Amaal J. Starling

Treatment of Cluster Headache: The American Headache Society Evidence-Based Guidelines.

Cluster headache (CH), the most common trigeminal autonomic cephalalgia, is an extremely debilitating primary headache disorder that is often not optimally treated. New evidence‐based treatment guidelines for CH will assist clinicians with identifying and choosing among current treatment options.

Sensitivity of MRI of the spine compared with CT myelography in orthostatic headache with CSF leak

Objective: To investigate the sensitivity of MRI of the spine compared with CT myelography (CTM) in detecting CSF leaks. Methods: Between July 1998 and October 2010, 12 patients with orthostatic headache and a CTM-confirmed spinal CSF leak underwent an MRI of the spine with and without contrast. Using CTM as the gold standard, we retrospectively investigated the sensitivity of spinal MRI in detecting a CSF leak. Results: Eleven of 12 patients with a CSF leak documented by CTM also had extradural fluid collections on spinal MRI (sensitivity 91.7%). Six patients with extradural fluid collections on spinal MRI also had spinal dural enhancement. Conclusion: When compared with the gold standard of CTM, MRI of the spine appears to be a sensitive and less invasive imaging modality for detecting a spinal CSF leak, suggesting that MRI of the spine should be the imaging modality of first choice for the detection of spinal CSF leaks.

Risk of development of medication overuse headache with nonsteroidal anti-inflammatory drug therapy for migraine: a critically appraised topic.

Background:The development of medication overuse headache (MOH) is associated with frequent use of analgesics, especially opiates, for treatment of primary headache disorders, particularly migraine. Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat migraine. Objective:To critically evaluate evidence estimating the risk of MOH associated with NSAID therapy in patients with migraine. Methods:The objective was addressed through the development of a structured, critically appraised topic. This included a clinical scenario, structured question, literature search strategy, critical appraisal, results, evidence summary, commentary, and bottom line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and headache neurology content experts. Results:The 1-year incidence of MOH was 2.5%. In patients with low (0 to 4 d monthly) to moderate (5 to 9 d monthly) baseline headache frequency, NSAIDs were not associated with progression to MOH and may be protective (odds ratio=0.31; 95% confidence interval, 0.27-0.34). However, in patients with a high baseline headache frequency (10 to 14 d monthly), NSAIDs are associated with progression to MOH (odds ratio=1.93; 95% confidence interval, 1.82-2.06). Conclusions:Acute NSAID therapy is associated with progression to MOH in migraineurs with a high baseline migraine frequency but may be protective in patients with low baseline headache frequency. However, a causal role for NSAIDs in progression from episodic to chronic headache has not been established.

Best practices for patients with chronic migraine: burden, diagnosis, and management in primary care.

Headache and migraine are common medical complaints among patients visiting primary care physicians (PCPs). A number of these patients may have chronic migraine, which is more difficult to diagnose and manage than many other headache disorders. Identification of those at risk, correct diagnosis, and establishment of a comprehensive management plan for patients with chronic migraine will require a joint effort between the PCP and the headache specialist. Together, the PCP and headache specialist will need to assess the patient for modifiable exacerbating factors and comorbidities while managing prophylactic and as-needed therapies. Herein, we provide a review of chronic migraine for the PCP and describe tools for improving patient care.

Improving the detection of chronic migraine: Development and validation of Identify Chronic Migraine (ID-CM)

Background Migraine, particularly chronic migraine (CM), is underdiagnosed and undertreated worldwide. Our objective was to develop and validate a self-administered tool (ID-CM) to identify migraine and CM. Methods ID-CM was developed in four stages. (1) Expert clinicians suggested candidate items from existing instruments and experience (Delphi Panel method). (2) Candidate items were reviewed by people with CM during cognitive debriefing interviews. (3) Items were administered to a Web panel of people with severe headache to assess psychometric properties and refine ID-CM. (4) Classification accuracy was assessed using an ICHD-3β gold-standard clinician diagnosis. Results Stages 1 and 2 identified 20 items selected for psychometric validation in stage 3 (n = 1562). The 12 psychometrically robust items from stage 3 underwent validity testing in stage 4. A scoring algorithm applied to four symptom items (moderate/severe pain intensity, photophobia, phonophobia, nausea) accurately classified most migraine cases among 111 people (sensitivity = 83.5%, specificity = 88.5%). Augmenting this algorithm with eight items assessing headache frequency, disability, medication use, and planning disruption correctly classified most CM cases (sensitivity = 80.6%, specificity = 88.6%). Discussion ID-CM is a simple yet accurate tool that correctly classifies most individuals with migraine and CM. Further testing in other settings will also be valuable.

