Acute Treatment of Migraine.

OBJECTIVE: Most patients with migraine require acute treatment for at least some attacks. This article reviews the approach to the acute treatment of migraine, migraine-specific and nonspecific treatment options, rescue treatment and options for management in the emergency department and inpatient settings, and treatment during pregnancy and lactation. LATEST DEVELOPMENTS: Triptans, ergot derivatives, and nonsteroidal anti-inflammatory drugs have historically been the main acute treatments for migraine. The development of new classes of acute treatment, including the small-molecule calcitonin gene-related peptide receptor antagonists (gepants) and a 5-HT1F receptor agonist (lasmiditan), expands available options. These new treatments have not been associated with vasospasm or increased cardiovascular risk, therefore allowing migraine-specific acute treatment for the more than 20% of adults with migraine who are at increased risk of cardiovascular events. Neuromodulation offers a nonpharmacologic option for acute treatment, with the strongest evidence for remote electrical neuromodulation. ESSENTIAL POINTS: The number of available migraine treatments continues to expand, although triptans are still the mainstay of migraine-specific acute treatment. There is no one-size-fits-all acute treatment and multiple treatment trials are sometimes necessary to determine the optimal regimen for patients. Switching within and between classes, using the maximum allowed dose, using combination therapy, and counseling patients to treat early are all strategies that may improve patient response to acute treatment.

Repercussions of Rejecting Unwanted Advances: Gender Differences in Experience and Concern.

Here we investigated how a history of experiencing unwanted advances-both sexual and romantic-impact a person's stress and strategies when rejecting future advances. In this study (N = 465; 71% women), women reported experiencing unwanted advances earlier in life compared to men, and these women were more likely to have greater worry over such advances. Additionally, women tended to worry more than men about the repercussions of rejecting these advances (e.g., being hit, being yelled at). Lastly, women were more likely to employ a myriad of strategies (e.g., run away, call a friend) to ensure their safety when rejecting an advance. In contrast, men were more likely to remain friends with the rejected person. Ultimately, women have to deal with rejecting advances at an early age and this early onset has consequences for future dating.

The call of the final frontier?

The target article is focused on locating the popularity of imaginary worlds in our adaptations for exploration. This commentary touches on developmental influences, vicarious enjoyment, the challenging of societal mores, plot, and whether men and women are drawn to the same features in the same ways.

Perceived Effectiveness of Flirtation Tactics: The Effects of sex, Mating Context and Individual Differences in US and Norwegian Samples.

Flirting involves various signals communicated between individuals. To attract potential mates, men and women exhibit flirtatious behavior to get the attention of, and potentially elicit sexual or romantic interest from, a desired partner. In this first large, preregistered study of judgement of the effectiveness of flirtation tactics based on Sexual Strategies Theory, we considered the effects of flirter's (actor) sex and mating contexts in addition to rater's (participant) sex across two cultures, Norway and the U.S. Culturally relevant covariates such as sociosexuality, extraversion, mate value, age, and religiosity were examined. Participants from Norway (N = 415, 56% women) and the US (N = 577, 69% women) responded to one of four different randomized questionnaires representing a factorial design considering either short-term versus long-term mating context and either female or male sex of actor. We found that sexual availability cues were judged more effective when employed by women in short-term mating contexts. Friendly contact, such as hugs or kissing on the cheek, was not. Cues to generosity and commitment were judged more effective when employed by men in long-term mating contexts. Humor was rated as more effective when used by men and in long-term contexts, and least effective when used by women in short term contexts. However, laughing or giggling at someone's jokes was an effective flirtation tactic for both sexes. Overall, predictions for culturally relevant covariates were not supported, but cultural differences were found in bodily displays, initial contact, and generosity. These findings dovetail neatly with findings from the self-promotion literature, and further support that flirtation is a universal mate signaling strategy.

The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice.

