Elliott A. Schulman

Repetitive intravenous DHE in the treatment of refractory headache

SYNOPSIS

Adverse Childhood Experiences and Frequent Headaches in Adults

Background.— A variety of studies have linked childhood maltreatment to headaches, including migraines, and to headache severity. This study assesses the relationship of adverse childhood experiences (ACEs) to frequent headaches during adulthood.

Defining Refractory Migraine and Refractory Chronic Migraine: Proposed Criteria From the Refractory Headache Special Interest Section of the American Headache Society

Certain migraines are labeled as refractory, but the entity lacks a well‐accepted operational definition. This article summarizes the results of a survey sent to American Headache Society members to evaluate interest in a definition for RM and what were considered necessary criteria. Review of the literature, collaborative discussions and results of the survey contributed to the proposed definition for RM. We also comment on our considerations in formulating the criteria and any issues in making the criteria operational. For the proposed definition for RM and refractory chronic migraine, patients must meet the International Classification of Headache Disorders, Second Edition criteria for migraine or chronic migraine, respectively. Headaches need to cause significant interference with function or quality of life despite modification of triggers, lifestyle factors, and adequate trials of acute and preventive medicines with established efficacy. The definition requires that patients fail adequate trials of preventive medicines, alone or in combination, from at least 2 of 4 drug classes including: beta‐blockers, anticonvulsants, tricyclics, and calcium channel blockers. Patients must also fail adequate trials of abortive medicines, including both a triptan and dihydroergotamine (DHE) intranasal or injectable formulation and either nonsteroidal anti‐inflammatory drugs (NSAIDs) or combination analgesic, unless contraindicated. An adequate trial is defined as a period of time during which an appropriate dose of medication is administered, typically at least 2 months at optimal or maximum‐tolerated dose, unless terminated early due to adverse effects. The definition also employs modifiers for the presence or absence of medication overuse, and with or without significant disability.

Defining refractory migraine: Results of the rhsis survey of american headache society members

Objectives.— To gauge consensus regarding a proposed definition for refractory migraine proposed by Refractory Headache Special Interest Section, and where its use would be most appropriate.

The American Academy of Neurology position statement on abuse and violence

Neurologists see patients with neurologic disabilities that render them susceptible to abuse or neglect. They also encounter patients with neurologic dysfunction that may be either directly or indirectly related to maltreatment. In 2008, the American Medical Association (AMA) encouraged physicians to “routinely inquire about the family violence histories of their patients, as this knowledge is essential for effective diagnosis and care.”1 Consensus-based guidelines for identification of intimate partner violence (IPV) have been adopted by numerous medical specialty organizations.2,–,11 The US Department of Health and Human Services has recommended that women be screened and counseled for domestic abuse.12 The consequences of not asking about IPV might include further physical and emotional harm, treatment failure, and when children are exposed, perpetuation of the intergenerational cycle of abuse.13,–,15 Providing resources to those being abused can result in improved outcomes.16 Further, identification of an abuse history may influence the assessment and treatment of presenting health concerns.17,18 By identifying this issue, and providing an appropriate referral, neurologists may improve quality of life and potentially ameliorate neurologic disability. The AAN is endorsing the assessment of abuse and neglect in our patients and supports the education of the neurologic community to achieve this end. Additional research on the physiologic and psychological consequences of abuse may lead to better treatment strategies to prevent related adverse health outcomes. Abuse may be defined in a variety of ways. The …

Refractory Migraine – A Review

Refractory migraine has long been a challenge to all headache specialists. This subgroup of migraine patients experience disability and impaired quality of life, despite optimal treatment. This article reviews the proposed definitions and epidemiology of refractory migraine, as well as the pathophysiology that may contribute to the genesis of this disorder. Aspects of treatment, including pharmacological, complementary/adjunct, and invasive approaches, are reviewed. Comorbid factors, medication overuse, potential pitfalls to treatment, and areas for future investigation are highlighted.

Refractory Headache: Historical Perspective, Need, and Purposes for an Operational Definition

The study of migraine has yielded many benefits for headache patients. Little research, however, has been performed on refractory migraine (RM) headache, a term often used interchangeably with intractable migraine. This may be a consequence of a lack of a well‐accepted definition. In a survey performed by the Refractory Headache Special Interest Section (RHSIS) on the American Headache Society (AHS) in 2006, 58% of the members agreed that a definition for refractory headache should be added to the International Classification of Headache Disorders‐2. A PubMed search identified 21 articles that defined refractory or intractable headache/migraine. Sixteen (76%) defined the term “refractory” and 5 (24%) defined the term “intractable.” Many of these definitions did not address the need for an adequate trial of a preventive medicine, disability, and medication overuse. An operational definition will allow us to better characterize the disorder, address unmet medical needs, and identify the most effective treatments. RHSIS of the AHS has proposed a definition of RM. It is our hope that this definition will spur interest in this entity and will lead to further research in the area.

Current concepts in refractory migraine.

Opinion statementThe Refractory or Intractable Migraine (RM) patient has long been a challenge to all healthcare providers (HCP). Headache specialists have recognized this sub group of patients who remain refractory to treatment. Despite this recognition, there are no formal criteria that characterize RM. This article will attempt to provide treatment approaches, some scientifically based and others that are empiric. A reasonable goal is to lessen disability. Combining the various modalities will improve the chances for successful treatment. The foundation of treatment is an emphasis on wellness. This includes optimizing mood, minimizing stress, practicing good sleep hygiene, and avoiding triggers. All comorbid factors should be addressed, including sleep and mood disorders, chronic neck pain, and obesity. Preventive treatment is necessary in the majority of patients, and a plan for “rescue” approaches is essential. Avoiding medication overuse, particularly narcotics, is advisable. Additional options for treatment include onabotulinumtoxinA, and more invasive modalities, such as neurostimulation. Adjunct treatment including supplements and relaxation may also be considered. Keeping a headache calendar is almost mandatory in management with attention to particular headache triggers, patterns and medication overuse (MOH). A trusting physician–patient relationship is also very important and will enhance compliance and foster communication. Patients often lapse from the management plan and the treating physician should be open minded about continuing care. RM is a long-term disease and requires close physician–patient interaction and cooperation for management of the problem. In those RM patients with multiple comorbidities, a multidisciplinary team should optimize management.

Claudication: an unusual side effect of DHE administration.

SYNOPSIS

An Unusual Angiographic Picture in Status Migrainosus

SYNOPSIS