Prospective cohort study of routine exercise and headache outcomes among adults with episodic migraine.

OBJECTIVE: To evaluate the association of routine exercise with headache frequency, intensity, and duration among adults with episodic migraine (EM). BACKGROUND: A comprehensive management plan for EM must aim at reducing disability and cost of care; to do so requires optimizing acute and preventive medications, and behavior changes. Prophylactic medication use is associated with adverse events and contraindications with comorbidities. Aerobic exercise is reported to decrease migraine frequency. However, no study has evaluated a potential synergistic relation between regular exercise and preventive medication use among patients with EM. DESIGN AND METHODS: This was a secondary analysis of data from a prospective cohort study of adults with EMs. In that study, adults with EM (using International Classification of Headache Disorders-3 criteria confirmed by study physicians) were recruited from three academic medical centers in Boston, MA. At baseline, participants provided information on exercise, clinical and demographic characteristics, and lifestyle behaviors. We prospectively collected daily information on headaches and health behavior over at least 6 weeks using electronic questionnaires from 94 participants. We assessed the association between baseline self-reported moderate-vigorous exercise at least three times per week, at baseline, and prospectively recorded headache frequency, intensity, and duration. We further assessed whether these associations differed by the prevalent use of prophylactic migraine medication. RESULTS: Data from 94 of 98 eligible participants were used in the analysis as 4 participants had missing data on routine exercise frequency or intensity at baseline. On average, patients who reported moderate-vigorous exercise at least three times per week at enrollment had 1.5 fewer headache days per month (-1.5 headache days/month; 95% confidence interval [CI] -3.1 to 0.1) compared to less exercise; this was not statistically significant (p = 0.066). The association between exercise and headache days per month varied by baseline use of migraine prophylaxis (p-value of interaction = 0.009). Among those who reported regular use of migraine prophylaxis, a report of moderate-vigorous exercise at least three times per week was associated with 5.1 fewer headache days (-5.1: 95% CI -8.2 to -2.0; p = 0.001) compared to those who reported lower levels of exercise. However, among those not using migraine prophylaxis, we observed only 0.4 fewer headache days per month (-0.4: 95% CI -2.2 to 1.3; p = 0.636) associated with moderate-vigorous exercise at least three times/week, a result that was not statistically significant. There was no association of self-reported moderate-vigorous exercise at least three times a week with headache intensity or duration. CONCLUSION: In patients with EM, those who reported moderate-vigorous exercise at least three times per week had fewer headache days per month, though not statistically significant. This association was significantly stronger in those who used prophylactic medication for migraines. Exercise appeared not to be associated with the severity or duration of headaches. Routine moderate-vigorous exercise may be an important adjunctive strategy for improving headache burden in patients eligible for migraine prophylaxis.

Cardiac involvement in hospitalized patients with COVID-19 and its incremental value in outcomes prediction.

Recent reports linked acute COVID-19 infection in hospitalized patients to cardiac abnormalities. Studies have not evaluated presence of abnormal cardiac structure and function before scanning in setting of COVD-19 infection. We sought to examine cardiac abnormalities in consecutive group of patients with acute COVID-19 infection according to the presence or absence of cardiac disease based on review of health records and cardiovascular imaging studies. We looked at independent contribution of imaging findings to clinical outcomes. After excluding patients with previous left ventricular (LV) systolic dysfunction (global and/or segmental), 724 patients were included. Machine learning identified predictors of in-hospital mortality and in-hospital mortality + ECMO. In patients without previous cardiovascular disease, LV EF < 50% occurred in 3.4%, abnormal LV global longitudinal strain (< 16%) in 24%, and diastolic dysfunction in 20%. Right ventricular systolic dysfunction (RV free wall strain < 20%) was noted in 18%. Moderate and large pericardial effusion were uncommon with an incidence of 0.4% for each category. Forty patients received ECMO support, and 79 died (10.9%). A stepwise increase in AUC was observed with addition of vital signs and laboratory measurements to baseline clinical characteristics, and a further significant increase (AUC 0.91) was observed when echocardiographic measurements were added. The performance of an optimized prediction model was similar to the model including baseline characteristics + vital signs and laboratory results + echocardiographic measurements.

Social Determinants of Adherence to COVID-19 Risk Mitigation Measures Among Adults With Cardiovascular Disease.

BACKGROUND: Social determinants of health (SDOH) may limit the practice of coronavirus disease 2019 (COVID-19) risk mitigation guidelines with health implications for individuals with underlying cardiovascular disease (CVD). Population-based evidence of the association between SDOH and practicing such mitigation strategies in adults with CVD is lacking. We used the National Opinion Research Center's COVID-19 Household Impact Survey conducted between April and June 2020 to evaluate sociodemographic disparities in adherence to COVID-19 risk mitigation measures in a sample of respondents with underlying CVD representing 18 geographic areas of the United States. METHODS: CVD status was ascertained by self-reported history of receiving heart disease, heart attack, or stroke diagnosis. We built de novo, a cumulative index of SDOH burden using education, insurance, economic stability, 30-day food security, urbanicity, neighborhood quality, and integration. We described the practice of measures under the broad strategies of personal protection (mask, hand hygiene, and physical distancing), social distancing (avoiding crowds, restaurants, social activities, and high-risk contact), and work flexibility (work from home, canceling/postponing work). We reported prevalence ratios and 95% CIs for the association between SDOH burden (quartiles of cumulative indices) and practicing these measures adjusting for age, sex, race/ethnicity, comorbidity, and interview wave. RESULTS: Two thousand thirty-six of 25 269 (7.0%) adults, representing 8.69 million in 18 geographic areas of the United States, reported underlying CVD. Compared with the least SDOH burden, fewer individuals with the greatest SDOH burden practiced all personal protection (75.6% versus 89.0%) and social distancing measures (41.9% versus 58.9%) and had any flexible work schedule (26.2% versus 41.4%). These associations remained statistically significant after full adjustment: personal protection (prevalence ratio, 0.83 [95% CI, 0.73-0.96]; P=0.009), social distancing (prevalence ratio, 0.69 [95% CI, 0.51-0.94]; P=0.018), and work flexibility (prevalence ratio, 0.53 [95% CI, 0.36-0.79]; P=0.002). CONCLUSIONS: SDOH burden is associated with lower COVID-19 risk mitigation practices in the CVD population. Identifying and prioritizing individuals whose medical vulnerability is compounded by social adversity may optimize emerging preventive efforts, including vaccination guidelines.