Effect of galcanezumab in women with episodic migraine meeting criteria for menstrually related migraine: A post hoc analysis of EVOLVE-1 and EVOLVE-2.

BACKGROUND: We evaluated galcanezumab for migraine prevention in patients who met International Classification of Headache Disorders, 3rd edition criteria for menstrually related migraine (MRM). METHODS: Patients were identified post hoc from three double-blind, randomized, phase 3 clinical trials in patients with episodic migraine. Patients completed a 1-month prospective baseline period and up to 6 months (EVOLVE-1 and -2, studies pooled) of double-blind treatment with galcanezumab (120 mg/month) or placebo. Menses and headache information were recorded by electronic daily diary. Patients with a migraine attack starting during the 5-day perimenstrual interval (first day of bleeding ± 2 days) for ≥2 of their first three diary-recorded menstrual cycles were categorized as having MRM. The primary efficacy measure was mean change in monthly migraine headache days from baseline, averaged over Months 4 through 6. Response rates, change in monthly perimenstrual migraine headache days, monthly non-perimenstrual migraine headache days, and quality of life were also assessed. RESULTS: Post hoc MRM analysis criteria were met by 462/1133 women (41%). Mean (standard deviation) baseline monthly migraine headache days were 9.7 (±3.1; n = 146) for galcanezumab-treated patients and 9.6 (±2.8; n = 316) for placebo-treated patients. The mean change (standard error [SE]) in migraine headache days over Months 4 through 6 was -5.1 days (±0.39) for galcanezumab versus -3.2 (±0.35) for placebo (p < 0.001). The mean change (SE) in perimenstrual migraine headache days over Months 4 through 6 was -0.75 days (±0.08) for galcanezumab versus -0.49 (±0.07) for placebo (p = 0.004). For migraine headache days outside the perimenstrual period, the mean change in migraine headache days was -4.6 (±0.38) for galcanezumab and -2.8 (±0.33) for placebo (p < 0.001). Improvements in response rates and the Migraine-Specific Quality of Life Questionnaire were also observed over Months 4 through 6. CONCLUSION: Galcanezumab was effective for migraine prevention in women with MRM.

Situational prevention: Pharmacotherapy during periods of increased risk for migraine attacks.

The small molecule calcitonin gene-related peptide receptor antagonists (gepants) are the only drug class with medicines indicated for both the acute and preventive treatment of migraine. Given this dual capacity to both treat and prevent, along with their favorable tolerability profiles and lack of an association with medication-overuse headache, headache specialists have begun to use gepants in ways that transcend the traditional categories of acute and preventive treatment. One approach, called situational prevention, directs patients to treat during the interictal phase, before symptoms develop, in situations of increased risk for migraine attacks. Herein, we present three patients to illustrate scenarios of gepant use for situational prevention. In each case, a gepant was started in anticipation of a period of increased headache probability (vulnerability) and continued for a duration of 1 day to 5 consecutive days. Although this approach may expose patients to medication when headache may not have developed, the tolerability and safety profile and preventive effect of gepants may represent a feasible approach for some patients. Situational prevention is an emerging strategy for managing migraine before symptoms develop in individuals who can identify periods when the probability of headache is high. This paper is intended to increase awareness of this strategy and stimulate future randomized, placebo-controlled trials to rigorously assess this strategy.

Effects of Eligibility Criteria on Patient Selection and Treatment Implications from 10 Multidomain Dementia Prevention Trials: A Population-Based Study.

