Evaluating Modern Therapeutic Interventions for Migraine Management: A Systematic Review.

This systematic review evaluates the efficacy and safety of contemporary migraine treatments, synthesizing evidence from recent randomized controlled trials (RCTs). The focus is on both pharmacological interventions, such as calcitonin gene-related peptide (CGRP) monoclonal antibodies and non-specific oral migraine preventives, and non-pharmacological approaches like myofascial release. Through a detailed examination of the studies, this review identifies superior strategies for acute and preventive migraine management, assessing their impact on patient-reported outcomes and determining the prevalence of associated adverse events. Findings suggest that while CGRP monoclonal antibodies show promise as first-line treatments due to their efficacy and safety, myofascial release offers considerable benefits for pain and disability in tension-type and cervicogenic headaches. Challenges such as the variability in individual response and potential side effects emphasize the need for personalized treatment plans. This review underscores the importance of integrating new therapeutic discoveries into clinical practice to enhance the quality of care for migraine sufferers.

Impact of an Electronic Health Record-Based Interruptive Alert Among Patients With Headaches Seen in Primary Care: Cluster Randomized Controlled Trial.

Background: Headaches, including migraines, are one of the most common causes of disability and account for nearly 20%-30% of referrals from primary care to neurology. In primary care, electronic health record-based alerts offer a mechanism to influence health care provider behaviors, manage neurology referrals, and optimize headache care. Objective: This project aimed to evaluate the impact of an electronic alert implemented in primary care on patients' overall headache management. Methods: We conducted a stratified cluster-randomized study across 38 primary care clinic sites between December 2021 to December 2022 at a large integrated health care delivery system in the United States. Clinics were stratified into 6 blocks based on region and patient-to-health care provider ratios and then 1:1 randomized within each block into either the control or intervention. Health care providers practicing at intervention clinics received an interruptive alert in the electronic health record. The primary end point was a change in headache burden, measured using the Headache Impact Test 6 scale, from baseline to 6 months. Secondary outcomes included changes in headache frequency and intensity, access to care, and resource use. We analyzed the difference-in-differences between the arms at follow-up at the individual patient level. Results: We enrolled 203 adult patients with a confirmed headache diagnosis. At baseline, the average Headache Impact Test 6 scores in each arm were not significantly different (intervention: mean 63, SD 6.9; control: mean 61.8, SD 6.6; P=.21). We observed a significant reduction in the headache burden only in the intervention arm at follow-up (3.5 points; P=.009). The reduction in the headache burden was not statistically different between groups (difference-in-differences estimate -1.89, 95% CI -5 to 1.31; P=.25). Similarly, secondary outcomes were not significantly different between groups. Only 11.32% (303/2677) of alerts were acted upon. Conclusions: The use of an interruptive electronic alert did not significantly improve headache outcomes. Low use of alerts by health care providers prompts future alterations of the alert and exploration of alternative approaches.

Complicated Form of Medication Overuse Headache Is Severe Version of Chronic Migraine.

Background: MOH (medication overuse headache) is regarded as a complication of chronic migraines (CMs), with a general acknowledgment of reciprocal triggering between these two conditions. The present study aims to investigate the clinical parameters of relevance for the development of MOH among patients with CM, as well as for the subtype classification of MOHs. Method: We compared two groups of CM patients, with and without MOH, separated based on their demographic data and migraine characteristics. A subgroup of MOH accompanied by psychiatric co-morbidities (depression, anxiety, sleep disorder) was delineated, and the clinical features of relevance for the progression of MOH into the complicated state were evaluated. Results: The study revealed a higher prevalence of a family history of migraine in both the MOH and potentially complicated MOH subgroups (p < 0.001, p = 0.036), along with a higher prevalence of bilateral pain localization (p = 0.033, 0.021). Symptoms commonly associated with migraines, such as nausea, vomiting, photophobia, phonophobia, and osmophobia, were more common in both the MOH and potentially complicated MOH subgroups (p < 0.05). Furthermore, a positive correlation was found for the frequency (p < 0.001) and severity (p = 0.010) of migraine attacks and the duration of headaches (p = 0.007), atopy (p = 0.017), sleep disturbances (p = 0.011), and emotional stress (p = 0.022) in the MOH group. Conclusion: We found a positive correlation between the prevalence of MOH among patients with CM and a family history of migraines, higher frequency and intensity of headaches, bilateral manifestation, sleep disturbances, and emotional stress. Moreover, symptoms accompanying migraines were found to be more prevalent in individuals with MOH and potentially complicated MOH.

