Psychotropic Medications in Metabolic and Bariatric Surgery: Research Updates and Clinical Considerations.

PURPOSE OF REVIEW: We review evidence for assessing and monitoring psychotropic medications in metabolic and bariatric surgery (MBS) patients. We describe weight gain side effects, potential perioperative risks, pharmacokinetic changes that occur after MBS, and conclude with clinical recommendations. RECENT FINDINGS: Research on psychiatric medication use and post-MBS weight outcomes is lacking and inconsistent; however, there is consistent evidence that, though variable, psychiatric medication use is associated with weight gain. Several meta-analyses and reviews provide guidance on lowering risk when appropriate. Perioperative lithium toxicity and SSRI discontinuation syndrome also warrant consideration, as do potential post-operative pharmacokinetic changes. In the absence of data for each psychiatric drug classification, close symptom monitoring and, where appropriate, serum concentration monitoring are recommended. MBS patients are a psychiatrically vulnerable population, and many are on psychiatric medications. Given potential weight/metabolic side effects, perioperative complications, and post-operative pharmacokinetic changes that occur with psychotropic medication use, providers should stay well informed on psychiatric medication management considerations.

Patient Behaviors and Characteristics Related to Weight Regain After Roux-en-Y Gastric Bypass: A Multicenter Prospective Cohort Study.

OBJECTIVE: To identify patient behaviors and characteristics related to weight regain after Roux-en-Y gastric bypass surgery (RYGB). BACKGROUND: There is considerable variation in the magnitude of weight regain after RYGB, highlighting the importance of patient-level factors. METHODS: A prospective cohort study of adults who underwent bariatric surgery in 6 US cities between 2006 and 2009 included presurgery, and 6-month and annual assessments for up to 7 years. Of 1573 eligible participants, 1278 (81%) with adequate follow-up were included (80% female, median age 46 years, median body mass index 46 kg/m). Percentage of maximum weight lost was calculated each year after weight nadir. RESULTS: Weight was measured a median of 8 (25th-75th percentile, 7-8) times over a median of 6.6 (25th-75th percentile, 5.9-7.0) years. ß coefficients, that is, the mean weight regain, compared with the reference, and 95% confidence interval, are reported. Postsurgery behaviors independently associated with weight regain were: sedentary time [2.9% (1.2-4.7), for highest vs lowest quartile], eating fast food [0.5% (0.2-0.7) per meal/wk], eating when feeling full [2.9% (1.2-4.5)], eating continuously [1.6% (0.1-3.1)], binge eating and loss-of-control eating [8.0% (5.1-11.0) for binge eating; 1.6 (-0.1 to 3.3) for loss of control, vs neither], and weighing oneself

Eating Pathology After Bariatric Surgery: an Updated Review of the Recent Literature.

PURPOSE OF REVIEW: The goal of this paper was to extend the prior literature on eating pathology following bariatric surgery by highlighting themes in data published over the past 3 years and identifying limitations and future directions for research. RECENT FINDINGS: Changes in eating pathology after bariatric surgery remain consistent with previous research. Specifically, diagnostic prevalence rates and incidence of related behaviors generally decrease following surgery. However, some research supports that these factors increase and/or remit over time following surgery, and that they subsequently have a negative impact on weight loss outcomes. While recent findings have extended knowledge on eating pathology following bariatric surgery, the overall body of literature is still relatively limited. Additional research is needed, including work focusing on the standardization of eating pathology definitions, development/validation of standardized eating pathology instruments for bariatric surgery patients, and predictors of risk for continued or new onset eating pathology following surgery.

Effect of Bariatric Surgery on CKD Risk.

