Optimized Acute Treatment of Migraine Is Associated With Greater Productivity in People With Migraine: Results From the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study.

OBJECTIVE: This study aimed to ascertain whether level of optimization of acute treatment of migraine is related to work productivity across the spectrum of migraine. METHODS: Data were from the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study, an internet-based longitudinal survey. Respondents with migraine who reported full-time employment and use of ≥1 acute prescription medication for migraine were included. We determined relationships among lost productive time (LPT; measured with the Migraine Disability Assessment Scale), acute treatment optimization (Migraine Treatment Optimization Questionnaire- ), and monthly headache days (MHDs). RESULTS: There was a direct relationship between LPT and MHD category. Greater acute treatment optimization was associated with lower total LPT, less absenteeism, and less presenteeism within each MHD category. CONCLUSIONS: Optimizing acute treatment for migraine may reduce LPT in people with migraine and reduce indirect costs.

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.

A Review of Underserved and Vulnerable Populations in Headache Medicine in the United States: Challenges and Opportunities.

PURPOSE OF REVIEW: This review will briefly summarize recent literature published on headache disparities in underserved and vulnerable populations. It will also report the personal observations of headache medicine providers working with underserved and vulnerable populations in the USA, specifically in an urban practice dedicated to patients in a safety net program and a rural practice dedicated to Native American patients. RECENT FINDINGS: Headache disorders are recognized as one of the most prevalent neurological conditions. People with headache and migraine encounter several barriers to obtaining appropriate care, which are magnified in vulnerable and underserved populations. Research has shown disparities in headache and migraine diagnosis, prevalence rates, treatment, and outcomes based on race, socioeconomic status, and geography. Continued research regarding disparities in headache medicine is required. Strategies to address the identified challenges, including structural competence and the underrepresented in medicine pipeline, are reviewed.

Elective Hospitalizations for Intractable Headache: Outcomes and Response Predictors.

OBJECTIVE: To review our inpatient experience treating a variety of headache disorders with heterogeneous therapies and to determine outcomes and predictors of response. METHODS: We conducted an institutional review board-approved retrospective chart review of elective inpatient headache admissions from the Montefiore Headache Center from 2014 to 2018. We examined factors associated with response and outcomes at discharge and posthospitalization follow-up in an intractable population. Patients received different classes of IV medications including antiemetics, neuroleptics, dihydroergotamine, lidocaine, steroids, valproic acid, and nerve blocks, and home preventive medications were either continued or changed before discharge. Improvements were defined at discharge by headache intensity compared with before hospitalization. RESULTS: Among the 83 admissions, pain improvement at discharge occurred in 90.4% (n = 75) of the overall sample, 89.5% (n = 60) of those with chronic migraine, 75.0% (n = 9) of patients with new daily persistent headache, and 89.5% (n = 34) of all those with acute medication overuse. Fifty-six patients (67.5%) reported improvement of a 3-or-more-point reduction in headache intensity at discharge, with a mean reduction of 4.84 ± SD 2.51 (range 1-10). Of the 66 patients who received IV dihydroergotamine, 59 (89.4%) of them improved at discharge. Of the 11 (13.2%) patients who received IV lidocaine, 7 (63.6%) improved. Of the 14 (16.9%) patients who received nerve blocks, all 14 (100%) improved at discharge. Of the 75 patients who had improved at discharge, 63 (84%) followed up and 50 (79.4%) of those patients remained improved. At the second follow-up, 68 (81.9%) patients returned for follow-up on average of 71 days (range 10-283) after discharge. CONCLUSIONS: Our inpatient headache experience featured numerous treatments with high rates of improvement in the short and intermediate term for all headache disorders. These results may suggest that stratified hospitalized care including polytherapy may be useful for many patients.

Barriers to care in episodic and chronic migraine: Results from the Chronic Migraine Epidemiology and Outcomes Study.

OBJECTIVE: To assess rates of and factors associated with traversing fundamental barriers to good medical outcomes and pharmacologic care in individuals with episodic migraine (EM) and chronic migraine (CM), including socioeconomic status and race. BACKGROUND: Barriers to good outcomes in migraine include the lack of appropriate medical consultation, failure to receive an accurate diagnosis, not being offered a regimen with acute and preventive pharmacologic treatments (if indicated), and not avoiding medication overuse. METHODS: The Chronic Migraine Epidemiology and Outcomes (CaMEO) Study was a longitudinal Internet-based survey. Respondents who met criteria for migraine consistent with the International Classification of Headache Disorders, 3rd edition, had a Migraine Disability Assessment score ≥ 6, and provided health insurance coverage status were included in this analysis. Successfully traversing each barrier to care and the effects of sociodemographic characteristics were examined. RESULTS: Among 16,789 respondents with migraine, 9184 (54.7%; EM: 7930; CM: 1254) were eligible. Current headache consultation was reported by 27.6% (2187/7930) of EM and 40.8% (512/1254) of CM respondents. Among consulters, 75.7% (1655/2187) with EM and 32.8% (168/512) with CM were accurately diagnosed. Among diagnosed consulters, 59.9% (992/1655) with EM and 54.2% (91/168) with CM reported minimally appropriate acute and preventive pharmacologic treatment. Among diagnosed and treated consulters, in the EM group 31.8% (315/992) and in the CM group 74.7% (68/91) met medication overuse criteria. Only 8.5% (677/7930) of EM and 1.8% (23/1254) of CM respondents traversed all four barriers. Higher income was positively associated with likelihood of traversing each barrier. Blacks and/or African Americans had higher rates of consultation than other racial groups. Blacks and/or African Americans and multiracial people had higher rates of acute medication overuse. CONCLUSIONS: Efforts to improve care should focus on increasing consultation and diagnosis rates, improving the delivery of all appropriate guideline-based treatment, and avoidance of medication overuse.

