The 2023 protocol for update to acute treatment of adults with migraine in the emergency department: The American Headache Society evidence assessment of parenteral pharmacotherapies.

OBJECTIVES: The primary objective of this proposed guideline is to update the prior 2016 guideline on parenteral pharmacotherapies for the management of adults with a migraine attack in the emergency department (ED). METHODS: We will conduct an updated systematic review and meta-analysis using the 2016 guideline methodology to provide clinical recommendations. The same search strategy will be used for studies up to 2023, with a new search strategy added to capture studies of nerve blocks and sphenopalatine blocks. Medline, Embase, Cochrane, clinicaltrials.gov, and the World Health Organization International Clinical Trial Registry Platform will be searched. Our inclusion criteria consist of studies involving adults with a diagnosis of migraine, utilizing medications administered intravenously, intramuscularly, or subcutaneously in a randomized controlled trial design. Two authors will perform the selection of studies based on title and abstract, followed by a full-text review. A third author will intervene in cases of disagreements. Data will be recorded in a standardized worksheet and subjected to verification. The risk of bias will be assessed using the American Academy of Neurology tool. When applicable, a meta-analysis will be conducted. The efficacy of medications will be evaluated, categorizing them as "highly likely," "likely", or "possibly effective" or "ineffective." Subsequently, clinical recommendations will be developed, considering the risk associated with the medications, following the American Academy of Neurology recommendation development process. RESULTS: The goal of this updated guideline will be to provide guidance on which injectable medications, including interventional approaches (i.e., nerve blocks, sphenopalatine ganglion), should be considered effective acute treatment for adults with migraine who present to an ED. CONCLUSIONS: The methods outlined in this protocol will be used in the design of a future systematic review and meta-analysis-informed guideline, which will then be assessed by and submitted for endorsement by the American Headache Society.

Treatment Options for Posttraumatic Headache: A Current Review of the Literature.

PURPOSE OF REVIEW: We evaluate evidence-based treatments for posttraumatic headache (PTH), a secondary headache disorder resulting from traumatic brain injury (TBI), comprising nearly 4% of all symptomatic headache disorders. Utilizing recent publications, we aim to inform clinicians of current treatment methods. RECENT FINDINGS: There is limited research on PTH treatment. A randomized controlled trial (RCT) of metoclopramide with diphenhydramine for acute PTH found that the treatment group (N = 81) experienced more significant pain improvement than placebo by 1.4 points. For persistent PTH, an open-label study of erenumab (N = 89) found that 28% of participants reported ≥ 50% reduction in moderate-to-severe headache days, but an RCT of fremanezumab showed a non-significant reduction in moderate-to-severe headache days. A randomized crossover study of 40 patients with persistent PTH found that onabotulinum toxin-A decreased cumulative number of headaches/week by 43.3% in the treatment group and increased by 35.1% among placebos. In a study of military veterans with severe posttraumatic stress disorder and persistent/delayed onset PTH (N = 193), patients who received Cognitive Behavioral Therapy reported significant improvements in headache-related disability compared to usual care (aggregate mean HIT-6, -3.4). A transcranial magnetic stimulation (N = 24) study found that 58% of participants with mild TBI-related headache experienced a 50% reduction in headache frequency. New studies indicate promise in improving clinically important outcomes of PTH. However, more research is necessary to determine the optimal treatment and whether combining pharmacologic and nonpharmacologic treatment versus a single modality is more effective.

Factors Associated with Patient Adherence to Biofeedback Therapy Referral for Migraine: An Observational Study.

Biofeedback has Grade A evidence for the treatment of migraine, yet few studies have examined the factors associated with patients' decisions to pursue biofeedback treatment recommendations. We sought to examine reasons for adherence or non-adherence to referral to biofeedback therapy as treatment for migraine. Patients with migraine who had been referred for biofeedback by a headache specialist/behavioral neurologist were interviewed in person or via Webex. Patients completed an enrollment questionnaire addressing demographics and questions related to their headache histories. At one month, patients were sent a follow-up questionnaire via REDCap and asked if they had pursued the recommendation for biofeedback therapy, their reasons for their decision, and their impressions about biofeedback for those who pursued it. Nearly two-thirds (65%; 33/51) of patients responded at one month. Of these, fewer than half (45%, 15/33) had contacted biofeedback providers, and only 18% (6/33) completed a biofeedback session. Common themes emerged for patients who did not pursue biofeedback, including feeling that they did not have time, concern for financial obstacles (e.g., treatment cost and/or insurance coverage), and having difficulty scheduling an appointment due to limited provider availability. When asked about their preference between type of biofeedback provider (e.g., a physical therapist or psychologist), qualitative responses were mixed; many patients indicated no preference as long as they took insurance and/or were experienced, while others indicated a specific preference for a physical therapist or psychologist due to familiarity, or prior experiences with that kind of provider. Patients with migraine referred for biofeedback therapy face numerous obstacles to pursuing treatment.