Obesity is linked to the development and progression of CKD, but whether bariatric surgery protects against CKD is poorly understood. We, therefore, examined whether bariatric surgery influences CKD risk. The study included 2144 adults who underwent bariatric surgery from March of 2006 to April of 2009 and participated in the Longitudinal Assessment of Bariatric Surgery-2 Study cohort. The primary outcome was CKD risk categories as assessed by the Kidney Disease Improving Global Outcomes (KDIGO) consortium criteria using a combination of eGFR and albuminuria. Patients were 79% women and 87% white, with a median age of 46 years old. Improvements were observed in CKD risk at 1 and 7 years after surgery in patients with moderate baseline CKD risk (63% and 53%, respectively), high baseline risk (78% and 56%, respectively), and very high baseline risk (59% and 23%, respectively). The proportion of patients whose CKD risk worsened was ≤10%; five patients developed ESRD. Sensitivity analyses using year 1 as baseline to minimize the effect of weight loss on serum creatinine and differing eGFR equations offered qualitatively similar results. Treatment with bariatric surgery associated with an improvement in CKD risk categories in a large proportion of patients for up to 7 years, especially in those with moderate and high baseline risk. These findings support consideration of CKD risk in evaluation for bariatric surgery and further study of bariatric surgery as a treatment for high-risk obese patients with CKD.

Enzyme-Responsive Liposomes for the Delivery of Anticancer Drugs.

Liposomes are nanocarriers that deliver the payloads at the target site, leading to therapeutic drug concentrations at the diseased site and reduced toxic effects in healthy tissues. Several approaches have been used to enhance the ability of the nanocarrier to target the specific tissues, including ligand-targeted liposomes and stimuli-responsive liposomes. Ligand-targeted liposomes exhibit higher uptake by the target tissue due to the targeting ligand attached to the surface, while the stimuli-responsive liposomes do not release their cargo unless they expose to an endogenous or exogenous stimulant at the target site. In this review, we mainly focus on the liposomes that are responsive to pathologically increased levels of enzymes at the target site. Enzyme-responsive liposomes release their cargo upon contact with the enzyme through several destabilization mechanisms: (1) structural perturbation in the lipid bilayer, (2) removal of a shielding polymer from the surface and increased cellular uptake, (3) cleavage of a lipopeptide or lipopolymer incorporated in the bilayer, and (4) activation of a prodrug in the liposomes.

Ecological Momentary Assessment in Eating Disorder and Obesity Research: a Review of the Recent Literature.

Our current understanding of the etiology and maintenance of eating disorders and obesity continues to be far from complete. Similarly, our understanding of determinants of both successful and unsuccessful weight loss surgery is also quite limited. While a number of research methodologies have been applied to these areas, one methodology that has recently seen a rise in popularity is the use of ecological momentary assessment (EMA). EMA allows one to study a variety of variables of interest in the natural environment. The study of eating disorders, obesity, and bariatric surgery has all been conducted using EMA recently. The current study is a review of these areas and summarizes the recent literature (past 3 years) in eating disorders, obesity, and bariatric surgery using EMA methodology.

Quality of Life, Body Image and Sexual Functioning in Bariatric Surgery Patients.

This article provides an overview of the literature on quality of life, body image and sexual behaviour in individuals with extreme obesity and who undergo bariatric surgery. Quality of life is a psychosocial construct that includes multiple domains, including health-related quality of life, weight-related quality of life, as well as other psychological constructs such as body image and sexual functioning. A large literature has documented the impairments in quality of life and these other domains in persons with obesity and extreme obesity in particular. These impairments are believed to play an influential role in the decision to undergo bariatric surgery. Individuals who undergo bariatric surgery typically report significant improvements in these and other areas of psychosocial functioning, often before they reach their maximum weight loss. The durability of these changes as patients maintain or regain weight, however, is largely unknown.

Body Contouring After Bariatric Surgery.