Benchmarking State-of-the-Art Large Language Models for Migraine Patient Education: Performance Comparison of Responses to Common Queries.

This study assessed the potential of large language models (OpenAI's ChatGPT 3.5 and 4.0, Google Bard, Meta Llama2, and Anthropic Claude2) in addressing 30 common migraine-related queries, providing a foundation to advance artificial intelligence-assisted patient education and insights for a holistic approach to migraine management.

Revolutionizing migraine management: advances and challenges in CGRP-targeted therapies and their clinical implications.

Migraine, a prevalent neurological disorder, affects approximately 14.1% of the global population and disproportionately impacts females. This debilitating condition significantly compromises quality of life, productivity, and incurs high healthcare costs, presenting a challenge not only to individuals but to societal structures as a whole. Despite advances in our understanding of migraine pathophysiology, treatment options remain limited, necessitating ongoing research into effective therapies. This review delves into the complexity of migraine management, examining the roles of genetic predisposition, environmental influences, personalized treatment approaches, comorbidities, efficacy and safety of existing acute and preventive treatments. It further explores the continuum between migraine and tension-type headaches and discusses the intricacies of treating various migraine subtypes, including those with and without aura. We emphasize the recent paradigm shift toward trigeminovascular activation and the release of vasoactive substances, such as calcitonin gene-related peptide (CGRP), which offer novel therapeutic targets. We assess groundbreaking clinical trials, pharmacokinetic and pharmacodynamic perspectives, safety, tolerability, and the real-world application of CGRP monoclonal antibodies and gepants. In the face of persisting treatment barriers such as misdiagnosis, medication overuse headaches, and limited access to specialist care, we discuss innovative CGRP-targeted strategies, the high cost and scarcity of long-term efficacy data, and suggest comprehensive solutions tailored to Turkiye and developing countries. The review offers strategic recommendations including the formulation of primary care guidelines, establishment of specialized outpatient clinics, updating physicians on novel treatments, enhancing global accessibility to advanced therapies, and fostering patient education. Emphasizing the importance of lifestyle modifications and holistic approaches, the review underscores the potential of mass media and patient groups in disseminating critical health information and shaping the future of migraine management.

The Clinical Relevance of Artificial Intelligence in Migraine.

Migraine is a burdensome neurological disorder that still lacks clear and easily accessible diagnostic biomarkers. Furthermore, a straightforward pathway is hard to find for migraineurs' management, so the search for response predictors has become urgent. Nowadays, artificial intelligence (AI) has pervaded almost every aspect of our lives, and medicine has not been missed. Its applications are nearly limitless, and the ability to use machine learning approaches has given researchers a chance to give huge amounts of data new insights. When it comes to migraine, AI may play a fundamental role, helping clinicians and patients in many ways. For example, AI-based models can increase diagnostic accuracy, especially for non-headache specialists, and may help in correctly classifying the different groups of patients. Moreover, AI models analysing brain imaging studies reveal promising results in identifying disease biomarkers. Regarding migraine management, AI applications showed value in identifying outcome measures, the best treatment choices, and therapy response prediction. In the present review, the authors introduce the various and most recent clinical applications of AI regarding migraine.

Safety and Efficacy of Zavegepant in Treating Migraine: A Systematic Review.

Drugs that act on the calcitonin gene-related peptide (CGRP) pathway herald the dawn of a new era in the management of migraine headaches. The blockade of CGRP alleviates neural inflammation and has been associated with reduced pain sensitization. Zavegepant is a third-generation drug and is the first intranasal CGRP antagonist to be developed. This systematic review aims to assess the safety, efficacy, pharmacokinetics, and tolerability of Zavegepant as an abortive treatment for migraine. Studies that assessed the safety, tolerability, and efficacy of Zavegepant for migraine were identified through a systematic literature review of PubMed, Clinicaltrials.gov, and Cochrane databases in April 2023. Our systematic review yielded a total of six studies that fit our inclusion criteria. Of these, data from only two randomized control trials (RCTs) was homogenous; hence, forest plots of results pooled from the included studies were not reported. The included studies showed that Zavegepant is an efficacious and well-tolerated abortive treatment modality for episodic migraine in adult patients. Zavegepant showed safety and efficacy in migraine treatment according to various parameters throughout the six included studies. These parameters include adverse events, pharmacokinetic properties, CGRP inhibition, effect on blood pressure/electrocardiogram, pain freedom, and freedom from most bothersome symptoms.

