Posttraumatic Headache.

Posttraumatic headache (PTH) is the most common secondary headache disorder, accounting for approximately 4% of all headache disorders. It is the most common symptom following concussion (mild traumatic brain injury) and can be debilitating for many who have persistent symptoms. With a recent increase in public awareness regarding traumatic brain injury, there has been a corresponding increase in PTH research. The pathophysiology of PTH remains poorly understood and the underlying mechanisms are likely multifactorial. Diagnosis of PTH is dependent on a temporal relationship to a head injury. PTH often resembles common primary headache phenotypes. Treatment of PTH utilizes known treatments for these other headache phenotypes, as there is no currently approved treatment specifically for PTH. Moving forward, further studies are needed to better define and validate the definition of PTH, understand the underlying pathophysiology, and find more specific treatments.

Sex Differences and Reporting of SCAT-5 Concussion Symptoms in Adolescent Athletes.

OBJECTIVE: To elucidate specific symptoms that may differ between adolescent female and male athletes after a sports-related concussion (SRC) and identify symptoms that may require greater clinical attention by medical and athletic staff. DESIGN: Prospective. SETTING: This study is part of a larger research project conducted at clinics in the North Texas Concussion Network (ConTex) Registry. PARTICIPANTS: Subjects (N = 491) aged 12 to 18 years who sustained a diagnosed SRC within 30 days of clinic visit. INDEPENDENT VARIABLES: Sex (female vs male). Covariates included age, race, current mood (anxiety and depression), learning disability/ADHD, and time to clinic. MAIN OUTCOME MEASURES: Twenty-two individual postconcussion symptoms as measured by the Post-Concussion Symptom Scale from the Sport Concussion Assessment Tool-5 (SCAT-5). RESULTS: Girls endorsed higher levels of anxiety and depression symptoms at initial clinic visit. analysis of covariance results revealed that girls had significantly greater symptom severity of headache, dizziness, sensitivity to light, sensitivity to noise, pressure in the head, feeling slowed down, fatigue, and drowsiness than boys. Ordinal logistic regression results also revealed that girls had significantly greater predicted odds of higher symptom severity on these 8 symptoms and in trouble concentrating than boys. CONCLUSIONS: Closer examination of specific symptoms with attention to patients' current levels of anxiety and depression symptoms may better inform medical and athletic staff to anticipate and address symptoms that may present greater challenges for adolescent girls than boys.

Evaluation of 2-Hour Post-Dose Efficacy of Lasmiditan for the Acute Treatment of Difficult-to-Treat Migraine Attacks.