Individuals who undergo bariatric surgery generally experience rapid and dramatic weight loss. While the weight loss typically confers significant health benefits, an undesirable consequence is often excessive quantities of hanging, surplus skin. Some patients undergo body-contouring surgery (BCS) in order to improve health, mobility, appearance and psychological adjustment. While the majority of post-bariatric patients desire BCS in one or more body regions, a small percentage of patients receive such surgeries. Lack of knowledge about procedures, cost and (in the USA and several other countries) difficulty obtaining insurance reimbursement likely prevents many patients from undergoing BCS. Those who do undergo BCS appear to be at heightened risk for wound-healing complications. Despite these complications, the majority of patients report satisfactory BCS outcomes. The extant literature in this area provides a great deal of information about these issues; nevertheless, additional research is needed to further inform clinical management and improve patient outcomes.

Alcohol and Other Addictive Disorders Following Bariatric Surgery: Prevalence, Risk Factors and Possible Etiologies.

Bariatric surgery is currently the most effective intervention for significant and sustained weight loss in obese individuals. While patients often realize numerous improvements in obesity-related comorbidities and health-related quality of life, a small minority of patients have less optimal outcomes following bariatric surgery. The literature on the emergence of alcohol use disorders (AUDs) following bariatric surgery has grown in the past several years and collectively provides convincing evidence that a significant minority of patients develop new-onset AUDs following bariatric surgery. Rouxen-Y gastric bypass (RYGB) has generally been associated with the risk of developing an AUD, while laparoscopic adjustable gastric banding generally has not, in several large studies. One theory that has been discussed at some length is the idea of 'addiction transfer' wherein patients substitute one 'addiction' (food) for a new 'addiction' (alcohol) following surgery. Animal work suggests a neurobiological basis for increased alcohol reward following RYGB. In addition, several pharmacokinetic studies have shown rapid and dramatically increased peak alcohol concentrations following RYGB. The prevalence of alcohol and other addictive disorders and potential etiological contributors to post-operative AUDs will be explored.

Prevalence of Alcohol and Other Substance Use in Patients with Eating Disorders.

OBJECTIVE: The major aim of this study was to investigate any association between binge eating and purging and alcohol and substance use. METHOD: The Eating Disorder Questionnaire was completed by 2966 patients. Each patient was assigned to an approximate diagnostic group based on a DSM-5-based algorithm. RESULTS: Patients with bulimia nervosa (BN) used alcohol/other substances with higher frequencies compared to patients with anorexia nervosa-restricting type (AN-R), binge eating disorder (BED), and eating disorder not otherwise specified (EDNOS; p < 0.001). Patients with anorexia nervosa-binge eating/purging type (AN-BP) were more likely to use alcohol/substances than those with AN-R [odds ratio for alcohol use: 3.58 (p < 0.01); odds ratio for substance use: 30.14 (p < 0.01)]. Higher frequencies of binge eating and purging were associated with higher frequencies of substance use. DISCUSSION: Patients who manifest both binge eating and purging behaviour are at higher risk of substance use which may have important treatment implications.

A pilot study examining diagnostic differences among exercise and weight suppression in bulimia nervosa and binge eating disorder.

OBJECTIVE: The objective of this study was to investigate diagnostic differences in weight suppression (e.g., the difference between one's current body weight and highest non-pregnancy adult body weight) and exercise among Bulimia Nervosa (BN) and Binge Eating Disorder (BED). Because exercise may be a key contributor to weight suppression in BN, we were interested in examining the potential moderating effect of exercise on weight suppression in BN or BED. METHOD: Participants with BN (n = 774) and BED (n = 285) completed self-report surveys of weight history, exercise and eating disorder symptoms. Generalised linear model analyses were used to examine the associations among diagnosis, exercise frequency and their interaction on weight suppression. RESULTS: Exercise frequency and BN/BED diagnosis were both associated with weight suppression. Additionally, exercise frequency moderated the relationship between diagnosis and weight suppression. Specifically, weight suppression was higher in BN than in BED among those with low exercise frequency but comparable in BN and BED among those with high exercise frequency. DISCUSSION: Our results suggest that exercise frequency may contribute to different weight suppression outcomes among BN and BED. This may inform clinical implications of exercise in these disorders. Specifically, much understanding of the differences among exercise frequency and the compensatory use of exercise in BN and BED is needed.

