Dystonia phenomenology and treatment response in migraine.

OBJECTIVE: To describe the phenomenology of cervical dystonia (CD) in patients with migraine and the effect of its treatment on migraine frequency. BACKGROUND: Preliminary studies demonstrate that treatment of CD with botulinum toxin in those with migraine can improve both conditions. However, the phenomenology of CD in the setting of migraine has not been formally described. METHODS: We conducted a single-center, descriptive, retrospective case series of patients with a verified diagnosis of migraine who were referred to our movement disorder center for evaluation of co-existing, untreated CD. Patient demographics, characteristics of migraine and CD, and effects of cervical onabotulinumtoxinA (BoTNA) injections were recorded and analyzed. RESULTS: We identified 58 patients with comorbid CD and migraine. The majority were female (51/58 [88%]) and migraine preceded CD in 72% (38/53) of patients by a mean (range) of 16.0 (0-36) years. Nearly all the patients had laterocollis (57/58) and 60% (35/58) had concurrent torticollis. Migraine was found to be both ipsilateral and contralateral to the dystonia in a comparable proportion of patients (11/52 [21%] vs. 15/52 [28%]). There was no significant relationship between migraine frequency and dystonia severity. Treatment of CD with BoTNA reduced migraine frequency in most patients (15/26 [58%] at 3 months and 10/16 [63%] at 12 months). CONCLUSIONS: In our cohort, migraine often preceded dystonia symptoms and laterocollis was the most described dystonia phenotype. The lateralization and severity/frequency of these two disorders were unrelated, but dystonic movements were a common migraine trigger. We corroborated previous reports that cervical BoTNA injections reduced migraine frequency. Providers treating patients with migraine and neck pain who are not fully responding to typical therapies should screen for possible CD as a confounding factor, which when treated can reduce migraine frequency.

Migraine Care Challenges and Strategies in US Uninsured and Underinsured Adults: A Narrative Review, Part 2.

OBJECTIVE: To review the challenges and potential solutions in treatment options for quality migraine care in adult patients who are under or uninsured. BACKGROUND: The Affordable Care Act has improved access to health care for many; however, those who are underserved continue to face treatment disparities and have inadequate access to appropriate migraine management. METHODS: This manuscript is the second of a 2-part narrative review which was performed after a series of discussions within the Underserved Populations in Headache Medicine Special Interest Section meetings of the American Headache Society. Literature was reviewed for key concepts underpinning conceptual boundaries and a broad overview of the subject matter. Published guidelines, state-specific Medicaid websites, headache quality measurement sets, literature review, and expert opinion were used to tailor suggested treatment options and therapeutic strategies. In this second part of our narrative review, we explored migraine care strategies and considerations for underserved and vulnerable adult populations with migraine. RESULTS: Although common, migraine remains untreated, particularly among those of low socioeconomic status. Low socioeconomic status may play an important role in the disease progression, prescription of hazardous medications such as opioids, outcomes, and quality of life of patients with migraine and other headache disorders. There are some evidence-based and guideline supported treatment options available at low cost that include prescription medications and supplements, though approved devices are costly. Resources available online and simple nonpharmacological strategies may be particularly useful in the underserved migraine population. CONCLUSIONS: We identified and discussed migraine treatment barriers that affect underserved populations in the US and summarized practical, cost-effective strategies to surmount them. However, more research is needed to identify the best cost-effective measures for migraine management in underserved and vulnerable patients who are uninsured or underinsured.

Migraine Care Challenges and Strategies in US Uninsured and Underinsured Adults: A Narrative Review, Part 1.

OBJECTIVE: To review the scope of the problem facing individuals with migraine who are under- or uninsured. In this first of a 2-part narrative review, we will explore migraine epidemiology and the challenges that face this vulnerable population. BACKGROUND: Implementation of the Affordable Care Act has improved access to health care for many individuals who were previously uninsured, but there are many, particularly those of certain demographics, who are at high risk for worse outcomes. METHODS: A narrative review was performed after a series of discussions within the Underserved Populations in Headache Medicine Special Interest Section meetings of the American Headache Society. Literature was reviewed for key concepts underpinning conceptual boundaries and a broad overview of the subject matter. Published guidelines, state-specific Medicaid websites, headache quality measurement set, literature review, and expert opinion were used to tailor suggested treatment options and therapeutic strategies. RESULTS: Migraine is common, yet remains underdiagnosed and associated with worse outcomes among those of under-represented backgrounds and those who are underinsured or uninsured. Low socioeconomics may play an important role in the disease progression, characteristics, outcome, and quality of life of patients with migraine and other headache disorders. Other barriers to optimal care include time constraints, lack of access to specialty providers, transportation, and financial limitations. CONCLUSION: There are many barriers and challenges that affect people with migraine who are underinsured or uninsured, particularly those of under-represented racial backgrounds and of lower socioeconomic status.