INTRODUCTION: Dementia prevention trials have so far shown little benefit of multidomain interventions against cognitive decline. Recruitment strategies in these trials often centre around dementia risk or cardiovascular risk profile, but it is uncertain whether this leads to inclusion of individuals who may benefit most from the intervention. We determined the effects of eligibility criteria on the recruitment of potential trial participants in the general population. METHODS: In a systematic search until January 1, 2022, we identified all published and ongoing large (≥500 participants), phase-3 multidomain trials for the prevention of cognitive decline or dementia. We applied trial eligibility criteria to 5,381 participants of the population-based Rotterdam Study (mean age: 72 years, 58% women), to compare participant characteristics, predicted risk of cardiovascular disease, and dementia risk, between trial eligible and ineligible persons. RESULTS: We identified 10 trials, of which 5 had been published (DR's EXTRA, FINGER, preDIVA, MAPT, and HATICE) and 5 are ongoing (US-POINTER, MIND-CHINA, MYB, AgeWell.de, and J-Mint). Among all Rotterdam Study participants, eligibility across published trials ranged from 48% for MAPT to 87% for preDIVA, in line with original trial reports. Variability in eligibility was wider for ongoing trials, from 1% for US-POINTER to over 94% for MYB trial. Over 70% of trial eligible individuals are recommended preventive intervention in routine care based on their cardiovascular risk, similar for lipid-lowering (71%) and blood pressure-lowering treatment (73%). Ten-year risks of dementia were similar for eligible compared to ineligible individuals (12 vs. 11%). CONCLUSION: Multidomain dementia prevention trials fail to preferentially include those at the highest risk of dementia and mostly include individuals who qualify for interventions already on the basis of cardiovascular prevention guidelines. These findings call for better targeted enrolment of individuals for whom trial results can improve clinical decision-making.

Sleep Symptoms and Disorders in Episodic Migraine: Assessment and Management.

PURPOSE OF REVIEW: We review research on sleep symptoms and disorders in patients with episodic migraine and propose a framework for evaluating sleep symptoms in this patient population. RECENT FINDINGS: Patients with episodic migraine consistently report poorer sleep on validated self-reports compared to those without migraine. In polysomnographic studies, children with migraine have objectively shorter sleep duration and lower percentage of REM sleep interictally. Prospective actigraphy studies in adults and children suggest that there are no significant changes in sleep duration, efficiency, or quality in the night before or after a migraine attack. The relationship between sleep and migraine is multifaceted. Patients with episodic migraine report poorer sleep and have higher risk of some sleep disorders, including insomnia, sleep-related bruxism, and restless legs syndrome. Sleep screening questions may be incorporated into headache evaluations. Care should be taken to avoid headache medications that may exacerbate sleep symptoms. Evidence-based treatments for insomnia may be initiated while patients await CBT-I. Further studies are needed to assess whether treatment of comorbid sleep disorders results in improvement in migraine-related burden in those with episodic migraine.

Association of Migraine and Blood Pressure-Does Obesity Severity Have a Moderating Role?

BACKGROUND: The relationship between migraine and blood pressure (BP) is equivocal, warranting exploration of potential moderators. Obesity associates with both migraine and BP in a dose-dependent fashion, although its role as a moderator has not been evaluated. We examined the relation between migraine and BP in women with comorbid migraine and obesity, and whether this relation was influenced by obesity severity. METHODS: Women with migraine and obesity (n = 134) completed a 28-day headache diary before randomization to lifestyle intervention or migraine education. BP (systolic (SBP)/diastolic (DBP)), body mass index (BMI), and waist circumference (WC) were measured before diary completion. Hierarchical linear regression assessed associations between BP and migraine characteristics (headache frequency, duration, and pain intensity), and obesity severity (both total (BMI) and abdominal (WC)) as moderators of these associations. RESULTS: Participants (BMI = 35.4 ± 6.5 kg/m2; WC = 105.4 ± 15.6 cm, SBP = 113.1 ± 12.1/DPB = 68.1 ± 8.0 mmHg) reported 8.4 ± 4.5 migraine days that lasted 20.2 ± 15.9 h with mean pain intensity of 5.9 ± 1.6 on a 10-point scale. DBP inversely related to migraine days in both total (ß = - 0.226, p = .010) and abdominal (ß = 0.214, p = .015) obesity severity models. SBP and obesity severity did not relate to migraine characteristics. Obesity severity did not moderate relations between migraine characteristics and BP (p's > .05). CONCLUSION: Among women with comorbid migraine and obesity, DBP inversely related to migraine frequency; however, obesity severity did not affect the strength of this or other examined associations. Future studies including healthy weight controls and men and women with continuous BP measures are needed to confirm these findings and identify mechanisms and moderators.

Efficacy of lasmiditan for the acute treatment of perimenstrual migraine.