A comparison of duloxetine plasma levels in postbariatric surgery patients versus matched nonsurgical control subjects.

BACKGROUND: Bariatric surgery such as the Roux-en-Y gastric bypass (RYGB) is currently used as a treatment for severe obesity. Alteration of the gastrointestinal tract by this procedure suggests a potential for clinically significant alterations in the bioavailability of ingested medications including antidepressants. OBJECTIVES: The purpose of this trial was to determine to what extent the RYGB procedure alters the area under the plasma concentration/time curve (AUC(0-infinity)) of the antidepressant, duloxetine. METHODS: Ten subjects who were 1 year post-RYGB where compared with healthy control subjects matched for body mass index, age, and sex. Ultrarapid or poor metabolizers for cytochrome P450 2D6 were excluded from the study. Subjects received a single dose of 60 mg of duloxetine. Nineteen plasma samples were obtained during 72 hours to characterize the plasma level profile. RESULTS: The mean AUC(0-infinity) was significantly smaller for the postbariatric surgery (PBS) group (646.74 ng × h/mL [SD, 79.70; range, 539.57-791.62], P = 0.017) compared to the nonsurgical control group (1119.91 ng × h/mL [SD, 593.40; range, 415.5-2426.56]). The Tmax was also significantly shorter for the PBS group (2.2 hours) compared to the nonsurgical control group (6 hours; P = 0.005). No significant difference in Cmax or half-life was identified. CONCLUSIONS: To our knowledge, this is the first reported study exploring duloxetine pharmacokinetics PBS. This trial found that the bariatric surgery group was exposed to only 57.7% of duloxetine as compared to the nonsurgery group. This finding suggests that clinicians need to monitor patients closely after bariatric surgery and that further exploration of the effects of bariatric surgery on antidepressant pharmacokinetic parameters is warranted.

Deficits in cognitive control during alcohol consumption after bariatric surgery.

BACKGROUND: While bariatric surgery results in substantial weight loss, one negative side effect of surgery is that patients often experience more rapid and intense intoxication effects after consuming alcohol. OBJECTIVES: Given that alcohol use has been associated with impaired cognitive functioning in the general population, this study examined whether acute alcohol consumption after bariatric surgery immediately led to impaired cognitive control, and whether this effect was impacted by baseline levels of cognitive control. SETTING: Nonprofit teaching hospital, United States. METHODS: Participants were 34 adults who attended a laboratory visit before and 1 year after Roux-en-Y gastric bypass surgery, wherein they consumed a weight-based dose of alcohol and completed cognitive testing over the course of 3 hours. RESULTS: A series of generalized mixed-effect models demonstrated that performance on the cognitive task generally improved over time, likely due to practice effects. However, following bariatric surgery, individuals with impaired cognitive control before consuming alcohol experienced greater commission errors immediately afterward. CONCLUSIONS: These findings suggest that alcohol use after bariatric surgery may produce immediate deficits in inhibitory control among individuals who are already vulnerable to impaired cognitive control. Clinicians should seek to educate bariatric surgery candidates on this possible effect, as deficits in inhibitory control may ultimately lead to risky behaviors and poor adherence with postsurgical medical recommendations.

Longer-Term Weight Loss Outcomes Are Not Primarily Driven by Diet Following Roux-en-Y Gastric Bypass and Sleeve Gastrectomy.

