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.

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.

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.

Stroke Telemedicine for Arizona Rural Residents, the Legacy Telestroke Study.

Background: Efficacy of telemedicine for stroke was first established by the Stroke Team Remote Evaluation Using a Digital Observation Camera (STRokE DOC) trials in California and Arizona. Following these randomized controlled trials, the Stroke Telemedicine for Arizona Rural Residents (STARR) network was the first telestroke network to be established in Arizona. It consisted of a 7 spoke 1 hub telestroke system, and it was designed to serve rural, remote, or neurologically underserved communities. Objective: The objective of STARR was to establish a multicenter state-wide telestroke research network to determine the feasibility of prospective collection, recording, and regularly analysis of telestroke patient consultations and care data for the purposes of establishing quality measures, improvement, and benchmarking against other national and international telestroke programs. Methods: The STARR trial was open to enrollment for 29 months from 2008 to 2011. Mayo Clinic Hospital, Phoenix, Arizona served as the hub primary stroke center and its vascular neurologists provided emergency telestroke consultations to seven participating rural, remote, or underserved spoke community hospitals in Arizona. Eligibility criteria for activation of a telestroke alert and study enrollment were established. Consecutive patients exhibiting symptoms and signs of acute stroke within a 12 h window were enrolled, assessed, and treated by telemedicine. The state government sponsor, Arizona Department of Health Services' research grant covered the cost of acquisition, maintenance, and service of the selected telemedicine equipment as well as the professional telestroke services provided. The study deployed multiple telemedicine video cart systems, picture archive and communications systems software, and call management solutions. The STARR protocol was reviewed and approved by Mayo Clinic IRB, which served as the central IRB of record for all the participating hospitals, and the trial was registered at ClinicalTrials.gov. Results: The telestroke hotline was activated 537 times, and ultimately 443 subjects met criteria and consented to participate. The STARR successfully established a multicenter state-wide telestroke research network. The STARR developed a feasible and pragmatic approach to the prospective collection, storage, and analysis of telestroke patient consultations and care data for the purposes of establishing quality measures and tracking improvement. STARR benchmarked well against other national and international telestroke programs. STARR helped set the foundation for multiple regional and state telestroke networks and ultimately evolved into a national telestroke network. Conclusions: Multiple small and rurally located community hospitals and health systems can successfully collaborate with a more centrally located larger hospital center through telemedicine technologies to develop a coordinated approach to the assessment, diagnosis, and emergency treatment of patients manifesting symptoms and signs of an acute stroke syndrome. This model may serve well the needs of patients presenting with other time-sensitive medical emergencies.Clinical Trial Registration number: NCT00829361.

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.

Telemedicine in neurology: Telemedicine Work Group of the American Academy of Neurology update.

PURPOSE: While there is strong evidence supporting the importance of telemedicine in stroke, its role in other areas of neurology is not as clear. The goal of this review is to provide an overview of evidence-based data on the role of teleneurology in the care of patients with neurologic disorders other than stroke. RECENT FINDINGS: Studies across multiple specialties report noninferiority of evaluations by telemedicine compared with traditional, in-person evaluations in terms of patient and caregiver satisfaction. Evidence reports benefits in expediting care, increasing access, reducing cost, and improving diagnostic accuracy and health outcomes. However, many studies are limited, and gaps in knowledge remain. SUMMARY: Telemedicine use is expanding across the vast array of neurologic disorders. More studies are needed to validate and support its use.

K-D Balance: An objective measure of balance in tandem and double leg stances.