OBJECTIVE: To identify factors predicting response (2-hour headache pain freedom or most bothersome symptom freedom) to lasmiditan based on individual patient characteristics, migraine disease characteristics, and migraine attack characteristics. Further, efficacy specifically in difficult-to-treat patient/migraine disease characteristics or attack characteristics (ie, historically considered less responsive to certain acute therapies) subgroups was analyzed. BACKGROUND: Knowledge of factors associated with a positive or negative response to acute treatment would be useful to practitioners prescribing acute treatments for migraine. Additionally, practitioners and patients would benefit from understanding the efficacy of lasmiditan specifically in subgroups of patients with migraine disease characteristics and migraine attack characteristics historically associated with decreased pain threshold, reduced efficacy of acute treatment, or increased burden of migraine. METHODS: Pooled analyses were completed from 2 Phase 3 double-blind clinical trials, SPARTAN and SAMURAI. Data from baseline to 2 hours after taking lasmiditan (50, 100, or 200 mg) or placebo were analyzed to assess efficacy based on patient characteristics, migraine disease characteristics, and migraine attack characteristics. A total of 3981 patients comprising the intent-to-treat population were treated with placebo (N = 1130), lasmiditan 50 mg (N = 598), lasmiditan 100 mg (N = 1133), or lasmiditan 200 mg (N = 1120). Data were analyzed for the following efficacy measures at 2 hours: headache pain freedom and most bothersome symptom freedom. RESULTS: None of the analyzed subgroups based on individual patient characteristics, migraine disease characteristics, or migraine attack characteristics predicted headache pain freedom or most bothersome symptom freedom response at 2 hours following lasmiditan treatment (interaction P ≥ .1). For the difficult-to-treat patient/migraine disease characteristics subgroups (defined as those with ≥24 headache days in the past 3 months, duration of migraine history ≥20 years, severe disability [Migraine Disability Assessment score ≥21], obesity [≥30 kg/m2 ], and history of psychiatric disorder), single doses of lasmiditan (100 or 200 mg) were significantly more effective than placebo (P ≤ .002) in achieving both endpoints. Headache pain freedom response rates for higher doses of lasmiditan were numerically greater than for lower doses of lasmiditan. For the difficult-to-treat migraine attack subgroups, patients with severe headache, co-existent nausea at the time of treatment, or who delayed treatment for ≥2 hours from the time of headache onset, both endpoint response rates after lasmiditan 100 or 200 mg were significantly greater than after placebo. Among those who delayed treatment for ≥4 hours from the time of headache onset, headache pain freedom response rates for the 200 mg dose of lasmiditan met statistical significance vs placebo (32.4% vs 15.9%; odds ratio = 2.7 [1.17, 6.07]; P = .018). While the predictors of response interaction test showed similar efficacy of lasmiditan vs placebo across subgroups defined by baseline functional disability (mild, moderate, or needs complete bed rest) at the time of treatment, analyses of lasmiditan efficacy within the subgroup "needs complete bed rest" appeared to show less efficacy (eg, in the 200 mg vs placebo group, 25.9% vs 18.5%; odds ratio = 1.56 [0.96, 2.53]; P = .070). CONCLUSIONS: Efficacy of lasmiditan 200 and 100 mg for headache pain freedom and most bothersome symptom freedom at 2 hours post-treatment was generally not influenced by the individual patient characteristics, migraine disease history, or migraine attack characteristics that were analyzed. In the analyses of difficult-to-treat subgroups, patients receiving lasmiditan achieved greater responses (2-hour headache pain freedom and most bothersome symptom freedom) vs placebo recipients.

Tweeting the Headache Meetings: Cross-Sectional Analysis of Twitter Activity Surrounding American Headache Society Conferences.

OBJECTIVES: To describe and analyze Twitter activity associated with American Headache Society (AHS) conferences and evaluate the potential for Twitter to promote education and public outreach. BACKGROUND: Many medical and scientific conferences have adopted Twitter as a method of promoting discussion among attendees as well as increasing visibility. Relatively little is known, however, about the composition of conference Twitter activity, the participants, and the impact on broader Twitter discussions. METHODS: We analyzed Twitter data from 5 AHS conferences held from 2014 to 2016 using their respective hashtags. Using the Symplur Healthcare Hashtags open social media search platform, we gathered data on numbers of tweets, impressions, participants, and mentions during a 10-day period surrounding each conference, as well as samples of Twitter accounts participating. Prominent accounts were categorized as individual medical professionals, other individuals, host organizations, health-related organizations, medical centers, and industry by cross-checking their Twitter profiles and conference registration lists. Larger samples of accounts participating in the 2016 conferences were also obtained and categorized similarly, with individual person accounts classified by conference registration status. A related prominent hashtag (#migraine) was also identified and Twitter usage before, during, and after each conference was analyzed to evaluate the impact of conference activity on broader Twitter conversations. RESULTS: Nineteen thousand nine hundred thirty-six tweets were generated across the 5 conferences, with 11,531 (58%) created by the Top 10 participating accounts in each conference, which were primarily individual medical professionals and host organizations. Thirty-two million six hundred eighty-three thousand impressions were generated across the 5 conferences, with 24,656,000 (75%) coming from the Top 10 participants in each, particularly host organizations and other individuals. An average of 331 accounts participated in each conference. The Top 10 mentioned accounts in each conference (consisting of 21 unique accounts with 14 accounts in the Top 10 across multiple conferences, primarily individual medical professionals) received a total of 15,093 mentions. Among 135 unique accounts participating actively in the two 2016 conferences, 39% were individual medical professionals, 38% other individuals, 16% health-related organizations (including the 2 host organizations), 4% medical centers, and 2% industry. From these samples, 34 of 70 (49%) and 43 of 66 (65%) individual person accounts participating in the Twitter discussion at each conference were not registered conference attendees, indicating substantial outside participation via Twitter. #migraine usage during conferences showed a significant increase from baseline in number of tweets (6080 in a 10-day period vs 3721, P < .0001) and participants (2332 vs 1830, P < .0001) but the increase was not significant for impressions (30,155 vs 25,361, P = .240). CONCLUSIONS: Consistent with the dynamics of Twitter conversations on other topics, AHS conference discussions featured a small group of accounts creating the bulk of content, with individual medical professionals and host organizations generating the largest shares of tweets and mentions while host organizations and other individuals produced the most impressions. Participating accounts were mainly individuals and health-related organizations, with more non-attendee participants than expected. Conference Twitter activity correlated with a significant increase in #migraine usage, suggesting a perceptible influence on the discussion of health-related topics beyond the conference itself.