A Comparison of Patients' and Neurologists' Assessments of their Teleneurology Encounter: A Cross-Sectional Analysis.

Background and Objectives: To better understand patients' and neurologists' assessments of their experiences regarding effectiveness of teleneurology encounters. Methods: Following an audio-video telehealth visit, neurologists asked patients to participate in a survey-based research study about the encounter, and then, the neurologists also recorded their own evaluations. Data were analyzed using standard quantitative and qualitative techniques for dichotomous and ordered-category survey responses in this cross-sectional analysis. Results: The study included unique encounters between 187 patients and 11 general neurologists. The mean patient age was 49 ± 17.5 years. Two thirds of the patients (66.8%, 125/187) were female. One third (33.2%; 62) were patients new to the NYU Langone Health neurology practices. The most common patient chief complaints were headache (69/187, 36.9%), focal and generalized numbness or tingling (21, 11.2%), memory difficulty (15, 8%), spine-related symptoms (12, 6.4%), and vertigo (11, 5.9%). Most patients (94.7%, 177/187) reported that the teleneurology encounter satisfied their needs. Patients and their neurologists agreed that the experience was effective in 91% (162/178) of encounters, regardless of whether the visit was for a new or established patient visit. Discussion: More than 90% of new and established patients and their neurologists agreed that teleneurology encounters were effective despite some limitations of the examination, the occasional need for patient assistance, and technical difficulties. Our results provide further evidence to justify and to expand the clinical use of teleneurology.

Headache clinicians' perspectives on the remote monitoring of patients' electronic diary data: A qualitative study.

OBJECTIVE: We assessed headache clinicians' viewpoints on potential remote access to patients' digital headache diary data and the practicalities of data utilization. BACKGROUND: With the ubiquitous nature of electronic medical records and the existence of remote monitoring (RM) for many medical conditions, there is now the potential for remote symptom monitoring for patients with headache disorders. While patients are asked to utilize headache diaries, clinicians may or may not have access to the data before patient visits, and their perspectives regarding this emerging technology are currently unknown. METHODS: After recruiting participants from the National Institutes of Health Pain Consortium Network, the American Headache Society Special Interest Section listservs, and Twitter and Facebook social media platforms, we conducted 20 semi-structured qualitative interviews of headache providers across the United States from various types of institutions and asked them their perspectives on remote access to patient headache diary data. We transcribed the interviews, which were then coded by two independent coders. Themes and sub-themes were developed using inductive content analysis. RESULTS: All clinicians felt the RM data needed to be integrated into the electronic medical record. Six themes emerged from the interviews: (i) Clinician perspectives on how RM could be beneficial but at other times could create obstacles/challenges, (ii) operationally, data integration could benefit headache care, (iii) there should be initial logistical considerations for bringing RM into clinical care, (iv) education may need to be provided to both patients and clinicians, (v) there are likely research benefits associated with RM, and (vi) additional suggestions for considering potential integration of RM into practice. CONCLUSIONS: While headache clinicians had mixed opinions on the benefits/challenges that RM presents to patient care, patient satisfaction, and visit time, new ideas emerged that may help advance the field.

Episodic Migraine and Psychiatric Comorbidity: A Narrative Review of the Literature.