Disparities and Trends in Migraine Management in Pediatric Emergency Departments, 2009-19.

OBJECTIVE: To assess the variation in migraine management over time across US children's hospitals and to identify factors associated with disparities in management. METHODS: We conducted a retrospective study of 32 hospitals in the Pediatric Health Information System from 2009 to 2019. We included children 7 to 21 years old with primary ICD-9 or ICD-10 diagnosis codes for migraine headache. We surveyed hospitals to assess for clinical guideline presence. We assessed medication use trends over time. To examine differences in medication and advanced head imaging use by patient characteristics and presence of clinical guideline, we performed multivariable logistic regression analyses reporting adjusted odds ratios (aOR) with 95% confidence intervals (CI). RESULTS: We identified 112,077 eligible visits. Opioid use decreased over time, while nonopioid analgesic, dopamine antagonist, and diphenhydramine use increased. Multivariable analysis for opioids revealed increased odds of use for those 14 to 17 (aOR 1.19; 95% CI, 1.06, 1.34) and 18 to 21 years old (aOR 1.69; CI, 1.37, 2.08), and clinical guideline presence had decreased odds (aOR 0.64; CI, 0.48, 0.84). For head computed tomography, increased odds of use were reported for Hispanic ethnicity (aOR 1.15; CI, 1.06, 1.24) and decreased odds for 14 to 17 years (aOR 0.85; CI, 0.80, 0.90), 18 to 21 years (aOR 0.87; CI, 0.77, 0.98), and female sex (aOR 0.74; CI, 0.70, 0.79). CONCLUSIONS: Opioid use decreased while other medications increased over time. Medication and imaging differed by demographic characteristics. Opioid use was less likely in hospitals with clinical guidelines. Standardization in management may decrease care disparities and variability.

De novo Migraine with Aura in the Third Trimester of Pregnancy: A Case Report and Literature review.

BACKGROUND: Among all headache disorders, migraine has the highest prevalence during gestation. The majority of migraineurs experience improvement during pregnancy, but a few may experience migraine for the first time. This poses a diagnostic challenge in the differential diagnosis between primary and life-threatening secondary headache disorders. Because pregnancy itself is an independent risk factor for secondary headache disorders, it is mandatory to exclude these conditions in order to diagnose migraine. There is a large body of literature about pre-existing migraine course during pregnancy and its link with adverse pregnancy outcomes, but there are no studies examining these aspects among women with new-onset migraine during pregnancy. CASE REPORT: A 31-year-old female at 33 weeks of gestation (gravida 2, para 2) was referred to the neurologist eds disturbances, which were followed by pressing severe headache, rated as 8 out of 10 on a numeric rating scale and accompanied by dizziness. The headache lasted for one day, and dizziness continued to the following day. The patient was investigated for a secondary headache disorder, but laboratory and neuroimaging results were unremarkable. A migraine with aura was diagnosed. The patient was advised to keep a consistent sleep schedule, maintain regular low physical activity, eat regularly and take magnesium supplementation. The patient was informed about a safe treatment approach in case of an acute attack. At 40 weeks of gestation the patient delivered female newborn, weighing 3750g, with Apgar scores of 8 and 9 (due to a nuchal cord). The postpartum period was uneventful. During the subsequent 4 years, the patient did not experience any recurrent migraine attacks and had no pregnancies. CONCLUSION: In order to diagnose a migraine during pregnancy, exclusion of secondary headache disorders is mandatory. Pregnant migraineur should be regularly monitored for adverse birth outcomes. It is essential to educate patients, provide information about the safe treatment of migraine attacks, and explain nonpharmacological prevention and supplementation benefits.