Chronic Daily Headache: Ten Steps for Primary Care Providers to Regain Control.

BACKGROUND: Chronic daily headache (CDH) affects 2% to 4% of the North American and European population. Various pathways lead to this condition, although chronification of migraine and the occurrence of central sensitization in tension headache are the 2 most common. Medication overuse headaches complicate a substantial portion of other primary headaches that have become chronic and often make their treatment more complex and less successful. METHODS/RESULTS: A 10-step process to help primary care providers evaluate and treat CDH patients begins with excluding secondary headache disorders, then moves on to classification of the primary underlying headache disorder. Next, the exacerbating factors, as well as relevant comorbid conditions, are identified. The patient's current acute therapy is examined, and attempts are made to identify and resolve medication overuse if present. Past preventive therapies are reviewed, allowing for thoughtful design of a headache action plan with preventive, acute, and lifestyle components. Patients are asked to keep a headache diary, used to initiate a cycle of continuous improvement in a patient's response to acute and preventive therapeutic approaches. CONCLUSIONS: A systematic approach and partnership with patients often make it possible to convert CDH to episodic headache that is responsive to both acute and preventive therapies.

Occipital nerve block for the short-term preventive treatment of migraine: A randomized, double-blinded, placebo-controlled study.

BACKGROUND: Occipital nerve (ON) injections with corticosteroids and/or local anesthetics have been employed for the acute and preventive treatment of migraine for decades. However, to date there is no randomized, placebo-controlled evidence to support the use of occipital nerve block (ONB) for the prevention of migraine. OBJECTIVE: The objective of this article is to determine the efficacy of ONB with local anesthetic and corticosteroid for the preventive treatment of migraine. PARTICIPANTS AND METHODS: Patients between 18 and 75 years old with ICHD-II-defined episodic (> 1 attack per week) or chronic migraine (modified ICHD-II as patients with > 10 days with consumption of acute medications were permitted into the study) were randomized to receive either 2.5 ml 0.5% bupivacaine plus 0.5 ml (20 mg) methylprednisolone over the ipsilateral (unilateral headache) or bilateral (bilateral headache) ON or 2.75 ml normal saline plus 0.25 ml 1% lidocaine without epinephrine (placebo). Patients completed a one-month headache diary prior to and after the double-blind injection. The primary outcome measure was defined as a 50% or greater reduction in the frequency of days with moderate or severe migraine headache in the four-week post-injection compared to the four-week pre-injection baseline period. RESULTS: Thirty-four patients received active and 35 patients received placebo treatment. Because of missing data, the full analysis of 33 patients in the active and 30 patients in the placebo group was analyzed for efficacy. In the active and placebo groups respectively, the mean frequency of at least moderate (mean 9.8 versus 9.5) and severe (3.6 versus 4.3) migraine days and acute medication days (7.9 versus 10.0) were not substantially different at baseline. The percentage of patients with at least a 50% reduction in the frequency of moderate or severe headache days was 30% for both groups (10/30 vs nine of 30, Δ 0.00, 95% CI -0.22 to 0.23). CONCLUSIONS: Greater ONB does not reduce the frequency of moderate to severe migraine days in patients with episodic or chronic migraine compared to placebo.The study was registered with ClinicalTrial.gov (NCT00915473).