BACKGROUND: Perimenstrual migraine attacks in women with menstrual migraine is difficult to treat. This post-hoc analysis evaluated the efficacy of lasmiditan, a high affinity and selective 5-HT1F receptor agonist, for perimenstrual attacks. METHODS: Patients from two randomized, double-blind, placebo-controlled clinical trials (MONONOFU and CENTURION) were instructed to treat an attack with a single dose of study medication within four hours of pain onset. After dosing, the proportion of patients who achieved freedom from migraine-related head pain, most bothersome symptom, and disability was reported at baseline up to 48 hours after dose and pooled data were evaluated. RESULTS: A total of 303 patients (MONONOFU N = 78; CENTURION N = 225) treated perimenstrual migraine attacks with lasmiditan 50 mg (N = 24), 100 mg (N = 90), 200 mg (N = 110), and placebo (N = 79). More patients achieved migraine-related head pain freedom with lasmiditan 200 mg versus placebo at all time points assessed. At 2 hours, 33.6% of patients in the 200-mg group (p < 0.001), and 16.7% of patients in the 100-mg (p = 0.11) and 50-mg (p = 0.19) groups were pain free, compared with 7.6% in the placebo group. CONCLUSIONS: Lasmiditan treatment of perimenstrual migraine attacks was associated with freedom from migraine-related head pain at two hours, early onset of efficacy, and sustained efficacy.Clinical Trial registration: NCT03962738 and NCT03670810.

Predictive models for determining treatment response to nonprescription acute medications in migraine: Results from the American Migraine Prevalence and Prevention Study.

OBJECTIVE: To identify predictors of acute treatment response for nonprescription (over-the-counter [OTC]) medications among people with migraine and develop improved models for predicting treatment response. BACKGROUND: Pain freedom and sustained pain relief are important priorities in the acute treatment of migraine. OTC medications are widely used for migraine; however, it is not clear which treatment works best for each patient without going through the trial and error process. METHODS: A prediction model development study was completed using the 2006 American Migraine Prevalence and Prevention Study survey, from participants who were aged ≥18, met criteria and headache day frequency for episodic migraine, did not take prescription medication for migraine, and used ≥1 of the following acute migraine medication classes: acetaminophen, aspirin, NSAIDs, or caffeine containing combination products (CCP). Two items from the Migraine Treatment Optimization Questionnaire were used to evaluate treatment response, adequate 2-h pain freedom (2hPF) and 24-h pain relief (24hPR), which were defined by a response to treatment ≥half the time at 2 h and 24 h post treatment, respectively. We identified predictors of adequate treatment response and developed models to predict probability of treatment response to each medication class. RESULTS: The sample included 3852 participants (3038 [79.0%] females) with an average age of 45.0 years (SD = 12.8). Only 1602/3852 (41.6%) and 1718/3852 (44.6%) of the participants reported adequate 2hPF and 24hPR, respectively. Adequate treatment-response was significantly predicted by lower average headache pain intensity, less cutaneous allodynia, and lower depressive symptom scores. Lower migraine symptom severity was predictive of adequate 2hPF and fewer monthly headache days was predictive of adequate 24hPR. Among participants reporting OTC monotherapy (n = 2168, 56.3%) individuals taking CCP were more likely to have adequate 2hPF (OR = 1.55, 95% CI 1.23-1.95) and 24hPR (OR = 1.79, 95% CI 1.18-1.88) in comparison with those taking acetaminophen. Predictive models were modestly predictive of responders to OTC medications (c-statistics = 0.65; 95% CI 0.62-0.68). CONCLUSION: These results show that response to acute migraine treatments is not optimized in the majority of people with migraine treating with OTC medications. Predictive models can improve our ability to choose the best therapeutic option for individuals with episodic migraine and increase the proportion of patients with optimized response to treatments.

Long-amplicon MinION-based sequencing study in a salt-contaminated twelfth century granite-built chapel.