OBJECTIVE: To incorporate recent research findings, expert consensus, and patient perspectives into updated guidance on the use of new acute and preventive treatments for migraine in adults. BACKGROUND: The American Headache Society previously published a Consensus Statement on the use of newly introduced treatments for adults with migraine. This update, which is based on the expanded evidence base and emerging expert consensus concerning postapproval usage, provides practical recommendations in the absence of a formal guideline. METHODS: This update involved four steps: (1) review of data about the efficacy, safety, and clinical use of migraine treatments introduced since the previous Statement was published; (2) incorporation of these data into a proposed update; (3) review and commentary by the Board of Directors of the American Headache Society and patients and advocates associated with the American Migraine Foundation; (4) consideration of these collective insights and integration into an updated Consensus Statement. RESULTS: Since the last Consensus Statement, no evidence has emerged to alter the established principles of either acute or preventive treatment. Newly introduced acute treatments include two small-molecule calcitonin gene-related peptide (CGRP) receptor antagonists (ubrogepant, rimegepant); a serotonin (5-HT1F ) agonist (lasmiditan); a nonsteroidal anti-inflammatory drug (celecoxib oral solution); and a neuromodulatory device (remote electrical neuromodulation). New preventive treatments include an intravenous anti-CGRP ligand monoclonal antibody (eptinezumab). Several modalities, including neuromodulation (electrical trigeminal nerve stimulation, noninvasive vagus nerve stimulation, single-pulse transcranial magnetic stimulation) and biobehavioral therapy (cognitive behavioral therapy, biofeedback, relaxation therapies, mindfulness-based therapies, acceptance and commitment therapy) may be appropriate for either acute and/or preventive treatment; a neuromodulation device may be appropriate for acute migraine treatment only (remote electrical neuromodulation). CONCLUSIONS: The integration of new treatments into clinical practice should be informed by the potential for benefit relative to established therapies, as well as by the characteristics and preferences of individual patients.

Learning the full impact of migraine through patient voices: A qualitative study.

OBJECTIVE: To better characterize the ways that migraine affects multiple domains of life. BACKGROUND: Further understanding of migraine burden is needed. METHODS: Adults with migraine randomized to mindfulness-based stress reduction or headache education arms (n = 81) in two separate randomized clinical trials participated in semistructured in-person qualitative interviews conducted after the interventions. Interviews queried participants on migraine impact on life and were audio-recorded, transcribed, and summarized into a framework matrix. A master codebook was created until meaning saturation was reached and magnitude coding established code frequency. Themes and subthemes were identified using a constructivist grounded theory approach. RESULTS: Despite most participants being treated with acute and/or prophylactic medications, 90% (73/81) reported migraine had a negative impact on overall life, with 68% (55/81) endorsing specific domains of life impacted and 52% (42/81) describing impact on emotional health. Six main themes of migraine impact emerged: (1) global negative impact on overall life; (2) impact on emotional health; (3) impact on cognitive function; (4) impact on specific domains of life (work/career, family, social); (5) fear and avoidance (pain catastrophizing and anticipatory anxiety); and (6) internalized and externalized stigma. Participants reported how migraine (a) controls life, (b) makes life difficult, and (c) causes disability during attacks, with participants (d) experiencing a lack of control and/or (e) attempting to push through despite migraine. Emotional health was affected through (a) isolation, (b) anxiety, (c) frustration/anger, (d) guilt, (e) mood changes/irritability, and (f) depression/hopelessness. Cognitive function was affected through concentration and communication difficulties. CONCLUSIONS: Migraine has a global negative impact on overall life, cognitive and emotional health, work, family, and social life. Migraine contributes to isolation, frustration, guilt, fear, avoidance behavior, and stigma. A greater understanding of the deep burden of this chronic neurological disease is needed to effectively target and treat what is most important to those living with migraine.

Preventive Migraine Treatment.