Neurostimulation for Treatment of Migraine and Cluster Headache.

OBJECTIVE: The objective of this narrative review is to summarize the current state of neurostimulation therapies for the treatment of migraine and/or cluster. METHODS: For this narrative review, publications were identified by searching PubMed using the search terms "migraine" or "cluster" combined with "vagal nerve stimulation," "transcranial magnetic stimulation," "supraorbital nerve stimulation," "sphenopalatine ganglion stimulation," "occipital nerve stimulation," "deep brain stimulation," "neurostimulation," or "neuromodulation." Publications were chosen based on the quality of data that were provided and their relevance to the chosen topics of interest for this review. Reference lists of chosen articles and the authors' own files were used to identify additional publications. Current clinical trials were identified by searching clinicaltrials.org. RESULTS AND CONCLUSIONS: Neurostimulation of the vagal nerve, supraorbital nerve, occipital nerve and sphenopalatine ganglion, transcranial magnetic stimulation (TMS), and deep brain stimulation have been investigated for the treatment of migraine and/or cluster. Whereas invasive methods of neurostimulation would be reserved for patients with very severe and treatment refractory migraine or cluster, noninvasive methods of stimulation might serve as useful adjuncts to more conventional therapies. Currently, transcutaneous supraorbital nerve stimulation is FDA approved and commercially available for migraine prevention and TMS is FDA approved for the treatment of migraine with aura. The potential utility of each type of neurostimulation has yet to be completely defined.

A Narrative Review of Evidence-Based Preventive Options for Chronic Migraine.

Chronic migraine is a debilitating disorder that affects 2 % of the global population and imparts a significant societal and economic impact. The cornerstones of chronic migraine management include making an accurate diagnosis, patient education, treatment of comorbid conditions, and selection of an appropriate, evidence-based acute and preventive treatment regimen. Although it is common to treat chronic migraine with preventive medications effective for episodic migraine, a number of treatment options exist with specific evidence for effectiveness in chronic migraine. Currently, onabotulinumtoxinA injections are the only FDA-approved preventive treatment for chronic migraine. A number of non-medication treatment options including occipital nerve and supraorbital nerve stimulation have shown promise as effective prevention for patients either unable to tolerate or unable to obtain relief from oral medications, but more research is necessary.

Imploding and exploding migraine headaches: comparison of methods to diagnose pain directionality.

