Diagnosis and Treatment of Spontaneous Intracranial Hypotension: Role of Epidural Blood Patching.

Purpose of Review: This review focuses on the challenges of diagnosing and treating spontaneous intracranial hypotension (SIH), a condition caused by spinal CSF leakage. It emphasizes the need for increased awareness and advocates for early and thoughtful use of empirical epidural blood patches (EBPs) in suspected cases. Recent Findings: SIH diagnosis is hindered by variable symptoms and inconsistent imaging results, including normal brain MRI and unreliable spinal opening pressures. It is crucial to consider SIH in differential diagnoses, especially in patients with connective tissue disorders. Early EBP intervention is shown to improve outcomes. Summary: SIH remains underdiagnosed and undertreated, requiring heightened awareness and understanding. This review promotes proactive EBP use in managing suspected SIH and calls for continued research to advance diagnostic and treatment methods, emphasizing the need for innovative imaging techniques for accurate diagnosis and timely intervention.

Rebound Intracranial Hypertension.

PURPOSE OF REVIEW: Rebound intracranial hypertension (RIH) is a post-procedural treatment complication in patients with spontaneous intracranial hypotension (SIH) characterized by transient high-pressure headache symptoms. This article reviews the epidemiology, clinical features, risk factors, and treatment options for RIH. RECENT FINDINGS: This article discusses how changes in underlying venous pressure and craniospinal elastance can explain symptoms of RIH, idiopathic intracranial hypertension (IIH), and SIH. The pathophysiology of RIH provides a clue for how high and low intracranial pressure disorders, such as IIH and SIH, are connected on a shared spectrum.

Stigma and Migraine: Developing Effective Interventions.

PURPOSE OF REVIEW: Migraine and other primary headache disorders do not receive adequate research funding, medical resources, or other forms of structural support relative to their prevalence and the disability they cause. In recent research, scholars have argued that stigma associated with headache disorders explains some of this discrepancy. This review will discuss (1) the factors contributing to stigma toward migraine and other primary headache disorders, (2) how structural and enacted stigma may perpetuate individual disability, (3) the impact of internalized stigma, and (4) interventions to mitigate stigma toward headache disorders with an emphasis on outcome monitoring. The review will also propose new areas of stigma research in need of further investigation. RECENT FINDINGS: Recent research shows that discrimination can exacerbate chronic pain. Stigma profoundly affects everything from the allocation of federal research funds and healthcare resources to individual patients' self-efficacy and ability to care for themselves. Understanding the stigma of migraine and learning how to develop effective interventions to mitigate this stigma will increase access to appropriate migraine care, improve healthcare providers' ability to care for their migraine patients, and help advocates reverse policies that discriminate against those with migraine. It is important to closely monitor outcomes of anti-stigma efforts for both positive and negative consequences and take note of outcomes and "lessons learned" from anti-stigma campaigns for other diseases.

Managing migraine in pregnancy and breastfeeding.

The disproportionate prevalence of migraine among women in their reproductive years underscores the clinical significance of migraine during pregnancy. This paper discusses how migraine evolves during pregnancy, secondary headache disorders presenting in pregnancy and puerperium, and acute and preventive options for migraine management during pregnancy and lactation. Migraine is influenced by rising estrogen levels during pregnancy and their sharp decline in puerperium. Migraine, and migraine aura, can present for the first time during pregnancy and puerperium. There is also a higher risk for the development of preeclampsia and cerebrovascular headache during these periods. New or refractory headache, hypertension, and abnormal neurological signs are important "red flags" to consider. This paper reviews the diagnostic utility of neuroimaging studies and the risks of each during pregnancy. Untreated migraine can itself lead to preterm delivery, preeclampsia, and low birth weight infants. Behavioral interventions and lifestyle modifications are the cornerstone for migraine treatment during pregnancy. In addition, one should consider the risks and efficacy of each treatment during pregnancy on an individual basis. The protective nature of breastfeeding for migraine is debated, but there is no evidence to suggest breastfeeding worsens migraine. Acute and preventive migraine treatment options are available for nursing mothers. Neuromodulation and neurostimulation devices are additional options for treatment during pregnancy and lactation, while the safety of using calcitonin gene-related peptide receptor antagonists during these times remains to be determined.

