals (unrelated to this study).

Source: Thaxter LY and Smitherman TA. The effect of the COVID-19 pandemic on headache-related disability among young adults with migraine. Headache. 2022;62(10):1293-1301 (Nov 23). Doi: 10.1111/head.14411

Key clinical point: The COVID-19 pandemic adversely affected psychological functioning in young US college students with migraine and increased depression and anxiety, attenuating potential improvements achieved in headache-related disability during the pandemic.

Major finding: Levels of depression, anxiety, and stress were significantly higher during vs before the COVID-19 pandemic (all P ≤ .01), whereas headache-related disability was lower (direct effect [c′] −1.6; 95% CI −3.1 to −0.1). However, anxiety (indirect effect [b] 0.3; 95% CI 0.01-0.9) and depression (b 0.7; 95% CI 0.07-1.4) mediated an increase in headache-related disability during vs before the pandemic, thereby canceling improvements achieved during the pandemic.

Study details: This cross-sectional study included 365 undergraduate students aged ≥18 years with episodic migraine with or without aura or chronic migraine who were surveyed before (n = 223) or during (n = 142) the COVID-19 pandemic.

Disclosures: This study did not receive any specific funding. TA Smitherman reported previously serving on the advisory board for Teva Pharmaceuticals (unrelated to this study).

Source: Thaxter LY and Smitherman TA. The effect of the COVID-19 pandemic on headache-related disability among young adults with migraine. Headache. 2022;62(10):1293-1301 (Nov 23). Doi: 10.1111/head.14411

Key clinical point: The COVID-19 pandemic adversely affected psychological functioning in young US college students with migraine and increased depression and anxiety, attenuating potential improvements achieved in headache-related disability during the pandemic.

Major finding: Levels of depression, anxiety, and stress were significantly higher during vs before the COVID-19 pandemic (all P ≤ .01), whereas headache-related disability was lower (direct effect [c′] −1.6; 95% CI −3.1 to −0.1). However, anxiety (indirect effect [b] 0.3; 95% CI 0.01-0.9) and depression (b 0.7; 95% CI 0.07-1.4) mediated an increase in headache-related disability during vs before the pandemic, thereby canceling improvements achieved during the pandemic.

Study details: This cross-sectional study included 365 undergraduate students aged ≥18 years with episodic migraine with or without aura or chronic migraine who were surveyed before (n = 223) or during (n = 142) the COVID-19 pandemic.

Disclosures: This study did not receive any specific funding. TA Smitherman reported previously serving on the advisory board for Teva Pharmaceuticals (unrelated to this study).

Source: Thaxter LY and Smitherman TA. The effect of the COVID-19 pandemic on headache-related disability among young adults with migraine. Headache. 2022;62(10):1293-1301 (Nov 23). Doi: 10.1111/head.14411

Key clinical point: Erenumab may serve as an effective and well-tolerated therapeutic agent for migraine prophylaxis.

Major finding: Compared with placebo, 28 mg (mean difference [MD] −1.1; P = .02), 70 mg (MD −1.4; P < .001), and 140 mg (MD −1.8; P < .001) erenumab led to significant reductions in monthly migraine days at 12 weeks, with each erenumab dose being associated with a significantly higher proportion of patients achieving ≥50% reduction in migraine days (all P < .001) and similar risk for adverse events.

Study details: This was a systematic review and meta-analysis of eight randomized controlled trials including 4860 patients with migraine who received erenumab (7, 21, 28, 70, or 140 mg) or placebo.

Disclosures: This study was funded by the Jiangsu Province Key Research and Development Program, National Natural Science Foundation of China, and Natural Science Foundation of Jiangsu Province. The authors declared no conflicts of interest.

Source: Gui T, Li H et al. Different dosage regimens of erenumab for the treatment of migraine: A systematic review and meta-analysis of the efficacy and safety of randomized controlled trials. Headache. 2022;62(10):1281-1292 (Nov 14). Doi: 10.1111/head.14423

Key clinical point: Erenumab may serve as an effective and well-tolerated therapeutic agent for migraine prophylaxis.

