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.
Objective: To apply a claims-based algorithm to identify potentially undiagnosed chronic migraine (CM) patients and compare 12-month direct costs of potentially undiagnosed versus diagnosed CM patients. Background: Approximately 7.7% of those with migraine have a CM diagnosis; however, it is estimated that 75% of those with CM are undiagnosed. Little is known about the economic burden of undiagnosed CM. Design/Methods: Adults having ≥2 migraine diagnoses (346.xx) ≥30 days apart with migraine claims between 7/1/14 and 6/30/15 and continuously enrolled ≥12 months pre- and post-index date were identified from a large US claims database. Patients with ≥2 CM diagnoses (346.7x) ≥30 days apart were assigned to diagnosed CM cohort. A recently developed algorithm was applied to identify potentially undiagnosed CM patients from the group of migraine patients without diagnosed CM (ie, no claim for 346.7x or onabotulinumtoxinA during study period). Algorithm predicts CM status based on gender, number of acute medication claims, unique preventive classes, and healthcare visits; it has 78% sensitivity and 73% specificity. The 12-month post-index all-cause costs were compared between diagnosed CM and potentially undiagnosed CM cohorts. Generalized linear models controlling for patient age, gender, region, plan type, comorbidity score, and other migraine-related comorbidities were used to estimate adjusted costs. Results: Study included 5555 diagnosed CM patients and 12,780 potentially undiagnosed CM patients. Mean adjusted total direct costs were significantly higher for undiagnosed CM group ($26,019) than for diagnosed CM group ($22,826, P Conclusions: Undiagnosed CM was associated with significantly higher total healthcare costs and direct medical costs than diagnosed CM. Initiatives to better identify and manage such patients are needed. Disclosure: Dr. Marcus has received personal compensation for consulting, serving on a scientific advisory board, speaking, or other activities with Allergan. Dr. Shewale has received personal compensation for consulting, serving on a scientific advisory board, speaking, or other activities as a full-time employee of Allergan plc. Dr. Shewale holds stock and/or stock options in Allergan plc which sponsored research in which Dr. Shewale was involved as an investigator. Dr. Young has received personal compensation for consulting, serving on a scientific advisory board, speaking, or other activities with Alder, Allergan, Cipla, Lilly, Supernus. Dr. Young has received research support from AGA, Alder, Allergan, Amgen, Autonomic Technology, Cumberland, Dr. Reddy Laboratories, Eli Lilly, Eneura Inc, Merz, and St. Jude Medical. Dr. Yu has received personal compensation for consulting, serving on a scientific advisory board, speaking, or other activities with Allergan, Inc. Dr. Yu holds stock and/or stock options in Allergan, Inc. Dr. Pavlovic has received personal compensation for consulting, serving on a scientific advisory board, speaking, or other activities with Alder Pharmaceuticals, Allergan, Dr. Reddy’s Laboratories, and the American Headache Society. Dr. Viswanathan has received personal compensation for consulting, serving on a scientific advisory board, speaking, or other activities with Allergan, Inc. Dr. Viswanathan holds stock and/or stock options in Allergan, Inc., which sponsored research in which Dr. Viswanathan was involved as an investigator. Dr. Viswanathan holds stock and/or stock options in Allergan, Inc. Dr. Doshi has received personal compensation for consulting for Alkermes, Forest Laboratories (now Allergan), Ironwood Pharmaceuticals, Shire, and Vertex Pharmaceuticals. Dr. Doshi holds stock and/or stock options in Merck and Pfizer, which sponsored research in which Dr. Doshi was involved as an investigator. Dr. Doshi has received research support from has previously received research funding from AbbVie, Biogen, Humana, Janssen, PhRMA, Pfizer, Regeneron, Sanofi, and the National Pharmaceutical Council.