The irregular damp dark staining on the stonework of a salt-contaminated twelfth century granite-built chapel is thought to be related to a non-homogeneous distribution of salts and microbial communities. To enhance understanding of the role of microorganisms in the presence of salt and damp stains, we determined the salt content and identified the microbial ecosystem in several paving slabs and inner wall slabs (untreated and previously bio-desalinated) and in the exterior surrounding soil. Soluble salt analysis and culture-dependent approaches combined with archaeal and bacterial 16S rRNA and fungal ITS fragment as well as with the functional genes nirK, dsr, and soxB long-amplicon MinION-based sequencing were performed. State-of-the-art technology was used for microbial identification, providing information about the microbial diversity and phylogenetic groups present and enabling us to gain some insight into the biological cycles occurring in the community key genes involved in the different geomicrobiological cycles. A well-defined relationship between microbial data and soluble salts was identified, suggesting that poorly soluble salts (CaSO4) could fill the pores in the stone and lead to condensation and dissolution of highly soluble salts (Ca(NO3)2 and Mg(NO3)2) in the thin layer of water formed on the stonework. By contrast, no direct relationship between the damp staining and the salt content or related microbiota was established. Further analysis regarding organic matter and recalcitrant elements in the stonework should be carried out. KEY POINTS : • Poorly (CaSO4) and highly (Ca(NO3)2, Mg(NO3)2) soluble salts were detected • Halophilic and mineral weathering microorganisms reveal ecological impacts of salts • Microbial communities involved in nitrate and sulfate cycles were detected.

Between and within-woman differences in the association between menstruation and migraine days.

OBJECTIVE: To investigate between and within-woman differences in the association between menstruation and migraine days. BACKGROUND: Prior diary studies have shown that at the population level, aggregating across individuals, the odds of migraine increase during the perimenstrual window (from day -2 to day +3, where +1 is the first day of bleeding). These studies have been neither long nor large enough to assess the association between migraine and menses from an individual perspective. Consequently, existing research on menstrual-related migraine has largely overlooked between and within-woman variation that is critical for progressing clinical understanding and practice. METHODS: Intensive longitudinal data for the current study were collected in a digital platform (N1-Headache® ) that tracks individual migraine-related factors daily. Participants for the current study were actively menstruating adult (18+ years old) women who used the platform. Two variables were of primary interest, migraine day (no/yes) and menstrual status (inside or outside the 5-day perimenstrual window). RESULTS: The sample consisted of 203 women with a mean age of 35.6 (SD = 8.7) years. At baseline, the women reported an average of 30.6 (SD = 23.6) headache days over the last 3 months. Analyses were based on a total of 53,302 days (median of 150 per person), 18,520 of which were migraine days (median of 44 per person), and a total of 2,126 menstrual cycles (median of 7 per person). Results showed that the 5-day perimenstrual window was associated with a 34% increase in odds of a migraine day compared to other days (OR = 1.34, 95% CI: 1.23-1.45, p < 0.0001). Importantly, there was between and within-woman variability in the association between menses and migraine days (between-woman variability: p = 0.002; within-woman [between-cycles] variability: p < 0.0001). Exploration of these individual differences demonstrated that relationship between menses and migraine days varied more within-person across cycles than between women. DISCUSSION: This study supports previous research and demonstrates that the odds of migraine days are elevated from day -2 to day +3 of the menstrual cycle. We also show that the effect of menses on migraine days varies more within-woman than between-women. This work provides an initial foundation for better understanding menstrual-related migraine from the perspective of the individual patient.

Evaluation of the 6-item Identify Chronic Migraine screener in a large medical group.

OBJECTIVE: To evaluate the sensitivity and specificity of the 6-item Identify Chronic Migraine screener (ID-CM[6]), designed to improve the detection of chronic migraine (CM). BACKGROUND: CM is often undertreated and underdiagnosed. Survey-based studies have found that approximately 75-80% of people meeting criteria for CM do not report having received an accurate diagnosis. METHODS: This study used claims data of patients enrolled in a large medical group who had at least one medical claim with an International Classification of Diseases 9th/10th revision diagnostic code for migraine in the 12-month prescreening period. The Identify Chronic Migraine survey was administered by e-mail, in-person, or over the telephone to all enrolled patients. A Semi-Structured Diagnostic Interview (SSDI) was administered by telephone by a trained physician. The ID-CM(6) and SSDI classifications of CM status were compared to evaluate sensitivity and specificity of the ID-CM(6) screening tool. RESULTS: The analysis of the ID-CM(6) screening tool included 109 patients, with 65/109 (59.6%) positive for CM based on the SSDI. The mean (standard deviation) age of the patient sample was 49 (15) years and 100/109 (91.7%) were female. Using the SSDI as the diagnostic gold standard, the ID-CM(6) had a sensitivity of 70.8% (46/65) and a specificity of 93.2% (41/44). CONCLUSION: The ID-CM(6) demonstrated acceptable sensitivity and good specificity in determining CM status. The results of this analysis support the real-world utility of the ID-CM(6) as a simple and useful tool to identify patients with CM.