PURPOSE OF REVIEW: This article provides an overview of preventive interventions for migraine, including when to start and how to choose a treatment, pharmacologic options (both older oral treatments and new monoclonal antibodies to calcitonin gene-related peptide [CGRP] or its receptor), nonpharmacologic treatment such as neuromodulation, and preventive treatment of refractory migraine. RECENT FINDINGS: The migraine preventive treatment landscape has been transformed by the development of monoclonal antibodies targeting CGRP or its receptor. These treatments, which are given subcutaneously or intravenously monthly or quarterly, have high efficacy and were well tolerated in clinical trials. Emerging real-world studies have found higher rates of adverse events than were seen in clinical trials. They are currently recommended for use if two traditional preventive therapies have proven inadequate. Since the commonly cited 2012 American Headache Society/American Academy of Neurology migraine prevention guidelines were released, clinical trials supporting the preventive use of lisinopril, candesartan, and memantine have been published. Neuromodulation devices, including external trigeminal nerve stimulation and single-pulse transcranial magnetic stimulation devices, have modest evidence to support preventive use. The American Headache Society/American Academy of Neurology guidelines for the preventive treatment of migraine are currently being updated. A new class of oral CGRP receptor antagonists (gepants) is being tested for migraine prevention. SUMMARY: Successful preventive treatment of migraine reduces disease burden and improves quality of life. Many pharmacologic and nonpharmacologic treatment options are available for the prevention of migraine, including newer therapies aimed at the CGRP pathway as well as older treatments with good evidence for efficacy. Multiple treatment trials may be required to find the best preventive for an individual patient.

The prevalence and impact of migraine and severe headache in the United States: Updated age, sex, and socioeconomic-specific estimates from government health surveys.

BACKGROUND AND OBJECTIVES: Accurate, up-to-date estimates of the burden of migraine and severe headache are important for evidence-based decision-making about workforce needs and the distribution of health resources. We used data from US government health surveys to report the prevalence, trends, and impact of this condition by age, sex, and poverty status. METHODS: We identified the most recent, publicly available summary statistics from the National Hospital Ambulatory Medical Care Survey, the National Ambulatory Medical Care Survey, and the National Health Interview Survey. We extracted and compiled relevant information from each study, with an emphasis on sex, age, and economic-related statistics. RESULTS: The age-adjusted prevalence of migraine and severe headache in the United States has remained stable over many years. In 2018, the age-adjusted prevalence was 15.9% across all adults. The sex ratio also remains stable, with 21% of women and 10.7% of men affected. Migraine continues to be an important public health problem, accounting for roughly 4 million emergency department (ED) visits in 2016, when headache was the fifth most common reason for an ED visit overall and the third most common reason for ED visits in females 15-64. Migraine also accounted for over 4.3 million office visits. Many adults with migraine or severe headaches are disadvantaged. In 2018, for example, roughly 40% of US adults with migraine were unemployed, and a similar proportion were classified as poor or "near poor." Roughly one in five had no health insurance and about a third had a high school education or less. CONCLUSIONS: Migraine and severe headaches are a serious public health issue in the United States, with the highest impact in women of childbearing age and those of lower socioeconomic status. Socioeconomic disadvantages also are highly prevalent among those with headaches. The economic consequences of the current coronavirus pandemic are likely to exacerbate all of these inequities. Increased attention to this high impact chronic pain condition, and improved funding for treatment provision and research, are warranted to reduce the future burden of disease.

Identification of work accommodations and interventions associated with work productivity in adults with migraine: A scoping review.

OBJECTIVE: To identify factors associated with work productivity in adults with migraine, and accommodations or interventions to improve productivity or the workplace environment for them. METHODS: We conducted a scoping review by searching MEDLINE, Embase, PsycINFO, Cumulative Index of Nursing and Allied Heath Literature, and Web of Science from their inception to 14 October 2019 for studies of any design that assessed workplace productivity in adults with migraine. RESULTS: We included 26 articles describing 24 studies after screening 4139 records. Five prospective cohort studies showed that education on managing migraine in the workplace was associated with an increase in productivity of 29-36%. Two studies showed that migraine education and management in the workplace were associated with increased productivity (absenteeism decreased by 50% in one study). One prospective cohort study showed that occupational health referrals were associated with more than 50% reduction in absenteeism. Autonomy, social support, and job satisfaction were positively associated with productivity, while quantitative demands, emotional demands, job instability, and non-conducive work environment triggers are negatively associated with productivity in workers with migraine. CONCLUSION: Despite migraine being the second leading cause of disability worldwide, there is a paucity of strong data on migraine-related work factors associated with productivity.Registration: None (scoping review).