A comprehensive overview and safety evaluation of fremanezumab as a preventive therapy for migraine.

Introduction: Fremanezumab, a humanized monoclonal antibody targeting calcitonin gene-related peptide (CGRP mAb), is a migraine-specific treatment for migraine prevention.Areas covered: This review will briefly discuss other available and emerging CGRP mAbs and the neurophysiology of fremanezumab. The review will focus on phase III trials of the efficacy of fremanezumab for episodic and chronic migraine, and a recent pooled safety and tolerability analysis of its use.Expert opinion: Continued efficacy and safety data collection will help guide long-term risk and efficacy counseling in the general population.

Preventive Treatment for Episodic Migraine.

Episodic migraine is a debilitating condition. Preventive therapy is used to reduce frequency, duration, or severity of attacks. This review discusses principles of preventive treatment with a focus on preventive treatment options for people with episodic migraine. Specifically discussed is evidence and use of new migraine-specific treatment options for episodic migraine, such as calcitonin gene-related peptide monoclonal antibodies, a noninvasive transcutaneous electrical nerve stimulation device, and a single-pulse transcranial magnetic stimulator device. Also discussed are evidence-based updates from the 2012 American Academy of Neurology and the American Headache Society guidelines regarding major medication classes recommended for preventive episodic migraine treatment.

Current Status of Antiepileptic Drugs as Preventive Migraine Therapy.

BACKGROUND: Antiepileptic drugs (AEDs) are an important class of agents used in the treatment of migraine, a neurological disorder that imparts significant socioeconomic burden. It is important for neurologists to understand the rationale for AEDs in migraine-preventive treatment, as well as each agent's efficacy and tolerability profile, in order to best determine clinical care. PURPOSE OF THIS REVIEW: This article specifically provides the following: (1) a review of the mechanism of action, efficacy, and tolerability of topiramate and divalproex sodium/sodium valproate, the most widely used AEDs for migraine prevention, (2) a discussion on emerging evidence regarding the efficacy of zonisamide and levetiracetam, and (3) comments on gabapentin, pregabalin, carbamazepine, oxcarbazepine, and lamotrigine, AEDs which have insufficient evidence for use in migraine prevention. RECENT FINDINGS: The potential role for new extended-release formulations of topiramate in migraine prevention is discussed. There is substantial evidence supporting the use of AEDs in migraine prevention. Specific agents should be chosen based on their efficacy and tolerability profiles. Further studies are needed to determine the efficacy of the newer AEDs, zonisamide and levetiracetam, in migraine prevention and to clarify the role of gabapentinoids in headache management.

Migraine: Stigma in Society.

Migraine is a prevalent disease with a substantial socioeconomic impact. However, stigma affects social attitude toward migraine, accruing additional burden on individuals with migraine and isolating them from a society that should be supporting them. PURPOSE OF THIS REVIEW: This review will discuss the following concepts: (1) the emergence of stigma toward migraine and its impact on medical care; (2) internalized stigma among those with migraine and its detrimental effect on quality of life and patient-physician relationships; (3) the structural impact of stigma on research funding, workplace support, and specialized care; and (4) strategies for "rebranding" the disease and alleviating stigma toward migraine. RECENT FINDINGS: Recent literature on condition rebranding offers strategies on how to define and communicate migraine to the public. Rebranding of migraine to alleviate societal stigma is paramount. This involves use of unified language, education, and advocacy.

Cerebrospinal Fluid Removal for Idiopathic Intracranial Hypertension: Less Cerebrospinal Fluid Is Best.