The small molecule calcitonin gene-related peptide receptor antagonists (gepants) are the only drug class with medicines indicated for both the acute and preventive treatment of migraine. Given this dual capacity to both treat and prevent, along with their favorable tolerability profiles and lack of an association with medication-overuse headache, headache specialists have begun to use gepants in ways that transcend the traditional categories of acute and preventive treatment. One approach, called situational prevention, directs patients to treat during the interictal phase, before symptoms develop, in situations of increased risk for migraine attacks. Herein, we present three patients to illustrate scenarios of gepant use for situational prevention. In each case, a gepant was started in anticipation of a period of increased headache probability (vulnerability) and continued for a duration of 1 day to 5 consecutive days. Although this approach may expose patients to medication when headache may not have developed, the tolerability and safety profile and preventive effect of gepants may represent a feasible approach for some patients. Situational prevention is an emerging strategy for managing migraine before symptoms develop in individuals who can identify periods when the probability of headache is high. This paper is intended to increase awareness of this strategy and stimulate future randomized, placebo-controlled trials to rigorously assess this strategy.
To compare daily sex hormone levels and rates of change between women with history of migraine and controls.History of migraine, daily headache diaries, and daily hormone data were collected in ovulatory cycles of pre- and early perimenopausal women in the Study of Women's Health Across the Nation. Peak hormone levels, average daily levels, and within-woman day-to-day rates of decline over the 5 days following each hormone peak were calculated in ovulatory cycles for conjugated urinary estrogens (E1c), pregnanediol-3-glucuronide, luteinizing hormone, and follicle-stimulating hormone. Comparisons were made between migraineurs and controls using 2-sample t tests on the log scale with results reported as geometric means.The sample included 114 women with history of migraine and 223 controls. Analyses of within-woman rates of decline showed that E1c decline over the 2 days following the luteal peak was greater in migraineurs for both absolute rate of decline (33.8 [95% confidence interval 28.0-40.8] pg/mgCr vs 23.1 [95% confidence interval 20.1-26.6] pg/mgCr, p = 0.002) and percent change (40% vs 30%, p < 0.001). There was no significant difference between migraineurs and controls in absolute peak or daily E1c, pregnanediol-3-glucuronide, luteinizing hormone, and follicle-stimulating hormone levels. Secondary analyses demonstrated that, among migraineurs, the rate of E1c decline did not differ according to whether a headache occurred during the cycle studied.Migraineurs are characterized by faster late luteal phase E1c decline compared to controls. The timing and rate of estrogen withdrawal before menses may be a marker of neuroendocrine vulnerability in women with migraine.
Dementia is a progressive disease that causes loss of mental abilities, which results in a change of personality, memory and loss of social skills. It is caused by conditions that damage the mind, memory, reasoning and speech. Dementia has become increasingly common, and can be detected as early as middle age although it is more common in old age. A positive link between diet and the development of mental disorders is reflected in a strong correlation between the intake of refined sugars and decrease bet awareness of patients with schizophrenia and the development of depression. Mental changes during aging and gradual separation from active social life are usually emotionally reflect the first stage of aging escape into the food, and in the second phase, after 75 years of lethargy, when the food loses its appeal. Dementia is one of the most important contemporary public health problems. Prolonged nutritional deficiency in the diet is associated with depressed mood, anxiety and cognitive deterioration.