Migraine in Women.

Migraine is one of the most common neurological disorders, affecting women disproportionally at a rate of 3:1. Prior to puberty, boys and girls are equally affected, but the female preponderance emerges after puberty. Migraine pathophysiology is not fully understood, and although the hormonal effect of estrogen is significant, other factors are at play. This article will focus on the hormonal influence on migraine in women. Here we review our most recent understanding of migraine and menstrual migraine, including epidemiology, pathophysiology, and treatment strategies for this challenging disorder, as well as migraine during pregnancy, postpartum period, breastfeeding, perimenopause, and menopause. We also review the risks and benefits of exogenous hormone use in this population and discuss stroke risk in women with migraine aura. By understanding these aspects of migraine in women, we hope to arm practitioners with the knowledge and tools to help guide treatment of this debilitating disorder in this large population.

Epidemiology of cluster headache.

Cluster headache was first described over 300 years ago, but in the last century our knowledge of the disorder has exploded through both clinical observation and epidemiological data. Although some of the data are conflicting and more need to be obtained, much is known about the disorder. This article reviews the data to date on the prevalence and incidence of the disorder, population differences including gender and race, genetics, comorbid conditions, risk factors for development of the disorder, prognosis, and socioeconomic burden.

Migraine in women.

Of the nearly 32 million Americans with migraine, 24 million are women. It is a disorder affecting women throughout their lifetimes, from childhood and puberty through the postmenopausal years. In childhood, before puberty girls are afflicted with migraine at approximately the same rate as boys, but after puberty, there is an emerging female predominance. Estrogen plays a key role in this epidemiologic variation but is not the only factor. There are numerous times when hormonal influences have an impact on migraine and its pattern, including menarche, oral contraceptive use, pregnancy, perimenopause, and menopause. Hence practitioners treating women with migraine need to have a clear understanding of these special considerations.

Adolescent issues in migraine: a focus on menstrual migraine.

Migraine commonly affects adolescents, and menstrual migraine often begins in young girls. If undiagnosed or ineffectively treated, migraine can lead to disability, school absenteeism, emotional or social difficulties, and chronification of headache. Thus, recognizing and accurately diagnosing migraine and menstrual migraine, developing effective treatment strategies (both pharmacologic and nonpharmacologic), and educating both the adolescent and her parents are important in order to minimize the potential early disability of this disorder and limit the otherwise likely progression of migraine to a disabling disorder of adulthood.

Preventative treatment of menstrual migraine.

More than 20 million US women suffer with migraine, two thirds of whom experience menstrually related migraine. Estrogen plays an important role in triggering migraine, and given the numerous hormonal fluctuations throughout a woman's lifetime, there are many opportunities for a hormonal impact. Accurate diagnosis is key to initiating effective treatment, and when acute therapy fails, the unique predictability of menstrual migraine lends itself to preventative treatment.

Cluster headache in women.

Cluster headache has long been considered a predominantly male disorder, with much of our knowledge based on studies of men. However, it has become increasingly more recognized in women. Although there are many similarities between men and women in the expression of the disorder, studies over the years have revealed gender differences. This article reviews epidemiologic, clinical, hormonal, and familial differences between male and female cluster patients, examines how they may affect treatment, and suggests studies that may give us a better understanding of the disorder.

Special considerations in the treatment of migraine in women.

Nearly 32 million Americans have migraine, 24 million of whom are women who suffer with migraine throughout their lifetimes. Prior to puberty, girls are afflicted with migraine at approximately the same rate as boys, but after puberty there is an emerging female predominance. Although hormones do not entirely explain the epidemiological variation seen in migraine, estrogen certainly plays an important role. Given the hormonal changes occurring throughout a woman's life, there are many opportunities for a hormonal impact on migraine, including menarche, oral contraceptive use, pregnancy, perimenopause, and menopause. The special considerations of migraine in women will be reviewed including epidemiology, pathophysiology, diagnosis, and therapy.