BACKGROUND: The study aims to compare methods of determining headache directionality (imploding, exploding, and/or ocular headaches) in women with migraine, investigate the concordance between physician assignment and patient self-assignment of pain directionality, and evaluate whether patients assigned their headaches to the same direction when queried using different methods. Directionality of migraine headache pain (imploding, exploding, or ocular) may reflect differences in the underlying pathogenesis of individual migraine attacks among and within individuals. Emerging evidence suggests that directionality of pain in migraine sufferers may predict response to onabotulinumtoxin A. The best method of determining headache directionality in migraine sufferers has not been systematically explored. METHODS: We conducted a prospective cross-sectional survey study of 198 female patients with migraine presenting to a Women's Health Clinic. Patients determined the directionality (imploding, exploding, and/or ocular) of their own migraine pain by choosing among 3 pictures graphically representing directionality and also by responding to a written question regarding directionality. Clinicians then classified directionality of migraine pain using structured interviews. Concordance between clinician assignment of directionality and patient self-assignment was determined with Kappa coefficients. RESULTS: Subjects were females between the ages of 18 and 77 years (mean 48 years). According to patient selection of representative pictures, 62 (31.6%) had imploding headaches with or without ocular pain, 36 (18.4%) had exploding headaches with or without ocular pain, 78 (39.8%) had ocular pain only, and 20 (10.2%) had imploding and exploding headaches with or without ocular pain. Two subjects did not respond. According to patient responses to a written question, 80 (41.0%) had imploding headaches with or without ocular pain, 53 (27.2%) had exploding headaches with or without ocular pain, 46 (23.6%) had ocular pain only, and 16 (8.2%) had imploding and exploding headaches with or without ocular pain. Three subjects did not respond. For physician assignment, 69 (34.9%) subjects had imploding headaches with or without ocular pain, 89 (45%) had exploding headaches with or without ocular pain, 14 (7.1%) had ocular pain only, and 26 (13.1%) had imploding and exploding headaches with or without ocular pain. The concordance (Kappa coefficient) between physician assignment of headache directionality with patient response to the written question was 0.33 (weak agreement), between physician assignment and patient assignment via selection of representative pictures was 0.35 (weak agreement), and between patient assignment via written question and via selection of representative pictures was 0.35 (weak agreement). CONCLUSIONS: The assignment of headache directionality varied substantially depending upon the method of determination. The concordance between clinician assignment, patient-self assignment via answering a written question, and patient self-assignment via choosing a representative picture was weak. Improved methods of determining pain directionality are needed.

Comparing the Efficacy and Safety of Galcanezumab Versus Rimegepant for Prevention of Episodic Migraine: Results from a Randomized, Controlled Clinical Trial.

INTRODUCTION: There have been no prior trials directly comparing the efficacy of different calcitonin gene-related peptide (CGRP) antagonists for migraine prevention. Reported are the results from the first head-to-head study of two CGRP antagonists, galcanezumab (monoclonal antibody) versus rimegepant (gepant), for the prevention of episodic migraine. METHODS: In this 3-month, double-blind, double-dummy study, participants were randomized (1:1) to subcutaneous (SC) galcanezumab 120 mg per month (after a 240 mg loading dose) and a placebo oral disintegrating tablet (ODT) every other day (q.o.d.) or to rimegepant 75 mg ODT q.o.d. and a monthly SC placebo. The primary endpoint was the proportion of participants with a ≥ 50% reduction in migraine headache days per month from baseline across the 3-month double-blind treatment period. Key secondary endpoints were overall mean change from baseline in: migraine headache days per month across 3 months and at month 3, 2, and 1; migraine headache days per month with acute migraine medication use; Migraine-Specific Quality of Life Questionnaire Role Function-Restrictive domain score at month 3; and a ≥ 75% and 100% reduction from baseline in migraine headache days per month across 3 months. RESULTS: Of 580 randomized participants (galcanezumab: 287, rimegepant: 293; mean age: 42 years), 83% were female and 81% Caucasian. Galcanezumab was not superior to rimegepant in achieving a ≥ 50% reduction from baseline in migraine headache days per month (62% versus 61% respectively; P = 0.70). Given the pre-specified multiple testing procedure, key secondary endpoints cannot be considered statistically significant. Overall, treatment-emergent adverse events were reported by 21% of participants, with no significant differences between study intervention groups. CONCLUSIONS: Galcanezumab was not superior to rimegepant for the primary endpoint; however, both interventions demonstrated efficacy as preventive treatments in participants with episodic migraine. The efficacy and safety profiles observed in galcanezumab-treated participants were consistent with previous studies. TRIAL REGISTRATION: ClinTrials.gov-NCT05127486 (I5Q-MC-CGBD).