BACKGROUND AND OBJECTIVE: Subjective grade-based scoring balance assessments tend to be lengthy and have demonstrated poor repeatability and reliability. This study examined the reliability of a mobile balance assessment tool and differences in balance measurements between individuals at risk for a balance deficit secondary to a diagnosed neurological or musculoskeletal condition and a control group of healthy individuals. METHODS: Objective balance testing was measured using K-D Balance on a compatible iPhone. Seventy-seven participants were enrolled (control group, n = 44; group at risk for balance deficits, n = 33). Mean and standard deviation of K-D Balance were recorded for each stance. Intra-rater reliability was calculated by repeating the trial. RESULTS: Overall balance scores were superior for the control group compared with the group at risk for balance deficits in double leg stance (mean (SD): 0.15 (0.12) versus 0.18 (0.13), p = 0.260), tandem stance right leg (mean (SD): 0.27 (0.17) versus 0.45 (0.49), p = 0.028), and tandem stance left leg (mean (SD): 0.26 (0.17) versus 0.35 (0.35), p = 0.136). Intra-rater reliability was good to excellent for K-D Balance double leg stance (intra-class correlation coefficient (ICC) = 0.80, 95% confidence interval (CI) 0.58-1.03), tandem stance right leg (ICC = 0.96, 95% CI 0.86-1.06) and tandem stance left leg (ICC = 0.98, 95% CI 0.95-1.0). CONCLUSIONS: K-D Balance revealed differences in balance performance between healthy individuals compared with individuals with neurological or musculoskeletal impairment. Objective balance measures may improve the accuracy and reliability of clinical balance assessment by detecting subtle differences in balance and aid in early detection of diseases that impair balance.

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.

Acute Treatment of Migraine.

PURPOSE OF REVIEW: This article provides a framework to help providers formulate a plan for the acute treatment of migraine. Topics covered include the cost-effective patient-centered approach known as stratified care and a summary of evidence-based treatment options that are currently available. Strategies for improving treatment response, troubleshooting suboptimal results, and addressing the needs of special populations are also reviewed. RECENT FINDINGS: Both the American Headache Society and the Canadian Headache Society have released evidence-based assessments and reviews of acute treatments for migraine that can be used to help guide treatment decisions. Although several older medications have been re-released with new formulations or new delivery systems, several new medications have also become available or are in the final phases of study, further increasing the number of options available for patients. SUMMARY: The acute management of migraine should incorporate a stratified care model in concert with evidence-based treatment options. The response to treatment should be monitored regularly, and measures should be taken to identify suboptimal tolerability or efficacy.

The Effect of In-School Saccadic Training on Reading Fluency and Comprehension in First and Second Grade Students.

Efficient eye movements provide a physical foundation for proficient reading skills. We investigated the effect of in-school saccadic training on reading performance. In this cross-over design, study participants (n = 327, 165 males; mean age [SD]: 7 y 6 mo [1y 1 mo]) were randomized into treatment and control groups, who then underwent eighteen 20-minute training sessions over 5 weeks using King-Devick Reading Acceleration Program Software. Pre- and posttreatment reading assessments included fluency, comprehension, and rapid number naming performance. The treatment group had significantly greater improvement than the control group in fluency (6.2% vs 3.6%, P = .0277) and comprehension (7.5% vs 1.5%, P = .0002). The high-needs student group significantly improved in fluency ( P < .001) and comprehension ( P < .001). We hypothesize these improvements to be attributed to the repetitive practice of reading-related eye movements, shifting visuospatial attention, and visual processing. Consideration should be given to teaching the physical act of reading within the early education curriculum.

Feasibility and accuracy of teleconcussion for acute evaluation of suspected concussion.

OBJECTIVE: To assess the feasibility and accuracy of telemedical concussion evaluations (teleconcussion) for real-time athletic sideline assessment of concussion, as such assessment may address the gap in access some populations of athletes have to providers with expertise in concussion evaluation. METHODS: A cohort of 11 consecutive male collegiate football players with suspected concussion was assessed using Standardized Assessment of Concussion (SAC), King-Devick test (K-D), and modified Balance Error Scoring System (mBESS). A remote neurologist assessed each athlete using a telemedicine robot with real-time, 2-way audiovisual capabilities, while a sideline provider performed a simultaneous face-to-face assessment. After the assessment, a remove-from-play (RFP) determination was made. The remote and the face-to-face providers were blinded to each other's examination findings and RFP decision until the end of the assessment. RESULTS: The teleconcussion and face-to-face SAC were in agreement 100% of the time (6/6; 95% confidence interval [CI] 54%-100%). The mean (SD) difference between remote and sideline K-D times was 0.7 (1.4) seconds. Remote and sideline K-D times were within a 3-second difference 100% of the time (11/11; 95% CI 72%-100%). Remote and sideline mBESS scores were within 3 points 100% of the time (6/6; 95% CI 54%-100%). RFP decisions were in agreement 100% of the time (11/11; 95% CI 72%-100%). CONCLUSIONS: The aim of this study was to investigate the feasibility of teleconcussion for sideline concussion assessments. These data suggest a high level of agreement between remote and face-to-face providers with regard to examination findings and RFP determinations.