PURPOSE OF REVIEW: We evaluate the evolving evidence of psychiatric comorbidities associated with episodic migraine. Utilizing recent research publications, we aim to assess traditional treatment option considerations and discuss recent and evolving non-pharmacologic treatment progress for episodic migraine and related psychiatric conditions. RECENT FINDINGS: Recent findings indicate that episodic migraine is strongly linked to comorbid depression, anxiety, posttraumatic stress disorder, and sleep disorders. Not only do patients with episodic migraine have higher rates of psychiatric comorbidity, but a higher number of headache days reported is also strongly linked to an increased risk of developing a psychiatric disorder, indicating there may be a link between frequency and psychiatric comorbidity and that patients with high-frequency episodic migraine should be assessed for psychiatric comorbidity. Few migraine preventive medications have examined the effect of the medication on both migraine and psychiatric comorbidity though we discuss what has been reported in the literature. Non-pharmacologic-based treatments including behavioral therapies and mind-body interventions previously developed for psychiatric conditions, e.g., mindfulness-based CBT (MBCT), acceptance and commitment therapy (ACT), and mindfulness-based stress reduction (MBSR) therapy, have promising results for patients diagnosed with episodic migraine and may therefore be useful in treating migraine and comorbid psychiatric conditions. Psychiatric comorbidity may affect the efficacy of the treatment of episodic migraine. Thus, we must assess for psychiatric comorbidities to inform better treatment plans for patients. Providing patients with episodic migraine with alternate modalities of treatment may help to improve patient-centered care and increase patients' sense of self-efficacy.

Neurologists' Evaluations of Experience and Effectiveness of Teleneurology Encounters.

Background and Objectives: To better understand neurologists' assessments of the experiences and effectiveness of teleneurology encounters. Methods: After completing an audio-video telehealth visit with verbally consenting patients, neurologists recorded their evaluations of the encounter. Data were analyzed using standard quantitative and qualitative techniques. Results: The study included unique encounters between 187 patients and 11 neurologists. The mean patient age was 49 ± 17.5 years. Two thirds of patients (66.8%, 125/187) were female. One third of patients (33.2%; 62) were new patients. The most common patient complaints were headache (69/187, 36.9%), focal and generalized numbness or tingling (21, 11.2%), memory difficulty (15, 8%), spine-related symptoms (12, 6.4%), and vertigo (11, 5.9%). Neurologists reported that they completed a virtual examination that provided enough information for medical decision-making in 94.9% of encounters (169/178, 9 missing responses). Fourteen of 25 examination elements important for medical decision-making could be performed sufficiently during virtual encounters. Examination assistance was needed for 16.4% (30/183) of patients, who were, on average, 17.3 years older than those who did not require assistance (62.9 years vs. 45.6 years, p = 0.0002). In 19.1% (34/178) of encounters, neurologists learned clinically relevant information from seeing patients in their homes. Neurologists' assessments of the effectiveness of encounters were not related to the presence (97.2%, 35/36 effective) or absence (95%, 134/141 effective) of technical difficulties (p = 0.5729) in 177 encounters (10 missing responses). Discussion: Neurologists reported that nearly 95% of teleneurology encounters were effective despite limitations of the virtual examination, occasional need for patient assistance, and technical difficulties.

Rethinking headache as a global public health case model for reaching the SDG 3 HEALTH by 2030.

The 2030 Agenda for Sustainable Development sets out, through 17 Sustainable Development Goals (SDGs), a path for the prosperity of people and the planet. SDG 3 in particular aims to ensure healthy lives and promote well-being for all at all ages and includes several targets to enhance health. This review presents a "headache-tailored" perspective on how to achieve SDG 3 by focusing on six specific actions: targeting chronic headaches; reducing the overuse of acute pain-relieving medications; promoting the education of healthcare professionals; granting access to medication in low- and middle-income countries (LMIC); implementing training and educational opportunities for healthcare professionals in low and middle income countries; building a global alliance against headache disorders. Addressing the burden of headache disorders directly impacts on populations' health, as well as on the possibility to improve the productivity of people aged below 50, women in particular. Our analysis pointed out several elements, and included: moving forward from frequency-based parameters to define headache severity; recognizing and managing comorbid diseases and risk factors; implementing a disease management multi-modal management model that incorporates pharmacological and non-pharmacological treatments; early recognizing and managing the overuse of acute pain-relieving medications; promoting undergraduate, postgraduate, and continuing medical education of healthcare professionals with specific training on headache; and promoting a culture that favors the recognition of headaches as diseases with a neurobiological basis, where this is not yet recognized. Making headache care more sustainable is an achievable objective, which will require multi-stakeholder collaborations across all sectors of society, both health-related and not health-related. Robust investments will be needed; however, considering the high prevalence of headache disorders and the associated disability, these investments will surely improve multiple health outcomes and lift development and well-being globally.

Association Between Migraine Comorbidity and Psychiatric Symptoms Among People With Newly Diagnosed Focal Epilepsy.