Galcanezumab and rimegepant are preventive treatments for episodic migraine. The goal of this study was to compare the efficacy of galcanezumab and rimegepant in reducing the number of monthly migraine headaches and to determine if galcanezumab was better than rimegepant. The study provides important information to doctors and their patients when making treatment decisions.People with episodic migraine were assigned to the galcanezumab (given as an injection under the skin) or rimegepant (given as a tablet that dissolves in the mouth) group and treated for 3 months. The doctor and the patient did not know which group they were assigned to, and to keep it unknown to both, people in the galcanezumab group got an injection with real medicine and a fake tablet, and people in the rimegepant group got a tablet with real medicine and a fake injection. The researchers wanted to know how many people in each group had at least a 50% reduction in their monthly migraine headaches.Of the 580 people in the study, 287 were assigned to galcanezumab and 293 to rimegepant. In both groups, most were female and white. After 3 months of treatment, 62% of the people in the galcanezumab group and 61% of people in the rimegepant group had at least a 50% reduction in monthly migraine headaches. Both treatments were effective, but galcanezumab was not better than rimegepant. About 20% of the people in each treatment group had a side effect from the medication, and most were mild or moderate in severity.

Primary exertional headache: updates in the literature.

Primary exertional headache (PEH) has been recognized by the International Headache Society as a primary headache diagnosis since 1994. It is an uncommon, self-limited, and short-lasting disorder that is precipitated by exertion and is frequently comorbid with migraine. PEH shares a number of features with other headache disorders, including thunderclap headache, primary cough headache, and headache associated with sexual activity. Upon its initial occurrence, PEH requires a thorough neurologic evaluation and imaging studies to help eliminate possible underlying secondary causes, including subarachnoid hemorrhage and sentinel bleed. Although PEH is incompletely understood with regard to its epidemiology and pathophysiology, it is generally considered to be a benign disorder that is self-limited and responsive to trigger avoidance and indomethacin.

Long-term outcome in occipital nerve stimulation patients with medically intractable primary headache disorders.

INTRODUCTION: €‚ Occipital nerve stimulation (ONS) may provide relief for refractory headache disorders. However, scant data exist regarding long-€term ONS outcomes. METHODS: €‚ The methods used were retrospective review of the medical records of all (nonindustry study) patients who were trialed and implanted with occipital nerve stimulator systems at our institution, followed by a phone interview. Up to three attempts were made to contact each patient, and those who were contacted were given the opportunity to participate in a brief phone interview regarding their ONS experience. Data for analysis were gleaned from both the phone interview and the patient's medical records. RESULTS: €‚ Twenty-nine patients underwent a trial of ONS during the 8.5-€year study period. Three patients did not go on to permanent implant, 12 could not be contacted, and 14 participated in the phone interview. Based upon the phone interview (if the patient was contacted) or chart review, ONS was deemed successful in five of the 12 migraine, four of the five cluster headache, and five of the eight miscellaneous headache patients, and therapy was documented as long as 102 months. In one of the 26 patients, success of ONS could not be determined. Among patients deemed to have successful outcomes, headache frequency decreased by 18%, severity by 27%, and migraine disability score by 50%. Fifty-€eight percent of patients required at least one lead revision. DISCUSSION: €‚ These results, although limited by their retrospective nature, suggest that ONS can be effective long term despite technical challenges. The number of patients within each headache subtype was insufficient to draw conclusions regarding the differential effect of ONS. CONCLUSIONS: €‚ Randomized controlled long-€term studies in specific, intractable, primary headache disorders are indicated.

The National Football League Concussion Protocol: A Review.

Sport-related concussion remains an area of high concern for contact sport athletes and their families, as well as for the medical and scientific communities. The National Football League (NFL), along with the NFL Players Association and experts in the field, has developed protocols for the detection and management of sport-related concussions. This article reviews the NFL's most recent concussion protocol including preseason education and baseline testing for players, concussion surveillance by gameday medical teams and neurotrauma consultants and athletic trainers, gameday concussion protocol and procedures, and return to participation guidelines.

Reliability of real-time video smartphone for assessing National Institutes of Health Stroke Scale scores in acute stroke patients.