Major finding: Compared with placebo, 28 mg (mean difference [MD] −1.1; P = .02), 70 mg (MD −1.4; P < .001), and 140 mg (MD −1.8; P < .001) erenumab led to significant reductions in monthly migraine days at 12 weeks, with each erenumab dose being associated with a significantly higher proportion of patients achieving ≥50% reduction in migraine days (all P < .001) and similar risk for adverse events.

Study details: This was a systematic review and meta-analysis of eight randomized controlled trials including 4860 patients with migraine who received erenumab (7, 21, 28, 70, or 140 mg) or placebo.

Disclosures: This study was funded by the Jiangsu Province Key Research and Development Program, National Natural Science Foundation of China, and Natural Science Foundation of Jiangsu Province. The authors declared no conflicts of interest.

Source: Gui T, Li H et al. Different dosage regimens of erenumab for the treatment of migraine: A systematic review and meta-analysis of the efficacy and safety of randomized controlled trials. Headache. 2022;62(10):1281-1292 (Nov 14). Doi: 10.1111/head.14423

Key clinical point: Erenumab may serve as an effective and well-tolerated therapeutic agent for migraine prophylaxis.

Major finding: Compared with placebo, 28 mg (mean difference [MD] −1.1; P = .02), 70 mg (MD −1.4; P < .001), and 140 mg (MD −1.8; P < .001) erenumab led to significant reductions in monthly migraine days at 12 weeks, with each erenumab dose being associated with a significantly higher proportion of patients achieving ≥50% reduction in migraine days (all P < .001) and similar risk for adverse events.

Study details: This was a systematic review and meta-analysis of eight randomized controlled trials including 4860 patients with migraine who received erenumab (7, 21, 28, 70, or 140 mg) or placebo.

Disclosures: This study was funded by the Jiangsu Province Key Research and Development Program, National Natural Science Foundation of China, and Natural Science Foundation of Jiangsu Province. The authors declared no conflicts of interest.

Source: Gui T, Li H et al. Different dosage regimens of erenumab for the treatment of migraine: A systematic review and meta-analysis of the efficacy and safety of randomized controlled trials. Headache. 2022;62(10):1281-1292 (Nov 14). Doi: 10.1111/head.14423

Key clinical point: High quality diet and higher total intake of phytochemicals and polyphenols are significantly associated with lower migraine severity in patients with episodic migraine.

Major finding: Migraine severity was negatively correlated with the intake of good quality diet (correlation coefficient [r] −0.37; P = .0003) and higher intake of phytochemicals (r −0.37; P = .0003) and phenolic components, such as flavanones (r −0.27; P = .01) and lignans (r −0.27; P = .01). The total intake of phenols and flavonoids from olive oil, oil, and fruits was also significantly negatively correlated with migraine severity (each P ≤ .04).

Study details: This questionnaire-based study included 90 patients with episodic migraine who were assessed for their migraine characteristics and dietary phytochemical and polyphenol intake.

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

Source: Bakırhan H et al. Migraine severity, disability, and duration: Is a good diet quality, high intake of phytochemicals and polyphenols important? Front Nutr. 2022;9:1041907 (Nov 21). Doi: 10.3389/fnut.2022.1041907

Key clinical point: High quality diet and higher total intake of phytochemicals and polyphenols are significantly associated with lower migraine severity in patients with episodic migraine.

Major finding: Migraine severity was negatively correlated with the intake of good quality diet (correlation coefficient [r] −0.37; P = .0003) and higher intake of phytochemicals (r −0.37; P = .0003) and phenolic components, such as flavanones (r −0.27; P = .01) and lignans (r −0.27; P = .01). The total intake of phenols and flavonoids from olive oil, oil, and fruits was also significantly negatively correlated with migraine severity (each P ≤ .04).

Study details: This questionnaire-based study included 90 patients with episodic migraine who were assessed for their migraine characteristics and dietary phytochemical and polyphenol intake.