OBJECTIVE: Little is known about psychiatric symptoms among patients with migraine and newly diagnosed focal epilepsy. The investigators compared symptoms of depression, anxiety, and suicidality among people with newly diagnosed focal epilepsy with migraine versus without migraine. METHODS: The Human Epilepsy Project is a prospective multicenter study of patients with newly diagnosed focal epilepsy. Depression (measured with the Center for Epidemiologic Studies Depression Scale), anxiety (measured with the 7-item Generalized Anxiety Disorder scale), and suicidality scores (measured with the Columbia-Suicide Severity Rating Scale [C-SSRS]) were compared between participants with versus without migraine. Data analysis was performed with the Kolmogorov-Smirnov test for normality assessment, the Mann-Whitney U test, chi-square test, and linear regression. RESULTS: Of 349 patients with new-onset focal epilepsy, 74 (21.2%) had migraine. There were no differences between the patients without migraine versus those with migraine in terms of age, race, and level of education. There were more women in the group with migraine than in the group without migraine (75.7% vs. 55.6%, p=0.0018). The patients with epilepsy and comorbid migraine had more depressive symptoms than the patients with epilepsy without migraine (35.2% vs. 22.7%, p=0.031). Patients with epilepsy with comorbid migraine had more anxiety symptoms than patients with epilepsy without migraine, but this relation was mediated by age in logistic regression, with younger age being associated with anxiety. Comorbid migraine was not associated with C-SSRS ideation or behavior. CONCLUSIONS: Among a sample of patients with newly diagnosed focal epilepsy, 21.2% had migraine. Migraine comorbidity was associated with higher incidence of depressive symptoms. Future studies should be performed to better assess these relationships and possible treatment implications.

The role of urgent care centers in headache management: a quality improvement project.

BACKGROUND: Patients with headache often seek urgent medical care to treat pain and associated symptoms that do not respond to therapeutic options at home. Urgent Cares (UCs) may be suitable for the evaluation and treatment of such patients but there is little data on how headache is evaluated in UC settings and what types of treatments are available. We conducted a study to evaluate the types of care available for patients with headache presenting to UCs. DESIGN: Cross-Sectional. METHODS: Headache specialists across the United States contacted UCs to collect data on a questionnaire. Questions asked about UC staffing (e.g. number and backgrounds of staff, hours of operation), average length of UC visits for headache, treatments and tests available for patients presenting with headache, and disposition including to the ED. RESULTS: Data from 10 UC programs comprised of 61 individual UC sites revealed: The vast majority (8/10; 80%) had diagnostic testing onsite for headache evaluation. A small majority (6/10; 60%) had the American Headache Society recommended intravenous medications for acute migraine available. Half (5/10) had a headache protocol in place. The majority (6/10; 60%) had no follow up policy after UC discharge. CONCLUSIONS: UCs have the potential to provide expedited care for patients presenting for evaluation and treatment of headache. However, considerable variability exists amongst UCs in their abilities to manage headaches. This study reveals many opportunities for future research including the development of protocols and professional partnerships to help guide the evaluation, triage, and treatment of patients with headache in UC settings.

Underuse of Behavioral Treatments for Headache: a Narrative Review Examining Societal and Cultural Factors.

Migraine affects over 40 million Americans and is the world's second most disabling condition. As the majority of medical care for migraine occurs in primary care settings, not in neurology nor headache subspecialty practices, healthcare system interventions should focus on primary care. Though there is grade A evidence for behavioral treatment (e.g., biofeedback, cognitive behavioral therapy (CBT), and relaxation techniques) for migraine, these treatments are underutilized. Behavioral treatments may be a valuable alternative to opioids, which remain widely used for migraine, despite the US opioid epidemic and guidelines that recommend against them. Identifying and removing barriers to the use of headache behavioral therapy could help reduce the disability as well as the personal and social costs of migraine. These techniques will have their greatest impact if offered in primary care settings to the lower socioeconomic status groups at greatest risk for migraine. We review the societal and cultural challenges that impose barriers to optimal use of non-pharmacological treatment services. These barriers include insufficient knowledge of migraine/headache behavioral treatments and insufficient availability of clinicians trained in non-pharmacological treatment delivery; limited access in underserved communities; financial burden; and stigma associated with both headache and mental health diagnoses and treatment. For each barrier, we discuss potential approaches to minimizing its effect and thus enhancing non-pharmacological treatment utilization.Case ExampleA 25-year-old graduate student with a prior history of headaches in college is attending school in the evenings while working a full-time job. Now, his headaches have significant nausea and photophobia. They are twice weekly and are disabling enough that he is unable to complete homework assignments. He does not understand why the headaches occur on Saturdays when he pushes through all week to get through his examinations that take place on Friday evenings. He tried two different migraine preventive medications, but neither led to the 50% reduction in headache days his doctor had hoped for. His doctor had suggested cognitive behavioral therapy (CBT) before initiating the medications, but he had been too busy to attend the appointments, and the challenges in finding an in-network provider proved difficult. Now with the worsening headaches, he opted for the CBT and by the fifth week had already noted improvements in his headache frequency and intensity.