BACKGROUND AND PURPOSE: Telestroke reduces acute stroke care disparities between urban stroke centers and rural hospitals. Current technologies used to conduct remote patient assessments have high start-up costs, yet they cannot consistently establish quality timely connections. Smartphones can be used for high-quality video teleconferencing. They are inexpensive and ubiquitous among health care providers. We aimed to study the reliability of high-quality video teleconferencing using smartphones for conducting the National Institutes of Health Stroke Scale (NIHSS). METHODS: Two vascular neurologists assessed 100 stroke patients with the NIHSS. The remote vascular neurologist assessed subjects using smartphone videoconferencing with the assistance of a bedside medical aide. The bedside vascular neurologist scored patients contemporaneously. Each vascular neurologist was blinded to the other's NIHSS scores. We tested the inter-method agreement and physician satisfaction with the device. RESULTS: We demonstrated high total NIHSS score correlation between the methods (r=0.949; P<0.001). The mean total NIHSS scores for bedside and remote assessments were 7.93±8.10 and 7.28±7.85, with ranges, of 0 to 35 and 0 to 37, respectively. Eight categories had high agreement: level of consciousness (questions), level of consciousness (commands), visual fields, motor left and right (arm and leg), and best language. Six categories had moderate agreement: level of consciousness (consciousness), best gaze, facial palsy, sensory, dysarthria, and extinction/inattention. Ataxia had poor agreement. There was high physician satisfaction with the smartphone. CONCLUSIONS: Smartphone high-quality video teleconferencing is reliable, easy to use, affordable for telestroke NIHSS administration, and has high physician satisfaction.

Smartphone teleradiology application is successfully incorporated into a telestroke network environment.

BACKGROUND AND PURPOSE: ResolutionMD mobile application runs on a Smartphone and affords vascular neurologists access to radiological images of patients with stroke from remote sites in the context of a telemedicine evaluation. Although reliability studies using this technology have been conducted in a controlled environment, this study is the first to incorporate it into a real-world hub and spoke telestroke network. The study objective was to assess the level of agreement of brain CT scan interpretation in a telestroke network between hub vascular neurologists using ResolutionMD, spoke radiologists using a Picture Archiving and Communications System, and independent adjudicators. METHODS: Fifty-three patients with stroke at the spoke hospital consented to receive a telemedicine consultation and participate in a registry. Each CT was evaluated by a hub vascular neurologist, a spoke radiologist, and by blinded telestroke adjudicators, and agreement over clinically important radiological features was calculated. RESULTS: Agreement (κ and 95% CI) between hub vascular neurologists using ResolutionMD and (1) the spoke radiologist; and (2) independent adjudicators, respectively, were: identification of intracranial hemorrhage 1.0 (0.92-1.0), 1.0 (0.93-1.0), neoplasm 1.0 (0.92-1.0), 1.0 (0.93-1.0), any radiological contraindication to thrombolysis 1.0 (0.92-1.0), 0.85 (0.65-1.0), early ischemic changes 0.62 (0.28-0.96), 0.58 (0.30-0.86), and hyperdense artery sign 0.40 (0.01-0.80), 0.44 (0.06-0.81). CONCLUSIONS: CT head interpretations of telestroke network patients by vascular neurologists using ResolutionMD on Smartphones were in excellent agreement with interpretations by spoke radiologists using a Picture Archiving and Communications System and those of independent telestroke adjudicators using a desktop viewer. CLINICAL TRIAL REGISTRATION INFORMATION: www.clinicaltrials.gov unique identifier NCT00829361.

Posttraumatic headache.

PURPOSE OF REVIEW: Posttraumatic headache (PTH) is a commonly occurring and potentially disabling consequence of concussion and mild traumatic brain injury (mTBI). This brief review highlights recent advances in the epidemiology, evaluation, and management of concussion, mTBI, and PTH. RECENT FINDINGS: Current epidemiological studies suggest that previous estimates of concussion and mTBI incidence are grossly underestimated and have also helped to identify specific activities and demographic groups that might be more susceptible. Concussion results in profound metabolic derangements during which the brain is potentially vulnerable to repeat injury and permanent damage. Imaging studies such as magnetic resonance (MR) spectroscopy and diffusion tensor imaging have proven to be effective at identifying these abnormalities both acutely and also weeks after symptoms resolution. To date, there have been no randomized, placebo-controlled studies supporting the efficacy of any treatment for PTH and current therapeutic decisions are guided only by expert opinion and current evidence-based guidelines for the treatment of specific primary headache phenotypes, the most commonly occurring of which is migraine. SUMMARY: Despite numerous advances in the awareness, pathophysiology, and diagnostic workup of concussion, mTBI, and PTH, there is a paucity of evidence-based guidance regarding treatment.

