A randomized controlled trial of a comprehensive migraine intervention prior to discharge from an emergency department.

OBJECTIVES: Patients who use an emergency department (ED) for acute migraine headaches have higher migraine disability scores, lower socioeconomic status, and are unlikely to have used a migraine-specific medication prior to presentation to the ED. The objective was to determine if a comprehensive migraine intervention, delivered just prior to ED discharge, could improve migraine impact scores 1 month after the ED visit. METHODS: This was a randomized controlled trial of a comprehensive migraine intervention versus typical care among patients who presented to an ED for management of acute migraine. At the time of discharge, for patients randomized to comprehensive care, the research team reinforced their diagnosis, shared a migraine education presentation from the National Library of Medicine, provided them with six tablets of sumatriptan 100 mg and 14 tablets of naproxen 500 mg, and if they wished, provided them with an expedited free appointment to the institution's headache clinic. Patients randomized to typical care received the care their attending emergency physicians (EPs) felt was appropriate. The primary outcome was a between-group comparison of the Headache Impact Test (HIT-6) score, a validated headache assessment instrument, 1 month after ED discharge. Secondary outcomes included an assessment of satisfaction with headache care and use of migraine-specific medication within that 1-month period. RESULTS: Over a 19-month period, 50 migraine patients were enrolled. One-month follow-up was successfully obtained in 92% of patients. Baseline characteristics were comparable. One-month HIT-6 scores in the two groups were nearly identical (59 vs. 56, 95% confidence interval [CI] for difference of 3 = -5 to 11), as was dissatisfaction with overall headache care (17% vs. 18%, 95% CI for difference of 1% = -22% to 24%). Patients randomized to the comprehensive intervention were more likely to be using triptans or migraine-specific therapy (43% vs. 0%, 95% CI for difference of 43% = 20 to 63%) 1 month later. CONCLUSIONS: A comprehensive migraine intervention, when compared to typical care, did not improve HIT-6 scores (a validated measure of the effect of migraine on one's daily life) 1 month after ED discharge. Future work is needed to define a migraine intervention that is practical and useful in an ED, where many underserved patients, of necessity, present for care.

Botulinum toxin for the treatment of chronic migraine: the placebo effect.

Botulinum toxin A used to treat headache evokes prominent placebo effects and it is likely that these effects are solely responsible for its apparent effectiveness.

Post-traumatic headache: commentary: an overview.

The history of post-traumatic headache begins in the middle of the 19th century, and its latest iteration has been defined in the International Headache Classification of 2004. Contrary to the latter, there are instances when mild head injury without symptoms or signs of concussion may evoke the pathophysiological changes of migraine. The mechanisms of chronic post-traumatic headache and the associated syndrome are complex and include pathophysiological, psychological, and socioeconomic factors. Treatment of these headaches is similar to that of the primary headaches with particular attention to nonpharmacological measures.

Cluster attacks responsive to recreational cannabis and dronabinol.

Pharmacological preparations of cannabinoid compounds have a variety of therapeutic uses in medicine, including different pain syndromes, but have not been previously reported as beneficial for cluster headache. We present a patient with cluster headache who was refractory to multiple acute and preventive medications but successfully aborted his attacks with recreational marijuana use; subsequent use of dronabinol provided equally effective pain relief. The beneficial effect may be related to the high concentration of cannabinoid receptors in the hypothalamus, which has been implicated as a site of dysfunction in neuroimaging studies of patients with cluster headache.

American headache through the decades: 1950 to 2008.

As the American Headache Society approaches its 50th anniversary, it seems worthwhile to step back and survey the many changes in the headache field since the 1950s. Many, perhaps most, of the trends, ideas, and changes we review in this article cannot easily be assigned to a particular decade but we have nonetheless chosen a by-the-decade format because it is a familiar and useful way of understanding history. Our focus is on events in the United States and the American Headache Society; space and the need to limit the scope of the article preclude a full description of the many parallel and influential trends, personalities, and ideas in other parts of the world or in other professional organizations. The authors hope you will find this summary of American Headache Medicine in the last half of the 20th and the beginning of the 21st centuries entertaining and educational.

Nummular headache.

Nummular headache is a rare primary headache disorder characterized by focal and well-circumscribed pain fixed within a round-, oval-, or elliptical-shaped region of the head. The pain is usually mild to moderate in intensity but may be severe. Nummular headache is most common in women in the fourth to fifth decade of life. The temporal pattern may be chronic and continuous since onset, chronic evolved from episodic, or episodic. These headaches typically are unilateral, side-locked, and fixed in location, commonly affecting the parietal region. Many patients experience superimposed exacerbations of pain, lasting from seconds to days. Sensory phenomena, such as paresthesias, allodynia, and dysesthesias, are frequently reported in the region of the pain. Treatment with gabapentin, tricyclic antidepressants, or botulinum toxin may be helpful.

Retinal migraine.

Retinal migraine is a primary headache disorder, clinically manifested by attacks of transient monocular visual loss associated with migraine headache. Although isolated reports suggest that retinal migraine is rare, it likely is under-recognized. Retinal migraine usually is reported in women of childbearing age who have a history of migraine with aura. It typically is characterized by negative monocular visual phenomena lasting less than 1 hour. More than half of reported cases with recurrent transient monocular visual loss subsequently experienced permanent monocular visual loss. Although the International Headache Society diagnostic criteria for retinal migraine require reversible visual loss, our findings suggest that irreversible visual loss is part of the retinal migraine spectrum, likely representing an ocular form of migrainous infarction.