Headache infusion centers: A survey on treatments provided, infusion center operations, and barriers to developing new infusion centers.

BACKGROUND: Infusion therapy refers to the intravenous administration of medicines and fluids for the treatment of status migrainosus, severe persistent headaches, or chronic headache. Headache practices and centers offer this treatment for patients as an alternative to the emergency department (ED) setting. However, little information is available in the literature on understanding the operations of an infusion center. OBJECTIVE: We sought to survey the Inpatient Headache & Emergency Medicine specialty section and the Academic Program Directors listserv of the American Headache Society (AHS) to better understand current practices. METHODS: A survey was advertised and distributed to the listservs of both the Inpatient Headache & Emergency Medicine specialty section and the Academic Program Directors, which combined included both academic and private practices. In addition, the survey was available on laptops at related events at an annual AHS meeting in Scottsdale. RESULTS: Of the 127 members of the combined group of both listservs, 50 responded with an overall survey response rate of 39%. Ten out of fifty were from programs with more than one responder completing the survey, leaving 40 unique headache programs. Academic programs made up the majority of programs (85%, 34/40). The total of 40 participating programs is comparable with the 47 academic headache programs listed on the American Migraine Foundation website at the time of the survey. Of the academic programs surveyed, most were hospital based (n = 23) compared with a satellite location (n = 11). Of all programs surveyed, 68% (27/40) offered infusion therapy. Of those that did not have an infusion practice (n = 13), the most common reason cited was insufficient staffing (n = 8). Key highlights of the survey included the following: The majority of programs offering infusions obtain prior authorization before scheduling (70%, 19/27) and offer patient availability 5 days/week (78%, 21/27) typically only during business hours (81%, 22/27). Programs reported that they typically give three to four medications during each infusion session (72%, 18/25). Treatment paradigms varied between programs. Programs surveyed were concentrated in the Northeast and Midwest regions of the United States. CONCLUSION: The limited number of headache infusion centers overall may contribute to the limited ability of headache infusion centers to prevent ED migraine visits. Headache patients can have unpredictable headache onset, and most of the infusion practices surveyed appeared to adapt to this by offering infusions most days during a work week. However, this need for multiple days per week may also explain the most common reason for not having an infusion practice, which is insufficient staffing. Various treatment paradigms are implemented by different practitioners, and future studies will have to focus on investigation of best practice.

Telehealth as a new care delivery model: The headache provider experience.

OBJECTIVE: To assess telehealth practice for headache visits in the United States. BACKGROUND: The rapid roll out of telehealth during the COVID-19 pandemic impacted headache specialists. METHODS: American Headache Society (AHS) members were emailed an anonymous survey (9/9/20-10/12/20) to complete if they had logged ≥2 months or 50+ headache visits via telehealth. RESULTS: Out of 1348 members, 225 (16.7%) responded. Most were female (59.8%; 113/189). Median age was 47 (interquartile range [IQR] 37-57) (N = 154). The majority were MD/DOs (83.7%; 159/190) or NP/PAs (14.7%; 28/190), and most (65.1%; 123/189) were in academia. Years in practice were 0-3: 28; 4-10: 58; 11-20: 42; 20+: 61. Median number of telehealth visits was 120 (IQR 77.5-250) in the prior 3 months. Respondents were "comfortable/very comfortable" treating via telehealth (a) new patient with a chief complaint of headache (median, IQR 4 [3-5]); (b) follow-up for migraine (median, IQR 5 [5-5]); (c) follow-up for secondary headache (median, IQR 4 [3-4]). About half (51.1%; 97/190) offer urgent telehealth. Beyond being unable to perform procedures, top barriers were conducting parts of the neurologic exam (157/189), absence of vital signs (117/189), and socioeconomic/technologic barriers (91/189). Top positive attributes were patient convenience (185/190), reducing patient travel stress (172/190), patient cost reduction (151/190), flexibility with personal matters (128/190), patient comfort at home (114/190), and patient medications nearby (103/190). Only 21.3% (33/155) of providers said telehealth visit length differed from in-person visits, and 55.3% (105/190) believe that the no-show rate improved. On a 1-5 Likert scale, providers were "interested"/"very interested" in digitally prescribing headache apps (median 4, IQR 3-5) and "interested"/"very interested" in remotely monitoring patient symptoms (median 4, IQR 3-5). CONCLUSIONS: Respondents were comfortable treating patients with migraine via telehealth. They note positive attributes for patients and how access may be improved. Technology innovations (remote vital signs, digitally prescribing headache apps) and remote symptom monitoring are areas of interest and warrant future research.