The portrayal of migraine in popular music: observations and implications.

OBJECTIVE: To describe the manner in which migraine and migaineurs are depicted in popular music. BACKGROUND: Prior studies have elucidated the ways in which the popular perception of neurological disorders is shaped by popular culture, from the inflated expectations of the prognosis of coma patients in television dramas to the association of intractable headaches with demonic possession and death by violence in the cinema. METHODS: searched popular online music sites for songs with the word "migraine" in their titles. Song lyrics were studied for tone, content, and the light in which they portrayed migraine sufferers. RESULTS: One hundred thirty-four songs met inclusion criteria, representing the work of 126 artists. The majority of the recording artists were male (112 of 126 artists, 89%). One hundred seven of the 134 songs (80%) were recorded since 2000. Of the 79 songs that contained lyrics, 16 (20%) included explicit content; 43 (54%) make reference to hopelessness, despair, or severe pain; and 27 (34%) contained references to killing or death. Only 9 songs (11%) made any reference to successful treatment, resolution, or hope of any sort, the same number that made lyrical references to explosions or bombs. CONCLUSIONS: The portrayal of a disease in popular music can reflect the artist's perceptions, anxieties, and prejudices about the disease and its victims. The public, including patients, may accept these portrayals as accurate. Clinicians familiar with the portrayal of headache sufferers in cinema will not be surprised that popular musicians (both migraineurs and non-migraineurs) portray migraines as intractable, violent, and all-consuming. The lack of any balancing view is disheartening, especially in light of the advances in migraine awareness and treatment over the past decade. Perhaps the most surprising finding is that the vast majority of migraine songs are written and performed by men.

Teleconcussion: an innovative approach to screening, diagnosis, and management of mild traumatic brain injury.

Concussion awareness and management in sports have gained a great deal of attention in light of research illustrating the potentially devastating consequences of repeated traumatic brain injuries. In order to address this public health crisis, numerous states have passed legislation that mandates medical clearance before being eligible to return to play of concussed athletes by a qualified healthcare provider. As the number of qualified healthcare providers with expertise in the diagnosis and management of concussions remains very small, patient safety and the ability to fulfill these legislative return-to-play requirements present unique problems to rural communities without easy access to subspecialty care. Telemedicine is a possible means by which to address the needs of the rural student-athlete.

The not so hidden impact of interictal burden in migraine: A narrative review.

Migraine is a highly prevalent neurological disease of varying attack frequency. Headache attacks that are accompanied by a combination of impact on daily activities, photophobia and/or nausea are most commonly migraine. The headache phase of a migraine attack has attracted more research, assessment tools and treatment goals than any other feature, characteristic, or phase of migraine. However, the migraine attack may encompass up to 4 phases: the prodrome, aura, headache phase and postdrome. There is growing recognition that the burden of migraine, including symptoms associated with the headache phase of the attack, may persist between migraine attacks, sometimes referred to as the "interictal phase." These include allodynia, hypersensitivity, photophobia, phonophobia, osmophobia, visual/vestibular disturbances and motion sickness. Subtle interictal clinical manifestations and a patient's trepidation to make plans or commitments due to the unpredictability of migraine attacks may contribute to poorer quality of life. However, there are only a few tools available to assess the interictal burden. Herein, we examine the recent advances in the recognition, description, and assessment of the interictal burden of migraine. We also highlight the value in patients feeling comfortable discussing the symptoms and overall burden of migraine when discussing migraine treatment needs with their provider.