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

Source: Bakırhan H et al. Migraine severity, disability, and duration: Is a good diet quality, high intake of phytochemicals and polyphenols important? Front Nutr. 2022;9:1041907 (Nov 21). Doi: 10.3389/fnut.2022.1041907

Key clinical point: High quality diet and higher total intake of phytochemicals and polyphenols are significantly associated with lower migraine severity in patients with episodic migraine.

Major finding: Migraine severity was negatively correlated with the intake of good quality diet (correlation coefficient [r] −0.37; P = .0003) and higher intake of phytochemicals (r −0.37; P = .0003) and phenolic components, such as flavanones (r −0.27; P = .01) and lignans (r −0.27; P = .01). The total intake of phenols and flavonoids from olive oil, oil, and fruits was also significantly negatively correlated with migraine severity (each P ≤ .04).

Study details: This questionnaire-based study included 90 patients with episodic migraine who were assessed for their migraine characteristics and dietary phytochemical and polyphenol intake.

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

Source: Bakırhan H et al. Migraine severity, disability, and duration: Is a good diet quality, high intake of phytochemicals and polyphenols important? Front Nutr. 2022;9:1041907 (Nov 21). Doi: 10.3389/fnut.2022.1041907

Key clinical point: The first two administrations of onabotulinum toxin A (onabotA) were well-tolerated in patients with chronic migraine, with adverse events (AE) being mostly mild and tolerability to onabotA not being correlated with AE or clinical response.

Major finding: The mean tolerability scores were 7.8/10 and 7.2/10 in the first and second onabotA administration sessions, respectively, with no association being observed between tolerability and AE occurrence or clinical response. The AE were mostly mild and were reported by 71.4% and 68.6% of patients after the first and second onabotA administration sessions, respectively; 49.5% of patients showed a 50% response rate between weeks 20 and 24.

Study details: This was an observational prospective cohort study including 105 patients with chronic migraine who had received onabotA for the first time.

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

Source: García-Azorín D et al. Real-world evaluation of the tolerability to onabotulinum toxin A: The RETO study. Toxins (Basel). 2022;14(12),850 (Dec 3). Doi: 10.3390/toxins14120850.

Key clinical point: The first two administrations of onabotulinum toxin A (onabotA) were well-tolerated in patients with chronic migraine, with adverse events (AE) being mostly mild and tolerability to onabotA not being correlated with AE or clinical response.

Major finding: The mean tolerability scores were 7.8/10 and 7.2/10 in the first and second onabotA administration sessions, respectively, with no association being observed between tolerability and AE occurrence or clinical response. The AE were mostly mild and were reported by 71.4% and 68.6% of patients after the first and second onabotA administration sessions, respectively; 49.5% of patients showed a 50% response rate between weeks 20 and 24.

Study details: This was an observational prospective cohort study including 105 patients with chronic migraine who had received onabotA for the first time.

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

Source: García-Azorín D et al. Real-world evaluation of the tolerability to onabotulinum toxin A: The RETO study. Toxins (Basel). 2022;14(12),850 (Dec 3). Doi: 10.3390/toxins14120850.

Key clinical point: The first two administrations of onabotulinum toxin A (onabotA) were well-tolerated in patients with chronic migraine, with adverse events (AE) being mostly mild and tolerability to onabotA not being correlated with AE or clinical response.

Major finding: The mean tolerability scores were 7.8/10 and 7.2/10 in the first and second onabotA administration sessions, respectively, with no association being observed between tolerability and AE occurrence or clinical response. The AE were mostly mild and were reported by 71.4% and 68.6% of patients after the first and second onabotA administration sessions, respectively; 49.5% of patients showed a 50% response rate between weeks 20 and 24.

Study details: This was an observational prospective cohort study including 105 patients with chronic migraine who had received onabotA for the first time.

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

Source: García-Azorín D et al. Real-world evaluation of the tolerability to onabotulinum toxin A: The RETO study. Toxins (Basel). 2022;14(12),850 (Dec 3). Doi: 10.3390/toxins14120850.