Strategies for Behavioral Research in Neurology: Lessons Learned During the COVID-19 Pandemic and Applications for the Future.

PURPOSE OF REVIEW: Behavioral therapies are proven treatments for many neurologic conditions. However, the COVID-19 pandemic has posed significant challenges for conducting behavioral research. This article aims to (1) highlight the challenges of running behavioral clinical trials during the pandemic, (2) suggest approaches to maximize generalizability of pandemic-era studies, and (3) offer strategies for successful behavioral trials beyond the pandemic. RECENT FINDINGS: Thousands of clinical trials have been impacted by the COVID-19 pandemic, from undergoing protocol revisions to suspension altogether. Furthermore, for ongoing trials, recruitment of diverse populations has suffered, thereby exacerbating existing inequities in clinical research. Patient adherence and retention have been affected by a myriad of pandemic-era restraints, and medical, psychiatric, and other complications from the pandemic have the potential to have long-term effects on pandemic-era study results. In the development of post-pandemic study protocols, attention should be given to designing studies that incorporate successful aspects of pre-pandemic and pandemic-era strategies to (1) broaden recruitment using new techniques, (2) improve access for diverse populations, (3) expand protocols to include virtual and in-person participation, and (4) increase patient adherence and retention.

The Functionality, Evidence, and Privacy Issues Around Smartphone Apps for the Top Neuropsychiatric Conditions.

OBJECTIVE: There are more than 325,000 health-related smartphone applications (apps) on the market. To better understand the apps currently on the market for the five most disabling neuropsychiatric conditions, the authors conducted a study investigating their intended uses (target population and intervention), the data collected, and any privacy policies. METHODS: This was a cross-sectional study of apps for the five most disabling neuropsychiatric conditions per the World Health Organization: stroke, migraine, depression, Alzheimer's disease and dementia, and anxiety. Up to 15 apps in the U.S. Google Play and Apple app stores were selected based on the following prespecified inclusion criteria: the app appeared in the top 50 search results, offered intervention or tracking capabilities, and listed the condition in the app title or description. Exclusion criteria were <$5.00 to purchase, solely motor versus cognitive-based intervention, or designed for use by caregivers or health care providers. Data abstracted included function, behavior change rewards, and information about intervention, privacy policy, and payment. RESULTS: Eighty-three apps were reviewed (stroke, N=8; migraine, N=25; Alzheimer's disease and dementia, N=8; depression, N=7; anxiety, N=14; apps targeting depression and anxiety, N=21). Sixty-nine percent of apps had an intervention component, 18% were deemed evidence based, 77% had a privacy policy, 70% required payment for access to all features, and 19% rewarded user behavior changes. CONCLUSIONS: Most apps on the market targeted migraine, depression, and anxiety and contained interventions, although most of the interventions did not appear to be evidence based. Additionally, although most apps had privacy policies, lay people may have difficulty understanding these policies due to their complexities.

Survey of Pain Medicine Specialists' Familiarity with Migraine Management.