Comparison of Seniors in the Community: Risk Evaluation for Eating and Nutrition, version II and Mini Nutritional Assessment - Short Form in detecting nutritional risk among community-dwelling seniors in Bosnia and Herzegovina.

OBJECTIVE: The aim of the current study is to compare Seniors in the Community: Risk Evaluation for Eating and Nutrition, version II (SCREEN II) and Mini Nutritional Assessment - Short Form (MNA-SF), where each is used to identify nutritional risk prevalence among community-dwelling people aged 65 years and above in Bosnia and Herzegovina. DESIGN: A cross-sectional study. Nutritional risk assessed using the nutritionist's risk rating, anthropometric measurements, functional indicators, cognitive parameters, SCREEN II and MNA-SF. SETTING: The municipalities of Foca, East Sarajevo and Bijeljina, Bosnia and Herzegovina. PARTICIPANTS: Eight hundred twenty-one community-dwelling individuals aged ≥65 years. RESULTS: The prevalence of high nutritional risk per nutritionist's risk rating, SCREEN II and MNA-SF was 26, 60, and 7 %, respectively. With the nutritionist's rating score ≥5 as the criterion, the MNA-SF cut-off point of ≤11 (indicating any possible risk) had poor sensitivity (55·7 %), specificity (46·6 %) and AUC (0·563; P = 0·024). When the criterion of >7 was applied, good sensitivity (95·3 %) and specificity (88·9 %) were obtained for the MNA-SF cut-off score of ≤7. AUC for this comparison was 0·742 (considered fair). Cut-off points of <54 (AUC = 0·816) and <50 (AUC = 0·881) for SCREEN II (indicating moderate to high risk) corresponded with good sensitivity (82·2 %; 80·9 %) and fair specificity (72·1 %; 75·0 %). CONCLUSION: MNA-SF may have a limited role in nutritional risk screening among community-dwelling seniors in Bosnia and Herzegovina. SCREEN II has promising results in regard to validity, but further studies are warranted.

Efficacy and safety of erenumab in women with a history of menstrual migraine.

BACKGROUND: We performed a post hoc, subgroup analysis of a phase 3, randomized, double-blind, placebo-controlled study of erenumab for prevention of episodic migraine (STRIVE) to determine the efficacy and safety of erenumab in women with self-reported menstrual migraine. METHODS: Patients received placebo, erenumab 70 mg, or erenumab 140 mg subcutaneously once monthly during the 6-month double-blind treatment phase of STRIVE. Women who reported history of menstrual migraine and who were ≤ 50 years old were included in the analysis. Endpoints were change from baseline in monthly migraine days (MMD) and monthly acute migraine-specific medication days (MSMD; among patients who took acute migraine-specific medications at baseline), proportion of patients achieving ≥ 50% reduction from baseline in MMD, and incidence of adverse events. RESULTS: Among 814 women enrolled in STRIVE, 232 (28.5%) reported a history of menstrual migraine and were ≤ 50 years old. Of the 232 patients, 214 (92%) had a baseline MMD > 5, suggesting a high proportion of women with attacks outside of the 5-day perimenstrual window (2 days before and 3 days after the start of menstruation). Information on "migraine days" includes (and does not discriminate between) perimenstrual and intermenstrual migraine attacks. Between-group differences from placebo over months 4-6 for erenumab 70 mg and 140 mg were - 1.8 (P = 0.001) and - 2.1 (P < 0.001) days for MMD and - 1.6 (P = 0.002) and - 2.4 (P < 0.001) days for acute MSMD, respectively. The odds of having a ≥ 50% reduction from baseline in MMD over months 4-6 were 2.2 (P = 0.024) and 2.8 (P = 0.002) times greater for erenumab 70 mg and 140 mg, respectively, than for placebo. Erenumab had an overall safety profile comparable to placebo. CONCLUSION: Data from this subgroup analysis of women with menstrual migraine are consistent with data from the overall STRIVE episodic migraine population, supporting the efficacy and safety of erenumab in women who experience menstrual migraine. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02456740. Registered 28 May 2015.

Anxiety sensitivity and intentional avoidance of physical activity in women with probable migraine.