Key clinical point: Erenumab demonstrated an early onset of and superior efficacy in achieving ≥50% reduction in monthly migraine days (MMD) than topiramate in patients with migraine.

Major finding: A significantly higher proportion of patients receiving erenumab vs topiramate reported ≥50% reduction in MMD at 1 month (39.2% vs 24.0%) and during the last 3 months (60.3% vs 43.3%) of treatment (both P < .001). Reductions in MMD over last 3 months were significantly higher with erenumab vs topiramate (mean difference −1.24 days; P < .001).

Study details: This post hoc analysis of the phase 4 HER-MES trial included 776 patients with migraine who were naive to migraine prophylactics or had failed or were ill-suited for metoprolol/propranolol, amitriptyline, or flunarizine and were randomized to receive erenumab (70 or 140 mg/month) or topiramate (50-100 mg/day).

Disclosures: This study was funded by Novartis Pharma GmbH, Germany. Four authors, including the first author, declared being employees of and holding stocks in Novartis. U Reuter reported receiving grants, personal fees, and other supports from Novartis and various other sources.

Source: Ehrlich M et al. Erenumab versus topiramate: Post hoc efficacy analysis from the HER‑MES study. J Headache Pain. 2022;23:141 (Nov 15). Doi: 10.1186/s10194-022-01511-y

Key clinical point: Erenumab demonstrated an early onset of and superior efficacy in achieving ≥50% reduction in monthly migraine days (MMD) than topiramate in patients with migraine.

Major finding: A significantly higher proportion of patients receiving erenumab vs topiramate reported ≥50% reduction in MMD at 1 month (39.2% vs 24.0%) and during the last 3 months (60.3% vs 43.3%) of treatment (both P < .001). Reductions in MMD over last 3 months were significantly higher with erenumab vs topiramate (mean difference −1.24 days; P < .001).

Study details: This post hoc analysis of the phase 4 HER-MES trial included 776 patients with migraine who were naive to migraine prophylactics or had failed or were ill-suited for metoprolol/propranolol, amitriptyline, or flunarizine and were randomized to receive erenumab (70 or 140 mg/month) or topiramate (50-100 mg/day).

Disclosures: This study was funded by Novartis Pharma GmbH, Germany. Four authors, including the first author, declared being employees of and holding stocks in Novartis. U Reuter reported receiving grants, personal fees, and other supports from Novartis and various other sources.

Source: Ehrlich M et al. Erenumab versus topiramate: Post hoc efficacy analysis from the HER‑MES study. J Headache Pain. 2022;23:141 (Nov 15). Doi: 10.1186/s10194-022-01511-y

Key clinical point: Erenumab demonstrated an early onset of and superior efficacy in achieving ≥50% reduction in monthly migraine days (MMD) than topiramate in patients with migraine.

Major finding: A significantly higher proportion of patients receiving erenumab vs topiramate reported ≥50% reduction in MMD at 1 month (39.2% vs 24.0%) and during the last 3 months (60.3% vs 43.3%) of treatment (both P < .001). Reductions in MMD over last 3 months were significantly higher with erenumab vs topiramate (mean difference −1.24 days; P < .001).

Study details: This post hoc analysis of the phase 4 HER-MES trial included 776 patients with migraine who were naive to migraine prophylactics or had failed or were ill-suited for metoprolol/propranolol, amitriptyline, or flunarizine and were randomized to receive erenumab (70 or 140 mg/month) or topiramate (50-100 mg/day).

Disclosures: This study was funded by Novartis Pharma GmbH, Germany. Four authors, including the first author, declared being employees of and holding stocks in Novartis. U Reuter reported receiving grants, personal fees, and other supports from Novartis and various other sources.

Source: Ehrlich M et al. Erenumab versus topiramate: Post hoc efficacy analysis from the HER‑MES study. J Headache Pain. 2022;23:141 (Nov 15). Doi: 10.1186/s10194-022-01511-y