Metabolic and bariatric surgery (MBS) is the most effective long-term treatment for Class III obesity. Reduced dietary intake is considered a behavioral driver of post-surgical weight loss, but limited data have examined this association. Therefore, this study examined prospective, longitudinal relationships between dietary intake and weight loss over 24 months following Roux-en-Y Gastric Bypass and Sleeve Gastrectomy. Relationships between weight loss and dietary intake were examined using a validated 24-h dietary recall method. Associations between total energy/macronutrient intake and weight loss outcomes were assessed at 12-, 18-, and 24-months following MBS, defining patients as "responders" and "suboptimal responders". Consistent with previous literature, 12-month responders and suboptimal responders showed significant associations between weight loss and energy (p = 0.018), protein (p = 0.002), and total fat intake (p = 0.005). However, this study also revealed that many of these associations are no longer significant 24 months post-MBS (p > 0.05), despite consistent weight loss trends. This study suggests a short-term signal between these dietary factors and weight loss outcomes 12 months post-MBS; however, this signal does not persist beyond 12 months. These results are essential for interpreting and designing clinical studies measuring long-term post-surgical weight loss outcomes.

Associations Between Changes in Activity and Dietary Behaviors after Metabolic and Bariatric Surgery.

INTRODUCTION: Patients who undergo metabolic and bariatric surgery (MBS) are advised to make healthy activity and dietary changes. While previous research has examined post-surgical changes in activity and dietary behaviors separately, no study has assessed whether changes in these behaviors are beneficially associated with each other. We evaluated whether post-surgical improvements in activity behaviors related to favorable changes in dietary behaviors overall and by surgery type (Roux-en-Y gastric bypass [RYGB], sleeve gastrectomy [SG]). METHODS: At pre-surgery and 6- and 12-months post-surgery, participants (N = 97; 67 RYGB/30 SG) wore an accelerometer for 7 days and completed 24-h dietary assessments on 3 days. General linear models assessed associations between pre- to post-surgical changes in activity (moderate-to-vigorous physical intensity activity [MVPA], sedentary time [ST]) and dietary (total energy intake [EI; kcal/day], dietary quality [healthy eating index/HEI scores]) behaviors, with surgery type as a moderator. RESULTS: Participants on average: demonstrated small, non-significant post-surgical changes in MVPA and ST minutes/day (ps > .05); and reported significant post-surgical decreases in EI (p < .001), but no changes in HEI scores (ps > .25). Greater 12-month post-surgical increases in MVPA were significantly associated with greater decreases in EI, but only for RYGB participants (p < .001). DISCUSSION: Participants reported large decreases in EI, but made minimal changes in other behaviors after MBS. Results suggest greater increases in MVPA could assist with achieving greater decreases in EI, although this benefit appears to be limited to RYGB patients. Additional research is needed to confirm these findings and determine whether activity-dietary behavior associations differ beyond the immediate post-surgical year.

Prevalence of alcohol use disorders before and after bariatric surgery.

CONTEXT: Anecdotal reports suggest bariatric surgery may increase the risk of alcohol use disorder (AUD), but prospective data are lacking. OBJECTIVE: To determine the prevalence of preoperative and postoperative AUD, and independent predictors of postoperative AUD. DESIGN, SETTING, AND PARTICIPANTS: A prospective cohort study (Longitudinal Assessment of Bariatric Surgery-2) of adults who underwent bariatric surgery at 10 US hospitals. Of 2458 participants, 1945 (78.8% female; 87.0% white; median age, 47 years; median body mass index, 45.8) completed preoperative and postoperative (at 1 year and/or 2 years) assessments between 2006 and 2011. MAIN OUTCOME MEASURE: Past year AUD symptoms determined with the Alcohol Use Disorders Identification Test (indication of alcohol-related harm, alcohol dependence symptoms, or score ≥8). RESULTS: The prevalence of AUD symptoms did not significantly differ from 1 year before to 1 year after bariatric surgery (7.6% vs 7.3%; P = .98), but was significantly higher in the second postoperative year (9.6%; P = .01). The following preoperative variables were independently related to an increased odds of AUD after bariatric surgery: male sex (adjusted odds ratio [AOR], 2.14 [95% CI, 1.51-3.01]; P < .001), younger age (age per 10 years younger with preoperative AUD: AOR, 1.31 [95% CI, 1.03-1.68], P = .03; age per 10 years younger without preoperative AUD: AOR, 1.95 [95% CI, 1.65-2.30], P < .001), smoking (AOR, 2.58 [95% CI, 1.19-5.58]; P = .02), regular alcohol consumption (≥ 2 drinks/week: AOR, 6.37 [95% CI, 4.17-9.72]; P < .001), AUD (eg, at age 45, AOR, 11.14 [95% CI, 7.71-16.10]; P < .001), recreational drug use (AOR, 2.38 [95% CI, 1.37-4.14]; P = .01), lower sense of belonging (12-item Interpersonal Support Evaluation List score per 1 point lower: AOR, 1.09 [95% CI, 1.04-1.15]; P = .01), and undergoing a Roux-en-Y gastric bypass procedure (AOR, 2.07 [95% CI, 1.40-3.08]; P < .001; reference category: laparoscopic adjustable gastric band procedure). CONCLUSION: In this cohort, the prevalence of AUD was greater in the second postoperative year than the year prior to surgery or in the first postoperative year and was associated with male sex and younger age, numerous preoperative variables (smoking, regular alcohol consumption, AUD, recreational drug use, and lower interpersonal support) and undergoing a Roux-en-Y gastric bypass procedure.