OBJECTIVE: Pain specialists treat patients with headache and interface with those who use opioids more so than neurologists and headache specialists. We assessed the headache medicine knowledge and needs of pain specialists. DESIGN/SETTING: Cross-sectional online survey. SUBJECTS: Members of the American Academy of Pain Medicine. METHODS: Survey was based on a prior survey of primary care providers' knowledge and needs and was iteratively updated by four headache specialists, two with pain medicine affiliations. RESULTS: Of the 105 respondents, 71.4% were physicians, 34.3% were women, and they averaged 20.0 ± 13.6 years in practice. The most common specialty was anesthesia (36.1%, n = 35/97) followed by neurology (14.4%, n = 14/97). About half of providers (55.7%, n = 34/61 and 53.3%, n = 32/60) were familiar with the American Academy of Neurology Guidelines for pharmacological migraine prevention and the Choosing Wisely Campaign recommendations for limiting neuroimaging and opioids. Less than half of all providers (39.7%, n = 23/58) were familiar with the American Headache Society guidelines for emergency management of migraine. Providers were aware of Level A evidence-based nonpharmacological therapies, with over three-fourths recognizing cognitive behavioral therapy (80.7%, n = 50/62) and biofeedback (75.8%, n = 47/62) as evidence-based interventions. About 80% of providers (n = 50/64) estimate making migraine diagnoses in ≤50% of their patients with headache. Providers consider starting preventive headache therapy at 7.1 ± 3.9 days/month and report referring 34.3%±34.2% of patients to behavioral interventions. CONCLUSIONS: Dissemination and implementation of headache guidelines is needed for pain medicine specialists. Providers may need help diagnosing migraine based on currently accepted guidelines and referring for evidence-based behavioral therapies.

Neuroscience Education as Therapy for Migraine and Overlapping Pain Conditions: A Scoping Review.

BACKGROUND: Neuroscience education therapy (NET) has been successfully used for numerous overlapping pain conditions, but few studies have investigated NET for migraine. OBJECTIVE: We sought to 1) review the literature on NET used for the treatment of various pain conditions to assess how NET has been studied thus far and 2) recommend considerations for future research of NET for the treatment of migraine. DESIGN/METHODS: Following the PRISMA guideline for scoping reviews, co-author (TR), a medical librarian, searched the MEDLINE, PsychInfo, Embase, and Cochrane Central Clinical Trials Registry databases for peer-reviewed articles describing NET to treat migraine and other chronic pain conditions. Each citation was reviewed by two trained independent reviewers. Conflicts were resolved through consensus. RESULTS: Overall, a NET curriculum consists of the following topics: pain does not equate to injury, pain is generated in the brain, perception, genetics, reward systems, fear, brain plasticity, and placebo/nocebo effects. Delivered through individual, group, or a combination of individual and group sessions, NET treatments often incorporate exercise programs and/or components of other evidence-based behavioral treatments. NET has significantly reduced catastrophizing, kinesiophobia, pain intensity, and disability in overlapping pain conditions. In migraine-specific studies, when implemented together with traditional pharmacological treatments, NET has emerged as a promising therapy by reducing migraine days, pain intensity and duration, and acute medication intake. CONCLUSION: NET is an established treatment for pain conditions, and future research should focus on refining NET for migraine, examining delivery modality, dosage, components of other behavioral therapies to integrate, and migraine-specific NET curricula.

Focus group findings on the migraine patient experience during research studies and ideas for future investigations.

OBJECTIVES: We conducted focus groups in people who had participated in mobile health (mHealth) studies of behavioral interventions for migraine to better understand: (a) Participant experience in the recruitment/enrollment process; (b) participant experience during the studies themselves; (c) ideas for improving participant experience for future studies. METHODS: We conducted four focus groups in people who had agreed to participate in one of three studies involving mHealth and behavioral therapy for migraine. Inclusion criteria were being age 18-80, owning a smartphone, and having four or more headache days per month. All participants met the International Classification of Headache Disorders third edition beta version criteria for migraine. Exclusion criteria were not speaking English and having had behavioral therapy for migraine in the past year. Focus groups were audio recorded, fully transcribed and coded using general thematic analysis. RESULTS: The 12 focus group participants had a mean age of 45 ± 15, a mean age of headache onset of 21 ± 13 and mean MIDAS disability score was 39 ± 56. Participants were women (100%), white (50%), Asian (33.3%) or members of other racial groups (16.7%). Certain themes emerged from each topic area. With regard to recruitment/enrollment (a), key themes were: (i) Participants joined their study out of an interest in research and/or a desire to try a new migraine treatment modality (behavioral therapy). (ii) Enrollment should be simple and study requirements should be carefully explained prior to enrollment. When asked about their experiences during the studies (b), the following themes emerged: (i) It is difficult to participate in study follow-up and compliance phone calls; (ii) participants prefer to choose from among various options for contact with the study team; (iii) there are barriers that limit app use related to migraine itself, as well as other barriers; (iv) completing diaries on a daily basis is challenging; (v) technical difficulties and uncertainties about app features limit use; (vi) being part of a research study promoted daily behavioral therapy use; (vii) progressive muscle relaxation (PMR) is enjoyable, and has a positive impact on life; (viii) behavioral therapy was a preferred treatment to reduce migraine pain. Ideas for improving study design or patient experience (c) included: (i) Increased opportunity to interact with other people with migraine would be beneficial; (ii) navigating the app and data entry should be easier; (iii) more varied methods for viewing the data and measures of adherence are needed; (iv) more information on and more varied behavioral treatment modalities would be preferred. CONCLUSION: Though people with migraine are motivated to participate in mHealth and behavioral treatment studies, better communication up front about interventions as well as greater flexibility in interventions and follow-up methods are desired.