Migraine accounts for substantial suffering and disability. Previous studies show cross-sectional associations between higher pain acceptance and lower headache-related disability in individuals with migraine, but none has evaluated this association longitudinally during migraine treatment. This study evaluated whether changes in pain acceptance were associated with changes in headache-related disability and migraine characteristics in a randomized controlled trial (Women's Health and Migraine) that compared effects of behavioral weight loss (BWL) treatment and migraine education (ME) on headache frequency in women with migraine and overweight/obesity. This was a post hoc analysis of 110 adult women with comorbid migraine and overweight/obesity who received 16 weeks of either BWL or ME. Linear and nonlinear mixed effects modeling methods were used to test for between-group differences in change in pain acceptance, and also to examine the association between change in pain acceptance and change in headache disability. BWL and ME did not differ on improvement in pain acceptance from baseline across post-treatment and follow-up. Improvement in pain acceptance was associated with reduced headache disability, even when controlling for intervention-related improvements in migraine frequency, headache duration, and pain intensity. This study is the first to show that improvements in pain acceptance following two different treatments are associated with greater reductions in headache-related disability, suggesting a potential new target for intervention development. NCT01197196
Objective The objective of this study was to test whether behavioral weight loss (BWL) intervention decreases headaches in women with comorbid migraine and overweight or obesity. Methods This randomized, single‐blind trial allocated women 18 to 50 years old with 4 to 20 migraine days per month and a BMI = 25.0‐49.9 kg/m 2 to 16 weeks of BWL ( n = 54), which targeted exercise and eating behaviors for weight loss, or to migraine education control (ME, n = 56), which delivered didactic instruction on migraine and treatments. Participants completed a 4‐week smartphone headache diary at baseline, posttreatment (16‐20 wk), and follow‐up (32‐36 wk). The primary outcome was posttreatment change in migraine days per month, analyzed via linear mixed effects models. Results Of 110 participants randomly assigned, 85 (78%) and 80 (73%) completed posttreatment and follow‐up. Although the BWL group achieved greater weight loss (mean [95% CI] in kilograms) than the ME group at posttreatment (−3.8 [−2.5 to −5.0] vs. + 0.9 [−0.4 to 2.2], P < 0.001) and follow‐up (−3.2 [−2.0 to −4.5] vs. + 1.1 [−0.2 to 2.4], P < 0.001), there were no significant group (BWL vs. ME) differences (mean [95% CI]) in migraine days per month at posttreatment (−3.0 [−2.0 to −4.0] vs. −4.0 [−2.9 to −5.0], P = 0.185) or follow‐up (−3.8 [−2.7 to −4.8] vs. −4.4 [−3.4 to −5.5], P = 0.378). Conclusions Contrary to hypotheses, BWL and ME yielded similar, sustained reductions in migraine headaches. Future research should evaluate whether adding BWL to standard pharmacological and/or nonpharmacological migraine treatment approaches yields greater benefits.
ABSTRACT PURPOSE OF REVIEW Women are greatly overrepresented among patients seeking treatment for symptoms of headache pain in general and migraine in particular. Understanding the presentation of headache in women in relation to hormonal changes both during the menstrual cycle and throughout the life span is essential for appropriate diagnosis and treatment. RECENT FINDINGS Although perimenstrual migraine attacks are generally without aura, the diagnosis of migraine with aura has been added to the headache classification for menstrual migraine to account for women with the diagnosis of migraine with aura who experience menstrual migraine attacks. Emerging knowledge regarding the differences between menstrual and nonmenstrual attacks, the variability of attack triggering within and between women, and the response of women with menstrually related migraine to new migraine drug classes is contributing to better understanding and more effective treatment of these particularly burdensome and refractory attacks. Given the burden of migraine, almost one-fourth of women with migraine avoid or delay pregnancy. Women who experience migraine during pregnancy are more likely to have a hypertensive disorder and stroke during pregnancy and/or delivery and the postpartum period. Treatment of headache in general and migraine in particular in pregnancy is challenging because of fetal and maternal risks; however, a 2021 systematic review suggests that triptans and low-dose aspirin may not be associated with fetal/child adverse effects and could be more strongly considered for headache treatment in pregnancy. SUMMARY Headache in general and migraine in particular are extraordinarily common in women of reproductive age and fluctuate with hormonal changes and phases of life. Improved knowledge of the epidemiology, pathophysiology, and response to treatment of perimenstrual attacks is essential for more effective response to this most burdensome headache type. Treatment of headache in pregnancy remains challenging.
Despite plausibility of migraine headaches contributing to impaired sexual function among women, data are inconsistent and point to obesity as a potential confounder. Prospective studies that assess the relative importance of migraine improvements and weight loss in relation to sexual function could help elucidate associations among migraine, obesity and female sexual dysfunction (FSD).