Efficacy and Tolerability of Calcitonin Gene-Related Peptide-Targeted Monoclonal Antibody Medications as Add-on Therapy to OnabotulinumtoxinA in Patients with Chronic Migraine.

BACKGROUND: We examined the efficacy and tolerability of calcitonin gene-related peptide-targeted monoclonal antibodies (CGRP-targeted mAbs) as add-on therapy for patients with chronic migraine (CM) undergoing treatment with onabotulinumtoxinA (onabot) who require additional preventive therapy. METHODS: We reviewed medical records of patients with CM receiving treatment with onabot who were subsequently prescribed a CGRP-targeted mAb medication. The primary outcome was the change in number of monthly headache days (MHDs) reported. Secondary outcomes were change in headache pain severity, discontinuation due to lack of tolerability, and severe adverse events. RESULTS: Of 153 patients, 111 (72.5%) reported a decrease in either MHDs or headache pain severity, with documentation of MHDs in 66 patients. Among these 66 patients, the average number of MHDs before initiation of onabot treatment was 25.7. After onabot treatment, an average decrease of 10.9 MHDs was reported (P < 0.001). After the addition of a CGRP-targeted mAb medication, patients experienced a further decrease of 5.7 MHDs (P < 0.001). With combined therapy, patients reported a total decrease of 16.6 MHDs (P < 0.001). Adverse effects occurred in 13 patients (8.5%) after addition of the CGRP-targeted mAb and included constipation, injection site reaction, and fatigue. No serious adverse events were reported. CONCLUSION: Adding a CGRP-targeted mAb to onabot in patients with CM was associated with further reductions in MHDs without major tolerability issues across a range of mAbs. This retrospective review supports the conduct of a well-designed double-blind study adding a CGRP-targeted mAb or placebo to onabot.

Introducing the National Headache Fellowship Opportunities Website.

OBJECTIVE: To build a national Headache Medicine fellowship opportunities website that promotes a unified application timeline and a more transparent application process. BACKGROUND: In July 2019, the Consortium of Academic Headache Program Directors unanimously accepted the recommendations of the American Academy of Neurology Fellowship Application Timing Position Statement. To implement the unified application timeline, the American Headache Society agreed to host a fellowship opportunities website with information on the application process and resources for each fellowship program. METHODS: We designed a main landing page that features the unified timeline for applications and offers. The page also features icons for all participating US fellowship programs (identified using the United Council for Neurologic Subspecialties certification database). The icons serve as links to each fellowship program's individual webpage. We sent an electronic form to each fellowship program director, asking them to submit program information to be included on each fellowship program's individual webpage. Key contents on each program webpage include an image of the program, brief program description, names of applicants who have filled positions, and open positions. Each institution webpage also includes an electronic form that allows applicants to directly send their name, contact, and a brief message to the program director. RESULTS: We launched the website on May 15, 2020. As of June 19, 2020, the website featured 24 participating headache fellowship programs, including 5 pediatric programs and 19 adult training programs, from all regions of the US. CONCLUSION: The website serves as a central resource for Headache Medicine fellowship applicants and promotes a unified application timeline and a more transparent application process.

The state of the headache fellowship application process and attitudes toward the match.

OBJECTIVE: To examine the current headache medicine fellowship application process and to propose recommendations for a more unified, systematic, and transparent process. METHODS: We identified 42 headache fellowship programs using the United Council for Neurologic Subspecialties certification database. After an initial contact via e-mail, we conducted individual telephone interviews with program directors. Qualitative data coding allowed identification of emerging themes. Quantitative data were summarized with descriptive statistics. RESULTS: Forty (95%) program directors (34 adult, 6 pediatric) responded. Emerging themes included the following. (1) There are benefits and disadvantages to having a match. (2) If the match were reinstated, programs would participate only if all programs participated. (3) There should be consequences for programs that do not participate. If the match were reinstated, 37.5% of program directors responded that their program would participate without conditions; 37.5% would participate only if every program were required to participate. Fifteen percent would not participate, and 10% were not sure if they would participate. Forty percent supported sanctions against programs that did not participate in the match. CONCLUSION: The fellowship match potentially makes the process more systematic for both programs and applicants; however, it does not currently appear to be a feasible option for the field of headache medicine. Until the number of applicants exceeds the number of programs, we recommend instituting a universal timeline for applications and offers.