King-Devick Test identifies real-time concussion and asymptomatic concussion in youth athletes.

BACKGROUND: Sports concussion has an annual incidence of approximately 3.8 million. Over half go unreported and a substantial number may be asymptomatic. A rapid, cost-effective, and reliable tool that facilitates diagnosis of concussion is needed. The King-Devick (K-D) test is a vision-based tool of rapid number naming for assessment of concussion. In this study, we evaluated the utility of the K-D test in real time for identification of symptomatic concussion in youth athletes and to determine if similar impairment (subclinical concussion) exists in youth athletes without an obvious head injury or symptoms. METHODS: Youth hockey players underwent K-D testing preseason, postseason, and immediately after suspected concussion. Additional testing was performed in a subgroup of nonconcussed athletes immediately before and after a game to determine effects of fatigue on K-D scores. RESULTS: Among 141 players tested, 20 had clinically diagnosed concussion. All 20 had immediate postconcussion K-D times >5 seconds from baseline (average 7.3 seconds) and all but 2 had worse postseason scores (46.4 seconds vs 52.4 seconds, p < 0.05, Wilcoxon signed rank test). Nonconcussed athletes saw minimal improvement postseason (43.9 seconds vs 42.1 seconds, p < 0.05) and 51 nonconcussed players assessed before and after a game revealed no significant time change as a result of fatigue. CONCLUSIONS: Rapid number naming using the K-D test accurately identifies real-time, symptomatic concussion in youth athletes. Scores in concussed players may remain abnormal over time. Athletes should undergo preseason and postseason K-D testing, with additional evaluation real time to inform the assessment of suspected concussion. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that the K-D test accurately identifies real-time concussions in youth athletes.

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.

ACE and ARB Agents in the Prophylactic Therapy of Migraine-How Effective Are They?

OPINION STATEMENT: Angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) are antihypertensive agents that can be considered for migraine preventative therapy. Although the exact mechanisms by which ACE inhibitors and ARBs may work for migraine prophylaxis are unknown, there are several plausible hypotheses as to why modulating the activity of the renin angiotensin system could result in migraine prevention. Clinical trials of ACE inhibitors and ARBs provide evidence that they are effective and generally well tolerated when used for migraine prophylaxis. Based upon biologic plausibility, the quality of evidence for efficacy from clinical trials, and recommendations in published guidelines, we consider ACE inhibitors and ARBs as second- or third-line options for migraine prophylaxis.

Variability of the modified Balance Error Scoring System at baseline using objective and subjective balance measures.

AIM: To investigate preseason modified Balance Error Scoring System (mBESS) performance in a collegiate football cohort; to compare scores to an objective mobile balance measurement tool. MATERIALS & METHODS: Eighty-two athletes completed simultaneous balance testing using mBESS and the King-Devick Balance Test, an objective balance measurement tool. Errors on mBESS and objective measurements in the double-leg, single-leg (SS) and tandem stances were compared. RESULTS: Mean mBESS error score was 7.23 ± 4.65. The SS accounted for 74% of errors and 21% of athletes demonstrated the maximum error score. There was no significant correlation between mBESS score and objective balance score. CONCLUSION: The high variability and large number of errors in the SS raises concerns over the utility of the SS in identifying suspected concussion.

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.