INTRODUCTION: Avoidance of physical activity is a common migraine management strategy. Anxiety sensitivity (i.e. fear of anxiety and bodily sensations due to physical, cognitive, or social consequences) is a potential correlate of physical activity avoidance and may strengthen beliefs about physical activity's detrimental effect on migraine. METHOD: Women (n = 100) with probable migraine diagnosis completed an online survey about migraine and physical activity, which included the Anxiety Sensitivity Index-3. RESULTS: Anxiety sensitivity was associated with significantly increased odds of avoiding moderate- and vigorous-intensity physical activity. Anxiety sensitivity, particularly cognitive concerns, was associated with more frequent vigorous and moderate physical activity avoidance. Social concerns about anxiety sensitivity were associated with stronger expected likelihood of vigorous-intensity physical activity as a triggering and worsening factor in migraine. DISCUSSION: Preliminary findings indicate that anxiety sensitivity may contribute to avoidance of moderate and vigorous physical activity and fear-based cognitions about exercise.

Development of a claims-based algorithm to identify potentially undiagnosed chronic migraine patients.

OBJECTIVE: To develop a claims-based algorithm to identify undiagnosed chronic migraine among patients enrolled in a healthcare system. METHODS: An observational study using claims and patient survey data was conducted in a large medical group. Eligible patients had an International Classification of Diseases, Ninth/Tenth Revision (ICD-9/10) migraine diagnosis, without a chronic migraine diagnosis, in the 12 months before screening and did not have a migraine-related onabotulinumtoxinA claim in the 12 months before enrollment. Trained clinicians administered a semi-structured diagnostic interview, which served as the gold standard to diagnose chronic migraine, to enrolled patients. Potential claims-based predictors of chronic migraine that differentiated semi-structured diagnostic interview-positive (chronic migraine) and semi-structured diagnostic interview-negative (non-chronic migraine) patients were identified in bivariate analyses for inclusion in a logistic regression model. RESULTS: The final sample included 108 patients (chronic migraine = 64; non-chronic migraine = 44). Four significant predictors for chronic migraine were identified using claims in the 12 months before enrollment: ≥15 versus <15 claims for acute treatment of migraine, including opioids (odds ratio = 5.87 [95% confidence interval: 1.34-25.63]); ≥24 versus <24 healthcare visits (odds ratio = 2.80 [confidence interval: 1.08-7.25]); female versus male sex (odds ratio = 9.17 [confidence interval: 1.26-66.50); claims for ≥2 versus 0 unique migraine preventive classes (odds ratio = 4.39 [confidence interval: 1.19-16.22]). Model sensitivity was 78.1%; specificity was 72.7%. CONCLUSIONS: The claims-based algorithm identified undiagnosed chronic migraine with sufficient sensitivity and specificity to have potential utility as a chronic migraine case-finding tool using health claims data. Research to further validate the algorithm is recommended.

The Association of Changes in Pain Acceptance and Headache-Related Disability.

BACKGROUND: Migraine accounts for substantial suffering and disability. Previous studies show cross-sectional associations between higher pain acceptance and lower headache-related disability in individuals with migraine, but none has evaluated this association longitudinally during migraine treatment. PURPOSE: This study evaluated whether changes in pain acceptance were associated with changes in headache-related disability and migraine characteristics in a randomized controlled trial (Women's Health and Migraine) that compared effects of behavioral weight loss (BWL) treatment and migraine education (ME) on headache frequency in women with migraine and overweight/obesity. METHODS: This was a post hoc analysis of 110 adult women with comorbid migraine and overweight/obesity who received 16 weeks of either BWL or ME. Linear and nonlinear mixed effects modeling methods were used to test for between-group differences in change in pain acceptance, and also to examine the association between change in pain acceptance and change in headache disability. RESULTS: BWL and ME did not differ on improvement in pain acceptance from baseline across post-treatment and follow-up. Improvement in pain acceptance was associated with reduced headache disability, even when controlling for intervention-related improvements in migraine frequency, headache duration, and pain intensity. CONCLUSIONS: This study is the first to show that improvements in pain acceptance following two different treatments are associated with greater reductions in headache-related disability, suggesting a potential new target for intervention development. CLINICAL TRIALS INFORMATION: NCT01197196.

Sleep Disorders Among People With Migraine: Results From the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study.