Depression, materialism, and excessive Internet use in relation to compulsive buying.

OBJECTIVE: The objective of the study was to examine the relationship between compulsive buying (CB), depression, materialism, and excessive Internet use. METHODS: An online survey of 387 consumers was conducted including questions about demographics and shopping venues, the Compulsive Buying Scale, the Patient Health Questionnaire Depression Scale, the Materialistic Values Scale, and questions concerning excessive Internet use. RESULTS: Seventeen percent of the participants reported Compulsive Buying Scale scores less than -1.34 and were considered to be having CB. Participants with CB did not significantly differ from those without CB regarding age, sex, marital status, annual household income, and shopping preferences. Individuals with CB reported more depressive symptoms, higher materialistic values endorsement, and more severe excessive Internet use compared with those without CB. Results of a stepwise logistic regression analysis with CB as the dependent variable showed that materialism and depression were associated with CB, whereas excessive Internet use was not. CONCLUSIONS: Materialism and depression jointly influence CB. Further research is needed to examine the influence of materialism on CB in a clinical sample consisting of patients with diagnosed CB.

A microbial signature following bariatric surgery is robustly consistent across multiple cohorts.

Bariatric surgery induces significant shifts in the gut microbiota which could potentially contribute to weight loss and metabolic benefits. The aim of this study was to characterize a microbial signature following Roux-en-Y Gastric bypass (RYGB) surgery using novel and existing gut microbiota sequence data. We generated 16S rRNA gene and metagenomic sequences from fecal samples from patients undergoing RYGB surgery (n = 61 for 16S rRNA gene and n = 135 for metagenomics) at pre-surgical baseline and one, six, and twelve-month post-surgery. We compared these data with three smaller publicly available 16S rRNA gene and one metagenomic datasets from patients who also underwent RYGB surgery. Linear mixed models and machine learning approaches were used to examine the presence of a common microbial signature across studies. Comparison of our new sequences with previous longitudinal studies revealed strikingly similar profiles in both fecal microbiota composition (r = 0.41 ± 0.10; p < .05) and metabolic pathways (r = 0.70 ± 0.05; p < .001) early after surgery across multiple datasets. Notably, Veillonella, Streptococcus, Gemella, Fusobacterium, Escherichia/Shigella, and Akkermansia increased after surgery, while Blautia decreased. Machine learning approaches revealed that the replicable gut microbiota signature associated with RYGB surgery could be used to discriminate pre- and post-surgical samples. Opportunistic pathogen abundance also increased post-surgery in a consistent manner across cohorts. Our study reveals a robust microbial signature involving many commensal and pathogenic taxa and metabolic pathways early after RYGB surgery across different studies and sites. Characterization of the effects of this robust microbial signature on outcomes of bariatric surgery could provide insights into the development of microbiome-based interventions for predicting or improving outcomes following surgery.