Vestibular evoked myogenic potentials in patients with vestibular migraine.

Objective Literature investigating otolith reflexes in patients with vestibular migraine (VM) is variable and primarily describes the descending saccular pathway. This research aimed to study ocular vestibular evoked myogenic potential (oVEMP) and cervical vestibular evoked myogenic potential (cVEMP) prevalence and response characteristics in patients with suspected VM and in control patients. The purpose is to assess vulnerabilities within the ascending utricular and descending saccular pathways in the VM population. Study Design Retrospective study Setting Tertiary academic referral center Patients 39 adults with VM, 29 control patients Main Outcome Measure(s) Air conducted oVEMPs and cVEMPs measured with 500 Hz tone burst stimuli Results Age of headache onset was most often in childhood or adolescence, with dizziness onset occurring later. The rate of bilaterally absent oVEMPs was significantly higher (28%, p < 0.01) in the VM group compared with the control group (0%). oVEMP amplitude asymmetry ratios were significantly higher for the definite VM (p < 0.01) and probable VM (p = 0.023) groups than the control group. Eleven patients also had history of concussion; they were significantly more likely to demonstrate bilaterally absent oVEMPs (p < 0.01) in comparison to the control patients. When VM patients with a history of concussion were omitted from analysis, differences in oVEMP amplitude asymmetry (p < 0.01) and bilateral oVEMP absence remained significant (p = 0.015). There were no differences in the rate of bilateral cVEMP presence or response parameters between VM and control groups. Conclusion VEMP presentation differs for some patients diagnosed with VM. The higher rates of abnormal oVEMPs may suggest greater vulnerability within the ascending utricular–ocular pathway in patients with VM.

Migraine in Pregnancy and Lactation

Migraine headache is a significant health problem affecting women more than men. In women, the hormonal fluctuations seen during pregnancy and lactation can affect migraine frequency and magnitude. Understanding the evaluation of headache in pregnancy is important, especially given the increased risk of secondary headache conditions. Pregnancy and lactation can complicate treatment options for women with migraine because of the risk of certain medications to the fetus. This review includes details of the workup and then provides treatment options for migraine during pregnancy and lactation.

Interictal photosensitivity associates with altered brain structure in patients with episodic migraine

Background Migraine attacks manifest with hypersensitivities to light, sound, touch and odor. Some people with migraine have photosensitivity between migraine attacks, suggesting persistent alterations in the integrity of brain regions that process light. Although functional neuroimaging studies have shown visual stimulus induced “hyperactivation” of visual cortex regions in migraineurs between attacks, whether photosensitivity is associated with alterations in brain structure is unknown. Methods Levels of photosensitivity were evaluated using the Photosensitivity Assessment Questionnaire in 48 interictal migraineurs and 48 healthy controls. Vertex-by-vertex measurements of cortical thickness were assessed in 28 people with episodic migraine who had interictal photosensitivity (mean age = 35.0 years, SD = 12.1) and 20 episodic migraine patients without symptoms of interictal photosensitivity (mean age = 36.0 years, SD = 11.4) using a general linear model design. Results Migraineurs have greater levels of interictal photosensitivity relative to healthy controls. Relative to migraineurs without interictal photosensitivity, migraineurs with interictal photosensitivity have thicker cortex in several brain areas including the right lingual, isthmus cingulate and pericalcarine regions, and the left precentral, postcentral and supramarginal regions. Conclusion Episodic migraineurs with interictal photosensitivity have greater cortical thickness in the right parietal-occipital and left fronto-parietal regions, suggesting that persistent light sensitivity is associated with underlying structural alterations.

A Randomized, Double‐Blind, Placebo‐Controlled Study to Evaluate the Effect of Erenumab on Exercise Time During a Treadmill Test in Patients With Stable Angina

To determine the potential impact of erenumab, a human anti‐calcitonin gene‐related peptide (CGRP) receptor monoclonal antibody, on total exercise time (TET), time to exercise‐induced angina, and ST depression in a double‐blind, placebo‐controlled study in patients with stable angina due to documented coronary artery disease.

New Investigator and Trainee Task Force Survey on the Recruitment and Retention of Headache Specialists

We sought to survey the New Investigators and Trainees Section (NITS) members of the American Headache Society (AHS) to better understand their exposure to headache medicine during training and to determine their perceptions and attitudes about the field and the future of headache medicine.