OBJECTIVES: We examined the cross-sectional association of sleep apnea and indices of sleep quality with both episodic migraine (EM) and chronic migraine (CM). BACKGROUND: Sleep apnea and abnormal patterns of sleep, such as insomnia, were associated with migraine onset, severity, and progression in previous research. METHODS: The Chronic Migraine Epidemiology & Outcomes Study, a longitudinal study, used a series of web-based surveys to assess migraine symptoms, burden, and patterns of health care utilization. Quota sampling was used from September 2012 to November 2013 to generate a representative sample of the US population. Persons who screened positive for sleep apnea on the Berlin Questionnaire are said to be at "high risk" for sleep apnea. Respondents indicated if they believed that they had sleep apnea, if a physician had diagnosed it, and if and how they were treated. Other aspects of sleep quality were assessed using the Medical Outcomes Study (MOS) Sleep Measures. RESULTS: Of 12,810 eligible respondents with migraine and data on sleep, 11,699 with EM (91.3%) and 1111 with CM (8.7%) provided valid data for this analyses. According to the Berlin Questionnaire, 4739/12,810 (37.0%) were at "high risk" for sleep apnea, particularly persons with CM vs EM (575/1111 [51.8%] vs 4164/11,699 [35.6%]), men vs women (1431/3220 [44.4%] vs 3308/9590 [34.5%]), people with higher body mass index, and older people (all P < .001). Among respondents to the MOS Sleep Measures, persons with CM were more likely to report poor sleep quality than those with EM, including sleep disturbance (mean [SD] values: 53.2 [26.9] vs 37.9 [24.3]), snoring (38.0 [33.9] vs 31.0 [32.1]), shortness of breath (34.9 [29.8] vs 15.3 [20.6]), somnolence (44.1 [23.4] vs 32.2 [21.2]), and less likely to report sleep adequacy (34.0 [24.2] vs 39.2 [22.1]). CONCLUSIONS: Compared with respondents with EM, a larger proportion of those with CM were at "high risk" for sleep apnea and reported poor sleep quality. This reflects an association between CM vs EM and sleep apnea and poor sleep quality; the potential relationships are discussed.

Anxiety Sensitivity as a Risk Indicator for Anxiety, Depression, and Headache Severity in Women With Migraine.

OBJECTIVE: The primary aim of this exploratory study was to assess the relationship between anxiety sensitivity and emotional disorders, migraine characteristics, and migraine-related fear and avoidance behaviors in women with probable migraine. BACKGROUND: Anxiety and depressive disorders are the most frequent comorbid psychiatric conditions in migraine, particularly in women; however, the underlying reasons for these comorbidities are uncertain. Anxiety sensitivity, the tendency to catastrophically appraise anxiety and bodily sensations in terms of their physical, social, or cognitive consequences, is a psychological factor that may contribute to the comorbidity of anxiety and depressive disorders and migraine. It was hypothesized that anxiety sensitivity would be associated with greater migraine severity and psychiatric symptoms. METHOD: Participants were women (n = 100) who screened positive for migraine on the validated IDMigraine Screener participated in an anonymous single-session online survey-based study on migraine. The Anxiety Sensitivity Index-3 total and subscales scores were used to assess anxiety sensitivity. Anxiety and depression symptoms were assessed with the brief Patient Health Questionnaire. RESULTS: On average, anxiety sensitivity was clinically elevated (mean ± SD: 24.0 ± 15.2). Anxiety sensitivity cognitive and social concerns were most strongly correlated with severity of anxiety (r's = .38-.46) and depressive symptoms (r = .35-.39, P's < .001), and all anxiety sensitivity facets were related to fear of head pain (r's = .35-.38, P's < .001). Anxiety sensitivity cognitive concern facet was uniquely related to headache patterns, including longer migraine attack duration (r = .22, P = .029) and pain intensity (r = .24, P = .029), pain-related avoidance, including avoiding movement and more frequent misuse of prescribed or non-prescribed pain medication (r's = .20-.21, P's < .01). CONCLUSIONS: These novel findings indicate that anxiety sensitivity, specifically fearful appraisal of bodily sensations, are linked to both psychiatric symptoms and migraine severity in women. In this cross-sectional study, causal sequence cannot be determined. If anxiety sensitivity leads to more severe pain and psychiatric distress, targeting anxiety sensitivity could lead to better headache outcomes.