Benefits of an on-line migraine education video for patients with co-occurring migraine and depression.

OBJECTIVE: To evaluate effects of an online, hour-long migraine education and management education program on health outcomes in people with migraine experiencing significant depressive symptoms. METHODS: Eligible individuals in the community with comorbid migraine and depressive symptoms (n = 95) participated in the 12-week study. Participants completed self-report questionnaires examining general functioning, headache-specific disability, migraine frequency, pain, and depressive symptoms, before, and at 2, 6, and 12 weeks following the migraine education and management program. Primary analyses evaluated change over time in each outcome, using individual linear growth curve models. RESULTS: After watching the migraine education and management video, there were significant effects of time (across all time points) for average pain level in the past 30 days (b = -0.20, p < .001), most intense pain level in the past 30 days (b = -0.33, p < .001) depression (Patient Health Questionnaire-8; b = -0.28, p = .002), and headache-specific disability (Headache Disability Inventory; b = -1.32, p < .001), such that each of these outcomes improved linearly over time. CONCLUSIONS: A brief, online educational video is practical and effective and can lead to enhanced migraine knowledge and self-management skills and lessen the burden of migraine and concurrent depressive symptoms.

Development and Optimization by Quality by Design Strategies of Frovatriptan Orally Disintegrating Tablets for Migraine Management.

BACKGROUND: Frovatriptan is a potent anti-migraine agent with unfavourable slow onset of action, available on the market as film-coated tablets. OBJECTIVE: Optimization, by Quality by Designs strategies, of an orally disintegrating tablet (ODT) formulation of frovatriptan aimed to make its oral administration easier and its dissolution faster than the commercial tablets, thus improving its effectiveness in migraine management. METHOD: A screening D-optimal design was applied to investigate the effects of different levels of kind and amount of ODT special excipient and disintegrant agents (identified as the critical variables) on disintegration time (DT) and % drug dissolved at 30 s (%Diss), selected as the responses to optimize. The best excipients combination, emerged by the screening step, was in-depth investigated by a Response Surface Methodology. RESULTS: A design space was defined where every combination of the selected variables fulfilled the required values for the responses with P ≥ 95%. In particular, the optimized formulation (Pharmaburst® 60% and Na alginate 15%), showed DT = 1.62±0.08 s and %Diss= 9.02±0.47%, with good agreement between measured and calculated values. Moreover, the developed ODT complied with the USP uniformity weight and drug content requirements, exhibited proper hardness and low friability, and provided 100 % dissolved drug within 5 min. CONCLUSION: A frovatriptan ODT formulation was successfully developed by Quality by Design. It represents an effective alternative to conventional tablets, allowing easier oral administration (also to paediatric and geriatric people) and very faster drug dissolution, enhancing patient compliance and facilitating an earlier treatment of migraine attacks.

Recent advances in the management of migraine.

Migraine remains one of the most disabling disorders worldwide. The high prevalence in the general population and the often-delicate treatment of patients account for that. Therapeutic management of migraine relies mainly on non-specific medical treatment and is affected by low patient adherence to the treatment regimens applied. The introduction of specific anti-migraine treatment occurred over 20 years ago when the first triptan was approved by regulatory authorities (sumatriptan, 28 December 1992). Triptan use is limited by side effects, time- and frequency-restricted application, and the risk of developing medication overuse headache. Within the past few years, new and promising drugs such as more specific 5-HT 1F receptor agonists (that is, lasmiditan) and monoclonal calcitonin gene-related peptide (CGRP) receptor antibodies entered advanced development phases while non-invasive neuromodulatory approaches were suggested to be potentially effective as non-pharmaceutical interventions for migraine.

Trigger factors in migraine patients.

The objective of this study was to examine potential trigger factors in migraine patients. A total of 126 migraine patients were interviewed about possible trigger factors for migraine. The most common trigger factors were emotional stress (79%), sleep disturbance (64%) and dietary factors (44%). Sleep and stress were significant trigger factors in patients with migraine with aura, whereas environmental factors were important trigger factors in patients with migraine without aura. Stress, sleep and environmental factors were important trigger factors in women and differed significantly from men. Trigger factors are frequent in migraine patients, and avoidance of such factors may result in a better control of the disorder.