A Brief Look at Urgent Care Visits for Migraine: The Care Received and Ideas to Guide Migraine Care in this Proliferating Medical Setting.

OBJECTIVE: There has been a rise in urgent care centers throughout the country over the past 10 years, leading to an increase in patients accessing medical care in these locations. These centers advertise an alternative to the Emergency Department (ED) for the evaluation and treatment of urgent medical conditions. The goal of this analysis was to examine the use of urgent care visits for migraine within 2 urgent care centers within a large academic medical system in New York City. We examined the trends in management and treatment of migraine in these urgent care settings, as well as prescriptions and instructions given to this patient population upon discharge. We paid particular attention to whether the medications administered and prescribed on discharge were those recommended by American Headache Society migraine management guidelines. METHODS: We conducted a retrospective chart review of patients with migraine diagnoses at 2 different urgent care locations within 1 large urban medical center. We determined baseline patient demographics, previous migraine characteristics, frequencies of reasons for urgent care visits as well as various medications administered, medications prescribed on discharge, and characteristics of patient outcomes post-discharge. RESULTS: Of the 78 patients who visited urgent care with a migraine diagnosis, 20 (25.6%) had a known primary care provider within the urgent care centers' healthcare system. More than three-fourths of all patients (78.2%) had a self-reported history of either recurrent headache or migraine prior to the urgent care visit. Of those with a documented frequency of prior headaches, 94.1% (32/34) had episodic migraine and 79.4% (27/34) experienced at most 1-2 headache days per month. Of those presenting to the urgent care during an episode of migraine, 12.3% (9/73) were given intravenous metoclopramide and none were given subcutaneous sumatriptan or intravenous prochlorperazine. Of those with reported nausea or vomiting with their migraine, 46.2% (18/39) received an anti-emetic at the visit and 33.3% (13/39) were given an anti-emetic prescription. Only 11.1% (6/54) of patients who did not have a record of previous triptan use were given a triptan prescription at the urgent care visit. CONCLUSIONS: The majority of patients in our study who sought medical treatment for migraine in these 2 urgent care centers were not established patients within the urgent care centers' healthcare system. While 93.6% (73/78) of patients were experiencing current pain upon presentation to the urgent care centers, only 12.3% (9/73) received administration of the medications with the highest level of evidence by the American Headache Society (Level B) for acute migraine treatment in an ED. In addition, the majority of patients with a migraine history presenting to the urgent care setting were not given triptans or anti-emetic prescriptions upon discharge from their urgent care visit. Having these migraine-specific prescriptions may improve self-treatment at home should a migraine attack recur.

What are Headache Smartphone Application (App) Users Actually Looking for in Apps: A Qualitative Analysis of App Reviews to Determine a Patient Centered Approach to Headache Smartphone Apps.

BACKGROUND: Many headache smartphone applications (apps) are commercially available. A Modified Delphi Study aimed to determine specialists' expectations of what a headache app should entail but consumer expectations of headache apps have not been evaluated extensively. OBJECTIVE: To evaluate publicly available reviews of headache apps to understand app features that motivate the consumers to use apps. METHODS: The Google Play and Apple App Stores were systematically searched for headache/migraine diary apps with 10+ consumer reviews. A maximum of 300 "Most Helpful" reviews for each app were extracted. Four coders coded reviews and resolved discrepancies. Themes and subthemes were created based on codes used 5+ times. RESULTS: About 15 apps met the study criteria (9 Android, 6 IOS). 945 reviews were coded. Four themes emerged: (1) App allows users to track headache characteristics, potential triggers, and treatments; (2) App usability; (3) Personalization and features to assess trends in data are key motivators for app use; (4) Ease with exportation and viewing data is critical. DISCUSSION: A user-centered design with the ability to (1) customize key features including headache characteristics, potential triggers, and treatments, (2) assess trends in data, and (3) view and export data would best optimize headache smartphone applications based on consumer preference.