Perceptions, attitudes, and expectation of baccalaureate nurses toward position of nursing in Bosnia and Herzegovina.

INTRODUCTION: Numerous challenges and barriers have emerged since changing the minimum requirement for those interested in pursuing employment as a nurse in Europe to a baccalaureate degree. To analyze the perceptions of baccalaureate nurses regarding the current status of their profession and the issues involved in implementing the prerequisite of earning a baccalaureate degree in order to practice as nurses in Bosnia and Herzegovina. METHODS: A series of six focus groups were undertaken with 49 baccalaureate nurses employed in primary health care centers and regional hospitals. The focus groups were recorded and transcribed verbatim. Data collected were analyzed using conventional content analysis approach. RESULTS: Baccalaureate nurses report dissatisfaction with their level of autonomy and anxiety over their limited career opportunities. They expressed concern over difficult working conditions, inadequate financial compensation, and ongoing resistance by physicians as the primary barriers to implementing advanced nursing education and professional reform. The global image of the nursing profession is negative. CONCLUSION: The perception is that revising the legal framework regarding nursing qualifications, duties, and standards will result in reform necessary to positively affect the during profession. Progress toward implementing reform of the nursing profession is negligible. Addressing barriers such as work environment, lack of job classification, fair payment, autonomy, and interdisciplinary collaboration toward the competences of baccalaureate nurse is essential if successful reform is to occur.

Normal Mode Analysis as a Routine Part of a Structural Investigation.

Normal mode analysis (NMA) is a technique that can be used to describe the flexible states accessible to a protein about an equilibrium position. These states have been shown repeatedly to have functional significance. NMA is probably the least computationally expensive method for studying the dynamics of macromolecules, and advances in computer technology and algorithms for calculating normal modes over the last 20 years have made it nearly trivial for all but the largest systems. Despite this, it is still uncommon for NMA to be used as a component of the analysis of a structural study. In this review, we will describe NMA, outline its advantages and limitations, explain what can and cannot be learned from it, and address some criticisms and concerns that have been voiced about it. We will then review the most commonly used techniques for reducing the computational cost of this method and identify the web services making use of these methods. We will illustrate several of their possible uses with recent examples from the literature. We conclude by recommending that NMA become one of the standard tools employed in any structural study.

Factors influencing health profession students' willingness to practice in rural regions of Bosnia and Herzegovina: a cross-sectional study.

INTRODUCTION: The literature indicates different factors influencing recruitment of health professional students to work in rural areas. The purpose of this study is to explore the willingness of health profession students in the Faculty of Medicine Foca, University of East Sarajevo, Bosnia and Herzegovina to work in a rural area following graduation and the factors influencing incentives to pursue a rural career. METHODS: The cross-sectional study included first-year through sixth-year students aged 18 years or older and enrolled in one of three study programs at the Faculty of Medicine: medicine, dentistry and nursing. The questionnaire was distributed at the beginning of the winter semester during the first required lecture for each year and study program class. Data was analyzed using student t-test, analysis of variance when appropriate, Kruskal-Wallis test and multivariate logistic regression analysis. RESULTS: A total of 519 students participated, an 88.3% response rate. Three hundred and ninety-nine (77%) participants responded positively to the question 'When you complete your studies, would you be inclined to accept a job in a rural region?' Factors associated with willingness to practise in rural areas included being female (p=0.027) and having a rural upbringing (p=0.037). Significant differences between medicine, nursing and dentistry students were found in their opinion that willingness to work in rural practice depends greatly on the possibility to get residency more easily (p=0.001). Compared to their peers, nursing students had better opportunities to attend national courses cost-free (p=0.027) and to be involved in the education of new generations of health profession students (p=0.001). Getting a post in an urban area after a work period in a rural area was most valued as an incentive by dentistry students (p=0.037). The multivariate logistic regression model was used to analyze predictors of willingness to practise in rural areas. Students who had been raised in a rural community (p=0.042) as well as female students (p=0.016) were more likely to accept rural practice. Statistical significance at an alpha level of 0.05 was not reached for study program and year of study. CONCLUSIONS: The results of the study showed a high willingness of medicine, dentistry and nursing students to work in rural areas following graduation. Female students and students who were raised in a rural community were more likely to choose a rural career. Stakeholders should be committed to strengthening the rural deployment of health professionals by creating a more attractive, rural environment.