Pain is adversely related to weight loss maintenance following bariatric surgery.

BACKGROUND: Pain and obesity are frequently co-morbid health conditions; thus, it is unsurprising that pain is commonly experienced by individuals seeking bariatric surgery. While pain is generally reduced in the short-term after surgery, there is also variability in pain outcomes and less is known about how unresolved or recurring pain may relate to long-term weight loss and weight loss maintenance. OBJECTIVES: This study evaluated trajectories of pain scores through 7 years following bariatric surgery and whether higher pain levels related to poorer weight loss and greater weight regain. SETTING: Data were collected from 3 university hospitals, 1 private not-for-profit research institute, and 1 community hospital. METHODS: Self-report measures of pain and weight change data were utilized for 1702 adults seeking Roux-en-Y gastric bypass surgery from the Longitudinal Assessment for Bariatric Surgery (LABS) cohort. A series of linear mixed models examined trajectories of pain scores and the concurrent predictive relationship between pain and weight outcomes from pre-surgery through 7 years post-surgery. RESULTS: Overall bodily-, hip-, and knee-pain improved through 2 years, deteriorated from 2-5 years, and then slightly improved from 5-7 years following surgery (P < .001). Greater pain was concurrently associated with less weight loss and greater weight regain over time (P ≤ .006). CONCLUSION: Pain is evident in the long-term following bariatric surgery and associated with suboptimal weight outcomes. More research is needed to identify mechanisms underlying this relationship, which may ultimately help develop appropriate pain assessment and treatment strategies to ensure optimal post-surgery outcomes.

Naturalistic assessment of patterns and predictors of acute headache medication use among women with comorbid migraine and overweight or obesity.

Given the potential for obesity to complicate migraine treatment outcomes, there is a need to understand patterns and correlates of acute medication use among individuals with this comorbidity. Experience sampling methodology (ESM) was used to characterize patterns of acute medication use among those with migraine and overweight/obesity and to examine individual and momentary factors related to medication use (both migraine-specific and nonspecific medications). Women with migraine and overweight/obesity (N = 170) seeking behavioral migraine treatment completed questionnaires followed by 28 days of daily ESM headache diaries. Participants used medications to treat 71.9% of attacks, 20% of which were treated with migraine-specific medications. Participants were more likely to use medication in the context of longer and more severe attacks that started earlier in the day. Presence of aura and greater work-related pain interference uniquely related to migraine-specific medication use. Questionnaire-assessed factors were not related to medication use, although older age and higher educational attainment related to more frequent use. A substantial proportion of attacks were left untreated, suggesting unmet treatment needs in this population. Results also suggest that ESM-assessed factors are more salient correlates of medication use compared to questionnaires. Additional investigation of barriers to medication use is needed.

Obesity may contribute to more severe migraine symptoms and negatively impact migraine treatment outcomes. The present study aimed to understand patterns of acute medication use among 170 women with migraine and obesity who were seeking behavioral migraine treatment. Data were collected in participants' natural environment using experience sampling methodology, during which participants reported daily migraine symptoms for 4 weeks. Approximately, 30% of attacks were not treated with any medications, and one in five attacks (i.e., 20%) was treated with migraine-specific medication. Participants were more likely to use medication during longer and more severe attacks that started earlier in the day. Participants were also more likely to use migraine-specific medication when attacks were precipitated by an aura and associated with work-related pain interference. Questionnaire-assessed factors were not related to medication use, although older age and higher educational attainment related to more frequent use. In general, these results also suggest that naturalistically assessed factors are more salient correlates of medication use compared to questionnaires. Additional investigation of barriers to medication use is needed among younger individuals and those of lower socioeconomic status.