BACKGROUND: Although lumbar punctures (LPs) are used for diagnostic evaluation in idiopathic intracranial hypertension (IIH), they can also provide relief from IIH-associated headache. Conversely, low-pressure headache secondary to LP can be debilitating. Low-volume cerebrospinal fluid (CSF) removal to a "high-normal" closing pressure (CP), approximately 18-20 cm H2O, may result in relief of IIH-associated headache with a lowered frequency of post-LP headache. METHODS: We conducted a single-center retrospective analysis from 2011 to 2016 of patients who underwent fluoroscopic LPs aiming for high-normal CPs. Inclusion criteria were as follows: 1) pre-existing diagnosis of IIH, or opening pressure (OP) and clinical findings diagnostic for IIH; 2) height and weight recorded within 1 year; 3) documented LP data parameters; and 4) one week post-LP follow-up documenting whether headache was worse, unchanged, or better. RESULTS: One hundred forty-six patients met the inclusion criteria. Mean age was 34.9 years ± 11.0, and mean body mass index was 39.2 kg/m ± 10.5. Mean volume removed was 9.7 mL ± 4.6. The mean CP was 17.9 cm H2O ±2.7. The mean pressure change (OP-CP) per volume removed was 1.50 cm H2O/mL ±0.6. Headache symptoms at follow-up were improved in 64% (80/125) of patients, worse in 26% (33/125), and unchanged in 10% (12/125). Eleven patients were headache-free, and 11 patients required hospital care for post-LP headache. CONCLUSIONS: Low-volume CSF removal to approximately 18 cm H2O resulted in relief of IIH-associated headache in most patients and a low incidence of post-LP headache. Although clinically variable, these data suggest that for every 1 mL of CSF removed, the CP decreases approximately 1.5 cm H2O.

Unique Populations with Episodic Migraine: Pregnant and Lactating Women.

PURPOSE OF REVIEW: Migraine is a disabling and prevalent neurological disease, commonly affecting women during their reproductive years. It is crucial for providers to be able to adequately counsel women who are pregnant, planning pregnancy, or nursing, regarding preventive and abortive treatment options for episodic migraine. This review will discuss (1) the expected course of migraine during pregnancy and the post-partum period, (2) recommended preventive therapies for migraine during pregnancy and lactation, and (3) recommended abortive medications for migraine during pregnancy and lactation. RECENT FINDINGS: Recent research has indicated safety for triptan use during pregnancy and ibuprofen use during the first trimester of pregnancy. Considerations for use of emerging migraine-preventive treatment, such as non-invasive neurostimulators, are discussed. For clinical decision-making and patient counseling, it is important to understand both the limitations in determining teratogenic effects in humans and the principles affecting medication transmission from mother to breast milk.

Alcohol use and hospital readmissions following stroke: A safety net hospital experience.

OBJECTIVE: The purpose of this study is to identify predictors of stroke-related readmissions at 30days on a safety net hospital level and suggest interventions to reduce the number of readmissions. BACKGROUND: Hospital readmissions are an important measure of the quality of health care services. Readmissions indicate unresolved problems from the index admission, inadequate post-hospitalization care, or a mixture of these factors. Additionally, hospital readmissions are associated with a substantial economic burden on the health care system. The study's purpose is to identify predictors of stroke-related readmissions within 30days on a hospital level and suggest interventions to reduce the number of readmissions. METHODS: We conducted a single-center retrospective study of patients admitted to Boston Medical Center (BMC) and diagnosed with ischemic and hemorrhagic stroke. Unadjusted and adjusted logistic regressions were used to evaluate possible predictors of stroke related readmissions. RESULTS: Of 352 patients admitted with a diagnosis of ischemic or hemorrhagic stroke at BMC during the study period, 44 (12.5%) patients were readmitted to BMC within 30days. Current alcohol abuse was significantly associated with readmission (OR 95% CI 1.03-5.62). Discharge against medical advice was also associated, though the sample size was small. CONCLUSIONS: These results suggest that early inpatient and post-hospitalization interventions to address alcohol abuse during the index hospital admission may reduce the rate of hospital readmission within 30days. The results have prompted interventions on the stroke service such as early inpatient social work and addiction medicine involvement for patients with risk factors of alcohol abuse.